The impact of exposure to cigarette advertising and promotion on youth smoking behavior in Malang Regency (Indonesia) during the COVID- 19 Pandemic

Abstract

The prevalence of teen smokers has increased during the Covid-19 pandemic. Smoking behavior occurs due to exposure to advertising and the promotion of cigarettes. This quantitative research was conducted using cross-sectional approach. The purpose of the study was to analyze the relationship between advertising exposure and cigarette promotion on adolescent smoking behavior in Malang Regency during the pandemic using the chi-square test. Random sampling on students from several high schools or equal degree in the Kepanjen District was done with a total of 145 respondents. The results showed that there was no significant relationship between age, types of cigarette advertising media at the point of sale, outdoor media, social media, internet, and newspapers or magazines by adolescent smoking behavior during the Covid-19 pandemic (p-value > 0.05). Exposure to cigarette advertisements on television, total exposure to cigarette advertisements, cigarette promotion, and gender had a significant relationship with adolescent smoking behavior during the pandemic (p value < 0.05). Adolescents are quite highly exposed to the various types of advertisements and promotions of cigarettes that can influence increased smoking behavior during the pandemic.

Introduction

Indonesia has experienced an increase in adolescent smokers by 20.1% during the Covid-19 pandemic.¹ The number of smokers who experienced an increase during the Covid-19 pandemic occurred among the early teens.² Beginner active smokers in Indonesia occur among adolescents aged 15-19 years, with a prevalence of 52.1%.³ The prevalence of smoking among adolescents has increased from 7.2% in 2014 and 2018 to 9.1%. The reduction in smoking prevalence among adolescents aged 18 years is one of the target indicators of the 2020-2024 National Medium-Term Development Plan (RPJMN) regarding smoking control, which states that adolescent smoking behavior in 2014 reached 7.2% while in 2024 must be reduced to 5,4%.⁴ The target of the RPJMN is still quite far from the prevalence in 2018, so reasonable efforts must be created to control the prevalence of smoking among adolescents. Research conducted by The World Bank shows that reducing the prevalence of teen smokers and stopping smoking initiation among Indonesian youth is urgent to do with the aim that the demographic benefits of the younger generation and Indonesia’s future can be reached.⁵

Indonesia is the third largest country after China and India, with the highest number of smokers.⁶ WHO predicts that in 2025 Indonesia will experience an increase in active smokers by up to 90%.⁷ Cigarettes in Indonesia have killed around 290,000 people every year and cause almost a quarter of, namely 25.3% of all male deaths and 7.2% of women in Indonesia.⁸ Half of all smokers in Indonesia die from health problems caused by smoking.⁹ Smoking behavior in adolescents causes addiction so that when there is an attempt to quit, several withdrawal symptoms will arise, such as depression, insomnia, mental disorders, and other physical health disorders that can harm school performance and daily behavior and cause death.⁴ Active adolescent smokers cause immune system disorders due to the presence of additives in the body of adolescents so that if they are sick, it will be more difficult to recover than other adolescents who do not smoke.⁴

Research conducted by Indonesia Global Youth Tobacco Survey (GYTS) (2019) stated that the number of adolescent smokers in Indonesia reached 39.1%. As many as 93.2% of these students smoked due to media factors, namely, advertisements and cigarette promotions from companies. Teenagers are the main target of cigarette advertising marketing because their age condition is easy to be influenced by something exciting, and teenagers have a longer time spend to smoke and tend to be loyal to the brand of cigarettes they know so that cigarette manufacturers can earn greater profits than ever.¹⁰ Cigarette advertising and promotion increase the desire of children and adolescents to start smoking and influence adolescents who quit smoking to redo to smoke.¹¹ Study Global Youth Tobacco Survey (GYTS) (2019) shows the number of student smokers who are aware of cigarette advertisements or promotions in outdoor media is as much as 60.9% of the total, while students who are aware of cigarette advertisements or promotions on the internet or social media are 36.2%.

