Not Just Public Housing: An Ethical Analysis of Expanding Smoke-free Housing Policies in the United States

The harms associated with smoking and the benefits of both quitting smoking and limiting exposure to secondhand smoke are clear, yet policies restricting tobacco use in homes are controversial.^1,2 Based on the increased risk of involuntary exposure to secondhand smoke in multiunit housing, public health officials have advocated for the implementation of state laws that prohibit smoking in all multiunit housing as part of the visions laid out in Healthy People 2020 and Healthy People 2030.^3,4 These goals reflect implicit and explicit ethical assessments that suggest the benefits of protecting nonsmokers from secondhand smoke outweigh the harms to smokers of requiring them to alter a chosen behavior. Still, despite the Healthy People 2020 goal published in 2010, as of February 5, 2022, only 67 municipalities in the United States have enacted smoke-free multiunit housing laws that apply to all private units, ⁵ and no statewide policies have been put in place, ⁶ indicating smoke-free housing rules are not universally prioritized and accepted.

In 2017, the US Department of Housing and Urban Development (HUD) announced that all public housing authorities (PHAs) in the United States would be required to adopt smoke-free policies by July 2018. ⁷ This rule applied to federally funded public housing (subsidized housing for low-income renters that is owned and operated by the PHAs) but not to market-rate or other subsidized housing, such as subsidized housing operated through public–private partnerships, voucher programs, or state-funded public housing. ⁸ Although HUD’s smoke-free public housing policy is a step toward the Healthy People goal of universal smoke-free multiunit housing, it affects only a subset of multiunit housing. As a result, the benefits and inconveniences of smoke-free housing are not equitably distributed in the population, and this inequity demands interrogation of the current state of smoke-free policies in multiunit housing.

Analyses of social justice and tobacco policies highlight how tobacco policies often disproportionately affect, both positively and negatively, vulnerable populations such as those with low income, poor mental health, substance use disorders, or other disabilities, because tobacco use is concentrated in these populations.^9,10 HUD’s smoke-free public housing policy invites scrutiny because the only people affected by the policy are low-income people receiving a particular form of housing assistance. Racial and ethnic minority populations are also disproportionately affected; 48% of public housing households are non-Hispanic Black compared with 19% of renter households overall. ¹¹ We assess the extent to which reductions in harm and restrictions to autonomy differ in public housing compared with other types of multiunit housing to help evaluate whether limiting smoke-free policies to public housing is warranted. We will conclude that although the ethical implications of smoke-free housing policies in public housing compared with other multiunit housing differ slightly, these differences are not substantial enough to warrant unequal distribution of smoke-free policies. Thus, following HUD’s lead, other legislative and regulatory bodies should establish smoke-free multiunit housing rules that cover all multiunit housing.

Key Principles: Autonomy and Harm

The principles of autonomy and harm are commonly at the center of discussions on the ethics of public health policies. Policies and legislation may limit autonomy through the imposition of guidelines, penalties, and restrictions that inhibit people from being able to choose specific behaviors. ¹² At the same time, policies can reduce harm to both individuals and populations caused by factors outside their direct control, such as smoking by members of their communities. Where autonomy and harm reduction intersect and conflict, they may be weighed against one another, while also considering principles and values such as solidarity, interconnectedness, community benefits, resource allocation, and social responsibility.^13,14

In the United States, tobacco use is legal behavior for adults, reflecting a collective assessment that people should be able to decide for themselves if they would like to accept the accompanying health risks. Telling people they cannot buy particular products or smoke in certain places restricts their right to make decisions for themselves. ¹⁵ Typically, policies restricting tobacco use apply to smoking in public spaces such as workplaces, restaurants, bars, parks, or beaches. By regulating tobacco use in private spaces, smoke-free multiunit housing policies affect autonomy in a way that is distinct from other smoke-free policies. ¹⁶ Although efforts have been made to restrict tobacco use in other private spaces (eg, automobiles), smoke-free policies for people’s homes go a step further, infringing on autonomy to a greater degree than other tobacco regulation. Nevertheless, it should be made clear that smoke-free housing policies have not prohibited residents who smoke from living in particular locales or buildings but, rather, prohibited them from using combustible tobacco inside multiunit housing buildings. In addition, residents who smoke may use other sources of nicotine indoors, such as pharmaceutical nicotine (eg, patches, gum) and, depending on the site, electronic cigarettes, thereby mitigating the loss of autonomy that smoke-free policies induce.

