Use of implementation science to plan adoption of a tobacco-free policy on a historically Black college/university (HBCU) campus

Abstract

Objective:

Implementation science tools were used to identify facilitators and barriers to adopting a tobacco-free policy on a historically Black college/university (HBCU).

Participants:

Study participants included 13 University staff, two students, and two public health educators/school alumni. Data were collected in 2015–2016.

Methods:

The Consolidated Framework for Implementation Research (CFIR) was used to develop questions for focus groups and individual interviews. The CFIR was also used by two research team members to code transcripts independently, using an iterative deduction process to achieve ≥85% agreement on CFIR domains. Coded quotations were evaluated using the Qualitative Implementation Framework (QIF) to ascertain next adoption planning steps.

Results:

Qualitative data suggested that building capacity for tobacco control, linking policy to HBCU identity and priorities such as addressing marijuana use might facilitate adoption of a tobacco-free campus policy.

Conclusions:

Implementation science tools may be useful for planning adoption of comprehensive tobacco-free policies at HBCUs.

Despite significant reduction of tobacco use in the U.S., 21–32% of adults ages 18–25 have reported using tobacco products on some days.^1,2 Increased use of hookahs and other nicotine-delivery devices among college students³ contributes to an urgent need to address tobacco use on college campuses. Comprehensive tobacco-free campus policies that restrict combustible and non-combustible tobacco product use (in contrast to smoke-free policies that prohibit only combustible products) and offer evidence-based prevention education and cessation programs⁴ are associated with reduced tobacco use,⁵ and are recommended by the Centers for Disease Control and Prevention (CDC)⁶ and the American College Health Association (ACHA).⁷

African American adults, who have higher rates of tobacco-related disease and mortality than other ethnic groups,^8,9 are more likely to initiate smoking during early adulthood.^10,11 Culturally-informed tobacco-use prevention programs for 18–25 year-old African Americans could help reduce tobacco-related health disparities,^12,13 and efforts to increase comprehensive tobacco-free policies at Historically Black Colleges/Universities (HBCUs) are underway.¹⁴

Strategies for promoting tobacco-free campuses include providing advice and toolkits to campus advocates,^15,16 organizing programs for student champions,^17,18 and partnering with public health agencies and foundations to organize campus policy initiatives.^19,20 However, despite such efforts, only 36% of 102 HBCUs have tobacco-free policies, slightly less than non-HBCU campuses (37.9%).²² Surgeon General David Satcher noted that the problem in advancing tobacco use reduction is “more the result of failure to implement proven strategies than it is the lack of knowledge about what to do.”²³

Barriers to implementing tobacco control policies at HBCUs have rarely been examined systematically,¹⁴ and may be similar to non-HBCU institutions.¹⁷ Studies of barriers to implementing tobacco-free campus policies have involved campuses with advocates for such policies,^14,17 and might not be generalizable to schools without such champions, or higher proportion of African American students. A central tenet of implementation science, which offers tools to support implementation of evidence-based health-promotion policies and programs,²⁴ is that understanding facilitators, barriers, and readiness for implementation within a specific context^25,26 improves implementation outcomes.^27,28.

More research is needed to guide implementation of tobacco-free campus policies,²⁹ including ones tailored for HBCUs.¹⁴ This paper reports use of implementation science frameworks to help plan adoption of a comprehensive tobacco control policy at an HBCU where few champions for comprehensive tobacco control had been identified.

Administrators at a public HBCU received funding through the Truth Initiative³⁰ to develop a comprehensive policy to replace its existing policy, which does not mention electronic cigarettes, hookahs or prevention education.⁷ The first author was invited to add a research component to the project, and recommended use of the Consolidated Framework for Implementation Research (CFIR),²⁷ which supports efforts that involve organizational level systems^31,32 to identify facilitators and barriers to policy adoption. The Quality Implementation Framework (QIF),³³ which describes 14 critical steps for achieving effective implementation, was used to identify next steps in the policy adoption process.

METHODS

Setting

The study took place at an HBCU located in a southeastern tobacco-producing state. The university has more than 400 academic faculty/staff and an enrollment of 7,200 undergraduate/graduate-level students, 70% of whom are African American.

Participants

Six university administrators in Student Affairs were recruited for a focus group as a means for clarifying their collaborative approach to policies affecting students. Five university staff with responsibilities for student wellness, and two alumni employed by public health agencies were interviewed individually, to provide confidentiality and to ascertain their unique perspectives regarding campus tobacco policy. Student focus group participants were recruited via multiple campus-wide media channels; however only two students came at scheduled meeting times. They were interviewed individually, for a total of 15 respondents. The University’s Institutional Review Board approved this study.

