‘Excuse me, sir. Please don’t smoke here’. A qualitative study of social enforcement of smoke-free policies in Indonesia

Abstract

Objective District policies were recently put into place in Indonesia prohibiting smoking in public spaces. This study sought to (1) assess participants’ general knowledge of secondhand smoke (SHS) dangers; (2) assess participants’ awareness of and specific knowledge of smoke-free (SF) policies; and (3) assess the extent to which such policies are socially enforced and gather examples of successful social enforcement.

Methods Qualitative in-depth interviews and focus group discussions were conducted in Bogor and Palembang cities with both community members and key informants such as government officials, non-government agency staff, religious leaders and health workers.

Results Participants in both Palembang and Bogor find SF policy important. Although there was awareness of SHS dangers and SF policies, accurate knowledge of the dangers and an in-depth understanding of the policies varied. There was a high level of support for the SF policies in both cities among both smokers and non-smokers. Many participants did have experience asking a smoker not to smoke in an area where it was restricted, even if their comfort in doing so varied. There was, however, a higher level of comfort in telling smokers to stop or to move away from pregnant women and children. Hesitation to socially enforce the policies was especially present when asking men of status and/or community leaders to stop smoking, but overall participants felt they could comfortably ask someone to obey the law.

Conclusion Palembang and Bogor may be evolving towards creating social norms in support of prohibiting smoking in public spaces. If provided with more support from government and law officials, such as government officials themselves promoting the policies and demonstrating compliance, and renewed efforts to promote and enforce policies in general were made, Indonesians in these cities may feel more confident protecting non-smokers from SHS.

KEY MESSAGES.

• To change long-standing Indonesian cultural norms to protect non-smokers’ health, social enforcement of smoke-free (SF) policies is needed.

• There is a high level of support for SF policies in two studied cities in Indonesia, indicating social enforcement of SF policies may be the norm in the near future.

• Despite awareness of the dangers associated with second-hand smoke and SF policies and a willingness to tell non-smokers to stop smoking near pregnant women and children, many reported a lack of confidence in asking men and/or community leaders to stop smoking.

• Increased government support of SF policies would lead to increased social support of SF policies.

Introduction

Indonesia has one of the highest rates of tobacco use in the world. Sixty million Indonesians smoke, representing 35% of the overall population (67% of men) (Centers for Disease Control and Prevention (CDC) 2012). In addition, there is considerable exposure to secondhand smoke (SHS): 51% of adults are exposed in the workplace, 78% at home and 85% in restaurants (CDC 2012). Smoke-free (SF) policies are an effective intervention to reduce exposure to SHS, reduce cigarette consumption and ultimately improve health outcomes (Brownson et al. 1997; Eriksen and Cerak 2008; Hahn 2010; Lin et al. 2013; Millett et al. 2013).

A few local jurisdictions in Indonesia have enacted SF regulations, known as Kawasan Tanpa Rokok (KTR). Bogor and Palembang cities enacted SF regulations in 2009, and Jakarta province did so in 2010. We chose Bogor and Palembang as the location of the current research because they are both early adopters of KTR but are markedly different in their cultures. Palembang City is the capital of the South Sumatra Province, located on Sumatra Island, the second largest island in Indonesia, with a population of 1.5 million people. It is a very multi-cultural city but has strong Malay and Javanese influences. It is the first city on Sumatera Island to adopt KTR policy, and it has been used as an example for other Indonesian cities seeking to adopt and enforce KTR. Bogor City is located about 60 km south of Jakarta, Indonesia’s capital. Bogor has a population of about 1 million people, many of who commute to Jakarta for work. On Java Island, Bogor is among the few cities that have enacted local KTR policies. Bogor’s experience in advocating for KTR is well recognized by the Ministry of Health, which has documented it as one of the country’s success stories regarding tobacco control (Centre for Health Promotion 2010).

Under general KTR policy, smoking is not allowed in designated public places, including public transport, schools, hospitals, mosques, restaurants, offices and malls. In Palembang, smoking is also banned at the airport (Palembang City Local Regulation #7 year 2009 on Free Smoke Zone), whereas in Bogor smoking is prohibited additionally in markets, factories and theatres.

