Smoking problem in Indonesia
56
Med.l Indones
Adirama
Smoking problem in Indonesia
Tjandra Yoga Aditama
Abstrak
Kebiasaan merokok merupakan masalah kesehatan penting di Indonesia. Sampai 60Vo pria Indonesia dan sekitar 4Vo perempuan di
negara kita punya kebiasaan merokok. Kadar tar dan nikotin beberapa rokok kretek ternyata juga cukup tinggi. Selain dampak
kesehatan rokok juga punya dampak buruk pada ekonomi, baik tingkat individu maupun keluarga. Dari sudut kesehatan, kendati data
nrorbiditas dan mortalitas berskala nasional sulit didapat, data dari berbagai kota menunjukkan timbulnya berbagai penyakit akibat
rokok seperti kanker paru, PPOK, gangguan pada janin dan sebagainya. Masalahnya lagi, kebiasaan merokok telah dimulai usia
sangat muda di Indonesia. Pada tulisan ini disampaiknn juga hambatan-hambatan dalam program penanggulangan masalah merokok
serta hal-hal yang perlu dilakukan untuk meningkatkan program penanggulangan yang ada. (Med J Indones 2002; l1: 56-65)
Abstract
Smoking is an important public health probLem in Indonesia. Up to 60Va of male aduk population as well as about 4Va of female adult
population are smokers. In fact, some of Indonesian kretek cigarettes have quite high tar and nicotine content. Besides health effect,
smoking habit also influence economic status of the individuals as well as the family. In heahh point of view, even though reliable
nation wide morbidity and mortality data are scarce, report from various cities showed smoking related diseases, such as Lung cancer,
COPD, effect of pregnancy, etc. Other problem is a fact that smoking habit start quite in early age in Indonesia. This article also
describe factors complicate smoking controL program as well as several things to be done to strengthen smoking controL progrant itt
Indonesia. (Med J Indones 2002; II: 56-65)
Keywords
: smoking, I ndonesia, impact
The Republic
of
Indonesia, which consists of
approximately 17,000 islands, had a population of 210
million; it is the fourth most populous country in the
world atter China, India, and the United States with
hundreds of ethnic groups and language / dialects
being practices in the country. An estimated 55.4
million persons (3lVo of the population) were living in
urban areas in 1990, compared with 73.4 million (36Vo
of the population) in 1997.t'23 All of these factors
complicate tobacco-control measures in Indonesia.
72Vo,
drivers of public buses
The Indonesian Smoking Control Foundation ('LM
3") compiled a meta-analysis study on smoking
patterns in Indonesia.
PuLmonology Department Faculty of Medicine University
I ndo ne s ia / P e r s ahab atan H o sp ital, J aknrta, I ndone sia
of
la
The conclusions of the meta-analysis study performed
by "LM3" included the following:rl
Smoking Pattern
current smokers among males ranges from 30.2Vo to
in
the
Jakarta. Among tèmales,
the percentage ranges from I .5Vo to 9.1Vo.
1.
Table I compiles the results from several studies on
smoking behavior in Indonesia. The percentage of
with the highest percentage belong to
The studies found that 59.O4Vo of males over ten
years of age in the 14 provinces in Indonesia were
currently smoking. Among females over 10 years
of a5e,4,837o were culrent smokers.
2.
There was a negative correlation between the level
of education and the percentage of current smokers.
3. On
average, cullent male smokers consume
almost ten cigarettes each day, while female
cuffent smokers consume around three cigarettes
each day.
Vol.
4.
5.
6.
I I , No l, January
-
March 2002
Smoking problem in
Among both current and former smokers, males
or females, the fiequency of smoking was still
fairly mild, less than 200 score indexed by
muftiplication of number of cigarettes and length
of smoking.
Ex-smokers generally reported smoking higher
numbers of cigarettes than current smokers. In
males it was 13 versus l0 cigarettes daily, and in
fèmales it was more significant at 6.2 versus 3
cigarettes
7.
Indonesia 5j
Clove-flavoured cigarettes (kretek) were the
favourite choice of smokers in Indonesia. For
male current smokers, 84,3l%o preferred kretek
cigarettes, as did'79,42Vo of the female smokers.
Similar figures were found in former smokers, as
84,31Vo of the males and 7294Vo of the females
preferred the clove cigarettes.
8.
For both current or former smokers, the age of
smoking initiation were quite young. Females
daily.
tend to start to smoke at the older age.
The average of ounces of tobacco per week was
0.79 in current users, and I.42in ex-users.
Table
L
Percentage of Current Smokers in some studies
No
I
in
Indonesia
Question
-investigator
1994- Doyoucunently
1996 in 7 Provinces, MOH, Rl4
srnoke?
lndonesian Farnily Life Survey 1993 in Have you ever
S
tudy -year
Surveyon EyeandENTHealth
2
I
3 Provinces
N
1407
I
Ages
l0years
and older
14638 l0 years
and older
srnoked?
Males Females
48,34Vo 3,l6Vo
Total
22,68Vo
67,7OVo 9]0Vo
36,50Vo
45,00Vo
22,90Eo
LD-trEUl. Rand Co'
3
National Household Survey, Module on
Susenas, 199-5, in -5 Provinces, MOH,
Rl6
4
Have
you
smoked in the
past lnonth?
