Indonesia: Reluctance on Tobacco Rules Puts Lives at Risk

A group of boys, about 10 to 12 years old, were squatting next to a sewer near a private university in Depok, West Java, one morning.

They were talking, laughing and puffing their cigarettes. Their hands expertly flicked the ashes. One of the boys suddenly asked the smallest in the group to get them more cigarettes, and each handed a Rp 2,000 (18 cents) bill to the boy, who ran to the nearest store to buy a few sticks, not even a whole pack.

“That is a very disturbing sight. They’re just kids, but nobody tells them not to smoke. The owner of the store also didn’t ask anything, whether the cigarette was for their parent or for them,” said Arini, a Depok resident who witnessed the event.

Arini said she believed the parents, society and the government should be held accountable for failing to protect the nation’s youth.

Smoking children, adults who smoke in public places, street vendors selling cigarettes anywhere with no restrictions, and a relentless barrage of cigarette commercials televised nationally while children are watching are only a few of the problems Indonesia is currently dealing with because of lax tobacco regulations.

According to 2010 data released by the Tobacco Control Support Center of the Indonesian Health Experts Association (Iakmi), smoking kills 235,000 Indonesians annually while second-hand smoking claims 25,000 lives.

While the tobacco industry claims the cigarette tax contributed Rp 55 trillion in earnings to the state in 2010, macroeconomic losses related to tobacco use in the same year totaled Rp 245 trillion, Iakmi said.

In Indonesia, street vendors are allowed to sell cigarettes anywhere, and customers do not have to show their identification cards revealing their age to buy cigarettes.

Indonesia is one of the countries with the cheapest cigarette prices — affordable even for the poorest households and children. A Marlboro pack of 20 cigarettes, including taxes, sells for $1.30 in Indonesia, compared to $9.70 in Singapore and $3.20 in Malaysia and $1 in the Philippines and Vietnam, according to The highest price, at $17.70, can be found in Australia, which has some of the strictest anti-tobacco rules.

While the Indonesian government sets no age limit to buy cigarettes, some convenience stores forbid selling to minors younger than 18 years old.

The World Health Organization’s 2011 Global Adult Tobacco Survey released last year showed that 67.4 percent of adult males and 4.5 percent of females in Indonesia are active smokers, while more than 90 million Indonesians are constantly exposed to second-hand smoking, which poses an even bigger health risk.

Indonesia remains the only country in the Asia-Pacific region that has not ratified the WHO’s Framework Convention on Tobacco Control (FCTC), despite being one of the most active countries in drafting the document in 2003.

The framework — signed by 168 countries — puts a ban on all forms of advertisement and sponsorship. It also suggests putting pictorial warnings covering at least 30 percent of the package and increasing the excise tax. Indonesia is the only country in the Asia-Pacific region not to sign it, and is only one of three countries in the world allowing TV advertisements.

Indonesia has been urged by the international community to accede FCTC to control the fast-growing tobacco addiction in the country, but the government has repeatedly stated its commitment to adopt FCTC principles with no significant effort to do so.

Time to act

“What our leaders have failed to see is that when it comes to smoking, Indonesia is already experiencing a national emergency,” Sudibyo Markus, the vice chairman of Indonesia’s second-largest Muslim organization, Muhammadiyah, told the Jakarta Globe. The organization has 30 million members across the country.

“It is now or never. Smoking is the most serious national emergency we are currently dealing with, followed by drug and alcohol abuse,” he said. Sudibyo is also an advisor to the Indonesian Institute for Social Development (IISD), a nongovernmental organization affiliated with Muhammadiyah advocating stricter regulation on social welfare and tobacco control.

The Ministry of Health has been showing good intentions by pushing through the some regulations to curb the number of smokers in the country, Sudibyo said.

The 2009 Health Law has classified tobacco as an addictive substance, and therefore it must be heavily regulated. In December last year Indonesia finally passed the long-awaited tobacco control regulation that mostly stipulates implementation of pictorial health warnings and no-smoking zones. But sponsorship and promotions are still allowed.

The ministry has previously issued at least two ministerial decrees to support tobacco-control efforts.

Sudibyo, though, said tobacco control has practically no regulation from an economic perspective.

