Statewide diffusion of 100% tobacco-free college and university policies

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1 TC Online First, published on May 14, 2010 as /tc Statewide diffusion of 100% tobacco-free college and university policies Joseph G L Lee, 1 Adam O Goldstein, 1 Kathryn D Kramer, 1 Julea Steiner, 1 Mark M Ezzell, 2 Vandana Shah 2 1 Tobacco Prevention and Evaluation Program, Department of Family Medicine, UNC School of Medicine, Chapel Hill, North Carolina, USA 2 North Carolina Health and Wellness Trust Fund, Raleigh, North Carolina, USA Correspondence to Dr Adam O Goldstein, 590 Manning Drive, CB 7595, Chapel Hill, North Carolina USA; aog@med.unc.edu Received 23 July 2009 Accepted 19 January 2010 ABSTRACT Objectives As smoking among college students reached new highs in the 1990s, most interventions for college student smoking prevention focused on individual student knowledge, attitudes and beliefs. No published studies report on statewide movements to accelerate the adoption of tobacco-free policies on college campuses. The results of the first 4 years of the North Carolina Tobacco-Free s Initiative are presented. Methods The North Carolina Health and Wellness Trust Fund developed a multilevel intervention to accelerate the diffusion of tobacco-free policies on college campuses, including funding campus coordinators and coalitions to tailor activities to the campus environment at 64 colleges. Evaluators tracked process and policy outcomes as well as the diffusion of policy adoption from January 2006eDecember Results Prior to the initiative, only one small, private college campus in North Carolina was tobacco-free. By 4 years into the initiative, 33 colleges and community colleges, representing more than students, have adopted comprehensive tobacco-free policies to protect students, faculty, staff and visitors. Participating campuses also adopted 68 policies restricting smoking in certain areas and limiting industry activity. Conclusions Tobacco-free policy adoption on college campuses can be accelerated with a multilevel statewide intervention. BACKGROUND Tobacco use remains the leading cause of preventable morbidity and mortality, with premature deaths and 5.1 million years of productive life lost per year in the USA. 1 In the 1990s, researchers observed large increases in college student cigarette use. 2 3 Even with recent declines in smoking among this population, almost one-third (30.9%) of college students smoked during Without intervention, smoking will remain well above the Healthy Campus 2010 objective of 10.5% smoking prevalence among college students. 56 To prevent tobacco initiation and improve quit rates, including among college students, the Centers for Disease Control and Prevention recommends comprehensive tobacco control efforts that focus on the creation of tobacco-free spaces. 7 8 Comprehensive legislation to remove secondhand smoke exposure in bars, restaurants and workplaces has occurred in almost one-half of states. 9 While the American Health Association recommends the adoption of campus-wide tobacco-free policies that include outdoor areas, 5 little data are available on the adoption of these policies. One survey of college health directors found that only a quarter of campuses prohibited smoking in all indoor areas. 10 In 2002, less than a third of large public universities had smoking restrictions in indoor areas and at building entrances. 11 Past interventions to reduce tobacco use on college campuses have focused on changing individuals knowledge, attitudes and beliefs. 12 Early, cross-sectional evidence also correlated smoke-free campus housing with lower smoking prevalence. Building on prior findings, it has become clear that smoke-free campus policies are effective at reducing cigarette consumption on campus and promote broad normative changes. 15e17 Tobacco-free policies may be particularly effective given that many college students are social, light, or intermittent smokers. 18 Tobacco industry marketing campaigns have targeted college students, 19e23 suggesting that efforts to reduce college student exposure to marketing are also warranted. In recognition of the higher prevalence of smoking and the marketing of tobacco products, the North Carolina Health and Wellness Trust Fund Commission (HWTF) funded the North Carolina Tobacco-Free s (TFC) Initiative. The HWTF receives tobacco settlement dollars, and a priority is improving health through the reduction and prevention of tobacco use. The TFC Initiative s four goals were (1) preventing tobacco initiation, (2) reducing exposure to secondhand smoke, (3) reducing health disparities and (4) promoting telephone cessation services (QuitlineNC). From January 2006eJune 2010, the TFC Initiative received $3 million in two phases of funding. The TFC Initiative was designed as a multilevel campus intervention based on diffusion of innovation theory. Diffusion of innovation theory posits that the adoption of policy innovations can be accelerated by replacing uncertainty with information on five attributes of innovation 24 : (1) documenting advantages of the policy, (2) showing the compatibility of the policy with existing campus environments, (3) providing examples to reduce the complexity of policy adoption and implementation, (4) allowing trialability through examples from other campuses experience and (5) illustrating the benefits by making effects observable to potential adopters. Diffusion of innovation theory shows how the innovation decision process is slowed or accelerated by knowledge, peer and expert persuasion, decisions by opinion leaders, implementation and confirmation. This report communicates outcomes from the first 4 years of this funding. Lee JGL, Goldstein AO, Kramer KD, et al. Tobacco Control (2010). doi: /tc of 7 Copyright Article author (or their employer) Produced by BMJ Publishing Group Ltd under licence.

