Managing public education on smoking behavior in families with stunted children: Between challenges and opportunities in Indonesia

Abstract

BACKGROUND:

Stunting remains a major public health concern in Indonesia, compounded by the country’s high prevalence of smoking. This study explores the smoking behavior of families with stunted children, parental knowledge of smoking-related risks, and their motivation for behavioral change.

MATERIALS AND METHODS:

Using a qualitative approach, data were collected through interviews, observations, documentation, and focus group discussions in East Nusa Tenggara and Aceh—two provinces with high stunting rates.

RESULTS:

Findings reveal that most fathers are active smokers and frequently smoke around pregnant women or children. Parental awareness of the link between cigarette smoke and stunting is limited, and fathers show low motivation to quit smoking even after stunting is diagnosed.

CONCLUSIONS:

The study recommends revising national stunting reduction strategies to include smoking prevention, enforcing smoke-free policies, restricting cigarette advertising and sales, and empowering families—especially fathers—to change harmful smoking behaviors to protect child health.

Introduction

In 2019, President Joko Widodo, through Indonesia’s Ministry of National Development Planning (BAPPENAS), launched the “Golden Indonesia 2045” vision.[1] This long-term vision aims to improve the overall welfare and equity of the Indonesian people, supported by higher-quality human resources, the transformation of Indonesia into an advanced economy and one of the world’s top five economic powers, and the achievement of just and equitable development across all sectors within the framework of a sovereign and democratic Unitary State of the Republic of Indonesia.[2]

However, realizing this vision remains a significant challenge due to persistent social and health disparities. Alongside poverty and inequality, Indonesia faces a major human capital crisis in the form of childhood stunting, a condition reflecting chronic malnutrition and inadequate early-life care.[3] Stunting, defined as impaired growth resulting in low height-for-age, affects not only physical stature but also cognitive development and long-term productivity, thereby undermining national development goals.[4]

Compounding this issue is Indonesia’s ongoing struggle with high tobacco use. Recent national surveys show that the prevalence of stunting among children under five remains around 24% in 2023, while smoking among adult men exceeds 60% one of the highest rates in Southeast Asia.[5] Stunting rates are particularly severe in eastern provinces such as East Nusa Tenggara (NTT, 35%) and Aceh (31%), both of which also record high smoking rates between 27% and 29%. The overlapping patterns of stunting, smoking, and poverty suggest a multidimensional challenge: household tobacco expenditure diverts essential income from food and healthcare, while second hand smoke exposure contributes to poor maternal and child health outcomes.[6]

Data from the Asian Development Bank, the Ministry of Health’s SSGI Survey, the WHO Tobacco Report, and SEACTA indicate that provinces with high stunting prevalence also show elevated smoking and poverty rates. For example, in NTT, 35.3% of children are stunted, 26.6% of adult males smoke, and 20.2% of residents live below the poverty line. Aceh follows with 31.2% stunting, 28.6% adult male smokers, and 14.7% poverty, while Papua records 34.5% stunting and 26.8% poverty. Nationally, Indonesia’s averages remain significant, with 24.4% stunting, 28% adult male smoking, and 9.4% poverty. These figures illustrate how nutritional deprivation, tobacco use, and economic hardship are closely intertwined.

Parental knowledge plays a vital role in preventing child stunting, particularly concerning the relationship between tobacco use and nutritional outcomes. Studies in Indonesia and other developing countries show that parental education strongly influences child growth.[7] Children born to mothers with higher education levels are, on average, 0.5 cm taller than those born to less-educated mothers, while low parental education increases the risk of stunting by more than twofold. Despite these findings, awareness of smoking’s contribution to stunting remains limited. Many parents understand that poor nutrition causes stunting but are unaware that cigarette smoke exposure and income spent on tobacco can exacerbate malnutrition and hinder growth.[8]

The Indonesian government has introduced various legal and regulatory measures to reduce tobacco-related harm. Law No. 36 of 2009 on Health and Government Regulation No. 109 of 2012 on the Control of Addictive Substances in Tobacco Products provide the legal basis for provinces and municipalities to establish Smoke-Free Area regulations (Peraturan Daerah Kawasan Tanpa Rokok or Perda KTR). These regulations prohibit smoking in public facilities such as hospitals, schools, offices, transportation hubs, and worship spaces. However, enforcement remains inconsistent, and coverage rarely extends to private households the primary environments where children and mothers are exposed to secondhand smoke.[9] Consequently, many Indonesian families continue to face daily exposure to tobacco smoke inside their homes, particularly in low-income settings.[10]