Prospective Study on Public Health,
Does the head of
Pasar Rebo, Cipayung & Ciracas, East
your house- hold
Jakarta 1993/94, Fac olPublicHealth srnoke?
-ur
5
Smoking And lts Socioeconornic
Aspects In J;rkarta, 1981, Soekidjo,
Siregar, Wibowo. Fac. of PH UF
6
Eifèct On Sntoking Decemed
Program
S
l0
years
and older
'17349
I
,50Eo
of
3020Vo
years
64.40Vo
Head
HH (adulQ
l0
and older
NA
Relationship Between Habit On Cloves Do you
Srnoking And Dental Destruction,
Arnong TIre Drivers Of PPD Company
ln Jakarlr, 1992,
8
HH
2-50
NA
Arnong Tlre Srnoker -Workers ln
St Carolus Hospital, Jakarta, I 995,
Judin. Tanjung, Fac of PH - Ul'r
7
6-5664
srnoke?
449
Adult
48,00Vo
-
48,NVo
3386
Adult
72Vo
-
12Vo
oetiartor0
Action on smoking, in: Comprlation
of
1000
NA
papers on Cancer Problem (Kumpulan
2,17o
64,4Vo
Naskah Masalah Kanker),
Hoepoedio, l98lrl
9
Ploportion Of Srnokers Arnong The
Male Ernployees ln The OfÏce Of
Ditjen Binkesrnas, MOH, 1996
Syalranelsar, Fac. of PH - UIr2
l0
Study On Knowledge, Attitude And
Behavior On Srnoking, Among The
Pupils of Eletnentary School Crades
And V[, ln East Jakarta 1992,
Shebubakar, Frc of Medicine - UIrl
(-)
:
Not available / not calculated
ever
186
Adult
smoke?
431
Crade
Have you
50,0Vo
-
50,OVo
smoked?
Do you
V
5
and 6
(primary
School)
l2,76Vo
58
Med J Indones
Aditama
smoked non-filtered kretek cigarettes,
The above data show no significant differences when
compared with the WHO (1997) estimation, where in
Indonesia the prevalence
of
current smokers was
reported to be 53.0Vo of the males and 4Vo of the
fèmales. But it should be noted that the WHO figures
were for people over the age of 15 years.r-t
The Indonesia Household Health Survey
in
1980
showed that about 54Vo of males and about 37o of the
f'emales over ten years
smokers.
of
age were regular (daily)
A similar survey carried out in
1986
reported simrlar prevalence rates (537o of males, 4Vo
of fèmales). Other surveys carried out during he 1980s
in Lombok, Jakarta, and Yogyakarta reported male
prevalence levels of 75Vo, 65Vo, and 67Vo,
respectively, and female prevalence levels less than
5Vo (except for Jakarta where 9.8Vo of the females are
smokers). Nationally, the prevalence of smoking is
approximately 607o for men and 5Vo for women.'7
According to
a
1985 survey
in
Semarang, 36Vo of
O.3Va
consumed cigars, 3.8Vo rolled their own cigarettes,
and 0.17o smoked tobacco using a pipe. The
comparative numbers for the rural population are
as follows: 11.6Vo, 2.8Vo, 33|7Va, 24.9Vo, O.6Vo,
25 .4Vo and O.5Vo respecti
vely.
Most of the tobacco consumed in Indonesia is in the
form of cigarettes, and between 85Vo and 90Vo of all
in Indonesia are kreteks. The
market
share
of kreteks increased from about
cigarette
1914
to
about
90Vo in the 1990s. Since the
30Vo in
per-capita
adult (over 10 years of
the
early 1970s,
age) consumption of cigarettes (all forms) has more
than doubled, from 500 to I 1 80 per adult. A survey
carried out in Jakarta in 1981 estimated that each
smoker consumed (on the average) twelve cigarettes
each day. About 5Vo of all smokers smoke more than
cigarettes smoked
20 cigarettes a day.
Table 2. Consumption of manufactured cigarettes
doctors smoked, as did'l9Vo of paramedical personnel.
Almost all (96Vo) of the "peddle rickshaw" drivers in
Annual average per adult (l 5+)
the survey smoked, as did over half (527o) of
government
civil servants. A 1992 survey of medical
stuclents revealed that 8Vo of males and lVo of femalès
were daily smokers, while 39Vo of males and l5Vo of
females were occasional smokers.
The Indonesian Household Health Survey in 1995 was
one of the biggest health survey performed in
Indonesia with over 200.000 respondents.o Among its
findings were the fbllowing:
l.
The prevalence of smoking in the male population
(10 years old and above) were 457o (daily smoker),
6.3Vo (occasional smoker) and 3Vo (fbrmer smoker).
For the fèmale population, the figures were l.5Vo,
0.57o and 0.270, respectively.
2. For people 20 years of age and above,
61 '27o
were regular smokers, and'7 .5Vo were occasional
smokers. The prevalence in urban areas was
hrgher than the rural areas, and the prevalence
decreased with higher levels of education.
above, 4l.8Vo of the
respondents consumed 1l- 20 cigarette per day,
and 5.3Vo consumed more that 21 cigarettes per
3. For 20 year old and
day. On average, 3.9 cigarettes were consumed by
a smoker per day, or 1,421 cigarettes per year.
