Abstract
Objectives:
To examine the institutional characteristics associated with the adoption of tobacco-free and smoke-free policies among US postsecondary educational institutions.
Methods:
Information on tobacco policy types and institutional characteristics of a national sample of U.S. post-secondary educational institutions (N=605) attended by the participants of the NEXT Generation Health Study was collected in 2017. Logistic regression was used to examine the relationships between these variables.
Results:
Overall, 35.2% of these institutions adopted tobacco-free policies (i.e., prohibit all tobacco product use on campus), 10.1% had smoke-free policies (i.e., prohibit smoking but not other tobacco product use on campus), and 53.7% did not have tobacco-free/smoke-free policies. Private and proprietary (privately owned, for profit) institutions (vs. public institutions) were the least likely to have tobacco-free/smoke-free policies (p<0.05), which were disproportionately attended by race/ethnic minority students. Adoption of these policies also varied by census region (p<0.05).
Conclusions:
Prevalence of smoke-free and tobacco-free policies among US post-secondary educational institutions is low.
Policy implications:
Wide dissemination of evidence-based interventions to accelerate adoption of tobacco-free policies in all post-secondary educational institutions is warranted.
INTRODUCTION
Tobacco use is the primary cause of preventable disease and premature death in the United States.1 Young adulthood represents a critical period for the development of tobacco use, with young adults (ages 18–24 years) having the highest prevalence of any combustible tobacco product use relative to other age groups.1 While education is inversely associated with prevalence of smoking,2 smoking behaviors continue to develop even among those who enrolled in a 4-year college.3
Studies have found negative associations between the adoption of tobacco-free policies, smoking behaviors, and secondhand smoke exposure.3–5 However, the literature on tobacco-free policies at postsecondary educational institutions is limited. Previous studies that examined the adoption of tobacco-free and smoke-free policies by postsecondary educational institutions only included 4-year colleges and universities4,5 and community colleges.6 Therefore, the prevalence of adoption of tobacco-free/smoke-free policies in proprietarily-funded (i.e., for-profit) institutions, which are disproportionately attended by racial/ethnic minorities,7 is unknown. Furthermore, most of the previous studies included post-secondary education institutions within a single state, which limited their ability to examine geographical variation in adoption of these policies, except one study that was conducted when most of the U.S. did not have smoke-free policies.8 In the current study, we investigated the prevalence of tobacco-free policy types in a U.S. national sample of postsecondary educational institutions, including publicly-, privately-, and proprietarily-funded institutions. Furthermore, we examined the institutional characteristics associated with the adoption of these policies.
METHODS
Sample
Postsecondary educational institutions attended by the participants during the 2012–2013 and 2013–2014 data collections of the NEXT Generation Health Study were included in this study (n=643). The NEXT Generation Health Study is a longitudinal study of a nationally representative sample of 10th graders recruited in 2009–2010 and followed annually through 2016–2017. This sampling approach allowed us to obtain a distribution of postsecondary educational institutions that is proportional to the distribution of U.S. young adults enrolled in these institutions,7 and provide us access to a list of non-degree granting institutions attended by young adults from the same source cohort. Tobacco-free policy and institutional characteristic information were obtained either from Americans for Nonsmokers’ Rights Foundation or through online research and phone inquiries conducted by three authors and reviewed by four authors between June and December 2017. Differences in coding were resolved through discussions. Institutions that only offer online courses (n=4), were permanently closed (n=13), or with unknown tobacco-free policies (n=21) were excluded from the analysis (final n=605).
Measures
Institutions were classified into three different tobacco-free policy types based on their published policies (websites and/or documents): tobacco-free (prohibit combustible and noncombustible tobacco use everywhere on campus, with few exemptions, e.g., one’s personal vehicle, research in a controlled lab setting, and/or religious/ceremonial purposes; prohibiting e-cigarette use is not considered), smoke-free (prohibit smoking but not noncombustible products everywhere on campus, with the same as tobacco free), and not smoke-free (non-comprehensive tobacco regulation, e.g., designated smoking areas on campus). Institutional characteristics included census regions, metropolitan status, historically black college or university status, degree program offered, sources of funding (public, private non-for-profit, and proprietary for-profit), total undergraduate student population, proportion of students who were racial/ethnic minorities, and proportion of students who were female. The information was obtained through the National Center for Education Statistics website (https://nces.ed.gov), the Common Data Set Initiative, (http://www.commondataset.org/) or institutional websites/correspondence.
