A Qualitative Study of Unfairness and Distrust in Smoke-free Housing

Abstract

Objectives:

While smoke free housing (SFH) has the potential to protect residents from tobacco smoke, evidence suggests that SFH could lead to increased indoor smoking. In this study, we examine how perceptions of a residential smoking ban could be related to non-compliance.

Methods:

We conducted 8 focus group interviews of low-income housing residents living in Norfolk, Virginia (N = 53). Interviews were semi-structured and based on a list of guided questions related to SFH compliance, developed in partnership with a standing community advisory board comprised of low-income housing residents.

Results:

Several themes emerged, including pervasive non-compliance, perceived unfairness and shame, barriers to compliance, and distrust of the housing authority. Smokers reported behavior primarily motivated by punishment avoidance, rather than out of any perceived obligation to comply with the ban.

Conclusions:

Results led us to consider Procedural Justice Theory as a conceptual framework, in which compliance is directly related to perceptions about the legitimacy of a rule or authority. When compliance is low due to a lack of perceived legitimacy, SFH should be adapted to promote changes in smoking behavior. We offer specific theory-supported adaptations to SFH focused on trust-building and improving perceived fairness.

Cigarette smoking is the leading cause of premature death in the U.S.¹ While overall rates have declined, disparities persist for many vulnerable sub-populations.² For example, data from the nationally representative Tobacco Use Supplement of the Current Population Survey from 2000 to 2015 suggest that public housing residents are 1.61 times more likely to be current smokers than the rest of the U.S. population.³ Non-smoking public housing residents, including children, are also exposed to much higher levels of secondhand smoke (SHS) than non-smokers in the general population.⁴

To address these disparities, the Department of Housing and Urban Development (HUD) required that all public housing agencies (PHAs) implement smoke-free housing (SFH) by July 31, 2018. HUD’s smoke-free rule required PHAs to implement policies that:

1. Prohibit lit tobacco products inside all dwelling units, indoor common areas, and housing authority administrative office buildings

2. Limit smoking tobacco products, which includes cigarettes, cigars, little cigars, pipe tobacco, and hookahs, at least 25 feet away from all housing and administrative buildings⁵

Additionally, housing authorities have the option of providing designated outdoor smoking areas to accommodate smokers, which can include partially enclosed structures, as long as they are outside the required 25-foot perimeter. Housing authorities can also make their entire grounds smoke-free. HUD’s rule did not explicitly ban the use of electronic cigarettes. Notably, the rule only applies to public housing (ie, instead of other federally subsidized housing programs; “public housing” refers to a specific low-income housing program). This distinction is important because the Rental Assistance Demonstration Program (RAD)⁶ and the Housing Opportunity Through Modernization Act of 2016 (HOTMA)⁷ have incentivized PHAs to convert existing public housing stock to a mechanism called Project-Based Section 8. The primary difference between public housing and Project-Based Section 8 involves financing and PHAs can own and manage both types of properties. While HUD has recommended SFH for Project-Based Section 8, they have not required it since private owners can also participate in the RAD program.⁸ Thus, local PHAs have the discretion to implement several important policy features, including whether to prohibit smoking on Project-Based Section 8 properties, whether to ban the indoor use of electronic vaping devices, and whether to allow designated smoking areas at least 25 feet from PHA buildings instead of a property-wide smoking ban. Other policy features, such as supporting smoking cessation services, have emerged as best practices; however, many of these recommendations had not been released when PHAs were drafting their initial policies.⁹

In theory, a complete smoking ban is the only way to prevent non-smoker exposure in multi-unit housing and well-implemented SFH could greatly benefit residents. For example, exposure to SHS has been linked to increased risk for asthma development and severity,^10–14 chronic airway inflammation,¹⁵ and increased difficulty managing asthma symptoms.^16,17 This is particularly concerning for African American children who suffer from disproportionately higher rates of asthma morbidity^18,19 and for whom 40–67% live in a home with at least one smoker.^20–23

While studies based on early adopters of SFH found that PHA staff and residents are generally supportive of the policies,^24–26 evidence for their effectiveness is mixed. Many early studies that highlighted successes of SFH relied on self-reported outcomes, particularly of SHS exposure;^27,28 however, the validity of self-reported SHS by non-smoking public housing residents has been found to be low, with 31% of those with measurable saliva cotinine and 53% living in an area with measurable airborne nicotine failing to report SHS.²⁹ A study by our team suggests that SFH implemented in response to HUD’s rule could lead to increased SHS.³⁰ We reported improvements in indoor air quality immediately after SFH was implemented; however, by 12 months PM_2.5 (particulate matter at the 2.5 micron threshold, a proxy for cigarette smoke) and airborne nicotine had increased by 33% and 25%, respectively.