“Unfortunately, it seems like the Ministry of Health is fighting alone while being attacked left and right by other state institutions and tobacco lobbyists,” Sudibyo said.

“It is very perplexing for me that after the Health Law was issued, tobacco control remains a divisive issue and challenged by many people. They should have known that a law is a national consensus. You have to oblige faithfully,” he said.

Sudibyo said the tobacco industry and state institutions supporting them have always been making excuses by pretending to fight for tobacco farmers’ welfare. However, he said, acceding FCTC and heavily regulating the tobacco trade would not harm farmers’ livelihoods. Even active smokers have realized the necessity of having stricter regulation, Sudibyo added.

A survey conducted by IISD and University of Muhammadiyah professor Hamka on the public opinion of FCTC and tobacco control measures in Indonesia found that even smokers supported better smoking regulations.

The survey, released in August involving mostly young people aged 18 to 30, found that the majority of the respondents, or about 95.8 percent, believed that smoking causes addiction and serious illnesses and 94.5 percent agreed that selling cigarettes to minors should be banned.

Surprisingly, 83.4 percent of current smokers questioned, believed Indonesia should adopt FCTC immediately.

Bujang Junaedy, a 58-year-old heavy smoker told the Globe that most smokers would not object to stricter regulations.

“I have been addicted to smoking since I was 11, but it doesn’t mean I don’t know it’s bad and deadly. I still don’t want my grandson to take up the habit, so if the regulations become stricter, I don’t think I would mind at all,’ he said.

“Without FCTC Indonesia will be a giant waste bin for the tobacco industry, and the foreign tobacco industry has started invading Indonesia by using the loopholes from our very lenient regulations,” said Tulis Abadi the operational manager of the Indonesian Consumer Protection Foundation (YLKI)

“We demand the president to immediately accede FCTC because it is a very elegant instrument to control the tobacco epidemic, both from the economic and health perspective, it’s a win-win solution,” Tulis said.

Global commitment

“Indonesia, the important country in global public health and development, should take advantages of WHO FCTC by acceding it,” Tara Singh Bam, technical advisor at the Tobacco Control International Union Against Tuberculosis and Lung Disease (The Union) told the Globe via e-mail. “Indonesia has repeatedly reiterated its commitment on the global level about tobacco control.”

Of the 57 member states that make up the Organization of Islamic Countries, only Indonesia and Somalia have not acceded the FCTC.

In the past few years, words proved to be stronger than taking action.

In 2011 at the United Nations General Assembly on the prevention and control of noncommunicable diseases attended by President Susilo Bambang Yudhoyono, Indonesia has made a commitment to recognize that the most prominent NCDs are linked to common risk factors, namely tobacco and alcohol use, an unhealthy diet and lack of physical activity. Indonesia also recognized the fundamental conflict of interest between the tobacco industry and public health.

In 2011, Jakarta Call for Action on Noncommunicable Diseases Indonesia, along with other participants from Southeast Asian countries, called on global leaders to galvanize a multisectoral response to NCDs by the ratification of FCTC and scale up a package of proven effective interventions, including the reduction of tobacco use.

In the 2007 summit of the ministers of health of the member states of the OIC in Kuala Lumpur, Indonesia stated its willingness to recognize that the tobacco epidemic is one of the greatest threats to health. Indonesia has also joined an effort to call upon OIC member states to introduce stronger tobacco control legislation.

“Unfortunately with all that global commitment our leaders did not seem to have the courage to own up to their own words,” Sudibyo said. “If our leaders are willing, to be honest, they will see that our long-term development program is in a serious danger because of smoking. Too bad most of our leaders are too blind to see that.”

Sudibyo said Indonesia’s efforts to improve its health care policy by implementing the social security bill and the national health coverage by January 2014 would be a wasted effort if the government did not use the momentum to save the country and the youth from the danger of smoking.

The Union’s Singh Bam echoed that sentiment, saying that FCTC should be adopted right now before the start of legislative elections in April 2014. He said that once the election begins the whole country would be too preoccupied with political issues and health concerns would be forgotten.

With Indonesia not being a party of FCTC, the tobacco industry continues to undermine Indonesia nationally and internationally, experts say.

