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US Public Universities' Compliance with Recommended Tobacco-Control Policies

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Title: US Public Universities' Compliance with Recommended Tobacco-Control Policies
Language: English
Authors: Halperin, Abigail C., Rigotti, Nancy A.
Source: Journal of American College Health. Mar 2003 51(5):181-188.
Availability: Heldref Publications. 1319 Eighteenth Street NW, Washington, DC 20036-1802. Tel: 800-365-9753; Tel: 202-296-6267; Fax: 202-293-6130; e-mail: subscribe@heldref.org; Web site: http://www.heldref.org
Peer Reviewed: Y
Page Count: 8
Publication Date: 2003
Document Type: Journal Articles
Reports - Evaluative
Education Level: Higher Education
Descriptors: Universities, College Housing, Smoking, Interviews, Advertising, College Students, College Administration, Program Effectiveness, Program Evaluation, Health Promotion, School Policy, Administrators
Geographic Terms: United States
ISSN: 0744-8481
Abstract: To address the rise in tobacco use among college students, several national health organizations, including the American College Health Association,recommend that colleges enact smoking bans in and around all campus buildings, including student housing, and prohibit the sale, advertisement, and promotion of tobacco products on campus. Key informants at 50 US public universities,one from each state, were interviewed during the 2001/2002 academic year to assess the prevalence of these recommended policies. More than half (54) of the colleges banned smoking in all campus buildings and student residences, 68 had no tobacco sales on campus, and 32 of the schools' newspapers did not accept tobacco advertising. Regional differences in adoption of these campus tobacco-control policies were present. Although this national sample of public universities had implemented some of the recommended policies, they must take further actions to comply fully with campus tobacco-control guidelines. (Contains 3 tables and 2 figures.)
Abstractor: Author
Number of References: 25
Entry Date: 2007
Access URL: https://www.heldref.org/jach.php
Accession Number: EJ770090
Database: ERIC
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  Value: <anid>AN0010257547;acl01mar.03;2003Jul21.10:09;v2.1</anid> <title id="AN0010257547-1">US Public Universities' Compliance With Recommended Tobacco-Control Policies </title> <p>Abstract. To address the rise in tobacco use among college students, several national health organizations, including the American College Health Association, recommend that colleges enact smoking bans in and around all campus buildings, including student housing, and prohibit the sale, advertisement, and promotion of tobacco products on campus. Key informants at 50 US public universities, one from each state, were interviewed during the 2001/2002 academic year to assess the prevalence of these recommended policies. More than half (54%) of the colleges banned smoking in all campus buildings and student residences, 68% had no tobacco sales on campus, and 32% of the schools' newspapers did not accept tobacco advertising. Regional differences in adoption of these campus tobacco-control policies were present. Although this national sample of public universities had implemented some of the recommended policies, they must take further actions to comply fully with campus tobacco-control guidelines.</p> <p> <bold> Key Words: </bold> campus policy, college students, smoking, tobacco use</p> <p>Tobacco use among college students increased markedly during the 1990s, after a decade of relative stability. The 30-day prevalence rate of cigarette smoking among college students in the Monitoring the Future survey rose from 21.5% in 1990 to 30.6% in 1999, although it subsequently declined to 25.7% in 2001.(<reflink idref="bib1" id="ref1">n1</reflink>) The Harvard College Alcohol Study (CAS) demonstrated a similar trend among a nationally representative sample of college students, whose 30-day cigarette use prevalence rose from 22.3% in 1993 to 28.5% in 1999.(<reflink idref="bib2" id="ref2">n2</reflink>, n3) Some of this increase is explained by the aging of the cohort of adolescents whose smoking rates increased between 1991 and 1997, but it also appears that young adults may be initiating tobacco use at later ages.(<reflink idref="bib4" id="ref3">n4</reflink>) In the 1997 CAS survey, 11% of college smokers were reported to have begun to smoke and 28% to have become regular smokers at or after the age of 19 years; and a recent cohort analysis from Monitoring the Future showed that an increasing percentage of nonsmoking high school seniors are initiating smoking as young adults.(<reflink idref="bib5" id="ref4">n5</reflink>) In another study, more than half (52%) of current undergraduate student smokers reported that they had increased the amount they smoked since they entered college.(<reflink idref="bib6" id="ref5">n6</reflink>)</p> <p>The campus environment has the potential to encourage initiation and progression of tobacco use. Contributing factors might include the visibility of tobacco use on campus, the lack of restrictions on smoking, the presence of tobacco advertising and promotion, and the ease of purchasing tobacco products. A 1999 survey of college health service medical directors found that only 27% of a national sample of colleges prohibited smoking in all buildings, including student residence halls and dormitories.(<reflink idref="bib7" id="ref6">n7</reflink>) In 2 studies, a policy that banned smoking in all campus buildings, including student housing, was associated with lower rates of smoking among students, particularly those who were not regular smokers before they entered college.(<reflink idref="bib8" id="ref7">n8</reflink>, n9)</p> <p>Another factor that might contribute to increased smoking in this population is that young adults (18-24 years of age) are the youngest legal targets of tobacco marketing. Federal Trade Commission (FTC) reports have documented major increases in tobacco company marketing expenditures, as well as shifts from print and traditional media toward point-of-sale marketing, sampling events, and other promotions.(<reflink idref="bib10" id="ref8">n10</reflink>) At the same time, previously secret tobacco industry documents describe how the industry targets young adults by sponsoring trendy social events at which free cigarettes are often distributed.(<reflink idref="bib11" id="ref9">n11</reflink>, n12) Most (of these events occur in bars and clubs,(<reflink idref="bib13" id="ref10">n13</reflink>) but many occur at on-campus social events, and students exposed to these activities are more likely to be smokers.(<reflink idref="bib14" id="ref11">n14</reflink>)</p> <p>Several organizations, including the American College Health Association (ACHA), the American Cancer Society (ACS), and the National Center on Addiction and Substance Abuse (CASA),(<reflink idref="bib15" id="ref12">n15-17</reflink>) have recommended tobacco control policies for colleges and universities. All 3 organizations recommended that colleges and universities prohibit the sale, advertising, sampling, and distribution of tobacco products on their campuses and prohibit smoking in all campus buildings, including residence halls and other student housing. ACS and ACHA also recommend restricting smoking outside of building entrances and doorways, and call upon colleges to adopt a policy of not accepting tobacco industry donations or sponsorships. Both ACS and CASA recommend that smoking be prohibited at all college-sponsored events, indoors or out, and endorse free tobacco-cessation services for all students who need them. The ACS further urges colleges to divest from tobacco company stocks, ban participation of tobacco company representatives from campus job recruitment or career fairs, and work toward the goal of prohibiting smoking entirely on all campus property.</p> <p>Little is known about the extent to which US colleges and universities have adopted these policies or which factors encourage or impede their adoption. The overall tobacco control environment of the state in which a college is located may influence the development of college tobacco policies. This could be especially true to public educational institutions. Higher state tobacco excise taxes and the presence of stronger laws restricting smoking in public places and work sites are associated with lower state smoking rates, according to the Centers for Diseases Control and Prevention (CDC).(<reflink idref="bib18" id="ref13">n18</reflink>) Increased cigarette prices and higher tobacco excise taxes deter smokers, especially youth and young adults, from using tobacco.