The relevance and prospects of advancing tobacco control in Indonesia☆
Introduction
Widely cultivated across Java, tobacco was added to the long-established social habit of chewing betel, or areca nut, throughout the 19th century. The Dutch began to import into Indonesia cigars and cigarettes during the late 1800s, and local elites emulated Dutch smoking habits [1]. Until today, the Indonesian term for smoking remains merokok, adapted from the Dutch verb, roken. Following a longstanding practice to flavor most consumables, cloves were mixed with tobacco cigarettes in the late 1800s, to create the uniquely Indonesian kreteks, or clove cigarettes. Early kreteks were thought to have originated in Kudus, Central Java, and were so named from the keretek–keretek sound of cloves burning and exploding. Initially a home industry, hand rolled kreteks were commercially produced in Indonesia in 1906 [2], and production of white (tobacco only) cigarettes followed suit in 1924 [1]. Smoking kreteks replaced chewing betel during the early to mid-1900s for many rural males, and their popularity soared after the mechanization of the industry in the 1970s [3], [4].
Widespread use of tobacco since the 1970s and the concomitant burden of non-communicable diseases have given rise to a more balanced view of the costs and benefits of tobacco production over the last decade. Indeed, several important advances in tobacco control have been made, including a series of regulations since 1999. The most cost-effective components of tobacco control policies have been described in detail elsewhere [5], [6]. Given that tobacco in Indonesia overlaps legal, political, and economic considerations, implementation of tobacco control policies must consider the perspectives of a broad range of stakeholders. In this paper, we first provide an overview tobacco consumption, its health effects, and the impact of tobacco production on Indonesia's social and economic sectors. We then present an overview of tobacco control regulation, and the political environment surrounding changes made in these regulations. Subsequently, we examine four cost effective strategies: price and tax measures, advertising bans, clean air legislation, and public education. We discuss the relevance and prospects of advancing each in Indonesia, the potential resistance, and other barriers to implementation. We conclude with several suggestions for action for the public health community.
Section snippets
Consumption and prevalence
Given its large population and smoking prevalence, Indonesia ranks fifth among countries with the highest tobacco consumption globally at 182 billion sticks per year [4]. Consumption has increased rapidly since the 1960s. Between 1970 and 1980, a 159% increase coincides with the mechanization of the clove cigarette industry [4]. With a doubling of the GNP per capita in real terms between 1980 and 1997 [7], tobacco consumption rose by 8.2% per year for a cumulative increase of 139% [4]. Quite
Agriculture
Commercial tobacco plantations were first established in the mid to late 1800s in Deli, Sumatra, and foreign currency from leaf and manufactured product exports was an importance source of revenue for the Dutch colonial government [1]. At present, less than 1% of arable land is dedicated to tobacco cultivation [27]. One of the top 10 global suppliers, Indonesia contributes less than 145,000 t, or 2.3%, to the world's leaf supply. The majority (96%) comes from three provinces: East and Central
Tobacco control regulations in Indonesia
Tobacco control was low on the public health agenda before the late 1990s. Reynolds [35] quotes President Suharto's Minister of Health as having “no intention” of regulating smoking through legislation, although tobacco was included among regular health education activities. Despite the Suharto family's far-reaching business interests, to the authors’ knowledge, only Suharto's son, Tommy, was involved in the tobacco industry; he owned the highly unpopular clove monopoly dissolved in 1998 under
Future directions
Clearly, substantial barriers to implementing tobacco control exist in Indonesia. However, we put forth several activities that can be conducted over the near to medium term, which aim to advance the most cost effective strategies outlined. Broadly, these activities include promoting leadership, strengthening legislation and enforcement, advancing price and tax measures, and informing the public.
Conclusions
In the Government of Indonesia's long-term strategic plan, human development is a central priority, with strategies aiming to reduce the high levels of poverty and unemployment. Overwhelming evidence indicates the benefits to human and social development of regulating tobacco promotion. The Indonesian industry, however, is viewed positively as contributing jobs and resources to the economy, and this perception is reinforced via direct lobbying to government officials and parliamentarians. In
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The article originated from data collected for The Tobacco Sourcebook, published by the Ministry of Health, 2004. English and Indonesian versions of the Sourcebook are available from Dr. Anhari Achadi or Dr. Widystuti Soerojo. For this article, the authors are responsible for all errors and omissions but gratefully acknowledge comments from Abdillah Ahsan, Joy de Beyer, Tei-Weh Hu, Puguh Irawan, Kartono Muhamed and reviewers of this journal.