Introduction

According to the Global Adult Tobacco Survey (GATS) conducted in 2016 in Ethiopia, 3.7% (approximately 2.5 million) of adults (6.2% of men and 1.2% of women) were current cigarette smokers [1], and the smoking prevalence is predicted to rise [2–4]. Exposure of non-smokers to the secondhand tobacco smoke (SHS) is a major concern [5]. From Ethiopia’s 2016 GATS, 31% of adults aged 15 years and older who visited restaurants, and 60% who visited bars/nightclubs, were exposed to SHS from tobacco in the 30 days preceding the survey [1]. It has been demonstrated that comprehensive smoke-free legislation effectively reduces SHS exposure among customers, bartenders and workers at hospitality venues (HVs) [6]. Furthermore, it reduces smoking among adolescents and young people [7].

Studies in sub-Saharan Africa (SSA) have indicated that there is a lack of knowledge among HV workers about the smoke-free laws and their requirements, leading to low levels of compliance [8–10]. Furthermore, research in SSA, including Uganda, Ghana, and Kenya, has shown a high prevalence of indoor smoking in HVs [8,11,12], with workers in bars and nightclubs experiencing higher levels of SHS exposure [13,14] and a greater risk of lung cancer mortality [15]. This environment not only endangers workers but also affects vulnerable populations, as children living with a smoker have a significantly higher prevalence of asthma and wheeze, underscoring the urgent need to prevent SHS exposure to safeguard respiratory health [16,17].

Ethiopia enacted a new comprehensive tobacco control law in 2019 (Proclamation No.1112/2019) [18]. The proclamation requires 100% smoke-free indoor public places and workplaces, including HVs. Smoking and the use of tobacco products are prohibited in all indoor workplaces, public places, public institutions, modes of transportation, and communal areas. The proclamation also prohibits designated smoking areas (DSAs) in public places. Additionally, it prohibits the use of any tobacco product in outdoor spaces within a 10-meter radius of any public place or workplace doorway, window, or air intake mechanism, thereby ensuring a comprehensive smoke-free environment. Furthermore, the proclamation mandates that the owner of the public place or another authorized person must post a ‘no smoking’ signage and prohibit tobacco use or sale in any part of indoor workplaces. Adherence to the law’s requirements involves implementing comprehensive measures designed not only to prevent active smoking in prohibited areas but also to eliminate enabling factors that may undermine a smoke-free environment [18].

A recent scoping review on SHS and smoke-free environments in Ethiopia identified only two studies that assessed compliance with smoke-free laws [19]. One of the two studies was restricted to five government hospitals in Addis Ababa [20] and was conducted prior to the enactment of Proclamation No.1112/2019 [11]. The second study was conducted in 2021 in public places such as those providing food and beverages, schools, health facilities, government offices, youth centers, parks and transit facilities in four regions [10].

Compliance with smoke-free laws is a key pillar of tobacco control policy implementation; however, there is a scarcity of evidence on the extent of compliance with smoke-free laws in Ethiopia, particularly in HVs, which exacerbates the health risks associated with SHS exposure. Therefore, we conducted an assessment of compliance with smoke-free laws in HVs in Ethiopia to provide decision-makers with the evidence they need to strengthen their efforts in protecting non-smokers from exposure to SHS.

In this study, we assessed the implementation of smoke-free laws, focusing on two related concepts: compliance with the smoking ban and adherence to the law’s requirements. Compliance refers to the law’s effectiveness in preventing active smoking in prohibited areas and serves as a key indicator of its success. While, adherence encompasses how HVs comply with various provisions, such as displaying ’no smoking’ signage, removing ashtrays and lighters, banning DSAs, absence of cigarette butts, prohibiting the sale of tobacco products in HVs, and forbidding tobacco use within a 10-meter radius of doorways, windows, or air intake mechanisms of public workplaces. By distinguishing between these concepts, this study aims to clarify the effectiveness of smoke-free legislation.

