Perceptions of Secondhand and Thirdhand Smoke Among Hispanic Residents of Multiunit Housing

Abstract

Despite the progressive adoption of smoking bans in public spaces, children living in multi-unit housing remain at risk of exposure to secondhand smoke (SHS) and thirdhand smoke (THS). Hispanic populations in California are particularly vulnerable to the harmful effects of SHS and THS because a large proportion of Hispanics live in multi-unit housing. Three focus groups were conducted in the fall of 2012 (in Spanish and English, N = 24) to understand Hispanics’ knowledge of and experiences with SHS and THS, including barriers to avoiding smoke exposure and strategies for protecting their homes from smoke. Hispanic residents reported unpleasant experiences with SHS and THS and were generally knowledgeable about the adverse health effects, although they were not familiar with the term “thirdhand smoke.” Some participants also mentioned marijuana smoke as a potential health hazard. Hispanic cultural values made participants reluctant to confront their neighbors but also motivated them to find ways to protect their families from smoke. Potential solutions included working with the smokers to designate a smoking area and gaining support from the building owners. Broad smoking policies should be implemented to help Hispanic residents overcome cultural and social barriers to smoke free air.

Introduction

A significant proportion of the United States population continues to be exposed to tobacco smoke despite significant declines in smoking prevalence and the progressive adoption of smoking bans in public spaces. Only one in three Americans lives in a place where there are complete smoking bans in public places and worksites [23]. Over 40 % of children between 3 and 11 years old are exposed to tobacco smoke at home, and smoke exposure is especially prevalent among children living below the poverty level [8]. Most adults in the United States are aware of the negative effects of smoking, but fewer are aware of the health risks of secondhand smoke (SHS) and thirdhand smoke (THS) exposure [26].

Secondhand smoke (SHS) is “the smoke inhaled by nonsmokers that contaminates indoor spaces and outdoor environments” [22]. SHS is a known carcinogen and increases the risk of coronary heart disease [2] among nonsmokers. Exposure to SHS also exacerbates medical conditions such as allergies, asthma, migraines, diabetes, heart disease, and hypertension [6]. SHS exposure during pregnancy increases the risk of low birth weight, sudden infant death syndrome, asthma, and mental developmental delay [12, 17, 22]. There is no safe level of exposure to SHS and it is especially harmful to children, pregnant women, and the elderly.

Thirdhand smoke (THS) consists of “the residual tobacco smoke pollutants that remain on surfaces and in dust after tobacco has been smoked” [5]. THS in the form of ashes and dust can penetrate surfaces such as furniture, curtains, walls, clothes, hair, and car upholstery. This dust, which contains numerous human carcinogens, can react with other chemicals and convert back into a gas that can be inhaled by nonsmokers [20]. In contrast to SHS, THS is invisible, lingers in the environment, and cannot be removed via usual cleaning methods [5]. THS chemicals are found in quantities 5–7 times higher in homes of smokers than non-smokers, even when the smokers smoke outside their home [15]. Although THS has received less research attention than SHS, recent studies have concluded that 5–60 % of the increased mortality risk associated with living with a smoker can be attributed to THS [19].

Home smoking bans can partially, but not completely, reduce SHS and THS exposure [15]. Unfortunately, only about one-half of households with smokers implement and enforce complete home smoking bans [16]. Smoking bans are more common among families with children [3], but they are less likely among residents with low socioeconomic status [28]. A larger proportion of foreign-born than U.S.-born Hispanics report full smoking bans at home, suggesting that acculturation to the U.S. leads to leniency towards smoking [7].

Children who live in multi-unit housing are significantly more likely to be exposed to tobacco smoke than are those who live in single-family homes [25]. Exposure in multi-unit housing occurs from SHS from neighboring units and from THS accumulated by previous tenants’ smoking. Even with closed doors and windows, SHS can drift inside apartments through air vents or walls [10]. Non-smoking residents who move into an apartment vacated by a smoker can be exposed to THS in carpets, draperies, and walls, even after the apartment is cleaned [14]. Hispanic populations in California are particularly vulnerable to the harmful effects of SHS and THS because 45 % of California Hispanics live in multi-unit housing, as compared with only 37 % of Whites [9].

