Previous studies have gauged support for implementing smoke-free multi-unit housing (MUH) policies in the United States, but none have specifically examined attitudes among racially and ethnically diverse elders living in low-income MUH. We surveyed a convenience sample of elders 62 years of age and older (
There is no level of SHS that is recognized to be safe (CDC
Low-income elders have a unique risk of the sequelae of SHS exposure including exacerbation of bronchitis, pneumonia, cancer, and cardiovascular disease (Helburn
Involuntarily, residents of MUH complexes might be exposed to higher levels of SHS due to building factors, such as shared air between units, units of reduced size and low levels of ventilation (Kraev et al.
No-smoking policies can reduce SHS exposure, thereby improving health (USDHHS
Efforts to implement smoke-free MUH are gaining momentum across the United States both at the state level and at the municipal level. In 2012, the US Department of Housing and Urban Development (HUD) reissued a 2009 notice encouraging Public Housing Authorities (PHA) to implement non-smoking policies in housing units (HUD
In many communities, stakeholders of smoke-free MUH surveyed residents in order to understand support and barriers for smoke-free MUH policy development and implementation. Surveys with residents in Oregon, Minnesota, Ohio and California have shown consistently that a majority of residents support smoke-free living (Pizacani et al.
Our study is unique in that we surveyed a large racially and ethnically diverse population of elders living in low-income MUH housing in order to understand current smoking behaviors and exposure to second-hand smoke and to determine support for no-smoking policies.
Broward County, FL, the 18th largest county in the United States, has nearly 400,000 MUH units. With funding from the Centers for Disease Control and Prevention, Community Transformation Grant (CTG), which granted 61 awards in 36 states from 2011 to 2014, community stakeholders worked towards implementing smoke-free MUH policies, with an initial focus on low-income senior housing (USDHHS
Public and low-income housing properties and housing properties operating in low-income zip codes were targeted for surveying between March 2013 and September 2013. Utilizing a convenience sample, properties were contacted by community stakeholders, including the American Lung Association, the Florida Department of Health in Broward County, and Nova Southeastern University Master of Public Health Program to identify their willingness to participate in the survey. Of the 24 properties surveyed and included in this study, 18 properties were HUD subsidized low-income senior properties, five were public housing authority managed properties and one was a low-income market-rate property (not senior-specific). e followed HUD age guidelines for low-income senior housing eligibility and included all elders 62 years of age and older in our study.
The smoke-free MUH survey included 19 questions that captured demographic characteristics of residents and assessed residents’ smoking behaviors, exposure to SHS, and support for smoke-free MUH policies. Our survey was a modified version of the “MUH Resident Survey,” developed by a group of experts for use by the CDC’s Division of Community Health (DCH) CTG awardees (DCH National Evaluation Team
We assessed attitudes towards smoke-free policies (our dependent variable) through three questions: “To what extent do you support a no-smoking policy in YOUR building for all individual apartments?” “To what extent do you support a no-smoking policy in YOUR building for all common areas (such as hallways, lobby, laundry room, stairwells, garage or lounge/party room?)” and “To what extent do you support a no-smoking policy in YOUR building for all outdoor areas (such as courtyards, yards, swimming pools, and children’s play areas?” Responses included, “Support, Do NOT support, Don’t know/not sure.”
We ascertained current exposure to SHS by asking, “How often does tobacco smoke enter your own apartment from somewhere else in or around your building?” Responses items were “Everyday, Sometimes, Never and Don’t know/Not sure.” For analysis we created a new dichotomous variable to compare “Every day” and “sometimes” verses “Never.”
We assessed smoking behaviors by asking, “Do you NOW smoke cigarettes every day, some days or not at all?” To understand residents’ current home smoking rules, we asked residents if they allow smoking anywhere in their home, some places in their home or not at all in their home. For analysis, we combined responses to create dichotomous variables assessing “smoker” verses “non-smoker” and “smoking allowed in home” verses “smoking not allowed in home.”
