thesis statement about restriction on smoking in campus

• Open access
• Published: 01 February 2017

College anti-smoking policies and student smoking behavior: a review of the literature

• Brooke L. Bennett 1 ,
• Melodi Deiner 1 &
• Pallav Pokhrel 1  

Tobacco Induced Diseases volume  15 , Article number:  11 ( 2017 ) Cite this article

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Currently, most college campuses across the U.S. in some way address on-campus cigarette smoking, mainly through policies that restrict smoking on campus premises. However, it is not well understood whether college-level anti-smoking policies help reduce cigarette smoking among students. In addition, little is known about policies that may have an impact on student smoking behavior. This study attempted to address these issues through a literature review.

A systematic literature review was performed. To identify relevant studies, the following online databases were searched using specific keywords: Ovid MEDLINE, PsycINFO, PubMed, and Google Scholar. Studies that met the exclusion and inclusion criteria were selected for review. Studies were not excluded based on the type of anti-smoking policy studied.

Total 11 studies were included in the review. The majority of the studies (54.5%) were cross-sectional in design, 18% were longitudinal, and the rest involved counting cigarette butts or smokers. Most studies represented more women than men and more Whites than individuals of other ethnic/racial groups. The majority (54.5%) of the studies evaluated 100% smoke-free or tobacco-free campus policies. Other types of policies studied included the use of partial smoking restriction and integration of preventive education and/or smoking cessation programs into college-level policies. As far as the role of campus smoking policies on reducing student smoking behavior is concerned, the results of the cross-sectional studies were mixed. However, the results of the two longitudinal studies reviewed were promising in that policies were found to significantly reduce smoking behavior and pro-smoking attitudes over time.

More longitudinal studies are needed to better understand the role of college anti-smoking policies on student smoking behavior. Current data indicate that stricter, more comprehensive policies, and policies that incorporate prevention and cessation programming, produce better results in terms of reducing smoking behavior.

Tobacco use, especially cigarette smoking, continues to remain a leading preventable cause of mortality in the United States (U.S.). Across different age-groups, young adults (18–29 year olds) tend to show the highest prevalence of cigarette smoking [ 1 ]. For example, past-30-day prevalence of cigarette smoking among 18–24 year olds is 17%, whereas the prevalence is approximately 9% among high school students [ 2 ]. Although most smokers initiate cigarette smoking in adolescence, young adulthood is the period during which experimenters transition into regular use and develop nicotine dependence [ 1 ]. Young adulthood is also the period that facilitates continued intermittent or occasional smoking [ 3 ], neither of which is safe. In addition to the possibility that intermittent smokers may show escalation in nicotine dependence, intermittent smoking exposes individuals to carcinogens and induces adverse physiological consequences [ 4 ].

Research [ 5 ] shows that smokers who quit smoking before the age of 30 almost eliminate the risk of mortality due to smoking-induced causes. Thus smoking prevention and cessation efforts that target young adults are of importance. Traditionally, tobacco-related primary prevention efforts have mostly focused on adolescents [ 6 ] and have utilized mass media as well as school and community settings [ 7 , 8 ]. This is only natural given that most smoking initiation occurs in adolescence. However, primary and secondary prevention efforts focusing on young adults have been less common. This is particularly of concern because tobacco industry is known to market tobacco products strategically to promote tobacco use among young adults by integrating tobacco use into activities and places that are relevant to young adults [ 9 ].

As more and more young adults attend college [ 10 ], college campuses provide a great setting for primary and secondary smoking prevention as well as smoking cessation efforts targeting young adults. According to the American College Health Association [ 11 ], approximately 29% U.S. college students report lifetime cigarette smoking and 12% report past-30-day smoking. Currently, most college campuses across the U.S. in some way address on-campus cigarette smoking, mainly through policies that restrict smoking [ 12 , 13 ]. One of the main reasons why such policies are considered important is the concern about students’ exposure to secondhand tobacco smoke [ 14 ]. Therefore, at their most rudimentary forms, such policies tend to be extensions of local- or state-level policies restricting smoking in public places [ 15 ]. However, some colleges may take a more comprehensive approach, by integrating, for example, smoke-free policies with anti-smoking campaigns and college-sponsored cessation services [ 16 ]. Further, some colleges may implement plans to enhance enforcement of and compliance to the smoke-free policies [ 17 – 19 ].

At present, there are a number of questions related to college-level anti-smoking policies that need to be examined carefully in order to scientifically inform how colleges can be better utilized to promote smoking prevention and cessation among young adults. Besides the degree of variation in anti-smoking policies, there are questions about students’ compliance with such policies and whether such policies have influence on students’ attitudes and behavior related to cigarette smoking. Past reviews of the studies on the effects of tobacco control policies in general (e.g., not specific to college populations) [ 20 – 22 ] emphasize the need for a review such as the current study. Wilson et al. [ 20 ] found that interventions involving smoke-free public places, mostly restaurants/bars and workplaces, showed a moderate to low effect in terms of reducing smoking prevalence and promoting smoking cessation. The review included three longitudinal studies, none of which showed that the policies had an effect on smoking cessation. Fichtenberg & Glanz [ 21 ] focused on smoke-free workplaces and found that the effects of such policies seemed to depend on their strength. That is, 100% smoke-free policies were found to reduce cigarette consumption and smoking prevalence twice as much as partial smoke-free policies that allowed smoking in certain areas. In a recent exhaustive review, Frazer et al. [ 22 ] found that although national restrictions on smoking in public places may improve cardiovascular health outcomes and reduce smoking-related mortality, their effects on smoking behavior appear inconsistent. There are reasons why college anti-smoking policies may be more effective than policies focused on restaurant/bars or even workplaces. For example, students tend to spend the majority of their time on campus premises. In fact, in the case of 4-year colleges, a large number of students live on or around campus premises. Strong anti-smoking policies may deter students from smoking by making, for example, smoking very inconvenient. However, the current state of research on college anti-smoking policies and student smoking behavior is not well documented.

The purpose of the current study is to systematically review quantitative studies that have investigated the impact of college-level anti-smoking policies on students’ attitudes towards tobacco smoking and smoking behavior. In the process, we intend to highlight the types of research designs used across studies, the types of college and student participants represented across studies, and the studies’ major findings. A point to note is that this review’s focus is on anti-smoking policies and cigarette smoking. Although the review does assess tobacco-free policies in general, our assumption at the outset has been that most studies in the area have had a focus on smoke-free policies and smoking behavior because of the emphasis on secondhand smoke exposure. Smoke-free and tobacco-free policies are different in that smoke-free policies have traditionally targeted smoking only whereas tobacco-free policies that have targeted tobacco use of any kind, including smokeless tobacco [ 23 ]. Both types of policy could be easily extended to incorporate new tobacco products such as the electronic nicotine delivery devices, commonly known as e-cigarettes. Given that e-cigarettes are a relatively new phenomenon in the process of being regulated, we assumed that the studies eligible for the current review might not have addressed e-cigarette use, although if addressed by the studies reviewed, we were open to addressing e-cigarettes and e-cigarette use or vaping in the current review.

Study selection

We searched Ovid MEDLINE (1990 to June, 2016), PubMed (1990 to June, 2016), PsycINFO (1990 to 2013), and Google Scholar databases to identify U.S.-based peer-reviewed studies that examined the effects of college anti-smoking policies on young adults’ smoking behavior. Searches were conducted by crossing keywords “college” and “university” separately with “policy/policies” and “smoking”, “tobacco”, “school tobacco”, “smoke-free” “smoking ban,” and “tobacco free.” Article relevance was first determined by scanning the titles and abstracts of the articles generated from the initial search. Every quantitative study that dealt with college smoking policy was selected for the next round of appraisal, during which, the first and the last authors independently read the full texts of the articles to vet them for selection. Studies were selected for inclusion in the review if they met the following criteria: studies 1) were conducted in the U.S. college campuses, including 2- and 4-year colleges and universities; 2) were focused on young adults (18–25 year olds); 3) focused on implementation of college-level smoking policies; 4) were quantitative in methodology (e.g., case studies and studies based on focus groups and interviews were excluded); and 5) directly (e.g., self-report) or indirectly (e.g., counting cigarette butts on premises) assessed the cigarette smoking behavior. References and bibliographies of the articles that met the inclusion criteria were also carefully examined to locate additional, potentially eligible studies.

Selected studies were reviewed independently by the first and the last authors in terms of study objectives, study design (i.e., cross-sectional or longitudinal), data collection methods, participant characteristics, U.S. region where the study was conducted, college type (e.g., 2- year vs. 4-year), policies examined and the main study findings. The review results independently compiled by the two authors were compared and aggregated after differences were sorted out and a consensus was reached.

Study characteristics

Figure  1 depicts the path to the final set of articles selected for review. Initial searches across databases resulted in total 71 titles and abstracts related to college smoking policies. Of these, 49 were deemed ineligible at the first phase of evaluation. The remaining 22 articles were evaluated further, of which, 11 were excluded eventually. Two studies [ 24 , 25 ] were excluded because these studies did not assess students’ tobacco use behavior. One study [ 26 ] was excluded because it was not quantitative. Five studies [ 17 – 19 , 27 , 28 ] were excluded because the studies focused on compliance to existing smoking policies and did not assess the impact of policies on behavior. One study [ 15 ] was excluded because although it studied college students, the smoking policies examined were county-wide rather than college-level. Two studies [ 29 , 30 ] were excluded because their samples consisted of college personnel rather than students. Thus, a total of 11 studies were included in the current review.

Chart depicting selection of the final set of articles reviewed

Table  1 summarizes the selected studies in terms of research purpose, study design, subjects, type of college, region, policies and findings. The majority of the studies were conducted in the Midwestern ( n  = 3; 27.3%) or Southeastern United States ( n  = 3; 27.3%). Other regions represented across studies were Southern ( n  = 2; 18.1%), Northwestern ( n  = 2; 18.1%), and Western United States ( n  = 1; 9.1%). Six studies (54.5%) included predominantly White participants (i.e., greater than 70%), and 2 studies (18%) included predominantly female participants. Nationally, women and Whites comprise 56% and 59% of the U.S. college student demographics, respectively [ 10 ]. Two studies (18.1%) assessed smoking behavior indirectly by counting cigarette butts on college premises, counting the number of individuals smoking cigarettes in campus smoking “hotspots,” or counting the number of smokers who utilized smoking cessation services. Across studies, the sample size ranged between N  = 36 and N  = 13,041. The mean and median sample sizes across studies were 3102 (SD = 4138) and 1309, respectively. Participants tended to range between 18 and 30 years in age. The majority of the studies ( n  = 6; 54.4%) were cross-sectional in design. Only 2 (18%) of the studies were longitudinal. The majority of the studies were conducted at 4-year colleges ( n  = 10; 90.9%). Only 1 study was conducted at a 2-year college ( n  = 1; 9.1%).

Three studies (27%) focused on tobacco-free policies and 3 studies (27%) on smoke-free policies. Three studies ( n  = 3; 27.3%) compared the associations of differing policies on smoking behavior. One study [ 31 ] examined the relative impacts of policies utilizing preventive education, smoking cessation programs, and designated smoking areas or partial smoking restriction. Another study [ 32 ] implemented an intervention to increase adherence to a partial smoking policy (i.e., smoking ban within 25 ft of buildings). The intervention involved increasing anti-tobacco signage, moving receptacles, marking the ground, and distributing reinforcements and reminder cards.

Anti-smoking policies and students’ smoking behavior

Table  1 lists the types of anti-smoking policies examined across studies and the corresponding findings. Major findings are as follows:

Partial smoking restriction

Borders et al. [ 31 ] compared colleges that utilized partial smoking restriction by providing “designated smoking areas” to curb smoking with college-level policies that incorporated preventive education and with those that provided smoking cessation courses only. Results indicated that the presence of preventive education was associated with lower odds of past-30-day smoking whereas the presence of designated smoking areas only or smoking cessation programs only was associated with higher odds of past-30-day smoking. Fallin et al. [ 16 ] found that college campuses with designated smoking areas tended to show higher prevalence of smoking, compared with campuses that enforced smoke-free and tobacco-free policies. Braverman et al.’s [ 33 ] findings indicate that enforcing smoke-free policies tends to reduce secondhand exposure close to college buildings but may increase smoking behavior on the campus periphery.

Smoke- and tobacco-free campuses

Fallin et al. [ 16 ] found that compared with policies that relied on partial smoking restriction, tobacco-free policies were associated with reduced self-reported exposure to secondhand smoke as well as students’ lower self-reported intentions to smoke cigarettes in the future. Studies [ 34 , 35 ] consistently observed fewer cigarette butts or smokers in campuses under smoke-free policies compared with campuses without smoke-free policies. Prevalence of cigarette butts was likely to be inversely related to policy strength [ 35 ]. A study that monitored smokers’ behavioral compliance to smoke-free policies [ 32 ] indicated that interventions to promote compliance, such as use of signage, are likely to be effective in improving compliance and reducing student smoking in areas were the policy is enforced.

Lechner et al. [ 36 ] conducted assessments at a single college campus before and after a tobacco-free policy went into implementation. The policy, which also involved making smoking cessation services available campus-wide, was found to reduce proportions of high- and low-frequency smokers, pro-smoking attitudes (i.e., weight loss expectancy), and exposure to second-hand tobacco smoke [ 36 ]. The study did not find an effect on smoking prevalence. Seo et al. [ 37 ] followed a similar design where a policy intervention was evaluated based on pretest and posttest surveys. However, this study [ 37 ] included a “control” campus where similar assessments as in the “treatment” campus were conducted but no intervention was implemented. The study found that compared with the control campus, the campus that implemented smoke-free policies showed an overall decrease in smoking prevalence.

Other policies

Borders et al. [ 31 ] did not find policies governing the sales and distribution of cigarettes on campus to be associated with smoking behavior. Hahn et al. [ 38 ] found that college smoking policies that integrate smoking cessation services may increase the use of such services as well as promote smoking cessation. This study kept track of students who utilized the smoking cessation service offered by a college after the policy offering such a service was enacted. Sixteen months after the policy was first implemented, smokers who utilized the service were surveyed. Based the results it was estimated that approximately 9% of them had quit smoking.

To our knowledge, this is the first study to systematically review studies examining the effects of anti-smoking policies on smoking behaviors among U.S. college students. We found that such studies are severely limited. Only 11 studies met the inclusion criteria in the present review, although the review appeared to encompass all policies aimed at smoking behavior on college campuses. Thus, this review stresses the need for increased smoking policy and smoking behavior research on college campuses.

Rigorous evaluation of existing college anti-tobacco policies are needed to refine and improve the policies so that national-level efforts to reduce tobacco use among young adults are realized. Key initiatives at the national level have recognized the importance of mobilizing college campuses in the fight against tobacco use. For example, in September 2012 several national leaders involved in tobacco control efforts, in collaboration with the ACHA, came together to launch the Tobacco-Free College Campus Initiative (TFCCI) [ 39 ]. The TFCCI aims to promote and support the use of college-level anti-tobacco policies as a means to change pro-tobacco social norms on campuses, discourage tobacco use, protect non-smokers from second-hand exposure to tobacco smoke and promote smoking cessation. The ACHA’s position statement [ 11 ] regarding college tobacco control recommends a no tobacco use policy aimed towards achieving a 100% indoor and outdoor campus-wide tobacco-free environment.

We found that the majority of studies on smoking policies were cross-sectional in nature. Researchers relied upon students to report their smoking behavior or their observations of other students’ smoking behavior after a smoke-free or tobacco-free policy had been implemented. It is difficult to draw conclusions about an anti-smoking policy’s ability to change smoking behavior without knowing the smoking behavior prior to policy implementation. This domain of research would benefit from additional longitudinal studies. Ideally, research studies should collect data before the policy is implemented, immediately after, and at follow-up time points.

We found inconsistencies in the measurement of smoking behavior across studies. Two studies [ 34 , 35 ] counted cigarette butts, one study [ 38 ] counted people seeking tobacco dependence treatment, one study [ 32 ] counted smokers violating policy, and seven studies [ 16 , 31 , 36 , 37 , 40 , 41 ] relied upon self-report of smoking behavior. Another study [ 33 ] used survey methods to obtain participants’ response on other students’ smoking behavior. Counting cigarette butts has been validated as an effective measure of smoking behavior [ 19 ], especially when validating compliance to an anti-smoking policy, and self-report measures are commonly used in public health research [ 42 ]. Despite the validity and feasibility of these measures, the lack of a consistent measurement tool makes comparing effectiveness of anti-smoking policies on smoking behaviors across campuses difficult. Research in this domain would benefit from a consistently used measurement of smoking behaviors.

Although the reviewed studies represented diverse U.S. regions, the majority of the research was set in the Southeastern and Midwestern United States; Northeastern and Southwestern regions were not represented. Only one of the reviewed studies reported a sample that contained less than 50% White participants. Across studies, the minority group most represented was Asian American; but only one of the reviewed studies [ 16 ] included 20% or more Asian Americans. Relatively few studies included or reported Hispanic participants, although Hispanics are the largest minority group in the United States [ 43 ]. None of the reviewed studies included 20% or more Black participants. Only three studies [ 33 , 36 , 37 ] included American Indian/Alaska Natives and in only one of those studies [ 32 ] was the proportion greater than one percent. Only two studies [ 33 , 37 ] included Pacific Islanders, and in both the proportion was less than one percent. Clearly, more research is needed on minority populations, specifically Black, Hispanic, Native Hawaiian/Pacific Islander, American Indian/Alaska Native students and the subgroups commonly subsumed under these ethnic/racial categories. The U.S. college student demography is ethnically/racially diverse [ 10 ], comprising 59% Whites. The remaining 44% include various minority groups. Thus, for research on U.S. college students across the nation, studies with more ethnically/racially diverse student samples are needed.

The review findings were helpful in elucidating the types of tobacco policies being implemented on college campuses and their effects on the smoking behavior of U.S. college students. Mainly, three types of smoking policies were studied: smoke-free policies, tobacco-free policies and policies that enforced partial smoking restriction, including prohibition of smoking within 20–25 ft of all buildings and providing designated smoking areas. Indeed, campus-wide indoor and outdoor tobacco-free policy is considered a gold-standard for college campus tobacco control policy [ 11 ]. But only one study [ 16 ] compared tobacco-free and smoke-free policies. Other policies such as governing the sale and distribution of tobacco products, preventive education programs, and smoking cessations programs were also studied, but to a lesser extent. In general, interventions regarding the implementation of smoking policies on college campuses were difficult to find in the existing literature.

The combined results of the studies reviewed suggest that stricter smoking policies are more successful in reducing the smoking behavior of students. Tobacco-free and smoke-free policies were linked with reduced smoking frequency [ 16 , 36 , 37 ], reduced exposure to second-hand smoke [ 16 , 36 ], and a reduction in pro-smoking attitudes [ 36 ]. Implementation of a campus-wide tobacco-free or smoke-free policy combined with access to smoking cessation services was also associated with increased quit attempts [ 38 , 40 ] and treatment seeking behaviors [ 38 ]. It appears that 100% smoke-free policies are not only successful in reducing smoking rates, but also have strong support from students and staff members alike [ 33 ]. These results remained consistent when compared to less comprehensive tobacco control policies, which was evidenced by student report and the number of cigarette butts found on campus [ 34 , 35 ].

There was one important consistent exception to the general success of anti-smoking policies: designated smoking areas. All three studies which included designated smoking areas [ 16 , 31 , 41 ] found that designated smoking areas were associated with higher rates of smoking compared with smoke-free or tobacco-free policies. Designated smoking areas were also associated with the highest rates of recent smoking [ 16 ]. Lochbihler, Miller, and Etcheverry [ 41 ] proposed that students using the designated areas were more likely to experience positive effects of social interaction while smoking. They found that social interaction while smoking on campus significantly increased the perceived rewards associated with smoking and the frequency of visits to designated smoking areas [ 41 ].

None of the studies included in this review addressed new and emerging tobacco products such as e-cigarettes. This is understandable given that the surge in e-cigarette use is relatively new and in general there have only been a few studies examining the effects of anti-smoking policies on student smoking behavior, which has been the focus of this review. However, going forward, it will be crucial for studies to examine how campus policies are going to handle e-cigarette use, including the enforcement of on-campus anti-smoking policies given the new challenges posed by e-cigarette use [ 44 ]. For example, e-cigarette use is highly visible, the smell of the e-cigarette vapor does not linger in the air for long and e-cigarette consumption does not result in something similar to cigarette butts. These characteristics are likely to make the monitoring of policy compliance more difficult. Moreover, because of the general perception among e-cigarette users that e-cigarette use is safer than cigarette smoking, compared with cigarette smokers smoking cigarettes, e-cigarette users might be more likely to use e-cigarettes in public places. The fact that the TFCCI strongly recommends the inclusion of e-cigarettes in college tobacco-free policies [ 39 ] bodes well for the future of college health.

The current study has certain limitations. It is possible that this review might have missed a very small number of eligible studies. We believe that the literature searches we completed were thorough. However, new studies are regularly being published and the possibility that a new, eligible study may have been published after we completed our searches cannot be ignored. In addition, we may not have tapped eligible studies that were in press during our searches. If indeed a few eligible studies were not included in our review, the non-inclusion may have biased our results somewhat, although it is difficult for us to speculate the nature of such a bias. Hence, we recommend that similar studies need to be conducted in the future to periodically review the literature. Second, non-peer-reviewed articles or book chapters were excluded from this review. Despite the potential relevance of non-peer-reviewed materials, the choice was made to limit the inclusion in order to maintain scientific rigor of the review. However, it is possible that some data pertinent to the review might have been overlooked because of this, thus increasing the possibility of introducing a bias to the current findings. Third, this study focused on anti-smoking policies. Although we used “tobacco free” as search terms, “smoking” dominated our search strategies. Thus our results are more pertinent to cigarette smoking than other tobacco products and may not generalize to the latter. Lastly, in order to be as inclusive as possible, we reviewed three studies [ 32 , 35 , 38 ] that focused on more on compliance to anti-smoking policy than on the effect of policy on student smoking behavior. The findings of these studies may not be comprehensive in regard to student smoking behavior, even though they are indicative of the success of the policies under examination.

Conclusions

Despite limitations, this study is significant for increasing the understanding of smoking policies on U.S. college campuses and their effects on the smoking behavior of college students. We found that research on smoking policies on U.S. college campuses is very limited and is an area in need of additional research contribution. Within existing research, the majority used samples that were primarily White females. More diverse samples are needed. Future research should also report the full racial/ethnic characteristics of their samples in order to identify where representation may be lacking. Future research would benefit from longitudinal and interventional studies of the implementation of smoking policies. The majority of current research is cross-sectional, which does not provide the needed data in order to make causal statements about anti-smoking policies. Lastly, existing research was primarily conducted at 4-year colleges or universities. Future research would benefit from broadening the target campuses to include community colleges and trade schools. Community colleges provide a rich and unique opportunity to collect data on a population that is often older and more racial diverse than a typical 4-year college sample [ 45 ]. Also, there is at present a need to understand through research how evidence-based implementation and compliance strategies can be utilized to ensure policy success. A strong policy on paper does not often translate into a strong policy in action. Thus, comparing policies on the strength of written documents alone is not enough; policies need to be compared on the extent to which they are enforced as well as the impact they have on student behavior.

