Findings of the 2013 Waterloo Region Housing and Region of Waterloo

SMOKE-FREE HOUSING POLICY EVALUATION Findings of the 2013 Waterloo Region Housing Tenant Survey Report to the Region of Waterloo Community Services Committee

Prepared by: Ryan David Kennedy, PhD Stephanie Ellens-Clark, MSW Pamela Kaufman, PhD Ornell Douglas, MPH

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This report was prepared by Ryan David Kennedy, Stephanie Ellens-Clark, Pamela Kaufman, and Ornell Douglas with review by the Region of Waterloo Smoke-free Housing Evaluation Committee which includes employees from Waterloo Region Housing and Region of Waterloo Public Health. Matt Grey, Stephanie Filsinger and Kayla Snyder of the Propel Centre for Population Health Impact provided assistance in the preparation of this document.

Suggested Citation: Kennedy RD, Ellens-Clark S, Kaufman P, Douglas O. 2013. Smoke-free Housing Policy Evaluation Findings of the 2013 Waterloo Region Housing and Region of Waterloo Community Housing Inc. Household Tenant Survey. Waterloo, ON: Propel Centre for Population Health Impact, University of Waterloo.

This report is available online at www.propel.uwaterloo.ca

Smoke-free Housing Policy Evaluation – Highlights The 2013 Waterloo Region Housing Household Tenant Survey Below are some key findings from the 2013 survey mailed to every household managed by Waterloo Region Housing in March 2013. The smoke-free policy was passed by Region of Waterloo Council in October 2009 and was approved by the Region of Waterloo Community Housing Inc. Board of Directors st in November 2009. A pre-policy survey was conducted prior to the policy enactment on April 1 , 2010 and is reported elsewhere i. A second survey was conducted after the policy was implemented, in April 2011, and is also reported elsewhere. ii The 2013 survey was completed by 619 households: 478 respondents indicated that the household had no smokers; 109 indicated that their household had one or more smokers; and 32 households did not indicate the smoking status of the members of their household. •

50% of all respondents reported that they, or others in their household, are sometimes or often exposed to second-hand smoke (SHS) in their home.

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44% of respondents reported someone in their household has health problems that get worse when they breathe SHS.

•

The majority of respondents, 79%, reported they support the Region of Waterloo smoke-free housing policy. o Support was approximately 90% from households with no smokers and approximately 32% from households with a person who smokes

•

Most respondents reported they already have households that are 100% smoke-free inside (88%) and on their patio or balcony (73%). o 94% of households with no smokers are 100% smoke-free inside, and 49% of households with smokers are 100% smoke-free inside; this represents a significant increase from the 2011 survey results o 89% of households with no smokers are 100% smoke-free on their balconies/patios while 28% of households with a smoker are 100% smoke-free on their outdoor spaces

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When asked how their smoking has changed since the smoke-free policy, 28% of smokers who have grandfathered leases (n=50) reported they smoke less since the policy was implemented and 8% said they have quit smoking (n= 7). For tenants who have always had a smoke-free lease, 37% (n=15) report they smoke less and 17% (n=7) report they have quit.

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Among all respondents who smoke, 45% reported that they tried to quit in the last year.

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26% of respondents who smoke reported that because of the new policy they are more likely to go outside to smoke.

