Compliance of Public Places in Bangalore to Anti-Smoking Laws - A CrossSectional Study

Introduction

Killing more than eight million people per year, tobacco stands as one of the greatest public health threats mankind has faced. Out of the eight million, seven million are due to direct tobacco use, while 1.2 million are due to second-hand exposure. Of the 1.3 billion users of tobacco, more than 80% live in low and middle income countries, and the burden of tobacco related illness and death is heaviest in these countries.¹

According to GATS 2016-17, 267 million adults in India, that is 29% of all adults are tobacco users. Every fourth adult who works indoors is exposed to secondhand smoke.²Second hand smoke has resulted in 1.2 million premature deaths per year. Majority of children regularly breathe polluted air filled with tobacco smoke in public places and 65000 die from illness attributed to tobacco smoke.¹

The Framework Convention on Tobacco Control (FCTC) 2003, mandates governments of all nations to take specific steps to reduce tobacco use. Article 8 of the FCTC binds governments to protect their citizens from exposure to tobacco smoke and requires them to adopt and implement effective legislative, executive, administrative and/or other measures for this purpose³ In 2003, the Government of India enacted comprehensive legislation for tobacco control called the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act (hereafter referred to as COTPA). Section 4 of COTPA prohibits smoking in public places, public transport, workplaces, and all places where public have access.⁴

Mere enactment of legislation is not enough to stop smoking in public places and it requires strong enforcement to ensure compliance to the law by the public. It is also necessary to regularly measure compliance to the law to monitor progress as well as inform and guide enforcement.³

As per WHO Global Adult Tobacco Survey 2016-17, 22.8% of adults (15 years and above) in Karnataka currently use tobacco products in some or other forms. Overall, smokeless tobacco use is 16.3% and smoking tobacco prevalence is 8.8%. The exposure to secondhand smoke is 23.9% in public places in the state.⁵

As per COTPA, smoking is not allowed in any public place. Any hotel, bar and restaurant having more than 30 rooms/ seats should provide a designated smoking area to allow smoking. This designated smoking area must comply with certain provisions such as: 1. In case of single floor facility, it has to be in a separate room in the same floor and it should not be at the entrance or exit of the facility. 2. DSA must be separated and surrounded by full height walls on all four sides 3. It should have an entrance with an automatically closing door normally kept in close position. 4. Smoke to be ventilated outside without permeating to non-smoking areas, including lobbies and corridors. 5. Marked as smoking area in English and regional language. 6. No cigarette, ashtrays, matches, lighters, or other things designed to facilitate smoking. 7. No other service should be provided in the smoking room.⁴

Though COTPA mentions these rules, many of the restaurants/hotels are violating these, putting nonsmokers at greater risk by exposing them to second-hand smoke. Therefore, this study was conducted to assess the compliance of DSA to the COTPA rules.

Materials and Methods

A cross-sectional study was conducted from July 2021 to August 2021 in two selected areas in Bangalore – Jayanagara and Indiranagara. These two areas were selected keeping in mind the density of population and public places in Bangalore, as a greater number of required sampling units were consolidated in these two zones. For the purpose of study, all the potential public places in each zone were divided into four categories:

1. Bar

2. Restaurant

3. Club/Pub

4. Hookah Bar

Bangalore consists of several administrative blocks. For this study, each administrative block was considered a cluster. The research team estimated that in each cluster, total number of public places vary from 1000 to 10000. Hence, the total sample size varies at a confidence level of 95% on a compliance rate of 70% using openepi software http://www.openepi.com/v37/Menu/OE_Menu.htm. Keeping in mind the density of population and public places in Bangalore, two clusters were selected for the sample. Since, we used the cluster sampling, the design effect of 1.1 was considered in the survey (Table 1).

After getting the required number of sampling units (Bar, Restaurant, Club/Pub, Hookah Bar), the field investigator was instructed to observe each of the selected units by the transect walk method. Each field investigator identified a fixed central point in each zone and followed a survey pathway - Observing compliance to DSA and filling the applicable checklist through mobile application. This process was continued until the recommended number was obtained. The data was collated, triangulated, entered, and analysed zone wise. Proportions was calculated for each domain of the checklist and results were expressed as mean, proportion and percentage.

Results

Among the surveyed facilities, 67.1% were restaurants followed by bars, hookah bars and clubs (Table 2). 83.9% of the surveyed areas were situated in commercial area and 16.1% were situated around the residential area (Table 3). No smoking signage was seen in 29.4% of the surveyed sites (Table 4). No smoking signage as per guidelines was seen in 10.5% of the surveyed facilities (Table 5). Presence of indoor smoking was observed in 29.4% of the facilities during the time of visit (Table 6). Cigarette smoking was the common indoor smoking observed in 85.7% of the surveyed facilities (Table 7). 73.4% of the surveyed sites had seating capacity of more than 30 (Table 8). 9.5% of the eligible facilities had DSA among the surveyed sites. 1.9 % of the facilities had NOC from BBMP during the time of survey (Table 9). 20% of the indoor DSA fulfilled recommended criteria for DSA (Table 10).

Discussion

The study revealed that majority of public places were not following the COTPA guidelines. In our study, only 29.4% of the sites displayed no smoking signage out of which only 10.5% were as per guidelines. While in a study conducted by Banandur P S et al in Bangalore, public places were compatible at 30.9%, out of which 6.5% completely complied with the guidelines.⁶ In our study, the presence of indoor smoking was observed in 29.4% of the facilities during the time of visit. While in the study conducted by Banandur P S et al., only 3.9% were found smoking.6 In the current survey of the eligible facilities, only 9.5% had DSA while in the study conducted by Banandur P S et al., 15.3% had DSA, and in a study conducted Williams A et al., in New Hampshire, 96.1% had DSA.^6,7

Conclusion and Recommendations

The survey was conducted in predominant commercial areas of Bangalore city with more specifically public places and densely populated areas. Study revealed that majority of the sites were not following COTPA recommended signages and guidelines, allowing indoor smoking. Compliance to DSA was observed in only 9.5% of the eligible facilities and among this only 20% followed recommended DSA criteria. Though the COTPA legislations were present since almost two decades, significant number of breaches in law were observed during survey and this study further emphasises on appropriate and necessary strict intervention from the local authorities at the earliest. Strict action against the facilities is required for repeated breach in rules even after repeated directives.

Acknowledgement

We would take this opportunity to acknowledge our deep sense of gratitude to the Director cum Dean and Principal of Bangalore Medical College & Research Institute, Bangalore for permitting us to take up this survey in the Bangalore, Karnataka. We would also like to thank the MAYA foundation for all the financial, technical support and co-operation for this survey.