Qualitative studies of early-adopting PHAs suggest important barriers to compliance with SFH.^31–33 For example, smokers report modifying their behavior by hiding their smoke (eg, sitting near a bathroom vent) and many smokers who previously smoked outside in courtyards or balconies started smoking indoors.³² A study of SFH implemented in response to the HUD rule in New York City suggests low compliance, with almost 50% of survey respondents reporting that SHS still entered their apartments (as noted, this is likely underestimated). In focus group interviews, smokers’ feedback was “If I pay rent, I’m gonna smoke.”^33(p112) Lack of enforcement was noted as an important barrier by both residents and staff; property managers admitted to focusing on enforcing SFH in common areas and exercising minimal effort intervening against smoking taking place inside residents’ apartments. Managers and staff reported that a lack of resources and difficulty establishing proof of smoking in apartments inhibit enforcement.³³

The current study aimed to explore the relationship between SFH implementation and smoking-related behavior in light of other findings suggesting that SFH in Norfolk, VA was associated with increased indoor smoking (details of the SFH policy can be seen in Table 1). To this end, we conducted focus group interviews in which we sought feedback on residents’ experiences with SFH.

Table 1.

Features of Norfolk, VA SFH

SFH was not implemented until required by the HUD rule.

Only public housing properties and administrative buildings are included; smoking is still allowed on Project-Based Section 8 properties.

Property-wide smoking bans on affected properties; there are no designated smoking areas.

Ban includes vaping devices.

Enforcement details only provided for residents and their guests. Smoking was banned for staff and contractors, but a process for ensuring compliance was not described.

Supportive services for smokers not included.

METHODS

Qualitative Approach and Question Development

Our approach was guided by ensuring that all findings were grounded in the experiences of individuals from affected public housing communities.³⁴ Using our empirical findings as a starting point (ie, that SFH could be associated with increased indoor smoking), an existing community advisory board (CAB) comprised of low-income housing residents was consulted to develop goals for the focus group interviews and create a list of guiding questions (the CAB fluctuated between 10–15 members throughout the study; all but 2 CAB members were women, all but 3 were elderly, and all were African-American/Black). CAB members were full partners during this process; the initial list of guiding questions was developed over the course of several meetings. The CAB also provided feedback on subsequent drafts of an interview guide and approved a final draft before submission to our Institutional Review Board, which approved the study. The list of initial guiding questions appears in Table 2.

Table 2.

Initial Guiding Questions

How do you feel about the smoking ban?

How do you think the smoking ban has been working so far?

How were you told about the smoking ban?

How do you feel about how the ban is being enforced?

Participants and Setting

Eight focus group interviews were conducted in Norfolk, VA in 2018, after the implementation of SFH in response to the HUD rule. The interviews occurred during a 3-month period, 2 to 4 months after SFH was implemented. All participants (N = 53) were residents of low-income housing owned and managed by a local PHA that had implemented property-wide smoking bans in all of its 9 public housing properties. Notably, the PHA also owned 3 Project-Based Section 8 properties that did not go smoke free. Two focus groups were comprised of participants from the 3 properties that still allowed smoking (N = 10 participants), while participants in the remaining 6 focus groups lived on properties with a smoking ban (N = 43 participants). Participants did not differ on demographics or smoking status based on whether they lived on a smoking vs. non-smoking property.

