Early adopter study
HUD’s Smoke-free Rule: Survey of Early Adopter Public Housing Authorities
Project period: May 2016–December 2017
Funding: Harvard Catalyst, Boston University, Boston University CTSI, American Cancer Society, and Robert Wood Johnson Foundation
Survey
From September 2016 to April 2017, our research team surveyed executive directors (or their designees; hereafter called “EDs”) at 155 public housing authorities (PHAs) that had voluntarily adopted a smoke-free policy. We developed our sampling frame from a September 2015 list of smoke-free PHAs provided by the Department of Housing and Urban Development (HUD). We stratified our sample by geography, date of initial implementation, and size (number of units administered by the PHA). To capture regional differences, we combined HUD’s 10 regional geographic units into five categories and selected similar numbers of PHAs from each grouping, as follows
- HUD Region 1: Study region 1-New England
- HUD Regions 2-3: Study region 2-Mid Atlantic
- HUD Region 5: Study region 3-Midwest
- HUD region 4, 6, and 7: Study region 4-South
- HUD regions 8, 9, and 10: Study region 5-West
Within regions, we further stratified by date of implementation so that the distribution of PHAs in the sample was:
- 20% adopted before 2012
- 70% from 2012-2014
- 10% from 2015
We also considered PHA size as an important characteristic; smaller PHAs may have fewer residents to engage but also fewer staff to engage them, whereas larger PHAs may have had the staff to support policy change, but the community may be more diffuse. Following HUD administrative categories, we consolidated PHA size into small (1-249 units), medium (250-1,249 units), and large (1,250+ units). Reflecting the general size distribution of HUD’s 3,400 PHAs, most of the PHAs that voluntarily adopted a smoke-free policy were small, so we included all medium-sized (n=90) and large (n=28) PHAs in the sample.
Of the 615 PHAs that had voluntarily adopted a smoke-free policy, 421 were eligible for inclusion in the sampling frame by having a smoke-free policy with 100% coverage that had been implemented prior to January 1, 2016. We initially sampled 200 PHAs with the previously stated stratifications and added an additional 52 PHAs with a goal of gaining 150 responses. The survey was conducted through Qualtrics. Emails contained unique survey links, and follow-up was conducted with non-respondents via email and phone call. Complete responses were received from 155 PHAs, for an overall response rate of 61.5%. The survey was conducted between September 2016 and April 2017.
Measures
The research goal of the survey was to understand activities related to the planning and preparation phase, the implementation phase, and any changes since implementation of the smoke-free policy. The survey asked about specifics of the policy, resident involvement, staff training, smoking cessation offerings, local partnerships and technical assistance, and enforcement activities.
Qualitative interviews and site visits
From 155 survey responses, 114 respondents agreed to be re-contacted for a follow-up interview. For the interviews, we selected executive directors who reported a variety of experiences in adopting the smoke-free policy. We considered components of the policy, including prohibiting or allowing e-cigarettes, and whether the policy is campus-wide or whether there was a buffer zone. We also looked for variability in experiences of resident engagement, staff training and support, smoking cessation support, local partnerships, and enforcement. We used the open-ended response questions from the survey to identify PHAs that used innovative mechanisms or techniques for implementation and enforcement. We also considered geographic region, PHA size, and date of implementation to ensure variability on those three key factors. Between November 2016 and February 2017, we interviewed 36 PHA EDs or designated staff about their policies. Prior to each interview, study staff reviewed the ED’s survey responses and asked follow-up questions to obtain more details about their experiences developing, implementing, and enforcing the smoke-free policy. All interviews were audio recorded and transcribed for future analysis.
Site visits
A sub-set of the EDs who participated in the qualitative interview were invited to participate in a one- to two-day site visit. Of the 26 PHAs invited to participate in the site visits, 14 agreed to participate. Between April-June 2017, 13 PHA site visits from all regions of the US were completed. The study team worked with each of the sites to schedule meetings with PHA staff members, Resident Advisory Boards, and PHA residents prior to the visit. Invitations were distributed to residents for the community meetings, including the date, time, and location. Food and a gift card lottery were provided for attendees.
A two-person study team traveled to the sites. Meetings were held with as many PHA staff members and residents as possible, with at least one meeting with PHA staff (property managers, resident services coordinators, maintenance staff, security officers, and executive directors) and a community meeting with PHA residents. A study team member took notes during the meetings and, when possible, meetings were recorded. The study team also documented the physical characteristics of the PHA development’s physical layout, including where smoking was allowed and no-smoking signs were posted.
Measures
During the meetings with PHA staff and residents, we asked about understanding of the smoke-free policy, perceptions of the benefits and challenges of the policy, understanding of the policy enforcement process, strategies to help smokers comply with the policy, and community support for the policy.
The activities described above were approved by the Harvard T.H. Chan School of Public Health and Boston University Medical Campus Institutional Review Boards.