THE ADVOCACY AND COMMUNICATION OF SMOKE-FREE AREA REGULATION IN EAST JAVA, INDONESIA

Background: The negative impact of tobacco, especially second-hand smokers, requires imperative actions. Introducing tobacco control measures helps protect the public health. Data suggest that there were approximately 44 million daily smokers in Indonesia comprising 49.8 million males and 3.9 million females over ten years of age. East Java Province had the biggest number of smokers in Indonesia. To reduce trends in smoking behavior, we need to advocate local government to release and implement smoke-free regulations. Aims: The study aims to do action research through advocacy and communication for the regulation of smoke-free areas in East Java Province. Methods: The action research involved 12 districts of East Java Province, Indonesia. The method used in this study was Focus Group Discussion (FGD), one-on-one meeting, in-depth interviews, public speaking, press conference, and press release. Results: Intensive advocacy and communication worked successfully. Eight districts of East Java Province implemented local regulations of smoke-free areas. The advocacy and communication of the regulations made it possible to be implemented. Conclusion: Intensive advocacy and communication improve the awareness of executive and legislative government about the importance of smoke-free area regulations. It will be successful if regular meetings, discussions, press conferences, public speaking, and team work are conducted with many stakeholders.


Introduction
Recent evidence suggests that annually, over eight million deaths can be attributed to tobacco use.Seven millions of those were directly linked to tobacco use, and an additional 1.2 millions occurred due to an exposure to second-hand smoke (WHO, 2020).Tobacco smoking may contributes to deaths among about 1.3 billion smokers worldwide (WHO, 2019).Tobacco smoke contain more than 7000 toxicants and up to 70 carcinogens which are damaging to the human body (Tobacco Atlas, 2022).Smoking tobacco increases the risks of multiple cancers, stroke, and respiratory diseases (Tobacco Atlas, 2022).Nicotine, for example, contains tobacco addiction, a major cause of disability and premature death (Benowitz, 2009).The health consequences of tobacco smoking are far-reaching, and people exposed to second-hand smoke also may be at risk of various serious cardiovascular and respiratory problems (WHO, 2020).Given the negative health consequences associated with tobacco, especially second-hand smoke, it is imperative to introduce tobacco control measures to help protect public health and well-being (Tobacco Atlas, 2022).
Tobacco smoke causes approximately 225,720 deaths in Indonesia annually (Tobacco Atlas, 2022).Hence, tobacco smoking is a prevalent health risk behavior.
Recently published data suggests that there were approximately 54 million daily smokers in Indonesia in 2015 comprising 49.8 million males and 3.9 million females aged over ten years (Tobacco Atlas, 2022).Further, overall smoking incidence and cigarette consumption have remained relatively stable over the past thirty years (Kemenkes, 2013).Of particular concern is the rising number of young smokers in Indonesia.A recent report shows an increase in the number of youth smokers (10-18 years old) from 7.2 % in 2013 to 9.1% in 2018 (Kemenkes, 2013(Kemenkes, , 2018)).Despite the prevalence of smoking within the Indonesian population, Indonesia is not a signatory to the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC).The convention regulates a global treaty to protect present and future generations from the health impacts of tobacco use that has been agreed by 168 countries (WHO, 2005;Sugiyo and Henshall, 2020).The FCTC is a key achievement to facilitate a drop in both smoking prevalence and exposure to secondhand smoke (Peruga et al., 2021).
To reduce the negative impacts of tobacco use on health and well-being of the Indonesian population, the Indonesian Government issued National Law Number 36/2009 and Government Regulation 109/2012.The regulations mandate strategies to promote tobacco control in Indonesia.One of the strategies is providing pictures on cigarette advertisements and packages to visualize the negative health consequences of tobacco; another one is formulating and implementing tobacco regulations together with districts in order to be suitable to the local seven smoke-free contexts i.e., health facilities, education institutions, places of worship, workplaces, child play areas, public transport, and public places.Within these seven settings, tobacco product sale, advertisement, and consumption are prohibited.This national government regulatory measure is aimed to fight against the tobacco industry such as tobacco companies and lobby groups.
Although regulations have been placed, tobacco companies pay advertisements, give scholarships, and hold sport competitions for their social responsibilities to what they have All provinces of Indonesia are encouraged to enact smoke-free regulations.However, East Java Province was identified as a priority for regulation due to being the largest province with 38 districts which total population was 40.67 million people (Kemenkes, 2018).Tobacco was identified as the second highest risk factor for death and disability after high blood pressure in the province (Vos et al., 2020).East Java provincial data reveals that of the eleven most common diseases in the province, seven diseases i.e., stroke, ischemic heart disease, cirrhosis of the liver, chronic obstructive pulmonary disease, lower respiratory infection, hypertensive heart disease, lung cancer are related to tobacco consumption (Dinkesjatim, 2020).
East Java only has one city with regulations of smoke-free areas.Therefore, we conducted action research to establish the regulations in every city/ district in all regions of East Java.Smoke-free regulation is important to actualize as public health measures against the danger of smoking (Sugiyo and Henshall, 2020).During the action research, we advocated and communicated with the local government and local parliament (legislative) to agree and support the implementation of the regulations.This study used action research to perform advocacy and communication about the regulation of smoke-free areas in East Java Province.

