In February 2017, a new regulation went into effect from the Department of Housing and Urban Development that requires all public housing units in the United States to become smoke-free by July 30, 2018. The rule was years in the making, and enacted on the basis of extensive and convincing research about the detrimental effects of tobacco smoke on public health. But one northern Kentucky city was well in front of the federal policy.

In Covington, a collaborative effort between the city’s public housing authority and the Northern Kentucky Health Department — started in 2011 and fully implemented in 2015 — has already resulted in substantial improvements in air quality and reductions in tobacco use by the residents of the city’s three public housing communities. The plan engaged residents from the start, set up an air quality testing framework to measure progress, and offered smoking cessation resources to those residents seeking to quit their habit.

With a federal deadline now established, Covington’s smoke-free public housing initiative is currently being summarized in a toolkit and distributed to other public housing authorities in the commonwealth for their use as a guide in the year ahead.

Policy Origins: Collaboration and a Detailed Plan

“Everything goes back several years, actually,” said Zachary Raney, tobacco coordinator with the Northern Kentucky Health Department. “The HUD statement back in 2009, suggesting that public housing go smoke-free, really got us thinking here at the health department that we really needed to get on that issue. And we had a champion at the Housing Authority of Covington, Chris Bradburn, the director of resident services, who was really instrumental in helping out with this project.”

In September 2011, Covington’s housing authority board approved a resolution to allow a smoke-free housing policy to be explored and eventually implemented. Working in partnership, the housing authority and the health department prepared and conducted staff and resident surveys and also started a resident education program throughout the properties.

“And in April 2012 they also did a pre-policy air nicotine test, which involved taking nicotine air monitors obtained from Johns Hopkins University,” Raney said. “We put those in resident units and in common areas and even in office spaces. We left those in place for a week, and we found that there was nicotine on every single monitor, no matter where it was placed.”

When the time came for tenants to renew their leases, new agreements with the smoke-free policy added were distributed on a rolling basis starting in 2014. Raney said that despite some initial resistance, most residents recognized the tangible benefits of enacting a comprehensive smoke-free policy on the grounds.

“Take it Outside”

The policy fully went into effect for all of Covington’s public housing properties in July 2015. On one campus, a designated smoking area was marked – a compromise for that specific property – but on the others, the ban was enforced at roughly a 25-foot distance away from all buildings. This 25-foot barrier is also part of the impending federal regulation.

“Some of the messaging that was actually stressed here in Covington was, ‘Take it outside,’” Raney said. “And that was just to drive home the point that the policy is not about the smoker, it’s about the smoke. That was something that I’ve heard come up before in these policies – people feel a little stigmatized. We really want to stress that that’s not the case. We’re not doing this to penalize one person, we’re doing it to protect everyone. That’s the true reason behind these policies.”

This measured approach is reflected in the policy’s penalty structure for non-compliance. Self-enforcement of the policy by residents is prioritized, and for those who continue to smoke indoors, the Northern Kentucky Health Department uses a tiered warning system beginning with letters and ending with a fine.

Better Air, Less Smoke

In early 2016, the public health department conducted a new set of air quality tests measuring nicotine levels, and the improvements were immediately made clear. Raney said that testing showed a 75 percent reduction in air nicotine levels averaged across all three communities. And some of the individual readings came back clean – “We had several zeroes in there as well,” Raney said.

Just as encouraging were the responses from another round of resident surveys conducted months after the policy took effect. They showed that, across all three public housing units, residents who said they smoked every day dropped from 56 percent to 34 percent, those who said they smoked several days a week rose from 11 to 22 percent, and those who said they did not smoke at all rose from 33 percent to 44 percent.

“Basically, what we saw was that people who were smoking every day kind of fell over into the other categories, and were reducing their tobacco use overall as a result of the policy,” Raney said. For those residents who sought to end their smoking habits, the public health staff offered resources such as the state Quit Line (1-800-QUIT-NOW, and available online), and also contracted with National Jewish Health, who runs the Quit Line, to offer four weeks of free nicotine replacement therapy patches.

Taking the Covington Model Statewide

Now, Raney and colleagues at the public health department have created a toolkit with funding support from the state Cabinet for Health and Family Services’ Tobacco Prevention and Cessation Program. The toolkit, which can be accessed here, presents health statistics, legal guidelines, cost-benefit analysis, a timeline, and additional information for other public housing authorities to use as a guideline. Covington’s policy history is also included as a case study.

“What we wanted to do was to show that in our community, in the real world, this policy actually made a difference,” Raney said. “It’s affecting people’s lives, it’s changing behavior, and it’s protecting the health of everyone in those communities… Now that the federal ruling is finalized and every housing authority is going to be moving toward this, we kind of wanted to demonstrate and showcase our example as well as lay out some of the benefits and the overall process of implementing a policy like this.”

An important statistic included in the toolkit draws from data compiled by the Covington Housing Authority in 2013, which shows the higher turnover costs associated with preparing a housing unit where smoking was allowed for re-use. These cost increases are brought about by tobacco smoke contamination of upholstery, carpet, curtains, and other materials, and range from 41 percent higher for a two-bedroom unit to 62 percent for a one-bedroom unit. The statistics offer additional evidence from a property owner/manager perspective on the benefits of having a smoke-free residence policy.

Raney said that the Northern Kentucky Health Department is also redoubling its efforts to address one Covington public housing property that had a lower improvement in nicotine air quality (around 50 percent) compared with the other two. Over the past few months, Raney and the facility’s staff created a graphic flyer describing the smoke-free policy rules and benefits, and they’ve enlisted a group of resident “health ambassadors” to go door to door and remind their neighbors of the policy and how it benefits their own families as well as the entire housing community.

This KET article is part of the 2017 Smoking and Health Initiative, funded in part by the Foundation for a Healthy Kentucky.