STRENGTHS AND LIMITATIONS OF THIS STUDY

Representativeness of sample size and inclusion criteria used in this study enhanced generalisation of the findings throughout Banda Aceh city.

The triangulation procedure of direct in-depth interviews and document reviews used in this study enriched the quality of collected data.

Since the data analysis was carried out using translated data, some nuances of language and culture may have been overlooked.

Some of the information collected through in-depth interviews cannot be confirmed through written documents as the information was not adequately reported and documented in formal government records.

Introduction

Indonesia has neither ratified the WHO Framework Convention on Tobacco Control (FCTC) nor had a national framework for tobacco control,1 and the country accounts for the highest smoking rates in the Southeast Asia region.2–4 The country has recorded an increase of smoking prevalence among young people (adolescents aged 10–19 years) from 7.2% in 2013 to 9.2% in 2019.2 5 Ongoing high rates of tobacco smoking are associated with cardiovascular-related diseases resulting in 225 720 deaths each year in Indonesia.2 To ultimately reduce morbidity and mortality rates and protect people from tobacco use in the country, the central government (through the Health Law No. 36/2009 and Presidential Regulation No. 109/2012) has instructed all local governments to develop smoke-free areas (SFAs) within their areas since 2009.6 7 However, as of 2020, only 324 of 514 districts have enacted policies related to SFAs within their locations.8

According to Banda Aceh city Mayor’s Qanun (local regulation) No. 5/2016, SFAs are defined as the areas or places that strictly prohibit smoking, and the selling, producing, advertising or promoting of tobacco products within eight area categories including health facilities, workplaces, teaching and learning areas, children’s playing areas, worship places, public transport, public places (sites or areas that can be accessed by all people or are commonly used collectively) and sports centres.7 9 10 In contrast, Article 8, point 2 of the WHO FCTC (protection from exposure to tobacco smoke) is less specific in its conclusion that indoor or enclosed workplaces, public places and public transport were the areas that needed to be protected from exposure to tobacco smoke.11 In summary, the concept of SFAs is that the areas must be 100% smoke free, since tobacco smoke is invisible, unable to be sensed (lacking odour) and can even be immeasurable.12

Many benefits of implementing SFAs within a particular setting include the effective implementation of SFAs that can protect non-smokers and the environment from tobacco smoke exposure, diminish smoking prevalence and discourage smoking initiation among young people.11 13 Also, previous studies on effective SFA implementation in developed countries demonstrated that it diminished indoor smoking in the UK, reduced secondhand smoke (SHS) exposure in New Zealand, lowered heart diseases-related mortality in Belgium, and improved air quality in enclosed areas in European and Northern American countries.8 14 15

Further, research in developing countries revealed that there have been positive economic impacts of smoke-free policy implementation on hospitality industries (eg, there was a 24.8% increase in financial profits following the implementation of the SFA law in restaurants and bars across Mexico city).16 Also, there is an increase of public support for SFAs after the regulations are implemented.17 For example, a survey conducted in Tijuana, Mexico revealed that most adults supported smoke-free policies in public places, for example, workplaces (85%), restaurants (79%), schools (93%), health facilities (95%) and public transport (90%).13 18 In addition, although the expected 100% smoke-free air has not been achieved throughout determined SFAs within developing countries, the compliance rates for smoke-free implemented policies are relatively high and vary among different cities.13 19 20 For instance, Bogor city, Indonesia has the highest overall compliance rate (78%) among other cities in the country,21 22 while the smoke-free policy compliance rates in Bengkulu city were the highest within health facilities (67%) and education facilities (63%) among other six area categories,8 which were higher than compliance rates with similar facilities in Jayapura city (50% and 29%, respectively).23

Despite these benefits, the implementation of SFA policies still faces many challenges especially in developing countries.13 Some major challenges include the absence of a legal framework to reinforce SFA policies, low public awareness of tobacco-induced health risks, inadequate penalties for violators and inadequate smoking cessation programmes.13 20 24–27 Also, research in Bengkulu city, Indonesia reported that a lack of sensitisation, poor coordination and inadequate budget were identified as the main challenges for implementing SFAs in the city.8 Yet, research on smoke-free policy implementation in low-income and middle-income countries concluded that various potential opportunities can be used to improve the effectiveness of implementing SFA policies, including the following: strong public support for smoke-free regulations and tobacco control advocates is required; SFAs need to be free of ashtrays; enforcement focused on venue managers is more important than punishment on individual violators; the public needs channels to report violations; governments need to provide adequate financial resources; and authorities are required to establish smoke-free law enforcement agencies and establish appropriate sanctions for non-compliance.11 13 25 28 29

