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Lisa Augustine, PhD

Lorain County Community College

Tavis Glassman PhD, MPH,

MSEd, MCHES, CCPH

University of Toledo

Results from a national study which assessed the policies,

procedures, and practices of 100% tobacco-free campuses

and the extent to which they adhere to the American College

Health Association, (ACHA) guidelines to promote tobacco-

free environments will be discussed. Rogers’ Diffusion of

Innovations (DOI) theory was used as the theoretical

framework to assess diffusion and enforcement of tobacco-

free policies. The results may help administrators consider

how best to develop, implement, maintain, and enforce

successful policy change.

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• The learner will comprehend new procedures and practices to

assist campuses in their quest to develop policies and/or adhere

to ACHA guidelines to promote tobacco-free policies within

higher-education environments.

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• Tobacco use and secondhand smoke are leading causes of many preventable, serious diseases and health problems, including all types of cancer, heart and lung disease, pregnancy complications, vision problems (U.S. Department of Health and Human Services [HHS], 2004, 2010, 2017).

• Secondhand tobacco smoke, a known carcinogen, may cause lung cancer and heart disease (Centers for Disease Control and Prevention [CDC], 2006, 2017).

• The annual national health care expenditure, both public and private, caused by smoking is $96 billion, with secondhand smoke exposure leading to $4.98 billion in healthcare costs (American Cancer Society, 2012).

• Preventing tobacco use among nonsmokers and helping current tobacco users to quit can significantly improve overall health, quality of life (CDC, 2006, 2017)).

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National Agenda launched in 1979 – Healthy People: The Surgeon

General’s Report on Health Promotion and Disease Prevention –

provided measurable health promotion objectives for the nation.

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• Healthy Campus – “sister document” to Healthy People – is a result of a

multi-year process that reflects the thoughts and perspectives of

600+ diverse higher education professionals representing

multiple professional organizations and disciplines.

• The American College Health Association’s (ACHA) Healthy

Campus Coalition (2010) provided leadership on the research,

planning and writing of Healthy Campus 2020 and assists

higher education professionals in implementing initiatives that

could have a lasting impact on their entire campus community.

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Purpose of this national study – to assess the policies, procedures,

practices of 100% tobacco-free campuses and the extent to which they

adhere to ACHA guidelines to promote tobacco-free, higher-education

environments.

• Public health theoretical framework , the Diffusion of Innovations theory (DOI),

guided this study.

• Results from study may help administrators develop, implement, maintain, enforce

successful policy change. 7

Source: (ANRF, 2014)

1. To what extent have 100% tobacco-free colleges and

universities established the procedures and practices that

appear in the ACHA’s 2012 Position Statement on Tobacco on

College and University Campuses?

2. To what extent, if any, do institutions of higher education's

adopter category within the Diffusion of Innovations theory,

predict adherence to the ACHA guidelines and

recommendations for tobacco-free campus environments?

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• Tobacco use causes serious disease and health problems including

cancer, heart disease, lung diseases, pregnancy complications,

and vision problems (HHS, 2004, 2010, 2017)

• The life expectancy of smokers is reduced by approximately 14

years compared to nonsmokers (Mokdad, Marks, Stroup, &

Gerberding, 2000, 2009)

• More than 40% of college-aged smokers either start smoking

(11%) or become regular smokers (28%) during college

(Wechsler, Rigotti, & Gledhill-Hoyt, 1998)

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• Each day, 1,300 Americans die from smoking

• Each of those people are being replaced by 2

young smokers

• 90% of all smokers start before age 18

• 99% of all smokers start before age 26

10Source: (CDC, 2016)

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U.S. Department of Health and Human Services (2014)

• 24.8% of full-time college students aged 18‐22 years

old were current smokers in 2010

• The number of smokers who initiated smoking after age

18 increased from 600,000 in 2002 to 1 million in

2010

Going tobacco-free increases graduates’ odds of gaining

employment (HHS, 2012). National trend within the Healthcare

industry

• Cleveland Clinic

• Metro Health Systems

• Numerous Skilled Nursing Centers

Financial Implications

• Smokers cost employers about $5,800 more per year (Berman,

Crane, Seiber, & Munur, 2013) due to excess health care

expenses, missed days of work, and lost productivity.

• Bower and Enzler (2005) found savings and benefits of a

Tobacco-Free Campus Policy include:

• Provides for a healthier campus for students, staff, faculty and

visitors

• Helps establish a new social norm

• Reduces cigarette and other tobacco litter on campus

• Decrease in grounds keeping due to litter from cigarette butts 12

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• E-cigarettes are unregulated devices which have not been approved by the FDA as a cessation device. Although the e-cigarette industry heavily markets them as such. There is little scientific research on the smoking simulating devices and the long-term risks of usage are unknown (Choi & Forster, 2013).

