Study on Tobacco Control-Related Stakeholders’ Perspective on Tobacco Control Policies and Practice Towards Teenagers and Children Under Sharia Law Setting in Aceh

: Acehnese's smoking culture has also made teenagers and children more likely to smoke. This study aimed to see the influence of sociocultural, religious views, and local policy on smoking practices among children and adolescents in Aceh. The study used a qualitative study design. However, the collecting data was held as a Focus Group Discussion with twelve people as representatives of Stakeholders in Aceh. The Acehnese people's smoking culture, which has integrated into their way of life, has made teenagers and children vulnerable to cigarette exposure. The result of the study indicated that the Islamic view on smoking is in line with the principles of tobacco control, where smoking can have a negative impact on children and adolescents, so it is strictly prohibited in Islam. Therefore, it is suggested that tobacco control interventions in Aceh for children and adolescents can focus on interventions that use sociocultural and religious approaches.


INTRODUCTION
Indonesia's high number of child and adolescent smokers is currently at a critical point. A report published in the Bloomberg Initiative to Reduce Tobacco Use series shows that 78% of smokers in Indonesia started smoking before the age of 19. Another ironic fact is that of children under 15 who smoke, 8 out of 10 try to quit smoking but are unsuccessful (Barber et al., 2008).
A few people are less likely to understand how addictive nicotine is, which could harm children and young people who tend to be prone to it. Those teenagers and children, who will occupy important positions in Indonesia in the future, could be the sick generation because of nicotine-related diseases (Rukmi, 2018). Yet, this can be prevented if all the potentials that endanger the children and adolescents' health could be anticipated or even eliminated.
The highest potentials might jeopardize them that are those who closely live with them. A Study conducted by Wakschlag, et al showed that among 344 children who were persistently observed when they talked to their smoking parents related to antismoking messages; the mother would be the one who leads to the conversation. On the other hand, such an anti-tobacco message from smoking parents would be much more challenging to be conveyed to their kids (L. S. Wakschlag et al., 2010).
Smoking parents might also lead to those children under their upbringing becoming smokers at an early age. A piece of evidence shows that adolescents with parents who were smokers tend to be premature as regular smokers (D. Mays et al, 2014).
Cultural acceptance of smoking is other aspect to be concerned. Considering that Indonesia is very sociocultural and environmental in forming their young people's habits (Rukmi, 2018).
In addition, in First International Conference on Health Promotion in Ottawa mentioned that the effort to normalize of health habits could be conducted by creating a healthy community, that focuses on achieving equal health in the community. The effort might aim to enable each other to attain their fullest health potential. This embraces a secure foundation in a supportive environment, access to information, life skills, and chances for deciding healthy choices. Such members of the community cannot attain their fullest health potential except if they are able to manage of those things which build their health. Therefore, the effort on making healthy young people's habits would highly rely on their surroundings (who, 2023).
Other factors that are also crucial to be scrutinised are the religious views and existing local policy, which might demolish the habit of smoking among those teenagers and children, specific cases in Aceh Province, which applies Islamic sharia rules.
In the book of Islamic rulings on smoking, citing consensus among Muslim scholars has resulted in totally inhibition of smoking. Moreover, The Council of Islamic Ideology of Pakistan echoed that tobacco use is un-Islamic activity (M.H. Khayat, n.d.).
However, even though Aceh province as the only province in Indonesia that has comprehensively implemented Islamic law based on the Peace Treaty concluded on 15 August 2005 (Manan, 2020), more than a fifth (27.9%) of adolescents over ten years old in Aceh still smoke. Ironically, it becomes common among community. This is shown by the high number of cigarettes consumed per day. It is noted that the total number of cigarettes consumed steadily to a level of 19 cigarettes a day. These numbers are higher than the average national rate of 12 cigarettes per day (Tahlil et al., 2013).
Improving the bad health condition of Aceh's adolescents and children by examining the habits of children and youth associated with cultural acceptance of these habits is an essential issue in this study. Starting from exploring the habits of the people of Aceh and how they might affect the increasing number of children and adolescents who smoke.
Tobacco use among Acehnese children and adolescents is one of the worrying problems in the community, and the smoking habit of those teenagers and adolescents could result from a lack of such assertive regulations implemented here in the community.