Tenant demographics were assessed through questions asking the tenant their primary language, gender, age, ethnicity, race, educational attainment, how long they lived in their apartment. We also assessed self-reported comorbidities among the tenant and other residents in the unit by asking “Does anyone living in your apartment have any of the following illnesses: Asthma, Lung Disease (such as chronic bronchitis or COPD), Heart Disease, Cancer.”
Residents in 22 of the 24 properties were surveyed as part of resident events; all residents were invited to come at an advertised time to the properties’ social or recreation hall, and the survey was administered in-person by community partners and public health graduate students to all interested tenants. Two properties were surveyed by the property manager leaving flyers on the residents’ doors and asking residents to come complete the survey in the property manager’s office. Across the 24 properties, the overall response rate was 23.1 %, ranging from a high of 100 % to a low of 2 %. The median response rate for properties in this study was 25.7 % across the 24 properties. In 15 of the sites, residents were encouraged to join the events and complete the survey in order to receive a raffle ticket for small prizes ($5 or less.)
Initially, all surveyors were trained by the PI prior to survey administration. As the surveying continued throughout Spring 2013, a trained surveyor and community stakeholder from either the American Lung Association, the Florida Department of Health in Broward County, or Nova Southeastern University Master of Public Health Program conducted the training prior to each survey event. Additionally, a survey procedure guide was distributed to new surveyors to help reduce interview bias.
Descriptive statistics were used to describe the surveyed population in terms of demographic characteristics and support for smoking policies. Subgroup analyses were performed using Pearson chi-square, two-tailed tests (
To assess predictors of support for an indoor no-smoking policy, we conducted multivariate modeling using binary logistic regression to examine if significant variables in the bivariate analysis, including current smoking behavior and home smoking rules, were mediated by demographic characteristics. We tested for multi-collinearity and interaction terms among variables selected for the adjusted model. The final model was adjusted for age group, gender, ethnicity, race, home smoking rule and current smoking status. All analyses were conducted in SPSS Ver. 22, and a
The research was approved as exempt by Nova Southeastern University’s Institutional Review Board.
Most respondents in our convenience sample were women (77.0 %.) In terms of age group, 72.6 % of the sample was between 70 and 89 years old. Only 30.5 % of the sample listed English as their primary language, with 57 % listing Spanish as their primary language and 8.1 % listing Creole or French. The sample was ethnically and racially diverse, with 60.8 % self-reporting as Hispanic and 22.2 % of the population self-reporting as Black or other races. In terms of education, 39 % of the residents surveyed had not graduated high school, and only 11.5 % were college graduates (Table Characteristics of MUH survey population, ≥62 years of age (No. of residents Column % Gender Male 168 20.8 Female 621 77.0 Unreported 18 2.2 Age group <=69 127 15.7 70–79 334 41.4 80–89 252 31.2 90+ 57 4.6 Unreported 37 4.6 Primary Language English 246 30.5 Spanish 464 57.5 Creole 65 8.1 Other 32 4.0 Race Black 172 21.3 White 569 70.5 Other race 8 0.9 Don’t know/Unreported 58 7.2 Ethnicity Hispanic 491 60.8 Non-Hispanic 276 34.2 Don’t know/Unreported 40 4.9 Education Less than high school 159 19.7 Some high school 151 18.7 High School grad 223 27.6 Some college/technical 166 20.6 College grad 93 11.5 Don’t know/Unreported 15 1.9
Nearly 22 % of respondents in our sample were former smokers (smoked at least 100 cigarettes in their lifetime), but only 9.3 % were current smokers. More than 29 % ( Reported smoking rates, exposure to second-hand smoke and comorbidity of asthma, lung disease, heart disease or cancer among elder residents of low-income housing properties (No. of residents % of total respondents Current smoking behaviors Current smoker 75 9.3 Former smoker 177 21.9 Exposure to second-hand smoke Everyday 79 9.8 Some days 157 19.5 Not at all 523 64.8 Don’t know 42 5.2 Unreported 6 0.7 Smoking related Co morbidity Asthma 123 15.2 Lung Disease 99 12.3 Heart Disease 150 18.6 Cancer 65 8.1 Home smoking rule Not allowed 626 77.6 Sometimes allowed 35 4.3 Always allowed 62 7.7 Don’t know 69 8.6 Unreported 15 1.9 All Residents 807
Overall, the majority of residents supported no-smoking policies: 75.2 % supported no-smoking policies for individual units; 76.8 % supported no-smoking policies in common areas (such as hallways, laundry room, lobbies), and 67.9 % supported no-smoking policies in outdoor areas such as courtyards.
