Tobacco & Tuberculosis Killing Indonesia

In the next few years, Indonesia is expected to jump from a lower-middle to an upper-middle economic position, according to its gross national income per capita. However, beneath the economic growth, there is an iceberg of a threat from a triple burden of diseases: infectious diseases, noncommunicable diseases (NCD) and reemerging diseases.

Without significant intervention, in the long run the burden will become a plague that hinders the growth of human resources and economic growth as a whole.

Tobacco has been one of the issues over which the government is still in limbo choosing between economic growth and the quality of human resources. As a country with the largest prevalence of male smokers in the world, tobacco is a commodity that contributes to the state revenues. On the other hand, tobacco consumption has a very broad impact not only on health, but also on other socioeconomic aspects.

For example, Statistics Indonesia (BPS) in 2016 found that 40 percent of the smoking population from the lowest income level spent 11.5 percent of family income per month on cigarettes, hampering the members from attaining their minimum daily calorie intake. Furthermore, a study done by Mark Goodchild and others in 2017 discovered that 21 percent of chronic smoking-attributable diseases in Indonesia are estimated to cause an economic burden of US$1.2 billion per year.

The World No Tobacco Day this year focuses on “Tobacco and Lung Health”, emphasizing the multiple ways tobacco affects the health of people’s lungs, including the association with tuberculosis (TB) infection. In fact, tuberculosis has become one of the top health priorities both in the world and in Indonesia, with the view of eliminating the disease by 2030. Although the bacteria is found to have infected people for thousands of years, TB remains the fourth leading cause of death in Indonesia and Indonesia has the third highest burden in the world.

There are links that need to be considered here. A study by the World Health Organization in 2009 showed that more than 20 percent of TB incidents globally were related to smoking habits. Smoking increases a person’s risk of being infected with TB by up to 2.5 times. It was found in 2014 that regular tobacco smoking doubles the risk of people who have been successfully treated for TB to develop the disease again.

Tobacco is the fourth highest risk factor for health in Indonesia. The fact that five countries with the highest TB burden also have high cigarette consumption suggests that controlling cigarette consumption may reduce the risk of TB infection and the occurrence of new cases, which would help Indonesia achieve the goal of TB elimination by 2030, as well as reduce NCDs related to smoking.

The government has made various efforts to deal with TB. Unfortunately, in regard to tobacco control, the government’s commitment is regretfully weak. Up to now, Indonesia has not yet ratified the Framework Convention on Tobacco Control (FCTC), which is an important international framework for tobacco restriction and control. Furthermore, at the end of last year the government dropped a decision to increase tobacco excise and annulled the road map for the simplification of excise structures.

The cancellation of these policies allows tobacco producers to sell their products for less than Rp 1,000 (7 US cents) per cigarette, making them affordable for children and the poor. No wonder the Health Ministry’s Basic Health Research (Riskesdas) shows a significant increase in the prevalence of young smokers from 7.2 percent in 2013 to 9.1 percent in 2018. Worse still, our National Health Insurance (JKN) continues to suffer a huge deficit, partly to cover the treatment of catastrophic diseases that are significantly related to smoking.

After his reelection, President Joko “Jokowi” Widodo said he would focus on human resources development in his second term, which has been outlined and mapped in the Technocratic Draft of the National Medium-Term Development Plan (RPJMN) 2020-2024 of Indonesia. Part of the plan is to decrease the prevalence of smokers year by year.

Later in October 2019, the new government of Jokowi is expected to prove its commitment to human resources development through aligned policies that have leverage for increasing the productivity of human capital.

To control cigarettes specifically, in the short term, the government must increase cigarette excise and reduce the complicated excise structure. Excise Law No. 39/2007 only imposes a maximum ceiling of 57 percent of the retail price, which is not enough and still allows cigarettes to remain very cheap. A significant raise in the price of cigarettes is the most effective instrument today to reduce cigarette consumption, according to many studies, and, of course, to reduce a person’s susceptibility to TB infection.

In the long term, the government must ratify the FCTC as a statement of its serious commitment to improve and protect Indonesians’ health. That way, the target to eliminate TB by 2030 can be achieved and economic growth, as well as human development, would go in parallel, supporting each other sustainably.