4. ln urban
populations, 12.l7o of the respondents
consumed filtered cigarettes, 3Vo non-filtered
c
i
garettes, 59 .8Vo smoked kr
et
ek ci gat ettes, 20.8Vo
Tar levels in domestically grown Indonesian tobacco
are high. In 1983, the average tar content of 18 brands
of kretek cigarettes was 58.0 mg (range 41 - 11),
while the average nicotine content was 2.4 mg (range
1.3 - 3.2). These are substantially higher than levels
usually found in industrialized countries. About 73Vo
of manufactured cigarettes are filter-tipped.r6 Table 3
shows the tar, nicotine and Carbon Monoxide (CO)
content of some kretek cigarettes in Indonesia. It is
particularly interesting to compare lhe difTèrences in
the levels of the domestic and exported products of
the same brands of cigarettes.
Production and Economic Impact
In
1990, 183,785 hectares of land were set aside for
tobacco farmrng, which was down from 288,000
hectares in 1985. Between lVo and 2Vo of all arable
land in Indonesia is used to grow tobacco. Between
1990 and 1992, Indonesia grew approximately 2.OVo
of all the tobacco in the world. In 1994, Indonesia
produced about 180,000 million cigarettes (about
Vol I
l,
No 1, January
Smoking problem in
- March 2002
of the world's production), which was up from
83,900 cigarettes in 1980. This increase in cigarette
3.3Va
is Iargely a reflection of the dramatic
in the production of machine-made kretek
production
increase
1992, Indonesia imported 21,650 tons of raw
tobacco (accounting for l.4Vo of all imports), while
exporting 18,900 tons (about l.lVo oT global exports)'
Indonesia imported 15 million cigarettes and exported
15,000 million cigarettes, or 2.27o of global exports.
In
In
Indonesia
1990, the costs importing tobacco leaf and
cigarettes amounted to US$ 42.1 million (O.lVo of all
import costs), compared with uS$ 17 million in 1985.
In 1990, Indonesia earned an estimated US$ 124.6
million from tobacco exports (0.4Va of all export
earnings), up from approximately US$ 48.2 million in
1985. On the other hand, Indonesian cigarettes
production could be seen in figure 1, which showed
the total
production
in the year 2000 was
23'7,206,000,000 cigarettes a year, while
w
as 204,365,000,000 a year.
Table 3. Tar, nicotine and CO content of kretek
Concentration I Kretek (rng)
Brand Name
No
Nicotine
Tar
CO
Gudang Garam Internasional
3 l'7
5'7.02
26.09
2
Gudang Garam Surya
308
52,87
23.85
3
Bentoel Internasional
2.35
47.37
21 .51
Djarum Super
231
53.98
27.61
5
Perdana Super
242
61.09
36.95
6
Filtra 100s
217
49.84
25.24
7
Gudang Garam King Size
4
l0
2.96
62.2
3t.23
224
42.29
25.05
r.26
1
8.05
9.84
34.t3
t6.37
8
Dji
9
Sampoerna A
l0
Sampoerna A Exclusive
191
Bentoel Merah
276
44.25
20.48
t2
Wismilak
313
56 48
23.92
t3
Minak Jinggo
207
53.4
25.59
t4
Gudang Garam Surya 18
269
46.09
19.3'7
21.52
u
Sam Soe
Mild
15
Bentoel Intenational Extra Lights
191
33.24
16
Bentoel International Mild
1.23
41.06
t9.21
075
1t .92
4.19
08
11.11
6.37
0.63
10.78
7.32
EXPORT
I
Dji Sam
2
Sampoerna A Exclusive
J
Sampoerna A
Soe
Mild
59
in
1995
it
'!
Med J Indones
Aditama
60
country (government perspective) was in the amount
of US$ 9,806,423,000 (almost 10 billion US dollars)
or about 50Vo of the total annual budget of the
Ministry of Health.
240,0(x)
2_r0,ux)
220,(rx)
!
Economic losses due to tobacco at the individual/
family level can be divided rnto:
zro.rxxt
.*
2(X),(XX)
r
90,(xx)
I
80,(XX)
Direct Loss:
995
I
996
I
99?
Indirect Loss:
loss of income due to illness and or
disability
cost for medical treatment
loss of income due to illness and or
disability
loss of income due to premature deaths
Figure
l.
loss
Indonesian cigarettes production
About 214,300 workers were engaged fÏll-trme in the
tobacco-manufacturing industry in 1989. The
Indonesian kretek industry ranks as the second largest
employer after the Government. Figure 2 below
showed tax fee target from cigarettes, which showed
that in 1995/1996 it was only 3.3 quintillion (thousand
billions) , in 2000 it was increased to 10,3 thousand
billions and in 2002 iT" was expected to be 22,4
thousand billions ruprah.
Estimated economic loss at community level fbr each
lung cancer patient was as fbllows:
r Average cost for medical treatment -- US$ 738.00.
o Average number of absenteeism per year due to
hospitalization -- 23 days.
