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Smoke-free Multi-Unit Dwellings--A Priority for Public Health Action

Contents

I Introduction
II Smoke-free Homes and Comprehensive Tobacco Control
III Smoke-free Multi-Unit Housing in Ontario
IV The Role of Local Public Health Departments
V Leadership Examples
VI Conclusion
VII Additional Resources
VII References

--submitted by Steven Savvaidis,  Senior Manager, Program Training and Consultation Centre (PTCC), with research and editorial support from Saeeda Irfan, Health Promotion Specialist at PTCC

I Introduction

Over the past decade, policies that protect non-smokers from exposure to second-hand smoke in indoor public places and workplaces have become widespread. The provincial Smoke-free Ontario Act, which took effect in 2006, prohibits smoking in all indoor public places, including bars, restaurants and workplaces. Smoking in automobiles with children present is also prohibited. Many municipalities are also passing amendments to local smoke-free bylaws which extend protection to outdoor public places, including playgrounds, parks and beaches. Despite this tremendous progress, far too many non-smokers including children and the elderly continue to be exposed to smoking in the home. For Ontarians living in apartments, social housing, condominiums and other multi-unit dwellings (MUDS), all too often the source of this tobacco smoke comes from outside of their own home, from smoking that is taking place in other building units, balconies, and patios.
 
Second-hand smoke

Second-hand smoke consists of both the side stream smoke that is emitted from the lit end of a burning cigarette as well as the mainstream smoke that is exhaled by the smoker. Second-hand smoke is a serious health hazard. It contains over 7000 chemicals, including at least 69 known human carcinogens (US Department of Health and Human Services [USDHHS], 2010). It is a known cause of sudden infant death syndrome, respiratory infections and asthma in children (USDHHS, 2010). Among adults, second-hand smoke causes lung cancer and coronary heart disease (USDHHS, 2010). There is no risk-free level of second-hand smoke exposure (USDHHS, 2006). Second hand smoke can disperse quickly through a building traveling between adjacent units through cracks in walls and ceilings, windows, heating and ventilation systems. Significantly elevated levels of nicotine (as measured through serum cotinine) have been found in children who live in non-smoking households within multi-unit dwellings as compared with those living in detached homes (Wilson, Klein, Blumkin, Gottlieb & Winickoff, 2011).

In addition to the harms caused by exposure to second-hand smoke, smoking in the home is one of the leading causes of fire in Ontario homes. Approximately 23% of all residential fires in Ontario took place within multi-unit dwellings (Wijayasinghe, 2011). Most smoking related fires result when lit cigarettes are left smoldering, and when smokers fall asleep in bed while smoking. These  are common risk behaviours among smokers (O’Connor, Bauer, Giovino, Hammond, Hyland, Fong & Cummings, 2007). Information about fire risk provides an additional compelling argument to engage landlords and housing providers in smoke-free policy development.

Exposure to Smoking in the Home

Smoking in the home has declined substantially in Ontario over the past decade.  Still, 5% (or 434,548) of non-smokers in Ontario 12 years of age and older continue to be regularly exposed to smoking in the home on a daily or near daily basis (Ontario Tobacco Research Unit [OTRU], 2012). Rates of exposure among children and youth 12–19 years of age are at 11% (or 133,404), more than double that of the general population (OTRU, 2012). It is likely that rates of exposure are much higher within households that include a family member who smokes, among lower income households and for non-smokers living in multi-unit dwellings. A survey conducted by the OTRU found that 28% of residents living in MUDS noticed second hand smoke entering their dwellings as compared with 18% of respondents who lived in a single family dwelling (OTRU, 2009).

II Smoke-free Homes and Comprehensive Tobacco Control

Although the primary objective of smoke-free homes is to protect non-smokers from exposure to second-hand smoke, there is also strong and consistent evidence that smoking bans provide an important support to smoking cessation. Recent reviews of the published literature indicate that home smoking bans are significantly associated with increased quit attempts, and increased abstinence among smokers who live in households with complete smoking bans. Even among continuing smokers, home smoking bans are associated with reduced daily cigarette consumption (Mills, Messer, Gilpin & Pierce, 2009). In a smoke-free home it is less convenient to smoke (requires going outside), and there are fewer visual cues that could trigger relapse (i.e., other people smoking).

