Substance Use
Impact of the adoption of smoke-free policies in Indonesia on tobacco use: A difference-in-differences approach Sarah Windle* Sarah Windle Wahyu Septiono Arijit Nandi
Background: More than two-thirds of individuals who currently smoke reside in low- and middle-income countries (LMICs). While the effectiveness of policy-based interventions to reduce smoking has been established in high-income countries, the optimal adoption of these policies in LMICs is unclear.
Methods: Using longitudinal cohort data from the Indonesia Family Life Survey (IFLS), we estimated the effect of provincial and district-level adoption of smoke-free policies (SFPs) on tobacco use among adults, using a difference-in-differences design. This approach compared trends in tobacco use from 1997-2014 among IFLS respondents (n=20,529 in 1997; n=36,391 in 2014) living in areas which did versus did not adopt SFPs.
Results: Current tobacco use across survey waves ranged from 59.4 to 64.1% among men and 2.6 to 5.9% among women. Cigarette smoking comprised the vast majority of tobacco use among men, and about half of current tobacco use among women. Nine provinces (33.3%) and 94 districts (n=30.4%) included in the IFLS adopted SFPs from 2005-2014. Provincial SFPs decreased current tobacco use by 2.2 percentage points (cluster-robust 95% CI: -4.4, -0.0) after controlling for district-level SFPs; bans on tobacco advertising and promotion; age; urbanicity; education; and sex. The effect was similar among men (RD: -2.3; CI: -4.7, 0.0), and very imprecise among women (RD: 3.0; CI: -5.3, 11.3). The adoption of district-level SFPs did not have a substantial impact on current tobacco use overall (RD: 0.9; CI: -1.0, 2.8), for men (RD: 0.7; CI: -1.1, 2.6), or for women (RD: 1.7; CI: -10.1, 13.5), after controlling for provincial SFPs and other covariates (as above).
Conclusions: Given the strongly negative health effects of tobacco, even small population-level reductions in tobacco use have important societal impacts. While provincial SFPs reduced tobacco use, more research is needed to determine why district-level SFPs did not have an impact on tobacco use in Indonesia.