A Smokefree Multi-unit Housing Anecdote Jonathan P. Winickoff, MD, MPH Associate Professor in Pediatrics Harvard Medical School September 24, 2011.

A Smokefree Multi-unit Housing Anecdote

Jonathan P. Winickoff, MD, MPHAssociate Professor in Pediatrics

Harvard Medical SchoolSeptember 24, 2011

…dedicated to eliminating children’s exposure to secondhand smoke and tobacco

Social Strategies

Scientific Knowledge

Political Will

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

Comparative Causes of Annual Preventable Deaths in the United

States

17

8141

19 14 30

430

0

50

100

150

200

250

300

350

400

450

(th

ou

san

ds)

Sources: (AIDS) HIV/AIDS Surveillance Report 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993; 270:2207-12; (Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997; (Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995

AIDS Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced

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)

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 (.015-2 ng/mL)

The Life Cycle Effects of SmokingThe Life Cycle Effects of Smoking

SIDSRSV/BronchiolitisMeningitis

Infancy

Low Birth WeightStillbirth

In utero

AsthmaOtitis MediaFire-related InjuriesCognitive Problems

Influencesto StartSmoking

Nicotine AddictionHealth Effects

CancerCardiovascular DiseaseCOPD

Adulthood

Adolescence

Childhood

Arch Pediatr Adolesc Med. . 1997

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.

Effect of a Single Cigarette on Indoor Air Quality

Ott et al. 2003. J. Air & Waste Manage. Assoc.

…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..

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.

11

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

Cotinine levels in children• 2001-2006 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

13

Cotinine levels in children by housing type

14

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

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

Support for Smoke-Free Private Areas

50

52

54

56

58

60

62

64

66

68

2007 2008 2009

Year

% S

up

po

rtin

g S

mo

kin

g B

an

Detached

Multi-Unit

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

18

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

19

Newsweek Magazine Article

The Media has Popularized theThird-Hand Smoke Concept

21

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.

22

Jessica Lin 1st Place winner, FAMRI/ AAP/Richmond Center Art Contest 2009

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.

Resources and tools to aid in your advocacy

efforts

HUD Smoke Free Toolkit – Coming Soon!

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

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

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.

29

AAP Richmond Center of ExcellenceAAP Richmond Center of Excellence

AAP Resources

• 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)

References

1. Winickoff JP, Gotlieb M, Mello MM. Regulation of smoking in public housing. New England Journal of Medicine. 2010 Jun 17;362 (24):2319-25. PMID: 20554988

2. Aligne CA, Stoddard JJ. An economic evaluation of the medical effects of parental smoking. Arch Pediatr Adolesc Med. 1997;151:648-653.

3. Winickoff JP. Ban smoking in public housing. Newsweek Magazine. June 13, 2009. PMID: 19655657

4. 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, 2011. http://www.pedialink.org/cme/eqipptc. Accessed April 11, 2011

References

1.Vital signs: nonsmokers' exposure to secondhand smoke --- United States, 1999-2008. MMWR Morb Mortal Wkly Rep 2010;59:1141-6.

2.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;24:333-9.

3.Benowitz NL. Cotinine as a biomarker of environmental tobacco smoke exposure. Epidemiol Rev 1996;18:188-204.

4.NHANES: Laboratory methodology and public data files. 2009. (Accessed at http://www.cdc.gov/nchs/data/nhanes/labdoc.pdf.)

5.Matt GE, Quintana PJ, Hovell MF, et al. Households contaminated by environmental tobacco smoke: sources of infant exposures. Tob Control 2004;13:29-37.

6.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.

References7.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:e7-14.

8.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;158:687-93.

9.Kitchens GG. Relationship of environmental tobacco smoke to otitis media in young children. Laryngoscope 1995;105:1-13.

10.Delpisheh A, Kelly Y, Rizwan S, Brabin BJ. Salivary cotinine, doctor-diagnosed asthma and respiratory symptoms in primary schoolchildren. Matern Child Health J 2008;12:188-93.

11.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;13:431-8.