There were no significant differences in support for no-smoking policies of any kind by race, exposure to SHS, or presence of a smoking-related comorbidity(ies). Hispanic residents, older residents, females and residents who do not allow smoking in their home were significantly more likely to support both indoor and outdoor smoking policies. ( Comparison of support for smoking policies by resident characteristics among elder residents of low-income housing propertiesa
a “Don’t know” and missing values removed from analysis for each comparison
bPearson chi-square
c Comorbidity includes Asthma, Lung Disease, Heart Disease and/or cancerNo. of residents % support indoor P valueb
% support common P valueb
% support outdoor P valueb
Gender 0.012 0.086 0.014 Male 157 73.2 77.6 59.6 Female 568 82.3 83.5 71.1 Age group 0.039 0.678 0.022 < =69 113 75.2 80.3 57.6 70–79 315 77.8 81.5 66.9 80–89 241 84.2 82.8 73.8 > =90 56 89.3 87.5 80.7 Primary Language <0.001 0.011 <0.001 English 222 70.7 75.8 60.1 Spanish 447 83.4 84.1 79.2 Creole 62 82.3 81.0 80.6 Other 27 96.3 96.4 92.0 Race 0.660 0.460 0.511 Black 156 81.4 79.9 72.1 White 540 79.8 82.4 74.7 Ethnicity 0.015 0.314 0.001 Hispanic 4 83.0 83.2 78.2 Non-Hispanic 253 75.5 80.2 66.5 Current smoking behavior <0.001 0.829 <0.001 Smoker 60 51.7 81.0 40.6 Non smoker 677 82.3 82.0 77.3 Exposure to SHS 0.471 0.150 0.788 Currently exposed 215 81.9 79.2 73.5 . Not exposed 498 79.5 83.6 74.4 Smoking related co-morbiditiesc
0.632 0.676 0.883 One or more co- morbidity 238 81.0 82.5 74.0 No co-morbidity 369 79.5 81.3 74.4 Home Smoking rule 0.000 0.741 0.000 Allowed 84 65.5 84.3 59.6 Not allowed 605 82.6 82.9 77.8
We modeled support for an indoor no-smoking policy for all individual apartments in the respondents' buildings using logistic regression. Our final adjusted model included age, gender, ethnicity, current smoker and home smoking rule. Residents who reported having a smoking rule were more than twice as likely to support an indoor policy compared to resident who allow smoking anywhere in their home (OR = 2.36; 95%CI 1.25–4.43; Predictors of support for indoor smoking policy among low-income eldersa
aOR = odds ratio; CI = confidence interval. OR estimates are based on the logistic regression model which included age, gender, race, ethnicity, current smoker and home smoking rule. ORs are considered significant if the 95 % CI does not include 1.0
b
Predictor Support for Indoor Smoking Policy Age group <=69 1.0 70–70 1.24 (0.67–2.29) 81–89 0.843 (0.43–1.65) > = 90 0.37 (0.10–1.39) Gender Male 1.0 Female 0.1.50 (0.903–2.46) Ethnicity Hispanic 1.0 Non-Hispanic 0.61 (0.369–1.00) Race White 1.0 Black 1.42 (0.78–1.61) Home smoking rule Allowed 1.0 Not allowed 2.36 (1.25–4.43) b
Current smoking behavior Non -smoker 1.0 Smoker 2.89 (1.44–5.79) b
Although there are other studies that have assessed support for smoke-free MUH in the United States, the work we present here is the first study to examine attitudes toward implementing smoke-free housing policies among a large group of racially and ethnically diverse elders living in low-income MUH. In our study, a clear majority of elders living in the low-income housing properties surveyed support no-smoking policies for individual apartments, common areas and outdoor areas. Overall, our findings are consistent with other studies exploring support for smoke-free MUH policies among residents which ranged from 42 to 79 % support (Ballor et al.
