INTRODUCTION

Internationally, tobacco control advocacy gained momentum as the mounting evidence established the negative health effects of smoking, followed by a shift from framing tobacco as an economic asset to viewing it as a public health threat [1]. In the majority of high-income countries, the adoption of strong tobacco control policies has led to decreasing smoking rates. However, many low-income and middle-income nations, where 80% of the world’s 1.3 billion smokers reside [2], are lagging behind in advancing reforms. Indonesia, home to the largest smoking population in the Southeast Asian region, is an outlier nation for not ratifying the World Health Organization Framework Convention for Tobacco Control (WHO FCTC).

The Indonesian government acknowledged the need to regulate tobacco for the first time under the Health Law No. 23/1992, which was then further developed under the government regulation PP 81/1999 [3]. Since then, there has been some progress in Indonesian tobacco control, marked by the adoption of the Health Law 36/2009 and the government regulation, PP 109/2012, which includes some tobacco control measures [4,5]. However, there are many loopholes in the regulation that enable tobacco companies to continue promoting products freely in all promotional channels [6,7]. Tobacco advertising is permitted on national television between 9.30 p.m. and 5.00 a.m., and the law only includes limitations on tobacco advertising, promotions, and sponsorship (TAPS) such as regulating the size and placement of outdoor billboards and the placement of print media promotion, as well as prohibiting publicity of tobacco sponsorship for sport, music, and community events. The regulation also requires a 40% pictorial health warning (PHW) on cigarette packs. The patchwork nature of PP 109/2012 is considered a highly compromised outcome that benefits the pro-tobacco sector [8].

Tobacco control progress in Indonesia is stagnant due to several factors, including tobacco industry (TI) interference in the policy-making process, the complexity of the policy system, and distorted public perceptions around smoking, tobacco companies, and tobacco control. Indonesian tobacco companies are well entrenched in the policy-making system and are directly involved in policy-making processes [9-12]. The industry has also gained significant political and public support due to positive framing of its contribution to revenue, the labour force, and so-called corporate social responsibility (CSR) initiatives [9,13]. In 2014 and 2015, the Philip Morris International CSR budget for Indonesia accounted for three-quarters of its total CSR budget for all Southeast Asian countries [13].

Meanwhile, tobacco control advocacy groups in Indonesia are constrained by limited resources, the absence of formal leadership, and a lack of capacity to fight tobacco companies [9]. Advocacy is also challenging due to the fragmented geography of Indonesia and complex government administration. Administratively, the Indonesian government is composed of 34 provinces and 514 districts/cities [14]. After the adoption of the decentralisation policy in 1999, sub-national governments gained considerable autonomy over their jurisdictions [15]. For tobacco control, both provincial and district governments can adopt bylaws as long as they align with the provisions of the regulations at the higher administrative level. With policymaking opportunities available at both the national and subnational levels, there is growing policy advocacy at the subnational level. As of mid-2020, 67% of Indonesian districts/cities have adopted smoke-free regulations, which also prohibit TAPS in designated public places [16]. Despite these improvements, tobacco control in Indonesia remains lax compared to international standards and has not impacted the growing tobacco use epidemic. The latest national health survey showed a small decline in the adult smoking prevalence from 36.3% in 2013 to 33.8% in 2018, but a significant increase in the smoking rate among youth 10-18 years of age, from 7.2% to 9.1% [17]. Cigarette prices are low and cigarettes are accessible to young people both in their neighbourhoods and near schools [18].

There is an urgent need for the Indonesian government to place stringent controls on TI marketing and retailing in order to reduce the appeal and accessibility of cigarettes, especially among young people. Exposure to TAPS through different media channels was reported by the majority of student aged 13-15 years old: 65.2% on the television and at points of sale, 60.9% in outdoor advertising, and 36.2% on the Internet and social media, while 60.6% could purchase cigarettes freely despite their age [19]. A study conducted in 2017 on self-reported TAPS exposure from online and offline platforms among 2820 school-aged adolescents from 22 schools in 7 cities of Indonesia found that exposure to TAPS on online platforms was high on Instagram (29.6%), while in terms of offline avenues, TAPS exposure was high on television (74.0%), through billboards (54.4%), and at live music events (46.2%). The students also reported seeing outdoor advertising mainly on the streets and at minimarkets [20].

Tobacco control stakeholders (TCSs) who are involved in tobacco control research and advocacy both at the national and sub-national levels are well placed to provide an assessment of the likelihood of advancing tobacco control measures. This information should be beneficial to guide tobacco policy advocacy in Indonesia and other settings with similar demographic, geographic, and political situations. This paper aimed to explore TCSs’ perspectives on the desirability and feasibility of strengthening tobacco advertising and retailing regulation, and tobacco control advocacy in Indonesia in the next 5 years (2019-2024). We also discuss factors and approaches to enhance the F of policy adoption and implementation.