According to Owusu-Dabo et al,30 smoke-free regulations and awareness of health risks associated with smoking were strongly connected to values and beliefs of certain religions (particularly Muslims and Christians), due to the fact that smoking is not in favour with both religions.30–33 The religious values and beliefs play a significant role in determining specific attitudes toward smoking, and hence to reduce tobacco smoke prevalence.34 Research in Ghana found that 97% of Ghanaians (mainly Muslims and Christians) supported comprehensive SFA regulations, and 76% of smokers had tried to quit smoking in the last 6 months.30 A detailed description of the influence of religious values and teachings on smoking within the study setting of Aceh context is provided in the next section.

Aceh, the westernmost province in Indonesia, has a high prevalence of tobacco users.3 Although the percentage of male smokers (aged ≥15 years) in the province reduced from 31.76% in 2018 to 28.06% in 2020, it is still higher than the national average of 23.21%.35 The Indonesian Cardiovascular Association reported in 2021 that nearly 72% of heart attacks registered at the Provincial General Hospital Banda Aceh were associated with smoking,36 and 37.0% of pregnant women had miscarriages due to SHS exposure.36 In addition, the 2020 survey results by the Association of Indonesian Pulmonologists reported that 27.3% of the total Aceh population suffered from lung infections, especially tuberculosis among females because of inhaling SHS.37

In response to the continuing high tobacco use prevalence in Aceh, the provincial government endorsed a Governor’s Regulation (Qanun No. 4/2020) concerning the establishment of SFAs in the province.7 This follows from the Banda Aceh city Mayor’s previous endorsement of Qanun No. 5/2016 also concerning the establishment of SFAs throughout Banda Aceh city district (municipality) in 2016.9

However, despite these positive regulatory developments, the implementation of the established smoke-free policies is ineffective, since the widespread non-compliance to SFAs can be observed within the defined eight area categories throughout Aceh province, including Banda Aceh municipality.38–40 For instance, many people can smoke freely within SFAs: the owners of coffee shops, restaurants, markets and shops (defined as public places) even sell cigarettes and provide cigarette ashtrays for their smoking customers.38 Similarly, designated smoking areas are provided in some government/private offices and in public transport settings.38 41 Furthermore, the 2020 survey by the Aceh Institute on compliance rates with the Qanun No. 4/2020 in Banda Aceh city indicated that indoor places (especially for health facilities, education institutions and public transport) had the highest level of compliance rate (84.93%) among other defined SFAs.42 The survey also elaborated the levels of non-compliance rates within SFAs based on the existence of some indicators. The highest level of non-compliance (70.40%) was in the areas without ‘no smoking’ signs, followed by ‘cigarette smoke odours’ (8.8%), ‘smoking persons’ (5.24%), ‘cigarette butts’ (4%) and ‘ashtrays’ (2%).42

However, little is known about why the implementation of the established smoke-free policies is not effective, and few studies have examined barriers and opportunities for implementing SFAs, especially in Banda Aceh throughout eight area categories using the WHO FCTC framework for analysis. Hence, this research aims to investigate the challenges and opportunities for implementing SFAs within eight area categories in Banda Aceh municipality using the three specific areas (indoor or enclosed workplaces, public places and public transport) recognised by the WHO FCTC as a framework for analysis. Further, the research provides recommendations in particular for Aceh governments in the Banda Aceh municipality and throughout the province to facilitate effective SFA policy implementation.

