Health Education Research Advance Access originally published online on September 20, 2006
Health Education Research 2007 22(6):794-804; doi:10.1093/her/cyl104
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‘If I don’t smoke, I'm not a real man'—Indonesian teenage boys' views about smoking
1 Department of Public Health, Faculty of Medicine, Gadjah Mada University, IKM Building 3rd Floor, Farmako St. North Sekip, Jogjakarta 55281, Indonesia and
2 Umeå International School of Public Health, Epidemiology and Public Health Sciences, Umeå University, Umeå 90185, Sweden
* Correspondence to: N. Ng. E-mail: nawi_ng{at}yahoo.com
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Abstract |
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With a lack of tobacco control and regulation at the national level, Indonesia has been targeted by many national and transnational tobacco companies. The prevalence of youth smokers in Indonesia in 2005 was 38% among boys and 5.3% among girls. The aim of this study was to describe and analyse beliefs, norms and values about smoking among teenage boys in a rural setting in Java, Indonesia. Six focus group discussions with boys aged 13–17 years were conducted using a thematic discussion guide. Four themes were derived from the descriptive content analysis: (i) smoking as a culturally internalized habit, (ii) striving to become a man, (iii) the way we smoke is not dangerous and (iv) the struggle against dependency. Cultural resistance against women smoking in Indonesia remains strong. The use of tobacco in the construction of masculinity underlines the importance of gender-specific intervention. National tobacco control policy should emphasize a smoking-free society as the norm, especially among boys and men, and regulations regarding the banning of smoking should be enforced at all levels and areas of community. A comprehensive community intervention programme on smoking prevention and cessation should be a major focus of tobacco control policies in Indonesia.
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Introduction |
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Tobacco use has been identified as an important risk factor for many non-communicable diseases both in developed and developing countries [1]. To date, about one-third of the world's population smokes, mostly in China, India and Indonesia. These three Asian countries with large populations have been the main targets for tobacco companies' expansion [2]. The three leading tobacco companies in Indonesia produced 146 billion cigarettes in 2004. The acquisition of 97% of HM Sampoerna, Indonesia's third largest tobacco company in 2004, by Philip Morris International in 2005 intensifies the threat to tobacco control efforts in Indonesia [3]. As one of the top five tobacco-consuming countries in the world, Indonesia is lagging behind in terms of the Framework Convention of Tobacco Control signature and ratification. The reluctance of the Indonesian government to promptly adopt this global strategy as national policy aimed at reducing tobacco supply and demand has created an opportunity for the expansion of the tobacco industry [4, 5]. Even in the latest amendment of government regulation about tobacco control, sanctions for violation on production, advertisements and sales were eliminated [5], and no laws prohibiting the sale of cigarettes to minors exist [6].
Youth smoking is a major concern throughout the world. The Global Youth Tobacco Survey showed country differences in the prevalence of the current use of tobacco products among schoolchildren between the ages of 13–15 years, which reached as high as 62.8% in India [7]. The prevalence of youth smokers in Indonesia in 2005 was as high as 38% among boys and 5.3% among girls [2]. Intrapersonal factors (such as being a male and having positive attitudes towards smoking), interpersonal factors (such as parental smoking, smoking teachers and peer influence) and exposure to cigarette advertisements have been shown to be significantly associated with youth smoking behaviour [8–13]. Becoming a smoker, or becoming addicted to smoking, is a process which proceeds through various stages of smoking initiation and adaptation [9].
Even though the pattern of youth smoking in Indonesia has been evaluated through different surveys [14], knowledge is still lacking regarding norms and values about smoking among youths. Most studies were conducted in the metropolitan area of Jakarta and, to our knowledge, no qualitative studies focusing on smoking in rural areas have been published. A qualitative approach helps to explore the driving forces behind youth smoking. The understanding of youth smoking in this social setting will provide guidance in designing more effective and culturally appropriate smoking prevention programmes.
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Objective |
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The aim of this study was thus to describe and analyse beliefs, norms and values about smoking among teenage boys in a rural setting in Java, Indonesia.
