Smoke-Free Public Housing: Research and Implementation

Smoke-Free Public Housing: Research and Implementation

Highlights

• HUD’s proposed rule to ban smoking in all public housing properties aims to reduce residents’ exposure to secondhand smoke while also reducing building maintenance costs and fire risks.
• There is consensus on the health dangers of secondhand smoke, especially to children. Because secondhand smoke moves between units in multifamily buildings, only the elimination of smoking in these buildings fully protects nonsmokers.
• Researchers estimate that the proposed rule will reduce healthcare costs related to secondhand smoke among nonsmoking residents and generate other cost savings for public housing agencies. Although the proposed rule will have costs to smokers in time and inconvenience, it may also reduce the prevalence of tobacco use by smokers.
• Evicting residents who repeatedly break nonsmoking rules is an action of last resort; public housing agencies with existing bans usually remedy offenses via warnings, referrals to smoking cessation programs, and other resources.

On November 12, 2015, HUD Secretary Julián Castro announced a proposed rule to require all public housing properties to become smokefree indoors. “We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” Secretary Castro said at a press conference with U.S. Surgeon General Vivek Murthy.1 The proposed rule, when finalized, will require public housing agencies (PHAs) to implement a policy within 18 months that bans lit smoking products “in all living units, indoor common areas in public housing, and in PHA administrative office buildings” as well as outdoor areas within at least 25 feet of these buildings.2 The policy, which applies to all public housing units except those in mixed-finance buildings, is intended to reduce PHA residents’ exposure to secondhand smoke and lower maintenance costs and the risk of fire.

More than 600 PHAs, with HUD’s encouragement, have already implemented smoke-free policies.3 Although these PHAs represent between 200,000 and 300,000 public housing units, the national smoke-free rule will reach more than 700,000 additional units, including more than 775,000 children and “over 500,000 units inhabited by elderly households or households with a non-elderly person with disabilities.”4 A regulatory impact analysis performed by HUD’s Office of Policy Development and Research found that approximately 1.2 million nonsmoking public housing residents are still exposed to secondhand smoke, including roughly 60,000 children under age 5 living in units where someone smokes.5

Considerable research on the dangers of smoking and exposure to secondhand smoke supports the need to protect residents from involuntary exposure to tobacco smoke. The proposed rule, however, will present a complex set of potential costs and benefits for PHAs and their residents. This article examines the research into the costs and benefits of eliminating smoking in public housing properties, considering the empirical evidence in favor of indoor smoking bans from the public health and policy perspectives.

A Growing Response to Evidence on Secondhand Smoke

HUD’s proposed indoor smoke-free public housing rule can best be thought of as a formalization and extension of the precedent set by local smoke-free policies and smoking-cessation programs. More than 600 of the nation’s approximately 3,300 PHAs have already made at least one of their buildings smoke-free.6 These provisions have spread rapidly: in 2005, only 16 PHAs had smoke-free measures in place, but between 2005 and 2011, 214 PHAs adopted them in some form — for example, by prohibiting indoor smoking outright, for new residents, or in certain buildings.7 Efforts to institute smoke-free rules escalated after HUD’s Office of Public and Indian Housing issued a notice in 2009 urging PHAs “to institute non-smoking policies in some or all of their public housing units,”8 a statement that was extended to subsidized multifamily properties in 2010 and renewed in 2012. HUD also published several guides for both residents and administrators of public housing that provided resources and suggestions for successful implementation.9 In addition to making information available, HUD issued a notice in the Federal Register in 2012 soliciting feedback about adopting smoke-free policies in PHAs and multifamily housing.10 Some of the responses HUD received are collected in “Change Is in the Air,” a comprehensive action guide for implementing smoke-free housing policies that was published in 2014.11

More than 600 PHAs nationwide have adopted smoke-free policies for some or all of their buildings.

