Practices related to tobacco sale, promotion and protection from tobacco smoke exposure in restaurants and bars in Kampala before implementation of the Uganda tobacco control Act 2015

Article 8 of the World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) states that “all countries recognize that exposure to tobacco smoke causes death, disease and disability while all parties are obligated to adopt and implement effective legislative, executive, administrative or other measures to provide protection from tobacco smoke exposure in indoor work places, public transport, indoor public places and other public places” [1]. Although the convention has been signed and ratified by most UN member states, implementation at the national level remains a prerogative of the individual FCTC Parties through the development of comprehensive tobacco control laws. A review that assessed the effect of legislative bans on the reduction of exposure to tobacco smoke established that the bans reduced exposure to tobacco smoke in work places, restaurants and pubs [2]. Another review of policies in 30 developing countries also concluded that comprehensive advertising and promotion bans resulted in a 23.5% reduction in per capita tobacco consumption, but only a 13.6% reduction with more limited bans [3]. The WHO recognizes that in order for tobacco control laws to be meaningful and comprehensive, it must include the total elimination of all forms of TAPS. Therefore, Parties to the WHO FCTC are required to adopt and implement a comprehensive ban on TAPS within 5 years after entry into force of the WHO FCTC [4]. However because the WHO FCTC has to be domesticated to the local context and because of the ever present threat of the tobacco industry undermining, diluting, and circumventing policy formulation [5], some countries like the Netherlands developed policies that were largely opposed by the public [6] while others like China have completely failed to meet their WHO FCTC obligations [7].

On 19 September 2015 the President of Uganda signed the Tobacco Control Act 2015 into law [8]. The goal of the act is to mitigate the negative public health consequences of tobacco use and exposure to tobacco smoke. The law mandates that all indoor public places, work places and public transport should be 100% smoke free and that smoking should be done 50 m away from every public place. The Act also bans all forms of tobacco advertising, sponsorship and promotion and obligates public places to institute visible no-smoking signs and posters.

The most recent Uganda Global Adult Tobacco Survey 2013 showed that 1 in every 5 adults who work indoors had experienced exposure to tobacco smoke [9] while another survey in Kampala showed that 12.1% of current smokers usually smoked in public places, 10.4% usually smoked at social events [10]. The Uganda government had previously banned tobacco advertising and promotion on state media in 1995, however in 2002, data from the Global Youth Tobacco Survey showed that almost 60% of people in that survey had seen a tobacco promotion advertisement on a billboard [11]. The current tobacco control legislation in Uganda includes The Tobacco (Control and Marketing) Act 1967 and the National Environment (control of smoking in public places) Regulations 2004. The Tobacco Control And Marketing Act regulates the production and marketing of the tobacco leaf while the National Environment control of smoking in public places regulations of 2004 prohibit the use of tobacco in an enclosed public place and stipulate that the owner of a public place should designate an area where smoking can take place. Currently, the extent to which owners of hospitality establishments institute measures to protect the public from tobacco smoke is not known considering that 62.3% of adults have experienced tobacco smoke exposure in hospitality venues in Uganda [9]. This study was aimed at describing practices related to protection of the public from tobacco smoke exposure as well as limiting access to tobacco products and tobacco advertising, promotion and sponsorship in restaurants and bars in Kampala Uganda prior to the implementation of Uganda’s Tobacco Control Act 2015.

The study found that half of the establishments allowed for tobacco products to be smoked on the premises of which 63% had designated smoking zones. Although there are efforts by owners of public places to protect the public from tobacco smoke exposure, the public needs to be educated about the ineffectiveness of designated smoking zones in achieving this objective. The guidelines for implementing Article 8 of the WHO FCTC assert that there is no safe level of second-hand smoke exposure and any engineering approaches such as ventilation, air exchange or designated smoking zones are ineffective in protecting against exposure to tobacco smoke [1]. A study that compared the concentrations of respirable particles and nicotine in no-smoking and smoking sections of restaurants found that although the differences in concentrations were significant, there was incomplete protection from tobacco smoke exposure in the no-smoking sections [19]. Although the existing legislation was the National Environment control of smoking in public places regulations of 2004 that prohibits the use of tobacco in an enclosed public place and stipulates that the owner of a public place should designate an area where smoking can take place; the Tobacco Control Act 2015 completely bans smoking in any place that is accessible to the public [8], something owners of public places need to be made aware of. The law can be disseminated through forging partnerships with stakeholders such as civil society organizations and media outlets that will package the law in a form that can be consumed by the public.

