Health beliefs related to secondhand smoke and smoke-free policies in a college community.
|Abstract:||The purpose of this study was to examine the health beliefs related to secondhand smoke exposure and perceptions of smoke-free policies among members of a college population. A stratified sample of students, employees, and community members (n = 1,069) completed a brief 7-item survey. Females were more likely than males to recognize secondhand smoke risks and were more supportive of smoke-free policies. Minorities were less likely to recognize secondhand smoke risks, but African Americans were more supportive of smoke-free policies than other minorities or Caucasians. Smokers who reported intent to quit smoking more closely resembled non-smokers in their health beliefs of secondhand smoke risks. Few differences existed among students, university employees, and community members. Implications for health education and smoke-free advocacy are discussed.|
Universities and colleges
Williams, Ronald D., Jr.
Barnes, Jeremy T.
Hunt, Barry P.
|Publication:||Name: American Journal of Health Studies Publisher: American Journal of Health Studies Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 American Journal of Health Studies ISSN: 1090-0500|
|Issue:||Date: Summer, 2011 Source Volume: 26 Source Issue: 3|
|Product:||Product Code: 8220000 Colleges & Universities NAICS Code: 61131 Colleges, Universities, and Professional Schools SIC Code: 8221 Colleges and universities|
|Organization:||Government Agency: United States. Department of Health and Human Services|
The 2010 U.S. Surgeon General's report on tobacco stated that
secondhand smoke is potentially more toxic than the direct smoke inhaled
from a filtered cigarette, in part due to the 69 known carcinogens and
over 7,000 chemicals found within such smoke (U.S. Department of Health
and Human Services, 2010). It is estimated that routine exposure to
secondhand smoke contributes to 46,000 coronary disease deaths and 3,000
lung cancer deaths among otherwise healthy, non-smoking U.S. citizens
each year (U.S. Department of Health and Human Services, 2006). In
addition to these cases of premature mortality, secondhand smoke has
also contributed to a number of preventable diseases such as asthma and
other respiratory tract infections (National Cancer Institute, 2007).
Considering the tremendous health risks of secondhand smoke, there is no
doubt that nonsmokers' exposure has contributed to the enormous
health and economic burden attributable to tobacco use in the United
States. The Centers for Disease Control and Prevention (2010) estimate
that tobacco costs over $96 billion annually in medical expenditures and
another $97 billion annually in lost productivity. In an effort to
reduce costs associated with tobacco, the Healthy People 2020 initiative
lists as one of its goals to "reduce illness, disability, and death
related to tobacco use and secondhand smoke exposure" (U.S.
Department of Health and Human Services, 2011). A known strategy to
reduce secondhand smoke exposure and reduce tobacco use is the adoption
of smoke-free ordinances (Bauer, Hyland, Li, Steger, & Cummings,
2005; Farkas, Gilpin, Distefan, & Pierce, 1999; Fichtenberg &
Glantz, 2002; Hopkins et al., 2001; Rigotti, Regan, Moran, &
As of February 2011, twenty-three states in the U.S., as well as the District of Columbia and the Commonwealth of Puerto Rico, have already enacted ordinances that prohibit smoking in all public workplaces (Americans for Nonsmokers' Rights, 2011). The Americans for Nonsmokers' Rights Foundation (2011) estimates that these smoke-free laws offer protection from public secondhand smoke exposure to 47.8% of the U.S. population. Additionally, smoke-free ordinances have led to decreased overall cigarette usage and improved the health of impacted communities (Alsever et al., 2009; Lightwood & Glantz, 2009; Meyers, Neuberger, & He, 2009; Rigotti et al, 2003).