Attempts to curtail smoking in public and subsidized housing are concurrent with the nationwide growth in voluntary, self-imposed in-home smoking bans. The Centers for Disease Control and Prevention (CDC) estimates that the number of U.S. households with smoke-free rules “increased from 43 percent in 1992–1993 to 83 percent in 2010–2011, including an increase among households with at least one adult smoker, implying that the smokers in these households agree to smoke outside of the home.”12 HUD’s proposed rule, then, aligns with formal and informal measures to curtail smoking in private and public spaces, building on these existing efforts while expanding their reach to share best practices and extend the benefits of smoke-free homes to a larger group of residents.

HUD’s efforts to first reduce and eventually ban indoor smoking escalated in the wake of a 2006 Surgeon General’s report declaring that “there is no risk-free level of exposure to secondhand smoke.”13 Secondhand smoke itself contains more than 7,000 chemicals; 250 of them, including ammonia and carbon monoxide, are known to be harmful, and nearly 70 are carcinogens.14 Living with a smoker can increase a nonsmoker’s chances of developing lung cancer by 20 to 30 percent, and approximately 7,300 nonsmokers in the United States die each year of lung cancer caused by passive exposure to cigarette smoke.15 The cardiovascular effects of secondhand smoke are even more far-reaching; according to CDC estimates, secondhand smoke increases nonsmokers’ risk of heart disease by 25 to 30 percent and stroke risk by 20 to 30 percent, resulting in more than 34,000 premature deaths from heart disease and 8,000 deaths from stroke annually.16 These are not just long-term risks — the CDC explains that “even brief exposure to secondhand smoke can damage the lining of blood vessels and cause your blood vessels to become stickier. These changes can cause a deadly heart attack,” especially in people who already have heart disease.17

Infants and children are also vulnerable to serious health issues caused by secondhand smoke. According to the CDC, pre- or postnatal exposure to secondhand smoke increases the risk of sudden infant death syndrome because “chemicals in secondhand smoke appear to affect the brain in ways that interfere with its regulation of infants’ breathing.”18 In older children, passive inhalation of smoke impedes lung growth and capacity, resulting in frequent episodes of wheezing and coughing and instances of bronchitis and pneumonia. Wilson et al. state that “[e]ven brief exposure to ambient tobacco smoke can decrease lung function” and raise the risk of inflammation.19 Secondhand smoke can also prompt more frequent and more severe asthma attacks.20 Wilson et al. say that “very low levels of tobacco-smoke exposure have been associated with attenuated endothelial function,” or damage to the arteries. Cognitive effects such as “decreased scores on reading, math, and block-design tests of cognitive function” and increased rates of conduct disorders are also present.21

U.S. Surgeon General Vivek Murthy and HUD Secretary Julián Castro participate in a White House convening on smoke-free public housing. Sammy Mayo Jr.

Although many people are aware of the dangers of secondhand smoke, fewer recognize the hazard created by what is known as “thirdhand smoke.” Defined as “residual tobacco smoke contamination that remains after the cigarette is extinguished,” it “take[s] the form of particulate matter deposited in a layer onto every surface within the home; in loose household dust; and as volatile toxic compounds that ‘off gas’ into the air over days, weeks, and months.”22 The residue in thirdhand smoke contains lead, a substance that has been declared unsafe for children at any level of exposure. Research has shown that the presence of a smoker in a household not only causes a statistically significant increase in the lead level of floor dust23 and an increase of more than 90 percent in the lead level of windowsill dust,24 but it also results in “significantly higher” blood lead levels in children who reside in the home.25

Thirdhand smoke accrues despite protective measures such as opening windows, turning on fans, smoking in other rooms, or waiting for smoke to dissipate, meaning, as Winickoff et al. state, that “breathing air in a room today where people smoked yesterday can harm the health of infants and children.”26 As a result, thirdhand smoke, although less damaging than direct exposure to tobacco smoke, still provides an important reason for indoor smoking bans.