Given these conditions, this study aims to strengthen existing evidence on the relationship between parental smoking behavior and child stunting in Indonesia. It focuses on two provinces NTT and Aceh where stunting prevalence and smoking rates are among the highest nationally. Specifically, the study explores three key aspects: (1) the history and pattern of smoking behavior within families of stunted children; (2) parental knowledge of the link between smoking and stunting; and (3) parental motivation to adopt smoke-free practices following a child’s stunting diagnosis.

The results of this study are expected to inform both local and national policy frameworks. By examining how household smoking practices, awareness, and motivation interact, the research provides insights into community behavior and the sociocultural dynamics that sustain tobacco use in domestic spaces. The findings can help policymakers develop more targeted interventions particularly the Smoke-Free Home concept which seeks to raise parental awareness and encourage healthier household environments. In the long term, this study supports the inclusion of private residences within regional Smoke-Free Area regulations, ensuring that public health protections extend to the most vulnerable setting of all the home.

Materials and Methods

Study design and setting

This study used a qualitative field research design aimed at exploring parental smoking behavior and its relationship to child stunting. The research was conducted over a six-month period, from March to August 2024, in two Indonesian provinces with the highest prevalence of stunting East Nusa Tenggara (NTT) and Aceh. The selection of these provinces was based on data from the 2021 Indonesian Nutritional Status Study issued by the Ministry of Health. Both regions were chosen to represent areas with distinct sociocultural contexts and consistently high rates of stunting and tobacco use.

Study participants and sampling

Participants were selected using purposive sampling, focusing on individuals capable of providing rich and relevant insights into parental smoking behavior and its influence on child health. The inclusion criteria required that participating families have at least one child under five years of age who had been clinically diagnosed with stunting by the puskesmas (community health center) or the provincial stunting task force. Either the father or mother (or both) had to reside in the same household, demonstrate willingness to participate by providing informed consent, and have lived in the research area for at least one year to ensure contextual familiarity. A total of 11 families were selected from each province, and sampling continued until data saturation was reached when no new themes or patterns emerged from the final interviews. To confirm saturation, one additional interview was conducted in each province. In addition to these primary informants, supporting participants, including local government officials, academic experts, and health workers, were interviewed to triangulate and strengthen the validity of the findings.

Data collection tool and technique

Data were collected using a combination of semistructured interviews and focus group discussions (FGDs) to obtain comprehensive insights into parental smoking behavior and its impact on child health. Individual and small-group interviews were conducted with both parents of stunted children using an interview guide containing open-ended questions such as: “What are the main reasons fathers smoke around children?” “How does smoking affect household spending on food?” and “What could motivate parents to create smoke-free homes?” In addition, two FGDs were organized in each province, each consisting of 6–8 participants including fathers, mothers, and local health cadres who met the same inclusion criteria as interview participants. Each session lasted approximately 60–75 minutes and was held in a private room at the puskesmas to ensure confidentiality. All interviews and discussions were audio-recorded with participant consent and later transcribed verbatim. The data were analyzed using a reflexive thematic analysis framework, which facilitated the identification of recurring themes related to smoking habits, parental knowledge, and motivation for behavioral change. Furthermore, the integration of interview and FGD data through methodological triangulation strengthened the credibility and validity of the study’s findings.

Ethical consideration

Ethical approval for this research was obtained from the relevant Institutional Review Board (IRB) and local health authorities in both provinces. Prior to participation, each respondent was informed about the purpose, procedures, and voluntary nature of the study. Written informed consent was obtained from all participants. Confidentiality was maintained throughout the process by anonymizing personal identifiers and ensuring that all recordings and transcripts were securely stored. Participants were also assured that they could withdraw from the study at any time without consequence.

Statistical analysis method

Because this study adopted a qualitative design, data were analyzed using nonstatistical, thematic methods rather than quantitative statistical tools. Thematic coding was performed manually and iteratively to identify key patterns and relationships among responses. Data from interviews and FGDs were compared and cross-verified to ensure consistency. Supporting descriptive data such as demographic and socioeconomic information were summarized using simple frequency distributions to provide contextual background.

