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May 1st, 2016:

Anti-smoking forces give big tobacco a fight in Indonesia

The densely packed houses along Yogyakarta’s Kali Code River went from drab to a riot of reds, blues, yellows and whites.

Residents did not know who had paid for the elaborate painting job last year. The Yogyakarta press speculated that an unknown company had painted the houses so they would resemble the colourful favelas of Rio de Janeiro.

It turns out the village’s benefactor was Philip Morris International and its “Show Your Colors” advertising campaign. On the side of the Gondolayu bridge that overlooks the settlements sits a giant picture frame, with tag lines hung above it reading, “Create your own story” and “Go ahead.”

The village had been transformed into a giant advertisement for a brand owned by the tobacco company.

The ads were another aggressive marketing attempt by an international tobacco company to gain market share in Indonesia. The country is the second-largest cigarette market in Asia after China, and had the highest male smoking rate in the world — 67 per cent, according to a 2011 survey — thanks in part to the popularity of
pungent clove cigarettes.

Over the last decade, it has become a last Eden for tobacco companies facing declining smoking rates at home. As late as 2004, international tobacco companies had a marginal presence in the Indonesian market.

Today, led by Philip Morris International, they control around 45 per cent.

Yet that push has been met by an increasingly potent coalition of mayors, health officials and anti-smoking groups that has scored some important victories.

In one prominent example, huge cigarette billboards that dominated the highways of Jakarta, the capital, were taken down in 2015, as part of a move to ban outdoor tobacco advertisements by mayors around the country.

Many of the lobbying efforts that led to local regulations, including in Jakarta, were substantially financed by the Bloomberg Initiative to Reduce Tobacco Use, the US$600 million (S$806 million) fund founded by former New York mayor Michael Bloomberg.

The Bloomberg Initiative has designated Indonesia one of its five priority countries, and has donated more than US$10 million since 2007. The initiative is largely focused on establishing local and regional tobacco control laws in a nation with a highly decentralised government structure.

“It’s a battle — like a war,” Dr Yayi Prabandari, a professor of public health at Gadjah Mada University in Yogyakarta, said of the clash between tobacco companies and tobacco control organisations.

Before the Bloomberg Initiative became active in the country nearly 10 years ago, fewer than 10 cities had laws that restricted smoking in public areas, according to the Campaign for Tobacco-Free Kids, which jointly administers the Bloomberg Initiative’s grant programmes in Indonesia. Since then, the group says, more than 170 cities have passed laws heavily restricting smoking in public spaces.

Yet tobacco growing has deep roots here. Indonesia is one of the few countries in Asia that has not signed the World Health Organization’s Framework Convention on Tobacco Control, which mandates strict limits on tobacco advertising and sponsorship.

The Bloomberg Initiative has also created a backlash from smokers’ rights groups, who portray Bloomberg as a foreign oligarch determined to stamp out Indonesia’s proud tobacco tradition.

“People who smoke today are stigmatised — we’re discriminated against,” said Mr Alfa Gumilang, the chainsmoking secretary-general of Komunitas Kretek, a smokers’ rights group that accepts funds from the tobacco industry.

The Indonesian government relies on the tobacco industry for around 10 per cent of state tax revenue.

Although tobacco is not nationalised, the government issues growth targets; in 2015, the Industry Ministry released a “road map” for the industry calling for expanded cigarette production.

In October, President Joko Widodo visited the United States to promote US investment in Indonesia. While he was there, Philip Morris announced a US$1.9 billion expansion of its tobacco factories in the country — the second-largest investment that Mr Widodo secured from a US corporation during his visit.

Philip Morris’ success — it controls 35 per cent of Indonesia’s tobacco market through its local subsidiary, Sampoerna — ushered in a new age of foreign expansion. In 2009, British American Tobacco purchased Bentoel, a local tobacco company that is now Indonesia’s fourth largest, with around 7.5 per cent market share.

According to Health Ministry officials, Indonesia’s fragmented government ministries often work at cross purposes when tackling the issue.

Because of the difficulty of making sweeping changes to tobacco control laws nationally, Indonesia tobacco control advocates are increasingly pushing for changes at the local and regional levels, where money from the Bloomberg Initiative comes in handy.

