198 European Journal of Public Health, Vol.
27, Supplement 3, 2017
Results
The program theory showed that STPs may trigger four
mechanisms and seven associated countervailing-mechanisms.
Adolescents’ smoking decreases if STPs make them feel they
can get sanctioned, feel less pressure to conform to smokers,
internalize anti-smoking beliefs, and find it easier to stick to
the decision not to smoke. This positive impact may reduce,
nullify or revert if the implementation of STPs causes
adolescents to find alternative places to smoke, develop new
social meanings of smoking, want to belong in smoker groups,
internalize beliefs that smoking is not bad or that it asserts
personal autonomy, or alienate from schools and schools’
messages. The program theory moreover indicated how
elements of STPs implementation trigger mechanisms and
avoid countervailing-mechanisms.
Conclusions
STPs’ impact can be influenced by adequate implementation
and embedding them in continuous monitoring and adapta-
tion cycles, so that schools can proactively deal with the
responses that lead to suboptimal or adverse outcomes.
What works and how in the implementation of
school tobacco policies: A realist review
Anu Linnansaari
A Linnansaari
University of Tampere, Tampere, Finland
Contact: anu.linnansaari@uta.fi
Background
School staff plays a key role in school tobacco policies (STPs)
implementation, but there is a lack of knowledge on what
factors influence staff members’ commitment to the implemen-
tation. We explored how different implementation activities
(e.g. law, school practices) trigger staff members’ cognitive and
behavioral responses (inner mechanisms), which influence their
commitment to the implementation (outcome).
Methods
We performed a realist review (RR) which synthesizes evidence
into a program theory. The program theory links implementa-
tion activities to outcomes by explaining the underlying
mechanisms. The RR consisted of two phases: 1) we iteratively
synthesized an initial program theory 2) the initial program
theory was refined in response to the literature. The systematic
literature search was conducted in multiple databases and 40
articles were identified for inclusion.
Results
Our program theory identified ten inner mechanisms that
explain how staff members responded to the implementation
activities leading to their commitment to STPs implementa-
tion. Implementation activities, such as reinforcing positive
outcome expectations (e.g., demonstrating the effectiveness of
the policy) and diminishing negative ones (e.g., concerns
causing resistance) trigger staff members’ support for the
policy. Furthermore, several factors such as school conditions
(e.g., location and environment) and individual characteristics
(e.g., staff members’ smoking status) may influence the
engendering of the mechanisms.
Conclusions
Staff members’ commitment to the implementation process
can be influenced by different implementation activities and by
taking into account contextual factors, which may hinder or
facilitate the mechanisms. Our program theory enables us to
explain and understand the conditions and mechanisms of
successful STPs implementation
School staff experiences on implementing school
tobacco policies: an interview study
Anu Linnansaari
A Linnansaari
University of Tampere, Tampere, Finland
Contact: anu.linnansaari@uta.fi
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Background
Little research exists on implementation of school tobacco
policies (STPs) and on factors that facilitate and hinder
effective implementation. We studied here school staff
members’ experiences on how contextual factors (national,
local, school) influence the implementation of STPs in their
school.
Methods
We present a preliminary analysis from the seven-country
study SILNE-R concerning Finland and Portugal. Semi-
structured school staff interviews were performed in Finland
(N = 12) and Portugal (N = 9) in 2016-2017. Our initial results
are based on an inductive thematic analysis.
Results
In both countries, school staff assessed that smoking bans outside
school (bars, workplaces) facilitated STPs implementation and
that enforcement was their official duty. The law was obeyed in
both countries, but enforcement practices and smoking visibility
varied between the countries. In Finland, students were not
allowed to leave school premises during school day, while in
Portugal, rules varied between schools and within schools
between students in basic and secondary education. If students
were allowed to leave school premises, students’ smoking took
place right outside school premises, where school staff had
neither authority nor responsibility to step in. In both countries,
most teachers considered themselves role models. In Portugal,
some teachers smoked during school hours even with students.
In Finland, teachers did not smoke visibly but other staff
members occasionally did. In Portugal, tobacco education
practices varied and were usually carried out in health programs
and during Non-Smoker Day celebrations, while in Finland,
tobacco education was part of health education, an independent
subject directed by the national curriculum.
Conclusions
STP law is a backbone of smoke-free schools. Our preliminary
analysis showed large differences in school staff experiences on
implementation practices.
The evolution of school tobacco policies and smoking
on school premises
Nora Mélard
N Mélard
IRSS, Brussels, Belgium
Contact: nora.melard@uclouvain.be
Background
The effectiveness of school tobacco policies (STPs) on
decreasing adolescents smoking remains a controversial
topic. For instance, in 2013 a comparison between 50 schools
in six European countries showed that stronger STPs did not
lead to lower smoking rates, although it reduced smoking on
school premises. The effectiveness of such policies may depend
on different factors driving their implementation: comprehen-
siveness, components, and enforcement. The aim of the
present research is to look at the evolution of STPs at the
school-level to see how these different factors have changed
over time and to analyze their effect on adolescents daily
smoking.
Methods
A longitudinal study was carried out in 2013 and in 2016 in 60
schools from seven European countries. A questionnaire was
completed by 12,000 adolescents from 3rd and 4th grades and
another one by school staff members. Chi-square tests of
independence were performed to examine the evolution of
STPs and their impact on adolescents smoking. We report here
preliminary results from Belgium.