(<reflink idref="bib19" id="ref14">n19</reflink>) In addition, tobacco excise taxes provide a revenue stream) that can support state tobacco-control programs.(<reflink idref="bib20" id="ref15">n20</reflink>) Thus, higher excise taxes and comprehensive smoking restrictions appear both to contribute to and to reflect a state's overall tobacco-control environment.</p> <p>Because tobacco-control policies may help deter students from developing or continuing a tobacco habit, we assessed such policies in a national sample of public universities to determine whether compliance with recommendations has changed, compared with that found in earlier studies. In addition, we sought to identify state and regional factors that might be associated with stronger tobacco-control policies. We hypothesized that (<reflink idref="bib1" id="ref16">1</reflink>) campus policies may be influenced by the tobacco-control environment in the university's home state, and (<reflink idref="bib2" id="ref17">2</reflink>) the decline in smoking prevalence reported one colleges campuses in the past few years may be associated with a progression in the development of more restricted campus policies (if that is, indeed, the case).</p> <hd id="AN0010257547-2">METHOD</hd> <hd id="AN0010257547-3">Sample</hd> <p>We used national enrollment data(<reflink idref="bib21" id="ref18">n21</reflink>) to select a sample consisting of the largest public university in each of the 50 United States. We chose this sampling strategy lo obtain a geographically distributed sample of schools that drew a broad socioeconomic range of students and also maximized the number of students enrolled in the colleges. To maintain consistency, we also elected to use only public universities because they were most likely to be affected by their state tobacco-control environment. Representatives from all 50 of the universities we approached agreed to participate in the study.</p> <hd id="AN0010257547-4">Data Collection</hd> <p>We surveyed a number of key informants at each university. In an effort to find those who would be most knowledgeable about the different campus tobacco policies, we sought to reach the following individuals or their designees at each college: (<reflink idref="bib1" id="ref19">1</reflink>) a student affairs administrator: (<reflink idref="bib2" id="ref20">2</reflink>) a director of residence life: (<reflink idref="bib3" id="ref21">3</reflink>) the editor or advertising manager of the student newspaper: (<reflink idref="bib4" id="ref22">4</reflink>) the medical director or health education director of the student health center, and (<reflink idref="bib5" id="ref23">5</reflink>) the manager of the student union, campus food service or other tobacco sales venue. The first author (ACH) used the college's Web site or the school operator to identify potential informants, and the author or a research assistant then contacted the individual to schedule a telephone interview. When a telephone interview was not possible, the informant could request that the surveys be conducted via electronic mail or fax.</p> <p>The response rates in each of the above categories were 94% to 100% with a minimum of 3 informants surveyed at each school We made additional contacts or university Web site searches to confirm or clarify the policies and to verify information in the few instances where 2 informants at the same school reported discrepancies in policy. Data were collected during the 2001/2002 academic year, primarily in fall 2001. We considered policies current that were already implemented or would be implemented by June 1, 2002 and included then in the data analysis.</p> <hd id="AN0010257547-5">Survey Questions</hd> <p>Surveys of key informants included short-answer, semistructured, and open-ended questions. We asked respondents to describe tobacco-control policies in 6 areas (<reflink idref="bib1" id="ref24">1</reflink>) restriction of smoking in and around campus buildings, including residence halls; (<reflink idref="bib2" id="ref25">2</reflink>) sale of tobacco products on campus; (<reflink idref="bib3" id="ref26">3</reflink>) advertising of tobacco products in the student newspaper; (<reflink idref="bib4" id="ref27">4</reflink>) promotion of tobacco products or tobacco industry sponsorship of events at university venues, (<reflink idref="bib5" id="ref28">5</reflink>) student health service tobacco prevention practices and cessation programs (including student health insurance coverage for tobacco-cessation visits aid medications); and (<reflink idref="bib6" id="ref29">6</reflink>) investment in tobacco company stocks.</p> <p>Additional questions included the year in which a smoking ban was enacted in residence halls (if they were currently smoke free) or whether there were plans to become smoke free (if they were not). We compared the information on university investments in tobacco stocks that the respondents gave us with reports from the Council for Responsible Public Investment.(<reflink idref="bib22" id="ref30">n22</reflink>)</p> <hd id="AN0010257547-6">Data Analysis</hd> <p>We used SPSS statistical software (SPSS Inc, Chicago, IL) to analyze data the informants gave us, and calculated the prevalence of each of 8 recommended campus tobacco control policies: (<reflink idref="bib1" id="ref31">1</reflink>) smoking ban inside all public campus buildings, (<reflink idref="bib2" id="ref32">2</reflink>) smoking ban inside all student residences, (<reflink idref="bib3" id="ref33">3</reflink>) smoking ban outside all building entrances, (<reflink idref="bib4" id="ref34">4</reflink>) ban on tobacco sales on campus, (<reflink idref="bib5" id="ref35">5</reflink>) ban on tobacco advertising in campus student newspapers, (<reflink idref="bib6" id="ref36">6</reflink>) ban on tobacco industry promotions and sponsorships at campus ventures, (<reflink idref="bib7" id="ref37">7</reflink>) divestment from tobacco company stocks, and (<reflink idref="bib8" id="ref38">8</reflink>) coverage for cessation treatment by the student health insurance plait. We created an additional category -- complete smoking ban -- for universities that prohibit smoking inside all campus buildings, including residence halls, and also restrict smoking outside building entrances and doorways (policies 1-3 above).</p> <p>Schools were given 1 point for each of the first 6 policies listed above to construct a summary score of campus tobacco-control measures. Because none of the colleges had a policy banning all tobacco company promotions and sponsorships, the maximum summary score obtained was 5. We elected to exclude divestment from tobacco stocks and student health insurance coverage from the summary score because these policies are not visible and do not have a direct impact on the college environment or the students in the same sense as do campus restrictions on smoking, advertising, sale, or promotion of tobacco products.</p> <p>We conducted univariate and bivariate analyses to identify state-level factors associated with the presence of individual tobacco-related policies, the complete ban variable, and the summary campus tobacco-control score. Additional factors we examined included geographic region (Northeast, South, North Central, and West),(<reflink idref="bib23" id="ref39">n23</reflink>) location in a major tobacco-producing state (Georgia, Kentucky, North Carolina, South) Carolina, Tennessee, and Virginia),(<reflink idref="bib24" id="ref40">n24</reflink>) comprehensiveness of state legislation restricting smoking in public places (as classified by the American Lung Association), and state tobacco excise tax level (as a proxy measure for state tobacco-control funding).(<reflink idref="bib25" id="ref41">n25</reflink>)</p> <p>To measure statistical significance of differences, we used chi-square statistics and analysis of variance (ANOVA). In addition, we used the Spearman correlation coefficient to measure the strength of the association between the summary campus tobacco-policy score and state tobacco-control laws and excise tax level. We used a linear regression model to assess the independent effects of geographic region and location in a tobacco-producing state on the summary policy score.</p> <hd id="AN0010257547-7">RESULTS</hd> <hd id="AN0010257547-8">Sample Characteristics</hd> <p>The 50 universities in the sample enrolled 1,250,700 undergraduate and graduate students, representing nearly 9% of all higher education students in the United Stales.