. Thus, the lost income due to illness for one patient
is 23 X US$ 5.00 -- US$ I 15.00.
Loss of income of family members (due taking care of
the patients) is also equal to US$ 115.00.'e
Reliable national mortality and morbidity data are
scarce. However, whatever data are available all point
to an increase in the major chronic diseases associated
Ëzo
É
=
=
members,
Health Impact
25
L
of income of family
due to taking care of the patients
rç
with smoking.
Estimates suggest
attributable mortafity has risen
Er0
l!
0
95196 96/91 97t98 98199 99/00
2000 2001 2002
year
Figure 2. Tax fee target
A study by the National Institute of Health Research
& Development (Ministry of Health) attempted to
analyze the economic impact of smoking in Indonesia.
With the GDP per capita in 1995 about US$ 1,100, it
is estimated that the macro economic loss for the
that
tobacco-
from l-37o of
all
deaths in 1980 to 3-4o/o in 1986. Thrs suggests that
about 57,000 deaths each year (primarily males) are
already attributable to tobacco use, and this number
can be expected to increase dramatically over the next
few decades.'
A study of COPD and smoking in East Java province
found that 1,546 men (60.3Vo) were smokers as
compared to only 71 (1.8Vo) of the women. COPD
prevalence was l3.l Vo overall. In men it was 15.67o,
and in women the prevalence was 77.3Vo. However,
among mde smokers the prevalence was 15.87o. The
relative risk of COPD in smokers was 1.02. Smoking
and impaired PEFR (Peak Expiratory Flow Rate) were
recorded in 12.47o of all respondents, and the results
of the testing correlated well with the results from the
questionnaire. Risk of impaired PEFR in smokers was
Vol 1 1, No 1, January
- March
Smoking problem in
2002
1.04. Asthma was found in 8Vo at all respondents,
while its prevalence in men was 9.67o, in women
6.4Vo, and in male smokers it was 9.2Vo. The relative
risk asthma in smokers was 0.88. All smokers smoked
cigarettes; none of them professed to being a cigar
smoker and only one was a pipe smoker. Kretek
cigarettes were the most widely smoked type of
cigarette (61.57o).
Only 270 (l'7.5Vo) of the respondents had stopped
smoking, but only 154 (57Vo) had done so for more
than I year, and only I2.6Vo of clove cigarette
smokers have tried quitting. Most of the smokers
(76.6Vo) can be classified as light smokers, smoking
/ day. The number of cigarettes
day comes to 6.7 cigarettes. The
prevalence of smokers goes up almost linearly with
age, being 22.47o in the under 20 group to 15.67o in
the over-S0 group. Although paradoxically almost
40Vo of them started smoking in their late teens
(38.5Vo) and more lhan 757o began to smoke before
the age of 25 (77 .2Vo).2o
less than 10 cigarettes
I
male smoker
/
In a study on smoking and lung cancer in Jakarta, it
was found that the relative risk to get lung cancer for
smokers 20 - 39 years of age was 6.'76, and for those
who had smokecl for more than 40 years, the relativd
risk was 9.37.'fhey found a significant relationship
between smoking and lung cancer among their male
respondents, but not among the females. The doseresponse impact was also discovered to be significantly
u-àng their male respondent.2l
Another survey
in
1993 assessed effects
of
passive
Indonesia 6l
Prevalence Among Youth
A 1985 survey of primary schoolchildren in Jakarta
found that 49Vo of the boys and 97o of the girls aged
10-14 were daily smokers. However, a study in
Jakarta in 1990 reported that only IVo of the 1l-14
year olds, 9Vo of the15 year olds, and 67o of the 16
year olds were daily smokers, although the figures for
occasional smokers were 157o, 22Vo, and 44Vo,
respectively. The latter study also revealed that9Vo of
the children started smoking when under l0 years old,
\Va at the age of ll, l87o at age I2,23Vo at age 13, and
40Vo at age 14-16. The vast majority (95Vo) smoked
kreteks, and 72Vo reported that their parents did not
know that they smoked.r3
The meta-analysis study done by "LM 3" found that in
both current and former smokers, most initiated
smoking between 10 and 29 years of age; there was
no clear difference between males and females.
However, the study did show that male teenagers start
smoking earlier, while females tend to wait to try
smoking at-ter the age of 20, but all were at the young
group. This was happened in the severity of smoking,
which both groups together majority were still stay in
the mild group, l.e. less than 200.14
This study also concluded that teenager smokers were
found in the proportion ranged from l2.8Va to 2'1,'lVo
in males, and among females were O.64Vo ro lVo.
Either in current or ex-smokers the age of smoking
initiation were quite young, since the highest
proportion was found in l0 to less than 30 years old.