Tobacco Control Support Center (TCSC) stated that 41.1% of adolescents living in districts received more exposure to cigarette advertisements and promotions compared to adolescents who lived in urban areas, which only 37.1%.¹² Malang Regency is one of Indonesia’s top ten districts, with the highest proportion of adolescent smokers, 27.6%.¹³ Kepanjen District is an area in Malang Regency with numerous adolescent smokers; a total of 325 out of 392 students currently studying at High School (SMA) in Kepanjen District are active smokers.¹⁴ The results of research mapping Ratih et al.,¹⁵ show that Kepanjen District has a total of quite many cigarette retailers, as many as 1,069 of which 61% of the places put on cigarette advertisement display and promotions and also based on the spot situation several cigarette companies are pretty close to the point location used for research. The location of schools that are close to the advertisements and promotion of cigarettes and cigarette companies can start to increase smoking among children and the number of teenage students attending the school was 2.16 times.¹⁶

Based on Selvia’s research (2021),¹⁷ it is known that the COVID-19 pandemic causes a high intensity of social media use by students, which is 82.5%, so it can increase the risk of adolescent students receiving exposure to cigarette advertisements. Exposure to cigarette advertisements obtained continuously by adolescents can lead to positive perceptions about cigarettes to encourage adolescent student behavior to smoke.¹⁸ Cigarette promotion activities through the provision of free cigarette samples and the placement of a logo on an object can increase the encouragement of smoking behavior in adolescents.¹¹ Those matters are the background of the importance of this research which aims to analyze the impact of exposure to cigarette advertising and promotion on adolescent smoking behavior in Malang Regency during the Covid-19 pandemic so that it can be used as an evaluation of cigarette advertising and promotion policies and can be used as a reference for program design regarding controlling adolescent smoking behavior, especially during the Covid-19 pandemic.

Materials and Methods

The research was conducted from March 2022 - May 2022 in several private and public high schools or equal degree in Kepanjen District, Malang Regency. This research method is quantitative and uses a cross-sectional approach. The research sample was taken using random cluster sampling. The number of research samples is as many as 145 respondents consisting of teenagers who are currently pursuing a high school education or equal degree in the research target area in Kepanjen District (residents in Kepanjen District or outside Kepanjen District). The process of filling in data by respondents is based on the last year’s experience, during the Covid-19 pandemic. The analysis used in this study was carried out using the test chi-square. The data that has been collected will be processed and analyzed throughSPSS 26.0 For Windows. The instruments used for data collection are the website and the questionnaire developed by Ratih et al. (2021),¹⁵ namely the Tobacco Retailer Assessment And Questionnaire (TRAQ), which aims as a medium of education to the public about the density of tobacco retailers as well as adolescent smoking behavior in the City and District of Malang. Several research variables contained in the instrument TRAQ consists of 6 indicators, namely gender, age, smoking status, exposure to types of advertising media often seen, exposure to giving free cigarettes, and exposure to giving objects/ merchandise, including the cigarette logo. Instrument TRAQ a constructs validity test was carried out in August 2021 by foreign researchers from Imperial College London, while the empirical validity test was carried out by redistributing the questionnaire to find out the obstacles that websites may cause.TRAQ instruments have been reliable because they follow the standard Global Youth Tobacco Survey (GYTS) to measure exposure to advertising and promotion of cigarettes and smoking behavior during the pandemic among high schools – or equal degree in Malang Regency. The ethical feasibility of this research has been carried out by the Health Research Ethics Commission of the Ministry of Health Polytechnic of Malang with ethical Approval Reg.No.:268 / KEPK-POLKESMA/2021.

Results

All respondents were exposed to cigarette advertisements by cigarette companies. Respondents who smoked were 22.8%, while those who did not smoke were 77.2%. The characteristics most of the respondents in this study were aged <18 years (66.2%) and male (57.9%).

