High prevalence of smoking among patients with suspected tuberculosis in South Africa

Markers of pulmonary TB in care-seeking patients with respiratory symptoms

SETTING

To appropriately triage and evaluate people with signs or symptoms of pulmonary TB, clinical, laboratory, and radiological variables, as well as biomarkers, have been prioritised to increase early detection. However, in high TB prevalence areas, few studies used standardised tools to assess both sociodemographic characteristics and accessible biomarkers comprehensively. This study aimed to describe the sociodemographic, radiographic, clinical, and laboratory characteristics associated with pulmonary TB (PTB) in patients with presumed pulmonary TB (pPTB).

DESIGN

A cross-sectional study was conducted at a public health centre in Duque de Caxias, Brazil, involving patients with pPTB from September 2017 to February 2020. Participants were evaluated using standardised tools: Patient Health Questionnaire 9 (PHQ-9) and the Mini International Neuropsychiatric Interview (MINI) Plus for depression, the MINI-Mental State Examination for cognitive functions, and the ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) questionnaire for substance use. Chest radiographs (CXRs) and blood tests were also performed. Logistic regression was used to identify associations between sociodemographic, radiographic and biological variables with PTB.

RESULTS

Of 315 patients, 149 (47%) were diagnosed with PTB. Factors associated with PTB included the presence of cavitation on CXR (OR 13.7, 95% CI 5.93-34.5; P < 0.001), high alkaline phosphatase levels (OR 3.89; 95% CI 1.68-9.47; P = 0.002), and C-reactive protein above 10 mg/L (OR 5.60, 95% CI 2.23-14.7; P < 0.001). Major depression disorder (OR 0.33, 95% CI 0.11-0.91; P = 0.036) suggested a protective association with PTB.

CONCLUSION

CXR findings and easy-to-perform blood tests can aid in PTB diagnosis, potentially reducing the time to treatment when microbiological or molecular tests cannot be performed.

Smoking cessation to prevent death and tuberculosis recurrence after treatment: A prospective cohort study with a seven-year follow-up in China

Background

Although there is consistent evidence that smoking is a risk factor associated with tuberculosis (TB), whether smoking cessation improves treatment outcomes and reduces the risk of TB recurrence remains understudied.

Methods

We conducted a prospective cohort study with a seven-year follow-up in China. We recruited newly-diagnosed TB patients and classified them as non-smokers, ex-smokers, and current smokers. Current smokers were invited to participate in a smoking cessation intervention programme. We used a Cox proportional hazards model to assess the risk of death among TB patients and the risk of recurrence among successfully treated patients.

Results

In total, 634 (79.2%) patients completed anti-TB treatments and 115 (14.4%) patients died. We confirmed the existence of a dose-response relationship between smoking frequency and the risk of TB recurrence (the slope of the fitted line >0; P < 0.05). Compared to those who continued smoking, the risk of death and recurrent TB for the patients who quit smoking during treatment decreased. The HR of mortality for smokers who smoked 30 or more cigarettes was 2.943 (95% confidence interval (CI) = 1.035-8.368), while the HR of mortality for those who smoked 30 or more cigarettes, but quit during treatment was 2.117 (95% CI = 1.157-3.871). However, the risk of recurrence remained high for ex-smokers who had a smoking history of 25 years or more.

Conclusions

Our study provides further evidence supporting the World Health Organization's call for co-management of smoking and other risk factors as part of routine TB treatment.

Tobacco Use Behaviors and Associated Factors among Newly Diagnosed Tuberculosis Patients in Benin and Burkina Faso

The objective of this study was to assess tobacco use (TU) behaviors among newly diagnosed pulmonary TB (PTB) patients and identify associated factors in Benin and Burkina Faso. A cross-sectional study was conducted in 20 randomly selected TB clinics. To ensure a representative study cohort, clinics were stratified during the sampling process. PTB patients were consecutively sampled in 20 of the clinics between 1 December 2021 and 30 September 2022. The study population comprised individuals aged 15 years and above who were newly diagnosed with PTB. Among the 1399 registered PTB patients, 564 (40.3%) reported a history of TU, including 392 (28.0%) current tobacco users and 172 ex-tobacco users. Cigarettes emerged as the predominant form of TU (86.2%), followed by smokeless tobacco (6.4%), and chicha smoking (2.6%). Factors independently associated with tobacco use were male gender (p < 0.001), being in Burkina Faso (p < 0.001), and an age of 25-59 years (p = 0.002). Our multicentric study reveals a substantial prevalence of tobacco use among TB patients, with cigarette smoking emerging as the predominant form. These findings underscore the imperative for implementing targeted cessation interventions within TB control programs. Special emphasis is warranted for male patients aged 25-59 years.

Pulmonary tuberculosis and multidrug-resistant Mycobacterium tuberculosis in northwestern Ethiopia: a hospital-based cross-sectional study among presumptive pulmonary tuberculosis patients

Introduction

Border areas are important sites for disseminating Mycobacterium tuberculosis among individuals living in such areas. This study examined patients with suspected pulmonary tuberculosis (PTB) visiting the Abrihajira and Metema hospitals in northwest Ethiopia to investigate the prevalence of rifampicin-resistant Mycobacterium tuberculosis (RR-MTB), multidrug-resistant Mycobacterium tuberculosis (MDR-MTB), and risk factors related to Mycobacterium tuberculosis infection.

Methods

A hospital-based cross-sectional study was conducted from February to August 2021 among 314 PTB presumptive patients. Xpert MTB/RIF and line probe assays (LPA) were used to process sputum samples. Data were imported into the Epi-Data 3.1 program and exported to Statistical Package for the Social Sciences (SPSS) version 20.0 (SPSS, Chicago, IL, United States) to conduct the analysis. A logistic regression analysis was used to investigate the relationship between the dependent and independent variables. A value of p of <0.05 denoted statistical significance.

