Public Health Advances

finding public health in unexpected places

A Smoke-Free Nation One Step at a Time

Eighty-two percent of Los Angelenos would prefer to live in smoke-free housing, and those who live in publicly funded housing just got their wish.


Under a new federal rule, smoking in public housing will be banned nationwide as of early 2017. The Housing Authority of the City of Los Angeles will be required to ban smoking in apartments, indoor common areas and outside areas within 25 feet of the building. They will have up to a year and a half to put smoke-free policies into place. These new policies will put Los Angeles on par with other nearby areas, such as Santa Monica, which previously passed similar ordinances.


Smoking can have many harmful health effects, including asthma and lung cancer. Although you often hear about the harms of tobacco for the smoker, you hear less often about second or third-hand smoke. However, these can be of real concern when living in close proximity to a smoker or living in the former space of a smoker. Smoke can travel through open windows or through shared wall vents. Third-hand smoke inhalation can come from carpet, rugs, walls, and furniture, because the smoke and its harmful compounds can linger there for months. Neighbors of a smoker can experience irritation of the throat, mouth and eyes, and experience nausea and dizziness.


Los Angeles has one of the largest public housing markets in the nation, with 47,804 units and 114,442 residents, although even this is small compared to New York, which has 631,749 public housing residents. According to the National Center for Health in Public Housing, there are 8.7 million residents in public housing nationwide, which includes residents that use housing vouchers. Of these, 28% of residents smoke compared to about 17% of the general population.


Smoking can be the result of stress related to poverty, which may explain some of the higher rates we see in low-income populations. However, the cost of cigarettes can have a significant financial impact on smokers. The average cost of a pack of cigarettes in the U.S. is $5.51, but the cost varies by state, reaching as much as $12.85 in New York. The ban on smoking in public housing could help to decrease smoking among residents, which in turn would result in financial savings of around $2,250 for a household that smokes a pack a day. That is a significant amount for low-income residents living below the poverty threshold.


Savings are also estimated for taxpayers. U.S. Department of Housing and Urban Development officials estimate that the ban on smoking in public housing sites nationally will save $153 million annually, about $94 million in secondhand smoke- related health care, $43 million in renovation expenses and $16 million in smoking- related fire losses.


Some residents are upset that their choices are being governed while they are inside their homes. But the policy is not intended to lead to numerous evictions, which would be costly anyway, but to improve the health of the residents and the community. Sanctions for policy violations will need to be determined by each jurisdiction, but could allow for some leniency for a small number of violations. In San Antonio, where the policy was passed in 2012, up to 3 violations are allowed before lease termination. Education and resources to help residents quit smoking will also be necessary to help make the ban successful in improving public health.


The new policy has some sharp elbows. The sanction of lease termination could lead to evictions and ultimately homelessness, which could be too high a price to pay to reduce smoking rates in this population. In addition, some people use cigarette smoking to help them cope with cravings for other drugs. Researchers will have to keep a close eye on the consequences of this policy change. If it succeeds in bringing down smoking rates without triggering any increase in homelessness or substance abuse it will be a welcome success, but the public health community must be vigilant and realistic about the potential for adverse effects.


Overall, eliminating smoking from public housing will cut down on the effects of second and third-hand smoking. It may also prevent people from becoming smokers due to the inconvenience of having to leave their building property to smoke. It will be worth keeping an eye on the sale and use of electronic cigarettes, though, which is not included in the ban. Next up, I hope smoking will be banned in all multi-unit apartment buildings.

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A woman’s maternity should not be a one-way ticket to eternity

Globally, maternal mortality is on its way to becoming a public health victory with decreased deaths for many countries in recent years. However, the U.S. has not followed that trend. In fact, we’ve gotten worse. Between 2000 and 2013, when the most recent data is available, the number of women who have died from pregnancy has risen. Our rates are above Iran, Vietnam, Russia and Romania, countries that all saw a decrease in the past decade, and we are last among all high-income countries.


Maternal Mortality Ratio (MMR) is the number of maternal deaths per 100,000 live births. The U.S. had a MMR of 28 in 2013, which is about a 27% increase since the year 2000. The Institute of Metrics and Evaluation, which released the MMR data in September, has projected that the U.S. MMR likely dipped to 25 in 2015, but data is not yet available to confirm this projection. While deaths are still relatively rare, we have a lot of work to do.


