Is Youth Smoking Related to the Density and Proximity of Outdoor Tobacco Advertising Near Schools? Evidence from Indonesia

Exposure to outdoor cigarette advertisements and cigarette retailers near Indonesian schools: Density, proximity, and students' self-report of exposure

INTRODUCTION

Adolescents are vulnerable to tobacco advertising, promotion, and sponsorships (TAPS). The presence of TAPS, specifically outdoor cigarette advertisements (OCA) and cigarette retailers (CR), impacts adolescent smoking behavior. This study examined the presence of OCA and CR near Indonesian schools and students' report of their TAPs exposure.

METHODS

We conducted a cross-sectional study in the three diverse districts (Serang, Banyuwangi, and East Lombok) and a city district (Padang), Indonesia on September 2022-April 2023. In each district, we selected the three subdistricts with the most schools and the highest population density. Enumerators mapped all outdoor OCA and CR using Global Positioning System (GPS) devices. In selected schools within the study areas, we surveyed 6715 students about their TAPs exposure using face-to-face interviews. Students were selected using multistage cluster sampling. Data were analyzed descriptively using STATA 14.2.

RESULTS

Of the 21460 retailers identified in the subdistricts, 30.4% were CR. The proportion of CR varied by district, between 24.8% and 40.7%. East Lombok had the highest percentage. Additionally, Banyuwangi had the highest density of CR. There were 13660 OCA points (district range 1918-6472). Around schools, banners were the most common OCA form (62.1%). Posters were second (32.8%). The retailers who sold the most cigarettes in the four districts were in kiosks. The density of CR and OCA per km2 increased as the distance from schools decreased. Students' self-reported exposure to tobacco products was higher from OCA and CR than from the internet, television, and magazines/newspapers.

CONCLUSIONS

OCA and CR are ubiquitous around schools. The Indonesian government should assess OCA and CR regulations and limit OCA and CR close to schools.

Compliance with tobacco advertising and promotion laws at points-of-sale in Ethiopia: an observational study in 10 cities

BACKGROUND

Ethiopia enacted a comprehensive tobacco control law in 2019, which bans tobacco advertising and promotion activities. However, compliance with these laws at points-of-sale (PoS) has not been studied, resulting in a lack of research evidence on how the regulations are implemented. The purpose of the study was to assess compliance with tobacco advertising and promotion laws at PoS in 10 cities in Ethiopia.

METHODS

Multi-stage cluster sampling was used to select 1468 PoS (supermarkets, minimarkets, merchandise stores, regular shops, permanent kiosks, khat shops, street vendors, and food and drink wholesalers). Data were collected using standardized observational checklists. Tobacco advertising and promotion indicators were used to compute indoor and outdoor compliance. Poisson regression models with log link function and robust variance were used to assess factors associated with open display of cigarette packages and indoor non-compliance.

RESULTS

The average indoor compliance rate was 92.9% (95% CI:92.3-93.5). Supermarkets had the highest compliance (99.7%), while permanent kiosks showed the lowest compliance (89.8%). The highest average indoor compliance was observed at PoS in Addis Ababa (98.0%). About 60% of PoS were fully compliant in indoors. Indoor open display of cigarette packages was prevalent (32.5%, 95% CI:30.0-35.1). The average outdoor compliance was 99.6% (95% CI:99.5-99.7). Outdoor full compliance was 96.5%. Open display of cigarettes was significantly higher in permanent kiosks (adjusted prevalence ratio (adjPR) 6.73; 95% CI: 3.96-11.42), regular shops (adjPR 5.16; 95% CI: 3.05-8.75), and khat shops (adjPR 2.06; 95% CI: 1.11-3.83), while indoor non-compliance was significantly higher in these same types of PoS.

CONCLUSIONS

While outdoor compliance rates were relatively high, the lower indoor compliance rates particularly due to the high prevalence of open cigarette package displays indicates a major area for improvement in enforcing anti-tobacco advertising and promotion laws.

District-Level Inequalities in Hypertension among Adults in Indonesia: A Cross-Sectional Analysis by Sex and Age Group

BACKGROUND

An estimated 1.28 billion adults 30-79 years old had hypertension globally in 2021, of which two-thirds lived in low- and middle-income countries (LMICs). Previous studies on geographic and socioeconomic inequalities in hypertension among adults have limitations: (a) most studies used individual-level data, while evidence from locality-level data is also crucial for policymaking; (b) studies from LMICs are limited. Thus, our study examines geographic and socioeconomic inequalities in hypertension among adults across districts in Indonesia.