Procedure

Questions reflecting five CFIR²⁷ domains (listed in Table 1) were developed using a web-based CFIR resource³⁴ for hour-long key informant interviews and focus groups. Three of the study’s authors conducted individual interviews and the first author facilitated the focus group. Questions focused on facilitators and barriers to adopting a comprehensive tobacco-free campus policy. All interviews and the staff focus group were audio-recorded and transcribed verbatim.

Table 1.

Sample quotations associated with five CFIR domains and related constructs¹

CFIR Domains/Constructs	Implementation Facilitators	Implementation Barriers
I. Characteristics of the intervention (a comprehensive tobacco-free campus policy)
C-Relative advantage (over status quo)	THEME: Perception that a new policy will create a healthier environment for everyone. “For myself with allergies…other people deal with asthma… I definitely agree with the policy.” (S1)	THEME: Perception that the current policy is not communicated clearly. “There’s a large part of students that don’t really understand the policy on campus.” (AD1)
F-Intervention complexity	THEME: We need a comprehensive policy that includes cessation services. “One of the ways that [policies] fail is that everyone’s telling them to stop smoking but there are no cessation services … in place for them.” (PH1)	THEME: The policy will require enforcement. ”Somebody’s got to be the smoking police. Does… anybody on this campus say anything or do anything when they see students or their faculty members smoking on campus?” (AD3)
II. Outer Setting
A-Students’ Needs & Resources	THEME: There are resources outside of campus that will support implementation of a new policy. “I think the Truth Initiative... message goes something like, “You cannot manipulate us any longer.” (PH2)	THEME: Tobacco marketing focuses on young adults. “[Tobacco companies]…want to make you think it’s the best thing going right now, to use these products. I think there’s even… cigarettes called Kool.” (PH2) THEME: It’s hard to get students involved in changing policy or behavior. “I didn’t see the student participation or even caring that [campus] was non-smoking.” (FG1)
III. Inner Setting
A- Structural Characteristics	THEME: Staff could introduce programs to support the new policy. “We can start putting certain measures in place to help counter some of the activities regarding tobacco.” (PH2)	THEME: Structural elements do not support the current no-smoking policy. “There are…built-in ashtrays on campus. We’re saying we’re a smoke free campus, but then we have places to throw away ashes.” (FG3)
B- Networks & Communications	THEME: Individual staff could be effective advocates for a new policy. “We have working relationships with… the International Office … we talk to in International Office and folks in Admissions.” (AD2)	THEME: Current tobacco policy is not discussed in official meetings, “Other than our committee that we’re on right now…I don’t meet with any students or faculty, staff, or administrative concerning the tobacco policy on campus.” (AD1)
C- Culture	THEME: The new policy could be part of a positive culture change. “If everybody starts looking at health and that become important… if I’m going to take care of my body, I’m not going to put anything bad in my body either, so maybe I need to stop smoking.” (AD5)	THEME: The current culture tolerates smoking. “Every day I see students and faculty members smoking. Sometimes they’re smoking together… It just sends a negative message to see cigarette butts on our campus.” (AD3)
D1-Tension for Change	THEME: Recent policy changes could support a new tobacco policy. “A lot of the new policies that have been put in place… [are] shifting the tide in the University.” (AD2)	THEME: There is little tension for change here. “I think [our campus] has a culture of being very slow to embrace any type of change.” (AD5)
D2- Compatibility	THEME: Some staff want to encourage student wellness. “I want the folks to be holistically well, not just well in certain parts of their life. … Any time a student is using any type of substances to manage anything, then that’s a cause for concern for me.” (AD5) THEME: Students who don’t use tobacco are more likely to graduate, which is important to the university. “…if they are coming into the health center with lung problems and other stuff and that is going to hurt with matriculation through the university.” (AD2) “…if money is one of the reasons why they have a difficult time…encouraging them to give up that habit of smoking can’t hurt, right? (AD3)	THEME: Marijuana is illegal and thus is a greater concern. “We have a number of students using…illegal substances. We talk about how to get them…at least using the legal substances…just as staff.” (AD5) “We don’t get a lot of cigarette users. We get a lot of marijuana users… [We ask] “Do you smoke? What do you smoke” 99.9 percent of the time it’s marijuana. It’s not cigarettes.” (FG5)
E2- Available resources	THEME: Key stakeholders may be supportive. “Police here [are] the eyes and ears of the institution… They know where the smokers are…Housekeeping. They sweep up the cigarette butts.” (PH2)	THEME: Little current attention to smoking-related data. “I don’t think that we collect anything about smoking on our student health history questionnaire….if we do collect anything we don’t do anything with that data.” (AD2)
IV. Characteristics of individuals who might deliver the intervention(s)
D-Individual identification with the organization	THEME: Staff value the HBCU image. “More so here than at other HBCUs …we’re able to take students …and make them productive and highly academic citizens in the community. (FG2) THEME: Staff want the campus to promote student wellness. “…we’re trying to do something positive, that’s going to affect their health and ultimately bring a good atmosphere to the university. (AD1) “I would just like to see (this university) be progressive and on top of this…it just sends a negative message to see cigarette butts on our campus.” (AD3) “My daughter has to marry one of these people, to make the world be healthy so she gets a good mate.” (AD5)
V. Process
A-Planning	THEME: Staff have ideas about how to approach adoption. “If we get a group of students that are wanting to create… a campaign “(FG3) “Go over the student handbooks so people can know what the rules are and expectations on campus - that might help.” (AD2)
D- Reflecting & Evaluating	“We would be able to provide information on our QuitLine… and give that information to you… to measure the effectiveness of the new policy.” (PH2)	THEME: Data related to tobacco use aren’t used. “I don’t think we collect anything about smoking [on our student health history questionnaire], and if we do collect anything we don’t do anything with that data.” (AD2).

