Abstract
OBJECTIVE
In Türkiye, anti-tobacco legislation (Law No. 4207 on the Prevention and Control of Harms of Tobacco Products) aims to ensure a “tobacco-free” life for current and future generations. Thus, there are observations of violations in the hospitality sector. In this study, we aimed to observe the status of hospitality venues’ violation of the law in 11 different cities in Türkiye.
MATERIAL AND METHODS
This descriptive study examined 772 hospitality venues in Ankara, Burdur, Diyarbakır, Giresun, Hatay, İstanbul, İzmir, Kars, Kayseri, Samsun, and Zonguldak between August 1 and October 10, 2023. The Google Forms survey, Microsoft Excel, and IBM SPSS Statistics (Version 23) programs were used for data collection, entry, and analysis. A logistic regression model was used to understand the associations between non-compliance and the characteristics of the venues.
RESULTS
During the observation of indoor spaces, tobacco products were used in 282 venues (37.1%). Non-compliance in bars, pubs, traditional coffee houses, and hookah cafes was statistically significantly higher than in the other venue types [odds ratio (OR)= 3.031, 95% confidence interval (CI): 1.699 to 5.408, P < 0.001]. The presence of a retractable roof and/or side wall (OR=5.362, 95% CI: 3.518 to 8.173, p < 0.001), later hour observations (OR= 2.120, 95% CI: 1.399 to 3.212, p < 0.001), and the existence of outdoor venues where smoking is permitted (OR= 3.165, 95% CI: 2.170 to 4.617, p < 0.001) also increased indoor violations.
CONCLUSION
The findings provided scientific evidence that violations of Turkish anti-tobacco legislation exist in hospitality venues. The public authorities are advised to play their vital role in preventing violations in indoor spaces.
Main Points
• There is a violation of tobacco-free legislation in almost all countries.
• The results of the study emphasized strong evidence about the existence of violations in different types of hospitality sectors in various cities in Türkiye. The use of other tobacco products in the venues has been confirmed with this study.
• The public authority can take the message of the study and play its role in preventing violations in the hospitality sector, as there is a strong legislative framework in the country.
INTRODUCTION
Tobacco control is a right to health that must be defended for the protection and promotion of individuals and communities. Türkiye is among the countries with the highest number of people aged 15+ years and older in millions in 2019.1In Türkiye, the prevalence of daily tobacco users has risen to 28.3% in 2022 according to the Turkish Statistical Institute data. The prevalence of male and female smokers is 41.3% and 15.5% respectively.2
Tobacco use also causes passive smoking, which is also a serious public health problem, increasing mortality and morbidity.3 Since the 2000s, efforts of the World Health Organization (WHO) have achieved impacts in many parts of the world.4 Framework Convention on Tobacco Control (FCTC)5 has been a milestone in tobacco control, and Türkiye, as a partner country6, modified its legislative acts compatible with the FCTC recommendations. In this regard, in Türkiye, the Law No. 4207 on the Prevention and Control of Harms of Tobacco Products, which was enacted in 1996 for tobacco control, was revised in 2008.7This revision constituted an important basis for strong tobacco control in the country, and with this revision, tobacco consumption in bars, cafes, and restaurants was banned.8, 9
Legislative acts promoting tobacco control should seek reciprocity in practical life. Observations of hospitality venues open to the public provide an idea of whether anti-tobacco legislation is applied or not. There are research findings that define the compliance status of hospitality venues in different countries. In 2002, Basnet et al.10 conducted a study to define the compliance status with smoke-free public places in Nepal and found only 26.3% compliance in entertainment, hospitality, and shopping venues, etc. Bangladesh data also defined a huge violation in hospitality venues, which Chowdhury et al.11 showed in their research in 2023. Türkiye also has previous non-compliance data (49.0% for 2013 and 29.7% for 2014) in the hospitality sector.12 Recent data are needed to define the actual situation in the country.
Based on the need to see the actual situation, we aimed to observe the hospitality venues open to the public in 11 different cities of Türkiye and to determine whether there are violations of anti-tobacco legislation.
MATERIAL AND METHODS
The Type of Research
The study is a descriptive epidemiological study.
Place and Sample of the Study
The study was conducted in Ankara, Burdur, Diyarbakır, Giresun, Hatay, İstanbul, İzmir, Kars, Kayseri, Samsun, Zonguldak cities of Türkiye (Figure 1).
İstanbul, Ankara and İzmir are the cities with the largest populations. The cities included in this study were selected based on their geographical regions. Finally, researchers living in these 11 cities collected the data.
Standardized observations of the hospitality venues located on popular streets were conducted.