Dr Theresia Sandra, a specialist in chronic lung disease at the Health Ministry, credits the Bloomberg Initiative with helping local governments counter the influence of big tobacco. The group “builds organisations to balance against the strength of industry and opens local governments to the necessity of protecting their communities”, Dr Sandra said.

In one national success, the Indonesian government, with help from the Bloomberg Initiative, passed a law in 2014 requiring manufacturers to put warning labels on
cigarette packaging.

The tobacco fight in Indonesia, the world’s most populous Muslim nation, even extends to the country’s most powerful Muslim organisations, and shows just how central the issue is for society and the economy.

Muhammadiyah, Indonesia’s second-largest Muslim organisation, became the first major Muslim group in the country to issue an edict declaring that smoking is forbidden in all circumstances, citing smoking’s devastating consequences to public health.

The 2010 decision was significant: Muhammadiyah operates thousands of schools, universities and hospitals around the country. Almost overnight, those places became smoke-free zones.

But the Indonesian media quickly pounced on a funding detail. Posted on the Bloomberg Initiative’s website was a US$393,000 grant to Muhammadiyah in 2009.

According to Bloomberg’s website at the time, the grant sought “the issuance and dissemination of religious advice on the dangers of tobacco use among Muhammadiyah/Islamic institutions”.

Critics accused Muhammadiyah of seeking to unite Muslim opinion against tobacco in return for the grant money.

Dr Sudibyo Markus, who led Muhammadiyah’s health department at the time, said there had never been any quid pro quo.

Meanwhile, religious leaders affiliated with Nahdlatul Ulama (NU), Muhammadiyah’s main rival, criticised Muhammadiyah for supposedly bowing to Bloomberg’s money. But NU, which does not view smoking as forbidden in most circumstances, receives funding from the foundation wing of Djarum, Indonesia’s third-largest tobacco company.

The group’s vice chairman, Mr Maksum Mahfudh, said there was “no relationship whatsoever” between the funding and its decision that it would not forbid smoking.

He added that moving “drastically” against tobacco would impoverish the farmers and sellers who are “grass-roots people of NU”.

For now, the two sides appear to have fought to a draw.

After steadily rising for a decade, the smoking rate has plateaued, according to the Indonesian Family Life Survey, funded by the US National Institutes of Health, that was released in April.

Still, Philip Morris International remains optimistic about Indonesia. In a February conference call with investors, Mr Andr Calantzopoulos, chief executive officer, said Indonesia remained a good bet.

“We remain optimistic about the profit growth opportunities in this key market thanks to its growing adult population and rising income levels,” he told them.

Young adults and e-cigarettes: a qualitative exploration of awareness, experience and attitudes

Executive summary

1. This report presents findings from qualitative research which investigated young adults’ awareness and experiences of, and attitudes towards, e-cigarettes. The study was intended to explore a broad range of issues with young adults, and to address a significant gap in the current evidence base. The research involved a series of focus groups and was carried out between October 2015 and February 2016 in three Scottish cities. This study specifically sought to hear from young adults, aged 16 to 25, who were no longer in school.

2. Surveys in Scotland and elsewhere have shown a strong association between smoking and e-cigarette use, and between smoking and deprivation. Thus, a purposive sample was constructed: participants were recruited on the basis of employment status, smoking and vaping status, and age. The study included smokers, vapers and, to a lesser extent, non-smokers in three socio-demographic groups: (i) in further or higher education; (ii) in employment; and (iii) not in employment, education or training (NEET).

Focus group participants and the generalisability of the findings

3. Thirteen focus groups were carried out – five groups of smokers, five with vapers and three groups of non-smokers. Altogether, 99 young adults (54 men) took part, with a roughly equal number aged 16-19 and 20-25.

4. The study deliberately „over-recruited‟ current smokers and vapers, since these groups were most likely to have views on, and experiences of using, e-cigarettes. Smaller numbers of non-smokers and non-vapers were also included to provide a basis for comparison. Thus, just over half (52%) of those who took part were regular smokers and a further 17% were occasional smokers. Most participants (77%) had tried vaping, although less than a quarter of the non-smokers said that they had ever vaped. Forty percent of participants reported that they were current vapers (defined as vaping at least once a week) and 39% of the regular smokers were also current vapers.