In multiunit housing, the effects of smoking extend beyond individual apartments. A nationwide survey of multiunit housing units finds that, at a given site, at least 26 percent and up to 64 percent of residents report secondhand smoke “incursions into their units from external sources (e.g., hallways or adjacent apartments),”27 a figure that does not take into account the invisible accrual of thirdhand smoke. A 2011 study measuring levels of cotinine, a biomarker used to indicate tobacco exposure, found that even children who do not live with any smokers display a “45 percent increase in cotinine levels if they live in apartments compared with detached homes.”28 As the Surgeon General’s report explains, only “[e]liminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke.”29 In public housing, “tobacco smoke exposure…is particularly troubling because it afflicts disadvantaged and vulnerable populations.”30 In 2014, 34 percent of households in public housing included elderly persons, 26 percent included disabled persons, and 38 percent included children, groups who are especially vulnerable to the effects of secondhand smoke exposure.31

Benefits and Costs of Implementation

Researchers have worked to quantify the savings in healthcare costs that reducing secondhand smoke exposure will generate as well as other savings from smoke-free public housing — primarily reductions in renovation expenses and in the risk of catastrophic fires. Although such analysis involves considerable uncertainty, the anticipated cost savings to both residents and PHAs are high. A 2014 study by King et al. estimates that prohibiting smoking in all subsidized or public housing nationwide “would yield annual cost savings of $496.82 million (range, $258.96–843.50 million), including $310.48 million ($154.14–$552.34 million) in secondhand smoke-related health care, $133.77 million ($75.24–$209.01 million) in renovation expenses, and $52.57 million ($29.57–$82.15 million) in smoking-attributable fire losses.”32 HUD’s regulatory impact analysis of smoke-free public housing estimates an aggregate annualized benefit to nonsmoker health ranging from $148 million to $447 million at a lower discount rate of 3 percent and $70 million to $137 million at a higher discount rate of 7 percent. The analysis also predicts a further benefit to nonsmoker well-being ranging from $96 million to $275 million per year, a reduction in PHA maintenance costs of $16 million to $38 million per year, and a reduction in fire risk of $32 million, which translates into approximately 150 fires averted and nearly 4 lives saved annually.33

HUD’s analysis, like the cost estimates by King et al., does not quantify the expected health benefit to smokers, as the rule’s purpose is to prevent nonsmokers from being exposed to secondhand smoke.34 However, one benefit to smokers from the rule arises from research indicating that the commonality of smoking in a community is a significant risk factor that can increase the prevalence of tobacco use. For example, a study of low-socioeconomic-status black women in Chicago public housing developments found that the most significant barriers to smoking cessation all “followed from social isolation and lack of support” in a highly stressful environment.35 For many of the women surveyed, “the lack of exposure to those who ha[d] tried to quit reinforced the belief that … those who quit must exert Herculean efforts.”36 Studies have shown, however, that the inverse is also true; the contagion effect caused by more visible efforts to reduce or curtail smoking can increase success rates by shifting norms around smoking, providing social support, and encouraging residents who struggle to quit to renew their efforts even if they are not initially successful. Even smokers who do not use these policies as an opportunity to quit are likely to reduce the amount they smoke. A study in Portland, Oregon, found that within a year of implementing a smoke-free policy, “almost half of ongoing smokers reduced their cigarette consumption,” and the quit rate increased from 2.6 to 14.7 percent.37 Although the damaging health consequences of secondhand smoke are especially pronounced in multiunit housing, the opportunities for meaningful intervention at such sites are enhanced as well.

HUD’s proposed rule will also have costs — mostly in time and inconvenience for residents who smoke and in time for training and enforcement for PHA staff. HUD’s regulatory impact analysis, in considering the opportunity cost of time smokers will spend going to and using outside smoking areas, values the lost time and inconvenience of residents who smoke at $209 million per year. They estimate the costs to PHAs to comply with the proposed rule — including drafting their policies, holding public discussions, disseminating the policies, training staff, updating leases, and monitoring — will average about $3.2 million per year in total, with higher costs over the initial implementation period.38

HUD’s proposed implementation of smoke-free public housing stands to improve long-term health outcomes for young children.

