Development of Indonesian Quit Smoking Campaign using Internet: a personal experience of an Indonesian Tobacco Control Researcher.

R. Wasis Sumartono Health Researcher, Center for Biomedical and Pharmacetical Research and Development, National Heath Research and Development, Ministry of Health, Rep. of Indonesia

Abstract National report on Basic Health Research 2007 discovered that the prevalence of smoking among Indonesian population aged 10 years or older is 24 % (male 45.8 % and woman 3 %). Among those Indonesian smokers, 9.6 % have started smoking since 10-14 years and 36.3 % started smoking since 15-19 years. The role and responsibility of Indonesian Government in smoking epidemic control is so far very weak. The budget for tobacco control activities, including for public heath education on harmful effect of tobacco smoking, in Ministry of Health was very small. This paper reported the author’s experience in developing quit smoking campaign videos for Indonesian through internet. Year 2005, the author started to make Indonesian quit smoking campaign videos, which was the Indonesian version of Australian Quit Smoking campaign videos. By 22nd of February 2009, one by one, the author uploaded into ’youtube’ website under the name of http://www.youtube.com/MUSAUP2009. Totally, there were 13 short public health education video films in that URL. In order to make that films spreading in the Indonesian community, the author asked relatives and friends to help to forward the URL of MUSAUP2009 to their relatives and friends too. From February 15, 2009 to March 9, 2010, there were 13,776 viewer who viewed MUSAUP2009 videos. MUSAUP2009 videos should be developed further through Indonesian key televisions in order to make public education on tobacco or health more accessible for the poor and less educated Indonesian who live in the big cities or isolated areas. Background: Health disparity between different community groups in a country and between different countries is one of important issues in public health studies1.

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While trends of tobacco use have decreased in developed countries the opposite situation is happened in Indonesia. According to Global Youth Tobacco Surveys (GYTS) year 2006, about 34 % (range 24% - 41%) of male school students aged 13-15 years in Indonesia are smokers2. National report on Basic Health Research 2007 discovered that the prevalence of smoking among Indonesian population aged 10 years or older is 24 % (male 45.8 % and woman 3 %). Among those Indonesian smokers, 9.6 % have started smoking since 10-14 years and 36.3 % started smoking since 15-19 years3. The role and responsibility of Indonesian Government in smoking epidemic control is so far very weak. For example, last 23rd of May 2009, Freddy Tulung (Director General of Communication and Information Dissemination, Ministry of Communication and Information, Republic of Indonesia) totally refused the request of Indonesian National Commission for Child Protection to ban tobacco advertising in Indonesian broadcasting media4. And last 10th of September, Mohammad Mahmud MD (Chairman of Indonesian Constitutional Court) refused the same request by National Commission on Child Protection5. The comparison between the amount of tobacco tax or excise tax received by the Indonesian Government and the Ministry of Health budget for public education on tobacco or health can further explain how low is the responsibility of Indonesian Government in smoking epidemic prevention and control. The Indonesian Government received about 43 trillion rupiah (4.432.989.690 US $) in the year 20086. But the budget of Ministry of Indonesia for tobacco control activities –including for quit smoking campaign- in the same year was only about 500 million rupiah (68.000 US $)7. While tobacco advertising and promotion are not banned in Indonesia, and billion rupiah are spent by tobacco industries to develop unhealthy promotion, only about 0,001% from the Indonesian total tobacco tax (excise tax) that is dedicated for tobacco control activities. This is much lower than what have been suggested by WHO FCTC (5 – 10 % of tobacco tax or excise tax). Since 1994, as a health researcher in Research Group of Major Non Communicable Diseases (Cardiovascular, Cancer and Endocrinal Diseases) in

