Vape store density and proximity to schools in Denpasar, Bali, Indonesia.

OBJECTIVE: Electronic cigarettes (e-cigarettes) use among youth in Indonesia is rising, and there is no regulation surrounding sale of e-cigarettes. This study aims to map the distribution and density of vape stores and their proximity to schools and cafes as well as assess selling of e-cigarettes to youth under 18 years in Denpasar, Bali. METHODS: Using QGIS V.3.18.1 software, we conducted a geographic mapping of all vape stores followed by a survey of the retailers (n=107). Data were collected in April 2022. Several measures explored included retailers' density based on the size and population of subdistricts, retailers' proximity to school. Retailers were asked about selling to youth under 18 years, then its association with distance to schools and other variables were explored. RESULTS: We mapped 122 vape stores across Denpasar city with a density of 1.56 per km2 of the occupied land for housing, 0.16 stores per 1000 total population and 1.06 stores per 1000 youth population. More than a quarter of the schools (28.3%) and the universities (25.6%) had at least one vape store in 250 m radius, while 97.2% of the stores were within 500 m of a café. Of the 107 vape store retailers interviewed, almost half (43.9%) reported selling vapes to youth under 18 years. CONCLUSIONS: Retail availability of e-cigarettes will contribute to the increasing use of this product, especially without a minimum legal sales age. The government should urgently prohibit selling to youth, regulate e-cigarette advertising, promotion and sponsorship and prohibit e-cigarette use where conventional smoking is prohibited.

From the international tobacco control arena to the local context: a qualitative study on the tobacco advertising, promotion and sponsorship legislative environment in Sudan and the challenges characterising it.

OBJECTIVES: The aim of the study was to assess the Sudanese tobacco advertising, promotion and sponsorship (TAPS) legislative environment and the challenges characterising it. We formulated three research questions: What is the TAPS policy context in Sudan? What circumstances led to the development of the current legislative text? Finally, what was the involvement of the different actors in these events? DESIGN: We conducted a qualitative analysis using the Health Policy Triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases or websites of national and international organisations, as published by February 2021. The thematic framework approach was employed to code and analyse the textual data and the generated themes were used to map connections across the data and to explore relationships among the generated subthemes and themes. SETTING: Sudan. DATA: Using a combination of the keywords "Sudan" and "tobacco advertising" (or "tobacco marketing" or "tobacco promotion"), we collected publicly available documents in the English language. We included 29 documents in the analysis. RESULTS: Three themes underpin the Sudanese legislative environment on TAPS: (1) limited and outdated TAPS data, (2) stakeholder involvement and tobacco industry interference and (3) TAPS legislation not aligned with the WHO Framework Convention on Tobacco Control Secretariat recommendations. CONCLUSIONS: Findings from this qualitative analysis suggest that recommendations to move forward in Sudan should include the systematic and periodic collection of TAPS surveillance data, addressing any remaining legislative content loopholes and protecting policy-making from tobacco industry interference. In addition, best practices from other low-income and middle-income countries with good TAPS monitoring systems, such as Egypt, Bangladesh and Indonesia, or with protective provisions against tobacco industry interference, such as Thailand and the Philippines, could be considered for adaptation and implementation.

Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh.

OBJECTIVES: This paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs). METHODS: We conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections. RESULTS: Four themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies. CONCLUSION: This study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

Gender differences in social environmental factors of psychological distress among Indonesian adolescents: Findings from the 2015 Global School-based Student Health Survey.

