Assessment of College and University Campus Tobacco- Free Policies in North Carolina

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1 This article was downloaded by: [NIH Library] On: 07 April 2015, At: 13:19 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Journal of American College Health Publication details, including instructions for authors and subscription information: Assessment of College and University Campus Tobacco- Free Policies in North Carolina Joseph G. L. Lee MPH, CPH a, Adam O. Goldstein MD, MPH a, Elizabeth G. Klein PhD, MPH b, Leah M. Ranney PhD a & Ashlea M. Carver a a Tobacco Prevention and Evaluation Program, Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina b Division of Health Behavior and Health Promotion, College of Public Health, Ohio State University, Columbus, Ohio Accepted author version posted online: 09 May 2012.Published online: 24 Sep To cite this article: Joseph G. L. Lee MPH, CPH, Adam O. Goldstein MD, MPH, Elizabeth G. Klein PhD, MPH, Leah M. Ranney PhD & Ashlea M. Carver (2012) Assessment of College and University Campus Tobacco-Free Policies in North Carolina, Journal of American College Health, 60:7, , DOI: / To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content ) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at

2 JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 60, NO. 7 Major Article Assessment of College and University Campus Tobacco-Free Policies in North Carolina Joseph G. L. Lee, MPH, CPH; Adam O. Goldstein, MD, MPH; Elizabeth G. Klein, PhD, MPH; Leah M. Ranney, PhD; Ashlea M. Carver Downloaded by [NIH Library] at 13:19 07 April 2015 Abstract. Objective: To develop a reliable and efficient method for assessing prevalence and strength of college/university tobaccorelated policies. Participants: North Carolina (NC) public universities, community colleges, and private colleges/universities (N = 110). Methods: A census of policies using campus handbooks and Web sites was conducted in March Results: The rating tool is reliable and valid. Ninety-nine percent of NC college/university campuses are smoke-free in all indoor areas. The majority (94/110 [85%]) of colleges and universities regulate smoking and/or tobacco in some or all outdoor areas. Less than 20% of campuses had restrictions for industry marketing, promotion, and sales. Conclusions: Clean indoor air policies are present at all but 1 NC college/university campus, and a growing number have enacted broad outdoor limits to protect students, faculty, and staff from secondhand smoke. Policy census approaches across all other states would quantify the national tobacco-free college campus policy environment and facilitate adoption of tobacco-free campus policies. Keywords: policy making, smoking, tobacco industry, tobacco smoke pollution, universities Although just under 15% of the approximately 4,600 degree-granting institutions of higher education in the United States have adopted tobacco-free campus policies, interest in such policy adoption is increasing. 1,2 Given the paucity of policy adoption, substantial need exists for ways to improve dissemination of such health-promoting 3 campus environments. Tobacco-free campus policies that cover all indoor and outdoor spaces, as well as prohibit tobacco industry marketing and sales, are Mr Lee, Dr Goldstein, Dr Ranney, and Ms Carver are with the Tobacco Prevention and Evaluation Program, Department of Family Medicine, at the School of Medicine, The University of North Carolina at Chapel Hill, in Chapel Hill, North Carolina. Dr Klein is with the Division of Health Behavior and Health Promotion at the College of Public Health, Ohio State University, in Columbus, Ohio. Copyright 2012 Taylor & Francis Group, LLC associated with decreases in smoking prevalence, 3,4 reductions in smoking near entrances to buildings, 5 and improved indoor air quality. 6 Moreover, tobacco-free campus policies are recommended as best practice by the American College Health Association (ACHA). 7 Smoking remains a leading cause of illness and premature death, and past-month cigarette smoking prevalence among 4-year college students remains between 16% and 27%, 8 10 and prevalence at community colleges is likely higher. 11,12 Although the majority of college students do not smoke, it is possible to identify a typology of smoking and the important role of social smoking in the epidemiology of college student smoking These findings likely reflect extensive tobacco industry marketing efforts to college students. 17 College students receive exposure to industry marketing in bars, through sponsored music events, by corporate philanthropy, through movie placements, and via social media such as YouTube Such efforts cause many students to move from occasional smoking to daily smoking or, for nonsmokers, to transition to occasional smoking. 15,21 Colleges have attempted implementation of a variety of interventions to address tobacco use on campus. 22 Recent work emphasizes development and implementation of college tobacco-free policies, given evidence that policy/environmental interventions are more effective than knowledge and information interventions Specifically, college tobacco-free policies appear to lead to reductions in smoking prevalence 3 when comparing rates before and after policy adoption 4 and are associated with less smoking near building entrances. 5,23 These effects are similar to other types of tobacco control policies, including clean indoor air policies, which have reduced smoking prevalence. 26 Comprehensive tobacco-free policies on college campuses fit within an ecological approach to health promotion and tobacco-free identity development

