Prepared by Polaris Research & Development 
Melinda Moore 
For the San Francisco Department of Public Health 
Tobacco Free Project 

With funding provided by the San Francisco Tobacco Free Project, the American Lung Association (ALA) sought to address the issue of secondhand smoke exposure in some of the City’s densest, multi-unit housing complexes through the:

•  Adoption of more comprehensive smokefree policies in the targeted buildings
•  Enforcement of existing policies in the targeted buildings

Their actual funded objective was:
“By December 2003, 5-8 core advocates will work with appropriate policy making bodies so that at least 4 to 6 multi-unit housing complexes in San Francisco receiving interventions will adopt, implement and/or enforce tobacco free policies governing indoor private living spaces, indoor common areas, and/or outdoor areas of the complex.”

As indicated in the table below, ALA was very successful in achieving their objective as five of the six multi-unit housing complexes (MUHC) adopted new and/or enforced existing smokefree policies. In addition to adopting a new smokefree policy, five of the six also institutionalized their policies by including it in written documentation such as a tenant handbook or Community Rules book. Another hotel (not one of the targeted six) owned by Caritas Management (along with Hotel Madrid and Apollo Hotel) also adopted a new smokefree entrances, balconies, patios and courtyards policy.)

Like all of the community capacity building projects funded by the Tobacco Free Project, ALA utilized the San Francisco Tobacco Free Project’s Community Action Model (CAM). The model is asset-based and builds on the strengths and capacities of a community to create change from within by galvanizing its resources (including community members and local agencies) to change environmental factors promoting economic and environmental inequalities. Fundamental to the model is a critical analysis that identifies the underlying social, economic and environmental forces creating the health and social inequalities that the community wants to address. This data gathering phase is called the “diagnosis”. Funded agencies undergo a process to select an “action” that fits the following guidelines: 1) it is achievable, 2) it is sustainable, and 3) it compels a group/agency/organization to change the place their live for the well being of all. The CAM Model includes the following steps:

1. Train participants (Community Action Teams)
2. Define, design and do a community diagnosis (process for finding the root causes of a community concern or issue and discovering the resources to overcome it.
3. Analyze the results of the diagnosis and prepare findings
4. Select, plan and implement an action based on the findings in Step 3
5. Enforce and maintain the action

ALA Advocates’ Strategy 

It was important to ALA staff and their advocates that they adopt an advocacy approach that was both “bottoms up” and “top down’. That is, they did not want to implement secondhand smoke policies that were not supported by the tenants, nor did they want to initiate an adversarial relationship with building managers, owners or other key decision makers who will ultimately be charged with enforcing such polices. This key decision was fundamental in guiding their approach to this work. The strategy also included educating tenants and owners about the dangers of secondhand smoke, assessing levels of support for various types of smokefree policies, and selecting and advocating those policies that had the greatest amount of support among tenants. A policy “menu” was presented to each MUHC that had been tailored specifically to the concerns of that building, and tenants and advocates then discussed which smokefree policy should be advocated for at that particular site.(See Appendix A for Project’s Theory of Change and Logic Model.)

CAM Step 1: Training 

The first step in the Community Action Model is recruiting and training advocates. ALA recruited and hired a total of 18 advocates at the project’s onset. Ten of the advocates were hired as “core” advocates and eight others as “housing” advocates. Core advocates came from throughout the City and were hired first. They were recruited using three primary methods including: 1) direct mail, email and fax, 2) site visits to a wide range of community based organizations, and 3) attendance at community events. The latter provided the most efficient source of recruitment, accounting for the majority (55%) of the advocates. The types of events used included Cesar Chavez Festival, tenants rally, Bayview Hunters Point Health and Environmental Resource Center Radon Fair, etc. According to ALA staff, events were particularly useful because they provided an opportunity for staff to reach potential advocates directly and in-person rather than relying on an impersonal form of communication or another organization to explain the project and engage potential advocates.

A total of 12 housing advocates were recruited and ten completed the orientation and began the project. The Community Housing Advocates were recruited from among the tenants of the buildings that would receive the intervention.