BACKGROUND: This study aimed to investigate gender differences in social environmental factors of psychological distress among Indonesian adolescents. METHODS: This was a cross-sectional study using the data from the 2015 Indonesia Global School-based Student Health Survey. Binary logistic regression was used to assess the influences of main independent variables - social environmental factors (i.e., peer support, having close friends, bullying victimisation, physical fight, physical attack, parental supervision, connectedness, bonding), demographic characteristics, and health-related behaviours on the measures of psychological distress (loneliness, anxiety-induced sleep disturbance, and a combination of both measures as psychological distress). RESULTS: The prevalence of psychological distress measured as loneliness, anxiety-induced sleep disturbance, and combined psychological distress was 6.12%, 4.52%, and 8.04%, respectively. Findings from multivariate analyses indicated that bullying victimisation, physical attack, experience of hunger (a proxy of socioeconomic status), and sedentary behaviour were associated with all measures of psychological distress. Meanwhile, age, gender, drug use, parental connectedness and bonding, and having no close friends were correlates of one or two measures of psychological distress. Based on gender-stratified analyses, experience of hunger, sedentary behaviour, bullying victimisation, and having no close friends were consistently associated with measures of psychological distress among both girls and boys. In addition, the influence of some social environmental factors, such as parental connectedness, peer support, and physical attack, were more salient among girls. CONCLUSIONS: The findings suggest that social environmental factors, demographic characteristics, and health-related behaviours were associated with psychological distress, and the associations appeared to differ by gender. Interventions that include improving positive social environmental factors (e.g., reducing interpersonal violence, encouraging positive relationships with parents and peers) and promoting healthy behaviours (e.g., less sedentary behaviour, preventing substance use) might help reduce the risk of psychological distress among Indonesian adolescents.

Disability and Lower Social Gradient Increased Risk of Depression Among Pre-Elderly in Indonesia: Finding From a Nationwide Health and Socio-Economic Survey.

Prevalence of depression in Indonesia was 6.1% in 2018, while disability was doubled from 11% in 2013 to 22% in 2018. Pre-elderlies are susceptible to experience both disability and depression. We conducted secondary data analysis of nationally representative data to measure the association between disability and depression among pre-elderlies, age 45 to 59 years old. This analysis involved 70,301 pre-elderlies with normal body mass index, and 70,090 with complete data for further analysis with multilevel logistic regression. We found 1.6% pre-elderlies experience depression, 19.1% have disability, while 3.3% of those with disability were depressed. We found likelihood of depression almost three time among pre-elderly with disability (AOR = 2.81). Other variables with independent association are residential area, sex, history of chronic illness, socio-economic, and education level. Preventive measures are needed to improve awareness and to screen for both disability and depression among these age-group, as well as rehabilitative programs to improve their wellbeing.

Global tobacco advertising, promotion and sponsorship regulation: what's old, what's new and where to next?

Tobacco advertising, promotion and sponsorship (TAPS) bans are a cornerstone of comprehensive tobacco control laws. Global progress in implementing TAPS bans has been enabled by the adoption of the WHO Framework Convention on Tobacco Control. Innovative TAPS policies are in place internationally and include: point-of-sale display bans, plain packaging of products, industry spending on TAPS disclosure reporting, bans on retailer incentive programmes, and regulation of TAPS in entertainment and online media. However, there is an over-reliance on entertainment and digital content producers and platforms to self-regulate TAPS. Ensuring TAPS laws are regularly examined to limit loopholes and remove exemptions is crucial to continued success. The definition of what constitutes TAPS can allow the tobacco industry to deploy corporate communication and political campaigns that skirt TAPS bans. TAPS laws must also maintain pace with the changing media landscape, which includes monitoring and reporting TAPS that cross international borders, primarily through digital media platforms. Limiting tobacco retail supply will also serve to prevent the continued undermining of TAPS bans. Leveraging global corporation to ensure enforcement of TAPS bans across borders is urgently needed.

The implementation of smoke-free workplace policy and the determinants affecting indoor smoking in Indonesia.

