Should smoking be banned in people’s homes?
Smoking is banned in the common areas of Yelena Lantsman’s home, a public-housing high-rise for the elderly in Brookline, Massachusetts, where she has lived for the last eighteen years. But it is not banned in the apartments themselves.
Lantsman, an immigrant from the Ukraine, does not complain about neighbors who smoke. It would be awkward. But asked if she would support a total, building-wide ban on smoking, she answers without a moment’s hesitation: “Absolutely. Smoking hurts those who smoke, and those who are nearby.”
Welcome to the next front in the battle against Big Tobacco: public housing. Following the passage in 23 states of laws that ban smoking in workplaces, restaurants, and bars, anti-smoking advocates are increasingly training their sights on private spaces in public buildings. Last June, in Boston’s Roslindale neighborhood, the Washington-Beech housing development became the city’s debut smoke-free public housing site—the first step toward the Boston’s Housing Authority’s ambitious goal of clearing the air by 2013 at all 64 public housing sites. And in 2009, an office within the federal Department of Housing and Urban Development issued a memorandum that “strongly encourages Public Housing Authorities … to implement nonsmoking policies in some or all of their public housing units.
A Controversial Policy
To be sure, the trend has sparked dissent. After all, smoking is legal for adults, and nicotine is known to be one of the hardest addictions to kick. Why should poor people be asked to give up smoking at home when rich people have the right to indulge this harmful vice? Is the intrusive government “nanny state,” as libertarians dub it, discriminating against those who are least powerful?
A new wave of published papers from the Harvard School of Public Health (HSPH) and elsewhere sheds light on why smoking should be banned in public housing, and how the policy question should be considered.
Living Down the Hall from Danger
An HSPH study in the December 2009 issue of the journal Tobacco Control, for example, documents how cigarette fumes can infiltrate the homes of nonsmokers in low-income housing. When nonsmoking residents reported the frequent odor of tobacco smoke from other apartments or hallways, tests in their homes subsequently turned up elevated nicotine concentrations, according to one of the study’s authors, Jack Spengler, Akira Yamaguchi Professor of Environmental Health and Human Habitation in the Department of Environmental Health.
Secondhand smoke can enter a smoke-free residence through shared air spaces, ventilation systems, windows, elevator shafts, hallways, holes in walls, and pipes and electrical outlets. Indeed, in older multi-unit buildings, about half to two-thirds of the air in a residence can infiltrate from neighboring apartments.
In another HSPH study, published in the July 2010 issue of Pediatrics, researchers tested the effects of smoke-free air laws on children, comparing counties with bans to those without. The good news was that among children who lived in homes where no one smoked, those who resided in locales where smoking was banned in public places had 39% lower levels of cotinine—a byproduct of tobacco that can be tested in blood—than their counterparts in places with no public bans. The bad news was that children who lived with smokers had no difference in cotinine levels, despite living in areas that banned public smoking.
The message: parents need to stop smoking to protect their children’s health, says Melanie Dove, the paper’s lead author, who received her doctorate in environmental health from HSPH in 2010. “Among children, the home is the primary source for secondary smoke exposure,” Dove explains. “Efforts to help parents either stop smoking, or stop smoking around their kids, would be really helpful.”
Meanwhile, research continues on “thirdhand smoke,” a term that refers to the toxins found to linger in smoking areas long after the smoking has stopped. Its risks look real. While researchers have not teased out the independent effects of thirdhand smoke from the known harm of secondhand smoke, thirdhand smoke contains many of the same toxins and carcinogens as secondhand smoke—tobacco-specific nitrosamines and formaldehyde, among others—plus additional compounds that emerge as time passes. Some of these chemicals are considered to have no safe threshold level, and children, who are in direct contact with floors and household dust, are more exposed than adults.
Turning Science into Policy
The question of bans in private space therefore becomes a tactical one, explains Michelle Mello, professor of law and public health in the Department of Health Policy and Management, and co-author of a paper in the June issue of the New England Journal of Medicine, where researchers spell out why the federal government can and should ban smoking altogether in the vast network of public housing complexes it controls.