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Method |
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Research setting
This study is part of a larger research project on non-communicable disease risk factor surveillance, which was conducted on a representative sample of 3000 individuals aged 15–74 years in the demographic surveillance system in Purworejo District. The demographic surveillance system in Purworejo is part of the INDEPTH network (International Network of field sites for continuous Demographic Evaluation of Populations and Their Health in developing countries) [15]. About 750 000 inhabitants live in 494 rural villages in this district, which stretches from the coastal area in the south to the mountainous area in the north. The majority are farmers with low socio-economic status. The illiteracy rate in the study area is about 16%. The high prevalence of smoking among men, as well as an early age of smoking initiation, in the study area is a public health issue that requires smoking prevention interventions to be appropriately tailored to this specific setting.
Research design and sampling selection
This study is based on a qualitative research approach. Qualitative data were gathered through focus group discussions (FGDs). By discussing different experiences and ideas relating to a few specific themes, the researchers were able to get a broader picture and better understanding of the topic than would have been possible if individual interviews had been used [16]. FGDs are considered to reflect norms, values and culture in groups and are therefore preferred when studying such topics [17]. When listening to each other in groups, participants can reflect on each other's opinions and express their own views on topics and ideas introduced by other participants or by the researchers.
We conducted six FGDs with a total of 50 teenage boys in four schools in Purworejo District, Central Java, Indonesia. The schools were selected purposively to represent rural villages and small urban settlements as shown in Table I. Three FGDs were held with smokers and three with non-smokers. The participants were between 13 and 17 years old, and were selected by their schoolteachers. Informed consent was obtained verbally from the school authorities, as well as from the participants. In this study setting, the school is responsible for granting consent for research on school students.
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Data collection
We developed a thematic discussion guide to explore different aspects of smoking among teenage boys (Table II). Tobacco advertisements from magazines were shown to the groups to explore the participants' views on tobacco advertisements. All FGDs were conducted without the presence of any school authorities. Group discussions were conducted in the village community hall, at the school hall or at the small mosque connected to the school. Two trained fieldworkers, who are also anthropologists, moderated the FGDs. The first author participated as note-taker and observer in all the groups, whereas the second and third authors were observers in one of the discussions. The FGDs were conducted during school hours with permission from the schoolteachers, and each group session lasted 1–1.5 hours. The last three FGDs were conducted after the preliminarily analyses of the first three. Thus, the study design was emergent [18], which in this case means that additional topics derived from earlier FGDs were included in the thematic guide for the proceeding groups. In this way, we attempted to be flexible and sensitive to issues/topics that emerged from the boys themselves during the FGDs. Tobacco smoking from a gender perspective and the association between smoking and the religious practice of circumcision in relation to smoking were the two most important topics added as a result of this process.
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The participants were informed beforehand about the study aims and topics to be discussed. Participants were aware of the data collection processes, including tape-recording and transcription of the discussions, and were also informed about the confidentiality of the research materials. Only the research team had access to the data and all results were documented without any possibility to trace the individual informants. Participants received snacks and a small amount of money for the time they spent participating in the FGDs.
Data analysis
A descriptive content analysis was employed [19]. We reviewed the verbatim interview transcripts several times, and thereby identified different meaning units. The meaning units were then condensed and developed into themes and subthemes. Table III shows an example of this analysis process. In order to increase trustworthiness of the study, we used triangulation of researchers in terms of professional expertise and cultural understanding [18], two physicians (N.N., L.W.) and one medical sociologist with specialist knowledge in gender research (A.Ö.), all three researchers work within the field of public health. The first author has an insider perspective regarding the Javanese culture, whereas the second and third authors employ outsider perspectives. The final negotiated outcome benefited from this triangulation in that we used our theoretical knowledge during the process of interpretation.
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Results |
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Four main themes were derived from the descriptive content analysis. The themes reflect the norms and values relating to smoking in Javanese society as described by the boys, the reasons for their smoking, their perceptions of health risks and their beliefs on addiction and on quitting.