While limiting autonomy, tobacco control policies are primarily justified because they can prevent the harms associated with secondhand smoke exposure.^17-23 Contributors to a 2006 Surgeon General’s report on smoking concluded that evidence was sufficient to determine causality between secondhand smoke exposure and diseases such as childhood asthma, adult cardiovascular disease, and lung cancer, among other conditions, and that no risk-free level of secondhand smoke exposure exists. ¹⁷ This evidence is a central justification for smoke-free policies because it is considered ethically permissible to restrict autonomy when an individual’s actions cause substantial harm to others. ²⁴ It is understood in ethics generally and public health ethics particularly that an individual’s autonomy is not absolute. When an individual’s tobacco use begins to infringe on other people’s health and well-being, ²⁴ public health policies are often considered justified restrictions of autonomy. ²⁵ For example, smoke-free policies in locations such as workplaces or restaurants are typically justified based on the argument that smoking in those places causes substantial harm to others.^26,27 This same argument holds with respect to policies preventing tobacco use and subsequent secondhand smoke exposure in multiunit housing. Other principles, such as solidarity (social and public heath good arises from people acting together) and social responsibility (policy makers are responsible for protecting nonsmokers, smokers are responsible to others for their actions), may be applied as well.

Research shows that the only effective way to control the circulation of residential secondhand smoke in multiunit housing and, thus, reduce or eliminate residents’ exposure to secondhand smoke, is through a total ban on indoor smoking. ²⁸ Because of the air exchange that occurs in multiunit housing through doorways, windows, crevices, and ventilation systems, residents are susceptible to the harms of secondhand smoke from their neighbors’ units and from common spaces.^29,30 Smoke-free policies in multiunit housing can protect residents and minors who do not smoke but live with people who do by reducing their exposure to secondhand smoke. Residential smoke-free policies also decrease risks to life and property because of fires and smoke damage.^31,32

While ameliorating the harms of residential smoking is the goal of smoke-free housing policies, there is concern that the policies themselves could cause harm, depending on how they are designed and implemented.^33,34 Enforcement mechanisms for smoke-free policies may include fines and eviction, which impose financial hardship and housing instability on violators. Even the threat of these penalties may cause harm if it is out of balance with the harm inflicted by tobacco use. If actual or threatened enforcement actions do not achieve the goal of reducing residents’ exposure to secondhand smoke, the balance of harms may shift against smoke-free housing policies. Notably, these issues are dynamic and need to be monitored over time; enforcement practices or the policies themselves should be updated as appropriate.

Implementation and enforcement of smoke-free multiunit housing rules have been challenging in both public^35-38 and market-rate housing. ³⁹ Thus, it is critical to acknowledge the need for adequate funding and resources to implement smoke-free rules so they succeed in lowering secondhand smoke exposure. Implementation measures such as providing tobacco treatment (counseling, medication), resident and community engagement, and effective communication strategies on impending policies and subsequent enforcement have been absent from existing efforts and are needed to facilitate a successful transition to broad smoke-free multiunit housing.^35-39 The costs of tobacco treatment can be largely absorbed through existing programs such as state tobacco quitlines, ⁴⁰ SmokeFreeText, ⁴¹ and both private and public health insurance, particularly in the wake of reforms instituted under the Affordable Care Act. ⁴² For measures such as resident and community engagement and funding for other implementation efforts, it may be necessary to set aside funding and resources as part of the policy-making process. Because of the public benefit derived from smoke-free housing and reduced exposure to secondhand smoke, federal, state, and local housing and public health agencies can also help support some of these efforts.

In sum, the moral calculus—the balance of societal and individual pros and cons—depends on the effectiveness of policy implementation; policy enforcement must be monitored and maintained while minimizing the harms that enforcement itself may cause.

