Smoke-free school policies in Europe: Challenges for the future.

Scholars commonly plea for the development and evaluation of new tobacco control interventions to further decrease smoking and exposure to second-hand smoke. We, in addition, emphasize there is still much that can be done to improve the impact of current tobacco control interventions. This commentary makes a specific case for improving the implementation of smoke-free school policies across Europe.

School tobacco policies and adolescent smoking in six European cities in 2013 and 2016: A school-level longitudinal study.

Assessment of the effectiveness of school tobacco policies (STPs) in reducing adolescent smoking remains inconclusive. Previous studies took insufficient account of different dimensions of STPs, the different views of students and staff, and policy changes over time. This study assessed how a multidimensional STP, as perceived by students and staff, was associated with adolescent smoking over time in six European cities. The SILNE and SILNE-R surveys were conducted among students (n = 18,502) and staff (n = 438) in 38 schools in 2013 and 2016. Three dimensions (comprehensiveness, enforcement, and communication) were assessed and we calculated total STP scores. Multilevel logistic regressions estimated associations of STPs with adolescent smoking on and just outside school premises and with weekly smoking. Further analyses estimated associations between 2013 and 2016 STP changes and smoking outcomes in 2016, controlling for STP and smoking prevalence in 2013. On average, there were few increases in STP scores over time. Greater STP enforcement, as perceived by students, was associated with lower odds of weekly smoking (OR:0.93, 95%CI:0.89-0.97) and of smoking on school premises (OR:0.80, 95%CI:0.72-0.90). Higher total STP scores were associated with lower odds of smoking on school premises (OR:0.76, 95%CI:0.67-0.86), but not of smoking just outside premises or smoking weekly. Greater increases in STP scores over time were associated with lower odds of smoking on school premises in 2016 (OR:0.65, 95%CI:0.47-0.89). Well-enforced STPs may help reduce adolescent smoking at school. Schools should be supported in adopting comprehensive policies that also extend to the surroundings of their premises.

The Association Between Smoke-Free School Policies and Adolescents' Perceived Antismoking Norms: Moderation by School Connectedness.

INTRODUCTION: Many European schools implement smoke-free school policies (SFSPs). SFSPs may decrease adolescent smoking by causing adolescents to perceive stronger antismoking norms, yet there exists no quantitative evidence that indicates for which norms and for whom such effects may occur. This study therefore assessed to what extent adolescents' perceived antismoking norms among best friends, teachers, and society at large were associated with SFSPs, and whether these associations were moderated by adolescents' level of school connectedness. AIMS AND METHODS: Survey data were collected in 2016/2017 on 10,653 adolescents aged 14-16 years old and 315 staff members in 55 schools from seven European cities. Associations of adolescent-perceived SFSPs and staff-reported SFSPs with best friend, teacher, and societal antismoking norms were estimated in multilevel logistic regression models, adjusted for demographics and school-level smoking prevalence. We tested for interaction between school connectedness and SFSPs. RESULTS: Adolescent-perceived SFSPs were positively associated with antismoking norms by teachers (odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.15-1.85), were negatively associated with antismoking norms by best friends (OR: 0.81, 95% CI: 0.67-0.99), but were not significantly associated with antismoking norms by society at large (OR: 0.87, 95% CI: 0.74-1.02). All interaction tests between adolescent-perceived SFSPs and school connectedness were nonsignificant. Staff-reported SFSPs were not associated with any norm and showed no significant interaction with school connectedness. CONCLUSIONS: We found that SFSPs are associated with adolescents' perception of more antismoking norms by teachers, but less antismoking norms by best friends, irrespective of adolescents' level of school connectedness. IMPLICATIONS: Smoke-free school policies, just as many other tobacco control policies, are assumed to foster adolescents' perception of antismoking norms. Still, current evidence does not demonstrate which antismoking norms may be influenced by SFSPs and whether this influence is equal for adolescents with different levels of school connectedness. This study suggests that SFSPs foster adolescents' perception of antismoking norms by teachers, but may concurrently lead to the perception of less antismoking norms by best friends, irrespective of adolescents' school connectedness. SFSPs may therefore need to be complemented with interventions that target antismoking norms in adolescent peer groups.

