Saturday, February 13, 2010

Tobacco Control in Indonesia and Thailand 2008

Tobacco’s Global Risk: Health, Poverty and Gender

The World Health Organizations defines health as “a complete state of physical, mental, and social well being, and not merely the absence of disease or infirmity.” Health is detemined by multiple, globally interlinked factors, such as climate change, food security and production, the cost and availability of medication and nutrition.[1] Tobacco use is closely associated with an increased risk of cancer and heart disease. It also results in respiratory illnesses, including Chronic Obstructive Pulmonary Diseases (COPD). Tobacco use has been shown to promote the onset of tuberculosis (TB) and negatively affect the outcome of TB. Thus fighting for a tobacco free world is a way to improve global health.

Ulrich Beck clearly state risk is not synonymous with catastrophe. Risk means the anticipation of the catastrophe that concerns the possibility of future occureness and developments; they make present a state that does not exist yet. This anticipation of catastrophe lacks any spatio-temporal or social concreteness.[2] Tobacco posed a disastrous risk towards global health, as the only legal consumer product that can harm everyone exposed to it, and kills up to half of those who use it as intended.

Based on the Tobacco Fact Sheet issued by the World Health Organization (WHO), Tobacco use is one of the biggest public health threats the world has ever faced, by killing more than five million people in 2008. With more than one billion smokers in the world, global use of tobacco products is increasing, although it is decreasing in high-income countries. More than 80% of the world's smokers live in low- and middle-income countries.[3]

Furthermore, Tobacco use kills an average of one person every six seconds - and accounts for one in 10 adult deaths worldwide. It has killed up to half of all users. It is a risk factor for six of the eight leading causes of deaths in the world. Unchecked, tobacco-related deaths will increase to more than eight million a year by 2030, and 80% of those deaths will occur in the developing world.

Tobacco tends to be consumed by those who are poorer. In turn, it contributes to poverty through loss of income, loss of productivity, disease and death. Together, tobacco and poverty form a vicious circle from which it is often difficult to escape. It is the poor and the poorest who tend to smoke the most. Currently, there are an estimated 1.3 billion smokers worldwide. Of these, 84% live in developing and transitional economy countries.[4]

Poverty has many dimensions. Reeves use the word poverty refers to the involuntary lack of suificient resources to provide or exchange for basic necessities- food, shelter, healthcare, clothing, education, and opportunities to work and to develop the human spirit. [5] There are several ways in which tobacco increases poverty at the individual, household and national levels. At the individual and household level, money spent on tobacco can have a very high opportunity cost. For the poor, money spent on tobacco is money not spent on basic necessities, such as food, shelter, education and health care. Tobacco also contributes to the poverty of individuals and families since tobacco users are at much higher risk of falling ill and dying prematurely of cancers, heart attacks, respiratory diseases or other tobacco-related diseases, thus depriving families of much-needed income and imposing additional health-care costs. Those who grow tobacco suffer as well. Many tobacco farmers, rather than growing rich from the crop, often find themselves in debt to tobacco companies. Furthermore, tobacco cultivation and curing can cause serious damage to human health.

At the national level, countries suffer huge economic losses as a result of high health-care costs, as well as lost productivity due to tobacco-related illnesses and premature deaths. Countries that are net importers of tobacco leaf and tobacco products lose millions of dollars a year in precious foreign exchange. Tobacco cultivation and curing also degrade the natural environment. Cigarette smuggling is also a cause for concern because it can lead to an increased consumption if the average price of all cigarettes falls, having a higher impact in in middle- and low-income countries and on the poor. Reduced government tax revenue is another consequence of smuggling. To sum up, tobacco’s contributions to the economy (through employment, and government tax revenue) are outweighed by its costs to households, to public health, to the environment and to national economies.

With more than one billion of tobacco consumers in the world, globally the prevalence is four times higher for men to use tobacco instead of women. Based on the WHO report on the gender, health and tobacco, there are relation between tobacco usage and gender relations.

