A tobacco-free campus (TFC) is the most advanced tobacco-control policy for college campuses, but it has rarely been explored in Korea. This study aimed to explore Korean college students’ attitudes toward TFC and related factors.
This cross-sectional descriptive study enrolled college students who were taking an elective course on smoking cessation and a healthy lifestyle at a university located in Incheon, Korea. Data were collected from March 1 to December 31, 2019 using a structured questionnaire, and study participants were recruited using convenience sampling.
Data on 309 college students were analyzed. Of those participants, 6.1% supported the TFC policy. Multiple logistic regression analysis showed that female gender (adjusted odds ratio [aOR]=5.80, 95% confidence interval [CI]=1.47-22.95), taking the course to quit smoking oneself (aOR=11.03, 95% CI=1.04-117.05), anxiety in the past month (aOR=4.27, 95% CI=1.06-17.31), and being a current smoker (aOR=0.06, 95% CI=0.01-0.70) were statistically significant independent predictors of TFC support.
According to national statistics, Korea has shown a rapid decrease in the rates of smoking among adults . 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 . 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 . 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 . 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 . In 2012, the Korean government banned smoking in public facilities and in elementary, middle, and high schools, both indoors and outdoors . 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 . Clearly, bans on indoor smoking are less likely than complete bans to restrict tobacco use (and smokeless tobacco products) in student lounges and dormitories .
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 . Enforcement of a TFC policy has been known to reduce smoking rates, the risk of exposure to secondhand smoke , and the use of alternative tobacco products .
Nonetheless, TFC is still a matter of debate on university campuses. Bartington and colleagues  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 . Users of electronic cigarettes have more negative attitudes toward electronic cigarettes and vaping restrictions on campuses . 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.
Ethics statement: This study was approved by the institutional review board of Inha University (No. 180514-2). Informed consent was obtained from the participants.
1. Study Design and Participants
This was a cross-sectional descriptive study. Participants were college students enrolled in an online class called “Smoking Cessation and a Healthy Life”. This course, which was a three-credit elective, was open to registered full-time or part-time undergraduate students at a university in Incheon, South Korea. We excluded only students who were younger than 19 years old. We calculated the sample size based on the results of the study by Mamudu and colleagues , which examined students’ attitudes toward TFC. We calculated the sample size using the odds ratio of female gender as a predictor of TFC support (1.72), with an ⍺ of .05 and power of .08; these settings yielded a sample size of 255 in G*Power .
During the study period, a total of 1,163 students registered in the course for two consecutive semesters. Among them, 311 students (26.7%) participated in the study, but the data of two students were excluded from the data analysis due to incomplete responses. At the time of the study, although the university had a ban on smoking, it permitted smoking in designated booths outdoors, and convenience stores were permitted to sell cigarettes on campus.
Data were collected using a structured questionnaire that gathered information on demographics (including researcher-specific questions), attitudes about TFC, and health-related characteristics. Health-related characteristics were assessed using questions from the Korea Youth Risk Behavior Web-Based Survey , the National Health and Nutrition Examination Survey  , and the Behavioral Risk Factor Surveillance System Questionnaire .
Demographic characteristics included age, gender, living status, grade point average, and the reason for taking the course. Attitudes toward the TFC policy were assessed using the following question from the North Carolina Tobacco Free College Assessment Survey: “Which type of college tobacco-use policy do you believe would be best for the college community?” Cooper and colleagues  used this question in their study and investigated its associations with gender, smoking status, and understanding of the current tobacco use policy on campus. The options were a policy that (a) allows smoking inside campus buildings, (b) allows smoking outdoors on campus in all locations, (c) allows smoking outdoors at specific locations only, (d) prohibits smoking anywhere on campus at all times, or (e) prohibits all tobacco use anywhere on campus at all times. Students were categorized as either a “supporter” of TFC if they answered (e) or a “nonsupporter” if they answered any of the other options.
Health-related characteristics included perceived health in general, psychosocial characteristics, and health behaviors. For general health, we asked, “Would you say that in general your health is: ___”, and students could respond with “very good”, “good”, “fair”, or “not healthy”. Psychosocial characteristics included happiness, stress, loneliness, depression, and anxiety. We asked participants how happy or stressful they felt and how often they felt lonely, depressed, or too anxious to function. Students could respond with “never”, “yes (in the last 2 weeks, 30 days, or 12 months)”, or “yes (but not in the last 12 months)”. Health behaviors included smoking status, the frequency of alcohol drinking, the number of days they engaged in moderate-to-vigorous exercise for at least 30 minutes in the past 7 days, and the numbers of nights in a week they got enough sleep. For smoking status, we asked, “Do you smoke cigarettes every day, some days, or not at all?” If students answered “every day or some days”, they were considered to be current smokers. The results of the psychometric evaluation of these question items have been presented previously [18,19].
