Korean college students’ attitudes toward a tobacco-free campus: a cross-sectional descriptive study

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Child Health Nurs Res. 2022;28(2):124-131

Publication date (electronic) : 2022 April 30

doi : https://doi.org/10.4094/chnr.2022.28.2.124

Min Sohn^,1, Boae Im², Minhee Suh¹, Hun Jae Lee³

¹Professor, Department of Nursing, Inha University, Incheon, Korea

²Researcher, Department of Nursing, Inha University, Incheon, Korea

³Professor, College of Medicine, Inha University, Incheon, Korea

Corresponding author Min Sohn Department of Nursing, Inha University, 100 Inha-ro, Incheon 22212, Korea TEL: +82-32-860-8212 FAX: +82-32-874-5880 E-MAIL: sohnmin@inha.ac.kr

Received 2022 February 19; Revised 2022 March 17; Accepted 2022 March 20.

Abstract

INTRODUCTION

According to national statistics, Korea has shown a rapid decrease in the rates of smoking among adults [1]. However, these rates differ by gender and age. Compared with 2015, the smoking rate in 2019 among men aged 30-39 years dropped by 8.8%, but the decrease was only 0.9% in men aged 19-29 years, and it increased by 3.3% in women aged 19-29 years [1]. These statistics indicate that further efforts are needed to promote smoking cessation in Korea, particularly among young men and women.

The Korean Statistical Information Service reported data from the Korea Population Census in 2015, including the most current rates of completing higher education by gender and age groups. According to this report, 78.7% of adults aged from 20 to 34 years old had graduated from a college-level school [2]. College students comprise a large population of young adults in Korea. Studies indicate that many young adults become regular smokers at college, even if they first took up the habit at a much younger age [3]. Thus, tobacco control efforts for college students could effectively decrease smoking rates among young adults.

Smoking bans have been shown to be a powerful tobacco-control strategy [4]. In 2012, the Korean government banned smoking in public facilities and in elementary, middle, and high schools, both indoors and outdoors [5]. However, college campuses adopted only a ban on indoor smoking, which seems to offer insufficient protection. Despite the ban on indoor smoking, 19% of college students reported that they did smoke on campus, and 68% reported that they had experienced secondhand smoke [6]. Clearly, bans on indoor smoking are less likely than complete bans to restrict tobacco use (and smokeless tobacco products) in student lounges and dormitories [7].

Since the American College Health Association advocated for a 100% tobacco-free environment [6,8], the tobacco-free campus (TFC) policy has been hailed as the most advanced tobacco-control strategy on college campuses. TFC refers to colleges and universities that have completely banned all types of tobacco products for both indoor and outdoor environment and the ban includes smokeless tobacco, whereas smoking bans restrict cigarette smoking only [9]. Enforcement of a TFC policy has been known to reduce smoking rates, the risk of exposure to secondhand smoke [10], and the use of alternative tobacco products [11].

Nonetheless, TFC is still a matter of debate on university campuses. Bartington and colleagues [12] surveyed attitudes toward campus-wide tobacco control policies and reported that 66.3% of students and staff members supported a smoke-free campus, but only 47.3% of them supported TFC, which would also include bans on electronic cigarettes and vaping. Previous studies have attempted to explore characteristics of students and staff members related to attitudes toward TFC. According to these studies, negative attitudes toward TFC tended to be found among ever smokers and male students [12,13]. Psychosocial characteristics might also be related to attitudes toward TFC. Adults with depressive mood, anxiety, and stress are more likely to relapse after smoking cessation and use electronic cigarettes [14]. Users of electronic cigarettes have more negative attitudes toward electronic cigarettes and vaping restrictions on campuses [15]. The attitudes of university students towards TFC can be a key component of achieving successful tobacco control using the TFC policy. Consequently, this study was designed to elicit Korean college students’ attitudes about TFC and to identify factors related to their attitudes.

METHODS

RESULTS

1. Demographics and Attitudes of College Students toward a Tobacco-Free Campus

Data on 309 college students were analyzed (Table 1). The participants were in their early 20s (22.4±2.3 years old). More than half were men (58.3%), and one-fourth (24.3%) reported that their grade point average was in the range of an “A”. Fewer than half of the participants (46.0%) lived with family, and only 17.2% reported that their reason for taking the course was to quit smoking. A small percentage (6.1%) of students reported that the campus should prohibit all tobacco use at all times.

Table 1.

Demographics and Attitudes of College Students toward a Tobacco-Free Campus (N=309)

2. Health-related Characteristics

The participants’ health-related characteristics are presented in Table 2. Large percentages reported that they were healthy (53.0%), happy (66.3%), and stressed (35.6%). The percentages of those who reported having felt lonely, depressed, and anxious within the past 12 months were 35.6%, 11.0%, and 22.7%, respectively. The proportion of current smokers was 33.6% (men 47.2%, women 14.7%, x²=35.53, p<.001). Most of the participants (70.6%) reported that they drank alcohol four or more times a month. The average number of days on which participants engaged in moderate-to-vigorous exercise for at least 30 minutes per week was 1.8±2.0. On average, they slept enough on 3.3±1.9 nights a week.

Table 2.

