Schools as smoke-free zones? Barriers and facilitators to the adoption of outdoor school ground smoking bans at secondary schools
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Department Tranzo, Tilburg University, Tilburg, The Netherlands
Academic Collaborative Centre for Public Health Limburg, Public Health Service South Limburg (GGD ZL), Geleen, The Netherlands
Department of Health Services Research, School for Public Health and Primary Care CAPHRI, Maastricht University, Maastricht, The Netherlands
National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
Submission date: 2016-02-01
Acceptance date: 2016-03-22
Publication date: 2016-03-29
Corresponding author
A.D. Rozema   

Department Tranzo, Tilburg University, P.O. Box 90153, Tilburg 5000 LE, The Netherlands
Tobacco Induced Diseases 2016;14(March):10
Whereas smoking bans inside secondary school buildings are relatively widespread, a smoking ban for the outdoor school grounds is less common. Therefore, this study investigates why many secondary schools fail to adopt an outdoor school ground smoking ban. The aim is to elucidate the perceived barriers and facilitators of stakeholders at schools without an outdoor school ground smoking ban.

Qualitative data were obtained from 60 respondents of 15 secondary schools. Semi-structured interviews were held with various key stakeholders and a thematic approach was used for analysis of the transcripts.

The perceived barriers and facilitators of the stakeholders fell into four categories: 1) socio-political characteristics (legislation and social norm), 2) school characteristics (policy, decision process, enforcement, resources, workforce conditions, communication and collaboration), 3) individual characteristics (support, knowledge, and target group), and 4) smoking ban characteristics (environmental factors, guideline recommendations, outcome expectations, and evidence).

These findings highlight the importance of legislation for outdoor smoking bans. Moreover, collaboration, communication and involving stakeholders during an early stage of the process should be stimulated, as this might increase adoption. These results can be applied in future studies on outdoor tobacco control policies; moreover, they may facilitate tobacco control initiatives leading to more smoke-free environments to further protect youth from the harmful effects of tobacco.

