Knowledge, attitude, and practice of tobacco control law among tobacco retailers of Dhaka City Corporation

Introduction

Background

Tobacco use is one of the foremost public health misadventures of the past century. More than 8 million people die from tobacco use each year, which is roughly equivalent to half of its users (1). Direct tobacco use causes more than 7 million deaths. Furthermore, second-hand smoke causes around 1.2 million deaths (1). Cigarette smoking is one of the main causes of preventable death worldwide and the leading cause of preventable death in industrialized countries; however, the epidemic of disease and death is rapidly shifting to developing and transitional market economies. Low- and middle-income countries are targets of rigorous tobacco industry interloping and marketing, and most tobacco-related deaths occur in those countries (1).

Most of the tobacco-related morbidity and mortality is contemporaneous, disproportionately in low- and middle-income countries like Bangladesh. Although tobacco smoking is lingering stagnant or declining in most of the developed countries because of enormous public health actions, it is increasing in the developing countries due to substantial promotional activities of cigarette companies and less public awareness programs (2).

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) came about to reinforce and harmonize global tobacco control efforts. The WHO FCTC was adopted in May 2003 and became international law on 27 February 2005 (3). The Convention is the motivating dynamism behind the global response to the pandemic of tobacco-induced death and disease. Bangladesh signed the FCTC in 2003, and it was ratified in February 2005 by the Parliament (4).

Bangladesh has laws amendable the tobacco industry and consumption, essentially focusing on banning advertising in all forms of public media (newspapers, television and radio). The specific laws and regulations issued for tobacco control in Bangladesh include: Law forbidding smoking in public places and on public transport; Law forbidding smoking in work places; Law prohibiting smoking in enclosed public places and introducing a fine for smoking on public transport (5). Bangladesh’s anti-smoking legislation is not, however, adequate to make a noticeable difference, especially as most smokers are unaware of these regulations. Enforcement is therefore the main obstacle to success in controlling tobacco use.

Understanding the operations of tobacco businesses, their evolving product offerings, the incentives they provide to retailers, and the presence of illicit trade is crucial. Tobacco retailers (TRs), with their first-hand experience, are the perfect respondents to provide insights into these dynamics. Their knowledge is invaluable in understanding the industry. However, it’s concerning that many retailers are unaware of the harmful effects of tobacco use and the laws governing it. This lack of knowledge underscores the urgent need for more education and awareness in this research (6).

Ideally, interventions that specifically address a market failure should be implemented as the “best” options. In the tobacco market such “best” interventions would include educating young people about the risks of addiction and disease from smoking or restricting their access to tobacco. However, the evidence suggests that these measures are relatively ineffective (7,8). The evidence suggests that freer trade in tobacco products has led to increases in smoking and other tobacco use (9).

Rationale and knowledge gap

A separate law-enforcing authority and a separate tobacco control cell [the National Tobacco Control Cell (NTCC) was established in 2007 as the operational arm of the Ministry of Health and Family Welfare’s Health Services Division in Bangladesh] at various levels may play a vital role in reducing the tobacco burden. Therefore, it is important to know the current knowledge and practice of tobacco sellers, their attitude towards tobacco control laws (TCL) to give further input on tobacco control in Bangladesh. It is imperative to know who these sellers are, what products are they selling, who are their client, knowledge about their product selling laws, what kind of incentives they are getting including discount, free sample, advertising materials, who help them making their business set up, decoration etc. for further implementation of TCL.

Objective

TRs’ population dynamics has not been studied yet, which is an important group of tobacco control. Tobacco use continues to be a serious public health concern in Bangladesh even after the country’s comprehensive tobacco control legislation were put into place, especially in cities like Dhaka. Although tobacco shops and retailers are vital to the implementation of these regulations, little is known about their attitudes, knowledge, and practices regarding tobacco control efforts. It is critical to evaluate the knowledge and compliance levels among these important stakeholders due to the high prevalence of tobacco use and the related health and financial costs. The objective of this research is to close the current research gaps and offer insights that can guide focused efforts to improve law enforcement and lower tobacco use. Policymakers and public health professionals can create more potent plans to combat tobacco use by having a better grasp of the viewpoints and practices of TRs. We present this article in accordance with the STROBE reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-24-52/rc).

