Transcript A Smokefree Multi-unit Housing Anecdote Jonathan P. Winickoff, MD, MPH Associate Professor in Pediatrics Harvard Medical School September 24, 2011

A Smokefree Multi-unit Housing Anecdote
Jonathan P. Winickoff, MD, MPH
Associate Professor in Pediatrics
Harvard Medical School
September 24, 2011
…dedicated to eliminating children’s
exposure to secondhand smoke and tobacco
Scientific
Knowledge
Social
Strategies
Political
Will
Smokefree multi-unit housing
• Imagine telling the home owner that they can’t
smoke in their own unit?
• Focus on the established evidence to build the
case for smokefree multi-unit housing
–
–
–
–
–
tobacco smoke causes harm
contamination occurs
cotinine levels of children are elevated
public support for smokefree multi-unit housing
legal/ethical framework supports smokefree
Comparative Causes of Annual
Preventable Deaths in the United
States
430
450
400
(thousands)
350
300
250
200
150
81
100
50
0
41
17
AIDS
Alcohol
19
Motor Homicide
Vehicle
14
Drug
Suicide
Induced
30
Smoking
Sources: (AIDS) HIV/AIDS Surveillance Report 1998; (Alcohol) McGinnis MJ, Foege WH. Review: Actual Causes of Death in the United States. JAMA 1993; 270:2207-12;
(Motor vehicle) National Highway Transportation Safety Administration, 1998; (Homicide, Suicide) NCHS, vital statistics, 1997;
(Drug Induced) NCHS, vital statistics, 1996; (Smoking) SAMMEC, 1995
Children and Tobacco Smoke
• There is NO safe level of exposure
• Increased risk of: Asthma, RSV pneumonia,
SIDS, Otitis media, Metabolic Syndrome,
Dental caries
• Hospitalizations
• Sleep disturbance
• School absenteeism
• Developmental delay—even at lowest
detectable levels (Yolton et al)
Biochemical changes at low
levels
• Wilson, et al
– Using NHANES
– Relationship between cotinine levels and
serum levels of antioxidants
– Significant association between levels of
cotinine and vitamin C, and carotenoids
– Association was significant even at low
levels of exposure (.015-2 ng/mL)
The Life Cycle Effects of Smoking
Asthma
Otitis Media
Fire-related Injuries
Cognitive Problems
SIDS
RSV/Bronchiolitis
Meningitis
Influences
to Start
Smoking
Childhood
Infancy
Adolescence
Nicotine Addiction
Health Effects
In utero
Adulthood
Low Birth Weight
Stillbirth
Cancer
Cardiovascular Disease
COPD
Arch Pediatr Adolesc Med. 1997
Contamination:
Reason for Concern
• Overarching issue is that smoke in multi-unit
housing affects everyone else
• Exposure through shared ventilation, along air
ducts, leaky walls.
• The numbers add up quickly, if just 5 people in a
building smoke ½ pack of cigarettes in their
apartment each day; the load to the building is
over 18,000 cigarettes each year.
Effect of a Single Cigarette on
Indoor Air Quality
…it takes TWO
hours for the air
quality to return to
minimum federal
safety standard
for levels of CO,
fine particles and
particulate
aromatic
hydrocarbons..
Ott et al. 2003. J. Air & Waste Manage. Assoc.
Can smoking in one unit
contaminate another unit?
• Kraev et al. (2009) demonstrated, using
“Hammond” filters, that air in 89% of nonsmoking units was contaminated with nicotine.
11
Smokefree Laws Mostly Protect Adults
• Increasingly, workplaces, restaurants, bars,
and other public places are going smokefree
• Young children spend most of their time in
the home
• Poor children live in multi-unit housing,
where smoking is most concentrated
Cotinine levels in children
• 2001-2006 National Health and Nutrition Examination
Survey (NHANES)
• Hypothesized and found that among children in
households that do not allow smoking in their own
home, children who live in apartments have a 140%
higher cotinine level than children living in detached
homes,
• This relationship persists when controlling for poverty
and race/ethnicity
13
Cotinine levels in children by housing type
14
What do people who live in
multi-unit housing actually think?
• 2009 Social climate survey
• Nationally representative based on US Census
Data
• 1500 respondents per year with approximately
70% response rate among eligible respondents
contacted
What do people who live in
multi-unit housing actually think?
