Background: Indonesia shoulders a significant tobacco burden, with almost two million cases of tobacco-related illnesses and more than two hundred thousand tobacco-related deaths annually. Indonesian tobacco control is progressing but lags behind other countries. Our study evaluates factors that contribute to the slow progress of tobacco policy change in Indonesia from the perspective of tobacco control experts (TCEs). Method: We conducted qualitative interviews with four international and ten national TCEs, who have been active in tobacco control for at least 5 years. Our interview guideline included questions on the current tobacco control situation in Indonesia and explored reasons why tobacco control is progressing so slowly. The interviews were conducted either in English or Bahasa Indonesia, recorded and then transcribed verbatim. We conducted a thematic analysis based on five core causal factors for policy adoption: institutions, networks, socioeconomic factors, agendas and ideas. Results: The multistage delay of tobacco policy adoption is principally due to political structures and policy hierarchy, complex bureaucracy, unclear roles and responsibilities, and a high degree of corruption. The low bargaining position and lack of respect for the Ministry of Health also contributes. There are contrasting frames of tobacco as a strategic economic asset and tobacco control as a sovereignty threat. There is an imbalance of power and influence between well entrenched and resourced tobacco industry networks compared to relatively young and less established tobacco control networks. The policy agenda is likely influenced by the privileged position of tobacco in Indonesia as a socially acceptable product with high consumption. There are constraints on transferring ideas and evidence to successful policy adoption. Conclusion: Tobacco companies have substantially influenced both policy decisions and public perceptions, signifying a power imbalance within the government system and broader networks. Acceding to and enforcing the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) would enable the Indonesian government to shift the power imbalance towards public health stakeholders. Tobacco control advocates must enhance their network cohesion and embrace other community groups to improve engagement and communication with policymakers.

Internet and social media channels are key to Sampoerna's marketing strategy in Indonesia. Internet-based marketing run alongside conventional advertising likely increases Indonesian youth exposure to cigarette marketing. This case study also provides evidence that Sampoerna evaded current tobacco advertising regulations. Subnational governments can play a stronger role in restricting tobacco advertising, promotion and sponsorship by more effectively enforcing current regulation.

INTRODUCTIONThe presence and density of tobacco retailers is associated with the perception of high availability of cigarettes and ease of purchase. Indonesia is the second largest cigarette market in the world with an increasing smoking rate among young people aged 10–18 years. Our study aims to assess density of cigarette outlets in neighbourhoods and around schools, and to evaluate correlation between retailer proximity to schools and retailer selling practices.METHODSWe conducted a geographical mapping and then an audit survey of 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia. We measured neighbourhood retailer density, and retailer proximity to schools. We linked the coordinate data to the audit data to assess the association between retailer distance from schools with likelihood of selling tobacco to young people and selling single cigarette sticks.RESULTSWe mapped 4114 cigarette retailers in Denpasar, the most common type was a kiosk, 3199 (77.8%), followed by mini market/convenience stores, 606 (14.7%). Retailer density was 32.2/km2 and 4.6/1000 population. We found that 37 (9.7 %) of the 379 schools in Denpasar have at least one cigarette retailer within a 25 m radius and 367 (96.8%) within a 250 m radius. Of the 485 audited retailers within a 250 m radius of a school, 281 (57.9%) admitted selling cigarettes to young people and 325 (67.0%) sold cigarettes as single sticks. Cigarette retailers were less likely to sell cigarettes to young people based on distance from schools, but this was only significant at the furthest distance of more than 500 m from schools.CONCLUSIONSIn an unregulated retailer setting such as Indonesia, cigarette retailers are ubiquitous and selling to young people is commonplace. The Indonesian government should enforce the prohibition on selling to young people and should regulate cigarette retailers to reduce youth access to cigarettes.

ObjectiveTo assess tobacco promotion intensity, retailer behaviours and tobacco company efforts to link retailer marketing to online channels.MethodsWe completed an audit of tobacco advertisements and promotions at 1000 randomly selected cigarette retailers in Denpasar, Bali, Indonesia that included an observation checklist, digital photos and structured interviews with retailers. We then calculated the tobacco promotion index for each retailer and made comparisons based on store types. Next, we conducted a photo analysis from 100 randomly selected retailers to explore links to online channels and other promotional cues to engage young people.ResultsMini-markets have both the highest total number of promotions and the highest indoor promotion index with a mean score of 5.1 and 3.7, respectively. Kiosks have the highest outdoor promotion index with a mean score of 1.6. Most of the retailers (98.9%) displayed cigarettes, more than half of kiosk retailers (54.8%) and mini-market retailers (56.3%) admitted selling cigarettes to young people, and 74% of kiosk retailers sell single stick cigarettes. We found links to online marketing, including two hashtags and a company website. Promotional materials also included youth-focused content such as English taglines, new products and small packs.ConclusionTobacco companies in Indonesia have strategically differentiated their advertisements based on retailer type and have bridged conventional retailer marketing to online channels. Reforming Indonesian tobacco laws to include bans on single sticks and small pack sales, point-of-sale advertising, including displays, and enforcement of laws on sales to minors is urgently required.

