Posted: June 18, 2021
Counting fewer and fewer cigarette butts— that’s how Ellen Hahn, PhD, RN, FAAN, first realized the University of Kentucky’s tobacco free policy was starting to work not long after it went into effect across the campus in late 2009.
The fewer smokers left behind, the more Dr. Hahn, a professor in the UK Colleges of Nursing and Public Health, could see that the Commonwealth—even situated in tobacco country—could lead the way in creating healthier campuses and communities. Dr. Hahn is also the director of the UK collaborative BREATHE (Bridging Research Efforts and Advocacy Toward Healthy Environments).
Now, a decade later, the program’s success is evident in various ways, including the phone calls the university still receives from other organizations seeking advice about implementing similar smoke-free policies across the state and around the country.
“We’ve been able to help them avoid having to reinvent the wheel,” says Dr. Hahn. “We know what to do; we know how to get everything into place; we know what land mines there are to avoid.” Dr. Hahn helped spearhead the task force implementing UK’s tobacco-free policy in 2009 that was established by then-UK President Dr. Lee Todd.
NOT THE EASY THING BUT THE RIGHT THING
One recent call for guidance came from Western Kentucky University. The Bowling Green campus went tobacco-free at the beginning of 2020. “We’re seeing more tobacco-free campus policies because we’re starting to be able to document the outcomes of those policies. When campuses go tobacco free, fewer people use tobacco,” Dr. Hahn says. “Fewer people get sick, and our health care costs are going to go down for that reason.”
Although Kentucky ranks among the top tobacco-growing states, UK was one of the nation’s first land-grant institutions to go 100% tobacco free; the university’s campus-wide move was also the first in the Commonwealth. The policy prohibits cigarettes, e-cigarettes, cigars, snuff, water pipes, hookahs, chew and any other non-combustible tobacco products.
In 2009, Dr. Todd said of the policy, “It might not be the easiest thing to do, or the most politically popular thing to do, but in my mind, it is the right thing to do for the University of Kentucky.” Dr. Todd is now a member of the BREATHE board of trustees.
“IF KENTUCKY CAN DO IT, WHY CAN’T WE?”
It wasn’t always clear that limiting tobacco usage on a Kentucky campus would be possible, especially when Dr. Hahn first moved to Lexington in 1994. At the time, she was taken aback seeing newspapers frame tobacco as an agricultural issue rather than a health issue. She soon joined Kentucky’s first tobacco control coalition, along with other like-minded people looking to change how tobacco was discussed publicly. Eventually the group was able to arrange a meeting with the editorial board of the Lexington Herald-Leader.
“They gave us five minutes to talk about tobacco. We had the most compelling data we could find at the time and said we’re just here to ask you to give us equal time in the media, because tobacco kills people. It’s the single most preventable cause of death. Can we just talk about that?”
Eventually, a small group of nurses and other health advocates were instrumental in convincing the Lexington-Fayette Urban County Government to enact a smoke-free ordinance. The city went tobacco-free in 2004.
“At that time, really nobody in the Midwest or the South had these laws, so we got a lot of phone calls saying, ‘Gee, if Kentucky can do it, why can’t we do the same in Indiana or Tennessee or elsewhere?,’” Dr. Hahn remembers.
Once the city restricted tobacco usage in public places, Dr. Todd knew that with students and staff getting used to visiting smoke-free restaurants and bars, it might be easier to take the campus in a similar direction. He developed a task force headed up by both Dr. Hahn and Anthany Beatty, the university’s assistant vice president for public safety. Beatty had been Lexington’s chief of police when the city enacted its own smoking ban.
“I thought it was pretty bold for a major research university, its president and board of trustees to take that step right in the heart of the tobacco industry,” Beatty remembers. “But they took it head on, and I’ve seen the positive impact this has had on so many lives.” Beatty’s role in administrating the university policy required him to work with campus and city leaders, as well as neighborhood residents, to make the transition.