Health-related Characteristics of College Students (N=309)

3. Predictors of Supporting a Tobacco-Free Campus

The results of multiple logistic regression analysis to identify predictors of being a TFC supporter among demographic variables, psychosocial characteristics, and health behaviors are presented in Table 3. In the bivariate analysis, only female gender (cOR=4.22, 95% CI=1.49-12.15, p=.007), anxiety (cOR=2.67, 95% CI=1.03-6.94, p=.043), and being a current smoker (cOR=0.22, 95% CI=0.05-0.96, p=.044) were associated with being a TFC supporter. However, after including all variables, the adjusted ORs revealed that female gender (aOR=5.80, 95% CI=1.47-22.95, p=.012), registering in the course to quit smoking oneself (aOR=11.03, 95% CI=1.04-117.05, p=.046), anxiety (aOR=4.27, 95% CI=1.06-17.31, p=.042), and being a current smoker (aOR=0.06, 95% CI=0.01-0.70, p=.025) were statistically significant independent predictors of TFC support.

Table 3.

Multiple Logistic Regression Analysis to Predict Support of a Tobacco-Free Campus (N=309)

DISCUSSION

TFC has been an effective policy in reducing all types of tobacco use and minimizing exposure to secondhand smoking among college students in many countries [7,22]. In this study, we found that most participants agreed with the university’s current tobacco policy allowing smoking in designated booths. The proportion of students who supported TFC was much lower than that found in previous studies. In a systematic review and meta-analysis of studies published through June 2013, Lupton and Townsend found that the acceptability of TFC ranged from 43% to 66% on average [22].

One of the possible reasons for the low proportion of TFC supporters is that the students were not very aware of the hazards of electronic cigarettes and did not consider it necessary to restrict their use. Although the course lectures included information about electronic cigarettes, that content might be not have been sufficient to change students’ perceptions about electronic cigarettes. Previous studies have reported that smokers considered electronic cigarettes to be less harmful than traditional cigarettes and often used them to aid smoking cessation [23].

The other possible reason for the low proportion of TFC supporters might have been the high proportion of male students in the study. According to Kang and Cho [24], normalization of tobacco use is associated with negative attitudes about total bans of tobacco use. The proportion of male students at the study site was almost 10 percentage points higher than average at Korean universities [25]. Of note, the smoking rate of young adults aged from 19 to 29 years old in Korea was 37.8% in men and 10.2% in women in 2019[1]. Our results are consistent with previous studies, which noted that nonsmoking status and female gender were statistically significant predictors of supporting TFC [12,21]. In our study, participants had higher smoking rates and a lower proportion of female gender than reported in previous studies [12,13,21,26].

Our study result showed that female gender, nonsmokers, and students who experienced anxiety in the past month were more likely to support TFC. Nonsmokers and women might be more aware of the health risks of secondhand smoke. Gong and colleagues indicated that nonsmokers strongly supported TFC because they were more aware of the risks of secondhand smoke than smokers [27]. In their descriptive study of 790 college tobacco users, Mamudu and colleagues [28] found that demographic factors were usually not associated with attitudes about TFC, but knowledge about the harms of secondhand smoke did increase TFC support. However, our study showed a somewhat unexpected finding regarding the association between anxiety and support for TFC. Previous studies reported that smokers with psychological difficulties such as depression and anxiety were more likely to use tobacco products as remedies and to relapse after quitting. In contrast, our study results showed that participants who reported being anxious in the past month were more likely to be TFC supporters. Although researchers have found that people with health issues such as asthma were more in favor of TFC [26], an association between anxiety and support of TFC has not previously been documented. Although our study did not attempt to assess the types and intensity of anxiety or to explain how anxiety is associated with TFC support, students with anxiety may be more worried about the health hazards of secondhand smoke, and this uneasiness may affect students with various health concerns.

Lastly, registering in the course to quit smoking oneself was an independent predictor of being a TFC supporter after adjusting for potential confounding factors. This finding is consistent with the results of previous studies that identified an association between intention to quit smoking and positive attitudes toward smoking bans in public places [29]. Lykke and colleagues [29] reported that smokers who are motivated to quit smoking could receive benefits from stronger smoking bans that would reduce their risk of relapse.

Our study has some limitations. Since all of our participants were Koreans, our sample is not representative of other races and countries. The cross-sectional nature of this study precludes causal associations from being derived from the study results. We did not fully examine the relationship between attitudes toward TFC and potential confounding factors such as use of new or emerging tobacco products and types or severity of anxiety. Glasgow and colleagues [30] reported that users of electronic cigarettes were barriers to TFC policies, since TFC policies ban electronic cigarettes while smoking bans do not. Our participants might already have been familiar with electronic cigarette use, and the number of electronic cigarette users could have been substantial. Further studies are necessary to include a more comprehensive assessment of potential confounding factors.

CONCLUSION

This study was conducted to elucidate the attitudes of college students toward TFC policies in Korea, where the smoking rate is high and the gender difference in smoking is significant in young adults. We found that most participants did not agree with the TFC policy. Considering that we enrolled students in a course about smoking cessation, agreement with TFC might be much lower among the general campus population. We found that gender and smoking status were associated with attitudes toward TFC. Further research is needed to explore other characteristics of people who favor TFC, such as their use of various tobacco products, mental health status, and diverse academic pursuits, with more representative samples. Such studies may help people to build organizations and regulations to work towards TFC policies that better fit their needs.

Health experts on campus, including school nurses, should participate in developing programs to expand awareness of the benefits of TFC. They could provide for-credit courses that focus on healthy behaviors, including smoking cessation. Experts could also support student initiatives, campaigns, and workshops on TFC. Researchers who aim to prove the effectiveness of a TFC policy on smoking rates and tobacco use should assess all related variables prior to its implementation. Such an approach will validate the effectiveness of this advanced tobacco-control policy.

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