Secondhand smoke exposure among Hispanics/Latinos living in multiunit housing: exploring barriers to new policies

Getting to effective housing policy for health: a thematic synthesis of policy development and implementation

Impacts of housing on health are well-recognised. Despite this, housing standards have been neglected and there are gaps in healthy housing policies, particularly in low and middle-income countries. Given the recent publication of the WHO Housing and health guidelines, and the need to implement these into policy at all scales, we carried out a focused search and thematic synthesis of available literature on the barriers and enablers to recent housing and health policy. We aimed to generate lessons of what works to support healthy housing policy development and implementation elsewhere. Twenty-three studies representing four countries were eligible for inclusion and covered housing-related risks of air quality, lead, accessible design, and housing conditions. Findings demonstrated that policy development and implementation were facilitated through awareness of housing and health, evidence of existing housing conditions and health impacts, collaborations across sectors and between residents and decision-makers and effective enforcement systems that employed incentives, tools such as certificates for compliance, and housing inspections. Concerns about economic viability and tensions between housing rights and responsibilities limited healthy housing policy for the 'common good'. Despite limitations in the diversity of available evidence, this thematic synthesis provides a starting point for healthy and equitable housing for all.

Differences in smoking behavior and beliefs about abstinence among Latinx individuals with and without depression who smoke cigarettes

There is a well-established relation between depression and smoking in the general population. However, past work focused on Latinx persons who smoke in relation to depressed affect has yielded inconsistent findings. The present investigation aimed to build on past research and evaluate differences among English-speaking Latinx adults who smoke combustible cigarettes with and without probable depression in terms of cigarette dependence, perceived barriers for quitting, severity of problems when quitting, and smoking abstinence expectancies. The current sample included 338 adult Latinx daily cigarette smokers (Mage = 35.53 years; SD = 8.65; age range 18-61; 37.3% female) that were recruited nationally throughout the US. Results indicated that among Latinx persons who smoke, those with probable depression (compared to those without) demonstrated higher levels of cigarette dependence, more severe problems when trying to quit, greater perceived barriers for quitting, and increased negative abstinence expectancies after adjusting for sociodemographic and concurrent substance use variables. Future work could build from this research to elucidate the role of depression in the maintenance and relapse of smoking among the Latinx population.

A randomized control trial to support smoke-free policy compliance in public housing

BACKGROUND

Smoke-free housing policies in multiunit housing are increasingly widespread interventions to reduce smoking and secondhand smoke exposure. Little research has identified factors that impede compliance with smoke-free housing policies in low-income multiunit housing and test corresponding solutions.

METHODS

We are using an experimental design to test two compliance support interventions: (A) a "compliance through reduction (via relocation and reduction in personal smoking) and cessation" intervention targets households with smokers and involves support to shift smoking practices to areas beyond the apartment or building setting, reduce personal smoking, and deliver in-residence smoking cessation support services via trained peer educators and (B) a "compliance through resident endorsement" intervention involving voluntary adoption of smoke-free living environments through personal pledges, visible door markers, and/or via social media. We will compare randomly sampled participants in buildings that receive A or B or A plus B to the NYCHA standard approach.

DISCUSSION

This RCT addresses key gaps in knowledge and capitalizes on key scientific opportunities by (1) leveraging the federal mandate to ban smoking in a public housing system of more than sufficient size to conduct an adequately powered RCT; (2) expanding our understanding of smoke-free policy compliance beyond policy implementation by testing two novel treatments: (a) in-residence smoking cessation and (b) resident endorsement, while (3) addressing population and location-specific tobacco-related disparities. At the conclusion of the study, this RCT will have leveraged a monumental policy shift affecting nearly half a million NYC public housing residents, many of whom disproportionately experience chronic illness and are more likely to smoke and be exposed to secondhand smoke than other city residents. This first-ever RCT will test the effects of much-needed compliance strategies on resident smoking behavior and secondhand smoke exposure in multiunit housing.

TRIAL REGISTRATION

Clinical Trials Registered, NCT05016505. Registered on August 23, 2021.