This review may be of particular interest to college or universities in the process of making their own anti-smoking policies. The combined results of the existing studies on the impact of anti-smoking policies on smoking behaviors among U.S. college students can help colleges and universities make informed decisions. The existing research suggests that stricter policies produce better results for smoking behavior reduction and with smoking continuing to remain a leading preventable cause of mortality in the U.S. across age-groups [ 1 ], college and university policy makers should take note. Young adults (18–25 year olds) show the highest prevalence of cigarette smoking [ 1 ], which places colleges and universities in the unique position to potentially intervene through restrictive anti-smoking policies on campus.

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Acknowledgements

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This research was supported by National Cancer Institute (NCI) grant 1R01CA202277-01.

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Data sharing not applicable to this article as no datasets were generated during the current study. All articles that contributed to the results and conclusions of the current study are included in the reference list.

Authors’ contributions

BB conducted the literature review, analyzed and interpreted results, and was a major contributor in writing the manuscript. MD assisted with the literature review. PP conceptualized the study, assisted with the literature review and manuscript preparation, and provided overall guidance. All authors read and approved the final manuscript.

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Cancer Prevention & Control Program, University of Hawaii Cancer Center, University of Hawaii at Manoa, 701 Ilalo St, Honolulu, HI96822, USA

Brooke L. Bennett, Melodi Deiner & Pallav Pokhrel

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Bennett, B.L., Deiner, M. & Pokhrel, P. College anti-smoking policies and student smoking behavior: a review of the literature. Tob. Induced Dis. 15 , 11 (2017). https://doi.org/10.1186/s12971-017-0117-z

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DOI : https://doi.org/10.1186/s12971-017-0117-z

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• Students’ perceptions of a university ‘No Smoking’ policy and barriers to implementation: a cross- sectional study
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• http://orcid.org/0000-0001-5995-1693 Ghadir Fakhri Al-Jayyousi ,
• Rana Kurdi ,
• Shahd Alsaei ,
• Haya AL-Kaabi ,
• Al Jaziya Alrushdi ,
• http://orcid.org/0000-0002-3719-5142 Hanan F Abdul Rahim
• Department of Public Health, College of Health Sciences, QU Health , Qatar University , Doha , Ad Dawhah , Qatar
• Correspondence to Dr Hanan F Abdul Rahim; hanan.arahim{at}qu.edu.qa

Objectives Effective policies are an important tool for reducing tobacco use. We examine student perceptions of the existing no-smoking policy in the country’s largest national university and identify perceived barriers to its implementation. We explore student support for a 100% tobacco-free campus policy.

Design We conducted a cross-sectional survey using a self-administered on-line questionnaire.

Setting This study was conducted at Qatar University (QU), the largest national institution of higher education in Qatar.

Participants A total of 199 students participated out of a stratified random sample of students aged ≥18 years with active registration in the Spring 2020 semester.

Primary and secondary outcome measures We assessed students’ knowledge of and attitudes towards QU’s current no-smoking policy, the perceived barriers to its implementation, and support for a 100% tobacco-free policy.

Results Only 26% (95% CI 19.97 to 32.03) and 16.6% (95% CI 11.70 to 22.49) of respondents correctly identified the current policy on traditional and electronic cigarettes, respectively. Less than 30% of respondents held positive attitudes towards policy enforcement, and more male respondents reported positive attitudes towards compliance than women. Support for a 100% tobacco-free policy was at 77.2%, but it was significantly lower among tobacco users compared with non-users (35.9% and 91.8%, respectively; p<0.001). Failure to establish clear penalties, opposition from smoking students, and lack of cessation services were perceived as major barriers to implementation.

Conclusions Clear and comprehensive tobacco-free policies are important tools for creating environments conducive to rejecting smoking and seeking cessation support. The findings underscore the need to increase awareness about the policy, advocate for clear penalties for violations, and promote cessation services on campus. Qualitative research is needed to further understand perceived barriers to successful enforcement of the policy.

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• health policy
• public health

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Data are available upon reasonable request.

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https://doi.org/10.1136/bmjopen-2020-043691

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Strengths and limitations of this study

This is one of very few studies in the region that focus on structural public health interventions addressing tobacco use among youth, who form a large segment of the population in the Eastern Mediterranean Region.

A stratified random sample was drawn from students of the largest national university in Qatar, which offers good representation of the target population despite a low response rate.

Using an anonymous self-administered questionnaire is likely to reduce social desirability bias.

The response rate in the study was characteristically low for internet-based questionnaires of college students.

The study did not include university faculty and staff.

Introduction

The tobacco epidemic is one of the greatest threats to public health worldwide. 1 According to the WHO global report on trends of tobacco smoking 2000–2025, one-fifth (19.9%) of youth aged 15 years and older are tobacco smokers (33.7% males and 6.2% females). 2 Tobacco consumption leads to psychological addiction 3 and increases the risk of cardiovascular and respiratory diseases, diabetes and cancer. 4 Annually, eight million individuals die worldwide because of tobacco use, including more than seven million deaths caused by direct tobacco use and 1.2 million deaths caused by exposure to either secondhand smoke (ie, smoke from burning tobacco products) or the smoke exhaled by a smoker. 1

Individuals between the ages of 15 and 29 account for roughly 30% of the population of the Middle East and North Africa. 5 The Eastern Mediterranean Region (EMR) is one of the fastest-growing consumers of tobacco products worldwide. By 2025, tobacco use prevalence will increase by 25% compared with other regions like Europe, Asia and North America. 6 In addition to the high prevalence of cigarette smoking in the Middle East, new tobacco products are on the rise, including waterpipe smoking and electronic cigarettes. 7 8

Tobacco use among university students is a significant public health problem in the EMR. In Lebanon, one study found that 40% of private and public university students were tobacco smokers. 9 Similarly, a recent systematic review of smoking prevalence among university students in 12 Arab countries found high rates of smoking among students, especially in Egypt (46.7%), Kuwait (46%) and Saudi Arabia (42.3%). 10 In contrast, tobacco use among university students in the USA for example was estimated at 14.3%. 11

Tobacco-free campus policies: student attitudes and barriers to implementation

Smoke-free policies reduce tobacco product use among youth. 12 Within university campuses, they have a positive impact on health and are associated with lower smoking rates among students, 13 reduced secondhand smoke exposure, increased socialisation, and fewer cigarette butts on campuses. 14 15 Globally, several universities have implemented smoke-free policies within their campuses, including universities in the USA, Australia, Canada and the UK. 16–19 However, very few campuses in the EMR seem to have such policies, and they are difficult to identify. In 2008, the American University of Beirut in Lebanon implemented a no-smoking policy across all campus areas (including student residence halls and campus buildings), except private faculty residences, and smoking was restricted to designated areas. 20 King Saud University, which is one of the largest universities in Saudi Arabia, implemented the Totally Smoke Free University Campus Policy. 21 However information on the existence and implementation of such policies is not readily available from other university campuses.

Understanding student attitudes is essential for the successful implementation and effectiveness of campus tobacco-free policies. 17 22 23 In one study in Australia, many participating students reported that smokers were unlikely to comply with no-smoking policies on campus and that penalties were needed. 24 In another study, both smoking and non-smoking students held positive attitudes toward the enforcement of a no-smoking policy on campus, but most of the smoking respondents were concerned about creating a completely smoke-free campus and had a strong preference for designated areas where smoking would be permitted. 17 In a study conducted among the students of the University of Birmingham, non-smoking students held more positive attitudes toward the tobacco cessation support and control services that were available on campus than smoking students did. 25

Barriers to the successful implementation of smoke-free policies on campus include students’ lack of awareness about such policies, familiarity with policy boundaries, 22 perceptions of their role in policy enforcement, student and staff beliefs that smoking is not a significant issue, opposition from smokers, and campus officials’ unwillingness to protect student and staff health. 24 In addition, students consider lack of support from the university administration and staff members and the unavailability of tobacco cessation services to be barriers. 24 26 Understanding barriers in the EMR is important for promoting effective tobacco-free policies among its youth.

Tobacco use in Qatar

Qatar is a state in the Arabian Gulf with a population of 2 878 506, of whom 12% are aged 15–24. 27 The Global Adult Tobacco Survey (GATS)Qatar 2013 found that 12.6% of adults in Qatar were tobacco users. Non-Qatari men were more likely to use tobacco than Qatari men, and approximately 15% of tobacco users had at least a college education. 28 Of tobacco users, 3.4 %, 0.7 % and <1% were shisha tobacco, smokeless tobacco and e-cigarette users, respectively. Between 2003 and 2014, smoking prevalence and cigarette accessibility and availability increased among Qatari youth. 29 However, recent findings from theGlobal Youth Tobacco Survey 2018 show a slight decline in current tobacco smoking from 12.3% in 2013 to 10.8% among 13–15 year olds. 30 The antitobacco legislation in Qatar prohibits smoking in enclosed public places (eg, vehicles, schools, hospitals, government institutions and restaurants) in accordance with the WHO Framework Convention on Tobacco Control that was signed in 2002. 28

No-smoking policies at Qatar University

Qatar University (QU) is the oldest and largest national institution of higher education in Qatar. It has approximately 20 000 students (with 15 350 woemn students and 4264 men students registered for Spring 2020 semester) and over 1000 national and international faculty members. In 2013, QU enforced a no-smoking policy to which all faculty members, students, employees, and visitors were required to adhere. This policy prohibits smoking in university buildings, indoor and outdoor environments, and vehicles, and ‘No Smoking’ signs were hung at the entrance of each building. Smoking is allowed in designated areas, which are located at least 7.6 m away from QU buildings and have proper cigarette receptacles. Students can find a description of this policy in their handbooks, including penalties for violation. Smoking inside campus facilities is included under ‘category 2 non-academic violations’, the penalties for which can range from a written warning to expulsion from the University, at the discretion of the judicial committee ( http://www.qu.edu.qa/static_file/qu/students/documents/Undergraduate-Student-Catalog-2020-2021-English.pdf ).

The American Nonsmokers’ Rights Foundation provides a model for smoke-free and tobacco-free policies. Elements of a model policy include clear and detailed definition of terms, the need to remove any areas where tobacco use is allowed on campus, a clear statement on promotion and sponsorship policy, wide dissemination of the policy, and a clear statement of violations specific to smoke- and tobacco-use ( https://no-smoke.org/model-policy-for-a-tobacco-free-college-university/ ). The current QU no-smoking policy allows smoking in designated areas, and the penalties for smoking-specific violations in the student handbook are not clear. It is noteworthy that the University is currently in the process of updating its no-smoking policy, but the new policy has not yet been approved.

In 2019, QU joined the fifth cohort of the Tobacco Free Generation Campus Initiative, which is a programme by the American Cancer Society’s Tobacco Control Center providing grants to ‘accelerate and expand the adoption and implementation of 100% smoke- and tobacco-free policies on college and university campuses across the nation’. ( https://www.cancer.org/health-care-professionals/center-for-tobacco-control/tobacco-free-generation-initative.html ). QU is the first and only international organisation to join this cohort, with the aim of moving towards a 100% smoke-free and tobacco-free campus. In the context of this award, we set out to assess students’ knowledge and attitudes towards the existing policy to facilitate the promotion of a new policy that would ban all forms of tobacco on campus and strengthen the provision of cessation support services.

To date, most tobacco use studies from the region have focused on individual behaviour change and health education efforts, with few attempts to address structural interventions creating and sustaining environments for healthy behaviours. This is the first study to focus on systemic interventions, especially among university students. There is no available information about the level of compliance with QU policy and the rate of reported violations among QU students. The purpose of this study is to examine student perceptions of the current No Smoking policy and the perceived barriers to implementation on campus. Specifically, this study aimed to examine (1) student knowledge about the policy, (2) student attitudes towards compliance and enforcement of the existing policy, (3) the perceived barriers to implementation and (4) the extent to which students support a 100% tobacco-free, smoke-free and vape-free campus policy.

This cross-sectional study was conducted as a part of a larger project titled, “Informed by the bio-ecological model: A cross-sectional study to assess factors shaping tobacco product use among university students.” A stratified random sample of QU students (men and women, Qatari and non-Qatari, age ≥18 years, with active registration in the Spring 2020 semester) completed an online self-administered questionnaire. The required sample size (741) was calculated using Cochran’s formula 31 (95% confidence level, 2.5% margin of error and cigarette smoking prevalence=14 %, as reported in a previous study). 32

Patient and public involvement

Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research

Data collection

Data were collected anonymously using an online self-administered questionnaire, available to students in English and Arabic versions. The participants were selected using a stratified random sample. Students were grouped into four strata based on their nationality and gender (Qatari men, non-Qatari men, Qatari women, and non-Qatari women). An introductory email, including a consent form, was sent to the institutional email addresses of students. In anticipation of the very low response rates that characterise internet-based survey, questionnaires were sent to 9807 addresses from the University’s Institutional Research and Analytic Department. A reminder was sent once a week for 4 weeks. Participation was voluntary. Students were assured of the confidentiality of their responses and reminded that they could skip questions they did not wish to answer or withdraw their participation at any time.

Overview of the questionnaire

The literature on smoke-free university policies was reviewed to identify measurement items. The questionnaire was adapted from the GATS Qatar 2013, 28 American Cancer Society Tobacco-Free Generation Campus Initiative: Cohort 5 Student Survey (2020–2021), 33 QU’s no-smoking policy, and a validated questionnaire from an Australian study. 24 The questionnaire was translated into Arabic by a research group, which consisted of QU public health students and faculty members. To evaluate item clarity and effectiveness, both versions were pretested on a group of public health students.

The questionnaire consisted of five sections: sociodemographic characteristics and smoking status, knowledge about the QU no-smoking policy, attitudes toward compliance and enforcement of the policy on campus, perceptions toward the quit support provided by QU, and the perceived barriers to implementation of the no-smoking policy. Questions on perceptions toward the quit support returned many missing values and were excluded from the analysis of results.

Study variables

This study examined tobacco use among students, as well as their knowledge about the University’s existing no-smoking policy, their attitudes toward policy implementation, the perceived barriers to implementation, and the extent of student support for a 100% tobacco-free policy.

Tobacco use was ascertained using the question “Do you currently use any tobacco product? This includes traditional cigarettes, e-cigarettes and other electronic vapor products, chewable tobacco, waterpipe/shisha? ” with a ‘yes/no’ response option. Smoking among family members and close friends was ascertained by the question “ Which of the following statements is true: My father is a current smoker; My mother is a current smoker; One or more of my siblings is a smoker; I have at least one close friend who smokes; No one in my family is a smoker; None of my close friends is a smoker .” Knowledge about the existing policy was measured using questions on whether and/or where traditional cigarettes and electronic cigarettes/ other electronic vapour products were allowed on campus: indoors; outdoors in specific locations , and an option of ‘don’t know ’ . Attitudes toward policy implementation in QU were assessed using eight statements, including two direct questions on perceptions of compliance and enforcement: “To what extent do people comply with the current campus tobacco product use policy on QU campus?” and “In your opinion, to what extent is the current tobacco product use policy enforced on QU campus?”, respectively. The response options for those questions were: ‘totally/ mostly/ somewhat/ not at all/ don’t know.’ Perceived barriers to policy implementation were examined using nine opinion statements, including the statement “Smoke-free policy is followed by students and staff members at QU” with five response options ranging from ‘strongly agree ’ to ‘strongly disagree’. Finally, support for a 100% tobacco-free and smoke-free campus was assessed using the question: “To what extent do you support your campus becoming 100% smoke-free, tobacco-free, and vape-free, with all tobacco product use prohibited on campus?” with response options including: “strongly agree, moderately agree, neutral, moderately disagree, and strongly disagree.”

Statistical analysis

Data were analysed using the Statistical Package for the Social Sciences (SPSS) V.26. Descriptive statistics were computed to examine the categorical variables (eg, demographic characteristics, knowledge, attitudes and perceived barriers). Responses from colleges with less than 30 participants were grouped together. Responses from health-related colleges (Health Sciences, Medicine, Pharmacy and Dental Medicine) were combined under one category, QU Health ( table 1 ). Participants’ attitudes toward No Smoking policy implementation on QU campus were examined by conducting descriptive analysis ( table 2 ).

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Socio-demographic characteristics and tobacco use of participants (N=199)

Participants’ attitudes towards ‘No Smoking’ policy implementation on Qatar University (QU) campus.

Due to the small number of observations in some cells, Fisher’s Exact test was used to examine bivariate associations. Results with p<0.05 were considered to be statistically significant. For the analysis of bivariate associations between attitude statements and sociodemographic and tobacco product use ( table 3 ), the ‘totally ’ and ‘mostly ’ response options were combined into a single category. For the bivariate associations between support for a 100% tobacco-free policy and gender and tobacco use, the response options for ‘strongly agree ’ and ‘ moderately agree ’ were combined into one category, and ‘strongly disagree’ and ‘moderately disagree ’ were also combined. The neutral responses were dropped from table 4 due to the small number of respondents.

Association between participants’ sociodemographic characteristics, tobacco use, and their attitudes towards policy compliance and enforcement

Support for a 100% tobacco-free and smoke-free campus by gender and current tobacco use*

The response rate in the study was 2% (199 respondents out of 9807 surveys sent). Approximately half of the respondents (48.2%) reported that they had at least one close friend who smokes, while less than one third (29.6%) reported that there were no smokers among their family members or close friends ( table 1 ). Of the respondents themselves, approximately a quarter (25.6%) reported being current smokers, with fewer women reporting smoking, although the difference was not statistically significant (32.4% and 21.6%, respectively; p=0.096). Among students who reported using tobacco products, waterpipe/shisha, traditional cigarettes, and electronic cigarettes were the most commonly used types, respectively.

Knowledge of the no-smoking policy

Responses revealed a gap in student knowledge of the existing no-smoking policy ( figure 1 ). Approximately, a quarter of the respondents (24.1 %) were unaware that the university had a no-smoking policy related to traditional cigarettes, and a third of respondents (33.7%) were unaware that there was a no-smoking policy related to electronic cigarettes. Only 26% reported correctly that the current no-smoking policy prohibits indoor smoking and allows outdoor smoking in specific campus locations.

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Participants’ knowledge of current Qatar University policy on traditional and electronic cigarettes.

Attitudes toward policy compliance and enforcement

Only 32.3% of the respondents held positive attitudes toward the level of policy compliance on campus, reporting that people totally or mostly complied with current smoking policy on QU campus, and more than 35% were unsure about the level of compliance ( table 2 ). Approximately half of the respondents (56 %) reported that they had never or only rarely been exposed to secondhand smoke on campus, and almost 80% reported the same regarding exposure to secondhand vapour from electronic vapour products. However, they considered exposure to secondhand smoke (47.6 %) and vapour (31.5 %) to be a cause for concern.

With regard to policy enforcement, only 25.6% of respondents held positive attitudes towards the extent of policy enforcement on campus. Over half of the respondents (57.8 %) agreed that it was QU’s responsibility to reduce the risk of tobacco addiction by implementing policies that discourage tobacco use on campus. Approximately 75% of respondents agreed (strongly or somewhat) that it was QU’s responsibility to implement policies that ensure that individuals inhale smoke- and vapor-free air within the campus.

Factors associated with attitudes towards policy implementation

Attitudes towards policy compliance were significantly associated with gender in the bivariate analysis ( table 3 ). Female respondents (45.7 %) tended to be unaware of the level of policy compliance on campus, and male respondents (35.4 %) were more likely to report that there was totally/mostly compliance with the policy (p<0.001).

Attitudes towards policy enforcement were significantly associated with gender and with tobacco use in the bivariate analysis, where 29.2% of male respondents reported that the policy was totally or mostly enforced, while over one half of female respondents (51.5%) did not know the extent to which the policy was enforced (p=0.003). One-third (34.8%) of tobacco users reported that the policy was totally or mostly enforced, while 47.5% of non-users reported not knowing the extent of policy enforcement on campus (p=0.020).

Perceived barriers to policy implementation

In the context of perception of barriers to policy implementation, approximately 40% of the respondents disagreed with the claim that QU students and staff members had been adhering to the smoke-free policy, and 57. 4% agreed that it would be difficult to enforce the smoke-free policy because there were no clear penalties for violations. They also considered opposition from smoking students and staff members (50.3 %) and a lack of resources such as no-smoking signs and cigarette receptacles (49.4 %) to be barriers to implementation ( figure 2 ).

Participants’ perception of barriers of policy implementation on Qatar University (QU) campus.

Support for a 100% tobacco-free and smoke-free campus

When asked about the extent of support for a policy that would make QU a 100% tobacco-free, smoke-free, and vape-free campus, 77.2% of respondents said they strongly or moderately agreed with the policy ( table 4 ). Support for such a policy was not significantly associated with gender, but it was significantly associated with the use of tobacco products. Students who reported using tobacco products expressed much less support compared with non-users (35.9% and 91.8%, respectively; p<0.001).

The study examined the knowledge and attitudes of students towards the no-smoking policy of the largest national university in Qatar. Awareness about no-smoking policies is essential to compliance within campuses. 34 In this study, only 25.6% of respondents were aware of the current QU policy regarding the use of traditional cigarettes. Approximately one third of the students were unaware that the policy addressed electronic cigarettes and other vapour products, and over one third of respondents were unaware or unsure of the extent of compliance with the policy or its enforcement on campus. These results indicate a significant gap in awareness of the policy’s existence and scope, which in turn implies the need for wider and more visible dissemination.

Gender was significantly associated with attitudes towards policy compliance and enforcement in the bivariate analysis. Female respondents were less likely to report tobacco use (21.6 %) compared with male respondents (32.4%), although the difference was not statistically significant. Nevertheless, the lower prevalence of reported tobacco use among women may reflect both the lower prevalence of smoking among women seen nationally or the social stigma associated with women smoking in the Arab region generally. The social stigma of female tobacco use may lead women to underreport the behaviour despite assurances of the confidentiality of the survey responses. 35 Another possible indication of the effect of social stigma is the finding that the majority of female respondents who reported using tobacco in this survey said that they did not do so on campus (67% of women compared with 17% of men tobacco users, data not shown). However, this finding could also be due to waterpipe being the most common tobacco product used among women, which is not a product that can be used on campus.

Tobacco use was also significantly associated with views on compliance with and enforcement of the current no-smoking policy on campus. Students who reported not using tobacco reported not being aware of the extent to which students complied with the policy or to which the policy was enforced. These responses may be due to not coming up against enforcement issues themselves. On the other hand, tobacco users were more likely to perceive compliance and enforcement levels to be high on compliance compared with non-users.

