Chapter 5 220 Discussion Between 2018 and 2022 repeated cross-sectional surveys among 5582 participants showed increasing or stable high levels of support for novel smokefree policies in the Netherlands. While support was highest among non- and ex-smokers, it was 50% or higher among smokers for all places except outdoor leisure areas. In the general population support was 50% or higher for all smokefree places. Regardless of smoking status, support was high for policies in places where children frequent, in particular for smoke-free cars when children are present. Our findings indicate high levels of support for extending smoke-free policies in the Netherlands, particularly in places where children often go. This corresponds with the smoke-free generation approach which has now become clearly embedded in Dutch society and national policy-making.17 In line with this, support for smoke-free school grounds for example is higher as the age of the children that the educational institutions serve becomes lower: support is far over 90% for elementary schools while for higher education it is slightly below 80%. The patterns and levels of support in our study correspond to support levels found in a recent systematic review and meta-analysis of over 100 studies from 33 countries, especially the high levels of support for smoke-free places where children often go,9 especially the high levels of support for smoke-free places where children often go. In line with findings from similar studies in other countries,9 support for novel smoke-free policies in the Netherlands also lagged behind in certain population subgroups, including people who smoke and those with low SES. And although support in these groups did not catch up over time, it was generally still quite high. Despites high levels of support the number of smoke-free policies beyond enclosed public places and workplaces is low in the Netherlands. Potential reasons might be lower belief in the effectiveness of smoke-free zones in these areas or challenges related to enforcement. Regarding implementation of smoke-free policies in outdoor areas an often heard counter argument is the rationale that in well ventilated areas the possible health gains are limited. SHS exposure in wellventilated places is however not insignificant, especially in outdoor places next to enclosed places with a smoking ban such as offices or hospitals.22, 23 Enforcement in these large open areas or in private areas indeed may be challenging, however high levels of support can be an indicator of a norm change where smoking
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