1. TOBACCO RELATED DISEASES IN INDONESIA, ECONOMIC IMPACT AND EFFORTS TO CURB THE HEALTH IMPACT*
Soewarta Kosen
National Institute of Health Research & Development,
Ministry of Health – Republic of Indonesia
Jakarta, Indonesia
*Presented at The sECOND Indonesia Tobacco Control research dissemination conference,
Yogyakarta, April 2015

2. BACKGROUND Smoking is preventable cause of morbidity and mortality
In 2013, there were 1,741,727 deaths from all causes in Indonesia, 240,618 of those deaths were due to tobacco attributable diseases
Nicotine dependency is considered as a disease; ICD-10 (Int’l Statistical Classification of Diseases and Related Health Problems, 10th revision): F17 Mental and behavioural disorders due to use of tobacco (WHO, 1993)
Reduced consumption of tobacco will decrease burden of tobacco related diseases and will make a better use of family income
Consumption of tobacco increases significantly in Indonesia, due to improved household income, population growth, low prices of cigarettes and modernization of Kretek industry

3. Global Burden of Tobacco-Related Diseases
Source: WHO Report on the Global Tobacco Epidemic. (2008).

4. Tobacco Smoke and Disease
U.S. SGR conclusions on tobacco smoke and disease:
“Smoking harms nearly every organ of the body.” (2004)
“There is no safe level of exposure to secondhand smoke.” (2006)
“Even 50 years after the first Surgeon General’s report, research continues to newly identify diseases caused by smoking, including such common diseases as diabetes mellitus, rheumatoid arthritis, and colorectal cancer.” (2014)
Source: Surgeon General’s Report (2004, 2006, 2014). 4

5. Tobacco Products Clove Cigarettes or Kreteks
70% tobacco and 30% cloves
Clove numbs the throat; mild carcinogenic for Liver (Safrol)
Densely rolled:
higher exposure to carcinogens
Source: Tobacco Atlas, 4th edition. (2012).

6. How Tobacco Smoke Causes Disease
There is no safe level of exposure to tobacco smoke.
Damage from tobacco smoke is immediate.
Smoking longer means more damage.
Cigarettes are designed for addiction.
There is no safe cigarette.
The only proven strategies for reducing the risk of tobacco-related disease and death are to never smoke or to quit if you are a current smoker.
Source: Surgeon General’s Report. (2010).

7. Twenty Leading Causes of Death, Sample Registration System – INDONESIA, 2013No
Cause of Death
Frequency
Percent 1
Cerebrovascular diseases (I60 - I69)
8793
21.1 2
Ischaemic heart diseases (I20 – I25)
5361
12.9 3
Diabetes mellitus with complication (E10 – E14)
2801
6.7 4
Respiratory tuberculosis (A15 – A16)
2382
5.7 5
Hypertensive diseases with complication (I11 – I13)
2221
5.3 6
Chronic lower respiratory diseases (J40-J47)
2050
4.9 7
Diseases of the liver (K70 – K76)
1105
2.7 8
Transport accidents (V01– V99)
1077
2.6 9
Pneumonia (J12 – J18)
879
2.1 10
Diarrhoea and gastroenteritis of presumed infectious origin (A09)
790
1.9 11
Malnutrition (E40 – E46)
492
1.2 12
Falls (W00 – W19)
489 13
Malignant neoplasm of breast (C50)
408
1.0 14
Disorders relating to length of gestation and fetal growth (P05– P07)
368 .9 15
Malignant neoplasm of liver and intrahepatic bile ducts (C22)
295 .7 16
Viral hepatitis (B15 – B19)
255 .6 17
Intrauterine hypoxia and birth asphyxia (P20 - P21)
246 18
Gastric and duodenal ulcer (K25-K27)
243 19
Malignant neoplasm of trachea, bronchus and lung (C33 - C34)
240 20
Malignant neoplasm of cervix uteri (C53)
219 .5

8. Prevalence of Tobacco Consumption of Population Aged > 15 tahun by Residence and Sex, Indonesia 1995, 2001, 2004, 2007, 2010, 2013
Location
1995
2001
2004
2007
2010
2013 L P
Total
Rural
58,3 2
29,5
67,0
1,5
34,0
66,8
4,7
36,5
69,2
6,3
36,6
70,1
5,3
37,4
69,4
8,6
38,9
Urban
45,1
1,2
22,6
56,1
1,1
28,2
58,6
4,2
31,7
61,1
3,8
31,2
62,1
3,1
32,3
62,8
4,9
33,8
53,4
1,7
26,9
62,2
1,3
31,5
63,1
4,5
34,4
65,6
5,2
34,2
65,9
34,7
66,0
6,7
36,3
Sources: SUSENAS 1995, SKRT 2001, SUSENAS 2004, RISKESDAS 2007*, 2010* dan 2013*
Notes: consumption daily and sometimes (smoked & chewed tobacco)

9. Trends of Smoking Prevalence By Sex, 2007, 2010, 2013
RISKESDAS 2007
RISKESDAS 2010
RISKESDAS 2013
Smoking Prevalence (>15 yrs)
33,4%
34,7%
36,3 %
Male Prevalence (>15 yrs)
65,29%
65,9%
64,9 %
Female Prevalence (>15 yrs)
5,06%
4,2%
2,1%
Environmental Tobacco Smoke
84,5 %
76,1%
76,8 %

10.     Prevalence of tobacco consumption (smoked & chewed) among population aged > 15 years by sex, Indonesia; 1995, 2001, 2004, 2007, 2010, and 2013