The most serious cost, and biggest challenge overall to smoke-free PHA policies, is the issue of enforcement and punishment. Bans on indoor smoking are legal; smokers are not a protected class under the Civil Rights Act of 1964, and the courts have ruled that the due process clauses of the 5th and 14th Amendments require only a reasonable basis for restricting smoking.39 PHAs, however, still face a number of difficulties in enforcing these bans. Some residents believe that smoke-free policies violate their rights as paying renters and refuse to comply. To counter this, PHAs attempt to make clear that “a resident’s status as a smoker or non-smoker is irrelevant,” that “smoking status cannot be used to determine eligibility for applying for or residing in public or assisted multifamily housing,” and that people “are allowed to smoke, just not in the areas that have been designated non-smoking.”40 Nevertheless, Sheila Crowley, president and chief executive officer of the National Low Income Housing Coalition, expressed frustration that neither homeowners nor recipients of other forms of housing assistance, such as vouchers or tax credits, are subject to these rules.41 Although indoor smoke-free policies are legal, attempt to avoid imposing an undue burden, and mirror policies increasingly adopted in market-rate rental housing, this equity issue remains.

In addition, short of repeatedly knocking on doors and inspecting apartments, which agency staff may not have time to do, finding instances of indoor smoking can be difficult. Many residents are reluctant to report their neighbors. In New York City, which has the nation’s largest PHA, some residents, outside observers, and city officials are concerned about the potential role of police officers in enforcement, noting that even if PHAs do not invite or encourage officers to assist in identifying violations, “the presence of officers acting as de facto hall monitors inside housing developments differentiates the smoking ban being proposed for public housing from those instituted by privately owned apartment buildings, co-ops and condos.”42 Nevertheless, HUD believes that the health, safety, and financial benefits of even an imperfectly comprehensive reduction in indoor smoking make the rule worth pursuing.

The eviction of repeat offenders is the most serious potential cost of indoor tobacco bans. The HUD rule itself recognizes that “there may be costs to residents as a result of eviction, particularly for persons with disabilities, and especially for those with mobility impairments” that may prevent them from reaching areas where smoking is allowed.43 For some residents, the Rehabilitation Act of 1973 and the Americans with Disabilities Act can provide relief in the form of a request for reasonable accommodation, which PHAs are required to consider and grant when appropriate.44 PHAs have met these requests by, for instance, transferring residents with mobility issues to units closer to elevators or doors so they can reach outdoor smoking areas more easily.45

The proposed rule makes clear that eviction, although a necessary enforcement option, is an action of last resort. To avoid evictions, PHAs ensure that residents are aware of the smoke-free policy and the consequences of repeat violations. HUD’s proposed rule stipulates that tenants’ leases include the prohibition on lit tobacco, whether through an amendment process or during the annual renewal period.46 Residents who violate the policy receive verbal or written warnings and, in many cases, also receive information about smoking cessation resources and referrals to smoking cessation programs. HUD’s guidance, which is consistent with smoke-free policies already implemented at PHAs nationwide, recommends “graduated enforcement to assist residents with compliance and prevent eviction.”47 Although enforcement procedures vary among PHAs, they all share the option to remedy noncompliance over a period of time. Rhode Island’s East Greenwich Housing Authority, for example, counts each violation only after a 20-day cure period has passed.48 “The mindset of the enforcement isn’t: ‘I’m going to catch you smoking, I’m going to evict you,’” says Rodger Moore, director of property management at Home Forward, the PHA of Portland, Oregon. “It is: ‘I’m going to work with you to give you as many resources and as many chances as we possibly can, without waiving our right for eviction.’ We hold the resident’s hand as long as we possibly can.”49 Between 2009 and 2014, Portland issued 51 notices to residents with an option to remedy and 9 notices with no option to remedy across 2,000 units.50

