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Increased adoption of smoke-free policies on campuses with schools of nursing

      Highlights

      • Ninety-one percent of deans of schools of nursing (n = 627) in 2017 reported that their campus had a smoke-free policy.
      • Fifty-five percent increase in smoke-free policies in campuses with schools of nursing from 2015 to 2017.
      • No significant differences in policy adoption by location of schools of nursing or use of web resources.

      Abstract

      Background

      In 2015, the majority of U.S. American Association of Colleges of Nursing (AACN)-accredited schools of nursing resided on campuses without smoke-free policies.

      Purpose

      To determine the presence of smoke-free policies at AACN-accredited after resolutions from AACN and the American Academy of Nursing, and the creation of online resources.

      Methods

      Smoke-free policies (2015-2017) were determined through listings on the ANRF College Campus Policy Database© and survey responses from nursing deans.

      Results

      Smoke-free policies for 689 schools of nursing increased from 36% in 2015 to 91% in 2017. There were no significant differences by nursing program types or geographic area. Twenty percent of deans reported using the resources, with over 1700-page views.

      Conclusion

      Smoke-free policies increased after support from two national nursing organizations. Learning in a smoke-free environment should be an expectation for nursing students to protect their own health, and to support their future critical role in tobacco control.

      Keywords

      Introduction

      Tobacco use and exposure to secondhand smoke, the leading cause of preventable disease and death in the United States (

      U.S. Department of Health and Human Services, Office of disease prevention and health promotion. Healthy People 2020. 2010. Available at: http://www.healthypeople.gov/2020/topics-objectives/topic/tobacco-use/objectives. Published November 2010. Accessed October 14, 2016.

      ), are an important focus for nursing leaders (
      • Sarna L.
      • Bialous S.A.
      • Chan S.S.
      • Hollen P.
      • O'Connell K.A.
      Making a difference: nursing scholarship and leadership in tobacco control.
      ). Policies that create smoke-free environments on college/university campuses are effective in denormalizing tobacco use and promoting quitting (
      • Fallin A.
      • Roditis M.
      • Glantz S.A.
      Association of campus tobacco policies with secondhand smoke exposure, intention to smoke on campus, and attitudes about outdoor smoking restrictions.
      ,
      • Seo D.C.
      • Macy J.T.
      • Torabi M.R.
      • Middlestadt S.E.
      The effect of a smoke-free campus policy on college students’ smoking behaviors and attitudes.
      ). Such policies ban the use of tobacco products, many including vaping or electronic cigarettes, on campus. Previous policy studies revealed only 35% of postsecondary institutions and 36% of schools of nursing had smoke-free policies (
      • Heath J.
      • Hollen P.J.
      • Bialous S.A.
      • Coyne B.
      • Sarna L.
      Few U.S. schools of nursing on campuses with smoke-free policies: a call for action.
      ,
      • Trad C.
      • Bayly J.
      • Saint-Fort L.
      • Andrews M.
      • Patel M.
      • Sabado-Liwag M.
      • Choi K.
      Adoption of tobacco- and smoke-free policies in a US national sample of postsecondary educational institutions.
      ).
      In an effort to galvanize nursing leadership to support smoke-free campus policies to provide a safe environment for nursing students, the American Academy of Nursing (AAN) adopted a resolution promoting smoke-free policies on college campuses in May 2013, followed by a similar resolution from the American Association of College of Nursing (AACN) in 2016 (
      • Sarna L.
      • Bialous S.A.
      Resolution: smoke-free campus policies for schools of nursing and college campuses. Tobacco Control Subgroup and Health Behavior Expert Panel, American Academy of Nursing.
      ,

      American Association of Colleges of Nursing. Smoke-free and tobacco-free schools of nursing toolkit. 2016. Available at: https://www.aacnnursing.org/Teaching-Resources/Tool-Kits/Tobacco-Free. Published March 21, 2016. Accessed June 2, 2016.

