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Smoke-free housing policies and secondhand smoke exposure in low income multiunit housing in Los Angeles County

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Smoke-free housing policies and secondhand smoke exposure in low income multiunit housing in Los Angeles County

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Content Smoke-Free Housing Policies and Secondhand Smoke Exposure in Low Income Multiunit
Housing in Los Angeles County
By
Ellen Galstyan
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
PREVENTIVE MEDICINE
(HEALTH BEHAVIOR RESEARCH)
May 2024

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Table of Contents
Abbreviations................................................................................................................................. iv
List of Tables .................................................................................................................................. v
List of Figures................................................................................................................................ vi
Abstract......................................................................................................................................... vii
Chapter 1: Introduction................................................................................................................... 1
Tobacco-Related Morbidity and Mortality ................................................................................. 1
Smoke-Free Policies in Multi-Unit Housing .............................................................................. 5
Electronic Cigarettes and Nicotine Aerosol Exposure................................................................ 8
Marijuana Use, Secondhand Marijuana Smoke, and Cannabis Aerosol Exposure .................... 8
Overview of the Dissertation Studies ....................................................................................... 11
Conceptual Framework for Dissertation Studies...................................................................... 11
Chapter 2: Study 1 ........................................................................................................................ 18
Perceived Barriers of Protecting Against Secondhand Smoke Exposure in MUH ...................... 18
Introduction............................................................................................................................... 18
Methods..................................................................................................................................... 20
Results....................................................................................................................................... 24
Discussion................................................................................................................................. 30
Chapter 3: Study 2 ........................................................................................................................ 34
A Qualitative Study of the Barriers and Facilitators of Smoke-Free Policy Support................... 34
Introduction............................................................................................................................... 34
Methods..................................................................................................................................... 39
Results....................................................................................................................................... 41
Discussion................................................................................................................................. 60
Chapter 4: Study 3 ........................................................................................................................ 65
Individual, Interpersonal, and Neighborhood-Level Factors that lead to Exposure to Secondhand
Smoke and Support for Smoke-Free Policies among Multiunit Housing Residents.................... 65
Introduction............................................................................................................................... 65
Methods..................................................................................................................................... 71
Results....................................................................................................................................... 76
Discussion................................................................................................................................. 90
Chapter 5: General Discussion...................................................................................................... 94
Summary of Findings................................................................................................................ 94

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Limitations................................................................................................................................ 97
Potential Implications, Policy Recommendations, and Future Research ................................. 99
References................................................................................................................................... 103
Appendix A: Study Measures................................................................................................. 116

iv
Abbreviations
MUH - Multi-Unit Housing SHS - Secondhand Smoke
SHMS - Secondhand Marijuana Smoke SFH - Smoke-Free Home
SDOH - Social Determinant of Health SEM – Social Ecological Model

v
List of Tables
Table 1: Associations Between Characterisitcs and Ethnic Neighborhood Composition ............ 26
Table 2: Ethnic Neighborhood and barriers to protecting from SHS (N = 272) .......................... 28
Table 3: Results of Multivariate Negative Binomial Regression Analysis .................................. 29
Table 4: Focus Group Participant Demographics (N = 54).......................................................... 42
Table 5: Participant Substance Use and Harm Perceptions (N = 54)........................................... 43
Table 6: MUH Focus Group Themes and Notable Tenant Quotes............................................... 44
Table 7: Sociodemographic Characteristics of MUH Residents (N = 272) ................................. 77
Table 8: Results of Bivariate Analyses (N =272)......................................................................... 80
Table 9: Multiple Logistic Regression Models for Secondhand Smoke Exposure ...................... 84
Table 10: Multiple Logistic Regression Models for Supporting Smoke-Free Policies................ 88

vi
List of Figures
Figure 1: The Social Ecological Framework of Dissertation Studies........................................... 14
Figure 2: Participant Ethnicity Distribution Within Ethnic Neighborhood (N = 272)................. 76

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Abstract
Tobacco smoking rates and secondhand smoke exposure (SHS) in the general population
have decreased between 2011 to 2022 in California due to the implementation of strict tobacco
control policies and indoor air laws, however, disparities remain among individuals living in
low-income ethnic minority communities in Los Angeles County (LAC) (California Department
of Public Health, 2023). The legalization of the use and sale of recreational cannabis in
California and the emergence of electronic cigarette (e-cigarette) nicotine and cannabis products,
have created a large area of overlap between tobacco and cannabis use. The use of e-cigarette
products with nicotine and cannabis, along with tobacco smoking in multiunit housing (MUH),
have increased exposure to multiple types of harmful secondhand smoke and aerosols in homes.
Many lower income and minority ethnic groups reside in rental units in MUH. This has been
found to be a large contributor to exposure to SHS from tobacco in these populations. Previous
research suggests that even though many MUH residents support comprehensive smokefree laws
in their buildings (Reyes-Guzman et al., 2023), living in MUH is still directly associated with
exposure to SHS.
There are limited studies (Patel et al., 2022; Hafez et al., 2019) that have focused on low
socioeconomic ethnic populations living in MUH, and even fewer addressing the issue of
exposure to secondhand tobacco and marijuana smoke and e-cigarette aerosol. This dissertation
is composed of three distinct studies and focuses on the five levels of the Social Ecological
Model to investigate the specific challenges, barriers, and facilitators of protecting from
secondhand smoke and supporting smoke-free tobacco and marijuana housing policies in lowincome MUH in Los Angeles, CA.

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Study One in this dissertation examines the prevalence of barriers to protecting from secondhand
smoke exposure in three ethnic communities and the unique multilevel barriers associated with
protection from secondhand smoke from tobacco and marijuana products. Study Two in this
dissertation is a qualitative study that explores the unique challenges to compliance,
implementation, and support for comprehensive smoke-free policies among low-income
communities in Los Angeles County. Study Three identifies the individual, interpersonal,
community, and policy-level correlates of exposure to three types of secondhand smoke in low
socioeconomic status MUH and support for smoke-free policies.
The findings from this dissertation highlight gaps in the literature that examine the
multiple dimensions, including individual level to community level factors, that may be
predictors of exposure to secondhand smoke, residents’ attitudes regarding support for smokefree housing policies, the unique barriers different ethnic communities may face, as well as the
barriers and facilitators of adopting smoke-free policies in MU

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Chapter 1: Introduction
Tobacco-Related Morbidity and Mortality
Tobacco use remains the number one cause of preventable disease, disability, and death
in the United States. Approximately 34 million American adults currently smoke cigarettes, with
most of them smoking daily (U.S. Department of Health and Human Services, 2020). Among all
tobacco products, cigarettes and other combustible tobacco products are the predominant cause
of tobacco-related morbidity and mortality (Cornelius et al., 2022). Tobacco use and secondhand
smoke exposure are significant public health concerns that have been linked to numerous adverse
health outcomes. Tobacco use is the leading preventable cause of death in the United States,
responsible for over 480,000 deaths annually and 42,000 deaths from SHS (U.S. Department of
Health and Human Services, 2014).
Ethnic communities and those with low SES suffer from health problems related to
tobacco product use at higher rates than their counterparts and are more likely to die from
tobacco-related disease (Centers for Disease Control and Prevention, 2022). Cigarette use
contributes to high rates of disease among African American and Hispanic individuals, becoming
the largest preventable cause of death and disease in the U.S. for these groups (Centers for
Disease Control and Prevention, 2022). In 2022, 15.3% of non-Hispanic Black adults, and 9% of
Hispanic adults currently used any tobacco product, compared to 9.8% of Non-Hispanic White
adults (Centers for Disease Control and Prevention, 2022).
In addition to the direct effects of tobacco use on the individual, exposure to secondhand
tobacco smoke – the smoke exhaled by a smoker or emitted from a tobacco product – has been
linked to numerous health concerns, including asthma, coronary heart disease, and stroke (U.S.
Department of Health and Human Services, 2014). The U.S. Surgeon General has extensively

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documented the harmful health effects of SHS, concluding that there is no safe level of exposure
(U.S. Department of Health and Human Services, 2006).
Smoke-free policies in MUH are especially relevant to addressing tobacco-related health
equity. Over 35% of public MUH residents are disabled, 41% are children, and 32% are elderly,
all populations that are vulnerable to SHS exposure and experience heightened morbidity and
mortality from SHS (Miller and Vijayaraghavan, 2022). Individuals with low socioeconomic
status (SES) and ethnic minority communities suffer from tobacco-related disease more than
other groups and are disproportionately situated in MUH, increasing their vulnerability to
environmental risks like secondhand tobacco smoke exposure (U.S. Department of Health and
Human Services, 2020; Curry et al., 2008).
Exposure to Secondhand Smoke (SHS)
While national cigarette smoking rates have declined, the prevalence of emerging
products such as electronic cigarettes (e-cigarettes) have increased, raising concerns about
undermining efforts to reduce overall tobacco use (U.S. Department of Health and Human
Services, 2019). Research has indicated that aerosols from certain e-cigarette products contain
nicotine and other harmful substances, posing potential risks to bystanders through involuntary
exposure (Zajac et al., 2022; Patel et al., 2022; U.S. Department of Health and Human Services,
2016; Williams et al., 2013). Data from the 2023 California Adult Tobacco Survey found that
approximately half (53.3%) of Californians reported being exposed to either secondhand tobacco
smoke or secondhand vape in the past two weeks in 2023. Higher rates of SHS exposure were
observed in Californians who used tobacco products in the past 30 days (77.7%) compared to
those who did not (46.4%). Among Californians who reported past two-week secondhand
tobacco smoke or secondhand vape exposure, sidewalks (51.7%) were the most reported location

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of exposure, followed by exposure at home (42.3%) and at recreational spaces (39.9%)
(California Department of Public Health, 2024).
Disparities in Smoking and Secondhand Smoke Exposure
Social determinants of health (SDOH) describe environmental conditions in which people
are born, live, learn, work, play, and worship that affect various health, functioning, and qualityof-life outcomes and risks. Some studies have examined the impact of SDOH on cigarette use
among racial/ethnic minority smokers to explain the intersectionality of race and increased health
burden (Bauer et al., 2019; Braveman et al., 2011; World Health Organization, 2008).
Racial/ethnic discrimination has been associated with racial/ethnic disparities in residential
environments, SES, and health status and exerts deleterious effects on an individual’s health,
independent of the material impact of institutional discrimination in causing differential access to
goods, services, and environmental exposures (Dawson and Fletcher, 2020).
Racial or ethnic discrimination is defined as an organized system of inferior ideology that
categorizes groups into races, assigns hierarchical status to these groups, and uses ranking to
preferentially allocate resources to those regarded as superior (Williams et al., 2019).
Experiences of racial/ethnic discrimination are associated with mental health disorders and
substance use disorder, independent of socioeconomic status, age, and gender (Vines et al.,
2017). African American and Hispanic smokers are more likely to report more racial/ethnic
discrimination episodes than their non-smoking counterparts, highlighting a relevant determinant
of health. Previous research (Bello et al., 2021; Dawson and Fletcher, 2020) has found that the
use of cigarettes in response to perceived discrimination possibly alleviates subsequent negative
affect and may reinforce use over time. High rates of cigarette use in ethnic communities may
then subsequently increase exposure to secondhand smoke.

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Housing is a key SDOH, and structural inequities have led to disparate access to
affordable, stable housing with health-promoting indoor environments, limiting the availability
of smoke-free housing options (Swope & Hernandez, 2019). Smoke-free policies have been
highly effective in reducing SHS exposure in public settings, such as bars and restaurants. As a
result, the home environment has become a major source of SHS (Nguyen et al., 2019).
Residents of MUH are especially at risk of the harmful effects of SHS exposure as they may be
involuntarily exposed for long periods of time and have limited means of finding new housing,
have higher rates of smoking, and poorer underlying health conditions among low-income
populations. Residents of MUH are further vulnerable, as smoke can travel between individual
residences and building ventilation systems, common spaces, hallways, and cracks in floors and
walls (Ahn et al., 2021; King et al., 2013).
Low-income communities of color are disproportionately situated in MUH, increasing
their vulnerability to environmental risks like secondhand tobacco smoke exposure (Zajacet al.,
2022; Curry et al., 2008). Despite ongoing initiatives aimed at mitigating tobacco-related
inequities among ethnic minorities, significant disparities still exist. In California, racial, and
ethnic minorities, young adults, and low-socioeconomic status populations are more likely to live
in MUH (Chambers et al., 2015). In California, 32% of Hispanics live in MUH, compared with
22% of Non-Hispanic Whites (Unger et al., 2019). Previous studies of MUH residents have
found that Hispanic residents prefer to live in smoke-free environments but are reluctant to ask
their neighbors not to smoke or to complain to landlords because of fear of retaliation by
smokers, fear of eviction, and cultural values against interfering in other people's business, or
challenging elders or authority figures (Unger et al., 2019; Rendon et al., 2019); thus, some
communities may rely on smoke-free housing policies to protect from SHS in MUH.

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The County of Los Angeles (LAC) has the second largest population of apartment renters
in the country after New York, where 23% of residents rent and live in MUH (vs. 26% in New
York; National Multifamily Housing Council, 2022). The highest concentration of renters in Los
Angeles are Hispanic/Latino (H/L), Black/African American (AA), and lower socioeconomic
status Non-Hispanic Whites (NHW) (Los Angeles Department of City Planning, 2021). Previous
research has found that these groups are more likely to use tobacco, be exposed to SHS, and lack
smoke-free home (SFH) policies in their buildings (Homa et al., 2015; Holmes et al., 2020).
Smoke-Free Policies in Multi-Unit Housing
Smoking in residential settings presents serious health hazards and significant challenges
in protecting the health and well-being of residents. Federal and state clean indoor air laws
protect people from SHS in public places (International Agency for Research on Cancer [IARC],
2009) and are associated with reductions in the incidence of cardiovascular disease and lung
cancer (Hahn et al., 2018; Lightwood & Glantz, 2009).
SHS can infiltrate smoke-free living units and common areas and travel from neighboring
units, balconies, and outdoor areas, drifting inside apartments through air vents, walls, stairwells,
and elevator shafts (Licht et al., 2012; King et al., 2013). Even where complete smoke-free
housing policies exist, they may be difficult to enforce by building managers and landlords
because of objections from current residents, concerns about limiting the potential pool of
residents, concern of legal liability, and increased vacancy and turnover.
To address the disparity in access to smoke-free policies in MUH, the Department of
Housing and Urban Development (HUD) implemented a smoke-free policy in 2018 that
restricted indoor smoking in public housing (U.S. Department of Housing and Urban
Development, 2014). As this rule only applies to smoking in public MUH, HUD has

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recommended that housing authorities, as well as operators of multi-family housing rental
assistance programs, such as Section 8, implement smoke-free building policies for some or all
their properties, however, there is no mandated state-wide policy for privately owned (or marketshare) MUH (U.S. Department of Housing and Urban Development, 2009). The HUD rule only
covers a quarter of all MUH residents and does not apply to the vast majority of residents living
in private MUH who are likely to be from historically disadvantaged populations and who may
be exposed to SHS from neighbors, even if their own household is smokefree.
Smoke-Free Policies in California
California municipalities are at the forefront of expanding smokefree air protections by
adopting policies that regulate smoking in MUH to create healthier living environments for
residents, but there are still gaps in protections for many Californians. As of April 2024, 190
municipalities in CA regulate smoking in MUH to some extent and 100 municipalities have
enacted ordinances that regulate smoking in private units of MUH. The strongest policies are in
49 municipalities and require all MUH properties with 2 or more units to be 100% smokefree
indoors—both rental units and condominium/owner-occupied units—and include e-cigarette use
and marijuana smoking/vaping; 62 municipalities require all MUH properties with 2 or more
units to be 100% smokefree indoors for tobacco—both rental units and condominium/owneroccupied units—but may not fully include e-cigarette use and/or marijuana smoking/vaping in
the policy; 9 municipalities require all rental MUH properties with 2 or more units to be 100%
smokefree indoors but exempt some or all condominium/owner-occupied units; 16 municipalities
have partial policies that require some, but not all, units or buildings to be smokefree, or contain
other exemptions such as allowing existing residents to continue smoking in their unit. Of the

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100 municipalities that regulate smoking in MUH to some extent cover 6,353,573 Californians,
or 16.1% of the state’s population (American Nonsmokers’ Rights Foundation, 2024).
In Los Angeles, California, the definition of a “multiple dwelling unit”, or multiunit
housing, refers to “any structure, including an apartment house, condominium, or any portion of
any structure, occupied, designed, or built, or rented for occupation as a home by five or more
families, each living in a separate unit and cooking within such structure” (Los Angeles Ord.
9578 § 5, 1968: Ord. 8609 Art. 2 § 72, 1964). As of January 2012, California landlords have the
right to implement smoke-free policies on all or parts of the rental premises, common areas, and
individual units (Cal. Civ. Code § 1947.5). Although it is not possible to legislate smoke-free
policies in most home settings, MUH is an exception, and a growing number of local laws or
ordinances have been enacted to prohibit smoking in MUH residential units and indoor and
outdoor common areas (American Nonsmokers’ Rights Foundation, 2013).
In Los Angeles County, as of April 2024, 17 municipalities include some level of smokefree policy. These municipalities include Baldwin Park, Bell Gardens, Beverly Hills, Burbank,
Calabasas, Compton, Cudahy, Culver City, El Monte, Glendale, Huntington Park, Manhattan
Beach, Pasadena, Santa Monica, Sierra Madre, South Pasadena, and West Hollywood. Of these
17 municipalities, all of them prohibit the vaping and smoking of marijuana, and 15 explicitly
prohibit nicotine e-cigarette use (except for Burbank and Glendale). Although some cities have
started to implement comprehensive smoke-free policies, large gaps remain. Los Angeles has the
largest population of any county in the nation and the largest in the state; however, a majority of
municipalities have not implemented smoke-free policies in MUH, creating a gap in access to
smoke-free housing.

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Electronic Cigarettes and Nicotine Aerosol Exposure
Along with exposure to SHS from tobacco, the rapid proliferation of novel nicotine ecigarette products has likely increased exposure to nicotine aerosol from e-cigarettes and in the
home. Tobacco use among youth is a major concern in California and is driven by the popularity
of e-cigarettes among this population. Current e-cigarette use, or vaping, among California high
school students in 2022 was highest among White youth (9.1%). Although fewer adults smoke
cigarettes now than ever before, e-cigarette use rates have increased ever since their introduction.
In 2021, 6.2% (1.8 million) of California adults reported current cigarette smoking and 4.3% (1.2
million) reported current vaping (Centers for Disease Control and Prevention, 2022). Research
suggests that e-cigarette use may expose others to secondhand aerosol, which can contain
harmful and potentially harmful constituents, including nicotine, heavy metals, ultrafine
particulates, volatile organic compounds, and other toxicants (U.S. Department of Health and
Human Services, 2019). Compared to SHS from cigarettes, less is known about the health effects
of secondhand e-cigarette aerosol, but the limited research indicates that indoor nicotine ecigarette use, although at lower concentrations than cigarette smoke, may expose non-users to
increased concentrations of particulate matter and volatile organic compounds, (Papaefstathiou,
2020; Volesky et al., 2018).
Marijuana Use, Secondhand Marijuana Smoke, and Cannabis Aerosol Exposure
In the United States, marijuana is the most used illicit substance at the federal level, with
smoking and vaping being the most common method of consumption (Substance Abuse and
Mental Health Services Administration, 2022; Centers for Disease Control and Prevention, 2022;
Hughes et al., 2016; Fataar et al., 2019; Hamilton et al., 2019; Odani et al., 2019; Lipari et al.,
2019). Given the rapidly changing policies surrounding legalization and use, research has found

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that use has risen, and overall harm perceptions of marijuana and cannabis use has declined
(Mariani and Williams, 2021). This is particularly concerning as recent research has found that
marijuana use has a strong association with adverse cardiovascular outcomes independent of
tobacco use (Jeffers et al., 2024).
Given high rates of co-use of tobacco and marijuana among young adults, as well as
transformations in the realm of policy and technology, tobacco, marijuana and e-cigarettes are
most effectively studied in relationship to one another. Referred to as ‘The Triangulum’ (Latin
for triangle), this approach reflects interest in the intersection of tobacco, marijuana and
electronic cigarette use, with implications for surveillance (e.g., evaluating tobacco and
marijuana use), policy (e.g., smoke-free policies related to marijuana and e-cigarettes) and
treatment (e.g., effects of dual use on cessation) (Tobacco Related Disease Program, 2016;
McDonald et al., 2016). Tobacco and cannabis smoke is highly similar in composition, including
in volatility, shape, density, and number concentration, suggesting their effects when exposed to
secondhand smoke from tobacco or marijuana may be similar. Tobacco and marijuana differ
primarily in the presence of nicotine in tobacco smoke and cannabinoids in cannabis smoke, and
result in the inhalation of many of the same harmful substances, such as tar and other toxic
compounds (Schick, 2022; Huang et al., 2022). Previous research (Schick, 2022; Huang et al.,
2022; Murphy, Huang, & Schick, 2021) conducted in residential and commercial settings where
cannabis smoking and vaping had taken place has shown significantly higher indoor levels of
particulate matter 2.5 (PM 2.5). Particulate matter are particles ≤ 2.5 in aerodynamic diameter
that can deeply penetrate the lungs and enter the bloodstream. This can especially happen during
periods of cannabis vaping and marijuana smoking when compared to smoke-free conditions
(Murphy, Huang, & Schick, 2021; Nguyen and Hammond, 2021). Although studies on