WHO: WHO Report On The Global Tobacco Epidemic. In: Raising taxes on tobacco. Luxembourg; 2015. Accessed 15 Jan 2016.
Welte JW, Barnes GM, Tidwell MO, Hoffman JH. Tobacco use, heavy use, and dependence among adolescents and young adults in the United States. Subst Use Misuse. 2011;46:1090–8.
Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A. Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis. Lancet. 2014;383:1549–60.
Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Rual EE. Effect of restrictions on smoking at home, at school, and in public places on teenage smoking: cross sectional study. BMJ (Clinical Research Ed). 2000;321:333–7.
Moore L, Roberts C, Tudor-Smith C. School smoking policies and smoking prevalence among adolescents: multilevel analysis of cross-sectional data from Wales. Tob Control. 2001;10:117–23.
Fallin AMSA. Association of campus tobacco policies with secondhand smoke exposure, intention to smoke on campus, and attitudes about outdoor smoking restrictions. Am J Public Health. 2015;105:1098–100.
Hublet A, Schmid H, Clays E, Godeau E, Gabhainn SN, Joossens L, et al. Association between tobacco control policies and smoking behaviour among adolescents in 29 European countries. Addiction. 2009;104:1918–26.
Verdurmen J, Monshouwer K, van Laar M: Smoke Youth Monitor. 2013. Accessed 1 March 2016.
Klaassen A: Smoking Youth Monitor. [Available on request at TNS NIPO]; 2012.
Kota D, Robinson SE, Imad Damaj M. Enhanced nicotine reward in adulthood after exposure to nicotine during early adolescence in mice. Biochem Pharmacol. 2009;78:873–9.
Kendler KS, Myers J, Damaj MI, Chen X. Early smoking onset and risk for subsequent nicotine dependence: a monozygotic co-twin control study. Am J Psychiatry. 2013;170:408–13.
O’Dea JA. Smoke free environments for children—the relationship between schools and wider smoke free environments. In current issues and controversies in school and community health, sport and physical education. Edited by O'Dea. New York: Nova; 2012.
Lungfoundation: Step-by-step plan outdoor school ground smoking ban. 2012. Accessed 8 Jan 2016.
Lungfoundation: Monitoring outdoor school ground smoking bans. 2014. http://www.alliantienederlandr.... Accessed 8 Jan 2016.
Hallfors D, Godette D. Will the ‘principles of effectiveness’ improve prevention practice? early findings from a diffusion study. Health Educ Res. 2002;17:461–70.
Fagan AAMS. Strategies for enhancing the adoption of school-based prevention programs: lessons learned from the blueprints for violence prevention replications of the life skills training program. J Community Psychol. 2003;31:235–53.
Blake SM, Ledsky RA, Sawyer RJ, Goodenow C, Banspach S, Lohrmann DK, Hack T. Local school district adoption of state-recommended policies on HIV prevention education. Prev Med: An International Journal Devoted to Practice and Theory. 2005;40:239–48.
Durlak JA, DuPre EP. Implementation matters: a review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008;41:327–50.
Little MA, Pokhrel P, Sussman S, Rohrbach LA. The process of adoption of evidence-based tobacco use prevention programs in California schools. Prev Sci. 2015;16:80–9.
Rogers EM. Diffusion of innovations. New York: Free Press of Glencoe; 1962.
Fleuren M, Wiefferink K, Paulussen T. Determinants of innovation within health care organizations: literature review and delphi study. International Journal For Quality In Health Care: Journal Of The International Society For Quality In Health Care / Isqua. 2004;16:107–23.
Bartholomew LK, Parcel GS, Kok G, Gottlieb NH, Fernandez ME. Planning Health Promotion Programs: An Intervention Mapping Approach, 3rd edn. Jossey-Bass; 2011. ISBN: 078797899X.
Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89:1322–7.
Fleuren M, Paulussen T, van Dommelen P, van Buuren S. Towards a measurement instrument for determinants of innovations. International J Qual Health Care. 2014;26:501–10.
Wolfenden L, Carruthers J, Wyse R, Yoong S. Translation of tobacco control programs in schools: findings from a rapid review of systematic reviews of implementation and dissemination interventions. Health Promotion Journal Of Australia: Official Journal Of Australian Association Of Health Promotion Professionals. 2014;25:136–8.
Sofaer S. Qualitative methods: what are they and why use them? Health Serv Res. 1999;34:1101–18.
Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77–101.
Lincoln YS, Guba EG. Naturalistic inquiry. Newbury Park: CA: Sage Publications; 1985.
Diepeveen S, Ling T, Suhrcke M, Roland M, Marteau TM. Public acceptability of government intervention to change health-related behaviours: a systematic review and narrative synthesis. BMC Public Health. 2013;13:756.
Jaine R, Healey B, Edwards R, Hoek J. How adolescents view the tobacco endgame and tobacco control measures: trends and associations in support among 14–15 year olds. Tob Control. 2015;24:449–54.
Widome R, Samet JM, Hiatt RA, Luke DA, Orleans CT, Ponkshe P, Hyland A. Science, prudence, and politics: the case of smoke-free indoor spaces. Ann Epidemiol. 2010;20:428–35.
Lee JGL, Goldstein AO, Kramer KD, Steiner J, Ezzell MM, Shah V. Statewide diffusion of 100 % tobacco-free college and university policies. Tob Control: An International Journal. 2010;19:311–7.
Shediac-Rizkallah MC, Bone LR. Planning for the sustainability of community-based health programs: conceptual frameworks and future directions for research, practice and policy. Health Educ Res. 1998;13:87–108.
Ringwalt CL, Ennett S, Johnson R, Rohrbach LA, Simons-Rudolph A, Vincus A, Thorne J. Factors associated with fidelity to substance use prevention curriculum guides in the Nation’s middle schools. Health Educ Behav. 2003;30:375–91.
Wold B, Torsheim T, Currie C, Roberts C. National and school policies on restrictions of teacher smoking: a multilevel analysis of student exposure to teacher smoking in seven European countries. Health Educ Res. 2004;19:217–26.
Coppo A, Galanti MR, Giordano L, Buscemi D, Bremberg S, Faggiano F. School policies for preventing smoking among young people. The Cochrane Database Of Systematic Reviews. 2014;10:1–36.
Galanti MR, Coppo A, Jonsson E, Bremberg S, Faggiano F. Anti-tobacco policy in schools: upcoming preventive strategy or prevention myth? a review of 31 studies. Tob Control. 2014;23:295–301.
Mamudu HM, Veeranki SP, He Y, Dadkar S, Boone E. University personnel’s attitudes and behaviors toward the first tobacco-free campus policy in tennessee. J Community Health: Publ Health Promot Dis Prev. 2012;37:855–64.
Polit DF, Beck CT. Generalization in quantitative and qualitative research: myths and strategies. Int J Nurs Stud. 2010;47:1451–8.
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