COMPARATIVE STUDY OF TOBACCO CONTROL POLICY IN SMOKING BEHAVIOUR BETWEEN LITHUANIA AND INDONESIA

Zhalsabilah. Z¹, Sadli Syam²

Universitas Tadulako, Central Sulawesi, Indonesia

zhalsabilah.zaman@gmail.com¹, sadlisyam.pk@gmail.com²

KEYWORDS	ABSTRACT
Tobacco Control Policy, Smoking Behavior, Indonesia, Lithuania	Indonesia is one of the countries that have a large number of smokers in the world and it keeps increasing every year. Lithuania compared to other European Union countries, is slightly bigger than the European Union average of smoking prevalence. Both of these countries have implemented Tobacco Control Policies for quite a long time. Three research objectives in this research are to review and compare Lithuania and Indonesia’s Tobacco Control Policies; to analyze the situation of smoking behavior in Lithuania and Indonesia; and to analyze the implementation and its impact on smoking behavior of Tobacco Control Policy in Lithuania and Indonesia. Qualitative methods are used to analyze the document for the policy and literature analysis to acquire information about the situation of smoking cases and the implementation of the policy in both countries. This study aims to accomplish a comparative analysis of the Tobacco Control Policy between Lithuania and Indonesia and its impact on the rise of smoking cases. The Indonesian government has set a good Tobacco Control Policy but the implementation of the policy it’s not strict and there are a lot of tobacco product advertisements in Indonesia, this could be the reason why Indonesia has so many smokers and increasing every year. Lithuania has stricter regulations and implementation, and the smokers are decreasing every year, but they have a new group of smoker which is youth smoker that growing rapidly nowadays.
DOI:

Corresponding Author: Zhalsabilah. Z

Email: zhalsabilah.zaman@gmail.com

INTRODUCTION

Tobacco in all forms is one of the biggest public health problems (Urrutia-Pereira et al., 2019). It is addictive and somehow mass-produced, so that it could lead to socio-economic problems. All forms of tobacco use are harmful, and there is no safe level of exposure to tobacco. Behavioral risk factors are primarily associated with high mortality and poor health in the Lithuanian population. It is estimated that around half of all deaths in Lithuania can be attributed to behavioral and environmental risk factors, one of which is tobacco smoking.

Meanwhile, Indonesia is the second-largest cigarette market in the world by retail volume. Also, Indonesia is Southeast Asia's only WHO member state that still needs to ratify the Framework Convention on Tobacco Control. In addition, the data also show an increasing trend of tobacco use among children and adolescents. Both of the countries have high cases of smoking, and the Government wants to decrease the instances in the form of policy. This study will see the differences and similarities between the policy, implementation, and its impact on smoking behavior in both countries.

Tobacco Control Policy in Lithuania has a long history since it was formed in 1995, and it is also a stringent policy to reduce smoking behavior in Lithuania (Liutkutė et al., 2017). They had several guidelines to regulate tobacco products, promotion, advertisement, and event tax. Adopting the law, based on recommendations from the World Health Organisation researchers in Lithuania and other countries, has made Lithuania known for its advanced legal framework regarding tobacco control (de Looze et al., 2022).

E-cigarettes shall be subject to the same strict restrictions on tobacco products as cigarettes under the Tobacco Products and Related Products Control Law of 2016. In most places and media, electronic cigarette advertising, promotion, or sponsorship is prohibited. Vaping is banned in places where smoking is forbidden, and cross-border sales of e-cigarettes and nicotine fluids are not permitted. In 2020, the Drug, Tobacco and Alcohol Control Department has been empowered to issue binding instructions to information hosting service providers to remove or exclude access to information on advertising of tobacco products and e-cigarettes, as well as domestic or long-distance sales of tobacco products and e-cigarettes (Snowdon, 2016)

Since the Republic of Lithuania adopted an Act on Tobacco Control in 1996 and followed it up with a ban on advertising for tobacco products in 2000, the falling prevalence of smoking may be linked to active, positive political developments. The WHO Foundation Convention on Tobacco Control proposes that a comprehensive tobacco control program in every country, which includes monitoring, smoke-free policies, cessation measures, preventive health warnings, advertising bans, and taxation, should consist of six cost-efficient MPOWER actions (Buettner-Schmidt et al., 2019). Lithuania regards WHO FCTC recommendations and periodically delivers recent, representative data on smoking among adults and youth; bans smoking in public places like bus stops and cafes, puts health warnings on tobacco packages with all appropriate characteristics; bans promoting or advertising tobacco on national television, radio and print media; and has made sure that more than 75% of tobacco retail price is tax (tax increases in 2004, 2007–2010, 2012–2015) (Rinkūnienė et al., 2019).