Our sampling strategy was based on recruiting participants living in all Norfolk, VA low-income housing owned and managed by the local PHA. Eligibility criteria included being a leaseholder of an apartment owned by the PHA and being at least 18 years of age. Participation was open to both smokers and non-smokers. Focus group recruitment was facilitated by advertised flyers in common areas of multi-unit properties (ie, mid- or low-rise apartment buildings). CAB members also assisted with recruitment on other properties owned and managed by the local PHA (primarily row-housing) during community events. Potential participants were provided with a phone number of a research staff member and interviews were scheduled after 9 individuals from each community had indicated their interest.

Focus Group Interview Procedure

Focus groups were convened in community rooms on the properties where the participants resided. Each interview was led by a moderator with several years of experience conducting community-engaged and qualitative research in low-income housing settings who facilitated the discussion based on the guiding questions. A note taker was also present. Both the moderator and note taker had developed relationships with residents and were known to most participants due to their prior work in these communities. Study staff obtained written informed consent beforehand. The focus group interviews followed a semi-structured format and lasted between 45–60 minutes. All participants received $20 for their time.

Data Analysis

All focus group interviews were audio-recorded and transcribed. Transcripts were analyzed using a grounded theory approach in which codes and categories were iteratively created in order to reconcile emergent themes. The first (a master’s-level public health practitioner with multiple years of practical experience working in low-income settings) and last author (a PhD-level ethicist and psychiatric epidemiologist with formal training in qualitative methods and multiple years of experience conducting qualitative and community-engaged research in low-income settings) read each transcript independently to identify emergent concepts, after which they began an iterative process of regularly conferring to identify themes, reevaluate codes, and resolve discrepancies. Inter-coder agreement was reached by consensus over the course of several meetings. The NVIVO12 software was used for data organization. This first phase of analysis resulted in a list of themes that was brought to the CAB for review. CAB feedback helped provide further contextual grounding and suggested possible causal mechanisms, particularly with respect to the role of internal and external motivations for compliance with SFH. This feedback was instrumental for the synthesis of our findings with Procedural Justice Theory. Final approval of the themes rested with the CAB; to formalize this process, 2 CAB members were included from the outset as study authors and participated in all stages of manuscript preparation.

RESULTS

Our sample consisted primarily of Black or African Americans (94.3%), followed by whites (3.8%), and Hispanics or Latinos (1.9%). The sample was primarily women (88.7%) and consisted of smoking (64.2%) and non-smoking (35.8%) participants; of the non-smoking participants 78.9% had previously been a regular smoker. Focus groups were not specific to smoking status; each contained a mix of smokers and non-smokers. Additionally, almost a 3^rd of the sample (32%) was comprised of elderly participants (age ≥ 65).

Certain advantages of SFH were acknowledged. Participants who identified as smokers agreed that SFH could benefit non-smoking residents, particularly children, and could also serve as a potential motivator to modify smoking behavior. Some non-smoking participants saw SFH as a welcomed change. However, despite these potential positive consequences, barriers to SFH compliance dominated focus group discussions. Six themes emerged from our analysis (Table 3).

Table 3.

Major Themes Elicited from the Focus Groups

Pervasive non-compliance

• Residents smoke after staff leave  • Punishment avoidance behavior (eg, “spray” to cover smell, smoking in bathroom with fan)  • Residents express that they should be able to smoke if paying rent

Ineffectiveness of penalization as an enforcement strategy

• Eviction is severe but unlikely given how many people still smoke  • Lack of perceived obligation to comply  • Preference for support over penalization

Physical and environmental barriers to compliance

• Inconvenience  • Danger  • Designated smoking areas

Low compliance efficacy

• Urges/craving for cigarettes  • Inability to comply due to addiction  • Smoking ban itself made compliance harder by adding stress

Perceived unfairness and shame

• Restriction of smokers’ autonomy  • Invasion of smokers’ privacy  • Humiliation  • Social isolation  • Contractors and PHA employees smoking after ban  • Increased police interaction

Distrust of stated PHA motives and decision making

• Resentment  • Doubt in goal of protecting health  • Smokers less willing to quit after ban  • Evicting “problem” residents

Pervasive Non-compliance

Resident non-compliance with SFH (ie, smoking indoors) was discussed by participants in all focus group interviews conducted where smoking had been banned (75%). Non-smoking participants repeatedly described conversations with other residents who smoked about how they would continue smoking in their apartments. For example, one participant stated that she “heard one young lady say that she wasn’t going to stop whether she get put out or not. And I feel sorry for her because I wouldn’t want to get put out” [elderly, non-smoking African American woman]. Another elderly non-smoking woman reported smelling more tobacco smoke in the evening because smokers were boisterously having a “party” after PHA staff left at the end of the workday.