Smoking as a culturally internalized habit
This theme reflects the norms and values about smoking and tobacco that the boys meet in Javanese society. The boys emphasized that smoking is common everywhere among men and that this has been the case ever since tobacco was first smoked. At home at least one of their family members smoked and in their social life most of their friends were smokers. At school, they often see the teachers smoking in their offices, in the schoolyard or even in the classroom. However, it seems as if the non-smokers perceived fewer smokers around them, whereas the smokers stressed that ‘everybody smokes’.
Since a long time ago (laughing) ... since cigarettes were produced, man has smoked.
In a class of 40 boys, thirty nine smoke... (laughing)...only one person does not smoke.
Male villagers smoke during social gatherings and during the traditional puppet shows that are occasionally performed in villages, for example during birth and wedding ceremonies, as well as religious festivals. In grieving ceremonies, the boys explained, villagers come together and spend the night praying and sharing feelings, snacks, coffee, and cigarettes. In addition, cigarettes were often used as a ‘gift’ to friends, visitors, or guests in traditional or religious ceremonies. The informants shared the same social norms as the community as a whole; when you are offered a gift, it is impolite to refuse it.
According to the informants, cigarettes are often introduced to young boys during the traditional religious ritual of circumcision, which in this society occurs at the age of 10–12 years. Circumcision, which is viewed as a sign of male maturity and adulthood, is celebrated in a village ceremony. During the ceremony, cigarettes are served to the guests, who are mostly teenage boys and friends of the boy being circumcised. Cigarettes are also believed to promote healing of the circumcision wound, which, according to the boys, is a belief shared by their parents and one that has been practiced for many generations. With the exception of smoking during the circumcision ritual, the boys admitted that their parents usually do not allow them to smoke before they have a job. Before they can earn their own money, smoking is regarded as a waste of the parents' money.
Although tobacco use is part of an old tradition in Indonesian society, the boys also regarded smoking as an aspect of modern culture. Their notion of modern life partly influenced their decision to dislike hand-rolled cigarettes, which they regarded as old-fashioned and used only by the older generation. They described the hand-rolled cigarettes as being cheap and of poor quality; having a strong, bad taste and causing headaches. Hand-rolled cigarettes were compared with coconut fibres and the boys believed that these kinds of cigarettes lead to an early death.
Cigarettes were used to increase the boys' social status among their friends. If they smoked a ‘good’, expensive and popular cigarette brand, they felt more confident, more mature and more richer than their peers. To them, smoking and tobacco advertisements were signs of several positive connotations, such as ‘a steady life’, ‘pleasure’, ‘good taste’, ‘feel so rich’, ‘impressive’, ‘good appearance’ and ‘attractive’.
The participants viewed smoking as a socializing factor; people smoke whenever and wherever they gather. For them, tobacco and smoking play important roles in making friends. Smoking is a reflection of being in a group and being a smoker among their smoking peers is a sign of solidarity. Peers were also an important source of one's first cigarette. The way they viewed tobacco advertisements as ‘truly friendly’, ‘helping each other’ and ‘cheerful’ showed how they use cigarettes to create their social and friendship bonds. They smoked to be ‘gaul’, slang used to show that they were social and followed the trends. They were proud of themselves if they could make and play around with their ‘smoke rings’. The boys felt brave and self-confident when they smoked, and they described themselves as ‘being a smoking warrior’.
If I don't smoke, I will feel inferior to my friends, because I'm the only one who doesn't smoke.
Cigarettes were easily accessible, and they could even receive credit from the warung's owner for single cigarettes when they did not have money. The informants were exposed to tobacco advertisements on television, billboards and posters which are found everywhere along the roads. They could easily name their favourite cigarette brands and describe the advertisements for them. If a new brand was introduced in an advertisement, they were curious to try it.
Striving to become a man
The phenomena of tobacco use during circumcision and smoking as a sign of male maturity have resulted in the development of a general view on smoking as normal male behaviour. According to the boys, smoking portrays the image of potency, wisdom and bravery, which they described as ‘machismo’ and ‘self-confidence’. For them, boys have to be brave enough to smoke otherwise they are seen as having an effeminate manner. The smokers stated: ‘If we don't follow our peers and smoke, they will call us feminine.’ Thus, smoking enabled them to reaffirm their identity as boys. However, the non-smokers showed relatively high degrees of self-confidence with their non-smoking status. When they were teased and called feminine, they responded ‘We don't care.’