Approximately 40% of the participants disagreed with the claim that QU staff members and students had been adhering to the no-smoking policy. They considered the opposition from smoking students and staff members (50.3 %) and a lack of clear penalties for policy enforcement (57.4 %) to be barriers to policy implementation. Guillaumier et al found that a higher number of students (when compared with staff members) believed that smokers were unlikely to follow the policy, and they underscored the need for staff enforcement and penalties for policy violations. 24

Almost 50% of our participants considered a lack of resources such as no-smoking signs and cigarette receptacles to be barriers. Such signs promote self-enforcement, serve as a reminder of smoke-free policies, and are a strong determinant of indoor smoking. 36 37 A small proportion of respondents reported that student services or Environmental Health and Safety answered questions about the policy. Almost 70% of respondents were ‘neutral’ on these questions, likely reflecting lack of information about the existence of the policy and the need for its further dissemination. Harbison and Whitman also found that most of their participants considered a lack of support from their university administration and staff members to be a barrier to the implementation of smoke-free policies. 26

Support for a 100% tobacco-free, smoke-free, and vape-free policy was high, at 77.2%. The proportion supporting such a policy is in line with the proportion who believed that it was the University’s responsibility to implement policies that provide a smoke-free and vape-free environment to students on campus (75%). Consistent with the literature on the factors that shape support for smoke-free policies, tobacco use was a significant determinant. 38 Students who reported using tobacco were considerably less supportive of a 100% tobacco-free, smoke-free and vape-free campus policy. This finding points to the importance of providing much greater access to cessation support services in order to assist current tobacco users and to focus on them in health education and counselling more effectively. As the University is developing an updated policy on tobacco, the findings will also be useful for reporting on baseline support as well as the factors associated with attitudes towards policy and compliance.

This is the first study in the Arab region to focus on systemic interventions against tobacco use, rather than individual behaviour change, especially in this segment of the population. The probability-based sample was drawn from the student body of the largest national institution of higher education, which is a good representative of the broader population of this age group. Findings of this study can be helpful across institutions of higher education to ensure effectiveness of written policies. Despite the small sample size, the study will provide baseline information and enrich the literature regarding students’ perception of tobacco product use policy and the barriers of policy implementation on university campuses in the region. The findings point to the importance of raising awareness of existing policies. They also highlight the importance of understanding students’ perceptions of policy implementation (compliance and enforcement) to support formulating and disseminating effective policies that address the totality of tobacco use. The findings underscore the gaps in the existing smoking prohibition policy, which fails to address the use of other tobacco products such as electronic cigarettes and other vaping products. Another strength of this study, is the stratified random sampling strategy followed.

Limitations

The main limitation of the study is the low response rate, which is not unusual for campus studies using online questionnaires. Due to the low response rate, associations could not be examined in multivariate models. Responses may also have been affected by social desirability bias, despite assurances of the confidentiality of responses. The wording of the questions assessing prevalence of smoking may have led to underestimation of the prevalence of smoking in this study, as infrequent smokers or those who identify themselves as non-smokers may have answered the question ‘Do you currently use any tobacco product?’ in the negative. Finally, the study did not include staff members, who are also important stakeholders in this policy and whose views on compliance and enforcement should be ascertained.

Implications

Our study provides evidence for the need of education, advocacy efforts and policy modifications. The findings suggest a need to promote knowledge of the policy among students, faculty and staff. Advocacy efforts are needed to promote cessation services by the QU health centre on campus, availability of resources such as ashtrays and smoking signage, and clear penalties for policy enforcement. The findings also suggest planning for awareness campaigns to enhance knowledge of health impact of electronic/vaping tobacco products among students.

Future research should use a larger sample size and assess attitudes of faculty and staff in regard to policy implementation and barriers. Further, a qualitative study can be conducted to explore barriers to seeking/attending cessation services at QU, which may range from issues of availability (as we found in our study) and information about available services to issues of social stigma.

QU students possessed limited knowledge about the no-smoking policy. Female undergraduate students and non-smokers tended to be less aware of the level of policy compliance and enforcement on campus than male smokers, who reported positive attitudes. Failure to establish clear penalties, opposition from smokers, and a lack of resources were found to have hindered policy compliance and enforcement within the campus.

Educational campaigns should be conducted and messages should be posted on social media platforms to create awareness about the no-smoking policy. To improve compliance, strict enforcement should be undertaken and clear penalties should be established. Advocacy for policy improvement, cessation support and resources will reduce smoking within the QU campus.

Ethics statements

Patient consent for publication.

Not required.

Ethics approval

The study was reviewed and approved by the Qatar University Institutional Review Board (Research Ethics Approval No is QU-IRB 1188 E-2019).

Acknowledgments

We acknowledge the support provided by the Institutional Research and Analytic Department at Qatar University in the sampling and data collection process.

Open Access funding provided by the Qatar National Library.

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Contributors GFA-J: conceptualisation of the study, questionnaire design, proposal and IRB writer/ approval recipient of the larger project which this study is part of, sampling design and data collection, statistical analysis and manuscript drafting. RK: questionnaire design, statistical analysis, and manuscript drafting. SA, HAL-K and AJA (public health students): statistical analysis and manuscript drafting supervised by GFA-J. HFAR: grant writer/recipient; conceptualisation; questionnaire design, manuscript drafting; critical review, and response to reviewers.

Funding This work was supported by the American Cancer Society Tobacco-Free Generation Campus Initiative Grant (ACS # 64331).

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

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Chicago Maroon

On-Campus Smoking Should Be Banned—But Not Yet

Are we idle while other universities take strides away from nicotine?

Isabella Liu

By Ryan Sanghavi May 11, 2023

There are two parties affected by smokers on campus: those who smoke, and those who do not. Who is more negatively impacted by the practice of smoking? Obviously, those who perform the action themselves. But as American colleges trend towards a no-smoking culture, UChicago has some adjustments to make.

In 2009, The Chicago Maroon published an op-ed titled “The case for smoking,” in which then-first-year Emmett Rensin argued that smoking provided a reliable comfort for certain students. Rensin doesn’t ignore the commonly seen statistics of exactly how many people die of smoking and smoking-related illnesses in the United States per year. The UChicago Student Wellness Center provides up-to-date information, citing that over 41,000 people die of secondhand smoke inhalation alone annually. So why do people still advocate for university-permitted on-campus smoking?

The most evident answer is one that the Wellness Center page itself answers: quitting smoking is hard. It’s hard for people who want to quit, and perhaps impossible for those who don’t want to quit. There are several other major research universities that have banned smoking—full stop—on campus, such as the University of Pennsylvania , Yale University , and Georgetown University , and numerous others have banned smoking in recent years .

Here’s the first question: Why  have these institutions banned the use of nicotine products? Georgetown, for one, has done so to support the “care of the whole person” through the individual’s health and wellness. Another underlying reason that some students and administrators would admit personally but struggle to word professionally is that some simply find smoking gross and would prefer not to walk through artificial, odorous clouds on their way to work.

The second question is this: Why has UChicago not followed suit? Let’s suppose that UChicago was to ban cigarettes, and some non-smokers were happy with the reduction of small-scale pollution. What about those with nicotine addictions or those who enjoy the occasional cigarette, like the demographic Rensin writes of? Georgetown attempted to address concerns of those with smoking addictions in its 2020 policy announcement regarding the prohibition of smoking. Part of the statement reads, “The University continues to offer resources to support tobacco cessation. More information about the many cessation resources available can be found at [link].” Following one more link will bring the viewer to a site called “Health Advocate.” The program touts “strategies to help you quit tobacco for good” in which “you will also create your own quit plan” with an available “free coaching” program via text and call. Yale, over the past several years, has also developed specific cessation resources for students.

When looking at how UChicago guides students to smoking resources, we can find that UChicago’s human resources page explains the university’s smoking policy. While it lists the policy itself, resources must be found externally through the UChicago Student Wellness Center. There are two main resources provided by the center. The first is “counseling and behavioral therapy with a tobacco treatment specialist” which leads the viewer directly to an email draft with the recipient and subject line autofilled. The second is an individual therapy session with an addiction counselor, for which one must call the provided number to make an appointment.

I cannot speak to the effectiveness of these resources, but the issue is that UChicago does not immediately appear to have the same cessation resources as other major universities, which draw attention to well-developed anti-smoking programs. This is not to say that UChicago’s resources are necessarily bad or difficult to find —but perhaps UChicago, in the absence of an on-campus smoking prohibition, has not felt the same urgency to provide cessation resources as other universities have.

So, should smoking be banned on campus? The general school policy is that smoking and the use of vaporizers are prohibited inside university buildings but permitted more than 15 feet away from building entrances and windows. The policy makes no mention of the use of cigarettes on main pathways or on the campus quadrangle. I personally have had many experiences of walking into a cloud of smoke or vapor while in transit between buildings. I’ve seen several posts on the social media platform Sidechat, particularly within the university-specific channel, complaining of the odor of cigarettes in university buildings or jokingly discussing the so-called ‘Reg smokers’—those who take a smoke break outside of Regenstein Library.

Although banning smoking might arguably benefit non-smokers, there is little to suggest that doing so would benefit those who do smoke. Presumably, these students and community members would just go to greater lengths to conceal the action without a decrease in consumption. I do ultimately believe that smoking should be banned on campus, but not until a stronger infrastructure and clearer programs are in place to ensure that a policy shift would have a positive impact on all parties—not just on those inconvenienced by the smell. If a ban were to be placed, the Wellness Center might struggle to support those who have no desire to seek addiction counseling but would have the duty to provide such services nonetheless.

The easiest and most decisive next step for the University would be to follow Columbia University’s approach of providing several designated smoking areas on campus and banning smoking everywhere else, including on sidewalks and other public spaces. This would reduce the inconvenience of poor air quality and odor to non-smokers. But beyond this achievable and more simple change, UChicago needs to openly consider the concerns and needs of smokers before an outright campus-wide ban.

Ryan Sanghavi is a first-year in the College.

Correction: The writer and Viewpoints editors changed l anguage discussing addiction from “addict” as a noun to “those with nicotine addictions,” in accordance with updated National Center on Disability and Journalism guidelines.    

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Isabella is a second-year illustrator for the Viewpoints section of The Maroon. She is from Oklahoma and enjoys tending to her chickens and crops, reading...

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• Research article
• Open access
• Published: 19 February 2020

Smoking behaviours and attitudes towards campus-wide tobacco control policies among staff and students: a cross-sectional survey at the University of Birmingham

• Suzanne E. Bartington   ORCID: orcid.org/0000-0002-8179-7618 1 ,
• Ruth Wootton 2 ,
• Philippa Hawkins 3 ,
• Amanda Farley 4 ,
• Laura L. Jones 4 &
• Shamil Haroon 4  

BMC Public Health volume  20 , Article number:  252 ( 2020 ) Cite this article

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Tobacco control policies have potential to be an effective strategy for the reduction of smoking prevalence and secondhand smoke (SHS) exposure in tertiary educational settings worldwide. The aims of this study were to collect baseline data among staff and students, to measure smoking behaviours and attitudes towards introduction of campus-wide tobacco control policies within a UK higher education setting.

Cross-sectional study using data collected by web-based questionnaire administered to employed staff and enrolled students (undergraduate/postgraduate) at the University of Birmingham from May 2016 to April 2017. Information was obtained regarding demographic characteristics, tobacco usage patterns and attitudes towards a revised campus tobacco control policy using a 21-item survey tool. Logistic regression analyses were used to explore associations between participant characteristics and support for smoke-free or tobacco-free campus policy options, evaluated by crude and adjusted Odds Radios (OR) after controlling for confounding factors (significance level: P  < 0.05).

A total of 934 survey responses were received, of whom 780 participants provided complete information on staff or student status and were included in the present analysis. Current smoking prevalence was 14% ( N  = 109; 95% confidence interval (CI) 11.6–16.6). Overall, 66.3% (95% CI: 62.9–69.7) of participants supported a smoke-free campus; 68.5% (95% CI: 65.2–71.8) endorsed restrictions for tobacco sales and just under half of respondents (47.3%; 95% CI: 43.8–50.9) supported a ban for electronic cigarettes/vaping device use on campus. Smoking status was an independent predictor of support for tobacco control, with the lowest level of support for a smoke-free campus among daily (adjusted OR 0.02; 95% CI: 0.01–0.05) and intermittent smokers (adjusted OR 0.06; 95% CI: 0.02–0.16).

Conclusions

Overall, the majority of staff and students participating in this baseline survey supported implementation of a smoke-free or comprehensive tobacco-free campus policy. These findings may inform the development and future implementation of a revised tobacco control policy at the university which reflects contemporary attitudes and considers a broad range of implementation issues, including behaviour change and environmental adaptations.

Peer Review reports

Smoking is a major avoidable cause of preventable disease and premature mortality in the UK responsible for approximately 78,000 premature deaths each year [ 1 ]. The harmful effects of involuntary environmental exposure to secondhand smoke (SHS) are well established, with no safe level of exposure for human health [ 2 ]. Since ratification of the World Health Organization Framework Convention for Tobacco Control (WHO-FCTC) in 2005, [ 3 ] many countries worldwide have introduced smoke-free legislative policies providing protection from exposure to tobacco smoke in indoor workplaces and public places, including educational establishments. There is consistent evidence for a positive impact of smoking bans in public spaces for improved cardiovascular health outcomes, and reduced mortality for associated smoking-related illnesses achieved primarily through reduced SHS exposure [ 4 , 5 ].

However, existing national UK smoke-free legalisation does not restrict smoking or use of tobacco products in outdoor public spaces or across postsecondary educational settings, where almost 50% of young people aged between 17 and 30 years participate in education and training in the UK [ 6 ]. This age cohort coincides with a recognised period of health behaviour transition, including change from intention to regular smoking [ 7 ]. Tobacco control policies in such settings have potential to deliver multiple public health benefits through protection of staff, students and visitors from SHS exposure, [ 8 ] prevention of smoking initiation and improved uptake of smoking cessation [ 9 ]. Furthermore, people who stop smoking before the age of 30 years avoid more than 90% of the lung cancer risk attributable to tobacco compared to those who continue to smoke [ 10 ]. Restrictions on outdoor smoking may also provide wider benefits including improved staff and student productivity, litter reduction, decreased fire risk and increased student retention [ 11 ]. Finally, influencing university students may be important for modifying social norms relating to smoking as many will become future opinion and thought leaders.

Voluntary campus-wide tobacco control policies may comprise a range of measures, in the United States context these have previously been defined as: (i) smoke-free: ban of smoking in all indoor and outdoor areas; (ii) tobacco-free: ban of smoking and smokeless tobacco product use in all indoor and outdoor areas, which may also be extended to include prohibition of all activities relating to tobacco promotion, sponsorship and sale, such as institutional disinvestment from tobacco companies and withdrawal of direct/indirect research funding strategies involving the tobacco industry [ 12 ]. In addition, smoke or tobacco-free policy measures may include specific provision for, or restrictions upon the use of electronic cigarettes or vaping devices. Such policies have gained increasing popularity for adoption among university and colleges worldwide, particularly in the United States (US) where in a 2018 national survey, over one third (35.2%) of US postsecondary institutions had adopted comprehensive tobacco-free policies, and 10.1% smoke-free policies respectively, with higher rates of adoption among public institutions [ 13 ].

Several studies have observed tobacco control policies implemented in such settings to be associated with significant reductions in smoking prevalence among university students, [ 14 ] reduced cigarette butt littering, [ 15 ] and a shift in social norms favouring smoke-free environments [ 16 ]; with stronger tobacco-free policies associated with reduced intention to smoke on campus [ 17 ]. The baseline level of support and engagement among staff and students has been recognised as a predictive factor for effective implementation, influencing both policy adoption [ 18 , 19 ] and compliance [ 20 ]. However, there remains limited information regarding contemporary smoking patterns and levels of support for different tobacco control policies among staff and students at university and college campus settings in the UK.

In this context, we sought to identify smoking behaviours and attitudes among staff and students working or studying at the University of Birmingham. This baseline assessment comprised the first phase of an ongoing programme of research to inform development and future implementation of a revised university campus tobacco control policy. For the purpose of this study: we adopted the following definitions for outdoor campus areas (as a voluntary extension of existing smoke-free legislation for enclosed public spaces and workplaces): (i) smoke-free campus policy – ban of smoking, and; (ii) a comprehensive tobacco-free campus policy –ban of smoking, use of e-cigarettes and sales of tobacco products on campus. Our research objectives were to: (a) determine baseline patterns of tobacco usage and smoking behaviours; (b) investigate levels of support for smoke-free or comprehensive tobacco-free policy options; (c) identify independent predictive factors associated with support for a smoke-free or comprehensive tobacco-free control policy.

Study design

This was a cross-sectional, population-based study using baseline data obtained by self-administered online questionnaire developed using items adopted from the Global Adult Tobacco Survey [ 21 ] and the Health Survey for England (HSE) [ 22 ]. The survey instrument was pilot tested among 45 staff and students attending a University Wellbeing Event, to assess acceptability and feasibility, and subsequently modified prior to implementation. Invitations to complete the web-based questionnaire were disseminated at university events and activities, staff and student electronic newsletters, and through promotion by representative bodies including the University College Union and Guild of Students (Student’s Union). Data collection performed from May 2016 to April 2017 when the online survey was closed.

Participants

Eligible study participants included all directly employed staff and undergraduate/postgraduate students enrolled on courses at the Edgbaston Campus, University of Birmingham during the data collection period (Total N  = ~ 38,000 persons).

Demographic variables

All respondents were invited to provide their age, sex, ethnic group and current university role (staff or student status). University staff were classified by staff employment group (professional services/academic staff) and students by degree level (undergraduate/postgraduate), and fee status (home/EU/international).

Tobacco usage, intention for smoking cessation and SHS exposure

Survey respondents were asked to provide their tobacco smoking status ( current smoker/previous smoker/never smoker ) and those who reported current smoking activity were sub-classified into daily smokers (tobacco smoking on a daily basis) or intermittent smokers (tobacco smoking less than daily) . Among current and previous smokers , information was obtained regarding tobacco smoking or use of e-cigarettes/vaping devices on the university campus and type(s) of tobacco products consumed (manufactured cigarettes, hand-rolled cigarettes, tobacco pipes, cigars, water or shisha pipe, e-cigarettes). Participants who reported being current or previous smokers , also responded to questions regarding smoking cessation, including current intention to quit status, defined as current intention to quit smoking or a quit attempt within the past 12 months.

Attitudes and support towards a campus tobacco control policy

Items reported in the study concerning staff and student’s attitudes and levels of support for specific policy options were obtained from the 21-item survey questionnaire. Questions related to aspirations for a tobacco or smoke-free campus, provision of smoking cessation services and level of support for no-smoking signage and smoking shelters. A Likert scale was used to assess level of agreement with statements, with response options ranging from 1 ( strongly disagree ) to 5 ( strongly agree ). Binary variables were created to measure agreement with selected statements, with values 0 ( strongly disagree/disagree/unsure ) and 1 ( agree/strongly agree ). Two dichotomous variables were created to reflect our selected policy definitions: (i) smoke-free campus policy support - coded as ‘1’ for those respondents providing a response of agree/strongly agree to the statement concerning an aspiration for a smoke-free campus ; (ii) comprehensive tobacco-free campus policy support - coded as ‘1’ for those respondents who provided a response of agree/strongly agree for all three statements concerning: (a) an aspiration for smoke-free campus, (b) restrictions for e-cigarettes/vaping on campus , (c) a ban of tobacco sales on campus.

Statistical analysis

Descriptive statistics including means, proportions (%) and corresponding 95% confidence intervals (95% CI) were calculated to summarise key demographic variables. Prevalence ratios (PRs) were calculated to evaluate comparisons between smoking status by demographic characteristics (gender, ethnicity) and staff/student status, with differences evaluated by Chi-square tests, with P  ≤ 0.05 considered statistically significant. Logistic regression analyses was conducted to calculate odds ratios (OR) to report associations between participant characteristics and support for a smoke-free or comprehensive tobacco-free campus policy, after controlling for confounding factors. All statistical analyses were performed in Stata v13 (StataCorp, US).

Ethical approval

Ethical approval for the study was provided by the University of Birmingham Research Ethics Committee (Ref ERN_16–0409). Confidentiality was assured for all participants and no identifiable information was collected from respondents. The survey did not include financial or other incentives for participation.

A total of 934 survey responses were received (estimated response rate 2.5%), of whom 93.6% ( N  = 874) provided consent for information to be used for research purposes. Those respondents who provided information regarding staff or student status ( N  = 780) were included in the present analysis (Table  1 ). The majority of participants were university staff (69.9%, n  = 545), most of whom were from professional services (72.4%, n  = 394) with a lower proportion of academic staff (20.6%, n  = 112). Just under one third of survey respondents were university students (30.1%, n  = 235), with most studying at undergraduate level (84.3% n  = 198). Among participants included in the analysis, 59.6% ( n  = 465) were females and 39.5% ( n  = 308) males, and 86% ( n  = 657) identified themselves as of White British/Irish ethnicity. The mean age was 42 years (SD 11.4) and 22 years (SD 11.4), for staff and students respectively.

Tobacco smoking and usage patterns

Prevalence of current tobacco smoking (daily or intermittent) was 14.0% ( n  = 109; 95% CI: 11.6–16.6%), with no significant difference between university staff and students (13.4% vs 15.5%, P  = 0.48). The proportion of current smokers was higher among males compared to females (19.0% vs. 11.0%, P  = 0.002) (Additional file  1 : Table S1). Overall, 34% (95% CI: 30.8–37.6%) of participants were former smokers, with the highest prevalence among males aged 45–54 years (40.0%). There was a higher prevalence of previous smoking among males (PR: 1.25, P  = 0.037), staff members (PR: 1.44, P  = 0.003) and those of White British/Irish ethnicity (PR: 1.54, P  = 0.005). Almost one half (49.5%, n  = 53) of current tobacco smokers reported they wished to quit smoking and almost one third (31.5%, n  = 34) had attempted to quit within the previous 12 months. Among current smokers ( n  = 109), the majority (90.8%, n  = 99) had smoked on campus, and the predominant tobacco product choice was manufactured (45.4%) or hand-rolled cigarettes (38.9%), with 8.3%, reporting ever to have used e-cigarettes on campus and a small number (7.4%, n  = 8) other tobacco products (e.g. cigars, shisha, hookah) (data not shown).

