J Community Health DOI 10.1007/s10900-015-0050-0
ORIGINAL PAPER
A Smoke-Free Community Housing Policy: Changes in Reported Smoking Behaviour—Findings from Waterloo Region, Canada Ryan David Kennedy1,2 • Stephanie Ellens-Clark3 • Laurie Nagge3 Ornell Douglas2 • Cheryl Madill2 • Pamela Kaufman4,5,6
•
Ó Springer Science+Business Media New York 2015
Abstract In 2010, Waterloo Region Housing (Canada) enacted a smoke-free (SF) housing policy that made all new leases in their community-housing portfolio (2722 units) 100 % SF. Existing lease holders were ‘grandfathered’—meaning tenants could still smoke in their homes. A survey to measure support for the policy and how the policy had impacted smoking behaviour was delivered to all 2722 households in the Waterloo Region Housing portfolio in 2010 (pre-policy), 2011 and 2013 (post-policy). The proportion of households that completed the survey was 26 % (n = 717) in 2010, 25 % (n = 685) in 2011, and 23 % (n = 619) in 2013. Support for the SF housing policy was 72 % pre-enactment (2010), and increased to 78 % in 2011 and 79 % in 2013; however, most smokers do not support the policy. In 2010, prior to the SF policy, 65 % of tenants who smoke reported someone smoked inside their home; in 2013 this was reduced to approximately half of
smokers (52 %). In 2013, 44 % of smokers reported smoking outside more often than before the SF policy was enacted, almost half of tenants with a smoke-free lease (46 %) and more than a third of tenants who have a grandfathered lease (34 %) reported they smoke less since the smoke-free policy. There has been no significant change in the proportion of respondents ([50 %) who reported being exposed to second-hand smoke in their home. This SF housing policy is associated with increased reported outdoor smoking and reduced smoking. Smokefree policies may support smokers interested in quitting.
& Ryan David Kennedy [email protected]
In Canada, tobacco use remains the leading cause of preventable disease and death [1]. In 2013 it is estimated that 14.6 % of Canadians (approximately 4.2 million people) were current smokers [2]. Canadians who have low socio-economic status (SES) smoke at much higher rates [3, 4], and are disproportionately affected by the harms of tobacco use [5]. For example, in 2011 the smoking prevalence was 42 % among men with less than secondary school education, compared to a smoking prevalence of 13 % among men who had completed university [3]. Canadian smokers reporting financial stress are more likely to want to quit but less likely to try or succeed [6]. Statistics Canada reports that 12 % of youth who live in low SES households are smokers, compared with 7 % from higher income households. Researchers have described the ‘‘constellation of disadvantage’’ that faces low SES smokers, where conditions make it more likely to start
1
Department of Health, Behaviour and Society, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, 2213 Mc Elderry Street, 4th Floor, Baltimore, MD 21205, USA
2
Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON, Canada
3
Public Health and Emergency Services, Region of Waterloo, Cambridge, ON, Canada
4
Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
5
Ontario Tobacco Research Unit, University of Toronto, Toronto, ON, Canada
6
Centre for Addiction and Mental Health, Toronto, ON, Canada
Keywords Tobacco control Community housing Smoking Social housing Second-hand smoke
Introduction
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smoking, and less likely to quit [7]. Some researchers have suggested designing specific, targeted policy interventions to benefit socio-economically disadvantaged smokers [4]. Greaves et al. [7] suggest addressing the complex challenges facing low SES smokers by linking policies, including housing policies, to tobacco policy, in order to create supportive environments to achieve lower smoking rates. Given the strong inverse relationship between income and smoking, the percentage of smokers in community housing is likely to be higher than in the population as a whole. Two US studies found smoking rates in public housing to be approximately double those of the general population [8, 9]. Smoke-free housing policies are often presented as a means to protect people from exposure to drifting smoke between units [10]. A study in Massachusetts reported that buildings with smoke-free policies had lower indoor air pollution concentrations from particulate matter (PM2.5) and tobacco smoke, than buildings without any policies [11]. Voluntary smoke-free households are associated with increased quit attempts [12, 13], reduced smoking [14], and lower relapse rates [15]. In Canada almost half of surveyed smokers report their home is 100 % smoke-free (43 %) in 2011 [16]. However, low SES households are less likely to have smoke-free homes [12, 17]. The present study reports findings from the evaluation of the first smoke-free community housing policy in Ontario. The evaluation sought to measure levels of tenant support for the policy as well as changes in reported smoking behaviour, and levels of perceived social acceptability of smoking. Survey respondents who smoked were asked about their interest in cessation supports. Waterloo Region Housing Smoke-Free Policy On October 14th, 2009, The Council of the Regional Municipality of Waterloo (Ontario, Canada) approved a smoke-free policy for all new leases and transfers in regionally-owned community housing (Waterloo Region Housing). This policy came into effect on April 1, 2010 and made all new leases signed with Waterloo Region Housing (WRH), in all buildings and properties, 100 % smoke-free [18]. These restrictions are applied to all living spaces in the lease, including patios and balconies. The policy also requires people to move at least 5 m from buildings when smoking. As per Ontario law, tenants with existing leases (lease signed prior to April 1, 2010) were ‘‘grandfathered’’—meaning these tenants would still be permitted to smoke in their unit, including on the balcony or patio, indefinitely. Detailed descriptions of the development and implementation of this smoke-free housing policy has been the
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subject of a comprehensive documentation of practice and are available elsewhere [19].
Methods Sample Cross sectional survey materials were delivered in three different waves of data collection. The first wave was conducted in March 2010 (pre-policy), wave two was conducted in March 2011 (post-policy), and wave three was conducted in March 2013 (post-policy). The number of households surveyed (2722) remained constant throughout the study period. Survey Data Collection An envelope containing a cover letter that described the smoke-free housing policy, a one-page (two-sided) survey questionnaire, and a letter providing instructions in 14 different languages on how to access translation support for completing the survey was delivered by a private courier to every household in the portfolio. Recipients were asked to complete and return the survey anonymously within a month using a prepaid, addressed envelope, or by dropping it off at a WRH office. No incentives were offered. Postpolicy surveys delivered to addresses with a smoke-free lease were discretely marked with an ‘X’. All completed surveys were scanned and responses were entered into an Excel spreadsheet. The surveys distributed in 2010 and 2011 did not have space for open-ended comments; however, many respondents included unsolicited written comments on their surveys. These written comments were transcribed and entered into the Excel spreadsheet along with their tabulated response options so comments could be linked to the respondent. In the 2013 survey, open-ended survey questions were included and these solicited responses, as well as unsolicited comments from other parts of the survey, were transcribed into an Excel spreadsheet. Analysis From the survey data, response percentages are reported for each question. Non-responses (missing data) are not included in the reported response proportions. Survey responses from the Excel spreadsheet were imported into SAS version 9.3 (SAS Institute Inc., Cary, NC, USA, 2011). Chi square tests were conducted to assess differences between groups; and alpha of 0.05 was used. A stepwise regression model was run for respondents who identified as smokers using survey responses from the 2013
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wave, to understand what variables were associated with supporting the smoke-free policy. Qualitative data were used to better understand quantitative results consistent with a sequential mixed-methods approach. Written comments, both solicited and unsolicited were coded using an analysis framework that relies on a priori determined themes [20] including ‘support or nonsupport for policy’, and ‘changes in smoking behaviour’. Results from the qualitative data are presented as complete or abridged quotes, based on these themes, and reported along with respondent smoking status.