Methods

Results

Characteristics of hospitality venues

Data were collected from a total of 1,370 HVs in 10 cities. About 76% (n = 1,041) of the 1,370 HVs only had indoor spaces, whereas 23.9% (n = 327) had both indoor and outdoor spaces, while two (0.1%) had only outdoor areas. Addis Ababa had the highest number of venues (20.8%), followed by Adama (11.4%), Hawassa (11.3%), and Bahir Dar (10.7%) (Table 1). The remaining six cities were represented by between 7.4% and 7.9% of the HVs. Hotels accounted for 19.3% of all venues, followed by bars and restaurants (17.4%), cafés and restaurants (14.8%), and restaurants (14.7%).

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Table 1. Type of hospitality venues by city.

https://doi.org/10.1371/journal.pone.0319079.t001

Indoor compliance with the law and adherence to the requirements

Table 2 shows compliance and adherence with indoor smoke-free indicators across cities and HVs. There was no active smoking in 67.8% of the HVs. The highest adherence was for the absence of DSAs (98.2%) and shisha equipment (98%). Absence of cigarette butts (64.0%), ’no smoking’ signage (64.8%), and no outdoor smoking within 10-meter range of doors or windows (50.2%) were the least adhered to. Adherence with no tobacco product sales was generally high, with Jigjiga showing full adherence, but it was lower in Semera-Logia (46.3%) and among nightclubs/lounges (50%). Most HVs showed high adherence for the absence of ashtrays and lighters, but these enabling aids were more common in bars and nightclubs/lounges. Overall, compliance varied by venue type, with cafés and restaurants showing high adherence, while bars and nightclubs/lounges had the lowest compliance or adherence rates for key indicators.

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Table 2. Compliance with the law and adherence to the requirements in indoor areas by city and HV type.

https://doi.org/10.1371/journal.pone.0319079.t002

Only 12.8% of the indoor areas were fully adherent to smoke-free law requirements, and full adherence was the highest in Addis Ababa (22.2%) and cafés and restaurant (23.5%), while poor adherence was the highest in Dire Dawa (25.2%) and nightclubs/lounges (41.4%) (Table 3).

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Table 3. Indoor adherence level with smoke-free requirements by city and HV type.

https://doi.org/10.1371/journal.pone.0319079.t003

Outdoor compliance with the law and adherence with requirements

Table 4 shows that there was no active smoking for 53.5% of the outdoor spaces. There was high outdoor adherence to the absence of ashtrays (98.8%) and DSAs (96.4%). However, lower adherence rates were observed for ‘no smoking’ signage (33.1%), and absence of cigarette butts (38.6%). City comparisons show significant variations: Bahir Dar reported 100% compliance for no active smoking and 100% adherence to the absence of ashtrays, but only 8.3% had ‘no smoking’ signage. Jigjiga demonstrated strong compliance (86.2%) for no active smoking, but there was no ‘no smoking’ signage observed. Semera-Logia had the lowest rates for no active smoking (34.3%) although it had the highest rate for signage (59.3%). Hotels and cafés also showed relatively high compliance and adherence, unlike bars and nightclubs/lounges, which had very low no active smoking and ‘no smoking’ signage.

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Table 4. Smoke-free indicators in outdoor spaces by city and HV type.

https://doi.org/10.1371/journal.pone.0319079.t004

About 39% of outdoor spaces in the HVs were highly adherent to smoke-free law requirements, whereas about 42% were found to be in poor adherence with the law requirements (Table 5).

