Tobacco Free Cities: implementation research with city governments in Bangladesh, Pakistan and Vietnam

It is well known that smoking tobacco is bad for your health, but breathing in other people's smoke is also dangerous. In fact, it estimated that in 2021 alone, tobacco killed more than 8 million people worldwide, and of these 1.3 million were due to second-hand smoke. Most of these deaths were in low- and middle-income countries. In crowded cities, exposure to tobacco smoke is particularly high, as is the supply and advertising of cigarettes. Yet, cities can be at the forefront of change by passing by-laws, working across sectors and using mass media.
Laws that forbid smoking in public places have been shown to be an effective way to reduce exposure to second-hand smoke. The challenge, however, is in enforcing these laws. This is particularly challenging in rapidly growing cities. For instance, in the three countries we plan to study i.e., Bangladesh, Pakistan and Vietnam, while there are laws that forbid smoking in public places, the compliance is very low. In Bangladesh 42.7% of adults who worked indoors and 44% of those who used public transport were exposed to tobacco smoke; in Vietnam compliance in restaurants is just 30.9%, in bars 36.2%, and 42% in cafes. In Karachi, Pakistan only 57% of public places complied with smoke-free laws.
In this 4-year study our aim is to use an action research approach to generate knowledge to enable city administrations in Bangladesh, Pakistan, and Vietnam to implement evidence-based, context-specific strategies to ensure compliance with laws on smoke free public places by 1) exploring strategies that promote smoke-free cities 2) Evaluating implementation of smoke-free laws and their economic value. 3) Understanding adaptation of evidence-based strategies to promote smoke-free cities. 4) Building capacities among researchers and implementers to conduct implementation research in urban contexts.
To understand implementation in a range of contexts, we will work in one mega and one smaller city in each country. The action research approach involves continuous cycles of 'plan-act-reflect-observe' involving those who are immersed in the issue in their everyday work and lives. We will work closely with city authorities to establish or strengthen existing taskforces that will bring together actors across city departments and sectors who are responsible for ensuring the implementation of these laws. The taskforce in each city will work through the action research cycles to optimise implementation strategies - our researchers will share data from 6 monthly observations of compliance and regular surveys in their selected public places to help them reflect and reshape strategies throughout the process. Qualitative observations and interviews will help understand the process.
Throughout we will share knowledge widely, and document lessons learnt through 'learning histories' for each city. These will serve as guidance to support sustainable implementation and scale up in other cities in study countries and beyond.

In 2021, tobacco killed more than 8 million people worldwide; of these 1.3 million were due to second-hand smoke (SHS). Two-thirds of these SHS-related deaths were among women and children in low- and middle-income countries (LMICs). Exposure to SHS increases risk of respiratory infections, asthma, cardiovascular diseases, cancers and poor birth outcomes. Protecting people from SHS offers major population health benefits. LMICs are urbanising rapidly; conditions in cities fuel uptake of smoking, particularly among those vulnerable to non-communicable diseases. Despite high smoking prevalence, existence of smoke free laws and potential health and liveability gains, implementation of smoke-free public places in Asian cities is inadequate.
Aim: To enable city actors in Bangladesh, Pakistan, and Vietnam to implement evidence-based, context-specific strategies to ensure smoke-free public places. Objectives: 1) Explore strategies that promote smoke-free cities 2) Evaluate implementation of smoke-free laws and understand their economic value. 3) Generate insights on adaptation of evidence-based strategies to promote smoke-free cities. 4) Build capacities among researchers and implementers to conduct implementation research in urban contexts.
To understand implementation in a range of contexts, we will work in one mega and one smaller city in each country (6 cities). We take an action research approach, guided by the RE-AIM framework.
Phase 1 - Reconnaissance (mnth 1-12): Baseline observation of compliance in public places, questionnaires, qualitative interviews with public space users, stakeholder mapping, rapid reviews, and analysis of existing datasets.
Phase 2 - Co-design (month 12-18): task forces of city actors and public panels will agree public places to target and select implementation strategies from an evidence-based toolbox.
Phase 3 - Action-research (mnth 18-45): Each taskforce will work through cycles of plan, act, observe and reflect, working with our