• tobacco industry
• public policy
• low/middle income country

Globally, countries recognised the detrimental effects of tobacco use when they collectively agreed to enhance tobacco control measures through the adoption of the WHO Framework Convention for Tobacco Control (WHO-FCTC). Positive progress has been made by many countries that have showed significant declines in their smoking rates. Effective tobacco control measures require strong political will and leadership, alongside concerted efforts across sectors. Those prerequisites are practically absent in Indonesia, a country with more than 65 million adult smokers and over 22 million youth smokers, which is also the only country in the Asia Pacific region that has yet to ratify the convention.1 Kramer et al’s paper in this issue highlights how the complex political environment and low political commitments have resulted in incoherence and poor implementation of policies.2

This analysis of Indonesia’s tobacco control–related policies showed a wide range of regulation for some aspects of tobacco control but with inadequate coordination and low accountability.2 The directly responsible ministries according to those regulations have not executed their role and responsibility optimally, while conflict of interest and intervention from the tobacco industry is also tolerated. The Ministry of Health (MoH), who are supposed to lead tobacco control measures, have shown poor leadership, a low bargaining position and have had inadequate support from other ministries. On the other hand, there are ministries who have demonstrated clear opposition to tobacco control and conflict of interest with the tobacco industry.3 This divided position of government stakeholders is one of the main factors preventing effective policy implementation, even though controlling tobacco use is one of the national objectives outlined in the Mid-term National Development Plan. In the paper, Kramer et al outlined how the lack of presidential leadership affects the coordination between related parties and compliance with agency roles and responsibility.

Historically, tobacco control gains its momentum when countries acknowledge the importance of investments in health over the short-term economic benefits of tobacco. In Indonesia, this momentum has yet to happen despite the increase of smoking among the young population, and the vast health and socioeconomic burden of tobacco use. The economic arguments of tobacco farming, tobacco production and even selling have always been used as a counter narrative to oppose strengthening tobacco control, but when these arguments come from government officials, they signify a division of views and interests within the government, weakening the resolve to protect Indonesia’s people from exploitation.4

Although in the last 20 years tobacco control in Indonesia has made some progress, it remains inadequate to curb the smoking problem. As outlined in Kramer et al, the current main tobacco control regulation is the government regulation No 109 Year 2012 (PP109/2012) which includes several provisions of the MPOWER measures; however, most of them are lenient compared with the international standard.4 The MoH has been processing the revision of PP 109/2012 since 2018 until the timeline expired in mid-2021. This was followed up by submitting an initiative letter to the president through the secretary of state seeking to continue the revision process, but the proposal was rejected, partly due to opposition from tobacco industry groups. Then, in December 2022, revision of PP 109/2012 was listed as the regulation to be discussed in the 2023 regulation development programme under Presidential Decree No 25 Year 2022, leading to new optimism among tobacco control advocates. However, the President also issued Presidential Decree No 26 Year 2022 that included presidential regulation on a tobacco industry roadmap on the agenda. The development of the roadmap led by Coordinating Ministry of Economy includes several provisions—advancing tobacco farming, absorption of labour, advancing tobacco product industry, optimising revenue from tobacco excise and controlling consumption; however, this is likely an intricate avenue for advancing tobacco control.5 The government appears unwilling or unable to control the tobacco industry and address the harms of widespread tobacco use.

Indonesia’s policy-making system involves legislative and executive realms. The legislative branch creates the law/bill and the executive creates the implementing regulations.2 Recently, the MoH initiated the merging of all health-related law into one Omnibus Law on Health. The initiative was publicly declared as the legislative initiative with unclear reason and with the goal to be passed by June 2023. The law also attracted opposition from health professionals’ organisations for some reasons including poor involvement during the drafting and reduce roles and independence of professional organisation.5 As of mid-April 2023, the draft of the law was submitted to the parliament with very weak provisions on tobacco control measures, weaker than those outlined in the already half-hearted provisions of PP 109/2012. One example is the health warning measures in the new draft, which fail to mention pictorial health warnings such as had been adopted under the PP 109/2012. This move by MoH will reverse tobacco control progress and potentially diminish the effects of 20 years’ worth of challenging public health advocacy and campaigns.

The MoH has not demonstrated real willingness to fight for tobacco control measures, and it is placed in an even more dubious position by this new development. MoH is the institution most responsible for achieving the previously mandated reduction of youth smoking. Regrettably, the accountability of government institutions for reaching the intended target outlined in the national plan was not adequately evaluated since the target will be reset to a new target. For example, the 2019 national target was the reduction of smoking among youth aged 10–18 years to 5.4% from 7.2% in 2013; however, since in 2018 the youth smoking rate rose to 9.1%, the new target was set at 8.7% by 2024—even higher than the rate in 2013. How can government departments hope to attain the intended targets as their performance indicators keep being weakened?

Kramer et al note that transparency of government or political parties to report ties with the tobacco industry is low, and tobacco companies still retain positive public images due to so-called corporate social responsibility actions. Indonesia has the highest tobacco industry interference index in Southeast Asia,6 implying entrenched tobacco industry involvement in policy spheres.

Tobacco control advocates, with the support of regional and international partners, have long been urging governments to reduce tobacco use both at national and sub-national levels by incorporating effective, evidence-based tobacco control measures. But without a commitment from government to ensure better health for Indonesia’s people, these efforts cannot succeed. Unfortunately, adoption of the WHO-FCTC which would enable more cohesive tobacco control measures is unlikely. As Kramer et al note, ‘the current president expresses no desire to ratify FCTC or create a comparable national framework’. Unless revolutionary changes happen within the government, Indonesia will remain an outlier globally, continuing to sacrifice its people to tobacco industry profits.