ObjectivesCompared with sighted individuals, people with visual impairment have a higher prevalence of chronic conditions and lower levels of physical activity. This review aims to systematically review physical activity interventions for those with a visual impairment and to assess their effectiveness.DesignA systematic review of articles reporting physical activity interventions in visually impaired individuals was conducted. Medline, EMBASE, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus and the Physiotherapy Evidence Database were searched in August 2018. Meta-analyses were conducted on randomised controlled trials with the same outcome measure.SettingMost interventions were conducted in a group setting, with some including an at-home, self-directed component.ParticipantsFollowing identification of a recent systematic review of physical activity interventions in children, our review focused on adults aged 18 years and older with a visual impairment.Primary and secondary outcome measuresOutcomes included measures of balance, mobility, mental well-being (eg, quality of life), number of falls, muscle strength, flexibility and gait.ResultsEighteen papers from 17 studies met inclusion criteria. Physical activity components include falls prevention and/or balance-based activities, walking, tai chi, Alexander Technique, Yoga, dance, aerobics and core stability training. Significant results in favour of the intervention were reported most commonly in measures of functional capacity (9/17 studies) and in falls/balance-related outcomes (7/13 studies). The studies identified were generally small and diverse in study design, and risk of bias was high across several categories for most studies. Meta-analyses indicated non-significant effects of the included interventions on the Timed Up and Go, Chair Sit Test and Berg Balance Scale.ConclusionsPhysical activity interventions in individuals with visual impairment incorporating activities such as tai chi, Yoga and dance can have positive results, particularly in physical measures such as mobility and balance. However, when performing a meta-analysis of randomised controlled trials, the evidence for effectiveness is less clear. More studies with larger sample sizes, stronger designs and longer follow-up periods are needed.PROSPERO registration numberCRD42018103638.

ObjectiveAt the end of 2012, the Indonesian government enacted tobacco control regulation (PP 109/2012) that included stricter tobacco advertising, promotion and sponsorship (TAPS) controls. The PP did not ban all forms of TAPS and generated a great deal of media interest from both supporters and detractors. This study aims to analyse stakeholder arguments regarding the adoption and implementation of the regulation as presented through news media converge.DesignContent analysis of 213 news articles reporting on TAPS and the PP that were available from the Factiva database and the Google News search engine.SettingIndonesia, 24 December 2012–29 February 2016.MethodsArguments presented in the news article about the adoption and implementation of the PP were coded into 10 supportive and 9 opposed categories. The news actors presenting the arguments were also recorded. Kappa statistic were calculated for intercoder reliability.ResultsOf the 213 relevant news articles, 202 included stakeholder arguments, with a total of 436 arguments coded across the articles. More than two-thirds, 69% (301) of arguments were in support of the regulation, and of those, 32.6% (98) agreed that the implementation should be enhanced. Of 135 opposed arguments, the three most common were the potential decrease in government revenue at 26.7% (36), disadvantage to the tobacco industry at 18.5% (25) and concern for tobacco farmers and workers welfare at 11.1% (15). The majority of the in support arguments were made by national government, tobacco control advocates and journalists, while the tobacco industry made most opposing arguments.ConclusionsAnalysing the arguments and news actors provides a mapping of support and opposition to an essential tobacco control policy instrument. Advocates, especially in a fragmented and expansive geographic area like Indonesia, can use these findings to enhance local tobacco control efforts.

Tobacco advertising, promotion and sponsorship (TAPS) bans are a cornerstone of comprehensive tobacco control laws. Global progress in implementing TAPS bans has been enabled by the adoption of the WHO Framework Convention on Tobacco Control. Innovative TAPS policies are in place internationally and include: point-of-sale display bans, plain packaging of products, industry spending on TAPS disclosure reporting, bans on retailer incentive programmes, and regulation of TAPS in entertainment and online media. However, there is an over-reliance on entertainment and digital content producers and platforms to self-regulate TAPS. Ensuring TAPS laws are regularly examined to limit loopholes and remove exemptions is crucial to continued success. The definition of what constitutes TAPS can allow the tobacco industry to deploy corporate communication and political campaigns that skirt TAPS bans. TAPS laws must also maintain pace with the changing media landscape, which includes monitoring and reporting TAPS that cross international borders, primarily through digital media platforms. Limiting tobacco retail supply will also serve to prevent the continued undermining of TAPS bans. Leveraging global corporation to ensure enforcement of TAPS bans across borders is urgently needed.

Introduction Indonesia shoulders a significant tobacco burden, with almost two million cases of tobacco-related illnesses and more than two hundred thousand tobacco-related deaths annually. Indonesian tobacco control is progressing but lags behind other countries. Our study evaluates factors that contribute to the slow progress of tobacco policy change in Indonesia from the perspective of tobacco control experts (TCEs). Method We conducted qualitative interviews with four international and ten national TCEs, who have been active in tobacco control for at least 5 years. Our interview guideline included questions on the current tobacco control situation in Indonesia and explored reasons why tobacco control is progressing so slowly. The interviews were conducted either in English or Bahasa Indonesia, recorded and then transcribed verbatim. We conducted a thematic analysis based on five core causal factors for policy adoption: institutions, networks, socio-economic factors, agendas and ideas. Results and Discussion The multistage delay of tobacco policy adoption is principally due to political structures and policy hierarchy, complex bureaucracy, unclear roles and responsibilities, and a high degree of corruption. The low bargaining position and lack of respect for the Ministry of Health also contributes. There are contrasting frames of tobacco as a strategic economic asset and tobacco control as a sovereignty threat. There is an imbalance of power and influence between well entrenched and resourced tobacco industry networks compared to relatively young and less established tobacco control networks. The policy agenda is likely influenced by the privileged position of tobacco in Indonesia as a socially acceptable product with high consumption. There are constraints on transferring ideas and evidence to successful policy adoption. Conclusion Tobacco companies have substantially influenced both policy decisions and public perceptions, signifying a power imbalance within the government system and broader networks. Acceding to and enforcing the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) would enable the Indonesian government to shift the power imbalance towards public health stakeholders. Tobacco control advocates must enhance their network cohesion and embrace other community groups to improve engagement and communication with policymakers.