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Center for Biomedical and Pharmaceutical Research and Development, National Institute of Health Research and Development, Ministry of Health, Republic of Indonesia, the author have focused interest into tobacco control research. By that days the author searched and developed materials and methods for public health education on harmful effects of tobacco smoking by adapting and modifying foreign materials and methods into it’s Indonesian version. Last November 20 December 2 year 2000, the author was invited by Key Center for Women’s Health in Society (KCWH), WHO Collaborating Center for Women’s Health, the University of Melbourne, for a ”Short Course in Tobacco Control and Gender”. There, the lecturer of KCWH showed and gave the author a series of Australian Quit Smoking Campaign Television Commercials. Since the year 2001, the author proposed research proposals to author’s office in order to make Indonesian version of Australian Quit Smoking Campaign television commercials. But years by years the author did not find financial support for such a research. The author have also tried to apply research proposals to WHO Kobe Japan, Development Marketplace of World Bank, Bloomberg Grant for Smoking control in Developing Countries, but so far it was not successful to win their financial supports. The author latest attempt to seek financial support was done in 2008 where the author tried to seek support from AIGRP (Australia Indonesia Governance Research Partnership). The author proposed that AIGRP financially support the making of high quality Indonesian Public Health Education on Harmful effects of tobacco smoking video films and it’s daily display in ten Indonesian key television for at least three months. But again, it was failed. Boring to face continuous rejections to the author’s research proposals, in the year 2005, the author started to make Indonesian quit smoking campaign videos. This work of the author tried to answer question on what can a health researcher in Indonesia can do to overcome such an obstacle in developing public education on tobacco or health in such a moral and financial circumstances? This paper will report the author’s experience in developing quit smoking campaign videos for Indonesian through internet.

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Material and Method Using simple and cheap camera, computers and volunteers for it’s video film artists. They were the author’s family members, neighbors, fellow medical doctors and nurses and anyone who have willingness to support the tobacco or health education film making voluntarily. The author only made film parts that is not too difficult to be made. For film parts that were too difficult to be made by the author (like cigarette smoke entering the respiratory tract, the bleeding brain etc), the author cropped from it’s original Australian version and inserted it into the Indonesian. Film shooting, editing, sound-mixing and subtittling was done by the author. The author put these videos in http://www.youtube.com/MUSAUP2009. MUSA UP is abbreviation of Multi-media Utilizing Against Unheathy Promotion. This name was inspired from the work of Professor Simon Chapman of the Universuty of Sydney who establihed BUGA UP (Billboard Utilizing Grafitists Against Unhealthy Promotion)6. By 22nd of February 2009, one by one, the author uploaded the Indonesian version videos of Australian Quit Smoking campaign into ’youtube’ website. The first videos uploaded into youtube website at 22nd of February 2009 were spons (adapted from ”Sponge”), koroner (adapted from ”coroner”), tangga (adapted from ”stair”). Videos of paru-paru (adapted from ”lung”), Chrisye (adapted and modified from ”Janet Sackman”) were uploaded at 23rd of February 2009. Tar – paru paru, stroke and mata (each was adapted from ”tar – lung”, ”stroke” and ”eye”) were uploaded into ’youtube’ at 25th of February 2009. Since the majority of Indonesian population are Muslim, on 26th of February 2009 the author also uploaded a video entittled ”Smoking is not an Islamic culture”. This video was insipired from International Seminar on Tobacco or Health in Bandar Seribegawan, Brunei Darussalam, 11-14 July 2002. The seminar –which is a first international seminar on tobacco or health in Islamic perspective- declared seminar resolution that stated ”smoking is not an Islamic culture” in addition to ”tobacco is a harmful product and that smoking is against Islamic teaching”7.

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Totally, there were 13 short public health education video films in http://www.youtube.com/MUSAUP2009. In order to make that films spreading in the Indonesian community, the author told almost every author’s relatives, family members, dental patients, fellow university students, researcher colleagues, office network etc about the present of this new Indonesian tobacco or health education website in ’youtube’. The author asked their help to forward the URL of MUSAUP2009 to their relatives and friends too. RESULT From February 15, 2009 to March 9, 2010, there were 13,776 viewer who viewed MUSAUP2009 videos. Number of daily viewers varied from 5 to more than 60 persons. In the month of February 2010 the daily viewers reached it’s peak at 120 viewers in a day (Figure 1). From February 24, 2010 to March 10, 2010, MUSAUP2009 videos have been viewed for 746 times. Number of viewers a day was fluctuated from about 60 viewers at the beginning, decreased to 40 viewer in one point, increased again to more than 80 viewer in another point and so on, but never reached 120 viewer a day (Figure 2). From among all of MUSAUP2009 videos, the most popular video was Tar – paru-paru (adapted and modified from Tar-Lung). 29.7% of MUSAUP2009 video viewers viewed this video. Followed by paru-paru (lung), karies yang berkaitan dengan merokok (smoking related dental caries), spons (sponge),
Figure 1.

