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The Family that Smokes Together (Expanded)

Before Dad was a physician, he was a smoker. And, because we lived in his house, we were smokers too.

Throughout my life, people have thought it odd that a doctor could also smoke, but it’s not really so strange because Dad started his habit at 14. Smoking was one of the things people did back then, all the time—at home, at work, at parties. Millions of soldiers received free cigarettes during World War II, and when they returned home from the war, they were hailed as heroes, role models for kids everywhere. And our heroes smoked.

My father was already a veteran of smoking before he ever set foot in med school, and any doctor will tell you that med school is incredibly stressful—it’s not the best environment for quitting anything, except maybe sleep. Plus, he enjoyed it. These were the days before the Surgeon General’s package warnings, the terrifying ads, and the lawsuits. By 1966, when the warnings started appearing on cigarette packaging, he’d already spent half of his time on Earth as a smoker.

As kids, my sister and I waged a failing war against the cigarettes: We begged and pleaded, we pinched our noses and complained about the horrible smell. We hid the packs and the ashtrays. I’ll bet many of you did the same things to your parents. One time I even “loaded” a cigarette, which resulted in a small explosion that angered Dad, not because he was surprised by it but because the cinders nearly burned his shirt. But every time we tried, he proved that his love of smoking was somehow stronger than we were.

Our success—such as it was—was comparable to everyone else who battled smoking at that time. Public policy (most notably, the 1964 Surgeon General’s report, which linked smoking to lung cancer) managed to curb smoking’s stratospheric popularity, but it didn’t result in a massive reduction in the overall quantity of smokers. By the mid-1970s, the anti-smoking movement was highly visible, and the number of smokers fell incrementally.

Dad eventually responded to our protests smoked by switching to a pipe for a year or so. He looked very distinguished, and the pipe smoke smelled better than that of the cigarettes; but it was still smoke that wafted through the halls.

So we grew up with smoke in the house every morning before, during, and after breakfast. Some people wake up to the aroma of eggs or bacon, but we woke to the acrid odor of cigarettes. The other thing I woke up to almost without fail was a lump in the back of my throat—an actual lump of gunk that accumulated there while I slept. Part of my morning routine was to get up and expel a gob of phlegm into the sink. It didn’t end there, either—several times a day I repeated this ritual, right up until bedtime. Every day, for years.

My mother thought it was disgusting, and she told me so. I agreed, but what was I supposed to do about it? “I gotta get it out somehow,” I muttered grimly as I continued to hack away.

Now, you’d think from this description that my house was absolutely hazy with smoke all the time, but it wasn’t. Dad had very long hours throughout the week and when he was away, we didn’t notice any lingering smell.

Something unexpected happened when I left for college. Within a few weeks, my coughing subsided. A few more, and it ended altogether. Honestly, I hadn’t noticed it happening, probably because it was so gradual and because I hadn’t made any conscious changes to my lifestyle. I only noticed it when I woke up on the first full day of my fall break. The lump in my throat was back, which must’ve meant that it had stopped sometime while I was away. My mother heard me and commented again about the horrible noise and what a disgusting habit it was. I told her that no one was more disgusted by it than I, but it was funny because this morning was the first time I’d done it in a long time—there must be something in the house that was making me sick.

It wasn’t long after that I started hearing about the dangers of secondhand smoke. Secondhand smoke is the smoke that the other people in the presence of a smoker breathe, the smoke that my father expelled from his lungs after every drag from his cigarettes or puff from his pipe as well as the smoke that rises from these tobacco products as they burn. In short, it’s what my sister and I complained about for roughly 20 years. All the things that can happen to a person as a result of smoking can happen to a nonsmoker too if they’re exposed to secondhand smoke. Secondhand smoke is a known trigger for people with asthma and can lead to lung cancer, too.

