INTRODUCTION

Tobacco use is the single most preventable cause of premature death in the world¹. In India, more than a million people die every year due to tobacco consumption and about 5500 youth initiate the use of tobacco every day². Consumption of tobacco imposes enormous direct and indirect economic losses across States in India².

In addition, tobacco smoke also affects the health of non-smokers by exposure to second-hand smoke (SHS)^4–6. The ill effects of exposure to SHS are well established. SHS is also known to cause cancers, respiratory illnesses and heart disease. Globally, exposure to SHS causes 0.6 million deaths each year⁷. According to the Global Adult Tobacco-Survey for India, 52% of Indian adults are exposed to SHS at home and almost 26% at the workplace. In Karnataka, 44.3% of adults are exposed to SHS at home⁸.

Exposure to second-hand smoke (SHS) is a major risk factor for disease and disability among 93% of the world’s population who are still not covered by 100% smoke-free public health policies⁷. The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act (COTPA) was enacted in the Indian parliament in 2004⁹, to address the exposure to second-hand smoking, and to regulate tobacco advertising, promotion, sponsorship and sale of tobacco products to or by minors. There are 33 Sections in the Act. The provisions of Section 4 relate to prohibition of smoking in public places. Any place to which the public has access, whether as of a right or not, and includes auditorium, hospital buildings, railway waiting rooms, amusement centres, restaurants, public offices, court buildings, educational institutions, libraries, public conveyances and the like, which are visited by general public⁹, are defined as a public place by the COTPA Act. As per the provisions of the Act, hotel or accommodation facilities having 30 or more rooms, restaurants or eateries having a seating capacity of 30 persons or more, and airports, need to have a designated smoking-area.

Even though the Act came into effect in 2004, the focus on implementing the Act remained low. Evidence from formal assessments on the compliance to the smoke-free legislation in India, showed partial compliance to the smoke-free legislation in hospital buildings (37%), office buildings (26.7%), public places outside hospital buildings (14.3%) and residential areas (11.4%)^10,11.

In addition to compliance being an issue related to enforcement and political will, compliance to the smoke-free legislation is a behavioural issue. Success of compliance to the smoke-free legislation depends on the willingness of persons responsible for compliance (PRC) to comply with the Act, in addition to awareness among authorized officers (AO)⁹ responsible for the implementation of the Act. PRCs include heads of all government departments at State level, local bodies, including Panchayat Raj Institutions (Local self-government), and all those in-charge of public places, that provide access to public gatherings, such as bus stands, railway stations, markets, parks, religious places, monuments and such places. Within the private sector, PRCs include owners and managers of different public places (hotels, bars, restaurants, eateries, shops and markets), managers of malls and multiplexes, all private offices including private practices (clinics, nursing homes and hospitals). Authorised officers include police officers, health inspectors, excise officers, inspectors of factories and boilers who are government officers under jurisdiction for these public places. Understanding the challenges to comply with the Act, and identifying solutions that are feasible and pragmatic are needed to progress towards a smoke-free society. Compliance assessment is an effective means of measuring progress towards a smoke-free society¹⁰. Thus, we undertook a study to assess the compliance to the smoke-free legislation of the Cigarettes and Other Tobacco Products Act (COTPA), in various public places and to assess awareness among PRC and AO under the Act, in the jurisdiction of the South Zone of Bruhat Bengaluru Mahanagara Palike (BBMP) (Local self-government).

METHODS

We conducted a cross-sectional study between January to April 2015 among the public places licensed by the respective departments in the South Zone of Bruhat Bengaluru Mahanagara Palike (BBMP). All licensed public places, as defined by COTPA, within the South Zone BBMP formed the sampling frame. Sample size for the study was 362 public places from the finite list of 4507 public places in South Zone BBMP. Sample size was estimated assuming a compliance rate of 50% to Section 4 of COTPA, with power of 90%, absolute error 5%, and an assumed design effect of 1.4. Sample size was calculated using CDC-Epi Info Version 7 software¹³. A total of 91, 116, 78, 65 and 9 public places were selected for observation in clusters 1 to 5, respectively (table 1).

Data collection involved both observation of public places and looking for direct and indirect evidence of smoking. The number of public places to be observed in each category was determined using a proportionate-to-population size-technique. The final numbers were rounded off to the nearest higher whole number (Table 1). A final list of public places within each category was drawn using simple random sampling by computer-generated random numbers.

Since different public places operate at different times of the day, and smoking habits of people might vary depending on the time of the day, we performed time-location sampling to identify the time of observation for a particular public place. Time-location sampling is a recognized sampling method utilized when the variables to be studied are likely to vary at different points of time in a day¹².