The current renewal of the Smoke-free Ontario Strategy announced in 2011, emphasizes smoking cessation as a key priority area. An ambitious target of reducing Ontario’s smoking rates to the lowest level in Canada has been set (Ministry of Health and Long-Term Care [MoHLTC], 2012). Given the population-level impact that smoke-free homes can have on both protection and smoking cessation, greater effort is required to promote the uptake of smoke-free homes through public education strategies and through voluntary policy development within multi-unit dwellings.

The state of California has in fact invested in smoke-free multi-unit dwellings as a pivotal strategy for reducing tobacco use and exposure. The California tobacco control strategy is based on a social change model where policy, media and systems changes are made to create an environment where tobacco use is “less desirable, less acceptable and less accessible”(Roseler & Burns, 2010). In the area of multi-unit dwellings, they have developed and implemented a state-wide media campaign that is coordinated with local media, and have supported community organizing and policy development efforts through training and technical assistance (Modayil, Consolacion, Isler, Soria & Stevens, 2011).

III Smoke-free Multi-Unit Housing in Ontario

Efforts to address smoke-free multi-unit housing in Ontario have been underway in Ontario for over five years. A provincial coalition was formed in 2010 which includes membership from provincial advocacy, not for profit organizations, and public health departments. The coalition’s goal is to work with landlords and other housing providers on a voluntary basis to increase the supply of smoke-free multi-unit housing to meet demand (Smoke-free Housing Ontario [SFHO], 2010). This goal is consistent with recommendations made by the provincial Tobacco Strategy Advisory Group (2010) which recommended intensifying a voluntary approach to smoke-free MUDS in Ontario.
 
At present there are 46 social housing buildings that are smoke-free in Ontario (SFHO, 2012). This is tremendous progress as five years ago only a few buildings were smoke-free in all of Canada. Still, this represents only a very small fraction of all smoke-free social housing and the supply of for-profit housing is likely even lower.

IV The Role of Local Public Health Departments

Increasingly, local public health departments are demonstrating leadership on this issue by working with both not for profit housing providers and the private housing industry within their health unit jurisdictions to encourage the adoption of smoke-free housing policies. This activity is consistent with the work that local public health departments are mandated to perform under the Ontario Public Health Standards (MoHLTC, 2008).  Specific recommendations directed at supporting the development of smoke-free housing can also be found in the accompanying Guidance Document for Comprehensive Tobacco Control (CTC Working Group, 2010).

As with any policy change effort, work in the area of smoke-free multiunit housing can face challenges and opposition from various interest groups. Those with libertarian views may argue that smoke-free multi-unit housing infringes upon individuals’ rights to smoke in their own homes. Landlords and property managers may erroneously believe that smoke-free housing policies are illegal, discriminatory and unenforceable (Smoking and Health Action Foundation, 2012). Public health staff may encounter these views in meetings with tenants, and landlords as well as in the media. In response to such concerns, public health advocates can emphasize the importance of protecting non-smokers, particularly children and the elderly from exposure to second-hand smoke, educate landlords and the public that these policies are legal and enforceable and cite examples of landlords, and social housing providers who have successfully implemented policies.

