Smoke-Free Policy in Low Income Housing

Abstract

Statement of Problem. There are inequities in tobacco use and second hand smoke exposure by socioeconomic status. Smoke-free housing is advanced as a strategy to reduce these inequities. In 2016, HUD issued a smoke-free rule for all Public Housing Authorities, however best-practice implementation and impact are largely unknown. My dissertation aim is to examine processes and outcomes of smoke-free implementation in low income housing by: assessing impact on smoking behaviors; examining factors affecting compliance; exploring how individuals and communities influence and are influenced by the policy; and, providing recommendations for implementation. Methods and procedures used. Study 1 compared smoking outcomes among participants in a cluster-randomized smoking cessation intervention study conducted among Boston Housing Authority residents. Participants completed baseline and three-month follow-up questionnaires before (n=73) or after (n=93) adoption of a smoke-free policy. Cluster-adjusted regression was used to examine the impact of policy on smoking outcomes. Study 2 used focused ethnography to identify the social-ecological factors affecting compliance with a smoke-free policy. Property observations, 17 staff interviews and 9 focus-groups with resident smokers (n=28) and non-smokers(n=47) in four HUD-assisted properties in Massachusetts were conducted. Theory-driven immersion-crystallization was used to identify themes across sites and respondent types. Study 3 used mixed-methods research to understand factors that facilitate implementation while furthering residents’ individual agency and collective power. Measurements of self- and collective efficacy were collected from 208 survey-respondents and 75 focus-group participants, to describe residents’ collective and individual ability to affect their community. Results or conclusions of the research. Findings suggest that the policy reduces smoking and SHSe. Factors affecting compliance result in new insights for policy implementation including: consistent and clear enforcement; messages that reach older residents; resident engagement (e.g resident ambassadors & committees) for decision-making (e.g. designated outdoor smoking, e-cigarettes); positive roles for non-smokers; transparent communication; forum for staff to discuss concerns; and individualized cessation support by community organizations. The smoke-free policy should be part of a broader community health and wellness effort. Future studies should use multi-level quantitative methods, with qualitative assessment to describe social dynamics and property context. Policy evaluation should include impact on self- and collective-efficacy, and attitudes/behaviors among smokers by stage of change, age and family status.