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Invest in tobacco control to end tuberculosis in Indonesia

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Over 61.4 million people in Indonesia smoke, with 65% of all adult men smoking. In 2020, the Joint External Monitoring Mission on Tuberculosis (TB) for Indonesia found that 36% of all TB cases (about 300,000 TB cases) were attributable to tobacco smoking. In response, The Union in partnership with the Ministry of Health, Association of All Indonesian Health Offices (ADINKES) and Asia Pacific Cities Alliance for Health and Development (APCAT) organised a high-level meeting under the theme “Invest in Tobacco Control to END Tuberculosis”.

In the Minister of Health Mr Budi Gunadi Sadikin’s keynote speech, he highlighted: “Indonesia is the third largest contributor of TB in the world. TB is estimated to cause economic losses of 136.7 billion Indonesian rupiah per year and 70% of patients lose their jobs. Smoking is a great contributor to these numbers.”

To support the reduction of TB, The Minister of Health has prioritised the revision of national tobacco control regulation, with the goal to reduce the prevalence of one of TB’s largest risk factors – smoking. These changes include essential tobacco control provisions, such as: 90% Pictorial Health Warning, a ban on all forms of tobacco advertising promotion and sponsorship, a ban on single stick sales and establishment of smoking cessation services. The Minister of Health also endorses higher tobacco taxes and simplification of the tobacco excise system.

Leadership at a subnational level is important to tackling smoking. Arifin Hutagalung, Head of Sub-Directorate of Health, Directorate General of Sub National Development, Ministry of Home Affairs said: “Local governments must adopt smokefree policies as well as ensure they are well implemented, enforced and monitored. There are clear directives and local budget allocated to do so.” He went on to add that the TB control programmes should be well planned out with the inclusion of tobacco control provisions.

A key barrier to timely TB diagnosis and treatment among people who smoke is the assumption that a cough is related to their smoking. On top of this, exposure to second-hand smoke increases the risks of both TB infection and development of active TB disease among children and adults. People with TB who smoke in the home are also placing their families at a greater risk of TB infection. Therefore, keeping homes smokefree is very important. The best course of action is not smoking at all.

Prof Dr Tjandra Yoga Aditama, Senior Advisor, Asia Pacific Cities Alliance for Health and Development (APCAT) said: “The Indonesian government has committed to ending Tuberculosis by 2030 in line with the global goals. However, our commitment for tobacco control is not as strong as TB as we have yet to sign the WHO FCTC. Effective tobacco control is needed to reach TB goals.” Indonesia is currently the only country in the Asia-Pacific that has not ratified the Framework Convention on Tobacco Control (FCTC).

Integration of TB and tobacco control can be done at the primary healthcare setting. Studies have shown that brief advice (5–10 minutes) with minimal cessation support to people with TB at every primary healthcare visit resulted in high quit rates and higher awareness of adverse health effects of second-hand smoke exposure, which led people to make their homes smokefree and health providers to make healthcare settings tobacco-free.

Dr Erlina Burhan, pulmonologist and TB advocate explained how the COVID-19 pandemic impacted Indonesia’s bid to end TB: “Data has shown that during the pandemic deaths due to TB increased and less cases were being diagnosed. Smoking is one of the major factors to fuel TB epidemic in Indonesia.” Dr Burhan warned: “If we continue business as usual, in TB control, TB elimination target in 2030 will not be achieved”.

Tara Singh Bam, Director, The Union Asia Pacific summarised three important actions to be taken as the next steps for Indonesia: “active bi-directional screening for TB and tobacco; smoking cessation with nicotine replacement therapy must be an integral part at regular TB services; and TB Control Programme must integrate and demand tobacco control best-buys- higher taxes and larger pictorial health warnings on tobacco products within national TB control strategy and policy advocacy framework.”

Dr Tiffany Tiara Pakasi, Coordinator for National Tuberculosis Control Program, Ministry of Health, said: “smoking and tuberculosis is a dangerous combination. We have policies from national government but implementation is still lacking to address the problems. We need multi-sectoral cooperation not only from the health sector but other ministries such as Ministry of Finance, Ministry of Home Affairs. The Ministry of Health is committed to improving TB control policies and programmes to better address the dual epidemics of TB and smoking in Indonesia.”  

The meeting recognized that smoking increases the risk of contracting TB, increases the risk of recurrent TB and impairs the response to treatment of the disease. It concluded with the key agreement to:

  1. Accelerate amendment of government regulation on tobacco control (PP109/2012) with provisions of 90% pictorial health warning on tobacco packs; ban tobacco advertising, promotion and sponsorship
  2. TB and Tobacco Control Programmes join hands to raise policy advocacy for making cigarettes less affordable by increasing tobacco tax
  3. TB Control Programme reviews and revises its guidelines to ensure smoking cessation services is provided through regular TB services
  4. TB Control Programme must initiate to integrate tobacco control strategies in TB control policy framework and programme budgets

Almost 2,000 participants attended the meeting, including national and subnational government officials, civil society, public health experts, academics and media from all over the globe.

You can watch the meeting again on YouTube.