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

Terveyden edistämiseen tähtäävät poliittiset toimet, kuten lait ja säädökset, ovat keskeisiä väestön terveydelle ja hyvinvoinnille, sillä ne auttavat rakentamaan terveyttä tukevia ympäristöjä. Poliittisten toimien vaikutukset riippuvat kuitenkin siitä, miten ne on toimeenpantu. Esimerkiksi globaalit tupakkapoliittiset toimet voivat vähentää nuorten tupakka- ja nikotiinituotteiden käyttöä vain, jos ne sisällytetään kansalliseen lainsäädäntöön ja sääntelyyn ja jos niitä toteutetaan osana organisaatioiden, kuten koulujen, arkea. Koulut ovat yksi keskeisistä terveyden edistämisen ja tupakkatuotteiden käytön ehkäisyn ympäristöistä, koska ne tavoittavat lähes kaikki nuoret. Vaikka ennaltaehkäisevät tupakkapoliittiset toimet ovat ratkaisevan tärkeitä kansanterveyttä edelleen rasittavan tupakkaepidemian lopettamiseksi, maiden välillä ja maiden sisällä koulujen välillä on huomattavia eroja siinä, miten kattavasti nämä toimet on implementoitu ja miten johdonmukaisesti niitä toteutetaan. Huolimatta tupakkapoliittisten toimien kattavamman ja johdonmukaisemman toimeenpanon tarpeesta tupakkatutkimus ei ole toistaiseksi juurikaan keskittynyt toimeenpanon tutkimiseen. Tämän väitöstutkimuksen tavoitteena oli selittää ennaltaehkäisevien tupakkapoliittisten toimien implementointia kouluissa ja kansallisella tasolla. Tutkimus keskittyi seuraaviin Maailman terveysjärjestön tupakoinnin torjuntaa koskevan puitesopimuksen (WHO FCTC) mukaisiin toimiin: savuttomat ympäristöt, verotus, tuotesääntely, pakkausmerkinnät, mainonta- ja markkinointikiellot sekä ikärajat. Väitöskirja koostuu neljästä kansainvälisestä artikkelista ja yhteenvedosta. Tutkimuksessa hyödynnettiin monikansallista tutkimusasetelmaa ja laadullisia tutkimusmenetelmiä, joiden tieteenfilosofisena lähtökohtana on kriittinen realismi. Ensimmäinen artikkeli oli realistinen katsaus, joka selitti koulun henkilökunnan tupakointikieltojen toteuttamista (artikkeli I). Katsauksen tuottamaa ymmärrystä täydennettiin analysoimalla kouluhenkilökunnan haastatteluja (n=84) seitsemästä Euroopan maasta temaattisen analyysin avulla (artikkelit II ja III). Neljännessä artikkelissa arvioitiin ja vertailtiin narratiivisen katsauksen avulla pohjoismaisen tupakkalainsäädännön ja sääntelyn kattavuutta ja sen toimeenpanoon vaikuttavia syitä (artikkeli IV). Yhteenvetoartikkelissa tulokset koostettiin ohjelmateoriaksi, joka selittää miten konteksti on vuorovaikutuksessa poliittisten toimien kanssa ja vaikuttaa niiden toimeenpanoon tiettyjen mekanismien kautta. Analyysia ohjasi monitieteinen käsitteellinen viitekehys toimeenpanosta. Se auttoi selittämään muun muassa kontekstitekijöiden roolia osana kompleksisia toimeenpanoprosesseja. Koulun henkilökunnan tupakointikieltojen toteuttamista selitti kolme mekanismia: velvollisuudentunto, motivaatio ja itseluottamus. Erilaiset kontekstitekijät vaikuttivat näiden mekanismien aktivoitumiseen, ja niistä yksi keskeisimmistä oli henkilökunnan toiminnan yhdenmukaisuus kieltojen toteuttamisessa. Toiminnan yhdenmukaisuutta haastoi kuitenkin kaksi asiaa. Ensinnäkin osa henkilökunnasta jätti puuttumatta