INTRODUCTION

The International Agency for Research on Cancer considers secondhand smoke (SHS) a ‘group 1’ carcinogen or ‘known human carcinogen’ because several carcinogenic compounds are found in the burning of tobacco or cigarettes¹. Therefore, WHO endorsed the Framework Convention on Tobacco Control (FCTC) in 2003. This international agreement was reached in order to achieve a 30% relative reduction of smoking prevalence by the year 2025 globally^2,3.

In Thailand, the smoking-attributed illnesses’ share of national healthcare costs was US$ 265.97 million in 2017, of which 7% was spent on medical care for non-smokers exposed to SHS⁴. Several anti-smoking campaigns have been underway since 1985, spearheaded by a non-governmental organization called the ‘Action on Smoking and Health Foundation, Thailand (ASHT)’, with the aim of lowering smoking prevalence while protecting non-smokers from SHS exposure⁵. The actions of the foundation resulted in the decrease of smoking prevalence from 43.7% to 34.7% in males and from 2.6% to 1.3% in females between 2004 and 2021⁶. Even though the Tobacco Product Control (TPC) Act legislated in 2017 permits legal action and the ASHT’s campaigns encourage smoking control, the magnitude of SHS exposure to non-smokers in public places in Thailand has not been effectively reduced.

Data from the National Statistical Office of Thailand in 2017 reported that Southern Thailand had the highest percentage of smokers in the country. Also, every province in the 12th healthcare administrative region in Southern Thailand, including Songkhla Province, had a higher average percentage of smokers (19.1%) than that of the nation (17.0%). Songkhla was notably one of the 4 provinces with the highest percentage of smokers in this region. Moreover, witnessing smokers, experiencing the smell of tobacco, or observing cigarette butts in public places were reported by more than 80% of respondents on the annual health survey of the province⁷. Furthermore, a national survey in Thailand in the same year supported the higher percentage of SHS exposure in public places, such as fresh-food markets, restaurants, and bars etc. (68.3%), than in households (32.7%)⁸.

Songkhla Province is a well-known commercial and tourism hub in the lower south of Thailand. Although modern facilities such as air-conditioned supermarkets, coffee shops, convenience stores, and buses, where smoking is strictly forbidden, are available, local open-air fresh-food markets, vans, high-roofed pickup truck taxis (called ‘songthaew’ in Thai), or motorcycle taxis are all still used by a significant portion of the local people. SHS was commonly experienced but under-recognized in these places, despite the TPC Act including these spaces as smoking-free areas.

This study aimed to explore the awareness of SHS-attributed illnesses and the legal control of the TPC Act among the local people living in Meung district, a municipality of Songkhla Province, Thailand.

METHODS

RESULTS

There were 330 participants, of whom 209 and 121 were from the marketplaces (market visitors) and bus terminals (bus passengers), respectively. Most of the participants were female (80%). The market visitors had a higher mean (SD) age [51.44 years (11.92)]. The education levels between the 2 groups were comparable. Most of the participants in both groups were non-smokers (89.7%). The market visitors commonly received knowledge about the SHS-attributed health hazards through printed materials (26.8%), while 43.8% of the bus passengers received it through online media, such as ‘YouTube’ or other online channels (Table 1).

There were 49.8% and 45.5% of market visitors and bus passengers who reported the experience of tobacco smells, whereas the number of visible smokers present at the sites were only 30.0% and 20.7%, respectively. The largest proportion of visible smokers were the goods transporters in the market (52.1%) and the bus or van drivers (80.0%). The market visitors (74.6%) and bus passengers (45.5%) did not take any actions against the smokers; only 10% of market visitors and 3.3% of bus passengers intended to report the event to an authorized officer or provincial agency; however, they did not know how to undertake any such action (Table 2).

The mean ± SD scores of knowledge regarding the law on smoking-free zones in public places were low in both groups (4.09 ± 1.61, market visitors; 4.07 ± 1.69, bus passengers), while that of SHS-attributed health harms was moderate in both groups (6.31 ± 2.14, market visitors; 6.30 ± 1.64, bus passengers) (Table 2). Also, we found that age and education level showed significant associations with awareness regarding the law of smoking restrictions in public places (Table 3), while age, education level, and religion had significant associations with the knowledge about SHS-attributed health harms (Table 4).

Based on the TPC Act 2017, the Songkhla Provincial TPC Committee was set up and composed of various local governmental agencies, such as provincial healthcare offices, police departments, provincial attorneys, academic institutional networks, provincial excise offices, and the Songkhla City Administration Office. The comments concerning the feasibility of applying the smoking restriction law in the province from the in-depth interviews were collected (see Supplementary file) and presented in the form of a thematic analysis (Table 5).