A smoke-free workplace is important to reduce secondhand smoke exposure, raise awareness, encourage smoking cessation, and increase productivity. This study aimed to assess indoor smoking in the workplace as part of a smoke-free policy implementation and the factors associated. This was a cross-sectional study at workplaces in Indonesia from October 2019 to January 2020. The workplaces were divided into private workplaces owned by a company for business and government workplaces that run for public services. Samples were selected using stratified random sampling. Data collection follows time and area observation guidelines, starting in the indoor area and then outdoor. The observation was conducted for at least 20 min for each workplace in 41 districts/cities. Of the 2900 observed workplaces, 1097 (37.8%) were private and 1803 (62.92%) were government workplaces. The proportion of indoor smoking at government workplaces was 34.7%, higher compared to private (14.4%). The results were consistent for each indicator such as people smoking (14.7% vs. 4.5%), electronic cigarette use (0.7% vs. 0.4%), cigarette butts presence (25.8% vs. 9.5%), and smell of cigarette smoke (23.0% vs. 8.6%). The factors associated with indoor smoking were indoor ashtray availability (adjusted odds ratio [AOR] =13.7; 95% confidence interval [CI]: 10.6-17.5), indoor designated smoking area (AOR = 2.4; 95% CI: 1.4-4.0), presence of indoor tobacco advertising, promotion and sponsorships (AOR: 3.3; 95% CI: 1.3-8.89), whereas the presence of no smoking sign was a preventive factor (AOR = 0.6; 95% CI: 0.5-0.8). Indoor smoking remains high, particularly in government workplaces in Indonesia.

Tobacco Control Stakeholder Perspectives on the Future of Tobacco Marketing Regulation in Indonesia: A Modified Delphi Study.

OBJECTIVES: Tobacco control in Indonesia is very lenient compared to international standards. This study explored the perspectives of tobacco control stakeholders (TCSs) on the likelihood of advancing tobacco marketing regulation in Indonesia. METHODS: Data were collected from TCSs who were members of the Indonesia Tobacco Control Network group in a modified Delphi study. We collected the data in 2 waves using a questionnaire that comprised a set of closed and open-ended questions. For this paper, we analysed 2 of the 3 sections of the questionnaire: (1) tobacco advertising, promotions, and sponsorship (TAPS) bans, and (2) marketing and retailing regulations. We conducted a descriptive analysis of the scores using Stata/IC.13 and summarised the comments for each item. RESULTS: The TCSs viewed the measures/strategies across all aspects of TAPS and tobacco marketing regulation as highly desirable, but provided varied responses on their feasibility. They rated political feasibility lower than technical feasibility for most measures. Advancing TAPS measures and prohibition of selling to minors were considered more attainable by sub-national governments, while prohibition of tobacco corporate social responsibility was considered as the least feasible measure in the next 5 years. CONCLUSIONS: Despite little optimism for substantial national-level change, there is a positive expectation that sub-national governments will strengthen their tobacco control regulation. It is paramount that the government reduce tobacco industry leverage by implementing Article 5.3 of the World Health Organization Framework Convention on Tobacco Control. Extending advocacy networks beyond tobacco control groups and framing tobacco control more effectively are necessary steps.

Implementation of smoke-free law in Denpasar Bali: Between compliance and social norms of smoking.

Background: Since 2013, City of Denpasar government has adopted a smoke-free law. Implementation of the law faces several obstacles, partly due to the high social acceptability of smoking in the city, where cigarette and smoking has been deeply engrained within social life and become part of hospitality. This study aims to assess the smoke-free law compliance and to explore the social norms that may affect the compliance. Design and Methods: The study was a mix of cross-sectional compliance survey and qualitative exploration conducted in Denpasar in 2019. Survey included 538 samples, which were selected using stratified random sampling and a walking protocol. The qualitative data was collected through in-depth interviews and Focus Group Discussion (FGD) in four sub-districts of Denpasar. Results: Of the 538 venues, 32.9% complied with the seven compliance indicators. The university has the highest compliance (83.3%), while public places including worship places have a low compliance. The three most common violations were the absence of no-smoking signage (58.6%), provision of ashtray (17.5%), and smell of tobacco smoke (15.8%). The poor compliance was related to the lack of awareness of the regulation, and the fact that smoking is highly acceptable and part of the culture. The informants highlighted the essential role of public figures and potency of local policy as social disapproval of smoking. Conclusions: Compliance to the smoke-free law in Denpasar remains low, continuous education, socialization and improved supervision are crucial. Meanwhile, social and cultural acceptance of smoking is considered as an essential factor that hampers the implementation of the smoke free law.