On the other hand, Indonesia adopted a tobacco control policy in 1999. The policy regulating smoke-free is also to handle advertisement and promotion of cigarettes. To be highlighted, Indonesia still needs to sign and agree to ratify the World Health Organization's Framework Convention on Tobacco Control (FCTC) so Indonesia still allows tobacco industry advertisement freely. Fear of economic loss due to the myth of the importance of tobacco in the Indonesian economy is supposed to be the reason for not signing the International Convention on Tobacco Control (Crosby et al., 2019).

In addition, Indonesia is among seven countries that have not ratified or signed the WHO Framework Convention on Tobacco Control (Moeis et al., 2022). As context, the largest regional producers and consumers of tobacco―India and China―have ratified the treaty despite the implications for tobacco-related employment and livelihoods. According to news reports, President Joko "Indonesia" Widodo has claimed that Indonesia is not interested in following this trend based on the fact that several other countries have already done so; however, we must also take into account our nation's interests, particularly citizens who are suffering from tobacco-related illnesses (Mietzner, 2021).

Reports suggest that several issues are holding back the Government's decision, among them there being good relations between the tobacco industry and the State, its role as a significant employer for Indonesians who will receive their income by way of taxes or advertisements, in addition to economic considerations such as tax revenues. Many think that Indonesia's reluctance to accept the Framework Convention on Tobacco Control reduces the efforts of the entire world community in combating tobacco, while Indonesia claims it has carried out a wide range of domestic policies, including increased cigarette taxes and restrictions on advertising, sponsorship or promotion; however, these measures have been regarded as inadequate (Azzahra et al., 2022).

The work of B.F. Skinner is based on the assumption that behavior is influenced by its consequences. The reinforcement theory is how behavior can be shaped to control its effects (Klumbiene et al., 2015). Reinforcement theory proposes that a person's actions can be changed through reinforcement, punishment, and Extinction. The reward is used to reinforce the behavior you want, and the penalty is used to prevent the behavior you do not want. Extinction is a means to stop someone from performing a learned behavior. The technical term for these processes is known as operant conditioning.

The goal is to accomplish a comparative analysis of the Tobacco Control Policy between Lithuania and Indonesia and its impact on the rise of smoking cases. This study aims to review and compare the tobacco control policies of Lithuania and Indonesia, analyze the situation of smoking behavior in Lithuania and Indonesia, and analyze the implementation and impact of tobacco control policies in Lithuania and Indonesia on smoking behavior.

METHOD

This research utilizes the Qualitative method with literature review and netnography approach. The study will include policy document analysis and literature analysis to obtain information on the smoking situation in both countries and a literature review on tobacco control policy implementation from existing journals. The object of this research is Tobacco control policies in Indonesia and Lithuania to reduce smoking behavior in both countries. The time used for this research is around 3 months starting from August to November 2023.

RESULT AND DISCUSSION

Overview of the Smoking Situation In Indonesia and Lithuania

1. Smoking Behavior in Lithuania

Behavioral Risk Factors such as alcoholism and tobacco consumption are the reasons for high mortality rates and poor health status in Lithuania. Tobacco use itself is considered to be an epidemic in Lithuania because of its harm to society. Tobacco consumption, including second-hand smoke, is responsible for an estimated 14 % (over 5300) of all deaths (Napierala et al., 2019). Each year, 5,384 people in Lithuania die from smoking.

Lithuania was slightly above the European Union average in terms of smoker prevalence. In 2019, adult smoking prevalence in Lithuania was 29%, and around 607,388 smokers. Based on gender, 37.9% of men (around 400,259 men) and 20.3% of women (207,129 women) are smokers (Kusumawardani et al., 2018). On the other hand, youth smokers are rapidly growing. In 2019, Youth smoking prevalence in Lithuania was 14%. By gender, it is around 15,6% men and 11,9% women (Kusumawardani et al., 2018).

The prevalence of e-cigarette use among Lithuanian school children and students is increasing and surpassing the consumption of conventional cigarettes. In 2022, 31 percent of schoolchildren have used electronic cigarettes. The use of e-cigarettes among teenagers aged 15 to 16 is one of the highest in Europe. The 2019 ESPAD results show an average lifetime e-cigarette use of 40 % among 16-year-old students, ranging from 18 % in Serbia to 65 % in Lithuania, with higher rates for boys than girls (Cerrai et al., 2022).

2. Smoking Behavior in Indonesia

Indonesia has an increasing smoking prevalence each year. Adding to that, Indonesia is also the country with the highest use of cigarettes in the world, especially among men. Around 290,444 people die from smoking each year. In 2019, Adult smoking prevalence in Indonesia was 31%, with a percentage of men were 58.3% and 3.6% for women. Meanwhile, Youth smoking prevalence in Indonesia is 7%, with 11.5% percentage of men and 1.4% percentage for women (Kusumawardani et al., 2018).

