Implementation of the Department of Housing and Urban Development’s Smoke-Free Rule: A Socio-Ecological Qualitative Assessment of Administrator and Resident Perceptions

Abstract

In July 2018, the United States Department of Housing and Urban Development (HUD) implemented a mandatory smoke-free rule in public housing. This study assessed administrator and resident perceptions of rule implementation during its initial year in the District of Columbia Housing Authority (DCHA). Assessment included nine focus groups (n = 69) with residents and in-depth interviews with administrators (n = 7) and residents (n = 26) from 14 DCHA communities (family = 7 and senior/disabled = 7). Semi-structured discussion guides based on the multi-level socio-ecological framework captured dialogue that was recorded, transcribed verbatim, and coded inductively. Emerging major themes for each socio-ecological framework level included: (1) Individual: the rule was supported due to perceived health benefits, with stronger support among non-smokers; (2) Interpersonal: limiting secondhand smoke exposure was perceived as a positive for vulnerable residents; (3) Organizational: communication, signage, and cessation support was perceived as a need; (4) Community: residents perceived mobility, disability, weather, and safety-related issues as barriers; and (5) Public Policy: lease amendments were perceived as enablers of rule implementation but expressed confusion about violations and enforcement. A majority of administrators and residents reported favorable implications of the mandated HUD rule. The novel application of a socio-ecological framework, however, detected implementation nuances that required improvements on multiple levels, including more signage, cessation support, clarification of enforcement roles, and addressing safety concerns.

Smoking cessation intentions and attempts one year after the federally mandated smoke-free housing rule

“…Results from other investigations indicate DCHA reported that they offered general smoking cessation classes and quitline resources to residents who wanted to quit, but the classes were poorly attended, and many residents reported not knowing about those resources. ( Horn et al, 2021;18(17):8908. )…”

Are excluding e-cigarettes a loophole in the smokefree public housing rule?

“…Results indicating few ever e-cigarette users are current users and most residents use e-cigarettes fewer than 10 times in their lives suggest residents use e-cigarette products a few times but do not adopt their use as a consistent behavior. Low interest and uptake among residents may be due to high cost and low availability of e-cigarettes ( Cheng et al, 2021 ), and the sample primarily consisting of respondents with lower levels of knowledge, access, and use of e-cigarettes ( Horn et al, 2021a , Horn et al, 2021b ).…”

“…An increase in use may adversely impact the health of residents as e-cigarettes are harmful to users and may carry unique health risks despite being less harmful than combustible cigarettes ( US Department of Health and Human Services, 2020 , National Academies of Sciences, Engineering, and Medicine et al, 2018 ), and secondhand e-cigarette aerosol exposure can impact the health of other residents ( Visser et al, 2019 ). If this is the case, the update to the rule should involve a community input to improve low levels of trust associated with implementing the rule to date ( Horn et al, 2021b , Wray et al, 2021 ).…”

“…National trends suggest that e-cigarette use may be less common among public housing residents compared to the general population given the sociodemographic makeup of public housing communities. Public housing residents in Washington, DC are more likely to be in older age groups and members of racial minority and low socioeconomic status communities have comparatively less e-cigarette knowledge, access, and use ( Horn et al, 2021a , Horn et al, 2021b ), while e-cigarette users are more likely to be young, non-Hispanic white, higher educational level, and higher income ( Wang et al, 2021 , US Department of Health and Human Services, 2020 , Hooper and Kolar, 2017 ). Additionally, the prohibition of combustible tobacco in certain settings, such as in the home, particularly with children present, is one of the most common reasons for e-cigarette use ( Spears et al, 2022 ).…”

Behavioural intentions in response to a potential menthol cigarette sales ban: a survey examining smokers in Washington, DC public housing

“…Flyers for the study were placed in common areas in buildings notifying residents where and when data collection events would be held, and resident council presidents and DCHA staff told residents about data collection events during community meetings. During data collection events, residents frequently found out about the event from other residents (word-of-mouth) 23 24. Interested residents completed a screening assessment to establish residence and age eligibility and past 30-day smoking status.…”