Assessing Smoke-Free Housing Implementation Approaches to Inform Best Practices: A National Survey of Early-Adopting Public Housing Authorities

Secondhand smoke (SHS) exposure causes chronic illness and occurs at a higher prevalence in low-income communities than the general public. In 2018, the U.S. Department of Housing and Urban Development (HUD) instituted a smoke-free housing rule for Public Housing Authorities (PHAs) to address persistent health inequities. However, the success of smoke-free housing requires evidence to inform effective implementation approaches. A mixed-methods, cross-sectional survey was conducted in a national sample of PHAs. Questions focused on housing officials' use of specific implementation strategies. Adjusted odds ratios were used to assess associations between implementation approaches and variations among PHAs (i.e., region, size, or recency of policy adoption). Qualitative analyses were conducted to assess the perceived effectiveness of implementation strategies. Resident engagement, staff training, and smoking cessation support were the most frequently used implementation strategies. Engagement with local stakeholders was cited less frequently. Enforcement actions were limited with no violations referred to housing court. Support for policy adherence was identified as a sixth implementation strategy. While most PHAs used at least some evidence-informed implementation strategies, a lack of a systematic approach may limit overall effectiveness. Further research is required to resolve implementation barriers experienced disproportionately by a subset of PHAs, and to inform a best practice implementation framework that meets the needs of a heterogeneous population.

Overcrowding and exposure to secondhand smoke increase risk for COVID-19 infection among Latinx families in the greater San Francisco Bay Area

INTRODUCTION

Environmental risk factors, including community level pollution burden and exposure to smoking and secondhand smoke, have not been evaluated in relation to risk for infection with COVID-19 in high risk, urban Latinx families.

METHODS

We evaluated risk factors for COVID-19 infection in three, preexisting, longitudinal, Latinx family cohorts in the San Francisco Bay Area from May through September 2020 (N=383 households, 1875 people). All households were previously recruited before the pandemic. For the COVID-19 sub-study, participants responded to a telephone interview where we assessed food consumption patterns, housing and employment status, and history of COVID-19 infection. Secondhand smoke exposure was based on previously collected selfreported data, and environmental pollution exposure was determined from census tract residence. Non-parametric tests and multiple logistic regression were used to assess independent predictors of COVID-19 infection.

RESULTS

Larger household size increased risk for infection (OR=1.58; 95% CI: 1.12–2.23, p<0.01) as did increasing number of children in household (OR=3.79; 95% CI: 1.51–9.56). Any exposure to secondhand smoke was also associated with increased risk for COVID infection (OR 4.69; 95% CI: 1.01–21.85) and having a greater number of family members eating at home was protective against infection (OR=0.10; 95% CI: 0.02–0.52, p<0.01).

CONCLUSIONS

Crowding, as indicated by larger household size, increases risk for COVID-19 infection in Latinx families, as does exposure to secondhand smoke. Public policy and health interventions need to ensure that multiunit residential complexes do not allow exposure to secondhand smoke between units, that individuals eat in the home environment, and that large households can safely separate individuals exposed to COVID-19.

Implementation of the Department of Housing and Urban Development's Smoke-Free Rule: A Socio-Ecological Qualitative Assessment of Administrator and Resident Perceptions

In July 2018, the United States Department of Housing and Urban Development (HUD) implemented a mandatory smoke-free rule in public housing. This study assessed administrator and resident perceptions of rule implementation during its initial year in the District of Columbia Housing Authority (DCHA). Assessment included nine focus groups (n = 69) with residents and in-depth interviews with administrators (n = 7) and residents (n = 26) from 14 DCHA communities (family = 7 and senior/disabled = 7). Semi-structured discussion guides based on the multi-level socio-ecological framework captured dialogue that was recorded, transcribed verbatim, and coded inductively. Emerging major themes for each socio-ecological framework level included: (1) Individual: the rule was supported due to perceived health benefits, with stronger support among non-smokers; (2) Interpersonal: limiting secondhand smoke exposure was perceived as a positive for vulnerable residents; (3) Organizational: communication, signage, and cessation support was perceived as a need; (4) Community: residents perceived mobility, disability, weather, and safety-related issues as barriers; and (5) Public Policy: lease amendments were perceived as enablers of rule implementation but expressed confusion about violations and enforcement. A majority of administrators and residents reported favorable implications of the mandated HUD rule. The novel application of a socio-ecological framework, however, detected implementation nuances that required improvements on multiple levels, including more signage, cessation support, clarification of enforcement roles, and addressing safety concerns.

