Indonesia: tobacco pack warnings need stronger enforcement

By Dr. Widyastuti Soerojo, SITT Project Coordinator

As reported in the September 2014 edition of News Analysis, pictorial health warnings (PHW) on cigarette packs in Indonesia were due to be implemented in June 2014. The Indonesian government approved the warnings, after a lengthy process, under Article 114 of the Health Law No 36/2009, with 18 months lead-in time from approval to implementation.

Considering Indonesian tobacco companies have been exporting cigarette packs with pictorial warnings to neighbouring countries for many years, 18 months was extremely generous to the tobacco industry before mandating Indonesians receive the same information as other people in the region about smoking’s dangers. Nonetheless, by 24 June, only about 13% of brands were reported to be compliant with the new law. The tobacco industry was then given a further two months to comply, bringing the transition period to a total of 20 months.

The Faculty of Public Health, University of Indonesia coordinated a survey in the last week of August 2014 – the end of the extended implementation period – to assess the progress of compliance at points of sales (POS). The survey was done in 54 subdistricts of seven cities of seven provinces in Java, including the capital Jakarta and less densely populated outer islands. The National Commission for Child Protection together with researchers from universities in Banda Aceh, Pontianak, Makassar, Jakarta, Semarang and Surabaya surveyed 525 POS. Each covered 10 randomly selected POS in five categories: distributor to retailer, supermarket, minimarket, kiosk and vendor.

No cigarette brand variants assessed in the survey fully complied with the pictorial health warning requirement at all POS sites. Between 40-60% of brand variants were non-compliant (had no PHW at all), and 4-5% were partially compliant (had a PHW, but with other violations of the law such as excise stamps obscuring the warning on the packs). In addition to pictorial health warnings, information is also required on all packs to advise that there is “no safe level” of tobacco use and that cigarette smoke “contains more than 4,000 hazardous chemicals and more than 43 cancer-causing agents”. No domestic brands of the top five manufacturers provided this information.

Five of the largest tobacco companies, which collectively control 90% of the market, showed low compliance. Bentoel/British American Tobacco (BAT) was the worst offender, with non compliance between 63-90% in six of the survey sites. BAT had distributed a notice to retailers providing misleading information that production of packs with new PHW would only begin after June 24, and retailers can continue selling old stocks without a deadline. Even shops located right outside tobacco factories in Surabaya were selling packs without PHW.

The packs that did carry the new pictorial warnings created strong reactions from smokers, consistent with the evidence from other countries. The pattern was similar in all cities, with the most common reaction to look for packs with no PHW (52-96%), or choose the least scary picture – one which shows a “smoking man” with a skull background (68-95%).

In Makassar, more than 30% of smokers expressed feelings of disgust, fright, thoughts of buying single sticks, looking for non-PHW packs in other POS, no desire to smoke, perceived change in taste, and “accused” the industry of reducing the amount of cloves and flavouring in the cigarettes. The head of Gudang Garam distributors in Makassar had earlier expressed concern that the PHW had an impact and was seeing declining sales. Similar smoker responses were recorded in other survey sites.

Smokers negatively affected by PHWs resorted to several ways of obscuring pictures on packs, such as covering them with stickers showing attractive women, asking the shopkeeper for a dark tape to cover the PHW, putting the pack inside a case and even discarding the pack altogether in favour of alternatives. Sampoerna’s “A Mild” branded metal cases were found available for sale after June 24.

Such consumer reactions suggest that most Indonesian smokers previously were not fully aware of the many dangers of tobacco use. The strong reactions the PHW evoked are consistent with those of smokers everywhere, and provide positive feedback that PHW are effective, even among those heavily addicted. This explains why the tobacco industry strongly opposes PHW policy in Indonesia in the same ways it opposes effective tobacco control measures globally; first by filing a case in the Constitutional Court, then intentionally misinterpreting the effective date of implementation, and now delaying compliance even after the generous 20 months after the deadline for full implementation.

The Food and Drug Authority responsible for enforcement has given the industry ample time and warnings for compliance. It is time for the government to take serious action against the industry’s prolonged and continuing violations of the regulations which, if implemented properly, will set Indonesia on the path to reversing the epidemic for which the country pays such a high health, social and economic price.

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