In terms of enforcement, in Bogor City it is directed towards the individual. Bogor officials established a mobile court that provides official warnings and fines to those caught in violation. According to Bogor regulation, a fine of 50 000 Indonesian rupiah (IDR) (∼$5.15 USD) to 100 000 IDR (∼$10.30 USD) is to be applied per violation. On the other hand, Palembang City directs enforcement of KTR to building owners and/or management. Building managers can be fined 10 000 000 IDR (∼$1 010 USD), their business permit can be revoked, or they could face 3-month imprisonment for violating the law. A 500 000 IDR (∼$50 USD) fine applies if an ashtray is found, 1 000 000 IDR (∼$100 USD) if non-smoking area signs are not posted and 500 000 IDR (∼$50 USD) if violators are not asked to smoke outside. Although these laws exist in principle, it is not known to what extent they are actually enforced.

Studies of social norms that are accepting of SF policies in other settings have shown policy compliance is related to several factors. For instance, a study in Greece and Bulgaria found that smokers’ compliance with such policies was associated with perceived health risks of smoking (Lazuras et al. 2012). Other studies have found that social norm change is key for long-term compliance with SF policies (Miller and Hickling 2006; Brown et al. 2009; Orbell et al. 2009; Thrasher et al. 2009; Satterlund et al. 2012). A study among rural communities in the USA suggests that emphasizing religiosity and social norms may be a culturally sensitive approach to promoting SF polices in these communities (Kostygina et al. 2014).

Despite a very high rate of tobacco use in Indonesia, there is little research focused on household and community reactions to SHS dangers or social support (or lack thereof) for SF regulations (Nichter et al. 2010). There is also limited public opinion data that illustrate high social support for SHS regulations in some locations in the country (International Union Against Tuberculosis and Lung Disease 2009). This study attempts to fill this knowledge gap.

Numerous studies in high-income countries have reported that SF policies are self-enforcing (Burns et al. 1992; Hyland et al. 1999; Borland et al. 2006). Furthermore, some studies have shown that non-smokers can be assertive about their right to clear air, providing social enforcement for these policies (Poland et al. 1999, 2000; Lazuras et al. 2012). With smoking so pervasive in Indonesian society, and with gender roles that equate smoking with masculinity (Ng et al. 2008), we were interested in assessing how comfortable ordinary citizens felt engaging in social interactions that could influence smokers to comply with KTR policies, such as asking smokers to move away from an area where it is restricted or to stop smoking altogether.

This study was conducted as rapid formative research for a potential strategic community mobilization campaign to increase compliance with KTR policies. This work was conducted with funding from the Bloomberg Initiative to Reduce Tobacco Use, which is focused on supporting low- and middle-income countries with the most numbers of smokers to enact the World Health Organization’s MPOWER policy package. The implementation of SF polices (protect people from SHS) is one of the MPOWER priorities. Although Palembang and Bogor had both enacted SF policies, there were reports from the ground that there was not complete compliance with these policies. Therefore, this study was undertaken to gather information that could be used for a strategic communication mobilization campaign to support increased compliance with the SF policies.

We were specifically looking at whether and how social norms (unwritten rules about behaviour; Chaiken et al. 1996) are applied in this context and how they could be harnessed to create further social change. Social norm change involves changes in beliefs, attitudes or behaviours that result from interpersonal interaction or other forms of communication, such as mass media (Turner 1995; Cialdini and Trost 1998). We wanted to investigate whether bans on SHS are socially acceptable, and if social norms permit people to enforce them. The specific objectives of this research were to: (1) assess participants’ general knowledge of SHS (also referred to locally as ‘passive smoking’); (2) assess participants’ awareness of and specific knowledge about KTR in Bogor and Palembang cities and, most importantly, (3) assess the extent to which such policies are socially enforced and gather examples of successful social enforcement.

