LESSONS LEARNED FROM THE N.C. SMOKE-FREE AFFORDABLE HOUSING SURVEY
Dec 23, 2015
LESSONS LEARNED FROM THE N.C. SMOKE-FREE AFFORDABLE HOUSING SURVEY
How is this survey different from previous surveys?
• Survey of properties, not individual operators
• Statewide census
• Asked questions that operators wanted to know answers to
Previous surveys
Author &Year
Title Sample Size & Response Rate
Main Findings
Limitations
Hewett et. al, 2007
Renter and Owner or Mgr. Perspectives
49 MUH operators in Minnesota; convenience sample
Operators unaware of policies, not interested
Convenience sample and small sample size
King et. al, 2010
Prevalence and Predictors of SF Policy
241 MUH operators in 2 NY counties; 62% response
13% reported smoking restrictions
Sampled operators, not properties
Cramer et. al, 2011
Landlord Attitudes and Behaviors
392 operators in Douglas County, Nebraska; 30.1% response
Identified main operator concerns about SF policies
Low response rate
Previous surveys
Author & Year
Title Sample Size & Response
Rate
Main Findings Limitations
Jackson et. al, 2011
A Systematic Examination of Smoke-Free Policies in MUH Dwellings in VA
263 operators in four VA cities, 51% response rate
Low availability of smoke-free MUH
Small sample
Ong et. al, 2012
Estimates of Smoking-Related Property Costs in California MUH
343 CA operators, 22.4% response
Smoke-free properties had lower smoking-related costs
Sampled operators, not properties; low response rate
SURVEY METHODS
Funding and Partners
• Funding from CDC’s Community Transformation Grant
• Carolina Survey Research Lab at UNC-Chapel Hill contracted to:– Clean sampling frame– Field survey– Analyze data
Survey Development
• Drafted survey questions using:– Past surveys of housing operators– Advice from smoke-free housing researchers– Input from housing industry professionals
• Tested survey questions with small group of regional property managers
• Finalized survey questions based on feedback
Final Survey• Three sections
1. Questions about property and unit characteristics completed by all properties
2. Questions about interest in smoke-free policies and resident experiences completed only by smoking-allowed properties
3. Questions about implementation and enforcement of policies and resident experiences completed only by smoke-free properties
Sampling
• Sampling frame created with lists from:– U.S. Department of Agriculture (Rural
Development)
– U.S. Department of Housing and Urban Development
– North Carolina Housing Finance Agency
• Identified 1,865 affordable multi-unit housing properties
• All properties surveyed
Recruitment
• CSRL called all properties to identify best survey respondent and verify contact information
• Reached out to company executive contacts at medium and large companies with reminder emails– Company executives contacted property
managers and encouraged them to participate
Data Collection
• June to October, 2013
• Online survey or mailed questionnaire
• $25 incentive for respondents
• 1063 properties completed survey
• Overall response rate: 57%– Online: 665 completed survey online (62.6%)
– Paper: 398 completed paper survey (37.4%)
Recommended Practices
Obtain input from housing industry professionals for instrument
Ask questions that operators are interested in knowing the answers to
Get buy-in from housing industry professionals to participate
Have an adequate budget for respondent outreach and incentives if possible
POLICY PREVALENCESURVEY RESULTS:
Smoke-Free Policy Prevalence in NC Allowed
in allAllowed in some
Not allowed in any
N/A
Rule type % % % %Rules about smoking in indoor common areas (hallways, laundry rooms, community rooms, and offices)
9.8 3.6 69.6 17
Rules about smoking in outdoor common areas (parking lots, playgrounds, lawns, and swimming pools)
67.2 22 10.8 --
Rules about smoking in outdoor private areas (patios, porches, and balconies)
65.4 6.5 7.9 20.2
Rules about smoking in residential units81.2 2.4 16.5 --
Smoke-free Policy Implementation
58.3% of properties had converted to smoke-free; 41.7% opened smoke-free
Median year of smoke-free policy implementation was 2010
Only 2.4% of properties allowed smoking in some residential units (vs. in none or all) 73.6% of those properties had “grandfathered”
smoking residents
Variables Associated with Smoke-Free Policies
Properties that were smoke-free were more likely to: Be built after 2001 (p=0.01) Not receive subsidies designated for families
(p=0.01) Be managed by medium-sized companies (vs.
small or large) (p=0.01) Have residential units accessed by an interior
hallway (vs. accessed from outside) (p<0.001)
How do these results compare to previous surveys?
