University Personnel’s Attitudes and Behaviors Toward the First Tobacco-Free Campus Policy in Tennessee

ORIGINAL PAPER

University Personnel’s Attitudes and Behaviors Toward the FirstTobacco-Free Campus Policy in Tennessee

Hadii M. Mamudu • Sreenivas P. Veeranki •

Yi He • Sumati Dadkar • Elaine Boone

Published online: 6 December 2011

� Springer Science+Business Media, LLC 2011

Abstract In 1994, Tennessee, the third largest tobacco-

producing state in the U.S., preempted tobacco regulation.

However, in 2005, higher educational institutions were

exempted from this preemption and the 2007 Non-Smoker

Protection Act required educational facilities to create

smoke-free environment. To this date, while all higher

educational institutions have some sort of smoke-free policy,

East Tennessee State University is the only public institution

with a tobacco-free policy. We investigated attitudes and

behaviors of the university personnel, the most stable seg-

ment of the population, toward the policy and compliance

with it using an internet-based survey. All employees (2,318)

were invited to participate in a survey; 58% responded.

Bivariate analyses found 79% of the respondents favored the

policy. Multiple variable logistic regression analyses

found support for the policy was higher among females

[OR = 3.14; 95% CI (1.68, 5.86)], administrators/

professionals [OR = 3.47; 95% CI (1.78, 6.74)], faculty

[OR = 2.69; 95% CI (1.31, 5.53)] and those affiliated with

the College of Medicine [OR = 4.14; 95% CI (1.45, 7.85)].

While only 67 employees (5.6% of sample) reported they

have not complied with the policy, around 80.8% reported

observing someone engaged in non-compliance. The high

level of support for the policy suggests it should be promoted

throughout the higher education system and nationwide. At

the same time, in preemptive states, higher educational

institutions should be targeted as venues for strong tobacco-

free policies. The gap in compliance, however, implies in

tobacco-friendly environments, a tobacco-free campus pol-

icy with no reporting and enforcement mechanisms could

lead to high levels of non-compliance.

Keywords Tobacco-free campus policy � University

personnel or employees � Tobacco-producing state �Tobacco-friendly environment � Socio-economic status

(SES)

Introduction

The smoking rates in the United States (U.S.) have been

declining in the past decades, [1] but remain generally high

among young adults between 18 and 24 years of age

(20.1% vs. 19.3% in 2010) [1]. About one-third of young

adults in the U.S. attend college or university, where they

are exposed to peer-smoking behavior and are also targeted

with tobacco industry marketing and other promotional

activities [2, 3]. The college years also provide a zone for

H. M. Mamudu (&) � S. Dadkar

Department of Health Services Administration, College of

Public Health, East Tennessee State University, S. Dossett Drive,

Lamb Hall, P.O. Box 70264, Johnson City, TN 37614, USA

e-mail: [email protected]

S. Dadkar


S. P. Veeranki

Department of Biostatistics and Epidemiology, College of Public

Health, East Tennessee State University, P.O. Box 12993,

Johnson City, TN 37614, USA


Y. He

Department of Biostatistics and Epidemiology, College of Public

Health, East Tennessee State University, S. Dossett Drive, Lamb

Hall, P.O. Box 70264, Johnson City, TN 37614, USA


E. Boone

Department of Management and Marketing, College of Business

and Technology, East Tennessee State University, P.O. Box

70625, Johnson City, TN 37614, USA


123

J Community Health (2012) 37:855–864

DOI 10.1007/s10900-011-9520-1

transition from an intermittent or social smoker to a regular

or permanent smoker [4]. At the same time, colleges and

universities provide opportunities for interventions to pre-

vent tobacco use and promote cessation [5]. For these

reasons, organizations such as the American College

Health Association have urged colleges and universities to

implement tobacco-free campus policies, [6] but the

prevalence of such policies in the country has been low [7].