Results The proportion of households that completed the survey for each wave was 26 % (n = 717) in 2010, 25 % (n = 685) in 2011, and 23 % (n = 619) in 2013. Sample characteristics for each of the three waves are reported in Table 1 below. The proportion of respondents that reported at least one smoker in the household, and the proportion of respondents that identified as a smoker (either daily or less) fell significantly between waves. In 2010, more than 30 % of surveys were completed by a respondent from a household that had a smoker; in 2013 this was less than 20 %. Similarly, the proportion of respondents who identified as a smoker fell from 24 % in 2010 to 17 % in 2013. In 2011, approximately 11 % of survey respondents completed a survey questionnaire that had been marked with an ‘X’; indicating it had been delivered to an address
that had a smoke-free lease; this proportion increased to approximately 30 % in 2013. This is consistent with the WRH database records of the proportion of the housing portfolio that had smoke-free leases at the time of surveying (12 % in 2011, and 31 % in 2013). The proportion of households that reported that smoking is permitted inside their home dropped significantly in post-policy waves. Approximately two-thirds of households with a smoker (65 %) reported smoking was permitted inside their household prior to the smoke-free policy coming into effect in 2010; in 2013 this dropped to approximately half of households (52 %). Prior to the smoke-free policy, 10 % of households that did not have any smokers reported someone smoked inside their unit— presumably a visitor. In 2013, virtually no households with tenants who do not smoke reported smoking ever taking place in their units. In 2010 more than a quarter of households without a smoker (26 %) reported smoking taking place on their patio or balcony; this was reduced to 15 % in 2013. Homes with a smoker in the household saw little change in reported outdoor patio/balcony smoking over the study period. In 2010, 69 % of respondents who lived in a household with a smoker reported that smoking takes place at least sometimes on their patio/balcony; this decreased slightly to 66 % by 2013, which is not a significant finding. All respondents were asked to report their support for the policy, if they permitted smoking in their home, if they planned to make their home smoke-free in the future, if members of their household were exposed to second-hand smoke in their home, if they had health problems that were
Table 1 Sample characteristics and reported household smoking 2010 (pre- policy) n = 717
2011 (post-policy) n = 685
2013 (post-policy) n = 619
Test
Survey returned with an ‘X’ (Smoke-free lease)
N/A
10.5 %
29.7 %
V2(1) = 75.8, p \ 0.0001
Respondent age 65 or older
59.1 % (n = 457)
50.5 % (n = 659)
57.6 % (n = 596)
V2(2) = 9.9, p = 0.007
One adult
66.5 %
68.6 %
70.9 %
N.S.
More than one adult, no children
11.7 %
9.5 %
7.8 %
At least one adult and at least one child
21.9 % (n = 668)
21.9 % (n = 650)
21.4 % (n = 590)
At least one smoker in household Survey respondent a smoker (daily or less)
30.4 % (n = 625) 24.2 % (n = 658)
21.4 % (n = 618) 17.1 % (n = 645)
19.4 % (n = 562) 16.8 % (n = 585)
V2(2) = 23.0, p \ 0.0001 V(2)2 = 14.4, p = 0.0007
Does anyone smoke inside your home?
25.2 % (n = 675)
18.1 % (n = 657)
12.3 % (n = 586)
V2(2) = 34.5, p \ 0.0001
No smoker in the household
9.5 % (n = 432)
7.5 % (n = 478)
3.2 % (n = 445)
V2(2) = 14.9, p = 0.0006
Smoker in the household
64.6 % (n = 181)
62.2 % (n = 127)
51.5 % (n = 103)
V2(2) = 5.0, N.S.
39.2 % (n = 671)
28.6 % (n = 657)
23.5 % (n = 595)
V2(2) = 38.5, p \ 0.0001
No smoker in the household
26.1 %(n = 425)
19.7 % (n = 478)
14.4 % (n = 446)
V2(2) = 18.9, p \ 0.0001
Smoker in the household
69.0 % (n = 184)
66.9 % (n = 127)
65.7 % (n = 108)
V2(2) = 0.4, N.S.
Household composition
Does anyone smoke on your patio or balcony?a
N/A not applicable, N.S. not significant a
Caution denominators differ because of differing response options across years
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exacerbated by second-hand smoke, if they were witness to cigarette litter on the property’s grounds, and if they experienced problems with neighbours due to smoking issues. Response options and response proportions are presented in Table 2 below. Support for the policy has increased modestly since 2010; non-smokers overwhelmingly support the policy while the majority of smokers do not. In each wave, approximately a third of survey respondents who permit smoking in their households, report that they anticipate making their homes 100 % smoke-free within the next 6 months. More than half of respondents in homes that do not permit smoking, reported, in each wave, that they are exposed to second-hand smoke in their home. Approximately a quarter of respondents in each wave reported that they or a member of their household experienced problems with neighbours due to smoking issues. The proportion of respondents who see cigarette butts lying on the ground on the property where they live has decreased significantly over time from 74 % in 2010 to 65 % in 2013 (p \ 0.05). A set of questions were asked to respondents who identified as a smoker to understand how the smoke-free policy may influence smoking behaviours including changes in amount smoked, quit intentions, and interest in accessing cessation services. Questions to measure the degree to which smoking was being denormalized were
also asked. Response proportions are reported in Table 3 below; proportions are only reported for respondents who indicated that they smoke cigarettes, either daily or less. In 2011 and 2013, approximately half of respondents who smoke reported they tried to quit smoking sometime in the last year. More than one-third of respondents that smoke reported that they have cut down how much they smoke since the smoke-free policy. After the policy was enacted, a significantly larger proportion of respondents who smoke reported there are fewer places where they feel comfortable smoking. Smokers were asked if they smoke outside more often since the smoke-free policy; in 2011 39 % of respondents reported ‘Yes’ or ‘Required by lease’; in 2013 this increased slightly to 43 %. The smoke-free policy requires people to move at least 5 m from buildings when smoking. In 2011 and 2013 the majority of smokers reported that they ‘often’ or ‘always’ step away from the building when smoking. Survey responses from the 2013 survey are presented below in Table 4, based on lease status (‘grandfathered’ or smoking permitted and smoke-free lease). Comparing the response proportions between respondents with a grandfathered lease and a smoke-free lease did not produce any statistically significant differences; however, the proportions do suggest there are differences
Table 2 Policy-related variables 2010 (pre-policy)
2011 (post-policy)
2013 (post-policy)
Respondents who support the new policy that will make [made] all new leases 100 % smoke-free
Smoker Non-smoker Households, in which smoking is allowed, that plan to make the home 100 % smoke-free within the next 6 months Considered only homes that allowed smoking in the homea Respondents who reported being exposed to secondhand smoke in their home
Test N.S. (testing smokers between time periods, and non-smokers between time periods)
26.0 % (n = 154) 86.7 % (n = 481)
22.9 % (n = 109) 88.5 % (n = 520)
29.4 % (n = 92) 88.2 % (n = 473)
30.0 % (n = 223)
31.7 % (n = 161)
36.1 % (n = 108)
N.S.
52.4 % (n = 483)
55.9 % (n = 533)
53.7 % (n = 479)
N.S.
40.0 % (n = 658)
40.2 % (n = 629)
43.9 % (n = 558)
N.S.
26.6 % (n = 616)
25.1 % (n = 630)
23.2 % (n = 569)
N.S.
74.1 % (n = 640)
65.1 % (n = 630)
65.1 % (n = 562)
V2(2) = 15.4, p = 0.0004
Considered only homes that didn’t allow smoking in the homea Households with a resident who has health problems that are exacerbated by second- hand smoke Households experiencing problems with neighbours due to smoking issues Respondents who see cigarette butts lying on the ground on the property where they live
N/A not applicable, N.S. not significant Caution denominators differ because of differing response options across years
a
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J Community Health Table 3 Variables for smokers only
Smokers who tried to quit sometime during the past year
2010 (pre-policy)
2011 (post-policy)
2013 (post-policy)
Test
41.2 % (n = 148)
41.0 % (n = 100)
45.5 % (n = 77)
N.S.
38.0 %
N.S. (between 2011 and 2013)
Change in respondent’s smoking since the smoke-free policy was enacted I smoke less
N/A
36.2 %
I smoke more
3.8 %
4.4 %
No change
60.0 % (n = 105)
57.6 % (n = 92)
Smokers who plan to quit smoking in the next 6 months
23.7 % (n = 135)
27.8 % (n = 97)
31.9 % (n = 72)
N.S.
Smokers who would consider using one of the Region of Waterloo Public Health’s quit smoking programs to help them quit smoking
21.8 % (n = 78)
28.6 % (n = 70)
22.9 % (n = 48)
N.S.