Methods

Qualitative data in the form of in-depth interviews (IDIs) and focus group discussions (FGDs) were collected in May 2012 in Bogor and Palembang cities. In March 2012, the first and third authors visited the cities and met with potential key informants to alert them to the need for participants in the coming months. Contacts for the recruitment of community participants were also obtained during that time. An interview schedule with potential participants was arranged ahead of fieldwork, and a team of four fieldworkers was dispatched to collect data in May 2012. The fieldworkers were local Indonesians who had at least a university degree and extensive experience collecting data on public health and community issues for non-governmental organizations universities and donors. Although they possessed ample research experience, the first and third authors trained the team on the research protocol, treatment of human subjects and how to gather rich, valid qualitative data.

Participants

IDIs were conducted with 19 participants in Bogor and 18 in Palembang. Of the IDIs, eight interviews were conducted with community members (four male, four female) in each city. The community informants were chosen from the lists of community members provided by health workers who fit the research criteria (which were verified during recruitment). In addition, the following key informants were interviewed: City Health Office Chief (a medical doctor by training), the Chief of a local health centre, hotel/restaurant/mall management personnel (n = 3 in each city), tobacco control NGO or advocacy staff (n = 2 in Palembang, n = 5 in Bogor), the Chief of the civil police (Bogor) or a key staff member (Palembang) and two religious leaders per city. The mayor of Palembang was also interviewed. Of the 31 IDI participants who disclosed their smoking status, only 5 were smokers (all of who were from the community member sample of 16 people, and a mix of men and women). Also, of the 31 IDI participants, 15 reported someone in their household is a smoker.

FGDs were conducted with two groups each of men and women per city, as well as a group of community leaders in each city that included teachers, health advocates and religious leaders for a total of 63 participants across five groups. FGDs were held with 8–10 people per group with genders separated. Of the FGD participants, 25 identified as smokers, and 31 reported someone in their household is a smoker.

Community member participants for both the IDIs and FGDs came from mid-low and lower socioeconomic classes and a wide range of educational levels (community leader participants were naturally from higher class and education levels). We chose these community member groups because cigarette smoking is higher among those with lower educational attainment in Indonesia (World Health Organization 2012). Community participants in this study belonged to a mix of smoking and non-smoking households.

Procedure

Participants were recruited through established contacts in the community [e.g., head of each health office, health cadres (trained personnel), NGO leaders working in KTR advocacy and religious leaders]. All contacts were invited to participate in an interview and to recommend additional key informants as needed via snowball sampling. Participants provided informed consent. Interviews were conducted in Bahasa Indonesia or Sudanese in private locations in the participants’ home, office or a community space. FGDs were conducted in community centres or health centres.

All interviews and FGDs were audio recorded, transcribed and translated into English. Two independent coders completed coding of IDI and FGD English transcripts using Atlas.ti qualitative software. Using thematic analysis (Braun and Clarke 2006), attitudes and experiences were classified and interpreted. A codebook was created based on the interview guide, which included broad themes such as SHS knowledge, policy awareness and understanding, and experiences with social enforcement of policies. Second, the data were categorized by subthemes emerging from each broader category in order to analyse the variation in perception and experience across participants. Two researchers coded the data autonomously using the same coding approach and codebook, and inter-coder reliability was assessed at >85% agreement of all coded excerpts (Lombard et al. 2002). The coders then compared and discussed their interpretations until reaching full agreement. An Indonesian colleague also assessed interpretations of emergent themes to ensure accuracy.

Interview questions addressed topics such as social norms around smoking, knowledge of KTR in each city, attitudes towards the policy, experience with personal enforcement of the policy, ideas for further enforcement and ways to move SF towards becoming a social norm. In addition, those in FGDs participated in a photo elicitation exercise. This involved showing five different photos of smokers in public spaces in different scenarios (e.g., people smoking in a closed space, government officials smoking, a man smoking near a pregnant woman). FGD participants were asked to describe what came to mind when seeing the photo, what was happening in the photo and what emotions it elicited, whether the photo represented their community and what they would do if they saw this situation occurring. This exercise was used as an icebreaker for the groups and was designed to elicit initial reactions to SHS and intended actions. We did not analyse the data specifically for responses to the photo elicitation exercise, but rather all conversation in the FGDs was analysed without distinction.