METHODS

We combined geospatial and quantitative analyses to assess the inequalities in hypertension across 514 districts in Indonesia. Hypertension data were obtained from the Indonesian Basic Health Survey (Riskesdas) 2018. Socioeconomic data were obtained from the World Bank. Six dependent variables included hypertension prevalence among all adults (18+ years), male adults, female adults, young adults (18-24 years), adults (25-59 years), and older adults (60+ years).

RESULTS

We also found significant geographic and socioeconomic inequalities in hypertension among adults across 514 districts. All hypertension indicators were higher in the most developed region than in the least developed region. Districts in the Java region had up to 50% higher prevalence of hypertension among all adults, males, females, young adults, adults, and older adults. Notably, districts in the Kalimantan region had the highest prevalence of hypertension, even compared to those in Java. Moreover, income level was positively associated with hypertension; the wealthiest districts had higher hypertension than the poorest districts by up to 30%, but only among males and older adults were statistically significant.

CONCLUSIONS

There were significant inequalities in hypertension among adults across 514 districts in the country. Policies to reduce such inequalities may need to prioritize more affluent urban areas and rural areas with a higher burden.

Disparities in Obesity Rates among Adults: Analysis of 514 Districts in Indonesia

BACKGROUND

Globally, it was estimated that over 650 million adults 18 years old and older were obese in 2016. It is an increasing global health challenge with a significant health and economic impact. Thus, understanding geographic and socioeconomic disparities in obesity among adults is crucial.

METHODS

We combined geospatial and quantitative analyses to assess the disparity in obesity across 514 districts in Indonesia. We used the Basic Health Survey (Riskesdas) 2018 for obesity data and the World Bank database for socioeconomic data. Dependent variables included obesity prevalence among all adults (18+ years), males, females, young adults (18-24 years), adults (25-59 years), and older adults (60+ years).

RESULTS

We found significant geographic and socioeconomic disparities in adult obesity in Indonesia. In terms of region, districts in Java and Bali had a significantly higher prevalence of obesity than those in Papua, Maluku, and Nusa Tenggara. Districts in Java had 29%, 32%, 60%, and 28% higher prevalence of obesity among all adults, female adults, young adults, and adults. By income, compared to the poorest ones, most affluent districts had a significantly higher prevalence of obesity; they had a 36%, 39%, 34%, 42%, 33%, and 73% higher prevalence of obesity among all adults, males, females, young adults, adults, and older adults. Similarly, by education, compared to the least educated ones, the most educated districts had a significantly higher prevalence of obesity; they had a 34%, 42%, 29%, 36%, and 80% higher prevalence of obesity among all adults, males, females, adults, and older adults.

CONCLUSIONS

There are significant disparities in adult obesity among 514 districts in Indonesia. Efforts by policymakers and stakeholders are needed to reduce obesity among adults, especially within districts with high prevalence.

Exposure to Outdoor Tobacco Advertisements Near Home is Associated with Smoking among Youth in Indonesia

BACKGROUND

The prevalence of cigarette smoking among adults is persistently high, and among youth is increasing in Indonesia.

OBJECTIVE

This study aims to examine the association between youth smoking behavior and outdoor tobacco adverts near home in Indonesia.

METHODS

We conducted a cross-sectional survey of 3,557 students in North Sumatera during September-November 2020. The main independent variables include seeing tobacco advertisements near home, near school, on social media. The outcome variables included ever smoked and smoked in the last ten days.

RESULTS

We found significant associations between exposure to outdoor tobacco adverts near home and youth smoking. High school students who reported seeing tobacco adverts near home were 1.42 times more likely to smoke and 2.29 times more likely to smoke in the last ten days. Moreover, students at private schools (a proxy for higher income) exposed to tobacco adverts near home were 1.56 times more likely to smoke and 2.93 times more likely to smoke in the last ten days.

CONCLUSION

Exposure to outdoor tobacco advertisements near home is associated with smoking among youth in Indonesia. Comprehensive tobacco control efforts are needed, including through a ban of outdoor tobacco adverts.

