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Non-Smokers’ Rights Association Smoking
and Health Action Foundation
________________________________________________________________________________________________________
Spring 2010
Smoke-Free Affordable Housing: Picking
on Poor People or a Case for Social Justice?
Introduction
What does tobacco control have to do
with social justice? The answer is, as it turns out, a
lot.
Demand for smoke-free housing in Canada
is increasing, and landlords are starting to take
notice. However, there remains an acute shortage of
multi-unit buildings for people who need or want to live
smoke-free. This is the case for Canadians seeking
market rate rental housing, and especially so for those
who cannot afford market rate and must rely upon
affordable housing.
It has been said that prohibiting
smoking in affordable housing is an attack on the poor
and vulnerable who are already at the margins of
society. Negative media coverage has claimed that such
policies are discriminatory and amount to enforced
smoking cessation because low income families are
over-represented in the smoking population.
This issue needs to be re-framed from a
social justice perspective, both for the nonsmokers and
smokers who live in affordable housing. Social justice
is about seeking (and achieving) equity for vulnerable
and marginalized populations. Health inequity is the
result of disadvantage in opportunities, in material
circumstances and in behaviours related to health.
Tobacco control with a social justice approach
recognizes the social determinants of health 1
and has the potential to
remove barriers and equalize opportunities to enable
marginalized people to enjoy better health, free of the
consequences of tobacco addiction.
Access to decent housing is an essential
component of a person’s physical safety and well-being,
contributing to one’s freedom to lead a full and
satisfying life. Housing that imposes sickness and
disease is not acceptable. It is well-established that
there is no known safe level of exposure to second-hand
smoke and that all exposure should therefore be avoided.
Second-hand smoke has been identified as both a “Class A
1
The social
determinants of health recognize the impact of an
unequal distribution of power, income, goods, and
services on a person or population… and how the
consequent unfairness in the immediate, visible
circumstances of peoples lives – their access to health
care, schools, and education, their conditions of work
and leisure, their homes, communities, towns, or cities
– impacts on their chances of leading a flourishing life
(Closing the Gap in a Generation: WHO Commission on the
Social Determinants of Health, 2008).
Non-Smokers’ Rights Association
Spring 2010
2
(known human) carcinogen” 2
and a “toxic air contaminant,”3
putting it in the same
category as the most toxic industrial and automotive
pollutants.
Exposure to second-hand smoke causes
premature disease and death in children and adults who
do not smoke. It has a variety of short- and long-term
negative health outcomes, including breathing problems,
persistent cough, itchy eyes, nausea, headache, ear
infections, asthma induction and exacerbation, as well
as increased risk of heart disease and cancer, to name a
few. In addition, and of significance for marginalized
people, involuntary exposure to second-hand smoke can
heighten one’s overall level of daily stress and sense
of helplessness.
Canadian landlords and property managers
have the legal right to prohibit smoking in multi-unit
dwellings beyond the common areas, which are already
required to be smokefree under provincial legislation. A
no-smoking policy simply prohibits tenants from
smoking anywhere in the building. The
policy can also be extended to include balconies, patios
or the entire property if the landlord chooses to
include these as well. To be clear, a no-smoking policy:
• Does not
prevent people who smoke from renting accommodation;
• Does not
mean tenants will be evicted because they are smokers;
and
• Does not
force people to quit smoking.
However, simply banning smoking in
affordable housing does not necessarily mean that social
justice has been achieved. A smoking prohibition must
not only be inclusive in its creation, but should also
be part of a more comprehensive approach that includes
special attention to the needs of low income tenants.
Possible unintended consequences must be avoided through
careful planning and consultation with all stakeholders
involved.
Allegations that no-smoking policies
amount to discrimination against low income people are
unfounded. In fact, NOT addressing the problem of
tenants’ involuntary exposure to second-hand smoke in
affordable housing perpetuates social injustice and is a
form of discrimination.
No-Smoking Policies and Social Justice
There are five strong reasons why
prohibiting smoking in affordable housing promotes
social justice for low income Canadians.
2
U.S. EPA.
Respiratory Health Effects of Passive Smoking (Also
Known as Exposure to Secondhand Smoke or Environmental
Tobacco Smoke ETS). U.S. Environmental Protection
Agency, Office of Research and Development, Office of
Health and Environmental Assessment, Washington, DC,
EPA/600/6-90/006F, 1992.
3
California
Environment Protection Agency, Air Resources Board.