Results

The findings are organized by the three research questions and integrate interview and FGD evidence with provincial context on stunting, poverty, and smoking in East Nusa Tenggara (NTT) and Aceh. Three major themes emerged: exposure history in households with stunted children, parental knowledge of the smoking–stunting link, and motivation for behavioral change following a stunting diagnosis.

Contextual background: Stunting and poverty patterns in NTT and Aceh

Across Indonesia’s 34 provinces in 2022, stunting ranged from 8% to 35.3%, while poverty ranged from 4.53% to 20.23%. NTT sat at the top end of both distributions, with stunting near 35% and poverty just above 20%, and Aceh also clustered high, with stunting slightly above 31% and poverty near 15%. As presented in Table 1, these provincial disparities illustrate how limited household resources and nutritional insecurity create conditions in which growth faltering is more likely. However, they do not imply that stunting is confined to low-income households, as suboptimal caregiving and dietary practices can also drive stunting even where material resources are adequate.

Table 1.

Key indicators for NTT and Aceh

Province		Stunting (%)		Adult male smoking (%)		Poverty (%)
NTT		35.3		26.6		20.2
Aceh		31.2		28.6		14.7
Indonesia (national)		24.4		28.0		9.4

These data closely reflect the socioeconomic profiles of the participating families, reinforcing the observed association between poverty and stunting prevalence in the study areas. As shown in Figure 1, the vast majority of parents of stunted children in West Sumba Regency, NTT, earned less than IDR 500,000 per month, indicating a severe limitation in household purchasing power for nutritious food and healthcare.

Figure 1.

Percentage of parental income in families with stunted children in West Sumba Regency, NTT, 2022

Household socioeconomic profile (prose in lieu of Tables 2 and 3)

The socioeconomic characteristics of families with stunted children in East Nusa Tenggara (NTT) and Aceh are summarized in Table 2 and Table 3. Among the eleven NTT families interviewed, fathers predominantly held informal or nonpermanent jobs mechanic, driver, construction laborer, small-shop owner, or similar with monthly income typically between IDR 1.5 and 3.0 million. When compared with the 2024 provincial minimum wage in NTT of IDR 2.2 million, most fathers earned below the local standard. In Aceh, economic constraints were even more evident: the eleven fathers generally reported income between IDR 1.0 and 1.5 million per month, which is far below the province’s 2024 minimum wage of IDR 3.5 million. This socioeconomic profile reinforces the financial trade-offs families face in meeting nutrition needs for mothers and young children.

Table 2.

Socioeconomic characteristics of families with stunted children in East Nusa Tenggara (NTT)

Characteristic		Description
Study location		Kupang City (Kayu Putih and Tuak Daun Merah)
Number of families		11
Fathers’ main occupations		Informal and non-permanent work (mechanic, driver, construction laborer, small-shop owner)
Monthly household income		IDR 1.5–3.0 million
Provincial minimum wage (2024)		IDR 2.2 million
Income relative to minimum wage		Mostly below provincial minimum wage
Child age range		Predominantly 1–2 years
Child nutritional status		Underweight or severely underweight; short or severely short for age

Table 3.

Socioeconomic characteristics of families with stunted children in Aceh

Characteristic		Description
Study location		Aceh Besar (Masjid Raya subdistrict: Neuheun and Meunasah Keudee villages)
Number of families		11
Fathers’ main occupations		Informal and low-income employment
Monthly household income		IDR 1.0–1.5 million
Provincial minimum wage (2024)		IDR 3.5 million
Income relative to minimum wage		Substantially below provincial minimum wage
Child age range		Predominantly 1–2 years
Child nutritional status		Underweight or severely underweight; short or severely short for age

Stunting–smoking patterns at provincial and household levels

Provincial data indicate that regions with high stunting prevalence often exhibit similarly elevated rates of smoking among adult men. NTT and Aceh exemplify this dual burden, with male smoking rates commonly ranging between the mid-20s and low-30s in percentage terms. Household interviews further revealed that most fathers in both provinces were moderate to heavy smokers, typically consuming about one pack per day, and in several cases up to two packs daily. Smoking was deeply embedded in household routines, frequently occurring indoors or on porches where mothers and children were present. As shown in Figure 2, most parents in families with stunted children in West Sumba were active smokers, underscoring the pervasive nature of tobacco use in low-income households. This combination of chronic secondhand smoke exposure and the diversion of limited household income from nutritious food to cigarettes emerged as a consistent mechanism linking tobacco consumption to child growth faltering.