(<reflink idref="bib21" id="ref42">n21</reflink>) Enrollment at individual schools ranged from 7,300 to 49.900 (M = 25, 132 students). Undergraduates (n = 957,800) constituted 77% of the total enrollment at the participating schools. Nine of the colleges (18%) were located in the Northeast, 16 schools (32%) were in the South, 12 schools (24%) were in the North Central area, and 13 schools (26%) were in the West. Six colleges (2%) were located in major tobacco-producing states, which are all within the southern region of the US.</p> <hd id="AN0010257547-9">Prevalence of Campus Tobacco-Control Policies</hd> <p>The prevalence of tobacco-control policies in the 50 universities surveyed is displayed in Table 1. All but I school prohibited smoking in all indoor public areas, but these restrictions did not necessarily extend to residence halls, Greek houses, apartments, or private offices. Approximately half of the colleges banned smoking in all residence halls and dormitories. Half of the colleges had written policies prohibiting smoking within a certain distance (range = 10-50 feet) of all campus building entrances, doorways, or air intake vents, although only 18 of the 25 colleges were reported to have signs indicating the policy. Several informants reported a lack of enforcement, even at schools where signs were posted. Overall, 15 colleges prohibited smoking in all 3 areas, meeting our definition for a complete smoking ban</p> <p>During the past several years, a marked increase in the number of campuses instituting totally smoke-free housing has been reported (Figure 1). Fourteen of the 27 colleges with smoke-free housing policies had adopted their policy within the past 2 academic years (2000-2002), bringing the total percentage from 26% in 1999 to 54% in 2002. Three more institutions reported plans to enact smoking bans in all residence halls during the 2002/2003 academic year. To explain the decision to adopt smoke-free policies, most residence life administrators cited financial issues, student demand, or liability concerns, rather than public health considerations. Two universities reported that smoking was banned in student housing as a means of complying with new state or county ordinances.</p> <p>Thirty-four colleges (68%) reported that tobacco products were not sold on campus, and 2 others, which currently permitted tobacco sales, reported that they were in the process of discontinuing tobacco sales for the 2002/2003 academic year. Eleven (69%) of the E6 colleges that sold tobacco products allowed students to use their meal cards or student accounts to purchase tobacco products. The information sources from campuses that permitted tobacco-product sales reported 38 retail outlets, including bookstores, newsstands, student union cafeterias, convenience stores, and snack bars or cafes. More than half of the retail outlets (55%) were owned and operated by the university, 24% were under the jurisdiction of a contracted food-service provider, 16% were privately owned campus stores or franchises, and 5% were cooperatively owned bookstores.</p> <p>Editors or advertising managers at 16 (32%) of the 50 campus newspapers reported that the publication did not accept tobacco advertising, although only half of those had written policies that specifically banned tobacco ads. Of the remaining 34 newspapers that accepted tobacco advertising, only 8 (24%) had run a tobacco ad in the current or most recent school term. Most of those who accepted but had not run tobacco advertisements said that tobacco advertisers had not approached them or they would have run the ads.</p> <p>The majority of informants were not aware of whether tobacco company-sponsored promotions or events had occurred on campus, anti none reported that their institution had a written policy that prohibited such activities if such activities were otherwise legal (i.e. distributing free tobacco products in states where this is allowed). Informants from 6 colleges described informal policies disallowing certain types of promotions or sponsorship>s such as tobacco-brand sponsored concerts or sporting events. Seven knew of specific tobacco industry-funded activities that had taken place at their university, including an annual rodeo, a museum exhibit, a concert, an agricultural school scholarship, and fraternity parties (at 3 schools).</p> <p>According to the Council for Responsible Public Investment, 4 of the universities we surveyed had divested themselves of tobacco company stocks in their portfolios at the time of the survey, and 2 more were contemplating divestiture.(<reflink idref="bib22" id="ref43">n22</reflink>) Respondents at the 4 schools that had divested themselves of tobacco stocks were aware they had done so, but the majority of informants from other colleges were unsure whether their university held tobacco stocks or not (most correctly thought that the institution did).</p> <hd id="AN0010257547-10">Student Health Center Tobacco-Cessation Services and Programs</hd> <p>Seventy percent of student health centers reported that clinic visits :for smoking cessation were covered by the university's student health insurance plan; 33 of 35 did so with no co-pay for the student, whereas 2 of 35 had a small co-pay ($5-$10). However, only 20% of college health plans covered medication to treat tobacco addiction (i.e., nicotine replacement therapy or bupropion), and only 18% covered both provider visits and medications for smoking cessation. Group cessation programs were offered by 22 (44%) of the college health centers, but informants from all but 2 of the schools reported extremely low student participation in these groups (rarely more than 1 or 2 students per semester). In addition, most informants to whom students were referred for cessation assistance reported that initial no-show rates were high and that follow-up for individual appointments was poor. In a few cases, special events or outreach efforts for smoking cessation, such as "Quit and Win" contests or challenges between residence halls or sororities attracted a much larger number of students attempting to quit.</p> <hd id="AN0010257547-11">State and Regional Variations in Campus Tobacco-Control Policies</hd> <p>As the data in Table 2 make clear, regional differences in the prevalence of bans on smoking in outdoor areas and complete smoking bars were significant. Fewer of those policies were in place at colleges located in southern states and more tobacco-control policies were reported in the western states. Universities in the major tobacco-producing states (see Table 3) were significantly less likely than schools in other states to have banned smoking in student residences or outside of buildings. The prevalence of tobacco-cessation treatment services did not vary significantly by region or location in a tobacco-producing state.</p> <p>We calculated the summary score for each school's tobacco-control policies on the basis of the 6 main campus tobacco-control policies assessed by the survey (Figure 2). One university had a score of 0, 5 schools had 1 policy, 10 had 2 policies, 17 had 3 policies, 13 had 4 policies, and 4 colleges had 5 policies in place. None of the colleges reported that they had all 6 policies in effect. The mean score across all schools was 2.98 (± 1.19).</p> <p>We found no statistically significant regional variation in summary policy scores, but universities in tobacco-producing states had a lower mean summary score than did those in non-tobacco-producing states (1.51 vs. 3.18, p = .001). This finding held in linear regression analyses that were adjusted for region and location in a southern state (β = -1.70, 95% confidence interval [CI] -2.825, -.574). The summary tobacco-control scores for the 50 universities were strongly associated with the 2 measures of statewide tobacco control: cigarette excise tax level (r = .407, p = .003) and comprehensiveness of laws restricting smoking in public places (r = .325, p = .021).</p> <hd id="AN0010257547-12">COMMENT</hd> <p>The findings in this study demonstrate that although the largest US public universities have made some progress in adopting tobacco-control policies, they still fall far short of recommendations made by the American College Health Association, the American Cancer Society, and the National Center on Addiction and Substance Abuse.(<reflink idref="bib15" id="ref44">n15-n17</reflink>) Only half of the schools provided completely smoke-free student housing. Few had written policies restricting tobacco advertising in campus newspapers, and none specifically banned all tobacco industry sponsorships and promotions on college property. One third sold tobacco on campus, and two thirds of those allowed students to charge tobacco products on their meal cards or other student accounts. Less than one fifth of the colleges' student health plans covered both visits and medications for tobacco-cessation treatment, and very few universities had divested their selves of tobacco company stocks.