3 Downloaded by [NIH Library] at 13:19 07 April 2015 Because of the high rates of tobacco use on college campuses and the large exposure to tobacco marketing, interest in tobacco-free policy adoption on university campuses is growing. Americans for Nonsmokers Rights reported a change in the number of tobacco-free campuses from 60 smoke-free campuses in 2007 to over 600 tobacco-free campuses in January ,30 Despite this growth in policy adoption, the majority of college campuses have not yet adopted tobaccofree campus policies. Further, no research exists that shows how to efficiently and systematically collect, compare, and track tobacco-free policy development, nor their outcomes, on college campuses. Many college administrators want to know how their campus tobacco policy compares with the policies on other campuses, data that can even aid policy adoption. 31 Comparative data on tobacco-free campus policy development could facilitate accelerated diffusion of tobacco-free policies, particularly if they are easily replicated by advocacy organizations and health departments. To address this gap, this research study had 3 aims: (1) to pilot a methodology of acquiring reliable, statewide data on colleges tobaccorelated policies; (2) to pilot a scoring mechanism for policy strength based upon the available policy characteristics; and (3) to identify the current prevalence of tobacco-free college policies across North Carolina (NC). METHODS In NC, collaboration between researchers at the University of North Carolina (UNC) School of Medicine, the NC Tobacco Prevention and Control Branch, and the NC Health and Wellness Trust Fund developed the NC Tobacco-Free Colleges Initiative in 2006, using diffusion of innovation theory to drive tobacco-free policy adoption indoors and outdoors at the state s 110 colleges and universities. 31,32 Due in part to this initiative, 46 campuses across NC have adopted the most protective campus tobacco-free policy allowed by state law, making NC a national leader in adopting 100% tobacco-free policies covering buildings and outdoor grounds. Data comparing universities that had adopted policies with those that had not adopted them has not previously occurred. The lead author (J.G.L.L.) and an undergraduate research assistant (A.M.C.) searched the Web sites of all UNC System (n = 16), NC Independent Colleges and Universities (an association of private colleges/universities) (n = 36), and NC Community College System (n = 58) campuses using the keywords tobacco, policy, and smoking to locate the most updated tobacco use policy on each campus. Searching was conducted during March If the policy was not available by searching the main Web site, the research assistant located the current student handbook and searched using the same keywords to locate the policy. If these procedures failed to identify any policy, the lead author ed student affairs administrators in residential life or housing services to solicit a copy of the policy. The research team developed a college tobacco-free policy-scoring tool to describe the indoor and outdoor Campus Tobacco-Free Policies in NC tobacco-free policy environment. This tool was modified from (a) an existing tool designed for secondary schools, 33 (b) a 6-point rating system developed by Halperin and Rigotti, 34 and (c) the elements outlined in the model policy from the ACHA. 7 The resulting 13-point college tobacco-free policy index evaluated campus smoking and tobacco policies regarding indoor and outdoor environments, including campus housing, campus vehicles, within a specified number of linear feet from building entrances (ie, a perimeter policy ), and/or all outdoor campus grounds (Appendix); bans on tobacco industry activity sponsorship, advertising, and tobacco product sales; and if the above policies addressed just smoking or all tobacco use were included. Iterations of the form were compared with the content of existing policies and piloted with a selection of campuses. Five experts on policy change and college/university policies from 3 universities reviewed the instrument for both content and face validity. The research team defined college and university to include community colleges in the