5. The purposive sampling approach means that the findings presented here are not typical of the wider population of 16- to 25-year-olds in Scotland (most of whom are non-smokers), and this has to be borne in mind in considering the findings.

Young adults’ awareness of and attitudes towards e-cigarettes

6. Participants in this study generally had a high level of awareness of the range of commercially available e-cigarettes. Across all groups, individuals recognised different types of devices when shown images of them; understood that some were disposable and others were refillable and rechargeable; knew that different e-cigarettes produced variable amounts of vapour; and were aware of the wide range of flavoured liquids available. There appeared to be less awareness of e-cigarettes among individuals in the non-smoking groups.

7. The use of e-cigarettes was common in the family and social networks of the young adults who took part and, when asked why these individuals had taken up vaping, the reason given in most cases was ‘to stop smoking’.

8. The focus groups included young people who were positive about e-cigarettes – they welcomed them as an alternative to traditional cigarettes, and in some cases actively enjoyed using them instead of, or as well as, cigarettes. These individuals commented favourably on taste and flavours, convenience, social acceptability, smoke tricks and vaping culture, and health. However, others thought that ‘they’re like a hobby, not seriously used for quitting'; or that they are ‘rubbish’ and ‘don’t work’. The last observation was usually from smokers who had tried an e-cigarette with the expectation that it would help them stop smoking but, for various reasons, the reality of their experience had been somewhat different. For example, these participants listed a number of perceived failures or shortcomings with the devices in terms of the sensory experience offered in comparison to smoking, including that: they do not curb the cravings for tobacco, ‘you don’t get any good smoke out of them’, and ‘they are not enjoyable’. There was also a view among some that switching to e-cigarettes was just swapping one addiction for another.

Young adults’ experiences of using e-cigarettes

9. The main motivation for participants initially trying an e-cigarettes was the desire to quit, or cut down on, smoking, and those who gave this reason generally believed e-cigarettes to be less harmful than tobacco. However, other reasons for trying e-cigarettes were: curiosity; the potential for saving money; convenience; a need for secrecy in ‘smoking'; social reasons (because ‘lots of people’ were using e-cigarettes); or to do ‘smoke tricks’. For some individuals, the decision to try an e-cigarette was taken on impulse, without a great deal of thought beforehand.

10. Participants obtained their first e-cigarette from a range of sources. Most commonly, they had bought their own; someone (often a family member) had bought one for them to encourage them to stop smoking; or they had tried a device that belonged to someone else.

11. Participants described both positive and negative experiences of their first e-cigarette. Those who had positive experiences said they liked the taste, which was contrasted with the ‘disgusting’ taste of tobacco. However, more often, participants said that their first experience of an e-cigarette was unpleasant in several respects: they disliked the taste; the vapour made them cough; they felt a burning or other uncomfortable sensation at the back of their throat; or they felt sick or lightheaded. Vapers frequently said that they did not initially enjoy using e-cigarettes and found the experience too different to smoking but, by persevering and trying different devices and flavours, they found something that suited them.

12. The accounts that young adults gave of the relationship between vaping and smoking in their lives were varied and complex. Dual use was common, and patterns of use appeared to be highly specific to each individual. Some people vaped during the day, but smoked at home (morning and evening); others did the opposite, vaping at home, but smoking elsewhere. Some vaped all week but smoked at the weekend when out with friends; others smoked all month, but vaped at the end of the month when they had little money.

13. The movement back and forth between e-cigarettes and tobacco cigarettes was also common. Some people said they vaped for weeks or months, but then the device broke, or they lost it, or ‘forgot about it’, and so began smoking again.

14. However, in general, regular vapers reported that they were smoking less – in some cases much less – than before they started using e-cigarettes, and that this had led to what they considered to be improvements in their health.

15. The research included a number of vaping ‘enthusiasts’ (individuals who enjoyed the technical aspects of vaping as much as the perceived health and social benefits), as well as those who had tried vaping but then stopped. The main reasons individuals gave for stopping were that: e-cigarettes were perceived to be an inadequate substitute for tobacco; e-cigarettes tasted unpleasant; or the individual had health and safety concerns about e-cigarettes.

Cessation experiences and views about the addictiveness of e-cigarettes

16. Many participants had attempted to quit smoking in the past and had tried a range of cessation aids (nicotine gum, patches, etc.). However, they were nearly unanimous in the view that these had not worked for them and, in some cases, had significant unpleasant side-effects.