Qualitative interviews and focus groups with Hispanic multiunit housing tenants [1] have shown that although most residents dislike smoke exposure, most choose not talk to their landlords or the smokers to address the issue directly. Some Hispanic cultural values such as respeto (treating others with respect and not interfering with their personal choices) and simpatía (the importance of maintaining smooth interpersonal interactions) may make Hispanics reluctant to ask their neighbors not to smoke [18]. Other cultural values such as familismo (responsibility to care for extended family and friends) can increase the likelihood that Hispanics will implement home smoking bans or ask others not to smoke to protect family members [11, 21, 24].

In cities that do not have smokefree multi-unit housing laws, an interim solution is for landlords and tenants to work together to implement and maintain smokefree rules. However, little is known about perceptions of SHS and THS among Hispanic multi-unit housing residents, their attempts to protect themselves and their families from smoke, and their communications with neighbors and landlords about reducing smoke exposure. The purpose of this qualitative study was to understand Hispanics’ knowledge of and experiences with SHS and THS, including barriers to avoiding smoke exposure and perception of strategies for keeping their homes free from smoke. The ultimate goal of this research is to develop culturally relevant health education tools to empower residents of multi-unit housing to take action to protect themselves and their families from SHS and THS.

Methods

Three focus groups were conducted in the fall of 2012, two in Spanish and one in English (total N = 24). Participants were recruited via teachers at a public elementary school in the East side of Los Angeles, California next to a large public housing development in a low-income, predominantly Hispanic neighborhood. The student body of the school is 98 % Hispanic, 93 % eligible for free or reduced price lunch, and 31 % English learners. Elementary school teachers distributed flyers to parents who were dropping off or picking up their children at the school. The flyer contained a brief description of the study and a phone number to call if they were interested. Parents who called the number spoke with the study’s project manager, who explained that the purpose of the study was to learn more about exposure to smoke among Hispanic residents of apartment buildings. Adults were eligible to participate if they were Hispanic, 18 years of age or older, and resided in multi-unit housing in Los Angeles. Several participants resided in the government subsided apartments located near the school. There were 7 men (29 %) and 17 women (71 %); 16 (67 %) preferred to speak Spanish and 8 (33 %) preferred to speak English; all were non-smokers except for two men who were current smokers and two men who were former smokers.

The research team developed a focus group guide that included questions about knowledge and misconceptions about SHS and THS, personal and family exposure to SHS and THS, personal home smoking bans, perceptions of the extent of the problem in multi-unit housing, perceived social norms about smoking inside apartment units, in common areas, and outside, conversations with neighbors and landlords about smoking, preferences for policies, barriers to avoiding exposure to SHS and THS, barriers to speaking with managers and landlords about smoking, intentions to avoid smoke and/or talk with neighbors or landlords, and tips for effective conversations with neighbors and landlords about reducing SHS and THS. Focus group methods were selected because they would help inform development of a fotonovela based on beliefs and experiences with smoking in their homes. The focus group guide was pretested with five Hispanics who lived in apartments. Participants provided written consent and received a gift card incentive. The discussions were tape recorded, transcribed, and the Spanish ones were translated by three bilingual staff members. During the focus groups, the participants were identified only by a code letter. The same code letter was used in the transcriptions so the respondents were not identified by name anywhere in the dataset. A bilingual research team member coded and analyzed the information in a thematic format according to defined groupings, with frequency of comments noted for the predetermined categories. All procedures were approved by the University’s Institutional Review Board.

Results

Knowledge and Misconceptions About SHS and THS

The participants were generally knowledgeable about the definition and health effects of SHS. Most of their knowledge came from hearsay sources, healthcare providers, and public service announcements. Most participants associated SHS with asthma, other respiratory problems, and an unpleasant quality of life at home. Several female participants were concerned about the safety of their children and unborn babies. A few stay-at-home mothers recalled being exposed to SHS throughout their pregnancies without options for a smokefree environment. Although their obstetricians had educated them about the harmful effects of smoking while pregnant, some of them were not informed about the risk of SHS.

None of the participants knew the definition of THS, which was unsurprising because this is a relatively new term. However, once it was explained to them, they were familiar with the effects:

Both of my parents smoked in the apartment, so that was second hand for me and my clothes would smell like cigarettes so I’m assuming that is third hand for me.

