Implementation of smoke-free law in Denpasar Bali: Between compliance and social norms of smoking.

Abstract

Background: Since 2013, City of Denpasar government has adopted a smoke-free law. Implementation of the law faces several obstacles, partly due to the high social acceptability of smoking in the city, where cigarette and smoking has been deeply engrained within social life and become part of hospitality. This study aims to assess the smoke-free law compliance and to explore the social norms that may affect the compliance.Design and Methods: The study was a mix of cross-sectional compliance survey and qualitative exploration conducted in Denpasar in 2019. Survey included 538 samples, which were selected using stratified random sampling and a walking protocol. The qualitative data was collected through in-depth interviews and Focus Group Discussion (FGD) in four sub-districts of Denpasar.Results: Of the 538 venues, 32.9% complied with the seven compliance indicators. The university has the highest compliance (83.3%), while public places including worship places have a low compliance. The three most common violations were the absence of no-smoking signage (58.6%), provision of ashtray (17.5%), and smell of tobacco smoke (15.8%). The poor compliance was related to the lack of awareness of the regulation, and the fact that smoking is highly acceptable and part of the culture. The informants highlighted the essential role of public figures and potency of local policy as social disapproval of smoking.Conclusions: Compliance to the smoke-free law in Denpasar remains low, continuous education, socialization and improved supervision are crucial. Meanwhile, social and cultural acceptance of smoking is considered as an essential factor that hampers the implementation of the smoke free law.Significance for public healthThe tobacco epidemic is one of the major challenges for public health across the world. Smoke-free law is recommended by WHO which aim to protect nonsmokers from cigarette smoke exposure. However, this policy will be more effective for public health if the society comply. Hence, the compliance appears as a big challenge in implementing smoke-free law. Numerous studies showed various strategies to improve the compliance. Nevertheless, there were few strategies based on local norms or culture, which are important particularly in developing countries where smoking behavior is reinforced by cultural and religious aspects. Through our study, we would like to find out the extent to which improvements in compliance have been made using conventional strategies and identify the potential of local wisdom among the society, which affect their smoking behavior. Ultimately, this study is expected to recommend also a culture-sensitive strategy to improve and sustain the compliance with the smoke-free law.