Implementation of 100% Tobacco Free Campus at the University of Riau, Efforts and the Challengees

ABSTRACT


INTRODUCTION
The use of tobacco in the form of cigarettes is a serious problem, and efforts have been developed worldwide to tackle the effects of smoking (Organization, 2015). Smoking kills more than eight billion people each year, more than seven billion of them are due to direct cigarette consumption, while 1.2 billion deaths are in persons exposed to secondhand smoke (DH., 2023).
Smoking is associated with 70% of lung cancer, 40% of obstructive pulmonary disease, and cardiovascular disease (Puswitasari A, Santosa S, Wijayahadi N. ). Smoking is not only bad for health, but also for the economy. The cost of smoking is close to the cost of basic necessities such as food and housing, this is due to the difficulty of stopping cigarette consumption because smoking has become an addiction . The World Health Organization (WHO) states that one in three adults in the world around 1.1 billion people smoke, 80% among them live in low and middle-IJSSR Page 1510 income countries. Efforts to prevent it without reducing cigarette consumption are estimated that by 2025 the number of smokers will increase to 1.6 billion .
Indonesia is the country with the fourth-largest cigarette consumption in the world with the fifth-largest cigarette market. Smoking is a normal culture in Indonesia and plays an important role in the social and political system. Efforts to control cigarette consumption in Indonesia face significant challenges due to weak legislation on taxes, prices, advertising, sponsorship, and smoking in public areas. In addition, there is protection in the cigarette industry and the number of domestic kretek cigarette factories . Globally, there has been a decrease in the prevalence of smoking over the age of 15, namely in 2000 (26%), 2005 (24.3%), 2010 (22.1%), 2015 (20.2%), and in 2025 it is targeted to 15.5%. While the prevalence of smoking in Indonesia is still high, namely 33.8% at the age of more than 15 years, the prevalence of smoking among students aged 13-15 years is 12.7% (Word Health Organization, 2019).
In an effort to realize a healthy Indonesia, the government issued a Joint Regulation of the Minister of Health and Minister of Home Affairs No.188 / Menkes / PB / I / 2011 No. 7 of 2011 concerning Guidelines for Smoking-free Areas. Smoking-free Areas is an area that is declared prohibited from smoking or producing, selling, advertising, and or promoting tobacco products.
Smoking free area includes health service facilities, places for teaching and learning, children's play areas, places of worship. public transportation, workplaces, public places, and other designated places. 7 Research at the Gadjah Mada University in Faculty of Medicine shows that the implementation of a Tobacco -free campus (TFC) policy has a positive impact on reducing smoking habits and promoting smoking cessation behavior. The majority of students strongly support the tobacco-free campus policy 8 . The results at the Stikes Hangtuah Pekanbaru showed that 236 people did not comply with the TFC policy (67.4%). CI: 7,530-32,292) and the social environment (OR: 17,118; 95% CI: 9,455-30,992) 9 .
As an institution that educates future professionals, the University of Riau should become a role model educational institution for the implementation of TFC policy. A smoke-free area is one way to create a healthy campus. This research will examine how the implementation of the TFC at the University of Riau. Knowing the description of the implementation of TFCat the University of Riau will provide input in various programs related to efforts to reduce cigarette smoke and smoking cessation programs on the campus of the University of Riau, which in turn support a healthy campus.

