Approximately a quarter of Americans, or 80 million people, live in multiunit housing.1 Multiunit housing is a classification of housing in which numerous, separate housing units for residential inhabitants are contained within 1 building or several buildings, such as apartments. In buildings that have many units, secondhand smoke cannot be controlled and can move from unit to unit through doorways, ventilation systems, plumbing, stairwells, and cracks in walls.2 More than 36% of American nonsmokers who live in multiunit housing are regularly exposed to secondhand smoke.2
Secondhand smoke in multiunit housing is a public health issue. No level of secondhand smoke exposure has been found to be safe.3 The inhalation of secondhand smoke gives rise to chronic diseases in vulnerable populations such as coronary heart disease, stroke, lung cancer in adults, and increased asthma attacks and respiratory infections in children.3 Every person deserves a safe and healthy home, free from environmental hazards. One way to safeguard this right is to prohibit the smoking of combustible tobacco products indoors. The Centers for Disease Control and Prevention (CDC) estimated that eliminating smoking in public housing could save nearly $497 million in health care costs.4
The Solution and Rationale
With increasing awareness of the risk of exposure to secondhand smoke, residents are creating a demand for smoke-free housing.3 Smoke-free public housing policies may be mandated or voluntary, do not discriminate against residents who smoke, and can apply to public or private housing settings. Across the country, owners, housing authorities, and health departments are creating smoke-free housing policies to aid residents and meet this demand.5 For residents, clean air greatly improves health outcomes.5 For landlords and owners, a nonsmoking policy saves money by reducing maintenance, tenant turnover, and hazard costs.5
Because benefits of smoke-free housing and living are extensive, the US Department of Housing and Urban Development (HUD) mandated a rule in February 2017 that required all federally funded public housing agencies (PHAs) to develop smoke-free indoor policies by July 31, 2018. In years past, smoke-free policies were voluntary based on landlord and owner discretion; to fully protect the health of residents, HUD decided to make the rule obligatory. The HUD smoke-free public housing rule prohibits the use of cigarettes, cigars, pipes, and hookah in all indoor areas and within 25 ft of buildings.3 Although the ruling does not specifically include electronic cigarettes or electronic nicotine delivery systems (ENDS), it does encourage PHAs, landlords, and owners to include these devices in their policies. HUD administers federal aid to local housing agencies that manage the housing for low-income residents at rents they can afford. HUD rental housing is for eligible low-income families, older adults, and persons with disabilities. It comes in all types, from scattered single-family houses to high-rise apartments for elderly families.5 HUD furnishes technical and professional assistance in planning, developing, and managing these developments. Since HUD implemented the smoke-free public housing rule, 1.2 million households that reside in federally owned housing have been positively affected.3
The Role of LHDs in Smoke-Free Housing Policy Development
Local health departments (LHDs) play a crucial role in implementing the HUD ruling by serving as neutral conveners between PHAs and creating clinical-community linkages. The National Association of County and City Health Officials (NACCHO) works with LHDs throughout the United States to build capacity for local-level tobacco prevention and control. NACCHO facilitates LHDs' understanding and implementation of best practices and evidence-informed tobacco control strategies specific to smoke-free air, tobacco and opioid associations, electronic nicotine delivery devices, and policies, systems, and environmental changes. LHDs also maintain and expand partnerships with national organizations, state health departments, and other interested agencies to coordinate tobacco control–related activities for specific community needs. In the past few years, LHDs and partners have focused efforts on implementing the HUD smoke-free public housing ruling.
LHDs can aid in the transition to smoke-free housing by sharing data about smoking rates in the community; providing education on secondhand smoke risks to multiunit property owners, managers, and residents; providing or connecting residents to tobacco cessation services; assisting with compliance; and delivering technical assistance to owners and managers on the policy change process.
To further assist LHDs in applying smoke-free housing policies in their communities, NACCHO conducted an environmental scan to identify LHDs with experience engaging in cross-sectoral partnerships to implement smoke-free private and public multiunit housing. This project was part of a CDC-funded project in NACCHO's chronic disease and tobacco portfolio. The goal of the environmental scan was to better understand the facilitators, challenges, lessons learned, and resources needed for the rule to effectively be executed.
