The Effect of Cigarette Content Marketing on Students' Smoking Behavior and Decisions: A PLS-SEM Approach.

OBJECTIVE: This research aims to analyze the influence of cigarette content marketing on student behavior, and on cigarette purchasing decisions, as well as the influence of behavior on cigarette purchasing decisions. METHODS: This research is quantitative, using a sample of 500 smoking students from twelve universities in the city of Medan, Indonesia, who were selected using a simple random sampling technique. Data collection was carried out by distributing questionnaires that had been tested for convergent validity with an Outer Loading value > 0.7 and an AVE value > 0.5, and for discriminant validity with an HTMT value < 0.9. The data was analyzed using a multivariate analysis technique which combines factor analysis and regression analysis. RESULTS: The research results show that the t-statistical value for the behavioral variable (BHV) is 4.128 (> 1.98) and the p-value is 0.000 (< 0.05), which means that the BHV variable has a significant effect on the cigarette purchasing decision variable (PD). The t-statistical value for the content marketing (CM) variable is 27.57 (> 1.98) and the p-value is 0.000 (< 0.05), which means that the CM variable has a significant effect on the BHV variable. The t-statistical value for the CM variable is 18,542 (> 1.98) and the p-value is 0.000 (< 0.05), which means that the CM variable has a significant effect on the PD variable.  93.2% of respondents admitted that they had seen cigarette marketing content on social media, many of them (43%) believed that smoking was detrimental to their health, but the most influential factor was their perception regarding the activity of smoking. CONCLUSION: Cigarette marketing content has been proven to influence students' behavior towards cigarettes, as well as directly influencing their decision to purchase cigarettes. Students' behavior towards cigarettes also influences their decisions in purchasing cigarettes.

Barriers and opportunities for improving smoke-free area implementation in Banda Aceh city, Indonesia: a qualitative study.

OBJECTIVES: To investigate the challenges and opportunities for implementing smoke-free areas (SFAs) within eight area categories using the WHO Framework Convention on Tobacco Control as a framework for analysis. DESIGN: This study used qualitative methods (in-depth interviews and document reviews). All transcripts from the interviews and formal documents were coded using NVivo V.11 software and analysed using an inductive thematic analysis. SETTING: Banda Aceh, Indonesia. PARTICIPANTS: Seventy-three participants were interviewed, stratified by ages (18-59 years): policymakers (n=4), SFA implementers (n=33), SFA's non-compliance prosecutors (n=2), SFA observers (n=4), communities/respected figures (n=30); and 10 documents were reviewed. RESULTS: Barriers to the effective implementation of SFAs were identified: conflict of interests of Banda Aceh authorities in implementing SFA policies; inadequate monitoring, evaluation and implementation of SFAs among involved actors; inadequate public communication of SFAs to communities; and misunderstanding of 'enclosed areas' as SFAs. However, some important opportunities were identified: the Ministry of Education promotes SFA at schools; and smoking prohibition as part of sharia and other religions' recommendations. CONCLUSIONS: This research is the first study to examine SFAs to understand the challenges and opportunities for improving SFA policy implementation by interviewing various key respondents in Banda Aceh (religious leaders and respected figures). These key stakeholders' roles are crucial to enhance the implementation of SFA policies in Banda Aceh (currently suboptimal) and other populous Muslim areas in Indonesia or other countries because smoking contradicts Islamic teachings and other religions' tenets. Further, the findings propose policymakers and involved agencies strengthen public communication, execution, monitoring and evaluation, and enforcement of SFA policies in Aceh. Finally, the application of methods and results from this study to other local areas in Indonesia or other developing nations is necessary to facilitate further understanding more about the applicability, advantages and limitations of this study.

Income Disparity and Healthcare Utilization: Lessons from Indonesia's National Health Insurance Claim Data.