Results

Several themes emerged from the data, including discussions of SHS dangers, opinions of the KTR policies, smoking social norms currently in place and, of most importance to this article, social enforcement of the policies.¹

SHS dangers

Participants (both community members and key informants) were generally aware of many dangers and harmful effects of tobacco use and exposure to SHS, although accurate details beyond harm in general were not always known. Community members learned the knowledge they did have from local tobacco control campaigns, mass media messaging and through interpersonal interactions with health workers and family members. They cited many illnesses, diseases and symptoms that result from smoking and SHS, including lung cancer, heart and throat disease, as well as coughing and dizziness. They also mentioned smoking is an addiction, poisonous, smells, pollutes and harms a foetus. Community participants generally felt smoking can be harmful only in closed or confined spaces such as buses, restaurants, hospitals, schools and air-conditioned areas. Smoking outside, such as in parks, was not considered harmful by most participants. The risks of SHS exposure are reflected in a comment related to the recent death of the Indonesian Minister of Health:

“… it [SHS] causes lung cancer. For example the Madame Minister of Health, she got lung cancer but she didn’t smoke. She was passive, I saw it on TV” (female, Bogor, FGD).

Although there was widespread understanding that exposure to SHS is dangerous and leads to disease, there was confusion and some misconceptions as to which kind of exposure is more dangerous. A number of community participants thought SHS exposure and inhaling smoke through the nose is more dangerous than smokers who inhale smoke through their throats.

Opinions of KTR

Almost all participants (regardless of their gender, own smoking status, or city, including both community and key informant participants) felt KTR is needed to protect the health of non-smokers. Although there were inconsistencies in the recall of the specific details of the warnings or fines associated with the policy, how enforcement was applied and who was responsible for enforcement, they did feel such policies are important. However, a few participants (both community members and key informants) thought some smokers may feel the policy is a violation of their human rights, and some reported seeing people unhappy with the associated fines or inability to smoke while eating in a restaurant or drinking coffee in a café. However, all participants were in agreement that the health of the non-smoker is more important. Participants also felt that health workers who meet with smokers who come to clinics (perhaps for reasons unrelated to smoking) could advise smokers to quit and at the same time educate them on the importance of the policy if they do continue to smoke. Participants felt this sort of health worker guidance could help secure smoker buy-in to the policy.

“It’s useful for the non-smoker. For smokers, they probably don’t want such regulation to exist. But we can’t blame the smoker, because it’s just a free condition [one’s personal choice]. But this regulation can be useful for the non-smoker. It’s respecting the non-smoking people” (male, Bogor, IDI).

Both community and key informant participants in both cities expressed support for the SF policy, but many were concerned about the lack of enforcement, and knowledge of the policy specifics does not allow for full compliance. In addition to overall support, community and key informant participants in both cities felt the policy needed to be accompanied by stricter regulation, including continuous enforcement and consequences for violation, as well as more promotion and prominent signage in areas where the policy is in place. Participants often mentioned the critical need for local government officials to set a good example in honouring the policy, and both community members and key informants stated this. Particularly in Bogor, many participants, particularly key informants, expressed displeasure at the fact that the local government put in place policy that city officials themselves often do not observe. Furthermore, some community participants suggested drastic measures such as closing cigarette factories to reduce access to tobacco products.

Social norms about smoking

To assess social norms around citizen enforcement of KTR, all participants were asked to describe norms around smoking in general. Many mentioned smokers’ addiction to tobacco and expressed empathy for smokers unable to quit. At the same time, smokers are considered ‘selfish’, ‘careless’ or ‘impolite’ if smoking in front of non-smokers, who often find it annoying and irritating.

“… he [the smoker] is careless to other people, just like we see the smoke goes everywhere and he has been addicted, so he is careless to this environment and other people” (male, Bogor, FGD).

However, there does appear to be social benefits for male smokers. According to community participants in particular, smoking portrays a masculine image, especially for young men smoking in front of young women. In fact, male participants said men may be considered ‘sissies’ (banci) if they do not smoke, although this sentiment was not echoed by women.