The advocates were fairly evenly mixed between male and female (55.5% vs. 44.5% respectively). There was a great deal of ethnic diversity among both community and housing advocates. The majority (55.5%) of the advocates were African American, followed by Asian (22.2%), White (16.7%), “other” (5.5%). The ages of the advocates varied greatly, from early teen to adults 40-60 years of age. The greatest proportion of the advocates (33.3%) was between 22 and 40 years of age.

Advocates were provided with ongoing training as well as attending smaller, regular team meetings facilitated by American Lung Association staff. Community Health Advocates received a total of 10 training/meetings and Housing Advocates from 7 to 10 training/meetings (equivalent to more than 36 hours of training).

Training topics included:

• Community Action Model
• Global tobacco issues
• Team buildings
• Introduction to Photovoice
• Asset mapping
• Policy presentations
• Media advocacy
• Working with the press

Sample Task Assignment 

• Info. gathering on housing units
• Community mapping
• Surveying residents
• Planning and implementing education awareness sessions
• Policy presentations to management
• Celebration planning

Following each of the meeting/training sessions advocates met in smaller teams to develop mini-workplans and assign responsibilities to advocates to take on various tasks before the next meeting with the large group.

Advocate Capacity Building 

Advocates were surveyed at the beginning and at the end of the project with regard to their skill acquisition. Using a rating scale from 1 to 10 with 1 being “don’t know how to do it a tall” and 10 being “I can do it well”, advocates were asked to rate how much they learned about a particular skill as a result of their participation in the project.

Advocates were also asked to indicate the skills they wished they had learned while participating in the project but didn’t.

Finally, advocates were asked if they believed they will use any of the skills they learned in the project in the future, and if so, how they might use those skills. Fully one hundred percent of respondents (14) indicated they had learned skills they will use in the future, and the their responses as to how they might use these future skills included a broad range of ideas:

• “The research we did will help me write papers in the future, I want to be a doctor.”
• “I will need public speaking abilities when I go to college and I feel like I am much better at it now.”
• “I will use the skills I learned to continue to empower my community.”
• “I can use the skills I learned to educate my community.”
• “I feel much more confident now about talking to people “

Advocate Retention 

ALA was very successful in maintaining both their Community Health and their Housing Advocates. Eight of the original twelve Community Health Advocates (66.6%) and nine of the original twelve (75%) of the Housing Advocates were retained throughout the two year project. Of the total of seven advocates that left the project before its conclusion, four (57.1%) left without notice or were let go because they missed too many meetings, and three (42.9%) left the because of personal commitments, e.g. school, etc.

I learned how to be responsible (this was my first real job). I also learned about how to make presentations to groups. I will use this skill in the future because I plan on running for office again (Youth Council). 

Advocate 

One youth advocate was even inspired to start his own “Youth to the Rescue” project in which he provider’s anti-tobacco information to elementary school youth. 

CAM Step 2: Community Diagnosis 

Advocates then began a “diagnosis” or data gathering phase to research the problem of secondhand smoke in San Francisco’s multi-unit housing complexes. The work was broken into two different sub-phases. First, advocates collected information about San Francisco’s 11 supervisorial districts to determine which districts had the highest density of multi-unit housing, the demographic and income data of the residents of these buildings, and what kinds of tobacco-related policies (if any) were already in place in these buildings. At the conclusion of this phase advocates compiled a list of 30 possible housing sites at which to conduct the intervention. Advocates then called and visited the 30 possible intervention sites and collected the following information on each site.

• Name and address of site
• In which district it was located
• Number of units or apartments
• Number of buildings
• Existence of smokefree policies
• Type of complex (private apartment, subsidized housing, senior housing, single resident occupancy (SRO) hotel, etc.)
• Willingness to adopt smokefree policies
• Names of gatekeepers, contact people, management companies
• Presence of active Tenant Board or Association

Once the data from the 30 buildings were collected, ALA project staff met with Tobacco Free Project staff and the evaluator to narrow the list down from 30 to 10 sites. Intervention sites were selected based on advocates’ estimates of the willingness of building managers and/or tenants to work with the project, and tenant needs, e.g. buildings with a lot of children. The 10 selected buildings were located in some of the most densely populated districts of the City: Mission, Tenderloin, Western Addition, Chinatown, South of Market, and Bayview Hunters Point, and three were Single Resident Occupancy (SRO) hotels. The breakdown of buildings and districts is located in the table below.