Results

Of the total (314) PTB presumptive patients who participated in this study, 178 (56.69%) were men, and 165 (52.5%) were from 25 to 50 years of age with a median age of 35.00 (inter-quartile: 25-45 years). Among all patients, 12.7% had PTB by Gene Xpert and 7/314 (2.23%) were resistant to rifampicin. Among patients enrolled, 4/314 (1.27%) had MDR-MTB (resistant to RIF and INH) by LPA. Regarding the risk factors assessed, primary level of education, sputum production, night sweating, respiratory disorder, contact history of TB, history of MDR-MTB infection, history of alcohol use, and cigarette smoking showed statistical significance with the prevalence of PTB (p ≤ 0.05).

Discussion

This study observed a high prevalence of PTB, RR-MTB, and MDR-MTB compared with many other previous studies conducted in Ethiopia. Among the assessed risk factors that could be associated with the prevalence of PTB, eight were statistically significant. This prevalence, resistance, and statistically significant variables are the evidence to which more emphasis should be given to the country's border areas.

Cigarette smoking is associated with an increase in blood monocytes in people with tuberculosis: A cross-sectional study

The effect of smoking on immune responses in people with tuberculosis (TB) is not well elucidated. We aimed to compare peripheral blood counts of CD4+ and CD87 + T-lymphocytes, monocytes, and neutrophils and the CD4:CD8 ratio in TB patients with and without history of cigarette smoking. We further determined factors associated with current smoking. Participants with TB were consecutively enrolled in a cross-sectional study at a national TB treatment center in Uganda in 2018. We compared cell counts and the CD4:CD8 ratio using the median test among never smokers, past smokers (>6 months ago) and current smokers (≤6 months). Factors associated with current smoking were determined using logistic regression. A post hoc analysis for factors associated with an increase in the monocytes was also performed. Of 363 participants, there were 258 (71.1%) never smokers, 50 (13.8%) past smokers, and 55 (15.2%) current smokers. Most current smokers (49.1%) had a high sputum mycobacterial load. They also had the lowest body mass index and the highest axillary temperature. The median (interquartile range [IQR]) monocyte count among current smokers was 815 (540-1425) cells/mm3 and was significantly higher than that among past smokers (610 (350-900) cells/mm3, P = .017) and never smokers (560 [400-800] cells/mm3, P = .001). The monocyte counts positively correlated with the number of cigarettes smoked per day among current smokers (R = 0.43, P = .006). Current smokers also had higher neutrophil and CD4+ T-cell counts than never smokers. In a multivariable logistic regression model, an increase in the monocyte count was associated with current cigarette smoking (adjusted odds ratio [aOR] = 4.82, 95% confidence interval 1.61-14.39, P = .005). Similarly, current cigarette smoking was independently associated with an increase in the monocyte count (aOR = 1.80, 95% CI 1.39-2.32, P < .001). Cigarette smoking is associated with an increase in the blood monocytes in people with TB in a dose- and time-dependent manner. Further, current smoking is associated with an increase in neutrophils and CD4+ T-lymphocytes. The findings suggest that current smokers have systemic inflammation that is not necessarily beneficial to TB control in TB patients.

Prevalence of modifiable risk factors of tuberculosis and their population attributable fraction in Iran: A cross-sectional study

BACKGROUND

The mycobacterium tuberculosis (Mtb) is necessary for the morbidity of tuberculosis (TB), but it is insufficient. Many risk factors increase the risk of disease among infected people. We aimed to estimate the prevalence of modifiable risk factors of TB and their related population attributable fraction (PAF) in the marginal population of Markazi province in Iran.

DESIGN

In this cross-sectional study, the prevalence of the modifiable risk factors of TB was estimated. We designed and validated a questionnaire to determine the risk factors. The measures of association for the modifiable risk factors of TB were obtained via the review of published literature. We calculated the PAF for each modifiable risk factor.

RESULTS

Out of the 1275 calculated sample size, 1146 people participated in this study, and the participation rate was 89.9%. The mean age was 39.26. Out of 1146 participants, 76% did not know anything regarding TB. The highest prevalence was related to the lack of physical activity (58.73%), lack of fish consumption (50.79%), lack of red meat consumption (21.20%), and secondhand smoke (19.02%). The highest PAF was related to secondhand smoke; this value based on the crude relative risk (RR) and crude odds ratio (OR) was 24.54% and 23.44%, respectively. Based on crude hazard ratio (HR) and crude OR, the PAF for smoking was 14.81% and 11.19%, respectively. PAF for lack of BCG vaccination based on the crude OR was 14.79%.

CONCLUSION

Based on this study's results, poor nutrition, secondhand smoke, smoking, lack of BCG vaccination, and diabetes are the main prevalent modifiable risk factors for TB. The highest PAF for TB was related to secondhand smoke, smoking, lack of BCG vaccination, and diabetes.

Efficacy of smoking cessation intervention delivered through mobile tele-counseling among smokers with tuberculosis in a Revised National Tuberculosis Control Program

BACKGROUND

India has high burden of tuberculosis and smokers. Prevalence of tuberculosis is three times higher in smokers than non-smokers. Active smoking causes severe disease, delay in seeking treatment, lost to treatment follow up, delayed sputum conversion and drug resistance. WHO advocates mobile phone technology to improve health outcomes (mHealth). We used mobile tele-counseling as a smoking cessation intervention in smokers with tuberculosis (TB) receiving treatment under tuberculosis control program.

AIM

To determine smoking quit rate at six months of TB treatment among smokers receiving mobile tele-counseling versus brief advice and to estimate smoking quit rates and relapse rates during the tele-counseling period.

METHODS

Open label randomized controlled trial. Newly detected pulmonary tuberculosis or pleural effusion patients received brief advice on smoking cessation as per The UNION's guiding framework. Subjects were then randomly allocated to intervention or control group. Intervention group was contacted telephonically at 2,3,4,5 and 6 months to assess smoking quit rates and provide continued smoking cessation advice.

RESULTS

Intervention group had 80 and 82 in the control group, mean (SD) age was 40.6(12.6), 43.5(12.7) p = 0.53. Quit rate at six months was 54 (67.5%) in intervention group versus 34 (42%) in control group; RR 1.60 (95% CI 1.19, 2.16) p = 0.001. Trend in smoking quit rates in intervention group was 81.3%, 61.3%, 55%, 73.8% at 2,3,4 and 5 months respectively. Smoking relapse rate was 43.1%, 53.1%, 20.5%,15.3% at 3,4,5 and 6 months respectively. 27.5%, 43.8% were abstinent for last three, two months.

