Health Risks of Kretek Cigarettes: A Systematic Review

Nuryunarsih, Desy; Lewis, Sarah; Langley, Tessa

Abstract

Objective To review the evidence on the health risks associated with smoking kretek cigarettes compared with not smoking or smoking regular cigarettes.

Data Sources: We conducted a systematic literature search in five electronic databases: EMBASE (Ovid), ASSIA, PubMed and Scopus. Since kretek use is largely restricted to Indonesia, we identified additional studies using an online search for grey literature and studies in Indonesian journals and the National Library of Indonesia. We included relevant search terms in English (“kretek” and “clove cigarettes”) and Bahasa (“rokok” and “merokok”).

Study selection: Studies which compared any health outcome between smokers of kretek cigarettes and non-smokers or smokers of regular cigarettes. We included studies in any smokers compared to non-smokers in Indonesia, since most Indonesian smokers use kretek, but analysed these separately.

Data Extraction: Study data were extracted by a single reviewer and checked by two reviewers. Methodological quality was assessed using the Newcastle-Ottawa scale.

Data synthesis: We identified 32 studies, all from Indonesia. There were 31 cross-sectional studies and one case control study. This systematic review identified a relatively limited number of studies, and most of these were of poor quality as assessed by the Newcastle Ottawa score. They were generally cross-sectional, small and lacking justification for sample size, had high potential for selection bias because of lack of data on non-respondents or those lost to follow up, and missing information about the statistical analysis. Fourteen studies looked specifically at kretek exposure and eighteen looked at any type of cigarette exposure but were conducted in Indonesia are therefore likely to predominantly reflect kretek exposure. Kretek were found to be associated with oral cancer, cardiovascular disease, chronic health disease, myocardial infarction, asthma, and oral diseases.

Conclusion: Although existing studies are of poor quality, kretek are likely to be at least as harmful as regular cigarettes.

Implications: Kretek cigarettes are the most commonly used tobacco product in Indonesia. Given the constituents of kretek cigarettes, there is no scientific basis for concluding that a kretek is any less hazardous than a regular cigarette; however, the evidence has not been systematically reviewed.

There are few studies on the health risks of kretek, and the quality of existing evidence is poor. Nevertheless, they consistently indicate that the health effects of kretek use are likely to be similar to those for regular cigarettes.

The current evidence base indicates that kretek cigarettes are at least as dangerous as regular cigarettes, and tobacco control efforts in settings where kreteks are commonly used must seek to incorporate measures to reduce kretek use.

Citation

Nuryunarsih, D., Lewis, S., & Langley, T. (2021). Health Risks of Kretek Cigarettes: A Systematic Review. Nicotine and Tobacco Research, 23(8), 1274–1282. https://doi.org/10.1093/ntr/ntab016

• Journal Article Type: Article
• Acceptance Date: Jan 16, 2021
• Online Publication Date: Jan 27, 2021
• Publication Date: 2021-08
• Deposit Date: Jan 28, 2021
• Publicly Available Date: Jan 28, 2022
• Journal: Nicotine & Tobacco Research
• Print ISSN: 1462-2203
• Publisher: Oxford University Press
• Peer Reviewed: Peer Reviewed
• Volume: 23
• Issue: 8
• Pages: 1274–1282
• DOI: https://doi.org/10.1093/ntr/ntab016
• Keywords: Public Health, Environmental and Occupational Health
• Public URL: https://nottingham-repository.worktribe.com/output/5272737
• Publisher URL: https://academic.oup.com/ntr/article/23/8/1274/6121573