sääntörikkeisiin, koska he eivät luottaneet selviytyvänsä oppilaiden kielteisten reaktioiden kanssa. Henkilökunnan itseluottamusta tukivat kuitenkin tietyt kontekstitekijät. Sääntörikkeisiin puuttuminen oli helpompaa silloin, kun henkilökunta koki oman toimintansa olevan legitimoitua, uskoi pystyvänsä rakentavaan vuorovaikutukseen opiskelijan kanssa ja luotti saavansa kollegiaalista tukea mahdollisiin haasteisiin. Toinen henkilökunnan yhdenmukaista toimintaa haastavista tekijöistä oli haavoittuvassa asemassa olevat opiskelijat, jotka toistuvasti rikkoivat tupakointikieltoja. Tulokset osoittivat, että henkilökunnan jäsenet eivät puuttuneet näiden opiskelijoiden sääntörikkeisiin, kun he kokivat kieltojen toteuttamisen olevan ristiriidassa opiskelijoiden koulumenestyksen tukemisen kanssa, kun he odottivat tiukempien kurinpitokeinojen olevan tehottomia ja aiheuttavan vakavampia ongelmia tai kun he eivät kokeneet saavansa tukea nuorten tupakointiin keskeisesti vaikuttavilta sidosryhmiltä, kuten vanhemmilta. Pohjoismaiden vertailu osoitti, että WHO FCTC sekä tupakkatuotteita, verotusta ja mainontaa koskevat Euroopan unionin (EU) direktiivit ovat yhdenmukaistaneet tupakkapoliittisten toimien implementointia eri maissa. Niillä on varmistettu, että keskeiset ehkäisevät toimet, kuten sisätilojen tupakointikiellot ja 18 vuoden ostoikäraja, on sisällytetty kansalliseen lainsäädäntöön. WHO FCTC ja EU-direktiivit selittivät kuitenkin myös eri maiden yhteisiä lainsäädännöllisiä heikkouksia, jotka näkyivät erityisesti savuttomien ja uusien tupakka- ja nikotiinituotteiden vaihtelevassa ja puutteellisessa sääntelyssä. Kansalliset tupakkapoliittiset toimijat, kuten terveysministeriö ja kansanterveysjärjestöt, ja näiden välinen yhteistyö olivat keskeisiä syitä kattavaan ennaltaehkäisevien tupakkapoliittisten toimien implementointiin. Nämä toimijat ovat myös mahdollistaneet sen, että useat Pohjoismaat ovat ottaneet käyttöön edistyksellisiä tupakkapoliittisia toimia jopa maailman ensimmäisten maiden joukossa. Tällaisia toimia olivat esimerkiksi sähkösavukkeiden makuainekiellot Suomessa ja kattavat ulkoalueiden tupakointikiellot Ruotsissa. Neljän artikkelin tulokset yhdistävä ohjelmateoria havainnollistaa, miten kontekstitekijät ovat vuorovaikutuksessa tupakkapoliittisten toimien kanssa ja näin vaikuttavat kansalliseen ja koulutason toimeenpanoon tiettyjen mekanismien kautta. Nämä kausaaliprosessit auttavat ymmärtämään, miten toimeenpanoa voitaisiin tukea kontekstitekijöitä vahvistamalla. Suosituksissa korostuu se, että toimijoiden välisen yhteistyön vahvistaminen on tärkeää eri toimeenpanotasoilla ja niiden välillä niin kansallisesti kuin kansainvälisesti. Yhteistyön vahvistaminen voi auttaa ratkaisemaan nykyisiä toimeenpanohaasteita, edistää kattavampien tupakkapoliittisten toimien implementointia ja tukea sellaisten keinojen löytämistä, joiden avulla eri toimeenpanotasot voisivat parhaalla mahdollisella tavalla tukea toinen toisiaan yhteisten tavoitteiden saavuttamiseksi: nuorten tupakka- ja nikotiinituotteiden käytön vähentämiseksi ja tupakkaepidemian lopettamiseksi.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

