Tobacco-Free Policy Proposal for Chaminade University (DRAFT)

Tobacco-Free Policy Proposal for Chaminade University (DRAFT) Submitted by Tracy Trevorrow, Ph.D. Department of Psychology With assistance from CUH students in Psychology 499, Applied Research in Psychology Katrina Heine, Daniella Montoya, Monique Tsang, Bryant Dela Cruz & Monique Miller Fall 2013

Executive Summary This paper provides a rationale for Chaminade University (CUH) to become a tobacco-free university. It proposes a policy statement, an implementation strategy, and a timeline to transition to a tobacco free campus. This proposal is open for review and comment by students, faculty, staff, and Marianist campus residents. After consideration of such feedback, the proposal will be submitted for review by CUH administration. Why a tobacco-free policy at CUH makes sense There is no safe level of smoking. Illnesses related to tobacco use are the leading cause of preventable mortality in the US and exposure to secondhand smoke contributes to preventable mortality, approximately 1,200 people in the US die each day due to cigarette smoking (Surgeon General, 2012). Smoke and cigarette butts have a negative impact on the environment. Smoke-free policies reduce second hand smoke, the prevalence of smoking and heart disease morbidity. The economic burden of cigarette use is $193 billion annually in health care costs and lost productivity in the US. In addition to causing direct health hazards, tobacco use contributes to institutional costs in other ways, including fire damage, cleaning and maintenance costs and costs associated with employee and student absenteeism, health care, and medical insurance. On average, smokers miss almost twice as many work days per year compared to nonsmokers, and businesses pay an average of $2,189 in workers compensation costs for smokers compared to $176 for non-smokers. There is a national trend for smokers to smoke fewer cigarettes per day making this an easier time to implement a tobacco-free policy. Prevention efforts must focus on young adults ages 18-25, as almost all smokers start by the age of 26 (Surgeon General, 2012). CUH should serve as a model in promoting health and wellness, consistent with Marianist values and the role the Chaminade Nursing program plays in community health care. Smoking at CUH is a problem The prevalence of smoking at colleges nationally is typically reported to be between 16% and 19% (ACHA, Romero & Pulvers, 2011). Approximately 11% of Chaminade undergraduate students report smoking on a regular basis (Montoya & Heine, 2013). This rate, while below national averages, is higher than other campuses that have smoke free policies e.g., UC system at 7.9% (Calfas et al., 2011). The CUH prevalence rate is only slightly less than that of the State as whole (14%) (BRFSS, 2010). CUH students are, therefore, smoking at higher rates than expected, as prevalence is typically much lower among highly educated college populations (Tobacco Use in Hawaii, 2010). 73% of CUH undergraduate students who smoke report having attempted to quit--most have tried twice (Montoya & Heine, 2013; Paeste et al., 2012). CUH students appear aware that their smoking presents a problem for them and are experiencing difficulties quitting. Allowing smoking on campus exposes Saint Louis students to models of smoking as well as to second hand smoke. Saint Louis students must walk past two CUH designated smoking areas along the sidewalk as they go to and from Chapel. 2

