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Abstract
Objectives To investigate the relationship between purchasing loose cigarettes and adolescent smoking habits in Indonesia.
Design and setting This study employed a mixed-methods sequential explanatory design. We analysed the secondary data from a national survey, the 2019 Global Youth Tobacco Survey, using multivariable logistic regression models to examine the association between loose cigarette purchase and smoking frequency and intensity and nicotine dependence. Based on the quantitative findings, we arranged focus group discussions (FGDs) in junior and senior high schools located in South Jakarta, Indonesia. The qualitative data were analysed using thematic analysis with an inductive approach to explore experiences in purchasing loose cigarettes and how it affected their smoking initiation and current cigarette consumption.
Participants For quantitative study, we included 785 samples after excluding the non-current smokers and those who had missing responses. For qualitative study, a total of 49 eligible students who met inclusion criteria (ever or current smokers, buying loose cigarettes and living with parents) and agreed to participate in FGD were later divided into 12 FGD groups.
Results Most students who smoked in the past 30 days are male (95%). More than half of the students (68%) reported buying loose cigarettes in the past 30 days, including 36% who smoked 1–2 days in a month and 34% who usually consumed one cigarette a day. One-third of the students had nicotine dependence (30%), with an average smoking duration of 3 years. Purchasing loose cigarettes in the past 30 days was significantly correlated with smoking for <20 days in the past month (adjusted OR (AOR)=1.56; 95% CI=1.17 to 2.07), consuming ≤5 sticks per day (AOR=2.15; 95% CI=1.54 to 3.00) and having lower nicotine dependence (AOR=1.55; 95% CI=1.08 to 2.22). Our qualitative findings further reported that affordability and accessibility were the main reasons that encouraged current student smokers to opt for loose cigarettes over other types of cigarettes (packs, cartons or rolled tobacco). Students reported the extensive selling of loose cigarettes and such a situation persuaded them to buy tobacco products more frequently, thus spending at least half of their weekly allowance on tobacco products, ranging from 30 000 to 200 000 Indonesian rupiah or equivalent to US$2–13 per week. Finally, our study highlighted that only a few students in this study either had to show their identity card or were denied when purchasing loose cigarettes in informal retailers.
Conclusion Our study demonstrates that students purchasing loose cigarettes is significantly associated with non-daily smoking, consuming five or fewer sticks per day, and lower addiction which could be interpreted as smokers in the experimental phase. They possessed a higher risk of becoming regular smokers. Our qualitative findings supported the quantitative study by shedding light on the role of loose cigarettes in smoking initiation and continuation among young people. In this case, we supported the notion of prohibiting loose cigarette sales in the country in order to reduce smoking uptake and tobacco consumption among the younger generation.
- Tobacco Use
- PUBLIC HEALTH
- Health policy
Data availability statement
Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information. We used data from GYTS for quantitative study which are available in public, open access repository. The data could be accessed through Global Tobacco Surveillance System Data (GTSSData) provided by Centers for Diseases Control and Prevention (https://www.cdc.gov/tobacco/global/gtss/gtssdata/index.html). On the other hand, data used in qualitative study were collected during FGD with students and due to the agreement with the schools we are not allowed to share the data to any external parties, thus data sharing is not applicable.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
Focus group discussion (FGD) participants in this study mainly consisted of smokers, loose cigarette buyers and male, reflecting the population of adolescent smokers in Indonesia.
The preference for purchasing loose cigarettes might not portray the behaviour in reality since it was determined based on the type of last cigarette bought within the past 30 days, with students being allowed to select only one response.
Data from the 2019 Global Youth Tobacco Survey and FGD were at risk of recall bias since the students assessed themselves retrospectively.
Our study recruited students only, resulting in the findings that might not be representative of all Indonesian adolescents, and was conducted in the schools where students are likely to give socially acceptable answers rather than being truthful.