</p> <p>These data are consistent with other limited data available. A 1999 survey of 116 nationally representative private and public universities reported that 27% banned smoking in all student residences,(<reflink idref="bib7" id="ref45">n7</reflink>) a rate that is similar to our finding that 26% of universities had smoke-free housing in 1999. Our data demonstrate a doubling in the number of colleges with complete bans on smoking in student residences over the subsequent 2 academic years so that all student housing at more than half (54%) of our sample schools is now smoke free. If this promising trend continues, it is feasible that's smoke-free student residences may become the norm within a few years.</p> <p>The number of universities that do not allow the sale of tobacco products on their campuses has also increased, but the increase is less dramatic. Although we found no study that assessed the impact of on-campus availability of tobacco products on student smoking, the ready access to tobacco products may make it easier for occasional smokers to progress to more regular use. Of greater concern is the finding that more than two thirds of the schools that sold tobacco allowed students to use their meal cards or student accounts to pay for tobacco products. Students' meal cards and college accounts are often funded by their parents or scholarships, thus diminishing or eliminating the cost of tobacco as a financial disincentive for smoking. Parents may not realize that they are paying for tobacco products for their children at these colleges, essentially subsidizing their tobacco habits, Profiting from campus tobacco sales can create an inherent conflict of interest if a university relies on tobacco sales as a source of revenue: in addition, universities are responsible for providing a healthy environment for students and other community members. Selling tobacco on campus may also serve to normalize and sanction smoking behavior, sending a mixed message to students about the dangers of tobacco use.</p> <p>Our survey found that respondents' awareness of tobacco company sponsorships and promotions on campus was very low, and that few policies prohibited this kind of activity. Informants at three quarters of our sample of universities were unaware of such tobacco promotions on campus, and only 6 reported any efforts to limit tobacco company sponsorships of campus events. In light of recent studies that have demonstrated dramatic increases in this type of tobacco marketing(<reflink idref="bib11" id="ref46">n11</reflink>, n12) and widespread student exposure to tobacco promotions that distribute free tobacco products both on and off campus,(<reflink idref="bib14" id="ref47">n14</reflink>) we suspect that the occurrence of these activities was underreported by our informants.</p> <p>The regional variation in campus tobacco-control policies found in this study corresponds, to some extent, with regional variation in state tobacco-control policies. Both cigarette excise taxes and public smoking restrictions are weakest in the southern states,(<reflink idref="bib25" id="ref48">n25</reflink>) where economic interests in tobacco are strong. Students attending public universities in the US South, especially in the major tobacco-growing states, appear to be less well protected by campus policies that could discourage the progression of tobacco habits and limit exposure to secondhand smoke. By contrast, students who attend state universities in the West are more likely to benefit from protective tobacco-control policies both off and on campus compared with students studying in other regions.</p> <p>As is often the case, this study has limitations. Because our sample included only large public universities, the findings cannot be generalized to other types of institutions of higher education, such as 2-year colleges, smaller public universities, and private independent or religiously affiliated schools. However, more than 1 million students were enrolled in the universities in our sample, and two thirds of all higher education students in the US attend public colleges. Therefore, our sample represents the type of institution attended by a majority of US college students. Furthermore, the policies of the largest state universities often set the stage for other colleges and universities in the state.</p> <p>Another limitation is that respondents may not have completely or accurately described their schools' tobacco policies. To minimize this problem, we contacted many individuals from several departments at each university to obtain consensus and attempted to verify conflicting information by communicating with additional sources. However, it is possible that other college personnel might have had more knowledge about tobacco policies and issues, especially concerning promotions and sponsorships, an area in which information was scant. Finally, our study could not assess the extent to which policies are communicated to students, implemented, and enforced on campuses. Policies require adequate implementation to achieve the desired results. In future studies, this variable should be assessed.</p> <p>Although adoption of stronger tobacco-control policies by state universities appears to be increasing, national recommendations are still far from being fully implemented. The lack of these policies is likely to contribute to a college environment that supports tobacco use rather than helping students avoid using tobacco in the first place or supporting them in their efforts to quit. Previous studies suggest that comprehensive campus smoking restrictions that include student residences may reduce tobacco use among students.(<reflink idref="bib8" id="ref49">n8</reflink>, n9) The current study demonstrates that a dramatic increase in this type of policy occurred coincident with a decline in smoking prevalence among college students during the 1999-2001 period.(<reflink idref="bib1" id="ref50">n1</reflink>) Such a temporal association does not imply causality, but it supports the possibility that a national increase in smoke-free campus policies may be contributing to this downward trend.</p> <p>Although it seems that adherence to national recommendations for tobacco policies is likely to be an effective deterrent to tobacco use among college and university students, we need more prevalence studies to produce evidence of this. At the same time, it is essential that campus leaders continue to champion the development of comprehensive smoking restrictions and that student health service providers seek innovative approaches to cessation that are tailored to this unique population. Evaluations of both the process and the outcome of such efforts should be conducted so that elements of success and strategies for overcoming barriers to policy implementation and student cessation can be identified. We urge readers to take stock of their colleges' tobacco-related policies and practices, see how they measure up to recommendations, and do their part to address tobacco use in this generation by making their campuses truly smoke free.</p> <hd id="AN0010257547-13">ACKNOWLEDGMENTS</hd> <p>Dr Halperin received support for this study from the American Legacy Foundation (Grant #5024), and Dr Rigotti was supported by a Mid-Career Investigator Award in Patient-Oriented Research from the National Heart, Lung, and Blood Institute (#HL04440) and by a Distinguished Professor Award from the Flight Attendant Medical Research Foundation. The authors would like to thank Alison Ensmninger and Gina Escamilla for their able and enthusiastic research assistance, and express our gratitude to Beti Thompson for her careful and insightful review of the manuscript.</p> <hd id="AN0010257547-14">NOTE</hd> <p>For comments and further information, please address communications to Abigail C. Halperin, MD, MPH, University of Washington Center for Health Education and Research, 901 Boren Avenue, Suite 11100, Seattle, WA 98104. (e-mail: abigail@u.washington.edu).