2 METHODS After placing a request for proposals and reviewing applications, HWTF funded 26 health department or college/university programs to promote comprehensive tobacco-free policies, policy compliance, telephone cessation services (ie, QuitlineNC) and other cessation services. These 26 programs worked on or with 64 public and private colleges, universities and community colleges. Phase I funded 18 programs working on 47 campuses from 2006 to 2007, and phase II funded 14 programs working on 42 campuses from 2008 to June In all, 6 programs and 26 campuses participated throughout the entire TFC Initiative. Because the HWTF promoted the TFC Initiative on a variety of different types of college campuses (eg, private, public and 2-year community colleges), the funded programs tailored activities to their particular policy environment, while following best practices. 25 A logic model guided program planning, implementation and evaluation (figure 1). The HWTF provided technical assistance (TA) through the initiative, and TA was made available to non-funded campuses starting in January The key outcome measure was a 100% tobacco-free policy, defined as a complete ban on tobacco use on all campus property or, for of North Carolina System schools, the most protective policy allowed by law: a complete smoking ban within 100 feet of every building. We included complete bans on smoking (ie, smoke-free not tobacco-free policies) (n¼6) in the analysis given the health impact of smoking. We mapped statewide campus policy changes over time and tracked the rate of policy adoption. Secondary outcome measures included policies restricting tobacco use to certain areas, prohibitions on tobacco sales, marketing and promotions, and the inclusion of activities to address priority populations. To avoid exacerbating disparities in tobacco use among different sociodemographic groups, the TFC Initiative addressed vulnerable populations on college campuses: students who were African American, Native American, athletes, first year, Latino/Hispanic, sexual minority, women and/or in fraternities and sororities. Data collection for funded campuses Programs prepared annual action plans. Evaluators tracked activities in four domains: (1) developing and strengthening campus coalitions, (2) advocating for adoption of and compliance with campus policies prohibiting tobacco use in on and off campus areas, the sale of tobacco products and tobacco industry advertising, free sampling and sponsorship, (3) the reach of the initiative to eight priority populations and (4) promoting the use of QuitlineNC. The s Online Reporting System (CORES), a customised, password protected, web-based reporting system, tracked activities, outputs and outcome Figure 1 Logic model for North Carolina tobacco-free colleges initiatives grants. 2 of 7 Lee JGL, Goldstein AO, Kramer KD, et al. Tobacco Control (2010). doi: /tc

3 indicators on a monthly basis, based on the content of the TFC Initiative logic model. The evaluation team followed a protocol on data cleaning and verification to ensure data quality, including obtaining copies of new tobacco-free policies to validate self-reports. Evaluation staff cleaned data monthly, developed reports and shared results and recommendations with grants managers and technical assistance providers. Data collection for non-funded campuses We calculated the number of tobacco-free policies on campuses not participating in the initiative. We identified policy changes at non-funded campuses via two passive surveillance systems. We used the North Carolina Tobacco Prevention and Control Branch s tobacco-related media watch service, which identifies tobacco-related news articles from North Carolina. With these methods, we identified only one tobacco-free policy at baseline. To ensure accuracy, we also systematically searched the web sites of all campuses not funded in any phase of the TFC Initiative (n¼46) using keywords to identify 100% tobacco-free policies. When campus web sites did not provide a search feature, we searched using Google, limiting to results found within the school s domain. We identified no new policies using this additional data collection strategy. Calculating the diffusion of policy adoption To evaluate the TFC Initiative s ability to accelerate policy adoption, we calculated the diffusion 24 of tobacco-free policy adoption to funded and non-funded schools during the TFC Initiative, using the total number of colleges and universities (n¼110) that were (1) part of the of North Carolina System (n¼16), (2) part of the North Carolina Community System (n¼58), or (3) members of North Carolina Independent s and Universities (n¼36). We calculated diffusion by level of participation in the TFC Initiative and for non-funded campuses. Evaluators counted policies once per institution (ie, we did not count satellite campus policy adoptions). Community colleges could adopt tobacco-free policies after 19 June 2006, (NCGA SL ) and the of North Carolina System s 16 higher education institutions could adopt and enforce smoke-free policies to 100 feet of each campus building after 1 January 2008 (NCGA SL , ). RESULTS Tobacco-free policy outcomes Prior to the North Carolina Tobacco-Free s Initiative, only 1 small college, with 687 students, had adopted a 100% tobacco-free policy. By the end of December 2009, 4 years into the TFC Initiative, 33 North Carolina colleges and universities had 100% tobacco-free policies (table 1). The diffusion of policy adoption occurred more rapidly for campuses participating in both phases of the TFC Initiative (figure 2). Campuses participating in only one phase of the TFC Initiative had less rapid adoption of policies. Non-funded campuses had the lowest levels of policy adoption. The 100% tobacco-free policy adoption did not differ substantially between types of campuses (ie, private, public, or 2-year community colleges; data not shown). The TFC Initiative s programs reported 86 tobacco-related campus policies placed under formal consideration by college officials. Programs reported that campuses adopted 27 designated non-smoking areas, 12 policies in off campus areas frequented by students and 14 campus organisation policies (table 2). Campuses adopted 15 policies prohibiting tobacco Table 1 date List of 100% tobacco-free policies and responsible grantees by No. Campus Passed Before 1. Bennett Pre-grant 2004 Phase I Phase II s initiative grantee involved (funded phases) Moses-Cone Wesley-Long CHF (1) and Guilford County Department provided support for compliance and QuitlineNC promotion 2. Gardner-Webb 11/2006 Mecklenburg CHD (1e2) 3. of the Albemarle 12/2006 Albemarle RHS (1) 4. Stanly Community 01/2007 Mecklenburg CHD (1e2) 5. Asheville-Buncombe Technical CC 02/2007 Asheville-Buncombe Tech CC (1) 6. Cleveland Community 03/2007 Cleveland CC (1e2) 7. Haywood Community 07/ Greensboro 08/2007 Moses-Cone Wesley-Long CHF 9. Wake Technical Community 08/2007 Indirect support from phase I special grantee 10. Roanoke-Chowan 08/2007 Albemarle RHS (1) Community 11. UNC Chapel Hill 10/2007 UNC Chapel Hill (1) 12. Guilford Technical Community 13. Winston Salem State 10/2007 Moses-Cone Wesley-Long CHF 12/2007 Moses-Cone Wesley-Long CHF 14. Wingate 01/2008 Mecklenburg CHD (1e2) 15. Montreat 01/2008 Montreat (2) 16. Louisburg 04/ Elizabeth City State 06/2008 Elizabeth City State (1) 18. UNC Pembroke 07/2008 UNC Pembroke (1e2) 19. Peace 09/ High Point 09/2008 Moses-Cone Wesley-Long CHF 21. Catawba Valley Community 10/2008 Mecklenburg CHD (1e2) 22. Blue Ridge Community 11/ Central Carolina Community 11/ Wayne Community 11/ Davidson County Community 26. Cape Fear Community 27. Richmond Community 28. Western Piedmont Community 29. Vance-Granville Community 01/2009 Guilford County Department of Public Health (2) 01/ /2009 First Health of the Carolinas (2) 02/2009 Western Piedmont Community (2) 03/ Craven Community 04/ Central Piedmont Community 09/2009 Mecklenburg CHD (1e2) 32. Forsyth Technical Community 33. Randolph Community 11/ /2009 Guilford County Department of Public Health (2) industry sales/influence on campus, which were designed to limit college students exposure to tobacco industry marketing. Program activity to accelerate policy adoption Following the TFC Initiative logic model, programs reported multiple activities that led to policy change. Over the first Lee JGL, Goldstein AO, Kramer KD, et al. Tobacco Control (2010). doi: /tc of 7