12.Weitzman M, Cook S, Auinger P, et al. Tobacco smoke exposure is associated with the metabolic syndrome in adolescents. Circulation 2005;112:862-9.

References13.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;11:517-46.

14.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;155:36-41.

15.Yolton K, Xu Y, Khoury J, et al. Associations between secondhand smoke exposure and sleep patterns in children. Pediatrics 2010;125:e261-8.

16.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;10:335.

17.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;72:209-14.

18.Tebow G, Sherrill DL, Lohman IC, et al. Effects of parental smoking on interferon gamma production in children. Pediatrics 2008;121:e1563-9.

19.Strauss RS. Environmental Tobacco Smoke and Serum Vitamin C Levels in Children. Pediatrics 2001;107:540-2.

References19.Strauss RS. Environmental Tobacco Smoke and Serum Vitamin C Levels in Children. Pediatrics 2001;107:540-2.

20.Wilson KM, Finkelstein JN, Blumkin AK, Best D, Klein JD. Micronutrient levels in children exposed to second-hand tobacco smoke. Pediatrics 2010.

21.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;115:3205-12.

22.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;113:98-103.

23. 2009. (Accessed at http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf.)

24.Winickoff JP, Gottlieb M, Mello MM. Regulation of smoking in public housing. The New England journal of medicine 2010;362:2319-25.

25.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;18:438-44.

26. 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.

A Child’s Perspective

Opportunities to get involved

• 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

Engage…

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 .015-.5 ng/mL

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

How important is it?

• How important an issue do you think secondhand smoke is for your patients?A. Not at all important

B. Somewhat important

C. Important, but we have so many things to address

D. Very important

E. Extremely important

Questions?

Smoke Free Multi-unit Housing:

Moving From Research to Action

Contact Information

Richmond Center of Excellence website: http://www.aap.org/richmondcenter/

Richmond Center of Excellence email: [email protected]

Join the Smokefree Housing Listserve:

[email protected] and ask to join the listserve!

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.

Background

• 18% of children ages 3-11 and 17% of those ages 12-19 are regularly exposed to secondhand tobacco smoke (SHS) in the home

• 54% of children 3-11 and 47% of children 12-19 had detectable cotinine levels in the 2007-2008 NHANES– 32 million children ages 3-19 with exposure

• Newer measurement techniques allow assessment of very low levels of exposure

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 .015-.5 ng/mL

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

Objective

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

Methods

• Data from the 2001-2006 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)

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

Results

Cotinine level (ng/mL) Single house %

Attached house %

Apartment % p-value

<.015 29.7 20.4 15.5 <.001

.015 - <.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

Results

Cotinine level (ng/mL) Single house Attached house Apartment p-value

<.015 29.7 20.4 15.5 <.001

.015 - <.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

Results

Cotinine level (ng/mL) Single house Attached house Apartment p-value

<.015 29.7 20.4 15.5 <.001

.015 - <.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

Results

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 White 76% (61, 86) <.05

African-American 92% (83, 96)

Hispanic 70% (52, 83)

Other 80% (54, 94)

Apartment White 99% (91, 99) <.001

African-American 96% (92, 98)

Hispanic 73% (64, 81)

Other 64% (40, 82)

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 White 76% (61, 86) <.05

African-American 92% (83, 96)

Hispanic 70% (52, 83)

Other 80% (54, 94)

Apartment White 99% (91, 99) <.001

African-American 96% (92, 98)

Hispanic 73% (64, 81)

Other 64% (40, 82)

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 White 76% (61, 86) <.05

African-American 92% (83, 96)

Hispanic 70% (52, 83)

Other 80% (54, 94)

Apartment White 99% (91, 99) <.001

African-American 96% (92, 98)

Hispanic 73% (64, 81)

Other 64% (40, 82)

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 White 76% (61, 86) <.05

African-American 92% (83, 96)

Hispanic 70% (52, 83)

Other 80% (54, 94)

Apartment White 99% (91, 99) <.001

African-American 96% (92, 98)

Hispanic 73% (64, 81)

Other 64% (40, 82)

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.

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

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?

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

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

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

66

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

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

68