METHODS

Study Design

This was a modified Delphi study [21]. The Delphi framework provided an organized method for correlating the different views of TCSs on what is essential for strengthening future TAPS, pack labelling, and marketing regulations, as well as policy advocacy in Indonesia. While Delphi studies usually aim to find consensus regarding an issue or a problem, in this study the method was modified to explore TCSs’ views while also providing an opportunity for them to review responses from other participants.

Respondents

Our respondents were Indonesian TCSs who were members of the Indonesia Tobacco Control Network (ITCN) WhatsApp group. The group was established on July 26, 2013, with about 40 members. Group membership is based on recommendation and approval from a minimum of 2 other existing group members. The ITCN group members are tobacco control advocates from different organisations, mostly based in Jakarta. As of April 15, 2019, the total group membership was 100, including the study leader, who did not participate in the research. The initial invitation to participate in the study was sent to the WhatsApp group, then again to each individual along with the participant information statement. When an ITCN member agreed to participate, a link to an online questionnaire and the consent form was provided to ensure anonymity of participation on the study.

Data Collection

We collected the information in 2 waves using a questionnaire from April to July 2019. The questionnaire comprised a set of closed and open-ended questions, which were divided into 3 sections: (1) TAPS ban and pack labelling regulation, (2) marketing and retailing regulation, and (3) strategies to improve tobacco control policy and advocacy in the next 5 years (to be reported in another paper). The questionnaire was developed based on the findings of a qualitative exploration of Indonesian and international tobacco control experts’ perspectives on factors influencing the slow progress of tobacco control policy in Indonesia, as reported in another published paper [12].

Survey Wave 1

In the first-wave questionnaire (Supplemental Material 1), we explored the desirability and feasibility of the 3 areas listed above. The respondents scored the items using an ordinal scale of 1 to 5 from 1 (least desirable/feasible) to 5 (highly desirable/feasible) and provided comments or arguments if they wished. We then summarized the scores and the comments, and presented these as part of the second-wave questionnaire.

Survey Wave 2

For the second wave, we focused on technical feasibility (TF) and political feasibility (PF) (Table 1). The respondents scored the items using an ordinal scale of 1 to 5 from 1 (least feasible) to 5 (highly feasible) and provided comments or arguments on any items they wished. We sent the second-wave questionnaire (Supplemental Material 2) only to those who responded to the first wave.

Data Analysis

We conducted a descriptive analysis of the scores using Stata/IC.13 and summarised the comments for each item. For the descriptive statistics, we reported the median (Md) to show the average response and interquartile range (IQR) to describe the dispersion of responses. Responses were considered to show strong agreement if the IQR was 0, good agreement if the IQR was 1-1.5, and a dispersed response if the IQR was ≥2.

Ethics Statement

The study was approved by the University of Sydney Ethics Committee (grant No. 2018/628).

RESULTS

Tobacco Control Stakeholders

Of the 99 ITCN group members, 41 responded to our firstwave questionnaire invitation, giving a response rate of 41.4%. We had proportionate male and female respondents and an almost equal proportion of advocates who were above age 40 years and below 40 years. The majority (28 of 40; 68.3%) had a master’s degree or above, and the respondents represented both experienced TCSs who had been working for more than 10 years in the field (11 of 41; 26.8%), and those who had been involved in tobacco control for less than 5 years (14 of 41; 34.2%). In terms of level of advocacy, respondents worked in both national and sub-national settings, and had different topic areas of expertise and advocacy (Table 2). Almost three-quarters (30 of 41; 73.2%) of the respondents went on to respond to the second-wave questionnaire.

Desirability and Feasibility of Tobacco Advertising, Promotions, and Sponsorship Bans and Pack Labelling

We listed 6 TAPS and pack labelling regulatory measures: TAPS ban in all media, product display ban, ban on direct promotional selling, ban on tobacco-sponsored events, ban on tobacco company CSR, and adoption of plain packaging (Table 3). In the first wave, the TCSs all agreed that all these TAPS measures are highly desirable (Md, 5; IQR, 0 to 1). They scored feasibility much lower than desirability with more dispersed responses (Md, 3; IQR, 2) for all measures, except for the feasibility of banning TI CSR, which had a lower median score of 2.