These local PHA strategies exist alongside HUD’s broader efforts to minimize the possibility of eviction. In addition to “develop[ing] guidance in reasonable accommodation,” HUD’s goal for the public comment phase of the rule’s implementation was to provide suggestions “on how to mitigate these potential adverse impacts.”51 As a result, nationwide, evictions are very rare. Although no comprehensive accounting of evictions due to smoking ban violations exists, at least three occurred between 2013 and 2015 — in Cincinnati, Ohio; Fairhaven, Massachusetts; and Manchester, New Hampshire.52

Conclusion

HUD’s proposed rule, which may still evolve before it is finalized and implemented, builds on strong evidence about the danger of secondhand smoke and on the experiences of PHAs who have already instituted smoke-free policies. Although administrators will need to clearly explain the new rule to residents, promote smoking cessation programs, and consider residents’ input to ensure that the rule is fairly applied, the rule stands to improve long-term health outcomes, especially for vulnerable residents such as the young and elderly.

— Keith Fudge, HUD Staff

Related Information:

Case Study: Housing Authority of the City of Austin

1. U.S. Department of Housing and Urban Development. 2015. "HUD Secretary Castro Announces New Rule Making Public Housing Smoke-Free," press release, 12 November.
2. U.S. Department of Housing and Urban Development. 2015. "Instituting Smoke-Free Public Housing: Proposed Rule," Docket No. FR 5597-P-02, 1.
3. For a list of these PHAs, see: Department of Housing and Urban Development. "Smoke-Free Public Housing and Multifamily Properties" (portal.hud.gov/hud­portal/HUD?src=/program_offices/healthy_homes/smokefree). Accessed 31 January 2016.
4. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 4, 15.
5. U.S. Department of Housing and Urban Development. 2015. "Regulatory Impact Analysis: Instituting Smoke-Free Public Housing — Proposed Rule," Docket No. FR-5597-P-02, 3–4.
6. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 12; U.S. Department of Housing and Urban Development. "Public Housing" (portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/ph). Accessed 17 December 2015.
7. U.S. Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control. 2011. "Smoke-Free Housing: A Toolkit for Residents of Federally Assisted Public and Multi-Family Housing," 4.
8. U.S. Department of Housing and Urban Development, Office of Public and Indian Housing and Office of Healthy Homes and Lead Hazard Control. 2009. "Non-Smoking Policies in Public Housing," Notice PIH-2009-21.
9. See: U.S. Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control 2011; see also: U.S. Department of Housing and Urban Development, Office of Lead Hazard Control and Healthy Homes. 2014. "Change Is in the Air: An Action Guide for Establishing Smoke-Free Public Housing and Multifamily Properties."
10. U.S. Department of Housing and Urban Development. 2012. "Request for Information on Adopting Smoke-Free Policies in PHAs and Multifamily Housing," Federal Register 77:193 (4 October), 60712–4.
11. U.S. Department of Housing and Urban Development, Office of Lead Hazard Control and Healthy Homes 2014.
12. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 10.
13. U.S. Department of Health and Human Services. 2006. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, 11.
14. National Cancer Institute. 2011. "Secondhand Smoke and Cancer" (www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/second-hand-smoke-fact-sheet). Accessed 17 December 2015.
15. Centers for Disease Control and Prevention. 2014. "Health Effects of Secondhand Smoke" (www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/health_effects/). Accessed 16 December 2015.