There are financial costs incurred by allowing smoking on campus, such as the cleaning and maintenance of designated smoking areas; and assumed lower productivity of smoking staff due to smoking break times, illness days, as well as costs of health insurance. Smoking is incompatible with Marianist educational values Creating a tobacco-free environment challenges those who use tobacco to develop their ability to manage their own health and to acknowledge the effect their behavior has on others and the environment. Tobacco use disproportionately affects the poor and less educated (CDC, 2011). The Chaminade community can promote the rights and responsibilities of all people by requesting those who smoke to stop exposing non-smokers to second hand smoke. Transitioning to a tobacco-free university This proposal articulates a rationale and plan for the transition to a tobacco-free university. It will be subject to review by all major stakeholders and modified by its authors accordingly before being submitted for review and potential implementation by CUH administration. It is recommended that a task force be created to write a transition plan and monitor its execution. A proposed timeline is presented from notification (May, 2014) to implementation (January, 2015). The approach to enforcing the new CUH tobacco use policy would need to be determined. The costs of such a transition would need to be calculated and budgeted by CUH administration. What does tobacco free mean? Tobacco free applies to the proscription of all tobacco products, smoked or otherwise consumed on the CUH campus and properties, including cigarettes, pipes, water pipes or hookahs, chewing tobacco, snus, and dissolvable tobacco that have been found to have harmful health effects. Tobacco products are not to be used in indoor or outdoor spaces. What about electronic cigarettes (e-cigarettes)? Electronic cigarettes do not use tobacco, although they can contain nicotine derived from tobacco. While the effects of nicotine from smoking are well understood (e.g., Lagrue, Lebargy, & Cormier, 2001), the health consequences of e-cigarettes have not been well documented (Odum, O Dell, & Schepers, 2012). This is partly due to the unregulated nature of the e-cigarette market as a relatively new product. Some argue that e-cigarettes are similar to other nicotine delivery systems (patches or gum) and should be considered as a healthier alternative to smoking (Boston Globe, 2013). Others express concern about dual usage (cigarettes and e- cigarettes) and the possibility that people may be attracted to e-cigarettes without ever having developed a habit of smoking (Odum, et al., 2012). It is recommended that e-cigarette use on campus be permitted so long as it is in conjunction with cessation programs. E-cigarettes, as a nicotine replacement system, may be used by students in their efforts to give up cigarettes. 3

Introduction This report is intended to serve as a white paper to guide a transition of CUH to a tobacco-free campus. It includes (a) rationale for adapting to a tobacco-free campus, (b) a review of undergraduate day students cigarette smoking (c) proposed language for a new tobacco policy, and (d) a proposed timeline and implementation plan. This report was generated by Dr. Tracy Trevorrow, Professor of Psychology, with support from students from Psychology 499: Research Experience in Applied Psychology. The content of this paper has been developed through consultation with Dr. Karen J. Calfas, Chair of the Smoking Policy Subcommittee for the University of California System and principal author of its Smoke-Free Policy Proposal (Calfas et al., 2011).The data regarding CUH cigarette smoking come from studies conducted by CUH undergraduate students (Psy 499). A. Rationale for Change Transitioning to a tobacco free rather than a smoke free campus is preferable as all forms of tobacco consumption are known to produce illness, disability, and death (CDC, 2010). Smoking and exposure to secondhand smoke are harmful. Approximately 443,000 people die from tobacco-related illnesses every year, making it the leading cause of preventable mortality in the United States (CDC, 2008). Numerous studies have found that cigarette smoking can cause chronic lung disease, coronary heart disease and stroke, in addition to cancer of the lungs, larynx, esophagus, mouth, and bladder. Smokeless tobacco products and cigars are known to cause lung, larynx, esophageal, and oral cancer (CDC, 2010). There is no risk-free level of exposure to secondhand tobacco smoke, ventilation cannot eliminate exposure of nonsmokers to secondhand smoke, and establishing smoke-free environments is the only proven way to prevent exposure (Surgeon General s Report, 2006). Any exposure to tobacco smoke even an occasional cigarette or exposure to secondhand smoke is harmful (USDHHS, 2010). The United States Environmental Protection Agency (EPA) found that secondhand tobacco smoke to be a risk to public health, and has classified secondhand smoke as a Group A carcinogen, the most dangerous class of carcinogen (USEPA, 1992). Smoking on campuses not only affects the individual's health but also exposes others to secondhand smoke. Exposure to secondhand smoke causes lung cancer, heart disease, and respiratory illnesses (MMWR, 2011). Approximately 3,000 lung cancer deaths occur each year among adult nonsmokers in the United States as a result of exposure to secondhand smoke. The Society of Actuaries calculated that secondhand smoke costs the U.S. economy about $10 billion a year. Specifically, $5 billion in estimated medical costs associated with secondhand smoke exposure and $4.6 billion in lost wages. This estimate does not include youth exposure to secondhand smoke. 4