You may not have heard of it, but there’s also a thing called “third hand smoke,” which is the chemical residue left behind on surfaces that we take into our bodies by touching contaminated surfaces, ingest from hand-to-mouth contact (or possibly via our food), or breathe in as dust after the actual smoking stops. These would be the chemicals trapped in curtains, on wallpaper or painted surfaces, or the foul odor you detect in a smoker’s car. Whatever you smell in the car is the particulate residue of various chemicals including carbon monoxide, arsenic, butane, lead, toluene, and hydrogen cyanide. If you’ve spent any time on our website at all, you may already know how dangerous carbon monoxide and lead are. Butane is used in lighter fluid and  fuel for camping stoves, and toluene is found in paint thinner. Anything with a name like “hydrogen cyanide” can’t possibly be good for you; this substance is used in chemical weapons. If that’s not frightening enough, polonium-210 is a radioactive carcinogen (meaning it can cause cancer). And arsenic is, well, arsenic. That’s what you’re taking into your lungs when you’re breathing second- and third hand smoke. And before you say anything about air fresheners, forget it: They’re masking the chemical smell, not removing it; you’re still breathing smoke residue and to it you’ve added other chemicals blended to smell like pine or vanilla.

Despite our efforts, our family was never able to convince Dad to quit, although he did smoke less in his later years—a minor victory that may have actually had more to do with changes in public policy. State and federal government have raised taxes substantially over the last twenty years, and laws now prohibit smoking inside or near entrances to almost all public buildings and many public parks, on planes, or on buses. Smoking is now a very expensive habit, and it’s hard to find anywhere to do it outside of your own personal property. As if to follow their lead, my mother—herself a former smoker—insisted that our father’s was no longer allowed to smoke in the house. In the winter, he was allowed to use the garage. Stubbornly, he persisted through the rain and the snow. After all, it was his life, and he wasn’t going to quit just because someone said he should.

And that’s what I say to you: Sure, it’s your life—you can do what you like with it, but what about your family and your friends? Are their lives yours too? And what about your pets? Does old Rufus have to suffer because you don’t feel like quitting? He might be “man’s best friend” to you, but if he knew what you were doing to him, he might not hold you in the same regard. So, if you're a smoker, why not quit? If not for yourself, then how about for your family? And if you’re not willing, or haven’t been able to break the habit, at least take it outside.

As for my own Dad, well, he finally did stop. It happened after he spent a month on the ventilator after a surgery, a procedure that followed angioplasty and an open-heart bypass. His lungs were really weak. When he finally left the hospital, roughly 20 days later than expected, he realized that he was never going to wake up from the next surgery at all if he kept smoking. All of the surgeries he'd endured might've been avoided had he not smoked or even if he’d quit sooner. Suddenly, smoking seemed to be a lot less enjoyable to him, and so he quit—at age 60—but he’d done too much damage to his body. He was already suffering from emphysema by then and often used an oxygen pump to assist his breathing. Still, I think quitting did allow him to live a longer life, and he got to meet his first grandchild before he passed.

This is an expanded version of a blog post that first appeared on in September 2016.

Post-Election Analysis: Healthcare Financing for Healthy Homes Services Still Hard, Still Possible, Still Important

Two days after the recent presidential election I had to make a decision. I was supposed to be getting on a plane to California so that I could give a talk about opportunities to finance healthy homes services through the healthcare sector. This is a presentation I have given many times. I think and talk about this subject every day (yes, even weekends, #PublicHealthNerd). But I found myself at a loss for what to say. My hesitation wasn’t even a commentary on the outcome of the election but rather a reaction to the plain fact that, regardless of whether the idea thrilled or repulsed me, our healthcare system might be about to undergo another radical transformation.

The word “might” in that sentence is important. Because it is the uncertainty of what the scale and nature of that transformation could look like that made me wonder why I should fly across the country to stand in front of a room full of people and pretend that I had any answers about how to navigate this new reality. About how we would continue our work to ensure and expand access to critical public health services like home-based asthma and lead poisoning follow-up services.

But then I remembered. I remembered three things.

First, I wasn’t going to this meeting for a one-way exchange. I always leave meetings like that with new knowledge and inspiration, and I was obviously in need of both.

Second, I started working on this issue back in 2005 when I was a research scientist with the New York State Department of Health, under such an unfavorable environmental health policy landscape that my supervisor at the time begged me not to throw away my young career on something that was, in her opinion, so fruitless and so fringe. True story.

