Abstract
While studies have shown the importance of pictorial health warnings (PHW) as a tobacco control strategy, empirical evidence on the efficacy of PHW in prompting smoking behavior remains inconclusive. The study aimed to examine the association between PHW and cognitive reactions, emotional/affective reactions, and smoking behavior. We conducted a mixed-methods study, which included a cross-sectional face-to-face survey of 401 smokers in four cities (Jakarta, Bandung, Semarang, and Yogyakarta) and three focus group discussions among 24 participants in Jakarta. We applied multiple logit regression in STATA for quantitative data analysis and explanatory sequential design for qualitative data analysis. Quantitatively, we found high (63-84% of respondents) understanding about PHW objectives (cognitive reactions), including to remind health risks and encourage smoking cessation. With only 40% PHW, we found relatively low (32%-39%) negative emotional reactions, including feeling scared, annoyed and disgusted and relatively low proportions (33-40%) of respondents that reported quit attempt. Consistent with the quantitative findings, qualitative data provided contexts, including in explaining that the professional worker group was the least affected by PHW, while the student and non-professional groups were the most vulnerable. All this is supportive of governments in Indonesia and other countries to increase the PHW size.
Highlights
Indonesia, a new upper-middle-income country with a population of 268 million, had an estimated 61.4 million current smokers and over 225 thousand tobacco-related deaths in 2018 (The World Bank, n.d.; World Health Organization [WHO], 2018a)
We found a minority of participants admit that they are quite disturbed with pictorial health warnings (PHW), even though their emotion did not reach to the level of scary
Our findings showed relatively high (63-84%) understanding about PHW objectives including to remind health risks, encourage smoking cessation, or avoid smoking for non-smokers
Summary
A new upper-middle-income country with a population of 268 million, had an estimated 61.4 million current smokers and over 225 thousand tobacco-related deaths in 2018 (The World Bank, n.d.; World Health Organization [WHO], 2018a). Tobacco control efforts is still lacking in Indonesia partly because the government is reluctant to ratify the FCTC (Kusuma et al, 2019). Indonesia has implemented PHW as tobacco control policy since 2014 which requires cigarette companies to cover 40% of the front and back of cigarette packages with five different PHWs. The size of Indonesia’s PHW is among the lowest in the world compared to at least 30%-50% recommended by the FCTC and 65% recommended by the European Union (WHO, 2018b). While Timor Leste, a new country once become part of Indonesia, is currently adopting a PHW policy of 92.5%
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