In response to the problem, as mentioned earlier, it is necessary to assess the perspective of tobacco control-related stakeholders regarding local policy, values of religion, and sociocultural indicators to be observed. Banda

METHOD
The study was conducted by interviewing related stakeholders. It aims to know how local policy, sociocultural, and religious aspects affect tobacco control efforts and needs to know what kinds of tobacco control potential support, challenge, and strategies might support tobacco control efforts.
The study was conducted through the Focus Group Discussion (FGD) on 22 August 2020 through the Zoom meeting platform.
The guideline for conducting the Focus Group Discussion is defined in Table 1. This guideline is limited to five tobacco control policy adoption topics, including sociocultural aspects, religious views, potential support, challenges, and strategies.

Sociocultural Aspects
This theme describes the sociocultural factors that could encourage young people and teenagers to use tobacco in the aftermath of surrounding exposures, such as the habit of the adult population of smoking. In addition, endorsed negative factors also contribute to adolescents' initiation and continued use of such tobacco (Bobo & Husten, 2000).
Social culture is a system of thinking that influences perception and acting in a group of people (Stjerna et al., 2004). For this analysis, researchers focused on finding information such social and cultural aspect might impact the increasing tobacco use among teenagers and children in Aceh. Researchers identified a key finding that smoking habits have become integrated into the culture of the Acehnese people.
Simultaneously, the FGD participants had the same views about the dangers of smoking for adolescents and children in Aceh. Therefore, the representative of Academia regretted such habit because smoking is more likely to integrate with the culture of Aceh for long time.
Some of parental habits include drinking coffee while smoking, smoking at home in front of their children, and telling children to buy cigarettes for their grandparents.
"There is still such a culture of smoking in the family. For example, smoking fathers or smoking grandfathers ask their children or their grandchildren to get cigarettes from the storage area and order their children to buy cigarettes." (Respondent 3, Academia).
The fact that this "habit" is called a transmission of smoking. It is written in a study conducted by S. E. T. El-Amin et al., (2016) where the data of 3535 Finn children in 2013 were analysed to get the evidence of how grandparents' smoking habit could heavily affect their heredity's habit in the long-term. The study indicated that 73% of the impact of grandparents' smoking on grandchildren's daily smoking was transmitted through parents' smoking. Moreover, a mother's smoking impacted more than a father's smoking. To sum up, this study mentioned that a mother, father, or any of the four grandparents were current or former smokers can be able to make their grandchild would become smokers as well.
Another respondent also mentioned that the parent smoking habit might influence children to imitate the habit.
"In Aceh, there is a culture of drinking coffee. For example, drinking coffee is usually done while smoking. Because of the habit of parents at home where every morning they drink coffee with cigarettes so that children imitate the habits of these parents." (Respondent 9, MTCC Unmuha).
A study that had been conducted among 100 children in the Netherlands with the range of 4-8 years-old that acted out as adults who were having dinner. In this situation, those kids played with a toy kitchen and a child-sized dining area, including a package of fake cigarettes on the table. The study results shown that 37% of them had at least one "smoke" during their play. The chance for such action was 3.16 times higher for children that are reported having smoking parents. To sump up, this study concluded that those who reported having smoking parents tend to act out having dinner with a (after-dinner) cigarette (de L. RN et al., 2010).
On the other hand, a study mentioned this kind of cultural acceptance is also connected to a gender view; teenagers are looking for an identity. The smoking habit in the community is a symbol of a boy transferring to be an adult man (Bobo & Husten, 2000). Those more likely to smoke are presumed to be well-accepted in the community.
It was corrected by a participant mentioned below.
"The smoking culture is closely related to the environment where the younger generation is influenced by their peers so that they become part of it to gain recognition, togetherness, satisfaction, release, peace, and togetherness." (Respondent 12,CICGS) The book on social norms and acceptability of tobacco use mentions that the teenage period change from childhood to adulthood. Firstly, they face a transitional duration that is forming them. In this case, they are presumed to have a prior requisition to enter adulthood life. Secondly, other development during this time also occurred to their physiological, emotional, and psychological alteration (Lynch & Bonnie, 1994).