The uniqueness of community structure in Aceh: sharia and adat

Most Acehnese are Muslims. They normally solve problems based on Islamic regulations (sharia) in mosques. A mosque is traditionally located in every subdistrict. Sharia means the rules, regulations or principles based on Islamic laws that have been practised by Acehnese people for generations.43 For Acehnese people, sharia practices represent their daily performances (eg, demeanour, attitudes, personalities).44 The term ‘adat’ originated from Arabic and means ‘habits’. Because the habit has been practised in daily life for years, it becomes a prerequisite before doing particular social activities.45

Basically, sharia and adat practices cannot be separated—they even support each other within community lives in Aceh.46 For instance, assisting destitute people by giving donations or being involved physically to assist them is highly commendable in sharia. This is consistent with one adat practice known as meuseraya (mutual assistance), in which Acehnese communities are eager to help others who are desperately in need (the poor, those affected by disasters or other difficult conditions).47 Further, showing respect for Islamic figures, local key leaders/stakeholders and older people is another adat practised in Aceh, which is also recommended in sharia law.46 Another example of adat is spending time for long hours in coffee shops among males, females and youths in Aceh. This practice does not conflict with the sharia because people can strengthen their social bonding with one another by meeting in coffee shops.44 The sharia also encourages people to be healthy by consuming halal and healthy foods and drinks while at the same time, it discourages or prohibits people from doing something that is harmful to their health and lives (eg, smoking, becoming drunk or dying by suicide).45 Similarly, the sharia recommends that followers protect and keep the environment clean.

Traditionally, both sharia and adat are preserved, maintained and implemented by imuem chieks (mosque imams), assisted by some respected figures, including village heads (keuchiks) and adat stakeholders.44 Understanding the community structure including the characteristics of Acehnese people and adat and sharia practices, and the role of key stakeholders is crucial for the effective planning of combined health and non-health campaigns on SFA policy implementation in order to enhance community compliance in Aceh.

MethodsStudy setting

This qualitative study was conducted from January to April 2022 in Banda Aceh municipality across nine subdistricts. Banda Aceh municipality was selected because there is a high risk of smoke exposure for non-smokers and the environment due to the city’s density.48 In addition, the percentage of daily smoking in male adolescents aged over 10 years in the city reached 44% in 2020.35

Study population and recruitment

This study applied a qualitative approach using various data collection techniques including in-depth interviews and document reviews to investigate the compliance of SFA policy implementation in Banda Aceh municipality, Aceh province, and the challenges and opportunities for implementing the smoke-free policies across the eight area categories of SFA in the province. A total of 73 respondents were finally interviewed in this study. This study defined some inclusion criteria to reach the saturation point before ultimately determining the total selected sample size for this study, namely 73 interviewees. First, the 73 participants were generally selected purposively (aged ≥18 years, willing to participate in the study) based on their capacity to provide detailed information on SFA policy, including the public communication, implementation, monitoring and evaluating, and the compliance and non-compliance of the policy in Banda Aceh. Second, respondents, specifically those who understood the barriers and opportunities for implementing the smoke-free policies within certain SFA area categories (health facilities, workplaces, teaching and learning areas, children’s playing areas, worship places, public transport, public places and sports centres), were selected. In other words, the selected participants were explicitly classified into six groups including (1) persons who were in charge of formulating and legalising SFA polices; (2) persons who were responsible for public communicating, implementing, and monitoring and evaluating SFA polices; (3) persons who were responsible for prosecuting the violation of SFA implementation; (4) persons who observed SFA implementation; (5) persons (smokers or non-smokers) who were in the most crowded and frequently visited areas (eg, markets, coffee shops and restaurants); and finally (6) respected figures in Syiah Kuala and Kuta Alam subdistricts. Other potential participants related to the study topic were also recruited via snowballing techniques. Details on categories of respondents, occupations and the number in each category of interviewed respondents are described in table 1.

Table 1

List of interviewed respondents (N=73)

Semistructured questions related to the implementation of SFA policy by governments and relevant actors (SFA implementation observers, respected figures, communities/costumers in markets, coffee shops, restaurants in Syiah Kuala and Kuta Alam subdistricts) in Banda Aceh municipality, Aceh province were developed based on the groups (characteristics, occupations) of selected participants. Specifically, the questions focused on identifying challenges and opportunities for implementing the SFA policy within the aforementioned area categories. These questions were developed in the Indonesian language. The question guides for interviews are provided in table 2.

