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A Smokefree Multi-unit Housing Anecdote

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1 A Smokefree Multi-unit Housing Anecdote
Jonathan P. Winickoff, MD, MPH Associate Professor in Pediatrics Harvard Medical School September 24, 2011 I want to acknowledge my colleagues who helped develop this line of research, Karen Wilson, Robert McMillen, Jonathan Klein, Mark Gotlieb, Sue Tanski, and Michelle Mello.

2 …dedicated to eliminating children’s exposure to secondhand smoke and tobacco
Smokefree housing as an issue helps to achieve this goal

3 The Richmond Model suggests 3 elements that can work synergistically to effect public policy. I’ll try to model these elements in this brief presentation and show how we use them to help achieve smokefree housing

4 Smokefree multi-unit housing
Imagine telling the home owner that they can’t smoke in their own unit? Focus on the established evidence to build the case for smokefree multi-unit housing tobacco smoke causes harm contamination occurs cotinine levels of children are elevated public support for smokefree multi-unit housing legal/ethical framework supports smokefree I think we need to acknowledge that, at first glance, it seems difficult. Smoke free laws mostly protect adults Young children spend most of their time in the home Poor children live in multi-unit housing, where smoking is most concentrated

5 Comparative Causes of Annual Preventable Deaths in the United States
Compared to some other common preventable causes of morbidity and death, smoking is the 500 pound gorrilla in the room. of public health. AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced Sources: (AIDS) HIV/AIDS Surveillance Report 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993; 270: ; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

6 Children and Tobacco Smoke
There is NO safe level of exposure Increased risk of: Asthma, RSV pneumonia, SIDS, Otitis media, Metabolic Syndrome, Dental caries Hospitalizations Sleep disturbance School absenteeism Developmental delay—even at lowest detectable levels (Yolton et al) Whether you are an internist dealing with vascular disease, heart attacks, stroke, COPD, and cancers. Or an OB dealing with tobacco use and involuntary exposure during pregnancy, or a childhealthcare clinician…smokefree multi-unit housing will benefit your patients. 2: Delpisheh et al, 2007; 3: Mahid et al, 2007 6

7 Biochemical changes at low levels
Wilson, et al Using NHANES Relationship between cotinine levels and serum levels of antioxidants Significant association between levels of cotinine and vitamin C, and carotenoids Association was significant even at low levels of exposure ( ng/mL) Even down to the lowest detectable levels

8 The Life Cycle Effects of Smoking
Asthma Otitis Media Fire-related Injuries Cognitive Problems Influences to Start Smoking SIDS RSV/Bronchiolitis Meningitis Childhood Infancy Adolescence Nicotine Addiction Health Effects In utero Smoking effects the entire human life cycle Adulthood Low Birth Weight Stillbirth Cancer Cardiovascular Disease COPD Arch Pediatr Adolesc Med. 1997 8

9 Contamination: Reason for Concern
Overarching issue is that smoke in multi-unit housing affects everyone else Exposure through shared ventilation, along air ducts, leaky walls. The numbers add up quickly, if just 5 people in a building smoke ½ pack of cigarettes in their apartment each day; the load to the building is over 18,000 cigarettes each year. But the problem doesn’t just manifest as the 7 minutes of active smoking that occurs 18,000 times per year in the building, it’s what happens after the cigarette is extinguished.

10 Effect of a Single Cigarette on Indoor Air Quality
…it takes TWO hours for the air quality to return to minimum federal safety standard for levels of CO, fine particles and particulate aromatic hydrocarbons.. This graph from Ott et al in the Journal of Air and Waste Management shows the effect of a single cigarette on indoor air quality. Note the initial spike up in the eight minutes while the cigarette is burning. Then note that it takes two hours for the air quality to return to the minimum federal safety standard for fine particles, CO, and particulate aromatic hydrocarbons. Think about the area under the curve as the true contaminant load of each cigarette. Note that even after 5 hours the air has not returned to zero… contamination remains. This phenomenon is occurring thousands upon thousands of times a year in multi-unit buildings where children are living. Ott et al J. Air & Waste Manage. Assoc.