All smoking participants in focus groups based on properties where smoking had been banned (75%) either openly admitted to SFH non-compliance or provided a first-hand description of non-compliance that they had witnessed, with the implication that they had participated in the same behavior. Several participants candidly described the multiple locations where they smoked after the ban; for example: “I’ll be honest with you, if I’m paying $750 in rent I’ll smoke where I want to smoke” [non-elderly, smoking African American woman] and “I smoke out on my front porch, kitchen, and living room. It’s my home. I’m the one who pays my bills” [non-elderly, smoking African American woman].

While participants discussed numerous ways that SFH had affected smokers’ behavior, they described being primarily motivated to avoid punishment by not getting caught smoking. Half of the participants (50%; representing all focus groups) described that, instead of fully complying with SFH by not smoking anywhere on the property, residents had modified their behavior by hiding their smoking in their apartments; for example, by smoking “in the shower” [elderly African American man] and using various methods to get rid of or conceal cigarette smoke, such as using fans with open windows, lighting incense, or spraying air freshener. As one participant described, the use of scents in an attempt to cover the smell of smoke had become so pervasive that she is unable to walk down some hallways in her building:

I had to turn back … by the time I got back up the steps I had to use a little oxygen to get my breath…because the incense is kicking off. Crazy! They burn them like mad. I guess [they are] trying to cover up the cigarette smoke [elderly, smoking African American woman].

Several other participants described using these strategies themselves; for example, “I’ve been buying more spray to cover the smell” [non-elderly, smoking African American woman].

Ineffectiveness Of Penalization as an Enforcement Strategy

Participants described the severity of punishment for non-compliance to be severe (ie, eviction, which would likely result in homelessness for many residents), but found the threat of punishment to be low, which in turn affected whether they thought that residents should comply with SFH at all. While non-smokers were generally supportive of SFH, they repeatedly described how they did not fault other residents for continuing to smoke in their apartments because they had not observed the PHA actively enforcing that part of the policy (ie, staff were only warning residents who smoked where they could easily be seen). Notably, there was a lack of a sense of obligation to change behavior in order to comply with the policy absent punishment. As one participant stated, “I don’t blame anyone for smoking in their apartments if they aren’t getting punished for it” [elderly, non-smoking African American woman].

Finally, while punishment was not reported to be an effective motivator to promote compliance, several participants suggested that they would be more likely to change their smoking behavior in order to more easily comply with SFH if they received additional smoking cessation support. “When you talk about an addiction, it’s not a mind over matter thing. People need, people have to get help” [non-elderly smoking African American woman].

Physical and Environmental Barriers to Compliance

Factors related to the inconvenience and danger of walking across the properties emerged as the primary, and often overlapping, barriers to changing smoking behavior in response to SFH. Participants in all 8 (100%) focus groups discussed how compliance with SFH as implemented in Norfolk, VA was inconvenient for residents. One participant stated that:

They need to find a place for these people to go smoke, because her getting up at 2, 3 o’clock in the morning because she wants a cigarette to walk down the street…That’s not cool. If you give them a spot, it doesn’t have to be no giant spot, just some place where they go and have a cigarette and go into their home, safely. I’m all good with that [non-elderly non-smoking Hispanic woman].

Both smoking and non-smoking participants in all but one (87.5%) of the focus groups were emphatic about the safety of the elderly and disabled. A non-elderly, non-smoking white woman stated, “They should have a designated spot right here on the property. You should not have to leave the property, which makes you unsafe.” Another participant echoed this sentiment:

We are older people. We don’t need to be walking out here, especially at night, if we wanna go outside and smoke a cigarette (…) it’s dangerous around here with these people that live around us. We got to go closer to the violence if you want to smoke a cigarette [elderly African American woman smoker].