With regards to our findings by race and ethnicity, we found that there was no difference in support for blacks verses whites or Hispanics verses non-Hispanics. This is relevant and important information in Broward County, which is home to a diverse population of elders from the Caribbean Islands and South America. The large sample size further suggests that low-income elders are in favor of smoke-free MUH policies, and it offers support for ongoing efforts by community partners to work with property owners and managers to continue to implement smoke-free MUH policies. Following surveying and dialogue among community partners, fifteen of the properties surveyed subsequently adopted prohibitive smoke-free MUH policies in October, 2013. Community partners noted that results from this large survey, which have been shared across numerous forums in Broward County, are a useful tool for them as they continue to build partnerships with property managers and owners interested in smoke-free MUH. Applying these results in ongoing work demonstrates knowledge of the local context, an important strategic step for partners working actively on developing and implementing smoke-free MUH (Satturlund et al.
The overarching goal of implementing smoke-free policies is to create healthy living environments by reducing smoking in areas where non-smokers can be exposed to SHS. Therefore, communities working towards smoke free MUH must be cognizant of meeting both smoker and non-smoker needs throughout the policy development and implementation process. While implementation of smoke-free policies have shown associated increases in cessation-related behaviors (Pizacani et al.
Limitations of this study include possible selection bias, due to the convenience sampling approach as well as low response rates at some of the properties surveyed. Other limitations include possible information bias, due to the nature of self-report surveys and the potential for socially desirable responses. In addition, as a gateway city to South America and the Caribbean Islands, Broward County, Florida is diverse; over 28 % of the population is Black or African American, and 27 % is Latino/Hispanic. More than 31 % of residents were foreign born (United States Census Bureau
This study is the first to evaluate levels of support for smoke-free policies among a large population of low-income racially and ethnically diverse elders living in low-income MUH properties. Findings demonstrate that elders living in low-income MUH properties overwhelmingly support smoke-free policies. As elders living in MUH can have serious health consequences due to SHS exposure, public health practitioners, property managers and residents must build on current momentum and continue to work together to foster healthy living environments for our elders by developing and implementing smoke-free policies.
This paper was supported in part by a cooperative agreement (#U58DP003661) with the Centers for Disease Control and Prevention. Portions of this project’s work involve the Communities Transforming initiative supported by CDC funding. However, the findings and conclusions in this paper are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Users of this document should be aware that every funding source has different requirements governing the appropriate use of those funds. Under U.S. law, no Federal funds are permitted to be used for lobbying or to influence, directly or indirectly, specific pieces of pending or proposed legislation at the federal, state, or local levels. Organizations should consult appropriate legal counsel to ensure compliance with all rules, regulations, and restriction of any funding sources.
The authors acknowledge and warmly thank Matthew Competiello and Kamalie Belizaire from the American Lung Association in Broward County, Florida; Juana Mejia and all the property managers and social service staff from Catholic Health Services, and the volunteers and staff from Tobacco Free Florida; Area Health Education Centers in Broward and Miami Dade Counties; the Florida Department of Health in Broward County; TOUCH Broward; and the Broward Regional Health Planning Council.