The purpose of this study was to evaluate the implementation of a smoke-free policy in a medical campus, by assessing attitudes towards the smoke-free campus policy, smoking habits and cigarette smoke exposure. Our findings further directed policy formation and implementation of the smoke-free Ein Kerem Campus. Less than 10 % of students and employees are current smokers but nearly two thirds reported being near smokers on a daily or almost daily basis. Strong support amongst both students and employees was found for a smoke-free medical campus policy. However, one year post-implementation, less than half the target population were aware of its existence and smoking in unauthorized areas was still prevalent.
There is little data available regarding smoke-free Medical campuses. However, several studies have reported findings for smoke-free universities. An online survey conducted in a large Australian university, one year after becoming a smoke-free campus, found lower smoking rates than in the general population, negative attitudes toward cigarette smoking and an overwhelming support for a smoking ban inside university buildings, but less support for a total smoking ban on the campus . Another web-based survey among students in Pacific Northwest public university (USA) found a high degree of support (76 %) for a smoke-free campus policy and that current smoking as well as past smoking was strongly associated with opposition to a smoke-free policy . Overall, a smoke-free campus policies have been found to be effective in reducing smoking rates in general and smoking in building foyers areas in particular [11–13].
The data gathered here provides a benchmark for the impact of the smoke-free policy on smoking behaviour and attitudes and will provide a comparison for future study. It further indicates where the focus of further intervention should be: increasing awareness and support to the policy, engaging ex-smokers and enforcing ban in areas such as the inner courtyard.
The smoking rate among health professional students at Ein Kerem campus in 2013 was much lower than that found in the general population (8.6 %, vs 19.8 %). Rates were lower for both genders, but particularly so for males (10 % vs 27 %) than for females (7 % vs 13 %) . The smoking rates found here are much lower than the global smoking rate for health professional students in 2005–2008 (22.4 %) , and comparable to the USA in 2010 (6 %) . In a single hospital study carried out in 2013, smoking rates among physicians was 16.7 %  compared to only 6.9 % found here for medical students. However, a larger scale study amongst Israeli physicians and other medical university campuses in Israel would be required in order to confirm that today’s medical students smoke less than physicians.
A study conducted in 2007 among dentistry students at Ein Kerem campus found a smoking rate of 17.0 % . The lower smoking rates in our study (11.6 %) are consistent with the decline in smoking rates found among the general population of Israel between 2007 and 2013 (23.2 and 18.7 % respectively). The steps taken at Hadassah Medical Center and the campus since 2000, declaring the hospital a smoke-free area , and later signing the Ein Kerem Smoke-free Campus Declaration in 2012 may also have contributed to this drop in smoking prevalence. The current study highlights the need for Tobacco surveillance data for health professional students in Israel, as described in the Global Health Professions Student Survey (GHPSS) .
It was shown previously that non-smoking physicians have a greater influence on people trying to quit smoking than smoking physicians . Therefore, a decrease in the rate of smoking among physicians would improve smoking cessation rates in the general population .
The higher smoking rate among males correlates with earlier studies demonstrating that male medical students generally have higher smoking rate .
The difference in smoking rates between men and women (10.0 % compared to 7.5 %) was comparable to that of health professional students in Europe and the USA [16, 21] but lower than the difference observed in the Israeli general population (27.3 % vs 12.6 %) .
Despite the smoke-free policy and consensus among students and employees that campus buildings should be smoke-free, and that smoking should only occur in designated areas, significant levels of exposure to tobacco smoke on campus were reported. 27 % of participants reported seeing people smoke within the buildings at least once a month and that the majority of participants observed smokers in open spaces, and in most cases, not in designated smoking areas. These findings suggest that enforcement of smoke-free campus policy should be stronger.
The percentage of students and employees (65.2 %) who spend time with smokers is comparable to the rate of second hand smoke in Israel 71.3 % . Students and employees 24 to 40 year olds, ex-smokers and unmarried individuals are more likely to be exposed to cigarette smoke.