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secondhand marijuana smoke (SHMS) and cannabis aerosol exposure are limited, they have
consistently produced similar findings that suggest they can potentially have adverse health
effects similar to that of tobacco smoke. This emphasizes the need for more research regarding
the potential health risks of SHMS exposure.
In 2016, California passed Proposition 64, The Adult Use of Marijuana Act, making adult
recreational use of marijuana legal (Proposition 64; Judicial Council of CA, 2022). However,
because marijuana is a federally prohibited substance, residents of publicly funded housing (i.e.,
Section 8 and other federally funded housing) are prohibited from using or possessing cannabis
(medical or otherwise) on their premises, regardless of any state law legalizing cannabis.
Moreover, HUD explicitly states that if applicants for public or Section 8 housing are known
users of marijuana, their applications must be denied. Under California law, landlords have the
right to prohibit marijuana use on their properties. Depending on the specific language and
clauses in lease agreement, landlords have the right to prohibit the smoking, vaping, and
consumption of edible marijuana from their properties. California’s Proposition 64 (Judicial
Council of CA, 2022) includes provisions that allow landlords to restrict marijuana smoking on
their properties. Because smokers are not a federally or state-protected class, MUH property
owners have the legal authority to make their properties completely smoke-free. This enables
them to prohibit the smoking or vaping of recreational or medically prescribed marijuana in
individual units and common areas. Although there is no recent literature regarding property
owners’ feelings and knowledge about smoke-free policies, previous research has found owners
and managers are reluctant to enforce comprehensive smoke-free policies in their buildings
because they are afraid it might be considered discriminatory or illegal and restricting use could

11
be difficult to enforce without direct guidance from state and local regulatory bodies (Delgado
Rendon et al., 2019; Baezconde et al, 2011).
Overview of the Dissertation Studies
This dissertation is a secondary analysis of data from a Tobacco-Related Disease
Research Program (TRDRP) study entitled Triangulum (Tobacco, E-cigarettes, Marijuana)
Secondhand Smoke Exposure in Low Socioeconomic Status Multi-Unit Housing (PI: Lourdes
Baezconde-Garbanati, Ph.D.), that examined knowledge, attitudes, beliefs, and behaviors of
MUH tenants regarding tobacco, e-cigarette, and marijuana use and smoke-free policies. The
overarching aims of this study were to examine the feasibility, barriers, and levels of support for
existing and future policies on smoke-free housing in California to provide scientific evidence to
reduce the burden of tobacco-related disease and improve the health of at-risk populations.
Conceptual Framework for Dissertation Studies
The overall theoretical foundation used to guide this dissertation is the Social Ecological
Model (SEM of Health; Bronfenbrenner, 1977). The Social Ecological Model posits that factors
at multiple levels influence health behaviors and outcomes. This model recognizes that
individual health behaviors and outcomes are shaped by various interconnected factors within the
larger social contexts and considers the associations between individual, interpersonal,
community, and societal level factors. Although this model has its origins in the study of human
development (Bronfenbrenner, 1977), it was later adopted more generally in the field of public
health by McLeroy et al. (1988) as a framework to promote health-related behavioral change,
including in tobacco control to help conceptualize and measure drivers of various health-related
and tobacco control issues (U.S. National Cancer Institute, 2017). The model states that health
behavior is influenced by one's physical environment, social relationships, and personal

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characteristics and provides a useful framework to examine macro-level risk factors that lead to
micro-level health behaviors aimed at reducing the risk of secondhand smoke exposure.
Applying this model to the studies in this dissertation may help to explain how SHS exposure as
well as support for smoke-free policies may be influenced by multiple factors.
At the center of the SEM model is the individual level, which considers individual-level
characteristics, such as demographic characteristics, substance use, including tobacco, ecigarette, and marijuana use, or other individual factors that may impact support for a health
behavior, which can influence or be influenced by higher levels of the framework. The second
level examines interpersonal factors and focuses on the immediate relationships of the
individual, such as interactions with family or neighbors, or factors that contribute to increasing
exposure to SHS and SHMS. Social relationships and living with or around regular tobacco and
marijuana users can influence one’s own perceptions of the harms associated with use and may
contribute to an individual’s exposure to SHS and SHMS and their feelings surrounding smokefree policies. The community level encompasses the individual’s physical and social
environment. This may include building characteristics of the MUH in which they live, social
norms in their community regarding tobacco or marijuana smoking, general smoking norms in
their building, compliance, and enforcement of smoke-free policies within the building, as well
as the socioeconomic status of the community. Taken together, these factors can greatly impact
the prevalence of tobacco, e-cigarette and marijuana use and exposure in an individual’s
environment. The organizational level considers the structured communities to which individuals
belong. In this case, living in a community with smoke-free MUH policies can help to reduce
exposure to SHS, SHMS, and e-cigarette aerosol. Finally, policies constitute the outermost layer
of the framework. The societal factors or public policy component considers broader societal

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norms and attitudes towards smoking, as well as tobacco and marijuana policies at the local,
state, and federal level. Policies are enacted to protect individuals from SHS and SHMS exposure
and should aid in reducing risk and the presence or absence of policies may influence how
individuals and communities perceive these behaviors and form their own perception of harms
associated with exposure. The SEM examines multi-level factors that are all interconnected and
each individually contributes to exposure on the individual. The Social Ecological perspective
has brought attention to the dynamic relationship between various SDOH and how they are
relevant for addressing both personal and societal factors influencing public health policies. This
model is well suited to evaluate the effectiveness of community and public policies on
individual-level exposure because of the inclusion of different micro and macro-level
determinants that have the potential to mitigate or contribute to the risk of secondhand tobacco
and marijuana smoke exposure, prevalence of barriers to protecting from SHS, and the unique
barriers and facilitators of supporting smoke-free policies for tenants of MUH (see Figure 1).
Study 1 of this dissertation, “Perceived Barriers of Protecting Against Secondhand
Smoke Exposure in MUH”, focuses on the individual level within the SEM and explores the
interpersonal and community-level factors within ethnic communities that increase the perceived
barriers for protecting against exposure to SHS. Study 2 of this dissertation, “A Qualitative
Examination of the Multi-Level influences of Barriers and Facilitators of Smoke-Free Housing
Policy Support Among Minority Populations in Los Angeles Multi-Unit Housing”, is a
qualitative study that utilizes focus group data that includes questions framed by the SEM to
examine the various barriers and facilitators of adopting comprehensive smoke-free policies in
MUH in ethnically diverse communities. Finally, Study 3, “Individual, Interpersonal, and
Neighborhood-Level Factors that lead to Exposure to Secondhand Smoke and Support for

14
Smoke-Free Policies among Multiunit Housing Residents”, examines the various dimensions of
the SEM to explore the associations between certain individual, interpersonal, and communitylevel factors and their role in SHS, e-cigarette aerosol, and SHMS exposure and residents’
support for comprehensive building smoke-free policies.
Figure 1: The Social Ecological Framework of Dissertation Studies
Study Summaries
Study 1
Study 1 analyzed door-to-door interview data from 272 MUH residents to assess reported
barriers to secondhand smoke protection. Using negative binomial regression, we examined the
prevalence of barriers reported within specific ethnic neighborhoods and the social ecological
factors linked to experiencing increased barriers. We hypothesized that residing in

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Hispanic/Latino or African American neighborhoods, older age, being foreign born, living in a
smoking household, and having less than a college education would be associated with increased
barriers to protecting against secondhand smoke.
Study 2
Study 2 is a qualitative study that utilized focus group data (N=54) to explore reported
instances of SHS, SHMS, and e-cigarette aerosol exposure among MUH residents and assess the
barriers and facilitators of adopting smoke-free policies in their buildings. Study 2 utilizes the
SEM to examine the individual, interpersonal, organizational, and community level influences
that may be barriers to or facilitators of support for comprehensive smoke-free policies in lowincome MUH. The research questions that were used to guide Study 2 are as follows:
Research question 1: What is the individual, interpersonal, organizational, communitylevel factors that facilitate support for smoke-free housing policies?
Research question 2: What factors act as barriers for implementing smoke-free policies
in low-income MUH?
Study 3
In Study 3, door-to-door interview data were used to examine the social-ecological
factors that may be associated with supporting 100% smoke-free housing policies and
secondhand tobacco, marijuana, and e-cigarette smoke and aerosol exposure in MUH. We
examined the associations between demographics, substance use characteristics, interpersonal
factors (e.g., living with a person who smokes), and building smoke free policies association and
exposure to SHS, SHMS, and e-cigarette aerosols and the factors that may be associated with
MUH tenants’ support for comprehensive smoke-free policies. This study employed multiple
regression models while accounting for clustering within ethnic community zip codes (N=27).

16
The aims of this study were to 1) examine the association between individual
sociodemographic and substance use characteristics, interpersonal, and community level factors
and self-reported secondhand tobacco and marijuana smoke, and e-cigarette aerosol exposure, 2)
assess the sociodemographic, individual, interpersonal, and community level correlates of
support for comprehensive smoke-free policies in MUH. It was hypothesized that interpersonal
(living with a person who smokes) and community level factors (living in a building with smokefree policies) would be associated with higher odds of exposure to secondhand smoke. For
support of smoke-free housing policies, individual (e.g., female, older age, higher educational
attainment) and interpersonal factors (not living with a person who uses cigarettes or marijuana)
would be associated with support for comprehensive smoke-free policies.
Taken together, the aim of these studies is to build upon the limited literature on the
correlates of exposure to SHS, SHMS, and e-cigarette aerosol in MUH in a large urban area with
legalized marijuana use and e-cigarette use. Each study adds a unique contribution to the limited
current literature available and aims to examine what factors contribute to experiencing SHS
exposure, increased barriers to protecting from SHS, and barriers and facilitators of adopting
smoke-free policies.
Data from the door-to-door interviews were collected from 2018 to March 2020, during
the start of the pandemic and is used in Study 1 and 3. This dataset offers perspectives from
tenants of MUH before stay-at-home orders and may be used to evaluate the multilevel
influences of SHS exposure and policy support. Although this data does not capture changes
caused by increased time spent at home, such as increased exposure, it may serve as a helpful
baseline when examining future MUH SHS exposure from these populations. Data from focus
groups were collected during the COVID-19 pandemic and helped to shed light on the unique

17
challenges tenants may have faced during stay-at-home orders and how increased time spent
inside the home may have led to increased exposure to SHS among MUH residents. Focus group
accounts are important as they foster open dialogue among participants and touch on problems
faced during the pandemic and the increased SHS experienced by tenants. Moreover, natural
conversations develop that address tobacco and marijuana use during the pandemic in MUH
buildings and potential issues tenants may have with complying with smoke-free policies. These
perspectives can help inform public health advocates to assist landlords with steps to implement
policies that tenants can slowly comply with. The findings from these studies may be utilized for
public health campaigns to address the gaps in knowledge about the harms associated with
exposure to nicotine and cannabis byproducts and contribute to a more comprehensive
understanding of the multidimensional barriers and facilitators that influence support for smokefree policies in MUH. Campaigns for smoke-free housing may use this data to help to promote
the establishment of comprehensive smoke-free housing policies at the state and municipal
levels.

18
Chapter 2: Study 1
Perceived Barriers of Protecting Against Secondhand Smoke Exposure in MUH
Introduction
Approximately 6.8% of California adults are exposed to secondhand smoke (SHS) in the
home, and there are large disparities in SHS exposure across demographic subgroups (ReyesGuzman et al., 2023; Schmidt et al., 2016). Research suggests that adults living in urban settings
may have greater exposure to SHS than adults living in rural settings (Sim and Park, 2021),
suggesting that those living in multi-unit housing (MUH) in densely populated urban areas are at
significant risk for SHS exposure. While the prevalence of U.S. households with voluntary
smoke-free home policies has increased considerably over the last two decades, homes still
represent a major source of SHS (Gentzke et al., 2019). Research has found that exposure to SHS
in the home is significantly higher among males compared to females, young adults aged 18–24
years or those aged 45–64 years compared to those aged 65 years or older, the less educated
compared to those with a college degree, lower income groups compared to high-income groups,
and those living in households of two or three people compared to those living alone (Chambers
et al., 2015).
Disparities in SHS exposure are also observed by socioeconomic status (SES), where the
magnitude of the decline in SHS has been smaller for lower SES populations, widening
disparities between low and high-income and minority groups (Gan, 2015). Active smoking has
been shown to place a disproportionately high burden on communities of color, including
Blacks/African Americans (AA) and Hispanics/Latinos (H/L) (Cuevas et al., 2020). Living in
disadvantaged neighborhoods characterized by a lack of socioeconomic resources and increased
neighborhood disorder has been associated with tobacco smoking (Holmes & Marcelli, 2014).

19
Residents living in disordered environments may experience high levels of stress, and smoking
may be viewed as a stress management function, thus exacerbating smoking levels (Twyman et
al., 2014). This is compounded by the fact that MUH is occupied by large proportions of
minority and lower SES groups that are already at higher risk for chronic disease and poor health
outcomes.
Several studies (Azagba et al., 2020; Gentzke et al., 2018) have identified disparities in
SHS exposure among those living in MUH, but few have addressed the specific barriers that
make it difficult to protect against secondhand smoke within these communities. As found in
previous studies focused on Hispanic residents of MUH (Rendon et al., 2019; Rendon et al.,
2017), Hispanic residents have noted substantial barriers to protection from secondhand smoke
and addressing smoke exposure with their neighbors. Some participants had invoked Hispanic
cultural values such as familismo to ask their neighbors not to smoke near their children, but
other participants cited other cultural values such as respeto and simpatía as reasons why it
would be inappropriate for them to ask their neighbors to change their smoking habits. Residents
also mentioned barriers to successful negotiations with neighbors, including fear of violent
retaliation and language barriers (Rendon et al., 2019), which make it difficult to protect from
exposure. Certain cultural habits and traditions may make it hard to ask others not to smoke,
whether in the home or in the building, and these populations may rely on smoke-free policies
alone to protect themselves from SHS.
Previous studies assessing barriers to protecting against secondhand smoke exposure
included living with a smoker, the inability to ask people not to smoke in their home, and the
inability to ask family members in the home to change their smoking behaviors (Hoehn et al.,
2016). A recent study of MUH residents has found that barriers to protecting against SHS and

20
implementing smoke-free home policies included the difficulty associated with making a smoker
obey smoke-free rules. Residents also cited that those who smoke in the home do not want to
quit, and having relatives, friends, or visitors that smoke indoors make it difficult to have a
smoke-free home (Berg et al., 2023).
There is a limited amount of recent research on the specific barriers related to protecting
against SHS and the difference challenges and barriers ethnic communities may experience is a
gap in our knowledge. More research is needed on the barriers tenants face that make it difficult
for them to protect against secondhand smoke in their homes. The current study uses data from
272 adults living in Los Angeles MUH to investigate the barriers reported by tenants living in
three different ethnic neighborhoods that make it difficult to protect from SHS and the factors
associated with higher numbers of barriers reported. We hypothesize that residing in
Hispanic/Latino or African American neighborhoods, younger age, being foreign born, living in
a smoking household, and having less than a college education would be associated with
increased barriers to protecting against secondhand smoke.
Methods
Participants and Procedures
This study uses data collected between June 2018 and March 2020 from a survey
administered to residents living in privately owned, low-income MUH located in Los Angeles,
California. Los Angeles has the second highest proportion of renters in the United States, after
New York City, with a high concentration of African American/Black, Hispanic/Latino, and
low-SES Non-Hispanic White populations, making these communities an ideal target population
to better understand their potential exposures to SHS and attitudes towards smoke-free housing.
Los Angeles zip codes were rank ordered by the percent ethnicity of each target ethnic

21
community and top-ranked zip codes with the highest percentages of each ethnicity and below
median household income based on the median household income of each focus community in
Los Angeles County were selected. Buildings in target zip codes were selected if they had 20 or
more tenant-occupied units in the building. Three households in each building were surveyed if
the building had between 20 to 39 units, six households in buildings with 40-59 units, and 9
households with buildings with 60 or more units.
Research staff used a random number generator to determine which unit numbers to
approach and consent. Residents were asked if they would like to participate in a study about
secondhand smoke exposure in their buildings and were eligible if they currently resided in the
unit and were 18 years of age or older. Participants received $50 for their participation in the
interview. The final dataset included 272 surveys collected from a total of 141 MUH buildings.
Study measures were modified from questions from the National Health Interview
Survey (NHIS), and validated scales used in previous projects by the team of investigators, and
other MUH studies addressing SHS (King et al., 2010), which were revised for inclusion of
marijuana and e-cigarettes. Measures in the study included questions related to individual,
interpersonal relationships, community, and organizational levels of the Social Ecological
Model.
Measures
Demographic Characteristics: Demographic information collected included age, gender
(female/other), race/ethnicity, nativity status (born in the U.S./born outside of the U.S.), and
education. Race and ethnicity were assessed with the question “What is your race or ethnicity?”,
with options to choose, 1) African American/Black or African, 2) American Indian or Alaska
Native, 3) Asian, 4) Hispanic/Latino, 5) Native Hawaiian and/or Other Pacific Islander, 6) Non-

22
Hispanic White, or 7) Other. Because the study design and survey targeted certain ethnic
communities, resulting in small cell sizes for other ethnicities, race was recoded as Non-Hispanic
White, Hispanic/Latino, African American/Black, or Other. Education was recoded into four
categories: less than high school, high school diploma or GED, some college, and college degree
or higher. Education is a plausible covariate because it is highly correlated with socioeconomic
status (SES), which has been found to be associated with smoking, where those in lower SES
groups are more likely to live in smoke-friendly environments, with other smokers, and access
smoke-friendly environments more frequently.
Substance Use: Substance use characteristics were collected by participants to classify
their smoking status (i.e., if they had used cigarettes, marijuana, or e-cigarettes in the last 30
days) (yes/no).
Smoking Household: Subjective norms are the individual’s perception of the behavior
(having a smoke-free home) and the perceptions of the behavior from those around them. This
will be measured by assessing if the participant lives in a smoking household. A smoking
household (household with at least 1 smoker/non-smoker household) dummy variable was
created (yes/no). Participants who had reported living with a person who smokes any tobacco
products (e.g., cigarettes, cigars, hookah), marijuana products (e.g., smokable marijuana,
vaporizers), and electronic e-cigarettes (e.g., used with nicotine or cannabis oil) or were a current
smoker of these products themselves, were coded as one.
Voluntary Smoke-Free Home Policy: Participants were asked, “Are any of the following
allowed to be smoked/vaped in your home?” (yes/no) separately for tobacco, marijuana, and ecigarettes. Individuals who reported “no” for all three products were classified as having a
voluntary smoke-free home policy.

23
MUH Smoke-Free Policies: Participants were asked; “Does your building have any rules
about smoking? (tobacco/marijuana)” (yes/no) and “Does your building have any rules about
vaping? (nicotine/cannabis)” (yes/no). Individuals who answered yes to both questions were
coded as living in a building with smoke-free policies (building with smoke-free policy/building
without a smoke-free policy).
Secondhand Smoke Exposure: Participants were asked if they had experienced any type of
secondhand smoke or vapor (tobacco, marijuana, or e-cigarettes) drift into their home with the
question, “In the last year, has secondhand smoke or vapor drifted into your home?” (yes/no).
Primary Outcome of Interest: Perceived Barriers
The barriers to protecting against secondhand smoke measure contained ten questions
adapted from previous MUH SHS exposure studies to assess participants’ perceived barriers of
protecting against secondhand smoke and vapor from tobacco, marijuana, and e-cigarette
products. Participants were asked: “Which of the following makes it hard for you to protect
yourself from secondhand smoke or secondhand vapor from tobacco or marijuana?” and the
option to select “yes” or “no” to the following ten items.
1) I have more important problems, 2) I don’t know how to protect my family or myself, 3) I
can’t control other people’s actions, 4) I don’t feel comfortable telling people not to smoke,
5) The people who smoke are my relatives, 6) I don’t want to make trouble in my building, 7) I
don’t want smokers to get angry with me, 8) I’m worried that I’ll get evicted if I complain, 9)
There is no rule against smoking, 10) The manager is not helpful.
Cumulative Protection Barrier Score: A cumulative barrier count score was created by summing
up yes responses from each of the perceived barrier questions, with higher scores indicating
more perceived barriers for protecting against SHS (mean: 3.1; range: 0-10).