Drifting Tobacco Smoke Exposure among Young Adults in Multiunit Housing

This study evaluated young adults' exposure to drifting secondhand smoke in San Francisco County housing units using the 2014 Bay Area Young Adult Health Survey (N = 1363). Logistic and geographically weighted regression models were used to determine whether residing in multiunit housing or in areas with greater neighborhood disorder were risk factors for exposure, and how drifting smoke exposure varied spatially within San Francisco County. Residing in buildings with five or more units significantly increased the odds of reporting drifting smoke exposure [OR (3.5 1.3, 9.9)], but neighborhood disorder did not have a significant association in the fully adjusted logistic regression model. At the local level, however, neighborhood disorder was significantly associated with exposure in lower income residential and downtown areas. Multiunit housing was significantly associated with exposure across all neighborhoods.

"It's Worse to Breathe It Than to Smoke It": Secondhand Smoke Beliefs in a Group of Mexican and Central American Immigrants in the United States

This analysis describes beliefs about secondhand smoke and its health effects held by Mexican and Central American immigrants in North Carolina. Data from 60 semistructured, in-depth interviews were subjected to saliency analysis. Participant discussions of secondhand smoke centered on four domains: (1) familiarity and definition of secondhand smoke, (2) potency of secondhand smoke, (3) general health effects of secondhand smoke, and (4) child health effects of secondhand smoke. Secondhand smoke was generally believed to be more harmful than primary smoke. Mechanisms for the potency and health effects of secondhand smoke involved the smell of secondhand smoke, secondhand smoke being an infection and affecting the immune system, and personal strength being protective of secondhand smoke. Understanding these health beliefs informs a framework for further health education and intervention to reduce smoking and secondhand smoke exposure in this vulnerable population.

Proposal for smoke-free public housing: a systematic review of attitudes and preferences from residents of multi-unit housing

A policy proposal to ban public housing smoking indoors has received support, but it is unclear how certain affected groups, specifically smokers in housing units, perceive such a policy. To review the literature on attitudes and perceptions of housing unit tenants towards an indoor smoke-free housing policy, using various databases, we searched articles for attitudes towards smoking ban enforcement in housing units. We identified fourteen articles. Non-smokers heavily favored indoor policies and current smokers heavily opposed them. Current smokers represented a substantial minority in the reviewed articles, resulting in overall outcomes of the surveys driven by non-smokers. Studies investigating attitudes about housing smoking bans largely represent the views of non-smokers and lack data about barriers and concerns of tenants who do not support a smoke-free policy. Future studies should investigate if such a discrepancy impacts the efficacy of smoke-free housing policies.

Smoking in apartment buildings - Spatiality, meanings and understandings

Increased higher density urban living may exacerbate exposure to environmental tobacco smoke. Using a social practices lens, this research explored the locations, experiences and governance of smoking in apartment buildings in Melbourne, Australia, through semi-structured interviews in high-rise buildings ranging from subsidised housing to luxury apartments. Tacit rules on acceptable locations, building rules and smoke alarms in public areas consigned smoking to balconies and building entrances. The perceived health threat from second hand smoke and mental stress due to invasion of olfactory and visual privacy undermined the full enjoyment of the home environment. Interventions may benefit from targeting the link between smoking and balconies.

Persistent tobacco smoke residue in multiunit housing: Legacy of permissive indoor smoking policies and challenges in the implementation of smoking bans

Secondhand smoke (SHS) is a common indoor pollutant in multiunit housing (MUH). It is also the precursor of thirdhand smoke (THS), the toxic mixture of tobacco smoke residue that accumulates in indoor environments where tobacco has been used. This study examined the levels, distribution, and factors associated with THS pollution in low-income MUH. Interviews were conducted 2016-2018 in a cross-sectional study of N = 220 MUH homes in San Diego, California. Two surface wipe samples were collected per home and analyzed for nicotine, a THS marker, using liquid chromatography-triple quadrupole mass spectrometry. Nicotine was detected in all homes of nonsmokers with indoor smoking bans (Geo Mean = 1.67 µg/m²; 95% CI = [1.23;2.30]) and smokers regardless of an indoor ban (Geo Mean = 4.80 µg/m²; 95% CI = [1.89;12.19]). Approximately 10% of nonsmokers' homes with smoking bans showed nicotine levels higher than the average level in homes of smokers without smoking bans from previous studies (≥30 µg/m²). Housing for seniors, smoking bans on balconies, indoor tobacco use, difficult to reach surfaces, and self-reported African-American race/ethnicity were independently associated with higher THS levels. Individual cases demonstrated that high levels of surface nicotine may persist in nonsmoker homes for years after tobacco use even in the presence of indoor smoking bans. To achieve MUH free of tobacco smoke pollutants, attention must be given to identifying and remediating highly polluted units and to implementing smoking policies that prevent new accumulation of THS. As THS is a form of toxic tobacco product waste, responsibility for preventing and mitigating harmful impacts should include manufacturers, suppliers, and retailers.

Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.

Empowering Hispanic Multiunit Housing Residents to Advocate for Smokefree Policies: A Randomized Controlled Trial of a Culturally Tailored Fotonovela Intervention

Purpose: Hispanic residents of multiunit housing (MUH) are disproportionately exposed to secondhand (SHS) and thirdhand tobacco smoke (THS) from neighboring apartment units and common areas. Comprehensive legislation and voluntary policies are needed to protect residents from smoke. We developed a culturally tailored bilingual fotonovela to educate Hispanic residents about SHS and THS and encourage them to talk to their neighbors and landlords about reducing smoke exposure. This article describes a randomized controlled trial of the fotonovela. The objective of the study was to evaluate the effect of the fotonovela on knowledge, attitudes, and behavioral intentions about reducing smoke exposure. Methods: Hispanic MUH residents (N=403) completed a survey and were randomly assigned to receive the fotonovela, a text pamphlet, or no materials. They completed a follow-up survey 6 months later. Results: Among the entire sample, there were no significant differences across the three groups in knowledge or attitudes at follow-up. However, when the analyses were restricted to respondents who actually read part or all of the booklets (77% in the fotonovela group and 71% in the text pamphlet group), there were significant differences in two of the six outcome measures; those who read the fotonovela had higher scores on self-efficacy to talk to others about smoke and positive attitudes toward advocacy actions, relative to those who read the text pamphlet. Conclusion: Results indicate that a fotonovela can be an effective tool to empower Hispanic MUH residents to advocate for voluntary smokefree policies, but more efforts are needed to encourage residents to read the materials.

Managers' Practices of Tobacco and Marijuana Smoking Policies in Hispanic-Occupied Multiunit Housing

Purpose: This study assessed the knowledge, attitudes, and practices of managers of Hispanic-occupied multiunit housing (MUH) related to the prevalence and prevention of secondhand smoke (SHS), thirdhand tobacco smoke, and secondhand marijuana smoke (SHMS). Methods: A narrative analysis was conducted of 20 interviews with live-in apartment managers. Their opinions on policies and an educational fotonovela were also gathered. Results: The properties were located in 10 cities within the Los Angeles County, representing a wide array of local policies and practices. Only two managers were correctly informed of the existing MUH smoking policies in their cities. Participants reported ambiguity in city laws and company rules regarding smoking. Managers do not distinguish between smoking recreational marijuana and medicinal marijuana. Several respondents believed the landlords have more power to create rules. Most favored a total ban on smoking of all substances on the premises. Conclusions: Most managers report low agency in being able to pass no-smoking rules. Participants support smoking policies that include all smokable products. Managers would like new government policies, manager trainings, tenant education, and ways to enforce rules to protect apartment tenants from SHS and SHMS. Educational interventions should coincide with the timing of key manager/tenant activities. Results can be used in policy development and educational interventions.

Qualitative Assessment of Smoke-Free Policy Implementation in Low-Income Housing: Enhancing Resident Compliance

PURPOSE

As public housing agencies and other low-income housing providers adopt smoke-free policies, data are needed to inform implementation approaches that support compliance.

DESIGN

Focused ethnography used including qualitative interviews with staff, focus groups with residents, and property observations.

SETTING

Four low-income housing properties in Massachusetts, 12 months postpolicy adoption.

PARTICIPANTS

Individual interviews (n = 17) with property staff (managers, resident service coordinators, maintenance, security, and administrators) and focus groups with resident smokers (n = 28) and nonsmokers (n = 47).

MEASURES

Informed by the social-ecological model: intrapersonal, interpersonal, organizational, and community factors relating to compliance were assessed.

ANALYSIS

Utilized MAXQDA in a theory-driven immersion/crystallization analytic process with cycles of raw data examination and pattern identification until no new themes emerged.

RESULTS

Self-reported secondhand smoke exposure (SHSe) was reduced but not eliminated. Challenges included relying on ambivalent maintenance staff and residents to report violations, staff serving as both enforcers and smoking cessation counsellors, and inability to enforce on nights and weekends. Erroneous knowledge of the policy, perception that SHSe is not harmful to neighbors, as well as believing that smokers were losing their autonomy and being unfairly singled out when other resident violations were being unaddressed, hindered policy acceptance among resident smokers. The greatest challenge to compliance was the lack of allowable outdoor smoking areas that may have reduced the burden of the policy on smokers.