11 Can smoking in one unit contaminate another unit?
Kraev et al. (2009) demonstrated, using “Hammond” filters, that air in 89% of non-smoking units was contaminated with nicotine. Kraev TA, Adamkiewicz G, Hammond SK, Spengler JD. Indoor concentrations of nicotine in low-income, multi-unit housing: associations with smoking behaviours and housing characteristics. Tob Control 2009 December;18(6): 11

12 Smokefree Laws Mostly Protect Adults
Increasingly, workplaces, restaurants, bars, and other public places are going smokefree Young children spend most of their time in the home Poor children live in multi-unit housing, where smoking is most concentrated Bullet 2….Leaving them unprotected by current legislative efforts.

13 Cotinine levels in children
National Health and Nutrition Examination Survey (NHANES) Hypothesized and found that among children in households that do not allow smoking in their own home, children who live in apartments have a 140% higher cotinine level than children living in detached homes, This relationship persists when controlling for poverty and race/ethnicity Is the air contamination getting into children? Cotinine is the metabolic byproduct of nicotine… and is a highly specific marker for tobacco smoke 13

14 Cotinine levels in children by housing type
This figure shows mean…(title) in households that do not allow smoking in their own home. The highest mean cotinine levels were found in apartments, attached homes were intermediate, and the lowest cotinines were found in children in detached homes—a category that included motor homes. 14

15 What do people who live in multi-unit housing actually think?
2009 Social climate survey Nationally representative based on US Census Data 1500 respondents per year with approximately 70% response rate among eligible respondents contacted

16 What do people who live in multi-unit housing actually think?
We hypothesized that people who lived in multi-unit housing would be more resistant to banning smoking in private units of buildings A majority support banning smoking in housing Those in apartments were more supportive, not less …than those who lived in detached homes. After the smell is gone, the home remains contaminated for weeks/months/and years

17 In 2009 compared to 2007 and 2008, support increased in general, and people who were ACTUALLY living in multi-unit housing had higher levels of support for banning smoking in private areas than the people living in detached homes.

18 Legal and ethical framework
HUD: 6.7% of housing authorities smokefree and increasing. NEJM article presents legal and regulatory precedent, health consequences of tobacco smoke, and inability of non-smokers to escape exposure…and argues that principles of social justice can only be met by smoke-free public housing policies. Bans could proceed as leases are renewed, and safe forms of nicotine replacement therapy could be offered to support addicted individuals the 2009 and 2010 HUD Memos urge public housing authorities to go smokefree—currently only 6.7% are smokefree. HUD Voluntary Smoke Free Policies 2009 – encouraging local public housing authorities to implement voluntary smoke free policies 2010 – encouraging Section 8 and private housing facilities receiving public subsidies to voluntarily go smoke free Third bullet…A recent paper in the most cited medical journal, the New England Journal of Medicine, presents 18

19 Use social strategies Social strategies can be very effective when you put a human face on the problem Build public support for protecting those at risk The press and the media can help Use anecdotes 19

20 Newsweek Magazine Article
This is a newsweek article about a patient of mine with CF who wanted to be a social worker when she grew up. Kimmy would cough and choke at home because Mom was a two pack a day smoker and smoked inside. Kimmy was always in the hospital. I used to visit her at night after my other patients were tucked in because she was such a night owl and a great kid. She was loosing weight and didn’t want to do ensure by NG tube…so at midnight, I came by and we both had cans of ensure through NG tubes together. She died at 21. Pause… Our research appeared on the today show where the Thirdhand smoke concept has been useful in articulating the notion of contamination of space.

21 The Media has Popularized the Third-Hand Smoke Concept
Our research appeared on the Today Show… where the thirdhand smoke concept has been useful in articulating the notion of contamination of space. you can see the video demonstration of thirdhand smoke on our website ceasetobacco.org 21

22 Thirdhand Smoke Accumulates
THS accumulates in the homes of people who smoke Matt et. al. showed that even after a home remains vacant for 2 months and prepared for the new residents, THS contamination remains on surfaces and in house dust. Non-smokers living in former smokers homes are exposed to tobacco smoke toxins. Tobacco control 2011. The Thirdhand smoke concept will also likely help move the public discourse toward smokefree public housing. 22

23 This is Jessica Lin’s First Place Submission for eliminating children’s exposure to tobacco smoke. the FAMRI/Richmond Center Art Contest Jessica Lin 1st Place winner, FAMRI/ AAP/Richmond Center Art Contest 2009