Statistical analysis
Chi-squared tests and one-way analysis of variance were used to compare institutional characteristics across tobacco-free policy types. Multiple logistical regression models were used to investigate characteristics associated with having smoke-free or tobacco-free policies (vs. not smoke-free policies) and having tobacco-free policies (vs. smoke-free or not smoke-free policies); these included variables that were associated with tobacco-free policy types in the bivariate analyses (p<0.2). The regression analyses excluded institutions without demographic information (n=24). All analyses were conducted in SAS® version 9.3 (SAS Institute; Cary, NC).
RESULTS
Overall, 37.9% (n=229) of these institutions were tobacco-free, 9.4% (n=57) were smoke-free only, and 52.7% (n=319) were not smoke-free. In the bivariate analysis, census region, degree program offered, sources of funding, and total undergraduate student population were associated with tobacco-free policy type (p≤0.05; Table 1) and included in the subsequent analyses. In the multiple logistic regressions, institutions offering only associate’s degree (vs. bachelor’s degree), located in the Midwest, Northwest, and South (vs. West) regions were more likely to have smoke-free or tobacco-free policies (p<0.05), while privately and proprietarily funded institutions (vs. publicly funded institutions) were less likely to have smoke-free or tobacco-free policies (p<0.05; Table 1). Further analysis showed that these institutions had higher proportion of racial/ethnic minority students (Proportion of racial/ethnic minority students: Midwest=34.3%, Northeast=44.9%, South=49.8%, West=63.2%; Publicly funded: 45.0%, Privately funded=45.9%, Proprietarily funded=64.7%). Characteristics associated with having tobacco-free policies mirrored those associated with having smoke-free policies, except that degree program offered was not associated with having a tobacco-free policy (p=0.34; Table 1).
Table 1.
Characteristics associated with different types of tobacco-free policy in a US national sample of postsecondary educational institutions, NEXT Generation Health Study, 2017.
| Characteristics | Overall | Tobacco-Free policies |
Smoke-free or tobacco-free vs. not smoke-free (AOR+95% CI)* |
Tobacco-free vs. smoke-free or not smoke-free (AOR+95% CI)* |
||
|---|---|---|---|---|---|---|
| Tobacco-free | Smoke-free | Not smoke- free |
||||
| Census Region (p<0.01) | N (%) | N (%) | N (%) | N (%) | ||
| Midwest | 180 (29.8%) | 40.0% | 16.7% | 43.3% | 4.70 (2.66, 8.31) | 2.81 (1.56, 5.04) |
| Northeast | 129 (21.3%) | 34.9% | 3.9% | 61.2% | 2.30 (1.26, 4.24) | 2.46 (1.31, 4.62) |
| South | 186 (30.7%) | 47.9% | 7.5% | 44.6% | 4.02 (2.30, 7.05) | 3.75 (2.10, 6.69) |
| West | 110 (18.2%) | 20.9% | 7.3% | 71.8% | 1.00 | 1.00 |
|
Located in a metropolitan statistical area (p=0.34) |
||||||
| Yes | 491 (81.2%) | 36.5% | 9.5% | 54.0% | -- | -- |
| No | 114 (18.8%) | 43.9% | 8.8% | 47.3% | -- | -- |
|
Historically Black College or University (p=0.90) |
||||||
| Yes | 25 (4.1%) | 36.0% | 12.0% | 52.0% | -- | -- |
| No | 580 (95.9%) | 37.9% | 9.3% | 52.8% | -- | -- |
| Degree program offered (p=0.04) | ||||||
| Bachelor’s degree | 430 (71.1%) | 37.2% | 8.4% | 54.4% | 1.00 | 1.00 |
| Associate’s degree | 125 (20.7%) | 43.2% | 14.4% | 42.4% | 1.80 (1.10, 2.93) | 1.36 (0.85, 2.17) |
| Other | 50 (8.3%) | 30.0% | 6.0% | 64.0% | 1.67 (0.62, 4.49) | 1.37 (0.53, 3.55) |
| Sources of funding (p<0.01) | ||||||
| Public | 394 (65.1%) | 44.4% | 11.4% | 44.2% | 1.00 | 1.00 |
| Private | 166 (27.5%) | 31.3% | 6.6% | 62.1% | 0.54 (0.35, 0.83) | 0.61 (0.39, 0.95) |
| Proprietary | 45 (7.4%) | 4.4% | 2.2% | 93.3% | 0.02 (0.00, 0.12) | 0.03 (0.00, 0.21) |
|
Total undergraduate student population (in thousands; * (p=0.05) |
10.4 (12.7) | 11.4 (0.9) | 12.9 (1.6) | 9.2 (0.7) | 1.00 (0.99, 1.02) | 1.00 (0.99, 1.02) |
|
% racial/ethnic minorities students
* (p=0.40) |
46.6% (26.6%) | 44.7% (1.8%) | 47.2% (3.6%) | 47.9% (1.5%) | -- | -- |
| % of female students * (p=0.97) | 56.1% (13.0%) | 56.2% (0.9%) | 55.7% (1.7%) | 56.1% (0.7%) | -- | -- |
Note: P-values were from bivariate analyses (Chi-square tests or one-way ANOVAs).