17. Although not everyone who used e-cigarettes did so because they wanted to stop smoking, participants did see e-cigarettes mainly as smoking cessation aids. When smokers and vapers were asked what it was about an e-cigarette that helped them to quit smoking (or why vaping did not help them to quit smoking), they generally focused on the perceived pleasure (or perceived unpleasantness) of vaping, or on the similarities (or differences) between smoking and vaping. Both these issues often came down to the devices or liquids that participants were using, with less pleasant vaping experiences attributed to poor quality, cheap devices and liquids.

18. There was considerable debate within the groups about whether e-cigarettes themselves were addictive. Some believed they were not as addictive as tobacco cigarettes. Such individuals argued that e-cigarettes are not as ‘enjoyable’ and did not give the same ‘draw’ and noted that some liquids have little or no nicotine in them. In contrast, those who believed e-cigarettes were as addictive as (or more addictive than) tobacco, pointed out that e-cigarettes usually contain nicotine, and people who use them seem to use them constantly and ‘don’t know when to stop’.

19. Those who used both e-cigarettes and cigarettes often said there were certain circumstances in which ‘only a cigarette will do’. These were: (i) when drinking; (ii) during times of stress; and (iii) first thing in the morning. Although not everyone agreed that e-cigarettes were ineffective (or less satisfying) in these circumstances, there appeared to be a shared understanding among smokers and vapers why some people might choose tobacco rather than e-cigarettes in these situations.

Young adults’ views about vaping as a gateway to smoking

20. Given the ongoing debate within the public health community about the possible ‘gateway’ effect of e-cigarettes, focus group participants were asked for their views about the likelihood of people who don’t smoke taking up vaping and then, from there, progressing to smoking.

21. There were individuals in all the groups who were aware of non-smokers who had taken up vaping, and there was a recurring view that e-cigarettes are made to seem particularly attractive to children because of the flavours and colours. Some of the non-smokers who took part in the research had tried vaping (usually out of curiosity), but all were adamant that they were not interested in vaping in the future.

22. Some participants suggested that for non-smokers, vaping is often ‘just a phase’, although others thought that the progression from vaping to smoking could happen in certain circumstances (for example, in a pub when the battery had run out of charge), or for certain people (who simply decide that they want to start smoking).

23. Across the groups, the general view was that it was unlikely that non-smokers would take up smoking after having tried an e-cigarette – not only because of the unpleasant taste and higher cost of cigarettes, but also because of the belief that smoking is bad for your health.

Health and safety issues

24. The safety of e-cigarettes was an issue for focus groups participants, and there was a spectrum of views, ranging from those who regarded them as ‘safe’ to those who saw them as ‘dangerous’. The most common view was that they are safer than tobacco cigarettes. However, a perception that e-cigarettes were ‘safer than cigarettes, but not entirely safe’ was often linked to a lack of information, with participants saying that they were concerned about the health risks as they did not know what was in them. Participants also frequently provided examples, either first or second-hand, of people who had been injured by an e-cigarette or liquid.

25. Some reported that their decisions about whether (and where) to use an e-cigarette had been influenced by their concerns about health and safety. However, for the most part, concerns about health and safety aspects were not a significant factor in overall attitudes and behaviours. Rather, health and safety concerns about tobacco cigarettes were more likely to influence behaviour, encouraging individuals to switch to e-cigarettes despite their concerns about the latter.

26. However, across all groups, there were calls for more information. Participants wanted to know what is in e-cigarettes, how their use affects the body, whether they are more or less harmful than tobacco cigarettes, and what the long-term effects are.

Young adults as consumers of e-cigarettes

27. Cost was an important motivator and a perceived benefit for those who used e-cigarettes regularly, either exclusively or in combination with tobacco cigarettes. Participants were aware of the wide price range of different types of e-cigarettes.

28. Although participants largely agreed that using e-cigarettes was cheaper than smoking tobacco cigarettes (and this was seen as one of their main advantages), not everyone was convinced that the case for saving money was so clear cut. There was a view that potential savings were influenced by the extent to which people vaped. Some suggested that the way in which e-cigarettes may be used ‘constantly’ had cost implications; others highlighted that better quality devices and liquids involved additional expense.

