Titus et al. Respond to “Guiding Comprehensive and Equitable Policy”

This article is linked to 'A Matched Analysis of the Association Between Federally Mandated Smoke-Free Housing Policies and Health Outcomes Among Medicaid Enrolled Children in Subsidized Housing, New York City, 2015-2019' and 'Invited Commentary: Use of Epidemiologic Methods to Guide Comprehensive and Equitable Approaches to Policy' (https://doi.org/10.1093/aje/kwac089 and https://doi.org/10.1093/aje/kwac184).

We thank Dr. Widome for her thoughtful commentary (1) on our study evaluating associations between smoke-free housing policies in New York City Housing Authority (NYCHA) developments and respiratory outcomes among Medicaid-enrolled children (2). Dr. Widome raised several themes pertinent to our study and to tobacco policy evaluations more broadly. Because each theme has significant implications for future epidemiologic research in this area, we offer our additional perspective on her commentary.

First, Dr. Widome notes the importance of engaging epidemiology across the policy life cycle, extending from the pre–policy-implementation phase and including long-term surveillance. We fully agree. Our finding that smoke-free policies were not associated with reduced respiratory health-care visits in the first 17 months following policy introduction mirrored our prior analysis of air quality (3), which similarly failed to find significant reductions in particulate matter less than or equal to 2.5 μm in aerodynamic diameter (PM_2.5) or airborne nicotine in the immediate postpolicy period. However, policy implementation does not happen overnight, and more recent work suggests that a longer time horizon may yield different insights. In a companion study, we found evidence of substantially reduced airborne nicotine levels in NYCHA hallways 3 years after policy implementation, as compared with hallways in developments not covered by the policy (4). To achieve measurable change in health outcomes similarly may take time. We are continuing to monitor rates of childhood asthma, birth outcomes, and other conditions. Our studies are not the first to suggest variable impacts of smoke-free policies over time (5), highlighting the importance of analytical techniques that examine temporal heterogeneity.

Second, Dr. Widome notes that while epidemiology can explore whether policies work to reduce secondhand smoke exposure in specific contexts, qualitative research is better equipped to answer “why” questions, highlighting an important interplay between disciplines. Our own qualitative research—guided by implementation science frameworks—identified that smokers did not feel sufficiently engaged in policy rollout and that there was low trust that there would be adequate enforcement, among other factors (6). These qualitative findings—in combination with air quality and health outcome monitoring—have informed NYCHA’s implementation approach, including the introduction of peer navigators and additional efforts to engage smokers. This work emphasizes that context matters for smoke-free policies and that there is considerable value in collaborations between epidemiologists and implementation scientists, especially in dynamically evolving contexts.

Finally, Dr. Widome underscores the importance of valuing equity in our policies. Patterns of smoking and secondhand smoke exposure are deeply impacted by inequities in housing conditions, access to cessation resources, tobacco marketing exposures, tobacco policy environments, and other societal factors that have concentrated many of the harms of smoking in marginalized communities. Inequities in tobacco-related exposures contribute to respiratory health disparities across housing environments. Indeed, our prior research in New York City suggests a particularly high prevalence of asthma among residents living in public and subsidized housing (7). In this context, smoke-free housing policies may be an important component of a broader “healthy homes” agenda, particularly for the nearly 80 million individuals in the United States who live in multifamily housing environments (8). Centering health equity in this work requires a principled approach to policy formulation and evaluation, which includes engaging multidisciplinary perspectives and involving those most affected by potential policies early in the process.

Few risk factors have been as widespread, or have caused as much harm, as combustible tobacco use. While the dramatic decline in smoking prevalence in the United States over the past several decades is a testament to the success of public health interventions, smoking continues to be the leading cause of preventable mortality in the United States, and its impacts are disproportionately distributed. We appreciate Dr. Widome’s insights (1), which provide actionable guidance for epidemiologists to prioritize health equity in tobacco control and other policy evaluations.