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Smokefree Multi-unit Housing: Community Engagement & Youth Advocacy with Public Housing Residents

State: OH Type: Promising Practice Year: 2018

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Cincinnati Health Department
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Smokefree Multi-unit Housing: Community Engagement & Youth Advocacy with Public Housing Residents
The Cincinnati Health Department (CHD) is committed to protecting and improving the health of the people of Cincinnati. CHD has a Federally Qualified Health Center designation status and serves over 40,000 patients annually. The Creating Healthy Communities Program (CHCP) at CHD addresses these disparities by focusing on policies, systems, and environmental changes around tobacco-free living, active living, and healthy eating strategies within three priority communities in Cincinnati. The prominent health inequity in all three priority communities is lower life expectancy, an outcome of higher than expected mortality rates for common chronic diseases. The leading causes of death in these communities include heart disease, cancer, stroke and chronic obstructive pulmonary disease, each of which can be caused by tobacco smoke. At least 20% of families have household income below the poverty level, and an average of 18% of adult residents lack a high school diploma or equivalent. People living below the poverty level and those having lower education levels have higher rates of cigarette smoking than the general population. In addition, African Americans, who are more likely to die from smoking-related illnesses, represent at least 50% of the population in these communities. CHCP has identified the implementation of smoke free multi-unit housing (SFMUH) policies as one of its key healthy living strategies. In multi-unit buildings, tobacco smoke travels from smokers' units into the units of non-smokers, lingering in the air for hours. Since there is no safe level of exposure to SHS, completely eliminating tobacco smoke indoors is the only way to fully protect residents. SFMUH policy goals are to protect residents from secondhand smoke exposure and to decrease the risk of smoking-related fires. Cincinnati Metropolitan Housing Authority's (CMHA) SFMUH policy protects 13,000 residents from SHS exposure. Beginning July 1, 2016, CMHA began implementing the policy, using a tiered approach, at 18 public multi-unit housing sites and 274 rental housing sites. The policy was fully implemented on January 1, 2017. Resident engagement was the foundation upon which successful policy adoption was built. CMHA residents participated in a focus group, attended SFMUH educational symposiums, and attended policy communication meetings for one year prior to implementation. CHCP partnered with Ohio Department of Health, Interact For Health, US Environmental Protection Agency, American Lung Association, Cincinnati Children's Hospital Medical Center (CCHMC), and the Creating Healthy Communities Coalition's Tobacco Free Living Subcommittee (Hamilton County Public Health, American Heart Association, American Cancer Society, CHD Maternal and Child Health, and Cradle Cincinnati). Experts from US Department of Housing and Urban Development, Toledo-Lucas County Health Department, CCHMC, and Northern Kentucky Health Department shared best practices and answered questions related to SFMUH. CMHA's CEO and the President of CMHA's Jurisdictional-Wide Resident Advisory Board (J-RAB) answered questions specific to CMHA's impending policy. Vendors provided residents with information and resources on health care, smoking cessation, and other community resources. Residents were instrumental in providing group smoking cessation support. Five residents were trained as Freedom From Smoking (FFS) facilitators by the American Lung Association in September 2016. The first 7-week class was co-facilitated by a CMHA resident in May 2017. Weekly FFS classes were scheduled to occur following a yoga class for residents, who reported that they were more likely to stay for cessation classes following yoga. Eleven residents attended at least one FFS meeting, with an average of seven residents attending each meeting. Seven residents quit smoking for several consecutive days and one resident quit for approximately three weeks before ultimately smoking again. Since it usually takes several attempts for smokers to quit, continued resident engagement around group smoking cessation has the potential of increasing the number of more nonsmokers among CMHA residents. The relationship established with residents, and CMHA leadership, led to the formation of Cincinnati STAND, a youth-led anti-tobacco