CONCLUSION

Smoke-free policy implementation to support compliance could be enhanced with information about SHSe for smokers and nonsmokers, cessation support from external community partners, discussion forums for maintenance staff, resident inclusion in decision-making, and framing the policy as part of a broader wellness initiative.

Smoke-Free Multi-unit Housing Policies Show Promise in Reducing Secondhand Smoke Exposure Among Racially and Ethnically Diverse, Low-Income Seniors

Secondhand smoke (SHS) exposure is a public health issue for residents of multi-unit housing (MUH) properties. We evaluated the impact of smoke-free policy implementation on reported SHS exposure among racially, ethnically diverse seniors living in low-income MUH properties. In Spring 2013 and Summer 2014, we surveyed residents (n = 960) at 15 MUH properties in Broward and Miami-Dade Counties, Florida. The percentage of residents reporting SHS exposure within their apartments from elsewhere in or around their building decreased from 31.1 %, before policy implementation, to 23.6 % at follow-up (p = 0.02). In multivariate analysis of non-smoking residents after policy implementation, residents who reported having one or more comorbidities were two times more likely to report SHS exposure (aOR 2.23, 95 % CI 1.12-4.40). Considering the vulnerability of low-income seniors to SHS exposure, our findings are relevant to residents, property owners/managers, and public health professionals making decisions about smoke-free policies for MUH properties in which seniors reside.

A Qualitative Study Among Mexican Americans to Understand Factors Influencing the Adoption and Enforcement of Home Smoking Bans

Introduction

One-third of Mexican-American children, in addition to nonsmoker adults, are exposed to secondhand smoke at home, yet few interventions target Mexican-American households. An effective, brief English language program, tested with United Way 2-1-1 callers in Atlanta, increased home smoking bans (confirmed by air monitors). Two randomized controlled trials in North Carolina and Texas replicated those results. We explored factors determining adoption and enforcement of smoking bans in Mexican-American households to inform program linguistic and cultural adaptation to broaden program reach and relevance.

Methods

Bilingual interviewers recruited convenience samples of Mexican-American smokers and nonsmokers living with at least one smoker in Houston and San Diego households and asked open-ended questions regarding conditions for implementing home and vehicle smoking bans and conditions for varying acceptance of bans. Investigators independently reviewed English transcripts and completed a descriptive analysis using ATLAS.ti.

Results

Participants (n = 43) were predominantly female (n = 31), current smokers (n = 26), interviewed in Spanish (n = 26), had annual household incomes less than $30000 (n = 24), and allowed smoking inside the home (n = 24). Themes related to difficulty creating and enforcing bans included courtesy, respect for guests and heads of household who smoke, and gender imbalances in decision making. Participants viewed protecting children's health as a reason for the ban but not protecting adult nonsmokers' health.

Conclusion

A dual-language, culturally adapted intervention targeting multigenerational Mexican-American households should address household differences regarding language and consider influences of cultural values on family dynamics and interactions with guests that may weaken bans.

Implications

Qualitative interviews suggested cultural and family considerations to address in adapting a brief evidence-based smoke-free homes intervention for Mexican Americans, including traditional gender roles, unique contexts of multigenerational households, and language preferences. Our work confirms previous research among Latinos regarding importance of common cultural constructs, such as respeto (deference), simpatia (courtesy and agreeability), and familismo (family attachment), which inform behaviors that may impede or facilitate adopting and enforcing home smoking bans. Decision-making gender imbalances, high regard for head-of-household and guest smokers, and less sensitivity to the health of nonsmoker adults compared with children may lead to permission to smoke indoors.

Attitudes and experiences with secondhand smoke and smoke-free policies among subsidised and market-rate multiunit housing residents living in six diverse communities in the USA

BACKGROUND

Given that higher smoking rates persist among lower socioeconomic populations, multiunit housing (MUH) environments may result in higher secondhand smoke (SHS) exposures among subsidised MUH residents. This cross-sectional assessment compares experiences with SHS and smoke-free policies among subsidised and market-rate MUH residents living in six US communities.

METHODS

MUH residents (n=1565) were surveyed regarding their smoke-free rules (home and building), SHS exposures and preferences towards smoke-free policies. Binary logistic regression identified predictors of each outcome, focusing on differences by subsidised housing status (subsidised vs market rate).

