Background:
Schools have been key settings for health education for over a century¹. Tobacco use is the leading cause of preventable death in Europe and smoking typically begins during adolescence. Therefore, the school setting is frequently used to provide tobacco-related health education, to educate about risks and to implement tobacco prevention and cessation programmes². Little is known about tobacco-related health education and how key school personnel understand and deliver it. This paper provides a cross-European analysis of tobacco-related health education, and policy recommendations for successful delivery.

Methods:
The SILNE-R study was carried out between 2016 and 2018 to evaluate the effectiveness of programmes and strategies to prevent youth smoking in Belgium, Italy, The Netherlands, Portugal, Finland, Ireland, and Germany, and to make policy recommendations. We used secondary data from SILNE-R, including a survey of 12979 students aged 14–16 years in 55 schools in 7 European cities. Content analysis³ of synthesized findings from 84 interviews among staff members of 28 schools was used to generate broad themes about tobacco-related health education, using an iterative, sequential process that involved organisation, immersion, and the generation of categories and themes through coding⁴.

Findings:
Five themes relating to formal tobacco-related health education and its delivery in schools were identified as having policy implications: multiple approaches to curriculum design and content; pedagogy and the need for instructional methods that are student-centred, supportive, dialogical, and age appropriate; the requirement for resources, including materials, personnel, and partnerships; the importance of leadership and whole-school approaches for successful implementation; and inadequacies in teacher education relating to tobacco-related health education.

Conclusion:
Recommendations are offered to support tobacco-control and educational policy-makers in developing, implementing, and supporting tobacco-related health education in schools to reduce and prevent youth smoking.