24
Data Analysis
A variety of statistics were utilized to analyze the data in this study. Pearson’s chi-square
tests were used to explore the relationships between each ethnic neighborhood of interest and
certain individual, interpersonal, and community variables that may potentially have a role in
acting as a perceived barrier. We used chi-square tests to determine whether prevalence of each
barrier varied across racial/ethnic communities.
Number of perceived barriers in this study are count data and are not properly modeled
using ordinary least-squares (OLS) regression because of the assumptions that data are bound by
zero, highly skewed, and have heteroskedastic error terms. These conditions suggest that Poisson
regression should be used; however, preliminary models’ goodness-of-fit indicated a poor fit to
the data due to overdispersion of the dependent variable where the variances were larger than the
mean (analyses not shown), thus negative binomial regression was used for this study.
To control for the potential of biased standard errors and similarities of ethnic
neighborhoods, we adjusted for this clustering effect by using the Stata cluster command (by
ethnic community zip code; N=27 zip codes) to obtain robust standard errors. This adjustment
accounts for the potential correlation of observations within each cluster. Variables that were
significant at p<0.05 in chi square analyses were entered into the multivariate model. Given the
sample size of the data, using a stepwise approach, as more variables were entered into the
model, non-significant variables were removed to allow for a more parsimonious model.
Results
Tenant characteristics

25
Most surveyed tenants were between the ages of 25 and 34 (24.6%), female (62.5%),
Hispanic (36.9%), were born in the U.S. (61%), and had a college degree or higher (31.7%). Of
the households surveyed, 49% of them had at least 1 smoker living in the home, 62% of
households had a voluntary smoke-free home policy, and half (50.7%) lived in buildings with a
smoke-free policy.
Self-Reported Substance Use: Tobacco, Marijuana, and E-cigarette Products
Table 1 displays the differences of substance use behaviors between communities.
Among the three ethnic neighborhoods, there were significant differences in rates of tobacco and
marijuana use and living with someone who uses these products, which may contribute to
barriers of protecting against secondhand smoke exposure.
A greater percentage of individuals that had smoked 100 or more cigarettes in their life
lived in AA neighborhoods (51.9%), compared to those living in H/L (14.8%) and NHW
(33.3%) ethnic neighborhoods (p <0.001). Current smokers were more likely to live in African
American communities (28.3%), compared to H/L (7.7%) and NHW (17.8%) (p=0.004).
Non-Hispanic White communities had the highest rates of having ever tried electronic
cigarettes at least once (52.3%), compared to AA (31.8%) and H/L communities (15.9%)
(p=0.001). There were no differences among communities regarding current e-cigarette use.
Marijuana use also significantly differed between ethnic neighborhoods. African
American communities reported the highest rates of use within the last 30 days (52%), followed
by NHW communities at 28% and Hispanic communities at 7.3% (p < 0.001). Among those who
used marijuana regularly, 74.1% of individuals in AA communities reported marijuana use was
recommended by a doctor, compared to 3.7% and 22.2% for Latinos and non-Hispanic whites (p

26
= 0.02). Participants in African American communities also reported living with someone who
uses tobacco (56.6%), and marijuana (51.3%) (p<0.001 for both).
Table 1: Associations Between Characterisitcs and Ethnic Neighborhood Composition
Participant Characteristics
Total Sample
(N=272)
African
American
Neighborhood
(N=106)
Hispanic/Latino
Neighborhood
(N=65)
Non-Hispanic
White
Neighborhood
(N=101) p value
N (%) N (%) N (%) N (%)
Individual Level
Smoked at least 100 cigarettes in lifetime*
Yes 108 (40%) 56 (51.9%) 16 (14.8%) 36 (33.3%) <0.001
No 162 (60%) 50 (30.9%) 48 (29.6%) 64 (39.5%)
Current Cigarette Smoker*
Yes 53 (80.5%) 30 (28.3%) 5 (7.7%) 18 (17.8%) 0.004
No 219 (19.5%) 76 (71.7%) 60 (92.3%) 83 (82.2%)
Frequency Smoked Cigarettes*
Every day 28 (10.4%) 16 (57.1%) 0 12 (42.9%) <0.001
Some Days 25 (9.2%) 14 (56%) 5 (20%) 6 (24%)
Not at all 217 (80.4%) 74 (34.1%) 60 (27.7%) 83 (38.3%)
Ever Used Marijuana**
Yes 192 (70.9%) 85 (44.3%) 28 (14.6%) 79 (41.2%) <0.001
No 79 (29.1%) 21 (26.6%) 37 (46.9%) 21 (26.6%)
Past 30-day Marijuana Use*
Yes 69 (25.5%) 36 (52.2%) 5 (7.3%) 28 (40.6%) 0.001
No 202 (74.54%) 70 (34.7%) 60 (29.7%) 72 (35.6%)
Doctor Recommended Marijuana Use*
Yes 45 (62.5%) 20 (74.1%) 1 (3.7%) 6 (22.2%) 0.02
No 27 (37.5%) 18 (40%) 4 (8.9%) 23 (51.1%)
Tobacco and Marijuana Co-Use Frequency
(N=70)
Usually 9 (12.9%) 4 (44.4%) 0 5 (55.6%) 0.5
Sometimes 14 (20%) 8 (57.1%) 0 6 (42.9%)
Never 47 (67.1%) 25 (53.2%) 5 (10.6%) 17 (36.2%)
Ever used e-cigarettes*
Yes 88 (32.4%) 28 (31.8%) 14 (15.9%) 46 (52.3%) 0.001
No 184 (67.6%) 78 (42.4%) 51 (27.7%) 55 (28.9%)
Interpersonal Level

27
Lives with person who uses Tobacco*
Yes 106 (39%) 60 (56.6%) 12 (11.3%) 34 (32.1%) <0.001
No 166 (61%) 46 (27.7%) 53 (31.9%) 67 (40.4%)
Lives with person who uses Marijuana*
Yes 117 (43%) 60 (51.3%) 9 (7.7%) 48 (41%) <0.001
No 155 (57%) 46 (29.7%) 56 (36.1%) 53 (34.2%)
Barriers to Protecting from Secondhand Smoke Exposure in MUH
In the total sample, 83.4% of participants reported “I can’t control other people’s actions”
as a significant barrier to protecting against secondhand smoke exposure, although this was nonsignificant among ethnic neighborhood group comparisons.
Mean barriers reported among the three ethnic communities were significantly different.
Hispanic neighborhoods reported the highest number of barriers, with a mean barrier score of
3.69 barriers, Non-Hispanic White groups had a mean score of 3.19, and African American
neighborhoods had a mean score of 2.62 (p=0.01). Participants in Non-Hispanic White
neighborhoods were significantly more likely to identify “I have more important problems”
(51.72%), “I don’t know how to protect my family or myself” (37.88%), “The people who
smoke are my relatives” (46.88%), and “I don’t want to make trouble in my building” (37.36%)
as barriers to protecting from secondhand smoke compared to those in African American or
Hispanic ethnic neighborhoods. Participants from Hispanic neighborhoods reported “I’m worried
that I’ll get evicted if I complain” (52.78%) as a significant barrier against protecting from
secondhand smoke.

28
Table 2: Ethnic Neighborhood and barriers to protecting from SHS (N = 272)
% of Total
Sample
Reporting
Barrier
% of African
American
Neighborhoods
Reporting barrier
(N=106)
% Hispanic/Latino
Neighborhoods
Reporting barrier
(N=65)
% Non-Hispanic
White
Neighborhoods
reporting barrier
(N=101)
I have more important problems 21.3% 37.90% 10.34% 51.72%**
I don’t know how to protect my
family or myself 24.3% 25.76% 36.36% 37.88%**
I can’t control other people’s actions 83.4% 37.44% 24.67% 37.89%
I don’t know how to protect my
family or myself 38.6% 35.24% 29.52% 35.24%
The people who smoke are my
relatives 23.5% 21.88% 31.25% 46.88%**
I don’t want to make trouble in my
building 33.5% 29.67% 32.97% 37.36%*
I don’t want the smokers to get
angry with me 27.9% 30.26% 31.58% 38.16%
I’m worried that I’ll get evicted if I
complain 13.2% 30.56% 52.78%*** 16.67%
There is no rule against smoking 20.6% 37.50% 23.21% 39.29%
The manager is not helpful 22.4% 34.43% 27.87% 37.70% 1 Bolded values are significant at* p<0.05 **p<0.01 *** p<0.001

29
Multivariate regression analyses of tenant characteristics associated with a greater
number of barriers to protect from secondhand smoke exposure revealed that individuals living
in Hispanic neighborhoods reported a significantly greater number of barriers to protecting from
secondhand smoke exposure (p=0.03). Surprisingly, those who were 65 years and older reported
significantly less barriers to protecting from smoke compared to those 18-24 years of age.
Table 3: Results of Multivariate Negative Binomial Regression Analysis
Beta
coefficient
Standard
Error
Female 0.05 0.11
Age (Ref=18-24)
25-34 years -0.14 0.15
35-44 years -0.21 0.21
45-54 years 0.01 0.16
55-64 years 0.02 0.15
65+ years -0.5* 0.21
Ethnicity (Ref = African American)
Non-Hispanic White -0.11 0.12
Hispanic/Latino 0.38 0.19
Other 0.004 0.15
Education (Ref = less than high school)
High School Diploma/GED -0.05 0.15
Some College -0.06 0.17
College Degree or Higher -0.17 0.18
Nativity: Foreign Born 0.09 0.11
Smoking Household (Ref = >1 person who
smokes)
Non-Smoking Household -0.02 0.09
Ethnic Neighborhood (Ref =African
American)
Non-Hispanic White 0.27 0.16
Hispanic/Latino 0.29* 0.13
1
Bolded coefficients are significant at p<0.05.

30
Discussion
This study explored the prevalence of barriers from protecting against SHS exposure
across different ethnic communities and the predictors of experiencing these barriers. The results
from this study indicate that people living in Non-Hispanic White neighborhoods have a higher
prevalence of barriers to protecting themselves from SHS exposure in their homes and buildings,
contrary to our hypotheses. We also found that individuals living in Hispanic neighborhoods
experience more barriers to protecting themselves from SHS in MUH compared to African
American communities. These findings are similar to previous research on barriers and
motivators to reducing SHS in the home in African American families (Hoehn et al., 2016).
Individuals living in African American communities may be more empowered to speak to
neighbors or family members about smoking inside of the home to protect their health. Specific
cultural social networks and environments, such as being a part of a church or workplace that
was smoke-free, may also increase confidence to enforce smoke-free home policies in these
groups. Previous research among Hispanic populations living in MUH reported the barriers they
face included confronting neighbors about their exposure to smoke (Rendon et al., 2017). People
living in Hispanic ethnic neighborhoods have strong cultural values such as familismo, respeto
and simpatía. These strong ties to family and cultural values may make residents feel as though it
is inappropriate for them to ask their family and neighbors to change their smoking habits or that
it may jeopardize their relationships with family or neighbors (Baezconde et al., 2011).
Interestingly, individuals in Non-Hispanic White communities had a higher prevalence of
specific barriers than Hispanic or African American communities. People in NHW communities
reported barriers as, having more important problems than addressing secondhand smoke, they
don’t know how to protect themselves or their families from SHS, they don’t want to make

31
trouble in their buildings, and that they live with other smokers or have relatives who smoke.
These barriers may suggest these communities may not be likely to address secondhand smoke
with other tenants or guests in their home or may not perceive secondhand smoke exposure
harmful to health.
As highlighted by the U.S. Surgeon General, private settings, including the home
environment, remain a major source of SHS exposure (U.S. Health and Human Services, 2016).
The findings from this study are important for identifying what factors may lead to increased
barriers regarding protecting oneself against SHS exposure. Our findings highlight the need for
additional tailoring of interventions targeted toward unique cultural groups living in MUH. The
data here may be utilized to encourage policymakers to provide funding for educational
campaigns that promote health behaviors among low-income minority populations and inform
residents on the most effective ways to protect against SHS. We found that older adults are less
likely to report barriers, which may suggest they are more likely to confront their neighbors
about secondhand smoke exposure than younger individuals. Given that this research was
conducted in ethnic populations, who may be more likely to live with multiple generations of
family in one home, this may also mean that individuals who live with older adults may tend to
refrain from smoking around older adults in the home out of respect.
The findings here have implications for research and practice. Successful implementation
of smokefree policies have been supplemented with promotion of free cessation programs for
individuals living in MUH to ensure compliance with policies. This is especially important given
that access to cessation programs may be limited for historically underserved populations living
in MUH (U.S. Department of Health and Human Services, 2020). Multi-level interventions to
prevent or reduce exposure to SHS in the home are also needed. Given the influence of

32
individual level factors, or one’s own cultural values, and interpersonal relationships (e.g., living
with an older adult, living with multiple generations of family), and community norms and
building smoke-free policies, to reduce barriers to SHS exposure, multi-level interventions are
urgently needed to reduce disparities between low income and ethnic populations living in MUH.
Limitations
The findings in this study may be limited by several factors. Although Hispanic
communities reported significantly more barriers than other ethnic neighborhoods, questions
about intentions of addressed secondhand smoke in their buildings were not included in this
survey. Multiple barriers may lead to higher intentions to address secondhand smoking and may
help to examine the issues within these MUH buildings that lead to higher exposure among
Hispanic tenants. Many other socioeconomic status variables were not available to be utilized in
this study, such as annual household income, health insurance status, or employment status.
Despite efforts to maximize participation, there was a relatively low participation rate for
our study. Of the 717 residents who were approached to participate, 272 (38%) agreed and
completed the interview. The low recruitment rate may be a limitation of this study and have the
potential for selection bias in the recruitment process. As potential participants were informed of
the study’s objective of assessing tobacco, marijuana, and e-cigarette smoke and aerosol
exposure in their homes, individuals who use tobacco and/or marijuana, or live with a smoker
might have been less likely to participate.
Conclusions
Residents living in privately owned MUH are not subject to the HUD smoke-free policies
and may rely on their building landlords and management to implement smoke-free rules in their
buildings. Despite this study’s limitations, the findings here have implications for addressing the

33
specific barriers different ethnic neighborhoods face when experiencing secondhand smoke
exposure in their homes, including individual, interpersonal, and cultural barriers other
communities might not experience. Improving access to informational resources to all tenants
regarding the harms associated with indoor smoking, including cessation resources, and
education about ways to address smoking in MUH is needed. To reduce barriers to protecting
against secondhand smoke, building managers and landlords need to address compliance-related
issues if they do have smoke-free housing policies in their buildings.

34
Chapter 3: Study 2
A Qualitative Study of the Barriers and Facilitators of Smoke-Free Policy Support
Introduction
Although any individual may experience tobacco-related disease and secondhand smoke
exposure, racial and ethnic minorities and those in lower socioeconomic levels are at the greatest
risk (Simmons et al., 2016). MUH environments may perpetuate these disparities, as almost 80
million individuals, or about 25% of the U.S. population, currently reside in MUH (King et al.,
2013). One third of Californians reside in MUH buildings (33%), which accounts for one seventh
of the total population living in MUH in the country (King et al., 2013), and a greater proportion
of MUH residents live below the poverty line and identify as racial or ethnic minorities
compared to the overall U.S. population (Centers for Disease Control and Prevention, 2020).
SHS can infiltrate smoke-free living units and common areas and travel from neighboring
units, balconies, and outdoor areas, drifting inside apartments through air vents, walls, stairwells,
and elevator shafts (Licht et al., 2012; King et al., 2013). Even where complete smoke-free
housing policies exist, they are difficult to enforce because of objections from current residents,
concerns about limiting the potential pool of residents, concern of legal liability, and increased
vacancy and turnover (King et al., 2010; 2013; Wilson et al., 2011). MUH facilities that have
implemented partial smoke-free policies have demonstrated a higher incidence of secondhand
smoke exposure for nonsmoking residents, primarily because of the increase in smoking taking
place within individual units and smoke infiltrating into adjacent nonsmoking units (Wilson et
al., 2014). Studies documenting the problem of SHS exposure in apartments due to migration
from other units have also established that tenants, particularly nonsmokers, are supportive of

35
smoke-free policies. This highlights the necessity of implementing comprehensive smoke-free
policies that encompass all areas of MUH aimed at preventing secondhand smoke exposure
among non-smokers and children living in MUH.
To address the disparity in access to smoke-free policies in MUH, the Department of
Housing and Urban Development (HUD) implemented a smoke-free policy in 2018 that
restricted indoor smoking in public housing (U.S. Department of Housing and Urban
Development, 2014). Some cities in Los Angeles County, such as Culver City and Pasadena
(CCMC § 9.11.215.B; PMC 8.78.085), prohibit smoking in all areas of MUH properties;
however, many cities have not implemented smoke-free policies in privately owned MUH,
creating a gap in access to smoke-free housing and limited implementation of smoke-free
policies in all types of MUH.
Since marijuana is a federally prohibited substance, residents of publicly funded housing
(i.e., Section 8 and other federally funded housing) are prohibited from using or possessing
cannabis (medical or otherwise) on their premises, regardless of any state law legalizing the
drug. Moreover, HUD explicitly states that if applicants for public or Section 8 housing are
“known users of marijuana” their applications must be denied. Because smokers are not a
federally protected class, California landlords have the authority to prohibit the smoking or
vaping of recreational or medically prescribed marijuana in individual units and common areas
of their buildings. California’s Proposition 64 (Judicial Council of CA, 2022) includes provisions
that allow landlords to restrict marijuana smoking on their properties, however, many owners
and managers may not be aware of their regulatory ability to do so, and restricting use could be
difficult to enforce without guidance and instructions from state and local regulatory bodies. In a
recent study among property managers’ practices of tobacco and marijuana smoking policies,

36
some property managers were afraid to be assertive about enforcing non-smoking rules in their
buildings because of the lack of designated smoking areas away from buildings, lack of legal
knowledge surrounding policies and enforcement, and perceptions that marijuana use is not
harmful to one’s health (Rendon et al., 2017). Tenants who live in buildings where there are
other smokers may also be hesitant in confronting their neighbors about transpiring smoke.
In states that have legalized marijuana for both recreational and medicinal use, it is
important to expand regulations to include marijuana use provisions and enforce regulations
pertaining to use in and around the surrounding areas of MUH, like that of tobacco use.
Implementing marijuana-specific provisions in lease agreements may help to mitigate exposure
to SHMS and address the concerns of non-users who may be hesitant to talk to their landlords
about issues with SHMS or take actions to protect themselves against exposure. The legalization
of recreational marijuana smoking and cannabis vaping in some states coupled with new
emerging tobacco products has created new challenges to public health and makes it increasingly
important to shape tobacco prevention and secondhand smoke control efforts to include all forms
of tobacco, nicotine, marijuana, and cannabis use.
The COVID-19 pandemic has greatly impacted communities and wide-ranging measures
were enacted to reduce the spread of the virus, including stay-at-home orders, working from
home, and social distancing. The pandemic, along with precautionary measures to avoid
exposure, have impacted individuals’ health behaviors, including increased use of tobacco,
marijuana, and e-cigarette products. Stressful life events have been shown to be negatively
associated with quitting smoking (Mckee et al., 2003) and greater coping-related marijuana use
(Wills et al., 2006). Research has found that during COVID-19 stay-at-home orders, there was a
notable increase of cigarette consumption among current tobacco users (Gonzalez et al., 2021),

37
higher rates of marijuana initiation and use (Knell et al., 2020; Clendennen et al., 2021), and an
increase in e-cigarette use by youth and young adults (Kalkhoran, Levy, & Rigotti, 2022).
Alternatively, some smokers might have decreased their tobacco or marijuana use because of
higher risk of negative outcomes from COVID-19. Thus, since the COVID-19 pandemic could
have potentially impacted the use of nicotine and tobacco products in the home, studies are
needed to understand changes in secondhand tobacco and marijuana smoke exposure during the
pandemic in multi-unit housing. The increased popularity and use of novel tobacco and cannabis
e-cigarette products, combined with stay-at-home orders for many individuals which may have
further increased daily tobacco and marijuana use, warrants further examination of the attitudes,
barriers, and facilitators of support for smoke-free housing by tenants living in privately owned
MUH that may not have smoke-free policies. Few studies since the COVID-19 pandemic have
analyzed the potential facilitators of support of these policies by MUH tenants and the potential
barriers of implementation encompassing multiple factors. Due to the increase of individuals
spending more time at home, more attention to positive health behaviors, and the relationship
between stay-at-home orders and substance use, there may be potential for increased support of
these policies or additional barriers to implementation to consider.
The Social-Ecological Model and Support for Smoke-Free Housing
The Social-Ecological Model of Health (SEM of Health; Glanz et al., 2008) considers the
associations between individual, interpersonal, community, and societal level factors that
influence health behaviors and outcomes. At the individual level, support for smoke-free policies
can be influenced by personal beliefs, attitudes, and knowledge regarding risks associated with
SHS, SHMS, and e-cigarette aerosol exposure, which can shape an individual’s support, or
produce barriers for support, towards smoke-free policies. At the interpersonal level, social

38
norms and interactions with family, friends, and other tenants play a crucial role in shaping
personal behaviors, such as smoking, which in turn may shape attitudes towards policy support.
These relationships may also make it difficult to comply with smoke-free policies if one lives
with individuals that smoke. Organization level (building smoke-free policies) and community
level factors (city or county-level enforcement and policies) may help in promoting positive
attitudes towards smoke-free environments among tenants and help garner support for smokefree public policies. Alternatively, policies at these levels may also make it difficult to enforce
these smoke-free policies and act as barriers to implementation.
The social–ecological perspective facilitates the understanding of the relationships
between various social determinants of health and how they are relevant for addressing both
personal and societal factors influencing support for public health policies. These findings have
the potential to be important in identifying the distinct barriers and facilitators of support within
each level of the SEM among different ethnic groups living in MUH. The findings from this
study can offer valuable evidence to inform interventions and educational campaigns tailored to
at-risk individuals and communities, which may produce positive outcomes by promoting
support for smoke-free housing initiatives.
The Current Study
In this exploratory qualitative study, we explored attitudes toward policies restricting the
use of all tobacco and cannabis products and evaluate the differences regarding barriers and
facilitators for supporting smoke-free housing policies during the COVID-19 pandemic. We used
the SEM model to describe the individual, interpersonal, organizational, community-level factors
that may act as barriers or facilitators of support for smoke-free housing policies.
The research questions that were used to guide Study 2 are as follows:

39
Research question 1: What are the individual, interpersonal, organizational, community-level
factors that facilitate support for smoke-free housing policies?
Research question 2: What factors act as barriers for implementing smoke-free policies in lowincome MUH?
Methods
Focus Group Sample and Recruitment
The MUH focus group recruitment strategy involved selecting participants who had
agreed to participate in the larger study of 272 resident door-to-door interviews. To be eligible to
participate in the focus groups, participants were required to meet the following eligibility
criteria; were 18 years of age or older, were residents of an apartment complex located in one of
the three targeted communities within Los Angeles County, California, had completed the initial
door-to-door interview survey and had access to a phone line. Of the 62 residents who were
contacted to participate, 54 (84%) provided consent and completed a focus group interview using
Zoom video teleconferencing.
Data Collection
A team of two bilingual research team members conducted interviews in English and
Spanish. Before beginning the interview, moderators explained the purpose of the study and
obtained verbal consent from all participants. A total of ten focus groups with 3 to 8 participants
each were conducted between September and October 2020 in English (N=8) and Spanish (N=2)
with African American, Hispanic/Latino, or Non-Hispanic White MUH tenants. Focus group
recordings ranged from 30-50 minutes in length and participants received $75 for their
participation in the focus group interview. Two data collection instruments were used, a prefocus group questionnaire and a focus group guide. Focus group transcripts served as the primary