BACKGROUND: Indonesia's National Health Insurance Program, known as Jaminan Kesehatan Nasional (JKN), has a variety of membership pathways for those wishing to gain access. Claim data from JKN offers a cost-effective way of observing who is accessing healthcare services and what types of services are being used. This study is a novel attempt to measure disparities amongst JKN users in their engagement with services, providing an opportunity to reflect on patterns of use. METHODS: Using claims data collected from JKN users between 2015-2016, we used the Ordinary Least Square estimation model to compare health services utilization among subsidized and non-subsidized users. We focused primarily on the individual use of the hospital for outpatient and inpatient treatment. RESULTS: Analysis reveals that subsidized users access primary healthcare services more frequently than non-subsidized users. Conversely, non-subsidized users access secondary and tertiary health care services more frequently than other users. Subsidized users who utilize secondary and tertiary health care tend to suffer more severe health illnesses than non-subsidized members. CONCLUSIONS: This study concludes that income disparity affects healthcare utilization. Non-subsidized members are more likely than subsidized members to access secondary and tertiary health care services. Our study offers evidence of the potential underutilization of secondary and tertiary healthcare (STHC) by subsidized members, which could lead to inefficiency since subsidized members seeking STHC treatment had severe health conditions, thus needing to be treated longer and requiring higher healthcare expenditures.

Assessing the Policy of Non-Smoking Areas in Schools in Indonesia: A Mixed Methods Study.

BACKGROUND: Regulations in the form of Regional Regulations on Non-Smoking Areas are efforts to prevent smoking in schools. We will show qualitatively and quantitatively whether the policy can control smoke-free schools since 2015 in Muaro Jambi Regency. However, the implementation is still not optimal, even almost not implemented following the mandate of government regulation Number 109 of 2012 and regional regulation Number 5 of 2018. This study aims to evaluate the implementation of the smoke-free area policy in schools in Muaro Jambi Regency. METHOD: Research using mixed method study employing quantitative through distribution survey of smoke-free zones and qualitative by interviewing 31 schools of informants and observing 499 points of educational institutions. Selection of informants by considering the criteria of adequacy and suitability of data analysis with content analysis. RESULTS: The cause of the non-implementation of the smoke-free area policy is the lack of socialization of local regulations. The regulation of non-smoking area bylaws has not been made, implementing rules with the decree of the law. Schools do not run areas without cigarettes because they do not fully understand the rules, namely that they are not allowed to smoke in all school environments and health facilities. Oversight of the no-smoking area policy has not been carried out due to the lack of policy support from policymakers and sources of funds for monitoring the no-smoking area. CONCLUSION: No smoking area policy is meaningless if there is neglect in its implementation so that it does not impact the compliance of smoking behavior following the No Smoking Area policy. The need for the commitment of school leaders in implementing and operational rules from the regional regulations in the implementation of smoke-free areas.

Health taxes in Indonesia: a review of policy debates on the tobacco, alcoholic beverages and sugar-sweetened beverage taxes in the media.

INTRODUCTION: One of the WHO's 'best buys' in controlling non-communicable diseases and their risk factors is to impose health taxes. While the Indonesian political process inhibits the implementation of health tax policy, studies to discuss the issue remain limited. METHODS: We employed media analysis to document health tax policy dynamics, for example, the changes in policy timeline and key actors' statements. We conducted an article search in the Open-Source Intelligence database using appropriate terminology on three commodities, for example, tobacco, alcoholic beverages and sugar-sweetened beverages (SSB). RESULTS: Throughout the 15 years of implementation (2007-2022), tobacco has received the most policy attention compared with the other two commodities. This is mainly related to the increasing tariff and reforming the tax structure. As Indonesia is a Muslim-majority country, alcohol consumption is low, and a tax on alcoholic beverages was nearly unchanging and lacked media coverage. Ministry of Finance (MoF) officials are key opinion leaders often cited in the media for health taxes. MoF's support for health taxes is important to pass and implement health taxes. While SSB taxation is emerging, key opinion leaders' media statements imply policy contestation, leading to delayed implementation. The policy debates on tobacco taxation implied election years as a major challenge for health tax passages. During the political years, anti-health tax arguments emerged from politicians. While the political contestation on SSB concluded that accentuating the health tax arguments in favour of public health generates the strongest opposition against taxation from the industry. CONCLUSIONS: Politics of tobacco tax implementation are complex-compared with the other two commodities. The political context drives the divided views among policy-makers. Policy recommendations include generating public allies with key religious opinion leaders, continuing capacity building for politicians and Ministry of Health, and generating evidence-based arguments in favour of public health for MoF.

Framing health taxes: learning from low- and middle-income countries.

