Normalised, accessible, and addictive: Socioecological drivers of gutka consumption among urban cloth shopkeepers in Karachi, Pakistan

Gutka, a commercially prepared smokeless tobacco product, is widely consumed in Pakistan and poses significant public health risks, including oral cancer and other chronic conditions. Cloth shopkeepers represent a particularly vulnerable occupational group due to long working hours, affordability pressures, and high-exposure social environments. This study aimed to examine the multi-level drivers of gutka initiation and sustained use among cloth shopkeepers in Karachi using a socioecological framework and to understand participants’ perceived health impacts and perspectives on existing public health and regulatory interventions. A qualitative exploratory study was conducted with 25 male cloth shopkeepers recruited from five markets across Karachi using quota sampling. In-depth interviews were conducted within participants’ workplace settings. Data were analysed using an inductive-deductive thematic analysis approach guided by the socioecological framework. Ethical approval was obtained from the Aga Khan University Ethics Review Committee. Four overarching thematic categories emerged across 12 sub-themes. At the individual level, participants demonstrated awareness of gutka's health risks, yet continued use through cognitive rationalisation, psychological and physical dependence, early initiation in adolescence, and affordability. At the interpersonal level, peer and family influence during formative years and within the workplace drove initiation and sustained use through normalisation. At the community level, gutka use was deeply embedded in market culture, with widespread social acceptance and unrestricted accessibility through informal supply networks. At the policy and structural level, participants described a clear policy-practice gap, with regulatory bans perceived as ineffective due to systemic corruption, advance raid warnings, and adaptive supply and consumption strategies that circumvented enforcement. Gutka consumption among cloth shopkeepers in Karachi is a complex, multi-determined behaviour sustained by addiction, social normalisation, affordability, and structural failures in regulation. Effective control requires strategies that simultaneously strengthen enforcement, address informal supply networks, provide accessible cessation support, and tackle deep-rooted social norms within occupational settings.