Figure 1 shows that as many as 74 respondents who got exposed to cigarette advertising (51%), one respondent was exposed to 1 cigarette advertisement, while the other 71 respondents (49%) were exposed to more than one cigarette advertisement. The types of promotions from cigarette companies that respondents often obtain are 18 respondents (12.4%) who have received free cigarettes from one of the representatives of cigarette companies, and as many as 39 respondents (26.9%) have received promotions from cigarette companies in the form of gifts which includes the cigarette brand logo. The types of advertising media that respondents often see consist of several types advertising media, namely those in cigarette sales places as many as 53 respondents (36.6%), television, as many as 69 respondents (47.6%), outdoor media, as many as 101 respondents (69,7%), social media as 41 respondents (28.3%), internet media as many as 23 respondents (15.9%), and newspaper media or magazines as many as 4 respondents (2.8%). Table 2 shows that respondents aged 18 years were more likely to have smoking behavior than respondents aged <18 years but there is no significant relationship between the age of the respondent and smoking behavior (p-value > 0.05). Respondents of this study smoked entirely occurred in male respondents (39.3%). The Chi-Square test found a significant relationship exists between gender and respondents’ smoking behavior during the Covid-19 pandemic.

Table 1.

Characteristic of respondents smoking behavior.

Characteristic	n	%
Age
<18 years old	96	66,2
≥18 years old	49	33,8
Gender
Man	84	57,9
Woman	61	42,1
Smoking Behavior
No	112	77,2

Figure 1.

Types of cigarette advertising media that are often seen.

Based on the advertisement type, It did not found a significant relationship between exposure to cigarette advertisements from on point of sale, outdoor media, social media, internet, or newspaper/magazine and the smoking status of respondents (p-value > 0.05). Respondents who received 1 type of cigarette advertisement exposure were more likely to smoke (31.1%) than respondents who were exposed to more than 1 type of cigarette advertisement (14.1%). It shows a significant relationship between the amount of exposure to cigarette advertisements and the smoking behavior of respondents during the Covid-19 pandemic.

Respondents who were exposed to receiving free cigarettes from one of the representatives of the cigarette companies were more likely to smoke (66.7%) than respondents who did not receive free cigarettes (16.5%), with a score of p value= of 0.000, which indicates that there is a significant relationship between the promotion of cigarette companies in the form of giving out free cigarettes and the smoking behavior of respondents during the Covid-19 pandemic. Respondents who were exposed by receiving things or logos related to the cigarette company promotions were more likely to have smoking behavior (43.6%) than respondents who did not receive things or logos related to cigarette company promotions (15.1%) with p value= of 0.000, so there is a significant relationship between the promotion of cigarette companies by giving objects that include cigarette logos and the smoking behavior of respondents during the Covid-19 pandemic.

Table 2.

Relationship between cigarette advertising exposure and smoking behavior.

	Smoking Behavior
Variable	Yes		No		Total		P value
	n	%	n	%	n	%
Characteristics
Age
<18 years old	21	21,9	75	78,1	96	100
≥18 years old	12	24,5	37	75,5	49	100	0
Gender
Man	33	39,3	51	60,7	84	100
Woman	0	0	61	100	61	100
Ad Type
Point of Sale
Yes	13	24,5	40	75,5	53	100	0,7
No	20	21,7	72	78,3	92	100
Television
Yes	6	8,7	63	91,3	69	100	0
No	27	35,5	49	64,5	76	100
Outdoor Media
No	10	22,7	34	77,3	44	100
Social Media
Yes	6	14,6	35	85,4	41	100	0,143
No	27	26	77	74	104	100
Internet
Yes	3	13	20	87	23	100	0,226
No	30	24,6	92	75,4	122	100
Newspaper or Magazine
Yes	1	25	3	75	4	100	0,914
No	32	22,7	109	77,3	141	100
Number of Ads
Exposed to 1 Type of Ad	23	31,1	51	68,9	74	100	0,015
Exposed to >1 Ad Type	10	14,1	61	85,9	71	100
Company Promotion
Free Cigarettes
Yes	12	66,7	6	33,3	18	100	0
No	21	16,5	106	83,5	127	100
Cigarette Logo Items
Yes	17	43,6	22	56,4	39	100	0
No	16	15,1	90	84,9	106	100