• We hypothesized that people who lived in multiunit housing would be more resistant to banning
smoking in private units of buildings
• A majority support banning smoking in housing
• Those in apartments were more supportive, not
less
Support for Smoke-Free Private Areas
% Supporting Smoking Ban
68
66
64
62
60
Detached
58
Multi-Unit
56
54
52
50
2007
2008
Year
2009
Legal and ethical framework
• HUD: 6.7% of housing authorities smokefree and
increasing.
• NEJM article presents legal and regulatory precedent,
health consequences of tobacco smoke, and inability
of non-smokers to escape exposure…and argues that
principles of social justice can only be met by smokefree public housing policies.
• Bans could proceed as leases are renewed, and safe
forms of nicotine replacement therapy could be
18
offered to support addicted individuals
Use social strategies
• Social strategies can be very effective when
you put a human face on the problem
• Build public support for protecting those at risk
• The press and the media can help
19
Newsweek Magazine Article
The Media has Popularized the
Third-Hand Smoke Concept
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Thirdhand Smoke Accumulates
• THS accumulates in the homes of people who
smoke
• Matt et. al. showed that even after a home
remains vacant for 2 months and prepared for
the new residents, THS contamination remains
on surfaces and in house dust.
• Non-smokers living in former smokers homes
are exposed to tobacco smoke toxins.
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Jessica Lin 1st Place winner, FAMRI/ AAP/Richmond Center Art Contest 2009
Partner with Pediatricians
• AAP policy recommends that pediatricians support cleanair and smoke free environment ordinances and
legislation in their community and state. To aid in
accomplishing smoke free multi-unit housing you can:
• Work with AAP chapters to pass state legislation or local
ordinances requiring that multi-unit housing be smoke
free
• Work with local zoning administrators to require that
multi-unit housing, including owner-occupied
condominiums and apartments, are smoke free
• Work with housing association boards and local
government coalitions.
• Educate landlords and homeowners associations about
the importance of maintaining smoke-free multi-unit
housing environments - for the health of their tenants and
residents, and to improve their own bottom lines.
Resources and tools
to aid in your advocacy
efforts
HUD Smoke Free Toolkit –
Coming Soon!
HUD Smoke Free Toolkit
• Toolkit for residents
– Education materials
– Legal options
– Steps for residents to start making their buildings
smoke-free
– Resident organizing letter
– Sample petitions
– Sample letter to owners/manager
– SAMPLE DOCTOR LETTER!!!!!
– Home pledge kit
– List of resources
HUD Smoke Free Toolkit
(con’t)
• Toolkit for owners/managers
– Reasons to consider going smoke-free
– FAQs about the benefits of smoke-free
housing
– Steps for owners/managers to take to
implement smoke-free policies
– Sample resident letter
– Sample lease addendum
– List of resources
Summary
• Provided key research studies:
– cotinine levels - significant exposure
– public support - for protecting those at risk
– legal framework - analysis of strategies for action
• Told anecdotes and shown media support
• Explained partnership among clinician types
• Together these components provide the
scientific evidence and social strategies to
build the political will for banning smoking in
multi-unit housing.
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AAP Richmond Center of Excellence
AAP Resources
• AAP Richmond Center Web Site – Smoke Free
Multiunit Housing Web Page
(http://www.aap.org/richmondcenter/SmokeFre
eHousing.html)
• Facebook (CEASETOBACCO)
Clinical and Community Effort Against Secondhand Smoke Exposure
• AAP eLearning…Maintenance of CertificationTobacco Control Module
(http://www.pedialink.org/cme/eqipptc)
References
1.
2.
3.
4.
Winickoff JP, Gotlieb M, Mello MM. Regulation of smoking in
public housing. New England Journal of Medicine. 2010 Jun
17;362 (24):2319-25. PMID: 20554988
Aligne CA, Stoddard JJ. An economic evaluation of the medical
effects of parental smoking. Arch Pediatr Adolesc Med.
1997;151:648-653.
Winickoff JP. Ban smoking in public housing. Newsweek
Magazine. June 13, 2009. PMID: 19655657
Winickoff J, Dempsey J, Friebely J, Hipple B, Lazorick
S. EQIPP: Eliminate Tobacco Use and Exposure [online course].
PediaLink. American Academy of Pediatrics. March 1, 2011.
http://www.pedialink.org/cme/eqipptc. Accessed April 11, 2011
References
1.Vital signs: nonsmokers' exposure to secondhand smoke --- United States, 19992008. MMWR Morb Mortal Wkly Rep 2010;59:1141-6.
