“I think everybody will have to get together for it to work”: NYCHA Tenant Perspectives on HUD’s 2018 Smoke-Free Mandate Captured Prior to Policy Implementation

Abstract

Introduction

In July 2018, a new federal mandate by the Department of Housing and Urban Development went into effect requiring all US public housing authorities to implement policies banning smoking in living units, indoor common areas, administrative buildings, and outdoor areas within 25 feet of these buildings. Although some housing authorities had smoke-free policies in place for decades, others had to implement them for the first time. Housing authorities continue to face challenges in ensuring compliance with these policies, and resident perspectives can greatly inform measures to promote adherence.

Aims and Methods

We conducted in-person interviews with 20 New York City Housing Authority tenants in April 2018. Our thematic analysis examined resident opinions on the upcoming smoke-free housing policy.

Results

Although 65% of residents supported the policy, 50% anticipated poor adherence due to expected lack of enforcement, safety issues with smoking outdoors, and general discontent with the housing authority and living conditions. However, many participants felt adherence could be improved if the housing authority optimized resource-provision and communication with tenants.

Conclusions

Our study adds to existing literature examining tenant views on the controversial topic of mandatory smoke-free housing policies, and our interviews were conducted at a unique time prior to policy implementation in the country’s largest public housing authority. Based on our results, we provide recommendations for housing authorities including: (1) information and resource-provision, (2) safety enhancement, and (3) relationship building with tenants in order to maximize policy adherence.

Implications

Our study is unique because we captured resident views prior to policy implementation in a housing authority without a preexisting smoke-free policy in place. In comparison, most recent research on this topic has focused on the postimplementation period or used survey research methods in the preimplementation phase. Our findings add to extant research about tenant perspectives on smoke-free housing policies and offer suggestions to address barriers to compliance.

Introduction

As knowledge about the negative health effects of smoking and secondhand smoke has accrued over the years, governments have enacted various tobacco control measures.^1,2 There is abundant research detailing the health benefits of tobacco control policies, ranging from improved indoor air quality to lower rates of asthma exacerbations and heart attacks and improved infant and birth outcomes.³ Most tobacco control policies limit smoking in public places.⁴ However, because Americans on average spend 69% of their time at home, housing is a major potential source of secondhand and thirdhand smoke exposure.⁵ Moreover, the home environment is the single greatest source of secondhand smoke exposure among children.⁶ Residential smoking is associated with fire-related injuries, higher direct and indirect medical costs for tenants, and reduced productivity for employers and society.^1,7 For these reasons, measures banning smoking in the public domain can only go so far, a limitation which can be addressed with interventions targeting smoking in the home.

Over 1 million US households receive public housing assistance, and multiunit and public housing residents are particularly at risk for smoke exposure.^8,9 Smoking rates are almost twice as high (34% vs. 15%) among adults receiving federal housing assistance when compared with the general US population.⁸ Racial/ethnic minorities and low-income populations are more likely to reside in public housing, and cigarette smoking is a major cause of morbidity and mortality among these disadvantaged groups.^8,10 Because multiunit housing involves air exchange between apartments through shared areas such as hallways, ventilation systems, contiguous walls, windows, elevator shafts, and pipes, it carries an especially high risk of secondhand smoke exposure.^11–14 This is especially concerning because multiunit and public housing units are often occupied by families with children along with elderly and disabled persons, groups especially sensitive to the effects of cigarette smoke.¹⁵

Although the drivers of higher smoking rates in public housing and among disadvantaged groups are multifactorial, data show that access to a home with a smoke-free housing policy (SFHP) in place is not equally distributed among groups.¹⁶ One study found that although the prevalence of home smoking bans in US households including both smokers and children more than tripled from 1992/1993 to 2006/2007, these improvements were smallest among African American households.¹⁶ In addition, fewer home smoking policies were in place in households below the poverty line.¹⁶ If these aforementioned groups were provided SFHPs at the same rates as others, it is likely that their smoking rates would fall along with the associated morbidity and mortality. This is supported by existing literature, as Pizacani et al. found that the implementation of a SFHP was associated with reduced secondhand smoke exposure and increased smoking cessation rates in a population of low-income adults.¹⁷