Health taxes are effective policy instruments to save lives, raise government revenues and improve equity. Health taxes, however, directly conflict with commercial actors' interests. Both pro-tax health advocates and anti-tax industry representatives seek to frame health tax policy. Yet, little is known about which frames resonate in which settings and how framing can most effectively advance or limit policies. To fill this gap, we conducted qualitative research in 2022, including focus group discussions, in-depth interviews, document reviews and media analysis on the political economy of health taxes across eight low-income and middle-income countries. Studies captured multiple actors constructing context-specific frames, often tied to broader economic, health and administrative considerations. Findings suggest that no single frame dominates; in fact, a plurality of different frames exist and shape discourse and policymaking. There was no clear trade-off between health and economic framing of health tax policy proposals, nor a straightforward way to handle concerns around earmarking. Understanding how to best position health taxes can empower health policymakers with more persuasive framings for health taxes and can support them to develop broader coalitions to advance health taxes. These insights can improve efforts to advance health taxes by better appreciating political economy factors and constraining corporate power, ultimately leading to improved population-level health.

Cigarette Smoke Exposure and Stunting Among Under-five Children in Rural and Poor Families in Indonesia.

Cigarette smoke exposure in mothers and children is highly prevalent in Asia, especially among rural and poor families. Second-hand smoke exposure might affect the nutritional status of children. Despite the emerging double burden of malnutrition and the very high prevalence of smoking in Indonesia, few studies have examined the effects of parental smoking on children's nutritional status. This study aims to measure the relationship between family smoking behavior and the occurrence of stunting in children under 5 years. This cross-sectional study used a purposive sampling technique, with 221 households with children aged 0 to 59 months from poor areas in Indonesia. Exposure to cigarette smoke is assessed using The Secondhand Smoke Exposure Scale questionnaire. The outcome measured is child stunting (height-for-age Z-score). The prevalence of stunting was estimated at 145 (65.6%). Children living with smoking parents were counted for 157 (71%), and most smoking exposure comes from fathers 147 (67.4%). The predictors of stunting in children under 5 years were a smoker father with (AOR 1.8; 95% CI 1.281-4.641), both parents are smokers increasing the risk of stunting with (COR 3.591; 95% CI 1.67-3.77), being exposed of smoke for more than 3 hours a day increase the risk of stunted children (COR 2.05; 95% CI 1.214-3.629), and using traditional cigarette or kretek expand the risk of stunting (AOR 3.19; 95% CI 1.139-67.785). The findings demonstrate the negative impact of parental smoking on children's growth, reinforcing the importance of reducing smoking prevalence by imposing a smoke-free home policy in the stunting prevention strategy.

Association between cigarette smoking patterns and severity of COVID-19: Findings from a study in 15 private Hospitals in Indonesia.

INTRODUCTION: Indonesia is ranked fourth among countries with the highest smoking rates and has the highest number of male smokers globally. This study aimed to assess the association between cigarette smoking patterns and the severity of COVID-19 among patients in 15 Indonesian hospitals. METHODS: A cross-sectional study was conducted from April to August 2020 using medical records of 490 COVID-19 patients, including the history of their smoking patterns from 15 private referral hospitals in 5 provinces. The severity was defined based on the Guidelines on the Prevention and Control of COVID-19 issued by the Indonesian Ministry of Health, which was indicated by the care provided to patients, namely outpatient, inpatient, and Intensive Care Unit (ICU) services for mild, moderate, and severe symptoms. Smoking patterns were grouped based on adult tobacco use classifications of the Centers for Disease Control and Prevention (CDC). Univariate and bivariate analyses were performed. RESULTS: The results showed that 69.8% of respondents had not smoked cigarettes, 17.1% were active smokers, and 13.1% were former smokers. A significant difference was seen in the number of cigarettes smoked by patients in the ICU, inpatients, and outpatients, among current smokers and passive smokers (p=0.018 and p=0.005, respectively). Furthermore, there was no significant difference in the severity of COVID-19 among current smokers, former smokers, and non-smokers. The time from when smoking was stopped among former smokers was not associated with the severity of COVID-19. CONCLUSIONS: There was no significant difference in COVID-19 severity between groups of smokers. Passive smoking and the number of cigarettes smoked by smokers daily were associated with the severity of COVID-19. Smoke-free policies should be implemented continuously to protect people from the dangers of secondhand smoke.

