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, 19-23 APRIL 2015

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

Global Burden of Tobacco-Related Diseases

Source: WHO Report on the Global Tobacco Epidemic. (2008).

Tobacco Smoke and Disease

4

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).

Clove Cigarettes or Kreteks 70% tobacco and 30% cloves Clove numbs the throat; mild carcinogenic

for Liver (Safrol) Densely rolled:

higher exposure to carcinogens

Tobacco Products

Source: Tobacco Atlas, 4th edition. (2012).

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.

How Tobacco Smoke Causes Disease

Source: Surgeon General’s Report. (2010).

Twenty Leading Causes of Death, Sample Registration System – INDONESIA, 2013

No Cause of Death Frequency Percent1 Cerebrovascular diseases (I60 - I69) 8793 21.12 Ischaemic heart diseases (I20 – I25) 5361 12.93 Diabetes mellitus with complication (E10 – E14) 2801 6.74 Respiratory tuberculosis (A15 – A16) 2382 5.75 Hypertensive diseases with complication (I11 – I13) 2221 5.36 Chronic lower respiratory diseases (J40-J47) 2050 4.97 Diseases of the liver (K70 – K76) 1105 2.78 Transport accidents (V01– V99) 1077 2.69 Pneumonia (J12 – J18) 879 2.110 Diarrhoea and gastroenteritis of presumed infectious origin (A09) 790 1.911 Malnutrition (E40 – E46) 492 1.212 Falls (W00 – W19) 489 1.213 Malignant neoplasm of breast (C50) 408 1.014 Disorders relating to length of gestation and fetal growth (P05– P07) 368 .915 Malignant neoplasm of liver and intrahepatic bile ducts (C22) 295 .716 Viral hepatitis (B15 – B19) 255 .617 Intrauterine hypoxia and birth asphyxia (P20 - P21) 246 .618 Gastric and duodenal ulcer (K25-K27) 243 .619 Malignant neoplasm of trachea, bronchus and lung (C33 - C34) 240 .620 Malignant neoplasm of cervix uteri (C53) 219 .5

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 L P Total L P Total L P Total L P Total 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

Total 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 4,2 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)

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 %

Trends of Smoking Prevalence By Sex, 2007, 2010, 2013

 

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

1995 2001 2004 2007 2010 20130

10

20

30

40

50

60

70

80

90

100

53.4

62.2 63.165.6 65.8 66

1.7 1.34.5 5.2 4.1

6.7

2731.5

34.4 34.2 34.3 36.3

Laki2PerempuanLk+Prmpn

Average Number of Cigarette Sticks consumed per day, (population aged >= 10

years) by Province, 2013

DIY

NTT

Jatim DK

IBali

INDONESIA

Malut

Papbar

Sulut

Sulteng

Sultra

Jambi

Kalbar

Kalteng

Aceh

Sumabr

Kalsel

0.0

5.0

10.0

15.0

20.0

25.0

12.3

Methods and Sources of Data

Mortality data were obtained from 2013 Sample Registration System data that covered 128 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

TOTAL NUMBER OF TOBACCO ATTRIBUTABLE CASES BY DISEASE AND

SEX, INDONESIA 2013

Disease Total Cases Males FemalesLow Birth Weight babies 216.050 112.870 103.190Tumor Mulut dan Tenggorokan 6.670 3.350 3.310Neoplasm of Esophagus 1.710 1.010 700Neoplasm of Stomach 10.440 2.780 7.660Neoplasm of Liver 13.400 6.740 6.660Neoplasm of Pancreas 2,910 1,870 1,040Neoplasm of Lung, Bronchus and Trachea 54.300 47.790 6.510Neoplasm of Cervix 28.940 0,00 28.940Neoplasm of Ovary 7.690 0,00 7.690Neoplasm of Gall Bladder 10.160 5.990 4,170Coronary Heart Disease 183.950 112.760 71.190Cerebrovascular Disease/Stroke 144.780 70.410 74.360Chronic Obstructive Pulmonary Disease 284.310 206.640 77.670

Total 962.403 570.342 387.885

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

Total 240.618 127.727 112.889

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 2.274.200 1.249.520 1.024.680Tumor Mulut dan Tenggorokan 828.340 418.300 410.040Neoplasm of Esophagus 152.998 89.888 63.110Neoplasm of Stomach 65.500 34.990 30.510Neoplasm of Liver 148.360 75.260 73.090Neoplasm of Pancreas 49.560 30.100 19.460Neoplasm of Lung, Bronchus and Trachea 403,16 383,62 19,54Neoplasm of Cervix 312.555 -- 312.555Neoplasm of Ovary 175.513 -- 175.513Neoplasm of Gall Bladder 218.511 129.013 89.497Coronary Heart Disease 204.349 127.612 76.736Cerebrovascular Disease/Stroke 847.740 777.085 783.031Chronic Obstructive Pulmonary Disease 901.744 669.943 231.801Total 6,179,773 3,602,095 3,290,043

Total Medical Expenditures of Tobacco Attributable Diseases, Indonesia 2013Disease Total Cases Cost per episode Total Cost (Rp)

Low Birth Weight babies 216.050 6.185.362 1.336.347.460.100

Tumor Mulut dan Tenggorokan 6.670 3.733.141 24.900.050.470

Neoplasm of Esophagus 1.710 3.733.141 6.383.671.110

Neoplasm of Stomach 10.440 3.733.141 38.973.992.040

Neoplasm of Liver 13.400 3.733.141 50.024.089.400

Neoplasm of Pancreas 2,910 3.733.141 10.863.440

Neoplasm of Lung, Bronchus and Trachea 54.300 3.733.141 202.709.556.300

Neoplasm of Cervix 28.940 3.733.141 108.037.100.540

Neoplasm of Ovary 7.690 3.733.141 28.707.854.290

Neoplasm of Gall Bladder 10.160 3.733.141 37.928.712.560

Coronary Heart Disease 183.950 6.017.579 1.106.933.657.050

Cerebrovascular Disease/Stroke 144.780 7.726.946 1.118.707.241.880

Chronic Obstructive Pulmonary Disease 284.310 4.551.951 1.294.165.188.810Total 5.353.829.437.990

TOTAL MACRO EXPENDITURES

Average cigarette consumption per person per day in 2013 was 12,3 sticks or 369 sticks per month. With the average price of Rp. 600.00 per stick, total cost to purchase cigarettes was Rp 221.400,- per month or Rp 2.656.800,- 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 103.02 Trillions Rupiah.

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

TERIMA KASIH