Compliance with Smoke-Free Policy and Challenges in Implementation: Evidence from Bengkulu, Indonesia

BACKGROUND: Smoking is among the top contributors to deaths and disability-adjusted life years in Indonesia, particularly among males. In 2012, a presidential decree encouraged provinces and districts to implement a smoke-free policy (SFP). This study aims to evaluate compliance and explore the challenges in the implementation. METHODS: Through a mixed-methods design, we used quantitative methods to examine the compliance with six criteria including signage, no active smoking, no selling, no advertisement, no smoke, and no ashtray at SFP facilities in Bengkulu city. We observed SFP compliance at 105 facilities, including health/educational facilities, places of worship, workplaces, and indoor/outdoor public facilities. We also used a qualitative method to explore challenges in the implementation through interviews with the government and legislators. RESULTS: The compliance rate to all six criteria was 38% overall, ranging from 17% at outdoor public facilities to 67% at health facilities. We found no spatial patterning, as shown by non-significant differences in compliance rates between SFP facilities inside and outside of 1-kilometer around the provincial and city health offices. Implementation challenges included lack of sensitization, lack of coordination, and limited budget. CONCLUSION: The compliance was relatively low due to several challenges, which could serve as a tobacco control policy lesson in a lower-middle-income country.