RWJF Statement on Notice of Proposed Rulemaking Requiring all Public Housing Agencies to Implement Smoke-Free Policies

    • January 19, 2016

The following is a statement from Risa Lavizzo-Mourey MD, president and CEO of the Robert Wood Johnson Foundation (RWJF), on the Notice of Proposed Rulemaking (NPRM) requiring all public housing agencies (PHAs) to implement smoke-free policies.

"The proposed Instituting Smoke-Free Public Housing rule builds on decades of public health victories that have made more and more spaces smoke-free. We believe that the proposed rule will promote a Culture of Health, including enhanced equity, by ensuring that public housing residents have the same access to clean air in and around their homes as do most Americans living in single-family homes or in market-rate multi-unit housing and by creating new opportunities, systems, and partnerships to promote smoking cessation among public housing residents, who, like other low-income Americans, have persistently high rates of tobacco use despite decades of tobacco control efforts. We support extending the proposed restrictions on traditional cigarettes to waterpipes (also known as hookahs) and electronic nicotine delivery systems (ENDS), including e-cigarettes. We also hope that the restrictions in this rule will eventually be extended to Section 8 and mixed-finance public housing units. To maximize the health and equity benefits of the rule, we believe that HUD will need to identify and support best practices for 1) making cessation services available to all public housing residents who want to quit using tobacco products; 2) developing fair, consistent enforcement strategies, which are informed by authentic resident input and minimize the number of residents who are evicted for smoking; and 3) accommodating residents with mobility limitations.

RWJF’s Commitment to Clean Air and a Culture of Health

RWJF is the nation’s largest philanthropy dedicated to improving health and health care in the United States. Twenty-five years ago, we joined forces with researchers, scientists, tobacco control advocates, and others to address smoking, one of the most intractable problems in the field of public health. Since that time, we have invested significant resources, focusing on policy and systems change, including higher tobacco excise taxes; access to cessation treatment; and smoke-free indoor air laws. These investments, and those of governmental, non-profit, and private sector organizations, have led to substantial and sustained reductions in smoking among youth and adults.

The percentage of people in the United States covered by laws requiring all workplaces, restaurants, and bars to be smoke-free has increased from less than 1 percent in the early 1990s1 to nearly 50 percent today.2 The federal government has made all flights within or to and from the United States smoke-free;3 municipalities across the country have created hundreds of smoke-free beaches and over one thousand smoke-free parks; at least 1,475 college and university campuses have gone smoke-free4; and in just the past five years, several major hotel chains, including Westin, Marriott, Sheraton, and Comfort Inn, have gone 100 percent smoke-free.5 Thanks to these and other tobacco control measures, the rate of cigarette smoking continues to decline, dropping from 21 percent in 2005 to 17 percent in 2014.6

Nevertheless, smoking and SHS exposure continue to place a heavy burden on our nation’s health. Smoking results in over $300 billion in direct health care expenditures and about 480,000 premature deaths each year.7 Approximately 41,000 of these deaths are attributable to SHS, and SHS exposure poses particular health risks for children, including increased risk of respiratory infections and more frequent and severe asthma attacks for children with asthma.7,8 Moreover, the burden of diseases related to smoking and SHS exposure remain alarmingly high among low-income populations and racial/ethnic minorities.9 We must do more and we must do better.

In this spirit, RWJF has undertaken an even larger commitment over the last two years: to help build a Culture of Health that provides everyone the opportunity to be as healthy as they can be. In our diverse society, the phrase, Culture of Health will have multiple meanings. There are, however, touchstones that will be common across all definitions. One touchstone is the recognition that our homes and other places where we live, learn, work, and play have enormous influence on our health and well-being. A second touchstone is the recognition that we are all in this together and that we must collaborate to promote health equity so that everyone has the opportunity 'to attain their full health potential.'10 By requiring all PHAs to implement a smoke-free policy, HUD’s proposed rule creates healthier homes, promotes health equity, and advances a Culture of Health.

