Going Tobacco-Free on Campus and Why it Matters

1. Going Tobacco-Free on Campus and Why it Matters Clifford E. Douglas, J.D. Director, University of Michigan Tobacco Research Network Lecturer, University of Michigan School of Public Health October 2, 2013 Center for Public Health Initiatives, University of Pennsylvania

2. The tobacco epidemic: more work to do College students & smoking Environmental impact Economic impact U.S. Government leadership & TFCCI Acceleration of campus policies nationwide University of Michigan experience Effectiveness of campus policies Why many campuses now go tobacco-free Topics

3. The Tobacco Epidemic: More Work to Do

4. Smoking Kills More Americans thanAll of these Combined AIDS Alcohol Fires Car crashes Cocaine Heroin Suicide Homicide

5. Each day, 1,200 Americans die from smoking • Each smoker who dies is • replaced by 2 young • smokers • 90%of all smokers start before age 18 • 99% of all smokers • start before age 26

6. #1 Cause of Cancer Death in Women

7. The Dirty Dozen Acetone (solvent and paint stripper) Ammonia (poisonous gas and toilet bowl cleaner) Arsenic (potent ant poison) Benzene (poisonous toxin) Butane (flammable chemical in lighter fluid) Cadmium (carcinogenic chemical in batteries; lung & intestinal irritant) Carbon monoxide (poisonous gas in auto exhaust) Formaldehyde (dead frogs love it) Hydrogen cyanide (deadly ingredient in rat poison) Methanol (jet engine and rocket fuel) Polonium-210 (radioactive element and spy-killer) Toluene (poisonous industrial solvent)

8. Simple Math for theOne-Pack-a-Day Smoker • One day’s inhalations: 10 per cigarette x 20 cigarettes per day = 200 • One year’s inhalations = 200 inhalations x 365 days = 73,000 • 50 years of smoke (by the average smoker’s mid-60s, if still alive) = 3.65 million inhalations from365,000 cigarettes There is no safe level of tobacco use or exposure to secondhand smoke

9. College Students & Smoking • 24.8% of full-time college students aged 18-22 years old were current smokers in 2010 • The number of smokers who initiated smoking after age 18 increased from 600,000 in 2002 to 1 million in 2010 • Progression from occasional to daily smoking almost always occurs by age 26 Tobacco companies have carefully studied the attitudes and behaviors of young people, particularly as they go through life transitions, such as attending college.

10. College Students – Projected Toll Based on current rates, it is predicted that more than 1 million current college students will die prematurely from tobacco use “If young people don’t start using tobacco by age 26, they almost certainly will never start.” - Surgeon General Regina Benjamin

11. Environmental Impact

12. Cigarette Litter - #1 Source of Waste • Cigarette butts = single most commonly collected waste item found each year in park and beach clean-ups, and not biodegradable • Cigarette butts = 25-50% of all collected litter from roads and streets • 5.6 trillion butts dumped into the global environment annually

13. Cigarette Litter - Poison • Cigarette butts contain all of the carcinogenic (cancer-causing) chemicals, pesticides and nicotine that make tobacco use the leading cause of preventable death

14. Cigarette Litter – Given a Pass “Cigarette butt waste is the last socially acceptable form of littering in what has become an increasingly health and environmentally conscious world. We [must] find solutions for eliminating this especially toxic form of trash.” - Cheryl Healton et al., “Butt Really? The Environmental Impact of Cigarettes,” Tobacco Control, May 2011 A study by the University of North Carolina at Chapel Hill, concluded that 77% fewer cigarette butts were found on county college campuses that adopted 100% smoke-free campus-wide policies.

15. Economic Impact

16. Reduced employee health care costs Reduced absenteeism Increased employee productivity Cost savings in grounds and building maintenance The costs of cleaning up this extensive pollution are borne entirely by communities and institutions, not tobacco manufacturers or their customers Reduced fire damage Economic Benefits of Strong Campus Policies

17. U.S. Government Leadership

18. Health Sec. Kathleen Sebelius Asked Assistant Sec. for Health Howard Koh to Develop the First-Ever HHS Strategic Plan to Combat Tobacco Vision: A society free of tobacco-related death and disease First Charge: Base the new HHS strategic action plan on the tobacco control goals set forth in Healthy People 2020 www.hhs.gov/ash/initiatives/tobacco/tobaccostrategicplan2010.pdf

19. Reduce tobacco use by adults and adolescents Reduce the initiation of tobacco use by children, adolescents, and young adults Increase successful cessation attempts by tobacco users; and Reduce the proportion of non-smokers exposed to secondhand smoke Healthy People 2020’s Tobacco Prevention Objectives

20. A Key Pillar of HHS’s Plan is to Lead by Example (“Walk the Talk”) • In July 2011, HHS established a comprehensivetobacco-free campus policy covering all indoor and outdoor properties • The announcement stated: “Taking this action will protect the health and safety of all HHS employees, contractors and visitors and will serve as a role model for workplaces everywhere … Educational and promotional efforts will be provided in support of the policy’s implementation. We know that quitting tobacco can be difficult for even the most motivated people, and we want to help employees succeed.”