A list of hospitality venues in the relevant cities was obtained from the website of the Confederation of Turkish Tradesmen and Craftsmen.13 City center populations were determined according to the results of the Address-Based Population Registration System 2021 of the Turkish Statistical Institute.2 The estimated number of venues was calculated from a linear regression model estimating the number of workplaces in the cities according to the population of the cities. Since the Confederation of Turkish Tradesmen and Craftsmen does not provide the number of venues such as hotels, restaurants, and cafes separately, the minimum number of observations to be made in the cities was obtained by dividing the estimated number of each city by one thousand and rounding up to the whole number. Finally, 772 observations were made in 11 different cities.
Data Collection Form, Pre-test, Data Entry, and Analysis
The data collection form was developed by the researchers in July-August 2023. The form was pre-tested by the researchers in each city. In the pretest phase, each researcher observed five venues. After the observations, the data collection form was finalized in “online meetings” attended by the researchers together. After finalizing the data collection form, a Google Forms survey was created.
Statistical Analysis
Data were collected between August 1 and October 10, 2023. The researchers entered the data they collected through Google Forms survey. The data were transferred from Google Forms survey to Microsoft-Excel and IBM SPSS Statistics (Version 23) programs. IBM SPSS Statistics (Version 23) was used for data entry and analysis.
The observed venue was recorded only once. The client characteristics observed were also recorded. Age categories were recorded based on the observation.
In addition to basic analysis, a binary logistic regression model was performed to analyze the associations between the violation status in the indoor places and selected variables like type of venue, time of observation, existence of a retractable roof and/or side wall in the venue, and existence of outdoor venues where smoking is permitted. Odds ratios (OR) [95% confidence interval (CI)] were estimated for each variable. A two-sided P value of less than 0.05 (two-sided) was set as statistically significant.
Ethical Issues
The written approval of the Hacettepe University Health Sciences Research Ethical Board was obtained to conduct the study (session dated: 23.05.2023, session numbered: 2023/09 and decision numbered: 2023/09-60). Official permission to participate in the study was also obtained from the institutions of the researchers. The researchers participated in the study as members of the Association of Public Health Specialists-Tobacco Control Working Group.
The preliminary findings of the study (in Turkish) were presented at the 25th National Public Health Congress in December 2023 12.14 With the feedback obtained from the congress experience, another original work, the manuscript preparation phase, has been launched. This time, the authors planned the manuscript from a global tobacco control perspective and performed logistic regression modeling to understand the relationship between violations of the anti-tobacco legislation and selected variables. Because the authors came from 11 different cities, online communication tools were used. At each step, the content is approved. Finally, all authors have read and approved all the details.
RESULTS
In Table 1, selected characteristics of the venues were presented. The categories of 765 out of a total of 772 hospitality venues were evaluated. Of the 765 hospitality venues, 417 (54.5%) were café-pastry shops, 271 (35.4%) were restaurants, 62 (8.1%) were bar-pubs, 8 (1.0%) were coffee houses, and 7 (1.0%) were hookah cafes. Within the scope of the research, 485 (62.8%) of the 772 hospitality venues were observed on weekdays and 287 (37.2%) were observed on weekends. It was reported that it was raining during 38 (4.9%) observations. Most observations were made during and after noon. Of the 772 hospitality venues, 760 had indoor spaces (98.4%). Among the hospitality venues, 12 had completely open areas. In 579 of the venues, tobacco use was observed in open spaces (75.0%). Fifty venues (6.5%) had “designated non-smoking area” in their outdoor settings. During the observation, butts, packets, mouthpieces, paper, and similar waste related to tobacco products were thrown at 167 hospitality venues (22.3%).
Table 2 presents some of the indoor spaces (n = 760). In 282 (37.1%) venues, clients smoked in indoor spaces as a violation of Law No. 4207 on the Prevention and Control of Tobacco Products (PaCoTPs). Existence of obligatory legal warnings can be assessed in 733 hospitality venues. There were no legal warnings in 416 hospitality venues (56.8%). Of the 760 hospitality venues that were observed and assessed for the presence of ashtrays, 286 had ashtrays on the tables (38.0%). Of the 758 hospitality venues observed and assessed for the presence of tobacco smoke, 264 were reported to have tobacco smoke (34.8%). In addition, 391 hospitality venues were observed to have retractable roofs (51.7%), 441 venues to have retractable side walls (58.2%), and 414 venues to have air conditioning systems (67.6%).
Table 3 presents the selected characteristics of those who use tobacco products. There were violations in 282 venues (37.1%). In 194 venues (68.7%), women were smoking, and in 260 venues (92.2%), men were smoking where violations were detected against PaCoTPs. In 17 of 282 hospitality venues (where violations were detected), individuals under the age of 18 (6.0%), in 278 hospitality venues, individuals aged 18-64 (98.5%), and in 36 hospitality venues, individuals aged 65 and over (12.7%) were observed to use tobacco products. Cigarette smoking was observed in 267 of the venues (92.9%), hookah smoking was observed in 44 hospitality venues (15.6%), and e-cigarette smoking was observed in 31 hospitality venues (10.9%). Cigars, heated tobacco products, and pipes were also smoked in the hospitality venues.