TOBACCO CONTROL IN COLLEGE POPULATIONS
Tobacco control in college populations has been a public health focus for some time. Considerable research has been published addressing various tobacco-related issues among college students including smoking rates, predictive behaviors, and behavioral influences (Gilpin, White, & Pierce, 2005; Johnston, O'Malley, Bachman, & Schulenberg, 2007; Katz & Lavack, 2002; Ling & Glantz, 2002; Sutfin, Reboussin, McCoy, & Wolfson, 2009; Wetter et al., 2004). Despite research on personal smoking behaviors, there are few studies that examine issues related to secondhand smoke among college students. College students are known to patronize establishments that allow or even encourage indoor smoking such as bars, clubs, and restaurants frequently (Wolfson, McCoy, & Sutfin, 2009). In a study of over 4,000 college students in North Carolina, it was determined that common sites for secondhand smoke exposure were bars, restaurants, homes, and cars (Wolfson et al., 2009). Because students' secondhand smoke exposure is often higher than comparable populations, it is necessary to examine the issue of secondhand smoke among college students. Few studies have examined college students' perceptions of smoke-free policies (Loukas, Garcia, & Gottlieb, 2006; Ridner, Hahn, Staten, & Miller, 2006).
According to the American Nonsmokers' Rights Foundation (2011), at least 466 colleges and universities in the United States have enacted campus-wide 100% smoke-free policies. While this represents a significant public health achievement, these smoke-free policies represent just over 9% of the country's 4,352 degree-granting, postsecondary institutions (U.S. Department of Education, 2010). With an estimated 18.2 million students seeking higher education, it is imperative that public health protections from secondhand smoke exposure be available to college students. In addition to the benefits for college students, smoke-free policies can provide a healthier environment for university faculty, staff, and members of the surrounding community. While the focus of college smoke-free policies is often geared towards student health, it cannot be overlooked that many others in the university community may see environmental improvements. No studies have been published to date examining the perceptions of college staff and surrounding community members regarding secondhand smoke and smoke-free policies. The purpose of this study was to examine health beliefs related to secondhand smoke and smoke-free policies among people in a college community.
This study was conducted at a Midwestern, public university located in a city with no existing smoke-free ordinances. Although local advocacy coalitions were active in pursuing an ordinance through secondhand smoke awareness campaigns, no formal city-wide initiative existed at the time of this study. Surveys were administered during a two-week period in the fall of 2008 and another two-week period in the fall of 2009. Researchers stratified the sample selection by choosing six high traffic on-campus sites at which to collect data. The sites included the main cafeteria, student union, campus library, recreational center, a large residence hall, and an outdoor campus congregation area. Additionally, survey administration times were purposefully selected to provide for maximal coverage of campus population, as data was collected during morning, mid-day, and evening hours on all five days of the week. Individuals were asked to complete the survey and given passive consent forms. If they agreed to participate, each person completed the brief instrument. This resulted in a sample of 1,069 participants including students (n = 985), university employees (n = 56), and community members (n = 28). For purposes of this study, the term" community status" will be used to refer to the variable identifying participants as students, university employees, or community members. Females made up 56.1% (n = 600) of the sample. The sample was 74.0% (n = 791) white/Caucasian and 12.8% (n = 137) black/ African American, with 12.3% (n = 132) identifying as other races including Hispanic, Asian, Native American or other. These percentages accurately reflect the racial composition of the campus population including students and employees. The sample was slightly under-representative of white community members, while consisting of slightly higher percentages of black/African American and other race categories when compared to the actual population. University employees were not asked to identify if they were faculty, staff, or administration. Participants self-identified their smoking status in one of four categories: non-smoker (79.4%, n = 849), smoker with no intent to quit (5.6%, n = 49), smoker with intent to quit (9.3%, n = 99), or former smoker (6.2%, n = 66). Participants were given a standard definition that a person who has smoked one cigarette or more in the past 30 days is considered a smoker.
After reviewing other validated smoking-related instruments, a thirteen-question survey to reflect health beliefs related to secondhand smoke was designed. Eight of these items were scored on a five-point Likert scale ranging from 2 to -2 with positive scores representing beliefs that secondhand smoke is harmful to health and attitudes are favorable toward smoke-free environments. Four questions measured perceived severity of secondhand smoke exposure, one question measured perceived susceptibility, three questions asked about perceptions of smoke-free policies with remaining items asking demographic characteristics. Criterion validity was tested through a review of the survey items by a panel of five experts in tobacco control and college health. As a result of this review, minor editorial changes to the instrument. Face and content validity were examined by piloting the instrument with a small sample (n = 39) of college students. The students were asked to review the instrument for comprehension and content; but, no changes were suggested. The item was also tested for readability yielding a Flesch-Kincaid grade level of 5.3.
