How Tobacco Companies Influence the Global Youth Peer Review 2019

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• Published: xix April 2020

Why is tobacco control progress in Indonesia stalled? - a qualitative analysis of interviews with tobacco command experts

BMC Public Health book xx, Article number:527 (2020) Cite this article

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Abstract

Groundwork

Republic of indonesia shoulders a pregnant tobacco brunt, with virtually two million cases of tobacco-related illnesses and more than two hundred k tobacco-related deaths annually. Indonesian tobacco control is progressing but lags behind other countries. Our study evaluates factors that contribute to the slow progress of tobacco policy change in Republic of indonesia from the perspective of tobacco control experts (TCEs).

Method

We conducted qualitative interviews with four international and 10 national TCEs, who have been agile in tobacco control for at to the lowest degree 5 years. Our interview guideline included questions on the current tobacco command situation in Republic of indonesia and explored reasons why tobacco command is progressing so slowly. The interviews were conducted either in English language or Bahasa Indonesia, recorded so transcribed verbatim. We conducted a thematic analysis based on v cadre causal factors for policy adoption: institutions, networks, socio-economical factors, agendas and ideas.

Results

The multistage delay of tobacco policy adoption is principally due to political structures and policy hierarchy, complex hierarchy, unclear roles and responsibilities, and a high degree of corruption. The low bargaining position and lack of respect for the Ministry of Health as well contributes. There are contrasting frames of tobacco as a strategic economic asset and tobacco command as a sovereignty threat. At that place is an imbalance of ability and influence between well entrenched and resourced tobacco industry networks compared to relatively young and less established tobacco command networks. The policy agenda is likely influenced by the privileged position of tobacco in Republic of indonesia as a socially acceptable production with high consumption. There are constraints on transferring ideas and testify to successful policy adoption.

Decision

Tobacco companies accept substantially influenced both policy decisions and public perceptions, signifying a power imbalance within the regime system and broader networks. Acceding to and enforcing the World Health Organization- Framework Convention on Tobacco Control (WHO-FCTC) would enable the Indonesian government to shift the power imbalance towards public health stakeholders. Tobacco control advocates must enhance their network cohesion and cover other community groups to improve engagement and advice with policymakers.

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Background

The adoption of the World Health Organisation Framework Convention on Tobacco Control (WHO-FCTC) marked the global consensus of the urgency to command the alarming tobacco epidemic. Ratifying countries recognised the detrimental consequences of tobacco use on health, socioeconomic condition, and the environment [1]. Indonesia is the only land in the Asia Pacific region that has yet to ratify the treaty despite the significant tobacco burden within the country.

Indonesia is habitation to almost i hundred million smokers, where 33.6% of the adult population and 19.4% of immature people age 13–15 years are smokers [2, 3]. A 2018 national survey showed smoking prevalence among youth 10–18 years former was ix.1%, a significant increment from 2013 at 7.two%, [four] and far higher than the government target of 5.four% in 2019. Republic of indonesia suffers an economic loss of United states$ 45.9 billion due to tobacco use, with almost ii million cases of tobacco-related illnesses and 230,862 tobacco-related deaths in 2015 [five].

Conversely, tobacco industry proponents argue that tobacco control will cause economic harm through loss of revenue and depriving tobacco farmers and manufacture workers from earning a living [half dozen]. A report of 1350 smallholder tobacco farmers in Indonesia showed that tobacco farming is not profitable for the farmer, nearly farmers are poor, and many suffer from green tobacco disease [vii]. Like to other settings, smoking prevalence in Republic of indonesia is higher among the lower socio-economical quintiles [viii]. Cigarettes are the second highest household expenditure after rice in both urban and rural area of Indonesia [9]. Cigarette smoking also contributes to long term family deprivation, specially children, due to reduced admission to proper diet and teaching which in plow makes it harder for the children to escape the poverty cycle as they go older [10].

Tobacco control advocates in Republic of indonesia accept been working at both the national and sub-national level with some promising results, with several sub-national governments adopting smoke-free regulations and fractional tobacco advertizement bans. At the national level, with the noted exception of the adoption of a 40% pictorial on-pack health alert, no meaning progress has been made. Indonesia remains one of the few countries that broadcasts cigarette advertisements on television, and its cigarette tax is amidst the lowest in the world. The size of the cigarette business in Indonesia seems to be an essential factor in this dull progress. Indonesia is the second largest cigarette marketplace in the earth, with an overall retail book of 316.1 billion sticks per twelvemonth in 2016 [11].

While there is evidence of complicities betwixt the tobacco industry and governments in almost all South East Asian (Association of southeast asian nations) countries, [12] the level of tobacco industry interference in policy making in Indonesia is the highest [13]. Additionally, tobacco companies present themselves equally upstanding corporations that contribute to authorities revenue, enact then-called corporate social responsibleness programs, and honor sponsorships [14]. However, the Indonesian government must increase its commitment to tobacco control measures if it hopes to stem the ascension epidemic and to harness the benefits of the predicted demographic dividend, where the working age grouping will reach 70% of the population by 2030 [xv].

Understanding what tobacco control experts (TCEs) perceive the underlying factors stalling and blocking tobacco command policy reforms in Indonesia provides insight for future advancement efforts. Our study evaluates factors that contribute to stagnant tobacco policy changes in Indonesia.

