Multi-Level Influences of Smoke-Free Policies in Subsidized Housing: Applying the COM-B Model and Neighborhood Assessments to Inform Smoke-Free Policies

Abstract

Smoke-free policies in multi-unit housing are associated with reduced exposure to secondhand smoke (SHS); however, attitudes toward comprehensive smoke-free policies among residents in subsidized multi-unit housing are unknown. In this mixed-methods study, we explored the socio-ecological context for tobacco and cannabis use and attitudes toward policies restricting indoor use of these products through interviews with residents (N = 134) and staff (N = 22) in 15 federally subsidized multi-unit housing in San Francisco, California. We conducted a geo-spatial and ethnographic environmental assessment by mapping alcohol, cannabis, and tobacco retail density using ArcGIS, and conducted systematic social observations of the neighborhood around each site for environmental cues to tobacco use. We used the Capability, Opportunity, and Motivation behavior (COM-B) model to identify factors that might influence implementation of smoke-free policies in multi-unit housing. Knowledge and attitudes toward tobacco and cannabis use, social norms around smoking, neighborhood violence, and cannabis legalization were some of the social-ecological factors that influenced tobacco use. There was spatial variation in the availability of alcohol, cannabis, and tobacco stores around sites, which may have influenced residents' ability to maintain smoke-free homes. Lack of skill on how to moderate indoor smoking (psychological capability), lack of safe neighborhoods (physical opportunity), and the stigma of smoking outdoors in multi-unit housing (motivation) were some of the barriers to adopting a smoke-free home. Interventions to increase adoption of smoke-free policies in multi-unit housing need to address the co-use of tobacco and cannabis and commercial and environmental determinants of tobacco use to facilitate smoke-free living.

Keywords: cannabis use; neighborhood environment; smoke-free housing; smoke-free policies; subsidized housing; tobacco cessation; tobacco-related disparities.

Figure 1

Social-Ecological Model Describing the Context of Tobacco Use Among Residents and Staff in Subsidized Multi-Unit Housing in San Francisco, CA

Figure 2

Capability Opportunity Motivation-Behavior (COM-B) Model for Barriers to Smoke-Free Home Adoption in Multi-Unit Subsidized Housing in San Francisco, CA

Figure 3

Map of All Housing Sites With Neighboring Alcohol Outlets, Cannabis Dispensaries, and Tobacco Retailers Around Each Site (N = 15 Sites)

Figure 4

Map of Alcohol Outlets, Cannabis Dispensaries, and Tobacco Retailers Around Site 1, Site 2, Site 8, and Site 14^{a a}Site score is the composite score (range 0–4) of neighborhood-level exposure to alcohol, cannabis, substance use, and tobacco paraphernalia around each site. A score of 4 with a red buffer indicates high level of exposure around each site. For example, Sites 1 and 2 had neighborhood assessment scores of 4.

Figure 5

Map of Alcohol Outlets, Cannabis Dispensaries, and Tobacco Retailers Around Site 13, Site 15, Site 7, Site 6, and Site 10^{a a}Site score is the composite score (range 0 to 4) of neighborhood-level exposure to alcohol, cannabis, substance use, and tobacco paraphernalia around each site. A score of 4 with a red buffer indicates high level of exposure. For example, site 15 had neighborhood assessment scores of 4.