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Table 5. Outdoor adherence level with smoke-free laws by city and HV type.

https://doi.org/10.1371/journal.pone.0319079.t005

Factors associated with indoor active smoking and presence of cigarette butts

Table 6 presents results from a bivariate and multivariable Poisson regression model examining predictors of ‘active smoking’ and presence of ‘cigarette butts’ in indoor HVs. The prevalence of active smoking and cigarette butts were significantly higher in Semera-Logia and Dire Dawa, both before and after adjustment. After adjustment, venues in Semera-Logia were over two times more likely to have ‘active smoking’ (aPR: 2.71; 95% CI: 2.00–3.66), while cigarette butts prevalence was about three times higher (aPR: 2.96; 95% CI: 2.23–3.93) than Addis Ababa. Groceries, bars, and nightclubs/lounges had significantly higher prevalence of active smoking and cigarette butts than cafés/restaurants, both before and after adjustment. ‘No smoking’ signs were associated with reduced prevalence of ‘active smoking’ (aPR: 0.77; 95% CI: 0.67–0.89). The presence of lighters was strongly associated with higher prevalence of both active smoking (aPR: 1.69; 95% CI: 1.41–2.02 and cigarette butts (aPR: 1.90; 95% CI: 1.58–2.27), before and after adjustment. The presence of tobacco products for sale (aPR: 1.58; 95% CI: 1.34–1.86) and someone smoking within 10-meter range of air intake (aPR: 2.67; 95% CI: 2.13–3.32) strongly associated with higher prevalence of active smoking, before and after adjustment.

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Table 6. Bivariate and multivariable Poisson regression predictors of presence of ‘active smoking’ and ‘cigarette butts’ in indoor places.

https://doi.org/10.1371/journal.pone.0319079.t006

Discussion

About 68% of HVs in our study complied with smoke-free laws in their indoor spaces, defined as ‘no indoor active smoking’. The findings of this study highlight significant discrepancies in adherence to smoke-free laws across various indicators. Adherence was notably low for the presence of cigarette butts (64%) and the ‘no smoking’ signage (47%). In contrast, adherence was high for the absence of DSAs (98.2%) and shisha equipment (98%), along with the absence of ashtrays (94.8%) and lighters (89.2%). Outdoor compliance regarding active smoking was concerning at only 53.5%, with adherence to signage even lower (33.1%). Only 12.8% of venues were fully adherent in indoor areas.

Active smoking was observed in 32.2% of indoor areas and 49.5% of outdoor spaces across various HVs and cities, which is higher than a previous Ethiopian study from 2021 that reported active smoking in only 7% of bars, restaurants, and cafés, and 10% in hotels [10]. This discrepancy may arise from differences in observation timing, variations in venue types, and the higher prevalence of smoking in the cities included in our study compared to the regions assessed in the previous study. A study in Ghana found active smoking in 34.5% of restaurants and 63.6% of bars [11], while in Uganda, it was 18% in HVs [8]. These variations underscore the inconsistent implementation and enforcement of smoke-free laws across HV types, and within and between countries. The higher prevalence of outdoor smoking in our study raises the hypothesis that smokers may be shifting to outdoor areas in response to indoor smoking bans. Furthermore, it is plausible that the HV managers may encourage outdoor smoking if indoor smoking makes customers uncomfortable. A review of compliance facilitators and barriers highlights that smokers with greater knowledge of smoking harms and supportive attitudes toward bans are more likely to adhere to them, while heavier nicotine dependence and negative attitudes can impede adherence [26].

Although the presence of ‘no smoking’ signage was low in our study (35% in indoors and 33% in outdoor spaces), it was still higher than a previous study in Ethiopia, which reported only 17% of bars and restaurants, and 29% of hotels posted ‘no smoking’ signage [10]. In Ghana, the presence of such signage was 49.5% [11], with similar findings in other studies [27,28]. Interestingly, our study found exceptionally high adherence rates regarding the absence of DSAs and shisha equipment, suggesting that smoke-free legislation might be effective in specific contexts where enforcement and public health campaigns are prioritized. However, these findings must be viewed alongside lower compliance rates for key indicators such as absence of active smoking, suggesting that while venues may be successful in removing smoking aids, challenges remain in ensuring comprehensive adherence to all smoke-free law requirements [10,29]. Thus, strategies to maintain high levels of adherence to all aspects of smoke-free legislation are essential to protect public health effectively.