"When culture is dynamic, it can be influenced by many things. Teenagers today have their authority. There is a shift in smoking behavior, which was previously considered a disgrace but has now become commonplace. So that the negative image of smoking behavior no longer appears." (Respondent 12, CICGS) Those might not be detached from the context of family, friends, educational work, and the local community surrounding them. They build their sense of self and redefine themselves socially.
The family would take part in perceiving values, even though those who are more likely to adhere to the existing values of their parents regarding religion, education, and work, yet, the adolescent would also hold to the value of their surroundings, specifically their friends including to the culture such as music and appearance (Lynch & Bonnie, 1994).
At the local level, social alteration can take many kinds of shapes. Thus, this might involve heterogeneous communities, individual citizens, businesses, NGOs, and multiple levels of government in dynamic stakeholder arrangements. The local design programs can provide valuable insights and solutions tailored to a particular community's needs and conditions. It is specifically relevant in the case of tobacco control, where the effectiveness of national policies and enactments may be limited by factors such as cultural norms, economic disparities, and political resistance (Lynch & Bonnie, 1994).
The efforts that can be made includes strengthening existing policies and taking a cultural approach that is more tactical and requires an understanding of the dangers of smoking at the family level and in the broader community. Because even though there is a common understanding at the level of policymakers, the knowledge of families and the general public about the dangers of smoking for children and adolescents is another crucial part.
The study conducted by Oztekin, et al (2021) assessed 707 adolescents to study the relationship between parental attitudes to tobacco use among teenagers. The study indicated that smoking fathers could increase the number of daughters smoking 1.59 times. On contrary, a democratic mother descend the chance for boys to smoke 0.32 times. Yet, the mother's protective and demanding behavior induced the chance for girls to smoke 8.65 times. Oztekin et al suggested to make public health smoking prevention programs to be connected with changing parental behaviours and attitudes in prematurely years by applying authoritarian parenting styles.
Suwandari and Mumpuniarti (2020) mentioned that there is an observational learning parenting style that might lead children to shape their manners according to what they see from their parents, and make their parents as models. They also highlighted that parents have two roles, that are as a model and a training companion so that parents can have wellcomprehension toward the role function as parents of children, even this case is specifically aimed to children with autism;however, in general, this kind of parenting style would be helpful also for children in general (D. N. Swandari and M. Mumpuniarti, 2020).

Religious View toward Tobacco Use (specifically for teenagers and children)
The religious view as part of the beliefs are defined as the best indicators of the choices people make in their daily lives. But, there is still much discussion as to whether pedagogical beliefs influence decisions or decisions influence these belief (EERA, 2008).
The tobacco control policy under the rules of the Islamic religion, especially in Aceh, is firm. Aceh Ulema, a Consultative Council participant, emphasized that the implementation was still not optimal.
"…a hadith from Ibn Majah means don't harm yourself and don't harm others either. It means that cigarette smoke from smokers will harm other people, and the law of smoking, in this case, is unlawful.." (Respondent 1, Aceh Ulema Consultative Council (MPU) representative).
The previous study indicated that young generations would cease smoking for two leading causes: the pressure of the closest people who object to smoking behavior and feeling wickedness in health (Crosby et al., 2019).
Moreover, the other study indicated another idea to stop young people from smokingthat older people try to discipline their younger society. So, the collaboration between the ideas of the jeopardy of cigarettes, human nature, and assertive rules from the community to discipline its younger generations would bring the top plausible success in smoking cessation efforts (Marynak et al., 2016).
On the other hand, Aceh society, which is more likely to cling to the precept of Islam, would hold tightly onto Islam's commands. The people of Aceh generally carry out everything by adhering to the Shari'a. Still, the conditions for tobacco control based on Islamic rules in the form of the Aceh MPU fatwa number 18 of 2014 are not strict in terms of implementation like the representative of the Women and Children Empowerment office mentioned below.
"… smoking is haram, but there is an ustad, still smoking. We have to stop smoking, then our family will follow the example." (Respondent 8, Women and Children Empowerment office). On 8 March 2010, the Tarjih and Tajdid Council of Muhammadiyah Central Leadership issued a Fatwa citing that smoking is haram because smoking is an act that harms the individual concurrence of others.
Participants from the education office of Dayah Aceh representative also mentioned the lack of understanding of all legal regulations on smoking from an Islamic point of view.