2.Bernert JT, Jr., McGuffey JE, Morrison MA, Pirkle JL. Comparison of serum and
salivary cotinine measurements by a sensitive high-performance liquid
chromatography-tandem mass spectrometry method as an indicator of exposure to
tobacco smoke among smokers and nonsmokers. JAnalToxicol 2000;24:333-9.
3.Benowitz NL. Cotinine as a biomarker of environmental tobacco smoke exposure.
Epidemiol Rev 1996;18:188-204.
4.NHANES: Laboratory methodology and public data files. 2009. (Accessed at
http://www.cdc.gov/nchs/data/nhanes/labdoc.pdf.)
5.Matt GE, Quintana PJ, Hovell MF, et al. Households contaminated by environmental
tobacco smoke: sources of infant exposures. Tob Control 2004;13:29-37.
6.Gurkan F, Kiral A, Dagli E, Karakoc F. The effect of passive smoking on the
development of respiratory syncytial virus bronchiolitis.EurJEpidemiol 2000;16:465-8.
References
7.Bradley JP, Bacharier LB, Bonfiglio J, et al. Severity of respiratory syncytial virus
bronchiolitis is affected by cigarette smoke exposure and atopy. Pediatrics 2005;115:e7-14.
8.Leung GM, Ho L-M, Lam T-H. Secondhand smoke exposure, smoking hygiene, and
hospitalization in the first 18 months of life. Archives of pediatrics & adolescent medicine
2004;158:687-93.
9.Kitchens GG. Relationship of environmental tobacco smoke to otitis media in young
children. Laryngoscope 1995;105:1-13.
10.Delpisheh A, Kelly Y, Rizwan S, Brabin BJ. Salivary cotinine, doctor-diagnosed asthma
and respiratory symptoms in primary schoolchildren. Matern Child Health J 2008;12:18893.
11.Mahid SS, Minor KS, Stromberg AJ, Galandiuk S. Active and passive smoking in
childhood is related to the development of inflammatory bowel disease. Inflamm Bowel Dis
2007;13:431-8.
12.Weitzman M, Cook S, Auinger P, et al. Tobacco smoke exposure is associated with the
metabolic syndrome in adolescents. Circulation 2005;112:862-9.
References
13.Prandota J. Possible pathomechanisms of sudden infant death syndrome: key role of
chronic hypoxia, infection/inflammation states, cytokine irregularities, and metabolic
trauma in genetically predisposed infants. Am J Ther 2004;11:517-46.
14.Mannino DM, Moorman JE, Kingsley B, Rose D, Repace J. Health effects related to
environmental tobacco smoke exposure in children in the United States: data from the
Third National Health and Nutrition Examination Survey. Arch Pediatr Adolesc Med
2001;155:36-41.
15.Yolton K, Xu Y, Khoury J, et al. Associations between secondhand smoke exposure and
sleep patterns in children. Pediatrics 2010;125:e261-8.
16.Tanaka K, Miyake Y, Arakawa M, Sasaki S, Ohya Y. Household smoking and dental
caries in schoolchildren: the Ryukyus Child Health Study. BMC Public Health 2010;10:335.
17.Johnston BN, Preciado DA, Ondrey FG, Daly KA. Presence of otitis media with effusion
and its risk factors affect serum cytokine profile in children. IntJ PediatrOtorhinolaryngol
2008;72:209-14.
18.Tebow G, Sherrill DL, Lohman IC, et al. Effects of parental smoking on interferon gamma
production in children. Pediatrics 2008;121:e1563-9.
19.Strauss RS. Environmental Tobacco Smoke and Serum Vitamin C Levels in Children.
Pediatrics 2001;107:540-2.
References
19.Strauss RS. Environmental Tobacco Smoke and Serum Vitamin C Levels in Children.
Pediatrics 2001;107:540-2.
20.Wilson KM, Finkelstein JN, Blumkin AK, Best D, Klein JD. Micronutrient levels in
children exposed to second-hand tobacco smoke. Pediatrics 2010.
21.Kallio K, Jokinen E, Raitakari OT, et al. Tobacco smoke exposure is associated with
attenuated endothelial function in 11-year-old healthy children. Circulation 2007;115:320512.
22.Yolton K, Dietrich K, Auinger P, Lanphear BP, Hornung R. Exposure to environmental
tobacco smoke and cognitive abilities among U.S. children and adolescents. Environ
Health Perspect 2005;113:98-103.
23. 2009. (Accessed at http://www.hud.gov/offices/pih/publications/notices/09/pih200921.pdf.)
24.Winickoff JP, Gottlieb M, Mello MM. Regulation of smoking in public housing. The New
England journal of medicine 2010;362:2319-25.