</p> <hd id="AN0010257547-15">TABLE 1. Prevalence of Tobacco-Control Policies and Cessation Services at 50 US Public Universities</hd> <ct id="AN0010257547-16"> Legend for Chart: A - Policy B - Universities (N = 50) % C - Universities (N = 50) n A B C Smoking ban Inside public buildings 49 98 Outside building entrances 25 50 Inside student housing 27 54 Complete ban (all of above) 15 30 Tobacco sales ban 34 68 Tobacco advertising ban 16 32 Divestment of tobacco stocks 4 8 Insurance coverage for tobacco cessation Visits to provider covered 35 70 Medication covered 10 20 Both visits and medication covered 9 18 Group cessation programs offered 22 44</ct> <hd id="AN0010257547-17">TABLE 2. Prevalence of Campus Tobacco-Control Policies and Cessation Services by Geographic Region</hd> <ct id="AN0010257547-18"> Legend for Chart: A - Policy (%) B - Region Northeast (n = 9) C - Region South (n = 16) D - Region North Central (n = 12) E - Region West (n = 13) F - p A B C D E F Campus building ban 100 94 100 100 .538 Residence hall ban 56 56 50 54 .989 Outside restrictions 44 13 75 77 .001 Complete smoking ban 22 6 42 54 .031 Tobacco sales ban 56 69 75 69 .820 Tobacco advertising ban 67 31 17 31 .084 Divestment 11 0 8 15 .480 Cessation visits covered 67 69 75 69 .977 Cessation meds covered 11 25 17 31 .685 Cessation groups offered 56 44 25 54 .431 Summary campus policy score(M) 3.22 2.56 3.17 3.15 .088 Note. Summary campus policy score represents arithmetic sum of 6 tobacco-control policies (range 0-5, mean across all states 2.98).</ct> <hd id="AN0010257547-19">TABLE 3. Prevalence of Campus Tobacco-Control Policies and Cessation Services by Location in a Tobacco-Producing State</hd> <ct id="AN0010257547-20"> Legend for Chart: A - Policy(%) B - Tobacco state (n = 6) C - Nontobacco state (n = 44) D - p A B C D Campus building ban 83 100 .006 Residence hall ban 17 59 .050 Outside restrictions 0 56 .009 Complete smoking ban 0 34 .087 Tobacco sales ban 33 73 .052 Tobacco advertising ban 17 34 .391 Divestment 0 9 .441 Cessation visits covered 83 68 .447 Cessation meds covered 33 20 .475 Cessation groups offered 17 48 .150 Summary campus policy score (M) 1.51 3.18 .004 Note. Summary campus policy score represents arithmetic sum of 6 tobacco-control policies (Range 0 - 5, Mean across all states 2.98).</ct> <p>GRAPH: FIGURE 1. Increase in smoke-free student housing at 50 US public universities, 1994-2003.</p> <p>MAP: FIGURE 2. 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American Lung Association; 2002.</bibtext> </blist> </ref> <hd id="AN0010257547-22">Health Beliefs of College Students Born in the United States, China, and India</hd> <p> <bold> Abstract. </bold> The authors surveyed 243 urban public university students who were born in the United States, China, and India to compare the health beliefs of the China-born, India-born, and US-born students. Although the China-and India-born students shared beliefs in many preventive and therapeutic practices of Western medicine with the US-born students, they retained some of their traditional health beliefs. This suggests that student health service clinicians should assess students' cultural beliefs and individualize healthcare for students from different countries,</p> <p> <bold> Key Words: </bold> health beliefs, international students, university health services</p> <p>In this study, the authors present findings from a survey at an urban public university that examined the health beliefs of college students born in the United States, China, and India. Their findings are somewhat applicable to students from other Asian countries because Indian and Chinese medical systems have influenced practically all other Asian societies.(<reflink idref="bib1" id="ref51">n1</reflink>) Despite the growing importance of this issue to college and university health centers (SHCs), very few cross-cultural studies of the health beliefs of international college students have been published.(<reflink idref="bib2" id="ref52">n2</reflink>)</p> <p>Providing healthcare to international (foreign-born) students has become an increasing responsibility of many SHCs. In the 2000/2001 school year, 548,000 international students attended US colleges and universities, accounting for 3.9% of total enrollment, compared with 286,000 international students in 1979/1980, who constituted 2.4% of total enrollment. About 55% of all international students in 2000/2001 came from Asia, with the largest group (<reflink idref="bib60" id="ref53">60</reflink>,000), from China, and the second largest group (<reflink idref="bib55" id="ref54">55</reflink>,000) from India. Eighty percent of China-born and 73% of India-born students are enrolled as graduate students.(<reflink idref="bib3" id="ref55">n3</reflink>)</p> <hd id="AN0010257547-23">Theories of Health Beliefs</hd> <p>Two sociological theories have been used to understand individual differences in health beliefs and practices: one based on socioeconomic status and the other on cultural values. Socioeconomnic status is widely used to explain differences in health attitudes and beliefs in Western societies.(<reflink idref="bib4" id="ref56">n4</reflink>) Individuals from higher socioeconomic status groups tend to have more accurate knowledge of medical problems and are more likely to consult Western-trained health professionals promptly and to follow their recommendations. They also are more likely to engage in health-promoting behaviors such as maintaining proper body weight, having regular preventive health examinations, and exercising regularly.</p> <p>However, socioeconomic characteristics alone generally fail to explain differences in health status between native-born and international populations in developed countries. Immigrants from specific ethnic groups suffer from different diseases and have different mortality rates from the same diseases than immigrants from other ethnic groups or the native-born US population of the same socioeconomic status.(<reflink idref="bib5" id="ref57">n5</reflink>) This disparity has usually been explained by the immigrants' retention of traditional health beliefs and practices.</p> <p>The traditional health systems of India and China differ fundamentally from Western medicine. For example, the concept of anatomical body organs, which is the basis of disease pathology in Western medicine, does not exist in Taoist Chinese or Ayurvedic Indian medicine, the major traditional systems in China and the Indian subcontinent. These systems, therefore, have no counterparts to modern Western disease nosology, etiology, and symptomatology.(<reflink idref="bib6" id="ref58">n6</reflink>) Both Chinese(<reflink idref="bib7" id="ref59">n7</reflink>) and Indian(<reflink idref="bib8" id="ref60">n8</reflink>) medical systems emphasize the preventive and therapeutic benefits of specific foods and botanical medicines and have roles for indigenous folk healers and traditional drug providers. Family and friends are considered important sources of medical knowledge. In India, religious practices are accepted as methods for preventing and curing disease.</p> <p>Western medicine has been available for many years in urban areas of China and India, and persons of all socioeconomic levels use both Western and traditional medical care.(<reflink idref="bib9" id="ref61">n9</reflink>) Western medicine is often used for the treatment of infectious diseases and traditional medicine for chronic diseases. Some China-born and India-born immigrants in Westernized countries also use both Western and traditional medical care, even after they have become acculturated to their new societies or have health insurance.(<reflink idref="bib10" id="ref62">n10</reflink>)</p> <p>The hypothesis is that each of the 3 groups of students in this study' has its own distinctive pattern of health beliefs. US-born college students, who have above-average levels of education and socioeconomic status, are expected to accept most of the health beliefs of Western medicine. India-born and China-born students will also accept many aspects of Western medicine because they are being educated in America and come from families that are more educated and Westernized than the general population in their home countries. However, each group also retains some aspects of its traditional health beliefs.</p> <hd id="AN0010257547-24">METHOD</hd> <hd id="AN0010257547-25">The Sample</hd> <p>The sample included 167 students born in the United States, 36 born in China, and 40 born in India (Table 1). Most of the US-born students were undergraduate men aged 18 to 20 years, had lived in United States all their lives, and were US citizens. Most of the China born and India-born students were men aged more that 20 years; were juniors, seniors, or graduate students; had come to the United States when they enrolled in college; and were not US citizens.</p> <p>The family backgrounds and health status of the individuals in the 3 groups of students were similar in important respects. At least half of the students' fathers had earned college or professional degrees, as had almost as many of the mothers. One half or more of all 3 groups of students grew up in big cities or suburbs. These findings indicated that the China-born and India-born students were highly atypical of their fellow countrymen. All 3 groups were generally healthy, and few had had a health problem in the previous year that limited their activities for more than a short time. Thirty-six percent of the China-born and 38%) of the India-born students visited the University of Maryland, Baltimore County (UMBC) student health service at least once, compared with only 11% of the US-born students, most of whom were Maryland residents and had access to their family physicians.