Smoke-free school policies: understanding their implementation and impact by using the realist approach

Governments increasingly aim for reducing smoking among their populations. Adolescents are an important target group of tobacco control measures, since this group is highly susceptible to influences that may cause smoking initiation. A widespread measure to reduce the number of adolescent smokers are smoke-free school policies (SFSPs) at secondary schools. However, scientific evidence about the effectiveness of SFSPs on adolescent smoking behaviour remains largely inconsistent. Some studies show a decrease, whereas other studies show no change or even an increase in adolescent smoking behaviour. The key reason for this inconsistency is that most studies use methods that were designed for making universal claims about whether and to what extent policies are effective, yet these methods are insufficiently able to take into account the complexity of the school environment. This complexity causes varying effects of SFSPs from individual to individual and from school to school, because their effects strongly depend on how relevant actors respond to the implementation of SFSPs. This dissertation therefore applies an innovative theory-driven method for evaluation, in our case the ‘realist approach’, to develop a better understanding of variations in the effectiveness of SFSPs. Two objective will be addressed: 1. Develop a comprehensive understanding of how, for whom and under which circumstances smoke-free school policies may impact adolescent smoking behaviour. 2. Develop a similar understanding about rule enforcement by school staff members. The dissertation finishes with a set of practical recommendations on how to improve the effectiveness of SFSPs and a reflection on the realist approach.