40
source of data while the questionnaire asked participants general demographic questions such as
gender, highest education completed, the primary language spoken at home, the number of years
they have lived in their current apartment complex, and past 30-day cigarette, e-cigarette, and
marijuana use, and which products they would rank as most harmful and second most harmful if
they or their family were exposed to secondhand smoke or aerosol from that product (cigarette,
e-cigarette, or marijuana SHS).
The research team developed a focus group guide with input from community advisory
board members and questions addressed topics related to the different levels of the SocialEcological Model. The focus group guide included questions about knowledge, attitudes, beliefs
about tobacco and marijuana/cannabis use, perceptions about SHS, personal and family exposure
to SHS, personal home smoke-free rules, perceptions of the extent of the problem in multi-unit
housing, perceived social norms about smoking inside apartment units, in common areas, and
outside, conversations with neighbors and landlords about smoking, preferences for policies,
barriers to avoiding exposure to secondhand marijuana smoke (SHMS), barriers to speaking with
managers and landlords about smoking, intentions to avoid smoke and/or talk with neighbors or
landlords, and tips for effective conversations with neighbors and landlords about reducing all
forms of secondhand smoke exposure. The questions in the focus group guide were developed to
examine more in-depth issues raised in the door-to-door interviews and allow for more detailed
tenant input regarding their feelings and opinions about secondhand smoke exposure and smokefree policies.
Data Analysis

41
All interviews were audio-recorded, uploaded to a password-protected computer, and
transcribed verbatim by a contracted professional transcription service. Transcripts of focus
groups conducted in Spanish were transcribed and later translated into English. All focus group
transcripts were deidentified and analyzed using Atlas.ti software. A thematic coding approach
was used as this type of analysis provides a highly flexible approach that can be modified for the
needs of the study, providing a detailed account of data (Braun & Clarke, 2006; King, 2004).
Thematic analysis is a useful method for examining the perspectives of different research
participants, highlighting similarities and differences, and generating unanticipated insights. Data
were organized into conceptual categories or themes (e.g., individual, interpersonal, community
level) according to the social-ecological model. Two independent coders (one doctoral level
(E.G.) and one undergraduate student (G.P.)) read, reread, and coded a portion of the interview
transcripts independently (i.e., data triangulation) to ensure accuracy. The coded transcripts were
then compared and discussed among the two coders again and inter-coder reliability was
established (Cohen’s Kappa=0.87). Brief quotations illustrate the prominent and recurring
themes. Additionally, descriptive statistics including participants’ demographics (race/ethnicity,
gender, education) and other characteristics (e.g., primary language spoken at home, number of
years living in current MUH, harm perceptions and past-30-day use of tobacco, e-cigarette, and
marijuana products) were conducted to characterize the qualitative study sample using Stata
software (version 17.1; Stata Corp, College Station, Texas, USA).
Results
Participant Demographics and Characteristics

42
Participant demographic characteristics are presented in Table 4. A total of ten focus
groups were conducted with 54 tenants. The sample included 38 (70%) females, 14 (26%)
residents identified as AA, 29 (53%) that identified as H/L, and 11 (21%) that identified as
NHW. Among participants, the primary language spoken at home was English (61%), most had
lived in their apartment complexes for 13 or more years (29.6%) and were college educated
(37%).
Table 4: Focus Group Participant Demographics (N = 54)
N (%)
Gender
Male 16 (30%)
Female 38 (70%)
Primary Language Spoken at Home
English 33 (61%)
Spanish 21 (39%)
Ethnicity
African American/Black 14 (26%)
Hispanic/Latino 29 (53%)
Non-Hispanic White 11 (21%)
Highest Level of Education Completed
Less than High School 9 (16%)
High School 12 (22%)
Some College 13 (24%)
College Graduate 20 (37%)
Years living in Apartment Complex
0-2 years 8 (14.8%)
3-5 years 9 (16.7%)
6-8 years 13 (24.1%)
9-12 years 8 (14.8%)
13+ years 16 (29.6%)
When asked to rank the most and second most harmful type of SHS to be exposed to,
thirty-eight (78.4%) participants selected SHS from cigarettes as most harmful, and 23 (42.6%)

43
selected SHS from electronic cigarettes as second-most harmful. A majority of the sample were
current non-smokers, however, three participants (5%) reported using cigarettes in the past 30-
days, three (5%) currently used electronic cigarettes, and 9 (16%) reported using marijuana.
Harm perceptions of secondhand smoke exposure of the focus group participants are presented in
Table 5.
Table 5: Participant Substance Use and Harm Perceptions (N = 54)
Self-Reported Use
Past 30-day Cigarette Use 3 (5%)
Past 30-day E-cigarette Use 3 (5%)
Past 30-day Marijuana Use 9 (16%)
Harm Perceptions
Which of these products below would you rank as the MOST harmful, if you or
your family were exposed to SHS?
Cigarettes 38 (70.4%)
Electronic Cigarettes 10 (18.5%)
Marijuana 6 (11.1%)
Which of these products below would you rank as the 2nd MOST harmful, if you
or your family were exposed to SHS?
Cigarettes 14 (25.9%)
Electronic Cigarettes 23 (42.6%)
Marijuana 17 (31.5%)
Qualitative Themes
Analyses of the focus group transcripts identified several themes from participants’
testimony that were identified as potential barriers and motivators of supporting and
implementing smoke-free housing policies in their buildings using the dimensions from the SEM
model. Table 6 displays the themes, subthemes identified, definitions, and notable quotations.

44
Table 6: MUH Focus Group Themes and Notable Tenant Quotes
Themes Subthemes Code Definition Examples

Individual
Knowledge,
attitudes, and
preferences of
smoke-free
policies
Building Policy
preference -
smoking and
non-smoking
units
Tenants report
policy preferences
for smoking and
non-smoking units
In the apartment it should be the same
thing too. It should be when you’re in
your apartment it doesn't matter [if you
smoke].
(African American, Male)
Building Policy
preference - no
smoking in
units/designated
smoking areas
Tenants report
supporting policies
with no smoking in
units, but okay
with designated
smoking area
I will say 100% on no smoking inside
or outside the apartment. But I would
like for there to be clear designated
areas where people could smoke
because of course they're not going to
be able to control everybody.
Everybody has their own ways to relax
or whatever it may be, but I’d like to
define what designated areas are there
are, and then to have benches where
people could ash their cigarettes and
then dispose them in a safe manner.
(Hispanic, Male)
Building Policy
preference -
supports 100%
smoke-free
housing policies
Tenants support
100%
comprehensive
smoke-free policies
(no smoking in
building)
I prefer a smoke free building an area
in the back or the front or the sidewalk
or something that they could smoke. I
wouldn't care if they smoke like that,
but in the building, no. But if a person
smokes a lot of cigarettes and
marijuana and you smell it like in the
hallway and stuff, there should be laws
for that.
(African American, Female)
Secondhand
Smoke
Exposure and
Experiences
SHS Frequency Tenants report
frequency of
exposure to SHS
(e.g., every day,
sometimes, never)
Tobacco smoke comes here every day
because a lot of people in the building
smoke.
(Hispanic, Female)

45
SHS Type -
cigarettes,
marijuana, or ecigarettes
Tenants report
SHS from
cigarettes, ecigarettes, and
marijuana
I usually smell the cigarettes from the
unit next door. (African American,
Female)
Increasing
Enforcement
and
Compliance
Tenant
Empowerment
Empowering
tenants to report
problems with
secondhand smoke
exposure and
policy compliance
and encouraging
compliance with
smoke-free policies
I would say maybe get a little creative,
like some type of incentive where, if you
don't smoke in the month, you’ll enter
our raffle or something.
(Non-Hispanic White, Male)
Enforcement
Preferences
Tenants share their
preferences for
enforcement in
their buildings -
what happens
when someone
breaks a smokefree policy (e.g.,
eviction, fines,
etc.)
I'd say maybe a verbal warning,
warning first and then a written one
and then if it continues after that, a
fine.
(Hispanic, Male)

Interpersonal
Secondhand
Smoke
Exposure from
other tenants
SHS-from
neighbor
Tenants describe
experiences with
secondhand smoke
exposure from
other tenants and
neighboring units
The lady next door must smoke like at
least three packs a day, but she starts
early morning and doesn't end till after
midnight, and if I have my door open.
It's horrible. Even if I have it closed the
wall on that side. I can smell it.
(African American, Female)
Compliance Compliance
Tenants living in
buildings with
smoke-free policies
report that their
neighbors and
other tenants break
the smoke-free
rules (barrier to
implementation)
I would say, very often. So, they say
you're not supposed smoke like within
your house or not even like outside
your house, But I would say that
happens very often.
(Hispanic, Female)

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Organizational Tenant and
Smokers'
Rights
Smokers’ Rights
Tenants describe
barrier to
implementing
policy as impeding
on smokers' rights
You can’t really do too much - they
going to put a lawsuit and say, ‘well I
live here, I paid my rent, you can’t tell
me what to do’. Then people start
having an attitude and then it’d be like
where’d they get this money from that if
they win [in court] or something like
that and they proved their point. If you
get the police involved, they got too
many things, they going to tell you ‘It’s
not our problem.’ If you get the
landlord involved, they going to say it
signed in their lease. So, it's kind of like
kind of hard because all they can do is
put a sign up that says, ‘no smoking in
the area’. But giving a warning and
stuff like that, I don't know because you
know people nowadays want to sue,
because they go to their space, they
have a right to do everything in their
apartment.
(African American, Female)
Tenants’ Rights
Tenants describe
barrier to
implementing
policy as impeding
on tenants' rights
Besides the medical issue, I’ve lived in
my unit for 12 years. I would be very
upset if they made this into a no
smoking area, a no smoking unit after
12 years. I'm not so sure about the
legalities if they get even really do that.
But I would be very upset if they came
in after 12 years and said you can’t
smoke in your unit anymore, you can
only smoke in the designated area.
(African American, Female)
Addiction
Tenants describe
tobacco or
marijuana use as an
addiction that
needs to be
addressed before
In my case with the city of West
Hollywood there so trying to be so
careful with addiction, then they should
take it the next step and say, okay, we'll
help you with a smoking, you must
enroll in a smoking cessation program,
and we'll let you stay in the apartment.

47
Addiction and
Cessation
Resources
smoke-free policies
can be
implemented
That's number one. Number two. If you
don't smoke for a month will give you a
cut your rent by X amount. If they want
to use that approach money always
works. It's good incentive.”
(Non-Hispanic White, Male)
Cessation
Support and
Resources
Tenants mention
the need for
cessation resources
for residents
I think that, in addition to the incentives
and the rules, we need to start thinking
beyond the smoking cessation program.
I think that people that smoke, I don't
know the percentage, but I would
imagine a lot of these people would
benefit a lot from maybe like counseling
program too because smoking is
related to stress, is related to emotional
and other issues that might be
something that if the person confront
those issues, they might stop smoking.
(Hispanic, Male)
Barriers to
Compliance
and
Enforcement
Enforcement -
Communication
about policies
Tenants describe
their feelings and
opinions regarding
enforcement of
smoke-free policies
in buildings;
tenants also
provide examples
of who can enforce
these rules and
issues of lack of
enforcement in
buildings that have
smoke-free policies
(e.g., fines for
breaking rules;
mentions manager
smokes/doesn't do
anything when
someone breaks
the rules)
I feel like a smoke-free apartment
complex, if it was its unrealistic
because who would do it and how could
you invade my privacy you couldn’t
know that I was smoking unless you
were in my home often at different
hours. So, there's nobody who could
really do it without invading
somebody’s privacy and in any law,
you wouldn't be able to do that. I feel
like the best person was the health
department. Maybe a yearly inspection
and then they, a device was put in there
to show the proof because any other
way it’s my word against my landlords.
It wouldn’t be based on clear evidence
and that wouldn’t hold in any, I can go
to court for that. How many times, well
my landlord would be able to say I
came here three times, and I smelled
the smoke or however they’d say it, I
can’t say realistic how my landlord
would do it. thirdhand smoke that will
be the only way that somebody would to
me, realistically be able to get evicted.
(African American, Female)

48
Increasing
Compliance in
MUH
Tenants describe
ways to increase
compliance with
current or potential
future smoke-free
building policies in
MUH (e.g., signs,
lease amendments)
Just make sure that they're aware of it
when they sign the lease and maybe
having a separate section so that they
have a copy of what they're not
supposed to do and that way they can
have it to refer to later.
(Hispanic, Female)
Community
Structural and
Environmental
Barriers
Structural and
Environmental
Barriers
Tenants discuss
any environmental
or structural
barriers that
increase exposure
to secondhand
smoke; barriers of
implementing a
smoke-free policy
in building
I don't think that we have even thought
of policies in our case, the problem is
not in with my landlord or the tenants,
it’s the complex next door because it's
the proximity to your complex, they
don't allow smoking. However, the
apartment window goes to the street
and because of the homelessness
problem, there are people sleeping
outside the complex smoking. We
complained to the management already
but because these people obviously
don’t live there, they can’t do anything.
So, the management said just close
your window.
(Hispanic, Male)
Information
and
Community
Engagement
Receiving
information
Tenants describe
how they would
like to receive
information about
smoke-free policies
I probably wouldn't see that I would, to
be quite honest, what I would need is a
single sheet of paper. Like a like an
enlarged postcard with those bright
colors and had like a punchy statement
saying like you can't smoke in your
apartment any longer per state law
because otherwise I'm just not going to
enter my periphery.
(Non-Hispanic White, Male)
Covid-19 Covid-19 General statement
made regarding
Covid-19 and
building policies
and procedures
during stay-athome orders
I don't think our building has any rules
at all, but during this COVID, very lax
with all the management that they are
giving. So, I don't think they would
have- since there are no rules written in
the lease, they have not addressed it at
all, and I know a number of smokers in
the building.
(African American, Female)

49
Changes in SHS
during Covid-19
- increase,
decrease, or
stayed the same
Changes (increase,
decrease, stayed
the same) in
exposure to
secondhand smoke
since the start of
the Covid-19
pandemic
Due this whole thing with the
Coronavirus, I have the opportunity to
work from home some days of the week.
I've noticed that when I go outside and
take out some trash, I noticed that,
especially during the middle of the day,
the marijuana smoke from the
neighbors is there. Before COVID, you
smell in the morning and you smell at
night, but it's also in the day as well.
You can see the smoke.
(African American, Female)

50
Individual Level
Secondhand Smoke Exposure, Experiences, and Attitudes Toward Smoke-Free Policies
Participants in the focus groups discussed their opinions and attitudes towards the use of
cigarettes, marijuana, and e-cigarettes in their buildings. Tenants had varying opinions on the
harmfulness of exposure to the secondhand smoke from these products, but a majority (N= 38) of
participants believe SHS from cigarettes are the most harmful type to be exposed to. Almost all
participants reported that they had experienced some form of SHS exposure while living in their
buildings, with the majority reporting smoke from cigarettes as being the biggest nuisance. In
terms of marijuana use, tenants had more positive feelings towards the use of marijuana
compared to tobacco, as it can be used for stress relief or medicinal reasons. Tenants noted that
they would be okay with a neighbor using marijuana in their unit if it was used for pain or
medical treatment. Almost all participants believed that medical marijuana should be exempt
from smoke-free policies and that they would just “deal with the inconvenience” if someone was
using marijuana for medical reasons:
“If I knew that it was helping relieve their suffering, I'm not going to be the person to get
in the way of that. I can handle being a little inconvenienced, there's a level of it. So, there's no
saying if they could if they would be smoking all day, every day, or if it would be saturating, if it
was affecting my health, and I would probably mention it, or maybe find an alternative or a
middle ground. But I probably wouldn't report them, or I wouldn't want them to be doing what
they can to mitigate their pain or ailments or anything like that.” (Non-Hispanic White, Male)
When asked about the source of secondhand smoke, most tenants reported that they were
exposed to secondhand smoke from neighbors in adjoining units, from tenants smoking in the
parking lots, laundry rooms, smoke drifting from units and balconies into windows and hallways,
around building common areas, or from smoke drifting from outside of their buildings from the
street or businesses nearby. When tenants experience secondhand smoke, methods for addressing
the issue varied. Many tenants just dealt with the inconvenience because they were

51
uncomfortable addressing the issue with other tenants, some addressed SHS with their building
managers by writing letters, emails, and scheduling meetings with the smoking tenant and
manager. Two tenants went as far as seeing lawyers to address the issue as a health hazard but
did not have success with enforcing smokefree policies in their buildings.
COVID-19
The COVID-19 pandemic led to various changes in tobacco and marijuana consumption
among respondents and other tenants living in and around their buildings, potentially leading to
increased secondhand tobacco and marijuana smoke exposure in the home and to others. Tenants
discussed changes in SHS exposure during the COVID-19 pandemic and a majority reported an
increase in SHS during stay-at-home orders. Non-smokers and previous smokers were more
bothered by SHS. Those who were exposed to SHS before COVID-19 continued to be exposed
to SHS after as well. Most noted that people are smoking more cigarettes and marijuana to “cope
with the pandemic”, because of pandemic-related changes, or out of boredom. A previous
cigarette and marijuana smoker recounted his experience seeing individuals smoking and how he
addressed the issue:
“Yeah of course there's going to be an increase in secondhand smoke primarily because more
people are staying at home now. You’re staying home longer hours and that provides a nervous
tension. People are not only eating more but they are smoking more. I was a smoker; I would
always enjoy a cigarette after a meal. Now because of this pandemic people are staying home
more so they're eating more out of boredom and they're smoking more primarily out of boredom,
even on my block when I’m going to my car and leaving, I see people standing outside smoking. I
can see the smoke drifting into the units that they are standing in front of - I can visibly see that.
So, if it’s bothering me directly like that, I think that if we can, let’s talk about it. We talk to the
person smoking and say, “hey man that smoke is really bothering me, could you not smoke so
close to my window and not smoke close to my door” I think they will respect your wishes if you
just talk to them and ask them, but that’s my opinion.” (African American, Male)
Another tenant who started working from home during the pandemic noted:
“I think I have experienced an increase. My first thought was, maybe I'm just
experiencing it more because I'm always home working from home and people were already

52
home doing that [smoking], but I feel like it just generally has. People are home and they're
probably stressed out, but I feel like I've experienced it, or it's increased since we’ve been on
lockdown.” (African American, Female)
Individuals that did not experience SHS before the pandemic mostly did not experience
an increase during either:
“Nothing's changed for me because this building, I mean, it's all dedicated for people living with
disabilities, so we've already been here, even before COVID mostly.” (Hispanic, Male)
Notably, one tenant reported that they see less smoking around their building because of
COVID-19 mask mandates, however, a few individuals did report tenants from their building
and surrounding buildings had started smoking on the sidewalks during the pandemic to “get out
of the house” or as a method of stress relief from being inside all day.
Policy Preferences
Tenants in general expressed a desire for implementation of stricter tobacco and
marijuana policies in their buildings. While there was no consensus among participants regarding
the implementation of comprehensive 100% smoke-free policies that would limit tobacco,
marijuana, and e-cigarette smoking, all residents believed that there should be some type of
restriction on cigarette smoking in individual units, especially if it was exposing other tenants to
harmful smoke. Several participants reported that there should be designated smoking areas in
their buildings or should only be allowed off the premises. However, since enforcing the use of
designated smoking areas may prove difficult for property managers who may not live on the
property or who are responsible for managing larger buildings, many expressed that the best way
to limit secondhand smoke exposure to tenants was to enforce complete smoking bans.
” It’s my word against theirs [individuals smoking], so all the more reason to have a
100% policy, but then it becomes too difficult for a manager to do all the management work and
police all the tenants and I don’t know if I’d want that job.” (African American, Female)

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When asked what kind of penalties those who violated smokefree policies should face, almost all
tenants said that they would like to see some kind of graduated system, where individuals would
receive multiple warnings or face fines for each reported offence. Most tenants were reluctant to
impose evictions on tenants who violated smoking policies, citing that eviction may be too harsh
but fines would help increase compliance since many tenants were sensitive to costs.
” I would like to see more concrete policies with more concrete penalties. Now I’d like to
see stiffer policies such as, no smoking within 50 feet of the building because I'd see a lot of
people hanging out in front of the garage or out-front smoking. To me, even though they're
outside. Still, I still consider that a nuisance. I would like to see that eliminated as well. So, I'd
like to see a more comprehensive approach to dealing with the problem and you know a better
enforcement structure because as I said with people on the balconies smoking. It's kind of a free
reign system for them. I would like to see maybe a way to empower other tenants to report these
problems” (Non-Hispanic White, Male).
Resident opinions and preferences regarding compliance and enforcement
We asked tenants about their preferences and opinions about enforcement of their
building smoke-free policies and compliance practices. Overall, tenants supported enforcement
of smoke-free policies in their buildings, with non-smoking tenants highlighting the need for
action from management to address secondhand smoke and protect the health and well-being of
children and older adults that lived in MUH. Many tenants reported that even though their
buildings had some form of smoking restriction, whether smoking was prohibited in individual
units, common areas, or anywhere on the premises, there was lack of enforcement from
management regarding smoking policies. When asked about enforcement, most tenants echoed
that enforcement should be up to the buildings homeowners’ associations (HOA), managers, and
landlords; however, enforcement may be difficult because managers are not able to enforce
policies around the clock and without receiving written complaints from other tenants.
” Right now, you got a sign in the area “no smoking”, I never seen anybody got caught
because the building manager is doing her thing. At night can't watch everybody 24 hours 7 days
a week, you can't watch. It's really kind of hard. I go out at nighttime to take my trash out, I've