Designated smoking areas were mentioned by all (100%) focus groups as a solution to keep smokers safe and provide them with a more convenient avenue to comply with SFH. Participants in half (50%) of the focus groups expressed concern that without a designated area, smokers would line up on the perimeter of the properties and discourage people from visiting their communities. For example, “You’re gonna see them stand around that corner more, see the cigarettes butts just piled up. And that’s the first thing you gonna see when you are pulling into these apartment complexes” [non-elderly, African American woman]. However, while most participants expressed that designated smoking areas would be a viable solution, a small number were concerned that they would become a hub for illegal activity or littering.

Participants in 6 of 8 focus groups (75%) expressed frustration at the locations that management had suggested for them to smoke. Participants in 3 of 8 focus groups (37.5%) foresaw problems with residents smoking on someone else’s property, believing that store- or property-owners would have concerns about smokers either loitering or littering. For example:

But you can’t just go to 7–11 and stand on their property and smoke on their property and don’t go in there and buy nothing. When [the property manager] had that meeting down here she said, ‘Twenty-five feet is across the street on 7–11’s property.’ [The property manager] said that if you wanted to smoke you had to cross the street to the 7–11 [non-elderly, non-smoking Hispanic woman].

Another participant described her concern that staff at her property suggested that residents smoke on an adjacent property which is owned by an armed businessman:

[Smokers] got to go down there and [the store owner] is kinda prejudiced against black folks and he don’t ever want you walking across [his store]. He can come out and shoot you and say you trespassing so it’s your word against his. I think it’s so unfair to tell the people that they got to go to somebody, who they know that don’t like black folks and can’t wait to shoot you so why would you tell the people they got to go there [elderly, non-smoking African American woman]?

Other participants described smoking in parking lots of adjacent businesses or walking to adjacent apartment complexes not owned by the PHA and expressed similar concerns for safety and upsetting business owners.

Low Compliance Efficacy Due to the Impact of Nicotine Dependence

There was a consensus among smoking participants that modifying smoking behavior in order to comply with SFH is physically difficult because of their craving for nicotine. The smoking ban was also described as a stressor that could increase the desire to smoke. In all but one (87.5%) of the focus groups, the addictive quality of smoking was described as a barrier to traveling “across the property” and all smokers (100%) mentioned smoking as a coping method. One smoker used the word “desperate” to describe smokers who may try to comply with SFH; other participants indicated that smokers might increase the number of cigarettes that they smoke when they are outside their apartments as a way to cope with not smoking more casually indoors. Another participant described how “I don’t have nothing to keep me calm. So, I feel like the smoking ban is actually making it worse on people who is in their homes trying to relax the way they need to relax” [non-elderly smoking African American woman].

Perceived Unfairness and Shame

All focus groups comprised of participants residing on properties where smoking had been banned (75%) discussed how SFH restricted their autonomy and was an invasion of their privacy. Further, being subjected to this unfairness was also described as a source of shame. According to one elderly, smoking African American woman, “All I know is I love my freedom of choice. God gave me that. I don’t want nobody taking that away from me, but [the PHA] has done that.” Another elderly, smoking African American woman stated, “To me it’s like going back to slavery telling us what can do and can’t do.” In a separate focus group, a participant likened the smoking ban to prohibition, stating “Prohibition didn’t work. In the 20’s, they tried to get people to stop drinking, and that’s when the gangsters came out!”

Participants in 5 focus groups (62.5%) described feelings of humiliation; for example, by saying that it was “degrading” to be singled out and have to walk past neighbors to go off the property to smoke a cigarette [elderly, smoking African American woman]. Another participant described how she was less likely to invite friends and family over to her apartment, both because of the humiliation and because she could be punished if they smoked while visiting:

If they’re coming to visit you, and they your family, then that’s against me too. And it’s not fair, because you know, my family, if they don’t know, and if they haven’t been around me, and you still counting it against me cause it’s my family, and my friends, or whoever. I don’t wanna lose my unit. [non-elderly, smoking African American woman]

Relatedly, alienation from neighbors was another consequence of SFH that was described by participants, who described themselves as becoming “loners,” “distrustful of their neighbors,” and stating that they only “communed with close family members.” Participants also described how SFH had exacerbated a pervasive sense of mistrust between residents; for example, when asked about other residents reporting violations, one non-elderly, smoking African American woman stated “People get mad at each other. They just go snitching. They’re out there and they just do it because they’re mad.”