Introduction
While 87 countries worldwide have prohibited the sale of loose cigarettes, Indonesia is among the few countries in Southeast Asia that let the distribution of loose cigarettes unregulated until 2023.1 Loose cigarettes, which refer to the individually sold cigarette sticks removed from their pack, are prominently traded in lower income countries, including Indonesia.2 Up to 85% of informal retailers in Indonesia’s major cities admitted that they sold loose cigarettes.3 4 Studies conducted in Bali province revealed that more than half of retailers sold cigarettes, including as single sticks, to young people.3 5
The absence of regulation to prohibit the selling of loose cigarettes potentially undermines tobacco control measures in the country. For instance, distribution of loose cigarettes might hamper the objective of fiscal policies such as tobacco tax by providing affordable options for tobacco products.6 The cheapest loose cigarettes were sold at Indonesian rupiah (IDR) 1000 (US$0.07), and this amount is much lower than the allowance of most adolescents who received more than IDR 50 000 (US$3.5) (US$1 ≈ IDR 13 883 as of 13 December 2019 around the release date of the report) per week.3 7 8 Concerning non-fiscal measures, consumers of loose cigarettes are also less likely to be exposed to pictorial health warnings on the cigarette packaging.9 Finally, adolescents may be able to buy the products without showing an identity card since the loose cigarettes are widely traded in the informal markets or through unregulated channels.2
Due to the massive selling of loose cigarettes and its potential threats to public health measures, it is plausible for the consumption of loose cigarettes to influence adolescents’ smoking behaviour, despite the fact that the empirical study concerning this topic has received scant attention. On the contrary, we recognise a number of quantitative studies among the adult population have been conducted to examine the relationship between loose cigarette purchase and smoking behaviour including smoking frequency and smoking intensity.10–16 The present study uses the term smoking frequency to define the number of smoking days per month and smoking intensity refers to the number of cigarette sticks consumed per day.7 17 It has been well established that purchasing loose cigarettes is more likely to be reported among adults who are non-daily smokers compared with their daily counterparts.10–13 In addition, loose cigarette consumption was found to be a substantially influential factor of smoking intensity, and that the preference for buying loose cigarettes was associated with adults who consumed less cigarettes per day.14
Findings from the previous studies suggested that adult smokers buy loose cigarettes to limit their consumption or maintain a low level of smoking.10 11 On the other hand, one study argued that the availability of loose cigarettes might facilitate the early phase of smoking among the younger population,12 even though this notion is still unclear and is supported by a scarce number of empirical studies. We found only three qualitative studies that explored loose cigarette purchase during smoking initiation and continuation among young adults, yet those studies do not provide further discussion on loose cigarettes consumption in detail.18–20 Previous research also indicated a potential correlation of loose cigarette consumption with addiction to nicotine because the availability of loose cigarettes triggered the urge of occasionally smoking young adults to consume cigarettes.10 11 Nevertheless, no studies have been carried out to demonstrate the association of those variables; thus, further investigation is necessary.
Employing mixed methods, the present study examines the relationship between loose cigarette purchase and cigarette smoking among adolescents in Indonesia. For the quantitative methods, we investigated the association between loose cigarette purchase and smoking frequency, intensity and nicotine dependence. Our qualitative study aimed to explore students’ experiences in purchasing loose cigarettes and how it affected their smoking initiation and current cigarette consumption. To the best of our knowledge, this is the first mixed-method study conducted on loose cigarette purchase and cigarette use among adolescents, both globally and in Indonesia. Investigation of loose cigarette purchase and smoking behaviour using national-scale data is crucial to provide representative findings on loose cigarette purchase and its related factors that may have lifelong consequences on adolescents' health.21 22 From a broader perspective, the findings of the study seek to advocate stronger tobacco control policies for the adolescents in Indonesia.