Attitudes and support towards a tobacco control policy

Overall, 86.8% (95% CI: 84.2–89.1%) of survey respondents agreed that staff and students should not be exposed to SHS on campus, 66.3% (95% CI: 62.9–69.7%) supported an aspiration for a smoke-free university campus, and 68.5% (95% CI: 65.2–71.8%) endorsed restrictions for tobacco sales. In both staff and student samples, support for a smoke-free campus was strongly associated with smoking status; the highest level of support was among non-smoking students (80.6%; 95% CI: 74.4–85.9%) and staff members (72.6%; 95% CI: 68.3–76.6%) respectively (Table  2 ). Just under half of respondents (47.3%; 95% CI: 43.8–50.9%) supported a ban for e-cigarettes/vaping device use on campus, with significant differences by smoking status. Support for smoking cessation provision was higher among students (94.9%; 95% CI: 89.6–96.8%) compared to staff members (86.1%; 95% CI: 70.5–95.3), with the majority of respondents in both groups favouring smoking shelter and no-smoking signage provision. The majority of current smokers (90.8%) felt that a comprehensive tobacco-free campus would discriminate against and disadvantage staff and students who smoke, with fewer non-smokers considering it would be a discriminative policy, among both staff (34.6%; 95% CI: 30.3–39.2%) and student (28.3%; 95% CI: 21.9–34.9%) groups respectively. The majority of participants reported that a smoke-free campus policy would improve the health of staff and students (staff 80.6%; students 89.3%) and the University’s public image (staff: 67.2%; students 81.3%).

Table  3 displays the regression analyses to identify independent predictors of support for smoke-free and comprehensive tobacco-free university campus policies respectively. The strongest predictive factor was smoking status, with likelihood of support for both a smoke-free or tobacco-free campus significantly lower among daily smokers (Adjusted OR (AOR) 0.02, 95% CI: 0.01–0.05 and AOR 0.02, 95% CI: 0.00–0.10) compared to never smokers ( P  < 0.001) after adjustment for measured confounding factors. Support was also lower among previous smokers compared to never smokers for both smoke-free (AOR 0.28; 95% CI: 0.18–0.42) or tobacco-free policy (AOR 0.39; 95% CI: 0.26–0.60) policies respectively. Support for a smoke-free campus policy was also significantly more likely among females (AOR 1.45; 95% CI: 1.00–2.11) and those of Asian/Asian British ethnicity (AOR 5.46, 95% CI: 1.49–19.96), who were also more likely to support a comprehensive tobacco-free campus policy (AOR 2.07, 95% CI: 1.02–4.20). There were no significant observed differences in support level by university role (staff/student) or age group in adjusted analyses.

This study provides insights into the contemporary smoking behaviours and attitudes towards smoke and comprehensive tobacco-free policy options, among 780 staff and students attending a large UK University. Overall, smoking prevalence was 14.0% (95% CI 11.6–16.6%) and over two-thirds of respondents (68.5%; 95% CI: 65.2–71.8%) expressed support for a smoke-free campus and just under half (47.3%; 95% CI: 43.8–50.9%) support a ban for e-cigarettes/vaping device use on campus. Smoking status was an independent predictor of support for tobacco control, with the lowest level of support for a smoke-free campus among daily and intermittent smokers. Our novel findings provide valuable baseline information regarding patterns of smoking within a university campus environment, which may inform development and enable future evaluation of a revised voluntary campus-based tobacco control policy option in the context of a UK higher education institution.

Prevalence of current tobacco smoking (14.0%) was marginally lower than the UK adult population (15.1%), [ 23 ] but broadly consistent with smoking rates observed in postsecondary educational settings in the United States and New Zealand [ 24 , 25 ]. The proportion of current smokers reporting an intention to quit was lower than the national average (49.5% vs 60.8%) [ 26 ] potentially reflecting the demographic characteristics of our study population. Further differences were observed in e-cigarette usage patterns, with current usage reported by (8.3%) which is lower than the proportion of UK adult population who have tried an e-cigarette (19.4%), but higher than the proportion of current users in a national context (5.5%) [ 26 ].

Support for a campus-wide smoke-free policy was consistently high among both staff and students, with 86% of respondents expressing concern about SHS exposure and two-thirds (66.3%) supportive of an aspiration for a smoke-free campus. Attitudes towards inclusion of e-cigarettes or vaping devices within a smoke-free policy were less consistent; potentially due to mixed public awareness of the health impacts associated with vapour from these sources, or their role in supporting a smoke-free environment. Our findings are notably consistent with those of a meta-analysis of 19 studies performed by Lupton and colleagues, which found 58.9% of students and 68.4% of staff to be supportive of smoke-free campus policies [ 27 ]. Similar levels of support were observed within a cross-sectional survey at Curtin University, Western Australia, where 84.1% of respondents were concerned about the harms of SHS exposure and 65.7% supportive of a smoke-free campus policy option, with comparable differences by smoking status [ 20 ].

The majority of participants reported that a smoke-free campus policy would have a positive impact upon the health of staff and students, suggesting awareness of the links between smoking and tobacco usage and associated health harms. Although we did not seek specific views on the impact of a revised policy upon quality of life measures, given attitudes towards a smoke-free campus were broadly positive, such an association suggests potential to achieve wider improvements in staff and student wellbeing. Raising awareness of relevant health messages and reinforcement of the harms of SHS exposure are likely to improve acceptance and policy compliance, as previously observed in bar and restaurant settings [ 28 ].

Understanding the factors associated with support among population sub-groups may be beneficial for leveraging relevant support and promotion of positive attitudes towards change. Consistent with other investigators, [ 29 ] we observed a gradient across categories of smoking status, with the lowest level of policy endorsement among daily, compared to intermittent and former smokers, and highest among never smokers. These attitudes may be magnified by concern around stigma, reflected in the high proportion of smokers (90.4%), who considered a smoke-free policy to be discriminative [ 29 ]. Poland and colleagues (2012) [ 30 ] described the importance of characterisation of discrete types of smokers to inform targeted mitigation measures, identifying that ‘easygoing’ smokers were supportive of smoking restrictions if implemented sensitively and supported with appropriate messages.

In accordance with best practice in health promotion theory, [ 31 ] a comprehensive range of strategies including support for current smokers is most likely to achieve optimal outcomes. This assumption is further supported by existing evidence for workplace smoking restrictions as motivators for behaviour change; underpinned by the relatively high proportion of survey participants within the contemplative phase of health behaviour change [ 32 ] (intention to quit or quit attempt), suggesting policy implementation is likely to be most effective if integrated with smoking cessation provision.

This study had a number of strengths and limitations. Although the overall survey response rate was relatively low, the large study population comprises a diverse cohort of university staff and students. Males were slightly underrepresented comprising only 39.8% of participants, as were EU (10.3%) and international students (9.5%); however, this response pattern is similar to other campus smoking studies [ 18 ]. We did not assess income or composite measures of socio-economic status, which are potential confounding factors; however, information was available for age, sex, ethnic group and staff status. The element of selective non-response bias may have resulted in more positive attitudes towards tobacco control policies than among the total university population; however, with the sample size of 780, our findings provide the most comprehensive information available concerning contemporary smoking behaviours and attitudes in a UK tertiary educational setting.

Use of a self-administered questionnaire provides only a subjective assessment of smoking status, and could be influenced by social acceptability bias; however, we did not collect identifiable information and participants were able to exclude their responses from research purposes. Our survey did not include questions regarding symptoms of smoke related illness or awareness of the harms of SHS or Thirdhand Smoke (THS) exposure, which may be better explored through future qualitative research . We administrated the questionnaire at a single time point, yet plan to conduct a repeat cross-sectional survey at a future date to explore changes in prevalence, attitudes and levels of support over time [ 16 ].

Implications for policy and research

The WHO FCTC suggests that national bodies and organisations should protect the population from hazards of SHS ‘wherever the evidence shows that hazard exists’, including quasi-outdoor and outdoor places [ 3 ]. Despite gaining popularity worldwide, there remains limited research regarding attitudes towards and effectiveness of smoke- and tobacco-free campus policies. However, it is widely recognised that achieving effective adoption of smoke-free legislation in any setting requires population support and a high degree of compliance.

Potential challenges in local policy implementation include enforcement difficulties, smoking displacement, self-perceived workplace stress, negative community relations and safety concerns [ 20 ]; however, relevant mitigation measures may include phased smoke-free zones or designated shelter provision. These processes will require robust future implementation research, to develop the evidence base concerning policy implementation and organisational change processes, to inform widespread adoption of smoke-free and comprehensive tobacco-free policies across UK higher education institutions.

Our findings indicate that the majority of staff and students at the University of Birmingham broadly support introduction of a campus-wide smoke-free or comprehensive tobacco-free policy. Provision of a package of supporting measures including smoking cessation support and smoking shelters may improve policy implementation and compliance. Further research to improve our current understanding of social and organisational norms which might influence policy adoption and compliance, including exploration of preferences and priorities among specific population sub-groups, will help inform effective policy implementation.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Adjusted odds ratio

Electronic cigarette

Health survey for England

Prevalence ratio

Secondhand smoke

Thirdhand smoke

World Health Organization Framework Convention for Tobacco Control

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Acknowledgements

We would like to thank Lucy Austin for providing support for survey promotion including recruitment of participants and collation of participant responses, Tessa Hewitt for assistance with developing the draft manuscript. Sharon Murphy and Karen Biddle provided administrative support for administration of the survey. We are grateful to Professor KK Cheng for identifying the original research questions and for providing guidance on study conduct.

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SEB assisted with development of the survey questionnaire, conducted statistical analyses of the study datasets and wrote the first draft of the manuscript. RW and PH provided guidance regarding content and delivery of the survey questionnaire. AF and LJ provided guidance on the study design, data collection procedures and interpretation of study findings. SH was responsible for the study design, sampling framework and provided oversight for data analyses and interpretation. All authors critically commented upon the first draft and have reviewed and approved the final draft of the manuscript.

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Demographic characteristics of study participants by smoking status

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Engaging Students in Advancing Campus Tobacco-Free Policies: A Qualitative Study of California Community Colleges’ Efforts

ORIGINAL RESEARCH — Volume 20 — November 9, 2023

Setareh Harsamizadeh Tehrani, BS 1 ; Sang Leng Trieu, DrPH 1 ; Lien Dao, BS 1 ; Carissa Samuel, BA 1 ; Camillia K. Lui, PhD 2 ( View author affiliations )

Suggested citation for this article: Harsamizadeh Tehrani S, Trieu SL, Dao L, Samuel C, Lui CK. Engaging Students in Advancing Campus Tobacco-Free Policies: A Qualitative Study of California Community Colleges’ Efforts. Prev Chronic Dis 2023;20:230082. DOI: http://dx.doi.org/10.5888/pcd20.230082 .

PEER REVIEWED

Introduction

Acknowledgments, author information.

What is known on this topic?

In 2021, young US adults had the highest smoking and vaping rates, and smoking prevalence is higher among community college students compared with their 4-year counterparts.

What is added by this report?

Student engagement is recognized as a key strategy in tobacco control policy efforts. However, research on community colleges and on student engagement in policy efforts is limited. This qualitative study describes the levels, roles, and value of engaging students in advancing a 100% tobacco-free policy in California community colleges.

What are the implications for public health practice?

Colleges should leverage their campuses’ most important assets — students — as agents of change and involve them in the full spectrum of tobacco control efforts.

Tobacco use remains a serious problem for young adults. Given the large number of young adults attending college, a tobacco-free campus is one strategy to reduce tobacco use. Young adult engagement is recognized as a common strategic practice in tobacco control policy efforts, especially in changing social norms around tobacco use. Community colleges can leverage and engage students in adoption of campus 100% tobacco-free policies. This qualitative study examines the importance of student engagement in advancing 100% tobacco-free policies in community colleges and identifies strategies for campuses to involve students in such efforts.

We selected 12 community colleges and conducted key informant interviews with campus and community-based organizations that were involved in campus policy adoption efforts. We conducted 33 semistructured interviews and transcribed, coded, and analyzed them by using a thematic analytic framework with inductive and deductive approaches to examine student engagement processes.

Community colleges represented campuses with (n = 6) and without (n = 6) tobacco-free policy and varied by geography (urban vs rural) and student population size. Three main themes emerged: 1) no “wrong door” for students to engage in tobacco control work, 2) a myriad of ways for students to be involved in policy adoption, and 3) benefits of student engagement.

We found that students are doers, allies, and champions in adoption of 100% campus tobacco-free policy. Colleges should leverage their campuses’ most important assets — students — to be agents of change and to involve them in the full spectrum of interventions and advocacy.

In 2021, young US adults aged 18 to 25 years had the highest smoking and vaping rate (14.1% or 4.7 million people) (1). Given the number of young adults attending college, a tobacco-free campus is one strategy to reduce tobacco use through student engagement (2). California Community Colleges (CCCs), the nation’s largest higher education system, passed a 2018 resolution supporting the adoption and implementation of 100% tobacco-free policies (TFPs). Because the resolution is not binding, only 66% of CCCs are completely tobacco-free as of 2023 (3).

As more young adults pursue higher education (4), colleges are an opportune environment for tobacco prevention and cessation efforts. However, much of the research has focused on 4-year colleges, leaving community colleges an understudied population (5–8), which is surprising given that community college students make up more than two-fifths (42%) of all US undergraduates (9). Smoking prevalence, particularly daily smoking, is higher among community college students compared with their 4-year counterparts, and community college students are less likely to quit (10–12). Similarly, student engagement in community colleges differs from that in 4-year universities due to several factors. Community colleges tend to enroll a more diverse student body than 4-year universities, with higher proportions of low-income and first-generation college students (5). Additionally, community colleges often have fewer support services than 4-year universities (13), and the transitional nature of a community college along with a shared governance structure make TFP-related student engagement more complicated.

For more than 3 decades, student engagement has been recognized as a strategic practice in tobacco policy efforts (14). Student involvement can advance comprehensive tobacco control efforts through social norm change, particularly with counter-marketing efforts. Student engagement can yield high economic returns at low cost. The American College Health Association’s (ACHA) Position Statement on Tobacco on College and University Campuses recommends the development of a tobacco task force with student involvement (15). The literature on college students’ involvement in tobacco control efforts is limited. After passing a TFP, one campus found that student ambassadors improved compliance and reduced cigarette butts at campus hotspots (16). Given the dearth of research on student involvement in campus policy efforts, we conducted a qualitative study to examine the importance of student engagement in advancing 100% TFPs in community colleges and identify strategies for campuses to involve students in such efforts.

In this phenomenological study, 12 community colleges were purposively selected on the basis of criteria from our parent study that focused on facilitators and barriers to college TFP adoption. Selection criteria included geographic location and policy status and was informed by prior study results (17,18). Up to 3 key informants at each community college were recruited on the basis of their knowledge of or direct experience with the TFP adoption process and included students, staff, faculty, college leaders, or people employed with a tobacco-related community-based organization or public health department. Key informants were recruited through our study advisory board (including the California Youth Advocacy Network and the Health Services Association California Community Colleges), websites, and referrals from key informants. Recruitment was done via email and telephone. A total of 33 key informants participated.

A semistructured interview guide was developed using Ickes and colleagues’ Campus Assessment of Readiness to End Smoking (19) (including resources, leadership, knowledge, campus climate, political climate, and existing tobacco control policies) and Frohlich and Abel’s Institutional Study of Inequalities in Smoking (ISIS) framework (20) (including individual efforts and collective networks). Questions included experience working at the community college or in the tobacco control field, knowledge or insights on the policy adoption process, and key players, including students. Virtual interviews were conducted from January 2021 through January 2022. All key informants provided informed consent and permission to record the interview. The Public Health Institute’s Human Subjects Review Committee provided institutional board review approval (study exemption no. I18–015a).

We followed Braun and Clark’s reflexive thematic analytic framework, in which we acknowledged our positionality that reflects our own experiences (as students, a college administrator, and an external community partner) and our role as researchers in the interpretations of the participants’ experiences (21,22). Based on Ickes and colleagues’ campus readiness assessment and ISIS framework (19,20), a codebook was developed deductively (eg, campus leadership, student engagement) and, after review of the first 6 interviews as a group, inductively as new concepts emerged. The coding process began as a group with the first 3 transcripts to ensure consistency with interpretation of codes. Subsequent transcripts involved 2 coding teams (2 community college–level research assistants with support from S.L.T. and 1 graduate-level research assistant with support from C.K.L.) who independently applied codes again for the first 3 transcripts. When coding discrepancies occurred, the team discussed the issues, came to a consensus on code definition, and documented the resolution in the codebook, which was then applied to the remaining transcripts to ensure consistency. The coding teams independently coded the remaining interviews. Weekly coding sessions were conducted, and questions or conflicts were discussed and resolved. Dedoose software was used for coding (23). Excerpts under the “student” code were extracted for this study and entered into Microsoft Excel to identify patterns (Microsoft Corporation). After first review of the 132 excerpts, 10 potential themes emerged. After the second review, we prioritized 3 themes based on the study goals to highlight unique aspects of the community college experience and inform student engagement in policy adoption. Through group discussion, exemplar quotes were selected to best characterize each theme.

The selected community colleges differed by rural and urban geography and student population size. Key informants provided unique perspectives of community college students, given their relationship as students themselves or the fact that they worked closely with students through campus services or policy efforts ( Table 1 ). Eight colleges actively involved students in the policy adoption efforts, and among them, 6 colleges or community organizations paid students via stipend or employment. Three key themes and corresponding exemplar quotes are presented ( Table 2 ).

Theme 1: No “wrong door” for student engagement in tobacco efforts

The first theme emphasized that there is no “wrong door” for community college students to get involved in TFP work, with many opportunities for students to participate in committees advocating for TFP. Key informants reported that most students got involved formally through campus organizations such as student government (eg, Associated Students, student senate), student clubs, and health care–related majors. For example, one informant considered recruiting students mainly from health-related majors ( Table 2 , quote no. 1). Key informants expressed that many students were supportive of the efforts, and students viewed tobacco use as having dangerous health consequences (quote no. 2). Additionally, students can support the efforts regardless of their academic or athletic backgrounds (quote no. 3).

Students who served as campus leaders, student senate members, student health advisory committee members, or peer health educators played a crucial role in student engagement in tobacco-free efforts in CCCs, as they are respected by faculty and other leaders on campus (quote no. 4). Informants felt that it is important to educate students and staff to bring awareness to why a TFP is essential and beneficial (quote no. 5).

Key informants reported that hiring paid interns is an excellent way of getting students involved in TFP efforts and that colleges with paid and trained interns yielded better commitment and quality of work. According to one key informant from a community-based organization, the most helpful way to push the policy forward is to use students’ voices, whether in education or advocacy, and the best way to achieve that is through paid student internships (quote no. 6). A college administrator also expressed that student interns enhanced both themselves and the policy work (quote no. 7).

Theme 2: Myriad levels of student engagement in tobacco-policy work

The second theme describes the concrete tasks in which the students partake in TFP efforts. These efforts are categorized into information gathering, education and awareness, advocacy, and activism. Data collection, observational studies, surveys, and focus groups are examples of information-gathering activities. Health fairs, presentations, and tabling are examples of activities that promote education and awareness. Examples of advocacy activities for TFPs included generating peer support, being actively involved in meetings, creating videos, testifying at stakeholder or college board meetings, and participating in the student health advisory committee. Activism in TFPs can be participation in rallies, garnering letters of support from student clubs, picking up cigarette butts, and performing park clean-ups. As one key informant mentioned, involving students in TFPs is vital (quote no. 8). Similarly, by partaking in different activities, students can build support from other decision-making bodies.

The range of student engagement in tobacco control policy work also allows students to bring their own creativity to these efforts, such as with artwork or videos that use different mediums to highlight policy efforts (quote nos. 9 and 10). Key informants highlighted that students could either lead tobacco-control efforts or take a supporting role. One key informant described how students took ownership (quote no. 11). However, according to another key informant, efforts on their campus involved students in a less active, but still important, role (quote no. 12). Once students are in the space of tobacco control policy work, they are likely to become advocates for broader tobacco control efforts (quote no. 13). Finally, one key informant described the benefits of using the Truth Initiative grant funding to hire 1 to 2 students (quote no. 14). For community college students, compensation for participation was important.

Theme 3: Benefits of student engagement

The third theme describes the benefits of student engagement and the influence of students on the policy journey. A student services coordinator at one college best exemplified this theme (quote no. 15) by emphasizing the value of putting students in leadership positions. Three subthemes emerged on further analysis: 1) student influence on college decision-making communities or leaders, 2) student impact on policy, and 3) student skill-building and education.

Students influenced multiple groups, the first of which was faculty and staff, as they care about what students want on campus (quote no. 16). Moreover, students also influenced the board of trustees, a key community college governing body, to approve a TFP by providing evidence of student support on campus (quote no. 17). Given the shared governance of the CCC system, decision makers valued the support of students. Lastly, when a group of students is involved, they often attract other students to join advocacy efforts. For example, one college that has a strong collegiate athletics program worked with its student body president to bring the entire sports team to their tobacco-free campus events.

Second, students affect policy by bringing unique perspectives, roles, representations, and life experiences. One external community partner described just how extensive this impact was: what started with a paid internship ultimately led to the passing of a student government resolution (quote no. 18). The impact was especially relevant for campuses that heavily involved student leaders, such as the student body president and student trustee (quote no. 19). Multiple key informants acknowledged that students valued social justice and equity as part of the policy efforts, especially more so than groups that were more concerned about individual freedom (quote no. 20). As another unique contribution, several key informants described narratives of students who smoked but were still supportive of a TFP and how they played a crucial role in policy messaging (quote no. 21). Similarly, a student with asthma brought another powerful narrative at council meetings and on campus where they spoke about how smoke irritated their lungs. Finally, students themselves benefited greatly from being involved in these tobacco control opportunities (quote no. 22). In addition to gaining experience, they also learned about the college policy process and gained a passion for tobacco control work (quote no. 23).

Establishing 100% tobacco-free community colleges is an effective strategy to reduce tobacco use (24,25). Given that the demographic profile of community college students tends to be young adults from communities of lower socioeconomic status and racial and ethnic minority families, a TFP could address tobacco-related health disparities (26). As of 2023, only 66% of California community colleges are 100% tobacco-free; therefore, it is a high priority for the remaining community colleges to adopt a TFP (3). In addition, given CCC’s shared governance structure in which students have a voice along with faculty and staff in college- and district-wide decision-making processes, student engagement is a key ingredient for policy. However, research on student engagement in college tobacco control policy is limited. Studies that have examined student engagement were often conducted in already 100% tobacco-free campuses and focused on the role of student engagement to improve TFP compliance (2,27,28). Findings showed that students report mixed feelings regarding their role and level of authority and often feel uncomfortable approaching others who are smoking on campus (2,27,28). The policy violators also expressed feeling uncomfortable being approached by student ambassadors; however, most of them reported the ambassadors approached them with kindness and they had a positive experience interacting with them (2). Nevertheless, to our knowledge, this is the first study that explores the roles of student involvement in TFP adoption efforts on community college campuses using a sample of 12 community colleges in California. Findings on how campuses leveraged student voices and involvement can serve as a roadmap for other colleges who are advocating for a TFP.

