A multimodal assessment of tobacco use on a university campus and support for adopting a comprehensive tobacco-free policy

Tobacco-free university campus policies: A systematic review

Objective: This systematic review aims to provide an update of the scientific evidence regarding tobacco-free/smoke-free campus policies (TFC/SFC), using a complex interventions approach.

PARTICIPANTS/METHODS

We searched the PubMed, Scopus and Web of Science databases using a combination of 'tobacco-free' or 'smoke-free', 'campus', 'university or college' and 'policy' search terms on all indexed articles published up until June 2023. Studies were included if they presented research on pre-/post-implementation of TFC/SFC or policy components. Two coders extracted and synthesized the data and assessed the risk of bias.

RESULTS

A total of 113 studies were included, reporting data from 2005 to 2023 across 17 countries. The data was categorized into three of the four phases of the Medical Research Council (MRC) framework, i.e. "feasibility (n=24), "implementation" (n=34), and "evaluation" (n=69). This review finds that a policy draft, communication, enforcement strategies, and cessation services are critical policy components. TCF/SFC are effective for reducing tobacco use and secondhand smoke exposure, but they also increase vaping. Little research has investigated the effect of TFC/SFC on smokeless tobacco use.

CONCLUSION

This review addresses remaining uncertainties in evidence on the TFC/SFC implementation process. We go on to provide a series of recommendations for university administrators.

What are the effects of smoke-free and tobacco-free university campus policies, and how can they be assessed? A systematic review

OBJECTIVE

This article looks at the evaluation of smoke-free (SF) and tobacco-free (TF) university campus policies that ban smoking (and often vaping) both indoors and outdoors. To assess the effectiveness of these policies, we performed a systematic literature review to answer the following questions: what is the effect of SF/TF policies on campus users' behaviors/norms/perceptions around smoking? Are the SF/TF policies an effective measure for reducing smoking among young adults? What methods and indicators can we use to assess the impact of SF/TF campus policies? What is the theoretical model underpinning the influence of SF/TF policies on the behavior of campus users?

METHODS

Three databases (PubMed, Scopus, and Web of Science) were searched over the period from January 2005 to December 2022. The article selection process included 54 articles published in scientific journals that analyzed the post-implementation impact of SF/TF campus policies. The quality of these articles was analyzed using six ad hoc indicators based on the Critical Appraisal Skills Program checklist and Joanna Briggs Institute scoping tools.

RESULTS

Most of the research on SF/TF campus policies has been conducted in the United States using quantitative methodologies. Most of these studies show that SF/TF policies reduce positive beliefs about smoking and its acceptability, influence smoking behavior (reducing smoking initiation and increasing the number of quits and quit attempts), and reduce exposure to passive smoking and pollution from cigarette butts. User acceptability of SF/TF policies is generally high. Limitations of SF/TF campus policies include difficulty for smokers to comply with them, persistence of passive smoking around campuses, and limited uptake of on-campus cessation support services provided to smokers.

DISCUSSION

The various mediating and moderating variables identified in the literature have made it possible to propose a model of the potential influence of SF/TF policy on campus users, based on the theory of planned behavior. Based on this review, we provide health professionals and higher education institutions wishing to implement a SF/TF campus policy with a set of indicators that can serve to assess the impact of a SF/TF campus policy (attitudes, acceptability, beliefs, norms, exposure to passive smoking and pollution, changes in smoking behavior).

CONCLUSION

Based on scientific evidence, the implementation of SF/TF campus policies in France is an important measure to help combat smoking in young adults.

Public support for smoke-free policies in outdoor areas and (semi-)private places: a systematic review and meta-analysis

Background

Smoke-free policies are essential to protect people against tobacco smoke exposure. To successfully implement smoke-free policies that go beyond enclosed public places and workplaces, public support is important. We undertook a comprehensive systematic review of levels and determinants of public support for indoor (semi-)private and outdoor smoke-free policies.

Methods

In this systematic review and meta-analysis, six electronic databases were searched for studies (published between 1 January 2004 and 19 January 2022) reporting support for (semi-)private and outdoor smoke-free policies in representative samples of at least 400 respondents aged 16 years and above. Two reviewers independently extracted data and assessed risk of bias of individual reports using the Mixed Methods Appraisal Tool. The primary outcome was proportion support for smoke-free policies, grouped according to location covered. Three-level meta-analyses, subgroup analyses and meta-regression were performed.

