The role of deans in implementing smoke-free campus policies: the case of medical schools in France.

Background: Smoke-free campus (SFC) policies prohibit smoking and vaping on all university grounds and for all users. The literature on SFC shows that these policies reduce exposure to secondhand smoke and increase smoking cessation. Engagement from high-level leaders has been proven to be a key determinant in the SFC implementation process, but their attitudes toward SFC has rarely been investigated, and only in the USA. The aim of this research is to analyze deans' perceptions of SFC in medical schools in France, where smoking prevalence remains high despite broad awareness of the harms of tobacco.

Methods: We used semi-structured interviews to explore medical school deans' perceptions of SFC implementation in France. Between October 2022 and January 2024, we interviewed 31 deans and two associate-deans, representing 31 out of the 35 medical schools in mainland France. Interviews were transcribed and the results were thematically analyzed using Nvivo 14, mobilizing the "individuals domain" from the updated Consolidated Framework for Implementation Research.

Results: One school had a SFC policy, 6 were in the SFC implementation process, 23 had no SFC policy, and 1 had abandoned it. A majority of deans were unaware that a SFC goes beyond a smoking ban. However, 28 deans held a net-positive perception of SFC, arguing that it is a coherent multi-modal intervention and is effective in reducing smoking. However, SFC were also perceived as stigmatizing smokers and displacing the problem rather than solving it. Perceived barriers to SFC implementation were competing priorities, lack of funding, and opposition from smokers. Perceived facilitators of SFC implementation were access to existing resources, support from medical students, and natural legitimacy of medical schools. Deans felt they had a leadership role to play in initiating, promoting, and enforcing the SFC policy.

Conclusions: SFC are poorly developed in medical schools in France, mostly because medical school deans prioritize other issues over smoking prevention and are under-aware of the benefits of SFC policy. However, they hold a net-positive opinion on SFC policy and express a willingness to implement it. We provide a set of practical strategies to help remove the main barriers to SFC implementation.