Method

Study design

This report is a qualitative exploration of TCEs' perspectives of factors that influence the slow progress of tobacco control policy in Indonesia.

Respondents

Our respondents were TCEs divers as individuals involved in tobacco control advocacy, research or a tobacco control focused organization, for at least 5 years, or who accept published works or been quoted in the media regarding tobacco control issues, and do not have whatsoever connection to the tobacco industry. We invited in total 16 (5 international and 11 national TCEs), and finally interviewed four international and 10 national TCEs, who have been working in tobacco command ranging from 5 to 40 years.

The selection of the international interviewees was based on their knowledge of Indonesian tobacco control. The national tobacco control experts represented academics, community organisations, and national and sub-national authorities stakeholders. Their expertise included: police force, media, health economics, public health, homo rights, and youth advocacy. Nosotros sent the interview invitation by email, described the purpose of the written report and provided the participant information argument. Once they agreed to participate, an interview time was arranged and conducted in September/October 2018.

Data collection

Interviews were conducted through face up-to-confront meetings and video calls, each lasting upwards to 60 min. We used an interview guide that contained a set up of initial questions (Supplementary file one), which were and so farther probed based on interviewee responses. The guide included questions on the TCEs perspectives of the electric current tobacco control situation in Republic of indonesia and reasons why tobacco control is not progressing well. The interviews were conducted either in English language or Bahasa Indonesia, recorded and and so transcribed verbatim. We ceased conducting interviews when we were satisfied that we had reached data saturation and had collected a range of views.

Theoretical framework

In guild to explore factors that influence the ho-hum progress of tobacco control, nosotros adopted the v cadre causal factors of policy processes proposed past Peter John [16], and adapted past Cairney et.al for tobacco command [17]. These 5 factors, defined in Table i, include institutions, networks, socio-economic factors, agendas and ideas [17]. Nosotros selected these factors to systematically understand the data, and to discuss relationships between these factors in the context of Indonesian tobacco command policy adoption and policy changes.

Table 1 Definition of five core causal factors^a

Full size table

Analysis

We conducted a step-wise thematic assay [xviii]. Kickoff, we conducted information immersion, where we read and re-read the information, to become immersed and familiar with its content; this was followed by a line by line coding of all interview content, conducted by writer PASA. We created codes that indicated important features of the data that might be relevant to our written report aim of examining policy factors. Our third step was to generate, review and refine themes, we examined our codes to place patterns of significant equally potential themes. Nosotros used the five causal factors described in Table ane every bit our initial guide to identifying themes, and and then we checked the themes confronting the dataset, and adult more detailed sub-themes. We refined the themes and sub-themes to build a coherent story based on our study aims. The second author (BF) reviewed the terminal set of themes and sub-themes to check that it was aligned with the data. We defined the scope and focus of each sub-theme and assigned each an informative name (Table 2). The concluding stride was writing upwardly the analysis, we weaved the analytic narrative, the themes and data extracts, and contextualised the analysis in relation to existing literature and the Indonesian context. We supported the results with direct quotes from the interviews, some of which are translated from Bahasa Republic of indonesia. We accept also provided the respondent number and position of the quoted TCEs.

Table 2 Final Themes and sub-themes

Full size table

Results

Institutions

This theme describes institutional barriers to establishing tobacco policies in Republic of indonesia. National policy changes may be influenced past domestic and inter-governmental institutions. For this analysis, we focused on documenting domestic institutions that may impact on tobacco command policy. We identified three sub-themes including: 1) political structure and blazon of policy: multistage delay, 2) hierarchy and degree of corruption, and iii) function of Ministry building of Health (MoH).

Political construction and blazon of policy: multistage delay

The Indonesian authorities system is a presidential democracy, where the president serves the executive role as both head of state and government. Administratively, Republic of indonesia is comprised of provinces, and districts/cities [nineteen]. These sub-national governments gained considerable autonomy over their jurisdictions after the adoption of the decentralisation policy in 1999 [20].

The TCEs highlighted weaknesses in the current national-level tobacco control regulation, PP 109/2019 [PP] [21]. The PP is a joint regulation between three ministries and is considered a compromised outcome. As well the partial nature of most of the tobacco command policies contained inside it, the regulation is vague and provides significant loopholes during stages of implementation. Most elements of the PP crave further regulatory activeness at either the national or sub-national level in order to be implemented.

When the PP was adopted in 2012, many people viewed it every bit a victory, simply when the implementation started, nosotros were not winning at all except for adoption of pictorial health warnings. Smoke-gratuitous police force, is it automatically adoptable? No! We need a joint conclusion letter from three ministries so that the sub-national authorities tin can create sub-national bylaw. (Respondent 3, Advocate).

In addition to national level deportment, policy making is also taking place at sub-national/provincial and district/city level. Some aspects of the PP were mandated to the sub-national level, [21] which makes sense given the decentralisation of authorities. The TCEs highlighted this condition as another potential delay, due to the large number, 514 in full, of cities/districts in Republic of indonesia, [19] the lack of political will of some sub-national policy makers, and the authorization of tobacco manufacture interference.