54
seen cigarette butts, you know, here and there, but what could I do. I don't know who left it
because I didn’t see the person.”
One tenant noted that enforcement may be difficult because accusing someone of
smoking may become invasive and lead to legal consequences for the landlord while impeding
on one’s rights and clear evidence would be needed to prove someone was smoking.
“I feel like a smoke-free apartment complex, if it was its unrealistic because who would
do it and how could you invade my privacy you couldn’t know that I was smoking unless you
were in my home often at different hours. So, there's nobody who could really do it without
invading somebody’s privacy and in any law, you wouldn't be able to do that…It wouldn’t be
based on clear evidence and that wouldn’t hold in any court. I can go to court for that. How
many times, well my landlord would be able to say I came here three times, and I smelled the
smoke or however they’d say it, I can’t say realistic how my landlord would do it.” (African
American, Female)
When asked about what types of methods of enforcement would be helpful to switch to a
completely smoke-free environment, tenants agreed that no-smoking signs in their buildings,
warnings and fines for breaking smoke-free rules, evictions, and graduated enforcement policies
that included multiple warnings leading up to eviction would be the most effective method to
increase compliance and help to enforce smoke-free policies.
Organizational Factors
Tenant and Smokers’ Rights
Despite non-smoking residents experiencing daily secondhand smoke in their units, many
expressed ambivalence about reporting their neighbors for smoking to management or
addressing the issue with them directly. Tenant and smokers’ rights was a theme that commonly
emerged when tenants were asked if there were any concerns regarding implementing and
enforcing comprehensive smoke-free policies in MUH. Tenants expressed distrust towards their
landlords in enforcing the policies properly:

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“I think that additional rules around stuff is not always a good thing. If someone mentioned the
Salem Witch trials -not that it would turn into that necessarily, but I think at least in Los Angeles,
apartment building managers can be so sleazy that giving them any additional ammo to evict
someone or raise rent or do anything is not necessarily great idea.” (Non-Hispanic White, Male)
Even though tenants preferred living in 100% smoke-free buildings, many expressed that they
wouldn’t take action against reporting their neighbors or confronting those who violated the rules
because of fear of retaliation, fear of getting a tenant evicted, and impeding on their rights as
tenants.
“I don't wish to tell on nobody if there's a law that for a non-smoking building, I'm quiet, I am
not going to say nothing because I don't want nobody come to my door and knock on my door
and threaten me and stuff like that. I’d rather just leave it alone.” (African American, Female)
When asked how a policy should be enforced, many tenants cited that the public health
department, management companies and landlords, or third-party government organizations
should oversee compliance, but many options to ensure compliance would be impeding on tenant
rights.
“Maybe the health department...maybe a yearly inspection and then they were, a device was put
in there to show the proof because any other way it’s my word against my landlords...” (African
American, Female)
Addiction and Cessation Resources
Participants perceived substance use and addiction to be a direct facilitator of noncompliance and a barrier of adoption of smoke-free policies in buildings that had many smoking
residents. One of the most common themes in focus groups regarding enforcement and
compliance of policies mentioned the barriers resulting from nicotine addiction. Residents
expressed empathy for those who had been smoking in their homes for decades and that some
tenants’ addiction and limited access to cessation resources ahead of a smoke-free policy would
be a barrier to compliance with smokefree policies. Among some residents, marijuana was not
considered as addictive as nicotine and many cited the widespread availability of alternative

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forms of marijuana to aid in the cessation process, such as edible forms of marijuana. For
nicotine cessation, one tenant mentioned she had used e-cigarettes to cut down on her cigarette
use because her smoke was bothering other residents and others mentioned the need for mental
health counseling services, information for tenants to attend smoking cessation programs and
numbers to quit smoking hotlines, and offering coupons for nicotine patches for residents living
in MUH who were trying to comply with smoke-free policies.
“I think that, in addition to the incentives and the rules, we need to start thinking beyond the
smoking cessation program. I think that people that smoke, I don't know the percentage, but I
would imagine a lot of these people would benefit a lot from maybe like counseling program too
because smoking is related to stress, is related to emotional and other issues that might be
something that if the person confront those issues, they might stop smoking.” (Male, Hispanic)
Residents who smoked would be willing to comply with newly implemented smoke-free
policies but expressed that they would have trouble doing so without support from management,
adequate notice to start the cessation process, and that they had limited access to cessation
resources. A resident that smoked cigarettes and marijuana noted:
“I don't think that it's fair to come into a building and impose it to be a non-smoking building
when you already live there, because that's the same thing with health and health insurance.
Now you have a preexisting condition, and you want me to get well within a certain amount of
time or I become homeless. That's a vicious circle that I don't think that's the way it should work,
nor I just don't think that's fair at all.” (African American, Male)
Alternatively, a nonsmoking resident who had previously complained about SHS drifting into
their apartment from neighbors and the surrounding area outside of the building had previously
complained to their city council about the issue was not optimistic a smoke-free policy would be
enforced in and around her building.
“I got ahold of pro bono lawyer who wrote a letter to the apartment management, which is run
by the City of West Hollywood, it's a Section 8 apartment. West Hollywood takes the angle that
these people have an addiction and it's a disease and therefore, we can't do anything about it.
Because it's an addiction and they have to seek addiction treatment, and on and on and on. They
have a big song and dance. So that's what makes it so difficult to do anything because they're
protected.” (Non-Hispanic White, Male)

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Resident Empowerment and Increasing Compliance
Residents described their knowledge about the smokefree policies in their buildings but
highlighted the lack of communication from management about the rules and the measures taken
with issues with compliance.
“The owner of the management company should and needs to provide adequate information
regarding the policy from which they are turning into. For instance, if the building was not
smoke-free when you had been there for five years and the owner now states that because
smoking is killing so many people, and that he wants to make his or her unit now a smoke-free
unit, they have to stipulate, they have to issue memos to the current residents and give them six
months to a year to be to decide whether they want to stay there and move out.” (Hispanic, Male)
Tenants were asked how they would like to receive information about smoke-free
policies from management if a smoke-free policy was to be implemented in their buildings and
many tenants mentioned the need for direct efforts from management towards effective
communication with tenants about policies and expectations. Many noted that clear and direct
communication from landlords and management and information and signage regarding
designated smoking areas would increase compliance among tenants.
“That should be in writing before they even sign a lease so they would be aware of it. Otherwise,
if you just tell them not to smoke, they look at you kind of funny and say, ‘Hey, I got to smoke’,
and they'll do it regardless, you know they’ll do it.” (African American, Male)
Tenants also highlighted the need for clear acknowledgment of these policies from all tenants
before signing lease agreements, but that it would be harder to do for those already living in
buildings that do not have any smoke-free policies.
“Just make sure that they're aware of it when they sign the lease and maybe having a separate
section so that they have a copy of what, what they're not supposed to do and that way they can.
You know, have it to refer to later.” (Hispanic, Female)
Tenants believed that management and landlords should take measures to increase
compliance and empower tenants to follow smoke-free policies in their units and buildings.

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Tenants highlighted the need for incentives when implementing new policies that included
discounts off their rent, offering carpet cleaning, or gift cards. After policy implementation, to
ensure compliance among residents, many tenants said that continued education about the
harmful effects of SHS from tobacco and marijuana would be needed in the form of monthly
newsletters, educational videos, as well as counseling and mental health services for smoking
residents is needed to address root causes of addiction. One tenant who had previously tried to
complain to management about compliance-related issues noted:
“In my case with the City of West Hollywood they’re trying to be so careful with addiction, then
they should take it the next step and say, okay, we'll help you with a smoking, you must enroll in
a smoking cessation program, and we'll let you stay in the apartment. That's number one.
Number two, if you don't smoke for a month will give you a cut your rent by X amount. If they
want to use that approach money always works. It's a good incentive.” (Non-Hispanic White,
Male)
Increasing Policy Compliance and Enforcement
The lack of enforcement from management was a theme commonly cited in focus group
data. Tenants expressed their lack of confidence that building management adequately enforced
building smoke-free policies. Tenants highlighted the need for management to increase
monitoring of tenants that violate smokefree policies in buildings and clearly define smoking
areas and restrictions. Many of the tenants who lived in buildings with comprehensive smoking
policies mentioned that management will see violations but do not enforce their policies due to
the manager wanting to avoid conflict, or because the manager also smokes on the premises.
Tenants expressed their concerns over violations of the smokefree policies they had in place in
their buildings when others would smoke, but many tenants noted that when they did express
their concerns, there was lack of enforcement from building managers who did not address their
complaints, which led them to just dealing with the secondhand smoke in their buildings.

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Community Factors
Environmental and Structural Barriers
For many residents, there were notable environmental and structural barriers to attaining
smoke-free housing in their buildings. Two common themes found in the data were that the
building was too small to have designated smoking areas for residents, or if they did have
designated smoking areas, they were not clearly defined and did not have clear signage.
” I would just say, for me, the two biggest issues are communication… What is the policy. How is
it spelled out and communicated and then, what policies in place that needs to be enforced?
That's obviously not happening.” (Non-Hispanic White, Male)
Some tenants that lived in buildings that had comprehensive smoke-free policies noted that all
the secondhand smoke they experienced weren’t from neighbors, but from individuals on the
streets and walking on sidewalks that faced their windows. One tenant noted:
“I don't think that we have even thought of policies in our case, the problem is not in with my
landlord or the tenants, it’s the complex next door because it's the proximity to your complex,
they don't allow smoking. However, the apartment window goes to the street and because of the
homelessness problem, there are people sleeping outside the complex smoking. We complained
to the management already but because these people obviously don’t live there, they can’t do
anything. So, the management said just close your window.” (Hispanic, Male)
Another tenant noted that because her building was near a school and was not gated or secured,
they experienced secondhand smoke from individuals smoking in their laundry room.
“For me, it's my laundry room unit. Our lobby doors are not securely locked, so a lot of the
teenagers from the local school by my house, to our lobby door, and they will be in there,
smoking. So, then we're coming in and going to my mailbox, the laundry room is there so I can
smell it.” (African American, Female)
Tenants also noted that because they lived in a densely populated urban area, they experienced
secondhand smoke from other buildings and individuals smoking in their balconies, which would
drift through their parking lots and into their windows. A different tenant noted that along with
having neighbors who did not comply with the smokefree policy, they also experience

60
secondhand smoke from businesses nearby because of the layout of the building and the
proximity to a gas station.
Information and Community Engagement
Receiving additional information and education about smokefree policies and the health
effects of secondhand smoke was viewed favorably among all participants. Tenants highlighted
that if smokefree policies were to become implemented in their buildings, these should be clearly
defined in their lease agreements, signs should be posted restricting smoking in areas where it is
prohibited, and that property owners should have meetings with residents throughout the process
and routinely send tangible materials to their homes. These include educational pamphlets and
videos about smoking and SHS, clearly defined information sheets about where smoking will be
prohibited in buildings.
Discussion
This study explored the multiple dimensions of the social-ecological factors that may act
as enforcers for resident compliance and supporting policies and act as barriers for implementing
smoke-free policies in MUH. Although tenants included individuals who smoked cigarettes and
marijuana products and had differing views on the harmfulness of the use of these products, there
was largely support for implementing comprehensive smoke-free policies in MUH among
smokers and non-smokers. Tenants highlighted the need for clear rules and policies to be written
into leases and acknowledged by residents, and effective communication by building
management. Receiving clear and tangible information, like flyers at their doors, billboards near
their buildings, and having meetings discussing potential smoke-free policies would be a start to
introducing tenants to potential changes in policies. Asking tenants to read and sign new lease
agreements clearly highlighting smoke-free stipulations (e.g., no smoking in units or in common

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areas), providing copies to tenants, and posting no-smoking signs in building hallways and
common areas may increase compliance to new smoke-free policies in MUH.
This qualitative analysis revealed that there are many barriers for low-income MUH
tenants to overcome to increase compliance and increase support for comprehensive smoke-free
housing policies. Tenants should be made aware of any smokefree policies before moving into
buildings with policies and should be given educational materials that highlight the importance
of smoke-free homes and the potential harms caused by secondhand smoke. Many tenants who
smoked cited tenant and smokers’ rights, in that it may be illegal if they have been living in their
apartment units for decades and then suddenly are asked to stop smoking. Non-smokers also
cited that we live in a litigious society, and impeding on a person’s right to do what they want in
their home may lead to legal issues with landlords that do decide to implement smoke-free
policies. Speaking with tenants before deciding to implement a policy may be received better by
smoking residents instead of implementing policies without tenants’ feedback and concerns.
Nicotine addiction and substance use plays a large role in the lives of individuals living in
low-income housing where there are many tobacco retailers densely located near MUH
buildings. Among smokers and non-smokers, many cited nicotine addiction as a barrier to
implementation and compliance, where even if a resident wanted to comply with a new smokefree policy, it may be difficult without access to cessation and counseling resources. Structural
and environmental barriers also play a role in exposure to secondhand smoke and make it
difficult to enforce smoke-free rules. Where smoke can drift from nearby apartment units that do
not have smoke-free policies, or individuals smoking near buildings on the sidewalk may cause
drifting smoke to enter their buildings. In addition to increasing access to approved cessation

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treatments, interventions need to prioritize both the mental health of residents who smoke and
provide evidence-based smoking cessation interventions before implementation of policies.
In this study, we found that most residents supported smoke-free policies restricting
tobacco and e-cigarette use, but there were mixed attitudes on policies restricting indoor
marijuana use, especially if it was used for medical purposes and it would be morally wrong to
restrict marijuana if it is used for medical reasons. Many residents cited the legal ramifications
against landlords who wished to implement smoke-free policies. Barriers to enforcement may
include the potential for tenants who used tobacco and marijuana products to seek legal counsel
against their landlords for impeding on their rights as tenants to live comfortably in their homes,
which may be a legal “grey area” within tenant laws, where you are not able to go into a
resident’s home without their permission. One participant noted that the only way their landlord
would know they were continuing to smoke is after they moved out and there was the presence
of thirdhand smoke. Adequate monitoring and enforcement of smoke-free policies by
management and housing authorities are needed to ensure effective implementation of smokefree
housing policies. At the community level, our findings highlight the need for better enforcement
of building smoking policies by management. Tenants stated that they would be hesitant to
report or speak to their neighbors about their smoking, indicating that smoke free policies should
be enforced by building managers, landlords, and clear signage and verbiage in lease agreements.
The findings from this study highlight the need to address specific barriers of achieving a
smoke free home environment. Organizations like the American Nonsmokers’ Rights
Foundation (ANRF) have published guidelines for model ordinances for smoke-free buildings
and empower nonsmoking residents to educate themselves on the harms of secondhand smoke
exposure in their buildings and how they may be able to address their complaints with neighbors

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and their landlords. Recommendations from ANRF for handling unwanted tobacco smoke for
tenants are similar to the recommendations from focus group participants and include 1)
encouraging management to create a smokefree environment by adding no-smoking language to
tenants’ leases and around the building, 2) encouraging tenants to read their lease documents to
identify any language that include clauses prohibiting tenants from engaging in activities that
interfere with another tenant’s peace and well-being, including smoking 3) taking an educational
and friendly approach when confronting other tenants about their smoke and trying to resolve the
situation amicably; realizing that most smokers do want to quit but do not realize the negative
impact their smoking has on their nonsmoking neighbors. Finally, finding allies in other tenants,
keeping documentation and doctors’ notes regarding the effects of secondhand smoke exposure
as well as consulting an attorney may be used as a last resort to hold management accountable in
ensuring a health smoke-free environment for residents (American Nonsmokers’ Rights
Foundation, 2024).
Limitations
The qualitative nature of this study poses several limitations, including the lack of data
regarding key participant demographic variables, such as age, lifetime tobacco and marijuana
use, as well as having a small sample of tobacco and marijuana users and more long-term MUH
residents. Furthermore, our sample may not be representative of all residents of MUH in Los
Angeles or California. Participants were recruited if they had agreed to participate in the larger
study of the resident door-to-door interviews about SHS and SHMS exposure, thus our general
sample may not be representative of the feelings and opinions of regular tobacco smokers or
long-term marijuana users and the limited number who were tobacco or marijuana users may not

64
have been willing to participate in the larger tenant study, and smaller focus groups talking about
their use.
Another potential limitation is response bias or self-consciousness, a characteristic of
qualitative research, particularly when evaluating a sensitive topic like current tobacco or
marijuana use. Consequently, the study's sample was skewed towards an older population, those
who had been living in their apartments for more than 5 years and had lower rates of regular or
frequent tobacco or marijuana use (past 30-day use). The small number of tobacco and marijuana
users in the sample limits the generalizability of the study's findings to the larger population,
who may have more positive feelings about use, and may not accurately represent the views and
opinions of all residents residing in MUH.
This is one of the few studies to assess smoke-free housing policies within low-income
MUH during the Covid-19 pandemic. The findings in this qualitative study reveal residents’
experiences with secondhand smoke have likely increased since the start of stay-at-home orders
and many support smoke-free policies restricting tobacco and e-cigarette use, but there were
mixed attitudes on policies restricting indoor marijuana use. The focus groups conducted with
MUH residents revealed that there are many barriers for low-income MUH tenants to overcome
to increase compliance with potential smoke-free housing policies. These findings underscore the
importance of efforts to decrease secondhand smoke exposure from all tobacco, marijuana, and
e-cigarette products in homes and encourage compliance among individuals living in MUH.
These findings highlight the need for educational campaigns and outreach by community and
city organizations against smoking in MUH. Counseling and cessation resources should be made
available to those in low-income communities about the dangers of secondhand smoke and the
importance of expanding comprehensive smoke-free policies to all homes.

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Chapter 4: Study 3
Individual, Interpersonal, and Neighborhood-Level Factors that lead to Exposure to Secondhand
Smoke and Support for Smoke-Free Policies among Multiunit Housing Residents
Introduction
Tobacco use disproportionately impacts minoritized populations (Health Policy Research
Center, 2022) who are disproportionally exposed to secondhand smoke (SHS) in multi-unit
housing (MUH), and experience tobacco-related disease burden (Cornelius et al., 2020; Homa et
al., 2015; Jamal et al., 2016). An estimated 3.2 million adults reported current tobacco use in
California. Although Hispanic or Latino adults had a current tobacco use rate of 9%, Hispanic or
Latino adults made up 34.4% of all adults who reported current use of tobacco. Despite a lower
rate than other ethnic groups, tobacco use is a significant burden within the Hispanic population
(California Health Interview Survey, 2023).
Minority populations are more likely to live in MUH and are susceptible to SHS exposure
in the home, as smoke can infiltrate smoke-free living units from units and shared areas where
smoking occurs (King et al., 2013). SHS exposure has been causally linked to adverse health
outcomes, including heart disease and lung cancer in adults, and increased risk of acute
respiratory infections, ear problems, and sudden infant death syndrome in children (U.S.
Department of Health and Human Services, 2006).
Secondhand Smoke Exposure in MUH
Despite the implementation of comprehensive California smoke-free laws, private
settings, like MUH, remain large contributors to SHS (Kruger et al., 2015). Even in MUH where
smoke-free policies exist, there are still large gaps in protection against SHS exposure. Previous
research (Gentzke et al., 2018) has found that even in MUH that had smoke-free policies, 50% of

66
residents experienced smoke entering their units from adjacent units because of a lack of
enforcement of these rules). Like tobacco smoke, marijuana smoke incursions can occur and
have been more commonly reported in low-income MUH than in single-family homes
(Anastasiou et al., 2020). Although there are mixed findings regarding the harms associated with
passive nicotine e-cigarette aerosol exposure, research has found that the aerosol from some ecigarette products contains volatile compounds and other harmful substances (Williams et al.,
2013), however, these particles evaporate faster than tobacco smoke. The presence of known
carcinogens in e-cigarette liquid and aerosol, as well as the emerging evidence for e-cigarette
aerosol to increase endogenous formation of carcinogens also supports risk of cancer
(Bustamante et al., 2018).
Similar to the recent migration from tobacco cigarettes to nicotine e-cigarettes for many
tobacco users, cannabis users have switched from smoking marijuana to vaping cannabis. The
devices used to vape cannabis heat the cannabis oil or extracts, which aerosolizes cannabinoids
for inhalation. Although studies on cannabis aerosol exposure are limited (Murphy, Huang, &
Schick, 2021), they have consistently produced similar findings suggesting that aerosol from
cannabis e-cigarettes release harmful toxicants into the air and expose individuals to dangerous
chemicals. These findings suggest that exposure to e-cigarette aerosols from cannabis products
can potentially have adverse health effects like that of marijuana smoke. Given the increase in
popularity of new novel e-cigarette products, that may be used with nicotine or cannabis liquids,
it is important to examine the potential for aerosol smoke exposure in homes, which may have
adverse effects on the health of occupants that live near users of these products.