All the groups emphasized that their ‘boy identity’ was developed and reinforced in the company of their friends. The smokers smoked together with their friends on their way to and from school, at the bus/train station, at amusement centres when they socialize and even in the mosque. During daytime, the boys gathered in a small cigarette shop (warung rokok) near the school to smoke during break time; thus, they were able to create a male ‘togetherness’.
Both smokers and non-smokers admitted that most of them had first tried smoking their cigarette when they were very young. Being in an environment where smoking is so common among men, the informants stated that it was difficult for them to stay away from the temptation to smoke and sometimes they were subjected to pressure and even threats: ‘I saw my teacher smoke in the office, that's why I also wanted cigarettes’; ‘I received the cigarettes from my father, he gave them to me’; and ‘They said that if I did not want to smoke, then they will throw me in the gutter’.
Even though schools are supposed to be smoke-free areas, the informants often see their male teachers smoking in their offices, in the schoolyard and in classes. The participants felt that it was unfair that the teachers could smoke at school, while they were not allowed to do so. They said ‘Teachers teach smoking’ and ‘It's weird of him to smoke while he wants us not to smoke.’ Although they argued that the school regulation on smoking should be applied evenly, the participants felt helpless and afraid to talk about their teachers' smoking. They claimed that teachers sometimes ask the boys to buy cigarettes for them.
The informants perceived smoking among women and girls as a very bad sign. They stated that it is very unusual to see girls who smoke and argued that women and girls who smoke are impolite and ill-mannered: ‘Smoking is only common among hookers and bad girls.’
The non-smokers maintained their non-smoking status because they associated smoking with being naughty. When asked why they did not continue smoking after having tried their very first cigarette, they replied, ‘I was afraid of being caught by my parents.’ They were also afraid of the health hazards and the addiction caused by tobacco. They revealed unpleasant memories from their first cigarette: ‘It did not taste good, it tasted bitter’; ‘it made my tongue feel itchy’; ‘it made me sick, it was hard for me to breath’; ‘it is nglekií (felt hot on the eyes/eye irritation due to the smoke)’; ‘ it made me cough’; ‘ it caused me to feel faint’; ‘it made me want to vomit’; ‘it was uncomfortable’; and ‘I had bad smell of it’.
The way we smoke is not dangerous
Both the smokers and the non-smokers believed that smoking causes health problems such as shortness of breath, coughing, lung disease, cancer, heart disease, throat disease, infertility, impotency, and a reduction of cognitive ability, and that it harms foetus development. The participants learned about the health hazards mainly from the health warnings on cigarette packages, as well as from magazines, newspapers, friends, family and neighbours. Teachers only talked generally about tobacco and smoking in biology and civics classes.
Even though the smokers were aware of the health hazards of tobacco, they stated that they were not afraid of smoking. When asked about the number of cigarettes they smoke daily, they gave an estimate between one and six cigarettes. They claimed that smoking less than 1 or 2 packs of cigarettes or 12–24 cigarettes per day would not harm their health: ‘I think it's okay if I smoke just one cigarette because it is too little... The level of nicotine is too low.’ The boys also viewed locally produced cigarettes with no health warning as being less harmful.
In this local tobacco product, there is no warning label that smoking causes cancer... (laughing). Even if there was such a warning, I am not afraid of smoking, because it is so common.
The non-smokers stated that staying away from smoking would keep them healthier, fresher and physically fit because it meant they avoided the risks of heart disease and addiction. They thought that the smokers had unpleasant and difficult respiration, were prone to diseases and had poorer physical capabilities regarding running and working. In accordance with this, the smokers reflected on the effects of smoking on their health and felt that their health has been affected by smoking. They had all experienced coughing, shortness of breath, and an inability to run fast. The parents of all the boys forbid them to smoke, reasoning that smoking can damage their health. According to the informants, parents argue that the boys are still too young to smoke, and that their ‘hearts are not strong enough to smoke’.
