Many colleges are currently struggling with policies related to smoking on campus. The prevention and cessation program at Fullerton College is a model to be considered. It is coordinated through the Student Health Clinic with the assistance of Peer Health Educators, Minority Outreach Educators, and Health Educators. It demonstrates that a comprehensive approach can lead to success for students and the college.

In July 2002, Fullerton College received a grant from the Tobacco Free Communities Project. This Tobacco Free Communities project (TFC) is under the direction of the Orange County Health Care Agency’s Tobacco Use Prevention Program (TUPP). The County of Orange California has committed a significant portion of the Tobacco Settlement Funds for tobacco use prevention and cessation programs. Funds are provided by the 1998 Master Settlement Agreement with tobacco manufacturers. This grant allowed Fullerton College to provide significant tobacco prevention and cessation services in the student health clinic and in the health promotion program on campus. Part of the Innovative Tobacco Demonstration Project grant was to use Peer Health Educators to educate and encourage smokers to use campus identified designated smoking areas (DSAs).

When Fullerton College Health Services wrote the proposal for an Innovative Tobacco Demonstration Project grant, it chose to write three goals which were consistent with three of the Tobacco Free Communities project goals:

• To reduce the prevalence of Tobacco Use among young adults (ages 18-24)
  
• To increase the number of smokers attempting to quit
  
• To reduce the residents (in our case, students) exposed to environmental tobacco smoke
  
  

Implementation of the program began in June 2002 with presentations to administration, faculty and department deans. Although we received great support from our campus leaders, accessing agenda time with them proved a challenge, as other pressing issues faced the college at large last year. All activities were implemented with a team effort of Peer Health Educators, Minority Outreach Educators, Director of Health Services and Health Educators.

Minority Outreach Educators focused their attention on our Asian and Hispanic student population, while our Peer Health Educators focused on smokers age 18-25. The utilization of peers as health educators and for minority outreach during our program was a successful, positive way to approach students on campus. They became recognized as easily accessible, peer resources. They provided information not only during weekly tables, but also during health events and classroom presentations.

The most successful outreach activities were those held regularly so students could predict their presence. The information table was a weekly event, and eventually became so popular that students on campus noticed their absence if they missed a “regular” day on the quad. Classroom presentations, scheduled weekly reached a large group of students at one setting. Utilizing peers and providing

incentive/reward items were a very motivating factor for smokers on campus. When smokers are rewarded for using the campus designated smoking areas, they are more open to our suggestions to join the Student Health Clinic’s cessation program (also funded by the grant).

Services to the 2002 National Conference on “Tobacco or Health” in San Francisco. There they were exposed to a myriad of program tactics utilized on other campuses, and attended sessions specifically designed for College Peer Health Educators who are working on tobacco issues. All hired personnel were given identifying nametags and H.E.L.P (Health Education and Learning Through Peers) uniform shirt.

Other major training opportunities, which led to the success of our program, were the Mayo Clinic Nicotine Dependence Counselor Training and the Appreciative Inquiry Leadership Training. Both programs provide invaluable information, guidance and support when structuring and re-assessing our 8-week cessation program. The Mayo cessation model is very comprehensive and enabled staff to enhance our own services, especially with relapse prevention and follow up procedures. Utilizing the Appreciative Inquiry method of problem solving and leadership training, staff assisted the Peer Health Educators with their goal setting and improved their ability to conduct self-motivated peer interventions/activities on campus.

There were a number of ongoing activities that were supported by the grant that enabled the success of the Innovative Tobacco Demonstration Project Grant.

The Peer Health Educators, Minority Outreach Educators and Health Educators hosted an informational table, daily during the first two weeks of each semester and weekly during the course of the year. This afforded high recognition of Fullerton College grant staff from students on campus and enabled them to conduct outreach activities (daily Designated Smoking Area monitoring) with greater ease. Each Peer Health Educators who came into contact with students wore their H.E.L.P uniform shirt and Peer Health Educators name tag. Provided at every table was information on designated smoking area locations, Fullerton College smoking cessation program, ETS exposure fact sheets, and social norms marketing data. Along with tobacco information, thousands of promotional/incentive items were distributed throughout the year.