CONCLUSIONS

Mobile tele-counseling is an effective strategy for smoking cessation among TB patients.

Prevalence and socio-structural determinants of tobacco exposure in young women: Data from the Healthy Trajectories Initiative (HeLTI) study in urban Soweto, South Africa

BACKGROUND

Tobacco use is a major public health risk worldwide, which has increased on the African continent over the past 40 years. Socio-economic factors impact tobacco use and exposure, but little is known about the scope of this problem in young women living in an urban, historically disadvantaged township in contemporary South Africa. This study aimed to identify the prevalence of tobacco use in a cohort of young South African women using serum cotinine, and to assess the association between a number of socio-economic and social factors and tobacco use in this setting.

METHODS

Secondary analysis was conducted on cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Serum cotinine was measured and a cut-off of ≥ 10 ng/mL was classified as tobacco use. Household socio-economic, socio-demographic and health information were collected by an interviewer-administered questionnaire.

RESULTS

Cotinine data was available for 1508 participants, of whom 29.2% (n = 441) had cotinine levels indicative of tobacco use. In regression analyses, moderate to severe socio-economic vulnerability (score 2-3 OR 1.66, p = 0.008; score ≥4: OR 1.63, p = 0.026) and multiparity (OR 1.74, p = 0.013) were associated with tobacco use. In addition, alcohol dependence (OR 3.07, p < 0.001) and drug use (OR 4.84, p < 0.001) were associated with tobacco use.

CONCLUSION

Young women with multiple children, moderate to severe socio-economic vulnerability, and alcohol and drug use were identified as more likely to use tobacco, indicating the need for targeted anti-tobacco interventions to curb the impact of tobacco on the growing burden of noncommunicable diseases in this setting.

A position statement and practical guide to the use of particulate filtering facepiece respirators (N95, FFP2, or equivalent) for South African health workers exposed to respiratory pathogens including Mycobacterium tuberculosis and SARS-CoV-2

SUMMARY

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is transmitted mainly by aerosol in particles <10 µm that can remain suspended for hours before being inhaled. Because particulate filtering facepiece respirators ('respirators'; e.g. N95 masks) are more effective than surgical masks against bio-aerosols, many international organisations now recommend that health workers (HWs) wear a respirator when caring for individuals who may have COVID-19. In South Africa (SA), however, surgical masks are still recommended for the routine care of individuals with possible or confirmed COVID-19, with respirators reserved for so-called aerosol-generating procedures. In contrast, SA guidelines do recommend respirators for routine care of individuals with possible or confirmed tuberculosis (TB), which is also transmitted via aerosol. In health facilities in SA, distinguishing between TB and COVID-19 is challenging without examination and investigation, both of which may expose HWs to potentially infectious individuals. Symptom-based triage has limited utility in defining risk. Indeed, significant proportions of individuals with COVID-19 and/or pulmonary TB may not have symptoms and/or test negative. The prevalence of undiagnosed respiratory disease is therefore likely significant in many general clinical areas (e.g. waiting areas). Moreover, a proportion of HWs are HIV-positive and are at increased risk of severe COVID-19 and death.

RECOMMENDATIONS

Sustained improvements in infection prevention and control (IPC) require reorganisation of systems to prioritise HW and patient safety. While this will take time, it is unacceptable to leave HWs exposed until such changes are made. We propose that the SA health system adopts a target of 'zero harm', aiming to eliminate transmission of respiratory pathogens to all individuals in every healthcare setting. Accordingly, we recommend: the use of respirators by all staff (clinical and non-clinical) during activities that involve contact or sharing air in indoor spaces with individuals who: (i) have not yet been clinically evaluated; or (ii) are thought or known to have TB and/or COVID-19 or other potentially harmful respiratory infections;the use of respirators that meet national and international manufacturing standards;evaluation of all respirators, at the least, by qualitative fit testing; andthe use of respirators as part of a 'package of care' in line with international IPC recommendations. We recognise that this will be challenging, not least due to global and national shortages of personal protective equipment (PPE). SA national policy around respiratory protective equipment enables a robust framework for manufacture and quality control and has been supported by local manufacturers and the Department of Trade, Industry and Competition. Respirator manufacturers should explore adaptations to improve comfort and reduce barriers to communication. Structural changes are needed urgently to improve the safety of health facilities: persistent advocacy and research around potential systems change remain essential.

Cigarette Smoke Exposure Promotes Virulence of Pseudomonas aeruginosa and Induces Resistance to Neutrophil Killing

It is widely known that cigarette smoke damages host defenses and increases susceptibility to bacterial infections. Pseudomonas aeruginosa, a Gram-negative bacterium that commonly colonizes the airways of smokers and patients with chronic lung disease, can cause pneumonia and sepsis and can trigger exacerbations of lung diseases. Pseudomonas aeruginosa colonizing airways is consistently exposed to inhaled cigarette smoke. Here, we investigated whether cigarette smoke alters the ability of this clinically significant microbe to bypass host defenses and cause invasive disease. We found that cigarette smoke extract (CSE) exposure enhances resistance to human neutrophil killing, but this increase in pathogenicity was not due to resistance to neutrophil extracellular traps. Instead, Pseudomonas aeruginosa exposed to CSE (CSE-PSA) had increased resistance to oxidative stress, which correlated with increased expression of tpx, a gene essential for defense against oxidative stress. In addition, exposure to CSE induced enhanced biofilm formation and resistance to the antibiotic levofloxacin. Finally, CSE-PSA had increased virulence in a model of pneumonia, with 0% of mice infected with CSE-PSA alive at day 6, while 28% of controls survived. Altogether, these data show that cigarette smoke alters the phenotype of P. aeruginosa, increasing virulence and making it less susceptible to killing by neutrophils and more capable of causing invasive disease. These findings provide further explanation of the refractory nature of respiratory illnesses in smokers and highlight cigarette smoking as a potential driver of virulence in this important airway pathogen.