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.</p

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

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E-cigarette use in global digital youth culture : A qualitative study of the social practices and meaning of vaping among 15–20-year-olds in Denmark, Finland, and Norway

Background: The introduction of e-cigarettes on the tobacco market has brought new regulatory challenges, and particular concerns relate to e-cigarette uptake among young people. The aim of this study was to explore the use and social meaning of e-cigarettes among Nordic young people and to discuss this in the context of current legislation. Methods: Thirteen focus groups were conducted with 46 Danish, Finnish, and Norwegian young people (24 boys) with vaping experience aged 15–20 years (mean age 17 years). Results: Young people's vaping stood out as an inherently social practice that was commonly interlinked with experimental use patterns. Relative to smoking, vaping was seen as socially acceptable and less harmful to health. Product innovations like flavour additives and nicotine-free liquid options added to perceptions of low harm, and innovative device design features facilitated new and playful user practices. Finally, digital markets eased the young people's access to e-cigarettes, and the digital world also represented an arena for e-cigarette exposure and self-presentation. They commonly viewed vaping-related content in their social media feeds and also produced such content themselves. Conclusion: Young people's vaping is a social practice interwoven in contemporary digital and global youth culture. Transnational regulations are needed to support individual countries in preventing e-cigarette use and exposure among young people.publishedVersionPeer reviewe

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

Understanding school staff members' enforcement of school tobacco policies to achieve tobacco-free school: A realist review

Background: School tobacco policies (STPs) that aim to achieve a tobacco-free environment require consistent enforcement by school staff. However, little is known about why staff choose whether or not to enforce STPs. Therefore, we investigated staff members' responses to STPs that determine enforcement. Furthermore, we examined how these responses depend on contextual factors at the individual, interpersonal, school, implementation, and national levels. Methods: We performed a realist review (RR), which synthesizes existing primary evidence into a programme theory demonstrating key causal pathways through Context-Mechanism-Outcome configurations (CMOs). These CMOs link contextual factors to outcomes (i.e. staff enforcement) by explaining the underlying generative mechanisms (i.e. staff members' cognitive, psychosocial, and behavioural responses). A systematic literature search for the period 2000-2016 was performed using Academic Search Premier, PsycInfo, and MEDLINE. Forty English-language articles were identified for the synthesis. Results: Our programme theory demonstrated three CMOs: when contextual factors make staff members experience STP enforcement as part of their professional role and duties, it may lead to staff members showing responsibility for STP enforcement (CMO1); when contextual factors make staff members feel their contribution is leading to positive outcomes, it may lead to staff members showing motivation to enforce STPs (CMO2), and when contextual factors make staff members feel that they are able to deal with students' responses, it may lead to staff members showing confidence in STP enforcement (CMO3). Moreover, the programme theory provided more precise insights into what contextual factors contribute to triggering the individual mechanisms and the consequent outcomes. Conclusions: By applying a realist approach, we have been able to detect three CMOs explaining staff members' STP enforcement. The findings provide useful insights explaining how stakeholders can support staff members' STP enforcement and consequently improve the impact of STPs on adolescent smoking

Adolescents notice fewer tobacco displays after implementation of the point-of-sale tobacco display ban in Finland

Introduction Finland implemented a point-of-sale (POS) display ban for tobacco products and their trademarks in 2012, and for electronic cigarettes in 2016. In this study we examine whether noticing tobacco products changed among adolescents after the implementation of the display ban and describe the noticing of e-cigarette displays post-implementation. Methods Repeated cross-sectional national survey data of 12- to 16-year-olds from years 2011, 2013, 2015 and 2017 were used. Measures included adolescent self-report on noticing displays of tobacco and e-cigarettes in shops, kiosks and service stations. Adjusting for age, gender, smoking and academic achievement, logistic regression analyses were conducted by retailer type to test the association between survey year and noticing POS tobacco displays. Results The proportions of adolescents noticing tobacco displayed in shops, kiosks and service stations decreased from 2011 to 2013 (from over 80% to about 30%). Between 2013 and 2017, exposure to tobacco displays decreased for kiosks but slightly increased for shops and service stations. However, in all retailer types, rates in 2017 were still well below the pre-ban levels of 2011. In 2017, noticing e-cigarette displays by 12- to16-year-old adolescents was reported by 5.6% in shops, 20.5% in kiosks and 5.1% in service stations. Conclusions The pronounced decline in adolescents’ exposure to tobacco products at POS observed in the current study implies adherence to the ban, as intended by the law. We encourage more countries to enact POS tobacco advertising and display bans, and to enforce the POS regulations to all tobacco products and novel nicotine delivery systems