ABSTRACT:Youth smoking is prevalent in Indonesia. 90% of Indonesian children have smoked a cigarette by age 13 and many remain as smokers into adulthood. As a result of this addiction, many households have cigarettes as their second highest expenditure. Smoking is a considerable financial burden on families and the Indonesian health system. Previous international and domestic attempts to reduce Indonesian smoking rates from economic, political, and health systems fronts have not succeeded due to lobbying from tobacco corporations. A stronger stance must be considered —one of childhood development and a right to freedom from addiction. Advocating for physician-patient education, age limits, and childhood education to key stakeholders in the federal government may help leverage strategic foreign policies to internationally address this human rights issue.
IDENTIFYING THE PROBLEM: Tobacco use is the most preventable cause of mortality worldwide, yet it kills over seven million people annually.1 It remains widespread, especially in low and middle income nations. Indonesia has a particularly high prevalence of smokers, most notably among its youth. Over 90% of all Indonesian children have smoked a cigarette by age thirteen. Moreover, 76% of Indonesian males older than 15 smoke frequently.2 In comparison, only 7.6% of high school students are smokers in the US.3 Annually, smoking-related diseases kill 250,000 people and hospitalize over 600,000 people in Indonesia. It costs $45.9 billion USD to treat tobacco-related diseases.4,5
Some individuals prioritise cigarettes over basic necessities such as food and education. In fact, tobacco is the second highest household expenditure in Indonesia after rice.5 Indonesia lacks comprehensive tobacco control policies compared to other Southeast Asian countries, which have stricter anti-tobacco measures. Without action, youth smoking will perpetuate high rates of adult smoking, increasing mortality rates and healthcare costs. Thus, proactively preventing individuals from starting to smoke is key to ensuring the health of Indonesian youth.
POLITICAL, ECONOMIC, AND CULTURAL BARRIERS TO CHANGE:
The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was developed by 168 nations in response to the global tobacco epidemic. It provides demand and supply reduction strategies to limit the spread of tobacco.6 Although this non-binding agreement has been legally ratified by 181 nations, Indonesia has not signed, instead electing to continue its relationship with tobacco companies. In addition, the Tobacco Advertising, Promotion, and Sponsorship (TAPS) criteria under the Association of Southeast Asian Nations (ASEAN) aims to regulate cigarette advertisement.5 Similarly, this non-binding agreement provides little incentive for Indonesian adoption.
Economically, Indonesia cites financial losses in sales and exports as the main factor for not increasing cigarette taxation. The neighbouring state, Malaysia, imposes a 49% mark-up sales tax on the retail price compared to Indonesia’s 31%; however, both are below the WHO FCTC recommended tax of 70%.7 In comparison, the average Ontarian pays 170% (including HST) mark-up on tobacco duty.8 The Indonesian government’s reluctance to raise tariffs is largely based on speculation that higher tax rates will damage tobacco tax revenue, which forms 10% of the Indonesian domestic revenue.9 However, studies by both the World Health Organisation and the Million Death Study indicate that this is a misconception: in other countries like India, higher cigarette taxes yielded an increase in government tax revenue despite a decrease in cigarette consumption.10
Culturally, tobacco use has been associated with masculinity. Historically, male smoking is an expression of individual identity.11,12 Anecdotal evidence in Inside Indonesia depicts that teenage boys are given cigarettes following their circumcision, since cigarettes are believed to accelerate the healing process and signal the transition into manhood. Those who do not smoke are considered feminine or abnormal.13 Since their establishment, tobacco companies have leveraged this cultural association using targeted advertisements to young consumers, strengthening the bond to masculinity, which resulted in increased cigarette purchases.14 Native Indonesians in a youth focus group identified four cultural themes on tobacco addiction: (1) smoking as a culturally internalized habit, (2) striving to become a man, (3) the way we smoke is not dangerous and (4) the struggle against dependency—all of which are exacerbated by tobacco advertisements. The combination of factors, ranging from economic interests to cultural perpetuation, all pose barriers for youth on the road to liberation from tobacco.13