Our study revealed regional differences in compliance with smoke-free laws at HVs in Ethiopia, with higher rates in cities like Addis Ababa, Jigjiga, Adama, and Harar, and lower rates in Dire Dawa and Semera-Logia. These differences may be attributed to variations in the local tobacco control environment and the implementation of smoke-free laws. Compliance rates also varied across venue types, with cafés and restaurants demonstrating the highest adherence, while bars and nightclubs/lounges consistently displayed the lowest. This aligns with findings from other studies, indicating that HVs like bars and nightclubs often show low compliance [30]. In Uganda, compliance was particularly low in bars and restaurants, highlighting ongoing challenges in these venues [31]. Thus, targeted interventions in high-risk venues and cities where smoking is normalized are essential. Implementing stronger penalties, consistent monitoring, and removing enabling factors such as tobacco product sales and lighters could enhance compliance.

The presence of ’no smoking’ signage was significantly associated with reduced prevalence of venues with active smoking in violation of the ban. In contrast, the presence of lighters, tobacco product sales, and outdoor smoking within 10-meter range of indoor air intakes were associated with increased smoking rates and cigarette butt prevalence. This aligns with research from Turkey, where indoor cigarette sales and ashtrays were strongly associated with higher indoor smoking rates and cigarette butt availability [32]. In Greece, ashtrays were strongly associated with increased particulate matter (PM_2.5) levels, indicating their role in encouraging smoking behaviors [33]. However, our research found that ashtrays did not predict compliance with smoke-free laws. Notably, while the Turkish study indicated that ’no smoking’ signage did not associate with reduced smoking prevalence, our study showed a significant association between such signage and decreased prevalence of venues with active smoking and cigarette butts. This finding is supported by other studies [10,28], where a significant association was found between the presence of ’no smoking’ signage and reduced prevalence of venues with active smoking. While our study indicates a moderate association between the presence of ’no smoking’ signage and the reduced prevalence of venues with active smoking, the results highlight the potential benefit of context-specific enforcement strategies and enhanced visual enforcement, such as prominent ‘no smoking’ signage, along other measures.

Smoking within a 10-meter radius of indoor air intakes poses a significant risk for SHS exposure in HVs, as outdoor tobacco smoke concentrations can easily reach indoors [34]. Our findings show that smoking within this proximity is associated with increased indoor smoking activity in venues and a higher prevalence of cigarette butts, undermining smoke-free policies designed to safeguard indoor air quality. Studies confirm that outdoor tobacco smoke levels remain hazardous even at distances up to nine meters from the source and can infiltrate indoor environments via air intakes [34,35]. Implementing buffer zones around entrances and ventilation intakes could help mitigate SHS infiltration, ensuring better protection for patrons and staff in smoke-free venues.

In our study, full adherence to smoke-free law requirements was observed in only 12.8% of indoor venues, highlighting the significant challenges in enforcing smoke-free regulations, particularly in bars and nightclubs/lounges, and in cities such as Semera-Logia, where adherence was notably low. These findings are consistent with a recent study across four regions in Ethiopia, which reported 12% full compliance in public places [10]. However, the public places assessed in that study, which included government buildings, educational facilities, and transport hubs, differ from the HVs included in our research. Additionally, full compliance in their study was defined as both the absence of active smoking and adherence to smoke-free law requirements. Similar variability in compliance has been noted in other countries. For example, Ghana reported a 70% compliance rate [36], while Bangladesh showed 58% compliance indoors and only 27% outdoors [29]. Meanwhile, studies from Nepal [28] and India [27] reported compliance rates of 26% and 80% in HVs, respectively. These differences emphasize the variability of compliance across settings and suggest that targeted interventions are essential, particularly in environments where social activities and tobacco use are prevalent.