Methods

Study design, period and area

Our research, which rigorously combined both qualitative and quantitative approaches, aimed to provide a comprehensive understanding of tobacco sellers’ knowledge, attitudes, and practices. This thorough nine-month endeavor, spanning from March to November 2020, included a meticulous field data collection period from August 15th to September 14th, 2020.

We employed a multistage cluster sampling technique. Initially, 10 areas from 10 zones of Dhaka North City Corporation (DNCC) were randomly selected. From each zone, one ward was chosen, resulting in 12 areas (at least one from each ward) being randomly selected for data collection. All forms of tobacco sellers in each selected area were mapped, and the approximate number of retailers, including mobile sellers, was identified. Mobile or floating sellers operating within the selected areas were included in the study. These sellers were approached and selected for interviews. If the desired sample size was not met, tobacco sellers from adjacent areas within each zone were approached.

For qualitative study, a total of five key informant interviews were conducted among those persons who were in the top-level position of tobacco control and policy planning. The selection of participants was predicated by their experience and pertinence to the research.

Study population and sample

All forms of tobacco sellers aged 18 and above (GATS, 2017) of the selected areas who were engaged with selling for more than 14 days and were willing to participate (Table 1) in the study was the study population. The sample size was determined using Cochran’s equation, a standard statistical methods for proportion-based studies, considering a 95% confidence level, a 5% margin of error, and an estimated prevalence of 69.3% from a 2017 study in Chennai, India, on tobacco sellers’ awareness of the prohibition of tobacco sales to minors (10). Based on these parameters, the final calculated sample size was 327 participants.

With the design effect of 1.2 and 7% non-response rate the total sample size was 420. A total of 420 respondents were covered in the study for questionnaire survey among the tobacco sellers. Additionally, five key informants’ interviews (KII) have been conducted for qualitative study. Participants of the KII were selected using purposive sampling technique.

Data collection procedures

It is a descriptive cross-sectional study which was primary data-based, and its aim was to create evidence for policy implication. Three most essential data collection tools (survey questionnaire, observation checklist and key informant’s interviews) were applied in this study. A semi-structured interviewer-administered questionnaire was fixed for the survey from the tobacco seller where mostly closed ended questions were added. The questionnaire was developed through reviews of the TCL in Bangladesh and published articles and reports (10-12) GATS questionnaire and Bangladesh Tobacco Control Act 2005 was followed.

For the quantitative survey questionnaire, we appointed six highly qualified research assistants, all university graduates with extensive experience in data collection. They were selected after a rigorous interview process conducted by the Principal Investigator (PI) and supervisor. Before finalizing the questionnaire, it was translated into Bangla. A comprehensive two-day training on data collection techniques was conducted, ensuring that the data collectors and field supervisors were well-versed in the program’s aim and the research objectives.

The questionnaire was developed entailing several sections for conduction of the study. These sections included: (I) socio-demographic information; (II) habit of tobacco consumption; (III) exposure to second-hand smoking; (IV) knowledge, attitude and practice on TCL. The settled KII was conducted with the tobacco control activists, government officials and policy makers. The KII participants were chosen purposively. For collecting information from the key informant, a pre-determined guideline was employed.

An observational checklist to find out the current practices of tobacco sellers was developed mainly to focus on their practices of TCL and few others factors The focal area covered: (I) any form of advertisements at point of sale (POS); (II) sale of sweets, snacks, toys, tooth paste, tooth powder or any other objects in the form of tobacco products which appeal to minors and; (III) use of direct or indirect incentives that encourage the purchase of tobacco products. The observations were conducted, and the observational checklist was completed by trained field researchers/observers who were specifically instructed in the study’s objectives and the use of the checklist.

To test the validity of the instruments, pretesting was carried out. During the pretesting phase, a sample representative of the study population was given a total of 15 questionnaires. Certain changes were made to improve the questions’ relevancy and clarity considering the pretest findings. These included changing the questions’ phrasing, changing the response choices, and adding or deleting things.