Next an in-depth assessment of the 10 buildings was conducted to determine what types of smokefree policies would work best for each individual site. The assessment included community asset mapping, establishing relationships with management staff and conducting a survey of the tenants to assess their support of a range of possible secondhand smoke policies. Based upon the survey results, advocates used the data to develop a menu of potential policy options to implement, revise or enforce which were presented to the individual sites. Housing Advocates were hired in each of the buildings to work along with the Community Health Advocates.

As part of their diagnosis, advocates also prepared asset maps of the areas adjacent to the selected buildings. This activity proved to be quite enlightening to advocates who had not viewed many of these areas as having any assets or resources that could be capitalized on to improve the neighborhood. After conducting the mapping exercise, advocates often changed their view of the targeted neighborhoods, seeing expanded possibilities for change and acknowledging the many resources that exist even in these communities.

Tenant Surveys 

Advocates worked with project staff and the evaluator to develop an eight-question survey designed to measure residents’ knowledge of secondhand smoke issues and their support for smokefree policies. In order to maximize the number of surveys advocates could collect at any given time, advocates decided it would be best to host an educational event at each of the buildings and administer the survey to attendees. In some cases, attendance at the event was insufficient, so advocates also collected surveys door-to-door and by mail. Eventually, a total of 323 surveys were collected.

“It was really hard to get people to complete surveys. It look a lot of extra time to get the data we needed.” 

Advocate 

CAM Step 3: Analyze the Results of the Diagnosis and Prepare Findings 

Analysis of the tenant survey data revealed several key areas that advocates needed to address before moving forward with their organizing efforts:

1. Residents did not understand what a smokefree policy was, and sometimes reported that the wording of several survey questions was unclear.
2. Because they did not understand what smokefree policies were, they did not seem initially open to such policies being adopted at their buildings.
3. Many residents did not believe secondhand smoke is harmful to their health.

In spite of these issues however, tenants seemed very interested in receiving more information about secondhand smoke, including its link to asthma and appeared interested and willing to work with the project. Based upon the survey results it was determined that the advocates should design and implement an education campaign designed to inform tenants about the dangers of secondhand smoke and the benefits of smokefree policies. Initially 10 sites were selected as intervention sites, however that number was reduced to six.

As part of their efforts, advocates made every attempt to tailor their organizing efforts to the unique needs of each building. One of the tools developed by the advocates was a policy menu that was presented to each building using information about the building that had been collected by the advocates. The policy menu was based upon: building structure, resident composition, and survey responses regarding various types of smokefree policies.

SMOKEFREE MENU 

• Smokefree Common Areas
• Smokefree Play/Pool Areas
• Smokefree Units or Blocks of Units
• Smokefree Buildings or Blocks of Units
• Smokefree Entrances
• Smokefree Balconies & Patios
• Smokefree Patio Areas
• Phase in Smokefree Bldgs.

Structure: Did the building have patios, balconies or terraces where smoking could be prohibited? Was the site made up of clusters or single story buildings or tall, multi-storied buildings? Did the building have common areas like a laundry room, kitchen, garage or community room that could be designated as smokefree?

Resident composition: Did a majority of tenants smoke? Did the smokers express great interest in quitting smoking? Was there a significant number of lung sensitive tenants, e.g. children, elderly or people with lung disease?

Level of support: Which of the smokefree policies were supported by building residents according to survey results? (Common areas only, entryways, play areas, entire floors/buildings, etc.)

