Will Indonesia mitigate COVID-19 by enforcing stronger tobacco control and ratifying global tobacco treaty? By Bobby Ramakant

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President of Indonesia, Joko Widodo, has been sent an appeal to urgently strengthen the response to corona virus disease (COVID-19) in the country, by stronger enforcement of comprehensive and evidence-based tobacco control measures, which includes immediate ratification of the global tobacco treaty (World Health Organization Framework Convention on Tobacco Control). Studies in various countries globally show that people with pre-existing non-communicable diseases (NCDs) are more likely to become severely ill or die from COVID-19. Tobacco use is a common major risk factor of most NCDs.

 This appeal to the President of Indonesia is endorsed by forty two associations of senior academicians, medical doctors, specialist doctors (experts of cardiovascular diseases, lung diseases, internal medicine, children, among others), farmers, students, consumer rights groups, journalists, tobacco control and public health advocates, among others.

Two pandemics: Tobacco and COVID-19

- one is entirely preventable today -

The world is battling COVID-19. The deadly association between the two pandemics of tobacco and COVID-19, puts many millions of lives on risk. As of now, it is a worldwide public health emergency to contain the spread of corona virus which causes COVID-19. But tobacco epidemic which kills over 8 million people every year, is entirely preventable - and industry that reaps profits is propelling lies-after-lies to promote its markets, even in the times of the COVID-19 pandemic.

"Emerging scientific evidence suggests that tobacco smokers are at risk of more severe outcomes of COVID-19 than non-smokers, including death. There is an added urgency during the COVID-19 pandemic to take decisive actions for tobacco control. Governments around the world have to step up to phasing out tobacco. Its time to end tobacco" said Dr Tara Singh Bam, Regional Deputy Director (Asia Pacific), International Union Against Tuberculosis and Lung Disease (The Union).

In Indonesia, 5136 people have been infected with COVID-19 with 469 deaths (9.1% case fatality rate) which places the country among those with high case fatality rates (as of 15 April 2020). Globally there are over 2 million confirmed corona virus positive cases.

In Indonesia, tobacco smoking is a leading common risk factor for NCDs that already are the major cause of high burden of diseases and untimely deaths. The link with NCDs and smoking is especially concerning because Indonesia has one of the highest smoking rates in the world with 63% of adult males smoking. The high smoking rates exacerbates the high incidence of NCDs. RISKESDAS 2018 shows that the top causes of death in Indonesia are cancer, stroke, chronic kidney disease, diabetes and hypertension (all NCDs).

The report of the WHO China Joint Mission on COVID-19 similarly showed a higher fatality rate for patients with NCDs. Italy's National Institute of Health reported that 99% of those who died had pre-existing NCDs such as cardiovascular diseases, diabetes, hypertension, chronic respiratory disease, and cancer. In addition, early evidence is showing the increased risk of serious outcomes of COVID-19 in people with tuberculosis (TB) - both active disease and latent TB.

A study published in The Lancet showed that smokers in China were fourteen times more likely to be infected with corona virus and experience worse outcomes compared to non-smokers. Another study in China documented that 58% of people with COVID-19 who were critically ill were men. "It is theorised that this may be due to the fact that smoking prevalence among men in China is much higher than among women. In a study published by New England Journal of Medicine, smokers were 2.4 times more likely to have severe symptoms from COVID-19 compared to those who did not smoke. All the studies suggest that tobacco use is associated with a poor prognosis of COVID-19 and more serious results, including admission to intensive care units, use of mechanical ventilation and death" reads this letter to the Indonesian president.

According to Ministry of Health and Family Welfare, Government of India, “86% death cases [due to COVID-19] have exhibited comorbidity related to diabetes, chronic kidney issues, hypertension and heart related problems.” Tobacco use is a common risk factor for these comorbidities. Also, Indian data shows that 76% of those confirmed to be infected with corona virus, were males, and 73% of deaths due to COVID-19, were among males. Tobacco use among males in India is higher than females: 42.4% men and 14.2% of women consume tobacco in India.

Tobacco industry spreading lies even during a pandemic

"Shockingly the tobacco industry is spreading misinformation – through blog-posts and social media – and denying the link between smoking and COVID-19. The industry is capitalizing on the crisis to improve its public relations by offering donations and partnerships to governments under the disguise of corporate social responsibility. At the same time, tobacco companies continue to aggressively market their products which has aggravated the COVID-19 crisis" reads this appeal to the President of Indonesia.

This appeal letter underlines that "health of the people should be of highest concern." But for the tobacco industry, it has always been the profits that matter.

The appeal to the President of Indonesia, strongly recommends some of the following actions:

- Amplify messages that tobacco and vaping are a risk for COVID-19 and quitting tobacco smoking and vaping can help lower the risk of serious COVID-19 symptoms, reduce the risk of transmission and support the immune system.

- Ensure that smoking status is recorded in all data.

- Ensure an uninterrupted supply of medicines and healthcare services to people with chronic diseases such as hypertension, heart diseases, diabetes and TB.

- Activate a national tobacco quitline and ensure that it is fully staffed for counselling and assisting in tobacco cessation which is greatly needed at this time.

- Immediately enforce a ban on sale, rent and use of waterpipes, shisha, electronic cigarettes, heated tobacco products (such as IQOS) and chewing tobacco.

- Ensure education and public communication on health effects of tobacco use and vaping, unhealthy diet, alcohol, lack of physical activity, and mental health issues.

- Strengthen the implementation and enforcement of tobacco control policies, including 100% tobacco-free public places, workplaces and public transportation. Complete tobacco free environments are the only proven way to protect people from secondhand smoke exposure, which is linked to respiratory and cardiovascular conditions and increased vulnerability to serious COVID-19 symptoms and mortality.

- Ban all types of tobacco advertising and promotion, including on internet, to protect youth, students and children from being exposed to tobacco advertising during #StayAtHome and home-based learning.

- Prohibit tobacco industry donations and partnerships and reject pseudo-science funded by the tobacco industry and its allies, and prohibit the sale of tobacco products and vape during the COVID-19 pandemic.

- Immediately ratify the WHO FCTC (global tobacco treaty) and fully implement and enforce the WHO MPOWER measures (such as, raising taxes and prices of tobacco products to protect public health, especially the younger generation).

Some of the prominent organizations among forty two who have endorsed the appeal to the Indonesian President include: Pimpinan Pusat Muhammadiyah (Dr Agus Taufiqurrahman); Majelis Pembina Kesehatan Umum PP Muhammadiyah - MPKU (Dr S Mohammad Agus Samsudin); Ketua Perhimpunan Dokter Paru Indonesia (Dr Agus Dwi Susanto); Perhimpunan Dokter Spesialis Kardiovaskular Indonesia - PERKI (Dr Usman Firdaus); Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia - PAPDI (Dr Sally A Nasution); Pengurus Pusat Ikatan Dokter Anak Indonesia IDAI (Dr Aman B Pulungan); Tim Penanganan COVID-19 RS Persahabatan (Dr Erlina Burhan); Ketua Umum Ikatan Ahli Kesehatan Masyarakat JAKMI (Dr Ede Surya Darmawan); Forum Petani Multikultur Indonesia; No Tobacco Community - NOTC Bogor (Bambang Priyono); among others.

(Bobby Ramakant is a WHO Director General’s WNTD awardee and part of CNS and APCAT Media (Asia Pacific regional media network to end TB & tobacco and prevent NCDs. Follow him on Twitter @bobbyramakant, or visit www.citizen-news.org)

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