Due to the coronavirus disease 2019 (COVID-19) pandemic, many people have migrated from Dhaka city and changed their professions. We collected data considering the potential shortage and lack of POS in our selected area. We included mobile sellers in our study when we were assured of their ability to conduct business there, ensuring that all types of sellers were represented in our study.

The lead investigator performed five KIIs with semi-structured interviews that lasted between 45 and 60 minutes. Participants’ agreement was obtained before any data was captured, guaranteeing confidentiality. For conducting the KII, we took great care to ensure their comfort and privacy, holding interviews in calm, private locations. With the participants’ permission, audio recordings of every interview were made, respecting their right to privacy.

Data analysis plan

Quantitative data were subjected to a rigorous checking process to identify any logical errors. The collected quantitative data were then processed and analyzed using SPSS software. Continuous variables are shown as the mean ± standard deviation (SD) and categorical variables were shown as number (n) and percentages (%). Essential pictures, graphs etc. were used where necessary.

The knowledge component assessed respondents’ awareness and understanding of TCL. The attitude component was measured using a 5-point Likert scale, capturing responses across positive, neutral, and negative dimensions., while the practice component evaluated their compliance, and behaviors related to these laws.

Qualitative data were transcribed manually first, then coded and thematic analyses were carried out. The audio files of the collected data were transcribed verbatim by the research team. One of the team members went through all the transcripts, and then coding was done. The identified codes were further checked for accuracy. Concerned team members reviewed the codes and then finalized the emerging themes from the data. The coding of the transcripts and the identification of emerging themes were carried out using a thematic approach. To maintain confidentiality, all the data were identified and anonymized throughout the transcription and interpretation of the findings.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics review committee of Bangladesh University of Health Sciences (Memo No. BUHS/BIO/EA/20/20). This study also got a grant approval from Bangladesh Center for Communication Program (Ref: GC#BCCP/Tobacco Control/2020-54) and informed consent was taken from all individual participants.

Results

The study’s findings, presented in different sections, were collected with meticulous attention to detail. The first section comprised the demographic and behavioral characteristics of the tobacco sellers, with each data point carefully recorded. Along with this, other general information, like the type of shop, the selling pattern was also included and presented in table and chart forms. The next portion covered tobacco sellers’ knowledge of different domains of TCL, advertisement, punishment provision. Then, we focused on their attitude towards TCL, its punishment provisions, etc. Here, we cross-tabulated tobacco sellers’ attitudes to TCL with their educational level, and the association was displayed by applying the chi-square test. After that, tobacco sellers’ practice on TCL and an observational checklist were formulated. All types of tables and charts were used to depict the findings, reinforcing the reliability of the study’s data collection process.

The percentage of respondents was 87%, while the percentage of non-respondents was 13%.

Socio demographic, behavioral and selling related information of the respondents

Our research, conducted with meticulous attention to detail, found that about 65.0% of the respondents were from the age category of 25–44 years group, 79.5% respondents were married, and 27.9% had completed their primary level education. In terms of business characteristics, we found that 51.2% of the shops were fixed, with 61.4% selling a variety of products including tobacco, tea, cake, biscuits, banana etc. and 58.6% of the shops primarily focusing on tobacco sales (Table 1).

Knowledge on different domains of TCL and its punishment provisions

More than half (59.8%) of people have heard about TCL and the rest (40.2%) haven’t heard about TCL (Figure 1).

Figure 1 Frequency of awareness (heard about) of tobacco control laws (TCL) by the respondents.

The majority of respondents may be aware that smoking is prohibited in public areas, since just 17.9% of respondents thought it was acceptable. A tiny portion of respondents believed that smoking on public transportation is acceptable, indicating a high level of awareness that it is not. There are some misunderstandings about the limitations on advertising, as seen by the 22.1% of respondents who thought tobacco products may be marketed at the POS. A lack of knowledge about promotional restrictions is seen in the 31.2% of respondents who believed that tobacco marketing at POS is permissible.