Why staff at European schools abstain from enforcing smoke-free policies on persistent violators.

Secondary schools in European countries increasingly implement comprehensive smoke-free school policies (SFSPs) that prohibit most or even all adolescents from smoking during school hours. Consistent enforcement of SFSPs is essential for realizing optimum effectiveness. A main challenge represents adolescents who persistently violate the rules. We studied how staff in European countries respond to these persistent violators and why they may turn a blind eye. We used interview transcripts from 69 staff members at 22 schools in 6 European countries to identify cases in which staff turned a blind eye. We then applied thematic analysis for identifying the considerations as to why they turn a blind eye. Turning a blind eye on persistent violators happened among school staff in all six countries. Three considerations were identified. First, staff believe their primary role and duty is to support all adolescents to develop into well-functioning adults, and sometimes it is best to accept smoking. Second, staff expect that applying stricter disciplinary measures will not stop persistent violators and is more likely to create more severe problems. Third, staff do not feel supported by relevant actors in society (e.g. parents) in influencing adolescent smoking. We conclude that staff's considerations stress the need to support school staff in enforcing the increasingly comprehensive rules on the most persistent smokers.

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans.

INTRODUCTION: While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities. METHODS: We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities. RESULTS: The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. We identified "triggering trust," "increasing priorities," and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) limiting opposing interests through the use of the child protection frame. CONCLUSIONS: This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation. IMPLICATIONS: In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive SF laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO "Healthy Cities Network" objectives.

Smoking beliefs across genders, a comparative analysis of seven European countries.

BACKGROUND: Most European countries have seen a decrease in the prevalence of adolescent smoking. This decrease has, however, been patterned by gender. Girls' smoking rates have now overtaken boys' in many European countries. The two genders may not, however, share the same smoking beliefs and this could explain differences between the genders in smoking prevalence. We describe gender differences in smoking beliefs and investigate variations between countries, along with their gender context. METHODS: In 2016, we conducted the SILNE R study (Smoking Inequalities Learning from Natural Experiments - Renew) in 55 schools located in seven European countries: Belgium, Italy, The Netherlands, Portugal, Finland, Ireland, and Germany. We surveyed 12,979 students aged 14-16 years (50% were girls). We classified smoking beliefs into four categories: positive individual, positive social, negative individual, and negative social beliefs. We expected girls to score higher on the last three of those categories and we hypothesized that countries with a more gender-equal culture would have less gender difference in beliefs about smoking. RESULTS: One out of two smoking beliefs differed significantly between genders. Negative social beliefs were more common in girls, while beliefs about the dating-related aspects of smoking were more common in boys. We identified Germany and Belgium as the only countries with no gender differences in any of the belief scales. No correlation was found, however, between these scales and the Gender Inequality Index. CONCLUSIONS: In some countries, gender-specific interventions might be implemented; however, two opposing strategies might be used, depending on whether such programs are aimed at boys or girls.

Why Secondary Schools Do Not Implement Far-Reaching Smoke-Free Policies: Exploring Deep Core, Policy Core, and Secondary Beliefs of School Staff in the Netherlands.

BACKGROUND: Secondary schools that implement smoke-free policies are confronted with students who start smoking outside their premises. One solution is to complement smoke-free policies with prohibitions for all students to leave the school area during school hours, technically making school hours a smoke-free period. However, there are strikingly few Dutch secondary schools that implement this approach. This study explores why staff members in the Netherlands decide not to implement smoke-free school hours for all students. METHOD: We interviewed 13 staff members, with different functions, from four secondary schools. The analysis was informed by the Advocacy Coalition Framework (ACF) to delve into the values, rationales, and assumptions of staff with the aim to identify deep core, policy core, and secondary beliefs. RESULTS: We identified six beliefs. Two deep core beliefs are that schools should provide adolescents the freedom to learn how to responsibly use their personal autonomy and that schools should only interfere if adolescents endanger or bother others. Three policy core beliefs identified included the following: that smoking is not a pressing issue for schools to deal with; that schools should demarcate their jurisdiction to intervene in adolescents' lives in time, space, and precise risk behavior; and that implementing smoke-free school hours would interfere with maintaining positive student-staff relationships. One secondary belief identified was that smoke-free school hours would be impossible to enforce consistently. CONCLUSION: This paper was the first to demonstrate the many beliefs explaining why schools refrain from voluntary implementing far-reaching smoke-free policies.

