From a public health perspective, the Department of Housing and Urban Development's announcement that it will ban smoking in all public housing facilities is unambiguously good news. The evidence on smoking bans' effectiveness is sizable and almost unanimously positive: They both help people quit and reduce exposure to secondhand smoke.
But HUD's decision also plays into a long history of using social programs as means to impose behavioral restrictions on poor people that don't apply to the rich. This restriction only exists for low-income people and families living in public facilities; suffice it to say, the IRS isn't going to start banning recipients of the mortgage interest deduction — which is much costlier than public housing and goes overwhelmingly to rich people — from smoking in their homes.
So there's a dilemma. The smoking ban will make the low-income people to whom it applies healthier, extending their lives and preventing miserable diseases. But it will also limit their freedom, while leaving rich people completely untouched. Is it worth it?
The evidence is clear: Smoking bans work
What is almost certainly true is that banning smoking across all public housing will reduce smoking and likely reduce the incidence of smoking-related illnesses. My colleague German Lopez ran through the evidence recently, which is extensive and compelling. A 2010 systematic review of 37 studies found that smoke-free policies in workplaces, public areas, and the like reduce tobacco use by 3.4 percentage points,on average, and increase the percentage of people quitting smoking by 6.4 points. Another systematic review that same year from the Cochrane Review found more limited evidence on smoking rates, but did conclude that smoking bans reduce exposure to secondhand smoke. A 2011 study comparing Indiana University in Bloomington — which adopted a whole campus smoking ban in 2008 — with Purdue University in West Lafayette found that smoking dropped significantly in Bloomington but not at Purdue, even though enforcement was lax.
"It would be very difficult to estimate the number of lives a policy like this will save, although the answer is likely to be at least some," Kenneth Warner, a professor of public health at the University of Michigan and an expert on tobacco control policies, says. "Likely the largest life savings would be associated with encouraging smoking residents of the facilities to quit smoking."
But the major rationale for the policy, as articulated by HUD Secretary Julián Castro, is not promoting cessation but sparing other public housing residents from secondhand smoke. "We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke," Castro said in the press release announcing the policy change, "especially the elderly and children who suffer from asthma and other respiratory diseases."
Far fewer people die from secondhand smoke than from smoking themselves. But the toll of secondhand smoke is still massive — and bigger than prominent threats like gun violence. Between 2005 and 2009, 480,000 people died every year from smoking-related conditions; given that 2.44 million died each of those years on average, that means that smoking accounts for nearly one in five deaths in America. Only 42,000 of those deaths annually were related to secondhand smoke, but that's still enough to make secondhand smoke a bigger killer than guns or car accidents:
Given that a disproportionate share of people living in public housing are elderly or are children with asthma (a disease which is much more common among people living in poverty, like many public housing residents), the potential gains of a smoking ban for nonsmokers are considerable.
Smoking bans also get people — rarely, but sometimes — evicted
But smoking bans also have to be enforced, and in the case of public housing, enforcement sometimes takes the form of eviction. From talking to representatives of a number of local public housing authorities (PHAs) around the country that have already implemented smoking bans, it seems that taking the policy national definitely will lead to some evictions. But eviction is treated as a last resort, and PHAs make considerable effort to avoid it.
The Auburn Housing Authority in Auburn, Maine, was one of the first PHAs in the country to adopt a no-smoking policy. It went smoke-free in 2004, meaning it has more than a decade of experience in implementing the policy. Executive director Richard Whiting says that the organization has evicted people for smoking — but that this is very much the exception. "For the most part, we are successful in encouraging people who smoke illegally to move voluntarily," Whiting writes in an email. "They understand they are fighting a losing battle and are resented by the vast majority of residents, many with health problems, who do not smoke."
David Clark, the director of public housing for the San Antonio Housing Authority — which went smoke-free at the start of 2012 — says that he's never had to evict anyone, but San Antonio is tightening its enforcement to a three-strikes policy, which may result in evictions. He's also been keeping track of evictions nationally. An 89-year-old in Cincinnati was evicted last year; a resident in Fairhaven, Massachusetts, was evicted this year; and an elderly, disabled veteran in Manchester, New Hampshire, got booted in 2013. Philadelphia, as a matter of policy, evicts after the fourth smoking violation.
