Allergic to Alternative Medicine?

Back in May 2013, my father underwent a surgical operation to remove a mass in his stomach. Anon, the mass had been found out to be a signet ring adenocarcinoma—stomach cancer, stage 2. Upon diagnosis, he was referred by his attending surgeon to an oncologist so he could undergo the suited treatment for his type of cancer. Which, by the way, was chemotherapy.

However, my father opt not to take his chemo for the following reasons: (1) my aunt’s advice (2) high cost of chemo (3) uncertainty that he’ll be cure through chemo (4) availability of alternative medicine (alt-med) that offers better quality of life

Why think twice?

Chemotherapy, is, perhaps, the most common treatment accessible or known to many. But these treatments, though offering cancer cure doesn’t offer 100% survival assurance. For it’s always dependent on how the patient’s cancer responds and how well his or her body could endure the treatment. It’s always a hit-and-miss situation. While targeted cancer cells are being killed, healthy cells are dying, too.

My aunt’s been a nurse for years, and she’s seen several people die receiving chemo. She recalls how they’ve been weakened, and how cruel the drugs’ side effects were. For some, they die not of their terminal illness, which was, supposedly, cancer, but of secondary illnesses that arise from receiving treatment.

How could this possibly be?

While many of us may not know anything about chemotherapy, it is necessary that we at least understand a bit of how it works-in most cases, it ‘interferes with the cancer cell’s ability to grow or reproduce.’ Depending on the cancer type, it ‘can be used alone or with other treatment types such as radiation or surgery.’ My father’s combination of treatment should have been surgery and chemo.

It’s also important to recognize the fact that treatment are in themselves carcinogenic, and that they are biohazards to the normal person. Some of the most used chemo drugs have lethal side-effects.

While we may not be familiar of what it’s like undergoing treatment. I assure you, undergoing through chemo and radiation therapy is quite a tough endeavour. I have known people who’ve been through this kind of medical care. For one, her cancer was responding well to cobalt therapy, yet tests showed that she had developed renal cancer.

What if her kidney cancer once cured would lead to another cancer somewhere else? What would be the point of taking all medication? Will her everyday travel from Cavite to PGH’s Cancer Institute be all worthless?

Aside from lack of certainty, for most Filipinos, the treatments available for cancer are inaccessible mainly because of their costs. On an average, according to a blog, chemo treatment averages at PhP 50,000.00. Quite a huge sum for the common Filipino. And based upon experience, I doubt that this quote would include all other expenses as diagnostic tests and consultation fees. Not to mention the additional burden of transporting from far-flung areas.

Chemo drugs are expensive to the common people, especially the branded pharmaceuticals that don’t have generic equivalent available in the country. In countries, as the Philippines whose healthcare system is ailing and is threatened to privatization, ‘ever-greening’ or patent-extending of Big Pharma companies’ monopolize the cancer industry and offset policies that aim at lowering the cost of drugs in their host country. Some Big Pharma even pay generic manufacturers huge amounts of money for a strategy called pay-for-delay settlements. In an article I’ve read in nytimes.com, instead of Big Pharma defending its large selling, patented drug from a generic drug manufacturer that had already developed a chemical counterpart, they offer settlements to delay generic drug from entering the market. Making generic drugs off-the market for a time period, and denying many of the savings they could get.

Currently, my father isn’t taking his chemo. He turned to nature for natural cure—Guyabano or Soursop, and has changed his old diet towards a more cleansing one. Consuming more fruits and vegetables, and less meat. He’s currently scheduled to undergo CT-scan to detect any possible growth. He’s been examined via ultrasound and so far, so good, no metastasis.

He already told his attending surgeon that he’ll not take chemotherapy. He said he’s already taking alternatives. Somehow, my mom (who was then with him), felt that the doctor wasn’t that pleased with this decision. Apparently, the doctor encourages my father to choose from different modes of chemo just as much as he’s discouraging him away from alt-med.  He’s being sceptical on the alternatives my father was referring to.

Why not alt-med?

Personally, I really find nothing wrong about the doctor’s sentiments with regards to use and consumption of alt-meds. Especially that alt-meds are not just taking the form of natural herbs, fruits, and vegetables but is actually taking shape in the form of supplements that take advantage of the failure of the pharmaceutical industry to innovate better cures for cancer. A lot of multivitamins, and newly discovered compounds are joining the bandwagon claiming cure but are yet to be proven by science.