First, the changing norms of greater female autonomy and women’s roles may put women and girls at higher risks. The society became more acceptable towards women tobacco usage, then more women will use tobacco and face the risks. Second, there are different motivations in taking up, continuing and ceasing to use tobacco based on gender. For instance, women smoke to buffer against negative feelings whilst men smoke to enhance positive feelings. Third, In order to seek new market and sustain existing, tobacco industry exploits the socio gender norms to promote their products.[6]

In addition, Women often have less disposable income than men and are more likely to spend it on their children. The diversion of scarce family resources for tobacco (most frequently by men) may signifi cantly contribute to malnutrition and school drop-out, with potential longterm consequences. Thus economically, the household burden of tobacco usage by men, will be beared by women.

Framework Convention on Tobacco Control

In response to these global risks, the member states of the World Health Organization (WHO) negotiated and have now adopted the WHO Framework Convention on Tobacco Control (FCTC). The FCTC represents the first time that the WHO member states have harnessed the organization's right to develop a binding international convention to protect and promote global public health. The FCTC also represents the first time that states have cooperated worldwide to form a collective response to the cause of an avoidable chronic disease.[7]

The FCTC was developed as a scientific, evidence-based approach to global tobacco control. The final FCTC text commits member states to implementing proven tobacco-control measures, such as increasing prices and taxes, imposing bans on advertising, promotion, and sponsorship, disclosing tobacco product components, requiring labeling standards and health warnings, promoting public education and awareness campaigns, and conducting research and surveillance programs. On November 29, 2004, Peru became the 40th country to ratify the convention. As a result, on February 28, 2005, the world's first public health treaty came into force.

The FCTC provides a legal platform for the adoption and implementation of effective tobacco control strategies worldwide.[8] However, its implications go far beyond tobacco production, promotion, and use. The FCTC is, in essence, an attempt to develop a form of global health governance capable of effectively regulating transnational corporations. Its negotiation entailed wrestling with fundamental questions about the social impacts of globalization, particularly the relationship between trade and health. The negotiations also illuminated the important and evolving role of low- and middle-income countries and nongovernmental organizations (NGOs) in determining the future direction of global public health policy.[9]

Significant barriers exist to the treaty's long-term success, remain in many countries. States that have ratified the treaty must now follow through and implement their commitments. Other states, some of which have been active leaders throughout the FCTC process, now face major challenges in ratifying the treaty at home. Some states are lagging behind the global movement toward effective international tobacco regulation. In all countries, tobacco control programs need increased investment to fulfill the FCTC's potential to save lives.

It is important to understand the environment in which the treaty has taken effect in order to outline the steps necessary to ensure its successful implementation. Prior to the FCTC, many low- and middle-income countries viewed tobacco production and sales as necessary for economic development. However, by the end of the process, these countries had become the driving force behind many of the strongest measures included in the treaty. The FCTC now provides the governments with lever-age to overcome industry pressure and political obstacles encountered in their previous tobacco control efforts.


Parties of the WHO FCTC have committed to protect the health of their populace by joining the fight against the tobacco epidemic. To fulfil the task, WHO established MPOWER, a package of the six most important and effective tobacco control policies.[10]

1. M for Monitoring tobacco use and prevention policies. Monitoring provides essential data that governments need to fight the tobacco epidemic. Comprehensive monitoring tracks tobacco use as well as public attitudes and knowledge regarding tobacco and allow government to document the extent and nature of the epidemic, target groups for specific interventions, monitor the impact of various policies and improve policies as needed.

2. P for Protect people from tobacco smoke. Smoke free environments are crucial for protecting the health of smokers and non smokers alike, as well for sending a clear message that smoking in public places is not socially acceptable. Only completely smoke free places, without exception and loopholes that make enforcement easy and effective.

3. O for Offer people to quit tobacco use. Tobacco users who wants to quit, unable to do so because highly addicted to nicotine. Thus state need to provide access to treatment for tobacco dependence. This effective cessation services range from brief routine advice from health care worker, quit lines, and medications made available and easy to access.

4. W for Warn about the dangers of tobacco. Warn includes the health warnings on tobacco packs or other tobacco related materials. Also, widespread use of effective warning labels would provide important knowledge about tobacco’s health threat and counter false information by the tobacco industry.