"In the Islamic boarding school itself no smoking cases have been found in children at the Islamic boarding school. However, some of the teachers we met stated that smoking is makruh , so they still smoke." (Respondent 2, education office of Dayah Aceh representative). The blurring of "haram" to "makruh" often occurs because of the interests of individuals who incidentally are smokers. The role of scholars in understanding educators themselves is important because it is religious educators who are closest to adolescents and children. Religious educators will continue to be role models to be followed. The approach that needs to be taken in this case is cooperation and sitting together to equalize views for the common good.

Potential Support
Many studies shown that the deleterious effects of nicotine is long lasting. Logically, no one might place themselves at this harmful position; however, people normalize the smoking habit due to unresponsive effect gotten. This means that the tobacco effect might not impact as soon as like other harmful stuffs such as alcohol and so on.
The habit of smoking might effect to ones's personality; kinds of addictive, self-center characteristics of people as the personality embedded to young smoker. This is proven by the act of smoking at the public places acknowledged as arrogant personality (UHAMKA, 2007).
For those reasons, the researchers assumed that it is important for working together to do this kindness thing in life and avoid such bad things for young people become prominent supports for making such tobacco use habit could disappear.
The other potential to support tobacco control among teenager according to J Harvey (2016) is professional health worker; However even though the professional health workers as important actors in making effort to decrease number of young smoker, the role of family, and community also should take part in those attempts.
In Aceh itself, IIslamic leaders must take an active role in reminding the Acehnese community to stop smoking. M.N. Ichwan, et all assessed the recent (re)construction of citizenship in Aceh, which is actually based on two aspects, they are (1) sharia, and (2) on ethno-religious nationalism. Those aspects had become a cultural, social, political and legal fact in Aceh. As the result, the way Acehnese people act led by religion and protected by this religious ethno-nationalism (M. N. Ichwan et al., 2020).
Shari'a rules are generally a part that the people of Aceh highly consider. The people of Aceh are terrified of violating religious rules. Therefore if matters related to tobacco control are linked to Islam, it will be be easier to be adherence.
"..Prohibiting cigarettes from being sold in Aceh can be effective because Aceh has Islamic law. Some scholars forbid smoking, so banning the sale of cigarettes freely in Aceh because cigarettes are illegal will effectively reduce people smoking and people being exposed to smoke." Another idea to support tobacco control, in general, is by increasing the price of cigarettes. Recently, the prices are so cheap, so children can buy cigarettes on sticks with pocket money.
"Increasing the price of cigarettes 100% in Aceh also reduces smokers. The bigger potential is to make smoking restriction rules…" (Respondent 9, MTCC).
The Increasing cigarette price could discourage smoking initiation among young people, remind smoking quit trials, and decrease consumption (Reqyrizendri et al., 2020).
The young people transitioning from relying on friends for cigarettes to affording their own-and who are, so that, at most significant risk of being smokers-are critically more price-sensitive than older people (Reqyrizendri et al., 2020).
In addition, a cultural change is crucial for tobacco control among those groups of people. The smoking culture in society can be anticipated. Although this cannot be done instantly, it requires continuous effort and joint commitment (Reqyrizendri et al., 2020).
"…the law that can be adopted can be through Islamic law because, in Aceh, Islamic law applies according to the Law on the Government of Aceh that in Islamic law, scholars believe that smoking is makruh and there are also those who give a fatwa as haram. So, the potential for regulating smoking restrictions through Islamic law is enormous." (Respondent 1, Aceh Ulema Consultative Council (MPU).

Challenges
One of the challenges in tobacco control efforts is that cigarettes are still very cheap, making it easy for people and even children to buy them. Without the need to grapple with the price, cigarettes can be purchased by the public.
The affordable cigarette price here in Indonesia would be the most challenging in tobacco control. The representative of MTCC gave her view on the weakness of strengthening tobacco control policies, which can be seen from access to buying cigarettes, which is still very easy.
"…The challenge is how easily accessible cigarettes are. Think about raising the price of cigarettes high enough to make it out of the reach of the masses…" (Respondent 2, Education Office of Dayah Aceh).
Increasing tobacco excise taxes was a profound recommendation to prevent smoking consumption trial among teenagers and children, encouraging them to stop smoking. An initial target is to become $10 per pack or the higher average retail price as the ideal price (Reqyrizendri et al., 2020).