NC Community College System and private colleges in the association of NC Independent Colleges and Universities. Public universities were included through the UNC System. The lead author and undergraduate research assistant independently coded each policy, then reviewed discrepancies and agreed upon a final code. 32 When agreement could not be reached, a third author (L.M.R.) decided. To assess reliability between the 2 coders, we calculated the Pearson s correlation for campus policy scores based upon a random selection of 20% of the campuses. The instrument s policy scores showed good reliability, r(22) =.97, p =.01, and individual items reliability ranged from.82 to 1.0. One campus posted a policy on campus doors that appeared more protective than the version in student handbooks; we used the written policy. Two campuses had conflicting policies for students and employees; thus, we used the student policy. One campus allowed smoking in indoor areas (campus apartments) but not in outdoor areas within 10 feet of residential buildings; we coded the policy as the equivalent of no policy. Two UNC System schools had 100-foot-perimeter policies, with multiple designated smoking areas within the perimeter and no limits on designated area distance from doors, windows, or air intakes; we coded these as designated area policies. The policy-rating tool (Appendix) had 13 items, with a minimum score of 0 and a maximum of 13. Higher scores indicated more comprehensive policies, and items were additive. For example, a smoke-free residence hall policy yielded 1 point, and language extending that policy to a tobacco-free residence hall policy yielded an additional point. A totally smoke-free campus, by definition, earned points for smokefree residence halls and smoke-free buildings (equaling 2 points). As 2 points on the scale were for residence hall policies, community colleges, which lack residential options, were scored on an 11-point scale. We used SPSS 19 (IBM, Chicago, Illinois) for all data analysis and conducted analysis of variance (ANOVA) and Pearson chi-square tests to examine differences between VOL 60, OCTOBER/NOVEMBER

4 Downloaded by [NIH Library] at 13:19 07 April 2015 Leeetal campus types, and we calculated the proportion of possible policy factors for ANOVA. We identified policies for all 110 NC campuses. Only 1 campus had no policy posted, necessitating a request to administrators. Because the research was an examination of publicly available Web sites, it was exempt from institutional review board review. RESULTS All but 1 (109 of 110) NC college campuses prohibit smoking in all indoor areas. Ninety-four of NC s 110 colleges and universities (85%) regulate smoking and/or tobacco use in some or all outdoor areas. Table 1 shows overall campus smoke-free and tobacco-free policy protections for indoor and outdoor areas on campus. Twelve (75%) of UNC System schools have perimeter policies of 25 feet or more, and 4 of those policies (25%) are the most protective allowed by state law. All UNC System universities mandate smoke-free buildings and 8 (50%) mandate smoke-free vehicle policies. Only a minority (19%) of UNC System universities have restrictions on tobacco marketing, sales, and promotions (Table 2). No UNC System campuses restrict smokeless tobacco use. Only 9 private colleges and universities (25%) have 100% smoke-free policies. All but 1 private universities have completely smoke-free buildings. Ten (28%) have smoke-free vehicle policies. Three private colleges (8%) ban industry marketing and sales. Only 1 (3%) private college bans industry sponsorship of campus events and clubs. Forty-two percent ban smokeless tobacco products inside buildings. Over one-half (30 community colleges [52%]) have complete smoke- or tobacco-free campuses. An additional 7 community colleges (12%) have perimeter policies with an average distance of 24 feet. All community colleges have 100% smoke-free buildings, and 30 (52%) have smoke-free vehicles. Community colleges were significantly more likely to have total smoke-free and tobacco-free campus bans than other college campuses, χ 2 (2, N = 110) = 8.22, p =.02. Eleven community colleges (20%) have some prohibitions on industry sales or marketing on campus. On average 41% (SD = 27%) of potential policy items are included in the written campus tobacco policy (Table 2). Figure 1 shows the distribution of policy scores by campus type. Eighty-eight percent of campuses with policies covering all indoor and outdoor areas restrict smokeless tobacco products. Among campuses without policies protecting all indoor and outdoor spaces, 44 campuses (40%) across the state do not address indoor use of smokeless tobacco products. Protections from tobacco smoke differ by campus type, although no differences are present in restrictions on tobacco industry activity, which are uniformly low. COMMENT This study is the first to systematically examine written tobacco campus policies and their components for colleges and universities across a state. These results demonstrate a method to efficiently and reliably collect, compare, and analyze college and university tobacco-related policies. This approach provides a comprehensive, objective methodological improvement on previous reports, which have relied upon self-reported data and interviews with key administrators. 