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Secondhand Marijuana Smoke Exposure
In California, the recreational use of marijuana by adults is legal and can be consumed
legally in private residences, provided it is located >1000 ft. from a school (California
Department of Public Health, 2022); however, individuals are prohibited from consuming
marijuana (smoking or vaping) in any location where tobacco smoking is also prohibited.
Marijuana smoking frequently occurs indoors, particularly in MUH, putting children and
nonsmokers at risk for SHMS inhalation (Berg, 2018). Previous research conducted by Posis et
al., (2019) has found that children living in homes with indoor marijuana smoke exposure had
83% higher odds of adverse health outcomes, and there is evidence to suggest that SHMS
exposure produces detectable urine and blood cannabinoid levels, causes impaired cognitive
performance, and has sedative drug effects in non-ventilated conditions (Hermann et al., 2015).
Previous studies measuring indoor particulate matter 2.5 (PM 2.5) levels from secondhand
marijuana smoke found that the average PM 2.5 emission rate of the pre-rolled marijuana joints
was found to be 3.5 times the average emission rate of tobacco cigarettes (Ott, 2021), while
another study examining the PM 2.5 of a cannabis dispensary where vaping marijuana was
permitted, found that the average PM 2.5 concentration when the business was open (i.e. when
customers were usually vaping marijuana inside) was 28 times higher than when the business
was closed, which was similar to those observed in spaces where marijuana smoking is permitted
(Murphy, Huang, & Schick, 2021).
Exposure to secondhand tobacco smoke has been successfully reduced in public settings
like bars and restaurants through comprehensive smoke-free laws prohibiting all smoking and
vaping, but private settings, like apartments and condominiums, do not receive the same level of
regulation regarding the use of cigarettes, e-cigarettes, and marijuana, creating a gap in

68
protection for residents living in municipalities that do not have mandated smoke-free housing
policies. For example, currently there is no citywide policy in Los Angeles prohibiting tenants
from smoking in privately-owned apartment and condominiums, which include MUH (American
Lung Association, 2024). Therefore, voluntary adoption of smoke-free housing policies is at the
discretion of individual property owners and management companies. A large portion of
residents of major urban areas live in privately owned MUH, which have fewer tobacco control
policies compared to more affluent suburban communities (American Lung Association, 2019).
This is particularly concerning because most residents live in MUH close to busy public
sidewalks and other outdoor areas where people generally smoke, thus creating exposure for
those living nearby. This is compounded by the fact that MUH is unique in that different
households share the same ventilation system and air space and smoking behaviors in one
household have the potential to directly impact the health of other residents.
Smoke-Free Policies
MUH property owners have the legal authority to implement comprehensive smoke-free
policies that prohibit the use of tobacco, e-cigarettes, and marijuana in individual resident units
and common areas. Some landlords may try to implement comprehensive smoke-free policies
that restrict the use of tobacco or cigarettes in and around the building but may fail to explicitly
state marijuana or e-cigarette use restrictions in building signs and provisions in their lease
agreements, causing confusion about the use of these products in their buildings. Despite the
ability to do so, many managers and landlords may also choose not to institute smoke-free
policies. This is due to a number of factors, such as: challenges with enforcement, especially in
buildings where residents have been living for many years because of possible tenant resistance;
challenges enforcing such policies if tenants already smoke in their units and because of the

69
difficulty of monitoring whether tenants are smoking in their homes and how to penalize tenants
if they violate building policies (Delgado-Rendon, 2017). Despite these challenges,
implementing comprehensive smoke-free policies remains an important step toward promoting
healthier living environments for all residents. The legalization of marijuana and growing
popularity of e-cigarette products may contribute to the already high levels of secondhand smoke
exposure and undermine the necessity of comprehensive smoke-free housing policies by creating
confusion about differential policies for these two products. In states that have legalized
marijuana for both recreational and medical use, SFH policies must be expanded to also address
marijuana smoke and aerosols, especially in MUH.
The Social Ecological Model (SEM) in the Context of Secondhand Smoke Exposure
The conceptual framework used to guide this study is the Social Ecological Model (SEM
of Health; Bronfenbrenner, 1977). The SEM argues that health behaviors and outcomes are
influenced by factors at multiple levels and that individual health outcomes are shaped by
various interconnected factors within the larger social contexts and considers the associations
between individual, interpersonal, community, and societal level factors that influence health
behaviors and outcomes. The SEM provides a useful framework to examine risk factors that lead
to individual-level secondhand smoke exposures, identify personal factors that influence health
behavior and attitudes, like the relationships between familial smoking and exposure, and
community and organizational policies, like smoke-free building policies and city and county
ordinances. Because secondhand smoke exposure can be caused by multiple factors including
individual and interpersonal variables, this model is useful in guiding this research to examine if
public policy and community factors may mitigate or protect against individual level exposure.

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Previous research has assessed the extent of SHS exposure in the home and smoke-free
policies (Licht et al., 2012; Wilson et al., 2014); however, there is no study that we know of that
has assessed SHS, SHMS, and e-cigarette aerosol exposure in the context of MUH in minority
populations. The assessment of novel e-cigarette products that may be used with nicotine or
cannabis is becoming increasingly important given the diversification of smoking methods in
recent years. The proposed study adds to the growing literature on SHS, SHMS, and e-cigarette
exposure in MUH in Los Angeles, CA. This study may provide a better understanding of the
multiple levels of factors that may be associated with exposure to secondhand smoke and ecigarette aerosols. The aims of this study are to 1) examine the association between individual
sociodemographic and substance use characteristics, interpersonal, and community level factors
and self-reported secondhand tobacco and marijuana smoke, and e-cigarette aerosol exposure, 2)
assess the sociodemographic, individual, interpersonal, and community level correlates of
support for comprehensive smoke-free policies in MUH. Previous research has found that men
are more likely than women to smoke cigarettes (Centers for Disease Control and Prevention,
2023), thus causing more exposure to SHS to women who may live with a smoker or spend more
time in the home as a caretaker, increasing their risk. Education is a plausible covariate because
it is highly correlated with SES, which has been found to be associated with smoking, where
those in lower SES groups are more likely to live in smoke-friendly environments, with other
smokers, and access smoke-friendly environments more frequently. Those with higher
educational attainment may not smoke in their home but may be involuntarily exposed to those
smoking in their buildings. Previous research (Garcia et al., 2016) has found that older adults
may be at a higher risk of involuntary exposure to SHS. This is because these people spend most

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of their time indoors and are at a greater risk of economic dependence and may be more likely to
not smoke and support smoke-free policies.
It is hypothesized that interpersonal (living with a person who smokes) and community
level factors (living in a building with smoke-free policies) would be associated with higher odds
of exposure to secondhand smoke. For support of smoke-free housing policies, individual (e.g.,
female, older age, higher educational attainment) and interpersonal factors (not living with a
person who uses cigarettes or marijuana) would be associated with support for comprehensive
smoke-free policies.
Methods
Sample and Procedures
This study uses data collected between June 2018 and March 2020 from a survey
administered to residents living in low-income MUH located in Los Angeles, California. Los
Angeles has the second highest proportion of renters in the United States, after New York City,
with a high concentration of African American/Black, Hispanic/Latino, and low-SES NonHispanic White populations, making these communities an ideal target population for data
collection. City of Los Angeles zip codes were rank ordered by the percent ethnicity of each
target ethnic community and top-ranked zip codes with the highest percentages of each ethnicity
and below median household income based on the median household income of each focus
community in Los Angeles County were selected. Buildings in target zip codes were randomly
selected if they had 20 or more tenant-occupied units in the building. Three households in each
building were surveyed if the building had between 20 to 39 units, six households in buildings
with 40-59 units, and 9 households with buildings with 60 or more units. Study measures were
modified from questions from the National Health Interview Survey (NHIS), and validated

72
scales used in previous projects by the team of investigators, and other MUH studies addressing
SHS (King et al., 2010), which were revised for inclusion of marijuana and e-cigarettes.
Measures in the study included questions related to individual, interpersonal relationships,
community, and organizational levels of the Social Ecological Model.
Data Collection
After arriving at selected buildings, research staff used a random number generator to
determine which unit numbers to approach and consent. Research staff would knock on the
selected unit door and the resident was asked if they would like to participate in a study about
secondhand smoke exposure in their building. Residents were eligible if they currently resided in
the unit and were 18 years of age or older. If the resident agreed, one research team member
would conduct the structured survey interview with the resident at the door. Participants received
$50 for their participation in the survey interview. Despite efforts to maximize participation,
there was a relatively low participation rate for our study. Of the 717 residents who were
approached to participate, 272 (38%) agreed and completed the interview.
Measures
Outcomes of Interest
Two outcomes of interest were analyzed in the multiple logistic regression models:
exposure to secondhand smoke and intentions to support comprehensive smoke-free policies in
MUH.
Exposure to Secondhand Smoke: Exposure to secondhand smoke in participants’ homes was
assessed by using self-report data. Participants were asked, “In the last year, has secondhand
smoke or vapor drifted into your home?” (yes/no).

73
Support for Smoke-Free Building Policies: Support for comprehensive (i.e., including
tobacco, marijuana, and e-cigarette products) smoke-free policies in participants’ buildings were
assessed with the question, “Would you be in favor of a 100% Tobacco/Marijuana smokefree/vape-free policy at your housing complex that bans smoking or vaping in all outdoor
common areas (such as open spaces, playgrounds, parking lots and entrances) and all apartment
units (including balconies and patios)?”, (yes/no).
Covariates of Interest
Individual Level Factors
Demographic Characteristics
Demographic variables collected included age, gender (female/other), race/ethnicity,
nativity status (born in the U.S./born outside of the U.S.), and education. Participants in the
sample were 18 and over. Race and ethnicity were assessed with the question “What is your race
or ethnicity?”, with options to choose, 1) African American/Black or African, 2) American
Indian or Alaska Native, 3) Asian, 4) Hispanic/Latino, 5) Native Hawaiian and/or Other Pacific
Islander, 6) Non-Hispanic White, or 7) Other. Because the study design and survey targeted three
ethnic communities of interest, resulting in small cell sizes for other ethnicities, race was recoded
as Non-Hispanic White, Hispanic/Latino, African American/Black, or Other. For comparison
purposes, the referent group in the logistic regression models were set to Non-Hispanic Whites.
Educational attainment classifies the highest grade level of education completed and was recoded
into four categories: “less than high school”, “high school diploma or GED”, “some college”,
and “college degree or higher”. The reference group in analyses was set to less than high school.

74
Individual Level Characteristics
Self-Reported Substance Use
Use of Cigarettes, Marijuana, and E-cigarettes
Ever-use of cigarettes was assessed with the question, “Have you smoked at least 100 cigarettes
in your entire life?” (yes/no).
Current Cigarette Use: Those who selected yes were then asked, “Do you now smoke every
day, some days, or not at all?” with options to choose “every day”, “some days”, “not at all”.
Participants who selected every day or some days were classified as “current cigarette users”
(yes/no).
Current Marijuana Use: Marijuana use was assessed with the questions, “In the last 30 days,
how many days did you use Marijuana or hashish?” with options to choose 0-30 days, “I did not
use marijuana in the past 30 days”, or “I have never used Marijuana”. Participants were coded as
current marijuana smokers (yes/no) if they had used marijuana at least once in the past 30 days.
Doctor Recommended Marijuana Use: Participants who reported using marijuana were asked
if marijuana was recommended to them by a doctor with the question, “Did a doctor or other
health care professional recommend all of your Marijuana use in the past 30 days?”, with
options to choose yes/no.
Although the current study collected data on current e-cigarette use, because sample sizes
were small, current e-cigarette use was excluded from the final analyses.
Interpersonal-Level Factors
Living with a person who uses Tobacco, Marijuana, or E-cigarettes
Living with a person who uses tobacco, marijuana, and e-cigarettes were assessed with
the question, “Does anyone who lives here do any of the following? Participants had options to

75
choose, “smokes cigarettes”, “smokes cigars, cigarillos, or filtered cigars”, “smokes
marijuana”, “use e-cigarettes with nicotine”, and “use e-cigarettes with marijuana”.
Participants who selected “yes” for cigarettes and cigars, cigarillos, and filtered cigars were
classified as “yes” for “lives with a person who uses tobacco” (yes/no). Participants who
selected “yes” for living with a person who smokes “marijuana” and “uses e-cigarettes with
marijuana” were categorized as “yes” for the variable “lives with a person who uses marijuana”.
Voluntary Smoke-Free Home Policy
Participants were asked, “Are any of the following allowed to be smoked/vaped in your
home?” (yes/no) separately for tobacco, marijuana, and e-cigarettes. Individuals who reported
“no” for all three products were classified as having a voluntary smoke-free home policy.
Community-Level Factors
Building Smoke-Free Policy
The presence of building smoke-free policies was assessed with the question: “Does your
building have a smoke-free rule?” (yes/no/don’t know).
Data Analysis
Data were inspected to identify missing data and outliers prior to analysis. Data cleaning,
descriptive analyses, and logistic regression modeling were analyzed using Stata software
version 17.1 (Stata Corp, College Station, Texas, USA).
Descriptive analyses were used to describe the study sample. Then, bivariate analyses
were used to examine differences in correlates of interest between 1) exposure to secondhand
smoke and 2) supporting comprehensive smoke-free policies in MUH assessed at the individual,
interpersonal, and community level. Multiple logistic regression models were conducted to
evaluate the different levels of the SEM model and their associations with the outcomes of

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interest, while accounting for the nesting of data within zip codes. Ethnic neighborhoods were
selected by zip code and median household income. Previous studies have found that using zip
codes are a reliable indicator of participant income and SES (Kwok and Yankaskas, 2001). Since
individual level smoking is nested within zip codes, this allows for the inclusion of unmeasured
variables that may cause potential for bias. Results are presented as odds ratios (OR), adjusted
odds ratios (AOR), and 95% confidence intervals (CI), and p-values < 0.05 were considered
statistically significant.
Results
Sample Demographics
The largest demographic group in the total sample identified as H/L ethnicity (37%),
followed by AA (31%), and NHW (20.3%). Ethnic neighborhood composition was subdivided
by the dominant ethnic group within a community zip code. In African American dominant
neighborhoods, 68.6% of the population identified as African American, 87.7% identified as
Hispanic/Latino in H/L neighborhoods, and 52.5% identified as Non-Hispanic White in NHW
neighborhoods. The distribution of participant ethnicity within ethnic neighborhoods is presented
in Figure 2.
Figure 2: Participant Ethnicity Distribution Within Ethnic Neighborhood (N = 272)

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The demographic characteristics of the study sample (N=272) are similar to that of the
demographics of each ethnic neighborhood composition and are presented in Table 7. The largest
demographic group represented in the sample were H/L tenants at 37% (N=100), followed by
AA tenants at 31% (N=84), NHW tenants at 20% (N=55), and 12% (N=32) who identified as
more than one race or “Other”. Most (62.5%) participants were female (N=170), and the mean
age was 45.9 years (SD: ± 17.8 years). The majority of participants were not current users of
tobacco (19.5% current tobacco users) or marijuana products (25.4% current marijuana users).
Table 7: Sociodemographic Characteristics of MUH Residents (N = 272)
N (%) / M (SD)
Gender
Female 170 (62.5%)
Mean Age (years) 45.9 (±17.8)
Participant Race/Ethnicity
African American 84 (31%)
Hispanic/Latino 100 (36.9%)
Non-Hispanic White 55 (20.3%)
Other 32 (11.8%)
Ethnic Neighborhood
African American 106 (39%)
Hispanic/Latino 65 (24%)
Non-Hispanic White 101 (37%)
Nativity
United States 166 (61%)
Other 106 (39%)
Education
Less than High School 51 (18.8%)
GED/High School Diploma 49 (18.1%)
Some College 85 (31.37%)
College Degree or Higher 86 (31.7%)
Annual Household Income
< $25,000 70 (25%)
$25,000- $49,999 44 (16%)
$50,000-$$99,999 34 (12%)

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≥ $100,000 15 (5%)
Missing/Refused to Answer 109 (40%)
Correlates of Exposure to Secondhand Smoke and Support for Comprehensive Smoke-Free
policies
A total of 62.6% of MUH residents reported that they had been exposed to any type
(tobacco, marijuana, e-cigarettes) of secondhand smoke. Among those exposed, the highest rates
of exposure were among those living in AA communities (25.19%), followed by 16.79% in H/L
communities and 20.6% in NHW communities (Figure 3). Most residents (55.9%) in the full
sample reported favoring 100% comprehensive smoke-free policies. Of the individuals living in
African American neighborhoods, 38.2% supported these policies, followed by 31.6% in
Hispanic/Latino neighborhoods, and 30.3% of participants in Non-Hispanic White
neighborhoods.
Individual, Interpersonal, and Community Factors and Secondhand Smoke Exposure
A higher odds of exposure to secondhand smoke was reported by participants between
the ages of 45 and 54 (OR=3.59, 95% CI [1.29-9.97]) and between the ages of 55 to 64
(OR=2.70, 95% CI: [1.02-7.08]), compared to those 18 to 24 years old. All other individual level
factors were non-significant. For interpersonal level factors, only living with an older adult (> 65
years of age) was significantly associated with lower odds of exposure to secondhand smoke
(OR=0.51, 95% CI: [0.28-0.94]). Among community level variables, compared to those living in
buildings where residents reported people do not break smoke-free building rules, those who
reported other residents broke smoke-free rules reported 3.1 times higher odds of exposure to
secondhand smoke (95% CI: [1.56-6.14]).

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Individual, Interpersonal, and Community Factors and Support for Comprehensive Smoke
Free Policies
Among demographic variables, females had 2.79 times higher odds (95% CI: [1.68-
4.64]) of supporting comprehensive smoke-free policies than males. Similar to associations with
exposure, those between the ages of 55 and 64 had 3 times higher odds of supporting
comprehensive policies than those aged 18 to 24 (95% CI: [1.14-8.12]). Participants that selfidentified as Hispanic or Latino had 3 times higher odds of supporting policies compared to NonHispanic White participants (95% CI: [1.52-5.96]). Surprisingly, higher levels of education were
found to be significantly associated with lower odds of support for policies compared to those
with less than a high school education. Being born outside of the U.S. was associated with 2.12
higher odds of supporting smoke-free policies. Among individual level substance use
characteristics, those who had never used e-cigarettes, were not a current cigarette smoker, never
used marijuana, and never used e-cigarettes had higher odds of supporting comprehensive
smoke-free policies. Among interpersonal factors, those who lived with a minor, did not live
with a person who uses cigarettes or marijuana, and those who had voluntary smoke-free home
policies had significantly higher odds of supporting comprehensive smoke-free policies. For
community level factors, living in a Hispanic ethnic neighborhood was associated with 3.4 times
the odds of supporting smoke-free policies (OR=3.4, 95% CI: [1.71-6.65]).

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Table 8: Results of Bivariate Analyses: Participant Characteristics and Associations with
Exposure to SHS and Supporting Smoke-Free Policies in MUH (N =272)
Exposure to Secondhand Smoke Support Smoke-Free Housing
Policies
Unadjusted OR
(95% CI)
p-value1 Unadjusted OR
(95% CI)
p-value1
Individual Level Demographic Characteristics
Gender (Ref=Not female)
Female 1.19 (0.72-1.97) 0.48 2.79 (1.68-4.64) <0.0001
Age (Ref=18-24)
25-34 1.57 (0.68-3.63) 0.29 1.31 (0.56-3.02) 0.52
35-44 1.98 (0.82-4.78) 0.13 0.99 (0.41-2.37) 0.98
45-54 3.59 (1.29-9.97) 0.01 2.12 (0.81-5.57) 0.12
55-64 2.7 (1.02-7.08) 0.04 3.05 (1.14-8.12) 0.02
>65 1.2 (0.48-2.96) 0.69 1.91 (9.76-4.76) 0.16
Race/Ethnicity (Ref=NHW)
Hispanic/Latino 1.3 (0.67-2.54) 0.43 3.01 (1.52-5.96) 0.002
African American/Black 1.42 (0.71-2.84) 0.32 1.56 (0.78-3.1) 0.2
Other 1.07 (0.45-2.58) 0.87 0.77 (0.31-1.89) 0.58
Educational Attainment (Ref=Less than
high school)
GED/High School Diploma 0.52 (0.23-1.16) 0.11 0.17 (0.35-1.48) <0.0001
Some College 0.68 (0.32-1.41) 0.29 0.45 (1.03-3.51) 0.05
College Degree or Higher 0.84 (0.41-1.74) 0.65 0.24 (0.11-0.53) <0.0001
Nativity (Ref=U.S. Born)
Foreign Born 0.93 (0.56-1.53) 0.78 2.12 (1.28-3.53) 0.003
Individual Level Characteristics
Substance Use
Never User of Cigarettes (Ref=No) 1.28 (0.69-2.34) 0.42 4.75 (2.43-9.26) <0.0001
Non-User of Cigarettes (Ref=No) 1.14 (0.66-1.95) 0.63 2.94 (1.65-5.22) <0.0001
Never User of Marijuana (Ref=No) 1.25 (0.44-1.38) 0.41 9.35 (4.78-18.32) <0.0001
No Past 30-day Marijuana Use (Ref=No) 1.74 (0.63-4.79) 0.28 0.47 (0.14-1.67) 0.25
Never user of e-cigarettes (Ref=No) 0.67 (0.30-1.54) 0.34 20.74 (4.8-89.42) <0.0001
Current E-cigarette User (Ref=Yes) *** 1.42 (0.85-2.37) 0.17 5.73 (3.3-9.96) <0.0001
Interpersonal Level Factors
Lives with a minor (<18 years) (Ref=No) 1.61 (0.92-2.8) 0.09 2.14 (1.22-3.74) 0.007
Lives with an older adult (> 65 years)
(Ref=No)
0.51 (0.28-0.94) 0.03 1.68 (0.88-3.19) 0.11
Lives with person who uses Tobacco
(Ref=Yes)
0.88 (0.53-1.46) 0.64 3.66 (2.19-6.11) <0.0001
Lives with person who uses Marijuana
(Ref=Yes)
0.71 (0.44-1.17) 0.19 5.78 (3.41-9.79) <0.0001

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Voluntary Smoke-Free Home Policy (Ref=No) 1.31 (0.79-2.16) 0.28 5.46 (3.19-9.34) <0.0001
Community Level Factors
Building Has Smoke-Free Policy (Ref=Yes) 1.29 (0.69-2.37) 0.42 0.93 (0.51-1.67) 0.8
People Break Smoke-Free Rules (Ref=No)
****
3.10 (1.56-6.14) 0.001 1.14 (0.58-2.21) 0.71
Ethnic Neighborhood (Ref=NHW)
African American/Black 1.43 (0.82-2.49) 0.19 1.44 (0.83-2.50) 0.19
Hispanic/Latino 1.89 (0.99-3.63) 0.05 3.4 (1.71-6.65) <0.0001
1
Bolded p-values are significant at p<0.05

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Multiple Logistic Regression Analyses
Adjusted odds ratios from the multiple logistic regression analyses are presented in Table
9 for exposure to secondhand smoke and Table 10 for support for comprehensive smoke-free
policies. Four models with sets of variables representing the dimensions of Social Ecological
Model are presented for each of the two outcomes: exposure to secondhand smoke and support
for comprehensive smoke-free policies. Some variables that were not significant in bivariate
analyses were not included in the final models. Variables that were considered factors for each
level of the SEM were grouped together and entered into the model in groups to determine which
variables (e.g., individual, interpersonal, community) are the best predictors of exposure to SHS
and supporting smoke-free policies.
Individual, Interpersonal, and Community Factors and Secondhand Smoke Exposure
Individual-Demographic Factors
After adjusting for demographic variables only, compared to participants ages 18 to 24,
participants ages 45 to 54 (OR=3.00, 95% CI: [1.19-7.53]) and 55-64 (OR=2.39, 95% CI: [1.19-
5.1]) had significantly higher odds of exposure to secondhand smoke. All other demographic
variables were not significant.
Although all other demographic variables were not significantly associated with
exposure, compared to those who self-identified as Non-Hispanic White, all other race/ethnicity
groups had higher odds of exposure. For education, compared to individuals who had less than a
high school education, each level of higher educational attainment was associated with lower
odds of secondhand smoke exposure. Individuals who were born outside of the U.S. also showed
a lower odds of secondhand smoke exposure compared to those born in the U.S (OR=0.82, 95%
CI: [0.38-1.75].

