Academic journal article Bulletin of the World Health Organization

Compliance with Smoke-Free Legislation within Public Buildings: A Cross-Sectional Study in Turkey/Respect De la Legislation Anti-Tabac a L'interieur Des Batiments Public: Une Etude Transversale En Turquie/El Cumplimiento De la Lagislacion Que Propicia Edificios Publicos Libres De Humo De Tabaco: Un Estudio Transversal En Turquia)

Academic journal article Bulletin of the World Health Organization

Compliance with Smoke-Free Legislation within Public Buildings: A Cross-Sectional Study in Turkey/Respect De la Legislation Anti-Tabac a L'interieur Des Batiments Public: Une Etude Transversale En Turquie/El Cumplimiento De la Lagislacion Que Propicia Edificios Publicos Libres De Humo De Tabaco: Un Estudio Transversal En Turquia)

Article excerpt

Introduction

To protect everyone from the detrimental effects of exposure to second-hand tobacco smoke, (1,2) the World Health Organization's Framework Convention on Tobacco Control has called for comprehensive legislation to eliminate tobacco smoking in all indoor public places and workplaces. (3,4) In Turkey--ranked among the top 10 countries in the world for tobacco use in 2008 (5)--the mean cigarette consumption among the 41.5% of men and 13.1% of women who smoked was 20.3 and 15.3 per day respectively in 2012. (6)

Turkey passed a law in 2008 that prohibited smoking in indoor public places and workplaces. (7) Cafes, restaurants, bars, nightclubs and other hospitality venues were given until July 2009 to comply with this legislation. (7) Several studies have evaluated the impact of the legislation in eliminating smoking in public places in Turkey. (8-10) Most were based on convenience sampling (10) and on only a few types of public venues. (8-10) The Global Adult Tobacco Survey has monitored trends in exposure to second-hand smoke in Turkey--based on self-reported exposure in health-care facilities, government buildings, transport hubs and some hospitality venues--but it does not verify if or where smoking is occurring in any of the reported locations. (6,11) In an attempt to evaluate compliance with the legislation on smoking in indoor public places in Turkey more comprehensively, we adapted a guide on compliance studies that was published by the International Union Against Tuberculosis and Lung Disease, the Campaign for Tobacco Free Kids and the Johns Hopkins Bloomberg School of Public Health in 2014. (12) We used the presence of individuals who were smoking and/or cigarette butts as indicators of noncompliance with the legislation and the presence of ashtrays, the absence of no-smoking signs and the presence of cigarettes for sale as possible facilitators of non-compliance. In addition to evaluating compliance with the legislation on indoor smoking, we assessed outdoor exposure to second-hand tobacco smoke near the buildings.

Methods

Study population

In this cross-sectional observational study, we studied public venues in one city in each of the twelve first-level subdivisions used in Turkey by the European Union's Nomenclature of Territorial Units for Statistics: Aegean, north-eastern, middle, middle-eastern, south-eastern and western Anatolia, eastern and western Black Sea, Istanbul, eastern and western Marmara and Mediterranean. Our corresponding study cities were Adana, Ankara, Balikesir, Bursa, Erzurum, Gaziantep, Istanbul, Izmir, Kayseri, Samsun, Trabzon and Van respectively. Within the urban districts of each city, the Turkish Statistical Institute randomly selected either 10 sampling points for the three major cities (i.e. Ankara, Istanbul and Izmir) or five such points for the smaller cities. Around each sampling point, our fieldworkers visited the closest bars/ nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. The fieldworkers gradually expanded the search until one or two of each type of public venue had been located around each sampling point and a pre-specified target number of venues of each type had been located in each study city. The target numbers, which had been set by a consensus panel before the field work began (available from the corresponding author), took into account the size of the city, the rarity of the type of venue and the allocated fieldwork duration--of two weeks in each major city and one week in each smaller city. A letter from the Ministry of National Education authorized access to schools. All other venues allowed public access. The fieldwork was conducted in December 2012-January 2013 in Ankara, Istanbul and Izmir and in May-July 2013 in the rest of the study cities. Institutional review boards at the Johns Hopkins University in Baltimore (United States of America) and at Dogus University in Istanbul (Turkey) approved the study protocol. …

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