Autonomy and Harm Beyond Public Housing

Evidenced by public health and government initiatives, it is well-accepted that safe and healthy housing is a civic good worth protecting and promoting, regardless of the type of housing. ⁴³ Given commonalities in how buildings are engineered, those who live in buildings with people who smoke may be exposed to secondhand smoke, regardless of whether that building primarily serves low-income residents,^29,44 which argues for universal smoke-free multiunit housing rules.

Still, there are some important differences between public housing and other forms of multiunit housing that may alter the balance of protections and harms that inform whether a smoke-free policy is ethical. Many public housing residents are at a higher risk than the general public for various health conditions that are exacerbated by secondhand smoke, such as asthma and chronic obstructive pulmonary disease. ⁴⁵ In addition, the prevalence of smoking in public housing is greater than in other types of multiunit housing. ⁴⁵ Thus, the potential for harm from secondhand smoke exposure is greater in public housing than in other forms of multiunit housing, especially market-rate housing. Outside of public housing, there are fewer residents who smoke. As a result, there are fewer nonsmokers exposed to and harmed by secondhand smoke exposure and fewer smokers whose autonomy is reduced. As a result, we find that these factors do not ultimately alter our conclusion that the benefits of harms prevented outweigh concerns about reduced autonomy as a result of smoke-free multiunit housing policies. Therefore, all multiunit housing, not just public housing, should benefit from smoke-free rules.

Practical Considerations

HUD’s 2018 smoke-free public housing rule applied to all public housing funded under the US Housing Act of 1937 based on HUD’s available authority. That meant that state-funded PHAs, other forms of subsidized housing, and market-rate housing were not covered by this policy. If new smoke-free multiunit housing rules are to apply to other types of housing, other agencies, branches, and levels of government will likely need to be involved. One might posit that a federal policy including all multiunit housing nationwide would have the broadest impact. However, this strategy is untested, and there may be significant legal or constitutional constraints on the federal government’s ability to impose broad smoke-free housing policies. State and local governments are typically nimbler and may be better able to effect these changes. Indeed, at present, current policies outside public housing exist exclusively at the municipal and county levels.^5,6

Alternatives to Government Policy

Smoke-free housing policies are not the only mechanism for reducing the risk of residential secondhand smoke exposure. In theory, market forces—demand for smoke-free housing, if it exists—will stimulate the creation of more smoke-free housing, rendering government-mandated smoke-free housing unnecessary. Those who want smoke-free housing will be able to find it. ⁴⁶ However, this supposition holds true only in an unconstrained market. Housing supply is slow to react to market forces, and many housing markets in the United States are severely constrained, diminishing the possibility that these self-corrections will occur. ⁴⁷ Programs to achieve smoke-free housing through persuasion and encouragement rather than prohibition might also be considered as alternatives to smoke-free policies. However, there is no current evidence to suggest that persuasion-based approaches alone will achieve the public health goal of reduced secondhand smoke exposure. Social norms concerning smoking have shifted dramatically during the past half-century, but smoking is still permitted in many places, and smoke-free housing policies are rare. The history of smoke-free public housing illustrates the limits of persuasion as a tool. HUD first recommended PHAs adopt smoke-free polices in 2009, reiterating its guidance in 2012. ⁴⁸ However, it was not until the federal policy took effect that smoke-free public housing became widespread. As such, although persuasion-based efforts can be effective in some public health policy settings, experience indicates that is not the case with smoke-free multiunit housing.

Conclusion

The smoke-free rule in place nationally for HUD-funded public housing establishes an important precedent for smoke-free housing, stimulating consideration of whether it is sensible and ethical to establish smoke-free multiunit housing policies in other housing segments. The proven harms of secondhand smoke, the potential for exposure in all multiunit housing, as well as the value we place on safe, healthy living environments outweighs the arguments against comprehensive smoke-free multiunit housing, provided policies are effectively implemented. Implementation of smoke-free policies beyond public housing will increase equity in public health policy. For the health of all, smoke-free policies should be instituted by any level of government with the goal of ultimately reaching all multiunit housing.