In general, participants had not thought about the health effects of THS. Instead, they viewed THS as a way to detect that some was smoking secretly and trying to hide it:

I would leave, I parked the car and I would smoke a cigarette and I would come back. Although the smell never goes away even after you wash your mouth and everything; the odor of the cigarette is not removed. I’d say, hey what’s up? As I came from the bathroom…[my wife says] you smoked!… I know what you smell like.

Employed participants shared concerns about THS exposure in the workplace. Several men were day laborers who had been hired to paint apartments that smelled like cigarettes. A woman recalled cleaning the windows at work that had turned dark yellow from coworkers’ smoking.

Personal and Family Exposure to SHS and THS

Five of the 24 participants lived with a smoker in their household. The smokers were their fathers, wives, and/or husbands. Some had smokers who visited. There was a consensus among participants about smoking rules in the home. None of the smokers were given permission to smoke inside the home, regardless of their family status or gender. However, rules were not always easy to enforce if the smoker was an older male relative. In general, participants reported that their family members voluntarily went outside the apartment to smoke, especially when children were present:

I live with someone who smokes but before I would have kids he would always smoke at my place. When the years came that I had my children he began to smoke sometimes outside the house and sometimes not even outside the house… Today it’s almost rare to see him with a cigar… But he has tried [to stop] and my son got sick of asthma, an asthma attack… He usually did not smoke but also his brother was a smoker and when he would come he would smoke. And he would spend it smoking and I would just close the doors and get my children inside. But my husband did stop smoking, not definitely, but he did decide [to stop].

Other smoking family members needed to be reminded not to smoke indoors:

And I kick her [wife] out, “go over there” I tell her… no, no, no, I make her go further to the corner. There she is alone the way it should because it is what she wants.

Although these smokers smoke outside, they are usually still close to the buildings and smoke still drifts into the apartments via the doors, balconies, and windows, especially when the weather is too hot to close the windows:

My kids are like this the whole time in the living room so I just have to close the window or the door…They don’t like the smell.

My children don’t smoke and it does bother them. I have to close all the windows where they are and the doors too. During hot weather can you imagine how hot the house gets?

Respondents were especially concerned about the effect of SHS on people with asthma:

My cousin’s boyfriend smokes, even though he smokes in the balcony sometimes the smoke travels in and I’m asthmatic so that kind of like triggers everything.

Another recalled the economic and human cost to her family:

And if my kid has an asthma attack and I don’t have someone to take me fast enough to go to the hospital and I told them the paramedics charge 3000 dollars and you will have to be the ones to pay me that money.

Perceptions of the Extent of the Problem in Multi-unit Housing

Residents reported that SHS and THS compromised their quality of life:

So being in the apartment trying to watch TV, trying just to relax and rest and…just it smells nasty. It goes through the window, through the doors and like I don’t smoke so I don’t like the smell. That’s why I don’t go home and rest ‘cause you really can’t because the smell bothers.

SHS extended to public spaces in the apartment complexes:

Sometimes I have seen that there are parks inside housing apartments for the children and recreation. The children are taken there to play with their families and the smokers are there smoking.

However, the neighbors’ smoking habits did not necessarily strain existing relationships:

When [my friend] smokes she goes outside. I wait for her to finish and then we come back to do the chisme (gossip).

The non-smoking participants felt it was inappropriate for the neighbors to smoke in or near the building. Non-smokers held the cultural expectation of respeto from the smokers:

I think the people got to have respect for you. If they know you’re not smokers then why are they doing it in your house and you know people who live there should tell them smoke outside. Like I do have a cousin whose boyfriend is a smoker but he stands on my balcony and sometimes the smoke does travel in so we have to shut the door on him. But I think it’s out of respect, a lot of people just don’t, like my dad, if I’m giving him a ride somewhere, he has to smoke a cigarette before he gets in my car.

Conversations with Neighbors About Smoking

Some participants had attempted to ask their neighbors not to smoke or to smoke further away as politely as possible:

I go outside and I tell them, “You know what? I’m sorry but I know this is an open place, it’s not my place, I don’t own it but could you please stop smoking by my door because I have younger kids and I don’t like my kids to smell that”… and they go away, they go away. You know I’m just saying nicely I don’t want to have problems with anyone so can you please do that. And they do and they do go.