Figure 2.

Percentage of smoking parents in families with stunted toddlers in West Sumba, NTT, 2022

Theme 1: Exposure history in families with stunted children

In NTT, every mother interviewed reported exposure to cigarette smoke both inside the home and in the surrounding environment during pregnancy and the child’s early years. In Aceh, nearly all mothers ten of eleven reported similar exposure, with one exception in a household where the father was a nonsmoker and the neighborhood was relatively smoke-free. Interview narratives described long-standing, routine exposure, for example when a mechanic’s workshop shared a roof with the family dwelling or when shopkeeping meant sitting for hours in a space where husbands and visitors smoked. Even when fathers worked outside the home, smoke exposure often continued in leisure settings or informal gatherings after work.

Theme 2: Parental knowledge of the smoking–stunting link

Before the study interview, none of the eleven NTT parents reported knowing that secondhand smoke could contribute to stunting. In Aceh, two of eleven parents were familiar with stunting as a nutrition problem but did not connect it to cigarette smoke; most learned of the link only during the interview. Parents noted that growth monitoring and general nutrition messages were regularly provided by health workers at the puskesmas and posyandu, yet counseling rarely addressed tobacco exposure as a driver of growth faltering in pregnancy and early childhood. This gap helps explain why smoking around pregnant women and toddlers was normalized in many households, even when parents were broadly aware that “nutrition matters.”

Theme 3: Motivation for behavioral change

Following a stunting diagnosis, mothers consistently expressed readiness to avoid smoke exposure and to keep children away from smoking areas at home or in the neighborhood. Fathers’ motivation to quit was generally weak in both provinces, despite awareness of the child’s condition. Several mothers described short periods of abstinence among their husbands often during Ramadan followed by relapse, citing dependence and social norms. Only one household in Aceh reported a nonsmoking father. Overall, the asymmetry between mothers’ avoidance strategies and fathers’ limited cessation efforts underscores the need for targeted cessation support and stronger smoke-free-home norms.

Additional supporting evidence from routine data

Programmatic data align with these qualitative patterns. In NTT in 2023, records from the Elsimil system indicated that nearly half of prospective brides were exposed to cigarette smoke, while a slight majority of prospective grooms were active smokers. In Aceh in the same year, exposure among prospective brides was lower, at about one in five, and exposure among prospective grooms was roughly two in five; taken together, about one-third of all prospective brides and grooms reported exposure. Among pregnant women in Aceh in 2023, approximately three in ten reported smoke exposure during pregnancy, a level that raises concern for fetal growth and complements the mothers’ accounts of routine household exposure. Within NTT’s health surveillance, pediatric tuberculosis remained substantial in 2023, with more than eight hundred confirmed cases across twenty-three districts. While causation cannot be inferred from these descriptive data, the co-occurrence of tobacco exposure, undernutrition, and pediatric TB points to compounding respiratory and immunological risks for children living in smoking households.

Participant profiles (NTT and Aceh)

All eleven NTT informants resided in Kupang City, split between Kayu Putih and Tuak Daun Merah. At the time of assessment, most children were between one and two years old and were classified as underweight or severely underweight and short or severely short for age. In Aceh, the eleven informants lived in Aceh Besar, concentrated in the Masjid Raya subdistrict across Neuheun and Meunasah Keudee villages; anthropometric patterns were similar, with most children falling below expected weight-for-age and height-for-age benchmarks. These parallel profiles across provinces help explain why mothers’ narratives of smoke exposure, financial strain, and feeding difficulties were so consistent.

Integrative interpretation

Taken together, the results depict a consistent risk environment in which repeated secondhand smoke exposure during pregnancy and early childhood is common, parental knowledge of tobacco’s role in stunting is limited, and cessation motivation among fathers is weak even after a growth-faltering diagnosis. Financial constraints intensify this risk by shifting scarce resources toward cigarettes and away from nutrient-dense foods, while background morbidity including pediatric TB in NTT adds further stress to growth and immunity. The convergence of exposure, low awareness, and economic strain helps explain the persistence of stunting in these high-burden communities and clarifies why smoke-free-home interventions, father-focused cessation support, and nutrition assistance should be delivered together rather than in isolation.

