Purpose and objectives
The Bill and Melinda Gates Foundation commissioned Tulodo to undertake research to inform the design of a social marketing program to impact knowledge, attitudes, perceptions, and behaviors to help Indonesia reduce tobacco use among 12-18 year-olds. The study aims to explore the daily lives of young people in Jakarta – to understand their spheres of influence, challenges, and aspirations, including media access and exposure to tobacco marketing, in order to determine the priority groups with the highest potential impact.
Adolescence is the critical phase of life between childhood and adulthood – approximately age 10 to 19 years – affecting current and future wellbeing (Sawyer et al., 2012; WHO, 2014). In 2022, 68.82 million Indonesians identified as youth (24% of the population). In 2045, youth are expected to be the generation to achieve “Golden Indonesia”. However, young Indonesians continue to face economic and social challenges, including health issues. Smoking is a significant contributor to NCDs (WHO, 2022). In Indonesia, approximately 34.5% or 70.2 million adults use tobacco products – 65.5% of men are smokers, in contrast to 3.3% of women. Smoking is on the rise in Indonesia among youth aged 13- 15 years, from 11.8% in 2006 to 19.2% in 2019. Health expenditures related to smoking amount to USD 1.2 billion per year, and another USD 6.8 billion in indirect economic costs (Audrine, 2020). Indonesia is yet to ratify the WHO Framework Convention on Tobacco Control. Big tobacco spends between US$500 million and $1 billion annually on marketing in Indonesia. Indonesian political and business leaders promote policies to expand the tobacco industry, including export of products like electronic and vapor-based tobacco (Riri, 2023).
This formative research uses a mixed-method approach to analyzing data in order to produce recommendations for social marketing programs to address smoking among young people. Data collection methods were quantitative surveys, combined with qualitative interviews with various stakeholders (young people, parents, teachers, other relevant stakeholders), focus group discussions with young people, and video voice with young people.
For the survey, a total of 1,278 young people aged 12-18 years participated from 40 schools in Jakarta. For the interviews, a total of 60 respondents participated from youth groups, community leaders, parents, teachers, and tobacco sellers. An additional 80 respondents from junior and high schools in Jakarta participated in the FGDs.
A total of 1,278 students participated in the survey, with 51.17% (654 respondents) from junior high school and 48.83% (624 respondents) from senior or secondary high school. The majority of respondents came from government junior high schools, comprising 30.15% male and 24.84% female students.
Based on age, respondents ranged from under 13 to over 18 years old. The majority fell between 14 and 17 years old. In the junior high school category, ages ranged from under 13 to over 15 years (27.96% at 13 years old, 43.32% at 14 years old, and 19.66% at 15 years old). Meanwhile, senior high respondents were between 14 and over 18 years old (10.37% at 15 years old, 39.07% at 16 years old, 33.81% at 17 years old, and 13.08% at 18 years old).
A total of 1,212 (94.84%) respondents lived with their parents, while the remaining respondents lived with siblings (1.64%, n:21), other relatives (1.17%, n:15), friends (1.25%, n:16), and only 0.63% (n:8) lived alone. Also, 89.44% (n:144; non-smokers: 95.61%) of smokers lived with their parents, 4.35% (n:7; non-smokers: 1.25%) lived with siblings, and the rest lived with friends (1.24%; n:2; non-smokers: 0.36%), alone (1.24%; n:2; non-smokers: 0.54%), and other relatives (0.62%; n:1; non-smokers: 1.25%).
A total of 951 respondents (74.41%) could access smartphones to use the internet, social media, and online games, while 71.13% (n:909) had a TV and 38.81% (n:496) had a laptop. There was a significant difference between smartphone ownership (p-value=0.037), TV (p-value=0.001), and laptop (p-value=0.001) by smoking status. 67.70% smoker respondents stated there were smartphones in their house (n:109; non-smokers: 75.38%) and 27.33% had laptops (n:44; non-smokers: 40.47%).