Unfortunately, that will have time, correct? Because if y'all have 500 cities and then it volition take hopefully not l years; 50 years ways ten cities per year, right? (Respondent 12, International adept)

As head of Indonesian Mayor Brotherhood, I did roadshows to several districts/cities. The result depends on the leader. It is amend to showtime from the area with no tobacco farmers because information technology is harder if the districts accept tobacco farmers. (Respondent 6, Sub-national leader).

Government hierarchy and corruption

The TCEs outlined the complication of bureaucracy and lack of coordination betwixt stakeholders, Ministries, and other regime bodies equally a significant hurdle to tobacco control progress in Indonesia. Unclear authority and responsibilities of each stakeholder has created delays in adequate implementation of the current regulation. TCEs pointed out that Ministries failed to take responsibility for monitoring cigarette advertisements and would pass to other Ministries/agencies. Coordination betwixt national, provincial and district/city level is not a elementary undertaking. District regulations demand to exist synchronised with provincial governments which furthers complicates the policy making procedure.

1 of the debates, I retrieve, who is in charge of cigarette ads, MoH did non consider it was their potency. Who has the say-so? It should exist under Ministry of Trade, this Minister, that Minister, it has non resolved (Respondent 3, Advocate)

Some districts (in East Coffee) have drafted a fume free police, which is currently going through a synchronisation stage at the provincial level. At the provincial level, in that location is a recommendation to postpone the smoke gratuitous by-laws, instructed by the governor. The governor stated "fume free laws should non be discussed for at present". (Respondent xi, Academic)

The current regulation also mandates that dissimilar government agencies handle sure aspects of implementation. However, unclear descriptions within the regulation take allowed agencies to shirk their responsibilities. The TCEs also shared that the PP has crippled the role of the Indonesian Food and Drug Monitoring Agency (BPOM). BPOM can consequence a warning letter but cannot impose whatever farther sanctions, every bit other agencies take responsibleness for enforcement oversight. For example, the Indonesian Broadcasting Commission (KPI) should monitor and enforce any violations of any broadcast media advertisements and sub-national governments are responsible for any outdoor ads.

So, PP 109 is "gnawing" abroad the monitoring role of BPOM. The mandate to monitor overall advertising, promotion and sponsorship should exist held by BPOM, except outdoor advertisements by the sub-national regime. But when the BPOM conducts monitoring, they are only able to write a recommendation alphabetic character. (Respondent 4, Abet) .

This complex bureaucracy, coupled with decentralisation, increases vulnerability to corruption [22, 23]. The TCEs argued that tobacco funds provided may support governments programs or exist part of corporate social responsibility (CSR) efforts to halt regulations.

Even so, there is another combination, a country with a loftier caste of corruption. I prefer to say it is political interest rather than personal involvement fifty-fifty though it may go into their pocket. It has been stated openly for ballot, for something like that. Information technology has been publicly said, basically. (Respondent 9, Advocate)

Role of Ministry of Health (MoH): low bargaining position

Significant positive shifts in global tobacco control, peculiarly in adult settings, is partially due to the leadership role of Ministries of Health and the successful framing of tobacco as a pressing public wellness consequence, and not as an economic asset [17]. In depression-centre income countries, while Ministries of Health are considered the nearly active Ministry, most have low influence, with some notable exceptions such equally Republic of india and Thailand [17].

TCEs highlighted the lack of leadership by the current MoH, the weak position of the MoH as the sole champion of tobacco command, and that it is often undermined past other Ministries. There is only limited cross-government support, notably from the Ministry of Women Empowerment and Kid Protection (MWECP).

And the Ministry of health is the weakest, which should be the near powerful because it is their chore and responsibility to reduce (smoking) prevalence. (Respondent 4, Abet)

Fifty-fifty Ministry of Education and Ministry of Youth & sports hesitates to support us, they volition say "we need the coin for sports and scholarships" (Respondent fourteen, Government official).

Meanwhile, there is active opposition within the government, especially from ministries with directly involvement with tobacco such as the Ministry building of Industry, Ministry building of Merchandise and Ministry building of Agronomics [6]. The TCE we interviewed who are MoH employees expressed difficulties in negotiating tobacco command with other more strategic ministries. The MoH is relegated to a weaker political position as information technology is seen as the national budget spender while these other, powerful ministries are the income earners.

Those who opposed and on the other side are Ministry building of industry, merchandise and agriculture. It is hard. (Respondent xiv, Government official)

Agendas

In this theme, we present the framings of tobacco and tobacco control which contribute to shaping the tobacco control policy agenda in Indonesia. There are 2 framings that were derived from our assay including political economy framing of the tobacco industry and political ideology framing of tobacco control equally a strange agenda.

Political economy frame of tobacco: nosotros demand the money-we need the employment

Tobacco companies in Indonesia maintain a positive reputation through their perceived contribution to revenue, farming, and employment [24]. Meanwhile, tobacco farming is non a major contributor to the agricultural sector, bookkeeping for only 200,000Ha, less than i%, of the farming surface area, [25] yet information technology is seen equally important especially in the tobacco growing provinces. TCEs highlighted that the government is "protecting" the tobacco industry and relies on cigarette revenue, which will significantly undermine tobacco command.