The first theme highlighted that many ways exist for students to get involved in TFP efforts, advocate for policy change, and ultimately achieve a tobacco-free campus. Students have some of the most effective voices to advocate for what they believe is right (29). Students do not need to come from any specific background to get involved in this work, as long as they are passionate and interested in campus involvement. They can become ambassadors or student interns who deliver presentations at classrooms or board meetings. Students can even informally support policy efforts by completing surveys, participating in tobacco-free events such as the Great American Smoke Out, and voicing their opinions about passing a TFP on their college campus. Community colleges could use a range of methods and channels for engaging students.

Students majoring in health-related disciplines are often the most deeply involved in tobacco-free efforts because they are the ones who have an interest in public health. Most students who lead tobacco control efforts on their campuses tend to major in health-related fields and have a passion to serve and improve community health (2,27,28). Administrators can reach out to students who are passionate about social justice and public health issues who can become advocates for TFP efforts. They could build advocacy skills, provide training, and create a space for students to lead these policy efforts. If successful in educating young adults about the negative impact of tobacco smoke, students from other fields or majors may be willing to participate in TFP efforts.

Lastly, community colleges should consider dedicated funds for student engagement positions, such as through internal campus funding or external grants like the Truth Initiative (https://truthinitiative.org/) that supports campus tobacco policy efforts. Having paid student interns is an effective way to engage students because they commit their time and energy to the work more than they would with a volunteer position. As Hunt and Scott noted, paid internships require interns to be more responsible and therefore provide much higher quality work (30). The large population of low-income students at community colleges (5) may be more likely to look for paid positions, and paid student internships would offer them the opportunity to earn money while building their work experience.

Theme 2 highlighted the myriad ways in which students can be actively involved once they enter the space of TFP work. They bring their creativity into the space, and as agents of change (31), students understand social norms around tobacco use among their peers in ways that are different from campus administrators and other professionals. Providing such an environment also makes participation more appealing and encourages students to develop passion and investment in tobacco policy work. For example, through the creation of artwork, students visually expressed themselves and demonstrated how a tobacco-free campus matters to them.

Additionally, college administrators and staff need to recognize that having students involved in TFPs creates an environment that is open to change since students can be champions of change. This aligns with the Centers for Disease Control and Prevention’s 2010 Best Practices User Guide, which stated, “Youth enhance state and local tobacco control efforts by challenging conventional thinking, advocating for policies, and changing the social norms around tobacco use” (14). However, college administrators and staff should keep in mind that the benefits of student engagement should outweigh the risks in tobacco control efforts, as one TFP compliance study found that students may not be the best to deliver the intervention (27).

This theme also emphasized that students’ level of involvement in TFPs mattered. This pattern highlighted the value of student engagement as students took ownership of TFP efforts on their campuses. This is an essential lesson that community colleges that are not yet tobacco-free can incorporate for more successful efforts. Lastly, involving students in policies at their school creates an avenue for them to get more involved in local and statewide tobacco-free policies, an excellent opportunity for training students on policy advocacy and tobacco control experience for the future.

The third theme captured the benefits of student engagement, as students influence other stakeholders, including faculty, staff, and the board of trustees. Students themselves also gain knowledge, experience, and passion for advocacy. The investment of students in showing support for policy results in faculty, staff, and decision makers being interested in moving policy forward because students really are the “consumers” of community colleges, a mindset that has had a positive impact on universities (32). Thus, engaging multiple student groups results in the policy gaining more traction. Each student who is engaged also brings in more students who can continue to expand the circle of student supporters as exemplified by the sports teams supporting advocacy in one community college.

The student viewpoint often focuses on issues that students are facing first-hand and are passionate about. This perspective places students in the forefront in gathering the student body’s support while representing the student voice. If students are not engaged, ensuring the student perspective can be easily forgotten. Because students are also most affected by policy changes, the personal stories they share can carry weight throughout the campus community, so providing a platform for them to speak is critical.

Being engaged in TFP advocacy does not send students home empty-handed, but rather offers them distinct hands-on opportunities as they grow into more informed and empowered individuals. This type of experiential learning is what the Association of American Colleges and Universities calls “high impact practices” that provide significant educational benefits for students who participate in them (33). In fact, emphasizing student advocacy engagement through movements like this is a major part of most colleges’ mission statements. An urban Bay Area campus aims to “inspire participatory global citizenship grounded in critical thinking and an engaged, forward-thinking student body.” Students can best grow in participatory citizenship when involved in advocacy work. Similarly, a larger Southern California urban campus’s goal was to “create conditions for empowerment, critical thinking, and informed civic engagement” for their students. Adopting a 100% TFP on campus is a prime example to foster this goal and to empower students and showcases how central to the college experience student engagement can be.

Strengths and limitations

Although a multi-campus qualitative study provides a rich, nuanced lens to understanding student engagement efforts, our study has limitations. The semistructured interviews allowed respondents to discuss students’ involvement within the broader context of other barriers and facilitators of establishing campus TFPs. Among the 33 key informant interviews, 3 were students, which represented a small proportion. Identifying more students to participate as key informants may have shown a more in-depth perspective on their involvement, bringing in a greater volume of primary sources. This study team included 3 currently enrolled undergraduate students, all of whom were recent community college students themselves who were deeply involved in data collection, analysis, and writing of this manuscript; their engagement exemplifies yet another entry point to integrate student voices. Also, 4 campuses (2 with TFPs and 2 without) did not have student involvement in TFP efforts; nevertheless, we included them in this study, as key informants expressed difficulties in engaging community college students given their limited time on campus. Because the study was done with community college campuses and because of the small sample size (ie, 12 colleges), findings may not be generalizable to 4-year institutions or schools outside of California.

Implications

Students are important partners in the journey to TFP adoption. As Jazwa et al noted, students are the most commonly cited contributors to advancing policy change (34). This is no coincidence. ACHA standards recommend a community-based approach to facilitate change; students, one of the most impactful groups in the community, must be engaged. Moreover, students can be involved and empowered in multiple ways through many doors and a range of activities. Students can be agents of change in leading community college policy efforts. Whether through internship programs, student government, or survey responses, the student voice has power that can advance community college TFPs. Considering the limited amount of research on student engagement in TFP adoption, this article highlights the key role of students in moving campuses toward comprehensive policies in the CCC system.

Conclusions

Institutions of higher learning should leverage their campuses’ most important assets — students — and involve them in the full spectrum of interventions and advocacy. The themes described in this article emphasized not only multiple entry points for students’ involvement but that there is no “wrong door” to engage students. We recommend creating opportunities for students in a purposeful, intentional manner while being careful not to make them into tokens. Creating leadership opportunities for students can help to advance tobacco control opportunities and reduce tobacco-related disparities, especially in community colleges.

This work was supported by the California Tobacco-Related Disease Research Program’s New Investigator Award [grant no. T29KT0530; PI: Lui]. We recognize Anne-Marie Gomes, Nina Mulia, and Diane Schmidt for support with data management and analysis. For study recruitment, we thank Becky Perelli of Health Services Association California Community Colleges, Katie Moose at California Healthcare Collaborative, and Kim Homer Vagadori of the California Youth Advocacy Network. We express our deep appreciation to our key informants from community colleges and tobacco control partners for sharing their experiences. No copyrighted materials or tools were used in this research.

Corresponding Author: Setareh Harsamizadeh Tehrani, BS, Student Health Center, Ohlone College, 43600 Mission Blvd, Fremont, CA 94539 ( [email protected] ).

Author Affiliations: 1 Student Health Center, Ohlone College, Fremont, California. 2 Alcohol Research Group, Public Health Institute, Emeryville, California.

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Abbreviation: CBO, community-based organization. a At the start of the study CS4 did not have a tobacco-free policy but adopted the policy during this study.

Abbreviation: LLA, local lead agency.

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

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Article Contents

Introduction, study sites and methods, discussion: linking social norms and campus smoking policies, conflict of interest statement, acknowledgements.

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Social norms and smoking bans on campus: interactions in the Canadian university context

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Amy Procter-Scherdtel, Damian Collins, Social norms and smoking bans on campus: interactions in the Canadian university context, Health Education Research , Volume 28, Issue 1, February 2013, Pages 101–112, https://doi.org/10.1093/her/cys075

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Smoking bans offer practical protection against environmental tobacco smoke and highlight the decreasing normative status of smoking. At Canadian universities, indoor smoking is now completely prohibited, but regulations vary with respect to outdoor smoking. The purpose of this research was to conceptualize the interactions of smoking bans on campus with changing social norms around smoking. Interviews were conducted with 36 key informants, exploring the development and normative significance of smoking bans at three case study institutions. Five key themes were identified in the transcripts. First, universities were understood as community leaders and role models. Second, they were viewed as institutions with a mandate to promote health. Third, students were generally perceived to view smoke-free environments and lifestyles as normative. Fourth, respondents also acknowledged that students remain vulnerable to social and behavioural influences that can encourage smoking. Finally, they articulated bans’ normative effects: restricting where smoking occurs on campus may discourage initiation and support cessation. Our findings suggest that health-promoting policies, such as smoking bans, can be motivated by changes in social norms and that their implementation reinforces this norm shift. Moreover, the contextual and compositional characteristics of universities mean they are uniquely placed to adopt such initiatives.

In the 1980s, evidence emerged linking environmental tobacco smoke (ETS) exposure to the development of lung cancer in non-smokers. With this knowledge came increasing recognition that smokers were not only putting their own health at risk but also harming those near them [ 1 ]. Thus, smoking was transformed into a wide-scale ‘environmental’ public health problem that required regulatory action [ 2 , 3 ]. Today, ETS is linked to coronary heart disease, respiratory infections and asthma, as well as cancers at numerous sites [ 4 ]. Recognition of such risks has led most high-income nations to impose smoking bans covering publicly accessible buildings and indoor workplaces [ 5 ]. In Canada, where this research is centred, all 10 provinces currently offer this level of protection against indoor smoke. Smoking bans not only protect non-smokers’ health but also contribute to casting both smoking and exposure to ETS as socially unacceptable. This de-normalization has become especially pronounced in recent years—due not only to the expansion in smoke-free policy [ 6 ] but also to the influence of anti-smoking media campaigns and restrictions on tobacco marketing [ 3 ].

Recent research detailing the health risks posed by ‘outdoor’ ETS [ 7–9 ] as well as the cumulative nature of ETS-related harm [ 10 ] is increasingly prompting smoking bans in outdoor spaces, such as beaches, parks, hospital grounds and university campuses. Our focus is on the last of these examples, in the Canadian setting. Specifically, we ask how smoking bans and social norms interact at three case study universities. In so doing, we explore the institutional characteristics (contextual and compositional) that make tobacco use increasingly non-normative and support the extension of smoking bans. We also identify the ways in which bans encourage this norm shift, particularly among students.

Campuses are important sites for tobacco control. In Canada, many university students are drawn from the age group (20–24 years) with the country’s highest smoking prevalence rate (23%) [ 11 ]. Moreover, as recently as 2004, many Canadian universities permitted smoking in various indoor areas, particularly residences and bars [ 12 ]. However, this has changed rapidly: provincial laws across Canada now prohibit smoking indoors on campus (as elsewhere), and outdoor smoking is also increasingly subject to restriction. Policy options for restricting outdoor smoking on campus include the following: prohibiting it within a set distance of entrances and windows (buffer zones); restricting it to designated smoking areas (DSAs); and going entirely smoke-free. In practice, partial outdoor restrictions have been imposed by provincial, municipal and university authorities—with the option of a complete ban left to the discretion of universities alone [ 13 , 14 ].

The normative impact of spatial restrictions on campus smoking is important to establish. Students are uniquely vulnerable to peer influence during their transition to university life [ 15 ]; they may lose previous support networks as they move away from friends and family and feel pressure to ‘fit in’ with new social groups. Together with new time pressures and external demands, these influences can lead students to ‘initiate compromised health behaviours that can persist throughout their lives’ [ 16 ]. Both new and existing students may also be influenced by the negative health role model effect of seeing others smoking on campus [ 17 ].

There are two broad types of social norms: descriptive norms, which express typical behaviours, and injunctive norms, which convey group attitudes about behaviours, including what is socially acceptable practice [ 18 ]. These can guide behaviour in themselves—as Cialdini [ 19 ] observes, ‘people tend to do what is socially approved as well as what is popular’—and also act in combination with other psychosocial factors, such as facilitators, constraints and perceived control [ 20 ]. Norms constrain individual action by offering social consequences, or sanctions, for not complying with expectations [ 21 ]. Those who experience sanctions may amend their behaviour to conform with expectations in order to be (re)accepted, or risk experiencing short- and long-term social effects (e.g. tension, shame or rejection) [ 21–23 ].

Importantly, norms may shift over time. This can occur when formal rules such as laws or policies are enacted that require the adoption of new behaviours [ 24 ]. Individuals who do not agree with a new rule but are obliged to abide by it can experience cognitive dissonance, defined as a state of psychological discomfort caused by one’s actions not aligning with one’s beliefs [ 25 ]. However, this can be managed. If, for example, a new law forbids smoking inside public buildings, an individual may decide to justify the discontinuation of indoor smoking (behaviour change) by changing his/her attitude towards it (attitude change). This reduces cognitive dissonance, which in turn can protect self-esteem [ 24 ]. Many individuals acting to mitigate cognitive dissonance can contribute to a wide-scale norm shift.

Norm shift can also be understood in the context of normalization process theory. Its core postulate is that ‘[p]ractices become routinely embedded—or normalized—in social contexts as the result of people working, individually and collectively, to enact them’ [ 26 ]. Thus, collective actions that demonstrate mutual commitment to and investment in an idea allow that idea to gain currency. Normalization is therefore a social process that requires ongoing action and commitment from individuals.

The process of a previously dominant social norm falling out of favour is termed ‘de-normalization’. The term has its roots in research on student alcohol consumption, which found that positive behavioural changes could be achieved by correcting students’ misperceptions of the prevalence of drinking among their peers [ 27 ]. This work serves as a reminder that health education on campus is not restricted to pedagogic environments. Its key findings were also generalizable beyond the example of student drinking, and the notion of using social norms to influence behaviour to promote public health rapidly became widespread [ 28 , 29 ].

De-normalization of tobacco has occurred as societal norms have shifted to become intolerant of its use, and smoking has been pushed ‘out of the charmed circle of normal, desirable practice to being an abnormal practice’ [ 30 ]. Smoking bans—the policy on which we focus here—have contributed to this process by marginalizing smoking (as a behaviour) and smokers (as people), socially and spatially. However, this linkage is not unidirectional: de-normalization also ‘gives support’ to the enactment of smoking restrictions, as policy-makers and members of the public see smoking and ETS exposure as increasingly unacceptable [ 5 ].

This study invoked these ideas in order to conceptualize the development of smoking bans on campus. To do so, we explored stakeholder perspectives on institutional and population norms at three Canadian universities.

Our study sites were Dalhousie University, in Halifax, Nova Scotia; Lakehead University, in Thunder Bay, Ontario and the University of Alberta, in Edmonton, Alberta. An initial search of university websites and media reports identified three broad policy responses to outdoor smoking on campus, and these study sites were selected as examples of each. Specifically, Dalhousie, a compact ‘urban-style’ campus with 16 000 students, was the first Canadian university to enact a complete smoking prohibition policy. Since 2003, it has required all smoking to take place off-campus [ 31 ]. Lakehead, a large ‘rural-style’ campus with 7900 students, adopted the same stance in 2004. However, implementation proved problematic, and the policy was amended in 2005 to permit smoking in DSAs located on campus parking lots [ 32 ]. Finally, at Alberta, a mixed-density campus with 37 000 students, smoking is allowed in any outdoor area that falls outside a 5-m ‘buffer zone’ around doors, windows and air intakes. This policy is mandated by provincial law and is not specific to campuses [ 33 ].

Data collection occurred from September 2010 to January 2011. Semi-structured interviews were conducted with 36 key informants: 11 at Dalhousie, 9 at Lakehead and 16 at Alberta. We sought participants with detailed knowledge of the regulation of tobacco on campus and made initial contact via email on the basis of job titles. Those who agreed to participate had roles spanning administration, campus security, health services, student government, and research and advocacy around tobacco. We did not seek to control for participants’ attitudes towards tobacco control, but accepted that those best-placed to speak knowledgably about smoking restrictions and social norms on campus would likely have established opinions in this respect.

Ethical approval was obtained from the Research Ethics Board at the University of Alberta, and informed consent was obtained at the beginning of each interview. These were conducted face-to-face on participants’ home campuses. Questions were designed to generate discussion of their experiences and beliefs around the development and normative significance of smoking bans in the university setting. Discussions were digitally recorded, with permission, and transcribed verbatim. Each participant had the opportunity to review and edit his/her transcript for accuracy.

Data analysis was undertaken by the first author, using NVivo 9 software [ 34 ]. First, the text was coded, beginning with a small number of codes identified during the literature review process, but principally with codes that emerged through the process of reading the transcripts and being attentive to what participants deemed important (i.e. a largely inductive approach) [ 35 ]. Second, once all relevant text was coded, the overall structure was revisited to merge highly related codes [ 36 ]. Third, broad patterns within the codes were identified and classified as themes. Thematic analysis helped to generate theory about the relationships between campus smoking policy and social norms. Five key themes are presented as sub-sections in the results below. Where participants are quoted they are assigned pseudonyms to protect anonymity. Quotations are used to illustrate themes, but are not necessarily representative of the opinions of groups to which interviewees belonged (e.g. student government or university administration).

Universities as community leaders and role models

I think that public organizations like universities and hospitals have to be leaders in some of this thinking. I mean, if we don’t at least sort of give a good example, how does the rest of society look at it? And if we think back to the days when universities started, … they were basically the fore-thinkers and demonstrated things … that changed society. (Colin, Administrator, Lakehead) I think it’s not surprising that universities are sort of early adopters or innovators for these types of policies, because I think we always look to universities as, you know, the free-thinkers, the open-thinkers, the groups that will consider things that the wider population aren’t yet considering. (Kyle, Administrator, Dalhousie)

We have Dentistry, and the Health Professions; Health and Human Performance, Nursing, and Physiotherapy. So, when you think about students that are in those disciplines, learning about this in the classroom, faculty that are teaching this stuff, we just live and breathe it every day, literally. … So, I think the issue gets elevated … because of this type of environment. (Clarence, Administrator, Dalhousie)

Part of it comes down to the institution’s image, or accountability to be a role model or a leader in the area of health promotion, even. Because it’s a university that has a Faculty of Medicine, a Faculty of Nursing, a Faculty of Pharmacy … Like, there’s so many healthcare professionals coming out of this school, it seems backwards, to me that they don’t have [a more restrictive] policy in place. (Justin, Advocacy, Alberta) If a university that’s supposed to be an enlightened environment doesn’t [prohibit smoking], what incentive is there for Mom and Dad’s grocery store or roofing shop to do it? So if we’re not doing it, why would anyone else get on the bandwagon and do it? So I think it’s very important for leaders in the community to be at the forefront and at the cutting edge. (Peter, Researcher, Alberta)

They [administration] had to realize … they’re trying to sell this university that’s kind of in the middle of nowhere, they’re trying to increase the number of students enrolled. And you’re not going to do that very effectively if the students who go here, a whole segment of them feel discriminated against … and are spreading that kind of word, right? (Jeffrey, Student Government, Lakehead)

A university employee gets … 15 minute breaks, but if it takes 10 minutes to walk off campus, how fair is that? (Jeffrey, Student Government, Lakehead) Some of the [residence] buildings are amongst the trees and it’s dark in the evening, and there was concern that, you know, there may be some sort of violence or … dangerous unsafe situations. (Crystal, Administrator, Lakehead) It was a concern for the Student Union [because of] safety: people going out at night alone, smoking, having to walk off-campus by themselves and then having to walk back on-campus. (Logan, Student Government, Lakehead)

We’re just providing them with a safe location and a contained location in which they can smoke. There’s no shelters there, you know, it’s not like we’ve giving them a warm and snugly place that they can go have a smoke. (Elizabeth, Administrator, Lakehead) [The DSA policy] doesn’t take away from the rights of smokers … but at the same time, respect[s] the rights of non-smokers. And they’re finding that nice balance. (Neil, Student Government, Lakehead)

I definitely think universities have a place to be the leaders in social change and that kind of thing, but … there comes a certain point where regulating personal freedoms for the benefit of all, I think there is a balance there that has to happen. (Brayden, Student Government, Alberta) You should have freedom to do certain things, you know, I shouldn’t be forcing you to quit smoking, why should I be doing that? (Ernest, Administrator, Alberta)

We’ve had debates about going back a little bit and having a dedicated smoking space outdoors. … But how far do you roll things back, or is that seen as admitting some kind of defeat? Is that stopping your momentum? (Nathan, Administrator, Dalhousie)

Universities as unique policy environments

Well, a university campus is like a small city unto itself, and it is private property. So therefore you have freedom to create laws and procedures and policies that are unique to your facility and you have the ability to enforce them. (Sean, Administrator, Lakehead)

At Dal there’s a lot of researchers who do work around smoking cessation and issues like that, so I think the fact that we have those type of people on campus it goes hand-in-hand to implement more stricter policies around smoking. (Kevin, Health Services, Dalhousie)

However, participants also emphasized that ultimate regulatory direction in the university environment rests with a select few decision-makers who may or may not support tobacco control policies. At Dalhousie University, it was influential members of the University’s Health and Safety Committee, along with two high-ranking faculty members in the Health Professions, who brought the smoking prohibition policy to the table. At Lakehead University, a former president with a strong personal commitment to smoke-free places was identified as the main proponent for the 2004 smoking ban. However, at the University of Alberta, a 2003 proposal for a campus-wide smoking ban was opposed at the highest level of administration, the Board of Governors [ 38 ].

… it’s about helping people make good choices for themselves.… you know, definitely there’s also a lot of emphasis on supporting people who have been smokers for a long time in smoking cessation. (Jennifer, Health Services, Alberta) [Students are] getting more information, awareness, pestering, however you want to look at it, than the average Joe going down the street, where it’s just not in his or her face every day. So when we go at it, we go at it hard and put in resources—we don’t just put out a law, and say to live with it. We follow it through with the educational programming that goes with it. (Clarence, Administrator, Dalhousie)

Non-smoking as normative

Lower-income families smoke far in excess of those with higher income, with higher education, you know, all those criteria. All those things you’d find at a university you could paint a demographic picture of an individual who is the quintessential non-smoker on paper. … the very nature of what a university is [attracts] the kind of person who is aware and willing to embrace the idea of rules around smoking. (Nathan, Administrator, Dalhousie) [It’s] just the nature of our population, being either highly educated or individuals who want to be highly educated, they tend to not smoke as much as lower-income people do (Leon, Administrator, Alberta).