“It feels like a man if we smoke in front of our girlfriends” (male, Bogor, FGD).

Some participants suggested women who smoke have a poor image, indicative of smoking being seen as a male domain.

Despite the recognition that smoking is necessary for a young man to be viewed as masculine, there was considerable concern about how young youth are when they begin smoking. Both community and key informant participants stressed the importance of educating children at a young age about the dangers of smoking, and that parents must play a lead role in delivering prevention messages. Multiple examples of kids smoking at or near schools were mentioned by participants, as well as stories of teachers setting a poor example by smoking in schools, much like government officials who violate the policy in their offices.

Social enforcement of KTR

There was a wide range of comfort and experiences among the participants for asking smokers to adhere to the SF zones, ranging from complete confidence in intervening with a smoker (more common among key informants) to feeling a risk of offending the smoker (more common among community members). Despite discomfort expressed by some of the participants, the majority (regardless of their own smoking status) reported having asked smokers in buses, malls and villages to stop smoking on at least one occasion; some participants (particularly key informants) reported having done so multiple times. In malls, both community and key informant participants said they often pointed to the SF signage when asking a smoker to stop, and some cited the local regulations if they knew the details of KTR. It was common to mention SHS dangers in such interactions, especially regarding women and children, as a justification for their requests that smokers stop. One man, who was especially confident in his ability to intervene, described how he would do so during the photo elicitation exercise:

“I would be sharp and mean. [For instance] in the picture it is very clear that there is a local government regulation… I would be the fiercest directly. Why? It [smoking] is risky, clearly, and not in the right place. Moreover, it’s regulated by the local government” (male, Bogor, FGD).

Some community participants were not as confident and expressed discomfort in speaking up for fear of angering smokers and triggering retaliation, such as provoking a fight. They felt they were not ‘brave’ enough to take on a possible altercation:

“We let it happen because we don’t want a fight” (female, Bogor, FGD).

Some participants noted that smokers have rights, too, and it was their personal business when they smoked. Thus, some community participants in particular preferred walking away rather than confronting or offending a smoker, even if they did personally support the policy and might have intervened in a similar situation in the past. One man gave an example of when he would rather just walk away:

“Well, I can’t warn him since there is the officer who should do that. If I do that, it can be a misunderstanding, and the smoker will ask, ‘Who are you?!’ I will be ashamed, sir” (male, Bogor, FGD).

At the same time, many participants (both community members and key informants) had at least one experience of asking a smoker to observe a designated SF zone, perhaps signalling that these communities are evolving towards a social norm where intervening with a smoker in an SF zone is acceptable. Some of the participants are trying this type of intervention because they believe in the policy, even if it makes them uncomfortable in some situations. However, there were a number of situations noted in which participants felt justified in speaking up directly to the smoker, and those situations will likely build confidence in the community to intervene across multiple scenarios. Almost all participants (both community members and key informants) mentioned situations where a pregnant woman and children were nearby as acceptable for action, such as in a public bus or mall.

“I remember when I was in a small bus, there were senior high school students who smoked while there’s a mother who had just been breastfeeding her child. I warned, ‘Please put the cigarette off, there is a child.’ He understood and immediately put his cigarette off… The smoke was disturbing. It’s stuffy in the small bus” (male, Bogor, FGD).

Community participants also felt comfortable speaking up if they knew the smoker personally or when in their own community. These participants felt more empowered speaking up in clearly designated SF zones where signage was displayed. Many noted it is more effective to warn the smoker in a polite andnon-confrontational manner, such as with humour or gently pointing out a no smoking sign. In fact, these participants commented that it was more socially acceptable to alert asmoker to the signage instead of simply ordering him to stop.

“Maybe I do it with a joke so I feel comfortable, and there will be icebreakers… We can remind in a soft way so he doesn’t get offended” (male, Bogor, FGD).

Despite not wanting to offend smokers publically, almost all the participants (community and key informant) voiced support for SF enforcement at all levels and believed a new social norm in observance of SF zones is in order.

