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Epidemiology and Society Health Review| ESHR 
 

Vol 1 No1 2019 41 

Research Article 
 
EVALUATION of SMOKE-FREE AREA 
DECLARATION PROGRAM to ESTABLISH A 
HEALTHY CITY 
 
Desi Nurfita1*, Rokhmayanti Rokhmayanti1, Helfi Agustin1, Sandheep 
Sugathan2 
 
1Department of Public Health, Universitas Ahmad Dahlan, Yogyakarta, Indonesia 
2Faculty of Medicine, Quest International University Perak, Malaysia 
 
*Correspondence: desi.nurfita@ikm.uad.ac.id. Telp,: +6282191350472 
 Received 07 August 2019; Accepted 09 September 2019; Published 09 September 2019 
 

ABSTRACT 

Background: Indonesia is experiencing a major health challenge, that is triple 
burden diseases (communicable diseases, non-communicable diseases, and re-
emerging diseases). One of the programs established by the government to face the 
threat is Healthy Lifestyle Community Movement (Gerakan Masyarakat Hidup Sehat 
or GERMAS). The declaration of the smoke-free area is one of the efforts of the 
Government on this movement aimed to have smoke-free homes to create a healthy 
city. However, the monitoring and evaluation of the program do not run well. The 
goal of this research is to provide a description and analysis of the implementation of 
the smoke-free area declaration program. 
Methods: This was a qualitative research. The subjects or main informants of this 
study were the people in charge of smoke-free area declaration program and the 
head of the clinic at Puskesmas Gondokusuman 2. The supporting informants in this 
study were the community declaring the program as well as the elite figures of the 
community involved in the declaration. The method of primary data collection was 
through in-depth interviews, observation, and review documentation. The 
implemented analysis technique was content analysis. 
Results: The inputs of the smoke-free area declaration program were measured 
from the human resources, fund, facilities, organization, information, and guidelines. 
Further, the process of the smoke-free area declaration was viewed from the 
community roles, community responses, and reports. However, there was a 
shortcoming of the process variable, i.e. the in-existence of written reports done by 
the head of the program. Furthermore, the output variables were observed from the 
commitments, impacts on society, and the comprehensiveness of the reports. 
Conclusions: Based on the analysis, the inputs of the program were considered as 
well. The outputs of the program were considered to be positive. 
 

Keywords: evaluation, SMOKE-FREE AREA, healthy city 

 



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INTRODUCTION 
Indonesia is in the middle of a major health challenge known as triple burden of 
disease (infectious diseases, non-communicable diseases, and controlled diseases 
making a comeback). In 1990, contagious diseases, such as Infeksi Saluran 
Pernapasan Akut (ISPA), tuberculosis, and diarrhea, were the most common ones 
found in health facilities. However, the change of lifestyle caused the changing 
pattern of disease (epidemiological transition). In 2015, non-communicable diseases, 
such as stroke, coronary heart diseases (CHD), cancer, and diabetes, ranked 
highest(1).  
 
There have been efforts to control and prevent the diseases to reduce the number of 
cases and mortality rate. The goal is to create an optimum healthy community. One 
of the programs established by the government is Healthy Lifestyle Community 
Movement (Gerakan Masyarakat Hidup Sehat (GERMAS))(2).  
 
GERMAS is a planned and systematic effort involving all members of community 
with awareness, willingness, and ability to live healthily and improve their quality of 
life. It starts at families since family is the smallest part of a community which helps 
to form one’s personality. The program involves having regular physical exercises, 
consuming fruit and vegetables, not smoking, not consuming alcohol, having regular 
health check-ups, participating in environment cleaning activities, and using 
toilets(1). 
 
The city government of Yogyakarta supports GERMAS by establishing Mayor 
Regulation No 373 Year 2017 on the empowerment system of alert kelurahan in 
relation to healthy lifestyle community movement. One of the ways to support the 
movement is through the declaration of smoke-free area. The aim is to have free-
smoke houses so that a healthy city is created (3).  
 
At first, the smoke-free area declaration program was conducted by the District 
Health Office of Yogyakarta and Gadjah Mada University (UGM). However, later 
UGM decided not to be involved in the program, therefore, afterwards, the 
Yogyakarta District Health Office handled the program alone. The written declaration 
was done at the level of neighbourhood groups (RT). However, up to the present 
moment, the monitoring and evaluation of the program did not run well. 
 