I think the more educated people are on those kind of things, that would correlate with what sort of support or perspective people take when it comes to smoking. And direct policy on campus. (Malcolm, Student Government, Alberta) If you look around, [complete bans are] becoming the norm. … So when folks come here, yes they have to be educated as to what we’re doing, but the learning curve is a lot less steep than … a few years ago. It’s … what people expect when they come to an institution like Dalhousie. (Nathan, Administrator, Dalhousie)

I think that we should obviously not be smoking within a certain distance of buildings because people have health issues and I respect that, but we’re all adults here, you know? So if someone does smoke, I think it would be better to accept that rather than, like, demonizing them. (Meaghan, Student Government, Dalhousie) For [smoking] students, the problem with [the complete ban was] that they felt like it was discrimination. You know, just because you smoke doesn’t mean that you don’t have the same rights and privileges as other people. (Jeffrey, Student Government, Lakehead)

The social context of campus smoking

… a lot of students come to university and have never smoked before and then live in residence, and they start smoking. Or they start drinking and then people start smoking while they’re drinking. (Melissa, Advocacy, Alberta)

[Student smokers are] a population that is quite malleable, they are not firmly embedded people who smoke at rates of two or three packs a day …. (Lucy Researcher, Alberta). It’s a really controlled environment … you can really target the population, it’s a very reachable population, very easily targetable. And you can really regulate that population, you can tell then what’s what, as opposed to the general public where it’s more of a free-for-all. (Jeffrey, Student Government, Lakehead)

These qualities have also made students an attractive target for tobacco industry marketing, which continued on Canadian campuses via sponsorship and advertising into the last decade, but is now prohibited [ 12 ].

Normative effects of university policies

Well, the more socially normalized [smoke-free] is, the easier it is for others to join as well. So if the expectation is that you can’t smoke anywhere and it’s a strict policy, then it’s easier for people to say, “Ah, it’s not worth the headache of smoking, I’ll quit” …. (Peter, Researcher, Alberta) I’m not saying that our policy is the main reason why we’ve seen a decrease in smoking, but I’m sure it has had an impact, of people maybe making a decision, “Well I can’t smoke here, maybe I should think about quitting.” (Kevin, Health Services, Dalhousie)

It prepares them well for what’s inevitably coming down the tracks: “Yeah, we’ve had that on campus for four or five years, yeah we had no-smoking policies, I get it.” So I guess society as a whole … [won’t] have to spend as much, therefore, on educating because we’re doing so much of it, it’s running off us. (Clarence, Administrator, Dalhousie)

… if we saw 12 schools doing something that we weren’t doing, it wouldn’t be a matter of a week, this would be an agenda item to see what’s going on over there. Why are we missing out on this, you know? (Clarence, Administrator, Dalhousie University)

Basically what you’re talking about is an attitudinal shift, getting people to smoke in different areas than they did, and then to quit if they can and want to …. And I know that if you’re waiting for mass consensus buy-in, you’re unlikely to get that until you initiate a policy change, you have to have something around which to mobilize folks. (Nathan, Administrator, Dalhousie University)

Participants articulated a university’s role model function in terms of providing a health promotion example for others to follow and supplying a normative reference point regarding the social (un)acceptability of tobacco use and ETS exposure. This is consistent with understandings of education- and health-related institutions’ desire ‘to project a positive institutional image [and] convey a consistent pro-health message’ via outdoor bans [ 4 ]. However, our data suggest that universities are also concerned to balance the protective and normative benefits of smoking bans against other concerns, particularly the safety and rights of smokers. At Lakehead, such concerns were rendered prominent by the physical lay-out of campus, which led to a complete ban being scaled back to a DSA policy.

The extent to which those in positions of power at a university support smoke-free regulation, and value the promotion of health relative to competing concerns, can exert a marked influence on policy decisions. Institutional leadership on the issue of smoking bans at Dalhousie and Lakehead was driven by key personnel with a strong health focus. Conversely, smokers’ rights were more influential at Alberta, where administrators were content to follow provincial law.

Although such differences are important to note, they should not mask an overarching similarity: at all three of our case study sites, smoking is now completely prohibited indoors, and at least partially restricted outdoors. Accompanying this spatial marginalization of smoking (and smokers) on campus, we argue, has been a profound change in the social acceptability of tobacco use. The relationships between these processes can be explored in terms of the distinction between descriptive and injunctive norm effects.

Descriptive norm interactions

Declining smoking prevalence, particularly in those higher socioeconomic groupings in which university attendance is most common, means that there is a falling baseline level of smoking on campus, even before considering the effect of institutional smoking restrictions. Smokers are an increasingly small minority in this context, just as they are in many other societal settings. Students are less likely to perceive smoking as a ‘normal’ part of life when fewer of their cohort smoke [ 46 ].

The social unacceptability of tobacco use on campus is bolstered by smoking ban policy. Outdoor restrictions of any kind make smoking harder to perform, thereby encouraging more cessation attempts than would otherwise occur. When smokers are required to walk some distance to an appropriate outdoor location, many reduce their consumption or attempt to stop smoking altogether due to the inconvenience [ 47 ]. University policies that are more restrictive than those required by law further reduce both ETS exposure and the visibility of smoking on campus, by requiring it to occur off-site (as at Dalhousie) or in peripheral areas (as at Lakehead). This is likely to confer additional role modelling benefits [ 17 ].

The campus context for smoking, then, is that the behaviour is not permissible in many places and is increasingly atypical among students. Those who act in a non-normative manner may experience social sanctions. This may be harmful for students who are already experiencing social strain as they transition to a new environment and lose some of their previous social support networks [ 12 , 15 ]. The relatively small proportion of smokers on campus also makes smoking experimentation less likely: the historical meaning of smoking as a way for students to ‘fit in’ with others is not just eroded, but potentially reversed, as the behaviour becomes associated with social and spatial isolation from peers (via, e.g. removal from routine activity). However, some university decision-makers may be wary of offending, and possibly stigmatizing, even a small group of students via complete smoking bans.

As the proportion of smokers on campus decreases, opposition to proposed smoking restriction policy is also likely to be blunted, and attitudes may shift to become increasingly favourable towards the extension of smoke-free policy [ 48 ]. Descriptive norms regarding smoking behaviour can, in this way, become self-reinforcing. Tobacco use on campus has become less common and less popular, and this is both a result of, and a motivator for, the expansion of institutional smoking bans.

Injunctive norm interactions

University students can experience competing normative influences regarding smoking and ETS exposure on campus. On one hand, many are likely to come from backgrounds where smoking is non-normative, and ETS exposure is seen as abnormal. Accordingly, as noted by participants, many students ‘expect’ a smoking policy at their institution. The composition of the student population contributes to campus norms regarding the unacceptability of smoking and ETS exposure, which increases the acceptability of smoking bans. Implementation of restrictions, in turn, can strengthen non-smoking norms by reinscribing the social and political acceptability of smoke-free places.

However, other campus norms can impede smoking policy. In particular, many students experience newfound freedoms upon their transition to university life, which can include the freedom to experiment with tobacco use. Despite young people’s often skewed perceptions of the addictiveness of tobacco and optimistic exceptionalism regarding the personal health risks of smoking [ 44 ], students today are less likely than those in previous decades to consider smoking experimentation a normal and accepted part of the university experience [ 17 ].

Universities also have the ability to influence injunctive norms around smoking and ETS exposure on campus. They can isolate smokers from shared outdoor spaces on campus by requiring them to move to DSAs, or off the property entirely, in order to smoke. Those who comply with the new policy (behaviour) may not initially agree with the new smoking rule (attitude). This creates a state of cognitive dissonance, which requires alleviation by abandoning either the new behaviour or the old attitude. Because formal and informal sanctions generally encourage behavioural compliance, smokers’ attitudes typically shift to include an appreciation of the new rule and its valuation of smoke-free space. Additionally, norm formation can be viewed as a process. For example, through repeated treks to DSAs in distant parking lots, the removal of smoking from common, desirable social spaces becomes ‘routinely embedded or normalized’ [ 26 ]. From this perspective, the policy itself becomes a way to ‘mobilize’ support for smoke-free campus norms.

Limitations

This study’s focus on three case studies limits the generalizability of its findings, although the sites represent the range of current approaches to restricting outdoor smoking on Canadian campuses. Participants were those with a stake in the regulation of tobacco on campus; they brought detailed knowledge to interviews, but were not representative of university communities more generally. Some may have offered socially desirable answers regarding the non-normative status of smoking, although the research was not framed in terms of public health or tobacco control. Interviewing a greater number of campus stakeholders may have enhanced validity, although thematic saturation was achieved with the data collected. Future research into the interactions of social norms and smoking bans on campus could seek the opinions of students in general, and not only those in leadership roles. The potential for university decision-makers to compare policies on normative grounds also merits further investigation.

Smoking bans on campus do much more than limit non-smokers’ exposure to ETS; they also serve important normative, educational and health-related functions. Universities may enact innovative smoking bans in order to maintain their reputation for health promotion, and their image of being at the ‘cutting edge’ of societal change [ 4 , 16 ], as well as to meet the expectations of students and researchers. These restrictions not only make smoking harder to perform but also further weaken the behaviour’s previous normative status. As smoking prevalence decreases on campus, bans are further legitimized, and cessation is encouraged. In turn, smoking and ETS exposure are cast as increasingly socially unacceptable.

Norm change around smoking and ETS exposure has occurred on a societal scale, but at universities this anti-tobacco momentum has been extended due to particular contextual and compositional characteristics. Our findings suggest that universities may be uniquely positioned to implement health-promoting initiatives more generally. Indeed, university decision-makers are already aware of their ability to influence the normative values of student populations subject to institutional rules. This is especially meaningful given that students’ health-related behaviours and attitudes, which can be compromised in their transition to university life, have the potential for lifelong effect.

Social Sciences and Humanities Research Council of Canada; the Faculty of Science at the University of Alberta and graduate scholarships from the University of Alberta.

None declared.

We gratefully acknowledge the assistance of our interviewees, who spoke so candidly about campus smoking bans.

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College student reactions to smoking bans in public, on campus and at home

Carla j. berg.

1 Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, 1518 Clifton Road NE, 5th Floor, Atlanta, GA 30322, USA

Laura Lessard

Pratibha p. parelkar, james thrasher.

2 Department of Health Promotion, Education and Behavior, University of South Carolina, Columbia, SC 29208, USA

3 Department of Tobacco Research, Instituto Nacional de Salud Pública, Mexico, Mexico 62508

Michelle C. Kegler

Cam escoffery, kathryn goldade.

4 Department of Family Medicine and Community Health, Program for Health Disparities Research, University of Minnesota, MN 55414, USA

Jasjit S. Ahluwalia

5 Department of Medicine, Center for Health Equity, University of Minnesota, MN 55414, USA

We examined college student reactions to a statewide public smoke-free policy, campus policies and private restrictions through an online survey among 2260 students at a 2-year college and a university and 12 focus groups among smokers. Among survey participants, 34.6% smoked in the past month (35.0% daily, 65.0% non-daily). Correlates of receptivity to public policies included attending the university, not living with smokers and non-smoker status (versus daily and non-daily smoking). Correlates of receptivity to outdoor campus policies included being a university student, unmarried, without children, from homes where parents banned indoor smoking and a non-smoker. Correlates of having home restrictions included not living with smokers, no children, parents banning indoor smoking and non-smoker status. Correlates of having car restrictions included attending the university, not living with smokers, having children, parents banning indoor smoking and non-smoker status. Qualitative findings indicated support for smoke-free policies in public (albeit greater support for those in restaurants versus bars) and on campus. Participants reported concern about smokers’ and bar/restaurant owners’ rights, while acknowledging several benefits. Overall, 2-year college students and smokers (non-daily and daily) were less supportive of smoke-free policies.

Introduction

Over 18 million students are enrolled in colleges and universities in the United States [ 1 ]. During college, many people experiment with or initiate smoking and one-third become addicted [ 2 , 3 ]. Although pro-tobacco marketing attempts to normalize smoking particularly among young adults [ 4 ], smoke-free policies make smoking less socially acceptable [ 5–8 ]. Unfortunately, 83% of students reported any secondhand smoke (SHS) exposure in the past week, with exposure being most common in restaurants or bars or in personal settings (i.e. homes, cars) (38%) [ 9 ]. Thus, it is important to examine college student reactions to smoke-free policies in public places and on campuses as well as the practice of implementing private restrictions.

Firstly, assessing student reactions to public smoke-free policies is important in understanding their attitudes regarding tobacco control. In October 2007, Minnesota implemented a statewide smoking ban, the Freedom to Breathe Act. This law is applied to all public places, including bars, restaurants, private clubs, bowling alleys, hotel lobbies and public transportation. Minnesota was preceded by 22 other states, Washington, DC, and Puerto Rico in passing such a policy. Greater support for smoke-free policies has been associated with being female [ 10 , 11 ], higher education and higher income [ 10–13 ]. Among smokers, support for these policies is related to greater intent to quit and lower cigarette consumption [ 14 ]. The current investigation examines student reactions to the Minnesota ban.

Secondly, it is critical to understand college student reactions to campus policies. Although restrictive smoking policies on college campuses may discourage smoking onset or facilitate cessation, many colleges and universities are reluctant to establish them for fear of student objections [ 15 ]. A 2003 national study [ 16 ] indicated that 54% of the colleges banned smoking in all campus buildings and student residences [ 17 ]. Most students (88% of never smokers and 58% of smokers) favor smoke-free indoor policies, with less support for outdoor policies (43% of never smokers and 7% of smokers). Interestingly, the vast majority (98% of never smokers and 82% of smokers) indicates that the right to breathe clean air should take priority over the right to smoke [ 15 ]. Other research has corroborated these findings [ 18 ]. Central to the current study, this study examines reactions to current policies on two campuses that have not established outdoor smoke-free policies but are exploring that possibility, as endorsed by several national organizations, including the American College Health Association.

Third, it is important to understand how college students approach tobacco control and the management of SHS exposure in their personal settings, such as their homes and cars. This is especially relevant given that public smoke-free policies may increase implementation of private restrictions [ 19 ]. Having home restrictions is associated with lower reported levels of smoking and less SHS exposure [ 20 ]. Furthermore, having restrictions is associated with recent quit attempts [ 21 ], quitting smoking [ 22 ] and preventing relapse [ 23 , 24 ]. Less is known about the impact of having restrictions in vehicles. Thus, research is needed to examine this area.

Rates of non-daily smoking have increased alongside a national decline in daily tobacco consumption [ 25 , 26 ]. While non-daily smoking has been viewed as an unstable condition between daily smoking and quitting, newer research shows that this pattern of tobacco use may represent a chronic low-level (≤10 cigarettes per day) form of consumption [ 27–29 ]. This group represents a wide range of smoking patterns among the general population and particularly among college students [ 30 ]. The young adulthood population has been particularly affected [ 25 ]. This change may have occurred as a result of a rise in tobacco control policies [ 25 , 28 ]. Smokers enforcing smoke-free policies at home are much more likely to be light or intermittent smokers [ 25 ]. Thus, it is critical to examine how daily versus non-daily smokers respond to smoke-free policies.

Another interesting factor to consider in relation to attitudes regarding tobacco control policies is type of post-secondary education pursued. Two-year college and university students differ in their sociodemographic characteristics, as well as their smoking behaviors and attitudes. Two-year college students are more likely to be female, older, married and employed [ 31 ]. After controlling for sociodemographics, attending a 2-year college predicts smoking [ 31 ]. Moreover, 2-year college students have more positive attitudes regarding smoking; specifically, they are more open to relationships with smokers, less concerned about smoking-related health consequences and less supportive of tobacco control policies (e.g. tax increases, restricting tobacco marketing) [ 32 ]. Thus, these differences in attitudes toward smoke-free policies among technical college students and university students may be critical in developing effective intervention strategies for the two settings.

Given the aforementioned literature, the purpose of this study was to examine college student attitudes regarding public and campus smoke-free policies, implementation of private policies and specific factors related to reactions to smoke-free policies among students at a 2-year college and a 4-year university.

Materials and methods

Our mixed-methods approach utilized a quantitative survey and focus groups to examine college student reactions to public, campus and private smoke-free policies. This research was approved by the University of Minnesota Institutional Review Board (IRB# 0712S22941).

Survey research

In October 2008, a random sample of 5500 undergraduate students at a 4-year university (yielded from a random number generator and the list of student e-mails) and all 3334 young adults at a technical college were invited to complete an online survey. Students received up to three e-mails containing a link to the consent form with the option of declining participation. Students who consented were directed to the survey. As an incentive for participation, participants were entered into a drawing for cash prizes of $2500, $250 and $100 at each school.

Of those invited to participate, 2700 (30.6%) completed the survey (technical college: 30.1%, N = 1004; university: 30.8%, N = 1696). This response rate approximates response rates previously found using an online administration among college students [ 33 , 34 ]. Moreover, Internet surveys yield similar statistics regarding health behaviors compared with mail and phone surveys despite yielding lower response rates [ 35 ]. The present study focused on students aged 18–25 years; thus, 2260 (748 technical colleges and 1512 university students) are included in these analyses. Although we cannot assume that our sample is representative of the student populations present within the college settings, preliminary analyses indicated that gender, age and ethnic representations were not significantly different from the overall student body populations.

Demographic characteristics

Demographic characteristics assessed included age, gender, ethnicity and parental educational attainment.

Social factors.

We assessed marital status, place of residence (i.e. whether living with parents or elsewhere) and other smokers living in the home, children living in the home, parental home smoking rules and whether parents smoked.

Smoking behaviors.

Participants were asked, ‘In the past 30 days, on how many days did you smoke a cigarette (even a puff)?’ and ‘On the days that you smoke, how many cigarettes do you smoke on average?’ These questions have been used in previous research and have been shown to be reliable and valid with similar populations [ 36 , 37 ]. Students reporting smoking ≥1 day in the past 30 days were considered current smokers. For the multivariate analyses, smokers were further categorized into non-daily smokers (i.e. smoked between 1 and 29 days in the past 30 days) and daily smokers (i.e. smoked every day of the past 30 days) [ 38–40 ]. Among smokers, we assessed readiness to quit smoking in the next 30 days.

Attitudes regarding public smoke-free policies.

Participants were asked, ‘Because of the public smoking ban on smoking in restaurants and bars, do you go out more, less or does it make no difference?’ (1 = ‘less’, 2 = ‘no difference’, 3 = ‘more’) [ 41 ]. We asked, ‘How important is it to you to have a smoke-free environment inside bars, lounges, clubs and restaurants?’ using a four-point Likert-type scale (1 = ‘not at all important’ to 4 = ‘very important’) [ 42 ]. We also asked, ‘How do you feel about the law prohibiting smoking in all public buildings and restaurants?’ and ‘How do you feel about smoking being prohibited in Minnesota bars?’ using a four-point Likert-type scale (1 = ‘disapprove strongly’ to 4 = ‘approve strongly’) [ 42 ]. Exploratory factor analysis identified a common underlying factor among these items. Thus, the responses to these four questions were added to develop an overall score indicating level of receptivity to public smoke-free policies and demonstrated internal consistency (Cronbach's alpha = 0.86).

Attitudes about campus smoking policies.

Participants were asked, ‘What effect, if any, do you think a policy making this campus completely smoke-free would have on: student quality of life, student learning and student enrollment?’ using a five-point Likert-type scale (1 = ‘extremely negative’ to 5 = ‘extremely positive’) [ 43 ]. Exploratory factor analysis identified a common underlying factor among these items. Thus, the responses to these three questions were added to develop an overall score indicating level of receptivity to campus smoke-free policies and demonstrated internal consistency (Cronbach's alpha = 0.86).

Private smoking policies.

Participants were asked, ‘Which of the following best describes the rules about smoking in your home?: (i) no one is allowed to smoke anywhere, (ii) smoking is allowed in some places or at some times, or (iii) smoking is permitted anywhere; there are no rules’ [ 44 ]. This question was adapted to examine rules in cars; participants were asked which statement best describes the rules about smoking in their cars with the same response options as well as an option stating ‘I do not own a car’. These variables were dichotomized as complete restrictions versus other (partial or no restrictions).

Data analysis

Bivariate analyses were conducted examining differences between schools, genders and smoking status. Ordinary least squares regression was used to examine correlates of receptivity to public and campus policies, and binary logistic regression was used to determine correlates of implementation of private restrictions. Variables with a statistically significant bivariate relation to the outcomes of interest at P < 0.05 were entered into the models; using backwards stepwise entry, factors significantly contributing to the models at α = 0.05 were allowed to remain in the model. PASW 17.0 (IBM, Chicago, IL, USA) was used for all analyses.

Focus group research

In Spring 2009, we conducted 12 in-person focus groups with 73 college student smokers (i.e. any smoking in the past 30 days) aged 18–25 years recruited from the online survey. Focus group participants were recruited from those who completed the online survey the prior semester and indicated that they had smoked in the past 30 days. For each group, approximately 30 participants were invited to participate via telephone and e-mail. As an incentive, participants received $50. Participants were recruited into 1 of 12 groups (ranging from 6 to 12 participants per group), each being homogenous in gender (male and female) and school (2-year college, university; i.e. three groups per stratum).

Prior to beginning the focus groups, participants read and signed an informed consent and completed a brief questionnaire assessing demographics and smoking behavior using questions similar to those described above.

A trained focus group moderator (the lead author) facilitated group discussion on (i) attitudes about the statewide smoking ban, (ii) reactions to current campus policies and the potential implementation of outdoor smoke-free policies and (iii) the implementation of restrictions in private spaces (within the home or car). Each session lasted 90 min. All sessions were audiotaped, transcribed and observed by a research assistant.

Qualitative data were analyzed according to the principles outlined in Morgan and Krueger [ 45 ]. NVivo 7.0 (QSR International, Cambridge, MA, USA) was used for text coding and to facilitate the organization, retrieval and systematic comparison of data. Transcripts were independently reviewed by the first author and two master of public health graduate students to generate preliminary codes. They then refined the definition of primary (i.e. major topics explored) and secondary codes (i.e. recurrent themes within these topics) and independently coded each transcript. The independently coded transcripts were compared, and consensus for coding was reached. Quantitative data from the focus group surveys were analyzed using PASW 17.0 (IBM).

Table I provides survey participant characteristics as well as bivariate analyses comparing 2-year college and university students and males and females. Results of individual questions regarding receptivity to public and campus policies and implementation of private restrictions are presented in Fig. 1 .

Survey participant characteristics and attitudes regarding smoke-free policies

cpd, Cigarettes per day.

Percent of students reporting reactions to public policies, campus policies and private policies.

We examined correlations among our outcomes of interest, which are as follows: receptivity to public policies and to campus policies: r = 0.58, P < 0.001; receptivity to public policies and implementing home smoking restrictions: r = 0.31, P < 0.001; receptivity to public policies and implementing car smoking restrictions: r = 0.46, P < 0.001; receptivity to campus policies and implementing home smoking restrictions: r = 0.19, P < 0.001; receptivity to campus policies and implementing car smoking restrictions: r = 0.42, P < 0.001 and implementing home smoking restrictions and car smoking restrictions: r = 0.27, P < 0.001.