11. Average Number of Cigarette Sticks consumed per day, (population aged >= 10 years) by Province, 2013

12. Methods and Sources of Data
Mortality data were obtained from Sample Registration System data that covered subdistricts in 119 districts and cities (30 provinces).
Demographic data is based on projection of 2010 Population Census data.
Beban penyakit tidak menular terkait tembakau (DALYs/ Disability Adjusted Life Year Loss) is estimated using Global Burden of Disease method (WHO, 2000, IHME 2013):
DALY = YLL + YLD
YLL = years of life lost due to premature mortality
YLD = years of life lost due to disability
Epidemiological data of diseases are based on disease surveillance (CDC, MoH), local and national studies
Medical expenditures of selected tobacco related disease is based on the Minister of Health Regulation No. 69/2013 on Standard Tariff of health care at primary and secondary health facilities in health insurance program

13. TOTAL NUMBER OF TOBACCO ATTRIBUTABLE CASES BY DISEASE AND SEX, INDONESIA 2013
Total Cases
Males
Females
Low Birth Weight babies
Tumor Mulut dan Tenggorokan
6.670
3.350
3.310
Neoplasm of Esophagus
1.710
1.010
700
Neoplasm of Stomach
10.440
2.780
7.660
Neoplasm of Liver
13.400
6.740
6.660
Neoplasm of Pancreas
2,910
1,870
1,040
Neoplasm of Lung, Bronchus and Trachea
54.300
47.790
6.510
Neoplasm of Cervix
28.940
0,00
Neoplasm of Ovary
7.690
Neoplasm of Gall Bladder
10.160
5.990
4,170
Coronary Heart Disease
71.190
Cerebrovascular Disease/Stroke
70.410
74.360
Chronic Obstructive Pulmonary Disease
77.670
Total

14. Tobacco Attributable Deaths By Disease and Sex, Indonesia 2013
Total death
Male
Female
Low Birth Weight babies
34.800
19.455
15.345
Tumor Mulut dan Tenggorokan
19.017
8.543
10.473
Neoplasm of Esophagus
13.508
7.968
5.540
Neoplasm of Stomach
2.580
1.210
1.370
Neoplasm of Liver
7.059
3.549
3.509
Neoplasm of Pancreas
6.446
4.012
2.434
Neoplasm of Lung, Bronchus and Trachea
28.897
27.329
1.568
Neoplasm of Cervix
19.580 --
Neoplasm of Ovary
9.730
Neoplasm of Gall Bladder
15.598
9.087
6.511
Coronary Heart Disease
18.137
10.962
7.175
Cerebrovascular Disease/Stroke
45.012
22.656
22.356
Chronic Obstructive Pulmonary Disease
20.254
12.956
7.298
Total

15. DISABILITY ADJUSTED LIFE YEARS LOSS DUE TO TOBACCO ATTRIBUTABLE DISEASES BY DISEASE AND SEX, INDONESIA 2013
Disease
Total DALYs Loss
Male
Female
Low Birth Weight babies
Tumor Mulut dan Tenggorokan
Neoplasm of Esophagus
89.888
63.110
Neoplasm of Stomach
65.500
34.990
30.510
Neoplasm of Liver
75.260
73.090
Neoplasm of Pancreas
49.560
30.100
19.460
Neoplasm of Lung, Bronchus and Trachea
403,16
383,62
19,54
Neoplasm of Cervix --
Neoplasm of Ovary
Neoplasm of Gall Bladder
89.497
Coronary Heart Disease
76.736
Cerebrovascular Disease/Stroke
Chronic Obstructive Pulmonary Disease
Total
6,179,773
3,602,095
3,290,043

16. Total Medical Expenditures of Tobacco Attributable Diseases, Indonesia 2013
Total Cases
Cost per episode
Total Cost (Rp)
Low Birth Weight babies
Tumor Mulut dan Tenggorokan
6.670
Neoplasm of Esophagus
1.710
Neoplasm of Stomach
10.440
Neoplasm of Liver
13.400
Neoplasm of Pancreas
2,910
Neoplasm of Lung, Bronchus and Trachea
54.300
Neoplasm of Cervix
28.940
Neoplasm of Ovary
7.690
Neoplasm of Gall Bladder
10.160
Coronary Heart Disease
Cerebrovascular Disease/Stroke
Chronic Obstructive Pulmonary Disease
Total

17. TOTAL MACRO EXPENDITURES
Average cigarette consumption per person per day in 2013 was 12,3 sticks or sticks per month. With the average price of Rp per stick, total cost to purchase cigarettes was Rp ,- per month or Rp ,- per year. It is estimated that in 2013, expenditure to purchase tobacco was 138 Trillions Rupiah
Thus, the total macro economic loss in 2013 that included community expenditures to purchase cigarettes (138 Trillions), loss of productivity due to premature mortality, sickness and disabilities (235.4 Trillions), and total medical expenditures of tobacco attributable diseases(5.35 Trillions rupiah) was in the amount of 378,75 Trillions Rupiah.
This amount is 3.7 times than the tobacco excised tax obtained by the government in the same year (2013) that is Trillions Rupiah.

18. CONCLUSIONS
Results of the Basic Health Research, GATS and Sample Registration System confirm previous findings that Tobacco epidemic is still going on in Indonesia
Epidemic of Tobacco use creates unnecessary preventable Non Communicable Diseases, affects the social welfare of the poor and aggravates macro economic burden ; thus need to be curbed
Serious commitment of government and civil society including community groups and private sector to implement tobacco control policies as outlined by WHO FCTC and MPOWER Policy are urgently needed to lower tobacco consumption, reduce health and economic burden of tobacco attributable diseases and to prevent premature mortality

19. Terima kasih