Participants from larger communities also described how the police were using SFH as an excuse to interact with residents, which, even though smoking is legal, made them feel like they were being treated like criminals. For example, one woman said that “[the police] messing with people just because they’re standing out there smoking” [non-elderly, smoking African American woman]. Another stated, “[Police] could literally harass them for smoking. We try not to get in trouble for smoking and still get harassed” [non-elderly, smoking African American woman]. A single participant reported that police had used the smoking ban as a pretext to stop and question (“harass”) him even while he was smoking off the property.

Participants in a single focus group described how PHA workers and non-employee contractors still smoke on their property, which made them resentful. “[The PHA] go on about how we can’t smoke on the property, but their workers still smoke on the property! The maintenance people! They see you, they’ll snap a picture of you, but they smoke on the property also!” [non-elderly, smoking African American woman].

Distrust of Stated PHA Motives and Decision Making

Half of the focus groups (50%) questioned the stated motives and decision making of the PHA when implementing and enforcing SFH. In particular, participants doubted whether the true aim of the policy was to protect resident health, with some smoking participants stating that their resentment of SFH had affected their willingness to quit smoking (eg, “I want to quit on my own time” [non-elderly, smoking African American woman]). Other motives for the smoking ban were discussed, including “they’re trying to get folks out…every little thing” [non-elderly, smoking African American woman], “building up all these condominiums and stuff and that’s what all this about. Anything to get [public housing residents] out” [non-elderly, smoking African American woman], “this whole non-smoking on the premises and stuff is really about drug traffic” [non-elderly, smoking African American man], and “[the PHA] put us off their property so they are not responsible” [elderly, smoking African American woman]. In particular, participants spent considerable time discussing how SFH gave the PHA another tool for evicting residents for an ongoing revitalization effort that will require relocation of residents of several public housing properties.

DISCUSSION

Our findings suggest that public housing residents feel little obligation to modify their smoking behavior in order to comply with SFH on its own merits. Instead, residents seem to weigh the pros and cons of compliance based on 2 factors: (1) the impact of barriers to compliance, and (2) the likelihood of punishment. The relative importance of these factors likely depends on contextual features such as policy content and enforcement strategy, suggesting that our findings could generalize to other areas where SFH has been similarly implemented. For example, property-wide smoking bans are considered to be very inconvenient and unsafe by residents and, consistent with other research,^32,33 we would expect a similar preference for designated smoking areas in other locations with property-wide bans.

Emergent themes aligned closely with behavioral compliance predicted by Tyler’s Procedural Justice Theory. While we were initially agnostic with respect to a specific guiding theoretical framework, it soon became apparent that participants’ attitudes about the unfairness of SFH were directly related to their reluctance to comply with the ban by modifying where they smoked. This led us to consider Procedural Justice Theory as a conceptual framework. The theory notes that fear of punishment does not motivate most people to follow the law or to obey rules. Instead, institutional authority is more effective when rules are consistent with peoples’ values (ie, they feel morally obliged to comply).³⁵ However, obligation to comply with institutional authority varies based on whether people view an institution to be legitimate. In general terms, legitimacy is a quality of an authority, law, or institution that leads individuals to feel motivated to accept its directives. Operationalized as a social-psychological construct, legitimacy has 2 key dimensions: perceived fairness of decision making (ie, decisions are fair to all parties involved and do not prioritize certain voices or viewpoints), and perceived fairness of interpersonal treatment (ie, interactions are driven by trust and respect).^36,37 This implies that institutions or laws perceived to be illegitimate (ie, unfair and untrustworthy) will fail to motivate most people to comply on their own, thereby undermining the potential for SFH to protect residents from SHS exposure and lower smoking in public housing settings. Tyler describes internal and external motivations for complying with rules or institutional authority (Figure 1). Rules and authorities considered to be unfair and untrustworthy are reliant on external motivation (ie, punishment) to promote compliance. Unfortunately, punishment requires constant surveillance and very aversive consequences to effectively motivate behavior change. Yet, this could lead to a cycle wherein resentment of being unfairly forced to do something under the threat of severe punishment further undermines legitimacy. This may in turn impact policy compliance, especially if punishment is perceived as unlikely to occur.^35,38–41 Indeed, an enforcement strategy focused on policing only the most obvious violations—that is, residents who smoke where they are easily seen by PHA staff—seems to have decreased the perceived likelihood of being punished for smoking elsewhere, reinforcing smoking in those other areas as a punishment-avoidance behavior. For many residents, smoking in their apartments could thus be seen as the most convenient way to avoid punishment for violating SFH. However, our findings clearly suggest that residents continue to resent SFH after being able to avoid punishment in this way.

