Compliance with smoke-free legislation and smoking behaviour: an observational field study in Karachi, Pakistan

Objective: To observe compliance with smoke-free law at different public places in an urban setting. Method: The cross-sectional study was conducted from January to June 2022 after approval from the ethics review board of Jinnah Sindh Medical University, Karachi, at public places, including public and private offices, health institutions, education institutions, malls, markets and eateries, in 5 districts of Karachi. Boundary, entrance, waiting areas/corridors, toilet areas and eating areas were assessed using a checklist for smoke-free law compliance. Places were considered compliant if no smoking activity, cigarette butt litter or ashtrays was found. Data was analysed using SPSS 21. Results: Out of 400 places observed, there were 80(20%) in each of the 5 districts. Overall, 36(44%) of the venues showed indoor compliance and 10(12%) showed outdoor compliance. Presence of cigarette butts was observed at 350(87.5%) outdoor places around the boundary of the premises. Only 38(9.5%) of the places had no smoking boards outdoors and at the entrance, with 16(4%) being clearly visible. Also, 27(43%) of educational institutions had a cigarette shop within 50 metres of the boundary. Conclusion: The city was found to have poor implementation of smoke-free laws, especially for outdoor areas, exposing the public to constant second-hand smoke.


Introduction
According to the World Health Organisation (WHO), tobacco is responsible for around 6 million deaths worldwide annually 1 .If not curbed, the habit of smoking may lead to 1 billion deaths in the 21st century 2 .Tobacco is consumed commonly in the form of smoking, which is not only harmful to the smoker but also has detrimental consequences, like cardiovascular effects, coronary heart disease, lung cancer, breast cancer and genitourinary cancer, for those inhaling it as second-hand smoke (SHS) 3,4 .Among children, exposure to SHS can cause sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, allergies, severe asthma, growth stunting and cognitive impairments 5,6 .It is estimated that around 880,000 people are killed by SHS annually worldwide 7 .
A strict ban on smoking tobacco with 100% compliance with smoke-free laws can fully protect the citizens from SHS in public 8 .The implementation of smoke-free laws not only reduces exposure, but also promotes reduced cigarette consumption, and encourages quitting 9 .Currently, 96 countries, including Pakistan, have implemented moderate to complete smoke-free policies in accordance with Article 8 of the WHO Framework Convention on Tobacco Control. 10 .
While developed countries are seeing a decline in smoking burden due to strict laws, the burden is consistently increasing in developing countries.Research conducted in Europe, the United States and the United Kingdom shows a decrease of at least 15-22% in environmental tobacco smoke after enforcement of smoke-free policies 11 .Compliance with the laws in developed countries ranges from 75% to 95% 12 .While many low-and middle-income countries (LMICs) have implemented smoke-free laws, most still face challenges with implementation [13][14] .Implementing effective smokefree laws in LMICs presents distinct challenges.Limited awareness of smoking hazards and SHS's risks, coupled with deeply ingrained cultural norms, can impede policy support and adherence.Scarce resources hinder enforcement efforts, impacting the hiring of inspectors and monitoring systems.Additionally, the tobacco industry's influence on policy-making poses a significant obstacle.The prevalence of informal economies further complicates regulation implementation.Weak regulatory frameworks can undermine the efficacy of smoke-free laws 15 .
APPNA Institute of Public Health, Jinnah Sindh Medical University, Karachi, Pakistan.Correspondence: Hira Tariq.Email: hiratariq14@hotmail.com ORCID ID. 0000-0002-2841-2600 Submission complete: 13-02-2023 Review began: 21-03-2023 Acceptance: 28-10-2023  Review end: 27-09-2023 Pakistan has been facing a consistent increase in smoking burden over the last 2 decades 16 .In Pakistan, tobacco consumption is responsible for around 200,000 deaths annually 17 .In 2002, Pakistan became a signatory to WHO framework, and passed an ordinance for the prohibition of smoking in enclosed spaces 18 .The current study was planned to observe compliance with smoke-free law at different public places in a local urban setting.

Methods
The The sample size was calculated using OpenEpi software (20) with expected compliance with smoke-free laws 50%, confidence level 95% and bound on error of 5%.
Boundary, entrance, waiting areas/corridors, and toilet areas and eating areas were assessed using a checklist for smoke-free law compliance.The checklist had 4 items: number of people present and the number of people seen smoking, the presence or absence of cigarette butts, cigarette packets and ashtray, the presence or absence of no-smoking signs, and their level of visibility, and in the case an educational institution, the presence or absence of any shop selling cigarettes or any other smoking substance or any other tobacco product within 50 metres of the premises.
A place was considered compliant if no one was observed smoking, no cigarette butt litter was found, and no smoking aids, like ash trays, were present.
University students who volunteered for the study were trained as data collectors.Each study site was visited during regular working hours.There were 3 data collectors for each district, covering 4-6 places daily.Random checks by the principal investigator were done to ensure the quality of data collection.The districts were first studied through Google Maps, and places meeting the criteria were shortlisted along with peak operational time for such places.Shopping Malls, markets and eateries were covered mostly during lunch hours, evening and night to observe smoking behaviours during busy hours.Hospitals were observed during peak outpatient department (OPD) times and visiting hours.For universities and colleges, real-time data was collected during study breaks by the volunteer students.Private and public offices were observed during operational hours.Observations were made at a particular location ranging from 20 minutes for most locations till a maximum of 1 hour.Data was collected on printed checklists that were later submitted to the principal investigator.All the variables were categorised as yes/no.
A venue was considered compliant if no one was observed smoking, no cigarette butt litter was found, and no smoking aids, like ash trays, were present.
Data was analysed using SPSS 21, and was presented as frequencies and percentages.Occurrence of compliance indoors and outdoors was compared between different sites and types of places using chi-square test.P<0.05 was considered significant.
The trend for compliance indoors and outdoors was similar across all districts and the difference was statistically non-significant (p>0.05).Among the types of places, shopping malls had the worst compliance both indoors and outdoors (p<0.001)(Table 2).