An apparent solution to this disparity in access to smoke-free homes emerged in 2016 when the Department of Housing and Urban Development (HUD) issued a federal-level mandate requiring all public housing authorities (PHAs) to implement smoke-free housing policies by July 31, 2018.¹⁸ The policies were required to ban the use of prohibited tobacco products in living units, indoor common areas, administrative offices, and outdoor areas up to 25 feet from the aforementioned buildings.¹⁸ Prior to this mandate, SFHPs were increasingly employed in public housing, with policies in place in only 18 PHAs in 10 states in 2005 to at least 508 PHAs in 43 states in 2016.^19–21 The HUD mandate significantly increased these numbers and impacts an estimated 3300 PHAs and 1.2 million households nationwide.²²

Although this mandate appears to improve access to smoke-free policies for racial/ethnic minorities and low-income groups, research shows that adherence with SFHPs is a major challenge, greatly limiting their potential effectiveness.¹⁹ One 2010 study illustrated that almost 30 million US residents in multiunit housing with SFHPs in place continued to experience frequent secondhand smoke exposure.¹⁹ Recent research after the HUD mandate went into place shows similar findings; a cohort study in 2020 found no reduction in indoor air nicotine levels in a sample of New York City public housing buildings 1 year after the HUD mandate went into place.²³

Tenant insights can shed light on factors that encourage or hinder adherence with SFHPs, and a 2015 systematic review concluded that this was an underexplored area of research.²⁴ Recent research has begun to investigate this topic, pointing to key barriers to adherence with SFHPs in place, including issues such as tenant rights, safety, housing conditions, enforcement concerns, and landlord–tenant relations.^25–28 However, this research, particularly in subsidized housing facilities, has largely focused on residents in the postimplementation period or used survey research methods in the preimplementation phase.^25–27 Our paper is unique because we interviewed tenants in the preimplementation period who were facing a widespread smoking ban. Because of this, along with reinforcing findings from existing studies, we were able to uncover insights only available in the preimplementation setting. We obtained the perspectives of 20 New York City Housing Authority (NYCHA) tenants on HUD’s 2018 mandate several months prior to when the policy would come into effect. At the time of our interviews, smoking in common areas (such as hallways, stairwells, and elevators) was banned in New York City, but NYCHA did not have a SFHP in place banning smoking within living units.²⁹ We emphasized eliciting tenant opinions on the upcoming SFHP’s anticipated effectiveness, barriers to adherence, and recommendations for enhancing effectiveness. While we note some methodological limitations, the insights gleaned from this work can help inform ongoing efforts to support adherence with smoking bans and ultimately reduce tobacco-related disparities and improve health and quality of life for public housing residents.

Methods

Research Team

The research team was comprised of two researchers: Mandakini Mohindra (MM), a junior researcher in the process of obtaining her doctorate of medicine and master’s degree in public health and Diana Hernández (DH), an experienced qualitative researcher with a doctoral degree in sociology. DH is a professor of public health with prior mixed methods research experience related to smoke-free housing and an extensive research portfolio on housing and health in public and affordable housing settings.

Participant Sampling and Characteristics

We conducted in-person interviews with NYCHA tenants (n = 20) approximately 3.5 months prior to NYCHA’s SFHP implementation date of August 1, 2018. We targeted four separate NYCHA buildings in the South Bronx and interviewed five tenants in each building. While not representative of all NYCHA developments, the buildings were selected on the basis of a convenience sampling strategy since coauthor DH has extensive experience conducting research related to SFHPs in and around the developments we selected. This enabled a deeper understanding of the neighborhood context, which we believe justifies our sampling strategy. Our recruitment strategy involved knocking on doors at random in each building between 9 am and 6 pm, seeking out tenants from different floors of each building until we recruited five tenants in each building. We stopped after 20 interviews upon reaching data saturation. Interviews lasted approximately 20 minutes each, as the line of questioning was limited to the forthcoming policy change. We obtained verbal consent. Participants were primarily female (n = 14, 70%), and all were adults ranging from young adults to the elderly. The majority were people of color, as is consistent with NYCHA’s resident demographic profile. We interviewed both current smokers (n = 7) and nonsmokers (n = 13). We provided tenants with $5 gift cards as a token of appreciation for participating in the interviews. This study was approved by the Columbia University Irving Medical Center (protocol # AAP6854).