BACKGROUND Waterloo Regional Housing (WRH) Smoke-free Housing Policy Evaluation —Survey 2013 In October, 2009, Region of Waterloo Council approved a smoke-free housing policy. This policy came into effect on April 1, 2010 and made all new leases signed with Waterloo Region Housing – in all buildings and properties – 100 per cent smoke-free. These restrictions are applied to all living spaces in the lease, including patios and balconies. This smoke-free housing policy also restricted smoking outdoors at all properties in the portfolio to a distance of five metres away from any window, entrance or exit to the building/unit; outdoor restrictions applied to all tenants and visitors. Region of Waterloo Community Housing Inc. (ROWCHI) Board of Directors voted and passed the same policy on November 27th, 2009. ROWCHI housing has since been included with WRH. As per Ontario law, tenants with existing leases were “grandfathered” — meaning tenants who had previously been allowed to smoke in their units, including on the balcony or patio, would still be permitted to do so. This was the first policy in Ontario to make an entire housing portfolio smoke-free, and one of the first in Canada. Region of Waterloo Council requested that regional employees support other local community housing providers to implement similar smoke-free policies. A committee was created to evaluate aspects of the new smoke-free policy. The evaluation committee consists of membership from Waterloo Region Housing, Region of Waterloo Public Health, and a scientist from the Propel Centre for Population Health Impact at the University of Waterloo. The policy evaluation consists of an enforcement database, air quality monitoring, and a tenant survey. The survey of tenants is being conducted to measure support for the smoke-free policy, and to understand how the policy may affect smoking behaviour. Considering the policy permits “grandfathering,” it is expected that impacts from the policy may take several years to influence behaviour. This report provides the results of the March 2013 survey, which was administered to st tenants approximately three years after the no-smoking policy was passed on April 1 , 2010. A copy of the tenant household questionnaire is included in Appendix A of this report. This report makes some comparisons to the 2011 survey, which was conducted one year after the policy was implemented; and to the 2010 survey, which was conducted prior to the policy coming into effect. SAMPLE Waterloo Region Housing (WRH) manages 2722 affordable rental housing units. Building types in the portfolio include low and high-rise apartments, townhouses, semi-detached and single family homes. Housing is provided for different tenant groups including “seniors,” “adult, no dependant,” and “families.” Senior units are intended for residents who are 60 years of age or older. Seniors live in low or high rise apartments. “Adult, no

dependant” is typically for residents with no children who are younger than 60 years old. This adult housing is in low or high rise apartments. To simplify this report, the tenant group “Adult, no dependant” is referred to as “adult.” Most of the tenants in “family” units live in townhouses or semi-detached single family dwellings; however, some family units are also in low-rise apartments.

METHODS The questionnaire and research methods used in this study received approval from the Region of Waterloo Public Health Research Ethics Board, and the Office of Research Ethics at the University of Waterloo (ORE# 16168). An envelope containing a cover letter that described the new policy, the survey questionnaire, and letter that provided instructions on how to access language translation support for completing the survey was delivered by a private courier to every household in the portfolio. The envelope was labelled with the tenant’s name and address, and delivered to their mailbox, or in some cases right to the door. These envelopes were delivered in mid-March 2013, and respondents were asked to return the completed survey by April 15, 2013. Copies of the cover letter and translation support material are included in Appendix B. The survey was entitled “Survey – Evaluation March, 2013 – Smoke-free policy for New Leases and Transfers in Waterloo Region Housing.” The survey had 27 questions, 18 of which were for all households, and 9 of which were specifically for respondents who smoke cigarettes. Respondents were asked to return the completed survey using a prepaid, self-addressed envelope. Alternatively, respondents were invited to drop off the completed survey in person to the WRH office in either Kitchener or Cambridge.

ANALYSIS Response percentages are reported for each question. Non-responses (missing data) are not included in most response proportions. Some question responses are reported based on household smoking status; households are classified as either not having a resident who smokes, or having a resident who smokes. Response percentages for questions intended for people who smoke only report from the sample of respondents who identified as a person who smokes. Analysis was conducted in SAS9.2. Test of equal or given proportions was used to determine significance, using an alpha of 0.05. The 2013 survey included, for the first time, the opportunity for open-ended responses from tenants. These comments were also reviewed and a range of comments are included in the report. Like previous reports, some respondents also included written comments throughout the survey. These comments were entered into a spreadsheet along with the anonymous respondent identification and which question the comment was written beside.

FINDINGS Response Rates: The 2013 survey was distributed to all 2722 households and completed by 619 respondents, which represents a response rate of 23%. In 2011, the survey response rate was 25% (n=685). The 2010 survey response rate was 26% (n=717). •

This is considered a good or very good response rate given no incentive was offered for households to complete the survey.