The regime quote unquote wanting to protect the tobacco manufacture in Republic of indonesia. First, of course the farmers, there is a large tobacco farming sectors in Indonesia, I mean Republic of indonesia is one of the largest tobacco leaves producers in the region and even in the world. So, it is something that, while we don't desire that, Indonesia will be promoting tobacco, information technology is seen by many politicians equally one of those sectors of gild, Indonesian society that they experience they need to protect because they are after all the citizens of the state … .The arguments that government has to protect tobacco farmers is not really a valid one, but, that's how it seen by politician (Respondent 12, International expert)

Sovereignty framing: tobacco control is an "outsider" project

Tobacco command is not yet seen as a priority calendar in Indonesia, even though tobacco employ is the fourth leading risk gene of morbidity and mortality, later high blood pressure level, dietary risks and high fasting plasma glucose [26]. The TCEs highlighted the consequences of this low attention on tobacco command. For instance, the Indonesian delivery to universal wellness coverage and other sustainable evolution goals (SDGs) volition be significantly stalled by poor tobacco control policy. In 2018, the national health insurance implementing body (BPJS Kesehatan) experienced a deficit, partly due to 21.07% spending on catastrophic diseases attributed to tobacco use [27].

"And it's peculiarly, is very respectable that Republic of indonesia pushing for universal wellness intendance. If you going to push the universal health care you can get bankrupt if you don't get over from the tobacco or at least reduce information technology drastically. At that place are some figures from Malaysia a few years ago where they said that threescore% of the authorities budget for wellness care was due to tobacco use. I mean 60% that's just massive, so if they really have that aspiration to health care for all, I don't encounter how you gonna practice without doing a lot more on tobacco" (Respondent 8, International expert)

Nevertheless, tobacco control efforts are progressing in Indonesia, both at the national and sub-national level. There is increasing awareness of the demand to reduce tobacco use and tobacco control is positively framed in the local media, [6] and more sub-national governments accept been gradually adopting fume-free regulations. Yet, many politicians still view tobacco command equally an "outsider" agenda, partly because foreign donors do back up some of the tobacco control advocacy campaigns and enquiry. The tobacco manufacture supporters debate that strange interests will negatively bear upon on Indonesian sovereignty [half dozen]. This argument is grossly unfair when considering that "foreign" tobacco companies control 42.5% of the cigarette marketplace share in Indonesia [28].

Can you imagine General who is in power at present stated that FCTC will ruin Indonesia'southward sovereignty, how come? FCTC aim to protect people to be healthy, productive and leap out of poverty, why he/she said destruct sovereignty! (Respondent 2, Bookish)

Networks

There is a longstanding power imbalance betwixt the tobacco manufacture network and the tobacco control network in Indonesia, that heavily favours the industry [24]. While some progress in tobacco control advocacy has occurred at both the national and subnational level, it has not shifted the ability residuum. This third theme comprises sub-themes represent the ii networks; namely the established and well-funded tobacco manufacture networks and the younger and less resourced tobacco command networks.

Tobacco industry network: established and well-funded

The tobacco industry is a major manufacture in Republic of indonesia, with annual cigarette production reaching 342 billion sticks in 2016 [2]. Tobacco company networks are well established and are bound past perceived economic benefits and some are supported by funding from the tobacco manufacture [24]. These networks include tobacco manufacturers, tobacco leafage growers/farmers, clove farmers, and interested community groups [2]. It is also supported by other players who do good from tobacco advertizement and marketing such as media and advertising companies and sponsorship recipients. The tobacco company networks accept stronger links to the policymakers as evidenced by the tobacco interference index score, Indonesia is ranked the highest amidst South East Asian countries [13].

Our tobacco command advocates here in Indonesia study that they are regularly learn nearly meeting in the national level betwixt tobacco executive and policy makers. So, the tobacco companies are very well entrenched. (Respondent 5, International expert)

But, don't be surprise that within the ministries there are lots of TI's frontline, and then, for case the vocalization of Ministry building of Industry similar to cigarette companies which was stated during the debates (development of PP). (Respondent 4, Advocate)

TCEs highlighted the fact that tobacco companies infiltrate the policy making process both directly and indirectly. They presented several examples such as significant changes to draft tobacco control regulations, [24] prolonged delays in revising tobacco command laws, and possible interference in a judicial review of broadcasting laws that practise not prohibit cigarette ads on telly. The government witnesses who spoke positively for tobacco in the judicial review included the telly, advertizing, farmer, and tobacco industry associations [29].

The original draft from Parliament commission I, the draft was included prohibition of cigarette commercials, but, when the draft reached baleg (unit within parliament in charge for law making), ^{Footnote 1} the unit changed it, similar to the current dissemination law. It just means that someone has a vested involvement, only two, the Television association who received the order and the 1 who gives the order because it is involves a huge amount of money. (Respondent 4 Advocate)

Failure of the judicial review on broadcasting law because constitution viewed cigarette equally a legal product, and so information technology is legal to being promoted, (but alcohol is also legal?). That is the ambiguous point, why products that are both addictive; both divisional past excise, have different treatment? Is this the tobacco industry interference in the judicative sector? (Respondent 4, Advocate)

Nigh Association of southeast asian nations countries limit industry participation in the policy making process, except Indonesia and The Philippines. These governments allow representatives from industry to take role in committees/advisory groups for public health policy and accept or support legislation drafted in collaboration with tobacco industry [13].