Although many research studies on understanding atti-

tudes and behaviors of students toward smoke-free college

or university policies exist, [5, 8] yet, little is known about

the attitudes and behaviors of college or university per-

sonnel, the most stable population, towards such policies

[9]. Additionally, the general public’s attitude toward

smoke-free policies in tobacco-producing states in the U.S.

has been investigated, [10, 11] but little is known about

those of college or university personnel toward tobacco-free

campus policies in such environments. Tennessee is the

third largest tobacco-producing state in the U.S., where the

smoking rate is above national average (22.0% vs. 20.6%

for adults; 30.8% vs. 21.8% for young adults 18–24 years of

age in 2009). In August 2008, East Tennessee State Uni-

versity (ETSU), a four-year comprehensive university in the

northeastern part of the state, implemented a tobacco-free

campus policy (PPP-53) that stipulates, ‘‘ETSU is a

Tobacco-Free Campus, with smoking and all other tobacco

usage permitted only in private vehicles [emphasis origi-

nal]’’ [12]. The PPP-53 became the first tobacco-free

campus policy in the state’s public higher education system

(Tennessee Board of Regents and University of Tennessee

systems). The policy is applicable to everyone, including

employees, students, patrons, and visitors, and is in effect

year round, 24 h a day. Students who do not comply with

the policy are sanctioned or penalized, but employees’

compliance with the policy is voluntary and there is no

sanction or penalty for non-compliance.

Tennessee is a preemptive state, that is, under the 1994

Prevention of Youth Access to Tobacco Act (PYATA), any

tobacco-related ordinance enacted by local governments

and public institutions after March 15, 1994, is null and

void. However, in 2005, the legislature passed a law to

exempt higher educational institutions from this preemp-

tion. Additionally, in 2007, the state enacted and imple-

mented the Non-Smoker Protection Act, a statewide

smoke-free policy that required public and private educa-

tional facilities to create smoke-free environments [13]. In

this respect, educational institutions not only gained the

authority to enact stronger smoke-free campus policies, but

also have emerged as important venues for developing

strong policies, as the preemption has stifled the ability of

local governments and public institutions to develop

innovative tobacco control policies. Yet, as of 2011, out of

the total 50 public institutions (46 in the Tennessee Board

of Regents and four in University of Tennessee systems)

only ETSU has a tobacco-free campus policy [7]. Thus,

this study aimed to analyze ETSU personnel’s attitudes and

behaviors toward the tobacco-free campus policy to inform

policy initiatives among institutions in the higher education

systems, both in non- and pro-tobacco cultural environ-

ments, and facilitate the emergence of tobacco-free campus

movements in the state and elsewhere in the country. Given

that tobacco use is related to socio-economic status, [1] it

was hypothesized that there would be an overall high level

of support for the policy among the university personnel,

however, because the university is located in a tobacco-

friendly environment compliance would be a major draw-

back. This study highlights not only the receptivity of

tobacco-free policies among university personnel in a

tobacco-producing state but also promote higher educa-

tional institutions as venues to develop strong and effective

tobacco-free policies in states with preemptive laws.

Methods

Data Collection

In April 2010, all employees of ETSU (2,318) were invited

to participate in an anonymous internet-based survey. The

ETSU Human Resource department provided the list of

the employees and the survey was administered through the

ETSU Quillen College of Medicine survey system. Only

individuals older than 18 years of age were allowed to

participate in the survey.

Different channels approved by the Institutional Review

Board (IRB) of ETSU were used to recruit participants.

First, two emails were sent from the office of ETSU Pro-

vost and Vice President for Health Affairs to the employ-

ees. The first email, which included the informed consent,

invited the employees to participate in a voluntary anon-

ymous survey and a second email was sent after 2 weeks as

reminder. As an incentive, participants were provided with

an opportunity to enter a random drawing for $50 (20 in

total were available). A participant’s entry into the drawing

was distinct from the actual survey. Additionally, flyers

with the link to the survey were posted and distributed

across all ETSU campuses. Further, a card with the link to

the survey was placed in each employee’s campus mailbox.

The survey was made available for 26 days to ensure that

every employee interested in participating has enough time

to take the survey.

Measures

The dependent variable was support for the tobacco-free

campus policy (Table 1). Based on the survey instrument

856 J Community Health (2012) 37:855–864

123

developed by the Global Tobacco Surveillance System

Collaborative Group, [14] consisting of the World Health

Organization, U.S. Centers for Disease Control and Pre-

vention, Canadian Public Health Association and other

collaborators, we developed the measures for the indepen-

dent variables, including the ‘‘smoking status’’. Addition-

ally, we controlled for standard demographic characteristics

of participants. All the variables were nominal and mutually

exclusive, except smoking status where there was a possi-

bility that a cigarette smoker could be a user of other

tobacco products as well. Moreover, we recoded race as

Caucasian/white and non-Caucasian/non-white for the

regression analysis because of the small sample sizes in

other racial categories.

