The funding crises forced upon by the US government on several low- and middle-income countries is an opportunity in disguise to improve programme efficiency and outcome and invest optimally in health and development responses from domestic coffers.

Evidence shows that tobacco alone costs an economic loss of US$ 1.4 trillion every year. One can imagine the huge economic benefit if governments accelerate progress towards ending tobacco, and reducing burden of tobacco-caused diseases and untimely deaths, and averting this mountainous economic loss to global economy.

All governments can generate more domestic resources by following the science. “One of the scientific evidence-based tobacco control measures is to raise tobacco taxes. Taxation is one of the most effective ways of reducing tobacco use. Higher tobacco taxes raise tobacco prices, leading to reductions in tobacco consumption. Increasing the price of tobacco reduces tobacco use by discouraging initiation among potential users, encouraging current users to quit and helping to prevent relapse in those who have stopped,” said Dr Tara Singh Bam, Asia Pacific Director (Tobacco Control), Vital Strategies, and honorary Board Director of Asia Pacific Cities Alliance for Health and Development (APCAT).

Dr Bam was delivering a public health guest lecture in the Faculty of Medicine, Udayana University, Indonesia, on the topic: "Integrative approaches to end the double burden of tuberculosis and tobacco Use." It was organised by Udayana University and its Udayana CENTRAL (Centre for NCDs, Tobacco Control and Lung Health). This lecture was chaired by Dr Ketut Suarjana, Head of Department of Public Health and Preventive Medicine, Udayana University, Indonesia.

Follow the science and raise tobacco taxes

Raising tobacco taxes is one of the six cost-effective and high impact measures to reduce demand for tobacco recommended by the World Health Organization (WHO) as part of its MPOWER package since 2008 onwards. All these six measures are in line with the legally binding global tobacco treaty (formally called the World Health Organization Framework Convention on Tobacco Control or WHO FCTC) which is ratified by 182 countries and the European Union. “Indonesia should also ratify it as it is the only country in Asia Pacific which has not done so,” said Dr Bam.

“Governments can also levy similar taxes on alcohol, sweetened sugary drinks, or junk fast food – all of which is a major pushback for public health, as it increases the risk of preventable deadly diseases,” rightly said Dr Bam.

By raising taxes on products that are proven to increase the risk of deadly diseases, governments can get more financial resources to invest into public health. More importantly, raising such taxes would deter users to consume harmful products and dissuade those who are not yet consumers of unhealthy diets and drinks.

For every US$ 1 invested in TB control, return on investment is US$ 46

An important 2023 study shows that for every US$ 1 invested in science- and evidence-based TB control, the return on investment is US$ 46.

When hit with funding crises at several levels, does it not make a lot of sense to invest domestic resources in fully funding the domestic fight to end TB? If governments find ALL people with TB with best of screening and diagnostic tools, put them on the latest treatment regimens, then they would prevent TB too, reduce human suffering and untimely deaths. TB preventive therapy as well as addressing risk factors for TB is equally important.

“Stronger implementation of evidence-based tobacco control measures also has a positive impact on TB response as well as other health programmes, such as those addressing cardiovascular diseases, diabetes and other non-communicable diseases,” said Dr Bam.

Double trouble: tobacco and TB

Dr Putu Ayu Swandewi Astuti, Coordinator of Undergraduate Public Health Study Programme, Udayana University, said that tobacco use is the biggest risk factor for TB, as per the latest WHO Global TB Report 2024. Tobacco use was the risk factor for almost 150,000 people with TB disease in 2023 in Indonesia (one-fifth of the total number of TB patients notified in the same year in Indonesia). Undernutrition ranked 2ndbiggest TB risk factor in Indonesia with 84,000 people with TB disease notified in 2023. Diabetes, HIV and alcohol were the next three big risk factors for TB in the country.

“10.8 million people fell ill with active TB disease in 2023 worldwide as per the latest WHO Global TB Report. Out of these, 1.25 million died due to TB in the same year globally. However, if we look at tobacco use, there were at least 1.133 billion tobacco users aged 15 years or above. Over 8 million tobacco users lost their lives in a year,” said Dr Bam. “At least 0.73 million people get TB disease in a year due to tobacco use, and 16% of them die due to the dual pandemic of TB and tobacco.”

Dr Bam shared that a WHO and The Union monograph on TB and tobacco control shows how tobacco smoking amplifies the risk of TB infection, mortality, treatment relapse, heightened clinical severity, and delays in both diagnosis and treatment.

Another study done by Dr Tara Singh Bam, Dr Donald Enarson (legendary lung health expert), Dr Dirgh Singh Bam (former Health Secretary of Government of Nepal) and others, showed that there were worryingly long delays in TB diagnosis and initiation of treatment. Current tobacco smokers in Nepal had an average of 133 days of delay and ex-smokers had 103 days of average delay, compared to those who had never smoked but faced an average delay of 80 days. These delays in TB diagnosis and treatment result in mounting up catastrophic costs for many people in low- and middle-income countries.

Better TB treatment outcomes in those who quit tobacco

A study published in 2022 in the reputed journal Thorax showed that TB treatment outcomes were significantly better among those patients who had quit tobacco use during the TB treatment in Pakistan and Bangladesh. More than 91% of TB patients who had quit tobacco use during TB treatment were successful in completing the therapy (compared to 80% who did not quit tobacco use).

TB relapse rates were also higher among those who did not quit tobacco use during TB treatment- 6% among those who had quit tobacco use and 14% among those who had not quit tobacco use during the treatment reported TB relapse.

Leadership and accountability

Rights come with responsibilities. Dr Bam encouraged everyone to take individual responsibility to have a health seeking behaviour, help protect others from infection and access healthcare services promptly when needed. Current tobacco users also have a responsibility to quit tobacco use and stay away from deadly tobacco.

We also need to unite and hold governments to account to deliver on the promises made for saving our lives from both: TB and tobacco - along with all other sustainable development goals and targets.

Bobby Ramakant – CNS (Citizen News Service)

(Bobby Ramakant is a World Health Organization (WHO) Director General WNTD Awardee 2008 and Health Editor at CNS (Citizen News Service). He is also on the executive boards of Global Antimicrobial Resistance Media Alliance (GAMA) and Asia Pacific Media Alliance for Health and Development (APCAT Media). Follow him on Twitter/X: @BobbyRamakant)