The effect of the presence of children on adult smoking behaviour: empirical evidence based on China family panel studies

BACKGROUND

Despite a number of studies linking family and marriage factors with health behaviour, the effects of children on the health behaviour of parents are still understudied. This study explored the association between the presence of children and adults' smoking behaviours.

METHODS

This study used panel data from the China Family Panel Studies 2010 and 2012, and the data set included 23,157 households and 45,513 adults. Logistic regression was performed to analyse the association of the presence of children on adults' smoking behaviours. Subgroup regression was used to examine heterogeneous effects.

RESULTS

Full sample regressions showed that the number of children was significantly inversely associated with smoking behaviour (OR = 0.93; 95% 0.90-0.96). Further subsample regression finds that such effect is only significant among the high-education group (OR = 0.92; 95% 0.87-0.97), high-skill workers (OR = 0.89; 95% 0.80-0.99) and couples who had an age gap greater than 2 years (OR = 0.91; 95% 0.88-0.95).

CONCLUSIONS

Our findings confirm the existence of the upward intergenerational effect of the presence of children on adults' smoking behaviour in China. However, such effects are not equal across all demographic characteristics. Future research could explore other parts of the upward mechanism and possible pathways for a stronger effect. In resource-poor areas, targeting cessation activities at those who have children at an early age may be an effective strategy.

Effect of smoking on tuberculosis treatment outcomes: A systematic review and meta-analysis

INTRODUCTION

Numerous studies have explored an effect of cigarette smoking on tuberculosis treatment outcomes but with dissimilar conclusions.

OBJECTIVE

To determine the effect of cigarette smoking on tuberculosis treatment outcomes.

METHODS

PubMed, Cochrane library and Google scholar databases were searched last on February 27, 2019. We applied the random-effects model for the analysis. Publication bias was assessed using funnel plot and Egger's regression. Furthermore, we performed Orwin's Fail-Safe N and cumulative meta-analysis to check for small studies' effect.

RESULTS

Out of 22 studies we included in the qualitative synthesis, 12 studies reported p-values less than 0.05 where smoking significantly favored poor treatment outcomes. The remaining 10 studies reported p-values larger than 0.05 implying that smoking does not affect the treatment outcomes. Twenty studies met the criteria for inclusion in a meta-analysis. The meta-analysis found that smoking significantly increased the likelihood of poor tuberculosis treatment outcomes by 51% (OR = 1.51; 95% CI = 1.30 to 1.75 and I-square = 75.1%). In a sub-group analysis, the effect was higher for low- and middle-income countries (OR = 1.74; 95% CI = 1.31 to 2.30) and upper-middle-income economies (OR = 1.52; 95% CI = 1.16 to 1.98) than for high-income ones (OR = 1.34; 95% CI = 1.03 to 1.75) even though the differences in the effects among the strata were not statistically significant as demonstrated by overlapping of confidence intervals of the effects. Meta-regression analysis, adjusted for income economies, found the effect of smoking has not significantly improved over the years (p = 0.92) and thus implying neither of the covariates were source of the heterogeneity. Egger's regression test indicated that publication bias is unlikely (p = 0.403).

CONCLUSION

Cigarette smoking is significantly linked with poor tuberculosis treatment outcomes.

Epidemiological, Mycobacteriological, and Clinical Characteristics of Smoking Pulmonary Tuberculosis Patients, in Lambaréné, Gabon: A Cross-Sectional Study

Gabon carries a high burden of both tuberculosis (TB) and smoking. This study examines the disease characteristics of smoking pulmonary TB patients in Lambaréné. We interviewed adult pulmonary TB patients in Lambaréné, between March 2016 and April 2019. Clinical and biological patient characteristics were collected. Bivariate and logistic regression analyses were performed to assess factors associated with smoking. The mean age of patients included was 31 years (±13). The proportion of smokers in our study was 30% (89/295). Smoking was significantly associated with patient-related diagnostic delay (adjusted odds ratio [AOR] = 8.18; 95% CI = 3.67-19.56), a higher number of pulmonary TB signs and symptoms (AOR = 2.74; 95% CI = 1.18-6.73), and a higher sputum mycobacterial load (AOR = 3.18; 95% CI = 1.33-8.11). The prevalence of smoking among TB patients is high, and leading to aggravated disease as compared with controls. Our study findings suggest that smoking patients should be regularly screened for TB, to reduce diagnostic delay and TB transmission within community. Smoking cessation activities should be included in the national TB control program in Gabon.

The Role of Thiocyanate in Modulating Myeloperoxidase Activity during Disease

Thiocyanate (SCN⁻) is a pseudohalide anion omnipresent across mammals and is particularly concentrated in secretions within the oral cavity, digestive tract and airway. Thiocyanate can outcompete chlorine anions and other halides (F⁻, Br⁻, I⁻) as substrates for myeloperoxidase by undergoing two-electron oxidation with hydrogen peroxide. This forms their respective hypohalous acids (HOX where X⁻ = halides) and in the case of thiocyanate, hypothiocyanous acid (HOSCN), which is also a bactericidal oxidative species involved in the regulation of commensal and pathogenic microflora. Disease may dysregulate redox processes and cause imbalances in the oxidative profile, where typically favoured oxidative species, such as hypochlorous acid (HOCl), result in an overabundance of chlorinated protein residues. As such, the pharmacological capacity of thiocyanate has been recently investigated for its ability to modulate myeloperoxidase activity for HOSCN, a less potent species relative to HOCl, although outcomes vary significantly across different disease models. To date, most studies have focused on therapeutic effects in respiratory and cardiovascular animal models. However, we note other conditions such as rheumatic arthritis where SCN⁻ administration may worsen patient outcomes. Here, we discuss the pathophysiological role of SCN⁻ in diseases where MPO is implicated.

Smoking prevalence among tuberculosis patients: A crosssectional study in Bangladesh and Pakistan

INTRODUCTION

Smoking has a negative impact on TB outcomes. We estimated the proportion of TB patients who smoke and are willing to quit in two high TB burden countries, Bangladesh and Pakistan.

