Study design

In this qualitative study, the data collection took place in two of the largest cities of Türkiye – Istanbul and Ankara – between July and August 2021. First, districts were selected within each city as areas of the hospitality venues: Ankara – Altındağ, Çankaya, and Tunalı; İstanbul – Güngören, Üsküdar, and Zeytinburnu. Subsequently, two points were randomly chosen within each district as the start of a walking protocol, which was used to sample the venues nearest to these points¹⁰. Four types of venues were observed in each area: restaurants, traditional coffee houses, European-style cafés, and waterpipe coffee houses (Table 1). The collaboration for data collection involved Johns Hopkins University, IGTC, and Turkish academic experts from Kadir Has University, Hacettepe University, and Dokuz Eylul University, in partnership with the local Omega Contract Research Organization.

A total of 58 open-ended surveys were conducted with venue owners and staff. The interview guide was designed to address key topics related to compliance, including awareness of the smoke-free law, enforcement practices, perceptions of the law, and challenges faced in adhering to the regulations¹⁰ (Supplementary file). This study was planned before the pandemic and was postponed during the pandemic. During this pause, we decided to add a new component to understand the effects of this global crisis on the smoke-free policy in these most vulnerable types of hospitality venues. Consequently, the questionnaire included inquiries about any modifications in compliance levels with COVID-19 regulations.

Trained interviewers conducted interviews with Turkish venue representatives, which included owners, managers, and staff. Oral consent was obtained from each key informant before the interview commenced. In cases where interviewees opted out of audio recording, detailed written notes were taken to document their responses. Nineteen interviews were audio-recorded using recording devices, and the average interview duration was 15.19 minutes. Subsequently, these audio recordings were transcribed verbatim in Turkish and then translated into English.

This study was deemed non-human research by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. It also received ethics approval from Kadir Has University in Türkiye.

Data analysis

The data were analyzed using an inductive approach to allow for themes to emerge. The recordings and notes in Turkish were the primary sources of analysis. After becoming familiar with the data by reading the interview transcripts and listening to the audio recordings, the interview transcripts were entered into NVivo 12 software¹¹. The initial coding phase began with line-by-line coding of the text, followed by focused coding to identify patterns and to categorize the data into themes¹².

Venue owner and staff understanding of the smoke-free policy and its implementation

We asked the respondents what the positives of the smoke-free policy were, to understand their attitudes. The vast majority pointed towards protecting employees from SHS and eliminating SHS for customers and children. Some participants mentioned non-smoking customers’ satisfaction with the smoke-free policy:

‘I think these regulations work, people who smoke unintentionally violate the rights of people who do not smoke. These regulations eliminate this.’ (ID 6, Café owner, Ankara)

Some respondents believed the smoke-free policy worked, yet many saw issues with the implementation of the law. Even those who stated that the smoke-free policy was effective, mentioned that people only followed the rules and complied with the law when warned:

‘I think it has worked. Everybody is following the rules; they do not smoke when we say smoking is prohibited here.’ (ID 15, Café staff, Ankara)

However, others highlighted the importance of having proper enforcement and the business owner’s supportive attitude for the policy to work. The respondents who thought the smoke-free policy did not work, explained that the number of smokers does not seem to have decreased, and the main barrier to the implementation of the smoke-free policy is the high percentage of smokers:

‘I would allow smoking. No, as I said earlier, 90% of our customers smoke. Whatever they do, people still smoke. They put pictures of people with lung cancer and cerebral bleeding on it; people still smoke. I put it upside down on the table not to see them.’ (ID 50, Restaurant staff, Istanbul)

Some respondents added that the smoke-free policy did not work due to a lack of enforcement, and they thought the policy failed to prevent SHS:

‘I think it does not work, because there is no control for implementation.’ (ID 5, Café staff, Ankara)

Perceptions about what is working and what is not

The only part of the implementation process that is reported to be working were staff-to-customer warnings and negotiations, which were closely tied to the personal, smoke-free, supportive attitudes of the venue owners and staff. All other factors mentioned in the interviews can be considered as parts of the implementation that are failing and in need of improvement.