A tobacco-free environment changes behavior Smoke-free campus policies decrease current smoking prevalence in students, decrease the amount of cigarettes used by those who continue to smoke, positively influence students perceptions of peer smoking, change social norms around tobacco use, and increase favorable attitudes towards regulation of tobacco. College students, who live in smoke-free residences, were found more likely to be nonsmokers (Seo, Macy et al., 2011). Comprehensive policies changed tobacco use behavior in workplaces. Tobacco users who work in a smoke-free environment were more likely to quit than their counterparts working in areas where smoking was permitted. Individuals working in smoke-free environments are more likely to decrease the number of cigarettes they smoked throughout the day (Fichtenberg & Glantz, 2002). The Hawaii State Legislature passed the Healthy Air and Workplaces Law (S.B. 3262, C.D. 1, SLH 2006) which took effect in 2006. As CUH students graduate, they will be transitioning into tobacco-free work and community environments. Nationally, worksites, college campuses, health care centers, and outdoor recreational facilities are adopting comprehensive tobacco use policies. Traditional college-age students are at increased risk Young adults are at risk for becoming established smokers. Regular or daily smoking tends to develop between ages 20 and 21 even if an individual first tries smoking before the age of 18 (Green et al., 2007). The college years are a time of increased risk for smoking initiation and transition to regular tobacco use. The time between first initiation and the age of 25 is viewed by the tobacco industry as an important transitional period when young adults experiment with tobacco and evolve into a daily smoker (Ling & Glantz, 2002). Almost 99% of smokers start smoking by the age of 26 and as such, prevention efforts must focus on young adults ages 18-25 (Surgeon General, 2012). The American College Health Association states that tobacco use in all forms is addictive, hazardous, and costly to individuals and institutions and exceptions that allow its use, such as designated smoking areas, is not acceptable (ACHA, 2009). Tobacco free policies at colleges and universities nationally The ACHA adopted a no tobacco use policy and encourages colleges and universities to be diligent in their efforts to achieve a 100% indoor and outdoor campus-wide tobacco-free environment (ACHA, 2009). The American Lung Association recommends that all colleges and universities completely prohibit tobacco (ALA, 2013). 5

In July 2013, 793 campuses were reported to be completely tobacco-free and 1,178 campuses were smoke-free (ANRF, 2013). The BACCHUS Network (2009) conducted a study of 31 schools with a recent transition to 100% tobacco-free campus. 67% reported no problems with compliance and enforcement 33% reported only minor enforcement issues <1% experienced significant issues No schools reported a decrease in enrollment as a result of the new policy 16% reported an increase in enrollment, stating that the news of a tobacco-free campus is received positively much more frequently than it is received negatively. Colleges and universities that initially established designated smoking areas have revised their policies to becoming smoke-free due to challenges with such areas including increased exposure to secondhand smoke, litter, cost of implementing policy, and the heightened appearance of smoking on campus which affects the social norm around tobacco use (Calfas et al., 2011). The facilities management and staff of the UC University System prefer a total ban on smoking because it reduces litter and their workload (Calfas et al., 2011). Tobacco free policies save money In the United States, the direct medical costs associated with smoking totaled approximately $75.5 billion (average 1997-2001), according to the Centers for Disease Control and Prevention (CDC, MMWR 2005). The economic burden of cigarette use includes $193 billion annually in health care costs and lost productivity (2010 Surgeon General s Report, 2010). For each employee who successfully quits tobacco, an employer can expect to see an annual savings of nearly $3,400 (CDC, MMWR, 2002). A smoker costs a private employer in the United States an extra $5,816 per year compared with a nonsmoker. The largest cost, at $3,077 annually, came from taking smoking breaks. The second largest cost, at $2,056, was related to excess health care expenses. The remaining costs came from increased absenteeism and lost productivity at work (NBGH, 2013)..Businesses pay an average of $2,189 in workers compensation costs for smokers compared to $176 for nonsmokers (Musich et al, 2001). On average, smokers miss 6.16 days of work per year due to sickness (including smoking related acute and chronic conditions), compared to nonsmokers, who miss 3.86 days of work per year (Halpern et al, 2001). Each employee or dependent who quits smoking reduces annual medical and life insurance costs by at least $210 almost immediately (Fitch et al. 2006). 6