METHODS

A cross-sectional survey was conducted among TB patients to assess their eligibility and recruit them to a smoking cessation randomized controlled trial. Adults diagnosed with TB were recruited from 32 health facilities in Bangladesh and Pakistan. Data on smoking behaviour and willingness to quit were collected and analysed.

RESULTS

In total, 13934 TB patients completed the survey between June 2017 and April 2018. The prevalence of smoking in these TB patients was estimated to be 22.5% (95% CI: 21.8, 23.2). Moreover, the prevalence of smoking in TB patient population was 8% (RR=1.49; 95% CI: 7.1–8.9; p<0.01) and 8.3% (RR=1.24; 95% CI: 7.3–9.4; p<0.01) higher than smoking prevalence in the general population in Bangladesh and Pakistan, respectively. Among TB patients who smoke, 97.7% (95% CI: 97.2–98.2) were willing to quit.

CONCLUSIONS

The estimated prevalence of smoking was higher in TB patients than the general population; however, a vast majority of TB patients who smoke were willing to quit.

A narrative review of facilitators and barriers to smoking cessation and tobacco-dependence treatment in patients with tuberculosis in low- and middle-income countries

INTRODUCTION

Smoking is a substantial cause of premature death in patients with tuberculosis (TB), particularly in low- and middle-income countries (LMICs) with high TB prevalence. The importance of incorporating smoking cessation and tobacco-dependence treatment (TDT) into TB care is highlighted in the most recent TB care guidelines. Our objective is to identify the likely key facilitators of and barriers to smoking cessation for patients with TB in LMICs.

METHODS

A systematic search of studies with English-language abstracts published between January 2000 and May 2019 was undertaken in the EMBASE, MEDLINE, EBSCO, ProQuest, Cochrane and Web of Science databases. Data extraction was followed by study-quality assessment and a descriptive and narrative synthesis of findings.

RESULTS

Out of 267 potentially eligible articles, 36 satisfied the inclusion criteria. Methodological quality of non-randomized studies was variable; low risk of bias was assessed in most randomized controlled studies. Identified facilitators included brief, repeated interventions, personalized behavioural counselling, offer of pharmacotherapy, smoke-free homes and a reasonable awareness of smoking-associated risks. Barriers included craving for a cigarette, low level of education, unemployment, easy access to tobacco in the hospital setting, lack of knowledge about quit strategies, and limited space and privacy at the clinics. Findings show that the risk of smoking relapse could be reduced through consistent follow-up upon completion of TB therapy and receiving a disease-specific smoking cessation message.

CONCLUSIONS

Raising awareness of smoking-related health risks in patients with TB and implementing guideline-recommended standardized TDT within national TB programmes could increase smoking cessation rates in this high-risk population.

Outcomes of a smoking cessation intervention at follow-up after 5 years among tuberculosis patients in China

INTRODUCTION

Smoking cessation should be part of tuberculosis (TB) treatment, but a cessation service is not available as part of a routine TB service in most low- and middle-income countries. WHO and The International Union Against Tuberculosis and Lung Disease (The Union) issued a guideline and China implemented a pilot project 5 years ago. This study aimed to determine changes in smoking status among TB patients at 5 years after completion of anti-TB treatment to observe long-term outcome of a smoking cessation project whose baseline characteristics were associated with a relapse of smoking behavior.

METHODS

A prospective longitudinal study was conducted 5 years after completion of anti-TB treatment to assess changes in patient smoking status against individual baseline data that were entered into a database at the time of TB registration. The patients were tracked by trained village doctors and validated by township health staff. Their smoking status was assessed and entered into the database and analysed.

RESULTS

Of the 800 TB patients registered at baseline, 650 (81.2%) were tracked. Ninety-one (11.4%) patients died and 59 (7.4%) were lost to follow-up. The rates of remaining non-smoking after 5 years were 82.0%, 63.0%, 49.6%, 43.5% and 30.0%, respectively for non-smokers, ex-smokers, current smokers who received cessation intervention, recent quitters, and current smokers not on a cessation intervention. The odds of smoking relapse were significantly higher for those aged ≥65 years (p=0.003) and registered in Xingguo County (p=0.025).

CONCLUSIONS

Findings from this study confirmed that non-smokers, ex-smokers and current smokers who received cessation intervention at baseline maintained higher non-smoking rates compared with those who did not receive the intervention. To prevent relapse, intensive cessation support should be given to TB patients aged ≥65 years. TB programme managers need to ensure integration and provision of smoking cessation advice and smoke-free policy in routine TB services.

Management of hospitalized drug sensitive pulmonary tuberculosis patients during the Hajj mass gathering: A cross sectional study

Background

To document the management of drug-sensitive TB patients during the Hajj and assess compliance with the Saudi TB management guidelines.

Method

The study was conducted in hospitals in Makkah during the 2016 and 2017 Hajj seasons. Structured questionnaire was used to collect data on relevant indices on TB management and a scoring system was developed to assess compliance with guidelines.

Results

Data was collected from 31 TB cases, 65.4% (17/26) were Saudi residents. Sputum culture was the only diagnostic test applied in 67.7% (21/31) of patients. Most (96.8%, 30/31) confirmed TB cases were isolated, but only 12.9% (4/28) were tested for HIV and merely 37% (10/27) received the recommended four 1st-line anti-TB drugs. Guideline compliance scores were highest for infection prevention and control and surveillance (9.6/10) and identifying TB suspects (7.2/10). The least scores were obtained for treating TB (5.0/10) and diagnosing TB (3.0/10).

Conclusions

Healthcare providers training and supervision are paramount to improve their knowledge and skill and ensure their compliance with existing TB management guidelines. However, there may be a need for the introduction of an international policy/guideline for TB control and management during mass gatherings such as the Hajj to guide providers’ choices and facilitate monitoring.