To what extent and why adolescents do or do not support future tobacco control measures: a multimethod study in the Netherlands.

BACKGROUND: In the Netherlands, the adoption of new tobacco control measures is needed to further reduce rates of adolescent smoking. Adolescents' support for future measures could increase the likelihood of adoption as this provides political leverage for tobacco control advocates. There is, however, scant evidence about to what extent and why adolescents support future measures. We therefore assessed adolescents' support for a range of future measures and explored the criteria that adolescents use to underpin their support. METHODS: A mixed-method design involved surveys and group interviews with fourth-year students (predominantly 15-16 years). The survey, completed by 345 adolescents, included statements about future tobacco control measures and a smoke-free future where nobody starts or continues smoking. Thereafter, 15 adolescents participated in five group interviews to discuss their support for future measures. RESULTS: The survey showed that adolescents generally support a smoke-free future. They expressed most support for product measures, mixed support for smoke-free areas, ambivalent support for price increases and least support for sales restrictions. The group interviews revealed that differences in support were explained by adolescents' criteria that future measures should: have the potential to be effective, not violate individuals' right to smoke, protect children from pro-smoking social influences and protect non-smokers from secondhand smoke. CONCLUSION: Adolescents' high support for a smoke-free future does not lead to categorical support for any measure. Addressing the underlying criteria may increase adolescents' support and therewith provide political leverage for the adoption of future measures.

Facilitating conditions for staff's confidence to enforce school tobacco policies: qualitative analysis from seven European cities.

BACKGROUND: School staff members' consistent enforcement of school tobacco policies (STPs) is needed to decrease adolescent smoking and exposure to tobacco smoke. Staff's confidence, indicating their perceived ability to cope with students' negative responses, explains variations in staff's STPs enforcement, yet understanding of the determinants for confidence is lacking. We analyzed the conditions in which the staff feel confident in addressing students who violate STPs to support staff's enforcement.  METHODS: Data consists of 81 semi-structured interviews with the staff members from 26 secondary schools in seven European cities in Belgium, Finland, Germany, Ireland, Italy, The Netherlands, and Portugal. In every city, 3-4 staff members (senior management, teachers, supportive staff) in 3-4 schools (academic-vocational, high-low SES area) were interviewed. Transcripts were analyzed with thematic analysis. RESULTS: When staff felt confident in their ability to prevent, diminish, or handle students' negative responses, they were more likely to address students on STP violations. The staff was more confident (1) when consistent policy enforcement within school and regarding the wider society ensured staff legitimacy for STPs enforcement, (2) when dialog and mutual familiarity with students allowed the staff to facilitate constructive interaction with STP violators, and (3) when organizational backup structures provided staff collegial support to overcome challenges in the enforcement. These conditions would support consistent enforcement, especially with persistent misbehavers and among the more uncertain staff members. CONCLUSIONS: Our study stresses the need to implement strategies at multiple levels to strengthen staff's confidence for STP enforcement. To support staff's legitimacy for enforcement, we suggest reinforcing structures and practices that facilitate consistency in STP enforcement; to support staff's ability for constructive interaction with STP violators, we suggest strengthening staff's social and emotional learning; and to support staff's experience of collegial support, we suggest reinforcing staff's collective ability to cope with students' negative responses.

Using the realist approach to unravel the complexity of health programmes: the evaluation of smoke-free school policies as a case study.

Numerous commentaries plea for the use of methods that take into account complexity when evaluating health programmes. These commentaries provide compelling arguments on why evaluations of health programmes should not rely exclusively on methods that were designed for making universal claims about whether and to what extent a policy is effective. However, there exist only few concrete examples showing how to take this complexity into account during the evaluation of health programmes. One increasingly popular approach to do so is the realist approach. In this paper, we explain the realist approach for taking into account complexity, discuss how we applied this approach to study the impact of smoke-free school policies and reflect on the practical value of the resultant insights. We hope this case study may inspire fellow scholars to use the realist approach for evaluating health programmes.