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Individual-Characteristics
In model two, the 45 to 54 and 55 to 64 age groups remained significant after adjusting
for other individual level substance use characteristics. All other variables remained nonsignificant.
Interpersonal-Level Factors
In model three, being between the ages of 45 to 54 and 55 to 64 remained significantly
associated with exposure. For interpersonal factors, although none of these variables were
significant, those living with a minor (OR=1.4, 95% CI: [0.68-2.81], not living with a person
who used tobacco (OR=1.36, 95% CI: [0.62-2.97], not living with a person who used marijuana
(OR=1.06, 95% CI: [0.42-2.71]), and having a voluntary smoke-free home policy (OR=1.41,
95% CI: [0.76-2.6] showed an increased odds of exposure to secondhand smoke.
Community-Level Factors
In the final model with community level factors and all other covariates, being 45 to 54
and 55 to 64 years old remained significant. When adding the presence of building smoke-free
policies, this was not statistically significant. Notably, compared to Non-Hispanic White
neighborhoods, individuals in Hispanic/Latino neighborhoods had 2.8 higher odds of exposure to
secondhand smoke (95% CI: [1.05-7.42]).

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Table 9: Multiple Logistic Regression Models for Secondhand Smoke Exposure
Model 1
Individual
Demographic
Variables Only
Model 2
All Individual
Variables
Model 3
Individual and
Interpersonal
Variables
Model 4
Individual,
Interpersonal, and
Community
Variables
(N = 270)
Adjusted OR
(95% CI)
Adjusted OR
(95% CI)
Adjusted OR
(95% CI)
Adjusted OR
(95% CI)
Individual-Level
Variables
Gender (Ref=Not
female)
Female 1.13 (0.66-1.93) 1.16 (0.68-1.99) 1.16 (0.68-1.87) 1.11 (0.65-1.9)
Age (Ref=18-24)
25-34 1.37 (0.64-2.94) 1.41 (0.64-3.11) 1.41 (0.64-3.11) 1.37 (0.61-3.1)
35-44 1.76 (0.85-3.65) 1.92 (0.93-3.95) 1.84 (0.93-3.62) 1.68 (0.89-3.18)
45-54 3 (1.19-7.53) * 3.37 (1.38-8.22) * 3.18 (1.36-7.43) * 2.78 (1.17-6.61)
55-64 2.39 (1.19-5.1) * 2.69 (1.21-5.9) * 3.39 (1.51-7.6) * 3.24 (1.47-7.15)
>65 1.1 (0.47-2.54) 1.28 (0.52-3.11) 2.62 (0.69-9.99) 2.53 (0.59-10.87)
Race/Ethnicity
(Ref=NHW)
Hispanic/Latino 1.25 (0.57-2.72) 1.28 (0.61-2.69) 1.09 (0.48-2.48) 0.70 (0.26-1.91)
African
American/Black 1.34 (0.61-2.98) 1.32 (0.63-2.76) 1.20 (0.60-2.60) 0.97 (0.34-2.77)
Other 1.13 (0.49-2.79) 1.17 (0.46-2.79) 1.08 (0.43-2.71) 0.87 (0.31-2.45)
Educational
Attainment (Ref=Less
than high school)
GED/High School
Diploma 0.47 (0.22-1.01) 0.49 (0.23-1.04) 0.55 (0.25-1.20) 0.57 (0.26-1.26)
Some College 0.67 (0.37-1.22) 0.68 (0.37-1.26) 0.82 (0.44-1.54) 0.99 (0.51-1.94)
College Degree or
higher 0.84 (0.46-1.93) 0.87 (0.39-1.99) 1.05 (0.45-2.42) 1.41 (0.55-3.52)
Nativity Status
(Ref=U.S. Born)
Foreign Born 0.82 (0.38-1.75) 0.88 (0.42-1.85) 0.91 (0.42-1.95) 0.94 (0.44-2.00)
Individual Level
Characteristics
Substance Use
Current Cigarette
Smoker (Ref=Yes) 1.41 (0.79-2.5) 1.68 (0.86-3.3) 1.74 (0.9-3.36)
Past 30-day Marijuana
Use (Ref=Yes) 0.64 (0.38-1.08) 0.60 (0.29-1.25) 0.61 (0.31-1.21)

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Interpersonal Level
Factors
Lives with a minor
(<18 years) (Ref=No) 1.4 (0.68-2.81) 1.28 (0.62-2.67)
Lives with an older
adult (> 65 years)
(Ref=No) 0.44 (0.15-1.28) 0.36 (0.12-1.12)
Lives with person who
uses Tobacco
(Ref=Yes) 1.36 (0.62-2.97) 1.46 (0.68-3.14)
Lives with person who
uses Marijuana
(Ref=Yes) 1.06 (0.42-2.71) 1.10 (0.44-2.76)
Voluntary Smoke-Free
Home Policy (Ref=No) 1.41 (0.76-2.6) 1.32 (0.72-2.44)
Community Level
Factors
Building Has SmokeFree Policy (Ref=No) 0.95 (0.63-1.42)
Ethnic Neighborhood
(Ref=Non-Hispanic
White)
Hispanic/Latino 2.80 (1.05-7.42) *
African
American/Black 1.42 (0.57-3.54)
Model 1 variables include gender, age, race/ethnicity, educational attainment, nativity. Model 2 variables
include all variables from Model 1 and current cigarette use, and past 30-day marijuana use. Model 3 includes
Model 1 and Model 2 variables and living with a minor, living with an older adult, living with a tobacco or
marijuana user, and voluntary smoke-free home policies. Model 4 includes all previous variables and if
building has a smoke-free policy and ethnic neighborhood.

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Individual, Interpersonal, and Community Factors and Supporting Comprehensive
Smoke-Free Policies in MUH
Individual-Demographic Factors
Individual-level demographics associated with supporting comprehensive smoke-free
policies in buildings were similar to those exposed to secondhand smoke with the addition of
several significant factors. Females compared to Males and those who identified as “other
gender” had 2.83 odds of supporting smokefree policies [95% CI: (1.36-5.88)], which may
suggest that females have higher harm perceptions of exposure to secondhand smoke than males
and are more health conscious than males. Compared to 18–24-year-olds, those who were 55 to
64 (OR=5.28, 95% CI: [2.37-11.76] and 65 years and older (OR=2.49, 95% CI: [0.84-7.39]) had
significantly higher odds of supporting smoke-free policies. Compared to those who had less
than a high school education, those with a high school diploma had a significantly lower odds of
supporting policies (OR=0.37, 95% CI: [0.15-0.89]. Individuals who were not born in the U.S.
also had 2.04 higher odds of supporting smoke-free policies than U.S. born participants (95% CI:
[1.17-3.53]).
Individual-Characteristics
After adjusting for individual characteristics, the same age groups from the previous
models remained significant. Residents who were not current cigarette smokers had 4.6 higher
odds of supporting policies compared to current smokers [95% CI: (1.52-13.81)]. Individuals
who were not current marijuana users had 8.55 higher odds of supporting comprehensive policies
[95% CI: (4.12-17.6)].
Interpersonal-Level Factors

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At the interpersonal level, living with an older adult, not living with a person who uses
marijuana, and having a smoke-free home policy had higher odds of supporting a policy,
however these factors were not statistically significant. Residents who lived with a minor had 2.3
higher odds of supporting smoke-free policies (95% CI: [1.3-4.1]), and those who did not live
with a person who uses tobacco had 3.35 higher odds of supporting policies (95% CI: [1.42-
7.95]).
Community-Level Factors
In the final model that included community-level factors, having a building smoke-free
policy and ethnic neighborhood were not statistically significant. However, variables from the
previous model remained significant, including 45-54 and 65 and older age groups, not being a
current marijuana user, living with a minor, and not living with a person who uses tobacco.

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Table 10: Multiple Logistic Regression Models for Supporting Smoke-Free Policies
(N = 270)
Model 1
Individual
Demographic
Variables Only
Model 2
All* Individual
Variables
Model 3
Individual* and
Interpersonal
Variables
Model 4
Individual,
Interpersonal, and
Community
Variables
Adjusted OR
(95% CI)
Adjusted OR
(95% CI)
Adjusted OR
(95% CI)
Adjusted OR
(95% CI)
Individual-Level
Variables
Gender (Ref=Not
female)
Female 2.83 (1.36-5.88) * 2.14 (1.06-4.30) * 1.63 (0.77-3.49) 1.62 (0.75-3.49)
Age (Ref=18-24)
25-34 1.62 (0.71-3.67) 1.75 (0.68-4.46) 1.81 (0.67-4.92) 1.82 (0.67-5.02)
35-44 0.87 (0.71-3.67) 1.09 (0.48-2.48) 0.85 (0.35-2.09) 0.84 (0.33-2.09)
45-54 1.91 (0.38-2.00) 3.02 (1.11-8.93) * 3.26 (1.18-9.11) * 3.27 (1.16-9.15) *
55-64 5.28 (2.37-11.76) * 7.45 (2.91-19.04) * 8.78 (3.35-22.90) * 8.69 (3.31-22.90) **
>65 2.49 (0.84-7.39) * 2.81 (0.94-8.40) 2.41 (0.81-7.20) 2.43 (0.81-7.27)
Race/Ethnicity
(Ref=NHW)
Hispanic/Latino 1.91 (0.75-4.86) 1.16 (0.35-3.89) 0.74 (0.24-2.22) 0.73 (0.25-2.18)
African
American/Black 1.19 (0.41-3.47) 1.35 (0.36-5.1) 1.15 (0.31-4.29) 1.15 (0.31-4.31)
Other 0.82 (0.27-2.45) 0.82 (0.24-2.89) 0.78 (0.19-3.16) 0.79 (0.20-3.16)
Educational
Attainment
(Ref=Less than high
school)
GED/High School
Diploma 0.37 (0.15-0.89)* 0.39 (0.14-1.13) 0.33 (0.10-1.13) 0.33 (0.10-1.12)
Some College 1.10 (0.37-2.98) 1.13 (0.39-3.24) 1.20 (0.37-3.88) 1.20 (0.37-3.83)
College Degree or
higher 0.69 (0.23-2.13) 0.55 (0.16-1.89) 0.51 (0.13-1.90) 0.51 (0.14-1.90)
Nativity Status
(Ref=U.S. Born)
Foreign Born 2.04 (1.17-3.53) * 1.47 (0.80-2.70) 1.36 (0.62-2.98) 1.37 (0.63-2.98)
Individual Level
Characteristics

89
Substance Use
Current Cigarette
Smoker (Ref=Yes) 4.60 (1.52-13.81) * 1.46 (0.35-6.10) 1.47 (0.35-6.10)
Past 30-day Marijuana
Use (Ref=Yes) 8.55 (4.12-17.6) ** 6.72 (2.28-19.76) ** 6.69 (2.28-19.61) **
Interpersonal Level
Factors
Lives with a minor
(<18 years) (Ref=No) 2.30 (1.30-4.10) * 2.31 (1.30-4.16) *
Lives with an older
adult (> 65 years)
(Ref=No) 1.41 (0.54-3.72) 1.42 (0.54-3.76)
Lives with person who
uses Tobacco
(Ref=Yes) 3.35 (1.42-7.95) * 3.40 (1.46-7.92) *
Lives with person who
uses Marijuana
(Ref=Yes) 1.37 (0.49-3.84) 1.37 (0.49-3.82)
Voluntary SmokeFree Home Policy
(Ref=No) 2.16 (0.90-5.17) 2.14 (0.87-5.24)
Community Level
Factors
Building Has SmokeFree Policy (Ref=No) 1.09 (0.64-1.86)
Ethnic
Neighborhood
(Ref=Non-Hispanic
White)
Hispanic/Latino 1.10 (0.44-2.31)
African
American/Black 0.91 (0.34-2.47)

90
Discussion
The current findings add to the very few published studies on secondhand smoke
exposure from tobacco, marijuana, and e-cigarette products in low-income MUH. Our study
found that after older age, Hispanic communities are disproportionally exposed to SHS,
regardless of whether the MUH they live in has smoke-free policies. Similar to studies
comparing single family homes and MUH and exposure to secondhand smoke (Chambers et al.,
2015), we did not find many statistically significant associations with demographic variables and
exposure to secondhand smoke among residents living in MUH.
In this study of 272 MUH residents in Los Angeles, the strongest predictors for
supporting comprehensive smoke-free policies in the adjusted regression models were being ages
45-64, no current marijuana use, living with a minor, and not living with a tobacco user. For
exposure to secondhand smoke, individuals between the ages of 45 to 64 had higher odds of
exposure, in addition to individuals living in Hispanic/Latino communities. Although there were
not many predictors associated with exposure to SHS, we did find characteristics that were
associated with support for comprehensive smoke-free policies. These include all levels of
education, being foreign-born, never use of tobacco, marijuana, and e-cigarettes, not living with
a tobacco or marijuana user, and having a voluntary smoke-free home policy. Given the
generally high levels of support we found for policies prohibiting smoking tobacco, marijuana,
and e-cigarette use in MUH, additional jurisdictions in Los Angeles should consider
implementing such policies to extend smoke-free air protections.
To our knowledge, this is one of few quantitative studies examining individual level
factors with substance use that includes e-cigarette and marijuana in conjunction with
interpersonal and community level factors that may influence exposure to secondhand smoke

91
exposure and support for comprehensive smoke-free policies in MUH. Our study is also one of
the few studies examining policy support for prohibiting e-cigarette and marijuana use in MUH.
Given that there is little research on secondhand e-cigarette and cannabis aerosol exposure, and
the steady rise of the use of these products, stronger policies are needed to protect the health of
residents.
Our findings demonstrate that MUH residents do indeed support smoke-free and ecigarette-free MUH policies to reduce disparities among certain racial and ethnic and income
subgroups. Our research shows that most individuals identifying as a racial or ethnic minority
support both policies, with individuals identifying as Hispanic reporting the highest support for
each policy. This study’s findings highlight a need for increased availability, dissemination, and
awareness of low-cost or free cessation aids, such as free ‘quit lines’ or cessation hotlines that
residents may use to reduce their substance use, thus reducing secondhand smoke exposure in
MUH. Although previous research has focused on SHS exposure of tenants, more research needs
to be conducted with landlords and managers of MUH who do not have smoke-free policies to
assess their needs and provide information and guidance on how to implement these smoke-free
policies in their buildings.
Residents and advocacy groups have expressed concerns regarding smoke-free MUH
policy compliance and enforcement, including the need for cessation support for tenants and the
use of tiered enforcement for violating smoke-free policies (e.g., warnings, then fines, then
eviction as a last resort) as an enforcement strategy (Patel et al., 2022; Peterson et al., 2020). This
warrants additional research and should be considered in policy implementation. Some studies
and advocacy tools suggest that MUH resident engagement, graduated enforcement approaches,
and increased cessation supports may promote equitable enforcement. If implemented in a

92
structured and equitable way, MUH policies can have the potential of changing social norms,
making cigarette smoking and e-cigarette use in the home less socially acceptable in MUH
(Public Health Law Center, 2020; Durazo et al., 2021). Organizations like the American
Nonsmokers’ Rights Foundation and the California Department of Public Health offer guidance
and policy recommendations for landlords that want to implement smoke-free housing policies
and for tenants that are involuntarily being exposed to SHS and want these policies implemented
in their buildings. Recommendations include that policies describe enforcement provisions and
that policy compliance efforts emphasize education and social norm change approaches to avoid
unintended consequences. Marijuana-related recommendations include figuring out how
successful tobacco-related policies and language can be modified and applied to cannabis
regulation at the broader societal level. More outreach is needed in low-income communities to
approach the problem of tobacco and marijuana use at the population level. Future researchers
and policy makers should prioritize including the underrepresented ethnic groups that live in
MUH in policy research and policy implementation, greater support can be gained for MUH
cigarette, e-cigarette, and marijuana policies.
Limitations
This study has several limitations that should be considered. The sample of MUH
residents approached for this study was limited to African American, Hispanic/Latino, and lowincome Non-Hispanic White groups and those living in low-income MUH in purposely selected
neighborhoods in Los Angeles, which might limit generalizability to other socioeconomic and
ethnic minority groups living in other geographic areas. The reported data relies heavily on selfreport data for reports of secondhand smoke exposure from all products and may be subject to

93
measurement error and the cross-sectional design of this study does not allow us to make any
conclusions about the casual associations between exposure and support for smoke-free policies.
In previous SHS exposure research (Benowitz et al., 2017; St. Helen et al., 2019), urine
cotinine screenings have been a more reliable method for detecting exposure to tobacco and
marijuana smoke than self-reported data. however, these methods were not available for this
study. For self-reported smoking, sensitive topics such as substance use characteristics may not
be reliable estimates of participants’ use, as some participants may live in buildings that have
smoke-free policies and building residents may be hesitant to report behavior that may cause
consequences for their living situations.
Conclusions
This study is one of the handful of studies that aimed to determine the predictors of SHS
incursion and smoke-free policy support among MUH residents in Los Angeles, CA. Our study
is one of the few to include nicotine and cannabis e-cigarette and marijuana smoke incursions
with tobacco SHS. This study highlights that Hispanic ethnic communities are more likely to be
exposed to SHS and are also more likely to support smoke-free policies. Until there are more
widespread policies enforced by local municipalities, tenants should be empowered to approach
their landlords about implementing policies in their buildings.

94
Chapter 5: General Discussion
Summary of Findings
The overall goal of this dissertation was to identify the multilevel factors associated with
exposure to secondhand smoke and smoke-free policy support. The main goals of this
dissertation were to 1) assess the prevalence and identify the factors that may be barriers from
protecting against exposure in ethnic communities, 2) explore tenants’ experiences during the
COVID-19 pandemic and identify the unique barriers and facilitators of supporting
comprehensive smoke-free policies in MUH using qualitative focus group data and 3) identifying
the factors that are associated with SHS exposure and supporting comprehensive smoke-free
housing policies in MUH.
While this dissertation features three studies with distinct aims while utilizing the same
study population, it is linked together by the SEM model to conceptualize the multilevel
influences that contribute to a more comprehensive understanding of smoke-free policy support
and secondhand tobacco, marijuana, and e-cigarette aerosol exposure among socioeconomically
disadvantaged African American, Hispanic/Latino, and Non-Hispanic White tenants living in
Los Angeles MUH. The Social-Ecological Model is useful in better understanding MUH smokefree policies at the community level, the unique barriers, and facilitators of support for smokefree housing policies and can provide a better understanding risk factors associated with SHS
exposure. The SEM considers the associations between individual, interpersonal, community,
and societal level factors that influence health behaviors and outcomes, and the findings here
may help assess the effectiveness of smoke-free policies at the community level and evaluate the
need for additional federal and state smoke-free policies to protect vulnerable groups against all
types of SHS.

