Background: Since most tobacco users become addicted to nicotine as teenagers, prevention efforts for youth remain central to comprehensive prevention programs. National and state efforts that encourage adoption and enforcement of comprehensive tobacco-free school (TFS) policies can lead to significant reductions of youth tobacco use. In 2003, North Carolina (NC) Health and Wellness Trust Fund grantees began to focus statewide on the adoption of and compliance with TFS policies in NC schools. This study examined 46 NC districts that passed TFS policies between 2003 and early August of 2005 to see what factors were important in policy passage in order to support the continued promotion of TFS policy adoption across the state. Methods: Detailed interviews were conducted with 118 key informants who were intimately involved with passage of their school districts' TFS policies, and results were coded and analyzed for common themes. Results: The study found several strategies key to adoption of TFS policies: effective leadership from organizations and individuals in positions of influence, grassroots organizing from community coalitions and youth groups, and communication strategies that optimally position policy adoption and compliance. Conclusion: States that have not yet achieved TFS policy adoption can focus on leadership development, grassroots organizing, and improved communication to advance their advocacy efforts. (Contains 2 tables and 1 figure.)