“So the culture used to see smoking as cool, trendy and macho, but actually now we have to change the mind set” (female, Bogor, IDI).

Many participants (both community and key informant) pointed out they easily ask children or younger people to stop smoking in public settings. However, many felt the most discomfort in asking smokers who were respected elders and/or had a higher status than himself/herself, such as a boss, a recognized leader or someone from a higher socio-economic status. There were several participants, however, who did feel ‘brave’ enough to directly ask their bosses to stop smoking in government offices, since it is well known the law prohibits it.

As discussed, many participants felt comfortable asking a smoker to stop if there is a pregnant woman nearby or a woman with children. At the same time, a few community participants believed it is a woman’s fault if she does not move away from a smoker while pregnant or with her children. This may be to avoid potential conflict with the smoker, but it puts the onus on the woman to be inconvenienced rather than the smoker violating the policy.

“At one place, there was a women and her child waiting for something, and then a man who is standing near started to smoke. I didn’t feel comfortable when I saw it from the back, moreover when the smoke goes to them. The woman closed her mouth because she can’t stand the smoke. So I went to the smoker and said, ‘Excuse me, sir, can you move a little bit? That woman can’t stand your smoke,’ and then he moved away” (male, Bogor, FGD).

Some men suggested women are better suited to ask smokers to stop or move away from non-smokers since people seem more willing to stop smoking in front of a woman. Also, smokers are less likely to get into a fight with women.

Although some community participants are still tentative to consistently socially enforce KTR in all situations, it was clear that under certain circumstances, such as in the presence of children and pregnant women, when clear signage is in place, or when in one’s own community, it was easier to speak up to a smoker violating KTR. Some participants even noticed the change in SF zone norms themselves.

“The public has made their own norm, they say, ‘Please don’t smoke, it’s the old style. Why are you still smoking?’ So the existing norm that we’ve noticed [now] is that you can see in the mall nobody is smoking; it’s just one or two” (male, Palembang, IDI).

Both smokers and non-smokers, too, mentioned the support for movement towards respecting the law and ensuring others do.

Discussion

This study found a high level of community support for SF regulations. Even when looking at the data for smokers vs non-smokers, there was consistency of regulation support in both groups. Results also showed community and key informant participants in both Palembang and Bogor find the KTR policy important, but overall there is still hesitation in some circumstances to socially enforce these policies, even if participants have tried interventions in the past, as many participants (including community members) in both cities did have experience asking a smoker not to smoke in a restricted area at least once. There was also a high level of comfort in telling smokers to stop smoking or to move away from pregnant women and children. What appeared to be a lack of complete confidence in being able to speak up became relevant especially for women when asking men and/or community leaders or elders to stop smoking. Community participants spoke about their hesitation not so much in the context of being timid, but rather in the context of a socially acceptable intervention and a not socially acceptable one, with asking an elder or someone with more status being socially unacceptable. Clearly, the cultural context whereby elders and community leaders are the most respected members in the community plays a part in social enforcement techniques. Perhaps with more practice in social enforcement with one’s peers of equal status, or as such interventions become more common, a critical mass will be reached whereby intervening with smokers in SF zones, regardless of their status to the one speaking up, will become the social norm.

There were some misconceptions among community participants about SHS and specifics of the KTR policies in each city. However, there was clear awareness of SHS’s dangers, especially for pregnant women and children. All community and key informant participants were aware of the existence of SF regulations, although the level of recall of specific details varied. These findings indicate a need to further educate the public about the specific dangers of SHS and to increase awareness of the KTR policy details. With a more in-depth understanding, it is possible that a higher level of support for the policies will occur naturally (Center for Tobacco-Free Kids 2008; Hahn et al. 2012).

Any hesitation in speaking up to smokers violating the policy was also linked to a feeling by some participants that prohibiting smokers to smoke in public spaces is a violation of human rights. Even if such participants acknowledged the rights of non-smokers to breathe clean air, they felt smokers have equally important rights. Again, perhaps future promotion of the policy could include language emphasizing that exposing a non-smoker to SHS is perhaps a greater violation of the human and health rights than it is to ask smokers to refrain in public spaces. According to Gonzalez and Glantz (2013), implementation efforts need to deal with opposition to the law in order to be fully effective. Of course this would have to be done in conjunction with clearer understandings of the magnitude of SHS dangers (Currie and Clancy 2011; Kuiper et al. 2013). If community members were to view the violation of human rights to be greatest on the side of non-smokers, perhaps asking smokers to forego their right to smoke until in a non-regulated area may be more likely.

