Nuryunarsih, Desy
(2021)
A mixed methods investigation into attitudes, behaviours, and health risk perceptions of Indonesian people regarding the use of kretek cigarettes.
PhD thesis, University of Nottingham.
Abstract
Background
Smoking is very common in Indonesia: among adults, around 66% of males and 7% of females are smokers. Smoking is not only harmful for people who smoke but also for people who are exposed to second-hand smoke on a regular basis. An estimated 90 million Indonesian people involuntarily inhale cigarette smoke every day. Every hour 46 Indonesians die due to smoking-related diseases. Globally, most smokers consume regular factory-made cigarettes, but in Indonesia, kretek (cigarettes with cloves and other additives) is the most popular tobacco product, smoked by around 90% of Indonesian smokers (54.2 million people). To date, no systematic review has investigated the health effects of kretek cigarettes. Research exploring Indonesian smokers and kretek has focused on the social and cultural aspects of smoking behaviour in Indonesia, and most of this is out of date. No research was found that specifically investigated the attitudes, knowledge, and health risk perceptions of the Indonesian population regarding kretek use. Health professionals (HPs) can play a key role in providing smokers with support to stop smoking, however, in Indonesia many HPs are reported to be smokers themselves. Data are needed to understand the smoking behaviours and attitudes of Indonesian HPs and their perceived role in helping smokers to stop.
This research project seeks to: (i) evaluate and summarize the findings of all relevant individual studies investigating the health effects of kretek; (ii) investigate Indonesian smokers’ and non-smokers’ perceptions concerning the health risks of kretek cigarettes compared to regular cigarettes, and to gain a better understanding of the role of kretek cigarettes in the lives of Indonesian people; and (iii) to understand smoking-related attitudes and practices of HPs in Indonesia.
Methods
This research project has been conducted using three different approaches. (1) A systematic review of the health risks of kretek cigarettes. (2) A qualitative study with a total of 58 participants (smokers and non-smokers). All interviews were a semi-structured one-to-one telephone interview. The interviews with smokers covered the use of kretek and regular cigarettes, attitudes and beliefs about them, the perceptions of risks and benefits of kretek cigarettes compared to regular cigarettes, as well as the smokers’ attempts to quit. Interviews with non-smokers included concerns about the use of kretek cigarettes by family members or friends and perceptions of the health risks or benefits associated with passive exposure to kretek smoke. (3) A quantitative study about Indonesian the perceptions of health professionals (physicians and dentists) of the health risks or benefits of smoking and their perceived role in helping smokers to stop. Participants (Indonesian HPs) were asked a total of 20 questions in the survey. General demographic items covered age, gender, workplace location, occupation (physician or dentist), work location, and smoking status. Health risk perceptions were assessed using questionnaires adapted from the World Health Organization Health Professionals’ Tobacco Survey 2004.
Results
Systematic review
This systematic review identified a relatively limited number of studies (n=32), mainly cross-sectional studies of poor quality. After considering the strengths and limitations of the systematic review, the evidence showed that kretek have similar health risks to regular cigarettes. Included studies suggested that kretek increases the risks of oral cancer, coronary heart disease, asthma, and nicotinic stomatitis. One study shows significant association between passive kretek exposure and gingival melanin pigmentation.
Qualitative study
The results of qualitative study of 58 people showed gender differences in attitudes as well as behaviour, but a generally poor understanding of the health risks of smoking. Whilst kretek are favoured by older smokers, things are changing, and younger smokers seem to increasingly prefer regular and manufactured kretek cigarettes. There are misconceptions about the relative health effects of different types of cigarettes, and attitudes that seem to be influenced by tobacco advertisements, in a country where big tobacco has a major lobbying presence.
Quantitative study
The study found that one in five health professionals smoke, and this is much higher in men. The majority understand the risks of doing so but continue to smoke. This study highlighted the strong cultural values associated with smoking in Indonesian society that are challenging to overcome. Health professionals were largely supportive of comprehensive measures and policies such as smoke-free policies that would help to change the culture. The study also highlighted that most health professionals understood the need to ask, advise, and support their patients to stop smoking, but they lacked the training and the facilities and services to provide the types of support which have been shown to be most effective in other societies.
Conclusions
Smoking is very common in Indonesia, and the majority of Indonesian smokers use kretek. The systematic review study shows that existing evidence is insufficient to assess the health risks of kretek in detail, however, considering the strengths and limitations of the study, kretek are likely to be at least as harmful as regular cigarettes and that policy makers need to implement measures to avoid this harm. Qualitative study shows that smoking is dominated by males and seen as part of their culture; non-smokers and women are generally aware of the health risks of smoking and second-hand smoke, but lacked detail knowledge of the health risks and benefits to stopping smoking. There is little support to help people to quit.
Smoking is still common among HPs who understand the risks. Indonesian HPs lack confidence to assist patients to quit. This highlights the need for specific training for HPs to understand smoking cessation and to better advise and support their patients to quit.
Indonesia is the only Southeast Asia country that has not ratified FCTC. The situation is worsened by the strong influence of the tobacco industry in the economy and in politics. Indonesia has minimal smoke-free policy, cessation programs, health warnings, and advertising bans, and cigarettes remain relatively affordable. Indonesia needs a comprehensive tobacco policy, and it must enforce that policy, compliant with the MPOWER measures proposed by the WHO.
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