Addressing Environmental Quality: A Healthy People 2020 Story from the Field

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By Tiffani Kigenyi, MPH, Public Health Analyst, ODPHP and Blythe Miller, MPH, Editor, CommunicateHealth, Inc.

Our Stories from the Field series highlights how communities across the nation are addressing the Healthy People 2020 Leading Health Indicators (LHIs). LHIs are critical health issues that — if tackled appropriately — will dramatically reduce the leading causes of death and preventable illnesses.

This month’s story features a program that is tackling one of the Environmental Quality LHIs:

  • Air Quality Index (AQI) exceeding 100 (EH-1)
  • Children exposed to secondhand smoke (TU-11.1)

Read the story below, then check out other Stories from the Field on HealthyPeople.gov.

Exposure to secondhand smoke causes significant health problems in the United States. According to the Centers for Disease Control and Prevention (CDC), secondhand smoke harms both children and adults — and the only way to completely protect people who don’t smoke is to eliminate smoking in all homes, work environments, and public places.

Mandy Burkett, Section Chief of the Tobacco Use Prevention and Cessation Program at the Ohio Department of Health (ODH), says she knew the problem of secondhand smoke was an important one to address in her state. “State surveys show that there’s a lot of secondhand smoke exposure in Ohio. Respondents to our 2013 Tobacco Survey reported that 3 in 10 adults were exposed to secondhand smoke in the past 7 days. And results from our 2013–2014 Ohio Youth Tobacco Survey showed that secondhand smoke exposure in the past 7 days was as high as 6 in 10 for children. It was clear that secondhand smoke exposure needed to be a priority for us.”

Shifting Expectations
Ohio has a law that prohibits smoking in all public places and places of employment, which passed by voter referendum in 2016 with just over 50% of the vote. But attitudes are changing with time. “Now we see an 80% approval rating,” Burkett says. “And as approval for that law has increased, we’ve received more calls from residents looking for multi-unit public housing that’s guaranteed smoke free. People are beginning to expect that.”

As a result, the Tobacco Program at ODH decided to work on increasing the number of multi-unit public housing properties protected by smoke-free policies.

Protecting Vulnerable Populations 
“We’re especially concerned about children,” says Burkett, “because they’re disproportionately burdened. We see more severe cases of asthma and higher rates of SIDS. We also wanted to focus on people who are already disadvantaged — those with lower incomes, disability, or mental health problems. These are the populations more likely to live in multi-unit public housing,” she explains. “So it’s a good focus for us.”

The fact is that people are extremely vulnerable to secondhand smoke if they live in a building where other people smoke. “Up to 60% of the airflow can come from other units,” says Burkett. And, according to the standards for ventilation set by the American Society of Heating, Refrigerating and Air-Conditioning Engineers, there’s no effective way to control the health risks of secondhand smoke in multi-unit properties other than to prohibit smoking completely. This is consistent with the 2006 Surgeon General’s Report, which concluded that separating smokers from nonsmokers, cleaning the air, and ventilating buildings can’t eliminate exposures of nonsmokers to secondhand smoke.

Success by the Numbers
In 2015 and 2016, ODH grantees helped numerous Ohio housing authorities and public housing managers adopt smoke-free policies in public or low-income housing. Current data shows increasing numbers of smoke-free units in major Ohio cities, including:

  • 4,800 in Cincinnati
  • 3,000 in Dayton
  • 2,700 in Toledo/Lucas County

Straight to the Source
Recently, the U.S. Department of Housing and Urban Development (HUD) introduced a rule, slated to take effect in 2018, which requires all HUD multi-unit public housing in the country to become smoke free. Although federal regulations will soon change, some property managers have questions about smoke-free policies. Since Burkett and her team have chosen to approach their work on smoke-free housing by going directly to the managers of public housing complexes and properties, they are well positioned to help.500 in Columbus

“Managers worry about higher vacancy rates, complaints from current tenants, enforcement-related costs, and even whether or not it’s legal,” explains Esther Benatar, who works with Burkett. “But we’re prepared to address those fears. Managers [of smoke-free properties] don’t see higher vacancies — most residents want their properties to be smoke free. Also, smoke-free policies save managers money on cleaning and renovation fees when they need to turn over units that have had smoking tenants. And their insurance costs go down due to the lower risk of fires.”

A Systematic Approach 
The Tobacco Program’s approach is to provide property managers with a lot of hands-on support. The first step is sending people out to talk to managers about smoke-free policies. “Then we have a whole system set up to lead property managers through every step of policy development and implementation,” says Burkett.

This system includes an on-demand webinar and a toolkit with a model policy that managers can adapt to fit their needs, sample notification materials for tenants, and language about the policy to include in the lease. The Tobacco Program also helps managers engage current tenants with public meetings about pending changes — and arranges cessation services for tenants who want to quit. There are also incentives for managers who implement a smoke-free policy, like help advertising their policy through signage and press releases.

The program also does outreach to residents. “We go at it from the grassroots level, too,” Burkett says. “We want to help people understand that they can look for smoke-free public housing — and why it’s so important that they do.”

Looking Ahead
When discussing the future of smoke-free public housing, Burkett is optimistic — but she knows there’s more work to be done.

“The HUD rule is a good impetus for landlords to get ahead of this issue,” she says. “But policy change of any kind is difficult, and we need to figure out how we can provide more tailored assistance at key stages of the process. There are some important questions that I think we can find ways to address more effectively, like: Do you have the right partners involved? Do you have support from the community? Do you have a model policy that’s culturally appropriate for your area?”

“It’s rewarding work,” adds Benatar. “At the end of the day, we’re helping to promote safe, healthy, affordable housing — and that can transform lives.”

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