34,35 Inclusion of community colleges provides an important perspective that previously has not been reported, as these institutions serve almost half of the undergraduate students in the United States. 36 Assessment and reporting on the prevalence of campus tobacco policies is key to further work identifying trends in and accelerants of tobacco-free campus policy adoption. Piloting a scoring system for policy strength proved feasible and should be useful in future longitudinal surveillance and policy advocacy efforts. Policy strength ranged from 0% to 100% of the scoring items. Future efforts could determine the optimal way to calibrate the scoring system for policy advocacy efforts. For instance, the development of a grading system or another easily reportable operationalization of the scoring system might facilitate policy comparison and policy adoption both within and between states. Only an average of 41% of the maximum policy score was observed in NC, indicating large potential for improvement even in a state that is leading the tobacco-free campus movement. 31 Tobacco-free TABLE 1. Tobacco-Free Campus Policy Status of NC Colleges and Universities, March 2011 (N = 110) All campus building interiors Residence halls/ On-campus apartments # (n = 52) Some or all campus grounds (designated area or perimeter) All buildings and grounds Policy n % n % n % n % Smoke-free Tobacco-free Note.NC= North Carolina. # NC community colleges (n = 58) do not have residential options and are thus excluded. Due to state legislation, University of North Carolina System campuses can only enact policies to 100 feet of buildings. They are included here as the maximum legal policy. 514 JOURNAL OF AMERICAN COLLEGE HEALTH

5 Campus Tobacco-Free Policies in NC Downloaded by [NIH Library] at 13:19 07 April 2015 TABLE 2. Tobacco-Free Policy Scores by Policy Factor on NC College Campuses, March 2011 (N = 110) Community colleges (n = 58) State system (n = 16) Private colleges (n = 36) Average Range Average Range Average Range Policy rating factors % n % % % n % % % n % % p value Smoke-free housing Tobacco-free housing Smoke-free buildings Tobacco-free buildings <.001 Smoke-free vehicles Tobacco-free vehicles Smoke-free perimeter policies feet Smoke-free perimeter policies feet Smoke-free campus (indoors and outdoors) Tobacco-free campus (indoors and outdoors) # # <.001 Sponsorship prohibition Sales prohibition Marketing prohibition Proportion of possible policy factors Note. NC= North Carolina. # Due to state legislation, University of North Carolina System campuses can only enact policies to 100 feet of buildings. They are included here as the maximum legal policy. Statistically significant differences in policy inclusion between campus types, p <.05. VOL 60, OCTOBER/NOVEMBER

6 Leeetal Downloaded by [NIH Library] at 13:19 07 April 2015 FIGURE 1. Distribution of policy score strength. policy adoption by NC colleges and universities has likely been accelerated by the statewide tobacco-free college initiative and its focus on tobacco-free policy adoption, one of the few such policy-focused efforts that have occurred nationally in the last decade. 31 NC s focus on tobacco-free policies on college campuses stems from previous successes in tobacco-free primary and secondary schools 37 and acutecare hospitals. 38 This statewide census is the first to report prohibitions on smoking in outdoor spaces on college campuses. Whereas smoke-free spaces are virtually universal in indoor areas, college campuses offer far less protection in outdoor areas, from all tobacco products, and from tobacco industry marketing. Campuses may inadvertently encourage smokeless tobacco use by allowing its use in smoke-free indoor areas. The tobacco industry is marketing new smokeless tobacco products to smokers for use in smoke-free areas, 39 and instead of helping reduce smoking, such products likely lead to dual addiction to both cigarettes and smokeless products. 40 Additionally, policies should cover products beyond cigarettes as college students in NC are likely to have tried (40%) or currently use (17%) hookahs. 41 Creating comprehensive tobacco-free campus policies may be an important factor that supports and promotes smoking cessation to a population that has not been successful in quitting smoking. Although college students report intention to quit using tobacco during or after graduation, 42 the majority do not succeed. 