Data Collection and Analysis

We prepared a semistructured interview guide that covered various topics including tenant opinions about smoke-free housing policies, perceptions of smoking and health, and attitudes toward the residential environment. MM and DH conducted 16 semistructured interviews in English. DH conducted an additional four interviews in Spanish. All interviews were audio-recorded, transcribed verbatim (the Spanish recordings were translated into English), and analyzed using Dedoose, a qualitative data management and analysis software package. We used a two-tier analytical approach involving an open (descriptive) and axial (analytical) coding scheme. During the initial coding phase, MM created a codebook based on the guiding questions and emergent themes, which included codes such as “communication,” “perceptions of effectiveness,” “opinions of policy,” “safety issues,” and “perceptions of PHA.” DH reviewed the codebook, assessed the codes and associated text and offered feedback to refine the coding process. MM and DH discussed the final list of 25 codes and settled any minimal discrepancies in the application of codes. Using a thematic analytical approach, we identified key themes across the interview transcripts including (1) the prevalence of indoor smoke exposure, (2) impressions of the upcoming SFHP, (3) anticipated effectiveness, (4) barriers to adherence, and (5) recommendations for improved compliance. These key themes formed the basis of our primary findings as described in the results section below.

Results

Prevalence and Perceived Impact of Indoor Smoking

We inquired about the prevalence of smoking on NYCHA premises and its impact on residents. Over 50% of interview participants endorsed the widespread presence of indoor smoke, both tobacco and marijuana, with statements like “Everybody, they smoking…I see and smell it” (Participant 1), and “People smoke in the building, the staircases, the hallways” (Participant 6). Referring to marijuana smoke in particular, one respondent said, “Sometimes it feels like we are using it without using it” (Participant 20). Several participants perceived negative health effects from secondhand smoke in the building. One woman believed this exacerbated her daughter’s asthma, and said she had to put a wet rag or towel on the floor by the apartment door to block out smoke from the hallway, where her neighbor was “always…smoking…[e]very night after 9 o’clock” (Participant 3). Another stated “[T]he smell irritates me and also makes me nauseous” (Participant 8). Yet another remarked, “It’s terrible. Sometimes I have to take my kids out of their room ’cause the whole room smells like marijuana. So that’s crazy, they shouldn’t be exposed to that” (Participant 4).

Mixed Opinions on the Upcoming Policy

Despite agreement that indoor smoking was highly prevalent, opinions on HUD’s mandate were varied, with a majority of tenants (65%, n = 13) expressing support for the upcoming SFHP, a few (15%, n = 3) stating they did not support the policy, and others (20%, n = 4) with mixed opinions. Of the tenants who supported the policy, 77% were current nonsmokers.

Tenants who expressed support for the upcoming SFHP cited reasons such as “less people getting sick,” “increase[d]…air quality” and “for the better of everybody else, health wise” (Participants 9, 11, 13). One tenant stated, “I think it’ll be good…You know ’cause like usually people get from secondhand smoking, this is when we get sick” (Participant 3). Another responded, “My kids won’t have to go into the elevator holding their breath, getting the secondhand smoking. I think it’ll be better, be healthier…I think it’s very fair. The fires that it causes. The lack of consideration for your neighbor” (Participant 4).

Some tenants were staunchly opposed to the upcoming change. One reported “They [tenants] should feel comfortable in their own houses or the place where they reside… So if they want to smoke inside their apartments that’s fine…inside the apartments, it’s like people should be able to live comfortably” (Participant 16).

Lastly, some tenants had mixed opinions, captured in the following passage:

I feel everybody’s personal feeling is going to be the conflict because some people like I look at it like it’s beneficial to my health. It’s something I’m supposed to do so it helps me, cause it forces that I need to stop. But other people might look at it like well you know what you’re telling me what to do. I don’t want nobody to tell me what to do, I’m not going to do it (Participant 13).