There is a range of activities that public health departments can undertake to build support for and encourage the development of smoke-free multi-unit housing in their communities. These activities include:

  • Engaging in media relations activities (issuing press releases, writing letters to the editor, and pitching news stories) to help raise public awareness of the hazards of second-hand smoke and the need for smoke-free multi-unit housing options.
  • Conducting social marketing campaigns to build support and increase demand for smoke-free multi-unit housing within the general community and specific population subgroups.  
  • Engaging with local not for profit housing providers and private landlords to raise their awareness of the hazards of second-hand smoke and providing the business case for developing smoke-free policies.
  • Engaging local fire services as partners in educating the community and landlords about the hazards of smoking in the home and the importance of smoke-free policies.
  • Tracking and respond to complaints from tenants regarding tobacco use.
  • Assisting housing providers in drafting smoke-free policies that can be included in lease agreements.
  • Supporting policy implementation with promoting the policy to tenants and within the broader community.
  • Assisting tenants and landlords who are making applications to the Ontario Landlord and Tenant Board to resolve disputes related to smoking in rental housing.  
  • Developing smoke-free housing registries to promote the availability of smoke-free buildings locally.


V Leadership Examples

Two local public health department leadership examples are described in the next few paragraphs. These cases have been documented by the Program Training and Consultation Centre and are available at the links below.

The Region of Waterloo Public Health Department partnered with the Waterloo Regional Housing Department to help develop the first municipal smoke-free social housing policy in Ontario. This policy was successfully implemented on April 1, 2010, making a potential of 2722 apartment units smoke-free.  As part of this policy any lease signed after April 1, 2010 requires tenants and guests to refrain from smoking or holding lit tobacco (link to detailed case study description: http://www.ptcc-cfc.on.ca/cms/one.aspx?pageId=104032).

The Peterborough County-City Health Unit (PCCHU) has been actively supporting local landlords and housing providers to develop smoke-free policies for their buildings and complexes. This activity has also included supporting tenants and landlords in preparing applications related to second-hand smoke to the Ontario Tenant and Landlord Board.  Over one dozen not for profit housing providers in the Peterborough area have adopted no smoking policies thus far (link to detailed case study description: http://www.ptcc-cfc.on.ca/cms/One.aspx?portalId=97833&pageId=137615).

Additional success stories have been compiled by the Smoking and Health Action Foundation and posted to the Smoke-free Housing Ontario website: http://www.smokefreehousingon.ca/sfho/directory.html.

VI Conclusion

Increasing the supply of smoke-free multi-unit housing is an area of evidence-based action where local public health departments can demonstrate leadership. Action in this area can have tremendous reach and impact by protecting all non-smokers living within a building from involuntary exposure to second-hand smoke. Smokers living in a smoke-free building are also more likely to quit smoking and remain abstinent. Smoke-free multiunit dwellings should be a priority for any comprehensive tobacco control program.

VII Additional Resources

Smoke-free Housing Ontario  (http://www.smokefreehousingon.ca/sfho/)
Smoke-free Housing Ontario is a coalition of health organizations concerned about the lack of smoke-free housing options in Ontario and about the negative health effects involuntary second-hand smoke exposure has on those living in multi-unit dwellings. Its membership includes the Canadian Cancer Society, Heart and Stroke Foundation, Ontario Lung Association, Ontario Campaign for Action on Tobacco, Smoking and Health Action Foundation and Public Health Units across the province. The coalition offers information and support for individuals and families, landlords, condominium boards and other housing providers interested in going smoke-free. Many of these resources are available on the smoke-free housing website.

Non-Smokers’ Rights Association / Smoking and Health Action Foundation (http://www.nsra-adnf.ca)
The NSRA is a voluntary non-profit health organization that has worked exclusively in the field of tobacco control for over 30 years. Its mission is to promote public health by eliminating illness and death caused by tobacco, including second-hand smoke. The SHAF is the sister organization of the NSRA, and conducts public policy research and education designed to reduce tobacco-related disease and death. The NSRA / SHAF has developed various resources related to smoke-free housing which includes a literature review, smoke-free housing case studies, and information on how to implement a no-smoking policy for a multi-unit dwelling.

Program Training and Consultation Centre (http://www.ptcc-cfc.on.ca)
PTCC  provides training, technical assistance and knowledge exchange services in comprehensive tobacco control to local public health departments, local tobacco-free coalitions, Tobacco Control Area Networks, and other community health and social service agencies. The PTCC operates a Media Network to help build the capacity of health departments to strategically use the media. Media Network staff can provide assistance with media campaign planning, the development of key messages, press releases, and other media materials to help generate coverage of smoke-free multi- unit dwellings at the community level.

