Indonesia: Fight against tuberculosis requires fight against smoking

Smoking is the top preventable risk factor for worsening tuberculosis, Indonesia's health minister acknowledged at a national webinar. The fight against tuberculosis could thus provide a boost to the fight against tobacco, which has been stalled for several years in the country.

On March 23, 2023, the eve of World Tuberculosis Day, a national webinar was held in Indonesia with the theme: “Yes! We can end tuberculosis and smoking”. Co-organized by authorities and national and international civil society organizations, the webinar found that Indonesia is particularly affected by tuberculosis. With 969,000 tuberculosis cases recorded in 2021, including 714,000 new cases diagnosed, Indonesia ranks second among the countries with the highest incidence, just after India.[1] ; a figure which could however be an underestimate, by around 200,000 people.

Dr Guy Mars, President of the International Union Against Tuberculosis and Lung Disease (The Union), recalled on this occasion that tuberculosis can be significantly aggravated by five risk factors, including undernutrition (cause of 120,000 new cases in 2021) and smoking (113,000 new cases), as well as HIV positivity (35,000 cases), diabetes (28,000 cases) and alcohol (14,000 cases). Dr Tara Singh Bam, Asia Pacific Director of The Union and member of the Asia Pacific Cities Alliance for Health and Development (APCAT), pointed out that, like tuberculosis, smoking is an entirely preventable risk and also leads to the emergence of many other non-communicable diseases (NCDs).

Smoking, an aggravating factor in tuberculosis

Indonesian Health Minister Budi Gunadi Sadikin himself has called for stronger anti-smoking actions to stem the spread of the tuberculosis epidemic. "Over the past ten years, the number of adult smokers in Indonesia has increased significantly by 8.8 million people, from 60.3 million smokers in 2011 to 69.1 million in 2021.", he said[2], "During this period, the prevalence of passive smoking also rose to 120 million people." He also mentioned that 15 % of TB deaths are attributable to smoking, which reduces the effectiveness of treatments and increases the risk of TB progression by two to three times. Present in Indonesia in 77 % of TB patients, smoking is much more common there than in other countries in the region.

Indonesia lags behind in tobacco control

Among the measures being considered to combat tobacco use, Dr Bam suggests increasing taxes on tobacco products, banning all forms of advertising, promotion and sponsorship for these products, increasing the size of health warnings on packaging and banning smoking in public or workplace spaces. These are all provisions contained in the Framework Convention on Tobacco Control (FCTC), which Indonesia is the only country in Asia not to have ratified.

The world's second largest tobacco producer, Indonesia has long been criticized as "a playground for cigarette manufacturers" and struggles to materialize his intentions public health. The 2021 edition of the Global Tobacco Industry Interference Index places Indonesia in fourth place among the countries most affected by the weight of the tobacco lobby on public policies[3]. There ratification and the implementation of the FCTC seem to be the right way to strengthen the measures envisaged and those already in place, as recommended by the Global Burden of Disease Study 2019 report of the Institute for Health Metrics and Evaluation (IHME)[4]The fight against tuberculosis could therefore constitute an opportunity to breathe new life into the fight against tobacco in this country.

To go further, read our analysis: When the tobacco industry has a free hand: the Indonesian case

Keywords: Indonesia, tuberculosis, The Union, CCLAT.

M.F.

[1] WHO, Global Tuberculosis Report 2022, 68 p., published October 27, 2022, consulted April 12, 2023.

[2] Shukla S, Ramakant B, Ending tobacco use is the bedrock for progressing towards ending TB and SDGs, Citizen News Service, published April 6, 2023, accessed April 12, 2023.

[3] STOP, Global Tobacco Industry Interference Index 2021.

[4] GBD 2019 Indonesia Subnational Collaborators, The state of health in Indonesia's provinces, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019, Lancet Global Health 2022; 10:e1632–45