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This response rate is similar to previous surveys sent to the households across the portfolio by Waterloo Region Housing. iii iv

Surveys were colour coded based on tenant group. For example, family units were delivered surveys printed on blue paper. Based on the colour of surveys returned, a response rate was calculated for each tenant group, presented in Table 1 below. Table 1. Response rates by tenant group Response Rate 36.9%

Returned Surveys 397

Total Units in portfolio 1076

Adult

22.1%

68

307

Family

11.5%

154

1339

Seniors

Surveys were delivered to households by a private courier in an addressed envelope. If the survey was delivered to a household that had a lease signed on or after April 1, 2013, the survey was marked. Based on the number of marked surveys, it is possible to report the proportion of the sample completed by households with grandfathered leases, and leases signed since April 1, 2010. Results are presented in Table 2 below. Note – no personal identifying markers were put on any of the surveys. Table 2. Respondents with Leases since April 2010

Grandfathered Lease Lease since April 2010 Total

Percent 70.0%

Frequency 433

30.0%

186

100%

619

Waterloo Region Housing records indicate that on March 31, 2013, approximately 32% of households in the housing portfolio had smoke-free leases. The proportion of respondents to the survey closely matches this proportion.

Household and Respondent Descriptions: Household and respondent descriptions are reported for the entire sample (n=619) in tables 3-5 below. Table 3. Question 1) Are you: o 18 to 64 years old? o 65 years old, or older?

18 to 64 years old? 65 years old, or older? Total

Percent 42.5% 57.5%

Frequency 253 343

100%

619

There were 343 respondents that indicated they were 65 years old, or older; this represents approximately 58% of the sample. Missing responses:23; total sample 619. Table 4. Question 2) How many adults live in your household? Percent 18.8%

Frequency 111

One

81.2%

479

Total

100%

619

More than one

Missing responses: 29; total sample: 619

The majority of respondents reported that their household had only one adult (81% n=479).

Table 5a. Question 3) How many children live in your household? Number of infants/ toddlers: (0-2 years old) One More than one None Total

Percent 5.7% 0.2% 94.1% 100%

Frequency 26 27 456 456


Table 5b. Question 3) How many children live in your household? Number of children: (3-12 years old) One More than one None Total

Percent 12.5% 6.7% 80.7% 100%

Frequency 58 31 375 465


Table 5c. Question 3) How many children live in your household? Number of children/teens (13-17 years old) One More than one None Total

Percent 12.3% 3.7% 84.0% 100%

Frequency 56 17 383 456

Missing responses: 163; total sample:619

There were 215 households that reported that at least one child or teen (under 18 years of age) lived in their household. This represents 35% of the sample, which is greater than the 2011 survey (21%; n=145).

Note: Based on responses to questions 2 and 3, approximately 93% of the households that completed the survey (n=558) have a person from a population considered more vulnerable to SHS exposure – specifically seniors, who are more likely to have compromised pulmonary and cardiovascular health issues, and children/youth who have developing lungs.

Smoking Behaviour in the Household: The survey included questions for all respondents about smoking behaviour and home-smoking practices (questions 4-11). Question 11 asked about respondent’s anticipated future smoke-free home policies. The responses to these questions are detailed in Tables 6-14 below. Response percentages do not include non-responses; the number of missing responses is reported below each table. Table 6. Question 4) How many members of your household, including yourself, currently smoke, daily or less? 0 1 2-3 More than 3 Total

Percent 81.4% 16.4% 1.2% 1.0%

Frequency 478 96 7 6

100%

587

Missing responses: 32; total sample n=619

Respondents reported that approximately 18% of households have at least one resident who smokes daily or less (n=109). The responses to this question were used to classify households by smoking status; households that have a smoker (n= 109) or do not have a smoker (n= 478).

Table 7. Question 5) Do you smoke cigarettes, either daily or less? Percent

Frequency

No Yes

83.3% 16.8%

487 98

Total

100%

585

Missing responses:34; total sample n=619

Approximately 17% of survey respondents reported that they smoked cigarettes, either daily or less. The responses to this question were used to classify respondent by smoking status; respondents that reported they smoke (n= 98) or do not have a smoker (n= 487).

Table 8a. Question 6) Since the smoke-free policy have you changed how you smoke? (reported proportions from survey respondents who did not indicate “Do not smoke”) Percent

Frequency

No change

54.8%

69

Smoke less

31.0%

39

Smoke more

3.2%

4

I have quit

2.4%

14

Total

100%

126

Missing responses: 26; total sample n=619. This sample included smokers and non-smokers. There were 467 respondents who indicated that they do not smoke.