Meanwhile, setting the expensive “alt-med” supplements aside, I cannot help but also think about some of the earliest traditional or indigenous ways of healing.

In a country heavily influenced by western medicine, more specifically, by the rich countries, eastern alternatives are of no match. Asian approaches as Ayurvedic healing, or Chinese Traditional Medicine are less being heard of. Even our own ways of fighting cancer are in themselves trivial.

With our health system being curative more than preventive in approach, pharmaceuticals that offer cure are better put into light than newly discovered drugs or natural remedies available that prevent the illness in the first place.

For every type of cancer, there is a corresponding unique, chemotherapy drug, a unique treatment. Although I am not that sure of how great is the presence of Big Pharma companies in the medical school, I am quite sure that doctors are more familiar with branded, patented drugs more than they’re familiar with preventive concoction of herbs. Being medicine-based and hospital based, nature of cures are becoming more targetive than holistic. Our doctors may not be that good at ethnobotany, naturopathy, and the likes, more than they are experts at thousands of synthesized drugs.

What if we long found the cure?

According to some claims, there are already many cures against cancer. Some even claiming being able to bring back normal cells from a cancer growth.

Are we even aware of anti-cancer vaccines being developed by Cuba? Clinical trials for new alternative treatments that have also been found to offer higher percentages of cancer survival than current methods? These are all backed with scientific evidences, and yet, we continue being limited to cures that have already failed the many in the first world, and the third world, even more.

The reason for not knowing? The Cancer-Industrial Complex.

For conspiracy theorists, the war on cancer has been already over because it’s been won through simple measures that they, the Big Pharma can’t get millions of profits from. Through the years, there has been some kind of conspiracy over cancer patients’ welfare. The main reason why certain cures are forbidden and only few doctors that admit the power of nature and newly discovered drugs.

It’s even more frustrating how our incredulity from shifting our mind set away from the current paradigm are making us gullible to Big Pharma’s profit maximizing tactics. Take for example, Non-Small-Cell Lung Cancer, a common type of lung cancer, is being seen in the third world as a new business venture. South American countries as Argentina, Brazil and Mexico are being seen as a market that “will grow at six percent annually through 2018.”

My father was fortunate enough to have had access to consultation. Many in the Global South who may have the same illness may not have met any doctor till his or her death. No access to either alt-med or traditional medicine. Cancer types that can only be found in the third world are also being neglected. Having only a few cases to cure, Big Pharma will in no way spend $12B. Patients of these kinds of cancers will eventually become part of the cancer death statistics.

As of now, my father has completely recovered from surgery. He did not gain much weight but at least, he doesn’t look sickly anymore. He can still do some of his old work (his limitations being his quarter stomach left).

With all these being said, be the one to judge.

Lung Cancer Facts

India

            

                Lung Cancer stands as the second most common form of cancer in India. According to Globocan Report in 2008, there were 51,000 deaths due to lung cancer in India. This figure has double from the last five years (from 2008) accounting for 26,000 lung cancer deaths from few selected urban and rural registry centers. The tobacco related products smoked in India are Bidi (most carcinogenic with most number of consumption), Cigarettes, Hooka and mixed.  Increase consumption of Bidi had been more dangerous to human lungs that increases the number of lung cancer deaths in India, considering tobacco as the major factor of developing a lung cancer.

                There were several factors which make lung cancer more prevalent in their society. One of which is the literacy and illiteracy rate. In India, 75% are literate. The rest 25% are illiterate that pushes for more indulgence in tobacco use and smoking. The most number of lung cancer deaths is from the industry of farmers. Due to lack of wealth and employment, Indians were forces to work at the farm. Without awareness, they had made smoking one of their habit plus the other factor that accounts in the development of lung cancer.

                Apart from tobacco, air pollution has become a threat to human lungs. It contains many known carcinogens and exposure to this has been known to predispose to lung cancer mortality. According to Scientific and Environmental Research Institute, Koltaka the most polluted metropolitan city in India,  had more than 18 person per one lahk that falls into lung cancer per year. The worst contributor of air pollution were drivers that uses ‘kantatel’ – known as a deadly fuel made of kerosene and petrol. The national government can’t prevent these drivers due to the strong trade union and nobody can touch them.