</p> <p>Our sample was drawn from students at UMBC, an urban public university with 11,000 undergraduate and graduate students. Approximately 750 UMBC students enrolled in, 2000 were born in countries other than the United States, including 164 born in China and 103 born in India. The UMBC Institutional Review Board (IRB) gave its approval for this study.</p> <p>We obtained our convenience sample by administering the questionnaire in about 20 classes, mostly advanced undergraduate and graduate courses in computer science, engineering, and other fields popular with students born in China and India. The instructors gave the researchers permission to administer the questionnaire to the students, who were given the option of filling out the questionnaire or handing in a blank form. The usable response rate was nearly 90%, which effectively eliminated response bias. The predominance of computer and engineering classes produced some sampling bias, especially because of the small number of women in those disciplines.</p> <hd id="AN0010257547-26">The Instrument</hd> <p>The questionnaire included 3 sections designed to measure health beliefs. One was a list of behaviors that were important "in order for you personally to keep healthy," with response categories of very important, fairly important and not important (the statements are summarized in Table 2). A second section was a list of behaviors that were important "in helping you recover . . . when you become sick," with the same response categories (Table 3). The third section asked the respondents about their "confidence" in a list of persons and institutions who could help them recover when they were ill, with response categories of a great deal, some, and little or none (Table 4). A fourth section requested socioeconomic and demographic information.</p> <p>We included aspects of Western and traditional Indian and Chinese medicine in the health beliefs listed, along with several that overlap or cannot be clearly classified. For example, the health benefits of rest and sleep are accepted in many health traditions. Vitamins and botanical nutritional supplements are consumed by persons in many cultures, but health professionals consider them useful only in certain specific conditions.(<reflink idref="bib11" id="ref63">n11</reflink>) Many persons use the mass media to learn about health and disease, but experts question the usefulness of much of the information.(<reflink idref="bib12" id="ref64">n12</reflink>)</p> <p>We dichotomized the response categories into very important and all other or great deal and all other and used the chi-square test to compute levels of statistical significance, which are reported when the levels exceed p < .05. Subgroups of China-born and India-born students (eg, men and women) were too small for valid comparisons.</p> <p>The questionnaire included many commonly asked questions about Western health practices. We constructed additional questions to obtain information about non-Western health practices. We pretested the questionnaire with college students born in America and in several Asian countries.</p> <hd id="AN0010257547-27">RESULTS</hd> <p>Considering the factors that might help students personally "keep healthy." each group placed the same 4 factors at the top of its rankings (Table 2): "maintain proper body weight," "have enough physical exercise," "have enough rest and sleep," and "eat proper kinds of foods." Their belief in weight control and regular exercise probably indicated the influence of modern Western medicine, whereas the belief in rest and sleep may encompass both modern and traditional health beliefs. Acceptance of Western medicine is also evident in 3 factors that the 3 groups considered of little importance in keeping healthy--vitamins, nonprescription medicines, and traditional medications.</p> <p>The high ranking the students born in China and India gave to eating proper kinds of foods is consistent with the traditional health practices of those cultures. To most people born in the US, "proper kinds of foods" means foods with nutritional values considered desirable by experts. In traditional India(<reflink idref="bib13" id="ref65">n13</reflink>) and Chinese(<reflink idref="bib14" id="ref66">n14</reflink>) medicine, foods are believed to affect health and disease directly by maintaining or upsetting humoral (body fluid) balances. In conformity with these beliefs, 64% of the China-born and 58% of the India-born students believed that eating proper kinds of foods was "very important," compared with only 40% of the US-born students (p < .02 for China-born vs US-born; p < .052 for the India-born vs US-born students in the sample).</p> <p>Religious faith was another factor that reflected cultural differences. Thirty percent of the India-born students, compared with 23% of US-born students and 6% of China-born students, indicated that religious faith was "very important" in preventing illness (p < .002 for India-born vs China-born; p < .02 for US-born vs China-born).</p> <p>Our most unexpected finding concerned periodic medical examinations, which are a mainstay of Western medicine.(<reflink idref="bib15" id="ref67">n15</reflink>) Only 31% of the China-born, 20% of the India-born, and 14% of the US-born students stated that regular checkups by a doctor were very important in keeping healthy (p < .02 for China-born vs US-born). It is particularly surprising that the US-born students ranked lowest among the 3 groups with regard to the importance of this factor.</p> <p>The second set of questions concerned factors that were important in "helping you recover . . . when you become sick." More than 80% of each group agreed that "rest and sleep" were very important and more than 50% of each group agreed that "recommendations of doctors and nurses" and eating "proper kinds of foods" were very important. All 3 groups also gave low rankings to talking medications (non-prescription or traditional).</p> <p>The 3 groups of students often differed significantly in the percentages that considered specific factors to be very important in recovering from illness. Although 48% of the India-born and 40% of the China-born students agreed that seeing a doctor or nurse promptly was very important, only 20% of the US-born students shared this view (p < .001 for India-born vs US-born; p < .03 for China-horn vs US-born students). The India-born students continued to emphasize religious faith, with 35% responding that religious faith was very important, compared with 17% of the U.S-born and 3% of the China-born students (p < .001 for India-born vs China-born; p < .02 for India-horn vs US-horn; p < .03 for US-born vs China-born). Forty-eight percent of the India-born students believed that vitamins were very important, compared with 35% of the US-born and 31% of the China-born (p < .01 for India-born vs China-born; p < .02 for India-born vs US-born).</p> <p>The last set of factors evaluated the respondents' confidence in various persons and institutions "to help you recover" when "you are sick." The largest proportions of each participant group agreed on the same 2 groups--their families and their physicians. The 3 groups ranked nurses and pharmacists or druggists lower than these 2 groups; they gave the lowest rankings to religious leaders, folk or alternative healers, and television/newspapers/magazines.</p> <p>The groups differed significantly in the percentages of the participants who expressed a great deal of confidence in specific persons. Seventy-five percent of the India-born students considered family very important compared with only 41% and 42% of the other 2 groups (p < .003 for India-born vs China-born students; p < .001 for India-born vs US-born students). Forty-eight percent of the India-born students had a great deal of confidence in friends, compared with only 22% of each of the other 2 groups (p < .02 India-born vs China-born, p < .001 India-born vs US-born). Nineteen percent of the China-born students had a great deal of confidence in traditional or botanic healers, compared with only 8% of India-born students and 7% of US-born students (p < .02), China-born vs US-born). Nineteen percent of the China-born students also had a great deal of confidence in those who shared their culture or ethnic group, by contrast to 10% of Indian-born and 3% of US-born students (p < .001 China-born vs US-born).