Smokers who feel there are fewer and fewer places where they feel comfortable smoking
68.1 % (n = 144)
78.4 % (n = 97)
N/A
V2(1) = 3.1, N.S. (between 2010 and 2011)
Smokers who feel there are fewer and fewer places outside where they feel comfortable smoking
N/A
67.0 % (n = 97)
71.2 % (n = 73)
N.S (between 2011 and 2013)
33.0 %
23.9 %
V2(2) = 7.2, p = 0.03 (between 2011 and 2013)
60.6 % 6.4 % (n = 94)
56.3 % 19.7 % (n = 71)
Smokers who smoke outside more often since the smoke-free policy Yes
N/A
No Required to by lease
Smokers who step 5 metres away from the building when smoking outside Never
N/A
13.0 %
6.4 %
Sometimes
13.0 %
15.4 %
Often
7.0 %
20.5 %
Always
56.0 %
39.7 %
Never smoke outside
11.0 % (n = 100)
18.0 % (n = 78)
V2(4) = 12.1, p = 0.02 (between 2011 and 2013)
N/A not applicable, N.S. not significant a
Caution denominators differ because of differing response options across years
between these groups. Almost half of respondents with a smoke-free lease reported that they smoke less, compared to one-third of respondents with a grandfathered lease. More than 40 % of respondents with a new lease reported that they plan to quit in the next 6 months compared to 28 % of those with a grandfathered lease. The proportion of respondents with a smoke-free lease that reported they would consider using one of the Region of Waterloo Public Health’s (ROWPH) quit smoking programs to help them quit smoking was 35 %, more than twice the proportion of respondents with grandfathered leases (16 %). A logistic regression model was created using responses from smokers only from the 2013 survey to understand what respondent characteristics were associated with supporting the smoke-free policy. The results are presented in Table 5 below.
Respondents who reported that they smoke less since the policy was enacted were more likely to report they support the policy (OR 4.9; 95 % CI 1.1–22.8), compared to those who smoked the same or more. The respondents who reported that they plan to quit smoking in the next 6 months were also more likely to support the policy (OR 7.1; 95 % CI 1.0–52.4) compared to respondents who did not report a plan to quit. Respondents with a smoke-free lease were more likely to support the policy (OR 2.4), compared to those with grandfathered leases; however, this finding was not statistically significant. Solicited and Unsolicited Written Comments Written comments were provided by respondents in each wave; the number of unique respondents who provided
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J Community Health Table 4 Respondents who smoke, 2013 Sample—‘Grandfathered’ lease and smoke-free lease Grandfathered lease
Smoke-free lease
Test
I smoke less
34.4 %
46.4 %
N.S.
I smoke more
6.3 %
0%
Change in respondent’s smoking since the smoke-free policy was enacted
59.4 % (n = 64)
53.6 % (n = 28)
Smokers who tried to quit sometime during the past year
No change
40.4 % (n = 52)
56.0 % (n = 25)
N.S.
Smokers who plan to quit smoking in the next 6 months
28.0 % (n = 50)
40.9 % (n = 22)
N.S.
Smokers who would consider using one of the Region of Waterloo Public Health’s quit smoking programs to help them quit smoking Smokers who feel there are fewer and fewer places outside where they feel comfortable smoking
16.1 % (n = 31)
35.3 % (n = 17)
N.S.
77.6 % (n = 49)
58.3 % (n = 24)
N.S.
N/A not applicable, N.S. not significant Table 5 Odds ratios for variables predicting smokers’ support for the smoke-free policy [all variables controlled for; 2013 smokers only (n = 62)]
Supports policy
Does not support policy
New Lease
2.4 (0.5, 11.1)
1.0
Age 65 or older
3.8 (0.8, 18.9)
1.0
Smoker tried to quit in past year
0.7 (0.1, 5.6)
1.0
Smoker plans to quit in next 6 months
7.1 (1.0, 52.4)a
1.0
Smoker feels there are fewer places outside to smoke
1.1 (0.2, 5.9)
1.0
Smokes less since policy was enacted
4.9 (1.1, 22.8)a
1.0
a
Stepwise regression selected a model with just ‘‘Smoker plans to quit in next 6 months’’ and ‘‘Smokes less since policy was enacted’’
unsolicited comments was 137 in 2010 (19 %), and 117 (17 %) in 2011. In 2013 the survey included space for open-ended questions which were completed by 437 respondents (74 %). The most common theme addressed by respondents was reasons why they support or do not support the smoke-free policy. The main reasons reported were protection from exposure to second-hand smoke and the right to live in a healthy environment. One tenant explained, ‘‘Cigarette smoke is a proven carcinogenic substance; it is extremely irritating and debilitating to all of us. We are trying to live healthy lives but have no control of the smoke that we are forced to breathe in’’ (Nonsmoker 2010 survey). Many respondents explained their frustration with the limits of the smoke-free policy, specifically the issue around grandfathered tenants; many stated they wished the policy was more comprehensive and applied to all tenants. One respondent explained, ‘‘I think [the policy] should be for all tenants—not just the new ones!’’ (Non-smoker 2010). Others highlighted the inherent inequity that grandfathering created, ‘‘[the policy] should apply to everyone—even though I smoke’’ (Smoker 2011 survey), and ‘‘The smokers policy should have been banned outright for everyone regardless of how long they have lived in the apartments’’ (Non-smoker 2011 survey). Some non-smokers who reported they did not support the policy provided comments that indicated
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concerns about their neighbor’s ‘rights’ including, ‘‘I am a non-smoker but I feel if a person smokes they should have the right to do so especially in their own home’’ (Non-smoker 2010 survey). Other respondents who smoke commented on why they did not support the policy, ‘‘I strongly disagree with smoke-free policy, it affects my freedom’’ (Smoker 2011 survey); and ‘‘I am a working person and I pay top rent and I have the right to smoke if I wish’’ (Smoker 2011 survey). Several respondents wrote about the policy’s impact on smoking behaviour. One respondent explained that they support the policy because it may help them from relapsing, ‘‘I’m an ex-smoker (of 12 years) and know how difficult quitting is, therefore, I support the policy as I don’t want to be tempted to take up the lousy habit again and I do appreciate living in a smoke-free environment’’ (Nonsmoker 2013 survey). Another respondent wrote about how the policy may impact the number of cigarettes smoked by fellow tenants, ‘‘It encourages smokers to quit or at least cut down on the amount smoked. Eventually as people move out, etc., the building will become 100 % smokefree’’ (Non-smoker 2013 survey). A tenant who smokes and supports the policy described how they plan to quit, ‘‘I have COPD [chronic obstructive pulmonary disease]. My breathing is very bad sometimes. I am trying to quit smoking shortly. My unit will become a non-smoking unit’’ (Smoker 2013 survey).
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One respondent made it clear that no policy was going to influence when they quit, ‘‘I’ll quit when I decide to quit,’’ (Smoker 2013 survey). Others indicated they would like to quit and were interested in cessation supports, ‘‘I would love to see more information about what is available for trying to quit smoking’’ (Smoker 2013 survey).
