In British Columbia, as elsewhere in the world, we have become increasingly protected against the dangers and nuisance of secondhand smoke in many settings, including at work and in public. Ironically, for those of us living in multi-unit dwellings, be it as renters or owners, one setting in which there remains virtually no protection is where we spend the most time—in our homes.
In 1964 Surgeon General Luther Terry made clear the immense dangers of smoking, yet two generations later smoking remains, by far, the leading preventable cause of death in Canada and worldwide. In fact, worldwide mortality is rising rapidly. As shameful as that is, it is the effects that the smoker has on others that is most unambiguously morally unacceptable.
Secondhand smoke contains over 50 known cancer-causing chemicals, and the surgeon general has determined that no level of exposure to secondhand smoke can be considered safe.
Certain individuals are at increased risk, including pregnant women and their fetuses, infants and children, and adults with asthma or pre-existing heart disease. A very recent estimate put total deaths from secondhand smoke worldwide at 600000.
Given recent and ongoing trends toward urban densification, an increasing fraction of the population is now living in multi-unit dwellings (i.e., apartments and condominiums), and potentially exposed to the secondhand smoke of their neighbors. This occurs both indoor and outdoors.
Indoors, secondhand smoke seeps through connections between units via the ventilation system, electrical outlets, cracks and gaps in the walls and floors, and around sinks, countertops, and radiators, and off-gassing from carpets.
Outdoors, secondhand smoke rises from balconies of units below, preventing use of one’s patio and entering the homes of nonsmokers unless windows are always kept shut (especially problematic during summertime). Toxic residues persist on indoor surfaces, such as furniture and flooring, and are later re-emitted, a phenomenon referred to as thirdhand smoke.
The scope of the problem is quite surprising, and it is detailed by a 2008 BC Stats survey commissioned by the Heart and Stroke Foundation of BC and Yukon on their related smokefreehousingbc.ca website (an excellent resource which also lists actions that may be taken by those having the problem).
Thirty-four percent of apartment- and condominium-dwellers are exposed to unwanted secondhand smoke from their neighbors, and about half of those are bothered “quite a bit” by it. Nevertheless only 23% of those exposed complain to their landlords, with most failing to recognize that they are not alone, and instead suffering the problem in silence.
BC Stats calculates that up to 100 000 BC renters may move annually over this issue. A strong majority of those surveyed would prefer to live in a 100% smoke-free (including balconies) building—similar to results in surveys elsewhere. However, almost none exist in BC.
In downtown Vancouver this is true at any price level, as confirmed by my searches and communications with Condominium Home Owners’ Association of BC president Tony Gioventu, who brings the issue up regularly in the association’s seminars.
A parallel survey on the same site revealed that most strata corporations and apartment owners/managers recognize that there is a market for smoke-free housing and expect the issue to become more important in the future; however, to date, a combination of inertia and a misplaced fear of transgressing so-called smokers’ rights have prevented this from being translated into building policy or governmental legislation.
Although few academic studies have specifically looked at secondhand smoke exposure in multi-unit dwellings, two recent articles are worthy of mention.
One looked at actual gas transfer between units in buildings of various ages before and after careful implementation of best practice air-sealing procedures and ventilation improvements.
It concluded that while transfer was less in newer buildings, and moderately reduced after treatments, it could not be eliminated (including in units meeting LEED [Leadership in Energy and Environmental Design] criteria), and that such modifications were not a practical means of solving secondhand smoke transmission.
In the second, children in nonsmoking homes living in apartments had 45% higher cotinine levels than those living in detached houses. Author Dr Jonathan Winickoff commented to the BBC, “If your neighbors are smoking then you are exposed if you live through the wall… in apartment buildings this effect is magnified. Smoke contaminates the whole building.”
The concept that separate smoking and nonsmoking areas are ineffective is already reflected in the 100% smoke-free status of public buildings and hotels, where smoking floors are no longer permitted in much of the world, including here in British Columbia. Visitors to our cities are better protected against secondhand smoke than residents.
Accordingly, preventing secondhand smoke exposure in multi-unit dwellings is becoming increasingly recognized as a significant unmet need, including being cited by a recent New England Journal of Medicine article, and included in the 2010 shadow report, Canada’s Implementation of the Framework Convention on Tobacco Control, prepared by Physicians for a Smoke-Free Canada and others.
Furthermore, a memorandum issued by the Department of Housing and Urban Development on 17 July 2009 stated that it “strongly encourages public housing authorities to implement nonsmoking policies in some or all of their public housing units,” an important shift in American federal policy.
The inevitable response of smokers toward any call for increased availability of smoke-free housing is predictable. Tobacco is a legal product, and it is their presumed “right” to be allowed to smoke in their homes.
However, multiple legal opinions have concluded that no such right exists, only, for the moment, an unregulated freedom (court cases to date have tended to side with the nonsmoking complainants, but these are time-consuming and expensive—it is currently much easier to move and hope the problem doesn’t recur).