However, participants noted substantial barriers to talking with neighbors about smoking. Participants living in government-subsidized buildings expressed a fear of retaliation by gang members:

One can’t say anything because they will jump you. My husband got to experience it because something about the smoke. We had a bedroom where we would take care of our kid when she stepped outside to play. The teenagers didn’t like us being there because they thought we were spying on them so they took something and they broke all of the windows of our truck. One can’t tell them anything! They just smoke and smoke; One can’t say anything!

One day the next door neighbor tells us that we don’t even know what we are getting ourselves into. ‘I have a brother that is from a gang and he knows you.’

Well, I think it’s not fear, it’s simply just [our] security because if you talk, if the people notice that you talked I think they can cause harm to one because the police always arrives late and they never arrive in the hour that one calls. And it is not because it has happened to me it’s because I have heard from other neighbors that have told me.

Participants also spoke about the cultural value of simpatía and the importance of preserving good relations with neighbors:

‘Cause my neighbor is really good with me I don’t got no complaint. I could do whatever I want and make all kinds of noises and she won’t bother me… Well honestly in my house it should be but just honestly I don’t want to cause problems. So I just close my window [when that neighbor smokes] and that’s it. That’s how it’s going to be.

Yeah I have to remind them. But they don’t say nothing. I keep everything nice with them and everything and everybody with the neighbors, but you know I like last week I told them you know what if you have kids you have to understand me cause if you have kids you are not going to want this for your kids.

If one communicates nicely with the teenagers that they do pay attention. At my home I would go outside and knock and tell them, ‘you know what young ladies I have a headache and I really can’t stand the smoke. Can you girls please move to another place.’ Okay Mrs., and they would leave.

Another significant barrier was the participants’ inability to communicate with neighbors who spoke other languages:

There is a Chinese man who smokes every 5 min… It seems like he feels remorse when he sees the children outside. He tries to move away from his door but the smoke travels no matter what. He ‘gets it’ and tries to move away. I was going to invite him today but there we don’t have a translator. He doesn’t speak Spanish and very little English and I don’t speak English.

Some participants also noted that marijuana smoking was co-occurring, and the marijuana smokers were not always receptive to being asked not to smoke in or near their apartments:

I have a neighbor that looks like a chimney. Not only does she smoke cigarettes but she also smokes marijuana. I have talked with her because it is my right and because I have to protect my family. Then I go and talk with her and [say] ‘please don’t be smoking a lot in the bathroom because everything goes to my bathroom and I have a kid with asthma.

Well no that’s what they think. They’re like that’s my apartment, I pay rent, I pay my bills; so I could smoke here or blunt [smoke a cannabis cigar]. If you choose not to smoke in your apartment that’s on you, but this is my apartment. I paid my rent. I paid my bills so I could do what I want to do. That’s their opinion. Like I have a different opinion.

Last week I saw three teens smoking which I know their mothers and it was embarrassing to tell them this but I told them, ‘you know kids I want all of you to leave this place. I have a kid that is sick with asthma.’ The kids tell her ‘Marijuana is medicine for him.’ Guess what this is not medicine for a 10 year old kid. Then one of them wanted to give me attitude. Hey I am talking to you nicely to move to another place and if you don’t then I will have to call the police. Then they left.

Policy Awareness and Attitudes

At the time of the study, there was not a citywide law banning smoking in multi-unit housing. However, laws were in place allowing landlords to make their buildings smokefree (California Senate Bill 332). Some participants living in public housing had received a letter informing them of a new anti-smoking policy in their government-subsidized building with the possibility of eviction if caught smoking on the premises. However, most tenants ignore such notices because they perceived that enforcement of the policies was generally lax.

We do have our signs of no smoking within 100 feet and you know the offices are there. We have people sitting right there smoking and I have to go up to them as part of my job and ask them to please you know. There is a sign that we can evict them. Sometimes you get attitude from certain people but they do end up moving.

Most of us live in apartments and never has there been any rule. There’s no rule. It’s just out of respect if they want to [not smoke near the apartments]; they won’t do it, but out of respect. Some of them don’t really care. You can ask them not to smoke, but yeah they don’t care.