Association between percentage of smokers and prevalence of smoking attributable morbidity in Indonesia: one decade after implementation of smoke-free area regulation.

BACKGROUND: For more than ten years, Indonesia has health law, one of which states that local governments are mandated to establish Smoke Free Area (SFA). The results of 2018 National Basic Health Research shows tobacco consumption is still quite high and increasing compared to the results of 2007 and 2013 National Basic Health Research. The burden of disease in Indonesia is increasing every year.  METHODS: This study aims to describe SFA regulation and analyze the relationship between the percentage of smokers and the prevalence of smoking attributable morbidity. Data from the 2018 Basic Health Research in Indonesia with the number of units of analysis were 514 districts and cities level. The design of the study was cross-sectional study. The variables analyzed were the percentage of smokers, the prevalence of diabetes, hypertension, upper respiratory tract infections (URTI), pneumonia, lung tuberculosis, asthma, and mental emotional disorders. Geographical mapping of the distribution of District/City with Smoking-Free Areas was made using QGIS 3·16.  RESULTS: Around 72% of districts/cities in Indonesia already had local regulations of SFA after more than ten years implementation of the regulation of the health law. There was a significant relationship between the high percentage of smokers and the high prevalence of diabetes (p value: 0·000, PR: 1·342, 95%CI 1·135 to 1·587), hypertension (p value: 0·000, PR 1·631, 95%CI 1·252 to 2·124), and lung tuberculosis (p value: 0·008, PR 1·219, 95%CI 1·049 to 1·417) at the District/City level. However, there was no significant association between URTI, pneumonia, asthma, and mental emotional disorders. CONCLUSION: The percentage of smokers in an area was associated with diabetes, hypertension, and lung tuberculosis. The implementation of Smoke Free Area should be evaluated.

Cigarette Display Regulation At Point Of Sales (POS) And Its Impact On Cigarette Sales.

OBJECTIVE: This study aims to determine the impact of cigarette display settings on cigarette sales in the stores in Semarang City.

Methods: The research was conducted in August-October 2020 using a quasi-experimental study approach. It was conducted by setting the cigarette display in 3 methods where (1) the cigarette display was opened for 35 days in 5 stores, (2) the cigarettes display was covered with cloth for a pre and post-intervention period of 15 and 30 days, respectively, at five stores and (3) the cigarette display was hidden for a pre and post-intervention period of 15 and 30 days, respectively, at three stores. Cigarette sales were recorded based on how many packs or sticks were sold per day, and a visit to the store was made every two or three days without prior notification to the store owner to ensure the cigarette display was appropriate and recorded data. The sales data was descriptively evaluated using a paired t-test with a 95% confidence level.

Result: The results showed that one hidden cigarette display store (R3-1) experienced a significant decrease in sales, three hidden/covered display stores had a less significant decrease in cigarette sales and four hidden/covered display stores didn't have any decline in cigarette sales while the average decline in cigarette consumption in stores was -1.4packs/day. From the analysis of sales per day and the paired pre-post intervention test, the store with a covered display showed no difference in the pre-post intervention sales, while the stores with hidden displays showed differences.

Conclusion: Thus, covered displays did not affect stores and cigarette sales, while stores with hidden displays showed differences in sales.

Exposure to Outdoor Tobacco Advertisements Near Home is Associated with Smoking among Youth in Indonesia.

BACKGROUND: The prevalence of cigarette smoking among adults is persistently high, and among youth is increasing in Indonesia. OBJECTIVE: This study aims to examine the association between youth smoking behavior and outdoor tobacco adverts near home in Indonesia. METHODS: We conducted a cross-sectional survey of 3,557 students in North Sumatera during September-November 2020. The main independent variables include seeing tobacco advertisements near home, near school, on social media. The outcome variables included ever smoked and smoked in the last ten days. RESULTS: We found significant associations between exposure to outdoor tobacco adverts near home and youth smoking. High school students who reported seeing tobacco adverts near home were 1.42 times more likely to smoke and 2.29 times more likely to smoke in the last ten days. Moreover, students at private schools (a proxy for higher income) exposed to tobacco adverts near home were 1.56 times more likely to smoke and 2.93 times more likely to smoke in the last ten days. CONCLUSION: Exposure to outdoor tobacco advertisements near home is associated with smoking among youth in Indonesia. Comprehensive tobacco control efforts are needed, including through a ban of outdoor tobacco adverts.