Five different observation time-clusters were used in the study; Cluster 1: 9.00 - 11.59 am, Cluster 2: 12.00 noon – 2.59 pm, Cluster 3: 3.00 – 5.59 pm, Cluster 4: 6.00 – 8.59 pm, and Cluster 5: 9.00 - 11.00 pm. For each category of public place, the time-cluster for observation was randomly selected. Thus, each sampled public place was visited only during the randomly selected time-cluster (Table 1). If the public place was closed or had shifted, then the existing trade in those premises was observed. If there was none, a new public place was selected randomly from the sampling frame and observations were made during the same time-cluster.

Among the sampled public places, 35% were hotels, 25% were workplaces, 17% were educational institutions and 8.5% were hospitals (Table 2). Hospitals ranging from medical clinics, dental clinics, nursing homes, acupuncture clinics, Ayurveda hospital, eye hospital, 2 major governmental hospitals and 1 private hospital were observed. Three theaters and a mall constituted the remaining observed places. Two clinics and one private nursing home were outside the boundary of BBMP South Zone and hence excluded.

Data collection

Data collection had two parts; the observation of public places, and the interview of persons responsible for compliance (PRCs) in the respective public place and authoried officers (AOs) for awareness to the smoke-free legislation. The key item that was recorded during the observation visit was whether any smoking was observed in non-smoking areas. Additional information that serves as an indicator of non-compliance, for example, the presence of cigarette butts, ashtrays or matches, was also gathered. Public places were observed with the help of senior and junior health inspectors of BBMP.

Compliance to Section 4 of COTPA was assessed using the following criteria:

Data were collected by the investigators using Schedules 1, 2 and 3 adapted from the guide on ‘Assessing Compliance with Smoke-Free Laws’ developed jointly by the Campaign for Tobacco-Free Kids, Johns Hopkins Bloomberg School of Public Health and International Union against Tuberculosis and Lung Disease¹⁴. These Schedules have a standardized observational and interview data-collection format with items having yes/no options. These reflect the awareness about COTPA among PRC and AO, educated efforts made by them, acceptances or rejections, challenges or difficulties faced by them in implementing the Act, efforts and further course of actions adopted to implement the Act. It has items that reflect the key provisions of the law that were assessed. Schedule 1 is an interview cum observation Schedule for public places. Schedules 2 and 3 consist of questions for the PRCs and AOs of the COTPA Act, respectively. The investigators collected data between October and December 2014, after obtaining written informed consent from PRCs (Schedules 1 and 2) and AOs (Schedule 3). PRCs from all the sampled public places were interviewed using Schedule 2. All AOs coming under the jurisdiction of South Zone BBMP were interviewed using Schedule 3.

All data were entered on a password-protected excel worksheet. Descriptive statistics like frequencies for qualitative variables and proportions for quantitative variables were drawn from the observations and interviews done. Categorization of compliance of public places was done as: full compliance meaning all the above criteria were fulfilled (100%), no compliance meaning none of the above criteria was fulfilled (0%), and partial compliance meaning some of the criteria were fulfilled (0 to 100%).

Prior administrative approvals were obtained from appropriate authorities including the police and commissioner of BBMP. Ethical approval for the study was obtained by the Ethics Committee of the National Institute of Mental Health and Neuro Sciences (NIMHANS).

Findings

About one-third of the public places observed had partially complied with the provisions of COTPA Act (Table 3). A large proportion of them (70%) did not comply with any of the provisions of the Act (no signage; violations with respect to evidence of smoking during observation; cigarette butts, ashtrays etc. were seen). Full compliance was seen only in six (1.9%) public places.

There were about 65 public places that had to comply with having a designated smoking-area (DSA), but only 10 (15.3%) had DSA. Among the 4 designated smoking-rooms, 2 had their access closed to the non-smoking area and had a vent (data not shown). Compared to other public places, almost half of the eateries had ‘No Smoking’ signage. However, nearly half (46.8%) were not as per the Act (data not shown).

Most persons responsible for compliance (93.3%) were aware of the existence of the smoke-free law in public places (Table 4). They opined that the Act is to ban smoking in public places. Very few (16.4%) knew that the provisions included a penalty for those who violated the provisions of the law. A majority (84%) of the persons responsible for compliance undertook educational efforts, which included mostly oral warnings not to smoke (63.8%) and display of ‘No Smoking’ signboards (36.2%). Mostly, they received a positive response to their efforts (84.3%).

Every authorized officer among health and police were aware of the smoke-free Act (Table 5). Among the authorized police officers, the majority (96%) were aware that Section 4 of the COTPA Act involves a smoking ban in public places and that there is a penalty for offenders. All of them were aware that they were authorized to penalize offenders.

However, none of the authorized health officers was aware that they were authorized to penalize offenders. Two-thirds of the health officers and a large majority (92%) of police officers encountered difficulties while enforcing the Act. This includes passive resistance and arguments with the persons enforcing the Act. Nearly all the authorized officers undertook public awareness activities about the provisions of the Act.