Data and methods
We employed a mixed-methods sequential explanatory design in which quantitative research was carried out prior to the qualitative research. Findings from the quantitative research guided the data collection and analysis of the qualitative study. While the quantitative and qualitative data sets were initially analysed independently, the results from both quantitative and qualitative research were integrated in the final phase. We selected this study design to expand the findings from quantitative data that only featured one question pertaining to loose cigarette purchase in the past 30 days and qualitatively elucidate what has been obtained in the quantitative research.23
Quantitative study
Data
We used individual-level data obtained from the 2019 Global Youth Tobacco Survey (GYTS), a nationally representative cross-sectional school-based survey that collects extensive information related to tobacco consumption among students aged 11–17. The GYTS uses a standardised global methodology, employing a two-stage cluster sampling approach and encompassing 150 schools distributed across 30 provinces and three regions—Java, Sumatera and others.7 24 Further details of the GYTS survey methods and data can be obtained from the CDC website https://nccd.cdc.gov/GTSSDataSurveyResources/Ancillary/DataReports.aspx.
Of the 9992 eligible students in grades 7–12 who completed the survey, we only included adolescents who were current smokers (n=1710) in this study. Among these 1710 current smokers, only 785 (741 individuals for the nicotine dependence analysis model) students answered questions about the outcome variables, loose cigarette purchases and other covariates used in this study, and thus were included in the final sample for the regression analysis.
Measures
Outcomes
We focused on adolescents' smoking behaviour, measured by smoking frequency, intensity and nicotine dependence. Smoking frequency was categorised as ≥20, 6–19, 3–5 and 1–2 days, while intensity was categorised as >5, 2–5, 1 and <1 sticks. Both variables were assessed over the past 30 days. Nicotine dependence was assessed by whether the respondents smoked or felt the urge to smoke first thing in the morning (yes/no). The definition of each variable was aligned with the questions in the attached questionnaire and the definitions used in prior research.25
Main independent variables
The main independent variable was loose cigarette purchase, identified by how students purchased cigarettes in the past 30 days. The responses were then grouped into two categories: loose cigarettes or other than loose cigarettes (packs/cartons/roll-your-own tobacco).
Covariates
We also analysed potential covariates that encompass predisposing factors, enabling factors and reinforcing factors.26 The predisposing factors, the elements that motivate and direct behaviour, included the perceptions of the dangers of smoking (agree or disagree) and perceptions of the dangers of exposure to cigarette smoke (agree/disagree).
Enabling factors, defined as factors that facilitate or allow a behaviour to occur, were the price of loose cigarettes purchased by the respondents (<IDR 1000, IDR 1000–2500, >IDR 2500), the last place respondents bought cigarettes (a store or shop/a street vendor/given by someone else/another way) and the ability to purchase cigarettes near school (yes/no).
Reinforcing factors were the elements that strengthen or encourage individuals to engage in a behaviour consistently that included parental smoking (yes/no), witness of teachers smoking in the school building such as classrooms, teachers’ room, toilets or other rooms in school (yes/no), exposure to tobacco advertising through various media (eg, TV, radio, news, social media, billboards, posters and banners) and events (eg, sports events, music concerts, community events) (yes/no), and lack of exposure to tobacco control information through mass media, the internet, activities and information given in class (yes/no).
Control variables
The control variables included sociodemographic characteristics, such as age, gender, weekly allowance (Don't have any spending money, <IDR 11 000, IDR 11 000–20 000, IDR 21 000–30 000, IDR 31 000–40 000, IDR 41 000–50 000, >IDR 50 000) and smoking behaviour variable (duration of smoking (in year) and attempted to quit (yes/no)).
Statistical analysis
We described the sample characteristics both overall and by their preference for cigarette purchases—either loose cigarettes or other forms. The association between loose cigarette consumption and the odds of smoking frequency and intensity was examined using the ordered logistic regression, while the association between loose cigarette and nicotine dependence was investigated through a binary logistic regression. All regressions were controlled for sociodemographic, smoking duration and attempts to quit, as well as the predisposing, enabling and reinforcing factors. Due to the complex sampling design and varying non-response rates at the school, class and student levels in the GYTS surveys, weights were applied in the analysis using STATA 17, with significance determined at p<0.05.