initiative. The group of CMHA youth, ages 11-17, aims to eliminate the cultural acceptance, expose misguided social norms, and provide relevant and compelling facts about the dangers of tobacco use. Nearly all tobacco use begins during youth and progresses during young adulthood. Engaging and educating CMHA youth, who are already at greater risk to begin smoking, on the dangers of tobacco use can save thousands of lives. Members have participated in events which promote CMHA's SFMUH policy. CMHA residents, including those who smoke, have demonstrated support for Cincinnati STAND. Residents have helped serve food at meetings, provided transportation for members to attend community events, and encouraged Cincinnati STAND members to continue sharing their anti-tobacco message. Youth engagement provides another element to successful SFMUH policy adoption: smoking prevention. Website: https://www.cincinnati-oh.gov/health/cincinnati-health-department-divisions1/environmental-health/health-promotion-worksite-wellness/
Smoke-free multi-unit housing (SFMUH) is an emerging topic on the public health landscape. In multi-unit buildings, tobacco smoke travels from smokers' units into the units of non-smokers, traveling through doorways, cracks in walls, electrical lines, plumbing, and ventilation systems. Once secondhand smoke gets in an apartment, it can linger in the air for hours. Cigarette smoking kills more than 480,000 Americans each year, making it the leading preventable cause of death in the U.S. (including deaths from secondhand smoke). Because there is no safe level of exposure to environmental tobacco smoke, completely eliminating smoking inside of multi-unit housing sites is the only way to protect residents. Smoke-free multi-unit housing (SFMUH) is an emerging topic on the public health landscape. In multi-unit buildings, tobacco smoke travels from smokers' units into the units of non-smokers, traveling through doorways, cracks in walls, electrical lines, plumbing, and ventilation systems. Cigarette smoking kills more than 480,000 Americans each year, making it the leading preventable cause of death in the U.S. (including deaths from secondhand smoke). Because there is no safe level of exposure to environmental tobacco smoke, completely eliminating smoking inside of multi-unit housing sites is the only way to protect residents. The U.S. Department of Housing and Urban Development's (HUD) will require all public housing agencies (PHAs) to adopt a smoke-free policy by July 30, 2018. The Creating Healthy Communities Program (CHCP) at the Cincinnati Health Department worked with Cincinnati Metropolitan Housing Authority to successfully implement a SFMUH policy in July 2016. CMHA provides affordable public housing for 13,000 low-income residents at 18 multi-unit housing sites and 274 rental housing sites. CMHA residents are low income, predominately African-American, and generally have a lower level of educational attainment. Americans living at or below the poverty level and those having lower levels of educational attainment are more likely to smoke; additionally, African Americans are more likely to die from smoking-related diseases. CMHA's SFMUH policy effectively decreased secondhand smoke exposure for 100% of residents. Not only banned in building indoor common areas, smoking (including electronic cigarettes) is banned inside of individual apartment units. Designated outdoor smoking areas are provided, at least 25-feet away from the building, have been provided for smokers to use. In 2009, HUD began urging PHAs to go smoke-free. As of September 2016, HUD lists nearly 700 subsidized multi-unit housing locations as having gone smoke-free. Once HUD's smoking ban is fully implemented, over 700,000 units would be affected by the SFMUH rule. On November 7, 2006, 58% of Ohio voters approved the Smoke-Free Workplace Act, which set into law a requirement that all public places and places of employment in Ohio prohibit smoking. This began to create an awareness among Ohio voters around smoke free policies. Best practices in implementing SFMUH policies include several key steps, which include: communicating the health effects of SHS to residents and employees; engaging property managers/owners, policymakers, residents, and stakeholders; planning/implementing a policy; and identifying smoking cessation options for residents. Unique approaches to engage residents, particularly around smoking cessation, mindfulness/yoga, nicotine air sampling, and youth engagement were key strategies in ensuring successful policy implementation. CMHA residents had several smoking cessation options at their disposal, depending on personal preference. Eligible residents could utilize