Table 2

List of question guides for the interviews

The in-depth interviews were conducted in two subdistricts (Kuta Alam and Syiah Kuala) in Banda Aceh municipality. These subdistricts were selected as various government and private agencies, businesses and education institutions are located in both subdistricts, and they also have the highest (42 505) and second highest populations (32 969).49

Data collection

The data collection process commenced with interviewing the Banda Aceh District Health Office (DHO) head as the current work partner agency with the Aceh Health Polytechnics. Through his facilitation and a letter of support from Aceh Health Polytechnics, the primary researcher was able to secure an interview with the provincial secretariat (Sekda). Following this interview, a permission letter was provided by Sekda to assist the conduct of in-depth interviews for all listed stakeholders/institutions.

The primary researcher then continued interviewing other listed stakeholders/respondents by introducing himself to them, explaining the ethics and ensuring the confidentiality and anonymity, and also requesting them to sign informed consent sheets before conducting the interview. All interviews were conducted in Indonesian, digitally recorded and each took about 25–35 min.

Data management, analysis and reporting

Data from in-depth interviews were recorded using a voice recorder and transcribed into a Word document file (Indonesian language). The transcription process was conducted by facilitators before being translated into English by professional translators, while another qualified English translator checked the translation for accuracy and appropriateness. All transcripts including field notes and various important documents, for example, policies, regulations and reports related to SFA implementation issues, challenges and opportunities were managed and analysed using NVivo V.11 software (QSR International) through an inductive thematic analysing process.50 51

Nodes were created in NVivo and then developed into initial codes representing participant text quotes.52 The subcodes and codes were refined reiteratively, connected and compared between defined codes in order to find their similarities and differences and then developed into subthemes and the main themes (as shown in table 3). The coding process was conducted by the lead researcher (SS) and assisted by SB, MJ, AM and other Acehnese and Indonesian colleagues to understand the findings within the local context. Regarding the recurring responses, the lead researcher and SB were coupled with Acehnese who understand both Indonesian and the Acehnese languages in addition to the local culture, and hence we reached saturation with the research questions of this study.53

Table 3

Summary of qualitative data analysis process

All transcripts, field notes and official documents were required to suit the eight subcodes. The eight subcodes were summarised into three codes promoted by the WHO FCTC referring to the six subthemes and the two main themes: challenges and opportunities for improving the implementation of SFA in Aceh province.

A triangulation technique was applied to enhance the credibility of this study. It was conducted through in-depth interviewing of diverse groups with different occupations and responsibilities of selected respondents from provincial to Banda Aceh municipality levels (as listed in table 1). Further, we triangulated the in-depth interviews with various official document reviews derived from government and other formal institutions, so that the findings can be more credible as they are collected and analysed from multiple data sources.53 Then, the reporting of this study followed Consolidated criteria for Reporting Qualitative research criteria for qualitative research reports.54

Data protection

The participants were assured that no one could access the given information during data collection process, except those who were directly involved in this study. All information from transcripts and recordings was removed and/or saved in an unidentifiable form. A simple gift (valued about 20 000–50 000 rupiahs equivalent to $1.92–3.20) was given to respondents in appreciation of their involvement.

Patient and public involvement

Patients or the public were not involved in the development of research questions, design, recruitment, conduct, reports, and/or dissemination plans of this study.

ResultsParticipants’ description

The total number of included participants for interviews was 73, with a mean age of 36.5 years. Four of participants were policymakers, 63 were from eight category areas of SFA including respected figures (imams, village heads and adat figures), 2 were prosecutors for SFA non-compliance and another 4 were SFA observers.

Challenges for implementing SFA policies in Aceh province: assessing the compliance SFA policy implementation

For the purposes of characterising the challenges for implementation, the eight area categories are classified into three area categories of SFA including indoor workplaces, indoor public places and public transport (as described previously). These identified challenges are described in the following section.

Conflict of interests of local Banda Aceh leaders to implement SFA policies

This research identified that the commitment of local governments in Banda Aceh to implement the established SFA qanuns is weak. According to a public health observer and tobacco activist (ascertained via in-depth interview), Aceh governments are reluctant to implement the qanuns as they receive a lot of tobacco sharing funds from the tobacco industry and cigarette sponsors. As pointed out by one key informant from the education agency, the tobacco excise contributes the second highest revenue after oil and gas in the province. This revenue appears to influence implementation practices by the provision of exemptions to certain business/service owners, which appears as a loophole. For example, a review of SFA Qanun No. 5/2016 identifies in Article 6 of Chapter III Prohibitions, ‘everybody is prohibited to sell, promote, and or advertise cigarettes within SFAs, except when they obtain permission from the Banda Aceh Mayor’. Furthermore, point 2 of Article 6 of the Qanun clearly states that sports centres and public places are subject to exemptions from cigarette and other tobacco product advertisements and sponsors. As a result, over 267 cigarette ads were found in banners and billboards at soccer stadiums, shops, market places and crossroads in Banda Aceh (a senior lecturer from a university).