Discussion

The majority of respondents who smoked during the pandemic were 18 years old, while those who smoked at the age of <18 years had a lower smoking behavior, which shows no significant relationship between the age characteristics of the respondent and smoking behavior during the Covid-19 pandemic. This research follows Bennett, Romm, and Berg (2022),¹⁹ which stated that there was no significant relationship between early adolescence and smoking behavior because smoking can happen to all ages without any restrictions.

Smoking behavior occurs entirely in male respondents. There is a significant relationship between gender and smoking behavior during the Covid-19 pandemic. This is reinforced by previous research done by Evrenet al. (2021),²⁰ which showed a significant relationship between gender and adolescent smoking behavior during the Covid-19 pandemic, and the highest number of smokers occurred in male compared to female adolescents. Study Hopkins and Al- Hamdani (2021),21 showed the same result, namely a significant relationship between age and gender during the Covid- 19 pandemic. Based on the research of Widodo, Nurudin, and Widiya Yutanti (2021),²² the results show that Indonesia has implemented gender equality, meaning that men and women have the same right of authority in an action or decision. However, until now, there are still a lot of negative stigmas that have long circulated in the community. Society makes some gender equality things invalid; one of them is related to the stigma of society which thinks that women who smoke are considered not good women, while men who smoke are considered to be doing the right thing. This could be one of the factors related to the results of this study which showed that smoking behavior occurred entirely in male adolescents while none of the female adolescents smoked.

The exposure to the types of advertising media in this study is divided into seven variables, namely the type of media found at the point of sale, television, outdoor media, social media, internet, newspapers or magazines, as well as the amount of exposure to the types of advertisements available. This study found that there was no significant relationship related to exposure to types of advertising media, namely those at the point of sale, outdoor media, social media, internet, newspapers or magazines, with adolescent smoking behavior during the Covid-19 pandemic. Study Tobacco Control Support Center showed the same results.¹¹

The research that has been done can be concluded that before or during the Covid- 19 pandemic, exposure to cigarette advertising media types in the form of sales points and other outdoor media was not the leading cause of smoking behavior in adolescents.

Cigarette advertisements shown on television showed a significant relationship between exposure to cigarette advertising media types on television and adolescent smoking behavior during the Covid-19 pandemic. These results are in line with research Tobacco Control Support Center (2017),¹¹ which shows the results that there is a significant relationship between exposure to the types of cigarette advertising media found on television and adolescent smoking behavior. Exposure to the types of cigarette advertisements found on television is one of the factors associated with adolescent smoking behavior during the Covid-19 pandemic because this study also found a significant relationship between the number of types of exposure to cigarette advertisements and adolescent smoking behavior during the Covid-19 pandemic. Namely, adolescents exposed to 1 type of cigarette advertisement were more likely to smoke than adolescents exposed to more than 1 type of cigarette advertisement. Sudibyo’s research (2018) shows that one of the factors, namely the intensity of cigarette advertisements can affect the purchasing power of consumers so that if 1 type of cigarette advertisement has a higher broadcast intensity than other media, it can increase 2.64 times the interest in smoking with the brand as shown in the ad.²³