3. Data Collection
Data were collected from March 1 to December 31, 2019 after the Institutional Review Board at the researchers’ university approved this study (No. 180514-2). At the beginning of the semester, the researchers posted information about the study on the course’s online platform and provided contact information for the research assistant. Students who contacted the research assistant received in return an email with an informed consent form and a link to a survey. Signed informed consent could be returned by email, standard mail, or in person. The research assistant managed the process of obtaining informed consent and data collection for study participants, and she was not involved in any part of teaching or grading of the course. Students were asked to complete and return the survey within the first 2 weeks of the semester. They received $4 for participating in the study.
4. Data Analysis
Using SPSS for Windows version 25.0 (IBM Corp., Armonk, NY, USA), the researchers performed descriptive statistics using mean values with standard deviations and frequencies with percentages. Crude odds ratios (cORs) were estimated to assess the bivariate associations between dichotomous variables. Multiple logistic regression analysis was then performed to estimate adjusted odds ratios (aORs) including all variables; the results were presented with 95% confidence intervals (CIs). The dependent variable was attitude toward TFC. The dependent variable was coded “1, supporter” if students answered that an ideal tobacco control policy would “prohibit all tobacco use anywhere on campus at all times”. All other responses were considered to be “nonsupporter” and coded “0”. The independent variables were dichotomized using the mean, mode, or meaningful categories in context or suggestions in previous research.
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.
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.
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.
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 .
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 .
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 , 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 . 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. 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 . In their descriptive study of 790 college tobacco users, Mamudu and colleagues  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 , 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 . Lykke and colleagues  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  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.
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.
Conceptualization: all authors; Data collection, Formal analysis: all authors; Writing-original draft, Writing-review and editing: all authors; Final approval of published version: all authors.
Conflict of interest
No existing or potential conflict of interest relevant to this article was reported.
This study was supported by the Basic Science Research Program through the National Research Foundation of Korea (2018R1D1A1B07047731).
1. Korea Disease Control and Prevention. Korea health statistics 2019: Korea National Health and Nutrition Examination Survey (KNHANES VIII) [Internet]. Cheongju: Korea Disease Control and Prevention; 2022 [cited 2022 March 23]. Available from: https://knhanes.kdca.go.kr/knhanes/sub04/sub04_04_01.do
2. Statistics Korea. Korean population census [Internet]. Daejon: Statistics Korea; 2015 [cited 2022 March 23]. Available from: https://kosis.kr/statHtml/statHtml.do?orgId=101&tblId=DT_1PM1504&vw_cd=MT_ZTITLE&list_id=A11_2015_1_20_10&scrId=&seqNo=&lang_mode=ko&obj_var_id=&itm_id=&conn_path=MT_ZTITLE&path=%252FstatisticsList%252FstatisticsListIndex.do
3. US Department of Health and Human Services. Preventing tobacco use among youth and young adults: a report of the surgeon general. Atlanta, GA: US Department of Health and Human Services; 2012 [cited 2022 March 23]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK99237/
4. Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database of Systematic Reviews. 2016;27(5):CD011856. https://doi.org/10.1002/14651858.CD011856.pub2
5. Gunter R, Szeto E, Jeong SH, Suh S, Waters AJ. Cigarette smoking in South Korea: a narrative review. Korean Journal of Family Medicine. 2020;41(1):3-13. https://doi.org/10.4082/kjfm.18.0015
6. Fallin A, Roditis M, Glantz SA. Association of campus tobacco policies with secondhand smoke exposure, intention to smoke on campus, and attitudes about outdoor smoking restrictions. American Journal of Public Health. 2015;105(6):1098-1100. https://doi.org/10.2105/AJPH.2014.302251
7. Bennett BL, Deiner M, Pokhrel P. College anti-smoking policies and student smoking behavior: a review of the literature. Tobacco Induced Diseases. 2017;15, 11. https://doi.org/10.1186/s12971-017-0117-z
8. American College Health Association. Position statement on tobacco on college and university campuses. Journal of American College Health. 2012;60(3):266-267. https://doi.org/10.1080/07448481.2012.660440
9. Pignataro RM, Daramola C. Becoming a tobacco-free campus: a survey of student attitudes, opinions and behaviors. Tobacco Prevention and Cessation. 2020;6, 54. https://doi.org/10.18332/tpc/125915