Indonesia is the second-largest cigarette market in the world by retail volume. In 2018, 307.1 billion cigarettes were sold in Indonesia (Elliot, 2016). Nearly 77% of those who use tobacco reported that they were able to buy cigarettes from a store, shop, street vendor, or kiosk, and 61% said that they were not prevented from buying because of their age (Azzahra et al., 2022). It is straightforward in Indonesia to buy cigarettes or other tobacco products since the regulation is not implemented well, especially in small kiosks where 5-year-old children can even buy cigarettes as long as they pay. People must show their I.D. when purchasing tobacco products only in more significant markets. Sometimes, the cashier must check it. Cigarettes are accessible in Indonesia, and the price is also cheap for students.

Tobacco Control Policy Comparison between Indonesia and Lithuania

Table 1 Smoke-Free Area

	Health care Facilities	Educa national Facilities	Univer City	Government Facilities	Indoor Office	Restaurant	Pubs and Bars	Public Trans port	Funds for Enforcement
Indonesia	Yes	Yes	Yes	No	No	No	No	Yes	Yes
Lithuania	Yes	Yes	Yes	No	No	Yes	No	No	No

Source: Tobacco Atlas 2021

Smoke-Free Areas are implemented in both countries. Healthcare Facilities, Education Facilities, and Universities are free from smoking activities. Meanwhile, it is allowed in both countries to smoke in government facilities, indoor offices, pubs, and bars. There are differences between Indonesia and Lithuania. In Indonesia, it is not allowed to smoke in public transport when it is allowed in Lithuania. On the other hand, Lithuania banned smoking in restaurants, and it is free to smoke in restaurants in Indonesia. Indonesia has allocated funds for enforcement regarding smoke-free areas, and Lithuania has not regulated it.

Table 1 Tobacco Products Policy

	Ran a National Anti-Tobacco Campaign	Availability of Cessation Services	Tobacco Packaging Regulations
Indonesia	Yes	Yes	Graphic Warning Label Only (40% of Pack Covered)
Lithuania	No	No	Graphic Warning Label Only (65% of Pack Covered)

Source: Tobacco Atlas 2021

Both Indonesia and Lithuania regulate their tobacco packaging by putting graphic warning labels. Indonesia covered 40% of the pack with the warning label. Meanwhile, Lithuania's tobacco packaging covered 65% of it. In Lithuania, there are no National Anti-Tobacco Campaigns in mass media and cessation services for people who need help quitting smoking behavior. On the other hand, Indonesia runs a National Anti-Tobacco Campaign in Mass Media. It has cessation services in their country, and the Government covers the Government.

Table 2 Regulations on Tobacco Advertising, Promotion, and Sponsorship:

Direct Ban

	National T.V. and radio	International T.V. and radio	International magazines and newspapers	Billboard and outdoor advertising	Advertising at point of sale	Advertising on internet
Indonesia	No	No	No	No	No	No
Lithuania	Yes	Yes	Yes	Yes	Yes	Yes

Source: Tobacco Atlas 2021

Lithuania has strict regulations regarding Advertisement, Promotion, and Sponsorship. They banned all kinds of advertisements for tobacco products. Meanwhile, Indonesia does not even deny the advertising of tobacco products itself. It is a significant way to have a ban policy for the promotion of tobacco products by having some ads that will encourage people to smoke, and it becomes a normal phenomenon in society.

Table 3 Regulation on Tobacco Advertising,

Promotion and Sponsorship: Indirect Ban

		Indonesia	Lithuania
Free distribution by mail or through other means	Yes			Yes
Promotional discounts	Yes			Yes
Non-tobacco products identified with tobacco brand names	Yes			Yes
Brand name of non-tobacco products used for tobacco product	No			No
Appearance in T.V. and films: tobacco brands (product placement)	No			Yes
Appearance in T.V. and movies: Tobacco products	Yes			No
Prescribed anti-tobacco ads are required for any visual entertainment media product that depicts tobacco products, uses, or images.	N/A			No
A complete ban on sponsorship	No			Yes
Any form of contribution (financial or other support) to any event, activity, or individual	No			Yes
Ban on the publicity of financial or other sponsorship or support by the tobacco industry of events, activities, individuals	No			Yes

Source: Tobacco Atlas 2021

For indirect banning, Indonesia and Lithuania banned free distribution by mail or other means and excluded promotional discounts for tobacco. Lithuania refused to appear in T.V. and films (product placement), while Indonesia still allowed the product placement of tobacco products. In Indonesia, it is allowed to have a tobacco products sponsorship. When holding an event, it is also legal to seek contributions from the tobacco industry and announce it as a sponsor. Meanwhile, it is illegal in Lithuania to have tobacco product sponsorship and publicity of financial or other backing or support from the tobacco industry.