4 Figure 2 Diffusion of most protective tobacco policy allowed by law in North Carolina colleges and Universities (n¼110). Flattened lines indicate no change in diffusion. 4 years of the TFC Initiative, programs reported: establishing 37 new campus coalitions that remained active; conducting 175 surveys and 231 petition drives to document support for policy change; promoting policy change through 1810 meetings and presentations; generating 523 earned and 45 paid media messages on and around campus; and, documenting formal support by 506 college officials, 241 campus organisations and 1310 staff/faculty or student leaders. Starting in the third year of the initiative, programs reported on efforts to enhance compliance with adopted policies through similar activities. These included 598 meetings and presentations and 194 earned and 67 paid media messages on and around campus to promote compliance with policies. To promote QuitlineNC, programs reported developing and delivering promotional events including 986 campus-wide events, 766 class/organisational meetings and 270 other types of promotions; 580 earned and 101 paid media messages; and, 187 meetings to promote fax referral by health providers on campus. Programs also reported 77 meetings to promote the use of the 5 As of smoking cessation by campus health providers. To reduce health disparities, programs targeted 672 QuitlineNC promotions to priority populations, earned 15 and paid for 3 QuitlineNC media messages and reported 3 priority population campus organisation policies. Activities targeting the eight priority populations account for 32% of QuitlineNC promotions and 3% of QuitlineNC media messages. All program activities were tied directly to campus policy change and cessation efforts. General educational presentations about the dangers of tobacco without a clear link to stated program outcomes were not tracked or promoted. Programs held meetings about the benefits of tobacco-free policies with key stakeholders who had decision-making power (eg, Dean of Students, Chancellor) or those in an influential role such as athletic coaches, fraternity presidents and dorm resident advisors. Media outreach included letters to the editor, opinion pieces, public service announcements and paid advertising in high visibility outlets (eg, campus newspaper, radio station and campus buses). Programs leveraged well trafficked events (eg, freshman orientation, sporting events, health fairs and music festivals) to disseminate information about cessation resources, conduct surveys about campus attitudes and collect signatures in support of policy change. Programs frequently used results of petition drives and surveys when developing meeting content and media messages to demonstrate widespread support for tobacco-free campus policies. DISCUSSION The North Carolina HWTF TFC Initiative has successfully and rapidly accelerated the diffusion of 100% tobacco-free policies on colleges and university campuses in North Carolina. During the first 4 years of the TFC Initiative, the number of North Carolina college students protected by tobacco-free policies increased from 687 to (from 0.1% to 32% of students at of North Carolina System, community college and member institutions of the association of North Carolina Independent s and Universities). 28 Such success makes North Carolina a national leader in the passage of voluntary tobacco-free college policies. 4 of 7 Lee JGL, Goldstein AO, Kramer KD, et al. Tobacco Control (2010). doi: /tc

5 Table 2 policy restrictions on participating North Carolina campuses: type and location Type of policy restriction Campus Areay Off campus Industry promotionz Campus organisation Appalachian State Beaufort Community Belmont Abbey Caldwell Community Carolinas of Health Sciences and Mercy School of Nursing of the Albemarle* East Carolina Forsyth Technical Community Greensboro, * Bennett,* Guilford Technical Community, * Guilford High Point * Montreat * North Carolina Central Rockingham Community Sandhills Community South Piedmont Community Stanly Community * Surry Community UNC Chapel Hill* UNC Charlotte UNC Greensboro UNC Pembroke* Wake Forest Western Piedmont Community * Wilkes Community Wilson Technical Community Total: 64 policies adopted Campuses can report multiples of each policy (shown by no. of s). Each new policy change (eg, certain areas made smoke-free, limiting smoking near campus health, residential housing smoke-free policy, etc.) was counted. Campus organisation policy changes were counted once per organisation (eg, student government, Spanish club, etc.). *Denotes 100% tobacco-free campus (100% tobacco-free policies are reported in table 1). yperimeter and designated area policies. zbans on sales, promotions and/or marketing activities. Very few states have established, implemented, or evaluated programmatic or legislative efforts to address tobacco use on college campuses. The TFC Initiative, based on diffusion of innovation theory and focused specifically on tobacco-free policy adoption, provides a major tobacco control policy option. Previous programs have emphasised peer-to-peer education or coalition models to effect change. Florida s Department of Health funded the Tobacco Pilot Program that included a campaign to reach college students called Student Tobacco Reform Initiative: Knowledge for Eternity (STRIKE). 