DISCUSSION

Our study found that the reported percentage of visible smokers was lower than that of experiencing tobacco smell in the marketplaces (30.0% vs 49.8%) and public bus terminals (20.7% vs 45.5%). This implies that the number of smokers in both places is possibly higher than that which is visible, although participant report bias is possible. Age, level of education, and religion were significantly associated with the knowledge of SHS-attributed health harms. Meanwhile, age and education level were associated with the awareness of smoking-free areas following the TPC Act 2007. We selected marketplaces and regular public transportation systems in this province as study areas because the goods transporters in the markets and the drivers are commonly active smokers and smoking-ban enforcement was low in both places. The workers or laborers in Thailand habitually smoke. Their hard work, low income, and low literacy possibly cause them to be unaware of smoking harms and SHS-attributed health harms to non-smokers. Therefore, they were the major sources of SHS generation in the study places. A recent study on the people exposed to SHS reported that besides males, individuals who had lower education level, household incomes, or awareness of the public smoking-ban regulations had a higher percentage of SHS exposure in public places where they are commonly present for working or living¹⁰. A study on SHS exposure in 15 low- and middle-income countries (7 of them were in Asia, including Thailand) supports that people of low socioeconomic status have a higher risk of SHS exposure, especially where smoking ban regulations are poorly enforced¹¹. To improve knowledge, attitudes, and the appropriate practices on SHS exposure in public places, effective health education programs to enhance health literacy about SHS-attributed harms should be emphasized¹². Therefore, both active smokers and SHS-exposed non-smoker people should be intensively provided with knowledge about SHS-attributed health harms. In the meantime, legal stringency to prohibit smoking in public places has to be enforced to protect non-smokers from SHS exposure. The obvious declining prevalence of SHS exposure can be partially attributed to changes in a nation’s tobacco policy and early legislated smoking controls¹³.

Marketplaces and public transport vehicles, as well as their stops or terminals, were the sites where local people commonly congregated to use the facilities for daily living. Notably, the laborers who transported goods in the markets (52.1%) and the public vehicle drivers (80%) comprised the largest portion of smokers at the individual sites. To avoid the occurrence of an argument with the smokers, most of the people who were exposed to SHS chose to leave the places where the smokers were without action, or they protected themselves from any SHS exposure as best as possible (86.9%). Only a small number of the respondents from the marketplaces (10%) and the bus passengers (3.3%) intended to report the events to the provincial authorities. We thought that these reactions were possibly caused by the compromising manner in Thai culture. From the point of view of the market transport workers and drivers, it could be expected that they were not aware of the health complications of smoking, as well as the smoking-free zone regulations in their working areas. Based on the personal talk on this issue, the smokers themselves simply believed that the cigarette smoke commonly floated up into the open spaces or out of the windows of the vehicles, and that the shielding glass, separating the driver’s section and the passenger seats, could prevent the tobacco smoke from reaching the passengers. Therefore, correct understanding and practical guidelines should be provided and enhanced for smokers.

Various health measures and smoking cessation campaigns have been launched in Thailand since the founding of the ASHT in 1985, for example, the warning messages of tobacco-attributed health harms on cigarette packs, legally restricted cigarette purchasing among people under 18 years of age, and prohibiting cigarette advertisements on TV programs, online media, in public places, and sports stadiums, etc. Despite a favorable reduction in smoking prevalence, SHS exposure in Thailand remains in places with lower surveillance for smoking control^4,14,15. Encouragement of complying with the endorsed smoking-free areas, along with strict smoking controls, has been undertaken in Thailand by the Ministry of Public Health and non-governmental organizations, including ASHT. It was not until 2017 that the TPC Act authorized several governmental measures to control the tobacco business chain and create smoking-free areas in many public places across the country. The actions comply with Article 20 of the WHO FCTC, in which the adverse health effects of SHS exposure on non-smokers are the focus, and comprehensive control measures regarding smoking in public places are advocated².

Considering the implementation of top-down tobacco control national policies in the province, we found that some provincial official agencies involved in the tobacco control loop had limited understanding regarding their roles and responsibilities, as authorized by the law. This caused non-collaborative implementations of tobacco control measures in the province. Moreover, because of the limitations of manpower, budget, and the high routine workloads of many provincial governmental offices, the tobacco control measures undertaken in the province were less effective. Therefore, practical methods applied from the national policy, well-assigned responsibility, and a reformed collaboration of the provincial agencies to harmonize smoking regulations, particularly SHS exposure control, are crucial.

We believe that SHS exposure control in the province requires the incorporation of multidisciplinary provincial agencies, both governmental and non-governmental. While legal regulations, which would cost considerable monetary and human resources, might induce resistance or challenges against the smoking-ban regulations, the engagement of provincial people should be encouraged to facilitate legal action. Although comprehensive smoking legal restrictions in workplaces or public venues were previously reported as the most effective method in the elimination of SHS exposure among non-smokers^16-19, we think that strong public motivation, awareness, and participation in eliminating SHS exposure are more likely to create enforcement of the legal regulations.

While most of the early SHS studies focused on households, workplaces, schools, and social venues, we selected the marketplaces and public transportation systems as the study settings because they were the places with a higher risk but lower recognition of SHS exposure in the province and across Thailand. Also, the available studies in these settings were very limited.

CONCLUSIONS

The knowledge about SHS-attributed health harms was not ideal, while awareness about legal restriction on SHS exposure was also limited. Age, education level and religion were significant associated factors. The transport workers in fresh-food markets and the drivers of a public bus or a high-roofed pickup taxi, were the active smokers generating secondhand smoke. The collaboration on the legal regulations among the provincial official agencies was weak. Therefore, SHS control in this province remained below expectations. Future research should focus on encouraging public engagement and designing a comprehensive collaboration between the public and local governmental sectors for effective SHS exposure control.