Discussion The findings from this survey show that, since the smokefree policy was enacted, fewer households permit smoking inside their homes. In 2013, almost all households without a tenant who smokes (97 %), reported that smoking never takes place inside their home, up from approximately 90 % in 2010. Further, in 2013 almost half of households with a smoker (49 %) reported that their homes are 100 % smokefree, an increase from 35 % in 2010. These results are comparable to those reported by Ballor et al. [21] that found 90 % of non-smokers and 53 % of smokers did not allow smoking in their home, and may not be affected by a nonsmoking policy [21]. The smoke-free policy is also associated with reduced smoking. Almost half of respondents who have a smoke-free lease reported that they smoke less since moving into a unit with a smoke-free policy. Interestingly, more than a third of tenants with a grandfathered lease (with no smoke-free clause) also report that they smoke less since the policy was enacted. This suggests that the implementation of a smoke-free policy may be impacting community norms and support positive changes in smoking behaviour even among tenants who do not have a smoke-free lease. Further, post-policy, respondents who smoke reported that there are fewer and fewer places where they feel comfortable smoking further suggesting the policy is supporting tobaccouse denormalization. Second, there was no significant change in the proportion of respondents who reported being exposed to secondhand smoke in their home. The primary objective of many smoke-free policies is to reduce or eliminate exposure to dangerous tobacco smoke. Despite increases in reported outdoor smoking, it is clear that some tenants continue to smoke indoors and therefore it is likely that tobacco smoke will continue to drift into nearby units. Until provincial legislation is changed, landlords and community housing providers will need to rely on voluntary adoption of smokefree leases for tenants who have grandfathered leases. Third, this evaluation identified that the proportion of respondents who support the smoke-free policy has improved modestly since the policy was implemented in 2010. The majority of non-smokers support the policy, while the majority of smokers do not. Some tenants, including some who smoke, reported in their written comments that they felt the grandfathering dimension is
unfair; many respondents would prefer a smoke-free policy that is applied universally across the housing portfolio. Other respondents do not support the policy because they believe people who smoke should be allowed to smoke in their own homes. Ideas of smokers having the ‘‘freedom to smoke’’ are consistent with tobacco industry efforts in the past to build traction around the idea of ‘‘smokers’ rights’’, and presenting smokers as victims of tobacco control advocates [22]. In Canada, no federal or provincial law protects the act of smoking and therefore there is no right to smoke. This study has several limitations including the generalizability of some findings given the small sample sizes for respondents who smoke. The response rate for the survey (23 % in 2013) was lower than desired, although consistent with response rates observed in experimental studies where no incentives are provided [23], and higher than response rates recently reported by other Ontario housing authorities conducting similar household surveys (City of Ottawa survey of community housing tenants received a response rate of 21 %) [24]. With each new wave of surveying, fewer and fewer respondents identified as a smoker. This could mean that the housing portfolio has fewer smokers, or, more likely that smokers are less motivated to complete the survey. Only 19 % of the survey respondents in the 2013 survey indicated that there was at least one smoker in their household. Prior to the smoke-free policy being enacted, the Region of Waterloo Public Health estimated the proportion of adult tenants who smoked in 2009 to be approximately 30 % [25]. It will be important to continue monitoring the impact of this innovative policy to better understand how smoke-free housing policies can protect people from exposure to second-hand smoke, and further create conditions that discourage tobacco use initiation and support people to quit using tobacco. The initial findings presented here suggest that a greater proportion of respondents with a smoke-free lease are more interested in accessing cessation supports, to report they tried to quit in the last year, and that they plan to quit in the next 6 months (compared to respondents that did not have a smoke-free lease). The findings of this study provide insight into how long a smoke-free policy for new leases/transfers takes before the portfolio moves towards 100 % smoke-free leases. In the 3 years since the policy was enacted, approximately a third of the households in WRH portfolio (April 2010 and April 2013) have a lease that includes a smoke-free clause. At this rate, approximately half of households will have a smoke-free lease by the end of 2015, and more than 80 % will have a smoke-free lease by 2020, 10 years after the policy was enacted. Many factors contribute to people moving in and out of community housing, but this finding may be helpful for other communities.
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The findings from the WRH smoke-free policy evaluation suggest that smoke-free housing policies may help address health disparities that low income smokers face and that these policies may help change social norms around smoking. It will be important to understand how norms and behaviours change when most tenants who smoke have smoke-free leases. Acknowledgments The research team would like to acknowledge the residents of Waterloo Region Housing for completing the surveys. In addition the authors acknowledge the support from: Dr. Liana Nolan, Patricia Kingston, Stephen Drew, Julia Pilliar, Jonathan Mall, Mary Sehl, Anu Jhajj, Deborah Schlichter, Rob Horne, and Sharlene Sedgwick Walsh from the Region of Waterloo; Stephanie Filsinger and Matthew Grey of the Propel Centre for Population Health Impact assisted with data management. The Waterloo Region Housing smoke-free policy evaluation committee includes Irwin Peters, Kevin O’Hara, Jennifer Murdoch, Jonathan Mall, Lynda Fitzgerald, Mary Parent, Arlene Metz, Laurie Nagge, Stephanie Ellens-Clark, and Ryan David Kennedy. Past members include Bob Theisz, Carol Markow, Ann Derry, Janine Toms, and Sherry White. Conflict of interest declare.
The authors have no competing interests to
Funding This research was funded by the Region of Waterloo (Waterloo Region Housing, Region of Waterloo Public Health and Emergency Services, and Region of Waterloo Legal Services). The Propel Centre for Population Health Impact is supported by a Major Program Grant from the Canadian Cancer Society Research Initiative (CCSRI Grant #701019).
References 1. Statistics Canada. (2012). Health at a glance: Current smoking trends. Statistics Canada Catalogue no. 82-624-X Web site. Retrieved from http://www.statcan.gc.ca/pub/82-624-x/2012001/ article/11676-eng.htm. Updated 19 June 2012. 2. Reid, J., Hammond, D., Rynard, V., & Burkhalter, R. (2015). Tobacco use in Canada: Patterns and trends (2015th ed.). Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo. 3. Reid, J. L., Hammond, D., Boudreau, C., Fong, G. T., & Siahpush, M. (2010). Socioeconomic disparities in quit intentions, quit attempts, and smoking abstinence among smokers in four western countries: Findings from the International Tobacco Control Four Country Survey. Nicotine and Tobacco Research, 12(Suppl), S20–S33. doi:10.1093/ntr/ntq051. 4. Reid, J. L., Hammond, D., & Driezen, P. (2010). Socio-economic status and smoking in Canada, 1999–2006: Has there been any progress on disparities in tobacco use? Canadian Journal of Public Health, 101(1):73–78. http://www.ncbi.nlm.nih.gov/pubmed/20364543. 5. Barbeau, E. M., Krieger, N., & Soobader, M. J. (2004). Working class matters: Socioeconomic disadvantage, race/ethnicity, gender, and smoking in NHIS 2000. American Journal of Public Health, 94(2), 269–278. doi:10.2105/ajph.94.2.269. 6. Siahpush, M., Yong, H. H., Borland, R., Reid, J. L., & Hammond, D. (2009). Smokers with financial stress are more likely to want to quit but less likely to try or succeed: Findings from the International Tobacco Control (ITC) Four Country Survey. Addiction, 104(8), 1382–1390. doi:10.1111/j.1360-0443.2009. 02599.x.