                Other cause is the occupational risk. Exposure to different kinds of harmful chemicals can increase the risk of developing a lung cancer.  Insulation workers and shipyard workers are exposed to asbestos; Smelter workers and vineyard workers are exposed to arsenic; Nickel Refinery workers is more likely to acquire squamous cell carcinoma; Those exposed to Radiation such as Uranium mining can acquire oat cell carcinoma. Lung cancer is also prevalent to those engaging in Haematie mining due to radon exposure; some were due to the exposure to chromium, chloromethyl, ether and mustard gas.  Including farmers relaying heavily on the use of chemical pesticides are prone to the risk of lung cancer. The 85% of its active ingredients is produced annually in crop production in developing countries. All raw materials and labor were produced in developing countries which makes them more prone to lung cancer.

The problems in management of lung cancer are numerous. One of which, accounts for more than 85%, are cases in advanced stages. Around 90% of lung cancers are NSCLC which is known to be aggressive. If it was detected in stage 1, the cure rate is 70%, while in stage 3, rushes down to 20%. But major of the patients were detected to be in stage 4 and chemotherapy is the only treatment option. Another, many are misdiagnosed as tuberculosis. The burden of misdiagnosis and delayed diagnosis on the health care system makes a large number of patients that is incurable.

                The type of Lung Cancer most common in India is the squamous carcinogen which is caused basically by smoking or occupational exposure to harmful chemicals which is rampant in India.

                It has been observed that the tobacco companies are now targeting the developing countries rather than the developed countries. One reason could be that awareness, regulations and societal pressure have resulted in decreased number of smokers in developed nations.

CANCER FACTS & FIGURES WITH FOCUS ON LUNG CANCER IN INDIA

Oncologists available	0.98 per 100,000 population
On-going (all) clinical trials	1.5% of the world’s total41
Number of patients currently undergoing (all) studies	10,00042
Number of LUNG CANCER being detected each year	250,000 to 300,000

                India as compared to developed country has less count of lung cancer, however, because of the sheer size of its population, it is estimated that India adds 1 million new cases of cancer every year. According to D Behera and New Delhi, “for lung cancer, India has been labeled as hub since the widespread use of tobacco products primarily triggers this malignancy”.

                As a respond to the increasing number of cancer cases and deaths in India Central Drugs Standard Control Organization (CDSCO) prepared a National List of Essential Medicines (NLEM) of India in 2011. The NLEM is one of the key instruments that will ensure the balance of health care delivery system for the nation. The first NLEM released in 2003 are 354 medicines only including the 23 anticancer products, on the other hand, it has an additional new 8 oncology drugs in 2011 list – having a total of 348 medicines. The increase of anticancer drugs has emphasized the importance of oncology products in national health due to continuous increase of cancer cases.

Ano ba ang 'Balintatanaw?'

Ang Balintatanaw ay nabuong pangalan mula sa salitang balintatáw at tanáw.


Ang balintatáw ay ang dinaraanan ng liwanag patungo sa retina (isang bahagi ng pupil na 

lumalaki at lumiliit depende sa dami ng liwanag). 


Ang tanáw ay pagtingin mula sa malayo.


Ang pagsasama ng dalawang salita para sa mga manunulat, ay nangangahulugan ng malalim 

na pagsusuri sa mga isyu. 


Pagtingin mula sa isang tiyak na perspektiba, maliwanag man o napagtatakpan ng 

nakapangyayaring lakas ang tunay na kuwento o impormasyon. 


Pananaw na pilit lalayo sa pagkakakahon. 

Yan ang Balintatanaw, padayon!

A new level of risk from smoking residue: Third Hand Smoke

It is common knowledge that the smoke that comes from cigarettes and other tobacco products takes on two forms. The first of which is the smoke that goes inside the smoker’s body, inhaled directly. The second form is the smoke that the smoker exhales. However, a new form of cigarette smoke has been discovered and it is found to produce a new kind of health hazard. Coined “Third Hand Smoke”, this finding contributes to the known risks associated with cigarette smoking.