Anticipated Effectiveness

All tenants were asked whether they believed the upcoming SFHP would be effective, and responses were varied, with only one tenant believing the policy would work, several with mixed or ambiguous opinions (45%, n = 9), and the largest group believing the policy would not be effective (50%, n = 10). Anticipated barriers to policy adherence included a perceived infringement on personal autonomy, lack of enforcement, safety concerns related to smoking outside, and discontent with the housing authority and building conditions. Several tenants offered recommendations for promoting policy effectiveness, encouraging NYCHA to disseminate more information about the policy, provide smoking cessation resources, and engage in relationship-building efforts with tenants.

Perceived Barriers to Adherence

Right to Smoke

Multiple tenants did not plan to follow the upcoming policy because they felt they should have the right to smoke within their homes, especially since they were paying rent (Participants 1, 2, 6, 9, 12). One even referred to this as a “civil right” (Participant 12). The payment of rent was cited as the action which should give tenants domain over the private activities they engage in within their living space, a finding consistent with previous literature.^25,26,28 One current smoker stated in regards to the upcoming SFHP, “I don’t care. I pay my rent. I can do whatever I want in my house…Ain’t nobody gonna come to my house and say you cannot do this and you cannot do this… It’s not nobody’s business” (Participant 1). Another remarked, “I mean I can understand it for the air quality, but if people pay they rent why can’t they smoke in their home?… I mean it’s not illegal, it’s not like we’re doing something wrong” (Participant 9).

Poor Enforcement

Several NYCHA residents (n = 6, 30%) anticipated inconsistent enforcement of the upcoming SFHP and cited this as a reason tenants would not comply. One remarked, “[T]hey gonna smoke wherever they want to smoke anyway. I don’t think somebody’s going to come check your house every 10 minutes, oh are you smoking?…I don’t feel like they’re going to really catch people smoking cause they’re not going to go check on them” (Participant 2). Another agreed, stating, “I doubt it’s gonna be a lot of people out here enforcing the actual policy, like, it’s just, I doubt it. Nobody wants to deal with that” (Participant 16). One said he would continue to smoke indoors after the SFHP was implemented because “They’re not going to enforce it…It won’t happen. It’s not very realistic. Not in these apartments…waste of time” (Participant 10). When asked why he was skeptical about enforcement, this tenant pointed out NYCHA’s inconsistent enforcement of both rent collection and the existing policy banning smoking in indoor common areas.²⁹ He stated, “The policy is don’t smoke in the hallways which has always been that way, if you smoke in the hallways, you’re gonna get a so-called ticket, which they haven’t done in years… Nobody cares in these buildings. They can’t even pay their rent sometimes, that’s why housing sends it in the middle in the month praying that they all pay before the 6th or whatever day it’s due” (Participant 10).

Safety Concerns

Interview participants cited lack of safety as a significant barrier to adherence with the upcoming SFHP, as it was not safe enough to go outside every time they needed to smoke (Participants 8, 13, 15). One stated, “Honestly, I wouldn’t spend at night not even 10 minutes [outside]. Actually 10 minutes is too much, not even a minute…Cause you know at times it’s, there’s shooters between one part of the projects with this part of the projects” (Participant 15). Another agreed, explaining that residents likely smoked inside their apartments because “[t]hey probably feel like it’s safer to smoke inside their apartments than it is outside” (Participant 8). She described the prevalence of violence in the neighborhood in the following passage: “Yeah cause I know…especially during the summertimes it gets confusing as to gunshots or firework…a game we play, me and my sister sometimes, hey is it a gunshot or fireworks?” (Participant 8). When asked how she would feel as a current smoker having to go outside to smoke, another resident responded, “No, it does not make me feel safe at all. That’s why it’s like at that point you have to stop because if you go out, I mean honestly speaking you’re very, very brave women [referring to the interviewers], because people get robbed in this building. People come off the train, into the building and decide to rob people so while you’re standing outside trying to smoke a cigarette you could possibly get robbed” (Participant 13).

