Exploring Policy Options to Reduce Second-hand Smoke Exposure in Multi-unit Dwellings

1. Exploring Policy Options to Reduce Second-hand Smoke Exposure in Multi-unit Dwellings Laurie Nagge, Public Health Nurse, Region of Waterloo Public Health

2. Working Committee • 5 tenants (advisory capacity) • Staff: • Public Health • Waterloo Region Housing • Region of Waterloo Community Housing Incorporated (ROWCHInc.) • Legal Services • Communications • Process has been a joint Initiative of Public Health & Planning, Housing and Community Services

3. Timelines • Tenant complaints, April 2008 • Report to Community Services Committee (CSC) recommending tenant survey – June 24, 2008 • Tenant survey, October 2008 • Advisory group created – January 2009 • Memo to Council (survey results), Mar. 3, 2009 • Community forums/online survey, Apr. 2009 • Final report/recommendations to CSC, Oct. 6, 2009. Approved. • Council approval, Oct. 14, 2009

4. Step #1 - Describe the Problem • Causes– second-hand smoke, higher incidence of smoking, age of building stock • Impact– community housing residents • vulnerable populations (children, seniors) • higher incidence of exposure • ↑ chronic conditions • Perception– health concern vs. violation of rights • Possible solutions– no action  total ban • Types of data– opinion, experiences of other jurisdictions • Sources– survey, focus groups, resource centres, polling data, other housing providers

5. 2,723 housing units – 2591 WRH, 132 ROWCHI Family – 1207 units 31% receive assistance 12% work & receive partial assistance 57% work Non-elderly singles – 307 units 48% receive assistance 52% work Seniors – 1077 units 9% receive assistance 91% pension income Waterloo Region Housing (WRH) and Region of Waterloo Community Housing Inc. (ROWCHI)

6. Types of Data • Literature review • 2nd National Conference on Second-hand Smoke in Multi-unit Dwellings (MUDs) (January 2009) • Consultations with resource centres, other jurisdictions, academics • Tenant surveys • Community forums, online survey

7. Other Useful Resources • Internal research and evaluation support • Use of work plans and sub-committees • Member of Canadian smoke-free housing listserv

8. Step #2 – Assess Readiness for Policy Development Tenant Survey: • Cover letter offered translation services • Three-week response time – pre-stamped return envelope • Reminders posted in Housing buildings • 967 returned surveys; 36% response rate

9. Six community forums Online survey Two questions: How many buildings should be smoke-free? No buildings Some buildings (complexes or rows for town homes) All buildings How much outdoor space should be smoke-free? (If no smoking allowed indoors) Outdoor smoking anywhere Outdoor smoking at a distance Outdoor smoking on some properties (town homes) Outdoor smoking in designated smoking areas only Tenant Consultation cont'd…

10. Step #3 Develop Goals, Objectives, and Policy Options

11. Guiding Principles for Policy Decision-making • Effectiveness – achieve desired outcomes • Efficiency – minimize resources ($) • Adequacy - satisfy the needs, values, or opportunities that gave rise to the problem Dunn, W.N. (2004).Public policy analysis: An introduction. Upper Saddle River, New Jersey: Pearson Education Inc.

12. Guiding Principles for Policy Decision-making • Equity – fairly or justly distributes effects and/or efforts • Responsiveness - satisfies the needs, preferences, or values of particular groups • Appropriateness - believability of the policies objectives and assumptions Dunn, W.N. (2004).Public policy analysis: An introduction. Upper Saddle River, New Jersey: Pearson Education Inc.

13. Policy Decision Making • Tenant input (survey, forums, online survey) • Health protection • Legal • Feasibility • Cost/benefit • Enforcement Dunn, W.N. (2004).Public policy analysis: An introduction. Upper Saddle River, New Jersey: Pearson Education Inc.

14. Policy Decision Making • Did not know the policy outcome ahead of time • Selected top three policy options (based on tenant input) for analysis and debate • Working towards a policy NOT a by-law • Key – presenting recommended policy "options" – not final decisions

15. Step #4 – Identify Decision Makers • Understand the political process • Regional Council's history on smoke-free legislation • Medical Officer of Health • Commissioner and Director of Housing • Community Service Committee members (Board of Health) • Regional Council members

16. Influencers • Delegations: • Brian King, MPH., PhD. Candidate, Roswell Park Cancer Institute • Jim Bergman, Smoke-free Law Project, Smoke-free Michigan • Tenant representatives

17. Step #5 – Build Support for the Policy • Low profile – tenant sent letter to Council; Public Health, Housing, Legal staff and tenants identified policy options • Medium profile – CSC reports to propose survey and recommend policy • High profile: • Media question and answer • Key messages – counter arguments • CSC reports are released to the media

18. Step #6 - Write and/or Revise the Policy • Effective April 1, 2010, all new leases signed with Waterloo Region Housing (WRH) in all buildings and properties be 100 per cent smoke-free and restrict smoking outdoors to a distance of five meters or more away from any windows, entrances or exits to the building/unit; • The Board of Region of Waterloo Community Housing Incorporated and other Community Housing Providers be asked to consider implementing similar restrictions regarding smoking;

19. Policy Outcomes • Public Health investigate, develop and implement cessation support for tenants and those on the waiting list; • Public Health and Waterloo Region Housing staff work together to provide individualized support or other special arrangements to any tenants experiencing health conditions or other challenges that might complicate their ability to comply with the policy;

20. Policy Outcomes • Staff report back on the implementation process and results in October 2010; • This policy would not apply to existing tenants unless they move to a new unit and that staff be authorized to exercise flexibility to deal with hardship cases in the event of a transfer.

21. Lease Language • "The Tenant, all other occupants of the Leased Premises, the Tenant's Guests and business invitees shall not smoke or hold lit tobacco or similar product in the Leased Premises, including the balcony, patio or other areas specifically included in this Lease. Smoking is only permitted outdoors at a distance of not less than five metres away from windows, entrances or exits to the Residential Complex."

22. Step #7 – Implement the Policy • Implementation workgroup/work plan • Policy and Procedure document • Policy statement • Lease signing procedures • Inclusion/exclusion (e.g., medicinal marijuana, traditional use of tobacco) • Enforcement protocol • Staff responsibilities/training • Monitoring • Reference documents

23. Step #8 - Evaluate and Monitor • Formulate research questions • Logic model • Annual pre/post survey to all residents • Air quality testing • Complaint tracking • Tracking steps taken as per enforcement protocol • Media coverage • Costs to implement • Legal precedents - monitor

24. Challenges • Only able to implement policy with new leases, grandfathering existing tenants • Complex, emerging issue • Few examples from community housing • Low response at community forums and online • Political process – can only make recommendations – but this is also a good thing!

25. Keys to Success • Partnership between Housing and Public Health • Tenant involvement • U of T Student – Policy placement • Legal consultation • Tenant survey and consultation data • Regional Council has history of progressive smoke-free policies • Plan to provide cessation services • Recommendation "to provide individualized support or other special arrangements"

26. Contact Information • Laurie Nagge, RN, MHS Public Health Nurse Region of Waterloo Public Health 150 Main Street, 3rd floor Cambridge, Ontario Canada N1R 6P9 Phone: 519-883-2008 ext. 3439 E-mail: nlaurie@region.waterloo.on.ca