Introduction
Up till 2024, the regulation policies for tobacco control is unlikely to experience significant progress. This is despite tobacco consumption being a major risk factor for non-communicable diseases (NCDs). Reasons include strong resistance and protest from the majority of parliamentary factions and the tobacco industry. This issue is further confounded as political attention and national resources are prioritized for the management of the coronavirus pandemic and its direct health, economy and social impacts. Theoretically, tobacco regulation policies and the prevention of diseases caused by cigarette consumption are clear, easy to apply and will have a major impact on improving public health in the long term.
Lethality of Tobacco-associated Non-communicable Diseases
NCDs are the leading cause of death and disabilities worldwide. In 2018, the World Health Organization (WHO) recorded an annual 41 million deaths globally due to NCDs. This constitutes an estimated 70% of the total deaths worldwide. The top three lethal NCDs were cardiovascular diseases (17.9 million), cancer (9 million), and respiratory diseases (3.9 million). Causes of these top three killers include the consumption of highly toxic products such as cigarettes. Additionally, tobacco products are mass produced, thus, not only increasing access to these harmful products but also increasing society’s exposure to its toxins.
Unfortunately, Indonesia is not only one of the biggest producers of tobacco but also one of the biggest consumers in the world. Enabling this is the favourable environment in Indonesia that enables the tobacco industry to flourish. Collectively, these highlight the need for two simultaneous courses of action. Lacking one course of action would compromise efforts to mitigate NCDs. The first course of action would be targeted at the individual level with the promotion of a healthy lifestyle while avoiding the consumption of toxic products. The second is the need for structural changes through stricter tobacco control policies.
Without strong political will from President Joko Widodo, it is almost certain for the status quo to remain. This seems to be the reality as he completes his final tenure as President in 2024. And without stricter tobacco control policies, Indonesians susceptibility to sickness and poverty would increase. In addition to NCDs, tobacco consumption increases the risk and severity of communicable diseases such as influenza, tuberculosis, and nosocomial infections. Numerous studies have also shown that the majority of tobacco users in developing countries are the poor. Upon their addiction to tobacco products, a larger percentage of their income would likely be used on these products instead of basic essential items. This consequently increases their risk of falling ill and thus, worsening their financial standing.
Two factors that affect political will are the social norms of tobacco consumption and the delayed expression of symptoms. Unlike infectious diseases such as COVID-19 where their symptoms are immediate, ailments from NCDs usually require several decades to develop. Additionally, tobacco consumption, particularly smoking of kreteks (clove-flavoured cigarettes), is deeply entrenched in Indonesia.
To reverse the increasing number of deaths due to tobacco consumption, WHO has approved and encouraged countries to ratify the Framework Convention on Tobacco Control (FCTC) since 2003. FCTC entails a strong and comprehensive legal framework to control tobacco consumption. Currently, this convention has been ratified by 182 countries consisting of more than 90% of the world’s population. However, Indonesia is the only Asian country that has yet to do so but not without trying. In 2004, plans to ratify the convention by the Indonesian government failed and there have been no attempts ever since. Instead, in 2016, Joko Widodo stated that one reason for Indonesia to continue the status quo is to safeguard “national interest” on the basis of protecting tobacco growers and those employed in the tobacco industry. Similarly, the tobacco industry, association and its supporters in Indonesia have constantly lobbied Joko Widodo against the ratification on the pretext that the industry contributes a large amount of taxes to the government while ensuring the livelihoods of many Indonesians.
Due to this stance, Indonesia’s Health Ministry faces a losing battle against tobacco consumption. This is despite Indonesia’s Health Ministry reporting 230,000 tobacco-related deaths annually. The ministry has also uncovered a rising prevalence of teenage smokers, aged 10 – 18. Teenage smokers rose to 9.1% in 2018 from 7.2% in 2013. Ironically, the Indonesian government had targeted the prevalence of teenage smokers to be capped at 5.4% in 2019 despite their stance on tobacco consumption. This is indicative of the government’s failure to control cigarette consumption while highlighting the tobacco industry’s success at targeting teenagers. Targeting teenagers is a significant achievement by the industry as teenage smokers will become their long-serving patrons, replacing older smokers.
Economically, Indonesia’s Health Ministry has shown massive losses of nearly IDR 600 trillion (USD 40 billion) to the macro economy due to tobacco consumption. This amount is four times the amount of cigarette taxes received by the government in the same year. Losses are tabulated from the total number of productive years lost, inpatient and outpatient costs. Unfortunately, the amount of losses is envisaged to increase annually as these costs increase. A more grave concern is that the majority of smokers (60%) comes from low-income families.
These statistics, however, do not hinder 65 million Indonesians from continued tobacco consumption. Tobacco industries in Indonesia are relatively unimpeded in advertising, promoting and distributing their products. This population will continue to increase as children and teenagers are targeted by the tobacco industry as their new generation of consumers. Indicative of this is WHO’s estimation that the population of tobacco consumers in Indonesia to rise to 96 million by 2025. It is, thus, a monumental challenge for Indonesia to drop from its third ranking of countries with the highest number of smokers in the world without stricter tobacco control policies.
Restricting Outreach and Price Control: Easier Said Than Done
Outreach and price control are two effective policies to regulate tobacco consumption that are much needed and still lacking in Indonesia. Restricting outreach entails the total banning of its advertisements, promotions, and sponsorships in mass media and outdoor media. Meanwhile, price control entails increasing prices of tobacco products by setting minimum prices and increasing taxes on tobacco products.
Current outreach restrictions are still suboptimal. Tobacco product commercials continue to be broadcasted on television albeit restricted to airtimes of 09.30pm to 05.00am daily. Similarly, advertisements on print media are still allowed with certain restrictions such as no full-page advertisements. The Indonesian government, at the urging of the health ministry, must be recognized for its attempt at curbing online outreach. A total of 114 websites were shut down in 2019 for violations prohibiting the publication of tobacco product images in their advertisements. However, such regulations can be bypassed simply by removing such images. Additionally, there have yet to be regulations on advertisements on social media platforms. Another regulation that is lacking is the restriction on internet sales.
The affordable prices and taxes on tobacco products do not impede their purchase by the poor and children. Despite a revision in cigarette prices this year, one can still obtain a pack of 12 at IDR 12,300 (USD0.84). It must be noted that one of the lowest regional minimum wage (UMR) in Indonesia is around IDR 1.7 million. Setting a minimum price of IDR 50,000 could motivate consumers to stop their habit. It is also concerning that the sales of loose cigarettes are still permitted in Indonesia. According to a 2018 survey, the market price per stick of loose cigarette is approximately IDR 1,000 – IDR 2,000. Its cheap prices and lack of enforcement on age restrictions enable their purchase by children. Additionally, tobacco industries have yet to incur the maximum amount of tax that can be legally enforced on their products, set at 57% of the retail price. Currently, the highest tax bracket is capped at 43%. This was only after an increase this year as there was no revision of tax for tobacco products in 2019.
Should the stance of the next government administration on tobacco control policies change, ratification of the FCTC could still be a tall order. Nevertheless, continued lobbying could lead to tougher restrictions and increasing public awareness on the dangers of tobacco consumption. Such incremental toughening and increased awareness could one day culminate to Indonesia ratifying the FCTC.