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7. Greaves, L., Vallone, D., & Velicer, W. (2006). Special effects: Tobacco policies and low socioeconomic status girls and women. Epidemiology and Community Health, 60(Suppl. 2), ii1–ii2. doi:10.1136/jech.2006.052480. 8. Digenis-Bury, E. C., Brooks, D. R., Chen, L., et al. (2008). Use of a population-based survey to describe the health of Boston Public Housing residents. American Journal of Public Health, 98(1), 85–91. doi:10.2105/AJPH.2006.094912. 9. Hood, N. E., Ferketich, A. K., Klein, E. G., Wewers, M. E., & Pirie, P. (2013). Smoking behaviours and cessation interests among multiunit subsidized housing tenants, Columbus, Ohio, 2011. Preventing Chronic Disease, 10, E108. doi:10.5888/pcd10.120302. 10. King, B. A., Travers, M. J., Cummings, K. M., Mahoney, M. C., & Hyland, A. J. (2010). Second-hand smoke transfer in multiunit housing. Nicotine and Tobacco Research, 12(11), 1133–1141. doi:10.1093/ntr/ntq162. 11. Russo, E. T., Hulse, T. E., Adamkiewicz, G., et al. (2014). Comparison of indoor air quality in smoke-permitted and smokefree multiunit housing: Findings from the Boston Housing Authority. Nicotine and Tobacco Research,. doi:10.1093/ntr/ ntu146. 12. Borland R., Yong, H. H., Cummings, K. M., Hyland, A., Anderson, S., & Fong, G. T. (2006). Determinants and consequences of smoke-free homes: Findings from the International Tobacco Control (ITC) Four Country Survey. Tobacco Control, 15(Suppl. 3):iii42–iii50. Retrieved from http://www.ncbi.nlm.nih. gov/pubmed/16754946. 13. Pizacani, B. A., Martin, D. P., Stark, M. J., Koepsel, T. D., Thompson, B., & Diehr, P. (2004). A prospective study of household smoking bans and subsequent cessation related behaviour: The role of stage of change. Tobacco Control, 13(1), 23. doi:10.1136/tc.2003.003038. 14. Mills, A. I., Messer, K., Gilpin, E. A., & Pierce, J. P. (2009). The effect of smoke-free homes on adult smoking behaviour: A review. Nicotine and Tobacco Research, 11(10), 1131–1141. doi:10.1093/ntr/ntp122. 15. Hyland, A., Higbee, C., Travers, M. J., et al. (2009). Smoke-free homes and smoking cessation and relapse in a longitudinal population of adults. Nicotine and Tobacco Research, 11(6), 614–618. doi:10.1093/ntr/ntp022. 16. ITC Project. (2013). ITC Canada National report. Findings from the Wave 1 to 8 surveys, 2002–2011. University of Waterloo, Waterloo, Ontario Canada. Retrieved from http://www.itcproject. org/files/ITC_Canada_Report-English-Dec62013-web.pdf. 17. Vijayaraghavan, M., Messer, K., White, M. M., & Pierce, J. P. (2013). The effectiveness of cigarette price and smoke-free homes on low-income smokers in the United States. American Journal of Public Health, 103(12), 2276–2283. doi:10.2105/ AJPH.2013.301300. 18. Regional Municipality of Waterloo Consolidated Council Agenda. (2009). Delegations. Community services committee minutes. Retrieved from http://www.regionofwaterloo.ca/en/ regionalGovernment/resources/CC2009-1014.pdf. 19. McCammon-Tripp, L., & Stich, C. (2010). Region of Waterloo Public Health, Waterloo Region Housing Smoke-Free Multi-Unit Dwelling Committee. The development of a smoke-free housing policy in the Region of Waterloo: Key success factors and lessons learned from practice. Toronto, Canada: Program Training and Consultation Centre, LEARN Project. Retrieved from https://www.ptcc-cfc.on.ca/common/pages/UserFile.aspx?fileId= 104038. 20. Ritchie, J., & Lewis, J. (2003). Qualitative research practice—A guide for social science students and researchers. Retrieved from https://mthoyibi.files.wordpress.com/2011/10/qualitative-researchpractice_a-guide-for-social-science-students-and-researchers_janeritchie-and-jane-lewis-eds_20031.pdf.
J Community Health 21. Ballor, D. L., Henson, H., & MacGuire, K. (2013). Support for no-smoking policies among residents of public multiunit housing differs by smoking status. Journal of Community Health, 38, 1074–1080. doi:10.1007/s10900-013-9716-7. 22. Smith, E. A., & Malone, R. E. (2007). We will speak as the smoker: The tobacco industry’s smokers’ rights groups. European Journal of Public Health, 17(3), 306–313. doi:10.1093/eur pub/ckl244. 23. Larson, P. D., & Chow, G. (2002). Total cost/response rate tradeoffs in mail survey research: Impact of follow-up mailings and monetary incentives. Industry Marketing Management, 32(7):
533–537. Retrieved from http://www.sciencedirect.com/science/ journal/00198501/32/7. 24. Ottawa Community Housing. (2013). Ottawa community housing becoming smoke-free. Retrieved from http://www.och.ca/site/ images/stories/downloads/pressreleases/pr_nosmoking.pdf. 25. Region of Waterloo Public Health & Planning, Housing and Community Services. (2009). Report PH 09-046/P-09-073. Smoke-free policy for new leases and transfers in regionally owned community housing. Retrieved from http://www.regio nofwaterloo.ca/en/regionalGovernment/resources/SA2009-1006. pdf.
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ORIGINAL PAPER
A Smoke-Free Community Housing Policy: Changes in Reported Smoking Behaviour—Findings from Waterloo Region, Canada Ryan David Kennedy1,2 • Stephanie Ellens-Clark3 • Laurie Nagge3 Ornell Douglas2 • Cheryl Madill2 • Pamela Kaufman4,5,6
•
Ó Springer Science+Business Media New York 2015
Abstract In 2010, Waterloo Region Housing (Canada) enacted a smoke-free (SF) housing policy that made all new leases in their community-housing portfolio (2722 units) 100 % SF. Existing lease holders were ‘grandfathered’—meaning tenants could still smoke in their homes. A survey to measure support for the policy and how the policy had impacted smoking behaviour was delivered to all 2722 households in the Waterloo Region Housing portfolio in 2010 (pre-policy), 2011 and 2013 (post-policy). The proportion of households that completed the survey was 26 % (n = 717) in 2010, 25 % (n = 685) in 2011, and 23 % (n = 619) in 2013. Support for the SF housing policy was 72 % pre-enactment (2010), and increased to 78 % in 2011 and 79 % in 2013; however, most smokers do not support the policy. In 2010, prior to the SF policy, 65 % of tenants who smoke reported someone smoked inside their home; in 2013 this was reduced to approximately half of
smokers (52 %). In 2013, 44 % of smokers reported smoking outside more often than before the SF policy was enacted, almost half of tenants with a smoke-free lease (46 %) and more than a third of tenants who have a grandfathered lease (34 %) reported they smoke less since the smoke-free policy. There has been no significant change in the proportion of respondents ([50 %) who reported being exposed to second-hand smoke in their home. This SF housing policy is associated with increased reported outdoor smoking and reduced smoking. Smokefree policies may support smokers interested in quitting.
& Ryan David Kennedy [email protected]
In Canada, tobacco use remains the leading cause of preventable disease and death [1]. In 2013 it is estimated that 14.6 % of Canadians (approximately 4.2 million people) were current smokers [2]. Canadians who have low socio-economic status (SES) smoke at much higher rates [3, 4], and are disproportionately affected by the harms of tobacco use [5]. For example, in 2011 the smoking prevalence was 42 % among men with less than secondary school education, compared to a smoking prevalence of 13 % among men who had completed university [3]. Canadian smokers reporting financial stress are more likely to want to quit but less likely to try or succeed [6]. Statistics Canada reports that 12 % of youth who live in low SES households are smokers, compared with 7 % from higher income households. Researchers have described the ‘‘constellation of disadvantage’’ that faces low SES smokers, where conditions make it more likely to start
1
Department of Health, Behaviour and Society, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, 2213 Mc Elderry Street, 4th Floor, Baltimore, MD 21205, USA
2
Propel Centre for Population Health Impact, University of Waterloo, Waterloo, ON, Canada
3
Public Health and Emergency Services, Region of Waterloo, Cambridge, ON, Canada
4
Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
5
Ontario Tobacco Research Unit, University of Toronto, Toronto, ON, Canada
6
Centre for Addiction and Mental Health, Toronto, ON, Canada
Keywords Tobacco control Community housing Smoking Social housing Second-hand smoke
Introduction
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smoking, and less likely to quit [7]. Some researchers have suggested designing specific, targeted policy interventions to benefit socio-economically disadvantaged smokers [4]. Greaves et al. [7] suggest addressing the complex challenges facing low SES smokers by linking policies, including housing policies, to tobacco policy, in order to create supportive environments to achieve lower smoking rates. Given the strong inverse relationship between income and smoking, the percentage of smokers in community housing is likely to be higher than in the population as a whole. Two US studies found smoking rates in public housing to be approximately double those of the general population [8, 9]. Smoke-free housing policies are often presented as a means to protect people from exposure to drifting smoke between units [10]. A study in Massachusetts reported that buildings with smoke-free policies had lower indoor air pollution concentrations from particulate matter (PM2.5) and tobacco smoke, than buildings without any policies [11]. Voluntary smoke-free households are associated with increased quit attempts [12, 13], reduced smoking [14], and lower relapse rates [15]. In Canada almost half of surveyed smokers report their home is 100 % smoke-free (43 %) in 2011 [16]. However, low SES households are less likely to have smoke-free homes [12, 17]. The present study reports findings from the evaluation of the first smoke-free community housing policy in Ontario. The evaluation sought to measure levels of tenant support for the policy as well as changes in reported smoking behaviour, and levels of perceived social acceptability of smoking. Survey respondents who smoked were asked about their interest in cessation supports. Waterloo Region Housing Smoke-Free Policy On October 14th, 2009, The Council of the Regional Municipality of Waterloo (Ontario, Canada) approved a smoke-free policy for all new leases and transfers in regionally-owned community housing (Waterloo Region Housing). This policy came into effect on April 1, 2010 and made all new leases signed with Waterloo Region Housing (WRH), in all buildings and properties, 100 % smoke-free [18]. These restrictions are applied to all living spaces in the lease, including patios and balconies. The policy also requires people to move at least 5 m from buildings when smoking. As per Ontario law, tenants with existing leases (lease signed prior to April 1, 2010) were ‘‘grandfathered’’—meaning these tenants would still be permitted to smoke in their unit, including on the balcony or patio, indefinitely. Detailed descriptions of the development and implementation of this smoke-free housing policy has been the
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subject of a comprehensive documentation of practice and are available elsewhere [19].