24 Partner with Pediatricians
AAP policy recommends that pediatricians support clean-air and smoke free environment ordinances and legislation in their community and state. To aid in accomplishing smoke free multi-unit housing you can:  Work with AAP chapters to pass state legislation or local ordinances requiring that multi-unit housing be smoke free Work with local zoning administrators to require that multi-unit housing, including owner-occupied condominiums and apartments, are smoke free Work with housing association boards and local government coalitions. Educate landlords and homeowners associations about the importance of maintaining smoke-free multi-unit housing environments - for the health of their tenants and residents, and to improve their own bottom lines. For bullet #1: …particularly for environments in which children learn, live, and play, such as schools, multiunit housing, public parks, child care settings, public beaches, sidewalks, restaurants, and sporting arenas. These environments should be smoke free even when children are not present.

25 Resources and tools to aid in your advocacy efforts

26 HUD Smoke Free Toolkit – Coming Soon!
HUD has urged PHA’s to go smokefree… Myths about Smoke Free Multi-unit Housing I will have a hard time renting my units and my vacancy rate will increase. My tenants wouldn’t be supportive of a non-smoking policy. Smokers have a right to smoke in their homes. It will be too hard to enforce a non-smoking policy.

27 HUD Smoke Free Toolkit Toolkit for residents Education materials
Legal options Steps for residents to start making their buildings smoke-free Resident organizing letter Sample petitions Sample letter to owners/manager SAMPLE DOCTOR LETTER!!!!! Home pledge kit List of resources

28 HUD Smoke Free Toolkit (con’t)
Toolkit for owners/managers Reasons to consider going smoke-free FAQs about the benefits of smoke-free housing Steps for owners/managers to take to implement smoke-free policies Sample resident letter Sample lease addendum List of resources

29 Summary Provided key research studies:
cotinine levels - significant exposure public support - for protecting those at risk legal framework - analysis of strategies for action Told anecdotes and shown media support Explained partnership among clinician types Together these components provide the scientific evidence and social strategies to build the political will for banning smoking in multi-unit housing. one on child cotinine levels providing direct evidence for a background level of tobacco smoke contamination in multi-unit housing at levels associated with childhood morbidity, the critical public support piece, and the legal ethics presentation in the New England Journal. The Thirdhand smoke concept will also likely help move the public discourse toward smokefree public housing. 29

30 AAP Richmond Center of Excellence

31 AAP Resources Facebook (CEASETOBACCO)
AAP Richmond Center Web Site – Smoke Free Multiunit Housing Web Page (http://www.aap.org/richmondcenter/SmokeFreeHousing.html) Facebook (CEASETOBACCO) Clinical and Community Effort Against Secondhand Smoke Exposure AAP eLearning…Maintenance of Certification-Tobacco Control Module (http://www.pedialink.org/cme/eqipptc)

32

33 References Winickoff JP, Gotlieb M, Mello MM. Regulation of smoking in public housing. New England Journal of Medicine Jun 17;362 (24): PMID: Aligne CA, Stoddard JJ. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151: Winickoff JP. Ban smoking in public housing. Newsweek Magazine. June 13, PMID: Winickoff J, Dempsey J, Friebely J, Hipple B, Lazorick S.  EQIPP: Eliminate Tobacco Use and Exposure [online course]. PediaLink. American Academy of Pediatrics. March 1, Accessed April 11, 2011

34 References 1.Vital signs: nonsmokers' exposure to secondhand smoke --- United States, MMWR Morb Mortal Wkly Rep 2010;59: Bernert JT, Jr., McGuffey JE, Morrison MA, Pirkle JL. Comparison of serum and salivary cotinine measurements by a sensitive high-performance liquid chromatography-tandem mass spectrometry method as an indicator of exposure to tobacco smoke among smokers and nonsmokers. JAnalToxicol 2000;24: Benowitz NL. Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 1996;18: NHANES: Laboratory methodology and public data files (Accessed at 5.Matt GE, Quintana PJ, Hovell MF, et al. Households contaminated by environmental tobacco smoke: sources of infant exposures. Tob Control 2004;13: Gurkan F, Kiral A, Dagli E, Karakoc F. The effect of passive smoking on the development of respiratory syncytial virus bronchiolitis.EurJEpidemiol 2000;16:465-8. 34

