Smoke-free multi-unit housing benefits residents and property owners. The U.S. Department of Housing and Urban Development (HUD) requires every public housing agency to implement a smoke-free policy by July 2018. Local health departments play a key role in working with public housing agencies to prepare, implement, educate, enforce, and evaluate smoke-free housing policies.

The challenge remains in the entire process of adopting 100% smoke-free policy in multi-unit housing. The process must begin with buy-in support from management and residents. Next is the successful adoption and implementation of the smoke-free policy, education, compliance and enforcement, and assistance to those who want to quit; all of which could take years. The population most impacted by the HUD ruling are those with low income, the elderly, those with mental and physical disabilities, and single parents whose ability to earn a living wage is constrained by family responsibilities and sometimes limited education. These populations also have disproportionately higher smoking rates. One-third (33.6%) of adults in public housing smoke compared to 15.1 % of the general public. Thirty-six and a half percent of adults with any mental illness reported current use of tobacco in 2013 compared to 25.3% of adults with no mental illness. Nearly 32% of adults without a high school diploma and 50% of adults with a GED use tobacco every day or some days, compared to just 10% among adults with an undergraduate degree and 6% with a graduate degree. Those populations who smoke are more likely to suffer from asthma and chronic obstructive pulmonary disease.

The solution is to utilize the public health system and incorporate the 10 essential Public Health Services to solve the problem. Lake County General Health District began addressing the issue of smoking in multi-unit housing in the fall of 2015. The assessment portion had been completed by HUD so next was policy development and assurance. The first activity was to establish a relationship with the Lake Metropolitan Housing Authority (MHA) and discuss the implementation of a smoke-free policy. Management and residents were surveyed on the acceptance, challenges, and barriers to implementing a smoke-free policy and survey data were provided to them. Development of fact sheets and presentations are essential to educating both management and residents on the purpose and benefits of a smoke-free policy, and collaboration with management on the smoke-free policy, Non-Smoking Lease Addendum, and non-smoking enforcement procedure. Correct verbiage is important and documents should be reviewed by housing lawyers. Once Lease Addendum is approved, it is crucial to have the resident initial every point of the Non-Smoking Lease Addendum so they understand the policy. Evaluate the smoke-free policy implementation process and outcome. Lastly, work within the community to provide linkage to cessation services to the residents who want to quit.

Preliminary work with Lake MHA has situated them to be prepared to execute the mandated HUD ruling. Adoption of the 100% smoke-free policy is slow but implementation will occur before the required deadline of July 2018. Survey assessment of management and single individual residents was completed in July 2016. Management was in full support of adopting a smoke-free multi-unit housing policy but commented the greatest barrier will be successful enforcement. Of the 135 single residents surveyed, 78 (58%) wanted a smoke-free building; of those 17 were smokers. In 2017, 35 Lake County Family units were surveyed and found 20 (57%) wanted to live in smoke-free building/property. Survey result provides data that the majority of residents support a smoke-free policy. Process and outcome evaluation has yet to be quantified but will be advantageous if HUD decides to mandate Section 8 and other HUD-funded housing adopt smoke-free policies. The impact of Lake MHA’s smoke-free policy will affect 263 public housing units with a population of 468; of which 157 (34%) are children. The smoke-free policy does not require smokers to quit, but discussion with residents have shown that the new smoke-free policy will be the motivation to help them quit.

Public health practitioners should follow the public health model of assessment, policy development, and assurance to successfully implement smoke-free policies. Though progress was not without its struggles, these activities are replicable. Now that smoke-free housing is a requirement for all public housing agencies, the main challenges that arise are developing sustainable enforcement procedures and linkage to cessation services to those who want to quit. For public health practitioners, the findings support much-needed cessation services for vulnerable populations including the elderly, those with disabilities, and individuals with mental health issues. Working with mental health counselors may be necessary to provide cessation services. Survey data has shown to be a crucial tool to provide support for smoke-free housing. Providing evidence that the majority of residents agree with smoke-free housing will make the final adaptation more palatable for management and residents. There was a lot of uproars when Ohio voted for the Ohio Smoke-free Workplace Law but now it has become an accepted norm. The same will eventually occur with the smoke-free multi-unit housing law. Future studies should evaluate smoker quit rates, behavior changes, and if the health of those in public multi-unit housing improves due to less exposure to secondhand smoke.

1. https://www.acscan.org/cancer-candor/new-study-shows-public-housing-residents-are-smoking-higher-rate%C2%A0

2. https://www.cdc.gov/tobacco/disparities/mental-illness-substance-use/index.htm

3. https://truthinitiative.org/news/smoking-and-low-income-communities