Discussion

Smoking behaviors in families of stunted children can be explained through Giddens’ Structuration Theory, where daily household actions such as fathers smoking indoors both reflect and reinforce social norms of masculinity and relaxation. Over time, these practices become normalized within family life, shaping expectations that tolerate smoking around women and children.[11] Change occurs when individuals, particularly mothers, critically reflect on these norms and resist them by avoiding smoke exposure. Such acts of agency, when supported by community-based programs and smoke-free-home initiatives, represent early but meaningful steps toward transforming household structures and promoting healthier family environments.[12]

The Stimulus–Organism–Response (S–O–R) model explains how individuals react to health education and policy efforts. In this study’s context, public health messages, posyandu counseling, and smoke-free-home campaigns serve as external stimuli that influence parents’ perceptions, emotions, and knowledge.[13] The effectiveness of behavioral change depends on the credibility, consistency, and emotional strength of these messages. Fathers who receive repeated guidance from trusted health workers are more likely to reduce or quit smoking, while weak or irregular communication has minimal effect. Thus, the S–O–R framework complements Structuration Theory by illustrating how targeted interventions can reshape household smoking norms.[14]

The study’s findings highlight the close link between social structure, individual behavior, and health outcomes. Most fathers of stunted children were active smokers ranging from light to heavy users and commonly smoked inside the home. This mirrors national data showing that male smoking prevalence in NTT and Aceh remains among the highest in Indonesia. The widespread exposure of mothers and children to secondhand smoke demonstrates how domestic smoking has become socially normalized. These results align with research by the Center for Social Security Studies (PJKS UI), WHO, and ADB, which confirm that parental smoking increases children’s risk of stunting through health and economic impacts.

Empirical evidence shows that exposure to cigarette smoke during pregnancy or early childhood disrupts nutrient absorption, hampers fetal development, and heightens the risk of infections that impede growth. Prolonged exposure to toxins like nicotine and carbon monoxide reduces oxygen delivery and damages cell metabolism, impairing both physical and cognitive development.[15] This study also found that most parents of stunted children lacked adequate knowledge about stunting, its causes, and long-term impacts. While community health programs emphasize nutrition, they rarely address smoking as a risk factor. Similar findings in Bangladesh and the Philippines link higher maternal education to reduced stunting rates, underscoring this knowledge gap.

The findings reveal a strong interconnection between poverty, nutrition, and smoking behavior. Most families in NTT and Aceh live below the provincial minimum wage, limiting their capacity to meet nutritional needs for mothers and children. The allocation of scarce income to buy cigarettes worsens household food insecurity. Data from Statistics Indonesia (BPS) show that cigarettes are the second-largest expenditure among poor families, after rice. This financial strain, coupled with the health risks of secondhand smoke, perpetuates the cycle of poverty and malnutrition. The persistence of smoking, despite hardship, reflects both addiction and its cultural association with masculinity and social identity.[16]

Addressing this problem requires stronger coordination between government structures and community agency. Stunting prevention should move beyond top-down approaches to include the real needs, beliefs, and cultural contexts of families. Government budgets must prioritize direct support for maternal and child nutrition rather than administrative expenditures. Similarly, tobacco control policies should be enforced more consistently through advertising restrictions, smoke-free public spaces, and higher tobacco taxes. However, evidence indicates that raising cigarette prices alone does not significantly reduce smoking rates. Therefore, information campaigns must be paired with firm enforcement and community engagement to promote meaningful behavioral change and sustained public health improvement.[17]

According to Hovland’s theory of persuasion, information alone rarely drives lasting behavioral change without supportive policies that reinforce consistent public action. Poor health practices persist not only because of limited knowledge but also due to weak policy implementation and enforcement. Therefore, effective community education management must integrate clear, persuasive communication with structural support that makes healthy behavior easier to adopt. Key obstacles include low public awareness, cultural acceptance of smoking, restricted access to health education, and economic reliance on tobacco. Even so, several promising strategies can enhance public education and strengthen interventions to reduce smoking-related stunting risks.[18]