In males there were 8l,34Vo of current smokers, and
smoking on pregnancy outcomes in Jakarta. The study
77,80Vo of ex smokers, while in females looked
infants was2.3.22
older age.
for a pregnant women
exposed to passive smoking having a low birth-weight
concluded that odds ratio
to be lower, 49.O5Vo of current smokers, and 48.30Vo
of ex smokers. Females tend to start to smoke at the
Table 4. The Age of Smoking Initiation among Smokers
The age of smoking
initiation
Med.l Indones
Adirama
Smoking problem in Indonesia
Tjandra Yoga Aditama
Abstrak
Kebiasaan merokok merupakan masalah kesehatan penting di Indonesia. Sampai 60Vo pria Indonesia dan sekitar 4Vo perempuan di
negara kita punya kebiasaan merokok. Kadar tar dan nikotin beberapa rokok kretek ternyata juga cukup tinggi. Selain dampak
kesehatan rokok juga punya dampak buruk pada ekonomi, baik tingkat individu maupun keluarga. Dari sudut kesehatan, kendati data
nrorbiditas dan mortalitas berskala nasional sulit didapat, data dari berbagai kota menunjukkan timbulnya berbagai penyakit akibat
rokok seperti kanker paru, PPOK, gangguan pada janin dan sebagainya. Masalahnya lagi, kebiasaan merokok telah dimulai usia
sangat muda di Indonesia. Pada tulisan ini disampaiknn juga hambatan-hambatan dalam program penanggulangan masalah merokok
serta hal-hal yang perlu dilakukan untuk meningkatkan program penanggulangan yang ada. (Med J Indones 2002; l1: 56-65)
Abstract
Smoking is an important public health probLem in Indonesia. Up to 60Va of male aduk population as well as about 4Va of female adult
population are smokers. In fact, some of Indonesian kretek cigarettes have quite high tar and nicotine content. Besides health effect,
smoking habit also influence economic status of the individuals as well as the family. In heahh point of view, even though reliable
nation wide morbidity and mortality data are scarce, report from various cities showed smoking related diseases, such as Lung cancer,
COPD, effect of pregnancy, etc. Other problem is a fact that smoking habit start quite in early age in Indonesia. This article also
describe factors complicate smoking controL program as well as several things to be done to strengthen smoking controL progrant itt
Indonesia. (Med J Indones 2002; II: 56-65)
Keywords
: smoking, I ndonesia, impact
The Republic
of
Indonesia, which consists of
approximately 17,000 islands, had a population of 210
million; it is the fourth most populous country in the
world atter China, India, and the United States with
hundreds of ethnic groups and language / dialects
being practices in the country. An estimated 55.4
million persons (3lVo of the population) were living in
urban areas in 1990, compared with 73.4 million (36Vo
of the population) in 1997.t'23 All of these factors
complicate tobacco-control measures in Indonesia.
72Vo,
drivers of public buses
The Indonesian Smoking Control Foundation ('LM
3") compiled a meta-analysis study on smoking
patterns in Indonesia.
PuLmonology Department Faculty of Medicine University
I ndo ne s ia / P e r s ahab atan H o sp ital, J aknrta, I ndone sia
of
la
The conclusions of the meta-analysis study performed
by "LM3" included the following:rl
Smoking Pattern
current smokers among males ranges from 30.2Vo to
in
the
Jakarta. Among tèmales,
the percentage ranges from I .5Vo to 9.1Vo.
1.
Table I compiles the results from several studies on
smoking behavior in Indonesia. The percentage of
with the highest percentage belong to
The studies found that 59.O4Vo of males over ten
years of age in the 14 provinces in Indonesia were
currently smoking. Among females over 10 years
of a5e,4,837o were culrent smokers.
2.
There was a negative correlation between the level
of education and the percentage of current smokers.
3. On
average, cullent male smokers consume
almost ten cigarettes each day, while female
cuffent smokers consume around three cigarettes
each day.
Vol.
4.
5.
6.
I I , No l, January
-
March 2002
Smoking problem in
Among both current and former smokers, males
or females, the fiequency of smoking was still
fairly mild, less than 200 score indexed by
muftiplication of number of cigarettes and length
of smoking.
Ex-smokers generally reported smoking higher
numbers of cigarettes than current smokers. In
males it was 13 versus l0 cigarettes daily, and in
fèmales it was more significant at 6.2 versus 3
cigarettes
7.
Indonesia 5j
Clove-flavoured cigarettes (kretek) were the
favourite choice of smokers in Indonesia. For
male current smokers, 84,3l%o preferred kretek
cigarettes, as did'79,42Vo of the female smokers.
Similar figures were found in former smokers, as
84,31Vo of the males and 7294Vo of the females
preferred the clove cigarettes.
8.
For both current or former smokers, the age of
smoking initiation were quite young. Females
daily.
tend to start to smoke at the older age.
The average of ounces of tobacco per week was
0.79 in current users, and I.42in ex-users.
Table
L
Percentage of Current Smokers in some studies
No
I
in
Indonesia
Question
-investigator
1994- Doyoucunently
1996 in 7 Provinces, MOH, Rl4
srnoke?
lndonesian Farnily Life Survey 1993 in Have you ever
S
tudy -year
Surveyon EyeandENTHealth
2
I
3 Provinces
N
1407
I
Ages
l0years
and older
14638 l0 years
and older
srnoked?
Males Females
48,34Vo 3,l6Vo
Total
22,68Vo
67,7OVo 9]0Vo
36,50Vo
45,00Vo
22,90Eo
LD-trEUl. Rand Co'
3
National Household Survey, Module on
Susenas, 199-5, in -5 Provinces, MOH,
Rl6
4
Have
you
smoked in the
past lnonth?