the Ohio Tobacco Quitline which provides personal quit coaching and telephone counseling free of charge to Ohioans who are uninsured, have Medicaid, are pregnant, or are covered through the Ohio Tobacco Collaborative. Free nicotine replacement therapy options (patches, gum, or lozenges) are available for up to four weeks to participants. Additionally, the Ohio QuitLogix Online Tobacco Use Cessation Program is available to all Ohioans. Additionally, CHD's seven Primary Health Care Centers provides individual tobacco cessation counseling, administered by a pharmacist. Statistics show that group smoking cessation participants are more likely to quit smoking compared to those who quit on their own. With a twist on traditional group smoking cessation approaches, CMHA residents were trained as Freedom From Smoking (FFS) facilitators to lead smoking cessation classes on-site at their respective housing locations; thereby creating immediate community buy-in. Five residents were trained as Freedom From Smoking (FFS) facilitators by the American Lung Association in September 2016. The first 7-week class was co-facilitated by a CMHA resident in May 2017. Weekly FFS classes were scheduled to occur following a yoga class for residents, who reported that they were more likely to stay for cessation classes following yoga. Managing stress is a key element in quitting smoking and because yoga reduces perceived stress, it is believed to be an effective compliment to smoking cessation. Eleven residents attended at least one FFS meeting, with an average of seven residents attending each meeting. Seven residents quit smoking for a several consecutive days and one resident quit for approximately three weeks before ultimately smoking again. Since it usually takes several attempts for smokers to quit, continued resident engagement around group smoking cessation, complimented by a mindfulness/yoga practice, has the potential of increasing the number of more nonsmokers among CMHA residents. Group cessation participants were provided with nicotine replacement therapy options as needed. FFS facilitator training, participation in FFS classes, yoga classes, and nicotine replacement therapies were provided to CMHA residents at no cost. Nicotine air sampling, conducted by Cincinnati Children's Hospital Medical Center, took place in 30 individual apartment units across six CMHA multi-unit housing sites. Residents received compensation for anonymously participating. Sampling results, conducted pre-policy implementation (July 2016 – December 2016), will be compared to sampling results obtained one year after policy implementation to gauge the policy's effect on indoor air quality. Initial findings indicated that 46% of participants reported that someone inside of their apartments smoked inside of the home; nicotine was detected in 83% apartments that underwent air sampling. Initial data will be compared to data collected one year after policy implementation (July 2017 – December 2017)) to gauge the policy's effect on indoor air quality. Since nearly all tobacco use begins during youth and progresses during young adulthood, CHD began recruiting CMHA youth to join Cincinnati STAND, a youth-led anti-tobacco group, in early 2017. The group, which receives funding from Ohio Department of Health, uses traditional and non-traditional avenues to stand up and speak out against tobacco”. Members aim to eliminate the cultural acceptance of tobacco use, especially among their peers. Cincinnati STAND members have conducted tobacco retail store assessments and tobacco sales compliance checks. The group makes appearances at community events, has appeared on local television and radio, has presented to community leaders, and has a social media presence. CMHA residents, both smokers and nonsmokers, have demonstrated support for Cincinnati STAND. Residents have helped serve food at meetings, provided transportation for members to attend community events, and encouraged Cincinnati STAND members to continue sharing their anti-tobacco message. Youth engagement provides another element to successful SFMUH policy adoption: smoking prevention. Technical assistance and funding provided by Ohio Department of Health and Interact For Health, an organization that promotes health equity through community engagement, grants, research, education and policy. Their support helped to provide staff training, signage, nicotine replacement therapies, FFS facilitator training, and cessation resources. Ohio Department of Health's (ODH) SFMUH toolkit as a key resource while implementing CMHA's policy, resources from the Centers for Disease Control, and lessons learned from participation in NACCHO Big Cities Tobacco Subcommittee.