Results
Less students have tried smoking over time (57% in 2013 and
47.7% in 2016). However, as it was already the case in 2013, one
out of seven smokers reported smoking on school premises.
Accordingly, students reported seeing as many students smoking
on school premises than before. On the contrary, teachers were
less often seen smoking (56.3% in 2013 against 28.6% in 2016, p

< .05). Smoking just outside school increased over the years
(47.2% in 2013, 53.5% in 2016). In 2016, still 58 percent of
students thought that STPs were not strictly enforced.
Conclusions
Adolescent smoking has reduced over the years. Yet, smoking
on school premises did not evolve. This might be explained by
the insufficient implementation of STPs. Smoking around
school premises remains an issue.
School tobacco policies, complex contagion and
smoking inequalities among adolescents: a
longitudinal study in seven European cities
Pierre-Olivier Robert
P-O Robert
University of Health and Society, Brussels, Belgium
Contact: pierre-olivier.robert@uclouvain.be
Background
While schools are urged to enforce school tobacco policies
(STPs), spreading of smoking becomes more complex, riskier,
difficult to observe and illegitimate. Instead of decreasing
smoking prevalence, STPs may just make smoking more
complex and more unequal across academic performances.
Our aim is to assess whether smoking complexity has increased
over time and whether socio-economic inequalities in smoking
increased as well.
Methods
This research was based on the SILNE-R longitudinal study
conducted in seven European countries. Data on 60 schools
7.F. Workshop: Out-of-pocket costs in Europe and
their effects on health-care use
Chair: Judith de Jong, Netherlands
Organised by: EUPHA (HSR), Observatory
Contact: j.dejong@nivel.nl
Over the past decades, health care expenditures increased in
most OECD countries and are expected to increase even more.
A wide ranges of policies are implemented to try to limit this
development. Several governments (e.g. of Denmark, Estonia,
France, Greece, Ireland, Romania, Russian Federation,
Switzerland, and Turkey) increased or introduced patient
cost-sharing. Patient cost-sharing can take several direct and
indirect forms such as out-of-pocket costs and coverage
exclusions, ranging from full third-party payment (zero cost-
sharing) to full user charges (costs met completely by out-of-
pocket payments).
Macro effects of cost sharing on health care expenditures
generally prove to be limited. Nevertheless, there are indica-
tions that patient cost-sharing may lead to inequalities in
health status between groups and may have unintended effects
on the process and outcomes of therapy.
This workshop is aimed at giving an overview of the current
state of out-of-pocket costs in Europe. In particular, the
workshop will go through: a) out-of-pocket costs in different
European countries; b) Case study: potential effects of OOP on
compliance to specialty referrals in The Netherlands. The
workshop will end with a general discussion on cost sharing.
Key messages:
 The more countries spent on OOP the lower the growth rate
 In the Netherlands, noncompliance to specialty referrals
increased during the years in which OOP increased.
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10th European Public Health Conference: Parallel sessions 199
and 12,000 adolescents were collected in 2013 and 2016.
Smoking and academic performance were reported.
Complexity of smoking was measured using the five criteria
of DiMaggio and Garip: complexity, risk, observability,
legitimacy and sustainability without social support. The
association between smoking and school performance was
controlled for confounders.
Results
Between 2013 and 2016, smoking has not become more
observable on school premises by non-smokers. However,
smoking increased with observability of smoking among
students (OR: 4.21, 95%CI: 1.96-9.05) and among teachers
(OR: 1.73, 95%CI: 1.01-2.97), with smoking legitimacy in the
family (OR: 4.98, 95%CI: 2.21-11.20) and with more friends
smoking (OR: 7.32, 95%CI: 4.28-12.53). The association
between low academic performance and smoking remains
significant but the number of low performers who smoke
decreased between 2013 (66.8%) and 2016 (57.5%). Complex
contagion mediated part of this association.
Conclusions
The spreading of smoking has not become more complex
throughout the years. STPs do not decrease observability of
smoking on school premises. However, the observability and
the legitimacy among friends and family reinforce the
association between low academic performance and smoking.
School environment and the immediate network, i.e. family
and close friends, contribute to socio-economic inequalities in
smoking in young people.
Revisiting OOP Requirements: Trends in Spending,
Burden, and Policy
Ewout Van Ginneken
E Van Ginneken
Technical University/Observatory, Berlin, Germany
Contact: ewout.vanginneken@tu-berlin.de
Background
While all countries rely on out-of-pocket costs (OOP) to help
fund their health care systems, there is little recent, systematic
information on how OOPs are changing.
Methods
This study examines trends in 10 high-income countries
between 2000 and present: Australia, Canada, France,
Germany, the Netherlands, Norway, Sweden, Switzerland, the
UK, and the US. Most data sources are from these countries,
but the study also employs aggregate longitudinal spending
data from the OECD, and longitudinal data on the perceived
barriers of OOP from surveys conducted by the
Commonwealth Fund.
Results
Based on analysis of the data, the countries are divided into
three groups: (1) historically low OOP, higher recent growth;
(2) Historically moderate OOP, lower recent growth; and (3)
historically high OOP cost, low to no growth in recent years.
In-depth tables detailing the different types of OOP and
protection mechanisms in each of the countries, and changes
in policies related to OOP in the countries will be shown.
Conclusions
Generally speaking, the more countries spent on OOP the lower
the growth rate. This points to a converging of spending between
countries. Second, nearly all countries have tried to ensure that
those who are most vulnerable, either or both in terms of income