Qualitative study
Study design and samples
We conducted focus group discussions (FGDs) in two junior high schools and one senior high school located in South Jakarta between August and September 2023. The schools were selected through simple random sampling and should be public schools located in areas outside of business districts. South Jakarta district was selected as the study location because it has the highest prevalence (3%) of young smokers aged 10–18 years old of all other districts in DKI Jakarta Province based on our calculation using the National Socioeconomic Survey March 2021.
We purposively recruited FGD participants in August 2023 through an online screening form that contained questions about the students’ identity (their name, gender, age, class, living situation—whether they live alone or with parents—and contact number) and smoking behaviour (age of smoking initiation, type of cigarette purchased, current smoking status and loose cigarette consumption). Class representatives in each school assisted us in sharing the online screening form with other students through verbal announcement, brochures and online messaging. We also applied snowball sampling to expand the sample size by asking students who passed the screening to refer their peers. To validate their eligibility to join the research, researchers then asked the potential candidates to fill out the online screening form. This strategy has been suggested by previous studies in case the target participant of the study is difficult to access and not easily identified.27–29 The FGD participants should be those who are ever or current smokers, buying loose cigarettes, living with parents and willing to participate. We excluded students who only used electronic cigarettes. In the end, students who agreed to participate would receive an online pictorial guideline, which described our institution, research objectives and the conduct of FGD, and an online informed consent for them and their parents to sign.
Data collection
The FGD groups were made exclusive based on school level (junior/senior high school), students’ gender (male/female), smoking status (current smoker/ever smoked) and smoking experience (perceived smoking as a routine for less than 6 months/perceived smoking as a routine for 6 months and more). For example, group 1 consisted of four male students who were current smokers and perceived smoking as a habit for 6 months or more. In this setting, we expected the students to feel more comfortable expressing their thoughts without hesitancy. We also limit the group size to up to five students to allow each student more opportunity and sufficient time to share ideas. Finally, we avoided putting students of one clique in the same group to sustain their focus and open discussion.30 Each group had a moderator to lead the discussion and a note-taker to record important quotes.
We conducted several FGD sessions and continued until the data were saturated. We identified data saturation when the codes were duplicated and new concepts no longer emerged.31 Krueger30 suggested that 3–4 sessions of FGD are usually sufficient to have saturated theory or discover redundant information. Each FGD was conducted in the school for 30–60 min.
The FGD started with an ice-breaker game to create a relaxed atmosphere for students. During the discussion, the moderators managed to gain information about the students’ smoking initiation, current smoking behaviour, nicotine dependence, the availability of loose cigarettes and its impact on students’ smoking behaviour, the cost of smoking and experience of buying loose cigarettes (see online supplemental appendix 1 for the complete list of questions). The discussions that were carried out in the Indonesian language were audio-recorded and transcribed verbatim. In the end, all participating students received a lunch box and a voucher worth IDR 100 000 (approximately US$6.5) (USD$ ≈ IDR 15 432 as of 28 November 2023 at the time of report writing; this number will continue to be used to convert rupiah to dollars in subsequent sections) as monetary compensation.
Supplemental material
Qualitative analysis
The data were extracted by three researchers (SN, GM, and SRA) and supported by an intern (ANP) in Microsoft Excel after verbatim transcription was completed. We used the thematic analysis with an inductive approach to produce codes that were solely reflective of the data content. Then, the data analysis, conducted by three researchers (SN, GM, SRA), included reading the transcripts and highlighting the meaningful quotes related to the research problem; compiling the statements from students based on their smoking status; generating initial codes; combining or generating the codes into potential subthemes; and defining and naming themes. Lastly, some excerpts from the analysis selected to be key findings of the study were translated into English by a certified translator.