Prospective Study on Public Health,
Does the head of
Pasar Rebo, Cipayung & Ciracas, East
your house- hold
Jakarta 1993/94, Fac olPublicHealth srnoke?
-ur
5
Smoking And lts Socioeconornic
Aspects In J;rkarta, 1981, Soekidjo,
Siregar, Wibowo. Fac. of PH UF
6
Eifèct On Sntoking Decemed
Program
S
l0
years
and older
'17349
I
,50Eo
of
3020Vo
years
64.40Vo
Head
HH (adulQ
l0
and older
NA
Relationship Between Habit On Cloves Do you
Srnoking And Dental Destruction,
Arnong TIre Drivers Of PPD Company
ln Jakarlr, 1992,
8
HH
2-50
NA
Arnong Tlre Srnoker -Workers ln
St Carolus Hospital, Jakarta, I 995,
Judin. Tanjung, Fac of PH - Ul'r
7
6-5664
srnoke?
449
Adult
48,00Vo
-
48,NVo
3386
Adult
72Vo
-
12Vo
oetiartor0
Action on smoking, in: Comprlation
of
1000
NA
papers on Cancer Problem (Kumpulan
2,17o
64,4Vo
Naskah Masalah Kanker),
Hoepoedio, l98lrl
9
Ploportion Of Srnokers Arnong The
Male Ernployees ln The OfÏce Of
Ditjen Binkesrnas, MOH, 1996
Syalranelsar, Fac. of PH - UIr2
l0
Study On Knowledge, Attitude And
Behavior On Srnoking, Among The
Pupils of Eletnentary School Crades
And V[, ln East Jakarta 1992,
Shebubakar, Frc of Medicine - UIrl
(-)
:
Not available / not calculated
ever
186
Adult
smoke?
431
Crade
Have you
50,0Vo
-
50,OVo
smoked?
Do you
V
5
and 6
(primary
School)
l2,76Vo
58
Med J Indones
Aditama
smoked non-filtered kretek cigarettes,
The above data show no significant differences when
compared with the WHO (1997) estimation, where in
Indonesia the prevalence
of
current smokers was
reported to be 53.0Vo of the males and 4Vo of the
fèmales. But it should be noted that the WHO figures
were for people over the age of 15 years.r-t
The Indonesia Household Health Survey
in
1980
showed that about 54Vo of males and about 37o of the
f'emales over ten years
smokers.
of
age were regular (daily)
A similar survey carried out in
1986
reported simrlar prevalence rates (537o of males, 4Vo
of fèmales). Other surveys carried out during he 1980s
in Lombok, Jakarta, and Yogyakarta reported male
prevalence levels of 75Vo, 65Vo, and 67Vo,
respectively, and female prevalence levels less than
5Vo (except for Jakarta where 9.8Vo of the females are
smokers). Nationally, the prevalence of smoking is
approximately 607o for men and 5Vo for women.'7
According to
a
1985 survey
in
Semarang, 36Vo of
O.3Va
consumed cigars, 3.8Vo rolled their own cigarettes,
and 0.17o smoked tobacco using a pipe. The
comparative numbers for the rural population are
as follows: 11.6Vo, 2.8Vo, 33|7Va, 24.9Vo, O.6Vo,
25 .4Vo and O.5Vo respecti
vely.
Most of the tobacco consumed in Indonesia is in the
form of cigarettes, and between 85Vo and 90Vo of all
in Indonesia are kreteks. The
market
share
of kreteks increased from about
cigarette
1914
to
about
90Vo in the 1990s. Since the
30Vo in
per-capita
adult (over 10 years of
the
early 1970s,
age) consumption of cigarettes (all forms) has more
than doubled, from 500 to I 1 80 per adult. A survey
carried out in Jakarta in 1981 estimated that each
smoker consumed (on the average) twelve cigarettes
each day. About 5Vo of all smokers smoke more than
cigarettes smoked
20 cigarettes a day.
Table 2. Consumption of manufactured cigarettes
doctors smoked, as did'l9Vo of paramedical personnel.
Almost all (96Vo) of the "peddle rickshaw" drivers in
Annual average per adult (l 5+)
the survey smoked, as did over half (527o) of
government
civil servants. A 1992 survey of medical
stuclents revealed that 8Vo of males and lVo of femalès
were daily smokers, while 39Vo of males and l5Vo of
females were occasional smokers.
The Indonesian Household Health Survey in 1995 was
one of the biggest health survey performed in
Indonesia with over 200.000 respondents.o Among its
findings were the fbllowing:
l.
The prevalence of smoking in the male population
(10 years old and above) were 457o (daily smoker),
6.3Vo (occasional smoker) and 3Vo (fbrmer smoker).
For the fèmale population, the figures were l.5Vo,
0.57o and 0.270, respectively.
2. For people 20 years of age and above,
61 '27o
were regular smokers, and'7 .5Vo were occasional
smokers. The prevalence in urban areas was
hrgher than the rural areas, and the prevalence
decreased with higher levels of education.
above, 4l.8Vo of the
respondents consumed 1l- 20 cigarette per day,
and 5.3Vo consumed more that 21 cigarettes per
3. For 20 year old and
day. On average, 3.9 cigarettes were consumed by
a smoker per day, or 1,421 cigarettes per year.