Noncommunicable diseases risk factors and the risk of COVID-19 among university employees in Indonesia.

INTRODUCTION: Noncommunicable diseases (NCDs) are still a major public health problem in Indonesia. Studies have shown that risk factors of NCDs are associated with coronavirus disease 2019 (COVID-19) severity and mortality. However, it is unclear whether NCD risk factors are also risks for new COVID-19 cases. This study aimed to obtain an NCD risk profile among university employees and its associations with contracting COVID-19. METHODS: A cross-sectional study was conducted in October 2021. Participants were administrative employees of Universitas Indonesia (UI), Depok City, West Java. Assessment of NCD risk factors was based on the World Health Organization STEPwise approach to NCD risk factor surveillance (WHO STEPS). Demographic, working, and medical-history data were obtained electronically by using a Google Form. Physical and laboratory examinations were done in the Integrated Post for NCDs. Risks were expressed as adjusted odds ratio (ORadj) and 95% confidence interval (CI) in multivariate analyses. RESULTS: A total of 613 employees were enrolled. Men were predominant (54.8%), and about 36% of them work in shift as security personnel. About 66.7% were overweight or obese and 77.8% had hypertension. There were 138 (22.8%) employees who had COVID-19. Nearly all (95.6%) had been fully vaccinated against COVID-19. At-risk waist circumference (ORadj 1.72, 95% CI 1.15-2.56, p = 0.008) and total cholesterol level of 200-239 mg/dL (ORadj 2.30, 95% CI 1.19-4.44, p = 0.013) were independent risk factors, but shift work (ORadj 0.52, 95% CI 0.34-0.80, p = 0.003) was protective against COVID-19. CONCLUSION: The prevalence of NCD risk factors among university administrative employees was high, increasing the risk of contracting COVID-19. A behavioral intervention program to manage NCD risk factors at the university level is urgently needed according to the Health Promoting University framework.

Does Tobacco Affect Economy?

OBJECTIVE: The still debatable contribution of tobacco to the economy demands further discussion as tobacco remains controversial commodity due to its adverse health impacts. This paper aims to investigate the relationship between tobacco and the economy using macroeconomics indicators such as unemployment, inflation, and GDP growth. As a comparison, we include the tobacco price bands in USA because the sector is one of dominant affecting the economy and the price in some main areas in America is incredibly competitive. METHODS: This paper use tobacco data and Macroeconomics Indicators from Euromonitor International and World Bank Data. We extend linear regression models by controlling both the serial correlation and endogeneity bias problems. We also observe the properties in the ARMA(2,2) data generating process. RESULTS: We document that tobacco tends to affect the USA's future economy but not Indonesia. In our robustness check, we conduct a SUR analysis to control the contemporaneous correlations among Asian markets. We further document that tobacco variables tend not to affect the economy in the Asian markets. CONCLUSION: Our results show that the contribution of tobacco commodity to the economy is overstated. Therefore, the comprehensive and massive tobacco control implementations should be undertaken hence is relevant to put into actions.

Is Exposure to Social Media Advertising and Promotion Associated with E-cigarette Use? Evidence from Indonesia.

BACKGROUND: E-cigarette use is a growing public health concern globally, including in Indonesia. OBJECTIVE: Our study aimed to assess whether exposure to advertising and promotion in social media is associated with e-cigarette use in Indonesia, an upper-middle-income country. METHODS: We conducted mixed-method research including quantitative and qualitative methods. For the quantitative methods, we did an online survey in the five largest cities in the country with 1,239 participants during September-October 2020. For the qualitative method, we conducted an in-person focused group discussion during November 2020 (while complying to the COVID-19 protocols). RESULTS: We found high rates of e-cigarette ever use (29%) and current use (13%) among study participants. There was high exposure to e-cigarette advertising and promotion in social media, with a majority of participants (84%) reported ever seeing e-cigarette adverts or promotions on Facebook, Instagram, YouTube, and others. Both high rates of e-cigarette use and exposure to social media advertising are associated. Participants reported ever seeing adverts and promotions were 2.91 times and 2.82 times more likely ever to use and currently use e-cigarettes, respectively, after controlling for socioeconomic factors, region, and cigarette smoking status. CONCLUSION: Exposure to social media advertising and promotion is associated with e-cigarette use in Indonesia.