16. Ibid.
17. Ibid.
18. Ibid.
19. Karen M. Wilson, Jonathan D. Klein, Aaron K. Blumkin, Mark Gottlieb, and Jonathan P. Winickoff. 2011. "Tobacco-Smoke Exposure in Children Who Live in Multiunit Housing," Pediatrics 127:1, 86.
20. Centers for Disease Control and Prevention.
21. Wilson et al., 86.
22. Jonathan P. Winickoff, Joan Friebely, Susanne E. Tanski, Cheryl Sherrod, Georg E. Matt, Melbourne F. Hovell, and Robert C. McMillen. 2009. “Beliefs About the Health Effects of 'Thirdhand' Smoke and Home Smoking Bans," Pediatrics 123:1, 75.
23. Joanna M. Gaitens, Sherry L. Dixon, David E. Jacobs, Jyothi Nagaraja, Warren Strauss, Jonathan W. Wilson, and Peter J. Ashley. 2009. "Exposure of U.S. Children to Residential Dust Lead, 1999–2004: I. Housing and Demographic Factors," Environmental Health Perspectives 117:3, 464.
24. Ibid., 465.
25. Sherry L. Dixon, Joanna M. Gaitens, David E. Jacobs, Warren Strauss, Jyothi Nagaraja, Tim Pivetz, Jonathan W. Wilson, and Peter J. Ashley. 2009. "Exposure of U.S. Children to Residential Dust Lead, 1999–2004: II. The Contribution of Lead-Contaminated Dust to Children's Blood Lead Levels," Environmental Health Perspectives 117:3, 470.
26. Winickoff et al. 2009, 74.
27. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 7.
28. Wilson et al. 2009, 85.
29. U.S. Department of Health and Human Services, 11.
30. Jonathan P. Winickoff, Mark Gottlieb, and Michelle M. Mello. 2010. "Regulation of Smoking in Public Housing," New England Journal of Medicine 362, 2320.
31. Center on Budget and Policy Priorities. 2015. "United States Fact Sheet: Federal Rental Assistance."
32. Brian A. King, Richard M. Peck, and Stephen D. Babb. 2014. "National and State Cost Savings Associated With Prohibiting Smoking in Subsidized and Public Housing in the United States," Preventing Chronic Disease 11:140222, 1.
33. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 5; U.S. Department of Housing and Urban Development 2015. "Regulatory Impact Analysis," 2, 33.
34. U.S. Department of Housing and Urban Development 2015. "Regulatory Impact Analysis," 36.
35. Loretta P. Lacey, Clara Manfredi, George Balch, Richard B. Warnecke, Karen Allen, and Constance Edwards. 1993. "Social Support in Smoking Cessation Among Black Women in Chicago Public Housing," Public Health Reports 108:3, 389.
36. Lacey et al., 391.
37. Barbara A. Pizacani, Julie E. Maher, Kristen Rohde, Linda Drach, Michael J. Stark. 2012. "Implementation of a Smoke-free Policy in Subsidized Multiunit Housing: Effects on Smoking Cessation and Secondhand Smoke Exposure," Nicotine & Tobacco Research 14:9, 1027.
38. U.S. Department of Housing and Urban Development 2015. "Regulatory Impact Analysis," 71.
39. Winickoff et al. 2010, 2319–25.
40. U.S. Department of Housing and Urban Development, Office of Lead Hazard Control and Healthy Homes 2014, 17.
41. Dylan Matthews. 2015. "Banning smoking in public housing singles out the poor. But it also saves lives," Vox (15 November).
42. J. David Goodman and Mireya Navarro. 2015. "Smoking Ban Proposal a Surprise to Some Public Housing Tenants," The New York Times (12 November), A31.
43. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 15.
44. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 15.
45. U.S. Department of Housing and Urban Development, Office of Lead Hazard Control and Healthy Homes 2014, 70.
46. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 4.
47. Ibid., 12.
48. U.S. Department of Housing and Urban Development, Office of Lead Hazard Control and Healthy Homes 2014, 74.
49. Ibid., 62.
50. Ibid., 46.
51. U.S. Department of Housing and Urban Development 2015. "Instituting Smoke-Free Public Housing," 48.
52. Matthews.