Proposed identification of environmental tobacco smoke
as a toxic air contaminant. As approved by the
Scientific Review Panel on June 24, 2005.
http://www.arb.ca.gov/toxics/ets/factsheetets.pdf .
Non-Smokers’ Rights Association
Spring 2010
3
1.
Tenants in affordable housing have the least amount of
choice and mobility.
The waiting lists for access to
affordable housing are typically long. In many Ontario
municipalities, wait times have increased in recent
years, and the average wait for a single person is 5
years or more. In Peel Region the wait is up to 21 years
for singles and families. 4
Most people who wait for an extended
period to get into affordable housing are not likely to
vote with their feet and simply move out if they
experience unwanted second-hand smoke at home. Canadians
with higher incomes have the luxury of choice and
opportunity to protect themselves by seeking better
housing if they find themselves in an undesirable
situation. Affordable housing tenants are effectively
stuck. Relying on affordable housing should not relegate
tenants to involuntary exposure to second-hand smoke in
their own homes.
2. Many
affordable housing tenants are already marginalized by
higher rates of chronic disease and disability than
average Canadians.
Take asthma as one example. Using data
from the Student Lung Health Survey (1995-96),
researchers concluded that socially disadvantaged
Canadian school-age children have increased asthma
prevalence and morbidity. The study surmised that
interventions targeting second-hand smoke exposure among
low income groups have the potential of reducing the
disparity in asthma morbidity across social class. 5
An unpublished survey from the Region of
Waterloo in Ontario found that 36% of social housing
respondents reported that someone in their home had a
health condition made worse by inhalation of second-hand
smoke. 6
When asked about their exposure to
second-hand smoke in the home, 57% of social housing
tenants in the Region of Waterloo reported exposure.
This is in contrast to 30% of households in the general
population reporting exposure,7
which is in keeping with
survey results from other jurisdictions.
A recent peer-reviewed study from Boston
found that social housing tenants in that city reported
substantially poorer health than did other city
residents across a variety of conditions including
hypertension, asthma, diabetes, depression and
disability. 8
4
Ontario Non-Profit
Housing Association. ONPHA’s 2009 Report on Waiting List
Statistics for Ontario. June 2009.
http://www.onpha.on.ca//Content/ONPHA/About/ResearchReports/WaitingLists2009/2009_waiting_list_report.pdf .
5
Dales RE, Choi B,
Chen Y et al. Influence of family income on hospital
visits for asthma among Canadian school children.
Thorax
2002; 57:513-517.
6
Region of Waterloo
Public Health and Planning, Housing & Community
Services. Report PH 09-046/P-09-073.
Smoke-free policy for new leases and
transfers in regionally owned community housing
(Waterloo Region
Housing).
http://www.smokefreehousingon.ca/cms/file/Region_of_Waterloo_recommendations.pdf.
7
Region of Waterloo
Public Health and Planning, Housing & Community
Services. Report PH 09-046/P-09-073.
Smoke-free policy for new leases and
transfers in regionally owned community housing
(Waterloo Region Housing).
http://www.smokefreehousingon.ca/cms/file/Region_of_Waterloo_recommendations.pdf.
8
Digenis-Bury EC,
Brooks DR, Chen L et al. Use of a population-based
survey to describe the health of Boston
Public Housing residents.
American
Journal of Public Health 2008; 98:85-91.
Non-Smokers’ Rights Association
Spring 2010
4
Data from Statistics Canada indicate
that an individual’s low income status (below Statistics
Canada’s ‘low-income cut-offs’) is associated with
having more chronic health conditions than individuals
with higher income. 9
And what about the smokers who live in
affordable housing? This in turn needs to be examined
with a social justice lens. It has been said that
tobacco is not an equalopportunity killer. 10
In fact, the tobacco industry
capitalizes on social inequity and targets minority
groups to promote its deadly products. The 1998 U.S
Surgeon General’s report on tobacco use among racial
minorities notes that America’s four main racial/ethnic
groups have been the focus of targeted advertising and
promotion of tobacco products.11
Tobacco places an excess
burden on low income individuals and their
families—higher rates of smoking and exposure to
second-hand smoke, greater chances that their children
will start smoking, less social support for quitting,
less chance of receiving timely medical intervention and
a greater chance of dying younger.12
3. A
no-smoking policy can dramatically improve the indoor
air quality of a building.
