Secondhand smoke exposure in public and private high-rise multiunit housing serving low-income residents in New York City prior to federal smoking ban in public housing, 2018.

BACKGROUND: Tobacco remains the leading cause of preventable death in the United States, with 41,000 deaths attributable to secondhand smoke (SHS) exposure. On July 30, 2018, the U.S. Department of Housing and Urban Development passed a rule requiring public housing authorities to implement smoke-free housing (SFH) policies. OBJECTIVES: Prior to SFH policy implementation, we measured self-reported and objective SHS incursions in a purposeful sample of 21 high-rise buildings (>15 floors) in New York City (NYC): 10 public housing and 11 private sector buildings where most residents receive federal housing subsidies (herein 'Section 8' buildings). METHODS: We conducted a baseline telephone survey targeting all residents living on the 3rd floor or higher of selected buildings: NYC Housing Authority (NYCHA) residents were surveyed in April-July 2018 (n = 559), and residents in 'Section 8' buildings in August-November 2018 (n = 471). We invited non-smoking household participants to enroll into a longitudinal air monitoring study to track SHS exposure using: (1) nicotine concentration from passive, bisulfate-coated nicotine filters and (2) particulate matter (PM2.5) from low-cost particle monitors. SHS was measured for 7-days in non-smoking households (NYCHA n = 157, Section 8 n = 118 households) and in building common areas (n = 91 hallways and stairwells). RESULTS: Smoking prevalence among residents in the 21 buildings was 15.5%. Two-thirds of residents reported seeing people smoke in common areas in the past year (67%) and 60% reported smelling smoke in their apartments coming from elsewhere. Most stairwells (88%) and hallways (74%) had detectable nicotine levels, but nicotine was detected in only 9.9% of non-smoking apartments. Substantial variation in nicotine and PM2.5 was observed between and within buildings; on average nicotine concentrations were higher in NYCHA apartments and hallways than in Section 8 buildings (p < 0.05), and NYCHA residents reported seeing smokers in common areas more frequently. CONCLUSIONS: SFH policies may help in successfully reducing SHS exposure in public housing, but widespread pre-policy incursions suggest achieving SFH will be challenging.

A Cohort Review Approach Evaluating Community Health Worker Programs in New York City, 2015-2017.

The objective of this study was to describe how a cohort review approach was applied as an evaluation framework for a community health worker intervention among adult residents in 5 public housing developments in New York City in 2015-2017. The cohort review approach involved systematically monitoring participants engaged in the Harlem Health Advocacy Partners program during a given time period ("cohort") to assess individual outcomes and program performance. We monitored participation status (completed, still active, disengaged, on leave, or died) and health outcomes. In this example of a cohort review, levels of enrollment and program disengagement were higher in cohort 1 than in cohort 2. For 6-month health outcomes, the percentage of participants with hypertension who had controlled blood pressure was static in cohort 1 and improved significantly in cohort 2. The percentage of participants with diabetes who self-reported controlled hemoglobin A1c increased significantly in cohort 1 at 6-month follow-up. The cohort approach highlighted important outcome successes and identified workload challenges affecting recruitment and retention.

A protocol for measuring the impact of a smoke-free housing policy on indoor tobacco smoke exposure.

BACKGROUND: Tobacco remains a leading cause of preventable death in the U.S., responsible for more than 440,000 deaths each year. Approximately 10% of these deaths are attributable to exposure of non-smokers to secondhand smoke (SHS). Residents living in public multi-unit housing (MUH) are at excess risk for SHS exposure compared to the general population. On November 30, 2016, the U.S. Department of Housing and Urban Development (HUD) passed a rule requiring all public housing agencies to implement smoke-free housing (SFH) policies in their housing developments by July 30, 2018. METHODS: As part of a larger natural experiment study, we designed a protocol to evaluate indoor SHS levels before and after policy implementation through collection of repeat indoor air samples in non-smoking apartments and common areas of select high-rise NYCHA buildings subject to the HUD SFH rule, and also from socio-demographically matched private-sector high-rise control buildings not subject to the rule. A baseline telephone survey was conducted in all selected buildings to facilitate rapid recruitment into the longitudinal study and assess smoking prevalence, behaviors, and attitudes regarding the SFH policy prior to implementation. Data collection began in early 2018 and will continue through 2021. DISCUSSION: The baseline survey was completed by 559 NYCHA residents and 471 comparison building residents (response rates, 35, and 32%, respectively). Smoking prevalence was comparable between study arms (15.7% among NYCHA residents and 15.2% among comparison residents). The majority of residents reported supporting a building-wide smoke-free policy (63.0 and 59.9%, respectively). We enrolled 157 NYCHA and 118 comparison non-smoking households into the longitudinal air monitoring study and performed air monitoring in common areas. Follow up surveys and air monitoring in participant households occur every 6 months for 2.5 years. Capitalizing on the opportunity of this federal policy rollout, the large and diverse public housing population in NYC, and robust municipal data sources, this study offers a unique opportunity to evaluate the policy's direct impacts on SHS exposure. Methods in this protocol can inform similar SFH policy evaluations elsewhere.