Data Analysis

The survey responses were analyzed for descriptive and

inferential statistics, including frequencies, percentages

and proportions. Bivariate analyses between support for

ETSU tobacco-free campus policy and each of the

independent variables were explored using v2 test sta-

tistics. Regression diagnostics were conducted to identify

‘‘outliers’’. Finally, a multiple variable logistic regression

analysis was conducted to delineate the determinants of

support for the tobacco-free campus policy among the

university employees. The equation for the logistic

regression model used in this research study is as

follows:

Table 1 Questions in the survey instrument along with their recoded

responses

Questions and their responses Recoded

responses

Dependent/Outcome variable

Do you favor the ETSU tobacco-free policy?

Missing Deleted

Strongly favor 1

Favor 1

Unsure Deleted

Oppose 0

Strongly oppose 0

Independent/Exposure variables

How old are you?

Missing Deleted

19 years 1

20–29 years 0

30–39 years 2

40–49 years 3

50–59 years 4

More than 60 years 5

What is your gender?

Missing Deleted

Female 1

Male 0

What race or races do you consider yourself to be?

Missing Deleted

American Indian or Alaska Native 1

Asian 1

Black or African American 1

Caucasian/White 0

Hispanic 1

Native Hawaiian or Pacific Islander 1

Have you ever tried smoking cigarettes, even one or two puffs?

Missing Deleted

Yes 1

No 0

Do you currently smoke?

Missing Deleted

Yes 1

No 0

Have you ever used tobacco products other than cigarettes?

Missing Deleted

Yes 1

No 0

Do you currently use any tobacco products other than cigarettes?

Missing Deleted

Yes 1

No 0

What is your primary position in ETSU?

Missing Deleted

Table 1 continued

Questions and their responses Recoded

responses

Administrative/Professional 1

Faculty 2

Clerical/support staff 0

Others 3

Which college or school do you work for?

Missing Deleted

College of Arts and Sciences 1

College of Business and Technology 0

College of Clinical and Rehabilitative Health Sciences 2

College of Education 3

College of Medicine 4

College of Nursing 5

College of Pharmacy 6

College of Public Health 7

School of Continuing Studies and Academic Outreach 8

School of Graduate Studies 9

Others 10

J Community Health (2012) 37:855–864 857

123

logitðpiÞ ¼ lnpi

1� pi

� �¼ b0 þ b1x1;i þ � � � þ bkxk;i

where, pi represents the probability of support for the

tobacco-free campus policy, b0 represents intercept

co-efficient, b1, b2, …, bk represent co-efficients of the

variables, x1, x2, … xk represent independent variables.

Both unadjusted odds ratio (OR) and adjusted odds ratio

(AOR) along with 95% confidence intervals (CIs) were

calculated. The significance level was set at 95%

(P value B 0.05). The data analysis was performed using

SAS/STAT software, Version 9.1 (SAS Institute Inc., Cary,

North Carolina, USA).

Results

Sample Characteristics

The sample size for the analysis was 1,177 (50.8%). Most

of the study participants were Caucasian (89.5%), females

(67%), between 50 and 59 years (33.7%) and affiliated

with the College of Medicine (17.8%) and the College of

Arts and Sciences (16.5%) (Table 2). While 44.6%

(n = 525) were ever cigarette smokers, only 9% (n = 106)

were current smokers. Additionally, 11.4 and 2.7% of study

participants were ever and current users of other tobacco

products respectively.

Attitudes and Behavior Toward the Tobacco-Free

Campus Policy

Of the 1,177 sample size population, approximately 79%

(n = 932) of the employees favored the policy, 11%

(n = 134) opposed it, about 6% (n = 70) were ‘‘unsure’’ of

their position and 4% (n = 41) did not respond to the

question.

Table 3 shows that the support for the tobacco-free

campus policy was high across all categories of employees,

including age, gender, race, employment status and school/

college affiliation, but varied widely across smoking status.

While 69 and 61% of ever cigarette smokers and users of

other tobacco products supported the policy, only 27 and

38% of current cigarette smokers and users of other

tobacco products did. The strongest support for the policy

was among employees 60 years of age and older (91%) and

least among those between 30 and 39 years of age (75%).

Females (83%) supported the policy more than males

(74%). Additionally, the support for the policy was stron-

gest among Asians (93%) and lowest among American

Indians and Native Americans (80%). Furthermore, mem-

bers of faculty were the strongest supporters of the policy

(86%), and clerical/support staff (73%), the least.

