A Review of Tobacco Policies on University of California Campuses

Background and Purpose: College and university tobacco control programs have historically neglected cessation. In 2012, the University of California Office of the President (UCOP) released a Smoke and Tobacco Free policy that became effective in January 2014. The policy provided for a comprehensive education and outreach campaign that included resources and referrals for cessation. We sought to determine whether all University of California (UC) campuses met UCOP standards. Methods: We reviewed the Smoke & Tobacco Free policies created by UCOP and posted at ten UC campuses, searched the tobacco free websites of each campus for cessation resources, and contacted tobacco-free task forces. Results: We found that all UC campuses met the UCOP standard by addressing tobacco cessation in their campus policies. The provision of cessation services and resources was limited and varied substantially by campus, and no campuses reported collecting data on the use of cessation programs. Conclusion: Consistent with concerns that college and university tobacco policies neglect cessation, UC campuses mentioned tobacco cessation resources and programs but did not provide consistent services. These campuses also did not report on the use of tobacco cessation resources, making it difficult to assess the effects of offering different types of cessation programs.


Introduction
Tobacco use in the University of California (UC) system is estimated at 6%-10% of students and 3%-9% of employees (Guzman, 2013). While these rates are lower than national averages (Centers for Disease Control and Prevention, 2018a;Sutfin et al., 2012) there is no safe level of smoking. Half of all smokers who continue to smoke will end up dying from a smoking-related illness, quitting smoking is beneficial to health at any age, and cigarette smokers who quit before age 35 have mortality rates similar to those who never smoked (Centers for Disease Control and Prevention, 2011).
Tobacco control policies at the college and university level focus on making campuses tobacco free (Halperin & Rigotti, 2003;Plaspohl, Parrillo, Vogel, Tedders, & Epstein, 2012;W Wang et al., 2018). "Tobacco free" policies are defined as those in which the use of combustible and smokeless tobacco products is prohibited on the entire campus property, both indoors and out (W Wang et al., 2018). Studies have typically relied on surveying a convenience sample of informants at a subset of colleges and universities to identify policies (Halperin & Rigotti, 2003;Plaspohl et al., 2012;Wechsler, Kelley, Seibring, Kuo, & Rigotti, 2001), although more recent research has reviewed written policies to improve the reliability of findings (Lee, Goldstein, Klein, Ranney, & Carver, 2012). A review of interventions designed to reduce smoking prevalence among college students found that study designs in this population were typically weak and that smoking cessation programs were limited, with most policies emphasizing tobacco free campuses rather than effective cessation programs combining counseling and pharmacotherapy (Murphy-Hoefer et al., 2005). One existing survey addressing tobacco cessation at colleges found that more than 40% of campuses did not offer cessation services, and that these services should be expanded to discourage tobacco use (Wechsler et al., 2001). In the absence of comprehensive smoking cessation programs, efforts to create tobacco free campuses may result in hidden rather than reduced smoking (Centers for Disease Control and Prevention, 2018b). For example, qualitative interviews conducted on UC campuses suggest that some individuals switched from visible smoking areas to more secluded areas; four months after tobacco free policies took effect, 55% of students surveyed had seen a person smoking on campus at UC Riverside and 38% reported being exposed to secondhand smoke on campus in the past week (Fallin, Roditis, & Glantz, 2015).
There is overwhelming evidence that tobacco cessation programs are both highly clinically effective and cost-effective (Ekpu & Brown, 2015;Ruger & Lazar, 2012). Receiving advice from a health professional increases quit attempts and increases use of effective medications, which can nearly double to triple rates of successful cessation (Centers for Disease Control and Prevention, 2011). However smokers must know that safe, effective, and accessible cessation is available for these resources to decrease smoking rates (Centers for Disease Control and Prevention, 2018b).
In 2012, UC released a policy statement that mandated all campuses provide smoking cessation services, programs, and resources to students and staff (University of California Office of the President, 2014), including a comprehensive education and outreach campaign. However its implementation with respect to tobacco cessation services has not been assessed, despite the critical importance of tobacco cessation to reducing smoking prevalence. In this study, we sought to assess how all University of California campuses were addressing UCOP policy requirements, and specifically how much emphasis they placed on tobacco cessation resources. We hypothesized that (a) campus-specific policies were meeting the minimum standards set by UCOP and that (b) the availability of tobacco cessation services and education varied across campuses.