      ). In Phase I of a campaign by the AAN Tobacco Control Subgroup, a toolkit of web-based smoke-free campus resources was developed and posted on the AACN website (

      American Association of Colleges of Nursing. Smoke-free and tobacco-free schools of nursing toolkit. 2016. Available at: https://www.aacnnursing.org/Teaching-Resources/Tool-Kits/Tobacco-Free. Published March 21, 2016. Accessed June 2, 2016.

      ), with sample policies, articles about nurses and tobacco control, as well as successful examples of nurse-led efforts to implement smoke-free university policies (
      • Hahn E.J.
      • Fallin A.
      • Darville A.
      • Kercsmar S.E.
      • McCann M.
      • Record R.A.
      The three Ts of adopting tobacco-free policies on college campuses.
      ). The toolkit included model letters for incoming nursing students, stressing the importance of being a smoke-free role model and providing cessation resources information.
      The primary purpose of this study was to report changes in the presence of smoke-free policies on campuses where there were AACN-accredited schools of nursing in the United States from 2015 to 2017. The second purpose was to evaluate the use of a web-based toolkit offered on the AACN website after supportive resolutions from nursing organizations.

      Methods

      Study Design/Sampling Plan

      In Phase I, Smoke-Free Campus Policy for Schools of Nursing Campaign, only 247 (36%) schools of nursing were on campuses with smoke-free policies. A consort diagram of the school selection was previously published (
      • Heath J.
      • Hollen P.J.
      • Bialous S.A.
      • Coyne B.
      • Sarna L.
      Few U.S. schools of nursing on campuses with smoke-free policies: a call for action.
      ). In Phase II, the Tobacco Control Subgroup of the AAN's Health Behavior Expert Panel aimed to provide an educational web-based portal to support the initiation of smoke-free policies on college campuses and to evaluate changes in policy over a 2-year period (
      • Heath J.
      • Hollen P.J.
      • Bialous S.A.
      • Coyne B.
      • Sarna L.
      Few U.S. schools of nursing on campuses with smoke-free policies: a call for action.
      , p. 274). The intent was to help nurse leaders stay abreast of tobacco control initiatives and/or issues, as well as provide resources to help establish smoke-free campus policies, help students quit or avoid smoking initiation, and provide examples of successful programs.
      Four hundred and forty-two US campuses with US AACN-accredited schools of nursing (excluding those with online only programs or those that did not offer a nursing degree) without a smoke-free policy in 2015 were identified for Phase II of the campaign. A review using the 2017 Americans for Nonsmokers’ Rights Foundation (ANRF) College Campus Policy Database was conducted to determine if more campuses had enacted such a policy since 2015 (

      Americans for Nonsmokers’ Rights Foundation (ANRF). Americans for nonsmokers’ rights updated list of U.S. colleges and universities with smokefree and tobacco-free policies 2017. 2017. Available at: https://no-smoke.org/wp-content/uploads/pdf/smokefreecollegesuniversities.pdf. Accessed September 14, 2017.

      ). After the review, an additional 211 out of the 442 campuses were identified in the ANR data base as smoke-free, resulting in 458/689 (66.5%) schools of nursing on campuses with a policy, leaving 231 (33.5%) without a known policy. These remaining schools are the focus of this Phase II report.