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Figure 2. Views

mata (the eye), stroke, koroner (coroner), tumor, and merokok bukan budaya Islam (smoking is not an Islamic culture). The percententages of view to these videos were 29.7%, 11.8%, 5.3%, 4.3%, 3.6%, 3.2%, 2.9%, and 2.8% respectively (Table 1).

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Table 1. Views and attention of MUSAUP2009 videos (sort by most viewed) untill 10 of March 2010.

Though MUSAUP2009 videos can be seen from all over the world, when compared to those of other uploaders, MUSAUP2009 videos were found to be most popular in Indonesia and less popular in Malaysia (Figure 3).
Figure 3.

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Majority (80%) of MUSAUP2009 videos viewers were male, while female only 20 % of them. 58 % of MUSAUP2009 video viewers were between 45 – 54 years old, 12 % were between 18-24 years, and 11 % between 34-44 years old. The percentage of viewers in the age group of 13-17 years, 25-34 years and 5564 years were 8%, 7% and 4% respectively (Figure 4). Figure 4. Demographics (observed between February 24, 2010 – March 10, 2010)

Who is watching MUSAUP2009 channel?

Regional popularity of MUSAUP2009 videos was only 0.38 % in Indonesia and only 0.21% in Malaysia (Figure 5).

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Figure 5. Region popularity of MUSAUP2009 videos (observed between February 24, 2010 – March 10, 2010)

Among thirteen episode of MUSAUP2009, there was one video that have been given 5 star rating, namely “Merokok Bukan budaya Islam” (“Smoking is not an Islamic Culture”) (Figure 6. ). Figure 6. “Merokok bukan Budaya Islam” (Smoking is not an Islamic Culture) have been given a five star rating.

Discussion The number of MUSAUP2009 video viewers was increasing, though it was very slowly. When compared to the total number of Indonesian population

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the total number of these viewers was relatively very small. However small is the improvement of coverage of MUSAUP, there was an improvement. For example, between September 10, 2009 and September 19, 2009, demographically, 74 % of MUSAUP2009 video viewers were female and only 26 % of them were male. Majority (about 85 %) of them were 18 – 24 years old, and the rest 15 % were between 13-17 years old (Figure 7). Figure 7. MUSAUP2009 number of views, % of total views, Demographics and Popularity between September 10, 2010 - September 19, 2010.

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Since majority of Indonesian smokers are male (the prevalence of smoking among male about 60 % while among women about 5 %), that situation have made the author felt that MUSAUP2009 was failed to warn Indonesian male smokers about the dangerous nature of tobacco and smoking. But now, between February 24, 2010 and March 10, 2010 the percentage of male viewers have reached to a level of 80 % while the rest 20 % were female. A slight improvement was observed in the region popularity of MUSAUP2009 videos in both of Indonesia and Malaysia. For example, between September 10, 2009 and September 19, 2009 the region popularity of MUSAUP2009 videos in Indonesia and in Malaysia were 0.21 and 0.15 respectively (Figure 8), while between February 24, 2010 and March 10, 2010 the region popularity were 0.38 and 0.21 respectively.
Figure 8. Views and Region Popularity of MUSAUP2009 videos between September 10, 2009 – September 19, 2009

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The fact that after 13 months of displaying MUSAUP2009 videos in Youtube these videos was only viewed about 13,776 times –which is not as frequent as other kind of videos (such as music and song videos)- may suggest that to be effectively seen by more Indonesians, this kind of public health education videos should also be displayed in Indonesian key televisions. However, whenever possible, it should be shown through internet available in Indonesian schools –in computer laboratory or in school library. Indonesian teachers should be encouraged to ask their students to watch these kind of public education on tobacco or health videos (and that’s what the author have been trying to do in the on going “Gorontalo Youth Study”). Indonesian poor people who live in big cities and other Indonesian who lived in isolated areas, in the mountain areas or in the most faraway islands, can only be reached by television if their accessibility to internet is very poor. Unfortunately, in Indonesia, televisions still allowed to display tobacco advertisings and promotions – a stumbling block to the successful public education on tobacco or health.. This may explain why the finding of PATH in Bangladesh that : “tobacco advertising and promotion in a poor country have caused poor people considered tobacco as their basic need while children of the poor still feel that egg, milk and meat are luxurious things10” may applied in Indonesian population. Conclussion and sugestions: Smoking–as explained by one of MUSAUP2009 videos- is not an Islamic culture. If it have became an epidemic (smoking epidemic) in Indonesia, it is because the poor and less educated people have became the victim of information asymmetry on tobacco or health. This information asymmetry have been produced by collusion between tobacco industries in Indonesia with Indonesian government officers who have corrupted the poor and less educated people’s right to know the truth about tobacco or health. Among of these Indonesian Government Officers are Freddy Tulung (Director General of Communication and Information Dissemination, Ministry of Communication and 12