10. Lechner WV, Meier E, Miller MB, Wiener JL, Fils-Aime Y. Changes in smoking prevalence, attitudes, and beliefs over 4 years following a campus-wide anti-tobacco intervention. Journal of American College Health. 2012;60(7):505-511. https://doi.org/10.1080/07448481.2012.681816
11. Latimer LA, Batanova M, Loukas A. Prevalence and harm perceptions of various tobacco products among college students. Nicotine and Tobacco Research. 2014;16(5):519-526. https://doi.org/10.1093/ntr/ntt174
12. Bartington SE, Wootton R, Hawkins P, Farley A, Jones LL, Haroon S. Smoking behaviours and attitudes towards campus-wide tobacco control policies among staff and students: a cross-sectional survey at the University of Birmingham. BMC Public Health. 2020;20(1):252. https://doi.org/10.1186/s12889-020-8321-9
13. Braverman MT, Hoogesteger LA, Johnson JA. Predictors of support among students, faculty and staff for a smoke-free university campus. Preventive Medicine. 2015;71, 114-120. https://doi.org/10.1016/j.ypmed.2014.12.018
14. Lee S, Oh Y, Kim H, Kong M, Moon J. Implications of electronic cigarette use for depressive mood: a nationwide cross-sectional study. Medicine. 2020;99(40):e22514. https://doi.org/10.1097/MD.0000000000022514
15. Brown EM, Henes AL, Olson LT. E-cigarette policies on college campuses: student use behaviors, awareness, and policy support. Journal of Community Health. 2016;41(6):1110-1115. https://doi.org/10.1007/s10900-016-0262-y
16. Mamudu HM, Veeranki SP, He Y, Dadkar S, Boone E. University personnel's attitudes and behaviors toward the first tobacco-free campus policy in Tennessee. Journal of Community Health. 2012;37(4):855-864. https://doi.org/10.1007/s10900-011-9520-1
17. Faul F, Erdfelder E, Buchner A, Lang AG. Statistical power analyses using G*Power 3.1: tests for correlation and regression analyses. Behavior Research Methods. 2009;41(4):1149-1160. https://doi.org/10.3758/BRM.41.4.1149
18. Kim Y, Choi S, Chun C, Park S, Khang YH, Oh K. Data resource profile: the Korea Youth Risk Behavior Web-based Survey (KYRBS). International Journal of Epidemiology. 2016;45(4):1076-1076e. https://doi.org/10.1093/ije/dyw070
19. Kweon S, Kim Y, Jang MJ, Kim Y, Kim K, Choi S, et al. Data resource profile: the Korea National Health and Nutrition Examination Survey (KNHANES). International Journal of Epidemiology. 2014;43(1):69-77. https://doi.org/10.1093/ije/dyt228
20. Centers for Disease Control and Prevention. Behavioral risk factor surveillance system. 2018 BRFSS survey data and documentation [Internet]. Atlant, GA: Centers for Disease Control and Prevention; 2018 [cited 2022 March 22]. Available from: https://www.cdc.gov/brfss/annual_data/annual_2018.html
21. Cooper TV, Cabriales JA, Hernandez N, Law J. A baseline assessment of attitudes toward tobacco free campus policies in a U.S./ Mexico border university. Addictive Behaviors. 2016;60, 223-227. https://doi.org/10.1016/j.addbeh.2016.04.023
22. Lupton JR, Townsend JL. A systematic review and meta-analysis of the acceptability and effectiveness of university smoke-free policies. Journal of American College Health. 2015;63(4):238-247. https://doi.org/10.1080/07448481.2015.1015029
23. Al-Sawalha NA, Almomani BA, Mokhemer E, Al-Shatnawi SF, Bdeir R. E-cigarettes use among university students in Jordan: perception and related knowledge. PLoS One. 2021;16(12):e0262090. https://doi.org/10.1371/journal.pone.0262090
24. Kang H, Cho SI. Cohort effects of tobacco control policy: evidence to support a tobacco-free norm through smoke-free policy. Tobacco Control. 2020;29(1):96-102. https://doi.org/10.1136/tobaccocontrol-2018-054536
25. Korean Educational Statistics Service. Education statistics [Internet]. Jincheon: Korean Educational Statistics Service; 2021 [cited 2022 March 23]. Available from: https://kess.kedi.re.kr/mobile/stats/school?menuCd=0102&cd=5534&survSeq=2021&itemCode=01&menuId=m_01020902&uppCd1=01020902&uppCd2=01020902&flag=A
26. Wong SL, Epperson AE, Rogers J, Castro RJ, Jackler RK, Prochaska JJ. A multimodal assessment of tobacco use on a university campus and support for adopting a comprehensive tobacco-free policy. Preventive Medicine. 2020;133, 106008. https://doi.org/10.1016/j.ypmed.2020.106008
27. Gong M, Liang ZY, Zhang YY, Shadel WG, Zhou L, Xiao J. Implementation of the tobacco-free campus policy on college campuses: evidence from a survey of college students in Beijing. Nicotine and Tobacco Research. 2016;18(11):2083-2091. https://doi.org/10.1093/ntr/ntw125
28. Mamudu HM, Veeranki SP, Kioko DM, Boghozian RK, Littleton MA. Exploring support for 100% college tobacco-free policies and tobacco-free campuses among college tobacco users. Journal of Public Health Management and Practice. 2016;22(1):29-39. https://doi.org/10.1097/PHH.0000000000000262
29. Lykke M, Helbech B, Glumer C. Temporal changes in the attitude towards smoking bans in public arenas among adults in the capital region of Denmark from 2007 to 2010. Scandinavian Journal of Public Health. 2014;42(5):401-408. https://doi.org/10.1177/1403494814529034
30. Glasgow TE, Miller CA, Barsell DJ, Do EK, Fuemmeler BF. Assessing how a tobacco-free campus leads to attitude change and support among students, faculty, and staff. Tobacco Prevention and Cessation. 2021;7, 53. https://doi.org/10.18332/tpc/138224