• According to the American Lung Association (2016), several severe accidents regarding the use of e-cigarettes have been reported. • Explosion/overheated resulting in burn/fire

• Bodily injury/Teeth broken/blown out

• Bystander hit/injured by exploding device

• Lung damage/respiratory

• Poisoning

• E-cigarettes are a new method of introducing the public to nicotine, with the fastest growing group of users being 12-to-16-year olds (Schraufnagel, 2015).

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Trend line

• As of April 3, 2017, there are now at least 1,827 100% smoke free campus sites. Of these, 1,536 are also 100% tobacco-free

• 1,400 also prohibit e-cigarette use, 701 also prohibit hookah use, and 120 also prohibit smoking/vaping marijuana.

Source: (ANRF, 2017)16

The majority of students agree colleges should provide smoke-free

environments (Thompson, Coronado, Chen, Thompson, Hymer, &

Peterson, 2006)

Within the past decade, a shift in how students perceive tobacco

policies has occurred, and most students agree colleges should

enforce compliance with policies and penalize non-compliance

(Thompson et al., 2006)

Fallin, et. al (2015) found smoke and tobacco free policies are widely

accepted and are working on campus

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• Seminal study from Plaspohl et al (2012) identified enforcement efforts on smoke-

and tobacco-free campuses as an ongoing challenge

• Without clear messaging, consistency, and consequence, the intent behind such

policies has little effect on outcomes (Plaspohl et al., 2012)

• Reindl, Glassman, Price, Dake, and Yingling, 2014 concluded enforcement (68%)

was the most common barrier to implementation. They provided evidence for

gaining support from the organization’s president as well as designating a group

of advocates to assist in establishing the tobacco-free policy.

• Steps for implementation of tobacco-free policies include:

• creating a committee, identifying key stakeholders

• generating publicity and drafting policy—including enforcement.

• creating a comprehensive rationale, sound justification for advocacy initiatives, specific

action items for committee members and collaboration may remedy common barriers.

• evaluation, documentation, and dissemination so other institutions can establish a

tobacco-free campus. (Glassman et al., 2011)

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• Diffusion of Innovations Theory used to explain how, why, and at what rate the tobacco-free initiative spread through higher education

• In 1962, Everett Rodger, a sociology professor, popularized this theory in his book, Diffusion of Innovations

• Hallmark of DOI theory is that it deals with dissemination of new ideas and adoption by people in a systematic manner

Source: (Rogers, E. M. (1995). Diffusion of Innovations (4th ed.). New York, NY: Free Press.

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“Take off”

• Innovators - people who created Facebook - highly skilled, risk takers

• Early adopters responsible for the “take off” phase

• Early majority whole group of student body in high schools and college

• Late majority could be the 800+ million Facebook users.

• Laggards -not interested in the innovation. Personal preference or financial issues

• Most innovations have an s-shaped curve, steep curve signifies a rapid adoption; a regular slope indicates a slow adoption rate

• Present study will find rate of adoption within institutions of higher learning

• Tipping point or “take off”

• where the first 5-15% of adopters, known as the change agents, start to spread the new idea to others

• Innovation appears to have a life of its own and probably cannot be stopped

Source: (Rogers, 2003)21

Literature Review:

Diffusion of Innovations Theory

• Perceived Organizational Innovativeness (PORGI) (Hurt & Teigen, 1977) designed to measure an organization's perception toward change• PORGI scored using an algorithm that will calculate a score 25 - 125

(McCroskey, 2006a, 2006b)

• five-point Likert scale ranging from one (strongly disagree) to five (strongly agree)

• Survey question rated 25 items to categorize the organization into one of the five categories

• Five categories of Adopters (Rogers, 2003) 1. Innovators

2. Early adopters

3. Early majority

4. Late majority

5. Laggards

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• Population included key informants from 100% tobacco-free

campuses listed in the ANRF directory (2014)

• Directory consists of 1,043 schools, accounting for satellite

campuses

• Institutions with satellite campuses were treated as one

institution. Only flagship colleges and universities were used

as the population for this study (n=596).

• Survey: 39-item, online survey regarding tobacco policies,

practices, enforcement, and perceived innovativeness

• Three qualitative question captured open-ended responses

regarding “lessons learned,” challenges, and enforcement

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• Letters of support based on Baruch & Holtom (2008) found “the content of the study was found to be the most important factor in stimulating response rates.”

• Letter of support from Ty Patterson, Director of the National Center for Tobacco Policy mailed

• Dillman (2007) recommends a 3-day interval between letter and e-mail

• Follow-up email sent the following week

• Mixed-method approaches, including pre-notification letters coupled with e-mails, have been found to increase survey response rates (Baruch & Holtom; 2008; Cobanoglu, Warde, & Moreo, 2001)

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• In total, key informants from 338 of the 596 institutions of higher learning responded to the online survey for a response rate of 56.7%.