Health inequity stems from social
disadvantage which can include lack of access to
education, to fresh and nutritious food, to
opportunities for physical exercise, to social support,
etc. Health inequity can be further compounded by the
physical environment in which people live. In the case
of affordable housing this can include exposure to black
mould, bed bugs, cockroaches, dust mites, mice and
second-hand smoke. A no-smoking policy is an easy and
affordable measure that can dramatically improve the
indoor air quality of a building. In addition, removal
of tobacco smoke can help to reduce tenants’ reactions
to other allergens in theenvironment, tipping the scales
in favour of better health and well-being.
It is a huge disservice to all tenants
in affordable housing for a housing provider to not even
try addressing the problem of second-hand smoke.
Assumptions abound that there are too many smokers
living in affordable housing to address the problem, or
that they shouldn’t be “picked on” as smoking is one of
life’s few pleasures for them. However, a survey of
adult smokers from Canada, the United States, the United
Kingdom and Australia found near universal regret about
having started
9
Hou F & Chen J.
Statistics Canada Health Reports. Neighbourhood low
income, income inequality and health in Toronto. Vol.
14, No. 2, February 2003. Catalogue 82-003.
10
American Legacy
Foundation. Tobacco as a social justice issue. Remarks
of Dr. Cheryl Healton. National Conference on Tobacco or
Health, New Orleans, 2001.
http://repositories.cdlib.org/tc/surveys/SocialJustice.
11
U.S. Department of
Health and Human Services. Tobacco Use Among U.S.
Racial/Ethnic Minority Groups—African Americans,
American Indians and Alaska Natives, Asian Americans and
Pacific Islanders, and Hispanics: A Report of the
Surgeon General. Atlanta, Georgia: U.S. Department of
Health and Human Services, Centers for Disease Control
and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and
Health, 1998.
12
American Legacy
Foundation. Tobacco as a social justice issue. Remarks
of Dr. Cheryl Healton. National Conference on Tobacco or
Health, New Orleans, 2001.
http://repositories.cdlib.org/tc/surveys/SocialJustice.
Non-Smokers’ Rights Association
Spring 2010
5
smoking. 13
The majority of smokers want
to quit, but unfortunately there appears to be a social
gradient in quitting success. Evidence indicates that
smokers with lower socioeconomic status are more
addicted to nicotine, possibly due to more stress in
their daily lives, and are therefore more likely to need
intensive support in quitting.
Targeted interventions may therefore be
essential for narrowing the socioeconomic gap that
persists with respect to successfully quitting and
staying smoke-free. 14
4.
Smoke-free homes assist smokers cut back and even quit
smoking.
Consistent evidence indicates that
smoke-free homes not only assist smokers cut back and
even quit smoking, but also reduce relapse and protect
families and neighbours from involuntary exposure to
second-hand smoke. 15
As such, a nosmoking policy in
affordable housing can help to reduce health inequity
for both disadvantaged smokers, by creating a
pro-cessation environment, and for nonsmokers by
reducing or eliminating their exposure to second-hand
smoke.
Affordable housing providers can also
partner with public health organizations and other
stakeholders involved in tobacco control to bring
tailored smoking cessation assistance and resources to
low income tenants.
A no-smoking policy also demonstrates
that the landlord cares about the property, the health
of residents and holds a high standard to be met by
others. If low income tenants in affordable buildings
are indeed more likely to have a high prevalence of
unhealthy behaviours and passive attitudes toward
health, 16
a no-smoking policy can help to
create a different social norm.
5. The
opportunity to live smoke-free should be available to
all Canadians regardless of their income.
Concern has been voiced in the
literature that tobacco control strategies that are
successful in reducing smoking in the population overall
have the potential to widen social inequalities by
concentrating their benefits among more advantaged
groups. 17,18
It is entirely plausible that if only
market rate landlords and property managers adopt
no-smoking policies, the lack of smoke-free choices for
low income
13
Fong GT, Hammond
D, Laux FL et al. “The near-universal experience of
regret among smokers in four countries: Findings from
the International Tobacco Control Policy Evaluation
Survey.”
Nicotine & Tobacco Research 2004; 6:
341-351.
14
Siahpush M,
McNeill A, Borland R et al. Socioeconomic variations in
nicotine dependence, self-efficacy, and intention to
quit across four countries: findings from the
International Tobacco Control (ITC) Four Country Survey.
Tobacco Control 2006; 15(Suppl
III):iii71-iii75.
15
Borland R, Yong
H-H, Cummings KM et al. Determinants and consequences of
smoke-free homes: findings from the International
Tobacco Control (ITC) Four Country Survey.