VIII References

CTC Working Group, Ministry of Health Promotion and Sport (MHPS). (2010). Comprehensive tobacco control: Guidance document. Retrieved from: http://www.mhp.gov.on.ca/en/healthy-communities/public-health/guidance-d...

Mills, A. L., Messer, K., Gilpin, E. A., & Pierce, J. P. (2009). The effect of smoke-free homes on adult smoking behaviour: A review. Nicotine & Tobacco Research, 11(10),1131-1141.

Modayil, M., Consolacion, T., Isler, J., Soria, S., & Stevens, C. (2011). Cost-Effective Smoke-Free Multiunit Housing Media Campaigns. Connecting with Local Communities. Health Promotion Practice, 12(6),s2,173S-185S.

Ontario, Ministry of Health and Long-Term Care. (2012) Ontario’s Action Plan for Health Care. Better patient care through better value from our health care dollars. Retrieved from: http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/rep_healthych...

O’Connor, RJ, Bauer JE, Giovino GA, Hammond D, Hyland A, Fong GT, Cummings KM. (2007). Prevalence of behaviors related to cigarette-caused fires: a survey of Ontario smokers. Injury Prevention,13(4),237-242.

Ontario, Ministry of Health and Long-Term Care. (2008). Ontario Public Health Standards 2008. Retrieved from: http://www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/d...

Ontario Tobacco Research Unit. Reports of Tobacco Smoke Entering Ontario Homes. Retrieved from: http://otru.org/wp-content/uploads/2012/06/update_mar2009.pdf

Ontario Tobacco Research Unit. (2012). Smoke-Free Ontario Strategy Evaluation Report. Retrieved from: http://otru.org/wp-content/uploads/2012/12/OTRU_SER_2012.pdf
Roeseler, A. & Burns D. (2010). The quarter that changed the world. Tobacco Control, 19(Suppl. 1),i3–i15.

Smoke-free Housing Ontario. (2010). Overview. Retrieved from: http://www.smokefreehousingon.ca/sfho/overview.html

Smoke-free Housing Ontario. (2012). Ontario Social Housing Providers with No-Smoking Policies. Retrieved from: http://www.smokefreehousingon.ca/hsfo/file/files/Smoke-free_social_housi...

Smoking and Health Action Foundation. (2012). Looking Back, Moving Forward: Smoke-Free Multi-Unit Housing in Ontario. Retrieved from: https://www.nsra-adnf.ca/cms/file/files/Looking_Back,_Moving_Forward_S-F...

Tobacco Strategy Advisory Group. (2010). Building On Our Gains, Taking Action Now: Ontario’s Tobacco Control Strategy for 2011-2016. Report from the Tobacco Strategy Advisory Group to the Minister of Health Promotion and Sport. Retrieved from: http://www.mhp.gov.on.ca/en/smoke-free/TSAG%20Report.pdf

U.S. Department of Health and Human Services. (2006). The Health Consequences of Involuntary Exposure to Tobacco Smoke: A Report of the Surgeon General. Retrieved from: http://www.surgeongeneral.gov/library/reports/secondhandsmoke/fullreport...

U.S. Department of Health and Human Services. (2010). How Tobacco Smoke Causes Disease—The Biology and Behavioral Basis for Tobacco-Attributable Disease: A Report of the Surgeon General. Retrieved from: http://www.surgeongeneral.gov/library/reports/tobaccosmoke/full_report.pdf

Wijayasinghe, M. (2011). Fire Losses in Canada. Year 2007 and Selected Years. Calgary, AB: Offier of the Fire Commissioner, Public Safety Division, Alberta Municipal Affairs.

Wilson, K., Klein, J., Blumkin, A., Gottlieb, M. & Winickoff, J. (2011). Tobacco-Smoke Exposure in Children Who Live in Multiunit Housing. Pediatrics, 127(1),85-92.