Cigarette Consumption and Nutrient Intake in Indonesia: Study of Cigarette-Consuming Households.

OBJECTIVE: This study aims to investigate the impact of cigarette consumption on household's nutrition adequacy (NA). This study also examines the opportunity cost of cigarette expenditure to children's nutritional adequacy. METHODS: We used an Indonesian cross-sectional household level nationwide data of 2018 National Socio-Economic Survey (SUSENAS). Using multivariate Ordinary Least Square (OLS) regression, we estimated the impact of cigarette consumption on household's NA as defined by household protein and energy intakes. With the same specification, we further ran a segregated OLS regression by household quintile expenditure. While the opportunity cost of cigarette consumption to children's nutrition adequacy defined the estimated forgone nutrition due to cigarette consumption by following the Ministry of Health (MOH) definition of Recommended Dietary Allowance (RDA) for children aged 4 - 6. RESULTS: Cigarette consumption decreases household's protein and energy intakes. We found statistically significant correlation between household's cigarette consumption and household's per capita protein intake while no statistically significant correlation on energy intake. Furthermore, the segregated estimate is significant for both protein and energy intakes among 60% lowest household quintile expenditure groups. The lower the quintile expenditure, the higher the decline in household NA due to cigarette consumption. With the average cigarette expenditure of IDR12,956 per household per day, giving up daily cigarette spending could meet children's energy intake by 27% - 85,4% of RDA and protein intake by 180.12% - 300.48% of RDA. CONCLUSION: Household cigarette consumption has negative impact on household's daily energy and protein intakes. The poorest group is most vulnerable to nutrition inadequacy due to cigarette consumption. Giving up household's cigarette expenditure daily could result in a substantial nutrition gain for children at their critical growth stages.

Implementation of the Smoke-Free Policy in Medan City, Indonesia: Compliance and Challenges.

Background: Indonesia has an estimated 61.4 million current smokers, and the smoking prevalence among adults is persistently high while that among youth is increasing. In 2014, Medan city enacted the smoke-free policy (SFP) to protect community members against the adverse effects of smoking. Our study examines the implementation of SFP in terms of compliance and challenges. Methods: We conducted a mixed-methods study. Quantitative analyses examined the compliance with six criteria including having signage, no active smoking, no selling, no advertisement, no smoke, and no ashtray at SFP facilities. They included health facilities, educational facilities, places of worship, workplaces, and indoor/outdoor public facilities. The qualitative analysis examined the challenges through in-depth interviews of six key informants. Results: We found the overall compliance of 44%, ranging from 0% at outdoor public facilities to 83% at health facilities. We found relatively higher compliance among facilities within 1-km from the provincial and city health offices compared to those outside of the buffer (but not significant at 5% level, P = 0.070). The challenges identified were lack of budget, monitoring, enforcement, and sensitization. Conclusions: The implementation of SFP in Medan city still has lower compliance and faces many challenges.

FCTC ratification, smoking prevalence, and GDP per capita: lessons for Indonesia and the rest of the world.

BACKGROUND: Indonesia's stagnated progress towards tobacco control could be addressed through the implementation of a comprehensive national framework, such as the World Health Organization's (WHO) Framework Convention of Tobacco Control (FCTC). However, national tobacco industry supporters argue that accepting the FCTC will have negative economic implications for the country. These arguments have, thus far, discouraged the Indonesian government from ratifying the FCTC. Drawing from an analysis of the impact of the FCTC on other countries' smoking rates and Gross Domestic Product (GDP) per capita, this study offers empirical evidence against industry arguments concerning the potential negative economic impacts of FCTC adoption. This study applies a two stage least square estimation strategy to unbalanced panel data at country level. In the first stage we estimate the impact of FCTC ratification on smoking rates, and in the second step, we estimate the influence of smoking activity on macroeconomic performance. RESULTS: The result of this study shows that FCTC ratification has a negative impact on a country's smoking prevalence. While FCTC ratification positively correlates with reduced smoking prevalence, a decline in smoking prevalence is not related to a decline in GDP per capita. CONCLUSIONS: The results of this study shows that FCTC ratification, which can be an important driver for more effective tobacco control, does not necessarily have a negative impact on the economy. Instead, FCTC ratification may be beneficial for both health and economic outcomes, as it provides comprehensive guidance for reducing smoking prevalence that take into account social and economic factors.