Several participants were asked about smoking when they filled out their rental applications or when the company changed owners:

When I moved in 5 months ago to my new place. When I did the application they asked if I smoked so he said not inside. So it was in the application material, so you have that rule.

Talking to Landlords and Managers About SHS and THS

Several participants reported that they had talked with their building managers about their neighbors’ smoking. Although some managers were helpful, some managers either ignored them or requested evidence of the transgression, which was difficult to obtain. Some participants expressed fatalistic feelings about convincing the building manager to protect them from smoke:

I would always go to the office and they would say I needed pictures and video. How was I going to take pictures and video if they live in front of me, I couldn’t?

I always went to the office to report but they asked for proof, pictures. It was the fear that didn’t allow me to take pictures of these people. I had to see those people again.

Well I don’t complain with the manager because I don’t think he will listen to me to be honest. The truth is that he just puts a face of disgust.

Potential Solutions to Protect Tenants from SHS and THS

Tenants perceived that the building owner’s support is crucial to protect tenants from smoke:

A landlord has the first say because he owns the building.

Participants also mentioned that the owner and manager had a responsibility to protect the tenants’ health:

We have rights to tell the manager that the next door neighbor is smoking a lot and I have children and I am pregnant. It is the obligation of the managers to go speak with them and to tell them that their neighbors are complaining that you are smoking a lot and that the lady is pregnant. Now if the manager does not listen to you then he will hurt himself because you can sue him.

To prevent interpersonal altercations, they preferred a policy that would be both implemented and enforced from the top. Designating smoking areas away from the building emerged as a solution that would be acceptable to the nonsmokers and the smokers. Most participants indicated that they would be willing to participate in a meeting to talk about smoking policies. The participants thought it would be a good way to inform the community about SHS and THS. Also, since everybody would be invited to attend, nobody would feel targeted, either for being a smoker or for being a complainant:

Cause that way everybody would get the information and then nobody would be like oh it was her, it was him.

I honestly wouldn’t talk directly to the person. I would go straight to my landlord and ask him can you please ask them if they can move. Like being nice about it.

Several participants agreed that neighbors could relate to concerns about children’s health. They suggested that a theme of children with asthma would interest both smokers and non-smokers in working on a common solution.

Discussion

This study extends previous findings about Hispanics’ attitudes towards SHS and THS and generated new ideas for addressing the gap between knowledge and action that is needed to protect multi-unit housing residents from SHS and THS. Hispanic residents of multiunit housing reported unpleasant experiences with SHS and THS and were generally knowledgeable about the adverse health effects. Despite their dislike of smoke and their successful implementation of smoking bans in their own units, they had less self-efficacy to avoid being exposed to their neighbors’ smoke. Some participants had invoked Hispanic cultural values such as familismo to ask their neighbors not to smoke near their children, but other participants cited other cultural values such as respeto and simpatía as reasons why it would be inappropriate for them to ask their neighbors to change their smoking habits. Respondents also mentioned barriers to successful negotiations with neighbors, including fear of violent retaliation and language barriers.

Despite these reported barriers, our results also highlight some encouraging positive changes in smokers’ behavior. Several respondents reported that their family members or friends had stopped smoking in their presence and were now smoking outdoors. This suggests that California’s recent efforts to establish anti-smoking social norms by expanding smoking bans in public places might have made smokers more sensitive to the health and comfort of others. In some cases, more behavioral change might be needed, such as educating smokers not to smoke directly outside neighbors’ windows or air vents. However, these results suggest that many smokers are at least aware of the problem and are taking steps to protect other people from smoke.

These findings are consistent with those of other studies of Hispanic multi-unit housing residents (e.g., [1]). They are also consistent with a study of smoke exposure in extended-stay hotels [13], which found that residents have conflicting goals of trying to avoid exposure to smoke and trying to maintain friendly relationships with their neighbors who smoke. Other studies also have found that although many apartment residents dislike smoke, they also support their neighbors’ right to smoke (Berg et al. 2015). Similar to this study, other studies have found that apartment residents support the idea of establishing smoking areas in safe places away from the building [27]. Together, these studies highlight the complex issues surrounding interpersonal communication about protecting nonsmokers from smoke without vilifying the smokers.