And of grade, the tobacco companies are not helping, they said that they are legal visitor, they should be stakeholders that need to be consulted. (Respondent 12, International expert)

Tobacco control network: resources and cohesion

In Indonesia, the tobacco control network was pioneered by five diverse groups: well-connected social activists, not-regime organizations (NGOs), health professionals, public wellness and economic researchers and international organisations, including the WHO [24]. The network has evolved and grown to include stakeholders and public wellness professionals from the sub-national level and now known every bit the Indonesia Tobacco Control Network (ITCN). Some of the TCEs describe the history of how this grouping developed, and the challenges it faced at the time, now, and in the futurity. They highlighted some concerns regarding advancement progress such equally limited resource, contested interests, and the solidity of the network.

At that place is internal friction partly for gaining funder sympathy … there is friction between A and B, to claim the credit. In that location are different views and approaches between groups. … , too, overlapping and uncoordinated programs betwixt organisations. This is weakening the solidity of the group and the tobacco industry knows that. (Respondent 9, Abet)

Tobacco control groups have less established connections to policymakers in comparing with tobacco companies [24]. However, the formation of the Mayor Alliance for Tobacco Command, [30] which has contributed to the adoption of smoke free regulations in more than a third of Indonesian districts/cities, is a sign of changing power dynamics. Public back up for tobacco control has also been increasing with the involvement of more advocacy groups and government sectors supporting the adoption of smoke free regulations in some Republic of indonesia districts/cities. There is a close and positive connection between the MoH and MWECP, which should widen to include other government departments.

I think that is the possibility now, especially now in Indonesia in the last five- ten years has developed a very strong civil society movement on tobacco. I think that is real opportunity for them to, to jump forward and not to have to go through the aforementioned 40 years process that, that other countries were through to arrive where they are at present. (Respondent 8, International skilful)

Internationally, collaborative networks for tobacco control take been growing, this was intensified during the WHO-FCTC negotiations with the institution of Framework Convention Brotherhood [31]. The international and regional networks take regularly held meetings and conferences to share policy practices and evidence and conducted trainings and workshops to raise tobacco control capacity. The TCEs described the back up from regional networks such every bit South Eastern asia Tobacco Control Brotherhood (SEATCA) and international partners such equally The Marriage, Vital Strategies, and Campaign for Tobacco Complimentary Kids (CTFK). In 2018, Republic of indonesia hosted the Asia Pacific Conference on Tobacco or Health (APACT) which was considered not only an opportunity to support Indonesian tobacco command advocates, only also to shame the government for its apathy towards tobacco command.

Well, WHO has been supporting Indonesia to attempt ratifying the framework convention, I recollect there was also even at coming together like this (APACT), it sorts of naming and shaming! It's actually embarrassing for Indonesia to exist hosting this conference while at the same time its ain national government is non actually … hhmm … ratified the framework convention. I tin run into enough of countries coming hither, countries where it's really difficult like Mongolia and Laos and Kingdom of cambodia. (Respondent 1, International expert)

Socio-economic factors

In this theme, we described the exclusive positioning of tobacco in Indonesia which contributes to its exception within the law and barriers to policy change. In Indonesia, tobacco is far less regulated when compared to alcohol. The privileged position of tobacco in Republic of indonesia is expressed in the high social acceptability of smoking and the high smoking rate. This special handling of tobacco is well documented in several Indonesian laws which halt tobacco control progress.

Social acceptability of tobacco: cigarettes are legal, and smoking is normal

While politicians position tobacco as a positive product in an economic sense, the community considers tobacco a socially acceptable product. Cigarette smoking has been deeply assimilated into the daily and social life of Indonesians [32]. The term "uang rokok" pregnant "cigarette money for tipping" is still widely used [24]. Cigarettes accept always been role of being a skillful host during social occasions [32]. These common practices are then manipulated by tobacco companies through aggressive marketing, advertizement and promotion, which then preserve and overblow positive views around smoking as part of the culture, as normal and socially adequate behaviour [32,33,34].

Because advertizing and promotion are congenital around letters that talk virtually independence, being individualistic, being successful, existence attractive, being powerful and around also peer acceptance. So, these are letters that are quite preferable by the youths. And so, they feel that smoking is normal, right? (Respondent 12, International proficient)

Moreover, inexpensive cigarette prices, selling unmarried sticks, and easy access have made cigarettes highly accessible to the population [34, 35]. There is a growing awareness around the negative affect of smoking, just the TCEs stated people generally have vague views on these health issues. Meanwhile, the tobacco industry is seen every bit a "normal" concern and "supportive" through its CSR efforts and community sponsorships [fourteen].

Information technology is an addictive legal business organisation with long term impact. You smoke then die; it is non like that. The time perspective about risk, we don't have it! That is why insurance is non popular here. Because there is no long-term take chances awareness. (People) Tin can't relate it (cigarette) with cancer, heart disease, because of that fourth dimension perspective and risk awareness. So, this status makes cigarette until at present is perceived as a "normal" product, treated every bit normal, which is one source of the failures of all regulations. (Respondent 9, Advocate)

While tobacco control aims to reduce smoking prevalence, the current high smoking rate itself is a hurdle to adoption of a stronger tobacco control policy [17]. In Republic of indonesia, smoking is considered an adequate behaviour especially past male, although this is not true of females, as evidenced by the ten-fold gap betwixt male person and female smoking rates [4]. At that place is a global pattern that the willingness to innovate tobacco control measures is higher when smoking prevalence is lower [17].