The study also found that although 50% of establishments did not allow for products to be smoked on the premises, only 17% had noticeable no-smoking signs. No-smoking signs and posters are an important deterrent to initiation of smoking in an area where it is prohibited because they convey the rule that smoking is not allowed without necessarily conveying the fact that there is a law against it [20]. Although some studies have found minimal changes in smoke exposure after placement of no-smoking signs [21, 22] and worse still when there is minimal enforcement [22], others have found evidence of less smoking when the signs are instituted [23] and penalties for violations clearly stated. As the new legislation is being disseminated, owners of public places need to be informed of their responsibility to place no-smoking signs as a deterrent for people from smoking on their premises. This should be fortified with strict enforcement to ensure compliance.

Among the establishments that had tobacco products available for sale, 73.6% had manufactured cigarettes while 59.7% had ‘Shisha’ – a form of tobacco use in which flavored tobacco is inhaled through a water pipe. As most of the tobacco being accessed is manufactured tobacco, increasing taxes on tobacco products might be an effective way of limiting its access to and use by the public. Tax increases have been shown to have a direct influence on the level of access to and use of tobacco products particularly among the youth [24]. The high level of availability of flavored tobacco inhaled through a water pipe or ‘Shisha’ is noteworthy. Its’ perilous nature is such that it involves inhalation of a high amount of carbon monoxide produced when charcoal is used to heat the mixture of tobacco and molasses [25]. Shisha use has in fact been associated with carbon monoxide poisoning [26], pulmonary disease, coronary artery disease, and pregnancy related complications [27]. Enforcement will prove difficult, considering the complex nature of understanding the harms associated with Shisha and yet the new law completely bans the import, manufacture or sale of a water pipe tobacco delivery system (shisha), including the water pipe device or the water pipe tobacco product or other substances to be used in that system [8]. Law enforcers should be trained to understand and appreciate the harm due to the use of Shisha by the public.

In the study, 11% of respondents said they conducted tobacco product promotion within their establishment while tobacco advertising, promotion and sponsorship signs and products were visible in 11% of the establishments assessed. Tobacco product marketing through advertising, promotion and sponsorship promotes the initiation, continuation and re-uptake of smoking because it fosters positive attitudes, beliefs and expectations regarding tobacco use [28]. The WHO has called on countries that are party to the FCTC to institute legislation that completely bans any form of tobacco advertising, promotion or sponsorship [1]. It has been shown that regulation of tobacco product marketing significantly decreases smokers’ awareness of pro-smoking cues [29]. Pursuant to recommendations by the WHO FCTC, Uganda’s Tobacco Control Act provides for a comprehensive ban on all forms of tobacco advertising, promotion and sponsorship. The public needs to be informed about subtle forms of tobacco marketing such as offers of non-tobacco products that resemble tobacco products, provision of financial and other support to owners of hospitality establishments, product diversification through brand stretching and brand sharing, brand marking in hospitality establishments and a lot more that can be employed by the tobacco industry.

New legislations are only as good as the effectiveness with which they are enforced. However, the uniqueness of the Tobacco Control Act is that if managers and owners of hospitality establishments understand the perils of exposure to tobacco smoke, implementation of the law can rely on self-enforcement. This study revealed that only 25% of managers of establishments would ask someone to stop smoking if they smoked where they were not supposed to and 11% would do nothing. Self-enforcement involves managers of hospitality establishments either stopping anyone smoking in their premises or asking them to leave the premises. It is important that the dissemination of the new law to owners of public places covers issues to do with the dangers of inhaling tobacco smoke and the risks of disease and disability from exposure to tobacco smoke. The government could also partner with non-governmental organizations involved in tobacco control as well as associations such as hospitality industry associations that could provide effective platforms for disseminating the law. This would increase the possibility of self-enforcement in hospitality establishments.

The study has revealed that prior to implementation of the Tobacco Control Act, the practices in hospitality venues do not suffice to protect the public from tobacco smoke exposure. Rather the current practices promote tobacco use through point of sale advertising.. When not prohibited, it is common practice that the tobacco industry carries out TAPS activities in hospitality establishments. With the coming into force of the Uganda Tobacco Control Act 2015, effective dissemination of the law to hospitality venues and the public will be key in ensuring compliance and more so demand for clean environments by the public. Findings from the study also provide a baseline for future assessment of the failure or success of the legislation in terms of reducing exposure to tobacco smoke.