4. ln urban
populations, 12.l7o of the respondents
consumed filtered cigarettes, 3Vo non-filtered
c
i
garettes, 59 .8Vo smoked kr
et
ek ci gat ettes, 20.8Vo
Tar levels in domestically grown Indonesian tobacco
are high. In 1983, the average tar content of 18 brands
of kretek cigarettes was 58.0 mg (range 41 - 11),
while the average nicotine content was 2.4 mg (range
1.3 - 3.2). These are substantially higher than levels
usually found in industrialized countries. About 73Vo
of manufactured cigarettes are filter-tipped.r6 Table 3
shows the tar, nicotine and Carbon Monoxide (CO)
content of some kretek cigarettes in Indonesia. It is
particularly interesting to compare lhe difTèrences in
the levels of the domestic and exported products of
the same brands of cigarettes.
Production and Economic Impact
In
1990, 183,785 hectares of land were set aside for
tobacco farmrng, which was down from 288,000
hectares in 1985. Between lVo and 2Vo of all arable
land in Indonesia is used to grow tobacco. Between
1990 and 1992, Indonesia grew approximately 2.OVo
of all the tobacco in the world. In 1994, Indonesia
produced about 180,000 million cigarettes (about
Vol I
l,
No 1, January
Smoking problem in
- March 2002
of the world's production), which was up from
83,900 cigarettes in 1980. This increase in cigarette
3.3Va
is Iargely a reflection of the dramatic
in the production of machine-made kretek
production
increase
1992, Indonesia imported 21,650 tons of raw
tobacco (accounting for l.4Vo of all imports), while
exporting 18,900 tons (about l.lVo oT global exports)'
Indonesia imported 15 million cigarettes and exported
15,000 million cigarettes, or 2.27o of global exports.
In
In
Indonesia
1990, the costs importing tobacco leaf and
cigarettes amounted to US$ 42.1 million (O.lVo of all
import costs), compared with uS$ 17 million in 1985.
In 1990, Indonesia earned an estimated US$ 124.6
million from tobacco exports (0.4Va of all export
earnings), up from approximately US$ 48.2 million in
1985. On the other hand, Indonesian cigarettes
production could be seen in figure 1, which showed
the total
production
in the year 2000 was
23'7,206,000,000 cigarettes a year, while
w
as 204,365,000,000 a year.
Table 3. Tar, nicotine and CO content of kretek
Concentration I Kretek (rng)
Brand Name
No
Nicotine
Tar
CO
Gudang Garam Internasional
3 l'7
5'7.02
26.09
2
Gudang Garam Surya
308
52,87
23.85
3
Bentoel Internasional
2.35
47.37
21 .51
Djarum Super
231
53.98
27.61
5
Perdana Super
242
61.09
36.95
6
Filtra 100s
217
49.84
25.24
7
Gudang Garam King Size
4
l0
2.96
62.2
3t.23
224
42.29
25.05
r.26
1
8.05
9.84
34.t3
t6.37
8
Dji
9
Sampoerna A
l0
Sampoerna A Exclusive
191
Bentoel Merah
276
44.25
20.48
t2
Wismilak
313
56 48
23.92
t3
Minak Jinggo
207
53.4
25.59
t4
Gudang Garam Surya 18
269
46.09
19.3'7
21.52
u
Sam Soe
Mild
15
Bentoel Intenational Extra Lights
191
33.24
16
Bentoel International Mild
1.23
41.06
t9.21
075
1t .92
4.19
08
11.11
6.37
0.63
10.78
7.32
EXPORT
I
Dji Sam
2
Sampoerna A Exclusive
J
Sampoerna A
Soe
Mild
59
in
1995
it
'!
Med J Indones
Aditama
60
country (government perspective) was in the amount
of US$ 9,806,423,000 (almost 10 billion US dollars)
or about 50Vo of the total annual budget of the
Ministry of Health.
240,0(x)
2_r0,ux)
220,(rx)
!
Economic losses due to tobacco at the individual/
family level can be divided rnto:
zro.rxxt
.*
2(X),(XX)
r
90,(xx)
I
80,(XX)
Direct Loss:
995
I
996
I
99?
Indirect Loss:
loss of income due to illness and or
disability
cost for medical treatment
loss of income due to illness and or
disability
loss of income due to premature deaths
Figure
l.
loss
Indonesian cigarettes production
About 214,300 workers were engaged fÏll-trme in the
tobacco-manufacturing industry in 1989. The
Indonesian kretek industry ranks as the second largest
employer after the Government. Figure 2 below
showed tax fee target from cigarettes, which showed
that in 1995/1996 it was only 3.3 quintillion (thousand
billions) , in 2000 it was increased to 10,3 thousand
billions and in 2002 iT" was expected to be 22,4
thousand billions ruprah.
Estimated economic loss at community level fbr each
lung cancer patient was as fbllows:
r Average cost for medical treatment -- US$ 738.00.
o Average number of absenteeism per year due to
hospitalization -- 23 days.