To ensure the credibility of our study, the research team applied prolonged engagement, persistent observation and investigator triangulation.31 32 Prolonged engagement was performed by persuading FGD participants to express their statements with examples and requiring moderators to provide follow-up questions. To ensure persistent observation has been done, researchers continuously read and reread the data, recoded and relabelled codes, and revised the themes accordingly. Investigator triangulation has been applied by involving multiple researchers and holding regular meetings to solve different interpretations during data analysis. The details of FGD participants and research process also were provided for transferability in case readers intend to apply our research findings to their own settings.33
Patient and public involvement
Prior to FGD, we conducted a pilot study with students aged under 18 years old to test the FGD instrument and their feedback was used to improve and refine it. We also visited and conducted a series of consultative meetings in the schools where the FGD was proposed to be held in order to discuss the study design and finally to obtain consent for the study. Results were shared with the members of the schools through a public dissemination where teachers and students were invited to hear the findings and deliver further comments.
Results
Quantitative findings
Table 1 illustrates the characteristics of students (n=741) who smoked in the past 30 days. More than half of the students (68%) reported buying loose cigarettes in the past 30 days, including 36% who smoked 1–2 days in a month and 34% who usually consumed one cigarette a day. One-third of the students had nicotine dependence (33%), with an average smoking duration of 3 years. Most students are male (95%) aged 15 years old (SD 1.7). Students who smoked loose cigarettes exhibited a slightly shorter smoking duration (2.73 years) compared with their peers who smoked cigarettes in other forms (3.06 years). The majority of the students (82%) bought loose cigarettes for IDR 1000–2500 in a store or a shop (67%), and almost half of the students (42%) could purchase cigarettes from sellers near the school.
Characteristics of students who smoked in the past 30 days
Table 2 shows the multivariate analysis examining the association between cigarette buying preference and smoking behaviour among adolescent Indonesians. Purchasing loose cigarettes demonstrated a positive association with smoking for <20 days in the past month (adjusted odd ratio (AOR)=1.56; 95% CI=1.17 to 2.07) and smoking ≤5 sticks a day (AOR=2.15; 95% CI=1.54 to 3.00). It also showed a significant positive correlation with lower nicotine dependence (AOR=1.55; 95% CI=1.08 to 2.22).
Multivariate analysis of the association between loose cigarette purchase with adolescents’ smoking behaviour
Regarding enabling and reinforcing factors, the presence of cigarettes around schools was associated with lower odds of smoking <20 days in the past month (AOR=0.48; 95% CI=0.35 to 0.67) and smoking ≤5 sticks a day (AOR=0.54; 95% CI=0.39 to 0.76). However, no significant association was found with nicotine dependence. Sociodemographic characteristics and variables related to smoking, such as age, gender, attempts to quit and smoking duration, were identified as having an association with smoking behaviour. Specifically, higher age, longer smoking duration and being male were negatively associated with smoking <20 days in the past month and smoking ≤5 sticks per day, whereas attempts to quit were positively associated with smoking <20 days in the past month and smoking ≤5 sticks a day.
Qualitative findings
A total of 49 eligible students agreed to participate in FGD which we divided into 12 groups (see online supplemental appendix 2 for detailed recruitment process). Students were 14.86 years old on average, ranging from 12 to 18 years old. Most participants were male (n=37, 76%) and studied in junior high school (n=34, 69.4%). Students received weekly allowance ranging from IDR 10 000 to IDR 350 000 (US$0.7–23), with a median of IDR 105 000 and a mean of IDR 107 978 (US$7). The majority of the participants were current smokers (n=32, 65.3%) and only a few ever tried cigarettes (n=10, 20.4%). More than half of the students consumed their first cigarette since elementary school (n=28, 57.1%). Table 3 shows the characteristics of participants in detail.
Characteristics of students who participated in the focus group discussion
After conducting the thematic analysis using FGD’s transcripts (table 4), we highlighted four arising themes as follows.
Illustration of identifying themes and forming categories from verbatim transcripts
Theme 1: loose cigarette sale facilitated smoking initiation among students, particularly those with limited resources
Most students participating in FGD, particularly those with less weekly allowance than their peers (<IDR 105 000 or US$7), consumed loose cigarettes during their first attempt at smoking. Students who tried smoking when they were at primary school managed to spend on a tight budget and could not afford the cigarette packs. One student said that due to his limited allowance he probably would not have tried tobacco products at such a young age if cigarettes had not been sold in sticks.
