Experts Discuss Secondhand Smoke Exposure and Adverse Childhood Experiences in Home Environments

June 27, 2017|2:21 p.m.| Talyah Sands

Secondhand smoke exposure is not safe in any amount. In the United States, smoke exposure is most common among children ages 3 to 11 years, African Americans, people living below the federal poverty level, and those who rent housing. In multi-unit housing (MUH), smoke travels anywhere air can be exchanged, leading to involuntary secondhand smoke exposure. To address this unequal exposure, tobacco control advocates promote smoke-free MUH policies to eliminate secondhand smoke in one of the last indoor places where smoking is still allowed—the home. The U.S. Department of Housing and Urban Development (HUD) issued a rule requiring all public housing authorities to adopt smoke-free policies. State health departments support smoke-free housing through their tobacco control programs in collaboration with local health departments and community partners to provide technical assistance to property managers and residents in the transition to smoke-free.

ASTHO wanted to consider how to create healthy environments in MUH while taking into account how other public health issues like adverse childhood experiences (ACEs) play into smoke-free home policies. According to the ASTHO Essentials for Childhood Policy Guide, ACEs are incidents that harm social, cognitive, and emotional functioning and disrupt the safe, nurturing environments children need to thrive. As the number of ACEs increase, so does the risk for asthma, depression, smoking, diabetes, and other negative health outcomes across a lifespan.

To highlight the intersection of these public health topics, ASTHO held an Ask the Experts virtual session, moderated by Rahul Gupta, commissioner of the West Virginia Bureau for Public Health. Gupta serves as the chair of both the ASTHO Prevention Policy Committee, which oversees ASTHO’s commitment to state and territorial tobacco control, and ASTHO’s Tobacco Issues Forum, a national workgroup under the guidance of the Prevention Policy Committee that fosters collaboration and shares best practices between state and territorial tobacco control leaders and national partners. As state health officer, Gupta oversees the promotion of tobacco control and cessation initiatives in West Virginia, a largely rural state that faces significant health burdens from the use of both cigarettes and smokeless tobacco products.

During the virtual session, Gupta’s state public health leadership perspective anchored a conversation with five panelists about the public health implications of smoke-free housing, adult smoking, and ACEs. Gupta encouraged collaboration and partnership between state and local public health partners to achieve health equity, commenting, “It is critical that if we are going to succeed at the community level, [we should] understand the community and the inequities that exist and take a holistic approach.” The following key themes and recommendations emerged from the session:

Smoke-free housing is a health equity issue.

The impetus behind collaborating with MUH property managers to implement smoke-free policies is to protect residents from involuntary secondhand smoke exposure. “Secondhand smoke does not give [neighbors] a choice,” says Thomas Carr, director of national policy at the American Lung Association. This is especially concerning for residents with respiratory conditions like asthma. Tobacco control advocates have an opportunity to promote health equity through smoke-free environments by lending their smoke-free policy expertise to the housing industry. State health departments, such as those highlighted in an ASTHO case study, successfully collaborated with local and community partners to assist MUH managers in implementing smoke-free policies to reduce involuntary exposure to secondhand smoke.

Public health professionals are critical resources for residents.

As Carr states, such policies are “anti-smoking, not anti-smoker,” and do not require residents to quit smoking, however, they can motivate people to consider cessation. State and local partners play a vital role in offering existing public health cessation services and resources to MUH residents at every stage of policy development and implementation. Carr recommends providing a one-page list of community cessation resources, such as the state quitline or group quit programs, as a simple way to inform residents of available support. Offering these resources before and after the policy goes into effect encourages healthy lifestyles and provides support to residents at various points of the process.

Engage residents in smoke-free policy development.

Ana Novais, executive director of the Rhode Island Department of Health, encourages involving MUH residents throughout the policy adoption process to increase resident buy-in and help property managers tailor the smoke-free policy to community needs. State health departments that are experienced in smoke-free housing efforts emphasize resident engagement as key to policy success, as this approach creates a strong foundation for a smooth transition. HUD’s final rule also recognizes the importance of working with community members to create policy change by requiring resident engagement in policy development, further indicating that this method is essential practice in smoke-free housing.

Support property managers in taking a sensitive approach to enforcement.

Transitioning to living in a smoke-free community may be challenging for some residents due to mental illness, personal trauma, or addiction. Although some stakeholders may be concerned about unintended consequences of smoke-free housing policies such as the potential for eviction, public health partners consider eviction a last resort and work with property managers to leverage strategies to prevent adverse effects. In addition to communicating about the policy and how it will be enforced before it goes into effect, property managers can support residents who have a hard time complying by enforcing the policy sensitively through a multi-step process so as not to cause additional trauma or stress. Darlene Huang, staff attorney at the Tobacco Control Legal Consortium at the Public Health Law Center, recommends encouraging property management to provide multiple opportunities for compliance and to speak with residents directly to identify solutions for policy adherence. State and local partners can work together to support property managers with enforcement by providing resident education to reinforce the benefits of smoke-free living.

Smoke-free policies are one of many policies to improve health in the home environment.

Factors beyond secondhand smoke can negatively impact health in the home environment, such as traumatic experiences, such as emotional abuse, physical abuse, and neglect. Joan Gillece, director of the Center for Innovation in Trauma-Informed Approaches at the National Association of State Mental Health Program Directors, notes that ACEs are an indicator for risky health behaviors and chronic disease. This perspective broadens the context of MUH where more than smoking can contribute to toxic stress among residents. Tobacco control advocates working on smoke-free housing are encouraged to expand their work to mitigate poor health outcomes resulting from the home environment as a whole by partnering with injury prevention and chronic disease experts to incorporate policies and programs in MUH that promote health broadly.

Address the larger structures that contribute to health inequities by working with residents on community change.

While smoke-free housing addresses one aspect of adverse environments for children, Camara Jones, immediate past president of the American Public Health Association and senior fellow at the Morehouse School of Medicine, recommends that public health partners look at the larger context and find opportunities to address structures that contribute to health inequities. For example, Gillece advises considering the impact of other issues affecting community health, such as food deserts, on the experience of MUH residents. Without additional community resources to support health, it is challenging to influence health holistically through smoke-free housing policies alone. Jones challenges smoke-free housing advocates to work with MUH communities to identify the issues most important to residents. Though smoke-free housing may not be top priority, this approach allows the community to guide their own steps to wellness, which may include smoke-free living.

“True collaboration is about giving up power,” Huang says. Community members know their own challenges best. Tobacco control advocates and other public health partners can help communities find solutions by uncovering community history and bringing it to the forefront of discussion while supporting residents to be the drivers of change based on their own priorities. Although this collaborative approach takes time, it allows the community to tell their story, identify their strengths, and bring people together toward a holistic approach and agreed upon vision.

To hear the full conversation, view the session recording and slides online. ASTHO supports state health departments in tackling many of the tobacco issues shared above and serves as a resource on addressing health in housing, including through a compilation of key recommendations about the role of state health agencies in smoke-free housing. Visit the Tobacco or Tobacco Webinars web page to learn more about ASTHO’s tobacco control work.


Talyah Sands

Talyah Sands, MPH, is a senior analyst of tobacco and chronic disease prevention at ASTHO. She supports initiatives to enhance the capacity of state health agency tobacco prevention programs and strengthen state systems to improve diabetes management and outcomes.