Tobacco
Cigarette smoking, the primary cause of preventable death in the United States, kills more than 480,000 Americans each year. Tobacco use is not only deadly for the smoker; secondhand smoke (SHS) exposure causes nearly 41,000 premature adult deaths and 400 infant deaths in the US annually. Lung cancer, heart disease, and stroke are some health conditions attributable to SHS exposure. Additionally, smoking is the lead cause of fire-related deaths in multi-unit housing buildings. Smokefree Multi-Unit Housing (SFMUH), particularly in low-income public housing, benefits both the public housing authority (PHA) and residents. SFMUH lowers the risk of fire damage and deaths due to fires, provides potential insurance savings, and reduces the cost of cleaning and renovating units for the PHA. SFMUH policies protects the health of all tenants, employees, and visitors by eliminating SHS exposure inside of buildings, where tobacco smoke can travel from smokers' units into the units of non-smokers and into common areas and linger in the air for hours. For many public housing residents, moving from a building to escape SHS infiltration into their units may not be financially feasible. The process of implementing a SFMUH policy at Cincinnati Metropolitan Housing Authority's (CMHA) 18 multi-unit housing and 274 rental housing sites began one year prior to policy enactment. In partnership with the US Environmental Protection Agency, a tenant focus group and property manager focus group were both held in September 2015. The focus groups were followed by resident-focused informational events held at two housing sites. In 2016, two larger educational events, which included guest presenters and vendors, were held at a CMHA's main office. In addition, the pending policy was communicated to residents at community BBQ's, health fairs, policy communication meetings which took place in community rooms at MUH sites, and at a 2-day residents' conference. The policy was implemented at several CMHA sites on July 1, 2016 and was fully implemented across all sites by January 1, 2017. While respecting the rights of all tenants, several steps, focusing on resident engagement, were employed: 1. Communicate with residents frequently about the policy change, why it is being done and when it will be taking effect. 2. Clearly define smoking”, amend residents' leases, and develop enforcement strategies. Review this information with residents several months advance notice before the policy will go into effect. 3. Hold informational meetings with residents and staff to communicate about the new policy, answer questions and receive feedback. 4. Offer resources to current smokers seeking to quit. Cincinnati Health Department's (CHD) work with Cincinnati Metropolitan Housing Authority (CMHA) on implementing a smoke-free public housing policy in 2016 required teamwork from many groups. CMHA administration and property managers, the Jurisdictional-Wide Resident Advisory Board (J-RAB), CMHA residents, the U.S. Environmental Protection Agency, Cincinnati Children's Hospital Medical Center, U.S. Department of Housing and Urban Development, Toledo-Lucas County Health Department, Northern Kentucky Health Department, and members of the CHD's Creating Healthy Communities Coalition's Tobacco Free Living (TFL) Subcommittee, which includes : American Lung Association, Hamilton County Tobacco Free Partnership, American Heart/Stroke Association; Cradle Cincinnati; American Cancer Society, and Hamilton County Public Health. These partners and stakeholder provided technical assistance, reviewed and provided input on documents, and served as speakers and/or vendors at resident engagement events. Grant funding, obtained by Cincinnati Health Department, was provided by the Ohio Department of Health's (ODH) Tobacco Use Cessation and Prevention Program ($33,000) and by Interact For Health ($100,000), an organization that promotes health equity through community engagement, grants, research, education and policy. Funds were used to train residents as Freedom From Smoking facilitators and purchase cessation workbooks, signage, outdoor smoking receptacles, and nicotine replacement therapy options for residents.
Cigarette smoking, the primary cause of preventable death in the United States, kills more than 480,000 Americans each year. Tobacco use is not only deadly for the smoker; secondhand smoke (SHS) exposure causes nearly 41,000 premature adult deaths and 400 infant deaths in the US annually. Lung cancer, heart disease, and stroke are some health conditions attributable to SHS exposure. Additionally, smoking is the lead cause of fire-related deaths in multi-unit housing buildings. Smokefree Multi-Unit Housing (SFMUH), particularly in low-income public housing, benefits both the public housing authority (PHA) and residents. SFMUH lowers the risk of fire damage and deaths due to fires, provides potential insurance savings, and reduces the cost of cleaning and renovating units for the PHA. SFMUH policies protects the health of all tenants, employees, and visitors by eliminating SHS exposure inside of buildings, where tobacco smoke can travel from smokers' units into the units of non-smokers and into common areas and linger in the air for hours. For many public housing residents, moving from a building to escape SHS infiltration into their units may not be financially feasible. The objective of implementing a SFMUH policy was to Increase the number of people living and working in smokefree environments, increase the number of tobacco-free environments policies at CMHA from one to two, increase the number of CMHA residents who are non-smokers, and reduce levels on environmental tobacco smoke inside of CMHA housing sites. CMHA's policy effectively increased the number of people living and working in smokefree environments; as a result 13,000 (100%) CMHA residents and all staff members now live/work in a smokefree environment. Prior to policy implementation, CMHA had one smokefree policy which applied to