I would try (cigarettes anyway) but I would not start in elementary school, maybe in middle school or high school because I had less allowance in elementary school, right? (C2P2)
Theme 2: loose cigarette was the main preference for current student smokers and it tempted them to keep buying cigarettes
During the past 30 days, students mainly bought loose cigarettes rather than other cigarette types (packs, cartons or rolled tobacco). Regarding tobacco consumption, the majority of students who smoked stated that they puffed on cigarettes almost every day and bought around 1–5 cigarette sticks on their smoking day. They usually consumed cigarettes right after school, when hanging out with friends, in the evening or during leisure time.
In students’ perception, the extensive selling of loose cigarettes affected their smoking behaviour in a way that enabled them to buy the sticks repeatedly.
Loose cigarettes made me addicted to cigarette because it (the availability) tempted me to consume more and more. (A3L3)
Furthermore, one student expressed how the availability of loose cigarette hampered his effort to quit smoking:
(The availability of loosies has been) significantly affected me … (Stick cigarettes also) tempted me to keep consuming cigarettes even though I tried (to cut down). I am struggling to quit smoking … (B3L2)
Theme 3: loose cigarette was affordable and accessible, but it led to substantial spending
The main reason for students to buy loose cigarettes was the price. Almost everyone agreed that individual cigarette sticks sold at the store were cheap, ranging from IDR 1000 to 2500 (US$0.07–0.16). Highly affordable cigarette sticks have made many students buy loose cigarettes repeatedly and purchase tobacco products that are worth half or more of their weekly allowance, ranging from IDR 30 000 to 200 000 (US$2–13) in a week. These ideas were generated from the following statement:
Yes, it is because of the money, when we craved cigarettes but we only had a little money, we just bought the loosies … (C2P2)
(I spent) IDR 40,000 per week (for buying cigarettes, it’s more than my weekly allowance, IDR 25,000). (A3L5)
Lastly, access was another reason for students to purchase loose cigarettes. Students could easily find loose cigarettes sold in stores near their schools or living area. These so-called informal retailers were mainly unregulated by the government, and most students claimed that the storekeeper never asked them to show their identity card or to tell their age when buying cigarettes. Also, almost all respondents never experienced restrictions or rejection when purchasing cigarettes at these stores.
Discussion
Our study has demonstrated that approximately 66% of students bought loose cigarettes in the past 30 days. The magnitude is consistent with findings from the 2018 GYTS in several low- and middle-income countries such as Kiribati (73%), Uganda (66%) and Madagascar (82%).34 Our primary data collected in FGD added that almost 70% of participating students bought loose cigarettes in their first attempt at smoking. Furthermore, the present study found that buying loose cigarettes in the past 30 days was significantly associated with being non-daily smokers and consuming five or fewer cigarette sticks a day, which were in line with prior evidence among adults.10–13 The quantitative results also show that students with lower nicotine dependence are more likely to report their last purchase of loose cigarettes.
Adolescents who smoke intermittently for an extended period, consume five or fewer cigarettes a day and exhibit low nicotine dependence fall within the spectrum of the experimentation phase according to the five stages of nicotine addiction.35 Compared with adults who maintain a relatively stable pattern of irregular smoking, adolescents who smoke irregularly and consume fewer cigarette sticks per day have a higher risk of becoming regular smokers in the near future. Typically, youth smokers develop nicotine addiction within 3 years after they start smoking.11 35
Our findings that suggest the role of loose cigarettes in the early smoking phase are substantiated by the trend of cigarette consumption demonstrated in the 2021 Global Adult Tobacco Survey (online supplemental appendix 3). While the younger population is prone to consuming loose cigarettes, this trend gradually decreases in the older population who tends to purchase cigarette packs and demonstrates higher daily cigarette consumption. These trends represent the majority of the population who continue consuming loose cigarettes until they reach a higher addiction stage where cigarette sticks can no longer satisfy their daily tobacco craving, thus rendering them switch to cigarette packs.14
Furthermore, a population-based study in the USA demonstrated the risk of all-cause mortality in non-daily smokers was significantly higher compared with their never-smoked counterparts.36 37 Another study added that those who consistently smoked fewer than 1 cigarette and 1–10 cigarettes daily were at an increased risk of all-cause mortality.38 In this case, our study challenges previous findings that implied the potential benefits of loose cigarette consumption as a harm reduction strategy to cease smoking.12 The efficacy of using loose cigarettes to quit smoking remains unclear,10 11 13 whereas the threat of health-related risks is evident.