Tobacco Control
2006; 15:iii42-iii50.
16
Hou F & Chen J.
Statistics Canada Health Reports. Neighbourhood low
income, income inequality and health in Toronto. Vol.
14, No. 2, February 2003. Catalogue 82-003.
17
Thomas S, Fayter
D, Misso K et al. Population tobacco control
interventions and their effects on social inequalities
in smoking: systematic review.
Tobacco Control
2008; 17:230-237.
18
Greaves L, Johnson
J, Bottorff J et al. What are the effects of tobacco
policies on vulnerable populations? A better practices
review.
Canadian Journal of Public Health 2006; 97:310-315.
Non-Smokers’ Rights Association
Spring 2010
6
Canadians will serve to marginalize
vulnerable people further. As such, all landlords,
including municipalities involved in the provision of
affordable housing, have a role to play in increasing
the supply of smoke-free housing in Canada.
Contrary to what some may think, the
majority of people living in social housing are
non-smokers. For example, an unpublished survey by the
Region of Waterloo, enhanced by tenant consultations
revealed that approximately 31% of the social housing
tenants in Waterloo Region Housing smoke. Although this
is definitely higher than the 18% national average, it
still leaves a strong 69% majority of tenants who do not
smoke. When asked if they thought the Region of Waterloo
should make a no-smoking policy for Region-owned
community housing, 52% of Waterloo’s social housing
tenants agreed. 19
Similar but smaller surveys
done by other social housing providers in Ontario have
also found tenant support for no-smoking policies.20
More of these studies are
needed to gauge both the extent of the problem of
involuntary exposure to second-hand smoke and the level
of interest in no-smoking policies among affordable
housing tenants.
Smoke-free homes are a social norm in
Canada. Over three-quarters of all Canadian households
do not allow smoking indoors, 21,22
and this trend is increasing.23
However, more data focusing exclusively
on low income families and affordable housing tenants
are needed to help clarify whether this trend cuts
across socioeconomic lines.
Progress in the United States
The number of public housing authorities
and commissions with no-smoking policies in the U.S. has
grown astronomically in the past decade. In 2000 there
were only two public housing authorities that had
smoke-free policies for some or all their buildings. By
the beginning of 2010 at least 150 public housing
authorities in 22 states had adopted smoke-free policies
for some or all their buildings—a 6700% increase. 24
19
Region of Waterloo
Public Health & Planning, Housing and Community
Services. Report PH 09-046/P-09-073.
Smoke-Free Policy for New Leases and
Transfers in Regionally Owned Community Housing
(Waterloo Region Housing). October 6, 2009.
http://chd.region.waterloo.on.ca/web/region.nsf/0/240B6BE5CB4B99FA85257642006A81B9/$file/P-09-073.pdf .
20
Smoke-Free Housing
Ontario. Success stories: Collier Place & Haliburton
Community Housing Corporation.
http://www.smokefreehousingon.ca/sfho/landlords-success-stories.html .
21
Canadian Tobacco
Use Monitoring Survey. Summary of annual results for
2007.
http://www.hc-sc.gc.ca/hcps/
tobac-tabac/research-recherche/stat/ctums-esutc_2007-eng.php .
22
Health Canada.
Second hand smoke in multiple unit residential
buildings. Decima Research, March 30, 2007.
POR # 392-06.
http://www.smokefreehousingon.ca/cms/file/HC_Decima_survey_2007.pdf.
23
Canadian Tobacco
Use Monitoring Surveys. Summary of annual results for
2004 – 2007.
http://www.hcsc.
gc.ca/hc-ps/tobac-tabac/research-recherche/stat/index-eng.php#ctums .
24
Bergman J.
“Smoke-Free Multi-Unit Housing in Michigan & the Nation:
A Decade of Enormous Growth.”
Smoke-Free Environments Law Project, The
Center for Social Gerontology, Inc. Press release,
December 22, 2009;
personal conversation with Jim Bergman,
March 2010.