29. While cost was a factor in encouraging some to switch, it was not, in itself, enough to persuade everyone to stop smoking tobacco cigarettes. Participants generally understood that savings could be achieved over the longer term by switching to e-cigarettes but the up-front costs were a potential barrier, particularly for participants in the younger age groups and those not in employment. Poor experiences of using e-cigarettes were often attributed to the use of cheap devices and cheap liquids. Regular vapers suggested that the quality of the vaping experience was enhanced by using more expensive products.

Knowledge and information

30. Participants had varying levels of knowledge about e-cigarettes, how they work, and the ingredients of e-liquids. Regular vapers appeared to be most knowledgeable although there were also some regular vapers who said they knew nothing about how e-cigarettes worked and some non-vapers who had a basic level of knowledge. Knowledge levels appeared lowest amongst non-smokers who were least likely to have ever used an e-cigarette. Participants often expressed dissatisfaction or frustration with the available information. Smokers and vapers generally wanted more information about two linked issues: (i) the ingredients of e-liquids and (ii) the health (particularly long-term) effects of using e-cigarettes and the effects compared to smoking tobacco.

31. Young adults reported that they mainly got their information from family and friends who used e-cigarettes. More formal sources of information included retailers, the internet, social media and, very occasionally, health agencies and professionals. Participants had mixed experiences and views in relation to these sources, and often expressed misgivings about the reliability or credibility of information obtained from retailers, manufacturers, the internet and social media. When asked specifically what sources they would trust, participants mentioned: doctors and scientists; public sector organisations (e.g. the NHS, Health Scotland and the government), and organisations such as the World Health Organisation.

Regulation of e-cigarettes

32. This project did not specifically aim to explore the views of young adults on the regulation of e-cigarettes. However, the subject arose spontaneously in a number of early focus groups and so was covered more proactively in later groups.

33. Participants expressed a broad level of support for regulation of e-cigarettes, specifically in relation to product regulation, and sales and advertising. There was a clear view that there should be age-restrictions on the sale of e-cigarettes to deter use by children. There were more mixed views in relation to where vaping should be permitted, although the balance of opinion was in favour of some restrictions. However, not everyone was persuaded that this was necessary on health grounds and some saw indoor use as one of the advantages of vaping over smoking tobacco.


34. This research provides valuable information on young adults’ behaviours and attitudes relating to e-cigarettes, a rapidly changing area of interest to policy makers and practitioners in the health field. The findings point to a clear role for the public health community in providing good-quality information while continuing to acknowledge that this is an area of emerging evidence. Furthermore, increased understanding of the experiences and attitudes of young people will be of interest to health promotion policy makers and practitioners who are exploring the role that e-cigarettes might play in encouraging smoking cessation.

We ban tobacco sponsorship of sport in the UK. Let’s stub it out in the arts, too

Medical professionals call for a smoke-free approach to arts sponsorship

Smoking is a leading preventable cause of ill health and premature death, and a major contributor to health inequality. Current estimates are that the tobacco industry will kill one billion people in the 21st century.

Tobacco advertising has now been banned, along with sponsorship of sport. However, tobacco companies continue to use sponsorship of some high-profile arts organisations to promote the spurious idea that they are responsible corporate citizens. We suspect that most members of the Royal Academy in London will be appalled to learn that Japan Tobacco International (JTI) has been a premier sponsor for its exhibitions. British American Tobacco is also a sponsor, a position it shares with, among others, the Marie Curie cancer charity and Bloomberg. The latter is of note given Michael Bloomberg’s passionate tobacco control stance while mayor of New York.

These sponsorship arrangements are morally unacceptable and must be brought to an end. As healthcare professionals who deal daily with the harm caused by the tobacco industry, we call on arts, cultural and heritage organisations to sign the smoke-free arts declaration ( to affirm that tobacco sponsorship is unacceptable. We also call on sponsors of the arts to undertake that they will no longer support organisations that accept tobacco sponsorship.

Dr Nicholas Hopkinson

Reader in respiratory medicine, Imperial College, London on behalf of 1,104 other healthcare professionals

SEATCA Tobacco Packaging and Labelling Index

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Q & A on the International Tax and Investment Center (ITIC)

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