21. The Tobacco-Free College CampusInitiative (TFCCI): Vision and Goals Vision: Widespread expansion of tobacco-free policies to institutions of higher learning across the U.S. Goals: • Foster a collaborative, cooperative effort among academic institutions and partners in the public health community • Expand awareness in academia and among the public of the need for and benefits of such policies • Facilitate information flow and access to technical assistance

22. TFCCI = Collaboration • Lead Partners • U.S. Department of Health and Human Services • American College Health Association • University of Michigan • Sponsors • American Legacy Foundation • Americans for Nonsmokers’ Rights • Campaign for Tobacco-Free Kids • National Center for Tobacco Policy • Other Partners (a few examples) • American Lung Association • The BACCHUS Network • California Youth Advocacy Network (CYAN) • Center for Social Gerontology (Smoke-Free Environments Law Project) • Montana State University • Partnership for Prevention • State University of New York Upstate Medical University • Tobacco Control Legal Consortium • University of Kentucky

23. Accelerating Campus Policies Across the Nation

24. Walking the Talk and… Riding the Talk

25. Significant Progress • As of July 2013 • 1,178 campuses in U.S. are 100% smoke-free with no exemptions, including residential housing facilities (where applicable) • Of those, 793 – about two thirds – have a 100% tobacco-free policy • Examples of large campuses that have gone tobacco-free: • University of California (all 10 campuses) • City University of New York (all 24 campuses) • Arizona State University • University of Oregon • University of Oklahoma • University of Kentucky • Montana State University • University of Florida (“Gators don’t chew. They chomp!”) • Emory University • Ohio State University Source: Americans for Nonsmokers’ Rights Foundation, http://www.no-smoke.org/pdf/smokefreecollegesuniversities.pdf

26. Exponential Growth

27. The U.S. Department of Education identifies 4,583 colleges, universities and other institutions of higher learning in the U.S. Opportunity

28. Wouldbecome the first Ivy League school to adopt a comprehensive campus policy Penn’s Opportunity

29. The University of Michigan Experience

30. University of Michigan – Promoting a “Culture of Health” • Decision to go smoke-free on all three campuses (Ann Arbor, Dearborn and Flint) was announced in April 2009, and, following its development, was promoted for a year prior to implementation • Strong community involvement: committees, public forums, etc. • Policy went into effect on July 1, 2011 • If Michigan had adopted policy now, it probably would have gone fully tobacco-free … the norm has shifted rapidly

31. Michigan Policy - Coverage • Smoking prohibited on all university property • No designated smoking shelters • Smoking is allowed on thoroughfare sidewalks and in private vehicles

32. Michigan Policy - Implementation • Communications began more than a year in advance of effective date • Installation of new signage; currently being updated and expanded (ongoing process) • E-mail blasts, social media messages, posters, tent cards, bus posters, campus newspaper articles, sidewalk chalk, dedicated website, video • Advisory committee meets 3x a year www.smokefree.umich.edu

33. Michigan Policy - Enforcement • Enforcement is through peer education and multiple forms of communication, fostering ongoing social norm change • Respectful reminders to people who are observed failing to adhere to the policy • People who smoke where not permitted and decline to stop when informed – particularly repeat offenders – are subject to existing disciplinary processes

34. Michigan Piloting “Ambassador” Program, based on University of Kentucky model • University of Kentucky’s program enhanced compliance, using the “3 T’s” approach • Tell – conduct robust communications (repetition; and keep it fresh) • Treat – provide evidence-based tobacco treatment services • Train – supervisors, faculty, administrators & student leaders learn how to approach violators, serving as ambassadors and respectfully fostering a culture of compliance • At Kentucky, 4 part-time ambassadors and more than 50 student & staff volunteers

35. Promoting Cessation – Components * • Implement before campus policy goes into effect • Promote cessation as an opportunity, but not as an obligation • The message: Campus policy implementation = A Great Time to Quit • Three targeted populations: students, staff & faculty • Remove cost/access barriers to treatment • Implement ongoing systems of cessation, not just a one-time program • Integrate services into student, staff & faculty health services • Use free national quitline, 1-800-QUIT NOW, to supplement, but not substitute for, campus programs • Expand insurance coverage to include counseling and all FDA-approved medications * With thanks to Michael C. Fiore, MD, MPH, MBA, Professor of Medicine; Director, Center for Tobacco Research & Intervention; University of Wisconsin School of Medicine and Public Health

