Earlier this month, the Department of Housing and Urban Development (HUD) released a proposed federal rule to implement smoke-free public housing. The proposed rule would affect all living units, common areas, outdoor areas up to 25 feet away from the housing areas, and administrative offices. The change would affect over 700,000 units no later than 18 months from the final rule—giving ample time for adjustments and public comments on the draft rule. Importantly, the rule will attempt to protect the 750,000 children who live in the affected units from second-hand smoke (SHS).
Second-hand smoke was one of the principal motivators of the rule—particularly because of the risk to non-smoking individuals in multi-unit housing. SHS can enter residences in multi-unit housing in several ways; according to HUD, about half to two-thirds of the air in residences in older buildings may infiltrate from adjacent ones. Thus, having a household-only non-smoking rule does not fully protect residents. Both measured indoor air quality and surveys have confirmed bothersome incursions of smoke from neighboring residences (26-46% of residents reported such an incursion). In a survey of multi-unit housing residents in 2012, over half of respondents (56%) supported smoke-free policies for buildings. A 2010 article in the New England Journal of Medicine laid out the case that banning smoking in public housing is justified given its potential to improve the health and well-being of the population, especially if targets only the action of smoking, rather than smokers themselves (as the proposed rule does).
The writing on the wall for smoking inside public housing appeared in 2009, when HUD’s Office of Public and Indian Housing issued a notice encouraging Public Housing Authorities to implement non-smoking policies. Additional guidance followed in 2010, 2012, and 2014. HUD has also published detailed information on policies and provided online toolkits for both residents and property managers.
As estimated in recent studies (examples here and here), potential state and national cost savings are in the range of hundreds of millions of dollars a year—substantial amounts that include savings from SHS healthcare-related expenditures. Providing evidence-based smoking cessation programs to residents who smoke would likely yield additional savings not currently included in the estimates of the proposed rule’s costs and benefits. How best to give residents access to these programs is unclear. While the Centers for Medicare & Medicaid Services encourages states to cover tobacco cessation services for all beneficiaries, not all states include these services, and Medicaid doesn’t cover all individuals with public housing.
The proposed rule will provide ample opportunities for research, using the policy change as a natural experiment. Such research may provide additional evidence on health outcomes, supporting increased regulation of indoor air quality. The proposed rule is a start, and yet another battle in the effort to reduce smoking rates in the US.
Jess Williams