Table 2 Characteristics of the survey respondents (n = 1,177)

Characteristics Number of

respondents

(n)

Percentage

of respondents

(%)

Age

19 years 5 0.4

20–29 years 106 9.0

30–39 years 211 17.9

40–49 years 271 23.0

50–59 years 397 33.7

[ 60 years 154 13.2

Missing responses 33 2.8

Gender

Female 789 67.0

Male 367 31.2


Race

American Indian or Alaska Native 5 0.4

Asian 27 2.3

Black or African American 44 3.7

Caucasian/White 1,053 89.5

Hispanic 12 1.0


Smoking status*

Ever cigarette smoker 525 44.6

Current cigarette smoker 106 9.0

Ever user of other tobacco products 134 11.4

Current user of other tobacco

products

32 2.7

Employment status

Administrator/Professional 333 28.3

Clerical/Support staff 374 31.8

Faculty 392 33.3

Others 43 3.7


College

College of Arts and Sciences 194 16.5

College of Business and

Technology

75 6.4

College of Clinical and

Rehabilitative Health Sciences

31 2.6

College of Education 101 8.6

College of Medicine 209 17.8

College of Nursing 71 6.0

College of Pharmacy 24 2.0

College of Public Health 32 2.7

School of Continuing Studies

and Academic Outreach

30 2.6

Others 259 22.0


*Smoking status does not add to 100%, because of individual ques-

tions for cigarette smoking and usage of other tobacco products


123

Moreover, the support for the policy was strongest among

employees in the College of Nursing (94%), and least in

the College of Business and Technology (71%). Hence,

besides current smokers and users of other tobacco prod-

ucts, the tobacco-free campus policy was highly supported

by a substantial majority of the employees.

Table 4 delineates the determinants of support for

tobacco-free campus policy among the study participants.

The study participants significantly associated with

increased likelihood of support for the tobacco-free campus

policy were females, being a faculty or an administrator/

professional and affiliated with the College of Medicine. In

contrast, being an ever or a current cigarette smoker was

significantly associated with decreased support for the

policy. The support for the policy was 2.3 times [OR = 2.3;

95% CI (1.54, 3.43)] higher among female employees

when compared to male employees, and 3.14 times [AOR =

3.14; 95% CI (1.68, 5.86); P value 0.0003] when

adjusted. Additionally, faculty and administrators/profes-

sions were 2.12 times [OR = 2.12; 95% CI (1.33, 3.39)]

and 2.27 times [OR = 2.27; 95% CI (1.35, 3.84)] more

likely to support the policy than clerical or support staff,

and 2.69 times [AOR = 2.69; 95% CI (1.31, 5.53); P value

0.007] and 3.47 times [AOR = 3.47; 95% CI (1.78, 6.74);

P value 0.0002] when adjusted. Moreover, employees in

the College of Medicine were 3.39 times [OR = 3.39; 95%

CI (1.48, 6.78)] more likely to support the policy than those

in the College of Business and Technology, and 4.14 times

[AOR = 4.14; 95% CI (1.45, 7.85); P value 0.01] when

adjusted. Conversely, compared to those employees who

never used any tobacco product, ever and current cigarette

smokers were 62% [OR = 0.38; 95% CI (0.22, 0.63)] and

97% [OR = 0.03; 95% CI (0.01, 0.05)] less likely to

support the policy, and 58% [AOR = 0.42; 95% CI (0.23,

0.77); P value 0.005] and 97% [AOR = 0.03; 95% CI

(0.01, 0.06); P value\ 0.0001] when adjusted respectively.

The rest of the variables were not significant.

Compliance With the Tobacco-Free Policy

Table 5 presents two types of reporting mechanism, self-

reporting and reporting others, with respect to voluntary

compliance, showing both the percentage of people in each

category and the proportion of the entire sample popula-

tion. While only 5.6% (i.e., 67/1,177 9 100) and 1.7%

(i.e., 20/1,177 9 100) of the total study participants

reported that they have smoked cigarettes and used other

tobacco products on ETSU’s premises since the policy was

enacted (self-report), 80.8% (i.e., 952/1,177 9 100)

reported that they have observed others not complying with

the policy (reporting others). The percentage of those who

have observed others not complying with the policy ranged

from as high as 100% among teenage employees (19 years

of age) to 60% among American Indians or Alaskan

Natives. In essence, an overwhelming majority of the

participants have observed someone not complying with

the policy.