Implementation of Tobacco Control Policy in Indonesia and Lithuania

1. Implementation of Tobacco Control Policy in Indonesia

Indonesia's Government integrated the Tobacco Control Policy even though they still need to ratify the Framework Convention on Tobacco Control from WHO. They made several policies that could restrict smoking in Indonesia. Unfortunately, the implementation of the procedure itself did not work. For example, even though there are anti-tobacco campaigns, there are also massive advertisements of tobacco products that you can find everywhere, like on TV, social media, billboards, and other platforms.

Tobacco products are a big industry in Indonesia, the second-largest cigarette market in the world by retail volume. In 2018, 307.1 billion cigarettes were sold in Indonesia (Elliot, 2016). Indonesia could keep its income by having stricter policies towards the tobacco industry. The more problematic thing is that the Indonesian central Government Rp4.9 trillion from regional tobacco excise duty, one of the three taxes on cigarette sales, to cover a budget deficit in the country's health insurance program (Webb et al., 2022). It means Indonesia relied so much on tobacco industries that it would be a double-edged sword in their money flow.

Since Indonesia allows any sponsorship of tobacco products, many events, especially music concerts in Indonesia, either in the capital city or any region, usually have tobacco products as their sponsor. For its brand, it is a way to market and raise brand awareness of its tobacco products as well as sell the products, and it is worsening the cases of smoking in Indonesia. It only matters how many policies the Indonesian government releases if they are correctly implemented in society. The number of smoking prevalence is increasing every year even though there are Tobacco Control Policies, and the solution is to implement Tobacco Control Policy stricter and slowly ban the advertisement of tobacco products (Jayawardhana et al., 2019).

When we see the link between these cases and reinforcement theory, Indonesia wants to make a thing called Extinction, which means stopping someone from performing a learned behavior by creating a cessation service. Still, they cannot achieve it in reality because no punishments are used to prevent the behavior you do not want. In the end, people still engage in that unwanted behavior because they think that even though the policy exists, it has no impact on us or the procedure is just something written on paper.

2. Implementation of Tobacco Control Policy in Lithuania

Lithuania has a strict tobacco control policy and implementation (Chan et al., 2022). Every year, the smoking prevalence is decreasing, but the number is still high among other European Union countries. Lithuania has an excellent strategy to regulate its people by making policies such as banning the advertisement of tobacco products. The approach works because people might need more information about tobacco products, and products are less well-known. Also, Lithuania's Tobacco Control Policy opted for smoke-free areas, so people have fewer places to smoke. One thing that could make Lithuania's Tobacco Control Policy more compelling is the need to make cessation services to help people quit smoking behavior.

Lithuania needs to improve its strategy to reduce smoking because right now, there is a new community that they need to take care of, that is, the adolescent group who smoke e-cigarettes. The prevalence of e-cigarette use among Lithuanian school children and students is increasing and surpassing the consumption of conventional cigarettes. The use of e-cigarettes among teenagers aged 15 to 16 is one of the highest in Europe.

The Lithuanian Government has already made some ways to reduce teenage smokers by having more Tobacco Control Policies. Currently, Lithuania has a ban on selling e-cigarettes and their e-liquid cartridges if they contain vitamins and other additives that create an impression that they are good or do less damage to health. Moreover, Lithuania has an import ban for e-cigarettes and their e-liquid cartridges containing caffeine or taurine and stimulating compounds linked to energy and vitality. Even though the Lithuanian Government prohibited the selling of tobacco-flavored products, it is still not enough to prevent teenagers from using e-cigarettes (Snell et al., 2021).

Based on Skinner's reinforcement theory, punishment is one of the keys to reinforcement. In 2020, Lithuania banned smoking on a balcony. As stated in Made In Vilnius news, "In a year and a half, 30 people have been fined for smoking on the balcony of apartment buildings in three major cities of the country, Vilnius, Kaunas, and Klaipeda." (Gaitanos, 2020). From this, the key to the success of Lithuania's Tobacco Control Policy is reinforcement. Punishing people who break the rules can impose negative consequences to discourage unwanted behavior. As a government, it is essential to regulate what people can and cannot do by having a good policy.

CONCLUSION

The cases of smoking are still high in Indonesia because even though there is a Tobacco Control Policy, the implementation of the policy does not work and is not strict. In addition, there are many advertisements for tobacco products, but not as many as the anti-smoking campaign. The number in Lithuania is still high in the European Union, but it is decreasing yearly. Lithuania needs to make cessation services so people can try to stop smoking. It also needs to add a policy regarding the phenomenon of teenage smoking. There are similarities and differences between Indonesia's and Lithuania's Tobacco Control Policies, but Lithuania most likely bans the advertisement of tobacco products, while Indonesia still needs to implement that. Meanwhile, Indonesia has many anti-smoking campaigns compared to Lithuania and has cessation services.

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