The SUNSET Russian Tobacco Education Project seeks to change pervasive community norms around tobacco in the Russian-speaking community and to reduce the harmful effects of tobacco on this population. SUNSET is a program of Bay Area Community Resources (BACR) in collaboration with the Newcomers Health Program in the San Francisco Department of Public Health. SUNSET has spent a decade working to raise awareness and reduce exposure to secondhand smoke in Russian-speaking communities throughout the San Francisco Bay Area.

Over time, the project has worked to change community norms about tobacco use through several strategies, including:

• A comprehensive outreach campaign to merchants, health practitioners, and organizations serving the Russian-speaking community;
• Educational presentations related to complying with state and local secondhand smoke policies;
• Public service announcements placed in newspapers targeting the Russian-speaking community;
• Secondhand smoke workshops to educate participants about the health effects of SHS and strategies to address the issue; and
• Culturally relevant tobacco cessation clinics.

The Problem

Older Russian and Ukranian refugees make up a high percentage of the Russian-speaking immigrant community. This population has experienced wars, revolutions, famine, and religious persecution. Common health issues among refugees include inadequate health care, and heavy smoking and drinking. Russian-speaking patients are unfamiliar with preventive care and often believe their illnesses are the result of fate. Because Russian-speaking immigrants tend to believe that the absence of disease signifies health, their willingness to participate in prevention groups (e.g., smoking cessation) is typically very low.

What the advocates were trying to accomplish

By December 31, 2009, 2-3 multi-unit buildings will have adopted a policy that 80% to 100% of units are smoke free.

SUNSET utilized the Community Action Model (CAM), a process that builds on the strengths or capacity of a community to create change from within and mobilizes community members and agencies to change environmental factors promoting economic and environmental inequalities.

The Community Action Model includes the following steps:

• Train Participants: Community Action Team (CAT) members are recruited and trained to develop skills, increase knowledge and build capacity. The participants will use this knowledge and skills to choose a specific issue or focus and then design and implement an action to address it.
• Do a Community Diagnosis: A community diagnosis is the process of finding the root causes of a community concern or issue and discovering the resources to overcome it.

Choose an Action: to address the issue of concern. The Action should be: 1) achievable, 2) have the potential for sustainability, and 3) compel a group/agency/organization to change the place they live for the well being of all.

Develop and Implement an Action Plan: The CAT develops and implements an action plan to achieve their Action which may include an outreach plan, a media advocacy plan, development of a model policy, advocating for a policy, making presentations as well as an evaluation component.

Enforce and Maintain the Action: After successfully completing the action, the CAT ensures that their efforts will be maintained over the long term and enforced by the appropriate bodies.

With a 3-year grant from the San Francisco Tobacco Free Project, SUNSET implemented a project leading to policy change that would reduce exposure to secondhand smoke among low-income Russian immigrants living in multi-unit housing.

1. Train Participants

Sunset recruited seven adult advocates. Advocates from Sunset, along with advocates from other Tobacco Free Project funded projects participated in a 4 hour joint training on July 16 2008. The training covered a variety of topics including tobacco as a social justice issue, the global reach of tobacco, the impact of the tobacco industry on communities of color, and how to effectively implement the Community Action Model (CAM).

2. Do a Community Diagnosis

The community diagnosis included mapping, research, interviews, and surveys.

Mapping. The advocates first identified and mapped out existing housing units with 20 percent to 30 percent Russian-speaking residents and created a list of privately owned multi-unit homes in San Francisco. Next, they mapped out housing that was in the development stage and researched the possibility of getting names and contact information of people on the waiting list for a housing development that had not yet been constructed.

Research. The advocates researched which policymakers or decisions-making bodies are involved in getting policies adopted, such as creating smoke-free units and outdoor areas. They also researched existing policies in states and cities pertaining to cigarette smoke in outdoor and indoor areas of multi-unit buildings.

Interviews. The advocates interviewed 7 building managers to determine what if anything had already been done or could further be done to ameliorate harmful effects of secondhand smoke. In addition, the advocates contacted individuals from other projects that had been successful in getting similar policies passed and interviewed them about how they accomplished their goal and the challenges they faced. Key findings include:
All managers understood that secondhand smoke exposure is dangerous, and all seven were interested to see the tenant’s survey results and
The managers were willing to meet again to see and discuss those results.

Surveys. Advocates surveyed 264 low-income Russian-speaking immigrant tenants living in low-income, multi-unit housing. Surveys were collected over 2.5 months at housing sites, health fairs, and other community events.

When survey data were compiled and analyzed, it was clear that most tenants did not want to be exposed to tobacco smoke. Key survey findings include:

• Half of respondents are bothered by secondhand smoke.
• 80% of respondents support policies to create smoke-free units.
• Nearly three-quarters either “strongly agree” or “agree” that certain units should be designated as smoke free units.
• The greatest number of those surveyed (almost 50%) said that 100% of the units should be smoke free.
• More than three-quarters of tenants surveyed either “strongly support” or “support” smoke free outdoor common areas.
• More than three-quarters of tenants (76.3%) support smoke free outdoor areas near entrances (47.3% “strongly support” the idea and 29% “support” the idea).
• The majority of tenants (55.2%) surveyed said they would be most attracted to a housing complex that was completely smoke free.