5. E for Enforce bans on tobacco advertising, promotion and sponsorship. This includes ban on direct and indirect marketing activities. Direct focus on all forms of advertisements. While indirect includes price discounts, product giveaways, and sponsorship of sporting and entertainment events and festivals. Partial bans have limited impacts, because tobacco companies simply reallocate spending to other marketing channels.

6. R for Raise Taxes in tobacco. Tax increase is the most effective way to reduce tobacco use and have the benefit of increasing government revenues. Higher tax reduces consumption, lower health care costs, help households, save money by reducing tobacco use, and increase government revenues, which can pay for tobacco control interventions and other policy priorities.

Based on the six MPOWER framework, I will assessed Indonesia’s and Thailand’s tobacco control situation. As a South East Asian countries, categorized as developing countries that might have similarities or differences in combating tobacco epidemics. Whereas in every tobacco control measures, political will need to be generated.[11]

Indonesia and Thailand Tobacco Control

Indonesia and Thailand are both developing countries, located in the South East Asia. Both both path in tobacco control is not similar. Indonesia has not yet become a party in the WHO FCTC. Despite pressures from civil societies, they refuse to ratify it because they find tobacco already been control with current law. But the real reason is they do not want to be legally bind by an international treaty, because of the influence of the tobacco industries. Meanwhile, Thailand is a party of the FCTC. They signed it on 20 june 2003 and ratified on 8 November 2004. Nevertheless, both country can be assessed based on the MPOWER framework published in the WHO Report on Global Tobacco Epidemic 2008.[12]

Tabel 1. Industry Profile

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

The Industry profile shows that Tobacco industry in Indonesia is much more higher in terms of supply and demand. The Tobacco industry have done much efforts in Indonesia to create a favorable business climate by lobbying government. Meanwhile, the adult smoking prevalence both sexes, shows Indonesia have 31% of adult smokers compared to 16,1% Thai’s. This is to say, Indonesian where Tobacco industry is significant, use more tobacco than Thai’s. This can be reflected by the tables shown below.

Tabel 2.Retail Price a Pack and Tax as a % of Price


Price a pack *

Excise tobacco tax as a % of price

Local currency

in USD ex rate 2006

Specific Excise

Ad Valorum

Import duties



8500 IDR







42 THB






*Retail Price for a pack of 20 cigarettes of mostly wide consumed brand

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Meanwhile the price of tobacco per pack in Thailand is slightly higher, but Thai’s government impose higher tax on cigarettes. Still, the price of cigarettes in both countries is quite affordable for larger part of the populations.

Tabel. 3 Ban on Direct Advertising.


Ban on Direct Advertising


Nat TV and Radio

Int'l TV and Radio

Local Written News media

Int'l Written News media

Outdoor advert

Point of Sale




















Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Indonesia have partial or no ban on direct advertising in every marketing channels compared to Thailand’s ban on all national direct adverting media. Therefore Indonesians are more likely to be exposed with the tobacco advertising.

Table.4 Ban on Indirect Advertising

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Thailand also have stricter regulation on tobacco indirect advertising than Indonesia. Where discount promotion is the only indirect advertising exist in Thailand, Indonesia only ban free mail distributions. Also Thailand already ban tobacco in sponsoring events where Indonesia has not.

Table. 5 Smoke Free Environment Coverage

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Both Indonesia and Thailand have minimal, partial or no ban to most of the public spaces. Thus the population have more risk to be exposed as a second hand smokers.

Table. 6 Regulation on Packaging

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Health warning in Thailand’s cigarette packaging is more deterring than Indonesian’s. Thailand have larger display area, ban on deceitful terms and have a deterring pictorial warnings. While Indonesia still use deceitful terms such as ‘mild,’ and ‘lights,’ and with minimal health warnings instruction on the pack.

Table 7. Support for treatment of Tobacco dependence

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Both countries do not have quit lines accessible for the population. Nicotine replacement and bupropion is not available or only minimal, in Indonesia. Also the smoking cessation support in Thailand is much more diverse.

Table 8. Government programs and agencies for tobacco control

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

Both countries have national objective of tobacco control and have national agencies for it. But Indonesia do not provide data regarding the national agencies staff and budget allocated for it.

Source: WHO Report on Global Tobacco Epidemic 2008, based on countries monitoring data.

