INTRODUCTION

The act of smoking is a widespread phenomenon that has significant implications for public health since it is closely associated with the occurrence of major non-communicable illnesses and premature mortality on a worldwide scale¹. Approximately one-third of the worldwide population engages in tobacco use, with 80% of these individuals residing in low- and middle-income nations². Research findings indicate that there is a significant correlation between smoking and an elevated likelihood of developing heart disease, with the risk being three times higher. Similarly, the risk of stroke is 1.5 times higher among smokers. Additionally, smoking is associated with a 1.4 times increased risk of chronic respiratory illness and a substantial 12 times higher chance of developing lung cancer, as shown by several studies^3-7. Each year, smoking kills 7 million globally, including about 1.2 million passive smokers². The World Health Organization (WHO) has implemented measures to regulate and manage this highly preventable issue in public health through the Framework Convention on Tobacco Control (FCTC). The FCTC offers technical guidance to nations globally on the implementation of protective measures against tobacco consumption⁸.

In 2003, the Government of Bangladesh demonstrated its commitment to the global anti-tobacco movement by joining the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). Subsequently, in 2005, the government further solidified its stance by enacting the Bangladesh Tobacco Control Act⁹. Subsequently, Bangladesh has effectively implemented measures to regulate tobacco use, as shown by the findings of the Global Adult Tobacco Survey (GATS) in 2017¹⁰. Based on the survey findings, there was an observed decrease in the incidence of active smokers by roughly 8%, and a corresponding fall in the occurrence of passive smokers by an estimated 10%–30% during an 8-year period¹⁰. The previous study indicated that public transport saw the least change in terms of exposure to secondhand smoke, perhaps due to the existing legislation in Bangladesh that prohibits smoking in public transport^9,10. A research investigation carried out in Dhaka city, Bangladesh, revealed a notably high prevalence of smoking among bus drivers, estimated at around 93%. Furthermore, the study provided data suggesting that stress may contribute to an increase in the adoption of this habit¹¹. According to the study of Goon and Bipasha¹¹, around 38% of bus drivers were seen engaging in smoking behavior during periods of traffic congestion, so contravening the legislation pertaining to tobacco use¹¹. The presented research has prompted the need to examine the underlying issues related to the opposition to smoking restrictions, which provides a barrier to the goal of attaining a tobacco-free Bangladesh by 2040¹⁰. Given the absence of prior research addressing this urgent issue, we undertook a cross-sectional study in Dhaka, Bangladesh, a city where the predominant mode of transportation for its residents is buses and human haulers. The study aimed to explore the underlying causes of non-compliant attitudes towards the smoke-free policy among the professional male bus and human-hauler drivers of Dhaka City.

METHODS

Study design, setting, and population

This was a cross-sectional study, and the data collection was conducted for 6 months (January to June 2020). The study participants included drivers who had been driving buses and human haulers for common public transportation. The study was carried out in Dhaka City, the capital of Bangladesh, covering both Dhaka South City Corporation and Dhaka North City Corporation areas. Eight major bus and human hauler stations from these city corporations were selected conveniently to reach out to the study participants for data collection (Figure 1). The following inclusion criteria have been followed to recruit the study participants for this study: 1) adult male (aged ≥18 years); 2) having a valid professional driving license authorized by the Bangladesh Road Transport Authority¹²; 3) smoked at least 100 cigarettes in their lifetime; and 4) having no current plan to refrain from smoking. For recruiting the study participants, the study used a systematic random sampling technique (every 3rd driver waiting in the queue of departure from the respective bus station; if anyone did not want to participate then we approached or waited for the subsequent 3rd driver) in the selected bus and human hauler stations. In total, 460 drivers were enrolled in the study and interviewed for the data collection. The proportional allocation method was used for recruiting bus and human hauler drivers based on the number of BRTA-authorized buses and human haulers roaming inside Dhaka City, and, ultimately, 406 bus drivers and 54 human hauler drivers were interviewed.