      Procedures and Data Analysis

      This study was approved or deemed exempt by the institutional review boards of all participating schools of nursing.
      In November 2017, an AACN-approved letter was e-mailed to 231 deans of schools of nursing without a known smoke-free policy. The letter urged their active engagement to facilitate and implement smoke-free campus policies, to support quit efforts of faculty, staff and students, and reminded them about the resources on the AACN website. Deans (or their designee) were asked to complete a 11-item online survey to confirm the smoke-free status on their campus and in their school. Information was requested about the name of their school, their geographic location, and type of nursing degrees offered. Deans also were asked to respond to information about the dissemination of a letter about smoke-free policies and smoking cessation resources intended for prelicensure and graduate students that was created for Phase 1 of the project, and their perception of student's satisfaction with the letter. Deans were also asked about their use of and satisfaction with the AACN website resources in general and in helping with the campus become smoke-free, and if they would recommend the resources to other administrators.
      The percentage of new schools with smoke-free policies in 2017 was calculated. The total number of new schools with smoke-free policies (after the 2015 survey) was added to the number of schools (247) with smoke-free policies in 2015. This provided a total percentage of schools with smoke-free policies, and allowed for an assessment of percent change from 2015 to 2017. Descriptive statistics profiled schools of nursing and determined differences by presence of smoke-free campus policies by four geographic areas (Northeast, South, Midwest, and West) and by type of nursing degree offered (i.e., PhD/DNS, DNP, MS/MSN, MN, BS/BSN). Google analytics were used to evaluate website use from July 2016 (after the tool kit was posted) through November 2017 (the date when the survey was sent to the deans).

      Findings

      The survey results indicated that 169 additional schools among the 231 surveyed were on campuses with smoke-free policies, even though they were not listed as such on the ANR data base originally surveyed in 2015. Thus, a total of 627 (91%) of schools were now on campuses with smoke-free policies in 2017, a 55% increase from 2015 to 2017 (Figure 1). Deans from 15 of the schools without a policy reported that implementation was in progress.
      Figure 1
      Figure 1Changes in percentage of smoke-free policies on US campuses with schools of nursing accredited by the American Association of Colleges of Nursing, 2015 to 2017 (n = 689).
      Twenty percent of deans surveyed reported that they had used the AACN website resources. Total online page views for the AACN smoke-free website from July 2016 to November 2017 were 1,764. There were no differences in use of the website resources by those with or without campus smoke-free policies. In addition, there were no statistically significant differences in the presence/absence of smoke-free policies in schools of nursing by geographic location, by degree programs, or by use of the website resources. The majority of schools (81.3%, n = 192) had not disseminated the sample letter to students in their academic programs.

      Discussion

      This is the first report of changes in smoke-free college/university environments that house academic nursing programs. In 2017, the number of US colleges and universities with smoke-free policies doubled, reaching 2,082 (
      • Wang T.W.
      • Tynan M.A.
      • Hallett C.
      • Walpert L.
      • Hopkins M.
      • Konter D.
      • King B.A.
      Morbidity and Mortality Weekly Report (MMWR).
      ). From 2015 to 2017, the percentage of schools of nursing on campuses with smoke-free policies went from 36% to 91%, a 55% increase. This analysis supports a higher uptake of implementation of smoke-free policies on campuses with schools of nursing since the AAN and AACN resolutions. The AACN website traffic reflected interest in the topic, despite the reported low uptake of toolkit resources by deans.
      There are several limitations to this study. This sample only included schools of nursing accredited by the AACN (bachelor's or higher), making generalizability to all prelicensure (i.e., diploma and associate degree) programs limited. Our study only captured US schools of nursing accredited by AACN in 2015; in 2018, the number of accredited schools increased to 814, educating over a half million nursing students (

      American Association of Colleges of Nursing Membership. 2018. Available at: https://www.aacnnursing.org/About-AACN. Accessed October 25, 2018.