</p> <hd id="AN0010257547-28">Implications for College and University Health Services</hd> <p>Certain limitations of this study should be noted. The use of a convenience sample at a single university means that the findings are preliminary and require replication. Gender differences, which could not be examined because of the small sample of students born in China and India, have been shown to be very important in studies of college students in many countries.(<reflink idref="bib16" id="ref68">n16</reflink>) The students in our sample were primarily science and engineering majors, but the significance of this factor is unclear. Improvements in the design of cross-cultural health questionnaires should be part of future research.</p> <p>On the basis of this study, SHCs can expect college students with similar socioeconomic backgrounds who come from cultures as diverse as the United States, India, and China to share many Western medicine health beliefs. The 3 groups of students accepted some major risk factors for disease and health practices that experts consider important in recovering from illness. In addition, few of the international students from China and India attached importance to alternative sources of healthcare, such as botanic drugs, nonprescription medications, vitamins, and non-Western healthcare providers.</p> <p>The 3 groups also shared some health beliefs that were inconsistent with Western medicine. One was the lack of acceptance of regular medical check-ups. The Preventive Services Task Force of the US Public Health Service used a criterion of "compelling evidence of effectiveness"(<reflink idref="bib17" id="ref69">n17</reflink>) in specifying preventive services that the students should be receiving in 1996. The task force recommended that all adolescents have periodic screening for hypertension, obesity, and problem alcohol consumption. Those students who are at an increased risk, the report continued, should also be screened regularly for sexually transmitted diseases, cervical cancer, and human immunodeficiency virus (HIV). In addition, the task force also called for periodic counseling of all adolescents concerning drug use, tobacco and alcohol consumption, sexually transmitted diseases, effective contraceptive methods, a healthy diet, physical activity, dental health, and methods of preventing motor vehicle injuries. Students raised in developing countries with limited healthcare facilities may also need screening for dental disease, visual and hearing impairment, and tuberculosis, all of which were recommended for selected groups by the Task Force. SHCs need to add student education about some of these recommendations to the health information that they already provide.(<reflink idref="bib18" id="ref70">n18</reflink>)</p> <p>Another unexpected finding is the greater acceptance among China-born and India-born students, compared with US-born students, of prompt professional medical care when they are ill. We suggest 2 possible explanatory factors: (<reflink idref="bib1" id="ref71">1</reflink>) US-born students may have more confidence in their ability to treat themselves, based on their greater familiarity with over-the-counter American medicines(<reflink idref="bib19" id="ref72">n19</reflink>); and (<reflink idref="bib2" id="ref73">2</reflink>) US-born students may also be more familiar than international students are with the symptoms of minor self-limiting medical problems prevalent in the United States.</p> <p>Our findings from this study refute the common stereotype that students from Asian cultures all have similar health beliefs. The India-born and China-born students differed significantly from each other, as would be expected from the long and distinctive histories of their cultures. India-born students attached more importance than China-born students did to religious faith and had more confidence in their families and friends in helping them recover from illness. Because these sources of help are rarely available to students born in India who are no studying in than US, SHCs should develop surrogates (eg, India-born students with similar problems).</p> <p>Nurses staff most SHCs,(<reflink idref="bib20" id="ref74">n20</reflink>) but all 3 groups of students had more confidence in physicians than in nurses. (We did not distinguish between nurses and nurse practitioners, but few students are aware of the differences.) SHC authorities should develop methods of enhancing the trust of these students in nurses as healthcare providers.</p> <p>In short, providing health services for international students from China and India should not be "business as usual" for campus health services. Those who are in charge of SHCs should understand and be sensitive to cultural differences if they are to improve the quality of healthcare they provide to students of all nationalities.</p> <hd id="AN0010257547-29">NOTE</hd> <p>For comments and further information, please address communications to William G. Rothstein, Department of Sociology and Anthropology, University of Maryland, Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250 (e-mail: rothstei@umbc.edu).</p> <rj></rj> <rj>William G. Rothstein, PhD, Sushama Rajapaksa, MA</rj> <hd id="AN0010257547-30">TABLE 1. Characteristics of US-Born, China-born, and India-born Students in Sample, in Percentages</hd> <ct id="AN0010257547-31"> Legend for Chart: A - Characteristic (%) B - Birthplace US (167) C - Birthplace China (36) D - Birthplace India (40) A B C D Male 73.7 63. 9 77.5 Ages 18-23 years 89.8 55.5 77.5 Undergraduate 98.8 62.8 27.5 American citizen 98.2 25.0 5.0 Father's education College or professional 61.1 55.6 82.5 < College 38.9 44.4 17.5 Mother's education College or professional 53.3 47.2 85.0 < College 46.7 52.8 15.0 Time lived in US All my life 94.0 22.2 0.0 Since attending college 0.0 63.9 90.0 Other 6.0 13.9 10.0 Grew up in Big city/suburb 59.1 50.0 72.5 Small town/rural, farm 40.1 50.0 27.5 Health in last 12 months Limited activities only short time 83.2 91.7 77.5 Limited a little/lot 16.8 8.3 22.5 Visits to health service None 89.2 63.9 62.5</ct> <hd id="AN0010257547-32">TABLE 2. Factors Students Said Were Very Important for Keeping Healthy, in Percentages</hd> <ct id="AN0010257547-33"> Legend for Chart: A - Factor B - Birthplace US C - Birthplace China D - Birthplace India A B C D Enough rest/sleep 53 69 65 Physical exercise 50 58 43 Proper body weight 44 50 43 Eating proper foods 36 64 58 Religious faith 23 6 35 Taking vitamins 16 19 20 Regular checkups by doctor 14 31 20 Taking nonprescription medicines 4 6 3 Taking traditional medicines 3 11 3</ct> <hd id="AN0010257547-34">TABLE 3. Factors Students Said Were Very important for Recovering From Sickness, In Percentages</hd> <ct id="AN0010257547-35"> Legend for Chart: A - Factor B - Birthplace US C - Birthplace China D - Birthplace India A B C D Enough rest/sleep 84 81 83 Follow doctors' and nurses' recommendations 54 69 63 Eating proper foods 50 58 73 Taking vitamins 35 31 48 Seeing doctor or nurse promptly 20 39 48 Religious faith 17 3 35 Taking nonprescription medicines 13 14 15 Taking traditional medicines 8 19 13</ct> <hd id="AN0010257547-36">TABLE 4. Sources of Help in Which Students Have a Great Deal of Confidence When They Are Sick, in Percentages</hd> <ct id="AN0010257547-37"> Legend for Chart: A - Source B - Birthplace US C - Birthplace China D - Birthplace India A B C D Doctors 53 69 58 Family 41 42 75 Nurses 34 28 23 Pharmacists/druggists 22 22 13 Friends 22 22 48 Religious leaders 7 0 10 Traditional/botanic druggists 7 19 8 Folk/alternative healers 4 8 13 Television, newspapers, magazines 4 6 10 Persons who understand my culture/ethnic group 3 19 10</ct> <ref id="AN0010257547-38"> <title> REFERENCES </title> <blist> <bibtext> Bray F. Chinese Medicine. In: Bynum WF, Porter R, eds. Companion Enyclopedia of the History of Medicine. London: Rotutledge; 1993.</bibtext> </blist> <blist> <bibtext> Harju BL, Long TE, Allred LJ. Cross cultural reactions of international students to US healthcare. College Student Journal. 1998;32:1--7.</bibtext> </blist> <blist> <bibtext> "Open doors or the web" International Institute of Education, Available at http:/<ulink href="http://www.opendoorsweb.org">www.opendoorsweb.org</ulink>. Accessed March 27, 2002.</bibtext> </blist> <blist> <bibtext> Williams DR. Collins C. U.S. socioeconomic and racial differences in health: Patterns and explanations. Annual Review of Sociology. 1995;21:349-386.