Why is tobacco control progress in Indonesia stalled? - a qualitative analysis of interviews with tobacco control experts.

BACKGROUND: Indonesia shoulders a significant tobacco burden, with almost two million cases of tobacco-related illnesses and more than two hundred thousand tobacco-related deaths annually. Indonesian tobacco control is progressing but lags behind other countries. Our study evaluates factors that contribute to the slow progress of tobacco policy change in Indonesia from the perspective of tobacco control experts (TCEs). METHOD: We conducted qualitative interviews with four international and ten national TCEs, who have been active in tobacco control for at least 5 years. Our interview guideline included questions on the current tobacco control situation in Indonesia and explored reasons why tobacco control is progressing so slowly. The interviews were conducted either in English or Bahasa Indonesia, recorded and then transcribed verbatim. We conducted a thematic analysis based on five core causal factors for policy adoption: institutions, networks, socio-economic factors, agendas and ideas. RESULTS: The multistage delay of tobacco policy adoption is principally due to political structures and policy hierarchy, complex bureaucracy, unclear roles and responsibilities, and a high degree of corruption. The low bargaining position and lack of respect for the Ministry of Health also contributes. There are contrasting frames of tobacco as a strategic economic asset and tobacco control as a sovereignty threat. There is an imbalance of power and influence between well entrenched and resourced tobacco industry networks compared to relatively young and less established tobacco control networks. The policy agenda is likely influenced by the privileged position of tobacco in Indonesia as a socially acceptable product with high consumption. There are constraints on transferring ideas and evidence to successful policy adoption. CONCLUSION: Tobacco companies have substantially influenced both policy decisions and public perceptions, signifying a power imbalance within the government system and broader networks. Acceding to and enforcing the World Health Organization- Framework Convention on Tobacco Control (WHO-FCTC) would enable the Indonesian government to shift the power imbalance towards public health stakeholders. Tobacco control advocates must enhance their network cohesion and embrace other community groups to improve engagement and communication with policymakers.

Physical activity interventions for adults who are visually impaired: a systematic review and meta-analysis.

OBJECTIVES: Compared with sighted individuals, people with visual impairment have a higher prevalence of chronic conditions and lower levels of physical activity. This review aims to systematically review physical activity interventions for those with a visual impairment and to assess their effectiveness. DESIGN: A systematic review of articles reporting physical activity interventions in visually impaired individuals was conducted. Medline, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus and the Physiotherapy Evidence Database were searched in August 2018. Meta-analyses were conducted on randomised controlled trials with the same outcome measure. SETTING: Most interventions were conducted in a group setting, with some including an at-home, self-directed component. PARTICIPANTS: Following identification of a recent systematic review of physical activity interventions in children, our review focused on adults aged 18 years and older with a visual impairment. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes included measures of balance, mobility, mental well-being (eg, quality of life), number of falls, muscle strength, flexibility and gait. RESULTS: Eighteen papers from 17 studies met inclusion criteria. Physical activity components include falls prevention and/or balance-based activities, walking, tai chi, Alexander Technique, Yoga, dance, aerobics and core stability training. Significant results in favour of the intervention were reported most commonly in measures of functional capacity (9/17 studies) and in falls/balance-related outcomes (7/13 studies). The studies identified were generally small and diverse in study design, and risk of bias was high across several categories for most studies. Meta-analyses indicated non-significant effects of the included interventions on the Timed Up and Go, Chair Sit Test and Berg Balance Scale. CONCLUSIONS: Physical activity interventions in individuals with visual impairment incorporating activities such as tai chi, Yoga and dance can have positive results, particularly in physical measures such as mobility and balance. However, when performing a meta-analysis of randomised controlled trials, the evidence for effectiveness is less clear. More studies with larger sample sizes, stronger designs and longer follow-up periods are needed. PROSPERO REGISTRATION NUMBER: CRD42018103638.