Declines in adult blood lead levels in New York City compared with the United States, 2004-2014.

OBJECTIVES: To assess changes in lead exposure in the New York City (NYC) adult population over a 10-year period and to contrast changes with national estimates, overall, and by socio-demographics and smoking status. METHODS: We used measurements of blood lead levels (BLLs) from NYC resident adults who participated in the NYC Health and Nutrition Examination Surveys (HANES) in 2004 and 2013-2014. We compared estimates of geometric means (GM), 95th percentiles, and prevalence of BLL ≥ 5 µg/dL overall and by subgroups over time, with adults who participated in the National HANES (NHANES) 2001-2004 and 2011-2014. RESULTS: The GM BLLs among NYC adults declined from 1.79 µg/dL in 2004 to 1.13 µg/dL in 2013-2014 (P < .0001). The declines over this period ranged from 30.1% to 43.2% across socio-demographic groups and smoking status (P < .0001 for all comparisons), and were slightly greater than declines observed nationally. The drop in prevalence of elevated BLLs (≥ 5 µg/dL) was also greater in NYC (4.8-0.5%), compared with NHANES (3.8-2.0%). By 2013-2014, NYC adults with lower annual family income (< $20,000) no longer had higher GM BLLs relative to those with higher incomes (≥ $75,000), a disparity improvement not observed nationally. Likewise, GM BLLs and 95th percentiles for non-Hispanic black adults in NYC were lower than GM BLLs for non-Hispanic white adults. Non-Hispanic Asian adults had the highest GM BLLs compared with other racial/ethnic groups, both in NYC in 2013-14 and nationally in 2011-2014 (1.37 µg/dL, P = .1048 and 1.22 µg/dL, P = .0004, respectively). CONCLUSION: The lessening of disparity in lead exposure across income groups and decreasing exposure at the high end of the distribution among non-Hispanic black and Asian adults in NYC suggest that regulatory and outreach efforts have effectively targeted these higher exposure risk groups. However, Asian adults still had the highest average BLL, suggesting a need for enhanced outreach to this group. Local surveillance remains an important tool to monitor BLLs of local populations and to inform initiatives to reduce exposures in those at highest risk.

A Place-Based Community Health Worker Program: Feasibility and Early Outcomes, New York City, 2015.

INTRODUCTION: This study examined feasibility of a place-based community health worker (CHW) and health advocate (HA) initiative in five public housing developments selected for high chronic disease burden and described early outcomes. METHODS: This intervention was informed by a mixed-method needs assessment performed December 2014-January 2015 (representative telephone survey, n=1,663; six focus groups, n=55). Evaluation design was a non-randomized, controlled quasi-experiment. Intake and 3-month follow-up data were collected February-December 2015 (follow-up response rate, 93%) on 224 intervention and 176 comparison participants, and analyzed in 2016. All participants self-reported diagnoses of hypertension, diabetes, or asthma. The intervention consisted of chronic disease self-management and goal setting through six individual CHW-led health coaching sessions, instrumental support, and facilitated access to insurance/clinical care navigation from community-based HAs. Feasibility measures included CHW service satisfaction and successful goal setting. Preliminary outcomes included clinical measures (blood pressure, BMI); disease management behaviors and self-efficacy; and preventive behaviors (physical activity). RESULTS: At the 3-month follow-up, nearly all intervention participants reported high satisfaction with their CHW (90%) and HA (76%). Intervention participants showed significant improvements in self-reported physical activity (p=0.005) and, among hypertensive participants, self-reported routine blood pressure self-monitoring (p=0.013) compared with comparison participants. No improvements were observed in self-efficacy or clinical measures at the 3-month follow-up. CONCLUSIONS: Housing-based initiatives involving CHW and HA teams are acceptable to public housing residents and can be effectively implemented to achieve rapid improvements in physical activity and chronic disease self-management. At 3-month assessment, additional time and efforts are required to improve clinical outcomes.