TCSs scored TF consistently higher than political feasibility for all measures listed in wave 2. All the listed TAPS ban and pack labelling approaches were given a TF score of 4; some with a good agreement (IQR, 1), including banning TAPS in all media, banning tobacco-sponsored events and adoption of plain packaging, and a more dispersed score (IQR, 2) for banning TAPS and tobacco displays at all retailers, banning direct promotional selling, and banning all types of TI CSR. The PF scores were similar to the feasibility scores from wave 1, with most achieving a median score of 3. Whilst the median score for the adoption of plain packaging was also 3, the CSR ban was viewed as the least politically feasible with a median score of 2, the TCSs commented that the feasibility of each measure was dependant on the commitment of government stakeholders. Areas that could be adopted through sub-national governments were viewed as more feasible, including bans on outdoor/indoor billboards, tobacco display bans, and bans on sponsoring events. While the adoption of plain packaging was considered a stretch from current policy, a CSR ban was viewed as the least feasible measure due to the high dependence of some (public or private) organisations on tobacco money and the obligation of corporations to conduct CSR initiatives under Indonesian law.

Desirability and Feasibility of Marketing and Retailing Regulations

For the marketing and retailing regulations, we collated 5 measures, including prohibition of selling to minors, prohibition of selling single sticks, increased cigarette prices, adoption of a retailer licensing scheme, and adoption of retailer zoning around schools (Table 4). The TCSs viewed almost all measures as highly desirable, with median score of 5 and cohesive responses (IQR, 0 to 1), except for adoption of a licensing scheme, which had more diverse responses (IQR, 2). The TCSs considered adoption of zoning and prohibition of sales to minors as 2 of the most feasible marketing regulation measures, both technically and politically (Md, 4; IQR, 2). Measures to increase cigarette prices and to adopt a licensing scheme were considered technically feasible (Md, 4; IQR, 1 to 2), but regarded as less feasible politically with a median score of 3 and 2, respectively. Meanwhile, prohibition of selling single sticks was considered to have moderate feasibility from both technical and political aspects (Md, 3; IQR, 1 to 2).

The TCSs commented that while the prohibition of selling to minors and selling single sticks already exist in the current regulation, these measures have not yet been enforced. The prohibition of sales to minors has higher political appeal as it solely targets young people, while the prohibition of selling single sticks will potentially be resisted by the public. Adoption of zoning laws to prohibit cigarette selling around schools was also considered feasible, and some districts have introduced this measure as part of smoke-free bylaws. The TCSs viewed these 3 measures as attainable with high commitment from sub-national governments, collaborative action, and increased awareness among retailers and other stakeholders. However, the TCSs were concerned with difficulties in monitoring and enforcement and the challenges posed by the difference between formal and informal retailers (such as street vendors). Meanwhile, the introduction of a national licensing scheme was considered a far-off target for current Indonesian tobacco control, but it may be feasible at a sub-national level.

DISCUSSION

The current national tobacco control regulation (PP 109/2012) has not adequately addressed tobacco use in Indonesia. For the next 5 years (2019-2024), the Indonesian TCSs were more optimistic that real policy change, especially around TAPS bans, will occur at a sub-national level and less positive regarding provisions under the national governments’ control such as a CSR ban and adoption of larger PHW or plain packaging.

Tobacco Advertising, Promotions, and Sponsorship and Marketing Regulations: Navigating Through the Sub-national Level

Indonesia remains a TI “Disneyland,” [22] as tobacco promotion and advertising is pervasive, innovative, and amplified through the use of online media [6,7]. Without dismissing the urgency to strengthen national regulations and to ratify the WHO FCTC, sub-national governments are considered a more promising policy-making space for most TAPS ban measures. The TCSs viewed the adoption of measures that fall under subnational government jurisdiction as more likely to be attainable, despite being limited to outdoor/indoor advertising, sponsored events, direct/personal selling, and retailer advertising and tobacco product displays.

Political commitment and a strong stance on tobacco control of sub-national leaders have been observed as a significant boost for local change. The WHO reports on the case study of Bogor city [23] in Indonesia and Balanga city [24] in the Philippines suggest that sub-national governments are able to implement stronger measures to ban TAPS compared to national provisions and to create a smoke-free environment despite opposition from TI groups.

There are several strategies to improve sub-national leaders’ commitment. Firstly, acknowledgement of provinces/districts/cities that demonstrate progress in tobacco control could become a source of motivation for sub-national governments to act [25,26]. Secondly, strengthening and widening the membership of the Mayor/Regents Alliance for non-communicable diseases and tobacco control [27] is also important, and could be boosted with the involvement of Ministry of Home Affairs, as it is the reporting authority for sub-national governments. Thirdly, the promotion of child-friendly cities under the Ministry of Women and Child Empowerment should also be optimally employed by tobacco control advocates [28]. These strategies will also bring along several other ministries to join the tobacco control movement to leverage support for the Ministry of Health (MoH), which currently serves as the sole champion [12].