Figure 1.

Conceptual model of the influence of perceived fairness on the motivation to follow rules in Procedural Justice Theory

Several factors support viewing SFH enforcement and compliance in the context of procedural justice. The perceived overreliance of the local PHA on external motivation (ie, punishment of any sort) to promote compliance with almost all its rules was apparent after conferring with our partner CAB (the degree to which this defined the relationship between residents and PHA staff was a revelation to the academic members of the team due to fundamental differences in typical interactions with institutional authority). Despite a reliance on punishment, both the CAB and focus group participants consistently described how inconsistent punishment was an ineffective motivator (eg, “I don’t blame anyone for smoking in their apartments if they aren’t getting punished for it,” as noted above). Further, even though the likelihood of punishment was considered to be low, the perceived severity and inappropriateness of eviction in response to smoking contributed to a greater sense of unfairness. While participants did not use the language of legitimacy, their distrust in PHA decision making and sense that smokers were being unfairly singled out (eg, “they’re trying to get folks out…every little thing,” as noted above) is consistent with the construct as defined by Tyler.

Implications

Our findings have several important implications when viewed through the theoretical lens of procedural justice. First, trust-building and improving the perceived legitimacy of SFH and the PHA could be important strategies for improving compliance by shifting focus to an internal, values-driven motivation for smoking behavior change. For example, increasing residents’ perceived fairness of the policy-related decision-making process could decrease resentment of SFH associated with questions about local PHA motivations. This could potentially be achieved by increasing transparency and demonstrating that the PHA is open to adapting its SFH policy in response to resident feedback. Conversely, the theory also implies that soliciting resident feedback without adequate response by the PHA could be more damaging than not having conducted any community engagement on the issue at all.

Unfortunately, low perceived legitimacy of SFH and an over-reliance on severe but unlikely punishment for non-compliance also suggests that SFH could perpetuate disparities that it is meant to address. Trust has been shown to be a key factor in efforts to address the impact of health and social inequality^42,43 and PHAs are major sources of programs designed to alleviate socioeconomic disadvantage. Further, perceived legitimacy of an authority or institution can also impact how an individual views and interacts with other authorities.³⁸ Legitimacy is central to a “psychology of enfranchisement” that encourages participation in democratic processes and in which social exclusion is directly related to an individual’s distrust in the fairness of society.⁴⁴ Low perceived legitimacy of an important institution, such as a PHA, could thus be tied to a person’s overall sense of disenfranchisement, leading to increased marginalization. Our findings suggest that this concern is not merely theoretical. For example, participant feedback evoked a sense of marginalization and social isolation (eg, becoming “distrustful of their neighbors”), referenced interactions with police that they reported made them feel like criminals (eg, police “messing with people just because they’re standing out there smoking”), and directly stating that SFH was “like going back to slavery.”

Relatedly, both smokers and non-smokers in our focus groups questioned the public health justification for SFH due to low rates of compliance. This is particularly concerning, since low perceived legitimacy of SFH could plausibly affect perceptions of the legitimacy of other public health messaging and also potentially interact with existing mistrust in healthcare among many groups (eg, African Americans). Feedback from non-smokers suggested that increasing SFH compliance overall would confirm the messaging that SFH was motivated out of a concern for resident health. However, smokers pointed to a lack of smoking cessation support from the PHA as proof that health was not a primary concern. This suggests that PHAs should not only heavily promote smoking cessation as part of their SFH implementation strategies, but should also be seen as an active supporter and sponsor of smoking cessation programs, even if provided by other organizations (eg, an identified community partner providing technical support to the PHA or access to quitlines).