CAM Step 4: Select, Plan and Implement an Action based on the Findings 

Implementation 

As described earlier, the project decided to focus on 6 rather than 10 MUHCs after consulting with their Tobacco Control Section analyst. The final six buildings that were selected were:

• Hotel Marid (South of Market)
• Ping Yuen (Chinatown)
• Hayes Valley (Western Addition)
• Haight Ashbury Recovery Center, (Treasure Island)
• Cecil William Glide House (Tenderloin)
• Apollo Hotel (Mission)

After conducting tenant surveys at each of the buildings, advocates undertook the following steps.

1. Preparation of information packets (packets include summary of survey findings, media event materials, and background information on secondhand smoke.
2. Conducting awareness raising campaigns at each site
3. Presentation of policy proposals to decision makers

Awareness Raising Events 

Each awareness raising event was tailored to the specific building with the help of the housing advocates who lived in each of the selected buildings.

Hotel Madrid: An awareness-raising event was held on-site on April 17, 2003. The event included a short presentation on the tenant survey results and the menu of possible smokefree policies that might be enacted to reduce secondhand smoke. A smoking cessation facilitator also was present and gave a 1 hour presentation of what it takes to quit smoking. A total of 10 people participated and dinner was provided.

Ping Yuen: On May 3, 2003, advocates held a health fair in the outside courtyard of this large multi-storied building complex. Between 60-70 people visited the project’s table to pick up information and play a game that included questions on smoking, secondhand smoke, and asthma. Information materials were provided in both English and Chinese and prizes, snacks, and drinks were also provided to attendees at no charge.

Hayes Valley: Advocates selected a children’s art contest as the vehicle to educate building residents about secondhand smoke on May 21, 2003. Thirteen children submitted entries related to smoking and secondhand smoke and the drawings of all thirteen were used to create a calendar which was later distributed to building residents. The menu of possible smokefree policies was introduced to those present and a video “Poisoning Our Children, the Perils of Secondhand Smoke” was shown. Dinner was provided to all attendees.

Haight Ashbury Center for Recovery: At the Center for Recovery at Treasure Island, surveys were completed and collected during a regularly scheduled Health Education meeting in mid 2003. Clients at the recovery center watched a video, had lunch, and spent some time discussing how a rehabilitation program can provide an excellent support structure to help people quit smoking along with other substances.

Following the presentation, a discussion ensued at which recovery staff managers expressed the opinion that, because so many of their residents smoke, if the entryways were made smokefree, the individual unit’s balconies should remain a designated spot where people could smoke. They also expressed some concern that the new policy might be difficult to enforce. As a way to address these concerns, ALA advocates agreed to come back and provide an educational workshop for recovery center residents, describing what the new policy means and why it has been implemented.

The recovery center’s regularly scheduled Health Education meeting was again used as the venue for the secondhand smoke awareness session held on May 27, 2003. ALA staff and advocates presented information on smoking, secondhand smoke, and also showed a video on smoking cessation based upon the interest of the residents. Movie passes and nicotine gun were given to 3 of the 16 people who attended, who made a commitment to quit and surrendered their cigarettes that day.

Cecil Williams: The awareness event at Cecil Williams was presented as a Health Fair on June 7, 2003 coinciding with World No Tobacco Day. The event actually took place over a week. The advocates led a presentation discussing tobacco issues, the effects of secondhand smoke, and the menu of possible smokefree policies. A DJ played music and food was served along with activities and gifts for the children that attended. The site nurse also provided blood pressure screening to interested residents.

Apollo Hotel: A two-hour awareness raising event was also held at the Apollo Hotel during that same time period. The presentation included a short explanation about the tenant survey results and the menu of possible smokefree policies that might be enacted to reduce secondhand smoke.

Presentations to Decision Makers 

Presentations were made to decision makers at five sites, Haight Ashbury Center for Recovery, Cecil Williams, Ping Yuen, and the Apollo and Madrid hotels. As discussed earlier, five of the six sites adopted a new smokefree policy or began enforcing an existing policy as a result of the advocates efforts.