• The most prevalent demographic profile was a 4-year, public institution with an enrollment of less than 5,000 located in an urban setting within the South region of the United States. 25

Table 5. Profile of Key Contacts

Frequency Percent

Administrator 129 44.5

Staff 95 32.8

Student 35 12.1

Faculty 21 7.2

Other (please specify) 10 3.4

Answered question 290

Skipped question 48

• Nine categories appeared as follows:

1. involvement of stakeholders – students/faculty/union/community

2. implementation window of 12-18 months

3. assistance for current tobacco users to quit

4. consistent, across-campus, and in-class marketing/communication/education on the policy

5. no use of designated smoking areas

6. incorporate tobacco-free campus policy into employee/faculty policies

7. support from top management

8. penalties for policy non-compliance

9. designation of a policy enforcement entity, whether a department (i.e., campus public safety) or multi-disciplinary team

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• Almost half 168 (49.7%) of the campuses reported the following 8 themes :

1. verbal and written warnings

2. possible suspension from school

3. inability to register for classes

4. processed as a violation of the student code of conduct

5. campus police have the ability to issue a citation with fine

6. refer violators to cessation resources

7. approach violators in a non-confrontational manner, remind them of the policy

8. educate violators of the policy

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• “…verbal warnings, required educational module (which costs $25), community service work -including violations in

performance reviews (for employees), being asked to leave the premises, community reporting (to an e-mail address).

Individuals are to report the time and location of the violation so proper personnel can monitor the area. There are

tobacco cessation resource business cards we distribute and a video was created on ‘How to Approach a Smoker’.

• “We try to give a warning first, whether written or verbal and we log that information. The second offense, they

receive a city citation for smoking on campus which is a fine of $240.00. I have personally written several tickets and

the Judge has found all of them guilty in court. My concern is the cost; it is $240.00 for smoking on campus but $25.00

for smoking with children in a vehicle. Something about that causes a great concern for me.”

• “First offense is a written warning; second offense is a $25 fine, third offense is a $50 fine, and the fourth offense

involves an implementation of a contract with special conditions for faculty or staff and academic misconduct action for

students, based on the respective disciplinary process. Additional offenses include sanctions such as disciplinary leave

and/or termination of employment for faculty or staff and academic misconduct action for students, based on the

respective disciplinary process. “

• “…we encourage the campus community to approach them in a non-confrontational manner, remind them of the policy

and ask them to put out their cigarette. This approach is designed to educate violator of the policy and provide

information on where to receive cessation support. Preliminary results from the survey that is currently out highlights

that a majority of people do not feel comfortable approaching a smoker, so most do not say anything.

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• Roughly one-third (30.2%) of respondents provided 7

common themes relating to enforcement:

1. enforcement within vehicles

2. compliance among employees and visitors

3. consistent consequences for non-compliance

4. city property adjacent to campus; smoking simulating

devices

5. reporting system

6. leadership buy-in

7. lack of resources29

• “Major challenges include, enforcing the policy without a fining system, getting the employees on board with being the primary enforcers/educators, having a consistent penalty for non-compliance. Case-by-case basis right now. Enforcing the policy on city sidewalks that are adjacent/on our Campus property which is technically public property.”

• “We have failed miserably in the area of enforcement, so I am not aware of anyone being held accountable for penalties associated with any of the five levels of offenses. Although campus community members (primarily students) are often very brazen in their disregard for the policy, little to nothing is done to encourage compliance. No consequences means there is no deterrent.”

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• Does your campuses have enforcement challenges

regarding the tobacco-free campus policy?

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• Nearly all had written tobacco-free policy (93.8%)

• Most schools prohibited tobacco use at all locations

• Referrals to quit lines or websites and to outside programs were

more common practice

• Although most employees had smoking cessation programs

available through their university health insurance plan, this was

not true for students

• Enforcement of policies was inconsistent and rare at most

schools with campus police and security bearing the brunt of the

responsibility33

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Although the raw ACHA Compliance Scores were used in subsequent

analyses, a percentage compliance score was also computed; descriptive

statistics (see table) shows that compliance ranged from 0% to 89% with a

mean of 49.64%.

• DV = was the total score on the ACHA Compliance Scale

• IV = five adopter categories from Rodger's DOI PORGI scale.

• The results showed an institution's adopter category within the

DOI theory predicted adherence to ACHA guidelines and

recommendations for a tobacco-free campus.

• Specifically, early adopters had lower levels of compliance

than early majority and late majority adopters.