            The smoke directly inhaled by the smoker from the cigarette is known as ‘first hand smoke’ while the smoke exhaled afterwards is called ‘second hand smoke’. Second hand smoke can be inhaled by other people that are within the vicinity of the smoker. Numerous studies have been committed to studying the health risks of smoking on a first hand basis. The perils of second hand smoke has also received considerable attention for it affects a wider range of people. ^[1] However, it has been discovered by researchers and doctors from the Dana – Farber/Harvard Cancer Center in Boston, that second hand smoke generates another kind of hazard that pose threats to health, in the form of nicotine residue settling on furniture and other surfaces. ^[2][3][4] Doctors from the Mass General Hospital for Children, also located in Boston, called these residues Third hand smoke. ^[3]

            Third hand smoke is defined as the leftover nicotine from tobacco products that has accumulated on surfaces, clothes, body parts, etc. long after the second hand smoke has cleared.^[1][3][4] From a more technical and inclusive standpoint, researchers from ASH Scotland developed a three ‘r’ definition of third hand smoke. According to a fact sheet released by the organization, Third hand smoke:

“Describes the residual tobacco smoke pollutants which remain on the surfaces and in dust after tobacco has been smoked, are re-emitted back into the gas phase, or react with oxidants and other compounds in the environment to yield secondary pollutants”. – ASH Scotland ^[2]

The residue, in itself, is already dangerous because it consists of heavy metal, and radioactive materials. It is said to contain, among others, hydrogen cyanide used in weapons, butane or lighter fluid, lead, arsenic, carbon monoxide, and the highly radioactive Polonium 210, that was formerly used as weapon in Russia. ^[3][4] However, the more hazardous effect of third hand smoke emanates from the reactive nature of the residues, which can form carcinogens if combined with the right chemicals, one of which is nitrous acid which comes from gas appliances such as stoves, and ovens. ^[1][2] Once nicotine residues, and nitrous acid combine, ‘carcinogenic tobacco-specific nitrosamines’ (TSNAs) are formed, which is one of the most potent carcinogenic elements known. ^[1][2] Given that nicotine rapidly adheres to surfaces quickly and is difficult to remove, frequent smoking indoors can quicken the pace of carcinogenic TSNA production. ^[2]

Third-hand smoke was found to be particularly threatening for infants and toddlers. Infants and toddlers, especially crawlers, have comparably higher contact to surfaces than adults. Children of this age group are also known to frequently insert objects in their mouth. ^[2][4] In addition, infants have also been found to inhale 40% more household dust than adults. ^[2] TSNAs can be acquired through inhalation, ingestion, or even just plain contact with skin (dermal exposure). ^[1][2][3] From this, it can be said that surfaces, objects, even small particles such as dust, that have been exposed to TSNAs or nicotine residues would have already acquired the carcinogenic or radioactive properties and will be extremely dangerous to come into contact with children. 

Not only are these residues invisible, ^[3] but they are also accumulative and can persist on for months. ^[1] Simple washing cannot effectively remove these nicotine residues. Soap that is alkaline will not be able to remove these residues, and particles that have stuck on surfaces with textures similar to carpets are practically irremovable. Increasing ventilation as well has been proven to be incapable of removing third hand smoke though it may aid in clearing away second hand smoke.^[2]

But what sets apart the hazards of Third hand smoke from that of first hand smoke and second hand smoke? Aside from it being carcinogenic (especially in TSNA form), radioactive, and poisonous, ^[1][2][3][4] exposure to the lead content, even on small doses,  was also shown to contribute to lower IQs, especially if the exposure starts from a very young age. According to an article on third hand smoke published on the ‘Scientific American’, “the developing brain is uniquely susceptible to extremely low levels of toxins”. ^[4] In addition, third hand smoke has also been found to be ‘mutagenic’, or is capable of altering genetic material. Researchers from the Lawrence Berkeley National Laboratory in the US discovered that third hand smoke is capable of changing the structure of DNA, but in a damaging way. In addition, the damage that third hand smoke does on the DNA was also found to get worse over time. Aside from the mutagenic nature of third hand smoke, it was also found to be ‘genotoxic’ which, according to the article, is a “known player in the development of cancer and other disease as a result of smoke”. ^[5]

            At present, there has not yet been any recorded case of disease that was directly caused by third hand smoke. ^[4] In addition, there has been little real-life evidence to support its capability to directly cause disease although a definite system of TSNA production from third hand smoke has been traced. ^[2] Despite these, the discovery of third hand smoke, the longevity of its effects, and the risks associated with it still has major implications towards advocating to ‘kick the smoking habit’.

