Study Suggests HUD’s New Smoke-Free Policy Will Help More Low-Income Smokers Quit

Living in Smoke-Free Homes—Which Is Far More Common Among Higher-Income People—Improves the Odds of Quitting

By Laura Kurtzman on July 27, 2018

Enforcing residential bans on smoking could help large numbers of low-income people quit smoking, according to an analysis of federally funded national surveys by a California research team. The finding comes as public housing authorities across the country face a July 31st deadline from the U.S. Department of Housing and Urban Development (HUD) to implement indoor no-smoking policies.

The study, published Friday, July 27, 2018, in PLOS ONE, analyzes data from the National Cancer Institute funded Tobacco Use Supplement to the U.S. Census Bureau’s Current Population Survey—which asked about smoking habits, whether people allowed smoking in their homes, and whether they were able to quit—over a 10-year period from 2002 to 2011.

It found that, while low-income smokers were significantly less likely to live in smoke-free homes, those who did live in such homes were much more likely to be successful quitters. Implementing smoke-free policies in low-income housing is one way to increase the number of smoke-free homes, and the authors said this has the potential to affect a large group of vulnerable people. Public housing serves more than 1.2 million low-income households, including 700,000 children, predominantly from racial and ethnic minority groups. They said the impact of indoor no-smoking policies would likely be greater if low-income people in public housing also had access to smoking cessation programs. 

“Our findings imply that having a smoke-free policy could actually increase cessation rates among the very populations in public housing that are disproportionately affected by tobacco use,” said Maya Vijayaraghavan, MD, MAS, assistant professor of medicine at UC San Francisco and the study’s first author. 

“We haven’t thought of adopting a smoke-free home policy as a type of smoking cessation intervention, but our study shows that it can be an effective cessation mediator at the population level,” she said. “Given how many people this will ultimately affect, including hundreds of thousands of children from racial and ethnic minority groups who are disproportionately affected by exposure to secondhand smoke, this represents an unprecedented opportunity to reduce health disparities related to tobacco use.”

Smokers tend to be concentrated among low-income populations, a trend that intensified over the time period under study. Smokers also got significantly older, as younger people are increasingly less likely to start smoking. Smokers were also less likely to live in states with strong tobacco control policies, such as high tobacco taxes or tobacco control expenditures.

Over the study period, as more people across the country began to live in smoke-free homes—researchers found a 62 percent increase—more people quit smoking for more than a month, an early indicator of successful quitting. The smokers who remained also consumed fewer cigarettes. 

The researchers found no difference over the study period in how often U.S. smokers tried to quit, suggesting that other factors, such as living in smoke-free homes or stricter state tobacco control policies, explained the increase in smoking cessation.

Despite the overall progress, the study found that low-income smokers were 33 percent less likely than higher income smokers to live in smoke-free homes. They were also less likely to succeed at quitting. The main factors associated with successful quitting in the study were lighter smoking, higher income, and living in a smoke-free home.

The researchers concluded that if more low-income smokers had smoke-free homes, the disparity in cessation rates between low and higher income smokers would be reduced by 36 percent—a substantial reduction at the population level. 

“Higher income people have acted to make their homes smoke-free and protect their children from secondhand smoke, but those who live in multi-unit housing may be unable to keep their home smoke-free,” said John Pierce, PhD, a professor of family medicine and public health and the Moores Cancer Center at UC San Diego. “Smoke-free homes not only protect nonsmokers, but they also reduce the opportunities for smoking and make it easier for smokers to quit. HUD’s no smoking policies should help reduce the income disparity in smoking.”

Other authors of the study include Tarik Benmarhnia, PhD; Martha White; Jennie Kempster; Yuyan Shi, PhD; Dennis Trinidad, PhD; and Karen Messer, PhD, of UCSD.

Here is the abstract:

Background.  Lower rates of successful quitting among low-income populations in the United States may be from slower dissemination of smoke-free homes, a predictor of cessation.

Objectives. To explore the role of smoke-free homes in cessation behavior across income levels.

Participants. Current smokers who were ≥18 years and who participated in the longitudinal 2002–2003 (n = 2801) or 2010–2011 (n = 2723) Tobacco Use Supplements to the Current Population Survey.

Measurements.  We categorized income as multiples of the federal poverty level (FPL) (<300% FPL versus ≥300% FPL). We examined the association of smoke-free homes with 1+day quit attempts and 30+days abstinence at 1-year follow-up. We then conducted a mediation analysis to examine the extent that smoke-free homes contributed to income disparities in 30+days abstinence.

Results. Between the two surveys, heavy smoking (≥ 1 pack/day) declined by 17%, and smoking prevalence declined by 15% among those with higher-incomes (>300%FPL). Although similar in 2002, the prevalence of smoke-free homes was 33% lower among individuals living <300% FPL than those living ≥300% FPL. Although the quit attempt rate was similar, the 30+days abstinence rate was higher in the 2010–11 cohort than in 2002–3 cohort (20.6% versus 15.5%, p<0.008). Whereas smoking ≥ 1 pack/ day was associated with lower odds of 30+days abstinence (Adjusted odds ratio [AOR] 0.7; 95% CI 0.5–0.9), having a higher income (AOR 1.9, 95% CI 1.4–2.6) and a smoke-free home (AOR 1.6, 95% CI 1.2–2.1) were associated with greater odds of 30+day abstinence. Differential changes in smoke-free homes across income groups between the two surveys contributed to 36% (95% CI 35.7–36.3) of the observed income disparity in 30+days abstinence.

Conclusions.  Increasing the diffusion of smoke-free homes among low-income populations may attenuate at least a third of the income disparities in smoking cessation, highlighting the need for interventions to increase adoption of smoke-free homes among low-income households.

The full citation is Vijayaraghavan M, Benmarnhia T, Pierce JP, White MM, Kempster J, Shi Y, et al. (2018) Income disparities in smoking cessation and the diffusion of smoke-free homes among U.S. smokers: Results from two longitudinal surveys. PLoS ONE 13(7): e0201467. https://doi.org/10.1371/journal.pone.0201467.  It is available here.