Well the barrier the high prevalence among men, it just politically impossible to tell the majority of people, we gonna take abroad your, accept abroad your cigarette. Then, I, I think you gonna have to bulldoze that down in other way (Respondent viii, International expert)

Tobacco is special: pre-emption of other laws

There is evidence of several exceptions given to tobacco compared to booze inside existing Indonesian laws. Both alcohol and cigarettes are considered addictive substances nether the police and as such must be controlled, nevertheless they are treated very differently. Based on broadcasting and press police, alcohol advertisements are banned from mass media platforms, but tobacco advertisements are permitted with few limitations.

Several laws, 1) Bill No twoscore/ 1999 on the journalistic/press, ii) Bill No 32, are quite like. The bespeak is that addictive substance cannot be advertised in print media, TV and electronic media, simply, cigarettes can; as long as it does not prove the cigarettes. It is non acknowledging that cigarette is addictive. (Respondent 9, Advocate).

Excise law is farther bear witness that illustrates how tobacco has a privileged position in comparison with alcohol. Excise tax for alcohol products is set at 80% while for cigarettes, it is capped at a maximum 57% of the retail toll, [36] considerably lower than WHO-FCTC standard minimum of lxx% [37].

The excise law gives privilege to tobacco products, the taxation differs from other excised goods, its lower-at maximum of 57%, while ethanol and alcohol drinkable up to fourscore%. (Respondent 4, Advocate)

In 2017, cigarettes were taxed at effectually fifty% of the retail toll for automobile rolled Kretek, 45% for white cigarettes and only 20% for hand rolled Kretek [38]. In September 2019, the Minister of Finance appear a tax increase of 23 and 35% of the retail price from January 2020, without yet specifying the taxation increase of each cigarette type [39]. This initiative is positive progress for Indonesian tobacco control especially given the government also plans to simplify the multiple tax tiers, but any further revenue enhancement increases will be express by the excise law.

Ideas and transfer of ideas

The growing and strong evidence of the wellness consequences of tobacco use drives policy changes; even though there is a notable time lag between the publication of testify and policy adoption, especially in low-middle income countries [17, 40]. Government adoption of proven tobacco control policy and programme ideas in Indonesia has lagged behind other comparable countries. Indonesia is an outlier in non ratifying the WHO-FCTC when all other Asia Pacific countries are committed.

I'thousand trying to be very diplomatic hhm, merely it'southward really hard to be diplomatic, considering the reality is the Indonesia is an outcast, information technology's in situation on its own in Asia. … And then many things where Republic of indonesia is really lagging behind in term of not fulfilling the pledge to public health and to await later on the health of its people. That's the bottom line, it is not really doing what it should be doing in term of public health. (Respondent 1, International practiced)

The TCE expressed relatively unlike views on whether the electric current evidence is enough to support tobacco control advocacy in Indonesia. Almost of the experts stated that in that location is enough testify effectually best practice that ideas are prepare adaptable for the Indonesian context.

There is already enough I think, the evidence. It is actually up to the presidents and the cabinets to make certain that the policies follow the evidence. (Respondent 12, International proficient)

On the other hand, several experts expressed the need for more local bear witness to counter opposition claims that most evidence is from exterior Republic of indonesia. There is a need to counter bug that are specific to Indonesia, such as the dominance of Kretek manufacturing and sales.

… you know that in Indonesia, they volition ever say, it is overseas (evidence) not in Republic of indonesia. Information technology e'er come up back to deprival like that. (Respondent 14, Government official)

… we don't have plenty skillful data to counter (tobacco manufacture) arguments, and then I said to my colleague at Research and Development middle (MoH), delight help! MoH who have funds should analyse if kretek contain unlike chemic compare to white cigarette. (Respondent 2, Academic)

The TCEs also suggested there are signs of obstruction of transfer of ideas, considering of the wilful ignorance of policymakers to ameliorate understand public wellness testify. Some TCEs also observed blocking of the transfer of ideas and testify to the President. The TCE expressed a positive view of the current President but suggested there are attempts to go on the President unknowledgeable near the real benefits of tobacco control.

I tried to approach the president from dissimilar ways but did not succeed. I heard there was an attempt maybe from the manufacture, I am not sure, to halt this. The inner circumvolve tries to keep him (the president) not fully understanding. At that place are structural barriers which make u.s.a. ineffective in short period. (Respondent 2, Bookish)

Discussion

Tobacco control policy adoption and implementation is influenced past many complex factors; our study captured factors stalling tobacco command progress in Indonesia from the perspectives of TCEs. Beside the underlying political construction of the decentralised government of Indonesia and its bureaucracy, about factors point to the power of the tobacco industry to influence the tobacco control policy agenda and public perceptions.