New evidence of illicit cigarette consumption and government revenue loss in Indonesia.

INTRODUCTION: Illicit cigarettes because of their affordability could increase smoking prevalence, especially among young people. They also cause a large revenue loss for the government. This study aims to estimate illicit cigarette consumption and government revenue loss in Indonesia, a country with a very high smoking prevalence, especially among males. METHODS: We estimated illicit cigarette trade in terms of volume and revenue loss. Illicit trade was estimated as the discrepancy between legal cigarette sales and domestic consumption recorded by national representative surveys. Data sources included Basic Health Research Survey, Global Adult Tobacco Survey, National Socioeconomic Survey, and data from Ministry of Finance. RESULTS: We found that illicit cigarette consumption fluctuated from 19 billion sticks in 2007 to 14 billion sticks in 2013, and sharply increased to 59 billion sticks in 2018. Relative to cigarette consumption, illicit cigarettes were the lowest at 5% in 2013 and highest at 19% of consumption in 2018 (assuming 0% underreporting). The estimated government revenue loss ranged from IDR 24.2 to 42.0 trillion (US$ 1668 to 2897 million), which corresponds to 15.8% to 27.5% of cigarette excise revenue in 2018. CONCLUSIONS: In Indonesia, illicit cigarette consumption was found to be high and increasing, which contributed to a large government revenue loss (almost onethird of tobacco excise tax revenue). To reduce illegal cigarette production and smuggling, the government should increase resources to enforce the regulation on the excise tax system including stronger penalties, especially related to illicit cigarette production.

Opportunities and Challenges of Tobacco Control Policy at District Level in Indonesia: A Qualitative Analysis.

INTRODUCTION: Comprehensive tobacco control policies are lacking in Indonesia where smoking prevalence in males is among the highest in the world. This study aims to explore the knowledge, attitude, opportunities and challenges to tobacco control among local stakeholders. METHODS: This is a qualitative study using in-depth interviews. Four study areas included Bengkulu Province, Bengkulu City, Seluma District, and Kaur District. Eighteen participants interviewed were from policymakers, legislators, and civil societies during November-December 2020. Thematic data analysis was used. RESULTS: While knowledge and support of the existing Smoke Free Policy (SFP) were high, that of other policies such as outdoor tobacco advertising (OTA) ban and tobacco product display ban were low. Among others, one opportunity was there is already SFP regulation in each study area, to which such bans can be added. Among others, three major challenges were: (a) lack of enforcement of the existing SFP, (b) lack of national regulation to ban OTA and product display, and (c) counter actions by the tobacco industry. CONCLUSION: The opportunities and challenges identified could be lessons learnt for more comprehensive tobacco control especially by local governments in Indonesia and other countries with similar settings.

Policy incoherence and tobacco control in Indonesia: an analysis of the national tobacco-related policy mix.

INTRODUCTION: Indonesia has a high smoking prevalence that has not diminished significantly since 1990. Considering this, we aim to summarise the existing national tobacco-related policy mix and explore markers of policy incoherence in tobacco control between 2014 and 2020. METHODS: We conducted (1) a review and synthesis of Indonesian tobacco-related legislation and regulations; (2) a systematic search and synthesis of related literature and news reporting; and (3) interviews with tobacco control activists and academics to understand political will towards tobacco control regulations and the tobacco industry. RESULTS: Indonesia's existing tobacco-related policy mix lies across the president's office, six national ministries and one independent agency. However, current responsibility lies primarily with four government ministries: Ministries of Health, Finance, Communication and Information, and Trade and Industry, with the Ministry of Finance most active. Evidence demonstrates that official interministerial collaboration was lacking from 2014 to 2020 and suggests that institutional will to introduce more effective tobacco control varies considerably between different arms of government. DISCUSSION: Political will differs according to ministerial mandates and priorities, fostering a fragmented policy approach and undermining the development of a coherent response. Without political will from the president or national parliament to create an overarching framework for tobacco control, either via ratification of the Framework Convention on Tobacco Control or another mechanism, there remains no formal impetus for intragovernmental cooperation. Nonetheless, this analysis reveals some government progress and 'pressure points' that advocates can focus on to promote tobacco control policies within the current policy mix.