Tuberculosis (TB) is still a worrying global threat to human lives. WHO 2017 report recorded TB as the ninth-highest cause of death in the world and the leading cause from a single infectious agent, ranking above HIV/AIDS. 
As of 2016, some 10.4 million people across the world had fallen sick because of TB. Indonesia has not done much better either as the WHO ranked Indonesia as the country with the second-highest incidence of TB. 

It has become the fifth-highest cause of death in Indonesia, leading to an estimated economic burden of over Rp 90 trillion (US$6.48 billion) in productivity loss from premature death, morbidity and medical costs. 

The high number of new TB cases in Indonesia is caused by multi-faceted factors, including smoking, which is considered as an important risk factor in TB infection. Each year, more than 6 million people globally become victims of tobacco-attributable diseases. Competing with TB, Indonesia itself is the world’s third-largest tobacco consumer.

The international NGO Tobacco Atlas reported in 2015 that Indonesia had the world’s highest number of male smokers above the age of 15; and TB cases in Indonesia are much higher in males than females. 

Many studies have indicated the positive association between TB infection and smoking, in which smoking increases one’s risk 2.5 times to TB infection. 

Nearly a decade ago, a 2009 WHO report showed five countries with the highest burden of TB and at the same time, the highest cigarette consumption. More than 20 percent of TB global incidence is estimated to be associated with the smoking.

To kill two birds with one stone, reducing smoking should decrease the susceptibility of developing active TB, meaning that decreasing the number of smokers would also reduce the incidence of TB in Indonesia. 

There are already plenty of measures, financial resources and cross-sectoral partnership orchestrated towards TB elimination, yet very few on tobacco. TB elimination measures should involve studying the risk factors – which means the measures should be carried out hand in hand with tobacco control efforts. 

The Health Ministry is indeed aware of the link of tobacco and TB. However, not many stakeholders are willing nor brave enough to put the stake on tobacco control knowing the enormous power of tobacco industry in the country. 
Indonesia’s ratification of the global Framework Convention on Tobacco Control (FCTC), therefore, might be still difficult to attain. Nevertheless, there are still possibilities to push the application of the MPOWER measures – the six-policy guideline provided by provided by FCTC for countries to implement and manage tobacco control. 

The measures have been pushed by tobacco control activists and advocates to be implemented and mainstreamed in the policy. Some of them, though still ineffective, are already in place, such as pictorial health warnings, smoke-free public places, as well as limits on tobacco advertising, promotion, and sponsorship.

In addition, increasing the cigarette tax significantly should also be carried out to reduce smoking prevalence. Offering help to quit smoking is also imperative; for example, when a TB patient is treated, healthcare workers should also provide them help to quit smoking and refer them to the right clinic, if they lack the necessary services. 
In the future, there should be an integrated service for TB patient who at the same time is also a smoker. Preventive and promotive measures on TB and tobacco control should be amplified and run parallel with the curative and rehabilitative measures. 

Otherwise, attaining the national targets of TB elimination by 2030 and TB eradication by 2050 will be just a dream.

The article was published in The Jakarta Post, June 2nd 2018. 

Olivia Herlinda is a project manager for Stop Tuberculosis Partnership program at the Center for Indonesia’s Strategic Development Initiatives (CISDI)

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