Our quantitative findings were also supported by the results of qualitative analysis that revealed the role of purchasing loose cigarettes in smoking initiation, particularly among students with lower weekly allowances. Affordable loose cigarettes allowed lower-income groups with limited purchasing power to consume cigarettes, without paying the full price of a pack that was relatively more costly.39 40 In addition, our study revealed that high affordability, along with the ease of access, was the main reason for students to keep purchasing loose cigarettes during their recent purchase. We acknowledged that consideration of the affordability and accessibility expressed by adolescents was similar to the rationales of buying loose cigarettes in the older population.15 41 42 Nevertheless, unlike adult smokers who concomitantly use loose cigarettes as one of the strategies to limit their tobacco consumption or cease smoking, we did not find such intentions in our study participants. It is plausible since adolescents might be in an earlier phase of nicotine addiction.12 43
While buying loose cigarettes one at a time may seem economically favourable in the short term, previous studies have highlighted the potentially higher expenses incurred from purchasing loose cigarettes in the long term due to the higher cost per stick when sold individually.44 45 Our qualitative findings revealed that students often allocate a significant portion that at times exceeds half of their allowance to purchase loose cigarettes, amounting to IDR 30 000–200 000 (US$2–13) in a week. Remarkably, this expenditure is equivalent to half of the average weekly per-capita expenditure of the Indonesian population in March 2023 (the average per-capita expenditure per month in Indonesia for March 2023 was IDR 1 451 870 (US$94.08) or IDR 362 297 per week (US$23.48), as reported by the Central Bureau of Statistics (Badan Pusat Statistik)). This amount is significantly higher than the average weekly expenses for cigarettes among adolescents in Nigeria (US$0.85) and Eastern Nepal (US$0.26).46 47 The discrepancy in numbers between our study and the others may arise from the differences in sampling methods because studies in Nigeria and Eastern Nepal have used more representative samples to the adolescent population in specific age groups.
Our findings which reveal that loose cigarettes are relatively accessible for students to purchase are consistent with recent studies identifying a huge number of retailers selling cigarettes in the proximity of school areas. A study from Banyuwangi, Indonesia, revealed that almost all of the schools in their study area have cigarette retailers within a 250 m radius in their neighbourhood.48 Another study in Jakarta province also reckoned that the majority of retailers selling tobacco products were located ≤100 m from the school area (61%).8 Moreover, only a few students in our study were requested by the sellers to show their ID card, thus reinforcing the students’ perception of the easy access to purchasing loose cigarette.49 These findings may serve as evidence that the enforcement of age restriction (18 years old or older) to buy cigarettes in Indonesia has not been implemented as expected.
Strengths and limitations
This study contributed insights to our limited understanding of loose cigarette purchase among Indonesian adolescents. In addition, FGD participants in this study mainly consisted of smokers, loose cigarette buyers, and male—these characteristics reflected the population of adolescent smokers in Indonesia. This study may serve as empirical evidence to advocate the prohibition of selling loose cigarettes in Indonesia.
To interpret this study’s findings, we acknowledge the limitations of this study. First, the preference for purchasing loose cigarettes was based on the type of last cigarette bought within the past 30 days, with only one response allowed, which may not accurately reflect actual behaviour. Second, the cross-sectional nature of the quantitative study did not allow the present study to confirm the causal relationship between loose cigarette purchase and cigarette use among samples. Third, both GYTS and FGD were at risk of recall bias since the students assessed themselves retrospectively. Fourth, because the GYTS data are limited to youth attending school, it may not be representative of all adolescents in Indonesia. Lastly, this study was conducted in the schools where students were likely to give socially acceptable answers rather than being truthful.