Multi-unit dwellings represent a conflict of individual freedoms with respect to smoking, and one side must be given precedence over the other. We currently have bylaws prohibiting one from disturbing one’s neighbors in many comparatively minor ways. Prohibiting smoking in multi-unit dwellings is no different from prohibiting loud music or pets. That something is legal does not mean it is unregulated.
Approximately two-thirds of smokers already avoid smoking inside their homes. Requiring smokers to keep their smoke out of the homes of others as well is not too much to ask.
While any strata council or apartment owner can currently convert their building to a smoke-free status, only a very few have done so, despite obvious benefits including decreased maintenance and insurance costs, decreased fire risk, and improved tenants’ health.
Several jurisdictions in Canada and the US have implemented smoke-free policies for at least some of their public housing, including here in Vancouver. Several small cities in California have gone further, with partial or total bans applied to all multi-unit dwellings. If a total ban, although justifiable, is currently viewed as politically untenable, there are several less controversial steps that could be taken.
• Requiring all future buildings to be smoke-free (addressing the gross imbalance/social injustice of the current ratio of nonsmokers desiring smoke-free buildings to smoke-free multi-unit dwellings in the city of Vancouver and elsewhere).
• Requiring a contiguous portion of existing buildings to be declared smoke-free (such would require grandfathering, but an effect would be seen over time).
• Requiring leases to state the smoking status of units and floors.
• Listing secondhand smoke as a nuisance and breach of the “right to quiet enjoyment” in the Residential Tenancy Act so that this doesn’t have to be repetitively established in each incident or litigation.
• Various incentives for strata councils and rental building owners to convert to a nonsmoking status.
• An educational campaign aimed both at getting smokers to avoid smoking in their units and informing exposed nonsmokers of their rights and options.
I urge you to ask your patients living in multi-unit dwellings whether they are being exposed to unwanted secondhand smoke and, if so, educate them on what steps they may take toward a remedy. They should no longer remain among the many currently suffering in silence.
This article has been peer reviewed by the BCMJ Editorial Board.
1. US Surgeon General. The Health Consequences of Involuntary Exposure to Tobacco Smoke: A report of the surgeon general. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2006. Accessed 7 September 2011. www.surgeongeneral.gov/library/secondhandsmoke.
2. Oberg M, Jaakkola MS, Woodward A, et al. Worldwide burden of disease from exposure to secondhand smoke: A retrospective analysis of data from 192 countries. Lancet 2011;9760:139-146.
3. BC Stats/Smoke-free Housing in Multi-unit Dwellings Initiative. 2008 Baseline Survey. Accessed 7 September 2011. www.smokefreehousingbc.ca/tenants/market.html.
4. Bohac DL, Hewett MJ, Hammond SK, et al. Secondhand smoke transfer and reductions by air sealing and ventilation in multiunit buildings: PFT and nicotine verification. Indoor Air 2011;21:36-44.
5. Wilson KM, Klein JD, Blumkin AK, et al. Tobacco-smoke exposure in children who live in multiunit housing. Pediatrics 2011;1:85-92.
6. Flat-dwelling children exposed to neighbours’ smoke too. BBC News. 13 December 2010. Accessed 7 September 2011. www.bbc.co.uk/news/health-11969074?print=true.
7. Schroeder S, Warner KE. Don’t forget tobacco. N Engl J Med 2010;363:201-204.
8. Global Tobacco Control Forum. Canada’s Implementation of the Framework Convention on Tobacco Control: A civil society “shadow report.” Ottawa 2010. Accessed 7 September 2011. www.smoke-free.ca/pdf_1/FCTC-Shadow-2010-Canada.pdf.
9. Winickoff JP, Gottlieb M, Mello MM. Regulation of smoking in public housing. N Engl J Med 2010;362:2319-2325.
Dr Kreisman is a clinical assistant professor in the Division of Endocrinology at St. Paul’s Hospital and the University of British Columbia.
Above is the information needed to cite this article in your paper or presentation. The International Committee
of Medical Journal Editors (ICMJE) recommends the following citation style, which is the now nearly universally
accepted citation style for scientific papers:
Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
About the ICMJE and citation styles
The ICMJE is small group of editors of general medical journals who first met informally in Vancouver, British Columbia, in 1978 to establish guidelines for the format of manuscripts submitted to their journals. The group became known as the Vancouver Group. Its requirements for manuscripts, including formats for bibliographic references developed by the U.S. National Library of Medicine (NLM), were first published in 1979. The Vancouver Group expanded and evolved into the International Committee of Medical Journal Editors (ICMJE), which meets annually. The ICMJE created the Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals to help authors and editors create and distribute accurate, clear, easily accessible reports of biomedical studies.
An alternate version of ICMJE style is to additionally list the month an issue number, but since most journals use continuous pagination, the shorter form provides sufficient information to locate the reference. The NLM now lists all authors.
BCMJ standard citation style is a slight modification of the ICMJE/NLM style, as follows:
- Only the first three authors are listed, followed by "et al."
- There is no period after the journal name.
- Page numbers are not abbreviated.
For more information on the ICMJE Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, visit www.icmje.org