</bibtext> </blist> <blist> <bibtext> Marmot MG. (General approaches to migrant studies: The relation between disease, social class and ethnic origin. In: Cruick-shank JK, Beeveis DGC eds. Ethnic Factors in Health and Disease. London: Wright; 1989.</bibtext> </blist> <blist> <bibtext> Nakamura, RM. Health in America: A Multicultural Perspective. Boston, MA: Allyn and Bacon; 1999.</bibtext> </blist> <blist> <bibtext> Matocha LK. Chinese-Americans. In: Purnell LD, Paulanka BJ,eds. Transcultural Health Care: A Culturally Competent Approach. Philadelphia. PA: Davis: 1998.</bibtext> </blist> <blist> <bibtext> Assanand S. Dias M, Richardson F. Waxler-Morrison N. The South Asians. In: Waxier-Morison N, Anderson JM, Richardson E, eds. Crass-Cultural Caringa A Handbook for Health Professionals in Western Canada. Vancouver, BC: University of British Columbia Press; 1990.</bibtext> </blist> <blist> <bibtext> Bray F. Chinese Medicine. Wujastyk D. Indian Medicine. In: Bynum. WF, Porter R, eds. Companion Encyclopedia of the History of Medicine. London: Routledge; 1993.</bibtext> </blist> <blist> <bibtext> O'Connor BB. Healing practices. In: Loue S, ed. Handbook of Immigrant Health New York: Plenum; 1998.</bibtext> </blist> <blist> <bibtext> Nestle M. Nutrition. In: Woolf SHE, Jonas S, Lawrence RS, eds. Health Promotion and Disease Prevention in Clinical Practice. Baltimore. MD: Williams & Wilkins; 1996.</bibtext> </blist> <blist> <bibtext> Main CC. Press coverage: Leaving out the big picture. Science. 1995;269:166.</bibtext> </blist> <blist> <bibtext> Ramnakrishna J, Weiss MG. Health, illness, and immigration: East Indians in the United States. West Med J 1992;2157: 265-270.</bibtext> </blist> <blist> <bibtext> Waxler-Morrison N. Anderson JM, Richardson T:; eds. Cross-Cultural Caring: A Handbook Health Professionals in Western Canada. Vancouver. BCC: University of British Columbia Press: 1990.</bibtext> </blist> <blist> <bibtext> Woolf SH, Lawrence RS. The physical examination: Where to look for preclinical disease. In: Woolf, SH. Jonas S. Lawrence RE, ed. Health Promotion and Disease Prevention in Clinical Practice. Baltimore, MD: Williams & Wilkins 1996.</bibtext> </blist> <blist> <bibtext> Steptoe A, Wardle J. Cui W. et al. Trends in smoking, diet, physical exercise, and attitudes toward health in European university students from 13 countries. 1990-2000. Preventive Medicine. 2002:35:97-104.</bibtext> </blist> <blist> <bibtext> Woolf SH, Jonas S, Lawrence RS, eds. Health Promotion and Disease Prevention in Clinical Practice Baltimore. MD: Williams & Wilkins. 1996.</bibtext> </blist> <blist> <bibtext> Brener ND. Bowda, VR. US college students' reports of receiving health information on college campuses. J Am Coll health. 2000;49:223--228.</bibtext> </blist> <blist> <bibtext> Burak LJ, Damico ,A. College students' use of widely advertised medications. J Am Coll Health. 2000;49:118--122.</bibtext> </blist> <blist> <bibtext> American Nurses Association. A statement on the Scope of' college health nursing practice. Kansas City, MO; 1990.</bibtext> </blist> </ref> <aug> <p>By Abigail C. Halperin, MD, MPH; Nancy A. Rigotti, MD; William G. Rothstein, PhD and Sushama Rajapaksa, MA</p> <p></p> <p>Abigail C. Halperin is an acting assistant professor in the Departments of Family Medicine and health Services, University of Washington, Center for Health Education and Research, Seattle, Washington.</p> <p>Nancy A. Rigotti is an associate professor Department of Medicine, Harvard. Medical School, and director of the Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston,</p> <p>William G. Rothstein is a professor of sociology in the Department of Sociology and Anthropology, University of Maryland, Baltimore County</p> <p>Sushama Rajapaksa is a PhD candidate in the Department of Sociology, Temple University, Philadelphia.</p> </aug> <nolink nlid="nl1" bibid="bib60" firstref="ref53"></nolink> <nolink nlid="nl2" bibid="bib55" firstref="ref54"></nolink>
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  Data: US Public Universities' Compliance with Recommended Tobacco-Control Policies
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  Data: <searchLink fieldCode="AR" term="%22Halperin%2C+Abigail+C%2E%22">Halperin, Abigail C.</searchLink><br /><searchLink fieldCode="AR" term="%22Rigotti%2C+Nancy+A%2E%22">Rigotti, Nancy A.</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+American+College+Health%22"><i>Journal of American College Health</i></searchLink>. Mar 2003 51(5):181-188.
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  Data: Heldref Publications. 1319 Eighteenth Street NW, Washington, DC 20036-1802. Tel: 800-365-9753; Tel: 202-296-6267; Fax: 202-293-6130; e-mail: subscribe@heldref.org; Web site: http://www.heldref.org
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  Data: 8
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  Label: Publication Date
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  Data: 2003
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  Data: Journal Articles<br />Reports - Evaluative
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  Data: <searchLink fieldCode="EL" term="%22Higher+Education%22">Higher Education</searchLink>
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  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Universities%22">Universities</searchLink><br /><searchLink fieldCode="DE" term="%22College+Housing%22">College Housing</searchLink><br /><searchLink fieldCode="DE" term="%22Smoking%22">Smoking</searchLink><br /><searchLink fieldCode="DE" term="%22Interviews%22">Interviews</searchLink><br /><searchLink fieldCode="DE" term="%22Advertising%22">Advertising</searchLink><br /><searchLink fieldCode="DE" term="%22College+Students%22">College Students</searchLink><br /><searchLink fieldCode="DE" term="%22College+Administration%22">College Administration</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Evaluation%22">Program Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Promotion%22">Health Promotion</searchLink><br /><searchLink fieldCode="DE" term="%22School+Policy%22">School Policy</searchLink><br /><searchLink fieldCode="DE" term="%22Administrators%22">Administrators</searchLink>
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  Label: Geographic Terms
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  Data: <searchLink fieldCode="DE" term="%22United+States%22">United States</searchLink>
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  Data: 0744-8481
– Name: Abstract
  Label: Abstract
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  Data: To address the rise in tobacco use among college students, several national health organizations, including the American College Health Association,recommend that colleges enact smoking bans in and around all campus buildings, including student housing, and prohibit the sale, advertisement, and promotion of tobacco products on campus. Key informants at 50 US public universities,one from each state, were interviewed during the 2001/2002 academic year to assess the prevalence of these recommended policies. More than half (54) of the colleges banned smoking in all campus buildings and student residences, 68 had no tobacco sales on campus, and 32 of the schools' newspapers did not accept tobacco advertising. Regional differences in adoption of these campus tobacco-control policies were present. Although this national sample of public universities had implemented some of the recommended policies, they must take further actions to comply fully with campus tobacco-control guidelines. (Contains 3 tables and 2 figures.)
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  Data: 25
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  Data: 2007
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        PageCount: 8
        StartPage: 181
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      – SubjectFull: Universities
        Type: general
      – SubjectFull: College Housing
        Type: general
      – SubjectFull: Smoking
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      – SubjectFull: Interviews
        Type: general
      – SubjectFull: Advertising
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      – SubjectFull: College Students
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      – SubjectFull: College Administration
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      – SubjectFull: Program Effectiveness
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      – SubjectFull: Program Evaluation
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      – SubjectFull: Health Promotion
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      – SubjectFull: United States
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