“The challenges were just as you would anticipate,” he says. “But some of the folks who you felt would be against us turned out, in many cases, to be in favor of the antitobacco policy because once the proven health benefits were shown and all the data about lost work time and productivity, as well as secondhand smoke, was made available, those groups on campus rallied around the cause and helped change the whole campus.”
TELL, TREAT AND TRAIN
The university’s strategy for implementing and evaluating the tobacco-free policy over the past decade has taken shape with a “3T approach” (which stands for “tell, treat and train”).
Melinda Ickes, PhD, is a faculty associate for the Kentucky Center for Smoke-free Policy. She explains that the three-pronged approach makes policy communication with students and faculty a top priority (“tell”), along with encouraging treatment programs such as medication and counseling to aid tobacco cessation (“treat”), and enlisting students and staff to help reinforce the policy (“train”).
Dr. Ickes promotes the 3T approach to other universities. She is also the director of the UK program “Tobacco-Free Take Action!,” established in 2010, which hires student ambassadors to champion the tobacco ban among their peers. The ambassadors are advocates for the policy at university events and approach violators by using scripted messages and a firm but compassionate tone.
“When we first started, you could go anywhere on campus and see 20 to 30 people using tobacco products at a time,” Dr. Ickes says. “Now, days will go by when our ambassadors don’t see anyone violating the policy.” Surveys found that attempts to quit using tobacco among UK students and employees increased after the tobacco-free policy took effect.In the first two years, 335 people received tobacco dependence treatment, compared with only 33 in the year before the campus-wide policy.
Carrying out the tobacco-free policy has been challenged in recent years, though, by the growth in electronic cigarettes and vapes. Without the telltale plumes of smoke, use of those products is easier to hide; the pods and packaging left behind can be seen on campus. UK’s policy compliance efforts and scripting have been modified to address these challenges. The ambassadors—led by Dr. Ickes’ research and community engagement— have developed and implemented innovative, community-based programs to end the electronic cigarette/vaping trend.
“The tobacco industry changes with the times. It’s about their bottom line, and they will do everything they can to sell their products. So campuses are going to have to be vigilant,” Dr. Hahn says. “As soon as we passed the tobacco-free policy, the industry was in here marketing hookah pipes because the tobacco industry wants to keep people hooked. That’s their bottom line.”
But Dr. Hahn is confident that UK and BREATHE will always play an important role in improving the health of the university and of Kentucky at large.
“BREATHE has done a lot of policy outcome studies showing the impacts of comprehensive smoke-free laws, including reduced cases of lung cancer, asthma and heart attacks, and better control of emphysema,” Dr. Hahn says. “We’ve also found that children living in those communities are less likely to smoke or use smokeless tobacco. I think that’s a huge contribution.”
A summary of research posted to the BREATHE website shows that Lexington, Kentucky’s smoke-free policy led to a 22 percent decline in emergency department visits for asthma within 32 months, as well as a 23 percent decline of heart attacks among women. The site also shows that comprehensive smoke-free laws help reduce hospitalizations for COPD.
With only 36 percent of Kentucky communities protected by strong smoke-free ordinances, BREATHE continues to work with other towns to pass similar public and workplace policies. The outbreak of COVID-19 has even further highlighted the need for public tobacco cessation programs, with the virus affecting smokers and those with chronic lung conditions at a much higher and deadlier rate.
In their efforts to expand programming, BREATHE has launched the first online, accredited training program for coaching tobacco treatment specialists. The program is accessible in remote parts of Kentucky and around the world. It is designed to train nontraditional professionals, such as pharmacists and dentists, in helping tobacco users quit by offering behavioral support and medication.
“We still have a lot of work to do in Kentucky, but there are people who have courage and who value health and want to leave a better legacy for their children,” Dr. Hahn says.
The above article was featured in the 2020/2021 Winter edition of the UK College of Nursing's Engagement publication.