Young people’s passions, daily lives and aspirations
Figure 5a shows more smokers preferred sports (77.64%) and online games (66.46%) compared to the non-smokers group (65.53% and 65.89%). Only 33.54% of smokers had a passion for food compared to 58.64% non-smokers.
Young people had various passions which consisted of sports (67.06%; n:857; f:38.62%, m:61.38%), music (63.54%; n:812; f:57.51%, m:42.49%), online games (57.59%; n:736; f:29.21%, m:70.79%), food (55.48%; n:709; f:56.70%, m:43.30%), and traveling (50.39%; n:644; f:49.30%, m:50.70%). 77.76% of boys liked online games while only 35.36% of girls. Girls were more likely to like art (40.63%) and fashion (25%) compared to boys.
Outside school, activities were physical exercise (44.13%, n:564), hanging out with friends (42.10%, n:538), read non lesson book (21.52%, n:275), and hang out with their partner (12.75%, n:163). Late night activities included scrolling social media (75.12%, n:960), chatting in social media (69.09%, n:883), listening to music (64.87%, n:829), playing online game (46.64%, n:596), and browsing the internet (41.86%, n:535). 40.61% (n:519) of the respondents sometimes studied at night. Only 35.68% (n:456) sometimes ate out and 22.46% (n:287) hung out.
The study also explored factors contributing to young people’s stress. The following is the level of anxiety based on the problem they experienced. Skin problems (44.99%; n:575; f:62.43%, m:37.57%) and dental caries (35.29%; n:451; f:56.54%, m:43.46%) contributed to severe anxiety the most. Girls were more likely to mention skin problems as the main factor (28.09%, n:359) compared to boys (16.90%, n:216). Girls were also more likely to report bullying as a contributing factor to anxiety (8.61%, n:110) compared to boys (5.24%, n:67).
Of the respondents, 75.35% (n: 963; f:81.09%, m:70.15%) stated that their friends influenced their way of thinking, either positively (47.87%, n: 461), negatively (3.63%, n: 35), or both (48.49%, n: 467). Additionally, 33.72% (n: 431) of respondents mentioned that they had succumbed to peer pressure, with 77.49% (n: 334) reporting instances of doing things they didn’t want to do. Female respondents (81.09%) were more likely to have friends who influenced their thinking compared to males (70.15%).
Based on the figure 8B, peer pressure was a lower influence among smokers (27.95%; n:45) than non-smokers (34.56%; n:386). Only 17.39% (n:28; non-smokers:27.39%) of smokers did things when they didn’t want to.
71.55% (732 respondents) declined a cigarette when offered, while 10.17% (104 respondents) accepted and smoked it. Of those who accepted and smoked, 19.70% (132 respondents) were male, and 2.47% (15 respondents) were female.
Internet browsing and social media were the most commonly used by young people (more than 97%). YouTube (98.12%; n:1254), Instagram (91.39%; n:1168), and TikTok (89.74%; n:1147) were the most popular applications. The most frequently used platforms (more than two hours per day) were TikTok (63.46%, n:811), online streaming music (44.37%, n:567), online streaming games (42.80%, n:547), and Instagram (40.16%, n:512).
The most frequent social media activities were scrolling (85.29%) and chatting (67.68%).
Sphere of influence
The most (extremely and very) influential actors in young people’ lives were parents (92.96%, n:1,188), teachers (81.85%, n:1,046), religious actors (74.18%, n:948), and peers (58.53%, n:746).
Smoking among young people
12.60% (n:161) reported they currently smoke while 87.40% (n:1,117) identified as non-smokers (including 17.84% as ex-smokers). 95.03% (n:153) of current smokers identified as boys.
70.81% (n:113) of smokers were senior high school students.
Of current smokers, 55.00% (n:88; f:25%, m:56.21%) smoked regularly everyday or most days. The rest smoked occasionally at least once a week (26.25%; n:42; f:25%, m:26.14%) and less than once a week (18.75%; n:30; f:50%, m:16.99%). The average smoked per day was 2-6 cigarettes. Girls were more likely to be a non-smoker as only 6 girls said they smoked. 75% (n:4) of girls smoked occasionally, only 25% (n:2) smoked regularly. For boys, 56.58% (n:86) smoked regularly.