Contribution of Smoking to Tuberculosis Incidence and Mortality in High-Tuberculosis-Burden Countries

Globally, 10 million incident cases of tuberculosis (TB) are reported annually, and 95% of TB cases and 80% of tobacco users reside in low- and middle-income countries. Smoking approximately doubles the risk of TB disease and TB mortality. We estimated the proportion of annual incident TB cases and TB mortality attributable to tobacco smoking in 32 high-TB-burden countries. We obtained country-specific estimates of TB incidence, TB mortality, and smoking prevalence from the World Health Organization Global TB Report (2017), tobacco surveillance reports (2015), and the Tobacco Atlas. Risk ratios for the effect of smoking on TB incidence and TB mortality were obtained from published meta-analyses. An estimated 17.6% (95% confidence interval (CI): 8.4, 21.4) of TB cases and 15.2% (95% CI: 1.8, 31.9) of TB mortality were attributable to smoking. Among high-TB-burden countries, Russia had the highest proportion of smoking-attributable TB disease (31.6%, 95% CI: 15.9, 37.6) and deaths (28.1%, 95% CI: 3.8, 51.4). Men had a greater proportion of TB cases attributable to smoking (30.3%, 95% CI: 14.7, 36.6) than did women (4.3, 95% CI: 1.7, 5.7). Our findings highlight the need for tobacco control in high-TB-burden countries to combat TB incidence and TB mortality.

High HIV and active tuberculosis prevalence and increased mortality risk in adults with symptoms of TB: a systematic review and meta-analyses

INTRODUCTION

HIV and tuberculosis (TB) remain leading causes of preventable death in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends HIV testing for all individuals with TB symptoms, but implementation has been suboptimal. We conducted a systematic literature review and meta-analyses to estimate HIV and TB prevalence, and short-term (two to six months) mortality, among adults with TB symptoms at community- and facility level.

METHODS

We searched Embase, Global Health and MEDLINE databases, and reviewed conference abstracts for studies reporting simultaneous HIV and TB screening of adults in LMICs published between January 2003 and December 2017. Meta-analyses were performed to estimate prevalence of HIV, undiagnosed TB and mortality risk at different health system levels.

RESULTS

Sixty-two studies including 260,792 symptomatic adults were identified, mostly from Africa and Asia. Median HIV prevalence was 19.2% (IQR: 8.3% to 40.4%) at community level, 55.7% (IQR: 20.9% to 71.2%) at primary care level and 80.7% (IQR: 73.8% to 84.6%) at hospital level. Median TB prevalence was 6.9% (IQR: 3.3% to 8.4%) at community, 20.5% (IQR: 11.7% to 46.4%) at primary care and 36.4% (IQR: 22.9% to 40.9%) at hospital level. Median short-term mortality was 22.6% (IQR: 15.6% to 27.7%) among inpatients, 3.1% (IQR: 1.2% to 4.2%) at primary care and 1.6% (95% CI: 0.45 to 4.13, n = 1 study) at community level.

CONCLUSIONS

Adults with TB symptoms have extremely high prevalence of HIV infection, even when identified through community surveys. TB prevalence and mortality increased substantially at primary care and inpatient level respectively. Strategies to expand symptom-based TB screening combined with HIV and TB testing for all symptomatic individuals should be of the highest priority for both disease programmes in LMICs with generalized HIV epidemics. Interventions to reduce short-term mortality are urgently needed.

Impact of smoking on sputum culture conversion and pulmonary tuberculosis treatment outcomes in Brazil: a retrospective cohort study

OBJECTIVE

To evaluate the impact of smoking on pulmonary tuberculosis (PTB) treatment outcomes and the two-month conversion rates for Mycobacterium tuberculosis sputum cultures among patients with culture-confirmed PTB in an area with a moderate incidence of tuberculosis in Brazil.

METHODS

This was a retrospective cohort study of PTB patients diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 2004 and 2012.

RESULTS

Of the 298 patients diagnosed with PTB during the study period, 174 were included in the outcome analysis: 97 (55.7%) were never-smokers, 31 (17.8%) were former smokers, and 46 (26.5%) were current smokers. Smoking was associated with a delay in sputum culture conversion at the end of the second month of TB treatment (relative risk = 3.58 &091;95% CI: 1.3-9.86&093;; p = 0.01), as well as with poor treatment outcomes (relative risk = 6.29 &091;95% CI: 1.57-25.21&093;; p = 0.009). The association between smoking and a positive culture in the second month of treatment was statistically significant among the current smokers (p = 0.027).

CONCLUSIONS

In our sample, the probability of a delay in sputum culture conversion was higher in current smokers than in never-smokers, as was the probability of a poor treatment outcome.

Indoor air pollution from secondhand tobacco smoke, solid fuels, and kerosene in homes with active tuberculosis disease in South Africa

Objectives

Secondhand tobacco smoke (SHS), use of solid fuels, and kerosene may play an important role in perpetuating the tuberculosis (TB) epidemic. The purpose of this study was to explore the prevalence of household air pollution (HAP) from these sources in homes of someone with TB in a high HIV-prevalence setting. A convenience sample of homes and household members participating in an ongoing active case-finding study in Matlosana district townships surrounding Klerksdorp, South Africa were included.

Results

We found a high prevalence of air pollution from SHS, solid fuels, and kerosene among individuals in homes with a case of prevalent active TB disease in Klerksdorp, South Africa. Adults in 40% of homes reported a daily smoker in the home, and 70% of homes had detectable air nicotine. In homes with a history of previous TB (prior to but not including the index case) as compared to those without previous TB, both SHS (83% vs. 65%, respectively) and solid/kerosene fuel use for more than 1 h/day (27% vs. 21%, respectively) were more prevalent. Larger studies are needed to estimate the risk of TB from these types of air pollution in HIV infected individuals and settings with high HIV prevalence.