This question was asked to all respondents and the majority (n= 467) indicated they did not smoke. Table 8a reports the proportion of responses from the remaining sample (n=126). There was no reported change in smoking habits after the smoke-free policy came into effect for approximately 55% of respondents (n=69). Approximately 31% (n=39) reported they smoked less since the policy was implemented, and approximately 2% (n=14) reported they have quit smoking since the smoke-free policy.

It is important to understand how the smoke-free policy may have influenced smoking behaviour for people who lived in housing prior to April 1, 2010 (those that have grandfathered leases). Table 8b below reports responses to question 6 for only respondents who had a grandfathered lease and report smoking (n=85). Table 8b. Question 6) Since the smoke-free policy have you changed how you smoke? (reported proportions from survey respondents who indicated they smoke and had a grandfathered lease) Percent

Frequency

No change

58.8%

50

Smoke less

28.2%

24

Smoke more

4.7%

4

I have quit

8.2%

7

Total

99.9%

85


There were 85 respondents who had grandfathered leases and did not respond “I don’t smoke”. Of this sample of respondents, more than half (approximately 59%) reported they have not changed how they smoke. More than a quarter (28%, n=24) reported that they now smoke less, and more than 8% (n=7) reported they have quit. A smaller proportion, less than 5% (n=4) reported they now smoke more.

Table 8c. Question 6) Since the smoke-free policy have you changed how you smoke? (reported proportions from survey respondents who indicated they smoke and have a smokefree lease) Percent

Frequency

No change

46.3%

19

Smoke less

36.6%

15

Smoke more

0%

0

I have quit

17.1%

7

Total

100%

41


There were 41 respondents who had smoke-free leases who did not respond “I don’t smoke”. Of this sample of respondents, approximately half (46%, n=19) reported that they have not changed how they smoke. More than a third of respondents reported that they smoke less (37%, n=15), No respondent reported that they smoke more. There were 7 respondents (17%) that reported they have quit.

Table 9. Question 7) Does anyone, including yourself, smoke inside your home? Percent

Frequency

87.71%

514

Sometimes

8.7%

51

Often

3.6%

21

Total

100%

586

Never

Missing responses: 33; total sample n=619

The majority of respondents, approximately 88%, reported that their homes are 100% smoke-free (n=514); this is a greater proportion than that which was reported in 2011, at 82% and significantly greater than what which was reported in the 2010 survey, at 75% (alpha 0.05). Approximately 12% of respondents, (n=72) reported that their household permits smoking at least sometimes.

Table 10. Question 7) Does anyone, including yourself, smoke inside your home? Reported by Smoking Status of the Household No Smoker in Household

Smoker in the Household

Never

94.1% (n=450)

48.5% (n=50)

Sometimes

3.3% (n=16)

33.0% (n=34)

Often

0.2% (n=1)

18.5% (n=19)

Total

100% (n=450)

100% (n=103)

Missing responses: 17 (11 for no smokers in the household, and 6 for households with a smoker) ; total sample n= 587.

The vast majority of households that do not have a smoker report that smoking never takes place inside their home (approximately 94%, n=450). Approximately 3% of households that do not have a resident who smokes report that someone smokes “sometimes” or “often” inside their home. Approximately 49% of respondents from households that have a person who smokes reported that their homes are 100% smoke-free. In 2011 the proportion was 38%; this represents a significant increase (alpha 0.05). Of respondents who had a smoke-free lease, 32 respondents were in households that had a smoker. The majority of these (78.1%, n=25) reported that smoking “never” takes place inside their home – consistent with the requirements of their lease. Only one respondent with a smoke-free lease reported that smoking “often” takes place inside their unit. Of respondents who had a smoke-free lease and no smoker in the household, (n=140) almost all reported that smoking “never” takes place inside (99.3%, n=139) with only one reporting that smoking “sometimes” happens inside.

A similar question was asked of respondents to understand smoking behaviour on patios and balconies. Responses are reported in table 11 below. Table 11. Question 8) Does anyone, including yourself, smoke on your patio or balcony?