Based on an interview with the person in charge of smoke-free area declaration 
program at Puskesmas Gondokusuman 2, it was found that there were not any 
appropriate instruments to monitor and evaluate the program. Through the course of 
time, the program ran, and the report was done through direct report from each 
cadre to the health clinic staff.  
 
Based on those descriptions, the researchers were interested to conduct a research 
on the evaluation of smoke-free area declaration program at Puskesmas 
Gondokusuman 2. 
 
 
 



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METHODS 
Study design  
This research used qualitative methods.  

Setting 
The study was conducted in Puskesmas Gondokusuman 2. 

Data source and data collection 
The method of primary data collection was through in-depth interviews, observation, 
and review documentation. 

Sample population 
The key informant of this study was the person in charge of the smoke-free area 
declaration program at Puskesmas Gondokusuman 2. Meanwhile, the triangulation 
informants were the elite figures of the community involved in the declaration, as well 
as community representatives directly involved in the programs of Puskesmas 
Gondokusuman 2. 

Analysis 
The researcher evaluates the implementation of smoke-free programs using an 
evaluation system, discusses management programs through analysis of inputs, 
processes, and outputs. The input component discusses the main and core 
resources such as labor, funds, facilities, organizations, information and guidance. 
The process component is seen from the management program carefully monitored 
from how the community in Gondokusuman 2 Health Center formulates the 
performance seen from the planning process, implement and support programs by 
selecting indicators and targets, collecting data, analysing the data and giving 
feedback. The output component illustrates the performance of the quality 
achievement program in accordance with the achievement of the program targets 
against the indicator. 

FINDINGS AND DISCUSSIONS 

The city of Yogyakarhas declared smoke-free area. Puskemas Gondokusuman 2 is 
one among many community health clinics in Yogyakarta committed to conducting 
smoke-free area program. The smoke-free area program was formed based on city 
of Yogyakarta Regulation number 2 Year 2017. The commitment was set forth in the 
declaration of smoke-free areas. Contents of the Declaration of Smoke-Free Areas in 
Gondokusuman II Health Center are 1) no smoking in the house, 2) do not provide 
ashtrays in the house 3) no smoking in community meetings, 4) do not throw 
cigarette butts in any place, 5) do not smoke in front of babies, toddlers and pregnant 
women, 6) may not order small children to buy cigarettes.  
 



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The researchers in this study conducted an evaluation of the program by using 
system approach. The approach consisted of three parts, namely input, process, and 
output. The components of the input were the availability of main and fundamental 
resources, i.e. human resources, fund, facilities, organization, information, and 
guidelines.  
1. Input 

a. Human Resources 
Based on interviews to informants, the information on human resources 
involved in smoke-free area was obtained, i.e. the District Health Office of 
Yogyakarta (Health Promotion Programmer), Head of PKK (Family Welfare 
Establishment Program), Heads of Sub-districts, Heads of Villages, 
Community Groups (RW), Neighbourhood Groups (RT) and community 
members. The program was regulated by the Mayor Regulation No 2 Year 
2017. It regulateed the parties required to be involved in the program in 
relation to the field of health, regional work units, and community 
participation(4). 
 
The regional work unit conducting health matters was the District Health 
Office of Yogyakarta and community health clinics.  In addition, the involved 
regional work units were Head of PKK, Heads of Sub-districts, Heads of 
Villages, Community Groups (RW), and Neighbourhood Groups (RT). All 
parties worked together in the program. Meanwhile, community participation 
means the direct involvement of the community members in the program. The 
participation was observed through the implementation of smoke-free area 
declaration in Kelurahan (Village) Terban and Kotabaru. 
 
All parties have their own responsibilities and duties. Regional work units 
focusing on health matters have the responsibility to determine the smoke-
free area(5) The health units are the District Health Office of Yogyakarta and 
Puskesmas Gondomanan 2. Both act as the founder and organizer of smoke-
free area arrangement. It is in line with the Mayor Regulation No 2 Year 2017. 
 