Information, Republic of Indonesia) and Mohammad Mahmud MD (Chairman of Indonesian Constitutional Court) who rejected the request of Komite Nasional Perlindungan Anak (Indonesian National Commission for Child Protection) to totally ban tobacco advertising in Indonesian mass media –particularly in broadcasting media. Public education on tobacco or health like the one that author developed through http://www.youtube.com/MUSAUP2009 should be developed further in a more sophisticated ways, both through internet as well as through the other channels such as Indonesian key televisions in order to make public education on tobacco or health more accessible for the poor people of Indonesia who live in the big cities or isolated areas. In order to make the public education on tobacco or health more effective, all obstacles to this education should be removed. Tobacco advertising and promotion that is well known to be one of major obstacles of the public education on tobacco or health should be completely banned in Indonesia. In case that the present Indonesian executive, legislative and judicative councils prefer to give negative response to Indonesian tobacco control activists and advocates’ more educated ways in expressing the request on the total ban on tobacco advertising, it is better for Indonesian tobacco control activists and advocates to use more radical and ’subversive’ ways to express their request, such as the one that have been shown by Prof. Simon Chapman of Australia through the development of BUGA UP (Billboard Utilizing Graffitists Against Unhealthy Promotion). It is the time for Indonesian tobacco control activists and advocates to declare war on smoking in order to protect the health of the present and future generation. Reference:
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Umar Fahmi, Public Health Professor, the University of Indonesia ”Important Issues in current Public Health”, an inaugural lecture on the acceptance ceremony of post graduate Public Health students – the University of Indonesia, July 2008. Barber, S dkk, Tobacco Economy in Indonesia, Demograpihy Council, Faculty of Economics, the university of Indonesia, Depok -2000. Page 19 (in bahasa Indonesia).

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National report on Basic Health Research 2007, National Institute of Health Research, Ministry of Health, Rep. of Indonesia – 2008. Page 174, 170 (In Bahasa Indonesia). Melarang Iklan Rokok adalah Tindakan Diskriminatif, Pengujian UU Penyiaran ( Total ban on tobacco advertising is a discriminative action: a testing to Law on Broadcasting). News released on 25th of May 2009, downloaded from an online news on Indonesian law
rd

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http://www.hukumonline.com/detail.asp?id=21555&cl=Berita,

downloaded at 23 of September 2009. (In Bahasa Indonesia).
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MK Tolak Uji Materiil Dasar Hukum Iklan Rokok (Indonesian Constitutional Court refused material testing on Legal basic of tobacco advertising), an online news from http://www.tvone.co.id/berita/view/22739/2009/09/10/mk_tolak_uji_materiil_dasar_hu kum_iklan_rokok, downloaded at 23rd of September 2009. (In Bahasa Indonesia). Tobacco tax or excise tax received by the Indonesian Government, an information from Abdillah Ahsan, writer of Ekonomi Tembakau (Tobacco Economic), published by Demographic Council – University of Indonesia 2008. (in bahasa Indonesia). Data on budget of Ministry of Health for tobacco control activities is collected by the author through interviews with several officers of Ministry of Health. Chapman, S., Civil Disobedience and Tobacco Control, the Case of BUGA UP. Tobacco control 1996: 5: 179-185. Quoted from BUGA UP Australia official website: http://www.bugaup.org (downloaded at 9th of January 2009). Seminar Resolution, International Seminar on Tobacco or Health, Tobacco or Health – A New Hope, held by Mufti’s Office of Brunei Darussalam, Bandar Seri Begawan 11-14 July 2002. Effect of tobacco advertising in poor country is quoted from “Tobacco and Poverty”, downloaded from http://wbb.globalink.org/public/poverty_factsheet.pdf, 24th of September 2009.

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