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Improving Implementation of Smoke-Free Laws in Low- and Middle-Income Countries: Findings from Qualitative Research in Bogor, Indonesia

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Improving Implementation of Smoke-Free Laws in Low- and Middle-Income Countries: Findings from Qualitative Research in Bogor, Indonesia IMPROVING IMPLEMENTATION OF SMOKE-FREE LAWS IN LOW- AND MIDDLE-INCOME COUNTRIES: FINDINGS FROM QUALITATIVE RESEARCH IN BOGOR, INDONESIA by M. Justin Byron, M.H.S. A dissertation submitted to Johns Hopkins University in conformity with the requirements for the degree of Doctor of Philosophy Baltimore, Maryland September 2014 © M. Justin Byron All Rights Reserved ABSTRACT As the weight of the global tobacco epidemic shifts toward low- and middle- income countries (LMIC), local and international public health advocates are working to ensure tobacco control measures are there to meet it. One element of a comprehensive tobacco control law is the implementation of policies to protect the public from toxic secondhand smoke exposure. With the signing of the World Health Organization’s Framework Convention on Tobacco Control (FCTC), 178 countries have committed to enacting smoke-free laws to protect their citizens. One country that has not signed the FCTC is Indonesia, home to 252 million people, of whom 67% of men and 2.7% of women are smokers. These 60 million smokers expose an additional 100 million nonsmoking children and adults to secondhand smoke in public and private places. While national control laws are minimal in Indonesia, in 2009, Bogor became the first Indonesian city to pass a comprehensive smoke-free law, banning smoking in all indoor public spaces. Early reports indicated that compliance with the law was mixed, with success in areas such as schools and hospitals, but low compliance in restaurants and malls. If compliance can be raised in Bogor, the city can set an example for further smoke-free laws across the country. This dissertation sought to address three specific aims: 1) to conduct a systematic literature review and create a research agenda regarding implementation of smoke-free laws in LMIC; 2) to understand the current social norms around public smoking in Bogor, Indonesia and make recommendations for how to increase compliance with the smoke-free law, using the theory of normative social behavior as a framework; and 3) to ii describe the impact of Muslim leaders’ pronouncements about smoking on compliance with the smoke-free law. The ultimate purpose of this research was to learn how to improve implementation of the smoke-free law in Bogor and gain insight into improving implementation of smoke-free laws in other parts of Indonesia and other LMIC. The dissertation begins with a literature review on implementation of smoke-free laws in LMIC. For this review, 3,894 scientific articles and 174 other publications were considered, of which 131 met the inclusion criteria. Many of the health and economic aspects of smoke-free laws in high-income countries also carry over to LMIC, that the tobacco industry aggressively resists smoke-free laws, and that a number of obstacles to successful implementation are faced in LMIC. From this review, I suggest 4 areas for research that can impact public health practice in LMIC: 1) learning how to make the most effective use of limited resources; 2) determining how to increase political will among political leaders and smoke-free law enforcement officers; 3) finding new methods to increase compliance, and 4) assembling a descriptive and instructive theoretical model for the implementation of smoke-free laws. To address aims 2 and 3, in 2012 I traveled to Bogor, Indonesia to conduct qualitative field research to learn about the implementation of the smoke-free law in Bogor and how compliance with the law might be improved. In this fieldwork from April through August 2012, working with a team of focus group facilitators and interpreters, I completed 52 interviews with city leaders and venue managers, and oversaw the conduct of 11 focus groups with 89 residents of Bogor. In these qualitative data gathering components, we asked questions about the social norms about public smoking in Bogor, perspectives on the implementation of the law, and ideas for strengthening compliance. iii The focus groups were fruitful for understanding the experiences of everyday Indonesians while the interviews provided additional perspective about the process of creating and enacting the law. In the focus groups and interviews, it was explained that smoking in public in Bogor is quite common among men and discouraged among women. It is also normal that some local laws, such as the smoke-free law, are neither strictly enforced nor routinely complied with. Using the theory of normative social behavior as a framework to understand Bogor’s norms around public smoking and setting my findings in the context of the theory of normative social behavior, I identify points of leverage to increase compliance. These include correcting any misperceptions about the frequency of violations, making salient the moral and legal requirement to follow the law, increasing the expectation of social and legal punishment for violations, and endorsing a message that an Indonesian gentleman does not smoke indoors. These findings provide possible avenues for revisions to enforcement approaches and more constructive communication efforts. Addressing the third aim, I investigated the role of religious messages on the public’s compliance with the smoke-free law. Nonsmokers said that the anti-smoking pronouncements of national Muslim organizations reinforced their nonsmoking behavior, but smokers said these pronouncements had little effect on their smoking behavior. Instead, they said it is up to individuals to decide what to do, and that it made little sense for Muslim leaders to speak about smoking if the leaders themselves still smoke in public. However some participants said that it is helpful for religious leaders to support the smoke-free law. The overall finding is that while national pronouncements have little effect, there may be a value in having conversations with local Muslim leaders to enlist iv their help in setting a positive example and encouraging their followers to comply with the smoke-free law. This dissertation presents an introduction of background information about smoke-free laws and Indonesia, proceeds with three manuscripts describing the findings in detail, and concludes with a discussion chapter covering points of synthesis and ideas for future research. Throughout these chapters, I add depth and context to the implementation of smoke-free laws in low- and middle-income countries, using Bogor, Indonesia as a lead example. Advisor David Jernigan, Ph.D., Department of Health, Behavior and Society Thesis Readers Joanna Cohen, Ph.D., Department of Health, Behavior and Society Shannon Frattaroli, Ph.D., Department of Health Policy and Management Joel Gittelsohn, Ph.D., Department of International Health Alternates Ana Navas-Acien, M.D., Department of Environmental Health Sciences Katherine Clegg Smith, Ph.D., Department of Health, Behavior, and Society v In memory of Elaine and Nisya vi ACKNOWLEDGMENTS Foremost I thank my family, including my wife Kate, my parents, and my brothers and sister for their insights and support. I also thank the professors at Johns Hopkins who mentored me along the educational path, including my master’s advisors Marc Boulay and David Abrams, my current advisor in all things advocacy and research David Jernigan, and my dissertation project advisors Joanna Cohen, Shannon Frattaroli, and Joel Gittelsohn. Thanks also to my cohort of compatriots for adding fun and inspiration to the journey. The fieldwork in Indonesia was made possible through the guidance and support of Tara Singh Bam, the Bogor City Health Department, and No Tobacco Community of Bogor. Additionally, I am grateful for the patience and perseverance of the Indonesian fieldwork team: Dhani, Maulana, Nina, Novyan, Rochmah, and Sheren. My time living in Bogor was made all the more welcoming and meaningful by the graciousness of my host family. Terima kasih! vii TABLE OF CONTENTS Abstract ............................................................................................................................... ii Dedication .......................................................................................................................... vi Acknowledgments............................................................................................................. vii List of tables ....................................................................................................................... ix List of figures .......................................................................................................................x List of plates ....................................................................................................................... xi 1. Introduction ......................................................................................................................1 2. Research methods ..........................................................................................................40 3. Smoke-free laws in LMIC: An implementation research agenda ..................................60 4. Using the theory of normative social behavior to improve compliance ........................81 5. The influence of religious organizations’ statements ..................................................108 6. Discussion ....................................................................................................................125 Appendix A. Bogor’s required smoke-free signage ..................................................150 Appendix B. Recruitment materials ...........................................................................151
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