Integrating smoking cessation programs and tobacco-free policies with other campus programs that promote health and wellness is essential to facilitating and supporting successful behavior change and maximizing the health of the entire campus community (Calfas et al., 2011). Tobacco free policy reduces harm to the environment The amount of litter on college campuses can be substantial. Adopting a tobacco-free policy would have a major impact on reducing butt litter on campus, saving facilities staff time and costs as well as a related positive impact on the environment. A study of litter at UC San Diego and San Diego State University revealed that in 80 volunteer hours, 31,410 butts were collected at these institutions (combined). This represented about 380 butts per volunteer per hour (Sawdey, et al, 2011). The US Environmental Protection Agency estimates that employers could save $4-8 billion in building operations and maintenance costs with comprehensive smoke-free policies (NGBH, 2013). B. Smoking among CUH Students CUH students in an applied research course (PSY499) designed, administered and analyzed a series of surveys of smoking among CUH day undergraduates. The findings of these surveys are summarized below. CUH Undergraduate Smoking Survey, Spring 2012 (Brewer & Dunne, 2012; Paeste, Brewer, Dunne, & Stewart, 2012) A survey of 61 classes from March through April, 2012 found that 70 of 575 respondents (12%) reported smoking on a regular basis. Smoking was slightly more prevalent among men (54%) and significantly more likely among Caucasian and Native Hawaiian students. Smoking was equally distributed across class rank. Reported cigarette use tended to be light, typically 7 cigarettes per day. Student smokers most often started smoking at 17 years of age and smoked for an average of 5 years. The vast majority of CUH smokers had tried to quit (73%) and most had tried at least twice. About one-third of smokers were not considering quitting, one third was contemplating quitting, and the remainder was actively trying to quit. The greater the number of cigarettes smoked per day the less likely a student was to report that they were willing to quit. The greater the number of quit attempts the more likely that the student reported thinking about or trying to quit. CUH Undergraduate Smoking Survey, Spring 2013 (Montoya & Heine, 2013) A survey conducted in May of 2013 of 13 classes (188 students) found that 20 students (11%) smoked. Similar to the survey results of 2012, men smoked slightly more than women, most appeared to be light smokers (about 4 cigarettes per day). Smoking was equally distributed across class rank. Most students started smoking at 17 years of age and had been smoking for about 4 years. The majority of smokers (60%) had previously tried to quit and most had done so twice. Caucasians were more likely to be smokers compared to other ethnic groups but, unlike the previous survey, Native Hawaiian students were not found to be at greater risk for smoking. 7

In this survey, only one student stated that they were not thinking of quitting smoking. The vast majority was either thinking of quitting or was actively trying to quit. However, only about 20% reported a willingness to participate in smoking cessation classes if they were offered at CUH. The Spring 2013 smoking survey assessed dependency on nicotine (Heatherton, Kozlowski, Frecker, & Fagerstrom, 1991) and found most students reported few indications of nicotine dependency. Most students who smoke reported that refraining from smoking was not difficult. This survey also introduced questions regarding e-cigarette use. About 45% of cigarette smokers at CUH appear to also use e-cigarettes. Six of these students (30%) used e-cigarettes with nicotine, 2 (10%) without nicotine, and 1 student reported using e-cigarettes with and without nicotine. Smoking Survey of CUH 100 Students, Fall 2013 (Montoya & Heine, 2013) A survey of 90 freshman enrolled in the CUH 100 course found a prevalence rate of only 4%. It is not known why this rate is significantly lower than previous surveys. While it is hoped that this reflects a sharp decline in smoking rates, the possibility of measurement error should be considered. The 5 students who reported smoking appear similar in profile to student smokers in the previous surveys. Three of these students also report using e-cigarettes with nicotine. Interestingly, more students reported using e-cigarettes than smoking cigarettes. Of the 7 students who reported only using e-cigarettes, 3 used nicotine in their device. Summary of CUH student smoking The current prevalence of student smoking at CUH for undergraduate day students is about 11% which equates to approximately 145 students. The rate of smoking may be trending downward, which is consistent with national prevalence rates (Surgeon General s Report, 2012) and the rate found in CUH 100 classes. CUH prevalence is lower than most US mainland colleges and universities but higher than those that have instituted smoke free policies. Men and women at CUH appear to be smoking at similar rates. Students who identify themselves as Caucasian appear more likely than other groups to smoke. Smokers appear to be equally distributed across class rank suggesting that smoking rates do not increase with time at CUH. Student smokers at CUH tend smoke fewer than 10 cigarettes per day and report low levels of dependency on nicotine. Most CUH smokers established the habit before college and appear to be in a phase of smoking that is triggered by social and environmental cues rather than withdrawal from nicotine. A noticeable increase in the motivation to quit was noted when comparing surveys from 2012 and 2013. Most students who smoke, reported that they are either thinking of quitting or are actively trying to quit; the vast majority have attempted to quit several times. However, it does not appear that students are currently motivated to receive smoking cessation services if they are offered on campus. The use of e-cigarettes appears to be increasing for CUH students. This is consistent with the rising popularity of e-cigarettes in the broader community (CASAA, 2013). Most students who use e- cigarettes appear to use them with nicotine. Students who are not cigarette smokers report using e- cigarettes with and without nicotine. 8

