Wednesday 17 August marked the 71th Independence Day of Indonesia. This year, once again we found artistically scripted and shot videos that encourage Indonesians to carry the spirit of independence by attaining their dreams and aspirations in the hope of making a positive contribution to the nation - some published by a major tobacco company. While Indonesian advertisement laws do not allow tobacco branding or depictions of smoking; in the spirit of independence, I find it interesting to further explore the issues of tobacco in Indonesia.
Indonesia's Smoking Epidemic
Indonesia is the only country in the Southeast Asian region which is not a party to the WHO Framework Convention on Tobacco Control (FCTC) - a framework that - with 180 states parties - represents 90 per cent of the world population . In Indonesia, the Global Adult Tobacco Survey Data 2011 reported that despite 86 per cent of adults believing that smoking causes serious illness, 34.8 per cent of the overall population, or around 59.9 million adults, currently smoked tobacco and 78.4 per cent of adults, or around 133.3 million adults, were exposed to tobacco smoke at home. Six years after the video of an Indonesian baby smoking 40 cigarettes a day went viral, it has now attracted over 30 million views. Research published in Oxford's Health Education Research reported that the prevalence of youth smokers in Indonesia was 38 per cent among boys and 5.3 per cent among girls in 2006.
The health consequences of smoking and its costs to society in Indonesia are devastating. Smoking kills at least 225,000 people annually, many from lung disease. Despite 40 per cent of all people living around the national poverty line live with as low as around GBP 20 per month, a study on Tobacco Economics found that 11.5 per cent of monthly household expenditures are spent on tobacco, the second largest expenditure after food. The Global Burden of Diseases Study 2010 by the Institute for Health Metrics and Evaluation at the University of Washington produced a GBD profile of Indonesia, demonstrating tobacco consumption as one of the three risk factors that account for the most disease burden. While Indonesia has an optimistic outlook on the future of healthcare by progressing to Universal Health Coverage by 2019, tobacco consumption by health insurance participants poses a risk to the newly established Healthcare and Social Security Agency (BPJS). For instance, there is a steady increase in the NCD risk factors, including from tobacco use. The World Economic Forum estimates that NCDs (cardiovascular disease, cancer, chronic obstructive pulmonary disease) will cost Indonesia $4.47 trillion from 2012 through 2030.
A Long Walk to Freedom
Tobacco advertising in Indonesia is aggressive and creative. GATS 2011 says that 8 in 10 adults noticed cigarette advertisements, promotions or sporting event sponsorship. Tobacco companies, with their high revenues and representing a big source of income for the government, are actively involved in local celebrations and youth events sponsorship. The way cigarettes are marketed, associates smoking with masculine aspirational imagery for men, and the "torch of freedom" for women. Particularly in Indonesia, a research paper on the culture of smoking found that tobacco advertising has prominent key themes of country pride, patriotism and nationalism. Tobacco advertising videos show teachers, athletes, war veterans, dancers, and professionals working hard to attain their dreams - the people who represent a united hope for a better Indonesia.
Yet, here lies the problem. Health is an important matter for the functioning of individuals and States as people need some minimum level of health to engage in social interactions. Health facilitates the substantive freedom for people to lead and enrich their lives. Those athletes, youth, veterans, teachers, they first need to be healthy to be able to fulfil their aspirations in life. If we want to build a better nation, we need healthy Indonesians - not unhealthy Indonesians lead by some false aspirational hope. Unfortunately, tobacco companies are trying to forge a link between jingoism and consumption of their products. As the tobacco market expands and smoke subtly gets in people's eyes, they lure the people with nationalism values, promoting more and more people into unhealthy habits that may result in tobacco-related illnesses in the long-term, adding enormous burden to the individuals, their family, the society and the State. The statistics on the grave consequences of tobacco are the ugly truth.
Independence Day is the day where we celebrate the legacy of our heroes. Thus, in the same spirit of celebration, we should contemplate: when we think of the millions of lives that have been affected by tobacco-related illnesses, is this the kind of independence that was fought for by this country's heroes and the kind of legacy we want to leave behind for our young generation? Yes, Indonesia has been independent from colonisation for 71 years. However, freedom and independence can be defined in various ways - which also depends on the era that we live in. Reflecting on the above statistics on the grave harm of tobacco in Indonesia, we see that Indonesia is far from achieving freedom from tobacco. As health science progresses and the human right to health is being realised; in this celebration of independence, it is time for Indonesians to critically use their expanding knowledge to make decisions to maximise health gains for a better nation.
I am grateful for the critical and substantive comments from Dominic Wooler, a law graduate of University College London, and for Tom Gorringe for his thoughtful feedback.