Findings

14,749 records were screened, of which 107 were included; 42 had low risk of bias and 65 were at moderate risk. 99 studies were included in the meta-analyses, reporting 326 measures of support from 896,016 individuals across 33 different countries. Support was pooled for indoor private areas (e.g., private cars, homes: 73%, 95% confidence interval (CI): 66-79), indoor semi-private areas (e.g., multi-unit housing: 70%, 95% CI: 48-86), outdoor hospitality areas (e.g., café and restaurant terraces: 50%, 95% CI: 43-56), outdoor non-hospitality areas (e.g., school grounds, playgrounds, parks, beaches: 69%, 95% CI: 64-73), outdoor semi-private areas (e.g., shared gardens: 67%, 95% CI: 53-79) and outdoor private areas (e.g., private balconies: 41%, 95% CI: 18-69). Subcategories showed highest support for smoke-free cars with children (86%, 95% CI: 81-89), playgrounds (80%, 95% CI: 74-86) and school grounds (76%, 95% CI: 69-83). Non-smokers and ex-smokers were more in favour of smoke-free policies compared to smokers. Support generally increased over time, and following implementation of each smoke-free policy.

Interpretation

Our findings suggested that public support for novel smoke-free policies is high, especially in places frequented by children. Governments should be reassured about public support for implementation of novel smoke-free policies.

Funding

Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation and Netherlands Thrombosis Foundation.

Tobacco-free policy reduces combustible tobacco byproduct on a large university campus

Policy drives community-level behavior change, so behavior analysts should aid empirical policy development. University campus regulation is a useful proxy for broader policy initiatives and thus is a convenient inroad for behavior analyst involvement. This paper examines behavior analytic contributions to the planning and evaluation of a university tobacco-free initiative. We provided resources and guidance throughout early planning, and we then evaluated faculty and student compliance via byproduct (e.g., cigarette butts) counts taken at four high-traffic sites (as flagged by preliminary surveying of campus faculty, staff, and students). Visual analysis and supplementary statistical testing support notions of (a) a meaningful and sustained reduction of combustible tobacco byproducts in all locations, and (b) a demonstrative example of behavior analytic involvement with university policy planning and evaluation.

A three wave assessment of a tobacco free campus policy within a minority serving institution

OBJECTIVE

This study assessed changes (in relation to smoking status) in tobacco use, attitudes toward TFC policies, and tobacco use risk knowledge by applying a three Wave repeated cross-sectional assessment.

PARTICIPANTS

Participants were students at Wave 1 (n = 2,169), Wave 2 (n = 2,576), and Wave 3 (n = 2,169) and faculty at Wave 1 (n = 256), Wave 2 (n = 204), and Wave 3 (n = 180).

METHODS

Measures regarding sociodemographics, tobacco use, attitudes toward TFC policies, and tobacco use risk knowledge were completed.

RESULTS

Compared with Wave 1, more students reported having quit smoking within the last six months at Waves 2 and 3. The negative attitudes toward TFC policies of those who reported quitting in the last six months aligned with those of nonsmokers.

CONCLUSIONS

Study findings suggest smoking status as a relevant covariate to focus on to further strengthen and refine existing TFC policies.

Student tobacco use, secondhand smoke exposure, and policy beliefs before and after implementation of a tobacco-free campus policy: Analysis of five U.S. college and university campuses

The adoption of comprehensive tobacco policies by colleges and universities may help reduce student tobacco use. To this end, The American Cancer Society's Tobacco-Free Generation Campus Initiative (TFGCI) awarded grants to 106 higher learning institutions to adopt 100% tobacco-free campus policies. This study measured changes in student tobacco use, reported exposure to secondhand smoke, and support for types of tobacco policies among five TFGCI grantee institutions who implemented 100% tobacco-free policies. Students at five U.S. TFGCI grantee institutions completed two independent cross-sectional online surveys regarding tobacco use, exposure to secondhand smoke, and policy attitudes, once before (n = 2499) and once after (n = 1667) their campuses adopted a tobacco-free policy. Students were less likely to report current cigarette smoking (aOR: 0.73, 95% C.I.: 0.63, 0.85) and exposure to secondhand smoke on campus (aOR: 0.42, 95% C.I.: 0.23, 0.76) following the policy change. In contrast, students were more likely to report past 30-day use of electronic nicotine delivery systems (ENDS) (aOR: 2.16, C.I.: 1.77, 2.63) following the policy change, despite the policy's inclusion of all tobacco and nicotine products. Tobacco-free campus policies can be associated with decreases in tobacco product use and environmental smoke exposure. The extent of their effectiveness may vary by product and the inclusion of tailored messaging, cessation support, and enforcement approaches. To discourage use of these products among students, colleges and universities should adopt 100% tobacco-free policies, monitor product use trends, offer cessation support and messaging customized for specific groups and products, and utilize a comprehensive enforcement strategy.