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• An innovation is an idea, practice, or object that is perceived

as new by an individual or other unit of adoption (like an

organization).

• Innovativeness has to do with how early in the process of

adoption of new ideas, practices, etc. that the individual or

organization is likely to accept a change.

• How do you perceive your organization's innovativeness?

• http://www.jamescmccroskey.com/measures/orginnov.htm

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Mean ACHA Compliance Scores as a Function of Level of

Innovativeness Category

Level of Innovativeness Category N M SD

Laggard 7 23.14 14.79

Late Majority 30 30.57 10.27

Early Majority 224 29.54 12.51

Early Adopter 19 20.37 9.47

Innovator 0 0 0

Did not respond 57 25.46 10.79

Total 337 28.29 12.17

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College and universities should prepare their students to enter the

workforce by providing a tobacco-free environment.

• Graduates may have a competitive edge in the workforce

• An increase in nonsmokers for all members of campus will

help reduce future health care costs at the state and national

level.

Institutions of higher learning should assess their level of

innovativeness to help guide policy change, lead by example, and

embrace the ACHA guidelines and recommendations to protect

the overall health and well-being of the campus community.

• Inclusion of smoking simulating devices in policy

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• Replicating the study with larger sample to include the DOI to help

predict implementation and compliance to ACHA, list is growing

exponentially each year

• Explore how institutions define successful enforcement and evaluate

the policy’s effectiveness

• Best practices for disseminating the policy and addressing

budgetary needs

• Smoking simulating devices studied for inclusion in all tobacco-free

policies

• Educational approach based on respect and framed around the

public health initiative while applying ACHA guidelines to focus on

education and cessation services

• DOI applied to other public health initiatives on campus 39

HHS created the Tobacco-Free College Campus Initiative (TFCCI) to

promote and support the adoption and implementation of tobacco-free

policies at universities, colleges, and other institutions of higher learning

across the United States.

The TFCCI Challenge! is a national effort to engage all campuses and

universities in implementing 100% smoke- or tobacco-free policies.

• Campuses that sign up receive technical assistance if they are just

starting the process of adopting/implementing a policy.

• If a campus is already smoke or tobacco free, the Challenge! serves

as a platform via which the colleges are recognized on a national

level.

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Recommendations For Future Research by Learning from:

• January – L. Augustine presented to Administration & finalized Task Force

• February –Taskforce met

• March – Draft of policy, verbiage for signs, education and enforcement, presented to VP/OC

• March 14th - Reported back to Operational Council to review revised policy draft and implementation plan

• March 15 – April 8th vetted through all stakeholder groups

• April 11th – Feedback summary from Fulltime Faculty, Adjunct Faculty, Students, and Staff

• April - presented at OC again, recommendation to implement Aug. 1, 2017

• May/June information sessions during development days

• August – Convocation

• Fall – ongoing education, evaluation of policy

• Spring – take back summary to OC and have Board of Trustees vote

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Truth Initiative

• Is a non-profit public health organization dedicated to making

tobacco use a thing of the past. We speak, seek and spread

the truth about tobacco through education, research and policy

studies, and community activism and engagement.

• Mission- Dedicated to achieving a culture where all youth and

young adults reject tobacco.

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Awareness and fun

• Info table, spin wheel

• Welcome week inflatable obstacle course

Set the stage

• Target incoming students , contractors and visitors

• Cessation services

• Website

• CTTS - specially trained to develop plans for individuals seeking to stop using tobacco. Staff person earned CTT, Certified Tobacco Treatment

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• Stay on task with collaborating with Students

• Student Senate Meetings and Student Clubs

• Running ad in Collegian – adding images to current ad

• Plan for Outreach Centers, Satellite Campuses, and Community

• Education & Cessation for Faculty, Staff, Administrators

• Replacement strategies wellness talks

• Attending Adjunct Faculty Symposium

• Staff Council sessions

• www.lorainccc.edu/tobaccofree 44

• What are other strategies that can be used for

promoting tobacco free policies and

enforcement?

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• Tobacco-free campus taskforce is looking for some volunteers;

faculty, staff, administrators, students, and community members,

to be trained as tobacco-free campus ambassadors to help

educate the campus community on how the policy will be

enforced.

• It is essential that all members of our community work together

to eliminate tobacco use on our campus. All of us are

encouraged to respectfully explain that tobacco use is not

permitted on campus to any persons observed not complying

with the policy.

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• Questions

• Contact information Lisa Augustine, Ph.D., Professor & Program Coordinator of HPER

Allied Health, Nursing, Health, Physical Education & Recreation

Lorain County Community College|1005 N. Abbe Road| PE 104-C

Elyria, OH 44035

t: 440-366-7352

laugusti@lorainccc.edu

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