The following 2 LHD stories highlight successes, challenges, and recommendations for implementing smoke-free housing policies.
Cincinnati Health Department
In July 2016, the Cincinnati Metropolitan Housing Authority (CMHA) took a major step to improve the quality of life for its 13 000 residents by implementing a smoke-free policy that reduced exposure to secondhand smoke and minimized fire risks at its 18 multiunit housing sites and more than 350 single-family dwellings. Once CMHA's Board of Trustees decided in favor of smoke-free multiunit housing policy adoption, the Cincinnati Health Department began providing technical assistance and engaging residents at each step in the process: planning; education; implementation; enforcement; and identifying tobacco cessation options. Several CMHA residents were trained as American Lung Association Freedom from Smoking facilitators to lead group smoking cessation classes at CMHA sites.
Other initiatives included nicotine air sampling, which was conducted at 6 CMHA housing sites. Initial data will be compared with data collected 1 year after policy implementation (data analysis was underway at press time) to gauge the policy's effect on indoor air quality. In February 2017, the health department began recruiting CMHA youth, aged 11 to 17 years, to join Cincinnati STAND, a youth-led campaign that encourages kids to “stand up and speak out against tobacco.” Many residents—both smokers and nonsmokers—have shown support and expressed pride in members' activities. By engaging youth and residents, and working with the housing authority early in the process, smoke-free housing implementation was possible. Learn more at https://www.cincinnati-oh.gov/health.
Cook County Department of Public Health
As of September 2017, more than 6800 residents in suburban Cook County, Illinois, can breathe easier in their smoke-free multiunit homes. This success resulted from outreach, education, and technical assistance from the Cook County Department of Public Health (CCDPH) and its partners. This initiative was funded, in part, by the CDC.
According to a survey of suburban Cook County renters, 66% of residents lived in multiunit buildings that allow smoking. As air transfer cannot be completely controlled in multiunit housing, the air is therefore shared between units and common areas, resulting in residents having an increased risk of exposure to secondhand smoke.
To address this issue, CCDPH and its partners, American Lung Association of Greater Chicago, Respiratory Health Association, and South Suburban Mayors and Managers Association, supported property owners and managers in implementing smoke-free protections. Property owners, managers, and building residents were educated on the health, safety, and economic benefits of implementing smoke-free housing. The partnership contacted 550 property owner and managers, 460 management companies, and 100 community organizations, groups, and associations. In addition, CCDPH and its partners provided more than 1100 smoke-free housing tool kits and more than 150 technical assistance encounters. Because of these efforts, a total of 3185 units in 73 public and market-rate properties across 25 municipalities became smoke-free. More than 3300 residents have now been spared from secondhand smoke exposure.
A multifaceted approach was key to CCDPH's success and included several steps: (1) expanding outreach to nontraditional partners, such as municipal groups and crime-free housing coordinators, and leveraging those new relationships; (2) tailoring messaging to target audiences by emphasizing the potential savings in turnover costs, which was very important to property owners and managers; and (3) developing a stages-of-change assessment tool that helped gauge the readiness of property owners and managers to implement smoke-free housing. For more information, visit http://www.cookcountypublichealth.org.
The benefits of smoke-free public housing are wide ranging, and these policies will ultimately decrease secondhand smoke exposure in the units, creating a better environment for the residents and will also help landlords save money. With adequate workforce resources, collaborative partnerships, innovative educational strategies, and providing linkages to care and technical assistance needs to residents, managers, and owners, LHDs can serve as key health strategists in the facilitation of these policies. NACCHO can provide technical assistance and resources to LHDs related to tobacco prevention and control strategies and can also optimize strategic alliances to create meaningful partnerships between LHDs and organizations. LHD leaders can find policy statements, fact sheets, and stories from the field about smoke-free housing on NACCHO's Web site. For further information, visit naccho.org.