From glass boxes to social media engagement: an audit of tobacco retail marketing in Indonesia.

OBJECTIVE: To assess tobacco promotion intensity, retailer behaviours and tobacco company efforts to link retailer marketing to online channels. METHODS: We completed an audit of tobacco advertisements and promotions at 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia that included an observation checklist, digital photos and structured interviews with retailers. We then calculated the tobacco promotion index for each retailer and made comparisons based on store types. Next, we conducted a photo analysis from 100 randomly selected retailers to explore links to online channels and other promotional cues to engage young people. RESULTS: Mini-markets have both the highest total number of promotions and the highest indoor promotion index with a mean score of 5.1 and 3.7, respectively. Kiosks have the highest outdoor promotion index with a mean score of 1.6. Most of the retailers (98.9%) displayed cigarettes, more than half of kiosk retailers (54.8%) and mini-market retailers (56.3%) admitted selling cigarettes to young people, and 74% of kiosk retailers sell single stick cigarettes. We found links to online marketing, including two hashtags and a company website. Promotional materials also included youth-focused content such as English taglines, new products and small packs. CONCLUSION: Tobacco companies in Indonesia have strategically differentiated their advertisements based on retailer type and have bridged conventional retailer marketing to online channels. Reforming Indonesian tobacco laws to include bans on single sticks and small pack sales, point-of-sale advertising, including displays, and enforcement of laws on sales to minors is urgently required.

Raising generation 'A': a case study of millennial tobacco company marketing in Indonesia.

OBJECTIVE: To describe the Sampoerna A [A] brand marketing techniques and practices and how event-based sponsorship leverages company websites and popular social media channels to reach and engage young people. METHOD: This case study was built from three main data sources. First, HM Sampoerna company reports, corporate websites and other online sources were reviewed. Second, four pairs of observers conducted an observation survey; systematically auditing and documenting tobacco promotion and advertising at the 2016 SoundrenAline concert. Finally, social media data were obtained from an iterative search of hashtags of Instagram posts. The 10 most frequently used hashtags related to the concert were reviewed and documented. RESULTS: A brand marketing includes sponsorship of a music concert series, a limited edition A Mild cigarette package and promotion of virtual events on company websites and social media channels. Instagram boosted promotion with more than 25 000 posts for the two most popular hashtags endorsed during the concerts. Marketing activities targeted young people by focusing on creativity, freedom of expression and audience engagement. The corporate website 'goaheadpeople.id' served as both a promotional medium and online community. CONCLUSION: Internet and social media channels are key to Sampoerna's marketing strategy in Indonesia. Internet-based marketing run alongside conventional advertising likely increases Indonesian youth exposure to cigarette marketing. This case study also provides evidence that Sampoerna evaded current tobacco advertising regulations. Subnational governments can play a stronger role in restricting tobacco advertising, promotion and sponsorship by more effectively enforcing current regulation.

Factors Associated with Participation in Pulmonary Tuberculosis Screening Using Chest X-Ray among Diabetes Mellitus Type II Patients in Denpasar, Bali, Indonesia.

Diabetes mellitus (DM) increases the risk of developing pulmonary tuberculosis (TB) disease. Therefore, pulmonary TB screening among DM patients is essential. This study aimed to identify factors associated with participation of DM type II patients in pulmonary TB screening using chest X-ray. This was a cross-sectional analytic study and was part of TB-DM screening study in Denpasar, Bali, Indonesia. The sample consisted of 365 DM type II patients selected by quota sampling among DM type II patients joining the screening program from January until March 2016 in 11 public health centres in Denpasar. Data were collected via structured interviews. The contributing factors were determined by modified Poisson regression test for cross-sectional data. From the findings, less than half (45.48%) of DM type II patients participated in chest X-ray examination for TB. Factors associated with participation in pulmonary TB screening were having a higher educational level [APR = 1.34, 95% CI (1.07-1.67)], having family member who developed pulmonary TB disease [APR = 1.47, 95% CI (1.12-1.93)], the travel time to referral hospital for screening being ≤ 15 minutes [APR = 1.6, 95% CI (1.26-2.03)], having health insurance [APR = 2.69, 95% CI (1.10-6.56)], and receiving good support from health provider [APR = 1.35, 95% CI (1.06-1.70)]. Therefore, training for health provider on providing counselling, involvement of family members in screening process, and improving the health insurance coverage and referral system are worth considering.

