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This is partly due to preferential taxation given to kretek manufacturers

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Children born to mothers who smoke when pregnant have poorer lung functions and are more prone to develop asthma and other allergic diseases later in life

In Michigan, 18.6% of adults are exposed to secondhand smoke exposure at home or in a vehicle, as compared to 59.6% of adults in low socioeconomic status households (2020 Michigan BRFSS.) Pollution levels generated by secondhand smoke in vehicles can rapidly reach dangerously high levels

One flavoring thats quite concerning is diacetyl, which has been linked to a lung disease called bronchiolitis obliterans