Will Indonesia, a Key Tobacco Control Outlier, Keep Vaping Legal?

November 22, 2024

If Indonesia was already frowned upon by the World Health Organization (WHO) and tobacco control groups for its high and rising smoking rate, it sealed that outlier status in 2018. That’s when the country became one of the first in Asia, and in the Global South, to recognize vaping as a legitimate alternative to combustible tobacco.

Indonesia, one of few countries (alongside the United States) not to be a party to the WHO’s Framework Convention on Tobacco Control (FCTC), formally integrated vapes into its regulatory framework in 2023.

With the world’s fourth-largest population at over 280 million people, spanning more than 17,000 islands between the Indian and Pacific oceans, the country is a critical front in the global battle over tobacco harm reduction.

Men’s smoking rate is extraordinarily high there. A 2021 WHO report found 34.5 percent of Indonesian adults—70.2 million people—used tobacco. A stark gender split translated to 3.3 percent of women and 65.5 percent of men.

Smoking has increased significantly in the past 20 years. The Global State of Tobacco Harm Reduction cites even higher estimates—with a projection that men’s smoking rate will reach 83.5 percent in 2025, though women’s will decline.

The situation, you might think, is crying out for tobacco harm reduction. Yet tobacco control activists claim the country would be better off banning vaping.

Among the suggested reasons why smoking is expected to keep increasing at least until 2029 are cultural acceptance, failures of tobacco control efforts, aggressive marketing by tobacco companies and tobacco products’ low prices. Most sales are of a locally produced, clove-flavoured cigarette called kretek.

The situation, you might think, is crying out for tobacco harm reduction, which has prompted mass smoking cessation in a number of wealthier countries. Yet even as Indonesian vape regulation develops, tobacco control activists have continued to claim that the country would be better off banning vaping.

Such calls have a long history in Indonesia, with deliberations in the health administration as early as 2016. The strongest push came in 2019, after the US’ so-called “EVALI” outbreak created panic around the world. “We want to ban, not limit, vaping and e-cigarettes,” Anung Sugihantono, the health ministry’s director general of disease control and prevention, said at the time.

Indonesia’s government ultimately opted for regulation instead. But this has not stopped groups like the Southeast Asia Tobacco Control Alliance (SEATCA), a nonprofit funded by Bloomberg Philanthropies, from amplifying calls for prohibition and false claims that vapes are as harmful as cigarettes. Both SEACTA and another Bloomberg grantee, the Campaign for Tobacco-Free Kids, have helped cast doubt on media and public support for vaping in Indonesia.

A network including other Bloomberg grantees, such as the Saw Swee Hock School of Public Health in Singapore, has sought to pressure Southeast Asian nations by repeatedly highlighting vape bans in the region, playing up their supposed positive outcomes, and arguing that such bans can avert a looming youth vaping crisis.

These groups offer the usual health claims about vapes, neglecting to compare their risks to those of the cigarettes they can replace. Meanwhile regulation requires significant resources for formulation, monitoring and enforcement, they argue, which Indonesia cannot afford.

Others say that an estimated tenfold increase in vape use—from 0.3 percent of the population in 2011 to 3 percent in 2021—includes a sharp rise among adolescents, and blame legalization for permitting the vape industry to promote its products.

Saigain pushed back on the claim that regulation has an unacceptable price tag: On the contrary, it “generates tax revenue that can fund public health initiatives.”

Yet Indonesia is also home to experts who defend the path it has taken, and warn of the consequences if the country were to join the 34 others, including many in Asia, which have imposed prohibition.

“Regulating e-cigarettes balances harm reduction, public safety, and consumer choice by providing adult smokers with a less harmful alternative and allows the government to enforce safety standards,” Harris Siagian, managing director of the Indonesia Development Foundation, told Filter.

Saigain noted the evidence that vapes are “an effective tool for smoking cessation,” and pushed back on the claim that regulation has an unacceptable price tag. On the contrary, it “generates tax revenue that can fund public health initiatives,” he pointed out.

“Although the regulation of e-cigarettes could require the use of existing resources for public health campaigns, law enforcement and monitoring, completely banning e-cigarettes is not a cost-free solution,” Siagian emphasized. “The ban could lead to an increase in law enforcement expenses, a loss in tax revenue, and the emergence of potential public health risks as a consequence of illicit trade in low-quality products.”

