Jarron Saint Onge: US ban on smoking in public housing—policymakers must take into account the potential to harm

jarron-saint-ongeWhen the US Housing and Urban Development Department (HUD) recently announced it will require all public housing developments in the US to go smoke free, federal officials were correct to attack a significant and pervasive problem—smoking exposure among low income Americans.

However, it’s less clear if their attempted solution is the best and most effective way to solve this problem.

The goals are to reduce secondhand smoke exposure, aid smokers to quit, as well as to eliminate preventable fires, reduce the renovation costs associated with smoking, and to meet market demands. This new policy stems from global trends in smoke-free laws in public places, such as restaurants and bars, public parks, and university campuses. Research has consistently shown the significance of public smoking bans on reducing secondhand exposure, changing smoking norms, limiting smoking initiation, and preventing opportunities to smoke.

Although critics frequently contend that smoking bans undermine citizen’s individual rights, the facts that multi-unit public housing facilities expose residents to secondhand smoke exposure through air ducts and that children represent approximately one third of public housing residents highlight smoking in public housing as a formidable public health concern beyond privacy arguments.

However, the smoking ban in public housing is not without concerns, and care must be taken to address the unique needs of vulnerable residents.

While smoking rates in the US continue to decline, smoking remains concentrated among low income individuals, with 26% of individuals below the poverty line currently smoking, compared to 14% of those not in poverty. Importantly, the smallest reductions in smoking prevalence have been among groups with lower socioeconomic status. This highlights the consistent challenges and external circumstances that may undermine even the most effective clinical interventions among resource challenged individuals in public housing.

It is not that disadvantaged individuals do not wish to quit smoking, but rather that their external stressors; limited wealth; and increased risk of mental illness, discrimination, and marginalization frequently increase a sense of powerlessness that may inhibit attempts to quit. Sometimes, there are simply bigger problems to deal with.

For instance, my previous research has shown that increased exposure to social stressors reduces the likelihood of maintaining home smoking restrictions. While a non-smoking policy may provide a catalyst for some to quit, these policies are unable to address the broader social causes of poverty and need to be cautious that they do not intensify social stigma, which may further marginalize or increase stress for smokers living in public housing.

Dealing with noncompliance without increasing vulnerability remains a challenge.

Policies related to smoking related lease violations will need to continue to be incremental and non-punitive, with care taken to ensure that smoking violations do not impact current or future housing opportunities. Lease violations that result in fines and potential evictions may compromise the many benefits of a controlled non-smoking environment.

For example, fear of reprisal may lead smokers to take actions to conceal their smoking by either smoking indoors with closed windows or in vehicles, thereby increasing the potential risk of secondhand exposure.

Fear of surveillance may also undermine social support networks or diminish relationships with building supervisors. For instance, people who choose to smoke in their units may be less likely to report poor living conditions, call attention to safety concerns, or to have control over their environments for fear of being reported.

There are also potential safety concerns. While smoking away from the home reduces secondhand smoke for others, it may also increase additional exposure to unsafe areas, particularly at night time or in cold weather or for those with disabilities. Parents negotiating the choice between leaving children either unattended or with siblings, versus bringing children to unsafe and potentially dangerous environments at night, may favor a third option of smoking indoors.

All individuals have a right to a smoke-free environment. A smoking ban in areas typically overburdened by tobacco marketing and outlet density will help offset the culture of smoking. The partnering of HUD with local organizations to change tobacco culture and assist with smoking cessation in a high prevalence smoking environment is an admirable and urgent first step in reducing initiation, current smoking, and secondhand exposure.

But smoking cessation is a long term process that requires consistency and smoker buy-in, with attention paid to the broader social conditions and vulnerability of populations that smoke—all of which may challenge anti-smoking policies. Sustainable efforts need to ensure that smokers and their children are not at heightened risk of eviction, reduced accessibility to housing, or increased levels of stigma—factors that may undermine or compromise any efforts to quit or reduce smoke exposure.

As a sociologist dedicated to understanding how social policies affect health inequalities and disparities, I feel it is imperative that any implementation of smoke-free policies must continue to be undertaken in a fair manner, which acknowledges the unique needs and challenges of disadvantaged populations, and considers policies’ potential to harm as well as their numerous advantages.

Jarron Saint Onge is associate professor of sociology and health policy and management at the University of Kansas. His research focuses on the social determinants of population health. The view expressed here are his own.

Competing interests: None declared.

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