36. Effectiveness of Campus Policies

37. University of Michigan16 Months After Implementation • 89% of faculty/staff and 83% of students supported policy • 72% of faculty/staff and 65% students noticed decrease of smoking on campus • Smoking by faculty & staff dropped from 6% to 4% • 29% of smokers reduced consumption • 40% of smokers attempted to stop in last 12 months • 22% of smokers participated in MHealthy Tobacco Independence Program • 13% of faculty/staff reported the policy influenced them to quit or attempt to quit smoking • 16% of students reported the policy influenced them to quit or attempt to quit smoking • Source: University of Michigan, MHealthy & “Smoking Declines After U-M Campus Ban,” May 9, 2013

38. Indiana University vs. Purdue University • Study compared undergraduates’ smoking behaviors and attitudes at two Big Ten campuses with similar demographics … Purdue University (no policy) and Indiana University (tobacco-free policy implemented in 2008) • Indiana University smoking prevalence: 16.5% in 2007; 12.8% in 2009 (-3.7) • Purdue University smoking prevalence: 9.5% in 2007; 10.1% in 2009 (+0.6) • Indiana University consumption rate: 6.6 cigs/day in 2007; 5.9 cigs/day in 2009 (-0.7) • Purdue University consumption rate: 5.2 cigs/day in 2007; 6.8 cigs/day in 2009 (+1.6) • Study also showed significant favorable change in attitudes among Indiana University students regarding elimination of smoking in public places and on university property • Source: Dong-Chul Seo et al., The Effect of a Smoke-free Campus Policy on College Students’ Smoking Behavior and Attitudes, Preventive Medicine 2011;53:347-352.

39. Why Do Many Campuses Go Tobacco-Free?

40. What is “Smokeless Tobacco”? • Tobacco that is not burned (combusted) • Traditional smokeless products • *Chew (“spitting tobacco,” placed between cheek and gums) • *Snuff (dry snuff sniffed through nose; moist snuff, or “dip,” placed between cheek and gums) • Snus (finely ground tobacco administered in small packets) • New generation of products • Dissolvables (lozenges, orbs, sticks, strips) • E-cigarettes (not called “smokeless tobacco,” but are similarly not combusted, and the federal court system has ruled that, under the law, they are to be treated as “tobacco products” subject to regulation by the Food and Drug Administration) *Currently dominate the U.S. smokeless tobacco market

41. Examples of Smokeless Tobacco

42. E-Cigarettes

43. Health Effects of Smokeless Tobacco • Addictive • Not a safe alternative to cigarette smoking • Most smokeless tobacco products contain carcinogens (at least 28 have been identified, and nitrosamine levels are higher in smokeless tobacco than in cigarettes) • Most smokeless tobacco products cause oral, esophageal, and pancreatic cancer • Use of these products causes gum recession, gum disease, and tooth loss • Use also associated with greater risk of fatal heart attacks and stroke

44. Smokeless Tobacco Use “After years of steady progress, declines in youth tobacco use have slowed for cigarette smoking and stalled for use of smokeless tobacco. The latest research shows that concurrent use of multiple tobacco products is common among young people, and suggest that smokeless tobacco use is increasing among White males.” - Surgeon General’s Report, 2012 There are approximately 8 million smokeless tobacco users in the U.S.

45. Marketing of Smokeless Tobacco • Tobacco industry promotes dual use • Ads promote use of smokeless tobacco products not to replace cigarettes but as a way for smokers to satisfy addiction wherever they cannot smoke “There is a need to clearly position the [smokeless tobacco] product as a situational substitute for cigarettes rather than a replacement.” - R.J. Reynolds spokesman, 2009

46. (September 2013) E-Cigs Revolutionizing Tobacco • We think consumption of e-cigs could surpass consumption of conventional cigs within the next decade. • Importantly, growth of the combined profit pool could accelerate in the next decade. • We estimate total conventional & e-cig total profits will generate a CAGR of 7.2% over the next decade. Source for all charts: Company reports and Wells Fargo Securities, LLC estimates

47. Health issue is not e-cigarette’s level of harmfulness compared to conventional cigarettes, but rather the risk it poses for public health irrespective of whether it is as bad as ordinary tobacco use • If treated differently, implies acceptance of addiction to unregulated nicotine delivery products, complicating university’s health mission • Permitting e-cigs encourages dual usage (cigarettes and e-cigs) in lieu of cessation in some individuals who might otherwise quit • Creates potential confusion regarding rules and mixed health message A Final Note about E-Cigarettes

48. Tobacco-Free College Campus Initiative Position • “There is no safe tobacco product, and the Initiative encourages adoption of comprehensive tobacco-free policies. It is also recognized that each institution must make its own decisions when it comes to promoting health and preventing disease in its students, faculty, employees and visitors.” • “Tobacco-free policies go further in promoting a culture of health and wellness while reducing exposure to the variety of non-smoked forms of tobacco that cause cancer, heart disease and other serious illnesses.”

49. Please visit us at: TobaccoFreeCampus.org • “There is no higher priority in public health than ending the tobacco epidemic.” • – Dr. Howard Koh, U.S. Assistant Secretary • for Health