43 College students are less likely to self-identify as tobacco users, 13 which makes efforts to increase motivation to quit tobacco a serious challenge. As one might expect, denying being a user has been associated with not attempting to quit. 44 Relative to smoking, quitting by age 35 equates an individual s life expectancy to that of a nonsmoker, yet only 34% of ever smokers aged 18 to 35 have successfully quit. 45 These challenges to smoking cessation may be mitigated by the presence of a tobacco-free campus policy, given that other types of community-level tobacco control policies are associated with decreasing acceptance of tobacco use Some limitations exist to this research. Written campus policies do not always reflect campus enforcement or actual practice. The methodology described cannot differentiate between policies that are actively promoted and those that exist solely on the books, nor can it identify differences in 516 JOURNAL OF AMERICAN COLLEGE HEALTH

7 Downloaded by [NIH Library] at 13:19 07 April 2015 policy implementation or enforcement. Some policies that exist may not appear in student handbooks or online. More research is needed to understand the factors that promote the adoption of comprehensive campus policies, as well as those that describe the challenges and barriers to policy enforcement. Longitudinal research is needed to quantify the relationship between policy compliance and social norm change among students and/or employees, in particular for smokers and nonsmokers over time, and to determine longterm effects of more restrictive policies and light/intermittent smokers. Conclusion This census of college and university policies across one state gives clear indication that much has changed in efforts to protect students, faulty, and staff from secondhand smoke exposure since earlier surveys of smoke-free indoor areas. 34 Yet, the national prevalence and strength of tobacco-related policies remains unenumerated, hindering efforts to accelerate policy trends. Continued and ongoing work is needed to track campus tobacco policies and standardize reporting of their strength at a national level. Without such information, industry marketing will continue to find college and university campuses a lucrative space for addicting young adults. DISCLAIMER The UNC Tobacco Prevention and Evaluation Program s clinical Nicotine Dependence Program (Dr Goldstein, principal investigator) receives unrestricted educational funding from Pfizer Pharmaceuticals to support dissemination of comprehensive tobacco cessation programs. ACKNOWLEDGMENTS This work received funding from the North Carolina Health and Wellness Trust Fund Commission. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views and policies of the North Carolina Health and Wellness Trust Fund Commission. The funder had no role in the study design; the collection, analysis, and interpretation of data; or the decision to publish. The authors thank Amy Olson for her feedback on an earlier draft of the text. NOTE For comments and further information, address correspondence to Joseph G. L. Lee, Tobacco Prevention and Evaluation Program, Department of Family Medicine, School of Medicine, The University of North Carolina at Chapel Hill, CB 7595, 590 Manning Drive, Chapel Hill, NC 27599, USA ( jose.lee@unc.edu). REFERENCES 1. Americans for Nonsmokers Rights (ANR). U.S. colleges and universities with smokefree air policies. 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9 Campus Tobacco-Free Policies in NC APPENDIX. Campus Tobacco Policy Strength Rating Tool Instructions: Using all identified policies from campus Web sites and handbooks, have two people independently score campus each campus s policy. Identify and reconcile any differences in scoring. Then calculate each campus s score. Tobacco-Free Environment Score Campus Name: Downloaded by [NIH Library] at 13:19 07 April 2015 Score for residential campuses only: Yes No 1.1 Banned cigarette smoking in all residences or other campus owned housing Yes No 1.2 Banned tobacco use in all residences or other campus owned housing Count number of Yes s: (a) Score for all campuses: Yes No 1.3 Banned cigarette smoking in all indoor areas of any campus building Yes No 1.4 Banned tobacco use in all indoor areas of any campus building Yes No 1.5 Banned cigarette smoking in campus-owned vehicles Yes No 1.6 Banned tobacco use in campus-owned vehicles Yes No 1.7 Banned smoking within of building entrances Yes No 1.8 Banned smoking within of building entrances Yes No 1.9 Banned cigarette smoking on all campus outdoor grounds Yes No 1.10 Banned tobacco use on all campus outdoor grounds Yes No 1.11 Banned sponsorship of campus activities by tobacco or tobacco-promoting companies Yes No 1.12 Banned sales of tobacco products on campus Yes No 1.13 Banned advertising, promotions, and/or marketing on campus property Count number of Yes s: (b) Add all Yes s (a + b) and divide by 13 for residential schools or 11 for non-residential schools. ( (a) + (b)) / = CAMPUS SCORE VOL 60, OCTOBER/NOVEMBER