Treating tobacco dependence: guidance for primary care on life-saving interventions. Position statement of the IPCRG

Tobacco smoking is the world's leading cause of premature death and disability. Global targets to reduce premature deaths by 25% by 2025 will require a substantial increase in the number of smokers making a quit attempt, and a significant improvement in the success rates of those attempts in low, middle and high income countries. In many countries the only place where the majority of smokers can access support to quit is primary care. There is strong evidence of cost-effective interventions in primary care yet many opportunities to put these into practice are missed. This paper revises the approach proposed by the International Primary Care Respiratory Group published in 2008 in this journal to reflect important new evidence and the global variation in primary-care experience and knowledge of smoking cessation. Specific for primary care, that advocates for a holistic, bio-psycho-social approach to most problems, the starting point is to approach tobacco dependence as an eminently treatable condition. We offer a hierarchy of interventions depending on time and available resources. We present an equitable approach to behavioural and drug interventions. This includes an update to the evidence on behaviour change, gender difference, comparative information on numbers needed to treat, drug safety and availability of drugs, including the relatively cheap drug cytisine, and a summary of new approaches such as harm reduction. This paper also extends the guidance on special populations such as people with long-term conditions including tuberculosis, human immunodeficiency virus, cardiovascular disease and respiratory disease, pregnant women, children and adolescents, and people with serious mental illness. We use expert clinical opinion where the research evidence is insufficient or inconclusive. The paper describes trends in the use of waterpipes and cannabis smoking and offers guidance to primary-care clinicians on what to do faced with uncertain evidence. Throughout, it recognises that clinical decisions should be tailored to the individual's circumstances and attitudes and be influenced by the availability and affordability of drugs and specialist services. Finally it argues that the role of the International Primary Care Respiratory Group is to improve the confidence as well as the competence of primary care and, therefore, makes recommendations about clinical education and evaluation. We also advocate for an update to the WHO Model List of Essential Medicines to optimise each primary-care intervention. This International Primary Care Respiratory Group statement has been endorsed by the Member Organisations of World Organization of Family Doctors Europe.

Tobacco Smoking and Tuberculosis among Men Living with HIV in Johannesburg, South Africa: A Case-Control Study

SETTING

Although there is ample evidence that smoking increases the risk of tuberculosis (TB), the magnitude of impact on TB risk among HIV-infected persons is poorly described. Given that a high proportion of patients with TB are co-infected with HIV in South Africa, the risks arising from the intersection of smoking, TB, and HIV/AIDS have key relevance for tobacco control policies.

OBJECTIVE

To evaluate the association of pulmonary tuberculosis (PTB) with current tobacco smoking among men with HIV in South Africa.

DESIGN

Case-control study of antiretroviral therapy naïve men with confirmed HIV-infection in Johannesburg. Cases had laboratory-confirmed PTB and controls had no evidence of active TB. Participants were interviewed to collect detailed smoking histories.

RESULTS

We enrolled 146 men diagnosed with PTB and 133 controls. Overall, 33% of participants were currently smoking, defined as smoking a cigarette within 2 months (34% cases vs. 32% controls, p = 0.27). Median CD4 count was lower (60 vs. 81 cells/mm3, P = 0.03) and median viral load was higher (173 vs. 67 copies/ul per thousand, P<0.001) among cases versus controls. In adjusted analyses, current smoking tripled the odds of PTB (aOR 3.2; 95%CI: 1.3-7.9, P = 0.01) and former smoking nearly doubled the odds of PTB (aOR 1.8; 95%CI 0.8-4.4, P = 0.18) compared to never smoking.

CONCLUSIONS

Males with HIV that smoke are at greater odds for developing PTB than non-smokers. Extensive smoking cessation programs are needed to reduce odds of TB and promote health among adults living with HIV.

Factors associated with smoking among tuberculosis patients in Spain

BACKGROUND

To determine the prevalence of smoking and analyze associated factors in a cohort of patients diagnosed with tuberculosis (TB) in Spain between 2006 and 2013.

METHODS

Multicenter, cross-sectional, descriptive, observational study using a national database of TB patients, using logistic regression to calculate odds ratios (OR) and confidence intervals (CI).

RESULTS

We analyzed 5,846 cases (62 % men, mean age 39 years, 33 % foreigners). 23.4 % were alcohol abuser, 1.3 % were injected drug users (IDU), 4.6 % were co-infected with HIV, and 7.5 % had a history of TB treatment. 6.6 % and 0.8 % showed resistance to one and multiple drugs, respectively. The predominant clinical presentation was pulmonary (71 %) with a cavitary radiological pattern in 32.8 % of cases. 82 % of cases were confirmed microbiologically, and 54 % were smear-positive microscopy. 2,300 (39.3 %) patients were smokers. The following factors were associated with smoking: male sex (OR = 2.26;CI:1.97;2.60), Spanish origin (OR = 2.79;CI:2.40-3.24), alcoholism (OR = 2.85;CI:2.46;3.31), IDU (OR = 2.78;CI:1.48;5.52), homelessness (OR = 1.99;CI:1.14-3.57), pulmonary TB (OR = 1.61;CI:1.16;2.24), cavitary radiological pattern (OR = 1.99;CI:1.43;2.79) and a smear-positive microscopy at the time of diagnosis (OR = 1.39;CI:1.14;1.17).

CONCLUSIONS

The prevalence of smoking among TB patients is high. Smokers with TB have a distinct sociodemographic, clinical, radiological and microbiological profile to non-smokers.

High Tobacco Use among Presumptive Tuberculosis Patients, South India: Time to Integrate Control of Two Epidemics

Objectives

Tobacco is an important risk factor for tuberculosis (TB) infection and TB disease. Identifying tobacco users and providing tobacco cessation services is expected to reduce the burden of TB. We assessed tobacco use among presumptive TB patients attending a tertiary hospital and their willingness to attend tobacco cessation services.

Methods

A cross-sectional study was conducted among presumptive TB patients attending a designated microscopy center of a tertiary hospital in South India. All presumptive TB patients aged ≥ 18 years attending the designated microscopy center were interviewed using a semistructured interview schedule. Data on presumptive TB patient's age, sex, tobacco use and forms of tobacco, attempts to quit tobacco since 1 year, and willingness to attend a smoking cessation clinic in tertiary hospital were captured. History of use of tobacco in the past 1 month was considered as “tobacco use.”.