Regional work units were responsible to do a follow-up on the determination 
of smoke-free area. The work units were the Head of PKK, Heads of Sub-
districts, Heads of Villages, Community Groups (RW), and Neighborhood 
Groups (RT). Head of the PKK, Heads of Sub-districts, and Heads of Villages 
supported the program through their participation in the signing of an 
agreement on smoke-free area.  Community Groups (RW) and Neighborhood 
Groups (RT) had the roles in program implementation. The head of 
community groups was assigned as the leader of the program in the area and 
therefore holds responsibilities for the program. It is in line with the Mayor 
Regulation No 2 Year 2017. However, the evaluation of each community 
group has not been done yet. 
 
Regional work units conducted follow-ups on the arrangement of smoke-free 
area by collecting data and information on the smoke-free area, providing 
education on the dangers of cigarette to the community, conducting 
awareness programs on the laws and regulations related to smoke-free area, 



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Vol 1 No1 2019 45 

observing and evaluating the smoke-free area program implementation, and 
conducting assistance and observation in the smoke-free area(4). 
 

 
b. Funding 

The declaration of smoke-free area relies on three main sources of funding, 
i.e. the fund of the District Health Office of Yogyakarta, Puskesmas 
Gondokusuman, and community donation. The fund from the health district 
office was Rp. 960,000 (Rp. 8,000 x 120). It was aimed to pay for the 
refreshments during the declaration. The fund from the health clinic was taken 
from the Operational Aid for Health Program (Bantuan Operasional Kesehatan 
(BOK)). It was given once to community groups. The total amount was Rp. 
1,800,000 (Rp. 18,000 x 100 persons). It was expected that after the two 
funds were given, the community was willing to donate if the given fund was 
insufficient. Such donation was commonly taken from the treasury of the 
community. 
 
The first step that the district health office as the initiator of Smoke-Free Area 
program has to do was developing the conceptual framework and technical 
materials of Smoke-Free Area. Afterwards, the office advocated the decision 
makers, either the internal parties of health sector or legislative parties, to 
obtain support on policies, fund, and facilities(6). The results of this study are 
in accordance with the non-smoking regional guidelines of the ministry of 
health. Non-smoking areas at the RW level are not only provided with funds, 
but the community also demands self-financing. The findings of this study are 
also in line with the guidelines of smoke-free area of the ministry of health. 
The smoke-free area at community groups is supported with some fund as 
well as some donation from the community. It encourages the community to 
independently fund this smoke-free area program. 
 
The results of Nizwardi's study (2013) suggested that the funds available for 
the implementation of non-smoking areas in the city of Padang Panjang and 
Payakumbuh were sufficient and was not a problem in the implementation of 
non-smoking areas. The source of the funds came from the Regional Budget 
and Cigarette Excise. Even though it is not comparable to a puskesmas, in 
three regencies/cities, the funds provided were quite large, namely in the city 
of Padang, amounting to Rp.85,000,000.00 from cigarette excise for 
socialization activities, dialogues on smoking-free areas on television and 
increasing banners and leaflets. In city of Padang Panjang, the availability of 
funds for the implementation of smoking-free areas were as much as Rp. 
75,000,000.00 from cigarette excise and Rp. 24,000,000 which were used for 
monitoring and evaluation, supervision of government institutions such as 
hospitals, the District Health Office, puskesmas, government education 
institutions, and offices as well as socialization. While in Payakumbuh the 
funds available for the implementation of the non-smoking area amounted to 
Rp341,278,129.00 (7). 

 
c. Facilities 



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Based on the Indonesian Ministry of Health guidebook related to smoke-free 
area facilities which are indicators, among others, there are media promotions 
about smoking bans / smoke-free areas(6). The District Health Office of 
Yogyakarta and Puskesmas Gondokusuman 2 provide facilities to support the 
declaration of smoke-free area program. Some of the facilities are the media 
to publicize and urge the community on the program. A petition on the 
declaration of smoke-free area is also provided for all the involved community 
members to sign. Based on the guidelines provided by the Indonesian Ministry 
of Health on Smoke-Free Area, the required facilities are the promotion media 
on smoking restrictions/smoke-free area(6). It is provided and facilitated by 
Puskesmas Gondokusuman 2 and the District Health Office of Yogyakarta. 
 