employees only. After July 1, 2017, the number of smokefree CMHA policies increased from one to two. Increasing the number of residents who are nonsmokers was measured by participation in Freedom From Smoking (FFS) classes, which CMHA residents were trained to serve as facilitators. The first 7-week FFS class began in May 2017; eleven residents attended at least one meeting, with an average of seven residents attending each meeting. Seven residents successfully quit smoking for several consecutive days. FFS classes will continue to take place at other CMHA MUH sites throughout 2018. Measuring a reduction in residents' exposure to environmental tobacco smoke will be determined by results of nicotine air sampling being conducted by Cincinnati Children's Hospital Medical Center (CCHMC). Voluntary nicotine air sampling took place in 30 apartments across six CMHA sites. Residents received compensation for anonymously participating. Sampling results, conducted pre-policy implementation (July 2016 December 2016), established a baseline to be compared to results obtained one year post policy implementation. Initial findings indicated that 46% of participants reported that someone inside of their apartments smoked inside of the home; nicotine was detected in 83% apartments that underwent air sampling. Initial data will be compared to data collected one year after policy implementation (July 2017 December 2017)) to gauge the policy's effect on indoor air quality. CCHMC scientists used 24-hour active air sampling to measure tobacco-specific nicotine levels and 3-Ethenlypyridine (3-EP) (a tobacco specific, pyrolysis product of nicotine) levels. Although Round 2 (post-policy) of nicotine air sampling is still underway, preliminary results are promising. When compared to air sampling results from the same stage of testing conducted pre-policy implementation, there has been a 68% reduction in nicotine detection inside of apartment units during round two of nicotine air sampling. Modifications have been made in residents' role in tobacco cessation. The American Lung Association requires that persons, prior to being trained as Freedom From Smoking facilitators, have been smokefree for at least one year. Because each of the five residents who were trained as Freedom From Smoking facilitators were current tobacco users, they will now be trained as cessation advocates”, using a curriculum similar to FFS. In this role, residents can still serve as champions within their communities, take on a leadership role in FFS meetings, while participating in the cessation program themselves. Once cessation advocates have been smokefree for at least one year, they can be trained as FFS facilitators and hold classes on their own.
Resident (community) engagement proved to be the most important factor in the planning and implementation of CMHA's smokefree multi-unit housing policy. Including residents at each step, and continuing to do so, has ensured the sustainability of CHD's and CMHA's joint efforts. Beginning during the planning phase, when resident council leaders participated in a focus group (facilitated by the US EPA) to share their points of view and suggestions on smokefree multi-unit housing policy implementation. Subsequently, residents attended several smokefree housing educational events and participated at policy communication meetings held at CMHA multi-unit housing sites. Including residents in smoking cessation initiatives by training them as Freedom From Smoking facilitators/cessation advocates proved to be an effective model. Not only did this create resident buy-in, but exceeded expectations on residents' participation in cessation classes. Having residents trained to lead group cessation classes ensures that cessation services can continue beyond the implementation period. Residents also showed commitment to the policy's success by allowing their apartments to undergo nicotine air sampling so that air quality data can be collected. The Creating Healthy Communities Coalition's Tobacco Free Living (TFL) Subcommittee continues to meet with CMHA for discussion and ongoing evaluation around its smokefree policy. In July 2017, the TFL Subcommittee recommended incorporating Crime Prevention through Environmental Design (CPTED) strategies at designated smoking areas located at CMHA's 18 multi-unit housing sites to ensure residents' safety when using those facilities. CMHA residents regularly attend CHCC monthly meetings and sit with the TFL subcommittee to provide policy updates. Engaging CMHA youth around anti-tobacco initiatives is another important piece of the puzzle for creating sustainability around the SFMUH policy. With funding from the Ohio Department of Health, CHD started Cincinnati STAND, a youth-led anti-tobacco initiative, with CMHA kids (ages 11-17) in March 2017. Cincinnati STAND aims to prevent youth smoking initiation by empowering group members to educate their peers on the dangers using tobacco. Cincinnati STAND members also attend community events, present to community members about how big tobacco companies target youth to smoke, and share their anti-tobacco message on social media. Parents and other adult residents, many of whom are smokers, encourage the kids to attend the meetings and are very supportive of group efforts. Residents even rallied to ensure that members had transportation to present to the CHD Board of Health on the importance of adopting smokefree policies. An anonymous tip line was created and suggestion boxes provided at each housing site to promote policy compliance while providing sustainability. Additionally, CMHA added the SFMUH policy to its Annual Plan/5 Year Plan which demonstrates a continued commitment to safeguarding the health of all residents, staff, and visitors. Pending final results of round two of nicotine air sampling (concluding in December 31, 2017), the TFL subcommittee will report to CMHA Commissioners on the effectiveness of the Smoke-Free Housing Plan.
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