'[…] the situation in the schools still remains the Achilles heel.' Barriers to the implementation of school tobacco policies-a qualitative study from local stakeholder's perspective in seven European cities

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

Evaluation of the Implementation of a 25-Year Outdoor School Ground Smoking Ban: A Qualitative Interview Study With Implications for Prevention Practise

Introduction: Tobacco use, often initiated in younger ages, is a serious health challenge worldwide. In Sweden, smoking has been prohibited on school grounds since 1994. Municipal environmental and health inspectors control the compliance of the ban. Nevertheless, the enforcement and maintenance of the ban are inadequate. The aim of the current study was to identify facilitators, barriers, and the potential for improved implementation of a 25-year outdoor school ground smoking ban in upper secondary schools.

Materials and Methods: A process evaluation was conducted using semi-structured interviews with principals in upper secondary schools, local environmental and health inspectors, and local politicians (n = 30) in Stockholm County, with purposive sampling for informant recruitment. A qualitative content analysis of the transcribed interviews was performed.

Results: Three main categories and 10 subcategories were generated from the interviews, revealing facilitators, barriers, and the potential for improvement of the implementation of the ban. A prominent facilitator of the ban was informed and engaged principals and inspectors. Prominent barriers were conflicting goals governing the schools, which reduce staffs' motivation to maintain the ban, unclear school ground boundaries, and lack of resources. Potential for improvement was found in a new tobacco act with an extended ban on smoking at school entrances, extended support for schools and staff to strictly enforce the ban, and a continued denormalisation of smoking in society.

Conclusion: To achieve effective implementation of outdoor school ground smoking bans in upper secondary schools, authorities need to address conflicts between different goals governing the schools and give necessary support to the staff to strictly enforce the ban. Policies on smoke-free working hours in the municipalities along with tobacco restrictive policies in the surrounding society may increase the possibility to maintain the smoking ban in upper secondary school grounds.

[The association between school tobacco policies and the perceived smoking prevalence of adolescents]

BACKGROUND

In the German context, there is hardly any quantitative data about the implementation of school tobacco polices that include the perspective of both teachers and students. The aim of the study is to investigate the associations between implemented school tobacco policies and the perceived prevalence of smoking at the level of school staff and adolescents.

METHODS

The repeated cross-sectional study (2013 and 2017) is based on pooled responses of 13- to 17-year-old adolescents (N = 2393) and school staff (N = 85) from 25 schools located in the West German metropolitan region of Hanover. In linear regression models, average marginal effects (AMEs) with 95% confidence intervals (CI95%) and robust standard errors for perceived tobacco prevalence are reported separately for school tobacco policies assessed by teachers and students (scale 0-6). All models were controlled for sociodemographic, school-, and smoking-specific covariates.

RESULTS

On average, adolescents perceive a smoking prevalence of 30% ([Formula: see text]; s: 24.0) for their school. A comprehensive school tobacco policy is consistently associated with lower school smoking prevalence both from the point of view of teachers (AME: -3.54 CI95% -6.49 to -0.58) and students (AME: -1.69 CI95% -2.52 to -0.86). The number of smoking friends (e.g., "most of them are smokers" +14%: AME: 14.13 CI95% 10.46 to 17.80) and the type of school are the most relevant determinants of a high school smoking prevalence. School types with a nonacademic track report a 15% (AME: 15.03 CI95% 10.13 to 19.93) higher prevalence compared to grammar schools.

DISCUSSION

Progressive school tobacco control policies should focus more on school types with nonacademic tracks, certain groups at risk, and those schools that do not strictly enforce school tobacco policies.