References:

1.      1. LiveScience (2012, Feb 9). ‘Today news: Third hand smoke a danger to babies, toddlers. Retrieved from http://www.today.com/id/35318118/ns/today-today_health/t/third-hand-smoke-danger-babies-toddlers/

2.      2. ASH Scotland. Action on Smoking and Health Scotland, (2011). ASH Scotland: Third-hand smoke. Retrieved from ASH Scotland website: http://www.ashscotland.org.uk/media/3942/Thirdhandsmoke.pdf

3.      3. Rabin, RC (2009, Jan 3). ‘The New York Times: A new cigarette hazard: third-hand smoke’. Retrieved from http://wkeithward.com/Articles/A%20New%20Cigarette%20Hazard%20-%20Third-Hand%20Smoke.pdf

4.      4. Ballantyne, C (2009, Jan 6). ‘Scientific American: What is third-hand smoke? Is it hazardous?’. Retrieved from http://www.scientificamerican.com/article.cfm?id=what-is-third-hand-smoke

5.      5. No author (2013, June 24). ‘Huffington Post: Thirdhand smoke spurs DNA damage, study finds’. Retrieved from http://www.huffingtonpost.com/2013/06/24/thirdhand-smoke-dna-damage-cells_n_3474797.html

Aldi Rizal: The epitome of underage smoking in Indonesia.

I first heard about the case of Aldi Rizal way back in 2010 when the video of him entitled “Indonesian Baby on 40 cigarettes a day” became viral on YouTube. True to its title, the video did indeed show an overweight toddler in diapers, around 2-3 years of age, puffing cigarettes one after the other. An anachronism at its best, Aldi displayed proficiency in lighting up a cigarette using another one that is already lit, and exhaling cigarette smoke through his mouth and nose.

            According to a feature article written about him on Today, young Aldi started smoking when he was just 11 months old. ^[1]However, there is no information with regards to who introduced him to cigarettes. Within five months since his first drag, it was said that “he was up to four packs per day”. Because of this, Aldi is described as a ‘local celebrity’ in their fishing community in Sumatra. ^[1]A celebrity that is famous for all the wrong reasons.

            Aldi’s parents were presented to be completely incapable of controlling their child’s addiction. His father Mohammed, has been quoted saying that his son “looks pretty healthy” and that “there is no problem”. Aldi’s mother Diana mentioned that if her son is denied another cigarette, he “gets angry and screams and batters his head against the wall” and the only way to appease Aldi is by giving him another cigarette. Aldi will only smoke one brand, and this brand costs his parents 3.75 pounds (6 USD/273 php) per day. ^[2]

At present, Aldi apparently was finally able to kick his smoking habit. ^[1][2] Since the video of him smoking became popular, the National Commission for Child protection in Indonesia stepped in and provided him with 5 weeks’ worth of play therapy and treatment. However, he apparently has found a new addiction, junk food, and has gained 13 pounds since then. ^[1]

            Smoking has always been regarded as an adult activity, done with full knowledge and consent. For this reason, it can be said that the case of Aldi Rizal is definitely a perversion of smoking, and childhood most especially.  However, through further research I discovered that underage smoking is a common albeit unfortunate occurrence in Indonesia. ^[3]The ‘underage’ nature of it takes on an extreme form as children from the same age group as Aldi were seen as also taking a regular drag. ^[1][2]According to a statistic from the Central Statistics Agency of Indonesia, 25% Indonesian children, 3 to 15 years of age, were found to have already tried cigarettes. 3.2% of these children were regular smokers.^[2]The National Commission for Child Protection as well, has been said to receive information from 20 families with children aging from 11 months to 2 years old, has already started to form a smoking habit. ^[3]

            The influence of culture is perhaps the most dominant contributor in the proliferation of child smoking in Indonesia. Currently the third largest tobacco-consuming country, ^[2] smoking in itself is seen as an integral part of “coming-of-age” ceremonies. Clove cigarettes (locally known as kretek) are said to be introduced to boys as early as the age of 10, to mark the beginning of a new stage in life. ^[3] From this, it can be said that the influence of family, the most powerful perhaps are the parents, also play a crucial role. Children who grow up observing their parents smoke regularly, are likely to take up smoking as well in adulthood, if not during childhood, or pre-adolescence. (Determinants of smoking behavior)Peer pressure was also found to be another social factor that contributes to the increase in child smoking. ^[2]

