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