METHODS
The research conducted at the University of Riau in 2020, used a combination of quantitative and qualitative methods (mixed method). The study involved all faculties in the University of Riau (10 Faculties). Data were collected through observation and interviews used the TFC guidelines from the Indonesian Ministry of Health. Observations were carried out in public places such as at entrances, security posts, canteens, courtyards, toilets, lecturers' rooms, libraries, and places of worship. The interview involved 67 academicians consisting of 10 heads of faculty administration, 9 lecturers, 16 employees, and 32 students. Interviews were terminated when variations in information no longer found. Qualitative data were processed descriptively and presented in a frequency distribution table. Qualitative data used content analysis, validation was carried out by triangulation of methods and triangulation of sources. The qualitative data is presented in the form of tables and a brief narrative. This research has received ethical approval from the Medical / Health Research Ethics Unit of the Faculty of Medicine, Riau University, Number: B / 116 / UN.19.51.1.8 / UEPKK / 2020. Table 1 shows the implementation TFC at the University of Riau. The observation guideline consists of eight items, if the results of the observation meet the TFC standard are given a score of 0, and if they do not meet the standard, they are given a score of 1, the higher the score, the lower the implementation of TFC. According to the TFC observation guidelines from the Indonesian Ministry of Health, the institution is defined as implementing TFC if all observed items have a score of 0. Based on table 1, the Faculty of Agriculture is the faculty with the highest score (the most not met International Journal of Social Service and Research, Elda Nazriati, Zulharman, Firdaus, Muhammad Faris Alhakim IJSSR Page 1511 TFC standards), while the Faculty of Mathematics and Natural Sciences, The Faculty of Law, and the Faculty of Nursing had the lowest score at 4 (the ones that met the most TFC standards). The implementation of TFC based on the items observed is presented in Table 2, The results showed that the most items that did not meet the TFC standards. The standards were no designated smoking areas, nobody smokes, no smell of cigarette smoke, and no cigarette butts, while the items that best meet the TFC standards were the absence of logos or advertisements related to cigarettes and cigarette sellers on campus. There are no designated smoking areas 0 2.

RESULTS AND DISCUSSION
There are smoking bans sign on campus 60 3.
There is no smell of cigarette smoke 0 4.
There are no ashtrays or matches 40 5.
There are no tools / goods that have a logo related to cigarette advertising, promotion and sponsorship 80 8. There are no places or people selling cigarettes 80 Efforts and obstacles to the Implementation of Smoking-Free Areas at the University of Riau based on interviews are shown in table 3. Some of the efforts that have been made in the implementation of TFC include the TFC policy, the existence of smoking ban promotion media, TFC socialization, and sanctions for violators of TFC standards. Some of the obstacles that were found included the absence of a TFC policy in most faculties, the absence of a TFC monitoring team, the uneven distribution of promotional media in strategic places, the absence of TFC socialization in most faculties. faculty, sanctions for TFC violations have not been applied, academicians who are not obedient, and There are locations that are considered smoking areas Most of the faculties did not provide socialization on the dangers of smoking and smoking ethics, there were faculties that had conducted socialization, but it was more than 5 years ago, the students interviewed stated that they had never heard socialization. The places that are often used for smoking are the canteen, garden, lecturer room, courtyard, parking lot, security post, sports field, bathroom / toilet, front of the class, gazebo, classroom yard and open spaces. many assume that providing a smoking area is the right action

Discussion
The results showed that all faculties at the University of Riau had not implemented 100% TFC where there were still some standard items of TFC that were not fulfilled. All faculties provide designated smoking areas, it was probably due to misperceptions and misunderstanding of TFC. According to the regulation of the Minister of Health and Minister of Home Affairs No. 188 / MENKES / PB / I / 2011 No. 7 of 2011 concerning TFC Guidelines explains that building special smoking areas is only allowed in workplaces and public places. On the other hand, health service facilities, children's playgrounds, places of worship, public transportation, and places for teaching and learning as well as universities are prohibited from providing special places for smoking and are areas free from cigarette smoke to the outer limit (Prabandari SY, 2019). Designating indoor spaces for smokers breaks these standards and is not in conformity with the WHO Framework Convention on Tobacco Control guidelines (Renaldi R,214).
From the results of the interview, it is known that most of the faculties in the University of Riau do not yet have specific policies or regulations regarding 100% TFC. Several faculties have implemented special rules regarding TFC. This statement is in accordance with the results of observations, namely the discovery of the Dean's Decree document and the TFC signpost. The results of research at the University of Riau by Suhaimi (2018) -s., 2013). The teaching and learning process environment should be free from cigarette smoke. The policy on TFC aims to reduce the smoking population and people exposed to cigarettes (Suhaimi M, 2018). In fact, the implementation of TFC in universities is still not effective. Setianingsih's research (2015) shows that three of the four STIKES in Semarang City do not have internal regulations on TFC (Notoatmodjo S, Health promotion in schools, 2021). The Mayor of Pekanbaru has issued a regulation on TFC which states that one of the targets of implementing this TFC policy is a place for the teaching and learning process (1. Rahim FK, 2016). As an institution located in Pekanbaru municipality, Riau University is obliged to implement TFC. Legal provisions regarding TFC are also contained in the Joint Regulation of the Minister of Health and Home Affairs. The internal regulation is needed to enforce TFC rules in the campus environment and provide legal protection for institutions and serve as campus guidelines for implementing smoking-free areas (Setianingsih YA, Yustina EW, Widyorini E. , 2018).
