Why is tobacco control progress in Indonesia stalled? - a qualitative analysis of interviews with tobacco control experts

Abstract

Background: Indonesia shoulders a significant tobacco burden, with almost two million cases of tobacco-related illnesses and more than two hundred thousand tobacco-related deaths annually. Indonesian tobacco control is progressing but lags behind other countries. Our study evaluates factors that contribute to the slow progress of tobacco policy change in Indonesia from the perspective of tobacco control experts (TCEs). Method: We conducted qualitative interviews with four international and ten national TCEs, who have been active in tobacco control for at least 5 years. Our interview guideline included questions on the current tobacco control situation in Indonesia and explored reasons why tobacco control is progressing so slowly. The interviews were conducted either in English or Bahasa Indonesia, recorded and then transcribed verbatim. We conducted a thematic analysis based on five core causal factors for policy adoption: institutions, networks, socioeconomic factors, agendas and ideas. Results: The multistage delay of tobacco policy adoption is principally due to political structures and policy hierarchy, complex bureaucracy, unclear roles and responsibilities, and a high degree of corruption. The low bargaining position and lack of respect for the Ministry of Health also contributes. There are contrasting frames of tobacco as a strategic economic asset and tobacco control as a sovereignty threat. There is an imbalance of power and influence between well entrenched and resourced tobacco industry networks compared to relatively young and less established tobacco control networks. The policy agenda is likely influenced by the privileged position of tobacco in Indonesia as a socially acceptable product with high consumption. There are constraints on transferring ideas and evidence to successful policy adoption. Conclusion: Tobacco companies have substantially influenced both policy decisions and public perceptions, signifying a power imbalance within the government system and broader networks. Acceding to and enforcing the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) would enable the Indonesian government to shift the power imbalance towards public health stakeholders. Tobacco control advocates must enhance their network cohesion and embrace other community groups to improve engagement and communication with policymakers.

Tobacco Control Stakeholder Perspectives on the Future of Tobacco Marketing Regulation in Indonesia: A Modified Delphi Study

“…The questionnaire comprised a set of closed and open-ended questions, which were divided into 3 sections: (1) TAPS ban and pack labelling regulation, (2) marketing and retailing regulation, and (3) strategies to improve tobacco control policy and advocacy in the next 5 years (to be reported in another paper). The questionnaire was developed based on the findings of a qualitative exploration of Indonesian and international tobacco control experts’ perspectives on factors influencing the slow progress of tobacco control policy in Indonesia, as reported in another published paper [ 12 ].…”

“…Tobacco control progress in Indonesia is stagnant due to several factors, including tobacco industry (TI) interference in the policy-making process, the complexity of the policy system, and distorted public perceptions around smoking, tobacco companies, and tobacco control. Indonesian tobacco companies are well entrenched in the policy-making system and are directly involved in policy-making processes [ 9 - 12 ]. The industry has also gained significant political and public support due to positive framing of its contribution to revenue, the labour force, and so-called corporate social responsibility (CSR) initiatives [ 9 , 13 ].…”

Strict and Comprehensive Tobacco Control Policy is Needed: A Qualitative Study Exploring How People Responding a New Policy of Pictorial Health Warning on Cigarette Package in Indonesia

“…Otherwise, the government gets a negative impression as negated public opinion by not seriously controlling smoking because of fear of losing tobacco taxation earnings. This concern was one of the barriers of tobacco control in Indonesia [38]. Cigarette is a promising commodity from government economic perspective [38], besides this commodity has been socially and culturally accepted in the population [29].…”

“…This concern was one of the barriers of tobacco control in Indonesia [38]. Cigarette is a promising commodity from government economic perspective [38], besides this commodity has been socially and culturally accepted in the population [29]. Those facts together with the unclear roles and responsibility are the most difficult barrier of tobacco control effort in Indonesia.…”

SARS-CoV-2 Tackles the Tobacco Industry: Comment on “Tobacco Industry Interference Index: Implementation of the World Health Organization’s Framework Convention on Tobacco Control Article 5.3 in India”

“…2 Indonesia is one of the most affected countries with one hundred million smokers, of whom 20% are younger than 15 years. 3 In Indonesia, cigarettes are now second only to rice in rankings of household expenditure. Despite progress in regulation policy, the tobacco industry controls a large part of the Indonesian economy, including the revenue of many farmers and workers.…”