Methods
We conducted a cross-sectional observational study of reported tobacco cessation services and resources provided by UC campuses. The research team defined the study population as the ten campuses providing student education administered by UCOP, excluding the independently operated UC Hastings, noncampus locations (e.g. Education Abroad Program), research centers, and national laboratories. Between January and March of 2018, one author (JH) searched the website sites of all UC campuses (n=10) using keywords drawn from the UCOP policy title ("smoke," "tobacco," and "policy") to locate the policy for each campus and the resources listed. The match between the UCOP policy's emphasis on tobacco cessation services and each campus policy was assessed using the text comparison and word count tools in Microsoft Word 2016. Each author had previously completed training on the conduct of qualitative research and conducted prior research using comparable methods (Huey & Apollonio, 2018). The authors identified whether cessation was mentioned, the number of cessation resources posted (up to five: campus cessation resources, a link to the statewide smokers' helpline, links to online tools or mobile apps, links to the UC "how to approach a smoker" video series, and/or on-campus cessation classes), and how information about cessation was provided to visitors. Policies were independently reviewed by two researchers (DA, JH); discrepancies were resolved by discussion until reaching consensus. Policy comprehensiveness was determined by length; this assessment method was based on advisory guidelines for drafting policies drawn from government organizations, which explicitly state that longer policies are more user friendly and provide more guidance than shorter policies (Kennebec Valley Council of Governments, 2008; League of Oregon Cities, 2017). When the policy review was complete, in April 2018 one author (JH) made up to six attempts to contact each campus using the information provided on its website (email and/or phone) to request information about the usage of, and funding for, campus tobacco cessation programs, as no campus had provided this information on its website. Missing data were excluded. Because this research was an examination of publicly available data, it was determined to be exempt from human subjects review.

Results
Our findings suggest that the emphasis each campus placed on smoking cessation in its policy varied; the detail provided by policies was not associated with tobacco cessation resources available.

Policy Comprehensiveness and Cessation Description
As described in methods, the assessment of policy comprehensiveness was operationalized by policy length. Descriptions of tobacco cessation services within each campus policy ranged from 7-260 words. Overall policy length ranged from 449-2184 words. The baseline UCOP policy devoted 27 of 1023 words to tobacco cessation (2.6% of the total). The percentage of policy dedicated to an explanation of tobacco cessation services ranged from 1.5% to 13.9% for each campus.
The description of specific cessation resources in each policy varied. All campuses stated that they provided tobacco cessation programs, some campuses addressed what services would be offered on-campus and how tobacco cessation was advertised. For example, UC Davis stipulated that students received cessation services from Student Health while employees received services from nonprofit organizations or other healthcare groups, and that policy information would be provided to campus visitors and during all student/employee orientations. Other campuses included specific links and descriptions of non-campus affiliated tobacco cessation resources: UCSF tobacco cessation services were presented by listing the link "Living well at UCSF -Smoking cessation Programs." The length of policy descriptions did not correlate to more services being listed or available. The campus with the largest percentage of its policy (76 words; 14%) devoted to discussion of tobacco cessation did not provide on-campus counseling services, while conversely, the campus with the shortest description of cessation services (7 words; 1.6%) offered semiweekly on-campus cessation counseling services.