¹Participant key: FG=Focus group member; AD=Administrative staff individual interview; PH=public health agency staff; S=student

Analysis Plan

The first two authors created a codebook using CFIR constructs²⁷ associated with barriers and facilitators to adopting a comprehensive tobacco policy. They coded transcripts independently using Excel, meeting periodically to identify coding discrepancies. They used an iterative process to address coding disagreements, comparing their coding decisions with codebook definitions, and reviewing quotation contexts. They repeated this process until they achieved ≥85% agreement³⁵ on all transcripts. Results of the qualitative analysis were used to answer specific questions associated with the QIF.³³

Results

Themes associated with 28 constructs across five CFIR domains representing potential facilitators and barriers for tobacco policy adoption were identified. Table 1 provides a sample of quotations coded for each domain and acronyms used for respondent categories in this report.

I. Characteristics of the intervention (a comprehensive tobacco control policy):

Facilitators associated with this domain included the perception that a policy that includes prevention and cessation services will create a healthier campus environment. Two participants expressed positive views of Truth Initiative³⁰ prevention messages (PH2), and the American Lung Association’s smoking cessation program (PH1); however, no others identified specific tobacco-related education programs. Some participants suggested untested interventions like one described at another university where “…if they saw someone smoking on campus they were like whoot, they’d blow the whistle.” (FG 3). Barriers to adopting a new policy included challenges associated with enforcement, as well as general uncertainty about the effectiveness of education and cessation efforts. (Table 1)

II. Outer Setting:

This domain includes staff awareness of students’ needs and resources, ways staff could address students’ needs, and students’ priorities. Both students and two administrators mentioned stress as triggering tobacco use. Respondents said the University could help students manage stress in healthy ways; however, others commented that students seem unmotivated to participate in tobacco-related programs.

Participants also described barriers associated with influences outside of campus. Some stated that students’ use of tobacco products begins at home, and “They come here smokers.” (S2) One said that “International students… look at tobacco as …part of their culture.”(AD4) Others referred to the prevalence of tobacco use in popular music (S1), as well as tobacco advertising targeting young adults and African Americans (AD3, PH2).

III. Inner Setting:

Participants’ comments represented 10 CFIR constructs in this domain. Facilitators included staff willingness to advocate for a comprehensive policy and to promote a healthy campus culture. (AD2) One administrator linked a comprehensive tobacco policy to “a big push to help students graduate…” (AD3), and another commented that “a solid tobacco policy” could reduce respiratory problems that interfere with “matriculation through the university.” (AD2)

Several participants noted poor understanding about the current policy. One staff member said, “This policy has been in effect since 2011 and I’ve never seen it before.” (FG6) Another said, “We’ve had some people… ask us what the policies were [regarding e-cigarettes] …our staff didn’t know what the rule was either.” (AD2) Some observed that no one seems to have responsibility for educating the campus community about the policy, and one reported, “other than our committee that we’re on right now … I actually don’t meet with any students or faculty, staff, or administrator concerning the tobacco policy on campus.” (AD1)

Five participants indicated that administrators are more concern about marijuana than tobacco. One said [“We ask] ‘Do you smoke? What do you smoke?’ 99.9 percent of the time it’s marijuana.” (FG5) Additional facilitators and barriers associated with this domain are provided in Table 1.