Based on education level, 53.19% (n:25) smoked regularly from junior high school and 55.75% (n:63) from senior high school.
83.85% (n:135; f:25%, m:86.93%) of smokers preferred “white” (not flavored) cigarettes. Most female smokers (75%; n:6) usually smoked flavored cigarettes such as fruit or menthol. Flavored cigarettes were the second most preferred by smokers (40.37%; n:65; f:75%, m:38.56%), while the third and fourth option were e-cigarettes (21.12%; n:34; f:12.50%, m:21.57%) and kretek (clove) cigarettes (18.01%; n:29; f:0%, m:18.95%). Respondents who smoke e-cigarettes are dual smokers (smoke cigarettes too). Figure 16 shows the distribution and frequency of the types of tobacco products consumed.
We found 80.75% (n:130; f:87.50%, m:80.39%) of smokers purchased cigarettes from shops or sellers. Of those who bought cigarettes from a seller, 89.23% (n:116; f:57.14%, m:91.80%) purchased them at a small shop near their house, 23.85% (n:31; f:0%, m:25.41%) at a small kiosk around the school, and 37.69% (n:49; f:71.43%,m:36.07%) at minimarkets.
90.77% (n:118; f:42.86%,m:94.26%) bought single cigarettes, 69.23% (n:90; f:71.43%,m:69.67%) bought a pack, 6.15% (n:8; f:0%, m:6.56%) bought tobacco and rolled their own, and 3.85% (n:5; f:0%, m:4.10%) bought cartons.
Smoking Knowledge, Attitude, and Behavior
Knowledge was assessed by asking respondents to rate 20 statements as true/false, with answers scored as a total percentage correct. The respondents had quite good knowledge regarding the dangers of smoking from a health standpoint. Several things that the respondents did not understand were precisely in terms of tobacco product and variation such as electronic cigarettes, vapor, kretek vs white cigarettes, low-tar cigarettes.
According to Figure 19, 71.99% (n: 920) of respondents both agree and strongly agree that smoking cigarettes would be harmful to their health. Additionally, 65.41% (n: 836) of respondents agree and strongly agree that there are cool people who do not smoke. Despite this, the respondents’ attitudes toward smoking cigarettes did not associate it with coolness, as 68.86% (n: 886) agreed and strongly agreed. They also did not believe that girls who smoke cigarettes are more attractive (66.75%; n: 853), that smoking makes them confident (65.10%; n: 832), or that smoking cigarettes is enjoyable (61.43%; n: 785). Furthermore, they expressed no excitement about tobacco advertisements (63.69%; n: 814).
Most of the smoker respondents smoked with friends (68.94%; n:111; f:75%, m:68.63%), alone (50;31%; n:81; f:25%, m:51.63%), or with their family (5.59%; n:9; f:0%, m:5.83%). 75% (n:6) of female smokers smoked with friends and none with family.
A total of 71.75% (n:734) said they were unlikely or very unlikely to smoke in the next 12 months, while 9.97% (n:102) was likely, very likely, or certain to be a smoker. There were significant differences regarding intention to smoke based on gender (p-value=0.000), living with smokers (p-value=0.000) and smoking status (p-value=0.000). Boys were more likely to smoke next year (17.90%; n:119) compared to girls (2.8%; n:17). Those who live with smokers are more likely to start smoking and become smokers themselves.
We found 44.72% (n:72; f:75%, m:43.14%) of smokers had never tried to give up, while 53.42% (n:86; f:25%, m:54.90%) tried to give up and were successful for only one month.
Looking at efforts to quit, 34.16% (n:55; f:50%, m:33.33%) had the self motivation to quit smoking, 27.33% (n:44; f:25%,m:27.45%) refused offers to smoke, 18.01% (n:29; f:12.50%,m:18.30%) replaced cigarettes with candy, and 17.39% (n:28; f:12.50%,m:17.65%) avoided exposure to secondhand smoke.