The struggle against dependency
The smokers perceived themselves as being addicted to tobacco, something that made quitting impossible. They viewed their smoking experiences as a process in which smoking became more enjoyable and eventually led to addiction. They said ‘the first cigarette felt bitter, the second was rather comfortable, the third felt enjoyable, and after the fourth I was addicted’. They said that an addicted smoker (the term they used was salit) is someone who is a chain-smoker. When asked about their experiences regarding addiction, they described their feelings as ‘confused’, ‘weak’, ‘angry’, ‘want strongly’, ‘sleepy’ and ‘dizzy’.
I don't care if my parents are angry with my smoking, because I am already addicted.
When the boys were shown the tobacco advertisements with youngsters at parties, they described a smoker as a ‘smoking warrior’ and ‘an addicted hero’, relating these notions to the lives of American cowboys. The non-smokers said: ‘Smokers smoke because they are addicted and it has become a habit.’
The smokers emphasized that they have an intention to quit smoking, or at least to cut down on the number of cigarettes they smoke. They would like to quit smoking for several reasons, including respect of their parents' wishes, health aspects and career and economic reasons. However, they stated that they found quitting very difficult.
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Discussion |
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TopAbstractIntroductionObjectiveMethodResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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The results from this study reveal that smoking among Javanese teenage boys is associated with both traditional and modern culture, as well as religious practice. Tobacco smoking seems to be one mediator in a process of transformation from a traditional to a more modern society. Moreover, smoking was found to be essential in the formation of a male identity and an important part of the social construction of masculinity. The boys receive ambiguous messages about smoking. On the one hand, they are informed about the disadvantages of tobacco smoking, while on the other, they live in a social context where smoking is deeply rooted and accepted. In the following, we will discuss the results with reference to masculinity and health behaviour.
Tobacco is an important part of society
Our study depicts the beliefs and norms that smoking is deeply rooted in Indonesian men's lives. Tobacco was introduced in Indonesia in the 16th century [20] and is today a common and accepted activity and a social necessity. Smoking takes on particular meaning during culturally significant life transitions [21–23], such as the circumcision of boys aged 10–12 years in rural areas. In traditional Indonesian society, being offered a cigarette during circumcision ceremonies signals a young man's entry into adulthood and maturity. This is a symbolic act that also serves to introduce smoking as a normative behaviour among adult males.
The high smoking prevalence among men in Indonesia is similar to the prevalence in most Muslim countries [24]. Whether smoking is mukrooh (discouraged) or haram (prohibited) for Muslims remains debatable worldwide. Investment from Indonesia's largest Muslim associations in kretek manufacturing might lead to a potential conflict of interest in deciding whether smoking is considered religiously lawful [5]. During recent years, an increasing number of Muslim scholars from the Mediterranean countries have declared smoking as haram. Even though religious rulings alone will not have much effect on the smoking rate, by integrating them with behavioural and pharmacological approaches, they may have the potential to guide smoking cessation activities among Muslim smokers, especially during the month of Ramadan (during which smoking is prohibited) [24].
The study also showed that the most critical period for starting to smoke among Indonesian boys might be the early- to mid-adolescence periods, during which time peer identification and exploratory behaviours are strong [25]. Culturally, smoking is acceptable for an adult male, in their view ‘those who have undergone circumcision’. Economically, parents view children smoking as disadvantaging the family's economy. The clashes between these standards put the teenagers in a somewhat precarious situation during their psychosocial development to adulthood [25, 26].
This situation makes young men especially vulnerable to peer pressure, which can be intense and difficult to resist. Smoking then becomes a social signifier within a group of peers where the consumption and exchange of cigarettes are associated with group inclusion [27]. The boys in this study can be regarded as followers; since their social environment encourages and reinforces smoking, they themselves will smoke. Cigarettes are used to create social bonds among peers, to maintain the group's identity and to avoid exclusion by their peers [28]. An understanding of adolescents' stages of development, particularly self-development and identity search, are critical aspects of smoking interventions aimed at youths [25, 26].
