Bridging the gap between policy and practice: a mixed-methods study of tobacco control implementation challenges and community responses in Hyderabad, Sindh, Pakistan.

BACKGROUND

Pakistan is a party to the WHO Framework Convention on Tobacco Control and has enacted comprehensive tobacco control legislation, yet implementation remains weak. A mixed-methods study was conducted to explore implementation challenges, community response, and the health impact of this initiative among adult males in Hyderabad, Sindh.

METHODS

A convergent parallel design included 600 male adults (18-60 years) selected through multistage stratified random sampling and 15 in-depth interviews. Quantitative data were analyzed using structural equation modeling (SEM); qualitative data were analyzed thematically, guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

The prevalence of tobacco use was 67% (402/600). Among users, 52% had attempted to quit, while 0% had accessed cessation services despite wanting to quit. Low policy awareness: 16% were aware of cessation services, and 46% were aware of the smoke-free law. Most believed minors could easily obtain tobacco (74% thought enforcement was weak). The health burden also tended to be high: 76% of users showed tobacco-related symptoms, compared with only 43% of non-users (p < 0.001). The model fit the data well (CFI = 0.94, RMSEA = 0.048). Weak policy implementation directly predicted higher tobacco use (β = -0.41, p < 0.001), which in turn predicted poorer self-reported general health (β = 0.53, p < 0.001). Qualitative themes identified enforcement failures, the cultural normalization of noncompliance with public health laws, constructs within the healthcare system that enabled noncompliance, and economic constraints on enforcement.

CONCLUSION

The male population in Hyderabad faces a significant implementation gap, with the most severe failure being the absence of cessation services. Limitations, including male-only sampling, self-reported data, and a single-district focus, prevent generalization to women and to the whole of Pakistan. Immediate policy action is required to establish accessible cessation support, strengthen enforcement mechanisms, and integrate tobacco control into routine healthcare.