Attitudes regarding policies differed by gender, type of school and smoking status (see Table I ). Females, in comparison to males, were more receptive to public and campus policies and were more likely to have restrictions in their homes. Two-year college students were less receptive to public and campus policies and were less likely to have restrictions in their cars. Smokers, in comparison to non-smokers, were less receptive to public and campus policies and less likely to have restrictions in their homes or cars.

Multivariate analyses

Correlates of receptivity to public smoke-free policies..

Correlates of receptivity to public smoke-free policies included being older, being female, attending a university, being from an ethnic minority background, not living with smokers and being a non-smoker versus a non-daily smoker or a daily smoker ( Table II ).

Regression models predicting reactions to smoke-free policies in public, on campus and in private spaces

Correlates of receptivity to campus smoke-free policies.

In the multivariate model predicting receptivity to campus smoke-free policies ( Table II ), correlates included older age, being female, attending a university, not being married or living with a partner, not having children in the home, parents banning smoking in their home and being a non-smoker versus a non-daily smoker or a daily smoker.

Correlates of smoke-free policies in the home and car.

In the multivariate model predicting having complete home smoking restrictions ( Table II ), correlates included being older, being female, being non-Hispanic White, not living with other smokers, having children in the home, parents banning smoking in the home and being a non-smoker versus being a non-daily smoker or a daily smoker. Independent correlates of having complete car smoking restrictions included attending a university, not living with other smokers, having children in the home, parents banning smoking in the home and being a non-smoker versus a non-daily smoker or a daily smoker.

Table III provides the demographics and smoking-related characteristics of research participants by gender and type of school attended. Table IV highlights the themes that emerged in the discussion.

Focus group participant characteristics

Reactions to smoking policies in public, on campus and in private spaces

Public smoke-free policies

Among this sample of college student smokers, there was a high level of support for the public policy. Participants reported support for the ban for several reasons, including that the policy (i) reduced their smoking levels, (ii) protected people from SHS exposure; (iii) demonstrated respect for the rights of others, (iv) promoted freedom from smoke and smell, (v) was quickly acclimated to by the general public and bar and restaurant owners and (vi) allowed bars and restaurant owners who favored smoke-free policies to implement them without risk of substantially losing business. Participants indicated concern about the rights of smokers and bar and restaurant owners, particularly the economic impact that the policy may have on these businesses. They also reported more support for the ban in restaurants versus the ban in bars.

Campus smoking policies

At the 2-year college, campus policies included an indoor smoking ban and smoking being allowed only in designated areas outdoors. At the university, campus policies included indoor smoke-free policies and smoking at least 20 feet from all building entrances. Reported benefits of these policies included that it (i) helped to reduce smoking, (ii) protected non-smokers and (iii) improved the cleanliness of the campus. Concerns included the burden these policies imposed on smokers and difficulty enforcing these rules. Participants were largely receptive to implementing an outdoor smoke-free policy but reported concern about its impact on smokers living on campus and its impact on enrollment.

Smoking in private spaces

In regard to home smoking restrictions, the majority of participants had complete restrictions and the majority of the remaining participants had at least partial restrictions (see Table III ). In regard to restrictions in cars, half of the focus group participants had complete restrictions. The major motivators for implementing smoke-free policies included protecting others from SHS exposure and maintaining a clean smell-free space. Many participants commented on whether their parents had smoking restrictions, with mixed results regarding how they impacted their own implementation of restrictions.

The current study describes college student reactions to smoke-free public policies and campus policies and implementation of private smoking restrictions. College students largely support smoke-free policies in public, on campus and in private spaces. As has been documented in prior research, those who were older [ 11 , 13 , 46–49 ], female [ 10 , 11 , 50 ] and non-smokers [ 10 , 11 , 50 ] were more receptive to smoke-free policies in all three domains.

Our findings indicated that non-smokers were more receptive to smoke-free policies and more likely to implement personal restrictions (in homes and cars) than non-daily smokers and that non-daily smokers were more receptive to smoke-free policies and more likely to implement personal restrictions than daily smokers. Thus, current findings confirm and extend research documenting that non-smokers have more positive attitudes about smoke-free policies [ 10 , 11 , 50 ] and that smokers who enforce smoke-free policies at home have nearly three times the odds of being a light or intermittent user rather than a daily smoker [ 25 ].

In addition, compared with 2-year college students, university students were consistently more receptive to smoke-free policies and were more likely to have smoking bans in their cars. Although this greater receptivity among university students in comparison to 2-year college students has not been previously documented, higher rates of smoking have been found among 2-year college students [ 31 ]. Furthermore, it is important to note that parental education level did not contribute significantly to the models. We examined whether forcing parental education into the models would have changed the results; however, doing so did not yield different results. Thus, the differences in student body populations are not solely attributable to socioeconomic status.

Other factors were related to receptivity to public policies; specifically, being married or living with partner, having other smokers in the home, having children in the home and having parents that allowed smoking in the home were associated with more negative attitudes regarding the policies. These findings have not been previously documented; in fact, it seems counterintuitive that those with children in the home would be less receptive. However, it is reasonable that parents allowing smoking in the home may be associated with more negative attitudes regarding smoke-free policies. Interestingly, students were concerned about the impact of the public policy on rights of non-smokers, smokers and bar/restaurant owners. The vast majority recognized the impact of the policies on reducing SHS exposure. Smokers generally approved of the ban because of its impact on reducing smoking; they also continued to go to bars and restaurants despite the new policies. Prior research has documented that businesses, in fact, are not negatively impacted by such bans [ 51 , 52 ]. Thus, despite concern about the impact of these policies on smokers and other stakeholders, these groups reap some benefit or at least are not significantly harmed by them.

Similar to the reactions to the public ban, participants acknowledged that more restrictive campus policies increase burden on smokers but may ultimately benefit smokers by helping them quit or reduce their smoking. Moreover, participants were also supportive of outdoor smoke-free campus policies. They reported concern about the appearance of their campuses and believed that more smoking restrictions would result in improved campus cleanliness. Despite the challenges faced by campuses to implement tobacco control initiatives [ 53 ], receptivity to and compliance with campus policies can be increased by having activities on campus facilitated through campus coalitions [ 54 ], increasing enforcement, establishing consequences for non-compliance, improving signage and distributing reminder cards [ 55 ]. In addition, receptivity to campus policies was related to being single, not having children and parents not allowing smoking in their home; these relationships have not been previously documented. One explanation is that prior experience with one's family having home smoking restrictions and concern about children being exposed to SHS may make an individual more open to having increased smoking restrictions. In addition, single people may have had more exposure to smoke-free policies in bars that have prepared them to acclimate to campus smoking restrictions. These findings require further examination.

Having home and car smoking restrictions was associated with not having other smokers in the home and having children in the home, which has been previously documented [ 56 ]. In addition, coming from homes where parents banned indoor smoking was related to implementing restrictions. Interestingly, parental smoking status was not associated with having private restrictions. Thus, as has been shown previously [ 57 ], parental attitudes about smoking may be more important than their smoking behavior. In the focus group discussions, several students reported that they had home smoking restrictions because their parents had restrictions, while others reported having smoking restrictions because they disliked the smell of smoke in the homes where they grew up.

The present study has implications for research and practice. Firstly, the differences found between these student groups may reflect the variability that exists among young adults more broadly. For example, smoking rates for individuals in this age group are highest among young adults who did not finish high school (46%), followed by those who do not attend college (42%), those who attend 2-year colleges (34%) and those who attend 4-year colleges (29%) [ 58 ]. Future research is encouraged to target other segments of young adults, such as those not enrolled in college (e.g. those in the workforce or military). In addition, understanding attitudes about smoke-free policies among these groups as well as other psychosocial variables that contribute to different attitudes is critical for developing effective policies for campuses and promoting the implementation of private restrictions.

Study limitations

This study has some limitations. Firstly, it included two colleges in the Mid-west, with participants being primarily female and White/Caucasian. Although these characteristics reflect the demographics of the colleges from which the sample was selected, they may not reflect the demographics of all American colleges nor young adults more generally, limiting generalizability. In particular, the fact that these young adults are pursuing college educations might reflect a higher socioeconomic background than direct-to-work young adults; thus, the high rates of support for smoke-free policies might be reflective of the sample's higher socioeconomic background [ 44 , 59 , 60 ]. Also, because information from non-respondents was not assessed, we cannot infer how representative our sample is of the larger student populations. The same can be said of the focus group participants. In addition, we did not assess details regarding the nature of the home dwelling for these college students (i.e. dormitory, apartment, with parents). Thus, the extent to which their home smoking restrictions were volitional was not assessed. For example, the university students who lived in the dormitories were unable to smoke in their homes because of campus policies rather than because they elected to have restrictions. However, additional analyses of only students that lived in off-campus housing on their own (i.e. not with their parents) indicated similar findings, with 579 (55.8%) of 4-year university students and 317 (47.5%) of 2-year college students having complete home smoking restrictions. Furthermore, smoking status was assessed using self-report (i.e. no biochemical verification). However, there is no reason to assume differential rates of biased reporting. Lastly, the cross-sectional nature of the data does not allow us to determine causality.

Conclusions

Technical college students, compared with university students, report less receptivity toward smoke-free policies in public and on campus and less commonly implement private restrictions. Moreover, non-smokers have more positive attitudes about smoke-free policies than non-daily smokers, and likewise, non-daily smokers are more receptive to smoke-free policies than daily smokers. Therefore, tobacco control initiatives should attend to different psychosocial and smoking-related factors that influence attitudes toward smoke-free policies and implementation of private smoking restrictions among 2-year college and university students. Future research should identify other factors that might influence attitudes among these populations and test intervention strategies among these college settings in order to inform smoke-free policies affecting college students.

ClearWay Minnesota (RC-2007-0024).

Conflict of interest statement

None declared.

The Problem With Smoke-Free Campuses

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Some 10 years ago, Ozarks Technical Community College became the first higher education establishment to ban smoking even outdoors.  Since then, several hundred more universities and community colleges, especially in the South and Midwest, have followed suit. In a sense, the outdoor bans seem like a logical extension of 30 years of efforts to reduce tobacco use, given the harmful effects of smoking. The majority of the most elite schools, especially Ivy Leaguers like Harvard and Princeton, have yet to jump on the bandwagon, however. I can’t help but think that this is because they have more common sense than the rest of us: it’s only a matter of time before this “smoke-free campus” movement gets a student assaulted, raped or killed. Does this sound alarmist? I shouldn’t think so, given that the sequence of events is perfectly foreseeable, and quite likely, in the aggregate. Here's why: Some 20 percent of university students smoke. On big campuses like mine (over 20,000 students), many of these make the university residences their home. At some late-night hour after my university implements its intended ban, a student will want to go out for a smoke. To avoid or comply with the new rules, she’ll end up on the far periphery of the campus, in one of the dark places of the university, or on a street off campus. The university’s “walk safe” escort program will have informed her that they don’t have the resources to escort her, especially for an activity that university administrators want to stigmatize further. Later, the statistic in the newspaper may or may not mention why she was out there in the first place. Her bereaved parents may or may not have sufficient grounds to sue the university (but if other parents even suspect that one of their children smoke, they would do well to send them to study somewhere without a draconian outdoor ban). I find this, along with other aspects of the latest temperance movement, intensely depressing. I respect the new president at my university and think he does a good job in general (rare praise from a faculty member, I know), so I sent him a letter outlining some of my concerns with a complete outdoor ban on smoking.  Besides the safety issue, I listed some of the following concerns: Taking a conservative estimate of 20 percent of students who smoke out of a university body of 20,000  gives us the figure of 4000 smoking students.  Consequences of an outdoor ban on campus would include: 1 – Increased vehicle traffic. If just half of these 4000 students who smoke have access to a car and use it to leave campus just once more a week for lunch or a break (as a result of the ban), this equals two thousand extra car trips a week around the university.  Unlike tobacco outdoors, vehicle exhaust does pose a significant health risk to others, and the extra traffic (some 60,000 extra car trips an academic year as a conservative estimate) will increase the university’s carbon footprint accordingly. 2 – Increased risk of harm to students and other members of the university community.  If students are forced off campus when they want to smoke, this will lead them to negotiate traffic on foot or by car. In the case of differently abled students and those with reduced mobility, pushing them off campus seems a particularly hard to justify and even cruel approach. 3 – Avoidance strategies. If avoidance strategies of people addicted to tobacco are half as strong as tobacco researchers say they are, student enrollment will suffer as a result of the complete outdoor smoking ban. Particularly students in the arts and international students from countries such as China, which have higher smoking rates, have many choices and may look elsewhere for their education. Additionally, students who smoke will likely spend less time on campus and avail themselves less frequently of campus dining options – leading to a reduction in university revenues and a less vigorous student presence on campus. All these factors remain extremely difficult to measure, and anti-smoking activists who claim to have measured no impact from smoke-free campus policies elsewhere misrepresent the situation. 4 – Morale. Judging from student comments many of us have already heard around campus, the complete outdoor smoking ban alienates many and breeds resentment toward an administration seen as having gone too far.  Faculty in particular may find it frustrating to work so hard for student retention and morale only to see their efforts hampered in this regard. 5 – Honesty. The implication that tobacco smoke poses a significant health risk to others outdoors is disingenuous. A university’s first mission centers around truthful discourse, and we should be teaching our students to differentiate between significant risks (such as smoking) and totally insignificant risks (such as secon hand smoke outdoors).  We should be teaching our students to deconstruct misleading government and advocacy group statements, such as the claim that “these is no safe level of exposure to secondhand smoke.” By such criteria, there is no safe level of exposure to sunlight either. 6 – Liberalism. With the notable exception of some “Bible colleges,” which also ban alcohol, dating and other practices, most universities in this country value tolerance of people’s lifestyles and individual preferences. We enshrine this policy when our university handbook advises the following: “Don't attempt to impose your values -- whether political, religious or cultural -- on others.” My university president actually agreed with most of the points I made.  He replied, however, that he couldn’t rescind the coming ban because other universities in our state were also implementing similar policies, and the state legislature in neighboring Arkansas just legislated complete outdoor smoking bans at all universities there. “Besides,” he said, “I would have all the true believers on this campus banging on my door in outrage.” How misguided. Instead of respecting our students and offering them a safe, liberal environment on campus, our university administrators feel cowed by the new political correctness of the latest temperance movement.  How distressing that the groups pushing these policies, from the “true believers” to Anheuser-Busch funded organizations like the Bacchus Network (which would divert universities’ attention from alcohol to tobacco) or pharmaceutical company groups (who often get universities to buy their smoking cessation products and distribute them for free or at a subsidized price), couldn’t care less about the fallout. Call me old fashioned, but I think I actually prefer the image of a university with pipe-wielding, pontificating professors and arts students smoking and arguing politics by the campus fountain.  In any case, the proportion of the campus community and population in general that smokes has been steadily declining since the 1970s, without these draconian "smoke-free campus" bans.

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Smoke-Free and Tobacco-Free Campus

As a part of the campaign for better health, the School has established a no-smoking policy including e-cigarettes in school buildings and on school grounds. Smokers are encouraged to attend smoking cessation classes. The Tobacco Treatment Specialist, 617-495-2068, offers smoking cessation counseling at Harvard University Health Services in the Smith Campus Center in Harvard Square. HUHS waives the copay for these visits.

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Open Access

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Research Article

Going smoke-free: University staff and students’ qualitative views about smoking on campus during the implementation of a smoke-free policy

Roles Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliations School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia

Roles Formal analysis, Methodology, Writing – review & editing

Affiliation School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia

Roles Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing

Roles Writing – original draft, Writing – review & editing

• Marguerite C. Sendall, 
• Chantal Le Lievre, 
• Laura K. McCosker, 
• Lauren Brewis

• Published: August 20, 2020
• https://doi.org/10.1371/journal.pone.0236989
• Reader Comments

Despite many Australian universities introducing smoke-free policies on campus, there is little information about staff and students understanding of smoking on campus in the context of the implementation of a smoke-free policy.

This research explores the qualitative views of university staff and students about smoking on campus during the implementation of a smoke-free policy.

In 2016, an electronic survey was distributed to all current staff and students of a large university in Queensland, Australia during the implementation of a smoke-free policy. The survey consisted of multiple-choice questions about demographics, tobacco use, attitudes towards smoking, awareness of and attitudes towards the policy, and intentions to quit smoking. The final question asked for a short, open-ended response: “ Would you like to comment on the issue of smoking on QUT* campuses ? ” This question was extracted from the survey and analysed using inductive thematic analysis. This paper reports the findings from this question. *Queensland University of Technology.

The survey was completed by 641 staff and students. There were 351 responses to the final question. Five inductive themes emerged about smoking on campus during the implementation of a smoke-free policy: 1) the watering down of the policy, if it is not enforced, 2) the creation of hot spots on campus boundaries affecting those who pass by, 3) concern, especially by those who don’t smoke, about the impact on smokers emotional health and welfare, 4) disagreement about the value of designated smoking areas and 5) suggestions about how to better implement the policy.

Overall, participants views about smoking on campus during the implementation of a smoke free policy suggest broad agreement but reflect concerns about enforcement, boundaries, non-smokers and designated areas. Consistent and systematic processes for implementation, maintenance and enforcement of policy goals, and cessation support, is needed to create a non-smoking culture on university campuses.

Citation: Sendall MC, Le Lievre C, McCosker LK, Brewis L (2020) Going smoke-free: University staff and students’ qualitative views about smoking on campus during the implementation of a smoke-free policy. PLoS ONE 15(8): e0236989. https://doi.org/10.1371/journal.pone.0236989

Editor: Stanton A. Glantz, University of Calfornia San Francisco, UNITED STATES

Received: November 25, 2019; Accepted: July 17, 2020; Published: August 20, 2020

Copyright: © 2020 Sendall et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: There are data restrictions because the data contain potentially sensitive information. These restrictions are imposed by the approving Queensland University of Technology Human Research Ethics Committee. Data requests should be sent to QUT UHREC: [email protected]

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

In 2016, approximately 3 million (14.9%) Australians aged 14 years and over were current daily, less often than weekly or weekly smokers. Of these, 2.4 million (12.2%) smoked tobacco daily [ 1 ]. The negative health impacts of smoking tobacco are well-documented [ 2 ]. In 2016, tobacco smoking was the leading risk factor contributing to disease in Australia, accounting for 9.0% of the total burden [ 1 ]. In 2015, the most recent reporting year, tobacco smoking led to the death of nearly 21, 000 Australians [ 3 ]. The related social costs in 2015–2016 are estimated to be $136.9 billion, significantly higher than the $31.5 billion reported in 2004–5 [ 4 ]. Similar significant negative impacts associated with smoking are seen internationally [ 5 ]. Using a variety of strategies, including smoke-free legislation and policies, bans on advertising, plain packaging, price increases, restriction on sales to minors and public education, Australia has been successful in reducing smoking prevalence [ 1 ]. Legislation and policies for smoke-free environments are now commonplace in Australia, and internationally [ 6 ]. Since the late-1980s, all Australian states and territories have progressively implemented smoke-free legislation, banning smoking in workplaces and many public spaces such as sporting venues, shopping centres, restaurants, and building entryways [ 2 ]. Many organisations, including several Australian universities, have implemented comparable policies. A similar trend towards the implementation of smoke-free legislation and policies has been observed internationally. In 2012, Hyland et al. [ 7 ] estimated approximately 11% of the world’s population live in countries with smoke-free legislation and / or policies.

Arguments against smoke-free policies suggest they are not widely supported, are difficult to implement and result in negative impacts such as lost revenue, displacement of smoking from public spaces into the home, and increased stigmatisation of smokers [ 7 ]. However, there is a significant body of literature which demonstrates smoke-free legislation and policies result in smoking-related health improvements. International research has demonstrated smoke-free legislation and policies result in significant reductions in smoking rates [ 8 – 10 ]. A meta-analysis published in 2015 suggests smoke-free policies on university campuses specifically result in reductions in smoking rates of 14.7% after 1 year, and 8.3% after 3 years [ 11 ]. Smoke-free legislation and policies result in reduced rates of exposure to second-hand tobacco smoke [ 12 ]. Research indicates smoke-free policies are generally well-supported, by both staff and students, in university contexts both in Australia and internationally [ 11 , 13 ].

In 2016, when this study was undertaken, twenty-two Australian universities had introduced smoke-free policies and two had published research reporting the outcomes of these policies [ 14 – 16 ]. This research has been quantitative in nature except for one study [ 14 ], which explored reasons for non-compliance. While this study provides valuable feedback for effective policy evaluation, it fails to gain insights from smokers who do comply with new regulations. Staff and students’ views about smoking on campus during the implementation of a smoke-free policy will contribute to a better understanding of compliance and non-compliance and provide evidence-based guidance for policy implementation. This research fills this gap in current knowledge by exploring staff and students’ views about smoking on campus during the implementation of a new smoke-free policy.

Materials and methods

At the time this study was undertaken in 2016, approximately 5% of universities in the United Kingdom, 25% in the United States [ 11 ] and 32% in New Zealand [ 17 ] had implemented smoke-free policies. Twenty two out of forty Australian universities had adopted smoke-free policies. Western Australia and Australian Capital Territory had successfully implemented smoke-free policies at all universities. In Victoria, seven out of eight universities have smoke-free policies. New South Wales and South Australia had implemented smoke-free policies at four out of six and two out of four universities respectively. Tasmania and Northern Territory had yet to adopt smoke-free policies at their universities. The remaining eighteen universities still allowed smoking in designated areas or have other unspecified restrictions in place.

At the time, all Queensland universities and other tertiary institutions had smoking policies in place but only two Queensland universities were totally smoke-free. These policies replicate applicable prohibitions outlined in The Tobacco and Other Smoking Products Act 1998 (the Tobacco Act), such as prohibiting smoking in buildings or enclosed spaces, outdoor eating and drinking areas and near building entrances. Recent amendments to the Tobacco Act could see Queensland universities adopt stringent restrictions regarding smoking prohibitions. The Act suggests public universities in Queensland could act as a government precinct to prescribe regulations where smoking is prohibited in all buildings and grounds.

This research was carried out during the initial stages of the implementation of a smoke-free policy at a large tertiary institution in Queensland, Australia which has nearly 49 000 student enrolments and more than 12 500 staff [ 18 ]. The university implemented a smoke-free policy on 01 July 2016. The policy prohibits smoking by all people in all areas of all university campuses, including grounds, buildings and vehicles. This includes the use of cigarettes and all other tobacco-related products (e.g. herbal cigarettes, loose smoking blends, cigarette-making machines, cigarette paper and filters, and electronic cigarettes) [ 19 ]. The policy encourages staff, students and visitors to the university to remind others the university is a smoke-free environment including those who they see smoking [ 20 ]. The policy specifies ‘disciplinary action’ may be taken in cases of repeated breach of the policy in accordance with relevant Codes of Conduct [ 19 ]. The policy directs smokers to areas outside the campus boundaries where smoking is permitted, and to sources of support should they wish to quit smoking [ 20 ].