Repeated exposure to tobacco advertisements and youths' preferences and receptiveness towards tobacco advertisements have been shown to be significantly associated with smoking among youths [13, 29, 30]. Indonesians are highly exposed to the extensive tobacco promotions, such as advertisements on billboards and television, as well as at points of sale and kiosks, which are wallpapered with cigarette logos. Some tobacco advertisements, which reflect the images of freedom, openness and individuality, even specifically target youngsters. The teenage boys were very receptive to the tobacco advertisements, which can be seen a success for the tobacco advertisements aimed at desensitizing the population and making them more receptive for a smoking culture [6].
Smoking as part of the social construction of masculinity
As already stated, the results revealed that smoking is a symbol of masculinity, which in turn has a long cultural history. Our findings are in accordance with Courtenay's theorizing about men's unhealthy behaviour, which puts them at a higher risk than women for diseases and injuries related to smoking. Engendering health is also endangering health because the very construction of masculinity includes a risky behaviour expressing strength, invulnerability and bravery. Boys actively follow and adapt the social prescription that tobacco is an age-appropriate behaviour associated with masculinity [27, 31]. The boys in our study strive to acquire an important symbol of manhood—the cigarettes.
Smoking is used as a metaphor for masculinity, potency and bravery. A mixture of adventurous lifestyles, good looks and modern culture is the main content of contemporary tobacco commercials in Indonesia. This does not mean that all Indonesians see smoking as an act essential to masculine identity. While the boys that smoked believed that smoking enhanced their masculine image, the non-smokers did not view themselves as less masculine, instead they used other symbols to express their identity. How non-smokers deal with their male identity remains unknown and yet to be addressed in future research.
In Indonesia, smoking is culturally inappropriate for women. However, there are grounds for alarm as cultural resistance is loosening and young women are being targeted in smoking advertisements in Indonesia. The tobacco company Clas Mild's slogan of ‘Yesterday is gone—Clas Mild is today’, which is accompanied by the image of a modern, seemingly well-educated woman, is one example of how many cigarette brands are attempting to target women in Indonesia. In modern society, the tobacco companies market cigarettes as a ‘torch for freedom’ for women, a symbol of social desirability, emancipation, independence and success [32, 33]. The modernity thesis has also been used to explain the increase of smoking among Indonesian women in more affluent and urbanized areas [34]. Due to globalization, lifestyles cross borders effectively. This could be an important determinant of the fact that smoking has become more prevalent and accepted among young Indonesian women during the last decade. This is a major public health concern that has to be addressed in public health policies.
Misconceptions and denial of smoking hazards
Teenage boys appear to ‘know’ the health hazards of smoking; however, they do not really understand and evaluate each risk accurately, such as when they associated impotency and heart disease with some kind of cancer. The health risks of smoking were perceived in terms of lack of physical fitness and other symptoms and diseases related to smoking, particularly chronic coughing, lung cancer and heart diseases.
Ignorance, inaccuracy and underestimation of tobacco risks by the general population have led to an increase in tobacco consumption [35, 36]. The cumulative risks of tobacco are potentially being misperceived and underestimated because of the long lag period between tobacco exposure and the occurrence of diseases attributed to smoking [37]. The health risks of being a passive smoker are also ignored, and people are often not even aware of their existence.
In the construction of masculinity, men are regarded as invulnerable to health risks. Therefore, the use of tobacco as a masculinity signifier puts men at greater risk of starting to smoke, and later, of suffering from tobacco and smoking-related diseases. Courtenay hypothesizes that ‘denial of risk and other unhealthy behaviour are used by men in the negotiation of social status and to enact idealized forms of masculinity that enable them to assume positions of social power relative to women or less powerful, marginalized men’ [27].
Despite the tobacco advertisements' success in creating positive images of tobacco among the participants, the health warnings on tobacco advertisements have undoubtedly been the single most important source of health education regarding tobacco hazards. This is particularly important when appropriate health education from other sources is still lacking. However, providing information solely on health risks and negative impacts of tobacco might not be effective for tobacco control in many settings [38], especially in a country such as Indonesia where tobacco has been a social need and smoking has been used as a cultural signifier of masculinity.