Never Sometimes Often Total

No Smoker in Household 85.5% (n=395) 14.1% (n=64) 0.4% (n=2) 100% (n=462)

Smoker in the Household 28.3% (n=28) 46.5% (n=46) 25.3% (n=25) 100.1% (n=99)

Missing responses: 11 (10 missing from households with no smoker, and 1 missing from households with a smoker); Note, 16 reported they did not have a patio or balcony and were excluded from the analysis; total sample n=587.

For households with no smoker, the majority (86%) report that smoking never takes place on their balcony or patio. For households that had a person who smokes, approximately 28% reported that smoking “never” takes place on their patio or balcony. Approximately half (47%, n=46) reported that smoking “sometimes” takes place on a patio or balcony. Of respondents that had a smoke-free lease (which includes 100% smoke-free patio and balcony areas), 92% of households with no smokers (n=128) reported that smoking “never” takes place on their patio or balcony. Of respondents that had a smoke-free lease and had a person who smokes in the household, 41% (n=11) reported that smoking “never” takes place on a patio or balcony. The majority of respondents who had a new lease, and had a person in the household who smoked, reported that smoking takes place on the patio or balcony at lease “sometimes.”

Question 9a asked further details about smoking behaviour in outdoor spaces. Table 12. Question 9a) If someone smokes in your home or on your patio or balcony, is it: Yourself Another member of the household A neighbour/tenant in your building A non-tenant visitor No one smokes on my patio/balcony I do not have a patio or balcony Total

% 12.7% (n=71) 2.5% (n=14) 8.9% (n=50) 21.6% (n=121) 63.6% (n=357) 10.2% (n=57) n=561

Missing responses – 58 respondents; sample size 619. Note – respondents could select multiple responses.

Table 12 reports the responses to question 9a, which asked respondents to identify broadly who (if anyone) is smoking on their patio or balcony. Table 12 reports results from the entire sample; the majority of respondents (64%, n=357) reported that no one smokes on their patio/balcony. Further, 10% (n=57) reported that they do not have a patio or balcony. Of those who reported a person does go out to the balcony or patio to smoke (n=256), almost half (47%, n=121) reported it was a non-tenant visitor. More than a quarter (27.7%, n=71) reported that they themselves use the patio or balcony to smoke a cigarette. Question 9b asked further about visitors from the same building – to understand if tenants with smokefree leases are visiting smoking permitted units to smoke indoors or on neighbours’ patios/balconies.

Table 13. Question 9b) If a neighbour/tenant in your building or townhouse complex comes to visit, are they permitted to smoke in their own unit, or do they have a smoke-free lease? They are permitted to smoke in their unit

% 13.7% (n=73)

They have a smoke-free lease

8.8% (n=47)

No neighbours or tenants come to visit

33.2% (n=177) 44.4% (n=237) (n=534)

Don't know Total

Missing Responses 85; sample n=619 – note multiple responses were possible.

Less than 10% of respondents (9%, n=47) reported that visitors come who have smoke-free leases.

Table 14. Question 10) If you allow smoking in your home, do you plan to make your home 100% smoke-free within the next 6 months? Reported for households that indicated they permit smoking (question 7) Smoking Frequency Yes No 5.3% 94.7% Often (n=1) (n=18) 40.0% 60.0% Sometimes (n=16) (n=24) Missing Responses: 9 (2 missing for households that ‘often’ smoke inside, 7 missing from households that “sometimes” smoke inside); Excluded responses: 4 (4 respondents who previously reported that their households had indoor smoking “sometimes” reported that their indoor space was ‘already smoke-free’).

The results from question 10 indicate that a greater proportion of smokers who only smoke “sometimes” in their unit are planning to make their home 100% smoke-free in the next 6 months compared to respondents who smoke “often”.