Maintaining a strong marketing component to our program was essential to success. Health Services advertised cessation services weekly, throughout the semester in the campus newspaper. The campus paper staff wrote several articles regarding Environmental Tobacco Smoke and maps of all seven Designated Areas. PSA’s advertising free cessation services and designated smoking area locations were provided over the campus radio during all health events and several times weekly.

A full color map of all designated smoking areas was created and posted in all 13 approved quad posting sites, all departments, 15 library study rooms and all large classrooms on campus. Hundreds of advertisements of on-the- job opportunities (Minority Outreach Educators, Peer Health Educators), free cessation services, upcoming health events, designated smoking area locations and “Environmental Tobacco Smoke Effects” were distributed. This literature was available during all classroom presentations, new student orientations and during the weekly Peer Health Educators table on the quad.

A second double sided, card-stock, full color, 4x5 card size advertisement was created One side provided information about the free cessation program while the back had a small version of our Designated Smoking Area map. During the course of the year, 3000 cards were distributed to smokers on campus.

The 8 week smoking cessation program enrolled twice the number of participants during the grant period. The increase in student participation can be contributed to a several things. The grant paid for Nicotine Patches. Students received 8 weeks of Nicotine Patches and individual counseling with a Health Educator free of change. Simply offering free services however will not ensure success. Health Services secured the “buy in” of our participants by requiring them to sign a contract agreeing to pick a quit date. Students who want to participate in the program also agreed to a physical and behavioral assessment of their “readiness” to quit. Behavior modification is a key factor in overcoming nicotine dependence and all participants are engaged in weekly discussion on triggers, coping skills, relapse prevention skills and stress management.

Monitoring (reinforcing) the continued use of the five Designated Smoking Areas on campus was an activity implemented daily throughout the semester. Peer Health Educators followed a strict “approach protocol” when engaging any smokers on campus who were outside of the Designated Smoking Areas. Smokers outside of designated areas were given incentive items along with smoking cessation advertisements and a map of all seven Designated Smoking Areas while smokers who were caught utilizing the correct area were given promotional items along with cessation information.

Perhaps the most exciting activity implemented with the grant was the social norms marketing campaign “X-Pand”. The concept held that if you quit smoking you could “X-Pand” many areas of your life: for example, your money, health and friendships. Fullerton College Health Services collaborated with Graphic Arts classes to design and produce a series of original, visually stimulating full color posters. Each graphic art student involved was allowed great latitude with individual creativity; however the campaign theme (X-Pand your lungs, income, energy etc), logos, data and verbiage were all carefully chosen and provided by Health Services. Ten posters were chosen to be displayed weekly in campus posting areas, various classrooms, on pickets in the quad, and the marquee. Along with posters hundreds of promotional items with normative data (only 25% of Fullerton College Students Choose to Smoke) were purchased and distributed during classroom presentations, weekly Peer Health Educators tables, health events and during Designated Smoking Area monitoring. It was essential to educate students about the misperceptions regarding smoking on campus.

Weekly presentations in the classroom setting provided a unique opportunity to discuss services available to students. Hundreds of students were reached this year with information on smoking cessation, Environmental Tobacco Smoke exposure, Designated Smoking Areas and normative data. Most presentations were conducted by Associate Health Educator and Minority Outreach Educators, with some classes presented in Spanish.

Along with reaching the student population Health Services shared our program with our campus leaders, and other departments. Presentations were given during Deans, Manager and Associated Students meetings. This effort not only provided information but secured buy-in for our program. Director and Health Educators met with the groundskeeper staff and graphic arts departments individually since their participation was essential to grant activity success.

The specific goals, objectives and results for the Innovative Tobacco Demonstration Project grant demonstrated great successes.

Goal: Fullerton College Student Exposure to Environmental Tobacco Smoke (ETS) will be reduced by 20% by June 30, 2003.

The first activity was to encourage and monitor use of the Designated Smoking Areas (DSAs). The Peer Health Educators monitored the use of DSAs. The results included an increase in daily DSA use which was nonexistent (0) prior to grant activities to an average daily use post grant intervention of 40 students per DSA; Fullerton College has 7 areas @ 40 (average) students in each area=280 students per day utilizing DSAs. The average daily use varied from 32 to 58 students per day in each of the DSAs monitored.