Third, I ignored her advice and discovered that there were others already working at the fringe to expand access to preventive environmental health services through the healthcare sector. In fact, some of you had been there so long, you’d taken up permanent residence. And you welcomed me in, shared your stories, your strategies, your successes and failures. And as a result, I started to work. In those early years, that meant laying the groundwork for change that would come later. I learned as much as I could about different program models, about Medicaid and healthcare financing. I talked to absolutely everyone and anyone who had tried or even thought about trying anything remotely like what I was trying to do. I wrote policy proposals about once a quarter for four years, failing repeatedly to gain any traction but always listening to what fell short and using that information to sharpen my pitch and improve my approach. I led a team that invited the state Medicaid agency, a local health department home visiting program, and four Medicaid managed care plans to help design a pilot program that wasn’t aimed at adding to the evidence base that we could improve health outcomes and reduce costs but instead focused on answering their questions and concerns about how such a program could operate in the real world. And what happened is that we answered those questions, we did improve health outcomes, we did save money; and in 2011 when New York State’s Medicaid Redesign Team was looking for ideas for how to improve healthcare delivery in the state, they came to us to ask for a proposal to fund home-based asthma services (and other healthy homes services) through the Medicaid program. That proposal was recommended and endorsed by the Health Disparities Workgroup of the Medicaid Redesign effort, subsequently included in New York State’s approved mega-waiver application to the Centers for Medicare and Medicaid Services, and will ultimately be implemented by seven Performing Provider Systems across the state that are financed through a funding pool that is reinvesting $6.5 billion of the savings previous reforms generated for the federal program back into public health prevention initiatives, including home-based asthma services.

And by this point in the conversation with myself, I was on a roll. I reminded myself that as part of my work at the national level I already know that there are many ways to get this work financed and that many, if not most, of them predate the Affordable Care Act (ACA). I reminded myself that when we cross-tabbed the results of our nationwide survey of state Medicaid policies for home-based asthma and lead-poisoning follow-up services with states that had adopted Medicaid expansion, we found no pattern whatsoever. I reminded myself that the American Lung Association’s more recent map of coverage of home-based asthma services shows progress in both red and blue states and that the most recent state to join the ranks of those providing coverage of home-based asthma services was Missouri. Coverage of environmental health services can have bipartisan support.

Now, I’m not saying that the ACA hasn’t been important or relevant to this work. It is. It’s opened up some new opportunities, it’s meant that there were more people insured to benefit from the policies we put in place through the healthcare sector, and it has sparked a genuine interest from the healthcare sector in figuring out how to address social determinants of health, like housing, and how to shift costs from treating chronic diseases to preventing them. It’s meant there was momentum and enthusiasm to put these types of services and programs in place. So it has been important. But it hasn’t been everything. Because underneath that there was a foundation. There was a foundation made up of health plans like Priority Health in Michigan and the Monroe Plan for Medical Care in upstate New York who in the late 1990s and early 2000s were already investing in these services. And of community-based organizations, like the Asthma Network of West Michigan, who were ready to partner with them and tell the rest of us the secret to getting the job done. And of state- and local-funded initiatives, including the New York State Healthy Neighborhoods Program, which has operated continuously since 1985 reaching 7,500 homes or more every single year. And of ordinary people like me in red and blue states across the country who were busy laying the groundwork. And of the staff who designed the Asthma Community Network to help us find each other and the best practices we needed to get our work off the ground.

And here’s the thing: That foundation still exists, and it is stronger now than it has ever been. We have more examples than ever of how financing these services isn’t just good healthcare, it’s good business. We have good reason to believe that the value of this work will continue resonate across the political spectrum and evolving healthcare landscape. And we have a bigger army of ambassadors to carry that message for us.

So regardless of what happens next, we can always do those two things. We can look for the forward thinkers, the Priority Healths and the Monroe Plans, in each state or community, and in places where there aren’t any, we can shore up the foundation so that when the landscape changes again and the conditions are more favorable, we can be ready to transform these systems permanently. 

In the end, I got on the plane. I got back to work.

A few days later the Centers for Medicaid and Medicare Services announced their approval of a State Plan Amendment to use federal and state funding to expand lead abatement activities in the impacted areas of Flint and other areas of Michigan. And I remembered two more things. This work is not only possible, it’s imperative.

Note: Interested in putting home-based asthma services or lead poisoning follow-up services in place, but not sure where to start? Whether you’re a community-based organization, healthcare payer, healthcare provider, public health agency, or housing organization, NCHH and its network of partners can help. Contact for more information or check out our new state-specific case studies and other resources in our Healthcare Financing Resource Library.

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