Specific Cessation Resources Posted
We identified whether campus websites provided any or all of five specific cessation resources, as shown in Table 1. All ten campuses provided a tobacco cessation website with a link to resources. Five of the ten campus websites contained a link labeled with a general term such as "Resources" or "Cessation resources", while the other half provided a separate, explicit link to on-campus resources. Four campuses posted a link to the statewide California Smokers Helpline (1-800-NO-BUTTS); four campuses provided a list of websites and/or mobile apps to assist with tobacco cessation; and four campuses provided a link to a video series produced by the University of California containing tips for how to approach a smoker about quitting. Two websites gave information about on-campus tobacco cessation classes. Specific resources provided by each campus are provided in Table 1; no single campus posted information about all five possible resources. Three campuses had information about four of five specific resources, while two campuses provided only a link to general "cessation resources" that were not specific to the university environment. As of March 2018, the UCLA website was no longer functional. As examples of the differences between campuses, we captured screenshots of two campuses that provided a different set of resources to visitors in March 2018; one listed four of five of the specific resources identified, the other only one. In a screenshot from the main page of UC Davis's tobacco free website, resources for tobacco cessation were clearly displayed. At the top of the page was a link leading to cessation services on-campus, in the community, online, and by phone. Also listed on the main page was information about on-campus smoking cessation classes, a video series on how to approach a smoker on campus, and a phone app that aids in tobacco cessation. In contrast, the main page for UC Santa Cruz's website provided a link to the UC video series on how to approach a smoker, but did not describe on-campus services, the helpline, classes, or other tools. A list of websites, apps, phone hotlines, and community resources for tobacco cessation could only be found after clicking on the links labeled "Help quitting" and "Resources." Figure 1 shows the pages as displayed.

Figure 1. UC Davis and UC Santa Cruz Tobacco Free
Website Splash Pages

Task Forces
No campus provided information about the use or success of its listed tobacco cessation programs. As a result, one author sought contact with each campus using the phone numbers and email addresses posted on the tobacco free website to request this information. Only three of ten campuses responded after up to six attempts at contact. The first campus responding reported it did not offer on-campus cessation programs due to a lack of funding. The other two campuses indicated that they offered on-campus cessation counseling, but that they did not collect data on the success rate of these services. Both of the campuses that provided on-campus cessation services stated that the use of this service had decreased since 2014; at one the tobacco cessation program had been integrated with other university-provided health services, which did not report to the taskforce. The campuses providing on-site cessation reported that they received specific funding to provide classes, provision of nicotine replacement therapy, and educational materials.

Discussion
The goal of the UCOP Smoke & Tobacco Free policy was to create 100% tobacco-free campuses through education and by providing cessation resources (University of California Office of the President, 2014). This policy addresses previous research that found that university tobacco policies focused on tobacco free campuses to the exclusion of cessation, an imbalance that may result in hidden smoking rather than reduced prevalence. We found that all UC campus policies referenced tobacco cessation programs, however there were inconsistencies in the types of cessation resources identified. Half of campuses did not provide resources specific to the university setting. This outcome may reflect the fact that the UCOP was not directive regarding what types of resources and education that individual campuses should provide. In addition, while all campus tobacco websites mentioned cessation, some presented this information on the main page while others required users to attempt to navigate away from that page to find information; in one case, the suggested links were broken.

Limitations
The UC campuses may not be representative of all US universities, although they do provide a broad range of campuses that may not be available by studying other states. There was a low response rate from task force members because contact information was incomplete or inaccurate. The campuses that did respond had little data about cessation on their campuses.
Overall, it was difficult to assess the extent to which tobacco cessation programs at UC campuses are used or their effectiveness. It remains possible that the UCOP policy is associated with increased hidden or off-campus smoking rather than a tobacco-free student and employee population.

Conclusions
Our findings offer new information about including cessation resources in university tobacco policies. UCOP sought to reduce tobacco use on its campuses by both making campuses tobacco free and by integrating these policies with cessation resources. While past research has provided guidance for creating and implementing tobacco free policies on college and university campuses, our findings suggest that UCOP did not provide or identify clear standards for how to provide and assess cessation in this context. While all UC campuses listed tobacco cessation education and resources in their policies, the actual provision of such services was inconsistent from campus to campus. UC campuses collected very little information regarding whether and how on-campus tobacco counseling services were used, if on-campus services were offered at all. These results have implications for other universities developing similar campaigns, suggesting a need for additional tracking of outcomes data when attempting to create tobacco free campuses.