Bureaucracy and decentralized authorities

Different types of policy structures and power delegations are essential aspects of policy alter [17]. The intricate procedures inside a government organization, lack of coordination, poor accountability and competing interests betwixt regime sectors/agencies, contribute to policy adoption and implementation delays [41]. This circuitous hierarchy, coupled with ability decentralisation, increases vulnerability to abuse [22, 23]. The adoption and implementation of current national tobacco command regulation (PP) and overall tobacco control progress highlights the challenges of these institutional factors.

At a national level, coordination between ministries and government agencies remains a challenge given the opposing political and economical framing of tobacco coupled with the low bargaining position of the MoH. Besides opposition from ministries with direct ties to tobacco industry, overt supporters of the MoH are express. Ministries that focus on youth and future investment such equally Ministry of Youth & Sports, Ministry of Instruction & Culture, Ministry building of Inquiry & Higher Education, have not supported the MoH nor championed tobacco command, choosing instead to accept tobacco industry sponsorship [14]. Recently, the Ministry of Research and College Didactics publicly signed a memorandum of understanding with PT. HM Sampoerna, one of the largest tobacco companies in Republic of indonesia, for research investment and collaboration [42]. Meanwhile, at sub-national level, the PP is not readily implementable and is prone to implementation delay due to the vastness of Republic of indonesia. With substantial autonomy distributed to provincial and urban center/district level after the adoption of decentralised government system, [20] sub-national governments have not all urgently adopted tobacco control measures, specially when at that place is tobacco industry and/ or farming in their jurisdictions.

Tobacco industry power and influence

Likewise actors with decision making powers, such every bit legislators and government departments, the policy agenda is also contested past actors with non-controlling powers such equally individual corporations, in this example the tobacco manufacture [43]. The tobacco manufacture is a powerful industry in Republic of indonesia, 2 cigarette companies are in the superlative ten largest companies listed in the Indonesian stock exchange [44]. The owners of Indonesian tobacco companies pb the list of the wealthiest Indonesians: Hartono brothers, PT Djarum's owners and Susilo Wonowidjoyo, the possessor of PT Gudang Garam are the richest and second richest Indonesians respectively [45]. Historically, a fundamental tactic used by the tobacco industry to influence the policy agenda is to reframe public health arguments; this helps to shape policy preferences and divert attention from the importance of tobacco control [46, 47]. Tobacco industry coin, both straight and indirectly, influences political decision-making and inaction [24, 48]. For example, the cancelation of the almanac excise tax increase in Indonesia during the election year 2019, reflects the influence vested interests have on the election cycle and tobacco control.

To date, at that place is no code of conduct to prevent collaboration betwixt the tobacco industry and authorities bodies, except the policy adopted internally by The Ministry of Health, nor is at that place a requirement to report any tobacco industry contribution to political leaders/parties [13]. Nether the PP, tobacco company sponsorship is permitted, provided no brand logos are published, however, this has also been circumvented [33]. Advocacy for the adoption of a lawmaking of conduct past all regime agencies is necessary to minimise this complicit relation. Engaging with the Anti-Corruption Committee (KPK) is an opportunity for tobacco control stakeholders to open communication around reducing tobacco industry interference in policymaking [49].

Despite the stronger structural leverage and political connections to the tobacco company networks, [24] the tobacco control network is evolving. There is increasing public support locally and nationally, intensifying support from regional and international tobacco control networks and from local leaders through Mayor Alliance for Tobacco Control [30]. This positive progress is a sign of changing power dynamics, which should be nurtured by tobacco control advocates. The tobacco control advocates must also enhance their network cohesion and potentially embrace groups within other networks to build a more powerful coalition.

Tobacco exceptionalism and social norms

While the adoption of the WHO-FCTC equally the starting time international health treaty was celebrated as a pregnant public health movement, this special attending on the tobacco manufacture has raised critiques that the exceptionalism given to tobacco is counter-productive to the aim of tackling non communicable diseases (NCDs) more broadly; since the booze and junk food industries as well promote and sell products which significantly contribute to NCDs [l].

In Republic of indonesia, the near contrary situation exists, where tobacco is far less regulated when compared to alcohol. Besides the strong influence of the tobacco industry on the tobacco command policy agenda in Indonesia, this situation is probable correlated with religious norms in Indonesia, where there is a majority Muslim population. Alcohol consumption is haram (prohibited), under Islamic teaching, but views on cigarette smoking remain controversial, with smoking just frowned upon for young children, and women [51]. This controversy is reflected in the different views on smoking of the two major Islamic organisations in Indonesia. While Muhammadiyah released a fatwa (religious ruling) stating smoking every bit haram, the Nahdatul Ulama (NU) declared smoking as makruh (discouraged) [51]. The role religious institutions and perspectives play in shaping social norms around tobacco employ should also exist closely monitored by tobacco control stakeholders.

Additionally, positive norms and social acceptability of smoking is partially driven by omnipresent tobacco advertising, promotion and sponsorship (TAPS), and the high availability and accessibility of cigarettes among Indonesians. The current PP does not fairly restrict tobacco marketing and reduce TAPS exposure, especially among young people as reflected by the increasing smoking rate among immature people [iv]. Revision of the PP to optimally prefer TAPS ban outlined past in the WHO-FCTC article thirteen is urgently required [52].

Limitations

Our study is bailiwick to some limitations. The study merely considers TCEs perspectives on factors that are stalling tobacco control in Republic of indonesia and as such just covers the proponent side of tobacco command and may not reflects the views of other sectors. A future report could explore stakeholder perspectives from both proponents and opponents of tobacco control.