Method
The current action research was conducted in collaboration with The Tobacco Control Support Centre (TCSC).For this project, we implemented advocacy communication process and activities about local regulations of smokefree areas within 12 districts of East Java Province i.e., Surabaya City, Blitar District, Ngawi District, Mojokerto District, Madiun City, Madiun District, Lumajang District, Ponorogo District, Bojonegoro District, Pacitan District, Jember District, and Batu Districts.For the research method, we used one-on-one meetings where had in-depth interviews and discussions with the major/head of the cities/districts, local health districts office, and the legislative government.Then, we conducted a focus group discussion (FGD) among local health districtsofficers, law departments, nongovernmental organizations, mass media, and community organizations.Besides, we made a press conference and press releases on local and national mass media to reach more audience.After that, we conducted public speaking sessions to disseminate the regulations and encourage people to obey them.The data were analyzed by monitoring and evaluating the processes and the results of the action research.As the indicator of success, we counted how many cities or districts had the regulations after they participated in our advocacy and the communication sessions.As a final thought, we used the Original Research evaluation of the action research as basic standards for smoke-free advocacy in East Java Province.

Result and Discussion
The TCSC members started the action research by contacting the district health offices in Surabaya City, Blitar District, Ngawi District, Mojokerto District, Madiun City, Madiun District, Lamongan District, Ponorogo District, Bojonegoro District, Pacitan District, Jember District, and Batu Districts.We conducted in-depth interviews and discussion about the urgency of smoke-free regulations.Data on smokers in every city and the risk behavior factor were collected from TCSC.We did in-depth interviews, one on one meetings, and focus group discussion to identify the problems.From the methods, on average, most of the informants mentioned it was very difficult to implement smoke-free regulations due to increasing numbers of smokers in their city and tobacco farming.Some of the cities were the biggest tobacco industry in Indonesia.However, from the discussion about the tobacco impact on health, economic, and social aspects, the informants were mostly aware and agree with us to have local smoke-free regulations.
After meeting with the local stakeholders, we moved the process to creating local smoke-free regulations for the cities.Some activities of advocacy and communication were done by working with the law departments to make a draft of smoke-free regulations.We initiated a discussion about smoke-free regulation and drafted academic scripts with district health offices and the law departments before proceeding the draft to the parliament.
We found that the biggest challenge was to share perceptions with the legislative government/parliament.In the process, we conducted meetings with the parliament (legislative) in every city for several times over a year.We also conducted focus group discussions (FGDs) with the parliamentary councils to understand their perceptions about the impacts of tobacco use and smoke-free regulation.FGDs could generate a deliberate decision as it offered a participatory format for group members to build their collective understanding of issues and solutions such as tobacco control.We also encouraged informants to discuss the negative impacts of tobacco use.This, thereby, could shape a collective understanding of the urgency for action.The other activity we performed was oneto-one meetings with parliamentarians to advocate policy formation on smoke-free areas.
On average, after more than a year of sustained advocacy and communication, the executive council and parliament responded by prioritizing tobacco issues to be addressed immediately.As urging local smoke-free regulations, we gathered Non-Governmental Organizations (NGOs) (e.g.Children Protection Organization, Indonesian Women without Tobacco, and Consumer Protection Institution) to lead demonstrations during the meeting.During the demonstrations, the NGOs held banners and posters and distributed flyers to the attendees.Such actions demonstrate the potential of both advocacy and networking for positive social change whilst also highlighting the importance of working with multi-disciplinary stakeholders such as parliament, executive council, law departments, provincial law bureaus, NGOs, and the mass media.To further demand the parliament on the smoke-free regulation, we showed a baby doll with cigarettes on its head to symbolize the real impact of cigarettes on children.

