Residents living in multi-unit housing communities where smoking is allowed are affected by SHS and the negative health risks associated. MUH residents include vulnerable populations such as seniors, children, and minority groups. In addition, studies show that people who live in multi-unit housing tend to have limited or fixed incomes and are most likely to suffer from chronic disease and disabilities. Our project focused efforts in zip codes that that reflect the largest populations of Non-Hispanic Black and Hispanic residents with 20% or more of the population in poverty.
The estimated number of residents living in MUH in Clark County is 879,372. As of November 1, 2021, our smoke-free housing directory includes a total of 52,492 units that are designated as smoke-free which means that to date, an estimated number of 145,928 people or 18% of Clark County MUH have been reached and potentially benefited from a smoke-free policy at their MUH complex. During the two-year project period, a total of 6,098 units were added to the list of smoke-free housing, potentially reaching 16,952 individuals. This figure is inclusive of the 2,494 units located in priority zip codes.
According to the CDC, tobacco use among populations results from a complex interaction of factors including socioeconomic status, social and cultural characteristics, targeted advertising, and tobacco product pricing. Currently, there is no legislation the State of Nevada that prohibits indoor smoking in multi-unit housing. The Nevada Clean Indoor Air Act was originally passed by a majority of Nevada voters in 2006 and it protects children and adults from secondhand cigarette smoke and secondhand aerosol from electronic cigarettes or vaping products in most public places and indoor places of employment. However, the law does not include multi-unit housing communities.
This project aims to reduce exposure to secondhand smoke through the development and expansion of smoke-free policy in the MUH setting. Additionally, we connect MUH residents and staff with free and convenient cessation services. The 2020 Behavioral Risk Factor Surveillance report indicates that an estimated 13.1% of Clark county adult residents smoke cigarettes and 22.2% used e-cigarettes. The same report indicates that 24% of Clark County residents that made under $15,000 annually were current cigarette users. This is a significantly higher than the percent of current cigarette users who earned over $50,000 annually at 8.4%. This data highlights the disparities in smoking rates that exist among different socioeconomic groups.
While the SNHD developed components of a smoke-free housing program starting in 2010, the current project was the first time that a comprehensive approach focused in priority zip codes was implemented.
Compared to the general public, MUH residents, a predominantly minority, lower-income population, are at greater risk for SHS exposure. Low-income individuals generally have higher smoking rates; thus, there is increased exposure to SHS among underserved, low income-communities. Vulnerable populations such as minority groups, children and seniors make up a majority of multi-unit housing renters. Due to the low socioeconomic status (SES) of these vulnerable populations, residents who are exposed to SHS have limited resources to move to another community that is free of SHS. By increasing the number of smoke-free housing communities in priority zip codes, we can reduce the risk for exposure to SHS among our most disparate populations.
This program aims to address inequities by focusing efforts on the social determinants of health though increasing access to smoke-free MUH for Clark County residents. Concentrated efforts were made in zip codes that reflect the largest populations of Non-Hispanic Black and Hispanic residents with low-income levels in Clark County. Although efforts were concentrated on low-income housing properties, several other types of communities such as assisted living, market rate, senior living, and luxury living adopted smoke-free policies as part of this project. To support residents, telephonic cessation services are offered in any language spoken and for residents who preferred in-person cessation classes, a partnership with the American Lung Association provided on site cessation classes at MUH properties. Facilitating access to these cessation services removed transportation barriers. All program materials and the program website are available in both English and Spanish.
A long-standing partnership with the Nevada Minority Health and Equity Coalition was leveraged to assure that program materials and outreach were conducted in a culturally and linguistically appropriate manner. Project staff reflected the racial and ethnic composition of the priority zip codes when possible. Project plans and activities are founded in the evidence-based best practices outlined in the CDC's Best Practice User Guide for Health Equity in Tobacco Prevention and Control. Data on health and economic disparities was incorporated into presentations and stakeholder meetings. In order to provide support to tobacco users that have been historical targets of tobacco industry marketing, free, convenient cessation resources including telephonic (any language) and on-site cessation classes were offered in English and Spanish. Project staff and partners developed a plan to identify community events that were occurring in the priority zip codes and assured a presence at each event to promote the MUH directory and to answer community member questions. This increased visibility assisted us in developing new partnerships with MUH properties, stakeholder organizations, and community members.
Our smoke-free housing program was specifically designed to meet the current needs of Southern Nevadans. Due to COVID-19 more people have been staying home for longer periods of time. This has resulted in an increase in complaints from MUH residents exposed to secondhand smoke infiltrating their units from their neighbors.
The recreational use of marijuana in private residences is legal in Nevada. Studies indicate that exposure to secondhand marijuana smoke can cause significant health issues due to the combustion of carcinogens and toxins, which are concentrated in higher amounts in marijuana than in tobacco. Another concern in MUH is the secondhand aerosol that is emitted from electronic smoking devices (e-cigarettes). The aerosol that is emitted can contain harmful substances such as cancer-causing chemicals, heavy metals, volatile organic compounds, and ultrafine particles that can be inhaled deep into the lungs. The toolkit that was developed and distributed to MUH properties contained information about marijuana and e-cigarette smoke/aerosol to assure that these emerging issues were addressed.
Program staff took a proactive approach in identifying properties that would most benefit from a smoke-free policy and provided tools every step of the way through the phases of policy adoption. Recently, this project was featured during a CDC Racial and Ethnic Approaches to Community Health program call because of its comprehensive yet targeted approach to tackling this smoke-free MUH issue among priority zip codes.
Smoke-free housing initiatives have been in existence across the country for many years, however the comprehensive nature of the SNHD program distinguishes it from other MUH projects. The development and maintenance of the searchable online (English/Spanish) smoke-free MUH directory coupled with the toolkit, media initiatives, community outreach, and printed materials demonstrates the SNHD's commitment to addressing one of the social determinants of health (housing) in a comprehensive manner. The focus on zip codes with individuals at 20% of the poverty level also demonstrates a focus on achieving health equity.
Historically, smoke-free housing rules have primarily addressed SHS derived from tobacco products. However, recently legalized marijuana and e-cigarettes have emerged as causing concerns among MUH residents across the nation. The SNHD project addresses these emerging issues through providing guidance in the MUH toolkit and on the project website. The SNHD project team monitors emerging issues and modifies project materials accordingly.
The current marijuana legislation in Nevada restricts its use in public spaces, only allowing its consumption on private property. Although the law protects public spaces from marijuana SHS exposure, it does not protect residents of MUH units as they are considered private residences. As a result, Nevada faces a particular challenge when it comes to reducing secondhand smoke exposure from all plant-based products in multi-unit housing.
Program staff incorporated many of the practices outlined in the CDC's Best Practices for Tobacco Prevention and Control publication including the use of policy strategies at the MUH level, media interventions, and promoting cessation. Staff utilized the U.S. Housing and Urban Development guidebook on implementing smoke-free policy in public housing as a model in developing our own MUH toolkit. SNHD's toolkit was tailored to meet the specific challenges in Southern Nevada including information on secondhand marijuana smoke and e-cigarette aerosol. The toolkit aims to address common misconceptions and provides local data on the attitudes and opinions towards smoke-free policies in multi-unit housing properties by residents that live in MUH communities in Clark County, Nevada. U.S. Census tract data was analyzed to identify priority zip codes.
The CDC's Best Practices for Comprehensive Tobacco Control Program specifically recommends the implementation of smoke-free MUH policy to reduce exposure to secondhand smoke.