      ). Our study did not differentiate between private or publicly funded campuses, between campuses with smoke-free and the more comprehensive tobacco-free policies, nor was it able to determine if vaping or other tobacco products (such as hookah) were included in the policy. Although we invited deans to provide a designee, the dean or the designee may not have been familiar with the tobacco control policy or resources used within their school of nursing. Our study was unable to specifically determine if the resolutions from AAN and AACN resulted in increased support from nursing educators or other health professions for smoke-free policies. Schools of nursing may be on campuses with other health professional schools, such as schools of public health and medicine, that may have amplified support for smoke-free policies. Similar to the procedure used in Phase I, we did not confirm the presence of a smoke-free policy if the campus was listed on the updated ANR website. However, the ANR data base could have been inaccurate. We did confirm with those schools not listed and if positive for the presence of a policy updated the number of schools. Utilization of the AACN website toolkit resources was only evaluated by schools without known smoke-free policies. The resource use by deans from the additional 221 schools with new policies from 2015 to 2017 was not surveyed. Because of the general low uptake of use of the toolkit resources, we did not describe the satisfaction of specific individual resources.
      Decades ago, many students and faculty would smoke in lecture halls, in libraries and throughout college campuses; students and faculty in the health professions were not exceptions. The dramatic increase in smoke-free policies on college campuses has provided the next generation with protection from exposure to secondhand smoke, as well as support for quit efforts. Educating nurses, the largest group of health providers, in a smoke-free environment is important for their own health as well as serves as a model for future interactions with the public.
      With increases in smoke-free environments, there is increased demand and opportunities to help people quit smoking. The Office on Smoking and Health (OSH) declared 2019 as the “Year of Cessation” with the goal of increasing successful cessation attempts among the 38 million US adults who smoke (

      Office on Smoking and Health. Why cessation matters. 2018. https://www.cdc.gov/tobacco/about/osh/pdfs/1010-year-of-cessation-overview-508.pdf. Accessed January 10, 2019.

      ). There will be special attention to support quit efforts among those groups with higher smoking prevalence, including those with less education, low income (below the poverty line), lack of insurance, serious mental illness, sexual minority groups, men, adults aged 25 to 64, those living in the Midwest and South and American and Alaskan Indians as well as multicultural groups. In addition to implementing policies for smoke-free environments, other key strategies such as mass media campaigns and increasing tobacco prices, making quitting resources and support more available, are should reduce smoking overall. The focus on cessation by OSH is an opportunity for nursing organizations to partner with government agencies to support strategic efforts to protect the public from the harmful effects of tobacco by increasing the use of evidence-based cessation interventions. A simple goal for the profession could be that every nurse becomes knowledgeable, confident, and comfortable in delivering a smoking cessation intervention using evidence-based resources to help people quit. In order for this to occur, it will require focused efforts from nurse educators, practitioners, administrators, researchers, and policy makers. The support for smoke-free policies in academic settings could provide a model for future approaches.

      Continued Need for Action

      Leveraging increased support from academic nursing leaders to support policies that benefit population health is critical, especially in tobacco use which remains the leading cause of preventable death. This study demonstrated that two large leadership organizations could come together to support policy efforts for a major public health issue. Greater use of social media by nursing organizations to disseminate information about this policy and links to resources as well as other policies could be considered in the future. Most importantly, further exploration is needed about how to best communicate information about tobacco control to nursing students as well as assess the utility of specific smoke-free resources in nursing education.
      Continued efforts by nursing and other health care leaders are needed for ongoing monitoring, enforcing, and helping to develop new smoke-free policies as well as ensuring that resources are available to support quit efforts. Tobacco Free Nurses is one initiative that has been recognized as by the American Academy of Nursing as an Edge Runner for its efforts in promoting nursing involvement in tobacco control worldwide (

      American Academy of Nursing Edge Runners. Transforming America's health through nursing solutions. 2017. http://www.aannet.org/initiatives/edge-runners. Accessed June 6, 2019.

      ). Nurses’ interactions with the public should continue to include advice to reduce exposure to secondhand smoke, prevent tobacco use, support quit efforts, and support for other proven tobacco control policies to reduce prevalence.

      Acknowledgments

      The authors wish to thank the Tobacco Control Subgroup of the American Academy of Nursing Health Behavior Panel and the American Association of Colleges of Nursing for their support of the project. The authors also thank Marjorie Wells, PhD, RN, Jenny Brook, MS, from the University of California, Los Angeles, and Bethany Coyne, PhD, RN, and doctoral students from the University of Virginia: C Chu, J Crowder, and S Gwon.

      Appendix. Supplementary materials

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