This study provides a unique look into social norms surrounding SF policies in a country where smoking is highly prevalent and often viewed as part of the cultural heritage. The data reflect that SF norms may be evolving towards greater acceptance given widespread support for SF and willingness to experiment with speaking out in support of it. Increased government promotion and enforcement, as well as clearing up misconceptions related to SHS, would provide the support and social permission for men and women to speak up with more confidence and to socially enforce the SF regulations.

Limitations

Although generalizable findings are not a useful standard or goal for qualitative research, studies conducted to examine a particular phenomenon in a unique setting may contribute to the body of knowledge about that phenomenon. This study, with elaborate descriptions of attitudes towards the policies and examples of social enforcement (or reasons for the lack thereof) can inform future studies that aim to understand the larger social context and influence change. As a qualitative research study, the data collected and conclusions drawn cannot be generalized at the population level or even to the cities of Bogor and Palembang. These are the experiences of the community and key informant participants of this study only. However, these data are valuable in that they provide examples of how citizens from these cities are interpreting and socially enforcing (or not) these SF policies.

Implications

According to both community and key informant participants, the first step to social reinforcement of SF policies is further government promotion of KTR and visible enforcement by city officials. More visible and active government enforcement would increase the comfort level for ordinary citizens to feel greater confidence in socially enforcing KTR when they observe violations, especially among those of higher status. At the time of data collection, posters, signs, community education forums and public service announcements were already in place in both cities or had been carried out previously, with signage still in place. A majority of community and key informant participants felt true government promotion and enforcement of the policy were the next crucial steps to compliance. This was found to be a factor crucial to compliance in other contexts (Currie and Clancy 2011).

Relatedly, both community and key informant participants also felt role models are important to demonstrate compliance with the SF policies. Greater visibility of local officials adhering to and promoting SF zones could bolster citizens’ willingness to socially enforce the regulations. Government officials are seen as key role models for demonstrating the local government’s commitment to SF, principally in government offices as well as all SF areas. Additional potential role models suggested by community participants who could successfully promote KTR included community elders, teachers, medical personnel, certain celebrities and especially ulemas (religious leaders). Although not mentioned by participants, modelling of peer-to-peer social enforcement via mini dialogues on the radio or a public service announcement campaign depicting various role models enforcing KTR, including peers or regular citizens to which audiences could relate, would be important.

In addition, many community participants felt women are best suited for leading the social enforcement of KTR because of Indonesian gender norms whereby men are expected to show respect for and take care of women and children. If women were to collectively hold men accountable for protecting women’s health by asking men to observe SF zones, men may be more likely to do so. Participants also talked about the need for men to appear masculine in front of women, and that smoking sends a signal of masculinity. If women collectively decided they would rather have a non-smoking man, this could have severe implications for smoking as a masculine social norm.

In a society such as Indonesia where smoking is so pervasive and often viewed as an important part of cultural tradition (Ng et al. 2008; Nichter et al. 2009), it is likely that social enforcement of SF policies will be required to create a real cultural shift towards a social norm of protecting the health of non-smokers. SF social norms in Palembang and Bogor are evolving towards social change. Complete behaviour change in which citizens are comfortable speaking up to fellow citizens may take time, but it seems as if the participants in this study have started along the path towards enacting this behaviour on a regular basis. If provided with more support from government and law officials and renewed efforts to promote and enforce the policies, Indonesians may find themselves with more confidence to protect non-smokers from the serious effects of SHS.

Funding

This work was supported by an award from the Bloomberg Initiative to Reduce Tobacco Use to the Institute for Global Tobacco Control at the Johns Hopkins Bloomberg School of Public Health.

Conflict of interest statement. None declared.