Developing a smoke free household initiative: an Indonesian case study
Mimi Nichter, School of Anthropology, University of Arizona, Emil Haury Building, Tucson, Arizona, USA. E-mail: MimiN@u.arizona.edu
Little research has focused on women's exposure to secondhand smoke (SHS) in LMICs, local perceptions of SHS risk to women and children, and women's attempts to limit exposure to tobacco smoke in their households. This paper describes a community based survey in Indonesia that investigated these issues as one step in a movement to initiate community wide household smoking bans. The survey found high levels of exposure to SHS, high levels of awareness among both women and men that SHS placed women and children at risk for illness, a very low percentage of households having indoor smoking rules, great interest on the part of women to participate in a communitywide ban, and a promising level of male smoker agreement to comply with such a ban. Women expressed a low sense of self efficacy in individually getting their husbands to quit smoking in their homes, but a strong sense of collective efficacy that husbands might agree to a well-publicized and agreed-upon community household smoking ban. Men and women expressed concern about the social risk of asking guests not to smoke in their homes without a communitywide ban and visible displays communicating their participation in this movement. The smoke free initiative described requires the participation of doctors in community education programs, and is attempting to introduce household smoking bans as a way of turning tobacco control into a family health and not just a smokers' health issue.
Indonesia is a major grower and exporter of tobacco and is the fifth largest market for tobacco consumption in the world. Recent survey data reveal that 65% of Indonesian men and 4% of women are smokers (1). It is estimated that tobacco-related mortality accounts for 10% of total deaths in Indonesia. Tobacco companies are politically and financially powerful in Indonesia because they are the largest source of government revenue after oil, timber, and gas and are the second largest employer in the country (2, 3). Because of the economic value of tobacco and the industry's powerful political connections, Indonesia has minimal anti-smoking policies and regulations. Notably, it is the only country in the Asia Pacific region that has not signed or ratified the World Health Organization's (WHO) Framework Convention on Tobacco Control. At the local level, tobacco companies have a highly visible presence and are firmly entrenched in both rural and urban communities. Tobacco companies routinely advertise their brands, supply small shops with signboards framed with company logos, and hold community banner contests where winners are provided funding for community activities (3).
A tobacco control movement has begun to mobilize in Indonesia. We report on one project that is attempting to promote smoke free households. Given the high prevalence of smoking in Indonesia and the lack of legislation banning smoking in public places, there is little doubt that women and children have frequent exposure to secondhand smoke (SHS) across the lifespan. An estimated 97 million Indonesians, 43 million of whom are children, are regularly exposed to environmental tobacco smoke in their homes (4, 5). Little is known about SHS exposure during pregnancy and postpartum.
In this brief report, we describe the ongoing development of a smoke free household initiative in Java, Indonesia. This initiative is being promoted by Quit Tobacco International (QTI), a tobacco control project based in India and Indonesia that is engaged in both clinic- and community-based tobacco education and cessation programs (6, 7). We present findings from a recent survey that is part of our ongoing formative research documenting the frequency of SHS exposure to women and children, attitudes toward SHS, knowledge of health risks, and willingness to participate in a community smoke free household campaign. This collection of baseline survey data was a first step in engaging communities in dialogue about SHS and mobilizing tobacco control activities as a public health measure benefiting women and children.
The survey was carried out in six communities in Yogyakarta, Java between December 2008 and July 2009. Communities that had active women's groups were selected for participation. Households were selected for inclusion if both a husband and wife resided there, they had been resident in the community for at least one year, and if the husband was a current smoker. Based on these criteria, 530 households out of 864 were eligible for inclusion in the sample. In each household, husband and wife were interviewed separately. In this report, we primarily discuss data drawn from the surveys among women.
All households in the study communities agreed to participate in the survey. Of the 864 households meeting study criteria, over 60% had a husband or other male family member who currently smoked. Among smokers, the average number of cigarettes smoked per day was 10. Of these, an average of four were smoked inside the house. Seventy percent of women reported that they were sometimes or often exposed to SHS smoke in their household. We queried as to whether there were any household rules against smoking. Eighty-five percent of women having a smoker in the household reported that there were no such rules in their home. Among the 15% who had rules, the most common rule was that smoking was only allowed in one room of the house, a room which sometimes contained a fan. In other homes, the rule was that the husband could not smoke in the house, but could do so right just outside the front or back door. Women with household rules noted that when guests came to their home it was not comfortable for them to impose smoking restrictions given that smoking is viewed as a normative part of Indonesian male culture (7).