Community-based education programs that actively involve local leaders and families are vital for raising awareness about the dangers of smoking and its link to child stunting. Collaboration between government health offices, NGOs, and academic institutions can strengthen message credibility and expand outreach. Digital platforms and social media can further engage younger generations and fathers, who are often the primary smokers in households. At the same time, integrating smoke-free-home initiatives with nutrition education promotes a holistic understanding of child health.[19]

This study confirms that smoking in families with stunted children is a socially rooted behavior influenced by poverty, culture, and weak enforcement. Applying Structuration and S–O–R theories reveals that change requires both structural reforms and sustained behavioral reinforcement. Effective community education should prioritize active participation, culturally tailored content, and continuous monitoring to ensure sustainability. Locally driven programs, supported by technology and multi-stakeholder partnerships, can foster accountability, trust, and long-term engagement.[20] By combining education, enforcement, and collaboration, communities can gradually transform social norms, reduce tobacco exposure, and improve family and child health outcomes. Such efforts are essential to achieving Indonesia’s Golden Indonesia 2045 vision through stronger human capital and healthier future generations.[21]

Limitations and recommendation

This study has several limitations. It used a small purposive sample from only two provinces NTT and Aceh so findings cannot be generalized nationally. Data relied on self-reported interviews and discussions, which may involve recall or social desirability bias, especially concerning smoking behavior. In addition, the study lacked objective biological or environmental measures of smoke exposure. Future research should expand to more provinces, apply mixed-methods approaches, and include longitudinal designs to explore causal links between parental smoking and stunting. Evaluating smoke-free-home initiatives and community education programs is also essential to develop sustainable strategies for reducing smoking and child stunting.

Conclusion

Addressing and preventing stunting associated with parental smoking requires a comprehensive and collaborative approach that engages multiple stakeholders through effective community education management. This process involves careful planning, organizing, implementing, and evaluating educational interventions designed to improve public knowledge, skills, and awareness.

By strengthening community understanding of the health and economic consequences of smoking, and offering practical solutions for behavior change, Indonesia can make meaningful progress toward reducing stunting and improving family well-being. The study revealed that most fathers of stunted children in East Nusa Tenggara (NTT) and Aceh are active smokers, often smoking near their wives and children at home or in vehicles. As a result, mothers and infants experience routine secondhand smoke exposure, especially during pregnancy and early childhood. This exposure is compounded by low parental awareness of smoking’s link to stunting and fathers’ limited motivation to quit, even after diagnosis.

Active and passive smoking during pregnancy exposes mothers to nicotine and other toxins that can reduce appetite, impair nutrient absorption, and increase the risk of premature birth and low birth weight—major risk factors for stunting. Economically, household income spent on cigarettes reduces the budget available for nutritious food and healthcare, further deepening malnutrition. To address these dual challenges, health education on the dangers of smoking should be systematically integrated into existing programs such as prenatal classes, posyandu (community health posts), and nutrition education initiatives. Using the same platforms for anti-smoking and stunting-prevention campaigns ensures wider outreach and cost efficiency.

A holistic approach—combining smoking prevention, nutrition promotion, and behavioral counseling—can foster sustainable change. Education should target fathers, mothers, adolescents, and community volunteers, supported by trained health cadres and digital media campaigns. Implementation should include interactive sessions, group counseling, and culturally sensitive strategies that align with community norms. Evaluation must track improvements in awareness, behavioral change, and reductions in children’s exposure to cigarette smoke.

Despite these promising pathways, several challenges remain: limited community knowledge about the health risks of smoking for children; nicotine addiction among fathers; environmental influences such as cigarette advertising and social pressure; and traditional practices that normalize tobacco use. Nonetheless, growing public awareness, expanding stunting-prevention programs, and stronger stakeholder collaboration present opportunities for sustainable progress.

Using AI

No generative artificial intelligence (AI) tools were used in the design, data collection, analysis, interpretation, or writing of this manuscript.

Author’s contributions

All proposed the topic of this research and designed the study, collected the data. All the authors contributed to preparation of the final draft of the manuscript was reviewed and revised critically for intellectual content, as well as drafting and revising the final manuscript. All authors approved the final version of this manuscript.

Conflicting interest

The Author declares that there is no conflict of interest.

Funding Statement

Nil.