95
Study 1 evaluates the prevalence of unique barriers to protecting from SHS in ethnic
neighborhoods and factors associated with increased barriers to protecting oneself. When
examining health behaviors within ethnic populations, it is important to consider the unique
cultural factors and traditions that may influence specific health practices (i.e., asking people not
to smoke in the home may be disrespectful in some cultures). In this study we found that among
the three ethnic neighborhoods, there were significant differences in rates of tobacco and
marijuana use and living with someone who uses these products, which may contribute to
barriers of protecting against secondhand smoke exposure. Current smokers, individuals who use
marijuana, and living with someone who uses tobacco, marijuana, or both were more likely to
live in African American communities. When assessing prevalence of barriers, Non-Hispanic
White neighborhoods were significantly more likely to identify “I have more important
problems”, “I don’t know how to protect my family or myself”, “The people who smoke are my
relatives”, and “I don’t want to make trouble in my building” as barriers to protecting from
secondhand smoke compared to those in African American or Hispanic ethnic neighborhoods.
These findings suggest that individual level factors like substance use should be addressed in
conjunction with smoke-free policies in MUH.
Study 2 is a qualitative study that explored the multiple dimensions of the socialecological factors that may act as enforcers for resident compliance and supporting policies and
act as barriers for implementing smoke-free policies in MUH. Although tenants included
individuals who smoked cigarettes and marijuana products and had differing views on the
harmfulness of the use of these products, there was largely support for implementing
comprehensive smoke-free policies in MUH among smokers and non-smokers. Receiving clear
and tangible information, like flyers at their doors, billboards near their buildings, and having

96
meetings discussing potential smoke-free policies would be a start to introducing tenants to
potential changes in policies. Asking tenants to read and sign new lease agreements clearly
highlighting smoke-free stipulations (e.g., no smoking in units or in common areas), providing
copies to tenants, and posting no-smoking signs in building hallways and common areas may
increase compliance to new smoke-free policies in MUH.
Building upon Study 1, this study found that smoking is prevalent in low-income housing
and the surrounding communities where there are many tobacco retailers densely located near
MUH buildings. Among smokers and non-smokers, many cited nicotine addiction as a barrier to
implementation and compliance, where even if a resident wanted to comply with a new smokefree policy, it may be difficult without access to cessation and counseling resources. Unique to
this study, we found that structural and environmental barriers also play a role in exposure to
SHS and make it difficult to enforce smoke-free rules. Tenants noted smoke can drift from
nearby apartment units that do not have smoke-free policies, or individuals smoking near
buildings on the sidewalk may cause drifting smoke to enter their buildings. In addition to
increasing access to approved cessation treatments, interventions need to prioritize both the
mental health of residents who smoke and provide evidence-based smoking cessation
interventions before implementation of policies.
In this study, we found that most residents supported smoke-free policies restricting
tobacco and e-cigarette use, but there were mixed attitudes on policies restricting indoor
marijuana use, especially if it was used for medical purposes and it would be morally wrong to
restrict marijuana if it is used for medical reasons. Many residents cited the legal ramifications
against landlords who wished to implement smoke-free policies. Barriers to enforcement may
include the potential for tenants who used tobacco and marijuana products to seek legal counsel

97
against their landlords for impeding on their rights as tenants to live comfortable in their homes,
which may be a legal “grey area” within tenant laws, where you are not able to go into a
resident’s home without their permission. At the community level, our findings highlight the
need for better enforcement of building smoking policies by management. Tenants stated that
they would be hesitant to report or speak to their neighbors about their smoking, indicating that
smoke free policies should be enforced by building managers, landlords, and clear signage and
verbiage in lease agreements.
Study 3 combines the individual and the two previous studies together and is a broader
policy study that highlights the demographic, individual characteristics, interpersonal, and
community factors that are associated with exposure to secondhand smoke and supporting
smoke-free policies. There is a limited amount of research that has examined tobacco SHS along
with marijuana and e-cigarettes in MUH. Findings from this study are consistent with other
research that has found Hispanic communities experience SHS exposure at higher rates than
other communities (Reyes-Guzman et al., 2023; Rendon et al., 2019). This study is one of few
studies examining individual level factors with substance use that includes e-cigarette and
marijuana in conjunction with interpersonal and community level factors. We aimed to examine
what dimensions of factors, whether individual or community-level, were best predictors of SHS
exposure and policy support. Our findings demonstrate that MUH residents do indeed support
smoke-free and e-cigarette-free MUH policies to reduce disparities among certain racial and
ethnic and income subgroups.
Limitations
The sample of MUH residents approached for this study was limited to African
American, Hispanic/Latino, and low-income Non-Hispanic White groups and those living in

98
low-income MUH in purposely selected neighborhoods in Los Angeles, which might limit
generalizability to other socioeconomic and ethnic minority groups living in other geographic
areas. Despite efforts to maximize participation, there was a relatively low participation rate for
the door-to-door interview portion of this study. Of the 717 residents who were approached to
participate, 272 (38%) agreed and completed the interview. The low recruitment rate may be a
limitation of this study and may have the potential to cause selection bias in the recruitment
process. As potential participants were informed of the study’s objective of assessing marijuana
and tobacco smoke exposure in their homes, it is possible that families who use tobacco and/or
marijuana were less likely to participate. Since surveys were completed at respondents’ homes
and were not scheduled beforehand, some individuals may not have had an extended period of
time to devote to completing the survey. Other potential reasons for the low recruitment rate may
be attributed to generally lower participation rates among low-income and ethnic communities of
color and possible language barriers among foreign-born individuals. Given the nature of the
data and self-reports of exposure and use, recall and cognitive biases may have potential to affect
the results in these studies.
Regarding focus groups, the lack of data about participant demographics, such as age,
lifetime tobacco and marijuana use, as it was self-reported with one question about past 30-day
use, as well as having a low number of tobacco and marijuana users and more long-term MUH
residents may have been a limitation and limit generalizability to other MUH residents. As the
sampling strategy included recruiting participants that had agreed to participate in the larger
study of the resident door-to-door interviews about secondhand smoke exposure, our larger
general sample may not have a representative sample of regular tobacco smokers or long-term
marijuana users and the limited number who were tobacco or marijuana users and may not have

99
been willing to participate in smaller focus groups discussing their use or support for smoke-free
policies. Focus group interviews were conducted during COVID-19 lockdowns and attitudes and
feelings about secondhand smoke exposures may have differed from the door-to-door interviews
that were conducted pre-lockdown.
Potential Implications, Policy Recommendations, and Future Research
Despite these limitations, the three studies taken together contribute to the very limited
current research on marijuana smoke and e-cigarette aerosol exposure in low-income MUH.
Taking a mixed methods approach and examining focus group data is useful for more in-depth
analysis of unique barriers and challenges relating to support for smoke-free housing that may
not be adequately addressed in structured interviews. This may allow participants to speak freely
about sensitive topics they otherwise would not be able to elaborate on.
At the individual level, tenants that smoke would need to realize that smoke-free policies
can only be effective if they change their habits voluntarily. Previous research found that the
most persuasive messages to promote a smoke-free housing policy related to nonsmokers’
individual rights such as, “You have the right to breathe clean air in your home,” and the most
persuasive messages against the smoke-free policy related to smokers’ rights such as, “People
have the right to smoke in their own homes.” Possible strategies to address these challenges that
have not been reported in previous literature could include clearer messages about how smoke
travels through vent systems and the dangers of SHS, ensuring the focus is on the smoke rather
than the smoker, and tangible activities to involve nonsmokers in promoting (rather than only
enforcing) the policy. At the organizational level, the smoke-free policy may be implemented in
MUH with not much staff, providing challenges for constant enforce of the policy. Potential
strategies that rely less on enforcement could include partnerships with community organizations

100
to provide professional cessation support and separating out cessation from enforcement. At the
community level, education for landlords on the investment they are making on their properties
by implementing smoke-free policies can be helpful. In turn, residents may find it less socially
acceptable to smoke inside units and buildings that are well maintained.
These studies may provide insight into the effectiveness of building smoke-free policies
and if additional policy enforcement is needed to mitigate exposure to vulnerable populations.
These findings underscore the importance of tailored interventions that consider the unique
sociocultural contexts within ethnic communities to effectively address barriers to protecting
against secondhand smoke exposure. By acknowledging and addressing these disparities, public
health initiatives can better target resources and strategies to promote smoke-free environments
and mitigate the health risks associated with secondhand smoke.
Residents and smoke-free advocacy groups have expressed the need for cessation support
for tenants and the use of tiered enforcement for individuals that violate smoke-free policies
(e.g., warnings, then fines, then eviction as a last resort) as an enforcement strategy (Patel et al.,
2022; Peterson et al., 2020). This warrants additional research and should be considered in new
policy implementation along with language that includes e-cigarette and marijuana use in
provisions. If implemented in a structured and equitable way, MUH policies can have the
potential of changing social norms and make smoking in the home less socially acceptable.
Organizations like the American Nonsmokers’ Rights Foundation (ANRF) have
published guidelines for model ordinances for smoke-free buildings and empower nonsmoking
residents to educate themselves on the harms of secondhand smoke exposure in their buildings
and how they may be able to address their complaints with neighbors and their landlords.
Recommendations from ANRF for handling unwanted tobacco smoke for tenants are similar to

101
the recommendations from focus group data and include highlight encouraging management to
create a smokefree environment by adding no-smoking language to tenants’ leases, educating
themselves on the harms associated with smoking and SHS exposure, taking an educational and
friendly approach with tenants who may smoke and trying to resolve the situation amicably.
Finally, finding allies in other tenants, keeping documentation and doctors’ notes regarding the
effects of SHS on tenants’ health is important if it is disturbing one’s quality of live. As a last
resort, ANRF recommends consulting an attorney to hold building management for ensuring a
safe smoke-free home environment for residents (American Nonsmokers’ Rights Foundation,
2024).
In addition to these recommendations, broader policies may also prove to be useful by
establishing a single all-encompassing smoke-free policy requiring all MUH properties in the
County of Los Angeles to be 100% smoke-free to protect all tenants. By identifying a policyenforcement model that meets the needs of both tenants and owners, having open dialogue
among community organizations and tenants and landlords, and promoting access to resources
that help people quit smoking may aid in the process of implementing smoke-free policies. In
addition to address cigarette smoking cessation, equitable measures for medical marijuana use
are needed. Having smoking and non-smoking parts of buildings, and designated smoking areas
and “smoking times” during the day may aide in the implementation process to ensure equitable
enforcement for individuals who use medical marijuana for health reasons.
The findings from this research can be useful for identifying groups that do not support
comprehensive policies and aid in the implementation of targeted interventions, such as cessation
services for populations with high rates of tobacco or marijuana use, and health education to help
reduce SHS exposure in the home. Data from these three studies have the potential to facilitate

102
meaningful engagement among community stakeholders; including landlords, managers,
residents of MUH, and public health professionals to address these issues and improve
enforcement and implement strategies for reducing exposure. The data in these studies were
collected before and during the COVID-19 pandemic. Pre-pandemic data may be useful in
establishing baseline data which may be used to help assess the impact the pandemic may have
had on exposure to SHS and if policy support may increase, or decrease, because of pandemicrelated behavioral changes among the general population. Educational public health campaigns
and ongoing community engagement with smokers and nonsmokers, and addressing tobacco,
marijuana, and e-cigarette use in conjunction with one another are important steps towards
gaining community support for comprehensive smoke-free housing policies. Gaining support
will aid in optimizing implementation in communities at the highest risk for exposure. These
campaigns can be tailored to effectively communicate risks associated with tobacco and
marijuana use and secondhand smoke exposures to help empower residents to advocate for their
health. Future research should start to focus on implementing these policies to establish data and
processes about the implementation process and how best to ensure compliance among tenants.
Additionally, increasing education on the harms of SHS from tobacco, marijuana, and ecigarette aerosol will be important in the future for gathering support for smoke-free policies
among tenants. More outreach is needed in low-income communities to approach the problem of
tobacco and marijuana use at the population level. Future researchers and policy makers should
prioritize including the underrepresented ethnic groups that live in MUH in policy research and
policy implementation, greater support can be gained for MUH cigarette, e-cigarette, and
marijuana policies.

103
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Appendix A: Study Measures
TRDRP – Triangulum (Tobacco, E-Cigarettes, Marijuana)
SHS Exposure in Low SES MUH
Aim 2 Virtual Group Discussion or Phone Interview - Discussion Guide
Welcome & Explanation of Study (1 min)
Moderator tells the group: Welcome! Thank you for joining us today. My name is XXXX
and I am your group leader. (Present other staff by names) will also be helping me today.
We all work for the University of Southern California, Department of Preventive
Medicine and the Institute for Health Promotion and Disease Prevention. We have
invited you to this discussion to hear your opinions about smoking, vaping, marijuana,
and secondhand smoke in your apartment complex. We also want to hear what you think
about current and potential future policies at your apartment complex. We will also ask
you about the ways that you communicate with friends and neighbors in your apartment
complex and community.
Our goal is to better understand how we can create a healthier environment for
everyone. Our discussion will take between 30 minutes to one hour. There are no right or
wrong answers, just your honest opinions. We'd like to hear from each of you about these
questions.
Consenting Focus Group Participants (3-5 minutes)
Instruction: Prior to inviting participants the discussion, participants will be asked to for
verbal consent to participate in our research study and will be sent an anchoring internet
survey to complete. The survey will also be used to check for participant eligibility (meet
age, race/ethnicity, and live in a study selected zip code). Moderator will remind
participants what they verbally consented to before starting the discussion.
Moderator tells group: Before we get started with our focus group discussion, we would
like to obtain verbal consent for your participation. Feel free to ask any questions about
the study that you may have about completing this study.
Self-Introductions (5 min)
Moderator tells group: We now want to ask that each of you introduce yourself using
your first name and age.
Discussion Ground Rules (5 min)
Instruction: The moderator will cover all the rules about participation.
Moderator tells group: Before we begin, I would like to cover some ground rules about
your participation in this discussion.
1. This meeting will be like participating in a survey except that it is a talking
circle, not one-on-one; it’s an informal discussion.
2. Please relax and be comfortable.

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3. Please know that you don’t have to answer a question if you prefer not to.
When we come to you, if you prefer not to answer, just say “I pass.”
However, we hope that you will participate fully.
4. Please let us know if you agree or disagree with what others say; there are
no right or wrong answers.
5. Please speak one at a time. We are recording the discussion and the
discussion assistant is taking notes. The recording will be used for our
research study purposes so we can write out the information fully and do not
lose any aspect of what you tell us. Please share your comments with
everyone in the meeting.
6. Once the discussion has been completed, we will review the recording and
write a report on what we have learned. All of your responses will be kept
confidential. For reporting purposes, we might use your age and your first
name.
7. From time to time, I might have to move the discussion forward when
there is still more to say about the topic, we are on so that we can stay on
track. I hope you’ll understand.
8. If you have a cell phone, please make sure to turn it off or put it on mute.
We would like to reduce the number of distractions during this meeting.
Are there any questions?
Main Body of Interview
Moderator tells group: Thank you for introducing yourself. Let’s go ahead and get
started.
Knowledge, Attitudes, Beliefs about Tobacco, E-cigarettes, and Marijuana
1. First, I would like to ask, what are your thoughts about tobacco? (1-3 minutes)
a. Probe: Do you think that it is harmful to your health?
2. What do you think about electronic cigarettes?
a. Probe: Do you think that it is harmful to your health?
b. Probe: Do you think they are more harmful, just as harmful, or less
harmful than regular cigarettes?
3. What are your thoughts about Marijuana?
a. Probe: Do you think that it is harmful to your health?
b. Probe: Do you think there is a difference between medical and
recreational marijuana?
Knowledge Regarding Secondhand and Thirdhand Smoke
4. What is the first thing that comes to mind when you hear the words “secondhand
smoke.”? (1-3 minutes)
a. Probe (How do you define secondhand smoke?)
b. (Provide definition if participants struggle to explain what it is) \
c. Secondhand smoke definition – Secondhand smoke is the smoke blown by
a smoker from a cigarette, cigar, or pipe.

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5. Do you think secondhand smoke is a problem?
a. Probe: Why? /Why not?
6. Probe: How do you think that secondhand smoke affects our health? (1-3
minutes) Do you think that the smoke or aerosol from these three different products
(tobacco, marijuana, electronic cigarettes) have different levels of harm?
a. Probe: For example, is Marijuana secondhand smoke more harmful than
tobacco smoke, or aerosols from electronic cigarettes?
7. Have you heard about thirdhand smoke?
a. Probe: How do you define thirdhand smoke?
b. (Provide definition if participants struggle to explain what it is)\
c. Thirdhand smoke definition – Third hand smoke are the particles from
smoke that stick to things once the smoking is over. It can cling on things such
as walls, carpets, floors, curtains, furniture, etc.
8. Do you think Thirdhand smoke is harmful to people’s health?
a. Probe: Why?/Why not?
b. Probe: Do you think that the thirdhand smoke from these three different products
(tobacco, marijuana, electronic cigarettes) have different levels of harm?
9. What would you be interest in learning about third hand smoke?
a. Probe: what type of information would you like to have?
Moderator tells group: From now on, when I refer to smoking, vaping, secondhand or thirdhand
smoke, I will refer to it as it relates to tobacco, marijuana, and electronic cigarettes.

Exposure to Secondhand Smoke in Multi-Unit Housing
10. What kind of rules, if any, do you have about smoking or vaping in your
apartment?
a. Probe: are they the same for all three products (tobacco, marijuana,
electronic cigarettes)?
11. Have you ever had tobacco or marijuana smoke or e-cigarette aerosols drift into
your apartment?
a. Probe: If yes, how often does smoke drift into your apartment?
b. Probe: If yes, where did it come from? (Examples: another unit, air vents,
windows, laundry room, recreation area, balcony/patio, parking area,
elevator, courtyard, lobby/entrance, stairs/hallway, mailroom).
c. Probe: What have you done as a result of cigarette smoke drifting into
your apartment? (Examples: complain to smoker, neighbor, or manager;
raise issue at tenant association meeting; closed doors/windows; nothing.)
12. Do you ever smell cigarette smoke around your apartment or building? How
about other products, such as e-cigarettes or marijuana?
a. Probe: If yes, where did it come from? (Examples: another unit, air vents,
windows, laundry room, recreation area, balcony/patio, parking area,
elevator, courtyard, lobby/entrance, stairs/hallway, mailroom)
b. Probe: If yes, how often do you smell cigarette or marijuana smoke or ecigarette aerosols around your apartment or building?
c. Probe: What have you done as a result of smelling smoke or e-cig
aerosols around your apartment or building? (Examples: complain to the

119
smoker/vaper, neighbor, or manager; raise issue at tenant association
meeting; closed doors/windows; nothing.)
13. Since we have been asked to “shelter at home” due to the COVID-19, aka
coronavirus pandemic, have you experienced an increase in secondhand smoke
exposure in your home from either tobacco or marijuana?
a. Have you noticed an increase in smoking or vaping tobacco and/or
marijuana from your neighbors?
14. What are your thoughts regarding smoking tobacco or marijuana as it relates to
the COVID-19, AKA Coronavirus pandemic?
a. What do you know about the negative or positive effects of tobacco and
COVID-19?
i.Can it worsen illness?
ii.Can it alleviate symptoms?
b. What do you know about the negative or positive effects of marijuana and
COVID-19?
i.Can it worsen illness?
ii.Can it alleviate symptoms?
Housing Smoking & Vaping Policy Preferences
15. What kind of rules does your apartment complex/building have about smoking or
vaping?
a. Probe: Is it the same for all three products (tobacco, marijuana,
electronic cigarettes)?
b. Probe: How often do you ever notice someone breaking the rules about
smoking?
c. Probe: What happens if someone breaks the smoking rules at your
apartment complex/building?
16. What kind of rules about smoking or vaping would you like to see for your
apartment complex/building? (Examples: smoke/vape-free common areas, pools,
exercise areas, walkways, balconies, patios, laundry rooms, 20 feet from doors and
windows, individual units, entirely smoke/vape-free building.)
a. Probe: Would you include all three products (tobacco, marijuana,
electronic cigarettes) in a smoke/vape-free policy?
b. Probe: What would be some benefits of having smoke/vape-free rules for
your apartment complex/buildings?
c. Probe: What concerns would you have about having smoke/vape-free
rules for your apartment complex/buildings?
d. Are there areas in the building that you are ok with allowing people to
smoke? Like a designated smoking area?
17. How would you feel about living in a smoke/vape-free apartment/building that
includes restrictions on all three products (tobacco, marijuana, electronic cigarettes)?
a. Probe: If your apartment/building had a smoke/vape-free policy, would
you be in favor or opposed?
b. Probe: How do you think other tenants would feel if there was a
smoke/vape-free policy for the apartment complex?
c. Probe: Would tenants feel differently about the three products (tobacco,
marijuana, electronic cigarettes)?

120
18. If a smoke- or vape-free policy does not exist or cannot be implemented, would
you have any concerns?
Housing and Smoking/Vaping Policy Enforcement
19. How do you think that implementing a smoke and vape-free policy that restricts
that use of tobacco, marijuana, and e-cigarettes in apartments would work to protect
other from being exposed to secondhand smoke?
20. What should happen if a tenant violates the rules or laws that prohibit smoking or
vaping in apartment buildings?
a. Probe: What should happen if a tenant signs a smoke/vape-free lease and
breaks the agreement?
b. Probe: What type of consequences would be fair (for example paying a
fine, eviction, etc.)?
21. How difficult or easy do you think it would be to enforce a smoke-free policy
that restricts the use of tobacco, marijuana, and e-cigarettes?
a. Probe: What are some concerns you have about enforced such a policy in
your apartment complex.
b. Probe: Who should enforce smoke- and vape-free policies in apartment
complexes? (Landlords, the police, the health department)?
22. How can we make sure people follow the rules or laws that limit smoking in
apartment buildings?
a. Probe: Is there anything that can be done to make it easier to make the
switch to a smoke- and vape-free policy in an apartment building
b. Probe: educational materials? Media? Number to report?
Marijuana/Cannabis related questions
1. Would it make a difference to you, if your neighbors used Marijuana in an edible
form like brownies or cookies, instead of smoking or vaping it?
2. Would it bother you less or more, or not make a difference if a neighbor was
smoking marijuana for medical reasons?
Community Feedback
20a We would like to get some clarification from you. Based on our data when asked if people
prefer to live in a non-smoking section of a building, 70% said yes. However, when asked if they
would be in favor of a 100% Tobacco/Marijuana smoke-free vape-free policy, only 57% said yes.
What would you prefer?
a. why do you think that people would like to live in the smoke-free section but are
not in favor of a 100% Tobacco/Marijuana smoke-free vape-free policy?
Communication
3. How would you like to receive information about new laws that are implemented related
to smoke- or vape-free policies in apartments?
Closing
4. Is there anything else you’d like us to know about your experience or opinions of
second-hand smoke as it relates to the three products (tobacco, marijuana, electronic
cigarettes) in your apartment building/complex or anything else you’d like to share?
Closing Remarks: Thank you for our time and willingness to share your experiences. The next
steps in our project are to continue conducting discussions with tenants and property managers
and owners and determine similarities and trends concerning second and thirdhand smoke and
policies prohibiting smoking on the properties.

Abstract (if available)

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Asset Metadata

Creator Galstyan, Ellen (author)

Core Title Smoke-free housing policies and secondhand smoke exposure in low income multiunit housing in Los Angeles County

School Keck School of Medicine

Degree Doctor of Philosophy

Degree Program Preventive Medicine (Health Behavior)

Degree Conferral Date 2024-05

Publication Date 06/05/2024

Defense Date 05/24/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag electronic cigarettes,multiunit housing,OAI-PMH Harvest,secondhand marijuana smoke exposure,secondhand smoke,secondhand tobacco smoke exposure

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Advisor Sussman, Steven (committee chair), Baezconde-Garbanati, Lourdes (committee member), Palinkas, Lawrence (committee member), Steinberg, Jane (committee member), Unger, Jennifer (committee member)

Creator Email egalstya@usc.edu,elgalstyan@yahoo.com

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