Original Research
Moreover, we conducted a press conference to publish the agenda.Advocacy and communication by mass media was also effectively to accelerate the release of the regulation.More than twenty media were invited to come and make some publications about the regulation.Press releases were then distributed to reach other mass media which did not come in the press conference.
Passing smoke-free regulation was a challenging agenda for the parliamentarians, who had to consider both sides of positions.For example, tobacco use may lead to negative public health impacts.On the other, the potentially detrimental economic impact could be related to tobacco tax as one of the largest contributors to the Indonesian economy.This is particularly significant for Surabaya, where three of the largest tobacco factories in Indonesia operate.Parliamentarians were concerned about the decreasing government revenue.
Intensive advocacy and communication came to work effectively.Eight of 12 cities agreed to release the local regulations.Further, the Surabaya city's regulations warranted some revisions as only five of seven smoke-free areas were mentioned in the regulations.Following 15 months of deliberation regulation for smoke-free settings was passed in Surabaya City, and implemented one year later in October 2009 (titled: Local Regulation No.5 2008) The regulation only covered five types of areas: health facilities, education institutions, places of worship, child play areas, and public transport.This regulation was applied not only for traditional tobacco but also e-cigarettes which also contain nicotine.Toxicants, ultrafine particles, and carcinogens are also found in an e-cigarette, and they may cause adverse health effects (Walley et al., 2019).A study in the Netherlands shows that participants were unhappy about tobacco because of control experienced as a moral failure and as neglect of financial responsibilities (Thirlway, 2019).
Tobacco consumption in workplaces and public places was prohibited.Nosmoking signage was implemented across all seven settings of the cities.However, indoor places were equipped with designated smoking rooms.Further, as the regulation No.They evaluated the implementation of tobacco regulations in the seven areas with the East Java Provincial Health Office in April 2012.The TCSC conducted on-theground research on over 1,000 premises or locations in Surabaya.The results indicate that very few (1%) smoke-free settings adhered to the Government Law.The TCSC mentioned that increasing awareness of the smoke-free law in public places (e.g., schools and health facilities) as well as through mass media.However, few media bring the issue of smoke-free regulations.This issues receives less attention presumably because of strong smoking culture that pervaded among reporters.To foster the media's support, the TCSC reiterated the purpose of the law, which was not to forbid smoking, but rather regulate permissible smoking areas.The regulation is important for protecting women and children who can be affected by secondhand smoke.Besides, smoking can cause cigarette butt pollution and tobacco denormalization (Henderson et al., 2021).
In the next step, the TCSC provided journalists with training on how to write an with multi-disciplinary stakeholders such as parliament, executive council, law departments, provincial law bureaus, NGOs, and mass media.Some cities i.e., Pacitan, Ponorogo, Bojonegoro, and Jombang were on going to release their regulations at different levels of governance (Table 1).
The cities currently tried hard to implement their regulations in the community by collaborating with various partners such as health school officers, non-government organizations, and local communities.They bravely reinforced the regulation implementation by training the officers and educating people.Advocacy efforts are one of the ways to reducing the trends in smoking behavior.
Smoke-free regulation will effectively protect the population, which is at a higher risk of exposure.Implementing the regulation in the seven settings is an reinforcement of tobacco control (Cham et al., 2021).
After the smoke-free regulation establishes, it is recommended to follow up with law enforcement.A study in Hongkong shows that smoke-free regulations could be comprehensively implemented in all indoor workplaces (Wang et al., 2017).

Conclusion
The conclusion of the research is that intensive advocacy and communication raised the awareness of the executive and legislative government to fortify smoke-free area regulations.
Multi-disciplinary collaboration will enhance the success to implement the regulations.Good networking with non-governmental organizations, health schools, and local communities is the main key to the success of advocacy.
TCSC was formed in 2008 under the directive of the Indonesian Public Health Association.The organization was established to reduce tobacco consumption to improve population health.The action research started in 2008 -2021 was designed in line with the central government's aim to reduce smoking behavior.
. 36 of 2009 and 102 of 2012, it did not comply with the National Laws, especially on smoke-free areas To align Surabaya city's regulations on smoke-free areas, the TCSC initiated a revision to local regulation No.5 of 2008.