Cigarettes in small hands: Mapping cigarette retailers around children and adolescents in Denpasar, Bali, Indonesia

Project background

Tobacco consumption in Indonesia is amongst the highest in the world, with a staggering 61.4 million adult smokers. Worryingly, the smoking population is not limited to adults; while two-thirds of Indonesia’s adult male population smoke, one-third of boys aged 13-15 years are also smokers. The prevalence of smoking among those aged 10-14 years increased from 9 per cent in 1995 to 17.4 per cent in 2010. The growing number of young people smoking will have an impact on the future social and economic burden of chronic disease.

In December 2012, the Indonesian government issued a national regulation for tobacco control (regulation PP 109/2012). Most of the tobacco control measures it contained focus on addressing the demand side of tobacco control, with no apparent attempt, beyond prohibiting sales to minors, to address supply side issues. Indonesia is home to around 3800 cigarette manufacturers, with overall retail volume as high as 238.9 million cigarettes a year in 2014. The ubiquitous presence of cigarette retailers, coupled with cheap cigarettes and the ability to purchase single stick cigarettes, renders young people vulnerable tobacco industry targets.

This is the first study to provide visual mapping of cigarette retailer distribution in Indonesia. The study was able to highlight the high availability and accessibility of cigarettes by young people in Denpasar. The prevalence of cigarette retailers who also display extensive cigarette promotional materials and cigarette products exposes young people to tobacco brand imagery and the product itself. Moreover, the practice of selling cigarettes, including single sticks, to young people is common.

Smoking uptake among young people is partly attributed to tobacco promotions and cigarette retailer outlet density and proximity to schools and homes. Cigarette retailers present an effective promotional opportunity, right at the crucial time of purchase. In-store marketing increases the likelihood of smoking initiation among young people and hampers quitting attempts for existing smokers. Bans on point-of-sale promotions, including the display of tobacco products, has proven to be an effective measure to reduce smoking, especially among young people. Therefore, to complement current tobacco control measures, efforts to address supply side issues by acknowledging the role of cigarette retailing in uptake and continued smoking need to be seriously considered by the government. The research team aimed to assess cigarette retailer distribution and retail tobacco promotion intensity in Denpasar, a provincial capital city in Indonesia. By doing this, the study aimed to map the existing distribution of cigarette retailers in Denpasar and cigarette advertisements and promotions at the tobacco retailer level, with particular attention to areas with a high concentration of children and adolescents. The study took place between October 2017 and March 2018.

Method

The project was conducted in two stages:

• Documenting and mapping cigarette retailers and schools in the City of Denpasar. The data collection was conducted with electronic checklist using open data kit (ODK).
• Auditing tobacco advertisements and promotion at 1000 selected retailers. After randomly selecting 1000 retailers from the list mapped in stage one, the team conducted an audit survey to document advertisements, promotions, prices and retailing behaviors. The audit comprised of observation accompanied by digital photo taking and structured interviews with a questionnaire.

Findings

The research team mapped a total of 4114 cigarette retailers (excluding restaurants and hotels), finding a high cigarette retailer density of 32.2 outlets per square kilometer. The density was greater in more populated areas. There were about five tobacco retailers for every thousand people in Denpasar.

The majority of schools in Denpasar (367 out of 379) have at least one cigarette retailer within 250 metres, with two-thirds of schools having a retailer within 100 metres. On average, there were 10 cigarette retailers within 250 metres of each school, with one school having 44 retailers within the 250 metre radius.

The study documented a high intensity of cigarette advertisements, both in outside and inside retailers. Out of the 1000 retailers audited, 674 displayed outdoor cigarette advertisements, and almost all retailers, 989 out of 1000, displayed indoor ads, including cigarette displays at the point of sale. The most common form of outdoor adverts were banners, with most of the retailers displaying cigarettes. More than half of the retailers at both kiosks and mini markets admitted selling cigarette to young people, with retailers admitting to receiving incentives from the tobacco companies for cigarette sales and for displaying ads.

Conclusion

The omnipresence of cigarette retailers signifies that cigarettes are easily accessible and socially acceptable. A key success factor in tobacco control is changing social norms around cigarette use to ensuring that smoking is viewed as unacceptable behavior, especially among young people. Many countries have adopted a total ban on tobacco advertisements, including those at the point of sale. An example of this is Australia, where cigarette advertisement is not allowed and cigarettes cannot be displayed at point of sale. These efforts have contributed to the steep decline in youth smoking in Australia.

The research team recommends that the Indonesian government urgently adopt a comprehensive tobacco advertising and promotions ban, including at the point of sale. Additionally, governments should prioritize the enforcement of the ban on cigarette sales to young people and the development of a legislative framework to reduce cigarette retailer density.