Seventy percent of women surveyed disapproved of their husband's smoking inside the home and two thirds had directly asked their husband not to do so. When asked if these requests were heeded, women laughed and noted that their concerns were largely ignored. Notably, none of the women specifically asked their husbands to abstain from smoking around them while pregnant. With regards to awareness about the harm of SHS, about one-quarter of women reported that exposure to smoke could cause a mild illness, while two-thirds reported that SHS could cause serious illnesses. Knowledge about which illnesses were associated with SHS other than respiratory problems was limited and women expressed interest in learning more about children's illnesses caused by SHS exposure.
When asked if they would be willing to participate in a smoke free household ‘communitywide’ initiative, almost 90% of women said they would support such a program in their place. This overwhelmingly positive response shows the importance of mobilizing a smoke free household movement that focuses on the community as the unit of action first, and then seeks the support of individual households. Following social norms and adhering to a collective ethic is important in Indonesia. When asked if women would be willing to paste a sticker on their front door supporting the community smoking ban, over 85% of women responded enthusiastically that they would be happy to do so.
We asked women if they thought their husbands would agree to abstain from smoking inside the house if there was a community initiative to do so. Over one-half of wives responded that they thought that their husband would comply, 35% responded he would not, and 14% were unsure how their husbands would react to such a request. When we surveyed husbands who smoked, 68% responded that they would not smoke in their homes if a communitywide ban was agreed upon by community leaders. Importantly, the men's positive response was gathered before Project QTI initiated an educational program for men about the harm of SHS exposure to women and children. One would hope that after educational programs raised consciousness about SHS, more men would be willing to agree. Women in all the communities recommended that an educational program for men be introduced into the community and saw this as an important step in the process of developing smoke free households.
Another noteworthy survey finding among male respondents was that 75% recognized that SHS might be harmful or very harmful for the health of women and children, although they were not sure how much exposure was deemed excessive and what illnesses might be caused by such exposure. Many men were under the impression that smoking near a fan or in a room with an open window constituted an effective way of reducing risk. Like women, men expressed concern about social risk to relationships (8) if they introduced an individual smoking ban in their homes given the commonality of smoking among friends and relatives. However, some voiced the opinion that a communitywide ban, presented as a new norm of acceptable behavior, might lead guests to comply with the ban if it were posted prominently, and outside smoking areas were clearly demarcated.
The survey data reported in this paper speak to Javanese womens' support for a smoke free household initiative. The prevalence of SHS exposure reported in this study (70%) is probably underreported, as most women's self reports of SHS exposure are based on their exposure to visible smoke, and not the environmental smoke, which travels and lingers within confined spaces. Women were aware of the harm of SHS to themselves and their children, but felt powerless to alter their husband's smoking behavior in the household. Few women reported household smoking rules (15%) and those that did spoke of them as largely ineffective. In some cases, rules went into effect when a man was ill, but not when a woman was pregnant or breastfeeding.
Although women expressed little, if any, self efficacy to change smoking behavior among the men in their own households, they did voice the opinion that a communitywide ban might work. In other words, they entertained the possibility of mobilizing a form of collective efficacy that is more than just the sum of individual women's efficacy levels within their community. And as Bandura (9) has noted, a sense of collective efficacy can influence the effort, persistence, and performance of the group. Project QTI is engaged in fostering smoke free home collective efficacy through community meetings with both women and men, and framing household smoking bans as an expression of collective responsibility and cultural pride. Formative research has led us to believe that the best way of encouraging a no-smoking norm in the home is by framing SHS as a family health issue and an act of caring for one's family, which is an important Javanese value.
Survey results indicate that while a majority of men voice some degree of support for a household smoking ban, they are concerned about social risk, that is, risk to routine harmonious social relations. They described the difficulty of asking one not to smoke since it is considered to be a valued form of sociality and gift exchange. One reason men and women enthusiastically endorsed putting no-smoking stickers on their front doors is because it announces to outsiders a new set of social norms. A communitywide ban with signage would provide them with a non-confrontational means of dealing with an uncomfortable cultural situation.
Project QTI is in the process of initiating further steps in its smoke free household campaign in Indonesia as well as in India. We have taken up this campaign as an extension of our broad-based work on smoking cessation. We believe that it is important to engage in smoking cessation both at the level of ‘social spaces’, where women and children are affected by SHS, and at the level of individual smokers. This stance merges the agenda of tobacco control and maternal and child health and calls for a gender and family centered approach to SHS.
Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.