Non-Smokers’ Rights Association
Spring 2010
7
In the summer of 2009 the U.S. federal
Department of Housing and Urban Development (HUD) issued
a notice “strongly encouraging” the implementation of
no-smoking policies for public housing authorities in
the United States. The notice stated that 39% of public
housing residents are children aged 17 and under, and a
further 15% are senior citizens—meaning over half of all
residents could be at increased risk of the adverse
effects of second-hand smoke. The notice also stated
that there are a “considerable number” of public housing
residents with chronic diseases who are particularly
vulnerable to exposure. 25
Finally, HUD pointed out in
the notice that 65% of the public housing inventory in
the United States was built prior to 1970 and that it
would be hard to improve significantly the indoor air
quality in public housing through retrofits aimed at
reducing the amount of smoke migrating between units.26
Progress in Canada
It is not immediately clear how many
social housing providers in Canada to date have adopted
no-smoking policies. St. John’s, Newfoundland set a
Canadian precedent in 2008 when the city passed a
no-smoking policy for 124 units in its social housing
portfolio. Newfoundland and Labrador Housing followed
suit shortly afterwards with nosmoking policies for a
select number of buildings in St. John’s and Corner
Brook. 27
Another notable development is the
no-smoking policy adopted in 2007 by the Greater
Edmonton Foundation Housing for Seniors.
In Ontario there are approximately 30
social housing providers that have adopted nosmoking
policies in recent years. Of special mention is the
municipality of the Region of Waterloo which voted in
favour of a no-smoking policy for all new leases for its
2,700 affordable units, effective April 1 st,
2010. The decision in itself is notable; the way in
which it was reached is equally notable. Instead of
unilaterally banning smoking, the Region sought input
from the tenants themselves. Not entirely satisfied with
the volume of survey responses it received, the Region
then proceeded to hold tenant consultations to ensure
adequate tenant input on the decision.
The final policy recommendations
submitted to Waterloo Region Council were made jointly
by the Region’s public health and housing departments.
Interagency coordination, which recognizes that public
health practice is not limited to organizations with a
health mandate, is a key principle of social justice
practice. 28
Detailing the rationale for
25
U.S. Department of
Housing and Urban Development, Office of Public and
Indian Housing, Office of Healthy
Homes and Lead Hazard Control.
Non-Smoking policies in public housing. July 17, 2009.
http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf .
26
U.S. Department of
Housing and Urban Development, Office of Public and
Indian Housing, Office of Healthy Homes and Lead Hazard
Control. Non-Smoking policies in public housing. July
17, 2009.
http://www.hud.gov/offices/pih/publications/notices/09/pih2009-21.pdf .
27
Personal
communication with Kevin Coady, Executive Director,
Newfoundland-Labrador Alliance for the Control of
Tobacco. January 5, 2010.
28
National
Association of County & City Health Officials (NACCHO).
Incorporating principles of social justice to tobacco
control. NACCHO Issue Brief. July 2007.
http://www.naccho.org/topics/HPDP/tobacco/upload/TobaccoSocialJusticeIssueBrief-Final.pdf .
Non-Smokers’ Rights Association
Spring 2010
8
adoption of a no-smoking policy for the
Region of Waterloo, the report indicated that the policy
recommendations would have multiple benefits:
• “Support
safe and caring communities that enhance all aspects of
health;
• Promote
quality of life and create opportunities for residents
to develop to their full potential; and
• Foster a
culture of citizen/customer service that is responsive
to community needs.”29
It is clear that the Region of Waterloo
incorporated broad thinking into its decision to adopt a
no-smoking policy, focusing not just on disease
prevention but also on the social conditions that
influence tenants’ health.
Conclusion
Allegations that no-smoking policies
amount to discrimination against low-income Canadians
are unfounded. In fact, the lack of smoke-free choices
for those in the affordable housing market is arguably
discriminatory. Canadians who rely on affordable housing
for accommodation have the least amount of choice and
mobility, and suffer disproportionately from higher
rates of disease and disability than average Canadians.
Smoke-free housing choices should be
available to all Canadians regardless of their income.
Inequity in health is the result of
disadvantage in opportunities, in material circumstances
and in behaviours related to health. Accommodation in
affordable housing should not relegate low income
tenants to living with involuntary exposure to
second-hand smoke in their own homes. If adopted as part
of a comprehensive approach that recognizes and responds
to the needs of low income tenants, a nosmoking policy
can offer choice and hope for a healthier future. A
no-smoking policy for affordable housing simultaneously
provides all tenants with an opportunity to live in a
smoke-free environment and to be smoke-free.
29
Region of Waterloo
Public Health & Planning, Housing and Community
Services. Report PH 09-046/P-09-073.
Smoke-Free Policy for New Leases and
Transfers in Regionally Owned Community Housing
(Waterloo Region Housing). October 6, 2009.
http://chd.region.waterloo.on.ca/web/region.nsf/0/240B6BE5CB4B99FA85257642006A81B9/$file/P-09-073.pdf .
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