Internal consistency of the instrument was measured through a Cronbach's alpha estimation. The first survey administration in the fall of 2008 yielded an initial alpha level of .732; however, with the removal of one survey item, the alpha level increased to .849. This resulted in an instrument with a seven-item scale plus the additional demographic questions. The second survey administration in the fall of 2009 yielded a Cronbach's alpha estimate of .884 indicating that the scale has high internal consistency.
Statistical analysis was completed using the PAWS Statistics 18 program. Differences in smoking status and categorical demographic such as race, sex, and community status were tested using Chi-square analyses. Smoking status and the continuous variable of age was tested using independent sample t-test. Chi-square analyses were used to determine significant differences in smoking status and other demographic variables. Multivariate analysis of variance (MANOVA) was used to determine interaction of demographic classifications with secondhand smoke beliefs. Independent variables were sex, race, community status, and smoking status while the seven survey items on secondhand smoke and smoke-free policy beliefs served as dependent variables. A total of sixteen interactions were analyzed.
The mean age of the sample was 21.82 years with a mean of 20.75 years among students, 37.15 years among university employees, and 29.07 among community members. Chi-square analyses were used to determine significant differences in smoking status and other demographic variables. No statistically significant differences were found between smoking status and sex or community status. Statistically significant differences were observed among race where 82.0% of white participants, 79.1% of black participants, and 69.5% of participants of other races were non-smokers ([chi square] = 12.797; p = .046). Participants of other races made up the highest percentage of current smokers at 19.8% compared to 12.5% of white participants and 15.6% of black participants. Among all race classifications, smokers with stated intent to quit outnumbered smokers with no stated intent to quit.
SECONDHAND SMOKE BELIEFS
Multivariate analysis of variance (MANOVA) was used to determine interaction of sex, race, community status, and smoking status with secondhand smoke beliefs. Univariate analyses revealed that secondhand smoke beliefs were affected by sex (Wilks' [lambda] =.980, F(8, 982) = 2.454, p = .012, [[eta].sup.2] = .020), race (Wilks' [lambda] = .969, F(9, 1964) = 1.946, p = .013, [[eta].sup.2] = .016), community status (Wilks' [lambda] =.966, F(16, 1964) = 2.158, p = .005, [[eta].sup.2] = .017), and smoking status (Wilks' [lambda] =.945, F(24, 2848)=2.346, p [less than or equal to] .001, [[eta].sup.2] = .019); (Tables 1 & 2). MANOVA indicated that four different two-way interactions were statistically significant including sex-community status (Wilks' [lambda] = .969, F(16, 1964) = 1.924, p = .015, [[eta].sup.2] = .015), sex-race (Wilks' [lambda] = .970, F(16, 1964) = 1.887, p = .018, [[eta].sup.2] =.015), community status-race (Wilks' [lambda] = .961, F(24, 2848) = 1.650, p = .024, [[eta].sup.2] = .013), and community status-smoking status (Wilks' [lambda] =.906, F(48, 4835)=2.037, p [less than or equal to] 001, [[eta].sup.2] = .016). Sex-race-smoking status (Wilks' [lambda] = .925, F(48, 4835) = 1.612, p = .005, [[eta].sup.2] = .013) was the only statistically significant three-way interaction.
Statistically significant differences between males and females existed for all seven survey items with females being more likely to report secondhand smoke health risks and be more accepting of smoke-free policies. Although females were more likely to believe that secondhand smoke can be harmful to a non-smoker's health, cause cancer in a non-smoker, and cause death in a non-smoker, they were less likely than males to report that secondhand smoke may cause heart disease in non-smokers.
When examining race, a statistically significant difference was found in the beliefs that secondhand smoke can cause death, heart disease, and cancer in non-smokers. Caucasian participants were more likely to report such beliefs than were African American or other races; however, those participants of other races were substantially lower than both Caucasian and African American students. No differences were reported in the participants concern about their exposure to secondhand smoke. Additionally, beliefs about a smoke-free city did not differ among race. Conversely, participants did significantly differ in their beliefs about a smoke-free campus with African American participants being more supportive of a campus-wide policy than Caucasian or other races.
