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.

Keywords: Global health; Low/Middle income country; Public policy; Secondhand smoke; Smoking Caused Disease.

© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.

目标： 在公共场所、工作场所及其他环境中采纳无烟政策（SFPs）可以预防与吸烟相关的慢性疾病，如心血管疾病（CVD）和呼吸系统疾病。然而，在低收入和中等收入国家中，有关这些政策影响的队列数据证据仍然有限。我们评估了印度尼西亚地方层面采纳无烟政策与心血管疾病负担之间的关联。

方法： 本研究的数据来自2019年至2021年期间印度尼西亚国家健康保险索赔样本中的244602名成年人。我们使用多级泊松回归分析了省级和市级无烟政策对心血管疾病死亡率和发病率的影响，结果以相对风险（RR）表示。分析中考虑了社会人口统计学特征及区县层面的特性。

结果： 在有强力度SFP的省份，与未实施SFP的地区相比，心血管疾病相关的死亡率较低（RR: 0.83；95% CI 0.70至0.98）。在采纳中等强度SFP的区县，心血管疾病相关死亡风险也比没有SFP的地区低（RR: 0.89；95% CI 0.81至0.98）。与没有SFP的省份相比，在有强力度SFP的省份观察到了较低的心血管疾病相关的发病率（RR：0.88；95％CI为0.79至0.98）。区县层面中等强度和强力度无烟政策均未显著影响心血管疾病患病风险。

结论： 省级与市级采纳SFP与降低心血管疾病负担有关。然而，特别是在县级层面上的影响不一致，表明在这些政策的实施和执行方面可能存在挑战。尽管存在这些挑战，但研究结果表明，在具有分散化卫生系统的背景下，在地方层面实施烟草控制策略有可能减少人群的危害。

关键词： 全球健康；低收入/中等收入国家；公共政策；二手烟；吸烟相关疾病。