With each passing day, such scents and sights became commonplace, and she came to appreciate just how embedded smoking is in the everyday culture of Indonesia. Our foundation recently examined why that is so. The resulting report brought three key insights into sharp relief.

First, smoking is extraordinarily common in Indonesia. Anecdotes of children smoking and friends exchanging cigarettes as gifts abound. The statistics underscore just how valid those anecdotes are.

Recent data reveal that Indonesia has one of the highest―if not the single highest―rate of smoking in the world, with nearly 34 percent of adults being smokers, according to the Health Ministry’s Basic Health Survey (Riskesdas, 2018). Men make up almost all of these smokers, with over half of all Indonesian men reporting that they smoke and virtually all women reporting that they have never smoked.

The reasons for this are complex and multifactorial. Culture plays a critical role but so, too, does economics. Indonesia has a large tobacco industry and, by extension, is home to many whose livelihoods depend on tobacco across the value chain.

Other influences include policy (Indonesia has not signed the World Health Organization’s Framework Convention on Tobacco Control), social perception (many appear to perceive smoking as not only acceptable, but also desirable among men) and medical training (four out of five physicians report needing more training in smoking-cessation practices – see Yayi Suryo Prabandari et. al “Laying the groundwork for Tobacco Cessation Education in Medical Colleges in Indonesia”, Education for Health, 2015.

Second, the resulting toll of such widespread smoking is striking. Studies estimate that over 290,000 Indonesians died of tobacco-related deaths in 2019. That is nearly an order of magnitude more than the number of Indonesians who have died of COVID-19 since the start of the pandemic, and it is a toll that is exacted year after year after year.

The figure accounts for more than a quarter of all deaths in the country each year and represents a loss of life, livelihoods and loved ones that is unimaginably devastating. Tobacco use in Indonesia also significantly worsens other major health challenges, such as tuberculosis; one in every four tuberculosis deaths in Indonesia is due to smoking (Genet A. Amere et. al “Contribution of Smoking to Tuberculosis Incidence and Mortality in High-Tuberculosis-Burden Countries”, American Journal of Epidemiology, 2021).

Third, there are evidence-based ways to turn the tide, slowly but surely, against smoking and its harmful effects. One obvious place to start is by providing physicians with the training they desire. A survey revealed that nine out of 10 physicians do not feel fully prepared to promote smoking cessation, four out of five desire more training on the topic, a plurality of physicians smoke themselves, and many believe that smoking fewer than 10 cigarettes per day is safe (despite clear data stating that the opposite is true).

In addition to supporting physicians who are key to breaking through to patients, policymakers may want to consider innovations that appear to be effective in other countries to complement existing tobacco control measures. For example, the United Kingdom has been a leader in encouraging heavy smokers to transition to less harmful alternatives. The approach appears to be working because smoking rates are decreasing and quit attempts are increasing with such support.  

Although alternatives can facilitate smoking cessation, public acceptance depends on the economic and regulatory policies a country adopts. Policy responses that acknowledge the existence of a continuum of risk and then apply measures proportionate to that risk, effectively incentivizing persistent smokers toward cessation and less harmful alternatives.

Whether such approaches will work in Indonesia―in light of its unique cultural, economic, political, social and medical environments―is ultimately an empirical question. Given the seemingly ubiquitous smell and sight of smoking, especially among Indonesian men, it is a question well worth answering.

***

Derek Yach is president of Foundation for a Smoke-free World

Didik J Rachbini is rector of Paramadina University, Jakarta

Romita Shah is policy and economics staff, Foundation for a Smoke-Free World

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