Figure 1

Map of selected bus and human hauler station locations inside Dhaka City

RESULTS

Figure 1 shows that out of 460 drivers, only 20.9% were compliant with the smoke-free policy while on duty, indicating that they did not smoke while on public transport or in the bus station, and the rest were non-compliant (79.1%). The mean age of the participants was 30.6 years (SD=7.9), and the mean education was 5.9 years (SD=3.3).

DISCUSSION

This study aimed to measure the association between compliance with the smoke-free policy (SFP) and sociodemographic, employment, lifestyle, and behavior-related characteristics of the bus and human-hauler drivers in Dhaka city, to explain the reasons and extent of the habit of smoking among the mentioned population. Similar studies have been conducted in different populations, predominantly students; however, we could not find any other compliance study conducted on the same population as ours to compare the results. Even though no association was evident between any of the sociodemographic characteristics and non-compliance with SFP, we can safely assume that at least some of them played non-apparent roles in making the participants non-compliant with SFP. Smoking is considered to relieve stress in those who are habituated to or addicted to it. Sociodemographic conditions that possibly create stress and anxiety among the drivers could be a potential reason for the growing non-compliance. Maintaining a large family, mainly when the monthly income is low, is a cause of stress for the earning members of the household. We found higher odds of non-compliance among married drivers and those with four or more family members. Participants with more educational experience could understand the harms of smoking better than the rest, resulting in fewer chances of being non-compliant with the anti-smoking policy. The study also revealed that knowledge about the tobacco control law and attending any program significantly decrease the chances of non-compliance, possibly due to the fact that the contents of the awareness program are not appropriate for this group of the population; participants attend the program only for the refreshments and poor monitoring of the awareness program implementing organization.

Working conditions may significantly affect one’s adherence to smoking. Driving long distances daily means long working hours for the drivers. Bus and human-hauler drivers of Dhaka city, along with their helping hands, have to work from dawn till midnight most days, staying within the vehicle throughout the day, during which smoking is a distraction from the monotonous work. To them, smoking works as a stimulant and often as a relief from stress for those who are habituated to it. It may help the drivers to improve their focus and performance, as explained by Lasebikan et al.¹⁴ in their study. This could cause higher odds of non-compliance among drivers covering long distances or working for long hours at a time. Likewise, this could also be the reason why drivers with the habit of smoking inside the vehicles, either during break or working hours, showed significant association with non-compliance to the anti-smoking policy.

A few of the behaviors of smokers could be explained by a possible addiction to nicotine. Being heavily habituated or addicted to smoking compels drivers towards rule-breaking no matter how hard they try otherwise or how conscious they are about it. Smoking since early childhood and more than ten cigarettes daily could point towards a strong smoking habit. When asked, the smokers also disclosed that they found it difficult to refrain from smoking in prohibited places and hated the idea of quitting smoking. Another ongoing study by us on the same population unveiled a significant association between these behaviors and nicotine dependence, which could give rise to non-compliant behavior among smokers. Moreover, a study by Thankappan et al.¹⁵ found that those who had started smoking from teenage years had a significant association with nicotine dependence.

Other studies have provided evidence that addiction to cannabis and alcohol is frequently correlated to addiction to smoking as well^16,17. In addition, our study also revealed a significant association between smokeless tobacco consumption and non-compliance towards SFP. All of these traits strongly suggest that the participants are more inclined towards smoking and less worried about breaking the rules.

CONCLUSIONS

Based on the current study’s results, it is apparent that the majority of the public transport drivers were non-compliant. The most commonly used salary disbursement method in Bangladesh, i.e. the daily wage basis and trip-based basis payment, had a direct influence on being non-compliant with SFP among this population. Those who had a high dependence on cigarettes had features of non-compliance. Unexpectedly, those who had the knowledge of the tobacco control law, were more likely to break the rules.