Negative Opinions of the Housing Authority

Many interview participants reported feeling hesitant to comply with any of NYCHA’s policies due to discontent with NYCHA as a whole. One issue driving this discontent was NYCHA’s poor responsiveness to tenant needs such as maintenance requests (cited by 70%, n = 14). One tenant described NYCHA’s responsiveness as “They come when they feel like it” (Participant 9). Several stated that the building was dirty, poorly maintained, and with a dysfunctional heating system, often leading to tenants going without heat in the winter (Participants 4, 8, 12, 15, 16, 19, 20). Many went on to remark that this could disincentivize tenants from adhering to the upcoming SFHP. One said, “If you not fixing the problems in the building and you telling me, oh stop doing this, they’re not doing their part” (Participant 2). Another agreed, stating, “Yeah, of course. Like if you’re not helping me, why should I help you, or why should I follow that?” (Participant 16). Yet another expressed, “Like this is a give and take situation. You want me to do something, and I’m asking you to do something. There’s the balance” (Participant 9).

A few tenants expressed distrust of NYCHA’s motivations in implementing the SFHP in the first place, arguing that NYCHA intended to use the policy to evict tenants out of public housing. When asked if the upcoming SFHP could be a reason for NYCHA to turn over residents, one resident stated, “I honestly, I feel like that’s all a part of gentrification. You know it’s just the way to get all the low [income] tenants out because how they feel, you know low income people they do drugs, they smoke, they do; and they just want to get rid of everybody. That’s how I honestly how I feel” (Participant 13). Another espoused a similar belief, asserting, “That’s yeah because at the end of the day, they [NYCHA] don’t want a whole bunch of… gangsters around here” (Participant 6), and yet another tenant remarked, “And they want to get people out. But I feel that if that’s part of the mechanism that they’re going to use to get us folks out. Low income, then I really think that’s really low and underhanded” (Participant 12). This suspicion with NYCHA’s priorities in implementing the policy was an additional source of discontent with the housing authority.

Recommendations for Increased Policy Effectiveness

Provision of Information and Resources

When asked how NYCHA could promote an effective SFHP, several participants suggested improving communication and providing tenants with smoking cessation resources. One tenant explained, “[I]f you really want people to stop smoking, then you should give information about it. Like you can’t just be like oh stop smoking in apartments and around the building… and then not give any information” (Participant 16). Another tenant suggested that NYCHA should educate tenants on the real reasons it was enacting the new SFHP: “Have community meetings, get everybody involved. Get them to understand we’re not trying to tell you how to run your life, we’re not trying to tell you what to do in your personal space although you’re renting from us, but at the same time we’re concerned of everybody’s overall safety and health, because we have tenants who don’t smoke” (Participant 13). Residents further recommended that NYCHA support the SFHP’s mission by providing stress management courses, access to mental health services, and smoking cessation resources such as nicotine replacement therapies (ie, patches and gum). Many participating tenants believed that making such measures more easily accessible and readily available on PHA premises could facilitate policy adherence (Participants 3, 4, 5, 8, 9, 13, 16).

Initiatives to Promote Resident Cooperation

A lack of tenant cooperation or camaraderie was often cited as a reason the upcoming SFHP would not succeed (Participants 9, 10). One resident stated, “It’s the attitude of the people. If the people don’t care, guess what? Nobody cares. It’s going to get overlooked…The people were never unified in these buildings. It’s every man for himself” (Participant 10). To address this issue, several tenants recommended that NYCHA work on promoting resident cooperation, for example through community outreach meetings to encourage unification among building residents. One remarked, “I think everybody will have to get together for it [the policy] to work” (Participant 5). Another believed signing a petition with other residents to pledge to stop smoking indoors could bolster adherence with the upcoming policy (Participant 8).

Discussion

Gaining a better understanding of resident priorities and motivations can help ensure that SFHPs achieve their intended benefits. Our findings largely reinforce existing postimplementation studies examining tenant views on the controversial topic of mandatory SFHPs. However, by examining resident perspectives ahead of the implementation of the policy, we gleaned some unique information which can help guide PHAs moving forward.