RECOGNITION OF YOUTH NICOTINE ADDICTION AS AN INFRINGEMENT ON HUMAN RIGHTS & STRATEGIES:Strategies that address youth smoking through international treaties, domestic taxation, and advertisement regulation have not succeeded. Thus, perhaps it is time to explore the issue from the perspective of human rights. The United Nations Convention on the Rights of the Child, co-signed by Indonesia, maintains that children have the right to develop in a healthy manner free from addiction.15 As such, it is important for diplomats and government officials to also recognize nicotine addiction as an infringement of these rights. This declaration is echoed by the Office of the United Nations High Commissioner for Human Rights, who issued a statement that all people —regardless of race, religion, political belief, economic or social condition— are entitled to the highest standard of health.16 Documentation of the chain-smoking, two-year-old named Aldi Suganda provides anecdotal evidence of how tobacco can violate children’s rights.17 This story, along with many others, provides an avenue for dialogue with the Indonesian government so that it may enact stricter anti-smoking laws and improve protections for children.18,19,20 Hence, the Indonesian government’s inaction in addressing the smoking addiction epidemic is a serious infraction of the human rights code.
The problem can also be addressed from the perspective of child labour. It is estimated that thousands of child workers in Indonesia are involved in tobacco production for the country’s largest tobacco companies.15 British American Tobacco and Philip Morris International, the largest tobacco companies, generate $1.2 billion in unpaid children’s labour cost.21 Children working on these farms are at high risk for occupational hazards such as lacerations from equipment, exposure to chemicals, extreme weather conditions, and more. Due to the sensitive nature of a child’s developmental period, they are also at a high risk of “green tobacco sickness,” caused by dermal absorption of nicotine from the leaves of the tobacco plant. This is a form of nicotine poisoning that causes dizziness, vomiting, dehydration, and anorexia.22 Exposure to pesticides and herbicides may also increase the risk of chemical poisoning, cancer, reproductive health issues, and permanent neurological damage.22
PHYSICIAN EDUCATION AND POLICY PERSPECTIVE: Although dialogue between physicians and patients in Indonesia about the dangers of tobacco use is limited, it is key to inducing change at the individual level.23-25 Smoking cessation efforts require more than just population health campaigns and taxation; they also require communal and socio-political efforts.25 Until recently, physicians were not tested on their proficiency in smoking intervention materials. An independent assessment of the medical college curriculum concluded that “very little time had been devoted to the [education of the] harms [of smoking and] … no training had been provided… on how to talk to patients about smoking or how to assist them in their efforts to quit.”26 It was only in 2012 when the Indonesian Doctors Association introduced counselling skills on smoking cessation into the National Competency Standards for Physicians. Furthermore, education on smoking cessation programs was introduced into the medical school curriculum in 2015. This is the first attempt to integrate tobacco control throughout all four years of medical school in Southeast Asia.26 Physician voice, therefore, is instrumental in policy decisions, which has led to Indonesia becoming a leading regional medical authority in tobacco cessation education.26
CALL TO ACTION: Unfortunately, optimism among medical ranks has failed to translate into policies aimed at addressing youth smoking addiction. Mandating physician education for smoking cessation dialogue, implementing a cigarette purchasing age limit, and childhood health education on tobacco addiction are three potential policies that may improve the youth tobacco landscape. The Indonesian government refuses to take measures to prevent youth smoking, which infringes on children’s right to health. As Canadians, we stand by our belief in universal human rights. Hence, reaching out to stakeholders like the Director General of the Office of International Affairs for the Health Portfolio, has the potential to facilitate strategic bilateral partnerships with Indonesia that reflect Canadian interests in preserving children’s rights.
Written by Michael Yo-Han Lee and Puru Panchal
Edited by Anita Shah and Edward Cui
Reviewed by Dr. Godefroy Guindon and Sophiya Garasia
References may be found in the journal.