Factors that helped smokers to quit were mostly related to health. Prompts came from various channels, such as text-warnings on cigarette packaging (text form 39.47%; n:90; f:39.66%, m:39.41%) and graphic health warnings on cigarette packaging (37.28%; n:85; f:39.66%, m:36.47%), TV advertisements (21.49%; n:49; f:17.24%, m:22.94%) and other media (17.11%; n:39; f:24.14%, m:14.71%). Many were motivated by their own health (40.79%; n:93; f:48.28%, m:38.24%), wanted to be fit (32.02%; n:73; f:29.31%, m:32.94%), or got advice from the doctor (9.21%; n:21; f:10.34%, m:8.82%), and others had concerns about the health of those around them (34.21%; n:78; f:32.76%, m:34.71%). 19.63% quit smoking because of the cost (7.46%; n:49) and social reasons (12.18%; n:80) such as family (12.72%; n:29), peers (7.89%; n:18), and knowing someone who stopped smoking (10.09%; n:23).
Tobacco advertising and promotion
We found 51.03% (n:522; f:25.74%, m:25.82%) of respondents noticed tobacco advertising or promotions in the last 30 days. Here are the ads that they have seen. TV was the type of advertisement seen most (41.31%; n:528; f:8.39%, m:71.19%) in the last 30 days. Next was billboard or banner advertising (21.36%; n:273; f:3.95%, m:37.16%), internet (18.15%; n:232; f:5.43%, m:29.70%), and point of sales (16.82%; n:215; f:2.96%, m:29.40%). 4.15% (n:53; f:1.32%, m:6.72%) of respondents had received free samples of cigarettes and 0.94% (n:12; f:0.33%, m:1.49%) had found advertisements for other products that provided free gifts or discounts when buying cigarettes.
TV was also the most common media where smokers saw tobacco ads (31.68%), while banners on the internet were the second most common (20.50%).
Social media posts were the most common form of tobacco sponsorship that the respondents saw related to tobacco promotion, followed by movies or magazine pictures, music concerts, sports events, community events, and education events. Concerts or music events were the second most common (29.29%) type of tobacco promotion observed by smoker respondents.
Mapping tobacco marketing around schools.
There were a total of 434 cigarette advertisements and 899 cigarette sellers found near the 40 schools studied. The types of advertisements vary, but most common are banner (265), posters (152) and infographics (4). Cigarette advertisements based on the nearest location to the schools are as follows: posters (8.09 meters), banners (18.09 meters), others (18.9 meters), and infographics (118.3 meters). According to the distance category of cigarette advertisements from schools, the majority of cigarette advertisements were located within the distance of 100-250 meters (77.8%), followed by the 50-100 meters category (17.2%) and only 5% of the less-than-50-meters category (see Table 2). The cigarette advertisement with the highest density in the study area was the cigarette banners (33.75 per sqkm), followed by cigarette posters (19.36 per sqkm), other cigarette advertisement (1.65 per sqkm), and infographic cigarette advertisement with 0.5 per sqkm.
There were 899 cigarette outlets collected in this study. The cigarette outlets consist of warung/shops (783), minimarkets (61), street vendors (20), supermarkets (4), markets (1), warehouses (3), and other outlets (27). Cigarette outlets based on the nearest location to the schools as follows: warung/shop (10.1 meters), minimarket (13.2 meters), street vendor (22.6 meters), other retailer (22.6 meters), markets (26.4 meters), supermarkets (70.4 meters), dan warehouse (141.6 meters). According to the distance category of cigarette outlets from schools, the majority of cigarette outlets were located within the distance of 100-250 meters (76.1%), followed by the 50-100 meters category (17.3%), and only 6.6% of the less-than-50-meters category. The cigarette sellers with the highest density in the study area was the warung/shop (99.74 per sqkm), followed by minimarket (7.77 per sqkm).
Tobacco Health Warning
When it comes to smoking status, graphic health warnings are seen by more smokers (68.91%) than non-smokers (64.65%). However, tobacco health warnings on billboards, no smoking signs, and anti-tobacco videos are seen more by non-smokers than by smokers.