35 References 7.Bradley JP, Bacharier LB, Bonfiglio J, et al. Severity of respiratory syncytial virus bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics 2005;115:e Leung GM, Ho L-M, Lam T-H. Secondhand smoke exposure, smoking hygiene, and hospitalization in the first 18 months of life. Archives of pediatrics & adolescent medicine 2004;158: Kitchens GG. Relationship of environmental tobacco smoke to otitis media in young children. Laryngoscope 1995;105: Delpisheh A, Kelly Y, Rizwan S, Brabin BJ. Salivary cotinine, doctor-diagnosed asthma and respiratory symptoms in primary schoolchildren. Matern Child Health J 2008;12: Mahid SS, Minor KS, Stromberg AJ, Galandiuk S. Active and passive smoking in childhood is related to the development of inflammatory bowel disease. Inflamm Bowel Dis 2007;13: Weitzman M, Cook S, Auinger P, et al. Tobacco smoke exposure is associated with the metabolic syndrome in adolescents. Circulation 2005;112:862-9. 35

36 References 13.Prandota J. Possible pathomechanisms of sudden infant death syndrome: key role of chronic hypoxia, infection/inflammation states, cytokine irregularities, and metabolic trauma in genetically predisposed infants. Am J Ther 2004;11: Mannino DM, Moorman JE, Kingsley B, Rose D, Repace J. Health effects related to environmental tobacco smoke exposure in children in the United States: data from the Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med 2001;155: Yolton K, Xu Y, Khoury J, et al. Associations between secondhand smoke exposure and sleep patterns in children. Pediatrics 2010;125:e Tanaka K, Miyake Y, Arakawa M, Sasaki S, Ohya Y. Household smoking and dental caries in schoolchildren: the Ryukyus Child Health Study. BMC Public Health 2010;10: Johnston BN, Preciado DA, Ondrey FG, Daly KA. Presence of otitis media with effusion and its risk factors affect serum cytokine profile in children. IntJ PediatrOtorhinolaryngol 2008;72: Tebow G, Sherrill DL, Lohman IC, et al. Effects of parental smoking on interferon gamma production in children. Pediatrics 2008;121:e Strauss RS. Environmental Tobacco Smoke and Serum Vitamin C Levels in Children. Pediatrics 2001;107:540-2. 36

37 References 19.Strauss RS. Environmental Tobacco Smoke and Serum Vitamin C Levels in Children. Pediatrics 2001;107: Wilson KM, Finkelstein JN, Blumkin AK, Best D, Klein JD. Micronutrient levels in children exposed to second-hand tobacco smoke. Pediatrics Kallio K, Jokinen E, Raitakari OT, et al. Tobacco smoke exposure is associated with attenuated endothelial function in 11-year-old healthy children. Circulation 2007;115: Yolton K, Dietrich K, Auinger P, Lanphear BP, Hornung R. Exposure to environmental tobacco smoke and cognitive abilities among U.S. children and adolescents. Environ Health Perspect 2005;113: (Accessed at 24.Winickoff JP, Gottlieb M, Mello MM. Regulation of smoking in public housing. The New England journal of medicine 2010;362: Kraev TA, Adamkiewicz G, Hammond SK, Spengler JD. Indoor concentrations of nicotine in low-income, multi-unit housing: associations with smoking behaviours and housing characteristics. Tob Control 2009;18: Wilson KM, Klein JD, Blumkin AK, Gottlieb M, Winickoff JP. Tobacco-Smoke Exposure in Children Who Live In Multiunit Housing. Pediatrics 2011;127:85-92. 37

38 A Child’s Perspective By looking at difficult issues from a child’s perspective, we may see things that are not at first visible. The child’s perspective can help frame issues in a new way as we try to effect policy change.

39

40 Opportunities to get involved
Engage… Your state AAP/Medical chapter Pediatricians in areas where smoke free multi-unit housing is being considered to frame as a child health issue Colleagues representing other medical specialty societies In reference to AAP chapters—CPPW communities and their large network—joining up with these already existing forces.