Methods Sample Cross sectional survey materials were delivered in three different waves of data collection. The first wave was conducted in March 2010 (pre-policy), wave two was conducted in March 2011 (post-policy), and wave three was conducted in March 2013 (post-policy). The number of households surveyed (2722) remained constant throughout the study period. Survey Data Collection An envelope containing a cover letter that described the smoke-free housing policy, a one-page (two-sided) survey questionnaire, and a letter providing instructions in 14 different languages on how to access translation support for completing the survey was delivered by a private courier to every household in the portfolio. Recipients were asked to complete and return the survey anonymously within a month using a prepaid, addressed envelope, or by dropping it off at a WRH office. No incentives were offered. Postpolicy surveys delivered to addresses with a smoke-free lease were discretely marked with an ‘X’. All completed surveys were scanned and responses were entered into an Excel spreadsheet. The surveys distributed in 2010 and 2011 did not have space for open-ended comments; however, many respondents included unsolicited written comments on their surveys. These written comments were transcribed and entered into the Excel spreadsheet along with their tabulated response options so comments could be linked to the respondent. In the 2013 survey, open-ended survey questions were included and these solicited responses, as well as unsolicited comments from other parts of the survey, were transcribed into an Excel spreadsheet. Analysis From the survey data, response percentages are reported for each question. Non-responses (missing data) are not included in the reported response proportions. Survey responses from the Excel spreadsheet were imported into SAS version 9.3 (SAS Institute Inc., Cary, NC, USA, 2011). Chi square tests were conducted to assess differences between groups; and alpha of 0.05 was used. A stepwise regression model was run for respondents who identified as smokers using survey responses from the 2013
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wave, to understand what variables were associated with supporting the smoke-free policy. Qualitative data were used to better understand quantitative results consistent with a sequential mixed-methods approach. Written comments, both solicited and unsolicited were coded using an analysis framework that relies on a priori determined themes [20] including ‘support or nonsupport for policy’, and ‘changes in smoking behaviour’. Results from the qualitative data are presented as complete or abridged quotes, based on these themes, and reported along with respondent smoking status.
Results The proportion of households that completed the survey for each wave was 26 % (n = 717) in 2010, 25 % (n = 685) in 2011, and 23 % (n = 619) in 2013. Sample characteristics for each of the three waves are reported in Table 1 below. The proportion of respondents that reported at least one smoker in the household, and the proportion of respondents that identified as a smoker (either daily or less) fell significantly between waves. In 2010, more than 30 % of surveys were completed by a respondent from a household that had a smoker; in 2013 this was less than 20 %. Similarly, the proportion of respondents who identified as a smoker fell from 24 % in 2010 to 17 % in 2013. In 2011, approximately 11 % of survey respondents completed a survey questionnaire that had been marked with an ‘X’; indicating it had been delivered to an address
that had a smoke-free lease; this proportion increased to approximately 30 % in 2013. This is consistent with the WRH database records of the proportion of the housing portfolio that had smoke-free leases at the time of surveying (12 % in 2011, and 31 % in 2013). The proportion of households that reported that smoking is permitted inside their home dropped significantly in post-policy waves. Approximately two-thirds of households with a smoker (65 %) reported smoking was permitted inside their household prior to the smoke-free policy coming into effect in 2010; in 2013 this dropped to approximately half of households (52 %). Prior to the smoke-free policy, 10 % of households that did not have any smokers reported someone smoked inside their unit— presumably a visitor. In 2013, virtually no households with tenants who do not smoke reported smoking ever taking place in their units. In 2010 more than a quarter of households without a smoker (26 %) reported smoking taking place on their patio or balcony; this was reduced to 15 % in 2013. Homes with a smoker in the household saw little change in reported outdoor patio/balcony smoking over the study period. In 2010, 69 % of respondents who lived in a household with a smoker reported that smoking takes place at least sometimes on their patio/balcony; this decreased slightly to 66 % by 2013, which is not a significant finding. All respondents were asked to report their support for the policy, if they permitted smoking in their home, if they planned to make their home smoke-free in the future, if members of their household were exposed to second-hand smoke in their home, if they had health problems that were
Table 1 Sample characteristics and reported household smoking 2010 (pre- policy) n = 717
2011 (post-policy) n = 685
2013 (post-policy) n = 619
Test
Survey returned with an ‘X’ (Smoke-free lease)
N/A
10.5 %
29.7 %
V2(1) = 75.8, p \ 0.0001
Respondent age 65 or older
59.1 % (n = 457)
50.5 % (n = 659)
57.6 % (n = 596)
V2(2) = 9.9, p = 0.007
One adult
66.5 %
68.6 %
70.9 %
N.S.
More than one adult, no children
11.7 %
9.5 %
7.8 %
At least one adult and at least one child
21.9 % (n = 668)
21.9 % (n = 650)
21.4 % (n = 590)
At least one smoker in household Survey respondent a smoker (daily or less)
30.4 % (n = 625) 24.2 % (n = 658)
21.4 % (n = 618) 17.1 % (n = 645)
19.4 % (n = 562) 16.8 % (n = 585)
V2(2) = 23.0, p \ 0.0001 V(2)2 = 14.4, p = 0.0007
Does anyone smoke inside your home?
25.2 % (n = 675)
18.1 % (n = 657)
12.3 % (n = 586)
V2(2) = 34.5, p \ 0.0001
No smoker in the household
9.5 % (n = 432)
7.5 % (n = 478)
3.2 % (n = 445)
V2(2) = 14.9, p = 0.0006
Smoker in the household
64.6 % (n = 181)
62.2 % (n = 127)
51.5 % (n = 103)
V2(2) = 5.0, N.S.
39.2 % (n = 671)
28.6 % (n = 657)
23.5 % (n = 595)
V2(2) = 38.5, p \ 0.0001
No smoker in the household
26.1 %(n = 425)
19.7 % (n = 478)
14.4 % (n = 446)
V2(2) = 18.9, p \ 0.0001
Smoker in the household
69.0 % (n = 184)
66.9 % (n = 127)
65.7 % (n = 108)
V2(2) = 0.4, N.S.