Our results suggest that self-efficacy could also be affecting compliance. While the inconvenience of complying with SFH emerged as a clear theme, some smokers perceived themselves to be incapable of changing their behavior to comply with SFH due to their dependence on nicotine. This suggests that smokers’ beliefs about their ability to comply—for example, how long they can go between cigarettes—could also be a plausible pathway upon which to base an intervention to improve SFH compliance. However, it is unclear whether this would offer additional benefit over simply improving the perceived convenience of complying with SFH.

Taken together, our findings suggest several policy adaptation strategies with a trust- and legitimacy-building focus. First, meaningful resident engagement should be built into the planning stage of important PHA decision-making processes in order to promote transparency. This implies a bi-directional process in which feedback is addressed—requiring, at the very least, a good-faith effort to include resident suggestions when possible and an explanation when they are not—with deliberate and large-scale outreach to residents in which they are informed of changes made in response to their feedback. Second, PHAs should strive to be seen as a source of support for smoker compliance, rather than serving primarily or solely in an enforcement role. Active, ongoing engagement of smokers will be required in order to address compliance barriers (eg, building covered structures on the property to serve as designated smoking areas). Sponsoring smoking cessation is also important and should help address concerns about the public health justification of SFH. Third, agreed-upon and transparent rules and procedures should be in place to ensure that residents do not perceive enforcement to be unfair. Efforts should also be made to determine whether there are differences between the stated policy (eg, “do not smoke on the premises”) and the actual behaviors being penalized (eg, “do not smoke where I can see you”). When responding to these differences, PHAs should view them as an opportunity to learn how to support residents, rather than doubling-down on penalization, which will not necessarily promote compliance. Fourth, PHAs should ensure consistent messaging about SFH throughout the organization so that residents do not ascribe false motives to simple misunderstandings or confusion among staff.

While participant feedback suggested a clear preference for designated outdoor smoking areas over property-wide bans, it is unclear how this would affect resident exposure to SHS. There could be a benefit to non-smokers if those who are currently smoking in their apartments move to an outside space. However, there is likely little benefit to smokers themselves or those who might be close to the designated area—research suggests that outdoor SHS persists for some time at the actual site where the smoking occurs.⁴⁵ Exposure to SHS drops off as one moves away from the designated smoking area; however, while evidence about the rate of this reduction is mixed, significant decreases likely begin between 11 and 18 meters away from the site.⁴⁶ Arguments also remain about the allowability of any SHS exposure in outdoor settings.⁴⁷ As such, more research on the effectiveness of outdoor designated smoking areas in the context of SFH is needed.

Strengths and Limitations

Our focus groups included both smoking and non-smoking participants, which could have potentially affected participants’ willingness to share in a group setting. However, participant feedback did not suggest that this was a major problem. For example, while feedback skewed towards barriers to SFH compliance, non-smokers often drove these discussions. Difficulty in determining generalizability is a major limitation of this study. Further, this concern is not limited to the representativeness of our focus group participants. Our findings must also be considered in terms of the representativeness of the local SFH policy and the PHA’s enforcement strategy. For example, findings could be less applicable in settings where residents feel that complying with SFH is relatively convenient. However, to the degree that residents’ perceived unfairness of SFH affects compliance, generalizability likely hinges less on specific demographic or policy characteristics and more so on their sense of marginalization or level of distrust in the local PHA. This could signal a significant increase in the applicability of our work.

Conclusions

Perceived unfairness of SFH and distrust in housing authorities are likely significant barriers to compliance with indoor smoking bans in public housing. Fortunately, procedural justice theory implies that SFH can be adapted to increase its perceived legitimacy, which in turn could lead to concomitant increases in compliance. While we describe specific adaptations—such as designated smoking areas—it is likely more important to focus on broader themes; for example, giving residents convenient options for complying, providing smoking cessation support, promoting predictable and proportionate enforcement, and increasing transparency by including residents in the decision-making process.