We found 80.59% (n:1030) of respondents had noticed tobacco health warnings in the last 30 days. These included graphic health warnings on cigarette packing (65.15%; n:671; f:65.63%, m:64.67%), billboards (16.60%; n:171; f:15.63%, m:17.57%), no smoking signs (24.56%; n:253; f:27.15%, m:22.01%), and videos with anti-smoking messages (10%; n:103; f:8.40%, m:11.58%).
48.98% (n:626) had negative views of the marketing from tobacco companies and 42.18% (n:539) did not determine their views. As many as 72.69% (n:929) of respondents thought the government should put warnings on tobacco products. As many as 51.56% (n:312) of respondents felt scared when they saw a picture message on cigarette packs about the dangers of smoking.
Tobacco Control Campaign
37.01% (n:473; f:40.30%, m:34.03%) stated that graphic health warnings on cigarette packaging were the most effective in preventing smoking. However, there were 16.98% (n:217; f:16.94%, m:17.01%) of respondents who stated that there was no effective campaign to prevent smoking.
Exposure to tobacco control campaigns was primarily through graphic health warnings for both smoker and non-smoker groups. However, 24.22% of smoker respondents believed that there were no effective campaigns.
Segmentation of young people on smoking behaviors
Segmentation is the grouping of people according to similar characteristics with the aim to tailor interventions to each one. In social marketing, segmentation is based on the intensity of the behavior being addressed. We conducted segmentation based on (1) smoking behavior status (current smoker vs non smoker); (2) smoking intention (have intention, non decider, don’t have any intention to smoke); (3) smoking cessation behavior (peer influence related to smoking cessation, ever, never); and (4) knowledge related to tobacco (low, moderate, good knowledge). Based on the combination of these four characteristics, a total of 36 groups were produced, then we grouped and classified them into five segments as follows.
A. Champions: non-smokers with no intention to smoke; had tried to stop a friend from smoking; have good knowledge related to tobacco (24.51%).
B. Passive majority: non-smokers with no intention to smoke or not smoke (58.81%).
C. Wannabe smoker: non-smokers with intention to smoke (4.07%).
D. Indecisive smokers: smokers with no intention or undecided whether to smoke (6.02%).
E. Fanatics: smokers with clear intention to continue smoking (6.58%).
Among the respondents, the ‘Champion’ group (24.51%; n: 313) was classified as such due to their current behaviors and future plans. They neither smoke nor have any intention to start, and they possess good knowledge and a positive attitude related to tobacco. Champions tend to have preferences for music, education, and food compared to other segments, who show more interest in sports and online games.
The ‘Passive Majority’ (58.81%; n: 751) is categorized as such because most students in this group do not smoke, but they lack clear intentions or are undecided about smoking.
The ‘Wannabe Smoker’ category consists of non-smokers who express an intention to start smoking. Although they represent a small group (4.07%; n: 52), they are the demographic most likely to initiate smoking. They also rank highest among all segments in their interest in online games (71.15%; n: 37), education (36.54%; n: 19), and fashion (28.85%; n: 15).
The ‘Indecisive Smokers’ group is characterized by individuals who currently smoke but have no intent or are undecided about quitting. They have a moderate interest in online games (62.34%; n: 48). Their passion for art, fashion, traveling, music, and education is relatively low. Sports hold significant importance for them (75.32%; n: 58), and they are the most religious (35.06%; n: 27), with religious influence being the second highest (78.95%; n: 60).
Lastly, the ‘Fanatics’ category consists of smokers who clearly wish to continue smoking and consider it a part of their lifestyle. They exhibit the highest passion for sports (79.76%; n: 67) and the second-highest interest in online games (70.24%; n: 59), traveling (50%; n: 42), and fashion (25%; n: 21).
Based on gender, the champion group consisted mostly of girls (68.05%; n: 213), while the other group had a higher proportion of boys. The majority group had the most balanced proportions compared to other segments (male 50.20%, female 49.80%).