Conclusion
The findings of the present study show that purchasing loose cigarettes is significantly associated with smoking less than 20 days in the past month, smoking five or fewer sticks per day and lower nicotine dependence which could be interpreted as smokers in the experimental phase. Supporting the quantitative data, our qualitative findings have shed light on the role of loose cigarettes in smoking initiation and continuation among young people. Regarding cigarette purchases in the past 30 days, most students prefer loose cigarettes to other types of cigarettes because they are cheap and easy to get. Buying loose cigarettes one at a time is considered inexpensive, and yet, it encourages students to continue buying cigarettes frequently that result in substantial spending. However, a longitudinal study is needed to more sufficiently investigate whether the loose cigarette actually causes young people to initiate and continue smoking.
In terms of policy, our study supported the notion of the Indonesian government to prohibit the sale of loose cigarettes in order to curb tobacco consumption among adolescents in Indonesia. Enactment of the law should be followed by policy enforcement, such as routine inspections and clear statement of punishment in the law. Additionally, to reduce informal sales of cigarettes, a licence requirement for stores or retailers selling tobacco products should also be adopted and implemented. The government should also ensure tobacco products are not affordable for young people by raising the tax significantly and simplifying the tax tiers.
Data availability statement
Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information. We used data from GYTS for quantitative study which are available in public, open access repository. The data could be accessed through Global Tobacco Surveillance System Data (GTSSData) provided by Centers for Diseases Control and Prevention (https://www.cdc.gov/tobacco/global/gtss/gtssdata/index.html). On the other hand, data used in qualitative study were collected during FGD with students and due to the agreement with the schools we are not allowed to share the data to any external parties, thus data sharing is not applicable.
Ethics statements
Patient consent for publication
Ethics approval
This study complied with the Declaration of Helsinki and was performed according to the ethics committee approval issued by the Institute of Research and Community Service, Atma Jaya Catholic University of Indonesia, on 3 May 2023 (no.0004S/III/PPPE.PM.10.05/05/2023). In addition, a recommendation letter to conduct research activities in South Jakarta district was issued by the Provincial Government of DKI Jakarta on 3 July 2023 (no.3/AF.1b/2/TM.23.04/e/2023). Students and their parents gave online informed consent to participate in the study before taking part.
Acknowledgments
We acknowledge the contributions of Putu Ayu Swandewi Astuti, Susy K. Sebayang and Gumilang Aryo Sahadewo for their insights on this work. We are also very grateful for the collaboration with the schools that allowed us to conduct the research within their communities. Finally, we thank our colleagues (Iman Zein Mahaputra, Aufia Espressivo, Olivia Herlinda, Muhammad Anugrah Saputra, Lara Rizka, Nadira Esthevyani, Bagus Fachrudi, Muhammad Naufal Randhika Putra and Alessandra Nerissa Pradana) for their contribution during the study preparation, pilot study and data collection.
References
Footnotes
Contributors GM conceptualised the research and was involved in all aspects of analysis, data collection, interpretation and manuscript preparation. GM is also the guarantor of the study and accepts full responsibility for the finished work and the conduct of the study, had access to the data and controlled the decision to publish. FZK was involved in all aspects of study preparation, quantitative analysis and manuscript preparation. SRA was involved in study preparation, data collection and revision of the manuscript. SN was involved in data collection, qualitative analysis and revision of the manuscript. DK and VA supervised the overall project, gave insights on the study methods and revised the manuscript content.
Funding CISDI is supported by the Campaign for Tobacco-Free Kids (CTFK) grant number INDONESIA 29-12 to conduct research and advocacy to support tobacco control in Indonesia. The CTFK is a partner of the Bloomberg Initiative to Reduce Tobacco Use. The views expressed in this document cannot be attributed to, nor do they represent, the views of the CTFK.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.