29 STRIKE used peer-to-peer education and focused on denormalising tobacco use on 17 campuses. While STRIKE showed successes, its evaluators noted the need for more consistent and intensive efforts in the area of policy change. 30 Unfortunately, Florida s Tobacco Pilot Program s edgy and highly effective countermarketing campaign was defunded, eliminating support for STRIKE and other youth-led activities Mississippi used a coalition model and funded coalitions at campuses around the state; however, no standard policy objective existed for the coalitions. 33 Instead of programs designed to accelerate the adoption of policy change, other states have used three main strategies: legislation, top-down university system policies and technical assistance. The Arkansas Clean Air on Campus Act of 2009 made public colleges and universities smoke-free (Act 734, 2009 Regular Session). Iowa s legislature successfully included all college campuses and their grounds in this state s Smokefree Air Act. 34 The of Iowa announced the policy over a year before its implementation; provided a number of open forums and discussions for faculty, staff and students; offered cessation services; and, planned for implementation. 35 A less successful system-wide policy approach occurred in Pennsylvania. The Pennsylvania State System of Higher Education interpreted the state s clean indoor air act to include all college campus grounds, sparking controversy with students and faculty, in what was seen as a top-down policy approach. 36 Faculty representatives filed a labour complaint with the Pennsylvania Labor Relations Board and within months the system allowed outdoor smoking exceptions. 37 While policy changes by legislators, when planned and carefully implemented, are ideal, legislative bans on campus tobacco use in indoor and outdoor environments may not be politically feasible in many states at this point in time. Another drawback of statewide legislation is that it may fail to address tobacco sales, promotion, or marketing on college campuses and may not deliver the associated benefits seen from organised advocacy that have proved successful in local campaigns. Currently, the alternatives include technical assistance for policy change from national groups (eg, Bacchus and Gamma and Ozarks Technical Community ) and regional/statewide coalition TA (eg, American Cancer SocietyeNew England and coalitions in California, Maine and Oregon) on advocacy and implementation. No published reports exist about the effectiveness or outcomes of such TA provision. While the TFC Initiative clearly accelerated policy adoption, program planners can also learn from many other components of the TFC Initiative. For instance, programs did not report substantial numbers of policy adoptions in off campus areas frequented by students, suggesting that additional strategies are needed to extend campus policy adoption to off campus venues, where students report secondhand smoke exposure. 38 While programs reported almost one-third of QuitlineNC promotions targeting priority populations, efforts to reach members of priority populations through tailored media messages and organisational policies have remained limited thus far over the course of the TFC Initiative. This suggests that more robust emphasis on health disparities would benefit future programs, given the existing evidence of large disparities among college students in North Carolina While we did not collect data to evaluate if college student exposure to industry marketing was affected by the TFC Initiative, the 11 adopted policies Lee JGL, Goldstein AO, Kramer KD, et al. Tobacco Control (2010). doi: /tc of 7