Policy implications of CUH student smoking Results from repeated surveys of CUH undergraduate day students are instructive regarding the formation of policies to promote reduction and cessation of tobacco use on campus. While the prevalence of students smoking is relatively low compared to US mainland rates, it is not significantly below that of the community at large. It is not clear why a university student population should have a prevalence rate approaching that of the general population. It does appear that student smokers are smoking fewer cigarettes and are less dependent on nicotine than smokers in the general community. A multi-component program to prevent, reduce and eliminate smoking appears warranted and should include a PR and education campaign to address student smoking at CUH. This campaign should be marketed to men and women in the 18 to 22 age range and include Caucasian models. An on-campus smoking cessation program should also be provided to assist students who wish to reduce or stop smoking. While student smokers do not appear to be currently inclined to participate in such on-campus programs they are reporting a desire to quit smoking and experiencing failure in their attempts to do so. Marketing attempts may help shift this apparent reluctance. Establishing a tobacco free campus is likely to increase participation in such programs. Students appear to need encouragement to consider professional help in quitting smoking. Most appear to be considering or attempting to quit but repeatedly failing in their attempts. Young adults, at this age, are considered to be at a vulnerable stage where smoking transitions from socially cued and intermittent use to use that is driven by dependency on nicotine (Pierce et al., 2011). A smoking cessation program provided on campus should emphasize the behavioral, environmental, and psychological reasons for smoking as opposed to a reliance on nicotine replacement. However, CUH students who are most likely to be in a pre-contemplation phase of smoking (i.e., not considering quitting) also appear to be those who are most dependent on nicotine. As such, nicotine replacement should be included for students with higher rates of smoking. CUH students appear to be using e-cigarettes to help reduce their dependence on smoking cigarettes. Other students are using e-cigarettes without having previously established a smoking habit. E-cigarettes are broadly accepted as being less harmful than cigarettes (Burstyn, 2013; Etter, 2012) and as such can be considered as a means of harm reduction in the context of a smoking cessation program. The use of e-cigarettes should not be encouraged unless it is in the context of smoking cessation. 9

C. Tobacco-Free Policy Proposal CUH should be committed to providing a healthy and safe environment for students, staff, faculty, guests and visitors. As the health hazards of tobacco use are well-documented and the policy of allowing smoking to occur on campus presents a health threat to the CUH community, we respectfully recommend to the CUH administration that the University becomes a tobacco-free institution. The following is a proposed policy regarding tobacco use. The administration of Chaminade University of Honolulu prohibits the use of tobacco products by all persons, including students, faculty, staff, contractors, and visitors on the main Honolulu campus and at all Chaminade properties. Tobacco products are not to be used in indoor or outdoor spaces, including parking lots, dormitory space, courtyards and athletic fields. The use of tobacco products is also prohibited within all vehicles on University property and within all University vehicles, including ocean vessels at any location. Prohibited tobacco products include, but are not limited to, cigarettes, clove cigarettes, pipes, water pipes, hookahs, chewing tobacco, snuff, snus, cigars, cigarillos, and dissolvable tobacco. Products that are considered nicotine replacement systems, such as nicotine patches, nicotine gum, and e-cigarettes may be used in outdoor spaces so long as such use in done to assist the user in quitting smoking. The possession or storage of tobacco products does not constitute tobacco use. The prohibition on the use of tobacco products applies to those attending University or public events, such as conferences, cultural events, and sporting events held on University property. Organizers of such events are required to communicate this policy to attendees and shall enforce the policy. Tobacco sales, tobacco industry promotions, advertising, marketing and sponsorship of campus groups or events are prohibited at Chaminade University. Transition plan The following considerations are proposed to promote a reasonable and effective transition to a tobacco-free university. A transition plan be established and coordinated by a task force represented by all major stakeholders in campus life, including but not limited to students, faculty, staff (to include Dean of Students Office and Security), administration, and Marianist residents on campus. University administrators are directed to fund and implement the tobacco use policy. Prospective students are made aware of the tobacco policy (e.g., university brochures, website, campus tours, Student Handbook). The tobacco policy is reviewed in the CUH 100 course, along with education regarding the health benefits of refraining from using tobacco products. 10

