Tobacco use causes an estimated 480 000 deaths per year in the United States; of these, 41 000 are attributable to secondhand smoke exposure among nonsmokers.1 Secondhand smoke exposure is associated with serious health problems in infants and children, including respiratory tract infections, ear infections, more frequent and severe asthma attacks, and sudden infant death syndrome.1,2 The US Surgeon General has concluded that there is no risk-free level of secondhand smoke exposure and that elimination of smoking indoors is critical to protect nonsmokers.2
Recognizing this problem, the US Department of Housing and Urban Development (HUD), in collaboration with key federal agencies and nongovernmantal organizations, issued a proposed rule on November 17, 2015 (likely to go into effect by the end of 2016), that will prohibit indoor smoking on HUD-supported public housing properties and could potentially affect an estimated 2 million individuals living in 954 000 homes in all 50 US states and the District of Columbia.6 The proposed rule would require that Public Housing Authorities (PHAs) prohibit lit cigars, cigarettes, and pipes from all living units, indoor common areas, administrative offices, and outdoor areas within 25 feet of housing and administrative office buildings. Currently, the proposed rule does not apply to electronic cigarettes or tobacco waterpipes (hookahs).
Individual housing authorities will have some autonomy in their implementation of the rule: for example, they may expand the 25-foot buffer and make playgrounds and other outdoor areas smoke-free. Under the Fair Housing Act, special accommodations will continue to be available to residents with disabilities. To date, more than 600 PHAs have voluntarily gone smoke-free, with many doing so in response to a 2009 HUD notice (reissued in 2012) that strongly encouraged adoption of smoke-free policies. The proposed rule will extend the ban on indoor smoking to the remaining 2600 PHAs and ensure uniform rules for all 3200 PHAs nationally. In addition to expected health benefits, it is estimated that a nationwide smoke-free public housing policy could result in annual cost savings of about $153 million, including $94 million in health care savings, and $59 million in reduced property costs.6
The proposed rule is a logical extension of smoke-free laws that ban smoking in public places, including hospitality venues, child care centers, health care facilities, and airplanes. However, the implementation of smoke-free laws has not been without controversy, and questions of individual and collective rights have been raised. Residents of public housing, who by definition are a vulnerable population, have voiced concern about government intrusion into private behavior in their homes. Nonetheless, recent evidence suggests that majorities of public housing residents support smoking bans.7
Residents’ concerns emphasize the need for an implementation plan that is rigorous but sensitive to the needs of the community. Although residents of public housing have many pressing health and social issues, reducing secondhand smoke exposure for children, seniors, and residents with disabilities, and anticipated progress toward denormalization of tobacco use among public housing communities, may help to address long-standing disparities in tobacco-related health burdens. Further, implementation of the rule may contribute to more quit attempts and sustained cessation among residents who might not otherwise engage with those services.
A detailed understanding of the successes and challenges encountered by PHAs that have already adopted smoke-free policies, including the needs and concerns of residents, will provide vital data in support of implementation efforts by the remaining authorities. HUD has initiated this effort with the publication of guidance that includes a summary of the experiences of managers of PHAs and other federally assisted housing in which smoke-free policies have been voluntarily adopted. Federal officials and local PHAs should make strong efforts to involve residents in local implementation plans and the process of communicating plans to increase adherence to the policy. Successful implementation of the new rule will depend on resident engagement and support, and the perception that policies are implemented fairly and with sensitivity. PHAs will need to frame messages to residents focusing on “the smoke, not the smoker.” Safety issues must be considered for residents who need to go distances to smoke, and concerns about smoking in cold weather or having to bring a child outside while an adult smokes present challenges.
In the proposed rule, HUD recommends that the smoke-free prohibition be included in each tenant’s lease and enforced using the same mechanisms in place to enforce other lease requirements; no additional funding for enforcement efforts has been identified. PHAs will also be challenged by ways to administer lease violations, respond to resident reports of neighbors’ smoking, and enforce policies after numerous violations.
MAJOR OPPORTUNITIES FOR SMOKING CESSATION
Implementation of a smoke-free policy presents both an unparalleled opportunity and a duty to help low-income smokers quit and so narrow the gap in smoking rates that contributes to the higher burden of poor health outcomes experienced by this population. As a matter of equity, resources must be made available to help smokers quit. These resources must be appropriate for a population that confronts numerous economic and social challenges on a daily basis and for whom public housing often represents the last of a diminished set of options for stable housing. A plan to provide smoking cessation services, tailored to meet specific challenges experienced by public housing residents, is critical to maximizing the success of this opportunity. Funding for targeted smoking cessation services will likely require combined resources from federal partners, nongovernmental organizations, physician practice organizations, and private foundations in partnership with local and national organizations of public housing residents. Critically, best-practice smoking cessation services must be made available to every smoker who wants to quit smoking, both during and well after the transition to smoke-free housing.
A promising approach would offer a menu of options that are readily accessible and tailored for the needs of residents. For example, the National Smoker’s Quitline (1-800-QUIT-NOW) provides excellent reach and may prove more effective by employing public housing residents as dedicated cessation counselors to address the unique experiences and challenges faced by this population. Other resources include mobile phone applications, such as the National Cancer Institute’s SmokeFree.gov. Tailored counseling from physicians and other health providers, targeted outreach to the health care settings that serve public housing residents, and mass provision of nicotine replacement therapy (NRT) should be included in a strategic cessation services plan. An example of a mass counseling/free NRT program took place in New York City soon after passage of the Clean Air Act in 2006. Within 3 days, 425 000 New York City residents called the Quitline for counseling and free NRT. Evaluation of the effort found 5-fold quit smoking rates compared with controls (33% vs 6%).8
Tobacco control policies in the United States have yielded remarkable gains in the past 5 decades, but US residents of lowest socioeconomic position have not shared equally in these gains. Successful implementation of the smoke-free policy in public housing could have important implications for the nearly 80 million US residents who live in multiunit housing. Building a robust evaluation plan that assesses community knowledge, attitudes, and beliefs regarding the policy; reduction in secondhand smoke exposure; smoking cessation; health outcomes; and housing costs is of utmost importance. If enacted with sufficient funding, dedicated cessation support, and community engagement, the proposed rule will ensure that US residents from low-income communities are better protected from the effects of indoor tobacco use and improve the odds that children will grow up smoke-free, thus breaking the intergenerational cycle of tobacco use. A best-practice, systematic plan for implementation that is responsive to residents’ needs, while providing efficacious cessation support, will ensure that this momentous opportunity realizes its potential.