Some respondents (39.8%) had a modest level of awareness on the regulation of giving free samples to entice customers to make a purchase. There is a need for greater understanding of discount limits since 25.2% of respondents thought discounts on tobacco to entice purchase were acceptable. Of those surveyed, 31.9% were aware of the laws governing the distribution of gifts, such as chocolate, matchboxes, and key rings, to promote tobacco goods. The fact that 46.2% of the respondents knew that it was prohibited to give merchants presents or rewards suggests that they had a comparatively greater degree of knowledge in this area. Merely 10.2% of respondents thought it was acceptable for tobacco corporations to distribute goods with packaging like that of cigarettes, indicating a high level of knowledge of the ban. About 11.4% of respondents said that it is acceptable to use brand phrases such as “light”, “mild”, or “low tar” on packaging, suggesting that most people are aware of the limitations on branding. Only 37.1% of respondents knew that the words “Approved for sale only in Bangladesh” must be written on tobacco package, indicating a mediocre awareness of labeling regulations (Table 2).

A large portion (61.2%) does not have any knowledge about which cannot be used as advertisement at POS (Figure 2).

Figure 2 Knowledge of advertisement restriction (does know anything).

The data reveals different knowledge patterns for smoking and smokeless tobacco. While 55% of respondents correctly stated that smoking tobacco cannot be sold to minors, only 29.3% were aware of the same restriction for smokeless tobacco. Similarly, 51.7% knew that smoking tobacco cannot be sold by minors, but only 37.1% were aware of the same for smokeless tobacco. Amazingly, only 2.1% were aware of the punishment provision for violating these laws. This highlights the need for more research and continuous study. About 19.3% of tobacco sellers were aware of the space allocation for graphic health warnings (GHW), and only 10.7% knew about the changing provision of GHW (Table 3).

Tobacco seller’s attitude towards TCL

A great portion of sellers have positive attitudes towards the ban of smoking at public places, 78.5% had positive attitudes. A few portions had negative attitudes on this matter, which was 14.1% (Figure 3). Large portion (81.8%) had positive attitude on ban of smoking at public transports. Few had negative attitude which was 13.3% (Figure 4).

Figure 3 Attitudes of the respondents towards smoking at public places.

Figure 4 Attitudes of the respondents towards smoking at public transport.

We merged strongly agree and agree as ‘positive attitude’. Strongly disagree and disagree were merged as ‘Negative attitude’. Three categories of attitudes ‘positive, neutral and negative’ were displayed as a chart for smoking and smokeless tobacco separately. A positive attitude was prevalent in most of the domains except “Fine retailers who sell tobacco to minors”. More details is given in supplementary table (Table S1) for better understanding.

Practices of TCL by TRs

About half of the respondents (53.3%) never smoke at public places and (Figure 5). About three quarters (74.3%) never smoke at public transports. On the contrary only a least (0.7%) used to smoke always at public transports (Figure 6).

Figure 5 Practice of smoking at public places by tobacco sellers.

Figure 6 Practice of smoking at public transport by tobacco sellers.

On a concerning note, we found that practices in different domains of TCL had impaired practice patterns. Notably, the practice of ‘selling tobacco to minors’ was a major area of concern. Selling tobacco to minors is the most noticed concern, as evidenced by nearly half of the observations (48.8%).

Giving presents to customers who buy tobacco (14.5%) and selling tobacco without prominent health warnings (17.9%) are also somewhat typical practices.Although they are less common, other tactics like giving out free samples, offering discounts, and mislabeling still raise red flags (Table 4).

Few more information will be found on (Table S2).

Association of different factors with attitudes and practices of respondents

Our exploration into the factors influencing the knowledge, attitude, and practice of sellers was underpinned by the rigorous Chi-square test. This test revealed a significant association with the sellers’ level of education (P value <0.05), providing a reliable foundation for our findings. While no association was found with knowledge variables, we did uncover significant associations with several practices and attitudes, particularly with the participants’ level of education. Notably, among the many practice variables, selling smoking and smokeless tobacco to minors and selling these products without GHW displayed significant associations.

