Smoking and TB: Dual epidemics leading people to bleak end

“Around 77.6 percent of TB cases in Indonesia are related to smoking,” Mukta Sharma, of the World Health Organization points out.

Rita Widiadana

Rita Widiadana

The Jakarta Post


A health worker conducts a chest X-ray scan at Tangerang City General Hospital in Banten, on March 21, 2023.(Antara/Fauzan)

June 15, 2023

JAKARTA – “Ustad (Islamic religious teacher), are there any cigarettes in heaven?” asked a dying man. “Yes, of course, you can find anything you want in heaven. But, you must first go to hell to light up your cigarette,” the ustad answered calmly.

This story was shared by Imran Pambudi, head of the National Tuberculosis (TB) Control Program, during a recent webinar titled Yes, We Can End TB and Smoking, held to address Indonesia’s two most challenging public health concerns: tuberculosis and tobacco use.

The webinar, attended by more than 1,000 participants from the Asia Pacific countries, was jointly organized by the Health Ministry, the Association of All Indonesian Health Offices (ADINKES), the Asia-Pacific Cities Alliance for Health and Development (APCAT) and the International Union Against Tuberculosis and Lung Health (The Union), among others.

“[The story] really reflects how smoking has become an addiction to millions of people in Indonesia,” said Pambudi.

The Global Adult Tobacco Survey (GATS) in 2021, calculated that there were 70.2 million people who used tobacco (smoking, smokeless or heated tobacco products), and that 65.5 percent of Indonesian men and 3.3 percent of women used tobacco.

Mukta Sharma, technical advisor at the World Health Organization (WHO) for Indonesia, lamented that smoking was the strongest risk factor for TB in Indonesia in addition to undernourishment, diabetes and HIV.

“Around 77.6 percent of TB cases in Indonesia are related to smoking,” Sharma said.

“What is saddening, tobacco smoking prevalence in Indonesia did not change from 2011 to 2021. To make it worse, the use of electronic cigarettes significantly increased from 0.3 percent in 2011 to 3 percent in 2021,” she said, adding a positive finding that 63.4 percent of present smokers were thinking of quitting smoking.

Many studies reveal that compared to non-smokers, those who smoke tobacco have twice the risk of TB disease, and patients with TB who smoke have twice the risk of death during treatment.

In the last three years, the COVID-19 pandemic has diverted the world’s attention from TB, which remains as the leading cause of morbidity and mortality worldwide.

The 2022 WHO Global Tuberculosis Report reveals a gruesome picture of an estimated 10.6 million people falling ill with TB worldwide in 2021, an increase of 4.5 percent from 10.1 million in 2020, reversing many years of slow decline.

The global number of deaths officially classified as caused by TB in 2021 was 1.4 million and TB mortality has been severely impacted by the COVID-19 pandemic.

The overarching finding of the report is that the pandemic continues to have damaging impacts on access to TB diagnosis and treatment, and to the burden of TB disease.

Progress made in the years up to 2019 has slowed, stalled or reversed, and global TB targets are off track, the report said.

To make things worse, the major contributors to the global rise between 2020 and 2021 were India, Indonesia and the Philippines, collectively, with TB cases rising by about 0.4 million in the three countries.

Indonesia saw 969,000 of TB cases in 2021 or 354 persons per 100,000, making it the world’s second country with the highest TB burden. The TB mortality rate is 52 per 100,000 persons in the country.

Deadly combination

A key barrier to timely TB diagnosis and treatment among people who smoke is the assumption that coughing is causally connected to their smoking, instead of as a TB symptom.

Worse, exposure to second-hand smoke increases the risks of both TB infection and development of active TB disease among children and adults.

“The GATS results show that curbing TB would be impossible without addressing tobacco control in Indonesia,” Sharma said.

While TB and smoking is a deadly combination, Indonesia’s Joint External Monitoring Mission (JEMM) for TB study reveals that smoking is not mentioned in the operational component in the National Strategic Plan to end TB by 2030.

“There is no component that collaborates with wider efforts of smoking cessation to reduce tobacco smoking in the general population, and cut down on the 300,000 or so cases of TB each year that are thought to be caused by tobacco smoke,” the study says.

At the same webinar, Health Minister Budi Gunadi Sadikin said during the COVID-19 pandemic the number of people who could get diagnosed with TB in a year had dropped to around half a million, but in 2021 it again picked up to over 717,000.

But over 200,000 people were missing from TB care services in 2021.

The minister stressed the importance of reaching out to everyone with TB, providing them with easy access to proper health services and treatment.

In 2021, 86 percent of those who were diagnosed with drug sensitive TB were put on treatment, out of which 87 percent reported treatment completion in Indonesia. However, only one-third of those with drug resistant TB were put on treatment in the same year.

Budi emphasized that TB is one of the leading causes of death in smokers, with 15.2 percent of deaths from TB related to smoking.

The Indonesian government, the minister said, has shown a strong commitment in eradicating TB by 2030 with the issuance of Presidential Decree No. 67/2021, which requires multi-sectoral collaboration involving 17 ministries including the Finance Ministry, the Home Ministry, the Education, Culture, Research and Technology Ministry and the Office of the Coordinating Human Development and Culture Minister.

“TB is estimated to cause annual economic losses of Rp 136.7 billion. Seventy percent of patients lose their jobs, and smoking is one of the primary culprits to these numbers,” Budi noted.

The Health Ministry claims to have expanded the coverage of the national health insurance to reach 223 million citizens (84 percent of the entire population), who currently have access to free healthcare services, including TB treatment at 25,000 community health centers (Puskesmas) and 2,400 hospitals.

The government had also doubled its domestic funding for TB from US$109 million in 2019 to $155 million in 2020, right before the outbreak of the COVID-19 pandemic.

Tjandra Yoga Aditama, a medical professor at the University of Indonesia and a senior advisor of the Asia-Pacific Cities Alliance (APCAT) for Health and Development, explained it was challenging to end TB by 2030 without addressing and strengthening the country’s tobacco control policy.

“We have all legal instruments and initiatives to achieve our goals to end TB, but our commitment for tobacco control remains weak. Indonesia is the only country in the Asia-Pacific that has not ratified the Framework Convention on Tobacco Control (FCTC),” Tjandra said.

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