Limited to institutions with demographic information (n=581). Bolded estimates are statistically significant in the regression models (p<0.05).
DISCUSSION
We conducted the first U.S. national study examining adoption of tobacco-free policies in a sample of U.S. postsecondary educational institutions located across the country and include non-degree granting and proprietarily-funded institutions. We found less than half of these institutions have adopted any of these policies, and only about a third of them have adopted tobacco-free policies. A previous study among California institutions found the presence of tobacco-free policies was associated with lower secondhand smoke exposure and perceived acceptability of smoking among enrolled students.5 Thus, the low prevalence of adopting tobacco-free policies suggests many young adults enrolled at postsecondary educational institutions are exposed to tobacco use on campus, which may lead to development of tobacco use behaviors.
While the proportion of racial/ethnic minority students was not directly associated with tobacco-free policy types, we observed that institutions located in the West region, and those privately and proprietarily funded were less likely to adopt these policies. Noteworthy is that these institutions are disproportionately attended by racial/ethnic minorities young adults, and students at proprietarily-funded institutions are also likely to have lower income upon graduation.9 Therefore, initiatives to accelerate adoption of comprehensive tobacco-free policies in institutions that are proprietarily-funded and located in the West region could potentially contribute to reducing racial/ethnic and socioeconomic disparities in tobacco use and exposure to secondhand smoke.10 Adoption of comprehensive tobacco-free policies might be particularly challenging for proprietarily-funded institutions since they often operate from office-buildings that restricted their capacity to adopt these policies, making strategies at the local and state levels necessary to protect students of these institutions. The World Health Organization Smoke-free Cities initiatives provides guidance on how to implement policies to make cities smoke-free.11
Although we had a U.S. national sample, since it was not a true random sample, our findings may not be generalizable to all U.S. postsecondary educational institutions. Nonetheless, our findings provide the first U.S. national assessment of the adoption of tobacco-free policies among public, private, and proprietary post-secondary educational institutions.
Public Health Implications
Tobacco control is a critical public health priority that can be advanced through implementation of institutional tobacco-free policies. Our findings suggest many U.S. postsecondary educational institutions do not have comprehensive tobacco-free policies. Disseminating evidence-based interventions12 to accelerate adoption of tobacco-free policies at all U.S. postsecondary educational institutions is warranted.
ACKNOWLEDGMENTS
Catherine Trad, Mary Andrews, Melanie Sabado-Liwag, and Kelvin Choi’s effort on this study was supported by the Division of Intramural Research, National Institute on Minority Health and Health Disparities. This research was also made possible through the NIH Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and generous contributions to the Foundation for the NIH from the Doris Duke Charitable Foundation, the American Association for Dental Research, the Colgate-Palmolive Company, Genentech, Elsevier, and other private donors. Launick Saint-Fort’s effort was supported by the Office of the Director, National Institutes of Health. Minal Patel’s effort was supported by the Cancer Prevention Fellowship program, Division of Cancer Control and Population Sciences, National Cancer Institute. The NEXT Generation Study was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Heart, Lung, and Blood Institute, the National Institute on Alcohol Abuse and Alcoholism, and Maternal and Child Health Bureau of the Health Resources and Services Administration, with supplemental support from the National Institute on Drug Abuse (Contract # HHSN275201200001I).
