BACKGROUND: The adoption of smoke-free policies (SFPs) in public spaces, workplaces, and other settings has the potential to mitigate the prevalence of chronic smoking-related conditions, including cardiovascular diseases (CVD) and respiratory illnesses. However, there is a limited body of evidence on the impact of SFPs derived from cohort data in low- and middle-income countries (LMICs). This study evaluates the relationship between sub-national adoption of SFPs in Indonesia and the burden of CVD.
METHODS: This study analyzed data from 244.602 adults obtained from the claims database of Indonesia's national health insurance program (Jaminan Kesehatan Nasional or JKN) covering the period 2019–2021. Local smoke-free policies (SFPs) were compiled via official policy documents available in the Jaringan Dokumentasi Informasi dan Hukum (JDIH) database, a government-operated repository managed at the district and provincial levels. The impacts of district- and province-level SFPs on CVD morbidity and mortality were examined using multilevel poisson regression models, with results expressed as relative risks (RR). The analyses accounted for socio-demographic factors and district-level characteristics to ensure robustness.
RESULTS: The risk of CVD-related mortality was lower in provinces with strong SFP (RR: 0.83; 95% CI: 0.70-0.98) and in districts adopting moderate-strength SFP (RR: 0.89; 95% CI: 0.81-0.98), both compared to jurisdictions without SFPs. Lower risk of CVD-related morbidity was observed in provinces with strong SFP compared to those without SFP (RR: 0.88; 95% CI: 0.79-0.98). Both moderate-strength and strong SFPs at district level were not significantly associated with CVD morbidity risk.
CONCLUSIONS: The SFP adoption at both the provincial and district levels was associated with a reduction in the CVD burden. However, variations in the observed associations, particularly at the district level, highlight potential challenges related to the implementation and enforcement of these policies. Nevertheless, these findings highlight the potential of sub-national tobacco control strategies to mitigate population-level health burdens, especially in the context of decentralized health systems.