Discussion
The study highlighted a significant lack of adherence to smoke-free regulations across Karachi.When examining indoor compliance using a composite indicator, an average compliance rate of 44% was noted, while outdoor compliance fared even worse at 12%.A recent study in Karachi found an average compliance rate of 56%, slightly better likely due to the study's smaller scale 21 .Notably, the compliance rates did not show significant variation across different districts, indicating an overall poor adherence.This issue is compounded by the high presence of cigarette-associated litter across all districts, a common phenomenon in densely populated cities, with Karachi being the third most populous city globally.This correlation between population density and cigarette litter has also been confirmed in studies conducted in other urban areas, such as a coastal city in Iran 22 .
The current study revealed that compliance with smoke-free regulations was notably low in shopping malls and eateries.Despite "no smoking" signs being displayed in 45% of eateries and 59% of malls and markets, these establishments exhibited the worst adherence to smoke-free laws, both indoors and outdoors, along with a high incidence of active smoking near their boundaries and entrances.The observation aligns with findings from various studies conducted across different regions, including Indonesia, South India, Nepal and Turkey 13,[22][23][24][25][26] .
In contrast, public and private offices demonstrated the highest compliance rates for indoor composite indicators at 66.7% in the current study.Similar observations were reported from Nepal, where 75% of public offices complied with smoke-free policies 24 .This discrepancy could be attributed to better surveillance and enforcement mechanisms in formal office settings.
Analysing educational institutions and health facilities, the current study found indoor compliance rates of 50% and 59.4%, respectively.These figures differ from a previous study in Karachi which reported much higher compliance rates of 89% for health facilities and 70% for educational institutions.The differences in findings could potentially be attributed to the current study's inclusion of three additional districts beyond the South and East regions covered in the earlier research 21 .In Chandigarh, India, compliance within health institutions was as low as 37% 24 .Notably, 43% of educational institutions in the current study were located within 50 meters of cigarette selling facilities, contravening legal prohibitions.This parallels the findings of a study in Karachi, which revealed that 94% of universities had easy access to cigarette vendors within 500 meters of their entrances 18 .The presence of no smoking signage remained scarce overall, consistent with the outcomes of two other studies in Karachi 18,21 .
Interestingly, the current study demonstrated a higher level of compliance indoors compared to outdoors.Qualitative studies have repeatedly shown that smokers tend to prefer outdoor smoking spaces [27][28] .This observation helps explain the discrepancy between the number of smokers observed and the prevalence of cigarette butts in the current data.This trend was apparent across most types of locations, except for eateries where individuals were typically directed to designated outdoor smoking areas.Notably, the most robust indoor compliance was observed in public and private offices, likely due to vigilant monitoring by security personnel and staff members.
The current study has a few limitations.Data collection was difficult, particularly for West and Korangi districts, due to security issues because of which some locations were not observed for the designated 20 minutes.
Security guards for banks and some educational institutions did not allow the data collectors for the required time as well, and, therefore, the volunteers were asked to just observe, and then to fill the forms later while being in a safe spot.This could have led to recall bias.Some office complexes did not allow for observation indoors, and in such cases, the data collectors had to rely on information provided by their employees who were approached during their smoking break outside.Similar difficulty was observed for educational institutions.
Besides, the study employed convenience sampling technique, and that could have also introduced selection bias.
Despite the limitations, however, the current study offers significant insights into the compliance levels of 400 public venues with smoke-free regulations.Comprehensive surveillance needs to be applied to all public establishments to ensure rigorous enforcement of the relevant laws.It is equally imperative to provide training and education to staff members regarding smoke-free legislations.Additionally, it is crucial to prominently display awareness messages outlining the detrimental consequences of smoking and exposure to SSH at all public venues.

Conclusion
Karachi overall was found to have poor compliance with smoke-free laws, especially outdoors.Government and stakeholders need to realise the deadly impact of SSH exposure.With strict surveillance and enforcement, Pakistan can reach its goal of reducing tobacco use by 30% in 2025.

Table - 2
: Comparison with composite compliance indicator in indoor and outdoor environments between districts and types of place.