6 prohibiting industry promotions and sales on campus suggest less exposure. Further work on countermarketing tobacco products remains a priority that was not fully addressed in the TFC Initiative. This study has several limitations. While insufficient research exists to document the overall impact of tobacco-free policies on college student tobacco consumption, 100% smoke-free workplaces decrease the prevalence of smoking by 3.8% and lower the number of cigarettes smoked, together creating a 29% reduction in employee cigarette consumption. 40 If this level of impact applies to college students, it suggests that the potential impacts may be substantial and will also benefit the health of campus employees. Campuses with an institutional openness to tobacco-free policies may also have been more likely to respond to the request for proposals and be funded in the grant process or to participate with funded programs. We did not measure the social connections between college/university officials or other factors that could advance policy change. Changes in North Carolina s policy environment relevant to tobacco-free policies were occurring concurrently with all primary and secondary schools in the state going tobacco-free by July and all North Carolina hospitals by March Another factor influencing change statewide was the launch of additional TA provision by HWTF to non-funded campuses in February 2008, likely accounting for the increase in policy adoption on those campuses when combined with ongoing diffusion of the policy innovation across the state. The TFC Initiative aided the innovation decision process by providing new financial resources, administrative and staff support, and by building student involvement, which have been identified as barriers to campus policy adoption While the evaluation was designed to capture activities for the TFC Initiative s four goal areas, activities overlapped with diffusion of innovation accelerants. Technical assistance and grantee trainings documented advantages of policy change, examples from other campuses were shared between grantees illustrating benefits to other campuses, and grantees aided in demystifying the implementation process. While some of these processes likely occurred organically and were thus not captured by the evaluation, the logic model and evaluation emphasised building coalitions of stakeholders and providing information to leaders to accelerate diffusion of innovation. Given that all programs were able to use the multiple activities in the logic model, we could not link specific program activities to policy outcomes. Some activities may have contributed more to policy adoption than others, and this study only explores the impact of community specific, combined intervention strategies. Future program interventions should consider the ample evidence that smoking prevalence is highest among young adults who are not attending colleges and universities. 45 Funding and designing interventions to accelerate policy change that directly protects non-college young adults remains a challenge and illustrates the need for a national strategy to promote tobaccofree spaces and places for young adults. Additional research is What this paper adds < Acceleration of the adoption of tobacco-free campus policies at colleges and universities can be highly successful with multilevel interventions on campuses. < National and state strategic planning to increase the adoption of tobacco-free campus policies towards a tipping point should be a priority. needed to examine compliance with tobacco-free policies on college campuses. Replicating and expanding North Carolina s program across the US and internationally, as appropriate, could have major impacts on tobacco use among college students. The current program design may provide new opportunities to promote other policy-based interventions on campus, such as alcohol, nutrition and violence prevention policies. Acknowledgements Thanks to Mary Mathew, HWTF grants managers, Caroline Mage and the TFC Initiative s partners for helping make this project a success. Thanks to Leigh Welper for her work in developing our online reporting system. No conflicts of interest are declared. Funding This work was funded by the North Carolina Health and Wellness Trust Fund Evaluation and Outcomes Initiative. 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. Competing interests None. Ethics approval This research was approved as exempt by the of North Carolina Biomedical Institutional Review Board Office (05-FAM/MED-1117). Contributors JGLL performed all data analysis and drafted the manuscript. AOG, KDK, JS, ME and VS planned and implemented the intervention and edited the manuscript. Provenance and peer review Not commissioned; externally peer reviewed. REFERENCES 1. CDC. Smoking-attributable mortality, years of potential life lost, and productivity losseseunited States, 2000e2004. MMWR Morb Mortal Wkly Rep 2008;57:1226e8. 2. Rigotti NA, Lee JE, Wechsler H. 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