Attitudes of venue owners and staff

Participants reported that even though customers ask for ashtrays or indoor smoking, they understand and do not insist or object when the venue owners and staff say that smoking is prohibited indoors:

‘I mean people only ask if they can smoke here. Especially at these tables by the window, when we say no, they understand we don’t have any problems.’ (ID 11, Café staff, Istanbul)

The positive attitude of venue owners/staff was mostly seen to be rooted in this type of direct intervention. Their knowledge of the harmful health effects of SHS and the perception of the smoke-free policy motivated them to intervene and helped protect both customers and employees from SHS:

‘I think it is good in terms of protecting the health of both employees and non-smokers. I think it works to the extent that the controls are done. It can be ignored if compulsory controls are not done.’ (ID 53, Restaurant staff, Istanbul)

Attitudes of customers

Most of the respondents mentioned the negative attitude of customers towards the smoking ban as a barrier to the implementation of the smoke-free policy. They experienced some customers not staying for a long time, or leaving the venue, when they were warned and the smoke-free regulations were enforced. Moreover, some customers even insisted on smoking after being warned:

‘We experience some reactions like, “I will smoke indoors, who will be angry with me?”.’ (ID 43, Restaurant owner, Ankara)

With smokers leaving the venue and non-smokers complaining about exposure to SHS, the staff admitted to being in a difficult position as they either lost customers or condoned the non-compliance:

‘We are having issues with smokers among the customers, of course. He/she is sitting next to a closed window, there is a family at the next table, when we suggest changing his/her table they stand up and leave.’ (ID 54, Restaurant owner, Istanbul)

Furthermore, one participant highlighted that some customers feel justified in requesting to smoke in prohibited areas as they had been allowed to smoke in other venues/places that do not enforce the policy; this discourages some staff and venue owners to continue to implement the smoke-free policy:

‘You try to explain this, and they say no. They (the customers) yell in front of all the (other) customers saying, “Hey man, then I go and sit at the place across. They (other venues) will allow this”.’ (ID 14, Restaurant owner, Istanbul)

Economic concerns

The challenges in confronting customers on an individual basis have left many venue owners/managers concerned about losing customers. One participant stated:

‘The customer does not prefer us.’ (ID 27, Restaurant staff, Istanbul)

and another expressed concerns about the costs of providing a comfortable open space for smoking customers:

‘Customers do not want to smoke in the cold. We literally have to warm the street, which has a cost.’ (ID 38, Restaurant owner, Ankara)

all these accumulate to larger concerns about maintaining their businesses.

Physical properties of the venue

Several respondents brought up the definition of enclosed areas in the smoke-free policy as a barrier in their efforts to comply with the regulations. They elaborated that the policy prohibits smoking in areas with automatic or manual awning systems or windows for ceilings and side walls, even if they can stay open during the day:

‘The height of the wall is 60 cm to the windowsill [a glass wall]; it is totally an open space but still we are not compatible. We told them but they did not accept. They don’t want windows. They say it must be a garden. And very few places in Istanbul can accommodate this.’ (ID 14, Restaurant owner, Istanbul)

They added that the physical properties of their venue could not meet these standards and that having an ‘open space’ as described in the regulations was not possible for them. The current description of ‘open space’ is: ‘places without fixed or movable ceilings or roofs (such as open-air spaces), with at least three side surfaces permanently or temporarily open’. This type of description allows some, usually large, rooftop or garden access venues to have a ‘smoking open space’ while making such spaces very unlikely for small businesses. The respondents noted that if the regulations were equitably and forcefully enforced, worries about competitiveness would be greatly reduced.

Insufficient enforcement

All these concerns are tied to the main barrier that has been brought up by all our respondents: the issue of insufficient enforcement. The consensus among our participants was that the enforcement of the smoke-free policy was not being done or not being performed uniformly and effectively:

‘The rules do not apply to everyone equally.’ (ID 48, Restaurant staff, Ankara)

‘I think it works to the extent that the controls are done. It can be ignored if compulsory controls are not done.’ (ID 53, Restaurant staff, Istanbul)

In addition, the perception that violations have limited consequences due to insufficient enforcement causes some venue owners not to self-enforce the smoking ban as they witness unfair competition:

‘I was shocked when I saw people smoke there [A shopping mall]. When very big brands that we can’t even compete with don’t do this, it would be complete nonsense that we do.’ (ID 14, Restaurant owner, Istanbul)

COVID-19 pandemic and changes in compliance and implementation

All the above-mentioned issues were present before the COVID-19 pandemic occurred in the country. During the pandemic, all venues we interviewed were mandated to close for weeks and only re-open for take-away or delivery services for the following three months. This meant that small traditional tea and coffee shops that did not have deliverable menus had to remain closed, exacerbating economic difficulties.