Table 15. Question 11) Do you support the new policy that made all new leases in your building 100% smoke-free, including no smoking on patios or balconies? Reported for entire sample, and based on smoking status of respondent and smoking status of household Respondent Entire Sample

Non-smoker Smoker

Household has no smokers Household has a person who smokes

Yes 78.9% (n=463)

Sample size 587 (32 missing)

88.2% (n=417) 29.3% (n=27)

473 (14 missing) 92 (6 missing)

89.4% (n=414 32.4% (n=34)

463 (15 missing) 105 (4 missing)

Missing Responses: 32; total sample n=618

Support for the smoke-free policy is high across the sample (79%, n=546). A greater proportion of nonsmokers and households with no smokers support the policy compared to people who smoke or households that have a smoker. Understanding that there is a range of reasons for why a respondent may support or not support the policy, an open ended question was available. Some of the responses are included here:

Respondents who supported the policy: “Our world should be a smoke free world! We don't need to pollute this world more. (Even the old policies must be changed to allow smoke free homes which means cleaner air.)” “I don't smoke and I am concerned about health risks involved in second hand smoking.” Respondents who do NOT support the policy: “Inside yes, but outside no” “We (smokers) should be able to smoke wherever we want, when we want.” “It's up to the person!”

Second-hand Smoke Exposure and Health: Questions 12-15 asked about respondents’ second-hand smoke exposure (SHS) in their home and how SHS may impact the health of their household. Responses are detailed in tables 16-21 below. Table 16. Question 12) How often do you smell second-hand smoke coming into your home?

Never Sometimes Often Total

Percent

Frequency

49.6%

283

31%

177

19.4%

111

100%

571


Half of respondents (approximately 50%, n= 283), indicated that they are sometimes or often exposed to second-hand smoke in their home. This remains unchanged from the previous 2011 survey. Table 17. Question 13) If second-hand smoke comes into your home, where does it come from? [check all that apply]

Percent

Frequency

Neighbouring units

36.0%

196

From outdoors

26.1%

142

Other No, it doesn’t come into my unit

6.06%

33

43.8%

238

Missing responses: 75; sample n= 544 – Note frequency sums to 609as multiple responses were possible.

Approximately a third of respondents (36%, n=196) reported that smoke enters their home from neighbouring units. Approximately a quarter of respondents (26%, n=143) reported that smoke enters their home from outdoors.

Table 18. Question 14) Do you or others in your home have health problems that get worse when you breathe in second-hand smoke?

Percent

Frequency

No

56.1%

313

Yes

43.9%

245

Total

100%

558


Forty percent of respondents (n=253) reported that someone in their household has health problems that are made worse when exposed to second-hand smoke. Table 19. Question 15) If you live in an apartment building, do you smell second-hand smoke in other parts of the building such as hallways, lobby or other common indoor spaces? Reported for households that live in apartments Percent Frequency Always Often Sometimes Never Total

37.8%

165

15.1%

66

10.1%

44

36.9%

161

100%

436

Missing responses: 35; Note: sample n=619

More than half of respondents (53%, n= 131) report that they smell second-hand smoke in other parts of the building “often” or “always”.

Perceived Policy Compliance in Outdoor Spaces: Table 20. Question 16) In general, when people are smoking outside on the grounds of your property do they step 5 metres away from the building? Percent Frequency Always 14.4% 80 Often

9.7%

54

Sometimes

24.2%

135

Never

13.1%

73

Don’t Know

38.6%

215

Total

100%

557

Missing responses: 62; sample n=619

Approximately 13% (n=73) respondents reported that outside smokers “never” smoke 5m away from the building. Important to note is that one third of respondents (39%, n=215) reported they “don’t know” if people are smoking 5m from the building perimeters.

Cigarette butts: Question 17 asked respondents to report how often they see cigarette butts around their housing unit. Responses are detailed in Table 22 below, reporting from the entire sample. Table 22. Question 17) Do you see cigarette butts lying on the ground on the property where you live? Always Often Sometimes Never Total

Percent 13.9% 10.0% 41.3% 34.9% 100%

Frequency 78 56 232 196 630

Missing responses: 57; sample n=619

Almost two-thirds (65.2%; n= 366) of respondents reported seeing cigarette butts on their property at least “sometimes” in 2013. This is similar to findings in 2011(65%, n=410), however in. 2010, 74% of respondents reported that they saw cigarette butts on their property at least sometimes. This represents a statistically significant decrease in reported cigarette litter (p-value