Inadequate monitoring, evaluation and enforcement of SFA implementation among involved agencies

Effective implementation of any regulation including that related to the established qanuns includes public communication, execution, monitoring and enforcement.5 The public communication of qanuns is commonly conducted by the Provincial Health Office (PHO) or DHO targeting all relevant agencies and wider communities related to this case, the eight SFAs. Then, the leader or delegated lead of each relevant agency promotes the regulation internally prior to execution. Additionally, the PHO or DHO is responsible for monitoring the implementation of qanuns across different relevant agencies. To close the implementation loop, the Public Order Agency in coordination with the PHO or DHO and sharia police is tasked to enforce or prosecute qanun’s offenders.

Key informant interviews revealed that the responsible agencies in Banda Aceh municipality do not always carry out their responsibilities in relation to the implementation of the established qanuns on SFA. This starts with failure at the public communication stage. The qanuns on SFA were not introduced by the DHO to all involved SFA chiefs in Banda Aceh municipality; as a consequence, the chiefs do not communicate the qanun to their internal offices (a key person from a government agency).

Designated smoking areas are even provided inside premises, and others are attached to main buildings. This clearly contradicts principle 2 of Protection from Exposure to Tobacco Smoke: ‘all enclosed workplaces and indoor public places need to be smoke free’.6

However, one key person from Banda Aceh DHO challenged that many SFA chiefs, especially from government agencies in Banda Aceh subdistricts, have introduced and executed qanuns on SFA to their employees. Further, in 2017 and 2018, the DHO monitored and evaluated the progress on SFA execution within those government agencies.

Nevertheless, as identified by reviews of monitoring and evaluation of SFA execution progress reports by Banda Aceh DHO, the monitoring and evaluation process was suboptimal as it did not continue and was only conducted in some health facilities, for example, community health centres (Puskesmas) and public hospitals.

In relation to SFA policy enforcement, Aceh government, through public order officers, the DHO, PHO and sharia police officers (the SFA policy enforcer team) conducted some prosecutions (locally known as Tipiring/Tindak Pidana Ringan) on SFA violators, especially cigarette smokers (as part of policy enforcement) in 2018, 2019 and 2020 in some SFAs in Banda Aceh (a senior officer from Public Order Agency). The senior officer continued this in 2018, while the enforcer team conducted Tipiring in Zainoel Abidin public hospital. About 15 patients’ families were prosecuted for smoking within the hospital area and were fined 200 000 rupiahs or US$13.37 for each violator. Further, in mid-2019, the team prosecuted and charged other instances of non-compliance with SFAs within two different places, namely 22 hospital visitors including outpatients for smoking within the hospital area in Meuraxa Hospital and another 16 smokers in Ulelhueh harbour. Another Tipiring was conducted by the team within the mayoral office in 2020. Thirteen persons including security officers were sentenced and charged for smoking offences around the mayoral office.

Yet, the tobacco activist commented that SFA policy implementation was not being enforced consistently across Banda Aceh since the aforementioned Tipiring activities were sporadic, had been discontinued or had only been applied to a limited number of public facilities.

Inadequate promotion of the need for and requirements for SFAs to the wider community

In-depth interviews with community members found that in enclosed public places such as coffee shops, markets and restaurants, many people smoke and they do not understand the concept of an SFA, including the areas that need to be free from smoke exposure.

The majority of interviewees acknowledged that they did not know about the current SFA qanuns (both No. 15/2016 and No. 4/2020). This lack of awareness extends to the many popular coffee shop and restaurant owners in Banda Aceh and this, combined with the broader lack of public communication, makes it difficult for them to enforce the regulations with their customers.