On the other hand, among attitudes variables fine those who sell smoking and smokeless tobacco to minors and who engage minors for tobacco selling showed significant associations with level of education (Tables 5,6).

Findings from qualitative data

The study team verbatim transcribed the recorded interviews. The researchers then read the transcriptions several times to become acquainted with the material. The data’s recurrent themes and patterns were used to generate codes using a human coding procedure. This involved identifying key phrases or concepts that represented the themes and patterns observed in the data. The transcripts then underwent a methodical application of these codes.

To find important themes, related codes were grouped together and subjected to a thematic analysis. This was a collaborative process, with the study team deliberating and improving upon the themes to ensure they appropriately reflected the facts. This collaborative approach ensures the integrity of our research.

• The urgency of finding a proper solution regarding tobacco-free areas is evident. The question is whether law enforcement, proper implementation, and fines can effectively make tobacco-free areas possible. A fact may be the gaps in the rules and law. One of our key informants stated: “There is a huge gap on this law of restricted places. Where smoking is restricted, we need to do it restricted for tobacco sales too” (participant 2)
• Minor’s involvement in tobacco selling and buying: Tobacco is being sold and bought by the minors, though law strictly prohibited them both. But day by day, this is increasing tremendously. One of our informants said: “This section of the law is completely not under control. We have greatly failed to implement this. The main thing is, we do not have any identifying criteria of who is a minor. But, in developed countries, they have provision to show to their identity card to purchase any kind of tobacco.” (participant 1)
• Second-hand exposure of TRs: There is a large gap in tobacco sellers’ knowledge, which can be a place for concentration. If they can understand and get enough motivation regarding the harmful effects of tobacco, then it might discourage them from the business. In this context, one of our key informants said: “Sellers never forbid their customer not to smoke around the shop as if he does this it can reduce his sales. Rather some shops keep sitting arrangements to take tea and smoke together.” (participant 3)
• Tobacco companies’ persuasion on tobacco selling: It has been claimed that agents of tobacco companies play a vital role in these aspects. Although only a few respondents said they get incentives, rewards from companies, practically tobacco companies’ persuasions are beyond the control. Tobacco control activist, policymakers, law enforcers all were agreed on that one point: “If the government does not take the reins of the tobacco companies or if it does not have the will to suppress them, it will be impossible to stop such vast activities of them.” (participants 4, 5 and 1)

Discussion

There is a clear demographic trend of young to middle-aged, married individuals with limited education dominating the tobacco selling market. Knowledge gaps, particularly regarding specific TCL provisions and punishments, need to be addressed. Positive attitudes towards TCL do not always translate into compliant practices, highlighting the need for more robust enforcement and education strategies.

We found that tobacco sellers are unaware of “tobacco control laws”. However, despite getting a negative response, when we dug deeper, we found that, although the term is not clear to them, they have little knowledge regarding different sections of TCL. So, here, simplification of the term can give a better understanding of them.

TR were aware of a ban on supply of accessories to smoke, placing signage boards, and using leaflets as advertisements, ban on attractive illuminated board display, we found an open display of products were lacking at the point of cells. Eye-catching and exposed exhibition of tobacco products initiate habit among children, adolescents, and increase the urge a compulsion to purchase tobacco products (13). Although 66.7% of TR knows smoking is prohibited in a public place, 53.8% practice it strongly. Among 26 restricted places of smoking, 80.5% knew the “smoking is restricted at the educational institution”, and 49.3% knew “smoking is restricted at hospital and clinic buildings”. And all other places have very low responses.

Among all respondents, 21.7% said they never sold smoking tobacco to minors, and 37.1% said the same for smokeless tobacco. But on observation for such a short period, 48% of tobacco sellers are found to sell tobacco to minors. Although, over 55% knew that it is punishable and they also have a good attitude in this context, the reality is totally different. Qualitative findings also aligned with this.