            Poor regulation of tobacco products has also been noted to contribute greatly to the increase in the prevalence of child smoking. ^[1] It was only in 2009 when a health law oriented towards the hazards of smoking was passed by legislators in the country,^[2]but prior to that there has been no tangible regulatory measures at play that addresses the accessibility of tobacco products to the youth. . ^[1][4] Aside from this, the amount of promotional activity that the tobacco industry is able to undertake was also unregulated. Tobacco companies were able to advertise their cigarettes on television, radio, malls, conventions, and were even seen to provide scholarships. All of these done in ways that appeal greatly to kids. ^[1][4] The new health act however is being pushed to regulate the amount of air time that Cigarette Companies receive, as well as the sponsorships and scholarships that they are allowed to provide, it also requires warning labels to be printed on cigarette packets. ^[1][2][3]

            Despite the strong cultural entrenchment, protests and criticisms against smoking has started to come up. Some of which, are not entirely based on concerns over health and associated risks. The prevalence of smoking among the youth has also been found to affect the economy of Indonesia in the long term. ^[3]

            The tobacco industry contributes a sizable amount of income to the Indonesian economy. In a study conducted by the International Union against Tuberculosis and Lung Disease regarding tobacco taxation, it has been found that if the current tax of 46% ^[6]is doubled, an additional income of 3.2 to 6.5 billion US dollars can be incurred. The employment in the country can also be increased by approximately 250,000 jobs. ^[5] Though the effects of the tax increase on the levels of consumption was unstated, fundamental laws of economics state that an increase in price would mean a decrease in consumption. However, this decrease is still not enough to circumvent the long term detrimental effects of smoking on the economy. The prevalence and increase of smoking among the youth has been found to have extensive effects on manpower, threatening Indonesia’s labor potential. ^[3]A statement by Mr. Abdillah Ahsan, a professor from the University of Indonesia summarizes the effects of the phenomenon:

“Today’s junior high school students will enter working age by 2020, because of smoking in this age group, many will fall ill and be unable to work. The current youth smoking trend is alarming.” – Abdillah Ahsan ^[3]

            Labor, if compromised, will greatly reduce the productive capacity of an economy; especially being one of the components of the three-legged stool that is the factors of production. Much like a three-legged stool, if one of the legs of production become nonfunctional, the stool collapses. The human factor of production is oftentimes overlooked. Oftentimes, worker’s overall health, work conditions, and skills development are deemed marginal in importance, as compared to the quantity of plants and equipment, maximization of profits, and the like.

There is no doubt that the considerable attention that Aldi has received from the internet community has contributed greatly to the government intervening on his situation. However, the condition of other children who are under the same situation, but has not received the same degree of attention, must also be evaluated. Unfortunately, there is hardly any information available with regards to the evaluation of the implementation of the tobacco health act, and its ability to circumvent the harmful effects of tobacco smoking. In addition, hardly any studies that discusses the changes in child smoking in Indonesia since the law was adapted can also be found. This suggests that there has been a tangible lack of interest towards the issue, perhaps fueled once again by cultural factors determining this as normal, or perhaps corporate politics are once again in play. Nevertheless, unless something is done to effectively address the issue, the gradual deterioration of the health of these children can be seen as a metaphorical representation of the deterioration of the human quality, and labor capacity of the Indonesian economy as well.

             

References:

1.      1. Schiavocampo, M. (2010, May 11). ‘Smoking toddler’ kicked habit, but thousands more addicted. Today Health. Retrieved from http://www.today.com/id/40024399

2.      2. Mail Foreign Service. (no date) Too unfit to run: Two-year-old who smokes 40 cigarettes a day puffs away on a toy truck. The Dailymail UK. Retrieved from http://www.dailymail.co.uk/news/article-1281538/Smoking-year-old-Ardi-Rizal-40-cigarettes-day.html

3.      3. Rambe, Y. (2012 , June 23). Indonesia: Agency to sue over child smoking. Khabar Southeast Asia. Retrieved from http://khabarsoutheastasia.com/en_GB/articles/apwi/articles/features/2012/06/23/feature-02

4.      4. Martini S. & Sulistyowati M. (2005, December). The determinants of smoking behavior among teenagers in east java province, Indonesia. Retrieved from http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/IndonesiaYouthSmokingFinal.pdf

5.      5. Adioetomo, S., Ahsan, A., Barber , S., & Setyonaluri, D. International Union Against Tuberculosis and Lung Disease (The Union), (2008). Tobacco economics in Indonesia. Retrieved from Tobacco Free Kids website: http://global.tobaccofreekids.org/files/pdfs/en/Indonesia_tobacco_taxes_report_en.pdf

6.     6.  Southeast Asia Initiative Tobacco Tax: Indonesia

Retrieved from: http://tobaccotax.seatca.org/?page_id=89