Participants

An electronic survey was distributed to all current full-time, part-time, casual and sessional staff and all current full-time and part-time, domestic and international students, at all university campuses. The purpose of this survey was to gather information about participants’ (1) current smoking behaviours, and (2) attitudes about the university’s smoke-free policy. The invitation to participate in this survey was emailed during September 2016 via Registrar’s newsletter. The newsletter contained a short introduction about the research and a link to the survey. A follow-up email was sent in October 2016. Survey participants were offered the opportunity to enter a draw to win one of six $50 gift vouchers. Informed consent was obtained from all respondents before data collection. Ethical approval for this project was obtained from the QUT Human Research Ethics Committee (Approval Number: 1600000844).

Permission was obtained to use a survey instrument developed and validated by Burns et al. [ 15 ] This survey was anonymous and consisted of four sets of focused multiple-choice questions. The first set of three multiple choice questions collected demographic data about the respondents. The second set of questions (six) focused on agreement with smoking attitude statements. The next seven questions asked about agreement with tobacco control attitude statements and the last set of multiple-choice questions (four) focused on the effects of a completely smoke free campus policy. The analyzed data of these questions are reported elsewhere. The final question asked for a short, open-ended response: “Would you like to comment on the issue of smoking on [the university] campuses ? ” This question is the focus of this paper.

Data analysis

The free text responses to the final question were analysed using inductive thematic analysis. A deductive approach based on health behavioural frameworks such as the Diffusion of Innovation Theory [ 21 ] was considered. An inductive approach was determined to be most appropriate due to the rich and wide-ranging nature of the survey responses.

The process of thematic analysis involved reading each survey response several times to establish familiarity with the data. Most responses were single sentences, many responses were short paragraphs and some responses were long paragraphs. Responses were excluded from the study if (a) the participant did not provide an answer to the question, or (b) the participant’s response was “no” , “nope” , “nah” or “NA” . The second and third author, under the stewardship of the first author undertook initial stages of data coding. Significant statements were highlighted, and descriptive codes were generated to reflect the essence of the significant statements in context. This process was repeated three times to ensure codes were sound and trustworthy. The first, second and third authors undertook the later stages of data analysis. Codes were grouped and regrouped to form themes over several months. The themes represent the salient ideas which emerged from the data.

Inter-rater reliability was undertaken by the first and third authors. The process involved cross-checking the allocation of quotes to themes. Twenty-five quotes (approximately 10% of quote pool) were randomly selected to represent data. Identifying codes were removed from quotes. The authors read the quotes and assigned them to the theme which best represented the meaning of the quote. The match percentage was 75% for the first author and 79% for the third author. The authors discussed the mismatched quotes to agree on the theme. Authors did not reach agreement on a small percentage of mismatched quotes.

The survey was completed by 641 staff and students. Of these participants, 42.9% (n = 275) were staff and 57.1% (n = 166) were students. Most participants were female (74.5%, n = 458). There were 351 responses to the final question. Of these participants, 46.8% (n = 164) were staff and 53.2% (n = 187) were students. Most participants were female (71.5%, n = 251). The percentage difference between survey responses and responses to the final survey question across gender and primary role was 3–4%.

The second section of the survey, Tobacco use and second-hand smoke exposure asked respondents about their smoking status. Smoking status can be defined as non-smoker, ex-smoker, regular smoker and occasional smoker [ 15 ]. The results of respondents smoking status are presented here to provide context for the findings from the final open-ended survey question. Most participants report they ‘never smoked cigarettes at all, or never smoked them regularly’ (74.1%, n = 260). Approximately one-sixth (15.1%, n = 53) of survey participants report they ‘do not smoke now but used to smoke regularly (≥1 cigarette per day)’. Approximately one-fifteenth (6.8%, n = 24) report they ‘currently smoke cigarettes (>1 cigarette per day)’, and 3.1% ( n = 11) report they ‘occasionally smoke cigarettes (on average, <1 cigarette per day)’. Less than 1% ( n = 3) did not respond to the question about smoking status.

The following five themes emerged from analysing the answers provided to the final, open ended question, “Would you like to comment on the issue of smoking on [the university] campuses ? ” : (1) a lack of enforcement, (2) smokers on the boundary, (3) the effects of policy of personal experience, (4) the need for designated smoking areas and (5) suggestions for improving the policy.

Theme 1 –lack of enforcement

There is no point having a ban if it’s blatantly ignored .

Lack of enforcement of the smoke-free policy was identified as a key issue in its implementation. Participants, more so those who do not smoke, felt the lack of enforcement contradicted the implementation of a smoke free policy. Essentially, if the policy was not operationalised to its full extent, it would not achieve its strategic purpose. Participants concluded this because they had not observed university staff enforcing the policy on campus. One participant explained:

“There are current policies in place , however nobody checks or ensures that the policies are being adhered to . Hence people just smoke whenever and wherever they want” (309, female non-smoker).

Participants reflected a lack of enforcement created an environment permissive to smoking. Overall, non-smoking participants, disproportionally to participants who smoke, felt smokers seemed confident to a point of flaunting disregard for the policy. This view was linked to the lack of consequences for disobeying the policy and therefore seen as permission to smoke. Specifically, participants who do not smoke noticed smokers were not held accountable for disregarding the policy and felt enforcement of the rules was fundamental to achieving a smoke free environment. For example, one participant commented:

“I notice a lot of people ‘getting away’ with smoking on campus . For an effective smoke free campus , the rules must be enforced” (230, female non-smoker).

Theme 2 –smokers on the boundary

A mini gauntlet of thick smoke when entering and leaving the campus.

Participants provided valuable insights into the unintended consequences of implementing a total smoking ban. Effectively, participants thought those who smoke got around the total smoking ban by creating their own ‘designated smoking areas’ just outside the campus boundaries. Consequently, many participants who do not smoke expressed frustration at smokers congregating on the boundary of the campus. These participants explain the clusters of people smoking created large thick plumes of smoke which makes it difficult to avoid passively inhaling smoke. Some participants, predominately those who do not smoke, felt they were more exposed to smoke post implementation of the policy, as one participant explained:

“…This [the boundary area where smoking is permitted] is directly on the main drive when I walk in . This means that I have gone from , at most , once a month exposure due to walking near the smoker's area to , at least , once a week exposure due to smoker's smoking ‘in’ the botanical gardens but right next to the main drive . This is worse as before I knew exactly where to avoid if I did not want to go near smokers . Now I don't know when I will be exposed to secondhand smoke” (242, female non-smoker).

Theme 3 –effects on personal experience

Butt out of our lives.

Many participants expressed anger about the decision to eliminate designated on-campus smoking areas. Many participants identified a lack of consideration for the impact this could have on the smokers’ personal experience. Interestingly, participants who smoke and those who don’t smoke alike felt a total smoking ban might have unintended outcomes for some people who smoke. Further, some participants who smoke viewed this as impinging on their personal rights to smoke where they choose. Overall, the university was perceived as paternalistic in implementing this type of the smoke-free policy, as one participant argued:

“[The university] should not be a progressive nanny state . Adults should make decisions for themselves . Sick of [the university] being a progressive echo chamber for whichever fashionable cause low self-esteem bully's seek to virtue signal with this month” (194, male non-smoker).

Many participants, mostly those do not smoke, felt strongly about the effect this policy could have on the mental health of people who smoke. In particular, those who do not smoke expressed a genuine and heartfelt concern about the emotional health impacts and the ability to continue studying on those who smoke. This reflected a deeper understanding of the complexities associated with implementing a smoking ban. In fact, participants reflected a total ban could victimise a vulnerable population. Many participants felt sympathetic towards people who smoke. One participant said:

“I also think the smoking ban unfairly targets people with pre-existing mental health issues as they make up the greater majority of smokers” (152, female smoker).

Other participants developed this idea further to describe the policy as discriminatory towards people who smoke. Many participants, many who do not smoke, acknowledged difficulties the policy would create for people who smoke, considering there is no smoking area on-campus. Participants felt the University’s hard line failed to recognise smoking as physiologically based and the emotional impacts. Smoking was identified as an addiction which should be addressed through means other than an inflexible policy, as one participant stated:

“There should be designated smoking areas . Smoking is not illegal and it is discriminatory to constantly make it harder for people to exercise their right to smoke by making the entire campus smoke free” (365, female smoker).

Theme 4 –designated smoking area’s on-campus

Having a specific area they can go and indulge in their filthy habit away from us breathers.

Most participants, especially non-smokers, were considerate of people who smoke and felt the need for a designated smoking area. A designated smoking area would ensure people who smoke would be confined to areas which others could avoid. Many participants expressed their support for reducing the amount of smoke on campus but there was widespread disagreement between those who smoke and those who don’t about the university’s approach to addressing this. Participants, more likely to be smokers, felt implementing a total ban on smoking was unfair and did not consider the implications for people who smoke. However, participants, more likely to be non-smokers, felt designated areas would be fair and take into consideration the mental health of those who smoke. Participants support the overall goal of the policy but believe designated smoking areas are required for wider support and effectiveness, For example, one participant said:

“I think it is a great idea to ban smoking ! However , I could imagine that it would be very hard for smokers (particularly staff) as they now have to walk quite a long way until they are allowed to smoke . It might be fair to them to still have a designated area that is however away from usual walkways” (167, female non-smoker).

Theme 5 –suggestions for policy

Participants, more likely to be a non-smoker, expressed positive feelings towards the implementation of the policy, and were supportive of the university’s commitment to creating a healthier campus environment. They felt a healthier environment would be good for individuals, the university population and the broader community. Many participants, both those who smoke and those who don’t, emphasised the importance of improving the policy, and provided suggestions. These included: extending the ban, ensuring stronger enforcement, providing counselling to assist people who smoke to ‘quit’, and strategies (including increasing signage) to inform people of the policy. In particular, some participants suggest the smoking ban be extended to include entrance and exit points to the campuses. One participant proposed:

“Smoking should also be banned at entrances , especially from the ferry terminal walkway to the campus and along the stone wall areas towards the Botanical Gardens at Gardens Point . It should also cover any areas that would be considered a public access area to all QUT campus” (287, female non-smoker).

This research provides a unique understanding about staff and students views about smoking during the implementation of a smoke-free policy in an Australian university context. The findings from this research show there is some agreement for the need to introduce a smoke-free policy at the university. This may be a contextual finding due to Queensland’s early adoption of tobacco legalisation. However, the findings of this paper highlight some of the negative aspects of implementing a smoke-free policy such as ineffectiveness. This can be due to enforcement strategies, specifically the lack of enforcement by university staff. This finding is consistent with findings in similar studies involving smoke-free policies on university campuses [ 17 , 22 , 23 ]. Preceding research about smoke-free policies in Australian universities suggests staff do not perceive policy enforcement to be part of their role and are reticent to approach policy violators [ 16 ].

Enforcement is critical for the effective implementation of a smoke-free policy. When smoke-free policies are poorly enforced on university campuses, people are more likely to deliberately ignore them [ 24 ]. One study from the United States describes a shift towards a more formal approach to enforcing smoke-free policies on university campuses including punitive enforcement strategies such as mandatory participation in prevention classes after policy violation or monetary fines for repeat offenders [ 25 ]. However, the extent to which this would be effective and accepted in the Australian context remains unclear. Training opportunities about policy enforcement for staff, leading to a consistent approach to enforcement, have been shown to be effective in other Australian settings such as psychiatric inpatient units [ 26 ]. Furthermore, ongoing education and increasing permanent signage may promote increased self-enforcement of the policy [ 17 ].

Similar consistent findings to emerge from this research include smokers congregating on campus boundaries, leading to the problem of increased exposure to second-hand smoke for people entering or leaving the campus, and concerns regarding personal safety as many people go to secluded areas to smoke [ 13 , 17 ]. Procter-Scherdtel and Collins [ 23 ] discuss the need to better manage community relations as people who smoke are displaced from university campuses surrounded by residential and shopping precincts. Another significant finding to emerge from this research is the concern regarding the effectiveness of “blanket ban” policies on university campuses. This is consistent with research conducted at other Australian universities which found this policy approach is not widely accepted [ 13 , 14 ]. However, exposure to second-hand smoke is still a serious aspect to consider when evaluating the overall health of a campus community.

Another downside of implementing a smoke free policy is the impingement of personal freedoms, and the consequences. This research revealed concerns about the effects of a smoke-free policy on personal experience, and smokers’ rights to smoke where they choose. Similar findings are reported in another qualitative study exploring the effects of a smoke-free policy introduced at another large Australian university [ 14 ]. This is a finding supported by international literature [ 27 ] but challenged by another study which found most people believe the right to breathe clean air should take precedence over the right to smoke and people should only be exposed to harm if they understand the risks and choose to accept them [ 28 ].

Lastly, the victimisation of people who smoke by smoke-free policies was another key idea which emerged in this research. Authors Stuber, Galea and Link [ 29 ] agree smoke-free policies drive the social unacceptability of tobacco and, subsequently, the stigmatisation of people who smoke. These authors found smoker-related stigma may encourage people to quit or discourage initial uptake. However, the deterrent effects of stigma are not experienced equally across different socioeconomic and racial/ethnic groups, highlighting the need to better understand the stigma processes associated with the smoking epidemic [ 29 ]. Ultimately, the role of stigmatisation in the epidemic should be addressed by the tobacco control community to determine whether to promote or discourage this form of deterrence.

Limitations

There were more non-smokers (n = 251) than smokers who completed the final question on the survey and may reflect a more positive attitude toward the policy. This sample does not have an equal distribution of smokers and non-smokers. Selective non-response and underreporting means non-smokers are underrepresented. A similar study found non-responders were more likely to be people who smoke [ 30 ].

Smoke-free policies have impacted smoking prevalence and exposure to second-hand smoke, but policy implementation may not result in a smoke-free environment. An in-depth exploration of people’s views about smoking on campus during the implementation of smoke-free policies contributes to understanding why, how and under what circumstances smoke-free policies succeed. Our qualitative findings reveal five salient ideas reflecting views about smoking on campus during the implementation of a smoke-free policy; 1) the watering down of the policy, if it is not enforced, 2) the creation of hot spots on campus boundaries affecting those who pass by, 3) concern, especially by those who don’t smoke, about the impact on smokers emotional health and welfare, 4) disagreement about the value of designated smoking areas and 5) suggestions about how to better implement the policy. However, successful ecological approaches to tobacco control rely on consistent and systematic processes for implementation, maintenance and enforcement. Clear and frequent communication, education, regular and ongoing surveillance, permanent signage, positive reinforcement and tobacco cessation support services are essential during this transition period to assist in establishing a culture of compliance for a smoke-free environment.

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Should Smoking Be Banned in Public Places? Essay

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Introduction

Thesis statement, reasons for the ban of smoking in public places, the opposing views, economic point of view, social point of view, works cited.

Many governments across the globe have moved to ban smocking in public places. Whether the action is justified or not, is a matter of fierce debate. Often, the proponents of the proposition carry the day arguing that smoke from cigarette inhaled by non-smokers poses health risks.

Thus, the banning action is based on the premise that non-smokers should be protected from risks associated with proximity to cigarette smoke (Warner 71). The other premise is that effects of smoke whether directly inhaled or partially taken in proximity with smokers are the same. However, little attention has been given to the opposing views which have always been dismissed as baseless.

Most academic studies and researches have cited individual rights as the basis for smocking in public ignoring other factors such as economy, social as well as other individualistic reasons (Viscusi 31). Moreover, much attention has also been given to dangers posed by cigarette smoking specifically health problems while ignoring the opponent side of view.

Further, little research has also been conducted to ascertain some of the issues that support public smoking or smoking in general (Viscusi 31). This does not necessarily mean that smoking should be allowed. However, other factors should be considered. Besides, various options should be explored before imposing a ban on smoking cigarette in public.

Smoking in public places poses health risks to non smokers and should be banned. This paper will be discussing whether cigarette smoking should not be allowed in public places. First the paper will explore dangers associated with smoking in public and not on those who smoke, but on non-smokers.

The paper will then examine these propositions and ascertain whether they hold and establish counter arguments against the propositions. It is concluded that even though smoking poses health risks among the individuals, economic, social and individual values must be taken into consideration before a blanket ban on the practice is imposed (Abedian et al. 71).

The proponents of this rule have several arguments majorly based on scientific studies and results from health institutions. These arguments cannot be disputed, but over reliance on them is what makes the arguments a bit absurd (Warner 71).

However, various researches have always pointed health risks associated with smoking. Besides, smoking is an environmental hazard as much of the content in the cigarette contains chemicals and hydrocarbons that are considered to be dangerous to both life and environment (Lott and Richard 102).

Biologists and epidemiologists point out passive smoking is harmful to health. In other words, those who come in contact with second-hand smoke risk their health statuses (Lott and Richard 102). Several risks are associated with second-hand smoke that majority come in contact with in public places.

In most cases, partial smokers suffer from cardiac arrests, lung cancers, central nervous system impairments as well as other diseases caused by carcinogenic chemicals from cigarette smoke (Viscusi 35).

Other health conditions caused by smoking include asthma and other respiratory infections resulting from hydrocarbons and ammonia present in the second-hand smoke. Partial smokers also suffer from eye irritations, headaches and flu as a result of smoke particles (Viscusi and Joseph 10).

Findings from other scientific studies indicate that smoking reduces individual lifespan by a minimum of ten percent. The discovery also indicates that women are likely to suffer eleven years off their life expectancy. Moreover, people who smoke are more susceptible to certain forms of cancer that would have been avoided without smoking (Viscusi and Joseph 10). Smoking is injurious to health.

Those who have opposed the view on smoking ban in public places have been accused of citing individual rights to support their actions. In as much as they might be true, the weak point in this argument is that the rule applies to both smokers and non-smokers (Abedian et al. 71). Every one has a right to smoke and also not to smoke. Therefore, the argument based on the legal rights of an individual remains ambiguous.

From the economic point of view, smoking is an individual choice. Like any other product these individuals may be willing to buy, cigarette is a commodity that its consumers would want and willing to purchase. Indeed, people make everyday choices founded on their preferences, and these choices are often associated with hazards and reservations (Warner 71).

All social interactions that individuals are involved in could be associated with risks which, in most cases are greater than risks related to smoke that smokers’ exhale. The reason is that the expected outcomes of the social interactions are greater than the risks as well as the costs involved (Viscusi 40).

Therefore, it would be ridiculous to make a conclusion that smoking in public should be prohibited simply because it presents a number of risks.

Based on this argument, the number of fatalities from other causes such as accidents, sexual relations, other diseases such as flu and pneumonia which are communicable and easily spread in public places are by far numerous than the fatalities caused by the second-hand smoke.

In other words, the risk of contracting other diseases, dying from AIDS as a result of sexual relations as well as dying from accidents are five times higher than the risk of dying from a second-hand smoke (Abedian et al. 71).

The other attribute of the economic proposition is that it examines the method through which individual choices can be reconciled based on their preferences (Viscusi and Joseph 44).

That is, individuals who smoke and those who tend to avoid second-hand smoke. According to the economic studies, primary institutes such as contractual freedom and property rights offer an effectual solution more than formal regulations in fulfilling personal preference (Viscusi and Joseph 44).

Another factor that should also be taken into consideration is the degree to which a place is considered public (Warner 71). It should be understood that most of the public places were previously private places. The difference is that owners allow the public to access them purely for commercial purposes.

As such, the role of property rights should be implemented to stop public smoking. In this regard, much of the places considered public are private such as the work places, restaurants, buses and bars. These places are opened for all manner of customers’ smokers as well as non smokers. The owner should specify the target customers who are purely non-smokers.

Therefore, any smoker who enters in these establishments is held liable for any risk of second hand smoking. On the other hand, an establishment may require that only smokers enter its establishment. In such a situation, any establishment will not be held responsible for any risks associated with second hand –smoke in a case non smoker enters the establishment.

In both scenarios, there is economic efficiency for all the parties concerned based on their preferences. However, in the circumstances that there is no specificity and the definition of the public, the whole process becomes chaotic (Warner 71).

Socially, smoking has been perceived as being fashionable and stylist. This perception has been carried over from generations to generations. Smoking is not something new rather it has been practiced for centuries. In a critical examination as to why people have been smoking for centuries, the reason is because they derived pleasure that was closely related to fashion and style.

That is why people still smoke and younger generations find themselves to be smoking despite health warnings or knowledge of health risks associated with the practice (Lott and Richard 102). This value should not be undermined as scientists could not explain why some smokers stay longer than those who smoke. Moreover, smoking is not the only cause of all health related diseases.

The best possible strategy to control tobacco consumption should be put in place. This will uphold individual’s self-esteem and appreciate society preferences. Scientists and other health proponents argue that people should not be guaranteed to smoke openly.

However, the economical approach stipulates that the management should not impose a ban on some individuals’ day to day choices. In fact, people’s preferences are highly regarded in the general public. Banning public smoking could favor certain communities while offend the treaty-liberty and material goods privileges.

Abedian, Iraj, Merwe Rowena, Nick Wilkins and Prabhat Jha. The Economics of Tobacco Control: Towards an Optimal Policy Mix . Cape Town: University of Cape Town, 1998. Print. p. 71.

Lott, John and Richard Manning. “Have Changing Liability Rules Compensated Workers Twice for Occupational Hazards? Earning Premiums and Cancer Risks.” Journal of Legal Studies , 29.1 (2000): 99-128. Print.

Viscusi, Kip and Joseph Aldy. “The Value of a Statistical Life: A Critical Review of Market Estimates throughout the World.” Journal of Risk and Uncertainty , 27.1 (2003): 5-76. Print.

Viscusi, Kip. “The Value of Life: Estimates with Risks by Occupation and Industry.” Economic Inquiry , 42.1 (2004): 29-48. Print.

Warner, Kenneth. The Economics of Tobacco and Health . Cape Town: University of Cape Town, 1998. Print. p. 71.

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• Keys to leadership in HCA
• Cost-effectiveness of the global health programs
• Chicago (A-D)
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IvyPanda. (2019, April 15). Should Smoking Be Banned in Public Places? https://ivypanda.com/essays/should-smoking-be-banned-in-public-places/

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IvyPanda . 2019. "Should Smoking Be Banned in Public Places?" April 15, 2019. https://ivypanda.com/essays/should-smoking-be-banned-in-public-places/.

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Bibliography

IvyPanda . "Should Smoking Be Banned in Public Places?" April 15, 2019. https://ivypanda.com/essays/should-smoking-be-banned-in-public-places/.