Health outcomes and health care spending among residents of smoke-free public housing

摘要 烟草是美国主要的可预防的死亡原因，既影响烟草使用者， 暴露在二手烟和三手烟中。低收入、多单元住房的居民特别多， 易受烟草烟雾的影响。低收入者更有可能吸烟，这反过来又 增加了与他们共享环境的人接触烟草烟雾的机会。2015年11月，美国 住房和城市发展部（HUD）提出了一项规则，要求联邦政府资助的公共 住房当局（PHAs）为他们的住宅制定无烟政策，可能会减少 与吸烟和烟草烟雾暴露有关的发病率。马萨诸塞州的PHA已经在 无烟住房政策的前沿和他们的经验提供了一个早期的机会， HUD提议的无烟政策的健康益处，以及其他低收入国家的无烟政策 住房首席研究员和他的同事已经证明，有烟雾的公共住房开发- 免费政策的空气中烟草烟雾污染水平（细颗粒物[PM2.5]，尼古丁）低于 那些没有无烟政策的人。此外，他们发现，在波士顿住房管理局推出其 在2012年的无烟政策下，居民公寓中空气中的尼古丁下降了70%。虽然证据 无烟住房政策减少PHAs中的烟草烟雾污染是有希望的，现有的研究 具有明显的局限性。此外，还没有研究检查居民健康结果的变化 随着无烟住房政策的实施。吸烟者和不吸烟者都被期望 在多单元住房内禁止吸烟。我们建议评估潜在的健康影响 无烟公共住房政策在烟草治疗使用、信号不良临床事件和医疗保健方面的作用 马萨诸塞州所有公共住房居民的支出。我们的研究将使用强准实验 设计，以评估一系列自然实验所产生的交错引进无烟 在该州241个PHA中，有27%以上的政策。没有采取无烟政策的临时危险区居民将 作为同期对照。我们将使用2008-2018年的数据来衡量PHA居民的结果， 马萨诸塞州所有付款人索赔数据库（APCD），一个独特的综合资源，包括健康 该州几乎所有健康保险公司为所有被保险居民提出的护理索赔。此外，我们还将提供数据 在马萨诸塞州戒烟热线上的烟草治疗使用。这项研究的结果将有政策- 对国家资助的PHAs中无烟住房的相关影响（HUD政策不涵盖），其他 补贴和低收入住房以及全国的私人住房市场。

ABSTRACT Tobacco is the leading preventable cause of death in the United States, affecting both tobacco users and those exposed to second- and third hand smoke. Residents of low-income, multiunit housing are particularly vulnerable to tobacco smoke exposure. Low-income individuals are more likely to smoke, which in turn increases the tobacco smoke exposure of people sharing their environments. In November of 2015, the U.S. Department of Housing and Urban Development (HUD) proposed a rule requiring federally-funded public housing authorities (PHAs) to establish smoke-free policies for their residences, potentially reducing the morbidity associated with smoking and tobacco smoke exposure. Massachusetts PHAs have been at the forefront of smoke-free housing policies and their experience provides an early opportunity to assess the health benefits of HUD's proposed smoke-free policy, as well as smoke-free policies in other low-income housing. The principal investigator and colleagues have shown that public housing developments with smoke- free policies have lower levels of tobacco smoke pollution in the air (fine particle matter [PM2.5], nicotine) than those without smoke-free policies. In addition, they found that after the Boston Housing Authority introduced its smoke-free policy in 2012, airborne nicotine in residents' apartments went down by 70%. While the evidence that smoke-free housing policies reduce tobacco smoke pollution in PHAs is promising, the existing research has notable limitations. Furthermore, no studies have yet examined changes in health outcomes for residents following the introduction of smoke-free housing policies. Smokers and non-smokers alike are expected to benefit from the prohibition of smoking in multiunit housing. We propose assessing the potential health impact of smoke-free public housing policies on tobacco treatment use, signal adverse clinical events, and health care spending for all public housing residents in Massachusetts. Our study will use a strong quasi-experimental design to evaluate a series of natural experiments arising from the staggered introduction of smoke-free policies in ≥27% of the state's 241 PHAs. Residents in PHAs that do not adopt smoke-free policies will serve as concurrent controls. We will measure outcomes for PHA residents using 2008-2018 data from the Massachusetts All Payer Claims Database (APCD), a uniquely comprehensive resource that includes health care claims for all insured residents from nearly all health insurers in the state. In addition, we will include data on tobacco treatment use from the Massachusetts state quit line. Findings from this study will have policy- relevant implications for smoke-free housing in state-funded PHAs (not covered by HUD's policy), other subsidized and low-income housing, and private housing markets nationally.