Towards healthy school neighbourhoods: A baseline analysis in Greater London

Creating healthy environments around schools is important to promote healthy childhood development and is a critical component of public health. In this paper we present a tool to characterize exposure to multiple urban environment features within 400 m (5-10 min walking distance) of schools in Greater London. We modelled joint exposure to air pollution (NO₂ and PM_2.5), access to public greenspace, food environment, and road safety for 2,929 schools, employing a Bayesian non-parametric approach based on the Dirichlet Process Mixture modelling. We identified 12 latent clusters of schools with similar exposure profiles and observed some spatial clustering patterns. Socioeconomic and ethnicity disparities were manifested with respect to exposure profiles. Specifically, three clusters (containing 645 schools) showed the highest joint exposure to air pollution, poor food environment, and unsafe roads and were characterized with high deprivation. The neighbourhood of the most deprived cluster of schools had a median of 2.5 ha greenspace, 29.0 µg/m³ of NO₂, 19.3 µg/m³ of PM_2.5, 20 fast food retailers, and five child pedestrian crashes over a three-year period. The neighbourhood of the least deprived cluster of schools had a median of 21.8 ha greenspace, 15.6 µg/m³ of NO₂, 15.1 µg/m³ of PM_2.5, 2 fast food retailers, and one child pedestrian crash over a three-year period. To have a school-level understanding of exposure levels, we then benchmarked schools based on the probability of exceeding the median exposure to various features of interest. Our study accounts for multiple exposures, enabling us to highlight spatial distribution of exposure profile clusters, and to identify predominant exposure to urban environment features for each cluster of schools. Our findings can help relevant stakeholders, such as schools and public health authorities, to compare schools based on their exposure levels, prioritize interventions, and design local policies that target the schools most in need.

Compliance With Tobacco Control Policy and Visibility of Cigarette Retailers Around Educational Facilities in Riyadh, Saudi Arabia

Background

In Saudi Arabia, cardiovascular diseases are among the top causes of death and disability, and smoking is one of the leading risk factors, particularly among males.

Objective

Our study aims to evaluate the compliance with the anti-smoking law among cigarette retailers and examine the visibility of cigarette retailers around educational facilities in Riyadh city, Saudi Arabia.

Methods

We conducted a mapping survey and geospatial analysis of cigarette retailers around educational facilities from February to March 2020 (before the COVID-19 restriction) in Al-Olaya municipality in Riyadh city as a pilot study. We found 249 retailers, of which 152 sold cigarettes. Data analyses in ArcMap 10.6 compared the visibility within 250 and 500 meters from educational facilities.

Results

We found many retailers were not compliant with the tobacco control regulation: 57.1% of minimarkets sell cigarettes, 15.8% of cigarette retailers display the products openly, and 12.5% of cigarette retailers sold cigarettes by the stick. Moreover, 71% of the total cigarette retailers were within 500 m from schools, and 62% of all schools had at least one cigarette retailer within 500 m buffer (5-min walking or 2-3-min driving distance).

Conclusion

There is non-compliance with the anti-smoking law among cigarette retailers and high visibility of cigarette retailers around educational facilities in Saudi Arabia. Monitoring is needed for the effective implementation of tobacco control policies.

Density of Cigarette Retailers Near Facilities for Children and Adolescents in Urban and Rural Areas in Indonesia: A Geospatial Analysis

The lack of regulation banning cigarette retailers near facilities for children and adolescents has made cigarettes easily accessible to youth in Indonesia. This study aimed to investigate the density of cigarette retailer near children and adolescent facilities in urban and rural areas in the country. We mapped all cigarette retailers and facilities for children and adolescents in Surabaya city (urban) and Banyuwangi district (rural) in East Java province. All types of facilities for children and adolescents and retailers visible from the streets in the study areas were mapped. We conducted geospatial analysis of the density of retailers to the facilities for children and adolescents in QGIS 2.8 and STATA 14. We found that the density of cigarette retailers was 81% higher in the areas within 100 m from the facilities for children and adolescents, compared with the areas within 100 to 250 m from facilities. We also found that the density of cigarette retailers within 100 m from facilities was 2.35 times higher in the rural setting, compared with the urban setting. Controlling cigarette retailers through zoning and licensing is urgently needed in Indonesia.