In this study, knowing that all Heads of administration in faculty stated that Riau University did not yet have a special team to monitor TFC. The informant argued that establishing a team to monitor TFC was not necessary because the entire academic community, including lecturers, students, and employees, had the responsibility and obligation to monitor TFC. The absence of a special team to supervise the TFC will make it difficult for implementers to succeed in the TFC policy.
TFC supervisory team in teaching and learning places aims to record violations and apply sanctions according to applicable regulations and also report the results of supervision to the designated authority, whether requested or not (Ministry of Health of the Republic of Indonesia. , 22). Consistent and systematic processes for implementation, maintenance and enforcement of policy goals, and cessation support, is needed to create a non-smoking culture on university campuses (Sendall MC, Le Lievre C, McCosker LK, Brewis L. , 2020).
Smoking ban promotion media will increase the awareness and knowledge of the academic community about the application of TFC on campus. Observations show that most of the faculties already have smoking prohibition signs in the form of stickers and banners posted in strategic places, this is also supported by the results of interviews where 60% of the faculties already have promotional media about smoking bans. Research conducted by Ohmi, Okizaki et al (2013) at the University of Nayoro City, Japan, shows that media promotion of smoking bans can increase knowledge and motivation for smokers and reduce the number of smokers on campus (Ohmi H, Okizaki T, Meadows M, Terayama K, Mochizuki Y. , 2013). Research shows that there is a relationship between smoking prohibition signs in strategic places with compliance with smoking-free areas. Decision makers should also consider combining a community-based approach with a formal method of enforcement with punishments. universities should include campaigns based on cessation resources and informational signage (Seitz, C. M., & Ragsdale, T. L., 2018).
Even though the promotional media is already owned by most of the Faculties, its distribution is not evenly distributed in all strategic locations. Based on interviews with lecturers, students and employees, it was found that most of the faculties had not given a TFC sign in the teaching and learning process room. This is in line with the results of the researchers' observations with the finding of smoking ban signs only in some labs and rooms. According to the TFC implementation guidelines from the Indonesian Ministry of Health, the place for the teaching and learning process must provide an TFC sign in every learning room (Ministry of Health of the Republic of Indonesia. , 22).
One of the important factors in the operation of TFC is socialization. In her research, Fauziah found that the TFC socialization contributed to the practice of smoking-free areas, socialization such as direct delivery or seminars or important actions to be carried out so that the implementation of the TFC policy could be fulfilled (Fauziah M, Sugiatmi S. , 2019). The results of the interviews indicated that only a small proportion of faculties had disseminated the TFC policy. Socialization is carried out directly to lecturers and employees at meetings while students are carried out during the learning process. Indirect socialization took the form of stickers and signs containing the TFC policy. The Student Executive Board (BEM) also held a TFC policy outreach to classes in early 2016. This statement was not in line with the student's statement, where all the students interviewed admitted that socialization was only carried out indirectly through stickers and banners, while direct socialization never implemented. This shows that not all academicians have been directly exposed to socialization. Interviews with the Head of Administration found that there had never been any International Journal of Social Service and Research https://ijssr.ridwaninstitute.co.id/ IJSSR Page 1514 counseling on the dangers of smoking and smoking ethics to the entire academic community in each faculty. Most of the informants thought that it was the health personnel who had the right to convey information about the dangers of smoking and smoking ethics. This opinion is in line with the statements of students, lecturers and employees, where all informants admitted that they had never conducted any counseling about the dangers of smoking and smoking ethics to the academic community at the University of Riau. Low knowledge of the dangers of smoking and smoking ethics may lead to a lack of awareness of individual health, making smoking difficult to stop. Research by Putra and Widarsa in 2018 at Marwadewa University stated that students who smoke on the campus have low knowledge about the dangers of smoking and the health effects on themselves and others (Putra DM, Widarsa IK. , 2018). Sutrisno's research states that the implementation of TFC will be effective in controlling smoking behavior if it is supported by good leadership commitment, smoking behavior intervention through structured counseling, and socialization of the dangers of smoking (Sutrisno S, Djannah SN., 2020).