25.Kraev TA, Adamkiewicz G, Hammond SK, Spengler JD. Indoor concentrations of nicotine
in low-income, multi-unit housing: associations with smoking behaviours and housing
characteristics. Tob Control 2009;18:438-44.
26. Wilson KM, Klein JD, Blumkin AK, Gottlieb M, Winickoff JP. Tobacco-Smoke Exposure
in Children Who Live In Multiunit Housing. Pediatrics 2011;127:85-92.
A Child’s Perspective
Opportunities to get involved
Engage…
• Your state AAP/Medical chapter
• Pediatricians in areas where smoke free multiunit housing is being considered to frame as a
child health issue
• Colleagues representing other medical
specialty societies
Measurement of cotinine
• Can be measured in saliva, blood, urine,
hair, nails
• Immunoabsorbance assays- typical limit of
detection about 1-2 ng/mL
• Mass spectrometry- typical limit of
detection of .015-.5 ng/mL
Measurement of cotinine
Level
Significance
.015 ng/mL
Lowest limit of detection
.05 ng/mL
Limit of detection for earlier NHANES
1-2 ng/mL
Limit of detection for ELISA methods
2.32 ng/mL
Average urine cotinine of 6 month olds with only
outside smokers
10-15 ng/mL
Typical cut off for active vs. secondhand smoke in
adults
15.47 ng/mL
Average urine cotinine of 6 month olds with inside
smokers
How important is it?
• How important an issue do you think
secondhand smoke is for your patients?
A. Not at all important
B. Somewhat important
C. Important, but we have so many things to
address
D. Very important
E. Extremely important
Questions?
Smoke Free Multi-unit
Housing:
Moving From Research to
Action
Contact Information
Richmond Center of Excellence website:
http://www.aap.org/richmondcenter/
Richmond Center of Excellence email:
[email protected]
Join the Smokefree Housing Listserve:
[email protected] and ask to join the
listserve!
At the conclusion of this activity,
participants should be able to:
• Describe the health impact of
secondhand smoke in multi-unit housing.
• Describe prevalence of exposure to
secondhand smoke in multi-unit housing.
• Describe the consequences of exposure
to secondhand smoke.
Background
• 18% of children ages 3-11 and 17% of those
ages 12-19 are regularly exposed to
secondhand tobacco smoke (SHS) in the
home
• 54% of children 3-11 and 47% of children
12-19 had detectable cotinine levels in the
2007-2008 NHANES
– 32 million children ages 3-19 with exposure
• Newer measurement techniques allow
assessment of very low levels of exposure
Measurement of cotinine
• Can be measured in saliva, blood, urine,
hair, nails
• Immunoabsorbance assays- typical limit of
detection about 1-2 ng/mL
• Mass spectrometry- typical limit of
detection of .015-.5 ng/mL
Free market at work
• Increasing pressure from tenants to
restrict smoking in private multi-unit
housing
• Landlords see increased costs for
cleaning up smoking apartments,
increased fire risks, and increased
complaints from tenants
• Municipalities also banning smoking in
multi-unit housing
Objective
• To determine whether children who live
in attached housing have higher cotinine
levels than children who live in detached
housing
Methods
• Data from the 2001-2006 National Health
and Nutrition Examination Survey
(NHANES)
• 4,782 children ages 6 to 18 years
• Housing type: Apartment, attached
house, detached house
• Controlled for demographics and SES
• Cotinine cut off .015 ng/mL (HPLC)
Results
• Among children not living with a smoker:
– 73% had cotinine levels indicating exposure
• Exposure by housing type:
– 84% of children living in apartments
– 80% of children living in attached houses
– 70% of children living in houses
– p<.001
Results
Cotinine level (ng/mL)
Single house
%
Attached house
%
Apartment %
p-value
<.015
29.7
20.4
15.5
<.001
.015 - <.05
34.2
32.9
28.1
.05 - <.1
33.1
40.1
48.9
1 - <2
1.4
4.0
4.4
2 and greater
1.6
2.6
3.1
Results
Cotinine level (ng/mL)
Single house
Attached house Apartment
p-value
<.015
29.7
20.4
15.5
<.001
.015 - <.05
34.2
32.9
28.1
.05 - <.1
33.1
40.1
48.9
1 - <2
1.4
4.0
4.4
2 and greater
1.6
2.6
3.1
Results
Cotinine level (ng/mL)
Single house
Attached house Apartment
p-value
<.015
29.7
20.4
15.5
<.001