Household composition
Does anyone smoke on your patio or balcony?a
N/A not applicable, N.S. not significant a
Caution denominators differ because of differing response options across years
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exacerbated by second-hand smoke, if they were witness to cigarette litter on the property’s grounds, and if they experienced problems with neighbours due to smoking issues. Response options and response proportions are presented in Table 2 below. Support for the policy has increased modestly since 2010; non-smokers overwhelmingly support the policy while the majority of smokers do not. In each wave, approximately a third of survey respondents who permit smoking in their households, report that they anticipate making their homes 100 % smoke-free within the next 6 months. More than half of respondents in homes that do not permit smoking, reported, in each wave, that they are exposed to second-hand smoke in their home. Approximately a quarter of respondents in each wave reported that they or a member of their household experienced problems with neighbours due to smoking issues. The proportion of respondents who see cigarette butts lying on the ground on the property where they live has decreased significantly over time from 74 % in 2010 to 65 % in 2013 (p \ 0.05). A set of questions were asked to respondents who identified as a smoker to understand how the smoke-free policy may influence smoking behaviours including changes in amount smoked, quit intentions, and interest in accessing cessation services. Questions to measure the degree to which smoking was being denormalized were
also asked. Response proportions are reported in Table 3 below; proportions are only reported for respondents who indicated that they smoke cigarettes, either daily or less. In 2011 and 2013, approximately half of respondents who smoke reported they tried to quit smoking sometime in the last year. More than one-third of respondents that smoke reported that they have cut down how much they smoke since the smoke-free policy. After the policy was enacted, a significantly larger proportion of respondents who smoke reported there are fewer places where they feel comfortable smoking. Smokers were asked if they smoke outside more often since the smoke-free policy; in 2011 39 % of respondents reported ‘Yes’ or ‘Required by lease’; in 2013 this increased slightly to 43 %. The smoke-free policy requires people to move at least 5 m from buildings when smoking. In 2011 and 2013 the majority of smokers reported that they ‘often’ or ‘always’ step away from the building when smoking. Survey responses from the 2013 survey are presented below in Table 4, based on lease status (‘grandfathered’ or smoking permitted and smoke-free lease). Comparing the response proportions between respondents with a grandfathered lease and a smoke-free lease did not produce any statistically significant differences; however, the proportions do suggest there are differences
Table 2 Policy-related variables 2010 (pre-policy)
2011 (post-policy)
2013 (post-policy)
Respondents who support the new policy that will make [made] all new leases 100 % smoke-free
Smoker Non-smoker Households, in which smoking is allowed, that plan to make the home 100 % smoke-free within the next 6 months Considered only homes that allowed smoking in the homea Respondents who reported being exposed to secondhand smoke in their home
Test N.S. (testing smokers between time periods, and non-smokers between time periods)
26.0 % (n = 154) 86.7 % (n = 481)
22.9 % (n = 109) 88.5 % (n = 520)
29.4 % (n = 92) 88.2 % (n = 473)
30.0 % (n = 223)
31.7 % (n = 161)
36.1 % (n = 108)
N.S.
52.4 % (n = 483)
55.9 % (n = 533)
53.7 % (n = 479)
N.S.
40.0 % (n = 658)
40.2 % (n = 629)
43.9 % (n = 558)
N.S.
26.6 % (n = 616)
25.1 % (n = 630)
23.2 % (n = 569)
N.S.
74.1 % (n = 640)
65.1 % (n = 630)
65.1 % (n = 562)
V2(2) = 15.4, p = 0.0004
Considered only homes that didn’t allow smoking in the homea Households with a resident who has health problems that are exacerbated by second- hand smoke Households experiencing problems with neighbours due to smoking issues Respondents who see cigarette butts lying on the ground on the property where they live
N/A not applicable, N.S. not significant Caution denominators differ because of differing response options across years
a
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J Community Health Table 3 Variables for smokers only
Smokers who tried to quit sometime during the past year
2010 (pre-policy)
2011 (post-policy)
2013 (post-policy)
Test
41.2 % (n = 148)
41.0 % (n = 100)
45.5 % (n = 77)
N.S.
38.0 %
N.S. (between 2011 and 2013)
Change in respondent’s smoking since the smoke-free policy was enacted I smoke less
N/A
36.2 %
I smoke more
3.8 %
4.4 %
No change
60.0 % (n = 105)
57.6 % (n = 92)
Smokers who plan to quit smoking in the next 6 months
23.7 % (n = 135)
27.8 % (n = 97)
31.9 % (n = 72)
N.S.
Smokers who would consider using one of the Region of Waterloo Public Health’s quit smoking programs to help them quit smoking
21.8 % (n = 78)
28.6 % (n = 70)
22.9 % (n = 48)
N.S.
Smokers who feel there are fewer and fewer places where they feel comfortable smoking
68.1 % (n = 144)
78.4 % (n = 97)
N/A
V2(1) = 3.1, N.S. (between 2010 and 2011)
Smokers who feel there are fewer and fewer places outside where they feel comfortable smoking
N/A
67.0 % (n = 97)
71.2 % (n = 73)
N.S (between 2011 and 2013)
33.0 %
23.9 %
V2(2) = 7.2, p = 0.03 (between 2011 and 2013)
60.6 % 6.4 % (n = 94)
56.3 % 19.7 % (n = 71)
Smokers who smoke outside more often since the smoke-free policy Yes
N/A
No Required to by lease
Smokers who step 5 metres away from the building when smoking outside Never
N/A
13.0 %
6.4 %
Sometimes
13.0 %
15.4 %
Often
7.0 %
20.5 %
Always
56.0 %
39.7 %
Never smoke outside
11.0 % (n = 100)
18.0 % (n = 78)
V2(4) = 12.1, p = 0.02 (between 2011 and 2013)
N/A not applicable, N.S. not significant a
Caution denominators differ because of differing response options across years
between these groups. Almost half of respondents with a smoke-free lease reported that they smoke less, compared to one-third of respondents with a grandfathered lease. More than 40 % of respondents with a new lease reported that they plan to quit in the next 6 months compared to 28 % of those with a grandfathered lease. The proportion of respondents with a smoke-free lease that reported they would consider using one of the Region of Waterloo Public Health’s (ROWPH) quit smoking programs to help them quit smoking was 35 %, more than twice the proportion of respondents with grandfathered leases (16 %). A logistic regression model was created using responses from smokers only from the 2013 survey to understand what respondent characteristics were associated with supporting the smoke-free policy. The results are presented in Table 5 below.
Respondents who reported that they smoke less since the policy was enacted were more likely to report they support the policy (OR 4.9; 95 % CI 1.1–22.8), compared to those who smoked the same or more. The respondents who reported that they plan to quit smoking in the next 6 months were also more likely to support the policy (OR 7.1; 95 % CI 1.0–52.4) compared to respondents who did not report a plan to quit. Respondents with a smoke-free lease were more likely to support the policy (OR 2.4), compared to those with grandfathered leases; however, this finding was not statistically significant. Solicited and Unsolicited Written Comments Written comments were provided by respondents in each wave; the number of unique respondents who provided
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J Community Health Table 4 Respondents who smoke, 2013 Sample—‘Grandfathered’ lease and smoke-free lease Grandfathered lease
Smoke-free lease
Test
I smoke less
34.4 %
46.4 %
N.S.
I smoke more
6.3 %
0%
Change in respondent’s smoking since the smoke-free policy was enacted
59.4 % (n = 64)
53.6 % (n = 28)
Smokers who tried to quit sometime during the past year
No change
40.4 % (n = 52)
56.0 % (n = 25)
N.S.
Smokers who plan to quit smoking in the next 6 months
28.0 % (n = 50)
40.9 % (n = 22)
N.S.
Smokers who would consider using one of the Region of Waterloo Public Health’s quit smoking programs to help them quit smoking Smokers who feel there are fewer and fewer places outside where they feel comfortable smoking
16.1 % (n = 31)
35.3 % (n = 17)
N.S.
77.6 % (n = 49)
58.3 % (n = 24)
N.S.