CAM Step 4: Enforce and Maintain the Action 

At the conclusion of the first two-year funding period, contractors that had demonstrated significant progress towards their goals were provided with six months of additional funding and ALA was selected as one of these providers. ALA’s goals for the remaining six months included:

1. Formalizing informally adopted policies.
2. Introducing more comprehensive policies at 3 of the sites that have adopted smokefree entryway policies.
3. Conducting evaluation of the policies and enforcement mechanisms.

Formalizing Policies 

Five of the six MUHCs formalized their new smokefree policies during the last six months of the project’s efforts. This is important if the gains made while the project was funded are to continue after funding ends in June 04. The new policy was incorporated into the tenant handbook or Community Rules in all five buildings.

More Comprehensive No Smoking Policies 

Advocates also worked to get three of the sites that had adopted new smokefree policies during the first two years of the project to consider even more comprehensive smokefree policies by voluntarily making whole floors go smokefree. To accomplish this, advocates undertook new effort to get the tenants in each of three buildings to voluntarily sign a pledge to have smokefree units on particular floors in each building. This was done through tenant education and by going door-to-door to assess tenant support and, where tenants were willing, to get them to sign a statement documenting their support for their units to become smokefree (either now or in the future as part of a phase-in process). The results of the advocates efforts were as follows:

• Ping Yuen: Advocates obtained signed pledges for smokefree units from tenants on the first and second floors. The “Phased in Smoke Free Policy” for Ping Yuen covers all units on the affected floors with a phase in for smokers. Phase in units will become smoke free after current tenants move out. This policy is also being integrated into the building handbook.
• Cecil Williams: Tenants on the sixth and ninth floor have signed pledges as well. are almost all committed to smokefree units. The “Phased in Smoke Free Policy” for Cecil Williams covers all units on the affected floors with a phase in for smokers. Phase in units will become smoke free after current tenants move out. This policy is also being integrated into the building handbook.
• Hayes Valley: The process stalled at Hayes Valley because the manager was remained unavailable advocates were unable

Enforce the Action 

Finally, the advocates engaged in efforts to assess the extent to which the new smokefree entrance and common area policies were being enforced. ALA staff and the project evaluator met to develop two data collection tools for measuring compliance with the new smokefree policies. First, they did on-site observations using a tool designed by advocates and the project evaluator. During on-site observations, advocates would note the following information using a Site Observation Checklist.

• If the smokefree policy was posted or included in the tenant handbook/lease
• If “no smoking” signs were posted in the restricted areas
• If ashtrays were present
• If cigarette litter was present
• If they observed any tenants or visitors smoking
• If they saw educational/cessation materials available
• • If the manager had been notified about the results of the observation

“The front entrance is much more inviting. Peoplewill physical disabilities can enter the building without difficulty now.” 

Manager 

Advocates also conducted interviews with building managers. The interview protocol included a total of seven questions.

1. Are you aware of the smokefree entrances policy recently adopted at your site?
2. How is the policy enforced?
3. How is the policy reflected in the building rules/handbook/lease?
4. Were all tenants informed of the new policy? What was done to educate them?
5. Have you had any complaints about the policy not being followed? What is your procedure for responding to complaints?
6. Have you had any feedback or comments from the tenants on how the policy is working?
7. How has the policy affected your work? What are the benefits or having a policy at your site? What do you feel is not working or needs to be changed?

In general, data seem to indicate the new policies have been adopted without incident at the targeted buildings, and seem to be becoming part of the organizational culture. For example, at Treasure Island Recovery Center advocates observed clients smoking in the appropriate designated areas. However, according to the site observations at Ping Yuen, while there was no cigarette litter or ashtrays in evidence near the entrances to the building, and “no smoking” signs were posted in elevators and laundry rooms, the policy had not yet been incorporated into the tenant handbook as agreed.

Enforcement activities (policy/management interviews and multiple on-site observations) were conducted at the five buildings that passed smokefree policies (Ping Yuen, Treasure Island Apollo Hotel, Hotel Madrid and Cecil Williams). A management interview was completed for Hayes Valley but site observations could not be completed in time for preparation of the case study.

Download the case study here.