"The relatively low price of cigarettes makes it easy for children to buy cigarettes and sellers do not prohibit children from buying cigarettes, and there are no sanctions for children who smoke when underage." (Respondent 9,MTCC).
The affordability of the Indonesian community buying cigarettes has increased in the tobacco control literature in recent years as global tobacco consumption has shifted from high-income to low-and middle-income countries (Rodriguez-Iglesias & Blecher, 2018).
As many other low-and middle-income countries are attaining unprecedented rates of economic increase, sky-rocketed income growth allows cigarettes to become much more affordable (Rodriguez-Iglesias & Blecher, 2018). As such, gauging the affordability of cigarettes has been a crucial anchor for tobacco tax policy that leads to increasing prices of cigarettes. In contrast, cigarette affordability gauges, the divergence of affordability across a group of countries is not particularly useful since incomes quite differ more significantly among countries than cigarette prices (Rodriguez-Iglesias & Blecher, 2018).
The tobacco control activist, representative of CIGSS, gave their views on the strong smoking culture in Aceh, which has become another challenge in controlling tobacco consumption among children and young people in Aceh. The efforts to control tobacco in Aceh require extra work because the young people of Aceh are usually introduced with cigarettes at their own house.
"Children have been smoking since they were ten years old, and they imitate the habits of their parents who smoke at home..." (Respondent 12,CIGSS).
According to the survey compiled by The Arabic Health Ministry's Tobacco control program indicated that even though more than three fifth (73%) of Arabic adolescent believed that smoking should be banned in public places, the study also found that more than a fifth (29.4%) of smoking adolescent in Arab that those who grew up at home with smokers, and also more than a fifth (24%) had at least one or two parents who smoke (Arab News, 2011).
The other challenge is that smoking and the culture of the Acehnese people, as discussed earlier, social acceptance of smoking has made the "habit of smoking" become common.
The representative of The Aceh Institute stated this statement: "…the first challenge faced in Aceh is the culture of men being said to be slang if they sit in a coffee shop, while coffee shops drink coffee usually interspersed with Thus, the Province and District governments have the task of controlling any outdoor advertisement (Astuti et al., 2020 Another common thing that deserves attention is the seriousness of policymakers in implementing these policies, one of which can be seen from the application of sanctions to existing policies.
The government with the power might be able to make social restrictions regarding smoking the same as "social distancing" rules during the current Covid-19 pandemic. Sanctions and the involvement of all parties are the keys to success.
"... Following the example of Malaysia, the assembly there has banned smoking. So that people have control in smoking. Cigarette sterilization in all activities in society…" (Respondent 1, MPU).
It is recommended to make sanctions for smokers who prohibit the rules because if there are non-smoking areas but no sanctions, then the practices are ineffective. With sanctions for smoking in public places, the Qanun for Smoking Areas will run effectively due to the habit of the community only complying after being sanctioned.
Another response from one of the participants mentioned that one of the strategies to make clear the position of tobacco in Islam only by involving "non-smoking islamic school teachers to the forum, as mentioned below.
"Smoking is haram, but there is an ustad who usually smokes. We have to stop smoking behavior, then our students will follow it. Therefore, to open a discussion forum, we need to invite religious scholars who don't smoke so that the topic of smoking can be discussed, whether it is haram or makruh.
We have to do socializations and solicitations of the perceptions so that behavior change efforts can be made in schools." (Respondent 8, Banda Aceh Women's Empowerment and Child Protection Office representative).
A qualitative study in Thailand conducted to capture the opinions of students towards their teachers who smoked indicated that 22 out of 30 students conveyed smoking teacher is a negative role model for students, they assumed that It is not well-earned for a teacher to smoke because it will be a negative role model for students. They added that even though smoking is a personal right, but, the smoking habit could affect students' lives either inside or outside the school. They also mentioned that in the case of smoking teachers are not aligned to the ban of smoking implemented at the schools (T. Chirasatienpon et al., 2021) CONCLUSION One of the challenges in implementing tobacco control policies in certain areas, such as Aceh, is the sociocultural factor. The habit of smoking as part of the culture itself has been viewed in Islam as having a negative impact on children and adolescents. However, implementation of these policies is still limited due to the limited budget and experts to