Discussion

Policies to create smoke-free environments generally have

a strong public support [15]. This study investigated uni-

versity personnel receptivity for the first tobacco-free

campus policy in the Tennessee public higher education

system. Approximately 79% of the employees who par-

ticipated in the survey indicated that they supported the

policy. The strong support for the policy should be a

reassurance for the university administrators in a tobacco-

friendly environment, who may be overly concerned with

opposition to the policy, that, as in the case of local and

state smoke-free ordinances, with proper implementation

and enforcement, campus policies are effective and popu-

lar. Additionally, the finding suggested that since students’

exposure to tobacco promotion is associated with increas-

ing tobacco use [16] and smoking on campuses creates

ambivalence for nonsmokers; [17] colleges and universities

need to adopt a total ban on tobacco use (smoke and

smokeless). At ETSU, such policy was popular among the

school personnel. Indeed, the survey was administered

20 months after the implementation of the tobacco-free

campus policy, which likely affected the employees’ sup-

port of the policy, as receptivity of such policies improves

and increases in the few months after they are implemented

[18]. Both the descriptive and inferential statistical analy-

ses showed that support for the policy was high across all

categories of employees, except for current cigarette

smokers and users of other tobacco products. However,

consistent with previous studies, [10, 11] women employ-

ees were more likely to support the policy than men. In this

respect, there is a need for programs to inform men about

the relevance of smoke-free policies.

The most apparent determinant of opposition to the

policy was smoking status. Consistent with previous stud-

ies, [10, 11] current cigarette smokers were more likely to

oppose the policy than those who have never used any

tobacco product even among this educated population.

Additionally, because the university is located in a

tobacco-friendly environment, this finding is consistent

with studies, which found that in places with high smoking

rates and pro-smoking norms, [10, 11] it is the nonsmokers

who generally support policies to establish smoke-free

environments. Moreover, this finding suggested that, in

such environments, implementing tobacco-free policies

and cessation programs concurrently could not only reduce


123

Table 3 University personnel support for tobacco-free campus policy (n = 1,177)

Characteristics Support for ETSU tobacco-free policy

Favor

(n = 932)

n (%)

Oppose

(n = 134)

n (%)

Unsure/undecided

(n = 70)

n (%)

P value

Age

19 years 4 (80.0) 1 (20.0) 0 (0.0) 0.013*

20–29 years 83 (78.3) 12 (11.3) 11 (10.4)

30–39 years 158 (74.9) 35 (16.6) 18 (8.5)

40–49 years 210 (77.5) 40 (14.8) 21 (7.7)

50–59 years 330 (83.1) 37 (9.3) 30 (7.6)

[ 60 years 140 (90.9) 8 (5.2) 6 (3.9)

(Missing responses—33) 7 (21.2) 1 (3.0) 25 (75.8)

Gender

Female 657 (83.3) 65 (8.2) 67 (8.5) \0.0001*

Male 271 (73.8) 67 (18.3) 29 (7.9)


Race

American Indian or Alaska Native 4 (80.0) 1 (20.0) 0 (0.0) 0.5732

Asian 25 (92.6) 2 (7.4) 0 (0.0)

Black or African American 37 (84.1) 2 (4.5) 5 (11.4)

Caucasian/White 847 (80.4) 126 (12.0) 80 (7.6)

Hispanic 10 (83.4) 1 (8.3) 1 (8.3)


Smoking status

Ever cigarette smoker 361 (68.8) 102 (19.4) 62 (11.8) \0.0001*

Current cigarette smoker 29 (27.4) 51 (48.1) 26 (24.5) \0.0001*

Ever user of other tobacco products 81 (60.5) 39 (29.1) 14 (10.4) 0.005*

Current user of other tobacco products 12(37.5) 14 (43.8) 6 (18.7) 0.009*

Employment status

Administrator/Professional 281 (84.4) 27 (8.1) 25 (7.5)

Clerical/Support staff 274 (73.3) 61 (16.3) 39 (10.4)

Faculty 336 (85.7) 36 (9.2) 20 (5.1) \0.001*

Others 29 (67.4) 7 (16.3) 7 (16.3)


College

College of Arts and Sciences 153 (78.9) 25 (12.9) 16 (8.2) 0.001*

College of Business and Technology 53 (70.7) 15 (20.0) 7 (9.3)