The promotion of cigarette companies obtained by the respondents was the distributing of free cigarette samples by one of the company representatives and other promotional efforts in the form of giving objects/merchandise, which includes the cigarette logo. This study showed a significant relationship between cigarette promotion in the form of giving out free cigarettes by companies and youth smoking behavior during the Covid-19 pandemic. Another form of cigarette promotion, namely the giving of objects with free cigarette logos, shows a significant relationship between the giving of objects/merchandise cigarettes logo and adolescent smoking behavior during the Covid-19 pandemic. The results of the research are strengthened by research Tobacco Control Support Center (2017),¹¹ which shows that there is a significant relationship between exposure to cigarette company promotions and adolescent smoking status, and this can occur due to cigarette promotion as an effort to create an excellent first impression for teenagers so the teenagers will continue to re-consume and remember the cigarette brand. This is reinforced by research that has previously stated that adolescents are the main target of marketing advertising and promotion of cigarettes because adolescence is a state of age that is easily influenced by something exciting. Adolescents have a long smoking period and tend to be loyal to the first cigarette brand. Times that are smoked so that the cigarette factory can get a more significant profit.¹⁰

Theory Lawrence Green states that three determinants affect behavior/lifestyle/one’s behavior.²⁴ The determinant is a predisposing factor, namely the factors contained in the individual, enabling factor that enables or facilitates individuals to perform a behavior, and what is meant by the reinforcing factor is a factor that reinforces or requires an individual to perform a behavior. This theory follows several research results obtained; namely, there is a significant relationship between cigarette promotion in the form of giving free cigarettes and giving objects with cigarette brand logos as enabling factor that causes individual behavior, namely the smoking behavior of adolescents during the Covid-19 pandemic (behavior). Each variable contained in the promotion aspect of cigarette companies shows a significant relationship; it can be concluded that there is a significant relationship between cigarette company promotions and adolescent smoking behavior during the Covid-19 pandemic.

Government Regulation of the Republic of Indonesia Number 19 of 2003 concerning Safeguarding Cigarettes for Health states that the policy of allowing cigarette advertisements and promotions are limited to broadcast hours, namely in several electronic media, print media, outdoor media, and in other places at 21.30-05.00.²⁵ This shows different results from existing international agreements, namely: the Framework Convention on Tobacco Control (FCTC), which states that there is a complete prohibition on all types of advertisements, promotions and sponsorships that aim to introduce or promote tobacco products.²⁶ Indonesia is the only country that does not have a specific, firm policy to prohibit all cigarette advertisements and promotions, so advertisements and promotions of cigarettes are still often encountered by teenagers.²⁷ Malang Regency Regional Regulation Number 5 of 2018 concerning Areas Without Cigarettes in Article 6 reads that there is a prohibition on advertising and promotion of cigarettes in the KTR area and the prohibition does not apply to cigarette providers and cigarette production places.²⁸ This is not relevant to this study which shows that cigarette advertisements and promotions in any media can cause smoking behavior, therefore no matter the location of cigarette advertisements and promotions, including close to companies, places of sale, and the rest., more intensively against all parties related to the procurement of advertising and promotion of cigarettes if they violate predetermined policies.

Conclusions

This study concluded that adolescent smoking behavior during the Covid-19 pandemic is relatively high. Smoking behavior entirely occurs in respondents who have the characteristics of being male. Characteristics of the age of the respondents did not show a difference; namely, adolescents aged 18 years and <18 years had a high smoking behavior. Teenagers are more exposed to cigarette advertisements and promotions from various media and various types of cigarette promotions. The exposure to cigarette advertising media that was seen the most during the Covid-19 pandemic by teenagers was cigarette advertising media that was outside the room. The promotion from representatives of cigarette companies often obtained by respondents is the provision of objects with cigarette brand logos. The results indicate a significant relationship between the types of cigarette advertising media on television, gender, the number of ad type exposure, cigarette free promotion, and give the cigarette logo to adolescent smokers during the Covid-19 pandemic. Recommendations for local policymakers are expected to create and increase supervision related to more comprehensive Regional Regulations (Perda) so that they not only regulate cigarette advertisements that appear in electronic media and outside the room but also regulate other types of advertising media or cigarette promotions.