Korean college students’ attitudes toward a tobacco-free campus: a cross-sectional descriptive study

Purpose: A tobacco-free campus (TFC) is the most advanced tobacco-control policy for college campuses, but it has rarely been explored in Korea. This study aimed to explore Korean college students’ attitudes toward TFC and related factors.Methods: This cross-sectional descriptive study enrolled college students who were taking an elective course on smoking cessation and a healthy lifestyle at a university located in Incheon, Korea. Data were collected from March 1 to December 31, 2019 using a structured questionnaire, and study participants were recruited using convenience sampling.Results: Data on 309 college students were analyzed. Of those participants, 6.1% supported the TFC policy. Multiple logistic regression analysis showed that female gender (adjusted odds ratio [aOR]=5.80, 95% confidence interval [CI]=1.47-22.95), taking the course to quit smoking oneself (aOR=11.03, 95% CI=1.04-117.05), anxiety in the past month (aOR=4.27, 95% CI=1.06-17.31), and being a current smoker (aOR=0.06, 95% CI=0.01-0.70) were statistically significant independent predictors of TFC support.Conclusion: Women, students taking the course to quit smoking themselves, nonsmokers, and students who felt anxious in the past month were more likely to support TFC. Further research with more representative samples is required to examine the characteristics of people who favor TFC.

Campus tobacco control policies and cessation interventions in college students: a commentary calling for research and action to address tobacco-related health disparities

Tobacco-related health disparities (TRHDs) have a significant impact on population health in the USA. Effectively preventing and controlling TRHDs among young adult populations require multiple prevention and cessation points, including within college/university contexts. This commentary addresses current campus tobacco control policies and cessation interventions for U.S. college students, with an emphasis on TRHDs and opportunities for research and research translation to reduce these disparities. This commentary is informed by literature published between 2010 and 2020 regarding (a) prevalence and impact of campus tobacco control policies; and/or (b) behavioral outcomes from cessation interventions for young adults attending colleges. Despite a doubling of college campuses adopting tobacco-free policies from 2012 to 2017, roughly two-thirds continue to operate without such policies. Few policies address alternative tobacco products (e.g., e-cigarettes, cigars/cigarillos, and hookah), and communication about and enforcement of existing policies is extremely limited. A broad range of cessation intervention strategies have targeted individuals in this age group, but with little focus on TRHDs and limited intervention dissemination. Importantly, college students representing populations at risk for TRHDs (e.g., racial/ethnic/sexual/gender minorities, low socioeconomic status) are less likely to be exposed to strong tobacco control policies or supports for cessation. There are untapped opportunities for behavioral medicine approaches to reduce TRHDs in college settings. Research findings regarding multilevel (policy, community-level, and individual-level) interventions must be translated to policy/practice in order to address tobacco use, particularly among vulnerable college student populations.

Circulating Ionized Magnesium as a Measure of Supplement Bioavailability: Results from a Pilot Study for Randomized Clinical Trial

Oral supplementation may improve the dietary intake of magnesium, which has been identified as a shortfall nutrient. We conducted a pilot study to evaluate appropriate methods for assessing responses to the ingestion of oral magnesium supplements, including ionized magnesium in whole blood (iMg²⁺) concentration, serum total magnesium concentration, and total urinary magnesium content. In a single-blinded crossover study, 17 healthy adults were randomly assigned to consume 300 mg of magnesium from MgCl₂ (ReMag^®, a picosized magnesium formulation) or placebo, while having a low-magnesium breakfast. Blood and urine samples were obtained for the measurement of iMg²⁺, serum total magnesium, and total urine magnesium, during 24 h following the magnesium supplement or placebo dosing. Bioavailability was assessed using area-under-the-curve (AUC) as well as maximum (C_max) and time-to-maximum (T_max) concentration. Depending on normality, data were expressed as the mean ± standard deviation or median (range), and differences between responses to MgCl₂ or placebo were measured using the paired t-test or Wilcoxon signed-rank test. Following MgCl₂ administration versus placebo administration, we observed significantly greater increases in iMg²⁺ concentrations (AUC = 1.51 ± 0.96 vs. 0.84 ± 0.82 mg/dL•24h; C_max = 1.38 ± 0.13 vs. 1.32 ± 0.07 mg/dL, respectively; both p < 0.05) but not in serum total magnesium (AUC = 27.00 [0, 172.93] vs. 14.55 [0, 91.18] mg/dL•24h; C_max = 2.38 [1.97, 4.01] vs. 2.24 [1.98, 4.31] mg/dL) or in urinary magnesium (AUC = 201.74 ± 161.63 vs. 139.30 ± 92.84 mg•24h; C_max = 26.12 [12.91, 88.63] vs. 24.38 [13.51, 81.51] mg/dL; p > 0.05). Whole blood iMg²⁺ may be a more sensitive measure of acute oral intake of magnesium compared to serum and urinary magnesium and may be preferred for assessing supplement bioavailability.