We, therefore, strongly support the proposed rule and, for the reasons discussed below, believe HUD should extend it to include ENDS and waterpipes and should, eventually, apply similar restrictions to Section 8 and mixed-finance public housing. We applaud HUD’s inclusion of an 18-month period to allow PHAs time to engage residents and to ensure adequate time for implementation. We encourage HUD to use this time to identify and support practices that will minimize the burdens on residents of transitioning to smoke-free housing and to provide cessation services to those who wish to receive them in advance of the rule taking effect.

The Importance of a Healthy Home

Most Americans spend over half their lives inside their homes.11 Healthy homes protect us by providing security, stability, privacy, and control.11 Our homes can, however, also expose us to physical hazards. Recognizing the impact our homes have on our health, the RWJF Commission for a Healthier America highlighted in its recommendations the importance of keeping 'All homes... safe and free from health hazards.'12 Eliminating smoking in and around public housing facilities will be an important step towards fulfilling this recommendation.

Smoking makes homes less safe by exposing residents to secondhand smoke (SHS) and increased risk of fire. SHS exposure causes about 41,000 deaths a year, and children who are exposed to SHS suffer more frequent and severe asthma attacks and increased risk of ear infections and respiratory infections, including bronchitis and pneumonia.7,8

Most exposure to SHS occurs in workplaces and homes.13 Homes are also the primary source of SHS exposure for children.13 Individuals who live in multi-unit housing are at especially high-risk of SHS exposure. Smoke can travel throughout a multi-unit building via walls; ductwork; and common areas, such as hallways.14 Smoke can also enter buildings through vents and windows.15 The migration of smoke throughout and around buildings makes it impossible for residents in multi-unit dwellings to ensure their homes are smoke-free unless smoking is prohibited in and around their building. Among individuals who live in multi-unit dwellings and have personal smoke-free policies in their homes, 44-46 percent report incursions of smoke within the past year, 31 percent report smoke incursions 'often' or 'most of the time,' and 10 percent report smoke incursions on a daily basis.16,17,1 Children who live in smoke-free homes in multi-unit housing have 45 percent higher levels a cotinine (a marker for exposure to tobacco smoke) than children in smoke-free single-family homes.14 SHS exposure may be even higher for individuals and families living in public housing as a result of smaller units, poor ventilation, and higher smoking rates.15,19 In one study of low-income housing residents, nicotine was detected in 89 percent of non-smoking homes.15 Public housing buildings that have gone smoke-free, however, have been found to have lower concentrations of SHS contaminants.20

Smoking is also one of the leading causes of home fire deaths in the United States. The mortality rate in smoking-related fires is seven times greater than in non-smoking related fires. Between 2008 and 2010, smoking-related fires accounted for 2 percent of all residential fires but 14 percent of all deaths from residential fires.21 By prohibiting smoking in and around public housing facilities, HUD’s proposed rule will reduce the risk of fires and SHS exposure, thereby creating safer homes for all public housing residents.

Promoting Health Equity

Collectively, our country has made tremendous progress in promoting smoke-free laws, reducing exposure to SHS, and lowering cigarette smoking, but alarming disparities remain. We believe that the smoke-free public housing rule will effectively address persistent disparities in tobacco-related disease and, on balance, be tremendously promoting of healthy equity if implemented by local public housing agencies with authentic resident input, fair and consistent enforcement strategies, and robust smoking cessation supports. It is important to note that, based on studies from across the country, the majority of residents of public, private subsidized, and multi-unit housing support smoke-free policies and view them as a way to improve the health of their communities.16,22,23,24,25

As noted previously, public housing residents may be at particularly increased risk to SHS exposure due to smaller units, poor ventilation, and higher smoking rates in their communities. Most public housing residents do not have the option of moving to a single-family home or to a smoke-free, market-rate apartment building and, therefore, do not have the option of creating a home that is truly smoke-free. This rule promotes health equity by giving public housing residents that opportunity. Of the 2 million people who will be covered by this rule, 40 percent are children, 45 percent are African-American,26 and most live at or below the poverty level.27,28 In 2011–2012, about a quarter of the U.S. population was exposed to SHS. By comparison, during that same period, 41 percent of children aged 3 to 11, 47 percent of non-Hispanic blacks, and 43 percent of individuals living below the poverty level were exposed to SHS.13