Previous studies in NY, Virginia, and Nebraska have found similar prevalence of smoke-free policies (9%-16.2%)
Study in 2 counties in New York also found that older buildings were less likely to have smoke-free policies
No other studies have looked at company size or type of access to residential units
Children disproportionately live in smoking-allowed properties
10.49% of children live in smoke-free properties; 95% CI [5.6%-15.37%]
15.06% of adults live in smoke-free properties; 95% CI [10.54%-19.58%]
Additional regression analysis indicated that, at most properties, the odds of having a smoke-free policy decreased as the number of children per unit increased
Implications for Practice Overall policy prevalence is low, and more
smoke-free policies needed to protect vulnerable populations, including children
Operators need examples of older properties being successfully converted to smoke-free
Outreach to smaller companies
Housing operators may have misperceptions about the ability of secondhand smoke to transfer between units that open to the outdoors
SMOKING COSTS AND POLICY OUTCOMES
SURVEY RESULTS:
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
49.8% of smoke-free properties reported violations within the previous 12 months, mostly (80.9%) detected during routine inspections
Smoke-Free Policy Enforcement
Legal issues Very few properties had terminated leases or taken legal actions to enforce their policies in the past 12 mo.
•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 granted
Comparing Smoke-Free and Smoking-Allowed Properties
• No difference in:o Average annual occupancy rateoResidents moving away due to smoking-
related issuesoResident complaints about:
• Tobacco smoke in residential units• Tobacco smoke in outdoor common areas
Turnover Costs• 57.5% of smoking-allowed
properties reported that average turnover cost per unit was more in units that had been smoked inAverage cost more per unit: $347.74
• 41.3% reported the cost was about the same
Image: AC Vents from non-smoking and smoking unitImage credit: Mary Gillett
Smoking-Related Fires(in the last 36 months)
• Total: 49 fires– 45 at smoking-allowed
properties
– 4 at smoke-free properties
• Range of costs:
$0-$513,366Image credit: Scott Alderman,
Landura Management Associates
Implications for Practice: Concerns About Policies Unfounded
Previous surveys have identified concerns about enforcement, costs, and legal issues as the main barriers to smoke-free policy adoption
These concerns countered by our results
• Identical occupancy rates
• Less time dealing with smoking-related issues
• Rare need for legal intervention to enforce
• Courts will enforce the policies
OPERATORS’ RECOMMENDATIONSQUALITATIVE RESULTS:
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.”
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.”
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.”
Provide cessation resources
“Involve residents as much as
possible and offer/ refer available resources for
quitting”
Enforce the policy consistently and firmly
“To 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.”
Remind residents frequently
“Constant reminders,
such as smoke free signs and little blurbs in the monthly newsletters”
Image Credit: DHIC
FUTURE RESEARCH
Directions for future researchGreater exploration of cost savings for
operators going smoke-free• North Carolina Division of Public Health
beginning case study in the fall Impact of smoke-free policies on resident
health• Difficult to get sufficient sample size of residents
with measurable health conditions• Transient populations• May be able to see impact of large-scale policies
(e.g. municipality-wide)
References Cramer ME, Roberts S, Stevens E. Landlord attitudes and behaviors regarding
smoke-free policies: implications for voluntary policy change. Public Health Nurs. 2011;28(1):3–12. doi: 10.1111/j.1525-1446.2010.00904.x
Hewett MJ, Sandell SD, Anderson J, Niebuhr M. Secondhand smoke in apartment buildings: renter and owner or manager perspectives. Nicotine Tob Res. 2007;9(suppl 1):S39–47. doi: 10.1080/14622200601083442
Jackson SL, Bonnie RJ. A systematic examination of smoke-free policies in multiunit dwellings in Virginia as reported by property managers: implications for prevention. Am J Health Promot. 2011;26(1):37–44. doi:10.4278/ajhp.091005-QUAN-329
King BA, Travers MJ, Cummings KM, Mahoney MC, Hyland AJ. Prevalence and predictors of smoke-free policy implementation and support among owners and managers of multiunit housing. Nicotine Tob Res. 2010;12(2):159–163. doi:10.1093/ntr/ntp175
Ong MK, Diamant AL, Zhou Q, Park H-Y, Kaplan RM. Estimates of smoking-related property costs in California multiunit housing. Am J Public Health. 2012;102(3):490–493. doi:10.2105/AJPH.2011.300170