RESULTS

Among residents enforcing smoke-free home rules (76%, overall), 50% reported SHS incursions into their unit. Only 23% reported living in a smoke-free building; 56% of those living in smoking-allowable buildings reported preferences towards smoke-free building policies. Among market-rate housing residents, smoke-free home (OR=4.18) and building (OR=2.26) rules were significantly higher when children were present. Smoke-free building rules reduced the odds of SHS incursions among market-rate housing residents (OR=0.50), but no association was observed among subsidised housing residents. Non-smoking subsidised housing residents exhibited stronger preferences for smoke-free policies compared with those in market-rate housing.

DISCUSSION

Smoke-free home rules may not protect MUH residents from SHS exposures, particularly in subsidised MUH. Although strong preferences towards smoke-free policies were present overall, subsidised MUH residents may have fewer alternative smoke-free housing options available. Therefore, all publicly funded housing should be smoke free to protect these vulnerable populations. However, continued efforts to encourage privately owned MUH operators to adopt smoke-free policies are also necessary.

Perceptions of Secondhand and Thirdhand Smoke Among Hispanic Residents of Multiunit Housing

Despite the progressive adoption of smoking bans in public spaces, children living in multi-unit housing remain at risk of exposure to secondhand smoke (SHS) and thirdhand smoke (THS). Hispanic populations in California are particularly vulnerable to the harmful effects of SHS and THS because a large proportion of Hispanics live in multi-unit housing. Three focus groups were conducted in the fall of 2012 (in Spanish and English, N = 24) to understand Hispanics' knowledge of and experiences with SHS and THS, including barriers to avoiding smoke exposure and strategies for protecting their homes from smoke. Hispanic residents reported unpleasant experiences with SHS and THS and were generally knowledgeable about the adverse health effects, although they were not familiar with the term "thirdhand smoke." Some participants also mentioned marijuana smoke as a potential health hazard. Hispanic cultural values made participants reluctant to confront their neighbors but also motivated them to find ways to protect their families from smoke. Potential solutions included working with the smokers to designate a smoking area and gaining support from the building owners. Broad smoking policies should be implemented to help Hispanic residents overcome cultural and social barriers to smoke free air.

Support for smoke-free multi-unit housing policies among racially and ethnically diverse, low-income seniors in South Florida

Previous studies have gauged support for implementing smoke-free multi-unit housing (MUH) policies in the United States, but none have specifically examined attitudes among racially and ethnically diverse elders living in low-income MUH. We surveyed a convenience sample of elders 62 years of age and older (n = 807) across 24 low-income housing properties in Broward County, Florida in order to assess residents' smoking behaviors, exposure to second-hand smoke, and support for smoke-free policies. The study sample was ethnically and racially diverse with Hispanics comprising more than 61 % of the population, and 22 % identifying as Black or other races. Although close to 22 % of the sample were former smokers, only 9 % of residents reported being current smokers. The majority of residents surveyed supported no-smoking policies: 75 % support no-smoking policies for individual units; 77 % supported no-smoking policies in common areas; and, 68 % supported no-smoking policies in outdoor areas. Over 29 % of residents surveyed reported being exposed to secondhand smoke entering their units from elsewhere in their building. Residents who reported having a home smoking rule were more than twice as likely to support an indoor policy compared to residents who allowed smoking anywhere in their home (OR = 2.36; 95%CI 1.25-4.43; p ≤ 0.01), and nonsmoking residents were nearly three times as likely to support an indoor policy compared to smokers (OR = 2.89; 95%CI 1.44-5.79; p ≤ 0.01). Support for an indoor policy was not modified by age, gender, ethnicity or race. . This study demonstrates that elders living in low-income MUH properties overwhelmingly supported the implementation of smoke-free policies.

Smoke-Free Policies in Multiunit Housing: Smoking Behavior and Reactions to Messaging Strategies in Support or in Opposition

INTRODUCTION

Given the high proportion of US adults living in multiunit housing (MUH) and the related risks of secondhand smoke, we examined correlates of having smoke-free MUH policies, level of support for such policies, and reactions to related messaging among a quota-based nonprobability sample of US adults.

METHODS

In 2013, 752 adult MUH residents were recruited through an online survey panel to complete a cross-sectional survey assessing tobacco use, personal smoke-free policies in homes and cars, smoke-free MUH policies, and reactions to messaging on smoke-free MUH policies. We sought sufficient representation of smokers, racial/ethnic minorities, and residents of the Southeast.