Information regarding the new tobacco policy is made available to the University at large, including the Marianists who live on campus. This may be accomplished, in part, through University website, brochures, and email blasts. The campus environment is modified to accommodate the policy, such as removal of designated smoking areas, removal of ashtrays, and signage. Notices regarding the tobacco policy and the availability of smoking cessation resources need to be displayed on bulletin boards. The CUH administration supports the developing and maintaining smoking cessation resources on campus. Enforcement policies and procedures are established and education and training are provided to university personnel regarding how to manage cases where tobacco use is occurring. D. Timeline for Transition to a Tobacco-Free University It is advisable that the transition to a tobacco-free university be considered as a process rather than a specific event date. As the on-campus survey studies indicate, for CUH students who smoke, quitting cigarettes is difficult and most have repeatedly failed to do so. Such students would most likely be able to adjust to the new tobacco policy if the University community fosters a culture of understanding and support. Resources to assist smokers should be well established before the date the policy prohibiting tobacco use. Factors to be considered regarding the pace of planned changes include the size of the university, the number of tobacco users, availability of smoking cessation resources, ability of the University to garner multiple perspectives and support for the policy from stakeholders, establishment of a means of enforcement, and the time needed for physical removal of designated smoking areas and to create and display signage. The University of California System of Universities allowed 18-24 months from the time of the announcement of the new policy to the smoke-free start date for a thorough and supportive implementation plan. The transition, that began September 2013, has reportedly gone without significant problems across all campuses involved (personal communication, K. J. Calfas, October 30, 2013). This is consistent with the BACCUS Network study (2009) of 31 campuses that underwent such a transition. The University of Hawai i announced their Tobacco-Free Campus Policy Draft less than three months prior to the planned implementation on January 1, 2014. This has resulted in concern expressed by the Hawaii Government Employees Association that the process proposed is not gradual enough and that the UH system should be slower in weaning the campus off tobacco products (personal communication, L. Fernandes, HGEA Field Officer, October 3, 2013). CUH is a single campus institution with a small enrollment compared to any of the UC campuses or the University of Hawaii. It is estimated that CUH has 145 undergraduate day students who smoke. The rate of smoking among graduate students (721), staff and administration (240) faculty (101), administration, and Marianist campus residents (20) is not known. Applying the 11% prevalence rate would result in a total of approximately 265 smokers affected by the new tobacco policy. It is anticipated that a successful transition to a tobacco-free campus would require less than 18 months but greater than three months that has proved problematic for the UH system. 11

It is proposed that a new CUH tobacco policy be established by University administration and approved by the Board of Directors by the end of the spring term 2014. The summer terms and fall semester of 2014 may serve as a time for the CUH community to be informed of the new policy and for students who smoke to take advantage of smoking cessation resources on-campus. The physical transition to a tobacco free campus may take place during the 2014 winter break and the effective date of being tobacco free would be January 1, 2015. While it is proposed that the plan and its execution is the responsibility of the transition task force, the following tentative progression is suggested. Fall 2013 Tobacco-free policy draft is written. Policy draft circulated to students groups, faculty, staff, Marianist community campus residents, contracted employees for comment. Feedback incorporated and revised draft of policy language is made available for CUH community review. Final policy proposal is submitted to administration. Start of an on-campus smoking cessation program. Spring 2014 CUH administration review and revise the tobacco-free policy language. CUH administration submit revised policy to CUH community for review and feedback. Final version of tobacco policy (including a tobacco-free start date) is determined by CUH administration and submitted to Board of Regents for review and approval. Announcement is made to CUH Community and community at large of the new tobacco policy. All new students are notified of the new tobacco policy at the time of application. Those who already applied and accepted for admission in the fall 2014 are notified of this change. The administration selects a task force to determine specific actions and dates to implement the plan. Campus-wide education campaign is developed regarding health and wellness and tobacco use. Continued support and development of an on-campus smoking cessation program. Continued yearly survey of undergraduate smoking and e-cigarette use. Summer 2014 Materials for incoming students is updated to include new tobacco policy. 12