Siagian’s organization conducts economic research and policy and community development, so he is well aware of estimates that smoking-related illnesses cost Indonesia over 290,000 lives each year. The economic cost is meanwhile over $14.6 billion, or more than 1 percent of the country’s GDP. By banning vapes, Indonesia could exacerbate these harms and place further burdens on its health care system.

It could also “drive e-cigarettes into the illicit market and limit safer options for smokers,” Saigan said, “making regulation the more practical and balanced approach.”

“Regulating vaping will optimize the beneficence and minimize the maleficence of nicotine products. Human rights must also be protected.”

“Banning vaping will create more problems for the government, including trading of illicit products,” agreed Professor Amaliya Amaliya, of the Dental Faculty of Universitas Padjadjaran, Bandung. “In addition, we will miss the opportunity to have the benefit of vaping as an aid for reducing and quitting smoking for smokers unwilling to quit.”

“In contrast, regulating vaping will optimize the beneficence and minimize the maleficence of nicotine products,” Amiliya, who has authored research on vapes, told Filter. “Human rights must also be protected and facilitated.”

Banning tobacco harm reduction products was first proposed as an optional regulatory pathway at the WHO’s 2014 FCTC conference in Moscow. Vaping was then a nascent technology which few understood well.

Evidence of its relative safety and strong efficacy for smoking cessation has since mounted. Yet a number of nations in Global South have opted for bans, under pressure from a hostile WHO and international tobacco control organizations.

Such groups claim that vaping will create dual epidemics in low- and middle-income countries (LMIC) which are already struggling to control high tobacco use; divert resources away from current tobacco control efforts; negatively impact people who don’t smoke, especially youth; and enable industry interference in policy discussions.

Harm reductionists call prohibition a form of “philanthropic colonialism,” through which powerful Western interests undermine people’s right to health.

Harm reductionists, on the other hand, contend that vape bans in LMIC are overly simplistic, self-defeating in addressing the complexities of tobacco use, and create new harms through enforcement and violent struggles for control of illicit markets.

Prioritizing banning safer alternatives to combustibles, which cause 8 million annual deaths, is inherently illogical, they note. They call prohibition outdated, unrealistic and patronizing—a form of “philanthropic colonialism,” through which powerful Western interests undermine people’s right to health.

Of 10 Southeast Asian countries in the ASEAN grouping, five have imposed vape bans. Their stories are illustrative. Singapore, despite threatening a steep fine of $1,500 for using a vape ($15,000 for a repeat offense), is seeing an uptick in use. Thailand’s illicit vape market has grown significantly even though it has banned vaping since 2014. In October, Thai customs seized $100,000 worth of vaping products in just 10 days, prompting one senior minister to propose legalization, though this was later shot down by the health ministry.

In Malaysia, which in 2023 removed nicotine e-liquids from its “poisons” list, former customs director-general T Subromaniam said in a recent interview, “It is better to regulate and control these products … thus preventing the mushrooming of illicit trade,” adding that, “If we wish to nudge consumers towards alternative nicotine products, their fiscal treatment should be more favourable than the one on traditional nicotine products.”

Saigan called for the development of regulations which take into account local social norms and smoking patterns.

High excise taxes on vapes, which compare to and in some cases exceed those on combustibles in both Malaysia and Indonesia, also concern Siagian for their ability to impede tobacco harm reduction even without a ban.

“This makes e-cigarettes less affordable, especially for smokers seeking a safer alternative,” he said. “As a result, many smokers continue using combustible cigarettes, which are often cheaper, despite higher health risks.”

Saigan called for the development of regulations which take into account local social norms and smoking patterns. “The Indonesian government could establish mandatory quality standards for harm reduction products, implement strict age verification and vendor licensing, restrict marketing aimed at youth, and set minimum pricing policies to discourage youth access while promoting lower-risk alternatives,” he suggested.

“Additionally, ASEAN countries could benefit from regional coordination on product standards, risk-proportionate regulations, capacity building for enforcement and testing, and integrating tobacco harm reduction into broader tobacco control strategies,” he concluded.

Indonesia, with a huge and relatively young population smoking at high rates, faces a public health time bomb. Whether it can find a path to promote mass switching to safer products is a question of vital importance. And the outcomes of whatever approach it takes will resonate far beyond its shores.

 


 

Photograph by Danumurthi Mahendra via Flickr/Creative Commons 2.0

Both The Influence Foundation, which operates Filter, and the Indonesia Development Foundation have received grants from Global Action to End Smoking. Filter’s Editorial Independence Policy applies.

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Samrat Chowdhery

Samrat is a journalist and harm reduction activist based in Mumbai, India.