IV. Characteristics of Individuals:

Most study participants support a tobacco-free campus, with one saying “I will stop [people who are smoking on campus] and say, ‘It’s a no smoking campus.’” (FG1) Several mentioned personal experiences, such as, “I have always been vehemently against cigarette smoking because my grandmother died from lung cancer.” (AD2) Five staff members identified themselves as graduates of HBCUs who value serving HBCU students. One said, “I’m a product of an HBCU… I like to give back. That’s how I ended up here.” (FG2) Some also described the kind of image they want this HBCU to present, such as “I just don’t think we should have cigarette butts on our campus.” (AD3)

V. Process:

This CFIR domain refers to planning for policy adoption, and engaging essential participants. Several suggested recruiting students to “raise awareness” (S1) without identifying who would lead such activities. Several noted that there is no campus-wide data collection related to tobacco use, and outside of the project that triggered this research, no meetings to address tobacco use. (AD1)

VI. The Quality Implementation Framework (QIF):³³

This framework’s first step is to ask what problem the new policy addresses, and who will benefit from it. Respondents indicated that a comprehensive policy would address ambiguity about use of e-cigarettes on campus and reduce tobacco litter. Potential benefits include improving student health and providing compassionate cessation programs for smokers. It could enhance the University’s image by demonstrating a commitment to wellness.

The second QIF step is to assess the proposed policy’s fit for the organization. While study participants generally had positive views toward a comprehensive tobacco policy, most identified student matriculation and marijuana use as higher priorities, especially given the perception that few students use tobacco products.

The third QIF question addresses the University’s capacity for adopting the policy, with motivation, resources and skills for its implementation. Indications that the campus lacks readiness include lack of strategic communication regarding tobacco use on campus outside of those recruited for this study, no internal champions, and limited awareness of evidence-based tobacco use prevention and cessation programs. Based on these results, the research team concluded that work is needed at Steps 2 and 3 to advance policy implementation.

DISCUSSION

Although there is evidence that comprehensive college campus tobacco policies reduce tobacco use among young adults, some policy advocates have encountered numerous barriers to policy implementation.^14,17 This study demonstrates application of two implementation science frameworks to systematically identify facilitators and barriers, as well as potential next steps for implementing a comprehensive college tobacco policy.

The results of the CFIR²⁷-guided interviews and focus group identified context-specific facilitators that may be leveraged, and barriers that may need to be addressed in order to advance comprehensive policy implementation. The QIF indicated that next steps could include obtaining and sharing information about tobacco use among students, highlighting confusion about the current policy, and exploring interest among key stakeholders in a combined tobacco-marijuana policy, such as has been implemented at nearly 400 U.S. colleges/universities.³⁶

In following up on these findings, the investigators conducted a campus-wide survey, (n=313, ~5%), in which 30% of students reported using one or more tobacco products in the previous 7 days. They are sharing this information with faculty, staff and students who are interested in reducing campus tobacco use. The first author described the current and recommended campus tobacco policies during a campus panel and an interview for the student newspaper. The first and fourth authors have applied for funding for a research project that could support further efforts to address tobacco use on this campus, including development of a campus advisory group that will include students.

Limitations:

Data collection was designed to elicit attitudes about a comprehensive tobacco policy. Although several respondents highlighted concerns about marijuana, interest in a combination policy will need to be assessed before this is proposed. The small number of student participants may have been due to the end-of-semester timing. Future efforts to obtain input from students could include approaching leaders of campus organizations early in the academic year.

Implementation science, including tools used in this study and others,^{e.g., 31,37,38,39} offers guidance for increasing successful tobacco-free campus policy implementation. It complements approaches that others have suggested^14,15,25 for increasing the number of college campuses with effective interventions to prevent and reduce tobacco use among young adults. Campus-based tobacco control researchers can engage staff and students in efforts to understand a school’s distinctive culture, increase the number of colleges and universities with effective tobacco control policies, and advance the field of implementation science and its application to tobacco control policy.