.015 - <.05
34.2
32.9
28.1
.05 - <.1
33.1
40.1
48.9
1 - <2
1.4
4.0
4.4
2 and greater
1.6
2.6
3.1
Results
Race by housing type (% exposed)
Variable
House
Attached house
Apartment
% exposed (95%CI)
p-value
White
68% (61, 74)
<.001
African-American
89% (85, 92)
Hispanic
66% (60, 71)
Other
74% (60, 85)
White
76% (61, 86)
African-American
92% (83, 96)
Hispanic
70% (52, 83)
Other
80% (54, 94)
White
99% (91, 99)
African-American
96% (92, 98)
Hispanic
73% (64, 81)
Other
64% (40, 82)
<.05
<.001
Race by housing type (% exposed)
Variable
House
Attached house
Apartment
% exposed (95%CI)
p-value
White
68% (61, 74)
<.001
African-American
89% (85, 92)
Hispanic
66% (60, 71)
Other
74% (60, 85)
White
76% (61, 86)
African-American
92% (83, 96)
Hispanic
70% (52, 83)
Other
80% (54, 94)
White
99% (91, 99)
African-American
96% (92, 98)
Hispanic
73% (64, 81)
Other
64% (40, 82)
<.05
<.001
Race by housing type (% exposed)
Variable
House
Attached house
Apartment
% exposed (95%CI)
p-value
White
68% (61, 74)
<.001
African-American
89% (85, 92)
Hispanic
66% (60, 71)
Other
74% (60, 85)
White
76% (61, 86)
African-American
92% (83, 96)
Hispanic
70% (52, 83)
Other
80% (54, 94)
White
99% (91, 99)
African-American
96% (92, 98)
Hispanic
73% (64, 81)
Other
64% (40, 82)
<.05
<.001
Race by housing type (% exposed)
Variable
House
Attached house
Apartment
% exposed (95%CI)
p-value
White
68% (61, 74)
<.001
African-American
89% (85, 92)
Hispanic
66% (60, 71)
Other
74% (60, 85)
White
76% (61, 86)
African-American
92% (83, 96)
Hispanic
70% (52, 83)
Other
80% (54, 94)
White
99% (91, 99)
African-American
96% (92, 98)
Hispanic
73% (64, 81)
Other
64% (40, 82)
<.05
<.001
Results: Tobit regression
analysis
• Controlling for SES, race/ethnicity
• White children living in apartments had a 208%
increase in their cotinine level over those living
in detached homes (p.003)
• Black children living in apartments had a 45%
increase in cotinine over those living in
detached homes (p=.024)
• Relationships for those of Hispanic and Other
ethnicity were not significant.
What did we find?
• 9 of 10 White and African-American
children who live in an apartment without
a smoker in the home have evidence of
tobacco smoke exposure.
• These children also have higher mean
cotinine levels than those living in
detached houses.
• This relationship persists even when
controlling for socioeconomic status
Importance to pediatric
practice
• Tobacco smoke exposure is bad for kids
• Even at very low levels, second hand
smoke has negative consequences
• Studies haven’t examined the risks of
low level exposure for other problems:
– Asthma exacerbations?
– Bronchiolitis admission?
– Respiratory illness severity?
Importance to pediatric
practice
• Pediatricians should assess all potential
sources of exposure, particularly for
children with difficult to control asthma,
recurrent otitis, or other respiratory
infections
Conclusions
• Smoking bans in multi-unit housing may
help to reduce the seepage/ventilation
issues.
– Care is needed to avoid unintended
consequences
• Balconies
• Common areas
– Ethical issues around limiting smoking
for low income residents
What is Third-hand Smoke?
• Third-hand smoke is the left-over
contamination in a room/car/clothing that
persists after the cigarette is
extinguished
– The condensate on the glass from a smoking
chamber was used in one of the first studies linking
smoking and cancer (Wynder, 1953)
– Homes and cars in which people have smoked may
smell of cigarettes for long periods
66
We asked people about the
concept…
• Please tell me whether you strongly
agree, agree, disagree, or strongly
disagree with this statement:
• “Breathing air in a room today where
people smoked yesterday can harm the
health of infants and children”
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What did we find?
• Of parents surveyed:
– 93% agreed SHS harms kids
– 61% agreed that breathing the air where someone
smoked yesterday causes harm…
• 63% of non-smokers and 44% of smokers
• 22% didn’t know
• 17% disagreed
• Agreeing with this statement independently
predicted strict home smoking bans
68