41 Measurement of cotinine
Can be measured in saliva, blood, urine, hair, nails Immunoabsorbance assays- typical limit of detection about 1-2 ng/mL Mass spectrometry- typical limit of detection of ng/mL Vital Signs: Nonsmokers exposure to secondhand smoke: United States September 10, 2010 / 59(35); 41

42 Measurement of cotinine
Level Significance .015 ng/mL Lowest limit of detection .05 ng/mL Limit of detection for earlier NHANES 1-2 ng/mL Limit of detection for ELISA methods 2.32 ng/mL Average urine cotinine of 6 month olds with only outside smokers 10-15 ng/mL Typical cut off for active vs. secondhand smoke in adults 15.47 ng/mL Average urine cotinine of 6 month olds with inside smokers Vital Signs: Nonsmokers exposure to secondhand smoke: United States September 10, 2010 / 59(35); 42

43 How important is it? How important an issue do you think secondhand smoke is for your patients? Not at all important Somewhat important Important, but we have so many things to address Very important Extremely important Vital Signs: Nonsmokers exposure to secondhand smoke: United States September 10, 2010 / 59(35); 43

44 Smoke Free Multi-unit Housing: Moving From Research to Action
Questions? Smoke Free Multi-unit Housing: Moving From Research to Action

45 Contact Information Richmond Center of Excellence website: Richmond Center of Excellence Join the Smokefree Housing Listserve: and ask to join the listserve!

46 At the conclusion of this activity, participants should be able to:
Describe the health impact of secondhand smoke in multi-unit housing. Describe prevalence of exposure to secondhand smoke in multi-unit housing. Describe the consequences of exposure to secondhand smoke.

47 Background 18% of children ages 3-11 and 17% of those ages are regularly exposed to secondhand tobacco smoke (SHS) in the home 54% of children 3-11 and 47% of children had detectable cotinine levels in the NHANES 32 million children ages 3-19 with exposure Newer measurement techniques allow assessment of very low levels of exposure Vital Signs: Nonsmokers exposure to secondhand smoke: United States September 10, 2010 / 59(35); 47

48 Measurement of cotinine
Can be measured in saliva, blood, urine, hair, nails Immunoabsorbance assays- typical limit of detection about 1-2 ng/mL Mass spectrometry- typical limit of detection of ng/mL Vital Signs: Nonsmokers exposure to secondhand smoke: United States September 10, 2010 / 59(35); 48

49 Free market at work Increasing pressure from tenants to restrict smoking in private multi-unit housing Landlords see increased costs for cleaning up smoking apartments, increased fire risks, and increased complaints from tenants Municipalities also banning smoking in multi-unit housing 49

50 Objective To determine whether children who live in attached housing have higher cotinine levels than children who live in detached housing

51 Methods Data from the National Health and Nutrition Examination Survey (NHANES) 4,782 children ages 6 to 18 years Housing type: Apartment, attached house, detached house Controlled for demographics and SES Cotinine cut off .015 ng/mL (HPLC)

52 Results Among children not living with a smoker:
73% had cotinine levels indicating exposure Exposure by housing type: 84% of children living in apartments 80% of children living in attached houses 70% of children living in houses p<.001

53 Results Single house % Attached house % 29.7 20.4 15.5 <.001 34.2
Cotinine level (ng/mL) Single house % Attached house % Apartment % p-value <.015 29.7 20.4 15.5 <.001 <.05 34.2 32.9 28.1 .05 - <.1 33.1 40.1 48.9 1 - <2 1.4 4.0 4.4 2 and greater 1.6 2.6 3.1

54 Results Single house Attached house 29.7 20.4 15.5 <.001 34.2 32.9
Cotinine level (ng/mL) Single house Attached house Apartment p-value <.015 29.7 20.4 15.5 <.001 <.05 34.2 32.9 28.1 .05 - <.1 33.1 40.1 48.9 1 - <2 1.4 4.0 4.4 2 and greater 1.6 2.6 3.1

55 Results Single house Attached house 29.7 20.4 15.5 <.001 34.2 32.9
Cotinine level (ng/mL) Single house Attached house Apartment p-value <.015 29.7 20.4 15.5 <.001 <.05 34.2 32.9 28.1 .05 - <.1 33.1 40.1 48.9 1 - <2 1.4 4.0 4.4 2 and greater 1.6 2.6 3.1