Lydia Agro, chief of staff at the Boston Housing Authority, which is among the largest PHAs to adopt a nonsmoking policy, says that she's never had to evict or even fine any residents. "While our policy does involve an enforcement process that includes fines and eviction action as part of a lease violation, we view that as a last resort and prefer to work methodically and thoughtfully to encourage compliance rather than resort to eviction," she said.
It seems that eviction will likely be an option under the new nationwide rule. "There may be costs to residents as a result of eviction, particularly for persons with disabilities, and especially those with mobility impairments," the rule draft states. But a HUD official speaking on background insisted that this was a last resort: "We don't want to say that it won't happen. But the rule isn't intended in any way, shape, or form to have eviction as a final consequence." And of course, there will be punishments short of eviction, like fines.
Is it worth it?
How, then, do you weigh the interests of smokers and nonsmokers in reducing exposure to carcinogens against the personal liberty of smokers and the needs of smokers who may be evicted as a price of this policy?
If you frame it in terms of the rights of nonsmokers, the question becomes easy. As the saying goes, one person's rights end where another's begin. If smoking were a harmless activity to everyone but the smoker, a ban would be rank paternalism. But smoking actually victimizes nonsmokers, including vulnerable children and seniors. One thing PHA officials and other housing experts I talked to repeatedly emphasized was that public housing residents themselves have consistently complained about their neighbors smoking. In a private apartment building, complaints like that would probably translate into a new nonsmoking policy (which are increasingly common in private apartments). Why not in public housing too? "In comparing the smoker's right to foul the air of a nonsmoker to the nonsmoker's right to clear air, I'll go with the latter every time," Warner, the smoking expert at University of Michigan, says.
And the eviction issue, while tough for the handful of people affected, genuinely does not appear that widespread. It happens — there are anecdotes — but PHAs go to great lengths to try to accommodate people. There are outside smoking areas, programs to help people quit, and long phase-in periods. Auburn even experimented with grandfathering in smokers who started living in public housing before it banned smoking, before deciding that the effects on air quality for other tenants were unacceptable. And evicting people is hard. "Given that the eviction process is onerous and expensive for PHAs, it seems unlikely that evictions based solely on smoking violations would be common," Martha Galvez, a housing expert at the Urban Institute, says.
There will be genuinely hard cases. A 90-year-old who's smoked his whole life and doesn't want to quit, and lacks the mobility to regularly step outside for a smoke, could find himself evicted. But to be blunt, most smokers don't live to 90. The number of worst-case scenarios will likely be low, much lower than the number of nonsmokers helped.
The truly troublesome aspect of the policy is that it only applies to the poor. Sheila Crowley, the president and CEO of the National Low Income Housing Coalition, was generally sympathetic to the move for a smoking ban. "From a public health perspective, we do think helping people not smoke, and helping nonsmokers avoid secondhand smoke, is an extremely good move, especially for kids whose lungs are more susceptible to damage," she says. "It's something that has been a long time coming and maybe should have happened long ago." Crowley did call for "careful consideration over the fact that some people are seriously addicted to tobacco"; cessation programs and special dispensation for truly tough cases might be necessary. But overall, she sounded optimistic.
That said, Crowley also expressed frustration that these rules only apply to people in public housing — not to voucher recipients, not to people getting the low-income housing tax credit, and definitely not to the millions more people who benefit from the mortgage interest deduction. If you're getting a tax break on their mortgage, she notes, "You can be a criminal, you can be a drug addict, you can do any of the things that keep you from having public housing assistance." And you can absolutely still smoke in your house.
Banning smoking indoors outright — regardless of whether you own your house or rent or get public assistance — isn't in the cards right now. When restrictions apply to people outside of public housing, freakouts tend to ensue. But it'd be a far fairer way to save lives and prevent secondhand smoke than a ban that's only limited to public housing residents.