The second measure of ETS exposure was a Quad Survey. Peer Health Educators approached non-smokers in the quad and asked an ETS exposure question. The responses were tallied from an October 2002 survey (early in the intervention process) and compared to an April 2003 survey. The results of this survey showed a significant decrease after the interventions to increase usage of DSAs.

A third measure of ETS exposure included asking students on the Fullerton College Smoking Survey in April 2003 to agree or disagree with the statement “I believe Fullerton College Designated Smoking Areas have decreased my exposure to second-hand smoke”. Sixty-one percent (61%) of students agreed or strongly agreed with the statement.

Goal: Fullerton College students who identify themselves as smokers will be reduced by 10% by June 2003.

The activities around this objective included a 10 week Social Marketing campaign. Fullerton College activities included researching and designing education programs for Health Center staff and campus administration on the concepts and precepts of social marketing. Additional presentations were made to Peer Health Educators, Health Center staff, Deans’ Council, Student Services Managers, Associated Students’ Board which includes Campus Club Student Leaders.

Once the “orientation/education” was completed, Health Services obtained “posting permission” for the campaign. The Health Educator enlisted the help of a graphic arts class who received credit for creating posters for the campaign.

The Social Norming messages for the campaign were: 75% of Fullerton College Students do not smoke and 80% of Fullerton College Students who smoke want to quit. That was incorporated with an “X-pand” message; for example, X-pand your pocketbook, X-pand your lungs, X-pand your taste(s), X-pand your circle of friends, etc.

Students created graphics to get these messages into posters. PHEs changed the graphic art posters every week for 10 weeks. PHEs placed 50-80 posters in high visibility areas each week. Health Services was offering smoking cessation services in conjunction with the Social Marketing messages.

There were two ways we measured the outcome of our activities. The National College Health Risk Assessment (NCHA) questions identified 25% of Fullerton College students as smokers in 2001. Using the same questions from NCHA, 21% of students identified themselves as smokers in 2003 Using 21,000 students, these data represent a decrease from 5,250 student smokers in spring 2001 to 4,410 student smokers in spring 2003. That represents an average of a16% reduction in students who identify themselves as smokers (illustration graph 1).

The Fullerton College Smoking Survey utilized pre-grant intervention survey results from fall 2000 and post-grant intervention survey in spring 2003. The percent of students who identified themselves as smokers was 21.3% (4,473 students) in 2000 and 14.9% (3,129 students) in spring 2003 (Attachment 16).This represents a 30% reduction in the number of students who identified themselves as smokers (Illustration graph 2).

If we look at the average of the two surveys (each with approximately 425 responses), Fullerton College students who identified themselves as smokers decreased an average of 23% post intervention. Activities included a Social Marketing Campaign, classroom presentations, quad table tops weekly, and a Smoking Cessation program available at Fullerton College Health Services (Illustration graph 3). Objective goal was exceeded by 13%.

Goal: Fullerton College Students will have a 20% Increase in Quit Attempts

The evaluation measures were MedPro (clinical reporting system) reports for students who attempted the smoking cessation program.

Fullerton College Health Services compared school year 2001-2002 pre grant interventions to school year 2002-2003:

• Aug 2001-June 2002 (all ages) 55 students joined the cessation program and Health Center provided 214 visits
  
• Aug 2002-June 2003 (all ages) 122 students joined the cessation program and Health Center provided 505 visits
  
  

Data was arrayed by age and ethnicity and demonstrated that quit attempts increased by 188% for 18-24 year olds and by 121% for all students who attempted to quit smoking. Therefore the goal of increasing quit attempts by 18-24 year olds by 20% was far exceeded.

Tobacco cessation outcomes were very good. Fullerton College Health Services collected self-reported data on continuous abstinence rates for all participants in the 8 week program. All participants were contacted via-phone from a Health Educator and asked their tobacco use status at thirty days post last appointment. Grant staff defined continuous abstinence as being smoke free from the date of their last appointment through time of follow-up assessment Failure is defined as any tobacco use from date of last appointment through time of follow-up assessment.

