Smoke-free Turkey: Evaluation of outdoor areas of public places

Significance: Secondhand tobacco smoke (SHS) exposure is a major cause of morbidity and mortality around the world. The objective of this study was to evaluate the presence of smoking in outdoor areas of public places in three largest Turkish cities (Istanbul, Ankara, and Izmir). Method: For this cross-sectional observational study, the Turkish Statistical Institute randomly selected 10 sampling points in each city. Around each sampling point, fieldworkers visited the closest bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses, universities, children's playgrounds, parks and open markets. We observed smoking, ashtrays, and cigarette butts at the outdoor areas of public venues within the urban districts of each city. The fieldwork was conducted in April–May 2016. Results: 477 venues were observed, covering 1017 outdoor locations in which 17,737 people were observed. Smoking in outdoor areas ranged from 3.7% around schools to 90% in open markets. Ashtrays were almost ubiquitous in hospitals (95.6%), shopping malls (92.0%), and universities (90.9%). Cigarette butts were more often observed in open markets (100%), shopping malls (96%), universities (95.5%), and parks (93.3%). Smoking at outdoor areas around schools was significantly lower than around other venues. Conclusion: Smoking in outdoor areas was common in most public places in Turkey except schools. The current indoor SHS legislation should be extended to cover adjacent outdoor areas of public venues in order to effectively protect people from SHS exposure in Turkey.