The role of The District Health Office of Yogyakarta as the provider of facilities 
for this promotion is to spend substantial funds, as stated by Nizwardi (2013) 
that the use of television promotion media for socialization, increasing 
banners and printed leaflets. Thus, the production of promotional facilities is 
not the responsibility of the puskesmas. The role of the puskesmas is only as 
a mediator in the distribution to the community(7). 
 
Other than promotion media on health, smoking rooms should also be 
provided(6). It was found that Puskesmas Gondokusuman 2 has not provided 
such rooms yet. Based on interviews with some community members, it was 
revealed that they commonly smoke in certain designated-areas, such as river 
banks or cemetery area. It indicates that although smoking rooms are not 
provided yet, the community members are aware to smoke only in the 
designated-areas. The research is slightly different from Wati's (2014) 
research on the Application of Non-Smoking Areas in Metro City, at the Metro 
City Health Office and the City Planning and Environment Agency, specifically 
for smokers to encourage the operation of smoke-free areas quite well(8). 

 
d. Organization 

The declaration of smoke-free area was conducted at each community group 
(RW). Each would have its own committee involving the Head of the 
Community Group, the Secretary, the Treasurer, and any other parties 
(adapted to the need of each RW and community). The committee is 
responsible to conduct the smoke-free area program and educate community 
members.  
 
The guideline book of ministry of health on smoke-free area does not specify 
and require the community to form an organization in smoke-free areas(6). 
Nevertheless, the community had the initiative to form the committee. In 
addition, community members are expected to actively participate in 
succeeding the program of smoke-free area. Furthermore, the committee  
helped to coordinate all activities related to smoke-free area program.  

 
e. Information 

Some awareness raising programs were conducted by the District Health 
Office of Yogyakarta and Puskesmas Gondokusuman 2. Furthermore, the 
information media was in the written form. The distribution of information on 



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Smoke-Free Area was done by using many different methods and media in 
many different opportunities. The aim was to make all members of the 
community aware of this program and willing to actively participate, either as 
the observer or supervisor of smokers and non-smokers by giving necessary 
punishment as required(6). 

 
f. Guidelines 

The guideline of the smoke-free area is Mayor Regulation No 2 Year 2017. It 
was issued by the mayor of Yogyakarta. It regulates smoke-free area. 
According to Juanita (2012), the attraction of interest in setting cigarette 
policies at the central level needs to be addressed by the government by 
making local policies. The ban on smoking in public space at the local level 
can affect people's perceptions of the norm of smoking in the community. The 
guidelines issued by the Mayor of Yogyakarta answered the results of 
research conducted by Juanita(9).  

 
2. Process 

The indicator of smoke-free area is seen from the existence of staff obliged to 
observe smoke-free area in all vicinities. The vicinities are such as public health 
facilities, schools, playgrounds, places of worship, public transportations, offices, 
and public places(6). In this study, it was found that the program was conducted 
in each community group (RW). However, only some vicinity was involved in the 
smoke-free area of Puskesmas Gondokusuman 2. 
 
In relation to this regulation, community members’ participation is needed. Such 
participation can be done by: 
a. Sharing suggestions, opinions, and considerations related to the observation 

and implementation of smoke-free area policy. 
b. Providing guidance and assistance as well as sharing information on smoke-

free area. 
c. Declaring smoke-free area at home and the living environment.  
d. Reminding everyone not to break the restrictions of smoking, producing, 

selling, advertising, or promoting cigarettes at smoke-free areas. 
e. Reporting every incident of infringements on smoking, producing, selling, 

advertising, and promoting cigarette restriction at smoke-free areas to the 
administrator, head, the person in charge of the smoke-free area program, as 
well as related regional work units. 