"It is merely a paper tiger." Battle for increased tobacco advertising regulation in Indonesia: content analysis of news articles.

OBJECTIVE: At the end of 2012, the Indonesian government enacted tobacco control regulation (PP 109/2012) that included stricter tobacco advertising, promotion and sponsorship (TAPS) controls. The PP did not ban all forms of TAPS and generated a great deal of media interest from both supporters and detractors. This study aims to analyse stakeholder arguments regarding the adoption and implementation of the regulation as presented through news media converge. DESIGN: Content analysis of 213 news articles reporting on TAPS and the PP that were available from the Factiva database and the Google News search engine. SETTING: Indonesia, 24 December 2012-29 February 2016. METHODS: Arguments presented in the news article about the adoption and implementation of the PP were coded into 10 supportive and 9 opposed categories. The news actors presenting the arguments were also recorded. Kappa statistic were calculated for intercoder reliability. RESULTS: Of the 213 relevant news articles, 202 included stakeholder arguments, with a total of 436 arguments coded across the articles. More than two-thirds, 69% (301) of arguments were in support of the regulation, and of those, 32.6% (98) agreed that the implementation should be enhanced. Of 135 opposed arguments, the three most common were the potential decrease in government revenue at 26.7% (36), disadvantage to the tobacco industry at 18.5% (25) and concern for tobacco farmers and workers welfare at 11.1% (15). The majority of the in support arguments were made by national government, tobacco control advocates and journalists, while the tobacco industry made most opposing arguments. CONCLUSIONS: Analysing the arguments and news actors provides a mapping of support and opposition to an essential tobacco control policy instrument. Advocates, especially in a fragmented and expansive geographic area like Indonesia, can use these findings to enhance local tobacco control efforts.

Mortality among people living with HIV on antiretroviral treatment in Bali, Indonesia: incidence and predictors.

Indonesia has the third highest number of people living with HIV/AIDS (PLWH) and the greatest increase in proportion of AIDS-related mortality in the Asia Pacific region between 2005 and 2013. Longitudinal mortality data among PLWH in Indonesia are limited. We conducted a retrospective cohort study from medical records of antiretroviral treatment (ART) recipients attending Badung General Hospital (BGH) and Bali Medica Clinic (BMC) between 2006 and 2014. We explored incidence of mortality by Kaplan-Meier analysis and identified predictors using a Cox proportional hazard model. In total, 575 patients were included in the analysis; the majority were male. The overall mortality rate was 10% per year. Multivariate analysis suggested that being male (adjusted hazard ratio [aHR]: 2.74; 95% confidence interval [CI]: 1.34-5.59), having a lower education (aHR: 2.17; 95%CI: 1.31-3.61), having heterosexual (aHR: 7.40; 95% CI: 2.61-21.00) or injecting drug use (aHR: 13.20; 95% CI: 3.17-55.00) as the likely transmission risk category, starting treatment with low CD4 cell counts (aHR: 3.18; 95% CI: 1.16-8.69), and not having a treatment supervisor (aHR: 4.02; 95% CI: 2.44-6.65) were independent predictors of mortality. The mortality was high, particularly in the first three months after initiating ART. These findings highlight the need to encourage HIV testing and early diagnosis and prompt treatment. Applying aspects of BMCs targeted HIV services model in more generalised services such as BGH may be beneficial. Providing adherence support as part of ART services is key to promoting adherence to ART.