RESULTS

Overall, 56.3% had no smoke-free MUH policies and 16.2% had complete policies; 62.8% favored living in smoke-free MUH, and 28.9% said they would move if their building became smoke-free. Multivariate regression indicated that correlates of living in MUH with partial or no policies included younger age, less education, lower income, and current smoking (P's ≤ .01); more restrictive smoke-free MUH policies were associated with lower cigarette consumption and recent quit attempts among current smokers (P's < .05); and correlates of support for MUH policies included greater education, nonsmoker status, and having complete MUH policies (P's < .05). Of 9 messages opposing smoke-free MUH policies, the most persuasive was "People have the right to smoke in their own homes"; the most persuasive message of 11 in support was "You have the right to breathe clean air in your home."

CONCLUSION

Smoke-free MUH policies may reduce smoking. Messaging in favor of smoke-free MUH policies was more persuasive than messaging opposing such policies, indicating the potential for using these approaches.

Smoke-free multiunit housing: a review of the scientific literature

OBJECTIVE

Multiunit housing (MUH) residents are susceptible to secondhand smoke (SHS) exposure, which can transfer between living units. This review summarises existing scientific literature relevant to smoke-free MUH, discusses knowledge gaps and provides recommendations for future research to inform public health action.

DATA SOURCES

We conducted a systematic search of peer-reviewed articles using three databases: EBSCOhost CINAHL, PubMed and Web of Science.

STUDY SELECTION

Article titles, abstracts and text were reviewed to ascertain three inclusion criteria: (1) English language; (2) conducted in the USA; (3) reported on baseline data, development, implementation or evaluation of smoke-free MUH.

DATA EXTRACTION

We used a multistep process to identify eligible articles: (1) two reviewers separately evaluated article titles; (2) two reviewers separately evaluated abstracts and (3) one reviewer read each article and determined inclusion eligibility.

DATA SYNTHESIS

We identified and included 35 articles published during 2001-2014, grouped based on broad themes: MUH resident (n=16); MUH operator (n=6); environmental monitoring and biomarkers (n=9); economic (n=2); legal (n=3); and implementation process and policy impact (n=8). Studies with multiple themes were included in all relevant groups.

CONCLUSIONS

Existing literature has focused on self-reported, cross-sectional studies of MUH residents and operators; some studies of environmental markers, biomarkers and economic indicators have also been conducted. Future research on smoke-free MUH policy compliance and enforcement, and on the impact of these policies on smoking behaviours and health outcomes, could further inform public health planning, policy and practice. Despite these gaps, the current literature provides sufficient evidence for action to eliminate SHS exposure in MUH.

Neighborhood Social Context and Individual Polycyclic Aromatic Hydrocarbon Exposures Associated with Child Cognitive Test Scores

Childhood cognitive and test-taking abilities have long-term implications for educational achievement and health, and may be influenced by household environmental exposures and neighborhood contexts. This study evaluates whether age 5 scores on the Wechsler Preschool and Primary Scale of Intelligence-Revised (WPPSI-R, administered in English) are associated with polycyclic aromatic hydrocarbon (PAH) exposure and neighborhood context variables including poverty, low educational attainment, low English language proficiency, and inadequate plumbing. The Columbia Center for Children's Environmental Health enrolled African-American and Dominican-American New York City women during pregnancy, and conducted follow-up for subsequent childhood health outcomes including cognitive test scores. Individual outcomes were linked to data characterizing 1-km network buffers around prenatal addresses, home observations, interviews, and prenatal PAH exposure data from personal air monitors. Prenatal PAH exposure above the median predicted 3.5 point lower total WPPSI-R scores and 3.9 point lower verbal scores; the association was similar in magnitude across models with adjustments for neighborhood characteristics. Neighborhood-level low English proficiency was independently associated with 2.3 point lower mean total WPPSI-R score, 1.2 point lower verbal score, and 2.7 point lower performance score per standard deviation. Low neighborhood-level educational attainment was also associated with 2.0 point lower performance scores. In models examining effect modification, neighborhood associations were similar or diminished among the high PAH exposure group, as compared with the low PAH exposure group. Early life exposure to personal PAH exposure or selected neighborhood-level social contexts may predict lower cognitive test scores. However, these results may reflect limited geographic exposure variation and limited generalizability.