Footnotes
The authors would like to thank Ms. Cynthia Hallet and the American Nonsmokers’ Rights Foundation for providing tobacco-free policy information on some of the education institutions, technical support for the coding tobacco-free policies, and feedback on the manuscript.
HUMAN SUBJECT PROTECTION
This study is exempted from IRB review.
Contributor Information
Chatherine Trad, Divison of Intramural Research, National Insitute on Minority and Health Disparities, Bethesda, Maryland..
Jennifer Bayly, Divison of Intramural Research, National Insitute on Minority and Health Disparities, Bethesda, Maryland..
Launick Saint-Fort, Divison of Intramural Research, National Insitute on Minority and Health Disparities, Bethesda, Maryland., Office of the Director, National Institutes of Health, Bethesda, Maryland..
Melanie Sabado-Liwag, Divison of Intramural Research, National Insitute on Minority and Health Disparities, Bethesda, Maryland., Department of Public Health, California State University – Los Angeles, Los Angeles, California..
Kelvin Choi, Divison of Intramural Research, National Insitute on Minority and Health Disparities, Bethesda, Maryland..
Minal Patel, Cancer Prevention Fellowship Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Rockville, Maryland..
Denise Haynie, Health Behavior Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland..
Bruce Simons-Morton, Health Behavior Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Rockville, Maryland..
REFERENCES:
- 1.U.S. Department of Health and Human Services. The Health Consequences of Smoking -- 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health;2014. [Google Scholar]
- 2.Solberg LI, Asche SE, Boyle R, McCarty MC, Thoele MJ. Smoking and cessation behaviors among young adults of various educational backgrounds. Am J Public Health 2007;97(8):1421–1426. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Caldeira KM, O’Grady KE, Garnier-Dykstra LM, Vincent KB, Pickworth WB, Arria AM. Cigarette smoking among college students: longitudinal trajectories and health outcomes. Nicotine Tob Res 2012;14(7):777–785. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Seo DC, Macy JT, Torabi MR, Middlestadt SE. The effect of a smoke-free campus policy on college students’ smoking behaviors and attitudes. Prev Med 2011;53(4–5):347–352. [DOI] [PubMed] [Google Scholar]
- 5.Fallin A, Roditis M, Glantz SA. Association of campus tobacco policies with secondhand smoke exposure, intention to smoke on campus, and attitudes about outdoor smoking restrictions. Am J Public Health 2015;105(6):1098–1100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Lee JG, Goldstein AO, Klein EG, Ranney LM, Carver AM. Assessment of college and university campus tobacco-free policies in North Carolina. J Am Coll Health 2012;60(7):512–519. [DOI] [PubMed] [Google Scholar]
- 7.Staklis S, Bersudskaya V, Horn L. Students Attending For-Profit Postsecondary Institutions: Demographics, Enrollment Characteristics, and 6-Year Outcomes Washington, DC: Institute of Education Sciences National Center for Education Statistics;2011. [Google Scholar]
- 8.Wechsler H, Kelley K, Seibring M, Kuo M, Rigotti NA. College smoking policies and smoking cessation programs: results of a survey of college health center directors. J Am Coll Health 2001;49(5):205–212. [DOI] [PubMed] [Google Scholar]
- 9.Bureau of Labor Statistics USDoL. Median weekly earnings by educational attainment in 2014. The Economics Daily 2015; https://www.bls.gov/opub/ted/2015/median-weekly-earnings-by-education-gender-race-and-ethnicity-in-2014.htm. Accessed Jan 2, 2018.
- 10.Homa DM, Neff LJ, King BA, et al. Vital signs: disparities in nonsmokers’ exposure to secondhand smoke--United States, 1999–2012. MMWR Morb Mortal Wkly Rep 2015;64(4):103–108. [PMC free article] [PubMed] [Google Scholar]
- 11.World Health Organization. Making cities smoke-free Geneva, Switzerland: World Health Organization;2011. [Google Scholar]
- 12.Lee JG, Goldstein AO, Kramer KD, et al. Statewide diffusion of 100% tobacco-free college and university policies. Tob Control 2010;19(4):311–317. [DOI] [PubMed] [Google Scholar]