Impact of Indonesian subnational smoke-free policies on cardiovascular health outcomes: evidence from national health insurance (2019-2021).

Objective: Adoption of smoke-free policies (SFPs) in public venues, workplaces and other settings may prevent chronic smoking-related diseases, such as cardiovascular diseases (CVDs) and respiratory illnesses. However, evidence on the impact of SFPs from cohort data in low- and middle-income countries remains limited. We assessed the association between SFP policy adoption at subnational levels in Indonesia and CVD burden.

Methods: Data on 244 602 adults were derived from the data claim sample from the Indonesian national health insurance between 2019 and 2021. We assessed the impacts of district and province-level SFPs on CVD mortality and morbidity using multilevel Poisson regression, with results expressed as relative risk (RR). The analyses controlled for sociodemographic and district-level characteristics.

Results: The risk of CVD-related mortality was lower in provinces with strong SFP (RR: 0.83; 95% CI 0.70 to 0.98) and in districts adopting moderate-strength SFP (RR: 0.89; 95% CI 0.81 to 0.98), both compared with jurisdictions without SFPs. Lower risk of CVD-related morbidity was observed in provinces with strong SFP compared with those without SFP (RR: 0.88; 95% CI 0.79 to 0.98). Both moderate-strength and strong SFPs at district level were not significantly associated with CVD morbidity risk.

Conclusion: SFP adoption at both the province and district levels was associated with reduced CVD burden. However, inconsistencies in impact, particularly at the district level, highlight potential challenges in the implementation and enforcement of these policies. Despite these challenges, these findings suggest the potential for tobacco control strategies implemented at a subnational level to reduce population harm, when implemented in settings with decentralised health systems.