Consistent with earlier studies , ex-smokers were more likely to show more support of various components of smoke-free policy than smokers, but show less support than non-smokers. Although ex-smokers are not directly affected by such policy, it appears that they still identify with smokers and are more reluctant than non-smokers to promote a total smoking ban. Current smokers were less supportive of the smoke-free policy, as was found in other studies . Only 18 % of the study population believed that smoke-free policy is unfair toward smokers.
A total ban on smoking (including in designated areas) is more effective than a partial ban in lowering smoking percentage and SHS exposure [23–27]. Therefore, as public health planners, we should consider expanding the smoke-free policy to a total ban on smoking.
The smoke-free hospital policy became common in the USA in the early 1990s and in Europe in the early 2000s . Initially it was a voluntary recommendation, part of a general strategy to promote a general smoke-free policy and only banning smoking in indoor areas for staff members. Later, with the accumulation of evidences showing that a more restrictive smoke-free policy is more efficient , a new movement to promote completely smoke-free hospital campuses, which extended smoking bans to outdoor areas, emerged [30, 31] and, in 2008 in the USA, over 45 % of hospitals reported they had extended smoke-free policies to include outdoor spaces .
As opposed to a partial ban on smoking, whereby smoking is allowed in designated areas, a total ban on smoking requires intervention that could be considered by some as unjustified interference in their freedom of choice, even when it comes to leading unhealthy lives.
The assessment model for justification of intrusive lifestyle intervention sets a principle of support, which requires policy planners to ask two questions: Is the time ripe for coercion and is there enough support for the intervention? Positive answers to these questions are necessary to justify the intervention and to assess whether we will achieve proper implementation and enforcement or not .
Over 90 % of the participants agreed that indoor areas should be smoke-free and that smoking should be restricted wholly and solely to designated smoking areas. However, less than 50 % agreed that all campus areas should be smoke-free and smoking prohibited in campus entrances. This preference for restrictions rather than a total ban has been reported in other studies. A survey conducted in England (2011) among hospital employees and medical students found that only 40 % favoured a complete ban compared to 57 % who favoured restrictions only . Another survey conducted in Australia (2013) found similar results: 91.3 % agreed that the campus should be smoke-free inside all buildings whilst only 60.8 % agreed that the whole campus (indoors and outdoors) should be smoke-free .
Compared to a survey conducted at Ein Kerem campus among students of dentistry in 2006, a total ban policy has gained in support. In 2006, 51 % agreed to the statement supporting a total prohibition on campus , compared to 72 % in the current study. Introduction of a pro-active policy to reduce smoking in recent years on the campus and in the adjacent Hadassah Ein Kerem Hospital may explain the increase in support.
Support for all statements was stronger among non-smokers than ex-smokers and current smokers. However, even among smokers, the majority agreed that indoor areas should be smoke-free (94.2 %), and that smoking should be restricted to outdoor designated smoking areas (93.9 %). Similar findings were found in a national American study . On the other hand, when it comes to a total smoking ban on campus, smokers show less support. This pattern of limited support among smokers is consistent with earlier studies [34, 35]. Investment in advocacy for for a total smoking ban is needed in order to implement the new policy.
Awareness of the smoke-free campus policy was strongly associated with support of a smoke-free policy in our study, as was found in other studies . Less than 50 % were aware of the smoke-free campus policy.
These findings emphasize the need of a comprehensive intervention aimed to increase awareness of the smoke-free campus policy among students.
The choice of target population and their response rate could factor as limitations of the study. We targeted second year students and employees of the School of Pharmacy. Results for other years or other schools in the campus may differ. Whilst the response rate was high (72.5 %), our results could still be biased if those who did not participate differed in their smoking behavior or attitudes from participants. We minimized the possibility of selection bias by an objective presentation of the study and support of deans. Refusal was minimal and the main reason for non-participation was not being present in class or office.