Based on interviews, it has never conducted an evaluation of the implementation of TFC. The informant said that the implementation of TFC at the University of Riau has been effective so it does not require evaluation. This statement is not in accordance with the results of observations by researchers, where students, lecturers, and employees are still smoking on the campus.The evaluation is needed to assess the implementation of TFC, compliance, and law enforcement activities on the implementation of TFC, This evaluation and monitoring are carried out regularly (Ministry of Health of the Republic of Indonesia. , 22).
One of the indicators of non-fulfilled TFC is the presence of the smell of cigarettes and cigarette cuttings in the campus environment of the Faculty of Riau University. This indicates that the smoking behavior at the University of Riau is still quite high. Based on observations and interviews with lecturers, employees, and students, places that are often used to smoke are canteens, parks, lecturers' rooms, courtyards, parking lots, smoking rooms, security posts, sports fields, bathrooms/toilets, gazebos, classroom terraces, and open spaces. The high smoking behavior at the University of Riau is caused by various factors. Some of the factors that influence smoking behavior are biological factors, psychological factors, social environmental factors, demographic factors, socio-cultural factors, and socio-political factors. (Sarafino EP, Smith TW. , 2014) Rahim's research (2016) shows that the strongest predictor of smoking behavior in urban and rural areas in Indonesia is the rule of smoking in the house. 23 The failure to fulfill this indicator affects the implementation of the TFC as a whole. These results are consistent with research conducted by Chaaya, et al. in 2013 at a private university in Lebanon which stated that smoking behavior could affect the implementation of TFC (Word Health Organization, 2010).
The application of sanctions against TFC violators can have a deterrent effect on the perpetrators and increase discipline towards the established TFC policies. Research conducted by Puswitasari in 2012 at the Faculty of Medicine, Diponegoro, stated that one of the factors that can affect employee and student compliance with the TFC policy is the imposition of strict sanctions. (Organization,World Health,WHO news 26 July 2019) This is in line with the research conducted by Putra in 2020 at the Faculty of Public Health, University of Indonesia, which states that one of the factors influencing the low implementation of TFC is the absence of sanctions against nonsmoking violators so that it will create a stigma of "taking it lightly" on people in the environment. In the future, this will cause the rules to be formulated to be ineffective because the people in the environment think that the rules do not exist at all (Word Health Organization., 2018). Based on the interviews, almost all informants think that most of the faculties at the University of Riau have not applied special sanctions for TFC violators. Sanctions given to violators are limited to a warning. The absence of the application of special sanctions against violators has led to one factor in the discovery of students, lecturers, and employees smoking at the University of Riau, smokers can feel free to smoke in the TFC area without feeling guilty. The application of sanctions that are enforced firmly can certainly provide a deterrent effect on the violation of the law that has been committed (Notoatmodjo S, 2012). Several faculties have included sanctions for TFC violations in the Dean circular letter, in fact the application of these sanctions did not work properly, the notification of fines affixed in the form of stickers was limited to writing, there was no application of sanctions that International Journal of Social Service and Research, Elda Nazriati, Zulharman, Firdaus, Muhammad Faris Alhakim IJSSR Page 1515 were actually implemented, because people who smoked in the TFC environment and not followed up in accordance with the existing sanctions.

CONCLUSION
The results showed that all faculties in the University of Riau had not implemented TFC. efforts that have been made include the provision of promotional media for smoking bans, socialization of TFC, and inclusion of sanctions in the TFC policy. Some of these obstacles include the absence of a TFC policy in most faculties, no TFC monitoring team, not many promotional media spread in strategic places, no TFC socialization in most faculties, no sanctions imposed on TFC violations, academicians who do not meet TFC standards, and some locations are considered acceptable smoking areas This data will inform policymakers at Riau University and other universities in developing intervention programs to address problems with TFC implementation on campus. Increasing education and health promotion programs is needed to improve the quality of TFC implementation.