In the lead up to World No Tobacco Day later this month, it is high time we recognise and effectively address the deadly synergy between the two epidemics that fuel each other: tobacco use and tuberculosis (TB). Tobacco is the single-largest preventable cause of death worldwide and TB continues to be the deadliest of infectious diseases in high burden countries (even despite the COVID-19 pandemic).

Indonesia has the 2nd highest TB burden worldwide

According to the World Health Organization (WHO) Global TB Report 2023, Indonesia has the 2nd highest TB burden globally (with India being home to the largest TB burden worldwide). In 2022, approximately 1,060,000 individuals in Indonesia fell ill with TB, with an estimated 303,000 incident cases of TB attributed to tobacco smoking. Indonesia's battle against TB is marked by staggering statistics. Alarmingly, TB remains a leading cause of death in the country, claiming nearly 141,000 lives every year. The burden is disproportionately borne by the most vulnerable segments of society, including those living in poverty and marginalised communities.

Indonesia remains the global epicentre of tobacco consumption

Adding fuel to the fire is Indonesia's pervasive smoking culture, which exacerbates the TB crisis. According to the Global Adult Tobacco Survey, the prevalence of tobacco use among Indonesia’s adult population was 34.5% in 2021. The estimated 70 million Indonesian who smoked tobacco in 2021 is an increase from 60 million in 2011. Approximately 67% of adult males in the country are identified as smokers. Moreover, some Indonesian studies have revealed a 96.7% smoking prevalence in males with TB. Indonesia holds the dubious distinction of being a global epicentre for tobacco consumption. This addiction not only exacts a heavy toll on individual health but also contributes to the country's overall disease burden, including TB.

The deadly synergy: TB and tobacco smoking

The intertwining of TB and smoking creates a deadly synergy. Smoking weakens the respiratory system, compromising lung function and increasing susceptibility to TB infection. Moreover, smokers who contract TB are more likely to develop active disease and experience severe complications. The toxic chemicals in tobacco smoke impair the immune system's ability to combat TB bacteria, leading to prolonged illness and higher mortality rates.

Studies have shown that TB patients who smoke are up to four times more likely to die from the disease compared to non-smokers. Furthermore, smoking is associated with treatment failure, drug resistance, and increased risk of TB recurrence, as well as longer delays in TB diagnosis and treatment. Smokers who experience TB symptoms often do not present to the health services in the belief that their cough is due to smoking and does not require treatment. Longer delays result in increased spread of TB infection in the community and also increase healthcare costs.

These findings underscore the urgent need for targeted interventions to address the co-epidemic of TB and smoking in Indonesia. To combat this dual crisis, a comprehensive approach is imperative. Government must prioritize prevention, awareness, and access to healthcare services. Tobacco control measures, including higher tobacco taxes, smoke-free policies, complete ban of tobacco advertising, promotion and sponsorship, public awareness campaigns and cessation programmes play a crucial role in reducing smoking prevalence and mitigating TB risk.

Easy access to smoking cessation interventions within TB control programmes can contribute to promoting smoking cessation among persons with TB, which would improve TB treatment outcomes. Standard smoking cessation guidelines, training, monitoring and evaluation are critical elements to integrate into TB prevention programmes. Published evidence strongly suggests that smokers who quit, reduce both- their risk of becoming infected with TB and their risk of dying from it. Thus, prompt identification of smoking behaviour and smoking cessation are critical for improving TB treatment and reducing the transmission of TB in the community.

Government and health providers should make more accessible resources available to help tobacco users quit. The primary healthcare workers should be on the frontline of tobacco cessation and promotion of awareness programmes. As they reach many tobacco users and affected families directly, they can interact swiftly, and provide comprehensive guidance, as they are typically the most trusted source of information. Tobacco cessation should be integrated into their regular work by training them to:

- Ask the patient/ visitor if they smoke or are exposed to second hand smoke,

- Give advice about stopping tobacco use, and

- Give cessation support with regular monitoring.

All this can be offered within 5–10 minutes of interaction with the patient through existing services at the primary health centre.

WHO End TB Strategy and UN-HLM on TB promises

The WHO End TB Strategy provides an opportunity for greater alignment of efforts to fight both the TB and tobacco epidemics. Likewise, the world leaders who met at the United Nations General Assembly High Level Meeting in 2023, adopted a political declaration in which one of the action points is to effectively integrate tobacco control and TB control at the primary care level. There is no excuse for inaction. We must translate the WHO End TB Strategy and UNHLM on TB promises in ground realities now.

Government commitment and investment are essential for joint strategic policy development, planning, implementation, and monitoring. Elimination of tobacco smoking among TB patients will go a long way towards the elimination of TB.

In addition to cessation support through regular TB services, nicotine replacement therapy (NRT) and other medications can be included in the comprehensive package care for people with TB to improve quality of the services they receive. Stopping smoking or tobacco use has benefits at the individual and population level and go beyond fighting TB. Multisectoral efforts to stop tobacco use also support the non-communicable disease agenda. The support of TB control programmes to strengthen the implementation of the WHO Framework Convention on Tobacco Control is critical (legally binding global tobacco treaty) and will support the national TB programme targets to end TB in line with the WHO End TB Strategy and ultimately the SDGs.