The reason for the increase in mortality can’t be pinpointed to one issue, but likely a complex set of reasons such as access to health care, insurance coverage and pre-existing chronic conditions like diabetes, hypertension and obesity. A little over 40% of American women are obese and at least 1 in 10 adult women have diagnosed diabetes. Diabetes can cause harm to the unborn child, including miscarriage or birth defects. Between 1988 and 2012, the prevalence of diabetes increased significantly in every age group, in both sexes, in every racial/ethnic group, by all education levels, and in all poverty income ratio tertiles, a 2015 study of American adults found. However, we know that these chronic conditions (and maternal mortality) do not affect everyone equally. Socioeconomic factors and geographic location are tied closely to the risk of maternal mortality. American Indians are more than twice as likely as non-Hispanic Whites to have diabetes and African Americans have almost double the rate of Whites. Diabetes rates are also greater for people with less than a high school graduation. Geographically, Texas, a state known for its limited women’s reproductive health services, has seen its MMR double in a two-year period while California saw a decrease. MMR disparities exist and need to be addressed using targeted resources and interventions.


The health of a woman during and after pregnancy begins long before she may even be considering getting pregnant. Therefore as part of a multi-prong strategy, public health practitioners need to focus resources on preventing chronic conditions throughout the life course. For example, a multi-component school-based obesity program implemented in elementary school has been shown to decrease obesity in childhood and adulthood. Universal preschool, another early childhood program, has been shown to reduce smoking and smoking-related health risks later in life. Other programs implemented during pregnancy, such as a nurse-family partnership program where trained nurses visit low-income first-time mothers before birth and up to the baby’s second birthday, leads to reductions in mortality among mothers and their children. A program like this that targets at-risk women also helps to address the inequities of MMR.


Other programs that improve women’s health throughout the life course and especially target those most at-risk will be necessary in order to decrease inequities and reverse this troubling trend.

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A Win-Win Tool for Improving Local Public Health – Commentary from the Directors of CHA

Economic modeling is fast becoming an indispensable tool to advance public health and health equity. Center for Health Advancement (CHA) Co-Directors, Drs. Jonathan Fielding and Fred Zimmerman, wrote a commentary for the Journal of Public Health Management & Practice that discusses the value of modeling as a decision-support tool for public health practitioners. Using the CHA Win-Win modeling tool as an example, they provide lessons learned on developing a useful model based on over a decade of experience in the field, discussions with experts and users and collaboration with large public health departments. Please access the article here to read more.

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When Soda Companies Pay the Public Health Bills

Several cities will vote on soda taxes this November, but the beverage industry is doing everything they can to make sure they don’t pass, including giving funding to national health organizations.


Coca-Cola and Pepsi have spent millions on fighting public health interventions that would reduce soda consumption while simultaneously giving millions to public health groups, according to a new article in the American Journal of Preventative Medicine. The study found that between 2011 and 2015, the Coca-Cola Company and PepsiCo sponsored a total of 96 national health organizations, including the American Diabetes Association and the National Institutes of Health, as well as many medical and public health institutions whose mission it is to fight the obesity epidemic. Also during this time, they lobbied against 29 public health bills intended to reduce soda consumption or improve nutrition.


As a sector working within tight budgets, do donations from big soda companies help or hinder public health? The study reports several instances where organizations did an about-face on issues such as tax on sugary drinks after receiving funding. The organizations deny their stance has anything to do with soda’s financial support and Pepsi and Coca-Cola say they have long traditions of supporting community programs. The American Beverage Association (ABA) responded to the study stating that their support is the single-largest voluntary effort by any industry to address obesity and is not meant to sway health organizations’ study results. But others consider it a conflict of interest and are refusing to be bought. Colorado’s Boulder County Board of Public Health announced they will not take donations from the beverage industry. Although they have never taken money in the past, it is still noteworthy that they are taking a stand, especially because Boulder residents will vote on a soda tax in November.


Other cities are also taking action to curb soda consumption despite heavy pushback from the beverage industry. The ABA says it has defeated 45 soda tax measures nationwide since 2008. In New York they spent $12.9 million and in San Francisco, they spent $9.1 million to defeat such a tax. Philadelphia twice failed to pass a soda tax. One of those times, in 2010, the ABA offered $10 million to the Children’s Hospital of Philadelphia if the proposal was dropped. Ultimately the measure was voted down and they made the donation. However, the measure was finally passed this year when the new Philadelphia Mayor proposed the one-and-a-half cent per ounce tax as a way to fund universal preschool. This proved successful he says because they avoided the health angle and instead focused on poverty, a cause he thought more people were likely to get behind. His intuition was accurate, but it’s worth noting that universal preschool has many health (and educational) benefits so ultimately it was a win for public health too. The beverage industry has since filed a lawsuit in Philadelphia declaring the tax unlawful.


The soda companies have a strategy of donating millions to health organizations, while also working to defeat health-related measures. By maintaining financial ties to the public health industry, they are able to hide behind claims of philanthropy while manipulating the public health agenda in their favor. Public health organizations should avoid the murky waters of receiving financial aid from the beverage industry.

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