Table 4 presents violations of the legislation according to the category of the venue and the observation hours. Violations were more prevalent in bar-pubs, traditional coffee houses, and hookah cafes than in café-pastry shops and restaurants. Violations were also more common at late hours than at earlier times of the day. Violations were more common in venues with retractable roofs and/or side walls. Indoor violations were more common in venues with outdoor spaces where smoking was not permitted.
Table 5 presents the existence of non-compliance according to selected characteristics of the hospitality venue. Non-compliance in bars, pubs, traditional coffee houses, and hookah cafes was statistically significantly higher than in the other venue types (OR=3.031, 95% CI: 1.699 to 5.408, P < 0.001). The presence of a retractable roof and/or side wall (OR=5.362, 95% CI: 3.518 to 8.173, P < 0.001), later hours observations (OR=2.120, 95% CI: 1.399 to 3.212, P < 0.001), and the existence of outdoor venues where smoking is permitted (OR=3.165, 95% CI: 2.170 to 4.617, P < 0.001) also increased indoor violations.
DISCUSSION
In this descriptive study, 772 hospitality venues were observed in 11 Turkish cities, where compliance with anti-tobacco legislation was evaluated through observation. The venues were located in different categories of the catering sector, such as café-pastry shops, restaurants, and bar-pubs. Less commonly, coffee houses and hookah cafes were also observed among the hospitality venues (Table 1). This diversity enabled the evaluation of tobacco control compliance in the hospitality sector with different target groups and purposes of use.
This study revealed significant deficiencies in compliance with the legislation. In 37.1% (n = 282) of the indoor spaces of 760 observed hospitality venues, tobacco products were consumed (Table 2). Studies have evaluated compliance with Türkiye’s Law No. 4207. In a study conducted by Ay et al.12 (2016) in the hospitality sector in 2013 and 2014, the frequency of violations was 49% and 29.7%, respectively. In Türkiye, compliance with legislation is also evaluated in taxis, which are among categories other than catering. In studies conducted by Öztürk et al.15 (2018) and Erkoyun et al.16 (2019) in taxis in different years and cities, it was found that there were violations (7.2%) of the Law among taxi drivers and taxi users. The level of compliance with legal regulations on tobacco control can be considered an important indicator of the effectiveness of tobacco control.
It was observed that there were deficiencies in warning messages for the public in the hospitality venues. For example, it was determined that there were no legal warnings (57.1%), there were ashtrays on the tables (38.0%), and there was tobacco smoke in the indoor areas (34.7%). The presence of retractable roofs and side walls was observed in 51.7% and 58.2% of the cases, respectively (Table 2), which are illegal and commonly used by opening them quickly when there is a control. These identified situations are examples of violations of the anti-tobacco legislation in Türkiye.7
Within the scope of the research, it was observed that butts, packages, mouthpieces, paper, and similar wastes related to tobacco products were thrown at 167 hospitality venues (22.3%) (Table 1). These results demonstrate that the implementation of anti-tobacco legislation is not sufficient. In addition, the results also emphasize the weak link between individuals’ perceptions of maintaining indoor air quality. Therefore, there is a need to improve the awareness of tobacco users about the damage they cause to the environment while they smoke.
Cigarette smoking was observed in 267 venues (92.9%). Hookah use and e-cigarette smoking were the other frequent tobacco products observed in the indoor spaces of the venues (Table 3). This diversity is consistent with the tobacco products emphasized by WHO.17New generation tobacco products appear to be a growing risk, especially for young people.18
Table 5 shows that the existence of non-compliance was associated with a number of characteristics. Non-compliance in bars, pubs, traditional coffee houses, and hookah cafes was statistically significantly higher than in the other venue types. The presence of a retractable roof and/or side wall, later-hour observations, and the existence of outdoor areas where smoking is permitted also increased indoor violations. Fukuda et al.19 (2023) found a higher frequency of siha ban violation in bars and nightclubs than in restaurants in Kenya. Inspections should be focused on these issues by the public authorities.
Our study has some strengths. First, we conducted the study in 11 different cities of Türkiye. Second, the research gave us the opportunity to evaluate the current situation in venues that the public frequently use. Third, the public authorities may use our results as a strong scientific rationale to prevent violations. The study has some limitations. First, the results are limited to observations, and in-person communication is not applied. Second, because only selected venues were observed in 11 cities, the results cannot be generalized.
CONCLUSION
In conclusion, this research, which was conducted in different cities of Türkiye in areas frequently used by the public, provides important data. To prevent the existing violations, it is recommended that the mechanisms through which Law No. 4207 is audited be revitalized by the public authority immediately and its continuity be ensured. The public should be informed about all aspects of tobacco control, and similar studies should be conducted regularly with a wider scope.