So far, the local governments in Aceh have not communicated SFA Qanuns to businesspeople including coffee shop owners. So, we do not know the existence of the Qanuns: how can we ask customers for not smoking inside our coffee shops, sure, they will complain about the legal basis for this request… (a crowded popular coffee shop owner in Banda Aceh)

Misunderstanding the concepts of ‘enclosed areas’ in workplaces and public places

None of the local regulations (qanuns) in Aceh province clearly define the requirements of enclosed/indoor areas of workplaces and public places as SFAs and as a consequence of this lack of clarity, numerous SFA violations were identified in these places (as elaborated by a senior government officer). Most people in government and private offices, the seaport and airport and bus terminals assume that smoking in well-ventilated areas of public or working areas and public transport is acceptable. As employees from public agencies stated: “Smoking in our office canteen and security office is OK as the places are equipped with many ventilations.” Similarly, the manager at a sports stadium indicated:

We used to have a designated smoking area within our roof top stadium, but now is broken (unusable), so we let the spectators to smoke inside the stadium as it is a well circulated area.

Likewise, based on interviews with bus drivers and passengers of some private bus fleets using air-conditioned buses, the drivers usually smoke on the bus and open the glass window next to the driver’s seat. Passengers are also allowed to smoke in the smoking area located at rear of the bus. This clearly demonstrates a lack of understanding of the concept of smoke-free environments and how tobacco smoke circulates in closed environments, exposing non-smokers to smoke.

Opportunities for improving implementation of SFA policy in Aceh province

There is much improvement to be made regarding the implementation of the eight categories of SFA in Banda Aceh. The opportunities that can be used to improve implementation are provided in the following sections.

Ministry of Education and Culture Regulation No. 64/2015 on SFA at schools

The ministry regulation aims to create schools that are clean, healthy and present a smoke-free environment.55 The SFA applies to all schools and their patrons including headmasters, teachers, education personnel, students and other persons in the school environment; hence, effective implementation of SFA can be achieved.55

The regulation outlines that to support the SFA implementation at schools, it requires incorporating smoking prohibition into school regulations; refusing collaboration with tobacco advertising, sponsorship and promotion; banning tobacco and cigarette advertising billboards at schools; prohibiting cigarette sales at school canteens; and putting up SFA signs at schools.55

Hence, the ministry regulation is important to support the understanding of the need for and compliance with SFA, by introducing the health risks of smoking exposure at an early age, so as to discourage smoking practice among the young generation.

Islamic sharia laws and other religions’ teachings support smoking restriction policies

Although the Islamic sharia has been deeply rooted within the Acehnese society and practised for generations (as mentioned previously), the Aceh governor issued Regulation No. 5/2000 concerning the implementation of Islamic sharia law throughout the province in 2000.56 To complement the law, the governor established an additional Regulation No. 8/2014 concerning guidelines for Islamic sharia implementation in 2014.57

Essentially, Article 3 of the Regulation No. 8/2014 outlines that the Islamic sharia practice is based on the ‘Maqasid Syar’iyah’ principle (for the benefit of mankind in accordance with Allah’s law) to protect religion, individuals and society from any threats (eg, life, health, physical or/and psychological threats), and to preserve the environment (based on reviews on Qanun No. 8/2014). The principle is consistent with the previously mentioned section and the objectives of SFA to protect individuals, families, groups and communities from the direct or indirect negative consequences of smoking; create a clean and healthy environment for societies; and raise public awareness on the dangers of smoking habits (as mentioned in Article 3 of Mayoral Qanun No. 5/2016).

The Maqasid Syar’iyah principle of Islamic sharia practice is an effective legal instrument to support the implementation of SFA in Banda Aceh municipality. Muslims represent the highest percentage of populations among all faiths (98.56% of total 265 000 people) in the municipality,49 and hence, the Muslim figures including imams, village heads and other adat stakeholders have an important influencing role in the smoking restriction policies such as the SFA implementation in Banda Aceh (a key person from Provincial Religion Agency).

In addition, informants representing other religions in Aceh such as Christians, Buddhists and Hindus strongly expressed that their religious teachings do not condone smoking. ‘Cigarette smoking including electric smoking needs to be banned at any public place to protect other people’s rights’ (a key person from Banda Aceh church service).

