Implementing Preventive Tobacco Policies: The role of contextual factors in policy implementation at school and national levels

Healthy public policies play a crucial role in the health and well-being of populations, as they help to build health-promoting environments. However, the impact of these policies depends on their implementation. For example, global tobacco prevention policies can decrease adolescent tobacco and nicotine use only if they are implemented into national regulations and enforced in the everyday practices of organisations such as schools. Schools are one of the core settings for tobacco prevention and health promotion, as they reach almost all young people. Although preventive tobacco policies are critical for ending the tobacco epidemic, which continues to burden public health, countries vary considerably in how comprehensively the policies are implemented at the national level or enforced in schools. Despite the need for more comprehensive and consistent tobacco policy implementation, so far tobacco research has paid little attention to implementation.

In this doctoral thesis I explain the school- and national-level implementation of preventive tobacco policies. In line with the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) I focus on policies such as smoke-free environments, price and tax measures, product regulations, packaging and labelling, bans on advertising and promotion, and age limits. The thesis consists of four international journal articles and a summary article. I used a cross-country research design and qualitative methods with critical realism as an ontological basis. First, I conducted a realist review to explain school staff members’ enforcement of school tobacco policies (STPs) (Article I). This understanding was complemented by a thematic analysis of interviews with school staff (n=84) from seven European countries (Articles II and III). In the fourth article, I used a narrative review to assess and compare the comprehensiveness of tobacco policies in the Nordic countries and the reasons for their implementation (Article IV). In the summary article, I synthesised the findings into a programme theory that explains how context interact with policies and influence their implementation via specific mechanisms. The analysis was guided by a multidisciplinary conceptual framework on policy implementation, which helped to explain among other things the role of contextual factors in complex policy implementation processes.

The school-level results showed that three mechanisms – responsibility, motivation and confidence – explained school staff’s enforcement of STPs. The emergence of these mechanisms was influenced by certain contextual factors, with consistency of staff enforcement behaviour being one of the key factors. However, consistent staff enforcement was challenged by two key issues. First, some staff did not intervene in rule violations because they were not confident in their own ability to cope with students’ negative responses. Staff confidence was supported by certain contextual factors. Intervening in rule violations was easier when staff felt legitimised in their actions, believed they could interact constructively with students, and expected collegial support in the face of challenges. The second issue that challenged consistency was enforcement with vulnerable students who persistently violated smoking bans. The results demonstrated that staff did not intervene in rule violations if they felt that STP enforcement conflicted with support for students’ school performance, if they expected stricter disciplinary measures to be ineffective and cause more serious problems, or if they did not feel supported by other stakeholders involved in the young people’s smoking behaviour, such as parents.

The Nordic comparison showed that countries’ tobacco policies were harmonised by the WHO FCTC and European Union (EU) directives on tobacco products, taxation and advertising. These measures ensure that core policies, such as indoor smoking bans and the 18- year age limit on sales, are included in national legislation. However, the WHO FCTC and EU directives also explained shared deficiencies across the countries, which were especially visible in the inconsistent or absent regulation of smokeless and novel tobacco and nicotine products. The main reasons for the comprehensive implementation of tobacco policies were national tobacco control actors, such as health ministries and civil society and their networks. These actors also facilitated the Nordic countries to implement some advanced tobacco policies, and indeed to be among the first countries in the world to do so. These advanced policies included, for instance, flavour bans on e-cigarettes in Finland and comprehensive outdoor smoking bans in Sweden.

The programme theory that synthesises the results from the four articles outline how the context interact with policies and influence national- and school-level implementation via specific mechanisms. These causal pathways help us to understand how to support policy implementation by strengthening contextual factors. The recommendations highlight the importance of strengthening collaboration between actors, both within and between implementation levels, and both nationally and internationally. Strengthening collaboration may help to address current implementation challenges, contribute to the implementation of more comprehensive tobacco policies, and support the identification of ways in which different implementation levels can best support each other to achieve the common goals: reducing adolescents’ use of tobacco and nicotine products and ending the tobacco epidemic.