We asked venue owners and employees how the pandemic changed their compliance practices. Several respondents talked about increased compliance among both venue staff and customers at the beginning of the pandemic. During the first few months of the pandemic, customers favored non-smoking places, were more reluctant to sit next to a smoker, and were more persistent in obeying the restrictions:

‘People don’t come and sit where there’s someone smoking at the next table, or don’t go to crowded places here and there where people can smoke, they change their ways. They look from the door and don’t get in if someone is smoking inside.’ (ID 21, Restaurant staff, Istanbul)

In terms of implementation, while the majority stated that there were no changes, some participants noted an increased awareness and cooperation of customers. They gave examples of customers smoking less, not insisting on smoking, and responding positively when asked not to smoke in the prohibited area:

‘Well, it made it easy for the smoking bans. At least when we said it to the customer, they were already afraid to take off their masks. Normally when they smoke cigarettes or water pipe, we have an excuse to warn them because of the pandemic, we say it’s forbidden and they fine us if we allow so they put the cigarette out.’ (ID 28, Restaurant staff, Istanbul)

On the other hand, some respondents highlighted the negative changes by describing the emotional and financial effects of the pandemic, due to restrictions for a long time, as barriers to implementation. They mentioned that customers were depressed and more prone to smoke while venues had less seating capacity – due to social distancing regulation – and were desperate for customers. Therefore, venues become more lenient with compliance:

‘Some customers’ persistence is increased. Everybody is relaxed. Once they insist very much, we allow smoking one cigarette if they seem to leave the place.’ (ID 46, Owner of venue with waterpipe service, Istanbul)

Recommendations for better implementation

Venue owners and staff were asked for their recommendations about what could be done by the government and the local municipality to improve the smoke-free policy implementation, as well as what they would do if they had the power to change things. Respondents’ responses could be categorized into two themes: the smoke-free policy content, and enforcement.

Türkiye’s smoke-free policy prohibits smoking in all indoor public places, including bars, restaurants, cafes, and shopping malls. This includes not only enclosed spaces but also semi-enclosed areas, such as covered terraces or balconies. The comprehensive scope of the prohibited areas is perceived to be causing difficulties in complying with the smoking ban. As a result, many suggested softening the indoor smoking ban and changing the law’s definition of enclosed areas:

‘I think the government should leave people alone in this situation. Because people really got into financial difficulties within a year and a half, within two years. There are those (MoH regulators and local police officers) who act flexibly, there are also those who fine directly and go. If I were them, visiting places, I wouldn’t be so strict.’ (ID 50, Restaurant staff, Istanbul)

Some suggested ‘smoking areas’ or filtered air ventilation to allow smoking indoors:

‘There can be signs on the door such as “smoking is allowed here” so that customers come accordingly. I mean like a smoking area. And I would like them to accept sliding awning. I think it would be enough if it is ventilated by 70%.’ (ID 48, Restaurant owner, Ankara)

There were also several suggestions for changing fines and regulation visit routines to be more deterrent and effective:

‘Generally, like I said I would raise the fines a bit more because I think it is very little money.’ (ID 22, Café staff, Istanbul)

‘The municipal police can do more frequent checks, outside and inside. They mostly work on complaints.’ (ID 21, Restaurant owner, Istanbul)

Limitations

There are some limitations in this study. Although ensuring diversity among venue types was considered the strength of this research, due to COVID-19 restrictions, bars, nightclubs, waterpipe and traditional tea houses were not fully operational at the time of the study. Thus, only a few waterpipe and traditional coffee houses were included, and no bars or nightclubs were visited for the study. Additionally, the study did not consider the smoking status of the participants. While the focus was on venue-level implementation of measures, smoking status could potentially influence individual interpretations and experiences. This aspect should be considered in future research to gain a more comprehensive understanding of the impact of smoking on the implementation of the policy. Furthermore, the study’s qualitative design may limit the generalizability of the findings to all types of venues in Türkiye. However, the qualitative design allows us to gain a deep understanding of the real-world experiences of participants and to uncover insights that may not be apparent from quantitative methods.