DISCUSSION

This is the first population-based representative formal assessment of compliance to Section 4 of the Cigarettes and Other Tobacco Products (COTPA) Act 2008 in Bengaluru city. Full compliance was noted among a meager 2% of the public places. The majority of the public places in South Zone BBMP did not comply with Section 4 of the COTPA Act. The majority of persons responsible for compliance of COTPA in public places and all authorized officers were aware of the smoke-free law. Most of those who were aware made efforts to comply with the COTPA Act. Most efforts were educational in nature and about one-fifth reported encountering difficulties to implement the Act. One-third of public places had signage that partially complied with COTPA guidelines. A few public places, which were supposed to have designated smoking-areas, complied. Enforcement in terms of penalizing the offenders was done only by the police. Authorized health officers and persons responsible for compliance in public places were not aware of the provisions under the Act; that persons responsible for compliance of COTPA in public places can penalize the offenders. Our study shows that authorized officers and persons responsible for compliance encountered challenges in implementing the Act and in ensuring the area smoke-free.

Studies have concluded that Smoke-Free legislation is the most effective method for reducing exposure to second-hand smoke (SHS)^16–19. Comprehensive smoke-free air laws are effective in reducing indoor air pollution from second-hand tobacco smoke²⁰. Section 4 of the COTPA Act specifically deals with preventing second-hand smoke to non-smokers. The implementation of the Act is vital given the high attributable risk for any malignancies and other non-communicable diseases associated with smoking^21–24.

Our findings are similar with those of other studies on compliance assessment done in other cities of India²⁵. A study done in Chennai reported low compliance of smoke-free laws in restaurants, schools, and colleges²⁶. A study done in Himachal Pradesh reported that 42.8% of public places had signage, smoking was observed in 15.8% of public places, and in 16.3% of the public places there were smoking accessories such as ashtrays, matchboxes and lighters²⁵. Tobacco litter, like cigarette butts, was present in 35.3% of the public places. Our study also reported that awareness about the smoke-free Act among persons responsible for compliance was 93%, which is similar to the study done in Mohali, Punjab¹⁰. Most of the studies report compliance among restaurants, educational institutions and hospital buildings, by observation. In addition to observation of public places for signs of active smoking and smoking aids, we also interviewed persons responsible for compliance, as well as authorized officers to enforce COTPA in public places. This is an improvement from previous studies.

Improving on the methodology of previous studies, the present study is representative since we adopted time-location sampling, ensuring representativeness of both location and time. This allows adjustment for any diurnal variation in smoking habits and use of public places, if present. Our study also used the standardized checklist developed jointly by the Campaign for Tobacco-Free Kids, Johns Hopkins Bloomberg School of Public Health and International Union against Tuberculosis and Lung Disease utilizing the guide ‘Assessing compliance with smoke-free law’¹⁴, thus ensuring comparability with other studies.

CONCLUSIONS

Persons responsible for compliance in public places and authorized officers are the key to the success of implementing COTPA. In addition, effective implementation would help to reduce social acceptance, deter initiation and reduce consumption. Our study reports challenges faced in implementing the Act, especially among persons responsible for compliance in public places, similar to a study in China²⁴. Compliance is a behavioral issue and the first step towards compliance is making the PRCs aware of the Act.

Thus, awareness about the Act, importance of effective implementation on the health of people, awareness that even PRCs can penalize the offenders in public places, is likely to contribute to an increase in compliance and social acceptance. This will contribute to preventing the ill effects of SHS, thereby increasing health improvement, which is the main purpose of COTPA Section 4. Similar to our study, the protection from SHS exposure in restaurants, pubs and bars is reported to be very low in most countries^28,29. Our study results imply that stronger implementation of COTPA guidelines could be done using a multipronged approach. Constant efforts to create awareness regarding the public-health aspects of the smoke-free Act in public places are needed. Firstly, increasing awareness among persons responsible for compliance and authorized officers to ensure better compliance to the Act, and secondly by educating the public at large on the existence of the law and the health benefits to them and others. These would probably reduce the resistance faced by the persons responsible for compliance and authorized officers.

To achieve maximum gains, different strategies need to be adapted. A series of sensitization programs among authorized officers and persons responsible for compliance, and public-health campaigns to increase awareness of the public-health benefits of the Smoke-Free law, are more likely to smoothen enforcement, reduce resistance among stakeholders and eventually ensure compliance. Regular appraisals about the public-health aspects of the anti-smoking law might ensure compliance with the COPTA Act. Such an appraisal can be done if the current status of awareness, compliance, and enforcement is known. Our study reported the compliance levels in a cosmopolitan city like Bengaluru. Similar studies in rural areas will shed light on the rural aspects of compliance. We strongly recommend studies to be undertaken about other Sections of the COTPA that are of public-health importance (Sections 5 & 6), in rural and urban areas, to get a comprehensive assessment of compliance of the health-related Sections of the COTPA Act.