A qualitative evaluation of 40 voluntary, smoke-free, multiunit, housing policy campaigns in California

Background

Although it is legal for multiunit housing (MUH) property owners in all 50 states to prohibit smoking on their premises, including in individual units, MUH constitutes a relatively new setting to reduce exposure to secondhand smoke via voluntary smoke-free policy. This paper examines California state-funded smoke-free MUH policy campaigns between 2004 and 2010.

Methods

A cross-case analysis of 40 state-funded smoke-free MUH policy campaigns was conducted via an examination of final evaluation reports submitted to the California Tobacco Control Program.

Results

The most effective voluntary smoke-free MUH policy campaigns typically included: (1) learning the local [MUH] context, (2) finding and using a champion, (3) partnering with like-minded organisations, (4) building relationships with stakeholders, (5) collecting and using local data and (6) making a compelling case to decision makers.

Discussions

The aforementioned steps tended to be intertwined, and successfully securing voluntary smoke-free MUH policy required a strategic but flexible plan of implementation prior to entrance into the field. Campaigns designed to enhance voluntary smoke-free MUH policy adoption should underscore the economic viability of such policies during each strategic step.

Thirdhand smoke and exposure in California hotels: non-smoking rooms fail to protect non-smoking hotel guests from tobacco smoke exposure

INTRODUCTION

This study examined tobacco smoke pollution (also known as thirdhand smoke, THS) in hotels with and without complete smoking bans and investigated whether non-smoking guests staying overnight in these hotels were exposed to tobacco smoke pollutants.

METHODS

A stratified random sample of hotels with (n=10) and without (n=30) complete smoking bans was examined. Surfaces and air were analysed for tobacco smoke pollutants (ie, nicotine and 3-ethynylpyridine, 3EP). Non-smoking confederates who stayed overnight in guestrooms provided urine and finger wipe samples to determine exposure to nicotine and the tobacco-specific carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone as measured by their metabolites cotinine and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), respectively.

FINDINGS

Compared with hotels with complete smoking bans, surface nicotine and air 3EP were elevated in non-smoking and smoking rooms of hotels that allowed smoking. Air nicotine levels in smoking rooms were significantly higher than those in non-smoking rooms of hotels with and without complete smoking bans. Hallway surfaces outside of smoking rooms also showed higher levels of nicotine than those outside of non-smoking rooms. Non-smoking confederates staying in hotels without complete smoking bans showed higher levels of finger nicotine and urine cotinine than those staying in hotels with complete smoking bans. Confederates showed significant elevations in urinary NNAL after staying in the 10 most polluted rooms.

CONCLUSIONS

Partial smoking bans in hotels do not protect non-smoking guests from exposure to tobacco smoke and tobacco-specific carcinogens. Non-smokers are advised to stay in hotels with complete smoking bans. Existing policies exempting hotels from complete smoking bans are ineffective.

Eliminating second-hand smoke from Mexican-American households: outcomes from Project Clean Air-Safe Air (CASA)

Exposure to second-hand smoke (SHS) is a major public health problem and a risk factor for morbidity and mortality. The objective of this randomized trial was to estimate the impact of a culturally-sensitive intervention to reduce SHS exposure in Mexican-American households.

METHOD

A total of 91 households (with a child under 18 years of age and two adults, one of whom was a smoker) were recruited from a population-based cohort of Mexican-American households and randomized to receive the experimental intervention (EI; n=47) or standard care (SC; n=44). Of these, 74 households (83%) provided baseline, 6-month, and 12-month survey and nicotine monitor data (EI, n=39; SC, n=35). The EI materials, designed to increase the participants' likelihood of adopting a smoke-free indoor home air policy, included one culturally-appropriate bilingual comic book for children and two fotonovelas for adults.

RESULTS

Ambient nicotine levels significantly decreased over the 12 study months (F=13.6, DF=147; p<0.001); with a significantly greater decrease in the EI households compared to the SC households (F=4.1, DF=72; p<0.05). At 12 months, 73% of EI households had banned smoking vs. 56% of SC households. Ambient nicotine levels, measured using nicotine air sampling monitors, were significantly associated with self-reported SHS exposure at the 12-month follow-up. Knowledge of the health effects of SHS increased from baseline to 6 and 12 months in the EI condition but not in the SC condition (F=6.0, DF=238; p<0.01), and smokers and quitters in the EI group reported an increased perception of health vulnerability compared to those in the SC group.

CONCLUSION

Our low-cost intervention impacted SHS-related knowledge and exposure among Mexican Americans. This culturally-appropriate intervention has the potential to decrease SHS-related health problems in the target population substantially.