College of Clinical and Rehabilitative Health Sciences 26 (83.9) 0 (0.0) 5 (16.1)

College of Education 88 (87.2) 7 (6.9) 6 (5.9)

College of Medicine 178 (85.2) 15 (7.1) 16 (7.7)

College of Nursing 67 (94.4) 3 (4.2) 1 (1.4)

College of Pharmacy 21 (87.5) 3 (12.5) 0 (0.0)

College of Public Health 27 (84.4) 3 (9.4) 2 (6.2)

School of Continuing Studies and Academic Outreach 22 (73.3) 6 (20.0) 2 (6.7)

Others 200 (77.2) 41 (15.8) 18 (7.0)


*P value \ 0.05


123

tobacco use, [19] incidence of smoking-attributable dis-

eases, [20] health care costs, [21] and environmental

problems such as littering, [22] but also help to provide a

strong foundation for eventual development of smoke-free

policies. In particular, tobacco-free campus policies not

only help to improve health, but may also help to reduce

students’ exposure to tobacco industry marketing and

promotional activities [2].

With respect to employment status, differences in

likelihood of support for the policy suggested that there

was a positive association not only between socio-eco-

nomic status and tobacco use behavior but also support

for policies to create smoke-free environments. In this

case, faculty members and administrators/professionals

with relatively higher income and education were sig-

nificantly more likely to support the policy than clerical/

support staff, suggesting that education is a modifying

factor in support for tobacco-free campus policies among

personnel and calls for additional health promotion and

education efforts.

Table 4 Determinants of support for a tobacco-free campus policy (n = 1,177)

Characteristics Support for ETSU tobacco-free policy

Unadjusted OR* (95% CI) Adjusted OR (95% CI) P value

Agea

30–39 years 0.70 (0.32, 1.53) 1.49 (0.57, 3.85) 0.41

40–49 years 0.61 (0.29, 1.29) 0.64 (0.27, 1.56) 0.33

50–59 years 1.39 (0.65, 3.01) 1.60 (0.65, 3.94) 0.30

[ 60 years 1.96 (0.74, 4.18) 2.84 (0.91, 5.91) 0.07

20–29 years (referent) 1.0

Gender

Female 2.30 (1.54, 3.43) 3.14 (1.68, 5.86) 0.0003?

Male (referent) 1.0

Race

Non-Caucasians 2.39 (0.85, 4.68) 3.10 (0.80, 5.98) 0.10

Caucasians (referent)

Smoking status

Ever cigarette smoker 0.38 (0.22, 0.63) 0.42 (0.23, 0.77) 0.005?

Current cigarette smoker 0.03 (0.01, 0.05) 0.03 (0.01, 0.06) \0.0001?

Ever user of other tobacco products 0.35 (0.20, 0.62) 0.85 (0.38, 1.88) 0.69

Current user of other tobacco products 0.09 (0.04, 0.22) 0.34 (0.10, 1.11) 0.07

Never user of any tobacco products (referent) 1.0

Position

Administrator/Professional 2.27 (1.35, 3.84) 3.47 (1.78, 6.74) 0.0002?

Faculty 2.12 (1.33, 3.39) 2.69 (1.31, 5.53) 0.007?

Others 1.19 (0.44, 3.24) 1.56 (0.45, 4.36) 0.48

Clerical/Support staff (referent) 1.0

College

College of Arts and Sciences 1.58 (0.75, 3.34) 2.05 (0.81, 5.14) 0.13

College of Education 3.10 (1.16, 5.27) 2.09 (0.66, 4.68) 0.21

College of Medicine 3.39 (1.48, 6.78) 4.14 (1.45, 7.85) 0.01?

College of Nursing 5.44 (1.47, 8.12) 3.79 (0.84, 7.16) 0.08

College of Pharmacy 1.78 (0.46, 3.91) 1.40 (0.27, 4.22) 0.68

College of Public Health 2.21 (0.58, 4.45) 1.88 (0.42, 3.32) 0.41

School of Continuing Studies and Academic Outreach 0.93 (0.31, 2.78) 0.85 (0.20, 2.51) 0.82

Others 1.24 (0.62, 2.50) 1.46 (0.58, 3.68) 0.43

College of Business and Technology (referent) 1.0

* OR means Odds Ratioa Age group 19 years was deleted from regression analysis due to low sample size (n = 5)? P value \ 0.05


