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A Multiple Stakeholder Evaluation of Smoke-Free
Policy Implementation and Support in Multi-Unit
Dwellings
A Tenant and Landlord Perspective
Brian King, MPH
Bi-National Tobacco Control Series,
Part 2 More Smoke-Free
Air June 3, 2009 ? Holiday Inn ? Buffalo, New York
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Overview

• Introduction and Background
• Research Findings
• Conclusions
• Implications and Future Directions

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I. Introduction and Background
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Secondhand Smoke Exposure

• Secondhand Smoke (SHS)
• Mainstream Smoke
• Side Stream Smoke

• Human carcinogen
• EPA, NTP, and U.S. SG

• Contains more than 4,000 chemicals
• Toxic n250
• Carcinogenic n50

Sources National Toxicology Program. Report on
Carcinogens. Eleventh Edition. USDHHS, PHS, NTP,
2005. USDHHS. The Health
Consequences of Involuntary Exposure to Tobacco
Smoke A Report of the Surgeon General.
Rockville, MD USDHHS, CDC, Coordinating
Center for
Health Promotion, National Center for Chronic
Disease Prevention and Health Promotion, Office
on Smoking and Health, 2006.
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Protection Against SHS Exposure
Clean Indoor Air Laws
Policy prohibiting smoking in confined public
places with the intent of protecting non-smokers

• Thirty states have law requiring 100 smoke-free
  workplaces and/or restaurants and/or bars
  (06/09).
• Sixteen states have law requiring workplaces,
  restaurants, and bars to be 100 smoke-free
  (06/09).
• Immediate 19 reduction on AMI admission rates
  associated with implementation of laws

Sources Americans for Non-Smokers Rights
Foundation (ANRF), 2009. Glantz
S. Meta-analysis of the effects of smoke-free
laws on acute myocardial infarction An update.
Preventive Medicine. 2008 47 452-53.
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SHS Exposure in Personal Living Spaces

• Personal Living Spaces
• Average American spends 69 of time at home
• Smoking is completely prohibited in 66 of homes
• 37 of non-smoking Americans live with a smoker
• 43 of children (2 mo.-11 yrs) live with a
  smoker

Sources Klepeis NE, Nelson WC, Ott WR, Robinson
J, Tsang AM, Switzer P, Behar JV, Hern S, and
Engelmann W. The national human activity pattern
survey (NHAPS) A resource for assessing exposure
to environmental pollutants. Journal of Exposure
Analysis and Environmental Epidemiology.
200111231-52. Pirkle JL, Flegal KM, Bernert
JT, Brody DJ, Etzel RA, Maurer KR. Exposure of
the US population to environmental tobacco smoke
the Third National Health and Nutrition
Examination Survey, 1988 to 1991. Journal of the
American Medical Association. 1996
275(16)1233-40. Centers for Disease Control and
Prevention. State-specific prevalence of current
cigarette smoking among adults, and policies and
attitudes about secondhand smoke-United States.
2000. Journal of the American Medical
Association. 2002 287309-310.
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Who Lives in Multi-Unit Housing?
80 Million (26)
11 Million (55)
570,000 (38)
383,000 (33)
Source Adapted from the U.S. Census Bureau,
American Housing Survey, 2007.
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Importance of Scientific Inquiry
Smoke-Free Worksite Laws
Secondhand smoke is not a health hazard
1986 United States Surgeon Generals Report
Secondhand smoke can be controlled through
separation and ventilation
Ineffective in Controlling Exposure and
Protecting Health Repace Lowrey (1980)
Repace Lowrey (1985) Cains et al (2004)
Repace, Hyde Brugge (2006).
Compliance will be difficult and expensive
High Compliance and Support Hyland et al
(1999) Hyland Cummings (1999)
Kiser and Boschert (2001) Weber et al (2003).
Businesses will lose customers and close
No Economic Downturn Glantz
Charlesworth (1999) Hyland et al (1999)
Hyland Cummings (1999) Scollo et al (2003).
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Key Stakeholders
Health Effects Legislation
and Regional Policy
Economic Impact Legislation and
Regional Policy
Tenants
Landlords
General Population
Health Effects Legislation and
Regional Policy
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II. Research Findings
Tenants
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Tenant Experiences
Tenants

• New York State Adult Tobacco Use Survey (NYATS)
• Random digit dial survey of NYS residents 18
  years old
• Conducted quarterly since 2003
• 8,000 completes/annum (smokers and non-smokers)
• Data collected by SRDAR at Roswell Park since
  2007
• Four questions related to MUH added during
  Quarter II, 2007