N/A not applicable, N.S. not significant Table 5 Odds ratios for variables predicting smokers’ support for the smoke-free policy [all variables controlled for; 2013 smokers only (n = 62)]
Supports policy
Does not support policy
New Lease
2.4 (0.5, 11.1)
1.0
Age 65 or older
3.8 (0.8, 18.9)
1.0
Smoker tried to quit in past year
0.7 (0.1, 5.6)
1.0
Smoker plans to quit in next 6 months
7.1 (1.0, 52.4)a
1.0
Smoker feels there are fewer places outside to smoke
1.1 (0.2, 5.9)
1.0
Smokes less since policy was enacted
4.9 (1.1, 22.8)a
1.0
a
Stepwise regression selected a model with just ‘‘Smoker plans to quit in next 6 months’’ and ‘‘Smokes less since policy was enacted’’
unsolicited comments was 137 in 2010 (19 %), and 117 (17 %) in 2011. In 2013 the survey included space for open-ended questions which were completed by 437 respondents (74 %). The most common theme addressed by respondents was reasons why they support or do not support the smoke-free policy. The main reasons reported were protection from exposure to second-hand smoke and the right to live in a healthy environment. One tenant explained, ‘‘Cigarette smoke is a proven carcinogenic substance; it is extremely irritating and debilitating to all of us. We are trying to live healthy lives but have no control of the smoke that we are forced to breathe in’’ (Nonsmoker 2010 survey). Many respondents explained their frustration with the limits of the smoke-free policy, specifically the issue around grandfathered tenants; many stated they wished the policy was more comprehensive and applied to all tenants. One respondent explained, ‘‘I think [the policy] should be for all tenants—not just the new ones!’’ (Non-smoker 2010). Others highlighted the inherent inequity that grandfathering created, ‘‘[the policy] should apply to everyone—even though I smoke’’ (Smoker 2011 survey), and ‘‘The smokers policy should have been banned outright for everyone regardless of how long they have lived in the apartments’’ (Non-smoker 2011 survey). Some non-smokers who reported they did not support the policy provided comments that indicated
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concerns about their neighbor’s ‘rights’ including, ‘‘I am a non-smoker but I feel if a person smokes they should have the right to do so especially in their own home’’ (Non-smoker 2010 survey). Other respondents who smoke commented on why they did not support the policy, ‘‘I strongly disagree with smoke-free policy, it affects my freedom’’ (Smoker 2011 survey); and ‘‘I am a working person and I pay top rent and I have the right to smoke if I wish’’ (Smoker 2011 survey). Several respondents wrote about the policy’s impact on smoking behaviour. One respondent explained that they support the policy because it may help them from relapsing, ‘‘I’m an ex-smoker (of 12 years) and know how difficult quitting is, therefore, I support the policy as I don’t want to be tempted to take up the lousy habit again and I do appreciate living in a smoke-free environment’’ (Nonsmoker 2013 survey). Another respondent wrote about how the policy may impact the number of cigarettes smoked by fellow tenants, ‘‘It encourages smokers to quit or at least cut down on the amount smoked. Eventually as people move out, etc., the building will become 100 % smokefree’’ (Non-smoker 2013 survey). A tenant who smokes and supports the policy described how they plan to quit, ‘‘I have COPD [chronic obstructive pulmonary disease]. My breathing is very bad sometimes. I am trying to quit smoking shortly. My unit will become a non-smoking unit’’ (Smoker 2013 survey).
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One respondent made it clear that no policy was going to influence when they quit, ‘‘I’ll quit when I decide to quit,’’ (Smoker 2013 survey). Others indicated they would like to quit and were interested in cessation supports, ‘‘I would love to see more information about what is available for trying to quit smoking’’ (Smoker 2013 survey).
Discussion The findings from this survey show that, since the smokefree policy was enacted, fewer households permit smoking inside their homes. In 2013, almost all households without a tenant who smokes (97 %), reported that smoking never takes place inside their home, up from approximately 90 % in 2010. Further, in 2013 almost half of households with a smoker (49 %) reported that their homes are 100 % smokefree, an increase from 35 % in 2010. These results are comparable to those reported by Ballor et al. [21] that found 90 % of non-smokers and 53 % of smokers did not allow smoking in their home, and may not be affected by a nonsmoking policy [21]. The smoke-free policy is also associated with reduced smoking. Almost half of respondents who have a smoke-free lease reported that they smoke less since moving into a unit with a smoke-free policy. Interestingly, more than a third of tenants with a grandfathered lease (with no smoke-free clause) also report that they smoke less since the policy was enacted. This suggests that the implementation of a smoke-free policy may be impacting community norms and support positive changes in smoking behaviour even among tenants who do not have a smoke-free lease. Further, post-policy, respondents who smoke reported that there are fewer and fewer places where they feel comfortable smoking further suggesting the policy is supporting tobaccouse denormalization. Second, there was no significant change in the proportion of respondents who reported being exposed to secondhand smoke in their home. The primary objective of many smoke-free policies is to reduce or eliminate exposure to dangerous tobacco smoke. Despite increases in reported outdoor smoking, it is clear that some tenants continue to smoke indoors and therefore it is likely that tobacco smoke will continue to drift into nearby units. Until provincial legislation is changed, landlords and community housing providers will need to rely on voluntary adoption of smokefree leases for tenants who have grandfathered leases. Third, this evaluation identified that the proportion of respondents who support the smoke-free policy has improved modestly since the policy was implemented in 2010. The majority of non-smokers support the policy, while the majority of smokers do not. Some tenants, including some who smoke, reported in their written comments that they felt the grandfathering dimension is
unfair; many respondents would prefer a smoke-free policy that is applied universally across the housing portfolio. Other respondents do not support the policy because they believe people who smoke should be allowed to smoke in their own homes. Ideas of smokers having the ‘‘freedom to smoke’’ are consistent with tobacco industry efforts in the past to build traction around the idea of ‘‘smokers’ rights’’, and presenting smokers as victims of tobacco control advocates [22]. In Canada, no federal or provincial law protects the act of smoking and therefore there is no right to smoke. This study has several limitations including the generalizability of some findings given the small sample sizes for respondents who smoke. The response rate for the survey (23 % in 2013) was lower than desired, although consistent with response rates observed in experimental studies where no incentives are provided [23], and higher than response rates recently reported by other Ontario housing authorities conducting similar household surveys (City of Ottawa survey of community housing tenants received a response rate of 21 %) [24]. With each new wave of surveying, fewer and fewer respondents identified as a smoker. This could mean that the housing portfolio has fewer smokers, or, more likely that smokers are less motivated to complete the survey. Only 19 % of the survey respondents in the 2013 survey indicated that there was at least one smoker in their household. Prior to the smoke-free policy being enacted, the Region of Waterloo Public Health estimated the proportion of adult tenants who smoked in 2009 to be approximately 30 % [25]. It will be important to continue monitoring the impact of this innovative policy to better understand how smoke-free housing policies can protect people from exposure to second-hand smoke, and further create conditions that discourage tobacco use initiation and support people to quit using tobacco. The initial findings presented here suggest that a greater proportion of respondents with a smoke-free lease are more interested in accessing cessation supports, to report they tried to quit in the last year, and that they plan to quit in the next 6 months (compared to respondents that did not have a smoke-free lease). The findings of this study provide insight into how long a smoke-free policy for new leases/transfers takes before the portfolio moves towards 100 % smoke-free leases. In the 3 years since the policy was enacted, approximately a third of the households in WRH portfolio (April 2010 and April 2013) have a lease that includes a smoke-free clause. At this rate, approximately half of households will have a smoke-free lease by the end of 2015, and more than 80 % will have a smoke-free lease by 2020, 10 years after the policy was enacted. Many factors contribute to people moving in and out of community housing, but this finding may be helpful for other communities.
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The findings from the WRH smoke-free policy evaluation suggest that smoke-free housing policies may help address health disparities that low income smokers face and that these policies may help change social norms around smoking. It will be important to understand how norms and behaviours change when most tenants who smoke have smoke-free leases. Acknowledgments The research team would like to acknowledge the residents of Waterloo Region Housing for completing the surveys. In addition the authors acknowledge the support from: Dr. Liana Nolan, Patricia Kingston, Stephen Drew, Julia Pilliar, Jonathan Mall, Mary Sehl, Anu Jhajj, Deborah Schlichter, Rob Horne, and Sharlene Sedgwick Walsh from the Region of Waterloo; Stephanie Filsinger and Matthew Grey of the Propel Centre for Population Health Impact assisted with data management. The Waterloo Region Housing smoke-free policy evaluation committee includes Irwin Peters, Kevin O’Hara, Jennifer Murdoch, Jonathan Mall, Lynda Fitzgerald, Mary Parent, Arlene Metz, Laurie Nagge, Stephanie Ellens-Clark, and Ryan David Kennedy. Past members include Bob Theisz, Carol Markow, Ann Derry, Janine Toms, and Sherry White. Conflict of interest declare.
The authors have no competing interests to
Funding This research was funded by the Region of Waterloo (Waterloo Region Housing, Region of Waterloo Public Health and Emergency Services, and Region of Waterloo Legal Services). The Propel Centre for Population Health Impact is supported by a Major Program Grant from the Canadian Cancer Society Research Initiative (CCSRI Grant #701019).
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