Of the seven survey items, only one showed statistically significant differences among community status. University employees were much more likely to report that they were concerned about their secondhand smoke exposure than were students and community members. Although not statistically significant, it is worth noting that university employees were more likely to report acceptance of a smoke-free policy on campus and in the city as well as more likely to believe that secondhand smoke poses health risks of cancer and death in non-smokers.
As expected the smoking status variable yielded statistically significant differences for all seven survey items with non-smokers more likely to report health risks, concern about exposure, and be more accepting of smoke-free policies. Interestingly, the responses of smokers with intent to quit and former smokers more closely resembled those of non-smokers when asked if secondhand smoke is harmful to a nonsmoker's health and if secondhand smoke can cause heart disease in a non-smoker. However, regardless of intent, smokers were less likely to favor smoke-free policies on campus or in the city.
A large body of evidence documents the health hazards associated with exposure to secondhand smoke (Ahijevych & Wewers, 2003; Eisner, Jacob, Benowitz, Balmes, & Blanc, 2009; Faught, Flouris, & Cairney, 2009; Glantz & Parmley, 1995; National Cancer Institute, 2007; Pitsavos et al, 2002; Rosenlund et al, 2001; Steenland, Thun, Lally, & Heath, 1996; U.S. Department of Health and Human Services, 2006). It is clear that both habitual and even less frequent exposure causes many adverse health effects including increased morbidity and mortality from a wide variety of conditions. As a result, there has been a gradual increase in the numbers of U.S. residents protected from secondhand smoke by passage of state laws and local ordinances. Now almost half of the U.S. population is protected from secondhand smoke exposure.
However, college students are more likely than the general population to be exposed to secondhand smoke on a regular basis. In addition, many colleges do not have comprehensive policies limiting smoking on campus which translates into little protection for millions of individuals living in college communities around the U.S. Hence, colleges could play a more substantial role in promoting public health by implementing policies limiting smoking on campus. Additionally, college towns across the U.S. can serve as leaders in smoke-free advocacy by adopting smoke-free ordinances which protect not only students, but employees and surrounding community members as well. Colleges are locations where preventing exposure to secondhand smoke could play a substantial role in furthering public health initiatives. College administrators have a responsibility to provide a safe and healthy environment for all individuals on campus. Enacting smoke-free campus policies and offering smoking cessation services, such as those recommended by the American College Health Association (2009), are worthy goals.
To facilitate the implementation of smoke-free policies, it is imperative that health educators and advocates understand the college community's perceptions regarding secondhand smoke and smoke-free ordinances. The results of this study provide insights into the attitudes of college students, employees, and community members. Female participants were much more likely than males to recognize health risks of secondhand smoke exposure, as well as more likely to support smoke-free policies. Health educators may see benefit in recruiting female college community members for inclusion in advocacy efforts. Additionally, efforts in health education about the risks of secondhand smoke and benefits of smoke-free policies should be targeted to a whole community, with a specific focus on the male college population.
The differences in secondhand smoke beliefs among varying ethnicities highlight the importance of specific, targeted approaches to smoke-free advocacy. Health educators should seek to develop health education and smoke-free education messages that are targeted directly to the populations of need, as the results of this study that smoke-free support does not directly correlate to heath beliefs. Despite limited beliefs of the health risks of secondhand smoke, African American participants were more likely to support smoke-free policies confirming prior research of Loukas, Garcia, and Gottlieb (2006). As smoke-free policy supporters, African American college community members can potentially play a key role in smoke-free advocacy efforts, despite health beliefs. Health educators should recognize the differences when designing advocacy campaigns. Health education messages should be targeted to those sub-populations that see little health risk from secondhand smoke, while advocacy messages aimed at smoke-free policy supporters may be targeting a different sub-population.
Advocacy and education efforts should also consider differences among community status. While university employees were more concerned about their personal exposure to secondhand smoke than students and other community members, there were no significant differences related to other secondhand smoke health beliefs. Advocacy and health education efforts should include targeted messages to all three segments of a college community. Although not statistically significant, university employees were more likely to support smoke-free campus and community policies. Health educators should seek the support of university faculty and staff in advocacy efforts, particularly those related to smoke-free campus policies. One potential opportunity for university employee involvement in advocacy efforts is through the American Cancer Society's Smoke-Free College Campus Initiative (2001). Other examples of faculty and staff involvement in smoke-free advocacy include the Campus-Community Alliances for Smoke-Free Environments and faculty sponsorship for the student group Peers Advocating for Smoke-Free Solutions (2006).