Multi-Unit Housing
n4,885
Single Family Home
n7,575
n913
n3,972
n1,059
n6,516
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Tenant Experiences
Tenants
Percent of New York State Adult Smokers
who Reside in a Household where Smoking is
Prohibited?, by Type of Residence, NYATS Q2 2007
to Q3 2008.
p lt0.01 (?2) when compared with Single Family
Home NB No significant difference observed
between New York State and New York State
(Excluding NYC) for either residence type ? A
response of Smoking is not allowed anywhere
inside your home to the question, Which
statement best describes the rules about smoking
in your home?
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Tenant Experiences
Tenants
Percent of New York State Adult
Non-Smokers who Reside in a Household where
Smoking is Prohibited?, by Type of Residence,
NYATS Q2 2007 to Q3 2008.
p lt0.01 (?2) when compared with Single Family
Home NB No significant difference observed
between New York State and New York State
(Excluding NYC) for either residence type ? A
response of Smoking is not allowed anywhere
inside your home to the question, Which
statement best describes the rules about smoking
in your home?
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Tenant Experiences
Tenants
Percent of New York State Adults who
Reside in a Multi-Unit Housing Unit where Smoking
is Prohibited and have Experienced a Secondhand
Smoke Incursion? within the Past 12 Months, by
Smoking Status, NYATS Q2 2007 to Q3 2008.
p lt0.05 (?2) when compared with Smokers
plt0.05 (?2) when compared with New York
State ? A response of Daily, A few times a
week, Once a week, or Less than once a week
to the question, During the last 12 months, how
often has secondhand smoke entered your living
space from somewhere else in or around the
building?.
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Tenant Experiences
Tenants
Percent of New York State Adult Multi-Unit
Housing Residents who Would Favor? a Policy in
their Residential Building that Bans Smoking in
All Areas, Including Personal Living Spaces Such
as Balconies and Patios, by Smoking Status, NYATS
Q2 2007 to Q3 2008.
p lt0.05 (?2) when compared with Smokers
plt0.05 (?2) when compared with New York State

? A response of Definitely Yes or Probably
Yes to the question, Would you be in favor of a
policy in your residential building that bans
smoking in all areas, including personal living
spaces such as balconies and patios.
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II. Research Findings
Landlords
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Landlord Experiences
Landlords

• Western New York Multi-Unit Manager Survey
• Preferences and practices related to smoke-free
  policies (57 question instrument)
• Standard Industrial Classification (SIC) System
• Code 6513 Apartment Building Operators (? 5
  units)

Advanced Letter n241
Phone Survey n115
Paper Survey n12 ?HUD p0.043
March 2008 July 2008 n127, 52.7
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Landlord Experiences
Landlords
Percent of Erie/Niagara County Landlords
with a Policy Prohibiting Smoking Inside
Residential Units and/or Buildings.
Source King B, Hyland A, Billoni A, and
Cummings KM. Western New York Landlords
Preferences and Practices Regarding Smoke-Free
Building Policies Findings from Erie and Niagara
Counties. Roswell Park Cancer Institute, November
2008.
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Landlord Experiences
Landlords
Percent of Landlords Who Believe There is a
Viable Market for Smoke-Free Rental Housing
and/or are Interested in Implementing a
Smoke-Free Policy (Among those Without a Current
Smoke-Free Policy, n110).
Source King B, Hyland A, Billoni A, and
Cummings KM. Western New York Landlords
Preferences and Practices Regarding Smoke-Free
Building Policies Findings from Erie and Niagara
Counties. Roswell Park Cancer Institute, November
2008.
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Landlord Experiences
Landlords
Predictors of Erie and Niagara County Landlords
Who are Interested in Implementing a Smoke-Free
Policy, Binary Logistic Regression, n110.
Source King B, Hyland A, Billoni A, and
Cummings KM. Western New York Landlords
Preferences and Practices Regarding Smoke-Free
Building Policies Findings from Erie and Niagara
Counties. Roswell Park Cancer Institute, November
2008.
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Landlord Experiences
Landlords
Primary Concern About Implementing a Smoke-Free
Policy, ( n110)
Difficulty Renting Units 12
Legal Action 0
Tenant Complaints 12
Increased Turnover 20
100 of those with smoke-free units report that
it is likely they will continue to offer them
Source King B, Hyland A, Billoni A, and
Cummings KM. Western New York Landlords
Preferences and Practices Regarding Smoke-Free
Building Policies Findings from Erie and Niagara
Counties. Roswell Park Cancer Institute, November
2008.
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Landlord Experiences
Landlords
Motivators for Smoke-Free Policy Implementation
(Among Landlords Without a Current Policy
Prohibiting Smoking Inside Apartment Units and/or
Buildings, n110).
Source King B, Hyland A, Billoni A, and
Cummings KM. Western New York Landlords
Preferences and Practices Regarding Smoke-Free
Building Policies Findings from Erie and Niagara
Counties. Roswell Park Cancer Institute, November
2008.
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Landlord Experiences
Landlords
Baseline
Follow-Up
March 2008 July 2008 n127
March 2009 Anticipated
Intervention
July 2008 February 2009 n161
July 2009 Anticipated
Control
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III. Conclusions
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Conclusions

• Many NYS tenants have implemented personal
  smoke-free home policies
• Nearly half of NYS tenants have experienced SHS
  incursions
• A majority of NYS tenants support policy
  implementation

Tenants

• Few Erie and Niagara County landlords have
  smoke-free building policies
• Most Erie and Niagara County landlords are
  interested in implemented smoke-free policies
• Lack of knowledge is primary barrier to policy
  implementation

Landlords
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IV. Recommendations and Future Directions
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Recommendations and Future Directions

• Research
• National survey of multi-unit tenants and the
  general population
• National survey of multi-unit landlords

• Public Education
• Refinement of current interventions and
  development of novel, demographically targeted
  initiatives
• Subgroups with high prevalence of multi-unit
  housing residents
• Minorities, ? education, NYC residents
• Acceptance, implementation, and enforcement of
  policies among landlords (HUD)

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Acknowledgements

• Roswell Park Cancer Institute
• Andrew Hyland
• K. Michael Cummings
• Martin Mahoney
• Mark Travers
• Rayne Thoman

• Survey Research and Data Acquisition Resource
• Elissa Pierson-Mingo

• Erie-Niagara Tobacco-Free Coalition
• Anthony Billoni
• Annamaria Masucci

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Questions?
Brian King Department of Health Behavior Roswell
Park Cancer Institute [phone] brian.king_at_r
oswellpark.org