56 Results 56

57 Race by housing type (% exposed)
Variable % exposed (95%CI) p-value House White 68% (61, 74) <.001 African-American 89% (85, 92) Hispanic 66% (60, 71) Other 74% (60, 85) Attached house 76% (61, 86) <.05 92% (83, 96) 70% (52, 83) 80% (54, 94) Apartment 99% (91, 99) 96% (92, 98) 73% (64, 81) 64% (40, 82)

58 Race by housing type (% exposed)
Variable % exposed (95%CI) p-value House White 68% (61, 74) <.001 African-American 89% (85, 92) Hispanic 66% (60, 71) Other 74% (60, 85) Attached house 76% (61, 86) <.05 92% (83, 96) 70% (52, 83) 80% (54, 94) Apartment 99% (91, 99) 96% (92, 98) 73% (64, 81) 64% (40, 82)

59 Race by housing type (% exposed)
Variable % exposed (95%CI) p-value House White 68% (61, 74) <.001 African-American 89% (85, 92) Hispanic 66% (60, 71) Other 74% (60, 85) Attached house 76% (61, 86) <.05 92% (83, 96) 70% (52, 83) 80% (54, 94) Apartment 99% (91, 99) 96% (92, 98) 73% (64, 81) 64% (40, 82)

60 Race by housing type (% exposed)
Variable % exposed (95%CI) p-value House White 68% (61, 74) <.001 African-American 89% (85, 92) Hispanic 66% (60, 71) Other 74% (60, 85) Attached house 76% (61, 86) <.05 92% (83, 96) 70% (52, 83) 80% (54, 94) Apartment 99% (91, 99) 96% (92, 98) 73% (64, 81) 64% (40, 82)

61 Results: Tobit regression analysis
Controlling for SES, race/ethnicity White children living in apartments had a 208% increase in their cotinine level over those living in detached homes (p.003) Black children living in apartments had a 45% increase in cotinine over those living in detached homes (p=.024) Relationships for those of Hispanic and Other ethnicity were not significant.

62 What did we find? 9 of 10 White and African-American children who live in an apartment without a smoker in the home have evidence of tobacco smoke exposure. These children also have higher mean cotinine levels than those living in detached houses. This relationship persists even when controlling for socioeconomic status

63 Importance to pediatric practice
Tobacco smoke exposure is bad for kids Even at very low levels, second hand smoke has negative consequences Studies haven’t examined the risks of low level exposure for other problems: Asthma exacerbations? Bronchiolitis admission? Respiratory illness severity? 63

64 Importance to pediatric practice
Pediatricians should assess all potential sources of exposure, particularly for children with difficult to control asthma, recurrent otitis, or other respiratory infections 64

65 Conclusions Smoking bans in multi-unit housing may help to reduce the seepage/ventilation issues. Care is needed to avoid unintended consequences Balconies Common areas Ethical issues around limiting smoking for low income residents

66 What is Third-hand Smoke?
Third-hand smoke is the left-over contamination in a room/car/clothing that persists after the cigarette is extinguished The condensate on the glass from a smoking chamber was used in one of the first studies linking smoking and cancer (Wynder, 1953) Homes and cars in which people have smoked may smell of cigarettes for long periods The very first demonstration that SHS causes cancer wasn’t SHS at all, it was THS. After the smell is gone, the home remains contaminated for weeks/months/and years 66

67 We asked people about the concept…
Please tell me whether you strongly agree, agree, disagree, or strongly disagree with this statement: “Breathing air in a room today where people smoked yesterday can harm the health of infants and children” 67 67

68 What did we find? Of parents surveyed:
93% agreed SHS harms kids 61% agreed that breathing the air where someone smoked yesterday causes harm… 63% of non-smokers and 44% of smokers 22% didn’t know 17% disagreed Agreeing with this statement independently predicted strict home smoking bans We found no independent association between secondhand smoke beliefs and home smoking bans…That health message no longer has activity. The vast majority of adults in our sample already believed that secondhand smoke can harm the health of infants and children. The current health message that clinicians use may no longer be effective. Based on speaking with parents we’ve found that some perceive SHS as the visible smoke going into their child’s nose and mouth… they will therefore attempt to protect their child by turning on a fan, smoking in another room, or simply blowing the smoke in the other direction. The media has popularized the Third-hand smoke concept… 68 68


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