So, still there is a bit lacking in practical implementation and enforcement of the laws. There was variation in the knowledge regarding TCL’s several components, the least being about the punishment provisions. Many of the sellers do not have enough ideas on actions against disobeying the rules.

In our study, 95.5% believed smoking is harmful, whereas 58.8% believed smokeless tobacco is harmful, and 60.2% consider passive smoking harmful. 80.2%, 64%, 56.9%, 56.9%, 42.4% of people know smoking can cause lung cancer, stroke, heart attack, and HTN, respectively. But according to GATS 2017, the percentage of disease-specific knowledge for smoking tobacco is much higher, which is 94.8%, 88.9%, 89.5% for lung cancer, stroke, and heart attack, respectively (13). According to GATS, 91% of people know smokeless tobacco can cause oral cancer. However, the percentage of knowledge is much less at our findings (46.7%) compared to this. So, there is a large gap in tobacco sellers’ knowledge, which can be a place for focusing intervention efforts.

Despite having lower knowledge and awareness regarding the TCL, many of the sellers have positive attitudes towards different sections of TCL. The majority favored a ban on the sale of tobacco products to and by minors, ban on advertisements followed by most of them like to use graphic and pictorial health warning signs. We did not find any Bangladeshi studies on tobacco sellers, but these findings of the present study harmonized with a few of the studies conducted at our other countries like Russia, Germany and India (14-16).

The knowledge of the exact penalty and punishments for the violation of TCL was negligible. Our study found that only 2.1% were punished, and 3.1% have heard or been seen to be punished for violations of laws. This is in accordance with two other studies from India, and their poor knowledge was attributed to their belief that punishment is less for violation (16). Moreover, it has been claimed that agents of tobacco companies play a vital role in these aspects. Although only a few respondents said they get incentives, rewards from companies, practically tobacco companies’ persuasions are beyond the control. Tobacco control activist, policymakers, law enforcers all were agreed on that one point:

• Regarding practices of TCL in the current study we found that about half of the respondents (53.3%) never smoke at public places. Three quarters (74.3%) never smoke at public transports. But practice regarding different other sections was literally poor and some points we found few variations with their response and observation of us. Especially on using advertisements media, selling to minors, and using pictorial where we found variations with response. Most of the sellers mentioned having impact on tobacco business due to COVID-19 but practically we have not seen it on POS. People are buying and selling tobacco at the same rates as before although knowing COVID-19 has bad impact on smokers. TRs are the most important stakeholders among all as they are directly involved with the buying process and tobacco companies have close contact with them regarding manufacture.

It is the first ever study conducted on tobacco sellers in Bangladesh which will create important evidence. Although it is a cross-sectional study, the sample was picked up by using standard methods. The small sample size, potential biases, observation bias, limited qualitative data, cross-sectional design, inability to measure knowledge and attitudes, inability to establish causal relationships, and the fact that the findings are based on data collected at a specific time may not accurately reflect changes in practices, attitudes, or knowledge over time are some of the limitations of the study.

Conclusions

The findings obtained from this study provided valuable information regarding TRs’ KAP towards TCL. Knowledge regarding sections of TCL was less, attitude was well enough, but practice was literally minimal. Findings acquired from this study also proposed valuable intuition regarding reinforcement enactment of tobacco control policy of Bangladesh. Besides knowledge, attitudes and practice towards TCL, it revealed some influencing factors behind tobacco selling which have a treasured base for controlling tobacco company’s persuasions. In addition, the present study provides essential indication for future research to this community who are the important part and parcel for creating Bangladesh tobacco free one.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-24-52/rc

Data Sharing Statement: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-52/dss

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-52/prf

Funding: This study was supported by Bangladesh Center for Communication Programs (Ref: GC#BCCP/Tobacco Control/2020-54) with funding awarded by Bloomberg Philanthropies to Johns Hopkins University.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-24-52/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethical review committee of Bangladesh University of Health Sciences (Memo No. BUHS/BIO/EA/20/20). This study also got a grant approval from Bangladesh Center for Communication Program (Ref: GC#BCCP/Tobacco Control/2020-54) and informed consent was taken from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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