Several unique themes emerged in this study. Residents were generally successful at keeping their own apartment units smokefree, but they were still exposed to smoke when others smoked in adjacent units or outdoor common areas and sometimes had difficulty asserting rules with older male relatives. This suggests that previous health education efforts to convince people to establish smokefree homes have been successful but have not eliminated the problem. Additional health education messages are still needed to convince smokers to protect other people from their smoke.

Although this study focused on secondhand and thirdhand exposure to cigarette smoke, some participants also mentioned marijuana smoke as a nuisance and a health hazard. Multiunit housing residents may be even more reticent to confront marijuana smokers about their smoking for several reasons. First, whereas the health hazards of secondhand tobacco smoke have been well publicized and social norms have turned against exposing nonsmokers to tobacco smoke, marijuana smoking is becoming more normative and the health risks to nonusers have not been disseminated widely. Second, the participants perceived marijuana smokers as more defensive about their drug use and less likely to comply with a polite request not to smoke. Public health messages are needed to convey the message that exposure to any smoke could be harmful. Similar public health messages also might be needed to educate electronic cigarette users that their exhaled vapor also contains chemicals that could harm nonsmokers.

As reported in previous studies [1] Hispanic cultural values were mentioned both as facilitators and as barriers to asking neighbors not to smoke. The value of familismo motivated the participants to protect their family members and extended family from smoke, especially children, the elderly, and those with chronic diseases. However, the value of simpatía and fear of altercations with neighbors made them reluctant to create adversarial relationships with their neighbors by asking them to change their behavior. This is especially relevant in areas with a gang presence, where disrupting harmonious relationships with neighbors can be physically dangerous. The value of respeto appeared to have more complex effects; it made participants reluctant to interfere in their neighbors’ affairs, but participants also expected respeto from their smoking neighbors. One suggested theme that could create solidarity among smokers and non-smokers was protecting children with asthma. Health education efforts could appeal to these values to help Hispanic residents of multiunit housing protect their families from smoke and maintain mutual respeto between the smokers and the nonsmokers, without damaging interpersonal relationships.

Although few previous studies have examined the role of cultural values in protecting people from environmental exposures, a qualitative study of Chinese and Vietnamese immigrants in Boston [4] reported similar findings. The respondents in that study also reported the desire to protect children from SHS, but they also reported feeling reluctant to ask others not to smoke, especially if the smokers were guests in their homes, were community elders, or were attending special events such as weddings. If there is a general consensus across cultural groups that children should be protected from smoke and that many people find it uncomfortable to ask smokers not to smoke, perhaps health education messages should be targeted to smokers encouraging them to protect others from their smoke without waiting to be asked.

Location of smoke free areas was an important theme. The participants stressed the importance of finding solutions that would be acceptable to both smokers and non-smokers, such as a convenient, attractive space away from buildings and playgrounds in order to protect children.

The owners’ and managers leadership and ability to reinforce rules is fundamental for the tenants in the process of creating clean air zones. Residents reported that they would support smokefree rules if implemented by owners and managers, and rules that originate from management would protect individual residents from becoming the targets of retaliation by smokers. Interventions are needed to educate owners and managers about the health, economic, and safety benefits of smokefree multiunit housing, and technical assistance is needed to help them enact and enforce new policies.

This study has several limitations. Because the findings are based on a small sample of Hispanic parents who lived near one school, it is unclear whether the findings would generalize to other geographic areas or to adults without school-age children. Because this study did not collect detailed information about the focus group participants, and because all of the participants lived in the same neighborhood where cultural values and experiences might be more homogeneous than in the larger population of Hispanic Americans, future research is needed to determine whether these conclusions generalize to other communities. Although we emphasized the importance of confidentiality, the participants might have been reluctant to divulge controversial opinions in the presence of other parents from their children’s school.

Smoke-free environments are the most effective method for reducing smoke exposure, but they cannot come at the cost of the tenants’ safety. Tenants do not always feel secure enough to challenge neighbors but may feel driven to do so for their family’s safety, especially if someone has health issues like asthma. Ideally, they will not need to be a lone voice in asking smokers to move, but will have the support of managers, landlords, government officials, and members of the community, both smokers and nonsmokers, who could be engaged in the policy development process.