Discussion

Results from in-depth interviews and document reviews indicated that conflict of interests of local authorities in Aceh to implement SFA policies was due to the high tobacco tax revenues and payment from cigarette advertising and promotion received by the local government. Currently, the Aceh government receives approximately IDR12 billion of tobacco excise revenue each year; however, the local government expenditure on chronically smoking-related diseases has reached nearly IDR13.4 billion.19 58 There appears to be a disconnection in understanding by the local government that the actual economic burden associated with the treatment of smoking-related diseases is much greater than the tobacco sharing funds.59

Thus, decisive action is crucial for the Aceh government. It must stop receiving tobacco excise profit sharing from promoting tobacco products so that it can demotivate people to smoke, reduce smoking prevalence and lessen smoking-related morbidities and mortalities in the province.59 This firm action is recommendable and achievable for Aceh as it has been granted decentralisation in the area. Next, the Aceh government should approach central authorities to increase cigarette taxes and ratify the FCTC immediately. By ratifying the FCTC, the country (central and local authorities or leaders) is legally bound to support tobacco control regulations and demonstrate political commitment to strengthen the FCTC objectives. For example, Article 6 states that increasing price and tax measures for tobacco products can reduce tobacco demand. Further, the FCTC bans any affiliation or activities between member states and the tobacco industry. The state is completely prohibited from investing and receiving incentives and funds and other commercial assistance from the tobacco industry. By doing so, it can reduce or avoid conflict of interests among local leaders so as to enhance the implementation of SFA policies in Aceh province.59 Good examples of successful strategies associated with this are available from the Asia Pacific region. A study based on data from the Philippines, Thailand and Vietnam concluded that increasing cigarette taxes (25–100%) led to higher cigarette prices that effectively reduced the number of smokers and smoking-related diseases and deaths and hence reduced health expenses, and also to increase incomes from economic growth and productivity.60 Further, research in China, Indonesia and India revealed that annually increasing the average cigarette price by 9.5% reduced the annual average cigarette consumption by 3.56%, across all three countries.19

Yet, undoubtedly, strong political will and coordination between Aceh governments and central authorities are highly required to stop the sharing funds from the tobacco industry and to increase cigarette levies as part of enforcing the SFA policies.11 Some strategies to increase political will and the commitment of government leaders to enforce the SFA regulations11 25 28 include: top-down directive commands which can increase political commitments for lower-level enforcement actors since vigorous enforcement actions have support from upper levels; strong public support for SFA policies; public standing of tobacco control advocates; and strengthening familiarity and trust between civil society, government leaders and citizens. Providing a neutral space for discussion between the stakeholders regarding SFA policy and its enforcement is also important to share their opinions on effective strategies to enforce the SFA policies.

The other key finding indicated that the Mayoral SFA Qanun No. 5/2016 was communicated only sporadically to some involved public agencies, while the Provincial SFA Qanun No. 4/2020 has not been well communicated yet. Thus, it is crucial for DHO and PHO as a lead agency to introduce both qanuns comprehensively to all involved government agencies to support the implementation of SFA in Banda Aceh municipality and other districts in Aceh province. The WHO FCTC11 emphasises that comprehensive public communication of the established smoke-free legislation to all involved actors is crucial to raise their awareness about the importance of the regulation’s implementation. The Aceh government should learn from Zambia’s experience. In May 2009, the country successfully campaigned the existing smoke-free laws in Lusaka broadly to the city council, mayoral and environmental health officers, civil society organisations, the Zambian Consumer Association and the University of Zambia.25 Since then, the city council has supported the enforcement of the law in Lusaka.61

The other issue is the lack of communication of the need for SFA to reduce exposure to harmful cigarette smoke across communities. This leads to frequent violations of the regulations by community members in many public places and public transport fleets in Banda Aceh.

In response to this issue, intensive and extensive public health campaigns (at enclosed workplaces, public transport and public places) through health and non-health (eg, sharia/adat) combination approaches in Banda Aceh are essential. The campaign should be conducted by public health professionals (under local governments’ coordination) in collaboration with Islamic figures (mosque imams, religious leaders, adat stakeholders and other respected figures (eg, keuchiks/village heads)), and focus on various topics including campaigning on the health risks of cigarette smoking to encourage people to stop smoking. In fact, scientific evidence has shown that the harmful effects of tobacco are not only for the users but also those who are exposed to SHS with no risk-free level ever documented.34 62 Various public health problems are caused by SHS in adults (eg, heart diseases, lung carcinoma and stroke), and in children and infants (eg, severe asthma attacks, respiratory and ear infections, and sudden infant death syndrome).24 Another topic is introducing the concepts of SFA including the places that need to be SFAs to improve the compliance of smoke-free policy implementation and adherence by the community in Banda Aceh.