Fall 2014 Administration provides training of faculty regarding enforcement of smoking policy at faculty retreat. Training of security and staff regarding new tobacco policy and how to manage those who violate the policy. Training of vendors is done regarding the enforcement of the tobacco policy. CUH 100 students receive education regarding tobacco use, the new tobacco policy and resources on-campus to assist smokers. Campus wide notification of the new tobacco policy occurs through website, CUH radio, posters, and other promotional events (e.g., Great American Smoke Out.). Signage designed and produced. Plan made to remove designated smoking areas. On campus smoking cessation program continues. Winter break Designated smoking areas are removed along with old signage. New signage stating CUH as a tobacco-free campus is put in place. Spring 2015 The new tobacco policy begins January 1. Continued support occurs for on-campus smoking cessation program. The education campaign continues to discourage smoking and promote adherence to new policy. The annual survey assessment of undergraduate smoking and e-cigarette use is conducted. Permanent Tobacco Management Program Features Smoking cessation program is offered on campus. Education campaign continues regarding incoming students to tobacco issues and policy. Tobacco policy is clearly communicated to students, parents, and visitors. Yearly survey of smoking behavior of students is conducted. CUH Support for Smokers It is recommended that smoking cessation support should be made available at no cost to all in the CUH community. Removing cost barriers by providing full coverage for tobacco cessation medications and counseling will increase utilization and long-term quitting success. A comprehensive and effective smoking cessation program will usually cost between $3-$10 a day (PMPM) (Oz, 2013). Such support should include individual and group counseling. Smoking reduction and cessation programs may be provided by the CUH Center for Medical Psychology (CMP). The CMP smoking cessation program may include FDA-approved drug therapies, nicotine replacement systems such as nicotine patches, gum, and e-cigarettes. Referrals can be also made through the CMP to off-campus resources, such as community based cessation programs, telephone counseling, on-line programs and interactive websites. 13

Enforcement Consistent with Marianist values, good will and respect for the rights of others are essential in the successful implementation of the CUH tobacco policy. In faculty and staff meetings CUH personnel may be trained on how to respectfully remind violators about the smoke-free policy. Some campuses hand out cards to help explain the policy to those found smoking (Calfas, et al., 2011). All share in the responsibility for adhering to and enforcing of a new tobacco policy. If smoking continues after an individual has been told of the tobacco policy, campus security may be called to intervene. There shall be no reprisal against anyone seeking assistance in enforcing this policy. It is recommended that enforcement strategies use an educational approach in contrast to one where the offending individual is fined or otherwise sanctioned. This is reported to have worked well at other universities (Calfas, et al., 2011). It is unlikely that there will be complete compliance with the new tobacco policy. There will perhaps always be a small number of CUH members who will not comply. This being accepted, it should be recognized that the overall impact of the policy change will be substantial and positive. Safety A tobacco-free policy should increase safety on campus. Safety is more of a problem when a campus has a designated smoking area policy as people tend to smoke in parking lots and in cars. When this occurs, smoke is concentrated and increases the smoker s exposure and the exposure of those in the immediate vicinity. As such, it is important for parking lots and similar isolated areas, where students may be tempted to smoke, to be well lit. Since we are proposing a tobacco-free environment, we do not anticipate people standing around outside to smoke. Smoking and second hand smoke may be an issue around the perimeter of campus and the implementation plan should include recommendations to address this issue. Costs There will be costs associated with the implementation of a system-wide tobacco-free policy. At the system level there will administration time for meetings to coordinate direction, share information and resources. The costs include permanent signage, removal of ashtrays, educational campaign to announce the beginning of the policy, PR planning and execution, ongoing education to students, faculty, staff, and visitors, and smoking cessation program support. 14

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