. Thus, the lost income due to illness for one patient
is 23 X US$ 5.00 -- US$ I 15.00.
Loss of income of family members (due taking care of
the patients) is also equal to US$ 115.00.'e
Reliable national mortality and morbidity data are
scarce. However, whatever data are available all point
to an increase in the major chronic diseases associated
Ëzo
É
=
=
members,
Health Impact
25
L
of income of family
due to taking care of the patients
rç
with smoking.
Estimates suggest
attributable mortafity has risen
Er0
l!
0
95196 96/91 97t98 98199 99/00
2000 2001 2002
year
Figure 2. Tax fee target
A study by the National Institute of Health Research
& Development (Ministry of Health) attempted to
analyze the economic impact of smoking in Indonesia.
With the GDP per capita in 1995 about US$ 1,100, it
is estimated that the macro economic loss for the
that
tobacco-
from l-37o of
all
deaths in 1980 to 3-4o/o in 1986. Thrs suggests that
about 57,000 deaths each year (primarily males) are
already attributable to tobacco use, and this number
can be expected to increase dramatically over the next
few decades.'
A study of COPD and smoking in East Java province
found that 1,546 men (60.3Vo) were smokers as
compared to only 71 (1.8Vo) of the women. COPD
prevalence was l3.l Vo overall. In men it was 15.67o,
and in women the prevalence was 77.3Vo. However,
among mde smokers the prevalence was 15.87o. The
relative risk of COPD in smokers was 1.02. Smoking
and impaired PEFR (Peak Expiratory Flow Rate) were
recorded in 12.47o of all respondents, and the results
of the testing correlated well with the results from the
questionnaire. Risk of impaired PEFR in smokers was
Vol 1 1, No 1, January
- March
Smoking problem in
2002
1.04. Asthma was found in 8Vo at all respondents,
while its prevalence in men was 9.67o, in women
6.4Vo, and in male smokers it was 9.2Vo. The relative
risk asthma in smokers was 0.88. All smokers smoked
cigarettes; none of them professed to being a cigar
smoker and only one was a pipe smoker. Kretek
cigarettes were the most widely smoked type of
cigarette (61.57o).
Only 270 (l'7.5Vo) of the respondents had stopped
smoking, but only 154 (57Vo) had done so for more
than I year, and only I2.6Vo of clove cigarette
smokers have tried quitting. Most of the smokers
(76.6Vo) can be classified as light smokers, smoking
/ day. The number of cigarettes
day comes to 6.7 cigarettes. The
prevalence of smokers goes up almost linearly with
age, being 22.47o in the under 20 group to 15.67o in
the over-S0 group. Although paradoxically almost
40Vo of them started smoking in their late teens
(38.5Vo) and more lhan 757o began to smoke before
the age of 25 (77 .2Vo).2o
less than 10 cigarettes
I
male smoker
/
In a study on smoking and lung cancer in Jakarta, it
was found that the relative risk to get lung cancer for
smokers 20 - 39 years of age was 6.'76, and for those
who had smokecl for more than 40 years, the relativd
risk was 9.37.'fhey found a significant relationship
between smoking and lung cancer among their male
respondents, but not among the females. The doseresponse impact was also discovered to be significantly
u-àng their male respondent.2l
Another survey
in
1993 assessed effects
of
passive
Indonesia 6l
Prevalence Among Youth
A 1985 survey of primary schoolchildren in Jakarta
found that 49Vo of the boys and 97o of the girls aged
10-14 were daily smokers. However, a study in
Jakarta in 1990 reported that only IVo of the 1l-14
year olds, 9Vo of the15 year olds, and 67o of the 16
year olds were daily smokers, although the figures for
occasional smokers were 157o, 22Vo, and 44Vo,
respectively. The latter study also revealed that9Vo of
the children started smoking when under l0 years old,
\Va at the age of ll, l87o at age I2,23Vo at age 13, and
40Vo at age 14-16. The vast majority (95Vo) smoked
kreteks, and 72Vo reported that their parents did not
know that they smoked.r3
The meta-analysis study done by "LM 3" found that in
both current and former smokers, most initiated
smoking between 10 and 29 years of age; there was
no clear difference between males and females.
However, the study did show that male teenagers start
smoking earlier, while females tend to wait to try
smoking at-ter the age of 20, but all were at the young
group. This was happened in the severity of smoking,
which both groups together majority were still stay in
the mild group, l.e. less than 200.14
This study also concluded that teenager smokers were
found in the proportion ranged from l2.8Va to 2'1,'lVo
in males, and among females were O.64Vo ro lVo.
Either in current or ex-smokers the age of smoking
initiation were quite young, since the highest
proportion was found in l0 to less than 30 years old.
In males there were 8l,34Vo of current smokers, and
smoking on pregnancy outcomes in Jakarta. The study
77,80Vo of ex smokers, while in females looked
infants was2.3.22
older age.
for a pregnant women
exposed to passive smoking having a low birth-weight
concluded that odds ratio
to be lower, 49.O5Vo of current smokers, and 48.30Vo
of ex smokers. Females tend to start to smoke at the
Table 4. The Age of Smoking Initiation among Smokers
The age of smoking
initiation