The aforementioned campaign is applicable and recommendable in Aceh and other Muslim populous settings since tobacco use also contradicts Islamic sharia values because it has numerous and serious negative consequences for communities, both smokers and non-smokers, and for the environment.

Further, to enhance the effectiveness of communication of the SFA qanuns to communities and other involved government actors/agencies, the Aceh government should learn from the Ashanti region in Ghana that communicated smoke-free legislation to communities using radio and television broadcasts. Based on research results conducted in Ghana in 2020, 72% (representing the highest percentage) of the total population in the Ashanti region had noticed the SFA regulation dissemination through radio and television advertising.34 Hence, radio and television are the most effective and recommended media by the WHO to spread information related to anti-tobacco campaigns including SFAs’ public communication and implementation, because these media are inexpensive and have wider coverage in many countries, including low-income and middle-income nations.63 64

Nevertheless, the implementation of the smoke-free regulations is still a challenge in many developing countries, including Indonesia, Uganda and The Democratic Republic of Congo. Unless countries have the concerted intention of improving some important areas such as strengthening the political leadership; formulating and establishing simple, clear and enforceable regulations; committing to counter tobacco industry opposition; involving civil societies in planning and implementing the regulations; and conducting public education, monitoring and evaluation,13 the regulations will be implemented without much success.30

Another key finding is that many people do not clearly understand the concept of ‘enclosed areas’ of workplaces and public places as parts of SFA, and as a result, they smoke freely inside ventilated rooms or buildings which are supposed to be smoke-free zones. Clearly, more work needs to be done by the local governments to better define and explain what enclosed areas mean in the context of application of this regulation at workplaces and public places within the SFA qanuns (province and Banda Aceh municipality).

Conclusions

This study has examined the challenges and opportunities for improving the implementation of SFA policies within the eight focused area categories in Banda Aceh municipality. The data were collected in the provincial capital and Banda Aceh municipality using qualitative methods (in-depth interviews and document reviews).

The results identified that the implementation of SFA policies in Banda Aceh municipality remains suboptimal. Thus, it requires overcoming the various identified barriers, and taking advantages of identified opportunities for enhancing the implementation of the policies in the municipality and throughout Aceh province.

The results and recommendations of this study can contribute to changing the policy and practice of the Aceh government authorities and other relevant actors/institutions (eg, governor, Banda Aceh mayor, provincial and Banda Aceh municipality secretariats, PHO, Banda Aceh DHO, public order agencies and other involved private/public agencies) to improve the implementation of SFAs comprehensively in Banda Aceh and the entire Aceh province, hence reducing harmful smoke exposure and encouraging a transition away from tobacco smoking.

Further, the results provide useful information for health agencies and other relevant practitioners in other provinces throughout Indonesia and other developing countries about the importance of combining health and non-health (eg, sharia, adat, local culture, custom, values, indigenous knowledge, etc) campaigns to achieve effective public health communication and education about SFAs and the need for SFA policy implementation. Also, follow-up research is needed to evaluate the application of results from this study in Banda Aceh in order to understand more information about the potential challenges that the policymakers, PHO, Banda Aceh DHO, public order agencies and other relevant practitioners may face when implementing SFAs in Aceh province.

Data availability statement

No data are available.

Ethics statementsPatient consent for publication

Obtained.

Ethics approval

This study obtained ethical approval from Aceh Health Polytechnics Human Research Ethics Committee (no. 11300/KEP/131/2022). The study was conducted based on the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Further, participation in this study was voluntary, and all participants were required to sign informed consent sheets before being involved in this study. They could withdraw their participation at any time.

Acknowledgments

The primary author expresses gratitude to all those who were involved in this research project. Special thanks are due to Johns Hopkins School of Public Health and the Indonesian Tobacco Control Research Network (ITCRN) which provided financial support to this project.