123

Table 5 University personnel voluntary compliance with tobacco-free campus policy (n = 1,177)

Characteristics Compliance with ETSU tobacco-free policy

Self reporting Reporting others

Smoked cigarettes on

ETSU premises during

past 2 years

(n = 67)

Used any other tobacco

products on ETSU

premises during past

2 years

(n = 20)

Noticed anyone using

tobacco products outside

his/her private car on ETSU

premises

(n = 952)

N n (%) Prop* of N n (%) Prop of N n (%) Prop of N

Age

19 years 5 0 (0.0) (0.0) 0 (0.0) (0.0) 5 (0.5) (100.0)

20–29 years 106 8 (11.9) (7.5) 4 (20.0) (3.8) 88 (9.2) (83.0)

30–39 years 211 23 (34.3) (10.9) 6 (30.0) (2.8) 179 (18.8) (84.8)

40–49 years 271 12 (17.9) (4.4) 4 (20.0) (1.5) 223 (23.4) (82.3)

50–59 years 397 18 (26.9) (4.5) 4 (20.0) (1.0) 323 (33.9) (81.4)

[ 60 years 154 4 (6.0) (2.6) 2 (10.0) (1.3) 126 (13.2) (81.2)

Missing responses 33 2 (3.0) 0 (0.0) 8 (0.8)

Gender

Female 789 36 (53.7) (4.6) 2 (10.0) (0.2) 631 (66.3) (80.0)

Male 367 30 (44.8) (8.2) 17 (85.0) (4.6) 316 (33.2) (86.1)


Race

American Indian or Alaska Native 5 2 (3.0) (40.0) 0 (0.0) (0.0) 3 (0.3) (60.0)

Asian 27 1 (1.5) (3.7) 0 (0.0) (0.0) 23 (2.4) (85.2)

Black or African American 44 5 (7.5) (11.4) 2 (10.0) (4.5) 32 (3.4) (72.7)

Caucasian/White 1,053 58 (86.5) (5.5) 18 (90.0) (1.7) 876 (92.0) (83.2)

Hispanic 12 0 (0.0) (0.0) 0 (0.0) (0.0) 8 (0.8) (66.7)


Smoking status

Ever cigarette smoker 525 67 (100.0) (12.8) 16 (80.0) (3.0) 414 (43.5) (78.8)

Current cigarette smoker 106 46 (68.7) (43.4) 6 (30.0) (5.7) 78 (8.2) (73.6)

Ever user of other tobacco products 134 20 (29.9) (14.9) 13 (65.0) (9.7) 115 (12.1) (85.8)

Current user of other tobacco products 32 7 (10.4) (21.9) 12 (60.0) (37.5) 28 (2.9) (87.5)

Employment status

Administrator/Professional 333 19 (28.4) (5.7) 4 (20.0) (1.2) 274 (28.8) (82.3)

Clerical/Support staff 374 29 (43.2) (7.8) 5 (25.0) (1.3) 301 (31.6) (80.5)

Faculty 392 15 (22.4) (3.8) 9 (45.0) (2.3) 338 (35.5) (86.2)

Others 43 3 (4.5) (9.3) 1 (5.0) (4.6) 29 (3.0) (90.7)


College

College of Arts and Sciences 194 18 (26.9) (9.3) 2 (10.0) (1.0) 178 (18.7) (91.7)

College of Business and Technology 75 4 (6.0) (5.3) 4 (20.0) (5.3) 66 (6.9) (88.0)

College of Clinical and Rehabilitative Health Sciences 31 0 (0.0) (0.0) 0 (0.0) (0.0) 25 (2.6) (80.6)

College of Education 101 3 (4.5) (3.0) 1 (5.0) 91.0) 79 (8.3) (78.2)

College of Medicine 209 9 (13.4) (4.3) 5 (25.0) (2.4) 155 (16.3) (74.2)

College of Nursing 71 4 (6.0) (5.6) 0 (0.00) (0.0) 58 (6.1) (81.7)

College of Pharmacy 24 2 (3.0) (8.3) 0 (0.0) (0.0) 17 (1.8) (70.8)

College of Public Health 32 0 (0.0) (0.0) 0 (0.0) (0.0) 31 (3.3) (96.9)

School of Continuing Studies and Academic Outreach 30 2 (3.0) (6.7) 0 (0.0) (0.0) 24 (2.5) (80.0)

Others 259 16 (23.8) (9.7) 5 (25.0) (3.1) 221 (23.2) (85.3)


* Proportion of N


123

Previous studies suggested that support for smoke-free

policies varied across professions, even among medical

professionals [23]. Except the College of Medicine, the

likelihood of support for the policy was not significant,

when employees in the College of Business and Technol-

ogy were compared with those in other colleges and

schools. This relationship could be due to the generally

high level of education of the study population. Addition-

ally, the time lapse between the implementation of the

policy and administration of the survey (20 months) may

have blunted the views of employees in the other colleges

and schools because previous research suggests that sup-

port for smoke-free policies improves once they are

implemented [18].