 
According to the Ministry of Health RI, Smoke-Free Area Process is as follows: 
a. Meeting of Initiator Team 

Initiator team regularly conducts meeting to discuss many different things 
related to smoke-free area arrangement, such as the plans and regulations.  

b. Establishment of Smoke-Free Area 
It is done by the high-ranking officials and attended by all involved parties on 
the determination of smoke-free area. The team prepares implementation and 
technical guidelines as well as the publication materials so that the program 
can be started. 

c. Post-Establishment Publication  



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Distribution of information on smoke-free area is done using many different 
methods and media in many different opportunities. Thus, all parties are able 
to implement the program; either as the observer or supervisor of smokers 
and non-smokers by giving necessary punishment as required. The 
socialization was carried out by the District Health Office and Puskesmas 
Gondokusuman 2. Media information includes printed media. And residents 
are used as education for other residents. Dissemination of information and 
dissemination of Non-Smoking Areas are carried out by using various 
methods and media on various opportunities that exist so that the 
implementation of Non-Smoking Areas can be known and implemented by all 
parties, both observer andsupervisors of smokers and non-smokers by 
applying sanctions according to the law applied. 

3. Evaluation 
Assessment of the implementation of smoke-free area includes observing and 
erecting regulations on smoke-free area. The evaluation is done using 
determined indicators. When compared with Mayor regulation No 2 Year 
2017, some things have not been implemented, among others, have not yet 
been evaluated in each community group (RW). Ideally, the assessment is not 
only the responsibility of the community group (RW), but is the responsibility 
of all regional offices, such as the involved regional work units which was 
Head of PKK, the village head and the sub-district head.  

 
4. Output and outcome 

The output of the non-smoking area program is in the form of commitment 
documents signed by community members and all parties involved. Commitment 
to the Declaration of Smoke-Free Areas was held at the community group (RW) 
level. The Puskesmas had reported the number of community groups (RW) that 
had carried out the declaration to The District Health Office in Yogyakarta, 
accompanied by proof of declaration. There were 10 community groups (RW) 
that had carried out the declaration of smoke-free areas in Terban Village and 2 
community groups (RW) in Kota Baru Village. There were 4 community groups 
(RW) in Terban and Kota Baru that had not implemented the declaration of 
smoke-free areas. In addition, the community benefits from the declaration of 
smoke-free areas. The benefits felt by the community include: people became 
aware of the dangers of smoking, people became more ethical when smoking, 
and some people also stopped smoking. 
 
Opposing this research which focuses more on smoke-free offerings at the 
household level, the findings of Hamdan, et al. (2015) recommended that 
children in schools need to be vigilant even though the area is free cigarette 
smoke has been running, because it turns out that children are quite easily 
affected when exposed to cigarette advertisements by the media, especially 
television. According to Hamdan, the regulation of non-smoking areas is still 
weak, and there is no clear sanction regulation regarding the restrictions on the 
age of cigarette buyers. The community needs to pay attention to cigarette seller 
stalls that make it easier for people to get cigarettes, especially for children and 
adolescents(10). In addition, affordable prices with strong media exposure to 
children are things that need to be observed by the government. In terms of a 
social environment, adolescents tend to be more easily affected than other age 



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groups. The community group (RW) residents in the Gondokusuman Health 
Center area must focus on fostering a youth playing environment that supports 
teenagers to stay away from smoking behavior. Sutha’s (2016) study in 
Pangarengan Subdistrict, Sampang Regency suggests that an area which 
consists of family environment, school environment, and the playing 
environment has a very important role to play in the formation of smoking 
behavior in adolescents today(11). 

CONCLUSIONS 

The implementation of smoke-free area declaration ran well. It was found that the 
input was in line with the guidelines provided by the Indonesian Ministry of Health as 
well as the Mayor Regulation of Yogyakarta with the availability of committed energy 
resources, organization, the existence of guidelines, and funding from both the 
government and community self-help. However, some aspects did not run well. 
Among them was the availability of the smoking room. In terms of facilities, a special 
smoking corner had already available, even though they still used makeshift places 
such as patrol posts, youth posts, and tombs. Residents had no longer smoke inside 
the house. On the other hand, the process of the program was also considered to 
run well. Furthermore, there have been some outputs. There were only four 
community groups (RW) which did not conduct the declaration of smoke-free area.  
 
AUTHORS’ CONTRIBUTION 
DN designed the study, collected, analysed, interpreted the data, and wrote the 
manuscript. RR designed the study and conducted a literature review. HA wrote the 
manuscript and conducted a literature review. SS wrote the manuscript. 
 
FUNDING 
This work was supported by Universitas Ahmad Dahlan under Grant PDP-
033/SP3/LPP-UAD/IV/2018 
 
Conflict of interest 
There are no conflicts of interest.  
 

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