Health communication plays an important role in smoking prevention among youths. Tailoring appropriate and palatable health messages for youths may help them in making informed decisions about smoking [39]. Providing the skills necessary to recognize and resist negative influences, whether they be from peers, family or culture, is essential in preventing tobacco use, especially in situations where these influences play a significant role in encouraging smoking [38].
Methodological considerations
This study contributes to a qualitative understanding of teenage boys' beliefs, norms and values about tobacco smoking in a rural setting in a developing country. Of the 46 research studies documented on tobacco in Indonesia in the last 13 years, only 12 can be regarded to be epidemiological studies on smoking among youths (all in urban areas: nine surveys, two qualitative studies and one using a combination of qualitative and quantitative approaches) [14].
During the research process we realized that the teenage boys in this social setting were not particularly used to participating in groups where they are asked to discuss and reveal their views and opinions and to share their experiences with adults, and especially not to university researchers. Despite the moderator's efforts, the discussions were not as lively as we would have wished. The fact that the groups only met once might have hindered a more relaxed atmosphere between the boys and the researcher. However, the group dynamics were judged well enough for the purposes of this study. They boys seemed comfortable and relaxed enough to provide information about their beliefs and norms regarding tobacco smoking. We regard the results as contributing to a better understanding of young Indonesian boys' thoughts and beliefs about tobacco smoking. None of the researchers knew the informants prior to the study and no personal interests or biases are at hand. As such, the results of the interpretations developed through a negotiating process that aimed at encouraging open-mindedness to new aspects of the topic and utilization of our different professional backgrounds. Thus, we oscillated between bracketing our prior understanding and using it overtly [40]. We emphasize that our interpretations about masculinity and smoking behaviour are analytical and theoretical, not statistical. We adhere to the notion in qualitative research that findings like ours could also be applicable in other social contexts. However, we do not draw these conclusions based on any statistical inference to a target population, but on a theoretical understanding of health and ill-health behaviour and human social interaction [18].
Implication for policy
The prevalence of tobacco users and diseases related to tobacco in Indonesia clearly shows that Indonesia is in the early second stage of a tobacco epidemic. This is characterized by the high prevalence of smoking among men across different socio-economic classes, low but rapidly increasing smoking among women and no well-developed tobacco control activities. Lessons from many countries that implemented early Stage 2 interventions have shown their effectiveness in preventing avoidable deaths attributed to smoking.
In summary, the cultural use of tobacco in the construction of masculinity underlines the importance of and prompts the use of gender-specific intervention. The myth of tobacco as a sign of masculinity should be demythologized, and alternative signifiers of masculinity should be introduced to boys. Fathers, male teachers and peers play an important role in smoking initiation among boys and they should therefore be treated as the main targets of intervention. Attention should also be given to the prevention of smoking among young females, who are among the main target groups for cigarette companies' advertising campaigns.
Community interventions should be designed to address these issues, and should aim at raising community awareness of the hazards of tobacco smoking. Recognizing the importance of culture in effective health and tobacco risk communication, the development of tobacco prevention programmes should involve teachers as they have a high social position in the Javanese community. In Indonesia, the word guru, meaning teacher, is associated with the Javanese phrase digugu dan ditiru which means someone who has to be imitated.
Tobacco policy at the national level should aim to make smoking-free society the norm, especially among boys and men. Smoking regulation should be enforced at all levels of the community and a comprehensive intervention programme on smoking prevention and cessation should be a major focus of tobacco control policy in Indonesia.
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Conflict of interest statement |
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None declared.
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Acknowledgements |
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TopAbstractIntroductionObjectiveMethodResultsDiscussionConflict of interest statementAcknowledgementsReferences |
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We acknowledge the help of Utari Marlinawati and Tutik Istiyani in the focus group discussion, Yayi Suryo Prabandari for her critical comments on the manuscript and Charlott Nyman and Edward Fottrell for language editing. We also acknowledge the schools and schoolchildren in Purworejo District, Indonesia, who participated in this study. This research is supported by a special grant from Forskningsrådet för Arbetsliv och Socialvetenskap (FAS), the Swedish Council for Social and Work Life Research, No. 2003-0075.
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Received on January 22, 2006; accepted on August 7, 2006
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