As expected, non-smokers were more likely to report risks related to secondhand smoke and more likely to support smoke-free policies. However, not all smokers failed to recognize the health risks of secondhand smoke. The health beliefs of smokers who reported intent to quit more closely resembled non-smokers than smokers with no reported intent to quit. Although smokers with intent to quit did not show support for smoke-free policies, they were slightly more favorable to such policies than those with no intent to quit. Considering that smokers with intent to quit already recognize the health risks of secondhand smoke, health education messages targeting this group should highlight the impact that smoke-free policies can have on smoking cessation (Alsever et al., 2009; Fowkes, Stewart, Fowkes, Amos, & Price, 2008; Hahn, Rayens, Langley, Darville, & Dignan, 2009; Hyland et al, 2009; Lightwood & Glantz, 2009; Meyers, Neuberger, & He, 2009; Ong & Glantz, 2005; Rigotti et al, 2003).
The results of this study demonstrate that the majority of the non-smoking college community population considered exposure to secondhand smoke detrimental to health, that they were concerned about their exposure and that the University and city should have policies limiting smoking. Although, as might be expected the views of smokers are not identical, they are not vehemently opposed to policies limiting smoking. Health educators and smoke-free advocates should consider the characteristics such as sex, race, smoking status, and community status when designing educational and advocacy programs for a college population. Successful advocacy efforts for smoke-free legislation in college communities can have a drastic impact on the health of millions of adults in the U.S.
LIMITATIONS AND DELIMITATIONS
This study was delimited to those participants available due to logistical and demographic accessibility. As described in the methods section above, survey administration times and sites were stratified in an attempt to gather an appropriate probability sample; however, the sample still had a much higher proportion of students than employees and community members. Generalizability is limited due to the sample consisting of participants in one college community; however, this study has merit in health education as it serves to indicate variable differences that may impact smoke-free advocacy.
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Ronald D. Williams, Jr., PhD, CHES, is affiliated with the Mississippi State University, Jeremy T. Barnes, PhD, is affiliated with the Southeast Missouri State University, Barry P. Hunt, EdD is affiliated with the Mississippi State University. Heidi Winborne, BS, is affiliated with the Mississippi State University. Corresponding Author: Ronald D. Williams, Jr., PhD, CHES, Mississippi State University, Department of Food Science, Nutrition, and Health Promotion, Box 9805, Mississippi State University, MS 39762. Tel: 662-325-0401,
Table 1. Univariate Analyses of Participants Beliefs about Secondhand Smoke and Smoke-Free Policies by Sex and Race Female Male (n = 600) (n = 469) Mean(SD) Mean(SD) T(p) 1. Exposure to 1.44(.787) 1.29(.889) 2.73(.007) second hand smoke is detrimental to a non-smoker's health 2. Exposure to second 1.14(.937) 0.90(1.053) 4.03(.000) hand smoke can cause death in non-smokers 3. Exposure to second 1.37(.668) 1.54(.772) 2.84(.005) hand smoke can cause heart disease in non-smokers 4. Exposure to second 1.41(.835) 1.21(.989) 3.48(.001) hand smoke can cause cancer in non-smokers 5. I am concerned 0.75(1.133) 0.59(1.187) 2.28(.023) about my exposure to secondhand smoke 6. The University should 0.70(1.896) 0.48(1.320) 2.64(.009) have a policy making the entire campus smoke free 7. This city should have 0.69(1.316) 0.35(1.330) 4.07(.000) an ordinance prohibiting smoking in all public places including bars and restaurants Caucasian African (n = 791) American (n = 137) Mean(SD) Mean(SD) 1. Exposure to 1.41(.839) 1.30(.852) second hand smoke is detrimental