3. Choose an Action
The advocates worked with San Francisco apartment owners to designate non-smoking units and/or common and outside areas in low-income, multi-unit homes with large Russian-speaking populations.

4. Develop and Implement an Action Plan
Educational packets. During Spring 2009, the advocates developed two educational packets to use in their campaign. The first was a bi-lingual packet for tenants, written in Russian and English. It was intended to increase awareness of the negative effects of secondhand smoke and gain support for the proposed policy. Materials in the packet included: 1) a list of existing San Francisco laws that protect residents from secondhand smoke and illegal tobacco sales, 2) the effects of secondhand smoke, 3) how to help a family quit smoking, and 4) a list of Russian-language quit clinics.
The second packet was designed to educate building managers/owners about the negative effects of secondhand smoke in multi-unit housing and how tenants can be protected from exposure to secondhand smoke. Information was provided about: 1) health and legal issues, 2) models of smoke-free policies, 3) a model of a lease addendum, 4) the financial benefits of maintaining smoke-free buildings, and 5) highlights of the survey conducted among tenants.

Bilingual newsletter. The advocates also developed a bilingual tobacco control newsletter, which included information about secondhand smoke and smoke-free policies in multi-unit housing, California tobacco laws, and other related topics. The newsletter was mailed to community members.

Media campaign. A media campaign to increase awareness about secondhand smoke in multi-unit housing was implemented in Spring 2009. The advocates created a poster, which was distributed at health fairs, doctors’ offices, and other businesses in the community. The poster was advertised in two Russian-language newspapers – “Kstati” and “New Life” and on the website, Baraban.com. An advertisement was also developed and placed in Russian-language media outlets, including newspapers and websites. The media campaign ran through the end of 2009.

In Fall 2009, the advocates identified individual stakeholders (managers/owners) from 5 to 7 buildings that they would approach with information on secondhand smoke, results from the tenants’ survey, and options/benefits of adopting smoke-free policies. The advocates visited building managers to distribute the materials and talk to them about creating smoke-free units in their buildings. The project also advertised in Russian newspapers, designed a poster advocating smoke-free housing, and conducted presentations in about 10 buildings with 12 to 100 units.
As a result of working with the apartment manager of one of the targeted multi-unit buildings for over a year, the building adopted a 100 percent smoke free policy for all units, effective January 1, 2010.

5. Enforce and Maintain the Action
The Project Coordinator and advocates visited the building that adopted a smoke free policy several times in early 2010 to ensure that the policy was being enforced.

During the course of the project, the advocates encountered numerous challenges:

• The surveys were time-consuming, and not everyone wanted to talk to the advocates.
• It was difficult to find individuals or groups that had connections to the managers and it was particularly challenging to get results from knocking on doors without an appointment. In one case, the advocates made numerous attempts to schedule an appointment with a representative from a company that was building an apartment for low-income seniors in the Russian neighborhood of the Richmond, hoping to persuade the company to make the new building smoke free. No one ever responded to the phone calls and no one was ever available to talk to them when they went to the building site in person. “We tried to talk to the manager and left business cards. We were assured someone would get back to us, but no one did.”
• Getting appointments with building managers was a discouraging process. There were timing issues when it wasn’t convenient for project staff/advocates or the building manager, and often appointments, having been made, were rescheduled.

While there was overwhelming agreement among tenants and managers that secondhand smoke is undesirable, the question that always arose at trainings, conferences, and presentations was whether it is it legal to deny people the right to do what they want to do in their own apartment. “When you go to managers to ask their opinion, everyone agrees smoking is bad. Even smokers didn’t want to have smoking units next to them. Everyone agreed it’s nice to have clean air – even the managers. But when you come to the policy, the question always comes up about if it’s legal. Will it conflict with the right to do what you want in your own home; always the issue of ‘I should be able to do whatever I want in my house’.”

Occasionally, advocates encountered unfriendly tenants. One smoker grumbled, “I’m an old man. It’s hard for me to go outside to smoke.”

To meet with the managers, the project had to be flexible in scheduling meetings on their off hours, e.g., either very early in the morning or after work hours. Sometimes they had to give presentations and conduct surveys on Saturdays.

Finding someone who knew a manager helped to smooth a connection to the manager. Many of these connections were made through community members.

The success the project anticipates will be due to the relationship the advocates were able to establish with the manager.

Results were better when advocates were able to have face-to-face personal contact with managers, rather than trying to communicate over the phone or by email.

It can be very difficult to change a policy even when you are advocating for an issue that people are in basic agreement about. “Everyone knows smoking is wrong – you tell people it is the right thing to do, but it is not easy to convince people. My expectation two years ago was that everyone we would approach would go smoke free. I learned to take it easy, tame the expectations.”