1. Smoke-Free Multi-Unit Housing: Creating Healthy Environments Where it Matters Most Anna Stein, JD, MPH Legal Specialist NC Division of Public Health CAHEC Partners Conference May 20, 2014

2. Changing Smoke-Free Norms Government buildings and grounds Parks Beaches Restaurants and bars Retail establishments Worksites Schools Colleges and Universities Hospitals Rental housing

3. Health Reasons for Smoke-Free Housing

4. U.S. Surgeon General’s Call to Action to Promote Healthy Homes There is no risk-free level of exposure to secondhand smoke (SHS) In multi-unit housing, SHS moves between units through: Ventilation systems Cracks in walls Openings for plumbing and electrical systems Open doors and windows Cleaning the air or ventilating buildings does not eliminate exposure to secondhand smoke US DHHS, 2006

5. Dangers of Secondhand Smoke Secondhand smoke (SHS) is the smoke that comes from a lighted cigarette or tobacco product SHS contains 11 known cancer-causing poisons and 239 other known toxins Exposure to SHS increases the risk of: Heart attacks and stroke Lung cancer and emphysema Frequency and severity of asthma Sudden infant death syndrome (SIDS) 38,000-65,000 deaths a year in the US are caused by SHS 2006 and 2014 US Surgeon General’s Report on Secondhand Smoke

6. Thirdhand Smoke Thirdhand smoke is the residual nicotine and other chemicals left by tobacco smoke on a variety of surfaces, such as carpets, walls, and blinds It remains in the environment long after the act of smoking has stopped It reacts with common indoor air compounds to create a cancer-causing mix that can be breathed in or absorbed through the skin Children are particularly at risk for damage from thirdhand smoke Schick et al, 2013; Hang et al, 2013; Mayo Cinic

7. Smoke-Free Housing: Legal Issues

8. Smoke-Free Housing Policies are Legal There is no constitutional protection for smokers Smokers are not a protected class Smoking is not a fundamental right There are no federal legislative or regulatory barriers to the implementation of smoke-free housing policies In fact, HUD has specifically endorsed smoke-free policies (2009, 2010, 2012 notices) There are no state barriers to voluntary implementation of smoke-free policies by property owners

9. Potential Liability Issues for Landlords over Secondhand Smoke Violation of the implied warranty of habitability Violation of the implied covenant of quiet enjoyment Constructive eviction Negligence Reasonable accommodations for people with breathing problems or other health problems under the Fair Housing Act Changelabs, 2013; http://changelabsolutions.org/publications/legal- options-tenants-shs

10. The Business Case for Smoke-Free Housing

11. Cigarette Smoke Causes Costly Damage to Units Nicotine coating on walls, appliances—everything! Burns in carpeting and elsewhere Creates increased need for outside contractors One study showed costs for turning over a unit where smoking had occurred were two to five times greater, depending on the amount of smoking Smoke-Free Housing New England, 2009

12. Cigarette Use and Threat of Fire Improperly discarded smoking materials are the #1 cause of residential fire deaths in the US Between 2006 and 2010, smoking materials caused 1 out of 3 fire deaths in multi-unit housing Oxygen tanks are highly flammable and commonly found in elderly housing National Fire Protection Association, Fire Analysis and Research Division, 2012; photos courtesy of Scott Alderman and Rick Allen

13. QAP Incentives for Smoke-Free Housing 8 states include incentives for smoke-free policies in their QAPs Arizona (2-4 points) California (2 points) Colorado (1 point) Maine (threshold requirement) Minnesota (1 point) Montana (1 point) New Hampshire (2 points) Rhode Island (2 points)

14. Smoke-Free Housing: North Carolina Research

15. 2012 Survey of NC Public Housing Authorities (n=93) 36% of PHAs reported having some sort of smoking restriction in place on one or more of their properties (e.g., in common areas, community rooms, grounds, offices or units) 4 PHAs had one or more properties with smoke-free units: Wilmington, Charlotte, Wilson, and Pender County In 2013, the Northwest Regional Housing Authority and Oxford Housing Authority passed smoke-free policies for all of their properties NC Tobacco Prevention and Control Branch

16. 2013 NC Affordable Multi-Unit Housing Survey The NC Division of Public Health sent survey to all properties subsidized by HUD, NC Housing Finance Agency, and USDA Rural Development 1063 properties returned survey (57% response rate) Results showed 16.5% of affordable housing units in North Carolina were covered by a smoke-free policy in 2013 2014 update: 28% or greater of NC affordable housing smoke-free

17. Smoke-Free Policy Enforcement Staff time  Majority (84.8%) of smoke-free properties reported equal or decreased staff time devoted to smoking- related issues Violations  Half of smoke-free properties reported no violations within the previous 12 months; Properties which reported violations most commonly detected them during routine inspections

18. Smoke-Free Policy Enforcement Legal issues  Very few properties had terminated leases or taken legal actions to enforce their policies in the past 12 months Out of 16,168 smoke-free units in the state, 49 leases were terminated (0.3% of units), and 5 summary ejectment complaints were filed and all were granted

19. Comparing Smoke-Free and Smoking-Allowed Properties No difference in: o Average annual occupancy rate o Residents moving away due to smoking-related issues

20. Engage and inform residents “If you discuss and have educational information sessions in regards to 2nd hand smoke most persons who smoke will honor your policies. The more informed people are the better they react to your requests for no smoking.” NC Affordable Housing Survey: Suggestions from Managers

21. Provide enough time before policy change “As long as the tenants know and have a period of time to get used to the idea they will be fine.” “Ample notice must be given. Not all residents are going to abide by all rules.”

22. Clearly state policy in lease and at move-in “It is easier to enforce the smoke free policy because it is clearly stated in the lease that we are a smoke- free unit.” “The residents are made aware of the smoke-free policy before they move in.”

23. Provide resources for people who want to quit smoking “Involve residents as much as possible and offer/ refer available resources for quitting.”

24. Enforce the policy consistently and firmly “Be consistent with residents and keep them informed. Take the policy serious and make sure [it] is enforced at all levels.” “Be consistent and firm in making the residents aware of the smoke-free policy.”

25. Remind residents frequently “Give constant reminders, such as smoke free signs and little blurbs in the monthly newsletters.” Image Credit: DHIC

26. Smoke-Free Housing: Resources

27. www.smokefreehousingnc.com

28. Smoke Free Multi-Unit Housing Resident Brochure

29. Health Departments May Be Able to Provide Resources State and local health departments in your area may be able to assist with: Providing information sessions to residents on the health impacts of smoking and secondhand smoke Providing resources to help residents quit smoking Other health-promoting services for your residents

30. “When we rented here…this was our home, our castle to live in. I pay my rent, I keep my bills paid. It feels just like when you snatch a toy away from a child.” Mary L. 77 years old Smoking 62 years Policy Can Motivate Change “I’ve had 4 heart attacks. My doctors have been talking to me about quitting smoking. The smoke-free policy has been the push to get me started.” Mary expressed at a group meeting how she felt about the policy change Mary, 2 weeks later, after she decided to join a smoking cessation class

31. For Further Information or Assistance from the NC Division of Public Health Anna Stein, JD, MPH (919) 707-5406 anna.stein@dhhs.nc.gov Pam Diggs, MPH (919) 707-5407 pamela.diggs@dhhs.nc.gov