Our findings affirm the need for greater protections against secondhand smoke exposure based on resident accounts of a high prevalence of smoke on the premises and reported negative impacts on health and quality of life as a result. This coincides with existing literature showing disproportionally high rates of smoking and tobacco-related disparities among public housing residents.^8,11–13

Although a majority of study participants expressed support for the upcoming SFHP, most thought the policy would not succeed due to poor adherence. Residents pointed to four major barriers to policy adherence. The first was a perceived infringement on individual rights over one’s actions in the confines of one’s apartment. This reinforces existing literature, as Anthony et al. noted that smokers felt that SFHPs resulted in a direct effect on their rights and a loss of autonomy.²⁵ Hennrikus et al. also found that tenants felt their SFHP was an infringement of their rights.²⁶ Although PHAs can try to counter this by telling tenants they do not actually have this right in a rental apartment, this strategy is likely to garner opposition. Instead, residents in our study suggested that the PHA openly communicate with tenants regarding parameters and benefits of the policy, seeking to earn a resident endorsement rather than taking a more punitive approach. Accordingly, the PHA may focus on providing information on how smoke travels from apartment to apartment, the dangers of secondhand smoke, and the intended health benefit for all tenants, especially children and the elderly. This notion of reframing the issue to focus on the smoke rather than the smoker has been recommended in recent literature on health behavior and health communications regarding smoke-free housing policies.²⁵

A second anticipated barrier to policy effectiveness was doubt that NYCHA would effectively enforce the upcoming policy. Postimplementation literature on SFHPs has demonstrated that when residents don’t know how a policy is currently enforced, they are less likely to adhere.^25,26 For example, Anthony et al. noted that residents had a “hazy understanding of how the policy was being enforced” and this “lack of knowledge led some residents to believe that ‘nothing was happening.’”²⁵ Providing clarity about how the policy will be enforced is an easy and cost-effective solution to this problem. Because we conducted interviews in the preimplementation period, we uncovered an additional issue—tenants were unlikely to follow an upcoming policy if there was poor enforcement of existing policies, such as the policy prohibiting smoking in hallways and even the deadline for rent payments. Housing authorities which have a reputation for not enforcing existing policies may have a difficult time convincing tenants to adhere to a new policy such as a SFHP. We acknowledge that increasing the level of enforcement (eg, by maintaining a frequent staff presence on housing premises) can pose a challenge in a low-resource environment, as mentioned in recent literature.²⁵ In these cases, shifting resources toward other strategies, such as partnering with community organizations to provide cessation support, may be more cost-effective.²⁵

A third perceived barrier to policy effectiveness was the danger associated with going outside to smoke, given the shootings and robberies which occurred in the surrounding area. Tenants were hesitant to risk their personal safety simply to follow a rule. Housing authorities located in neighborhoods which are perceived to be dangerous may experience challenges related to adherence, especially at night, and safety concerns have been cited as a barrier to SFHP adherence in recent literature.²⁸ If tenants are expected to go outside to smoke, safety issues need to be addressed by the housing authority. Although these issues will be building and neighborhood-specific, potential mitigating steps may involve increasing lighting outdoors or designating an outdoor smoking area in a location where tenants feel safe alone and at night. In a recent analysis of smoking outcomes in a NYCHA complex that had undergone major renovations shortly after the SFHP went into effect, there was a significant reduction in indoor smoking after improvements in conditions throughout the development, including added safety features such as lighting and outdoor seating areas.³⁰ Future studies should examine the impact of physical changes and safety upgrades on smoking outcomes to better understand the mechanisms at hand that contribute to positive changes.

Lastly, general discontent with NYCHA was highlighted as a barrier to anticipated SFHP adherence. Several participants reported a lack of responsiveness by NYCHA to tenant needs, notably to maintenance requests, and felt unlikely to follow a new policy if NYCHA was not meeting their needs. Similarly, current smokers in the study by Anthony et al. believed smoking should not be singled out and enforced when other issues on the property were not being addressed.²⁵ Residents identified the notion of “give and take”—if the PHA was responsive to their needs, they would be more responsive to the new policy. Hernández et al. also found that maintenance defects and unaddressed repair needs compromised adherence to SFHPs.²⁸ This study introduced the “social contract of smoke-free housing,” a construct which posits that tenants consider smoking policies within the context of broader relationships with the housing authority and with fellow tenants.²⁸ In addition to frustrations over building conditions, suspicion that NYCHA would use the SFHP as a means to evict residents was mentioned by multiple interview participants, and also noted in recent literature.²⁷ Housing authorities should work toward (1) establishing a positive relationship with tenants, openly communicating about the motivations behind the policy and intention not to displace tenants, and (2) upholding a high-quality standard of living in the building while demonstrating responsiveness to tenant needs. These steps may play a large role in garnering buy-in from tenants around the smoke-free and other building policies.