In summary, the tobacco control in Thailand is more regulated than in Indonesia. Where Indonesia as a none parties of FCTC, have lower efforts in taxation, advertising bans, health warning, smoke free environment, cessation programs. This low efforts reflected in the adult smoking prevalence rate, where Indonesia is twice than Thailand.


Tobacco posed a great global risk towards humanity. The number of people killed each year by tobacco will increase unless action is taken. The WHO FCTC is the international umbrella for fighting tobacco, with the MPOWER as the six package of effective tobacco control mechanism. Although the tobacco epidemic can be countered, countries need to take more active steps in protecting their populations. Because, the means for countries to curbs tobacco epidemic are clear and feasible.

So far Indonesia and Thailand have different level of tobacco control. Until this paper was made, Indonesia with bigger tobacco industry interest are not a party in FCTC. They also have weaker control of tobacco in every MPOWER aspects compared to Thailand. Meanwhile Thailand, as a FCTC party, also need more efforts in combating Tobacco epidemic. Because the populations in both countries:

- is not fully protected from other people’s smoke.

- is not adequately protected from tobacco company advertising, promotions, and sponsorship

- is not paying tobacco prices that are high enough to reduce tobacco use.

- Does not receive suifficient health information from the tobacco pack warnings

- And does not have adequate access to help quitting tobacco use.

All tobacco control measures require political commitment, especially in Indonesia where the tobacco industry is bigger than Thailand. Because tobacco industry is far better funded and more politically powerfull, than civil society organization whose against the tobacco industries.

Thus much more to be done for both countries to reverse the tobacco epidemic. First, Indonesia must gain the political will to reduce tobacco usage by ratifying the WHO FCTC. Because FCTC promotes evidence based measures to control tobacco that can be applied in Indonesia. Also FCTC increase the government leverage in dealing with the tobacco industries.

Second, along with Thailand must ensure maximum efforts to meet the MPOWER standard. Monitoring, Protecting, Offering support, Warnings, Enforce advertising ban, Raise tax, is all proven method that needs to be implemented more fiercely in both countries.

Third, a possibility of joint action within the umbrella of South East Asian Nations cooperation for tobacco control is needed. Especially to reduce counterfeit and illicit trading among nations due to taxation and prices differences.

All in all, tobacco epidemic is entirely manmade and the end of it must also be manmade.


[1] Heninger, Lori and Swindler, Kelsey M, “Health,” p.221 in Snarr & Snarr, 2008, Introducing Global Issues, Lynne Rienner Publishers, London.

[2] Beck, Ulrich, World at Risk, Polity Press, UK, 2009, p.11

[3] Tobacco Fact Sheet,WHO (2008) available at accessed at 27 December 2009

[4] Report “Tobacco and Poverty a Vicious Cycle,” Ingcat (2007) available at accessed at 27 December 2009

[5] Reeves, Don and D’Costa Jashinta, ”Poverty in a Global Economy,” p.137 in Snarr & Snarr, 2008, Introducing Global Issues, Lynne Rienner Publishers, London.

[6] Report “Gender, Health, Tobacco,” WHO (1998), available at accessed at 27 December 2009.

[7] Mehl, Garret, et.all, “Controlling Tobacco: The Vital Role of Local Communities.” Available at accessed at 26 Dec 2009

[8] WHO Framework Convention on Tobacco Control, 2003, available at accessed at 27 Dec 2009

[9] Mehl, Garret, Ibid

[10] WHO Report on the global tobacco epidemic 2008: the MPOWER package, available at accessed at 28 Dec 2009

[11] Global Health Watch Report, Moving Government from inaction to action, 2001, available at accessed at 27 Dec 2009.

[12] WHO Report on the global tobacco epidemic 2008: the MPOWER package, available at accessed at 28 Dec 2009

;mo_Ȋguage:EN-US;mso-fareast-language: EN-US;mso-bidi-language:AR-SA'>[11] Global Health Watch Report, Moving Government from inaction to action, 2001, available at accessed at 27 Dec 2009.

[12] WHO Report on the global tobacco epidemic 2008: the MPOWER package, available at accessed at 28 Dec 2009

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