The central conflicting issue, which is consistent with

the working hypothesis of the study and the existing lit-

erature [24] is compliance with the policy. Although the

study could not compare employees’ compliance with the

policy and that of students, the results suggested that this

issue is the main drawback of the policy. While employees’

self-reports on non-compliance indicated that only a few

have not complied with the policy, an overwhelming

majority, across all categories, reported that they have

observed others engaged in non-compliance. This dis-

crepancy in the results could be due to the inability to

identify the status of people who were not complying with

the policy. However, it is important to note that the use of

tobacco products by personnel on campus sends mixed

messages to students and non-compliance by personnel has

negative effects on compliance by students [24]. As such,

to ensure compliance with this policy, the university

authorities should include strong reporting and enforce-

ment mechanisms. The lesson for other higher educational

institutions in the state, other tobacco-producing states and

elsewhere, is that tobacco-free campus policies with weak

or no reporting and enforcement mechanisms could lead to

high levels of non-compliance. As the leader of tobacco-

free campus policies in the higher education system in

Tennessee, the experience of ETSU could provide impor-

tant lessons for how to control the use of tobacco products

not only in the state but also in other tobacco-producing

states and economies worldwide. Thus, dealing with the

issue of compliance will make the tobacco-free campus

policy worthy of emulation and for diffusion as ETSU has

demonstrated how to use an authority granted by state laws

to develop an effective policy to reduce tobacco use and

improve health in a tobacco-friendly environment.

Limitations

The study faces limitations with respect to the sample for

the analysis. First, the data were from a single institution,

which makes it difficult to extrapolate the findings to the

entire higher education system in the state. Second, the

analysis was based on self-reports with no independent

means to verify the responses. Third, the absence of

baseline data and the cross-sectional nature of the data

limited the ability to make causal claims about change in

receptivity to the policy among the employees. Fourth,

employees’ compliance with the policy could not be dis-

entangled as the identity of people not complying with the

policy could not be determined. However, the study pro-

vided insight into the attitudes and behaviors of university

personnel in a tobacco-friendly environment toward the

first tobacco-free campus policy.

Conclusion

This investigation into the tobacco-free campus policy of a

university in a major tobacco-producing state delineated

key determinants for employees’ support for the policy.

The successful enactment and implementation of the ETSU

tobacco-free campus policy, the first in the higher educa-

tion system (public sector) of Tennessee, suggested that

colleges and universities (public and private) could use the

authority under the law for effective tobacco control. In

fact, with the state’s preemption of tobacco regulation,

colleges and universities present an important venue for

developing stronger tobacco-free policies to help reduce

tobacco usage rate in the state and attain Healthy People

2020 goal of 12% national adult smoking rate [25]. Addi-

tionally, the fact that current smokers and employees with

relatively lower socio-economic status were less likely to

support the policy demands more health education about

tobacco use and control, and the provision of cessation

services to assist tobacco users to quit. Moreover, the high

rate of non-compliance observed by the employees sug-

gested that reporting and enforcement mechanisms should

not only be included in tobacco-free campus policies but

also such mechanisms should be unambiguous. The lesson

for other higher educational institutions in the state, across

the country and worldwide is that in a tobacco-friendly

environment tobacco-free campus policy without reporting

and enforcement mechanisms could lead to high levels of

observed non-compliance.

Acknowledgments We would like to thank the East Tennessee

State University Foundation for providing the startup funds that

supported the research, the Department of Health Services Adminis-

tration, the College of Pubic Heath, and the College of Medicine for

providing the logistical support, and ETSU Provost and Vice Presi-

dent for Health Affairs for helping us in collection of the data.

Competing interests The authors have no competing interests to

declare.


123

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Documents

University Personnel’s Attitudes and Behaviors Toward the First Tobacco-Free Campus Policy in Tennessee