In addition to citing perceived barriers to adherence, tenants offered recommendations for enhancing policy effectiveness. Residents highlighted the importance of the housing authority communicating with and providing smoking cessation resources to tenants. Relatedly, residents desired reassurances that they would be secure in their housing and that the PHAs were focusing on smoking behavior rather than on evicting tenants that smoke. Providing tenants with ample information in the early stages and throughout the policy implementation period can go a long way in building trust. This low-cost approach can help tenants understand the motivations behind policy changes and reduce suspicions and insecurities on the part of tenants. Focusing on resident endorsement is critical to ensure buy-in, however resident buy-in is premised on honest communication between housing authorities and tenants and among tenants themselves.

For NYCHA tenants, several local efforts at improving communication, resource-provision, and relationship building are underway. An ongoing randomized controlled trial led by DH is testing a model of resident endorsement that involves bringing NYCHA tenants together to discuss issues such as secondhand smoke and encouraging tenants to sign a pledge to promote the health of other tenants to foster a sense of partnership and community among tenants.³¹ This study has a smoking cessation arm and a combined arm to measure the effectiveness of these various approaches alone and combined to support compliance.³¹ NYCHA has engaged in similar community outreach efforts since the HUD mandate went into effect in 2018.³² These include establishing clear consequences for people who break the rules involving meeting with the tenants, providing smoking cessation resources, and coming to agreements in writing that further violations can lead to commencement of termination.³² This stepwise process can help minimize tenant fear that SFHPs are designed to promote eviction. In addition, in 2020 NYCHA hired several Smoke-Free Liaisons to provide residents with support and information about the policy as well as deploy smoking cessation coaching and resource referral to residents.³³ Although individual PHAs will likely be encumbered by budget and personnel constraints, informational and smoking cessation resources can go a long way to ensure that residents understand and are equipped with the tools necessary to adhere to the SFHPs.

This study contains notable limitations, primarily the lack of generalizability. We captured the views of a small group of NYCHA tenants in the Bronx, NY. Their experiences may not resonate in other settings. For example, certain issues identified in this study, such as lack of safety going outside to smoke, may be unique to the participants interviewed and reflect their experiences living in a densely populated area in the South Bronx. Additionally, residents mentioned significant marijuana use in buildings; however, cannabis falls outside the parameters of the federal smoke-free mandate since all controlled substances are banned in public housing. Legal ramifications of smoking marijuana outdoors will vary by location and will likely affect a tenant’s willingness to go outside to smoke, which is beyond the scope of this study. As states and municipalities legalize marijuana use, PHAs will need to devise plans and guidance to ensure consistency with existing SFHPs.

Thousands of PHAs around the country continue to work to enforce their smoke-free policies. However, these smoking bans must be adhered to in order to achieve their intended health and economic benefits. Tenant perspectives are crucial to understanding drivers of poor adherence, and our interviews add to this underexplored area of research. Based on our results we argue that as housing authorities continue to support their smoke-free policies, they should engage in (1) information and resource-provision, (2) safety enhancement, and (3) relationship building with tenants in order to maximize policy compliance. Resident perspectives, engagement, and buy-in are central to ensuring successful SFHP implementation in public housing sites nationwide.

Supplementary Material

A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at https://academic.oup.com/ntr.

Funding

This project was supported by a HUD Healthy Homes Technical Study Grant# NYHHU0034-16 (Principal Investigator: Hernández) and the NIEHS Center for Environmental Health in Northern Manhattan (P30 ES009089). A follow-up study related to this topic is currently underway with funding from the National Cancer Institute Grant# 1R01CA240555-01A1 (Principal Investigator: Hernández).

Declaration of Interests

None declared.

Data Availability

Data not publicly available due to confidentiality and risk of sharing personally identifiable information.