Additionally, national data demonstrate that adults living in poverty are nearly twice as likely to smoke as those with higher incomes (26.3 percent vs. 15.2 percent),6 and data from Boston show even greater disparities when comparing public housing residents to other adults in the city (32 percent vs. 16 percent).29 Smoke-free policies in subsidized, low-income housing have been found to be associated with cessation among residents who currently smoke.30 Adolescents who live in public housing are considered to be at high risk of future smoking.31 A smoke-free home environment may discourage initiation and lower the risk of smoking for these adolescents.32,33,34

In a Culture of Health, everyone should have the opportunity to be as healthy as they can be. The proposed rule will advance a Culture of Health by ensuring public housing residents have the same access to clean air as individuals living in smoke-free, market-rate multi-unit housing or smoke-free single-family homes. It will also likely reduce the high smoking rates among public housing residents and may discourage initiation among younger residents.

Extending the Rule to Include Waterpipes and ENDS

RWJF supports extending the proposed rule to the use of waterpipes and ENDS. As use of these products has surged in recent years so has their potential public health impact.7,35 Lack of federal regulation and wide variation among products has made it difficult to assess that impact, but initial research on SHS from waterpipes and the aerosol emitted by ENDS users suggests that carving out exceptions for these products could reduce the proposed rule’s health benefits. Such an exception may also run counter to many public housing residents’ preferences: a recent study found that a majority of U.S. adults surveyed in 2014 agreed that vaping or using e-cigarettes should not be allowed in places where cigarette smoking is not allowed.36

ENDS are devices that heat and aerosolize a solution containing nicotine, flavoring, and other chemicals. Bystanders can be exposed to the aerosol when users exhale.37 Neither the devices nor the solutions, known as e-liquids, are regulated, and studies have found wide variation in the chemical content of e-liquids as well as the aerosol that is produced when using different devices.38 Studies have also found variation within products, highlighting the need for greater quality control and regulatory oversight.38,39 One recent study, for example, found that the nicotine concentration in 65 percent (35/54) of the liquids tested deviated by more than 10 percent from the manufacturer labels and that most had higher levels of nicotine than advertised.40

ENDS aerosol has been found to contain chemicals, metals, and contaminants that raise health concerns. Nicotine, which is present in most ENDS aerosols,39 is a psychoactive drug with a high level of toxicity and rapid addiction.41 Overdose of nicotine can lead to headache or dizziness or seizures and death.41 Studies have also found e-liquids and e-cigarettes to contain diacetyl, the flavoring chemical associated with the respiratory disease known as popcorn lung, and harmful metals that may be aerosolized, including chromium, nickel, and lead.42,43 Recently, the U.S.

Food and Drug Administration has issued warnings to e-cigarette manufacturers about selling e-liquids that contained the active ingredients in the weight-loss drug Zimulti® and the erectile-dysfunction drug Cialis®.44 The lack of regulation combined with the identification of numerous harmful substances raises serious concerns about the health risks ENDS aerosol may cause to bystanders.

The particles in ENDS aerosol also raise health concerns. A recent scientific review of e-cigarettes concluded that the particle size distribution and number of particles contained in e-cigarette aerosol are similar to those found in cigarette smoke, though it is not yet known whether they pose the same risk.37 Researchers have estimated that 73 percent to 80 percent of these particles would be exhaled by e-cigarette users, posing a potential risk to bystanders.45 Furthering concerns, one study found that e-cigarette use led to elevated levels of nicotine and several carcinogens in the ambient air,46 though research also suggests that e-cigarette users emit much lower concentrations of nicotine than cigarette smokers.47

