Tobacco smoking has rarely been mentioned among the challenges identified in tuberculosis (TB) control. The adverse association between smoking and TB is largely overlooked by clinicians treating TB [1]. In a large epidemiological study, 50 % of deaths from TB among Indian men was attributed to smoking [2]. A South Korean study demonstrated that current cigarette smokers had a 40 % increased risk of incident TB and were 55 % more likely to die of TB as compared with nonsmokers [3]. World Health Organization (WHO) reported that more than 20 % of global TB incidence may be attributable to smoking [4]. WHO and the International Union Against Tuberculosis and Lung Disease (The Union) published a Monograph on TB and Tobacco Control examining the associations between active and passive smoking and various TB outcomes including infection, occurrences of the disease, mortality, treatment outcomes and relapse after treatment [5].

The Union’s Lung Health Scientific Section established a working group on smoking cessation in TB patients in December 2009 at the World Lung Conference (WLC) in Cancun, Mexico to pilot a simple cost-effective approach that integrated TB and tobacco control measures within the existing health services. The working group consisted of governmental and non-governmental organisations from Bangladesh, Bhutan, Benin, Brazil, India, China, Indonesia, Nepal, South Africa, Pakistan, and Japan, Union members from different regions and countries, and staff of WHO [6]. This group’s efforts led to the development of the ABC (A=ask, B=brief advice, C=cessation support) approach outlined in The Union’s guide Smoking Cessation and Smokefree Environments for Tuberculosis Patients published in 2010 [7]. The ABC approach was piloted within the regular Directly Observed Treatment Short Course (DOTS) system in Bangladesh, Benin, Brazil, China, India, Indonesia, Mongolia, and South Africa.

We assessed the implementation and effectiveness of the ABC smoking cessation approach for TB patients and the establishment of smokefree environments in health care facilities and the TB patients’ homes in Indonesia. We report the findings of this assessment.

This was a cohort study assessing a field based intervention.

Establishing 100 % tobacco-free health care facilities

We obtained written commitment from the Director of the City Health Office and the Head of each participating health centre to create tobacco-free services. Tobacco-free was defined as the absence of tobacco advertisement, promotion and sponsorship, the absence of any indoor or outdoor active smoking in the health facility, and the display of “No smoking” signage at the main entrance of the facility and removal of smoking-related accessories and items, such as ashtrays, smoking areas and cigarette butts. A total of 80 health facilities (including 17 DOTS health centres) participated in the tobacco-free initiative. An ABC orientation programme was conducted for all health staff at the health centres. Compliance of the 80 health facilities with their tobacco-free health care policy was assessed twice a year by the City Health Office and No Tobacco Community (civil society based in Bogor) using a standard checklist (Fig. 1). Assessment was usually conducted during the busiest hours.

Data were analysed using SPSS version 13.0 (Statistical Package for the Social Sciences Inc. Chicago, IL, USA). Differences in frequency distributions were evaluated by the chi square test with p<0.05 as statistically significant. Odds ratio (OR) and 95 % confidence intervals (CI) were estimated using univariable and multivariable binary logistic regression analysis.

The ABC smoking cessation intervention was effective for: i) creating 100 % tobacco-free health services, ii) promoting quitting smoking (66.8 %) and iii) establishing smokefree environments at home (86.1 %). The high quit rates in our study are probably due to several factors, such as: i) the enabling environments in a health system that offers 100 % tobacco-free health services; ii) routine screening for smoking and smokefree homes; iii) brief advice to quit smoking and to create smokefree homes; iv) cessation support with additional information on the danger of tobacco smoking and secondhand smoke, and v) regular reminders and encouragement of family members to quit smoking. A similar intervention piloted in Bangladesh and India also reported high quit rates of tobacco use (Bangladesh 82 % and India 67.3 %). These studies identified brief advice through regular DOTS services as an effective intervention to promote quitting tobacco use [11, 12]. Guidelines for implementation of article 14 of the WHO Framework Convention on Tobacco Control recommend brief advice to stop using tobacco, usually taking only a few minutes, given to all tobacco users, usually during the course of a routine consultation or interaction [13].

Smoke-free environments encourage people to quit smoking and reduce the likelihood of exposure to secondhand smoke. Our study demonstrates that a smokefree environment at home is strongly associated with quitters, indicating that banning smoking inside the home might be a highly motivating act that convinces smokers to quit smoking and quitters to remain quitters. No smoking signage was used to conveying the message to family members and visitors to the home that smoking is prohibited. Therefore, our study suggests that smoking cessation counselling together with providing tobacco-free environments both at the health care facility and at home may produce a large public health impact.

Published evidence suggests that exposure to secondhand smoke increases the risk of developing a range of illnesses including lung cancer, heart disease, stroke, respiratory illness, sudden infant death syndrome (SIDS), ear infection, and severe asthma in children, pneumonia, and low birth weight [14]. We found 76.6 % (98/128) of the never smokers with TB were exposed to secondhand smoke at home at baseline, indicating that scaling up the creation of smokefree environments at home may contribute to TB control because exposure to respirable pollutants due to the combustion of tobacco increases the risk of both TB infection and TB disease [15].

Most research identified that tobacco smoking increases the risk of developing TB, delay in TB diagnosis, worse treatment outcomes and relapse [5, 16]. Smokers who quit reduce both their risk of becoming infected with TB and their risk of dying from it. One study showed TB mortality dropping by almost two-thirds for quitters, compared to those who continued to smoke, and the risk for quitters almost returned to the level of those who had never smoked [17].Thus, prompt identification of smoking behaviour and smoking cessation are critical for improving TB treatment and reducing transmission of TB.

Our study has several strengths. Smokefree environments in all public places and work places have been established in Bogor city since 2010. The involvement of local health staff right from the beginning of the intervention has helped to sustain the smoking cessation care and tobacco-free environments in primary health services. All health centres were located in the community, so it was straightforward for health staff to conduct random inspections in patients’ homes and to have informal interactions with patients to monitor progress. The study does, however, have some possible limitations. The outcomes of the intervention were largely evaluated on the basis of self-reporting. There might be a bias in the responses of the patients, in that they might have said what they thought the health worker would want to hear, thus overestimating the effect of the intervention. However, we have validated the status of the patients’ smoking and of their smokefree home with a family member at month six. Issues of time constraints and high workload were raised at the initial training by the health staff before the intervention; however, health care workers reported neither high workloads nor time constraints during the review meeting at month two, five and six.

Our study has demonstrated the effectiveness of the ‘ABC’ smoking cessation intervention, which was delivered in just 5 to 10 minutes by health staff as a part of existing DOTS services. The intervention resulted in high quit rates and higher awareness of the adverse health effects of secondhand smoke, which led patients to make smoke-free homes and health providers to make tobacco-free health care. The study also proved that ABC is feasible in DOTS services and primary health care in Indonesia. We believe that ABC can and should be generalised to other services and levels of care in Indonesia. It can be integrated into general primary health care services to enhance the impact of public health programmes, through implementing effective measures of tobacco control such as smoke-free environments, banning tobacco advertising, promotion and sponsorship and offering help to quit tobacco use.