“Tobacco use has become the second [greatest] risk factor for untimely death in Indonesia,” Health Minister Budi Gunadi Sadikin asserted when opening the 7^th Summit of Asia Pacific Mayors (APCAT) in Sanur, Bali, last week.

For decades, tobacco use has been the No.1 public-health enemy in Indonesia and the rest of Asia Pacific, home to 600 million smokers. Tobacco use kills over 8.67 million people every year globally, 2.3 million of them in Asia Pacific countries.

The active smoker population in Indonesia amounts to 70 million, which means Indonesia has one of the highest rates of active smokers in the Asia Pacific. The country is now facing a grave tobacco epidemic, contributing to preventable disease burdens of cancer, cardiovascular diseases and stroke. More than 225,700 people die every year from tobacco-related diseases here.

“To reduce tobacco use and exposure, especially in the youth population, we plan to revise the national law to include expansion of pictorial-health warnings, advertising restriction and e-cigarette restriction,” Budi said.

But, revising legislation or regulation on tobacco control is always beyond complex. The country has enforced Health Law No. 36/2009 and Government Regulation (PP) No. 109/2012 on tobacco control, but many believe they are toothless when facing Big Tobacco.

Experts have suggested that the government regulation be overhauled to include a ban on cigarette advertising (outdoor, indoor and social-media platforms), expansion of pictorial-health warnings and, more importantly, control of the use of novel tobacco products, including electronic cigarettes and smokeless or heated-tobacco products.

The Health Ministry proposed the amendment of the regulation in May 2021, only to stir a conflict with several other ministries. The plan has renewed the fierce tug-of-war between public health and the economy.

In Indonesia, any regulation regarding tobacco must involve at least the Agriculture Ministry, Health Ministry, Trade Ministry, Industry Ministry and Finance Ministry. The Finance Ministry, for instance, is expecting to generate Rp 193.53 trillion (US$12 billion) from tobacco-excise revenue by the end of 2022 fiscal year.

More importantly, the revision of the regulation will badly affect Indonesia’s flourishing tobacco industry, which produces over 340 billion sticks of cigarettes every year. The tobacco industry has been known to engage in influential lobbying to interfere with public-health policies in Indonesia and elsewhere in the world.

Interference from Big Tobacco has hampered government efforts to control tobacco use and to effectively implement any regulations banning tobacco advertising, sponsorship as well as raising taxes on cigarette prices.

Months of inter-ministerial meetings and discussions on the planned revision of the regulation went nowhere as it was returned to the Health Ministry for further studies in November 2021, proving once again the lack of political commitment on the part of the government to end tobacco use.

After a year of stalled progress on the planned revision, Budi found more-reliable allies in fighting against tobacco use and the tobacco industry in general.

“It is necessary to have a clear strategy and partnership with multi-stakeholders,” the minister said. “It was essential for us, the central government, to collaborate with local administration in the fight against tobacco use.”

Meanwhile, at the national level, ministries involved in regulating tobacco use continue to bicker with each other. As of November, around 360 city mayors and regents across Indonesia have passed bylaws or Perda for the establishment of smoke-free zone areas.

These bylaws also prohibit the tobacco industry from advertising their products outdoors, indoors and at point of sales, and prohibits people from smoking cigarettes in schools, health facilities, public transportations, government buildings, shopping malls and indoor facilities.

Given Indonesia’s current decentralization and regional-autonomy policies, district and municipal governments play crucial roles as executive bodies that implement regulations directly affecting their constituents. The policies aim, among other targets, to bring the subnational governments closer to their people as they have a better understanding of the needs and aspirations of their communities than the central government.

Bima Arya Sugiarto, the mayor of Bogor and co-chair of APCAT, believes that subnational leaders -- mayors and regents -- have the power and capabilities to bring changes that lead their people to wellbeing.

The Mayors and Regents Association (APEKSI), established in 2011, now boasts 150 members that can act as the driving force behind the nationwide campaign against tobacco use and tobacco-industry interference.

In the Asia Pacific region, mayors and regents have formed a strong collaboration called the Asia Pacific Cities Alliance (APCAT) for Health and Development since 2016. APCAT members have sharply increased from 12 cities to 82 cities in 12 Asia Pacific countries.

“Health is a political choice that should ensure leadership, accountability and sustainability for effective implementation of public-health policies and programs to prevent current and future pandemic,” said Tara Singh Bam, APCAT’s board director.

Under the theme, “Together we bring health solutions”, the summit gathered over 1,000 delegates from 130 cities in the Asia Pacific region.

“APCAT is a vital platform where mayors, regents and sub-national leaders share their best practices, experiences, innovation and solutions to advance tobacco control, NCDs and other health and development issues,” added Bam, who is also Asia Pacific director of the International Union for Tuberculosis and Lung Health (the Union).

Representing the mayor of Kuala Lumpur, Nor Halizam Ismail, the Malaysian capital city’s senior deputy director for the Health and Environment Department, shared her city’s experience in introducing the proposed Control of Tobacco Products and Smoking Bill 2022, aiming at prohibiting the use and sale of cigarette products and Vape (e-cigarette) to everyone born from 2007 onwards, one of the most progressive and visionary bills on tobacco control to be implemented in the region.

“This proposed bill, dubbed as generational endgame for smokers, is widely praised and accepted by the community, who want to protect their children from smoking and to prevent them from tobacco addiction. But we must face stiff challenges from various opposing groups, especially from the tobacco industry and the pro-vaping industry,” she added.

While it would be easier to control the use of conservative tobacco products, such as cigarettes, Malaysia is overwhelmed by the increasing number of Vape users, among school children in particular.

She regretted that this year’s APCAT Summit did not thoroughly touch on Vape and other novel-tobacco products.

The summit has given hopes to Asia Pacific countries in their concerted efforts to fight against tobacco use and tobacco industry. However, challenges are visible especially in Indonesia, which is facing the crucial political year in 2023.

Indonesia will elect new president in February 2024, and new governors, mayors and regents in more than 200 regions in November of that year.

Until next year, there will be 24 governors, 56 mayors and 191 regents who will leave office. Some of them are members of APCAT. Any change of guard is feared to impact on the bylaws and policies on tobacco control currently in place in 360 mayoralties and regencies across the country.

Bima Arya is upbeat the regulations and bylaws on tobacco control will remain strong, although “as far as I know the tobacco industry has already approached most potential candidates aggressively”.

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The writer is the founding board member of Asia Pacific Media Alliance for Health and Development and coauthor and coeditor of Medan Laga Pengendalian Rokok di Indonesia (The Battleground of Tobacco Control in Indonesia).

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