While advocacy on smoke-free laws is progressing, the inclusion of stronger and more comprehensive TAPS bans is vital. Advocates should also expand policy advocacy to tobacco retail regulation, which could include prohibition of selling to minors, prohibition of single stick sales, and prohibition of selling in certain areas, such as around schools [18]. Given that 7 years after the adoption of PP 109/2012, no sub-national government has adopted a bylaw to implement the prohibition of selling tobacco to minors, this reflects a missed opportunity for sub-national action. Capacity building for sub-national stakeholders and involvement of more stakeholders and community representatives, potentially including retailers, is necessary. Sub-national governments should also be informed of the opportunity to strengthen sub-national tobacco control by allocating their tobacco tax share to tobacco control initiatives [29].

A less optimistic view of progress at the national level was expressed—unless significant political changes, including the appointment of a Minister of Health who is more committed to advance tobacco control, happen in the next 5 years. It is the MoH’s responsibility to encourage other ministries to adopt the same perspective on tobacco control, and more assertive actions should be taken to achieve this goal. Coordination of tobacco control activities through a national collaborative centre, such as been adopted in Thailand through its “Thai Health” program [30], would assist both the MoH and tobacco control advocates in strengthening actions.

Plain Packaging and Corporate Social Responsibility Ban: A Challenge

Plain/standardised packaging is considered the best practice for minimising TI marketing and brand communication via cigarette packs [31]. In Indonesia, the adoption of the current 40% pictorial warning was in itself very challenging; therefore, the TCSs viewed it as less feasible to adopt plain packaging in the next 5 years. Moreover, Indonesia was one of the countries that challenged Australia’s landmark plain packaging laws through the World Trade Organization [32]. Nevertheless, the MoH is planning to increase the size of PHW on cigarette packs to 90% as part of the revision of PP 109/2012 [33]. This significant size increase, if implemented, will significantly reduce TI on-pack marketing effectiveness.

Prohibition of TI CSR was considered the least achievable measure under a TAPS ban in the next 5 years. This is due to the established positive image of CSR activities and reliance on TI support for educational initiatives and sports. Moreover, there is potential pre-emption from the Law on Corporation (UU PT) that obliges all corporations to conduct CSR activities [34]. The revision of PP 109/2012 should include a CSR activity ban, and in the future, revision of UU PT should be considered to exclude the TI and other harmful industries from conducting any CSR activities. Advocacy on CSR should involve advocates from different sectors outside tobacco control.

Besides CSR, there are other aspects that may intersect between advocates such as reducing corporate influence on policy-making and implementation of transparent procedures in policy development. This entails putting in place good governance measures as enshrined in Article 5.3 of the WHO FCTC, which addresses TI interference. This will enable the Indonesian government to reduce TI interference and structural leverage [35]. Another essential entry point is to align tobacco control advocacy with anti-corruption and efficient bureaucracy reform.

Our study is subject to some limitations. The response rate was only 41.4%, which may reflect the fact that our target respondents were busy professionals, although we made several attempts to contact all target participants. Nonetheless, we had a relatively balanced response in terms of sex, age, and experience in tobacco control. Another limitation of the study is that it may not fully reflect government stakeholder perspectives, as only 1 active and 1 retired government stakeholder were involved in the study; however, we optimally engaged 2 of the 3 group members with government links. A future study should explore the perspectives of government stakeholders across different sectors.

In summary, in the next 5 years, there are several positive expectations that sub-national governments will strengthen their tobacco control regulations, mainly focusing on smoke-free public spaces and TAPS bans. There is less optimism for meaningful changes at the national level, especially for a ban of TI CSR and adoption of a larger PHW. The PF of TAPS and marketing regulations depends on political commitment and conflicts of interest among stakeholders and the TI. It will be crucial to reduce TI leverage by implementing the measures found in Article 5.3 of the WHO FCTC, which impose good governance and steps to eradicate corruption. It is also essential to engage other ministries to support the MoH to flip the viewpoint on the public health impacts of tobacco to focus on factors beyond short-term economic interests.

SUPPLEMENTAL MATERIALS

Notes

CONFLICT OF INTEREST

The authors have no conflicts of interest associated with the material presented in this paper.

FUNDING

The study was funded by the Indonesian Endowment Fund for Education (LPDP), Ministry of Finance, Republic of Indonesia.

ACKNOWLEDGEMENTS

Notes

AUTHOR CONTRIBUTIONS

Conceptualization: PASA, BF. Data curation: PASA. Formal analysis: PASA, BF. Funding acquisition: PASA. Methodology: PASA, BF, MA. Project administration: PASA. Visualization: PASA, BF. Writing – original draft: PASA. Writing – review & editing: PASA, BF, MA.

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Figure & Data

References

Citations

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