to a non-smoker's health 2. Exposure to second 1.09(.973) 1.05(.973) hand smoke can cause death in non-smokers 3. Exposure to second 1.68(.688) 1.48(.816) hand smoke can cause heart disease in non-smokers 4. Exposure to second 1.40(.868) 1.29(.928) hand smoke can cause cancer in non-smokers 5. I am concerned 0.69(1.190) 0.80(1.017) about my exposure to secondhand smoke 6. The University should 0.62(1.330) 0.80(1.171) have a policy making the entire campus smoke free 7. This city should have 0.56(1.355) 0.67(1.224) an ordinance prohibiting smoking in all public places including bars and restaurants Other (n = 132) Mean(SD) F(p) 1. Exposure to 1.25(.823) 2.69(.068) second hand smoke is detrimental to a non-smoker's health 2. Exposure to second 0.72(1.029) 7.87(.000) hand smoke can cause death in non-smokers 3. Exposure to second 1.39(.788) 13.03(.000) hand smoke can cause heart disease in non-smokers 4. Exposure to second 0.96(.972) 13.74(.000) hand smoke can cause cancer in non-smokers 5. I am concerned 0.55(1.101) 1.65(.193) about my exposure to secondhand smoke 6. The University should 0.35(1.263) 3.98(.019) have a policy making the entire campus smoke free 7. This city should have 0.32(1.262) 2.57(.077) an ordinance prohibiting smoking in all public places including bars and restaurants Table 2. Univariate Analyses of Participants Beliefs about Secondhand Smoke and Smoke-Free Policies by Smoking Status and Community Status Non-smoker Smoker with Smoker with (n = 849) no intent intent to to quit quit (n = 49) (n = 99) Mean(SD) Mean(SD) Mean(SD) 1. Exposure to second 1.50(.762) 0.33(1.214) 1.06(.879) hand smoke is detrimental to a non-smoker's health 2. Exposure to second 1.17(.911) -0.10(1.21) 0.62(1.085) hand smoke can cause death in non-smokers 3. Exposure to second 1.72(.570) 0.55(1.385) 1.38(.817) hand smoke can cause heart disease in non-smokers 4. Exposure to second 1.46(.777) 0.22(1.403) 0.96(1.049) hand smoke can cause cancer in non-smokers 5. I am concerned 0.89(1.057) -0.78(1.046) -0.18(1.119) about my exposure to secondhand smoke 6. The University should 0.85(1.188) -0.90(1.242) -0.68(1.154) have a policy making the entire campus smoke free 7. This city should have 0.78(1.209) -0.96(1.290) -0.65(1.296) an ordinance prohibiting smoking in all public places including bars and restaurants Former Student Smoker (n = 984) (n = 66) Mean(SD) F(p) Mean(SD) 1. Exposure to second 1.03(.911) 45.40(.000) 1.36(.840) hand smoke is detrimental to a non-smoker's health 2. Exposure to second 0.77(1.020) 37.19(.000) 1.03(.985) hand smoke can cause death in non-smokers 3. Exposure to second 1.36(.757) 56.28(.000) 1.62(.717) hand smoke can cause heart disease in non-smokers 4. Exposure to second 0.95(.999) 44.06(.000) 1.34(.890) hand smoke can cause cancer in non-smokers 5. I am concerned 0.34(1.149) 65.22(.000) 0.66(1.152) about my exposure to secondhand smoke 6. The University should 0.35(1.243) 76.95(.000) 0.60(1.300) have a policy making the entire campus smoke free 7. This city should have 0.36(1.285) 66.46(.000) 0.54(1.317) an ordinance prohibiting smoking in all public places including bars and restaurants University Community Employee Member (n = 56) (n = 28) Mean(SD) Mean(SD) F(p) 1. Exposure to second 1.54(.830) 1.46(.693) 1.33(.266) hand smoke is detrimental to a non-smoker's health 2. Exposure to second 1.18(1.162) 0.96(1.071) 0.660(.517) hand smoke can cause death in non-smokers 3. Exposure to second 1.61(.731) 1.41(.747) 1.15(.316) hand smoke can cause heart disease in non-smokers 4. Exposure to second 1.16(1.118) 1.18(.983) 1.364(.256) hand smoke can cause cancer in non-smokers 5. I am concerned 1.14(1.197) 0.50(1.171) 4.96(.007) about my exposure to secondhand smoke 6. The University should 0.82(1.428) 0.43(1.399) 1.04(.354) have a policy making the entire campus smoke free 7. This city should have 0.80(1.482) 0.18(1.517) 2.17(.119) an ordinance prohibiting smoking in all public places including bars and restaurants
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