Conclusion

Large tobacco has essentially influenced both the policy decision process and public perceptions of its importance to the economy. WHO-FCTC ratification reluctance and the adoption of only partial tobacco command regulation is clear evidence of the power imbalance between the tobacco industry and tobacco command. The adoption of the PP was a pregnant stepping stone for tobacco control in Indonesia, merely its overdue evolution and delayed implementation signifies the ongoing struggle for tobacco control stakeholders to navigate complex and corrupt bureaucracies and powerful commercial interests. Engaging with the Anti-Corruption Commission (KPK) is an opportunity for tobacco command stakeholders to open up communication effectually reducing tobacco industry interference in policymaking [49]. Advocacy for the adoption of a code of acquit and revision of the PP to address loopholes regarding stakeholder responsibility should exist a priority.

The Indonesian regime could readily minimise the structural leverage of tobacco companies by adopting the WHO-FCTC and immediately fully implementing both Article five.3 on tobacco industry interference, [53] and Commodity 13 on tobacco advertizement bans [52]. The tobacco control advocates must likewise enhance their network cohesion and potentially embrace groups within other networks to build a more than powerful coalition. Date with policymakers could be improved by framing tobacco use as economic effect as well as a wellness business organization. The role religious institutions and perspectives play in shaping social norms around tobacco use should also be closely monitored by tobacco control stakeholders.

Availability of data and materials

The data are not publicly available due to containing information that could compromise research participant privacy/consent, but the data that support the findings of this report are bachelor on reasonable request. Delight contact the respective writer.

Notes

Abbreviations

ASEAN:

Clan of S East asia Nation

APACT:

Asia Pacific Briefing on Tobacco or Wellness

BPOM :

Badan Pengawas Obat dan Makanan (Food and Drug Monitoring Agency)

BPJS-Kesehatan :

Badan Penyelengara Jaminan Sosial-Kesehatan (Health Insurance Implementing Body)

CSR:

Corporate Social Responsibility

CTFK:

Campaign for Tobacco Free Kids

FCTC:

Framework Convention on Tobacco Control

ITCN:

Republic of indonesia Tobacco Control Network

KPI :

Komisi Penyiaran Indonesia (Indonesia Broadcasting Commission)

KPK :

Komisi Pemberantasan Korupsi (Anti-Corruption Commission)

MoH:

Ministry of Wellness

MWECP:

Ministry of Women Empowerment and Kid Protection

NCDs:

Non-Catching Diseases

NGOs:

Non-Regime Organizations

PP :

Peraturan Pemerintah (Authorities Regulation)

SEATCA:

South Eastern asia Tobacco Control Alliance

SDGs:

Sustainable Development Goals

TAPS:

Tobacco Ad, Promotion and Sponsorship

TCEs:

Tobacco Command Experts

WHO:

Globe Wellness System

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Acknowledgements

The authors thank the tobacco control experts for their valuable contribution to the study, and the reviewers for their thoughtful reviews of the newspaper.

Funding

PASA received scholarship from Indonesia Endowment for Education (LPDP) for her PhD. LPDP does non involve in the pattern of the study, in collection, analysis and estimation of the data and in writing of the manuscript.

Writer information

Affiliations

1. Department of Public Health and Preventive Medicine, Kinesthesia of Medicine, Udayana University, Denpasar, Bali, Indonesia

   Putu Ayu Swandewi Astuti

2. School of Public Health, The University of Sydney, Sydney, NSW, Commonwealth of australia

   Putu Ayu Swandewi Astuti & Becky Freeman

3. South Due east Asia Tobacco Command Alliance (SEATCA), Bangkok, Thailand

   Mary Assunta

4. Prevention Research Collaboration (PRC), Charles Perkins Eye, The Academy of Sydney, Sydney, NSW, Commonwealth of australia

   Becky Freeman

Contributions

PASA conceived the study, nerveless and analysed the data, and prepared the first typhoon of the manuscript. MA recommended choice of the TCEs and assisted with the manuscript editing and preparation. BF contributed to study blueprint, analysis, and writing and editing the manuscript. All authors hold with the last draft of the manuscript. The authors read and approved the final manuscript.

Respective author

Correspondence to Putu Ayu Swandewi Astuti.

Ethics declarations

Ethics approval and consent to participate

The study was canonical past The University of Sydney Research Ethics Commission. All respondents provided written consent to participate.

Consent for publication

For this manuscript, only the number of the respondents and their role in tobacco control were included, all participants consented for this to exist included in the publication.

Competing interests

The authors declare that they take no competing interests.

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Astuti, P.A.South., Assunta, M. & Freeman, B. Why is tobacco control progress in Indonesia stalled? - a qualitative analysis of interviews with tobacco command experts. BMC Public Wellness 20, 527 (2020). https://doi.org/10.1186/s12889-020-08640-half-dozen

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• Received: 05 November 2019

• Accepted: 02 April 2020

• Published: nineteen Apr 2020

• DOI : https://doi.org/10.1186/s12889-020-08640-6

Keywords

• Smoking
• Tobacco control
• Tobacco privilege
• Advancement
• WHO-FCTC
• Republic of indonesia

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