There are two lines of battle, Mello says: legal bans, or more public-health-style campaigns aimed at educating and persuading people.
The danger with trying to pass laws, Mello says, “is that you get so far out in front of social thinking that you get a backlash and laws that are not enforced.”
Policymakers who hope to win over smokers face the challenge of documenting the harm that secondhand smoke can do, even when produced by a neighbor. If smokers challenge public housing bans, backers of the bans may need to measure levels of secondhand smoke in specific units—still a technically challenging process, says Gregory Connolly, MPH ’78, director of the Tobacco Control Research Program at HSPH and member of the recently formed Tobacco Products Scientific Advisory Committee, which advises the U.S. Food and Drug Administration.
“For multiple-dwelling units, we need either clear laws or clear rules that protect the rights of exposed nonsmokers—or decisions made on a case-by-case basis and backed up by exposure measures,” says Connolly.
Nonsmokers Who are Poor Can’t Move Away
In answering the charge that smoking bans in public housing are unjust, the NEJM paper counters that the real injustice is to the nonsmokers in public housing. They, too, are poor and have few other housing options. Why should they have to suffer from secondhand smoke? Some 7 million Americans live in public housing, and 40% are families with children.
“This was the first peer-reviewed report discussing the rationale and explicit strategies for smokefree public housing,” says the NEJM’s paper’s lead author, Jonathan Winickoff, MPH ’01, a pediatrician at the MassGeneral Hospital for Children. “We have an opening here to protect millions of vulnerable individuals—children, elderly, and disabled, who are really quite susceptible to tobacco smoke.”
Residents of public housing suffer higher rates of asthma and other chronic diseases, which make them as a group more susceptible to tobacco smoke exposure in their own homes. “The highest levels of support for smokefree public housing come from those living in multiunit housing, as opposed to detached housing,” says Winickoff. “This finding suggests that those who are actually living in these conditions do not like it and want it changed.”
“There are so many asthmatic kids in public housing,” adds Spengler. “And they are not empowered to solve this themselves.”
Ban Smoking, not the Smoker
Advocates of the bans are not proposing that smokers should be kicked out of public housing. Rather, the activity itself should be banned—as are, for example, loud noise after hours or unsanitary trash disposal practices. But as the NEJM authors concede, enforcement won’t be easy. “The threat of eviction cannot be wielded lightly,” they write, “both because the process is legally onerous and because eviction undermines the purpose of public-housing programs—that is, protecting vulnerable populations from homelessness.”
Smokers with limited incomes also need strong support to quit, including aids such as nicotine patches and gum, says Winickoff. All quitting aids, he notes, should be covered by public insurance. Winickoff has been developing a family-centered program that works through the child health care system to help parents quit smoking.
Ultimately, with 80% of the American population now nonsmokers, and roughly 90% aware of the dangers of secondhand smoke, it seems likely that smoke-free buildings will become more and more the norm in time. Already, about 5% of local public housing authorities have passed blanket smoking bans.
Marketplace Motivates Private Landlords
Among private landlords, market incentives are working, because nonsmokers tend to want to live among nonsmokers. “In the last five to seven years, there’s been a tidal wave of adoption of smoke-free policies by private apartment owners,” says Jim Bergman, who tracks that trend as director of the Smoke-Free Environments Law Project. The decisive factor was information: many owners thought a smoking ban might be discriminatory.
Once owners understand that it is legal to ban smoking, he adds, economics comes into play. Smoke-free policies lower maintenance expenses—it can cost $10,000 to rehab an apartment after a smoker moves out—and reduce the risk of fires sparked by cigarettes. “Owners are realizing there are few, if any, downsides to smoke-free policies,” says Bergman.
But industry backing alone isn’t enough. Experience in vanguard states like Maine, Michigan, and Massachusetts shows that when the public health community turns up the pressure—“helping, prodding, assisting”—the move towards smoke-free housing goes much faster, Bergman says.
And with a victory on this front, Yelena Lantsman, and every other public housing resident concerned about secondhand smoke, might breathe a little easier.
Carey Goldberg is a Boston-based science journalist and author. Photo by Kent Dayton.