Strict enforcement significantly boosts compliance with smoking bans, as evidenced by a very high compliance rate of 98% in Punjab, India [27]. High compliance levels are often achieved through robust enforcement infrastructure, regular inspections, and penalties [26,37]. Countries that actively involve local authorities, strong political support for smoke-free legislation, and implement prominent ‘no smoking’ signage see substantial compliance improvements [26,37]. Involving local jurisdictions in enforcement, particularly through training for inspections, is crucial for maintaining high compliance rates [37]. This localized involvement enables authorities to address specific community dynamics, enhancing enforcement effectiveness. Efficient smoking ban implementation, including clear rewards and punishments, reduces non-compliance [26]. Conversely, inadequate surveillance leads to higher smoking rates, underscoring the need for consistent monitoring. Furthermore, enabling factors like ashtrays in public spaces contribute to increased smoking rates even after smoke-free laws are enacted [26].

The findings of this study have significant policy implications for enhancing tobacco control efforts in Ethiopia, particularly in cities and HVs with lower compliance. The observed variability in compliance across different locations underscores the necessity of tailoring strategies to fit local contexts and dynamics. Strengthening the implementation of Proclamation No. 1112/2019 [18] and Directive No. 771/2021 [23] is crucial for establishing a robust enforcement framework. Given the high non-compliance with the “no smoking within 10-meter” requirement of the law, the presence of lighters, and the sales of tobacco products, focusing on the enforcement of these factors seems advisable when designing implementation efforts, either through enforcement authorities or public education. Additionally, increasing the visibility and enforcement of ‘no smoking’ signage can serve as an effective policy measure. Despite the moderate association found in this study, international experience shows that clear signage and local authority involvement significantly boost compliance rates [26,37]. Future research should investigate the underlying factors contributing to the low compliance rates observed in HVs, such as bars and nightclubs/lounges, as well as in Semera-Logia city. This exploration will help identify targeted strategies for enhancing enforcement and adherence to smoke-free laws.

Strengths and limitations

This study is the first large-scale investigation of HVs across 10 major cities in Ethiopia, ensuring diverse context representations. The use of covert observations enhanced data authenticity, providing accurate compliance assessments. The inclusion of multiple indoor and outdoor smoke-free laws indicators offers a detailed understanding of compliance and adherence levels. However, incomplete lists of registered HVs may have led to sampling bias, and the cross-sectional design limits causal conclusions. Despite these limitations, the study provides valuable data and highlights areas needing targeted efforts to improve compliance with smoke-free laws.

Conclusions

Compliance with ‘no active smoking’ and adherence tosmoke-free law requirements in HVs remain low, particularly in bars, nightclubs/lounges, and Semera-Logia, with high rates of active smoking both indoors and outdoors. Key factors contributing to non-compliance include ’smoking within 10-meter’, the presence of lighters, and the sale of tobacco products. Stronger enforcement and targeted interventions are needed to address the low adherence to smoke-free laws. Collaboration among tobacco control stakeholders and the active engagement of local authorities is essential to educate the public and HV owners about the risks of SHS and foster a healthier community. Enhanced monitoring of compliance and adherence, alongside enhanced enforcement of the ’no smoking within 10-meter’ requirement, addressing the presence of lighters, regulating the sales of tobacco products, enforcing ’no smoking’ signage, and implementing stricter penalties for violations are crucial. These measures, combined with targeted interventions and collaboration among tobacco control stakeholders, can significantly enhance tobacco control efforts in Ethiopia. Expanding efforts to include informal venues could also provide a more comprehensive understanding of compliance.

Supporting information

Acknowledgments

We would like to thank the study team members from Addis Ababa University School of Public Health, Development Gateway: An IREX Venture, Tobacco Control Data Initiative Ethiopia, Ethiopian Food and Drug Authority, and Regional Tobacco Control Regulatory Offices for their valuable support in this study. We are also grateful to all of our data collectors, supervisors, and coordinators who actively participated in this study.