Secondhand smoke from waterpipes also carries health risks. Waterpipes are devices that use coal or other carbon material to heat tobacco. The smoke from the tobacco travels through water and a hose to the user. Bystanders can be exposed to the smoke that is exhaled by the user as well as to smoke emitted by the burning coal or other material used to heat the tobacco. According to the Surgeon General, waterpipes 'produce high levels of user and environmental carbon monoxide and other toxic substances.'7 A study of hookah lounges in Oregon found that air quality measurements ranged from 'unhealthy' to 'hazardous' according to U.S. Environmental Protection Agency standards.48 Additionally, a study in Virginia found that peak particulate matter concentration was higher in establishments where waterpipes were smoked than in establishments where cigarettes were smoked.49 Given the lack of regulation of ENDS and waterpipes as well as the evidence of harms from passive exposure to waterpipe smoke and ENDS aerosol, HUD should extend its rule to prohibit use of these devices in areas where smoking is banned.

Extending the Restrictions to Section 8 and Mixed-Finance Public Housing

We encourage HUD to extend restrictions on smoking and ENDS use to Section 8 and mixed-finance public housing. This could be done in the final rule, with additional time for implementation if necessary, or through subsequent rulemaking. From a Culture of Health perspective, individuals and families living in Section 8 or mixed-finance public housing should have the same opportunity to breathe clean home air as all other public housing residents.

Identifying and Supporting Best Practices to Minimize the Burdens on Smokers

RWJF’s strong support of smoke-free public housing comes with the understanding that the rule will burden individuals who continue to smoke after implementation. We encourage HUD to work with its national, state, and local partners to identify and support best practices for minimizing that burden. These practices include: 1) making effective cessation services available to all public housing residents, 2) minimizing the number of residents who are evicted for smoking, and 3) accommodating residents with disabilities.

Every effort must be made to ensure cessation services are available to public housing residents during the 18 months leading up to implementation and thereafter. While we believe the primary focus of this rule should be clean home air for all public housing residents, we recognize this rule will also benefit many public housing residents who currently smoke. Nearly 70 percent of adult smokers report wanting to quit,50 and quit attempt rates among public housing residents are as high as for the general population.29 Smoke-free public housing policies have been associated with higher cessation rates,30 and the effect of smoke-free housing could be compounded by ensuring residents have greater access to cessation aids, including counseling and/or pharmacotherapy. HUD can help ensure residents have access to cessation services by providing PHAs with cessation resources. For example, HUD could develop a cessation 'toolkit' that guides PHAs on how to forge partnerships with local health departments, cessation groups, and health centers and provide information on how to link residents to state quitlines and other cessation services. It will also be critical for HUD to coordinate national efforts with the Centers for Disease Control and Prevention, the Center for Medicare & Medicaid Services, the Health Resources and Services Administration, and leading tobacco control groups. By combining the smoke-free rule with access to widely accessible, free or low-cost evidence-based cessation services, there is a real opportunity to reduce smoking rates among public housing residents. Helping current smokers quit will be the best way to maximize the health benefits of the rule and to minimize its burdens. Moreover, decreased smoking will aid with policy compliance.

For residents who continue to smoke, it will be important to enable compliance with the new rule in order to minimize violations and evictions. HUD and its partners should study some or all of the over 600 PHAs that have gone smoke-free to identify best practices for promoting compliance and minimizing eviction, and those best practices should be shared with all PHAs. While RWJF supports requiring individuals to smoke outside and away from PHA buildings, the burden must not be so great as to encourage violations. If, as the NPRM suggests, a designated smoking area with shade and benches assists with compliance and reduces evictions, we would support such accommodations. We also support making adequate accommodations for smokers with mobility limitations.

Conclusion: Access to Clean Home Air is Essential to Building a Culture of Health

We applaud the Department for recognizing the centrality of housing to good health. By ensuring clean home air for 2 million public housing residents, the proposed rule is an important step toward building a Culture of Health, in which everyone can live healthier and longer lives, now and for generations to come. We look forward to working with HUD as the regulatory process continues and appreciate the opportunity to comment on this important proposed rule."

 

About the Robert Wood Johnson Foundation

For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives. For more information, visit www.rwjf.org. Follow the Foundation on Twitter at www.rwjf.org/twitter or on Facebook at www.rwjf.org/facebook.

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