During the 2001-2002 school year almost one-half of cessation participants completed 50% or more of the 8 week program. All participants were contacted for follow-up and a representative sample of 21% was available for comment. Of the follow-up sample, 75% were smoke free at 30 days.

During the 2002-2003 school year one-half of all cessation participants completed 50% or more of the program. All participants were contacted again via phone and the same representative sample (21%) was available for comment. On the follow up sample, 66% were smoke free at 30 days.

This slight decrease in abstinence rates (75%-66%) from 2001-2003 could be attributed to the decrease of older adults participating in the program. There was a much larger sample of older adults both participating in the program and in the follow-up assessment in the 2001-02 year than in 2002-03. This may confirm one of our findings of higher program commitment of older students than of their younger counterparts.

Conclusions

Fullerton College was very successful with the Innovative Tobacco Demonstration Project performance objectives. Each objective was accomplished and exceeded stated performance goals.

The most dramatic success (numerically) was the increase in the number and % of quit attempts. The expectation was a 10% increase and the actual was a 188% increase in 18-24 year olds who came to Health Services to join the cessation program. The success is attributed to many factors but certainly this objective would never have been attained without the grant support for the Nicotine Replacement Therapy (NRT). It was the NRT offer (provided at no cost) that brought the students to Health Services but the weekly 1:1 counseling kept the students in the cessation program.

The Peer Health Educators and Minority Outreach Educators were the key to the success of the other 2 objectives: Reduction of ETS by 20% and the Reduction of Students who identify themselves as smokers by 10%. Peer Health Educators received significant training and response protocols for student approaches and monitoring of DSAs. The Peer Health Educators and Minority Outreach Educators took on many of the activities that were successful in accomplishing the objectives. Fullerton College agrees with studies cited that using student peers is the most successful way to approach students and work on changing smoking behaviors.1

Environmental Tobacco Smoke reduction was measured most successfully by the Fullerton College Smoking survey question to which 61% of students “strongly agreed” or “agreed” that DSAs reduced their exposure to Environmental Tobacco Smoke. A quad pre and post survey showed a significant reduction in students’ perception of tobacco smoke exposure on post test.

The DSA monitoring demonstrated increased average use of the DSAs from no students in August to an average of 40 students per DSA per day for a total of 280 students after implementation activities. The process of measurement of DSA use proved to be the least effective measurement tool in the grant evaluation process.

The Fullerton College Innovative Tobacco Demonstration Project was able to clearly demonstrate the reduction of students who identified themselves as smokers. Two surveys, the Fullerton College Smoking Survey and the NCHA Survey were administered pre and post implementation of the grant activities.

The two evaluation tests detailed earlier demonstrated an average 23% reduction in the number of students who self identified as smokers, therefore exceeding the 10% expectation.

The final benefit was the interdepartmental and community collaboration that occurred as result of the Innovative Tobacco Demonstration Grant.

The project was managed by Jennifer Hoff, Health Educator, BA, Fullerton College Health Services. Her enthusiasm and commitment was essential to the success of the grant project. Special thanks to Ken Meehan, PhD (Fullerton College) and Dianne Barker MHS (Public Health Institute, Berkeley California) who performed grant evaluation activities.

Health Services worked with administration, faculty, Associated Students and Club Leadership, campus radio station, campus newspaper, graphic arts, grounds keepers and the Student Health Advisory Committee. Fullerton College took the opportunity to have tables at community events to showcase the Innovative Tobacco Demonstration Project.

Fullerton College Health Services is very proud to be selected for the Innovative Tobacco Demonstration Project to implement the new policies for Designated Smoking Areas on the campus and improve smoking prevention/cessation activities on campus. We believe that the Peer Health Educators that the grant allowed us to employ and train will be committed to the concept of smoke free communities far into the future. The Fullerton College Health Center staff was already committed to reducing smoking within our student population but the grant allowed us to implement strategies that would not have been possible without the grant from the Tobacco Free Communities project.

1 D. C. Barker et al., “Exploring Tobacco Cessation Services on California College Campuses”, California Tobacco Related Disease Research Program, Presentation to FC Health Service Staff, 6-23-03.

2 Innovative Tobacco Demonstration Project grant made possible by the County of Orange Health Care Agency through funds received from the National Tobacco Settlement.