One of the examples, Singh Bam said, is that the tobacco industry holds the annual World Tobacco Asia convention only in Indonesia.

“Why? The tobacco industry says, ‘Indonesia’s cigarette market is considered the world’s fastest developing market — 30 percent of the 248 million adult population smokes, which makes Indonesia the fifth-largest cigarette market in the world,” he said.

The four largest by potential users are China, India, Russia and the United States, according to WHO in a 2008 survey.

“This is the time, Indonesia should make a move right now,” he said.

Sudibyo said during previous elections, tobacco as an issue was often made a tool in political campaigns to win votes.

“There will be a lot of politicians selling promises that they will fight for the tobacco farmers and the local tobacco industry. We need a strong regulation to prevent that,” he said.

Indonesia’s efforts to curb the number of smokers has found hope with Indonesia’s second-largest Muslim organization declaring smoking as haram , or religiously sinful, and banned smoking in all facilities — to more than 7,000 schools, universities, mosques and hospitals.

“Right now, every time we have a national meeting, or muktamar , nobody will dare to smoke,” Sudibyo said.

He said religious leaders hold a very important role to help control tobacco use. However, there are still many religious leaders who are not willing to give their support, citing tobacco farmers’ welfare as an excuse, he said.

“There was a religious meeting in Padang Panjang, West Sumatra a while ago. Most of the ulema have agreed smoking should be declared haram, but it did not happen simply because there were two most-senior ulemas who disagreed,” he said.

Padang Panjang is one of the most progressive districts in Indonesia when it comes to tobacco control. It has a complete ban on sponsorship and billboards have been eliminated. Many of its public spaces prohibit smoking.

While Muhammadiyah’s effort to regulate smoking in its facilities has started to show results, Sudibyo said, the effect would be a lot more fruitful it is followed by the country’s largest Muslim group, Nahdlatul Ulama, which has more than 40 million members.

“I am very grateful that NU has started following our footsteps by banning smoking in its mosques and certain firms, but the efforts will be even more fruitful if they can formulate the ban in a more binding policy like a fatwa ,” he said, referring to a religious edict.

Human rights

“By looking at the data on how many people died from smoking, it is obvious that it has violated the right to live,” Ifdhal Kasim, former chairman of the National Commission on Human Rights (Komnas HAM) said in a statement.

Ifdhal, who is also an activist opposing tobacco use, said both the constitution and the 1999 law on human rights clearly mentioned that everybody has the right to live in a healthy environment and with proper health care.

“So, you can’t say you can smoke as you please because it’s your individual right. Living a healthy life is a human right, and human rights trump individual rights,” he said.

By acceding FCTC, he said, the government would show a strong commitment and willingness to protect human rights in Indonesia.

Komnas HAM commissioner Roichatul Aswidah said the right to be healthy could not be reduced in any circumstance, and therefore she said, the government should immediately adopt FCTC.

Indonesia’s reluctance to accede FCTC has also drawn serious concerns internationally.

The 2013 Asia Pacific Association for the Control of Tobacco (Apact) held in August in Chiba, Japan, highlighted the tobacco epidemic in Indonesia.

“Apact note[s] with grave concern tobacco use leads to increased health-care costs attributed to tobacco-related illnesses in Indonesia, which amounts to $1.2 billion each year,” the conference said in a joint statement.

Apact also noted that tobacco advertising, promotion and sponsorship aimed at youth are still rampant in Indonesia and contributed to a 400 percent increase in the prevalence of smoking among children between 5 and 9 years of age.

The association urged the Indonesian government to immediately ban indoor smoking in all public places, workplaces, and public transportation facilities. It also called for a ban on all types of tobacco advertising, tobacco sponsorship but called for larger pictorial warning that should cover more than 50 percent of cigarette packaging.

Under the 2012 tobacco control regulation, tobacco companies are only obligated to include pictorial health warning that covers 40 percent of the package.

Sudibyo noted that smoking most of the time violated the human rights of non-smokers.

“As you know more than 97 million Indonesians are exposed to second-hand smoking and countless more are exposed to tertiary smoking, from the toxins left by smokers,” he said. “As a non-smoker, why do you have to put up with this?”