Results

A total of 424 presumptive TB patients aged ≥ 18 years were interviewed. Tobacco use in the past 1 month was reported by 176 (41.5%, 95% confidence interval: 36.9–46.3%) presumptive TB patients. In total, 78 (18%) presumptive TB patients were eventually diagnosed with smear-positive pulmonary TB, of them 63 (80%) were tobacco users. Presumptive TB patients aged ≥ 30 years, male sex, and < 10 years of education were significantly associated with tobacco use. Of 176, a majority of 132 (75%) used some form of smoking. Of a total of 132 smokers, 70 (53%) were willing to avail of tobacco cessation services.

Conclusion

Tobacco use among presumptive TB patients was high. Considering the high willingness to quit among smokers, proven brief interventions to help quit smoking can be tried.

Clearing the smoke around the TB-HIV syndemic: smoking as a critical issue for TB and HIV treatment and care

The collision of the tuberculosis (TB) and human immunodeficiency virus (HIV) epidemics has been described as a 'syndemic' due to the synergistic impact on the burden of both diseases. This paper explains the urgent need for practitioners and policy makers to address a third epidemic that exacerbates TB, HIV and TB-HIV. Tobacco use is the leading cause of preventable death worldwide. Smoking is more prevalent among persons diagnosed with TB or HIV. Smoking is associated with tuberculous infection, TB disease and poorer anti-tuberculosis treatment outcomes. It is also associated with an increased risk of smoking-related diseases among people living with HIV, and smoking may also inhibit the effectiveness of life-saving ART. In this paper, we propose integrating into TB and HIV programmes evidence-based strategies from the 'MPOWER' package recommended by the World Health Organization's Framework Convention on Tobacco Control. Specific actions that can be readily incorporated into current practice are recommended to improve TB and HIV outcomes and care, and reduce the unnecessary burden of death and disease due to smoking.

Intention to Quit Smoking and Associated Factors in Smokers Newly Diagnosed with Pulmonary Tuberculosis

BACKGROUND

Several studies have shown that smoking, as a modifiable risk factor, can affect tuberculosis (TB) in different aspects such as enhancing development of TB infection, activation of latent TB and its related mortality. Since willingness to quit smoking is a critical stage, which may lead to quit attempts, being aware of smokers' intention to quit and the related predictors can provide considerable advantages.

MATERIALS AND METHODS

In this cross-sectional study, subjects were recruited via a multi-stage cluster sampling method. Sampling was performed during 2012-2014 among pulmonary TB (PTB) patients referred to health centers in Tehran implementing the directly observed treatment short course (DOTS) strategy and a TB referral center. Data analysis was conducted using SPSS version 22 and the factors influencing quit intention were assessed using bivariate regression and multiple logistic regression models.

RESULTS

In this study 1,127 newly diagnosed PTB patients were studied; from which 284 patients (22%) were current smokers. When diagnosed with TB, 59 (23.8%) smokers quit smoking. Among the remaining 189 (76.2%) patients who continued smoking, 52.4% had intention to quit. In the final multiple logistic regression model, living in urban areas (OR=8.81, P=0.003), having an office job (OR= 7.34, P=0.001), being single (OR=4.89, P=0.016) and a one unit increase in the motivation degree (OR=2.60, P<0.001) were found to increase the intention to quit smoking.

CONCLUSION

The study found that PTB patients who continued smoking had remarkable intention to quit. Thus, it is recommended that smoking cessation interventions should be started at the time of TB diagnosis. Understanding the associated factors can guide the consultants to predict patients' intention to quit and select the most proper management to facilitate smoking cessation for each patient.

A smoking cessation intervention among tuberculosis patients in rural China

OBJECTIVE

To assess the integration of a smoking cessation intervention into routine tuberculosis (TB) services.

METHOD

Consecutive TB patients registered from 1 March to 31 August 2010 were enrolled in an intervention for self-reported smoking to promote tobacco cessation during treatment for TB. Information on the harmful health effects of tobacco smoke and smoking and TB were provided to TB patients who self-reported as current smokers. Smoking status was reassessed at every follow-up visit during anti-tuberculosis treatment with reinforced health messages and advice to quit.

RESULTS

Of 800 TB patients enrolled, 572 (71.5%) were male and 244 (30.5%) were current smokers. Females were more likely to be non-smokers (100% vs. 35.8%, P < 0.001). Of the 244 current smokers, 144 (59.0%) started smoking at <20 years, 197 (80.7%) consumed ⩾20 cigarettes per day, 211 (86.5%) had perceived smoking dependence and 199 (81.6%) had made no attempt to quit before the diagnosis of TB. Of the 244 current smokers, 234 (95.9%) were willing to quit, and 156 (66.7%) reported abstinence at month 6. Challenges to implementing smoking cessation intervention were identified.

CONCLUSION

The majority of current smokers among TB patients were willing to quit and remained abstinent at the end of anti-tuberculosis treatment. This intervention should be scaled up nationwide.

Effect of Flow Rate on In Vitro Aerodynamic Performance of NEXThaler(®) in Comparison with Diskus(®) and Turbohaler(®) Dry Powder Inhalers

Background: European and United States Pharmacopoeia compendial procedures for assessing the in vitro emitted dose and aerodynamic size distribution of a dry powder inhaler require that 4.0 L of air at a pressure drop of 4 kPa be drawn through the inhaler. However, the product performance should be investigated using conditions more representative of what is achievable by the patient population. This work compares the delivered dose and the drug deposition profile at different flow rates (30, 40, 60, and 90 L/min) of Foster NEXThaler^® (beclomethasone dipropionate/formoterol fumarate), Seretide^® Diskus^® (fluticasone propionate/salmeterol xinafoate), and Symbicort^® Turbohaler^® (budesonide/formoterol fumarate).

Methods: The delivered dose uniformity was tested using a dose unit sampling apparatus (DUSA) at inhalation volumes either 2.0 or 4.0 L and flow rates 30, 40, 60, or 90 L/min. The aerodynamic assessment was carried out using a Next Generation Impactor by discharging each inhaler at 30, 40, 60, or 90 L/min for a time sufficient to obtain an air volume of 4 L.

Results: Foster^® NEXThaler^® and Seretide^® Diskus^® showed a consistent dose delivery for both the drugs included in the formulation, independently of the applied flow rate. Contrary, Symbicort^® Turbohaler^® showed a high decrease of the emitted dose for both budesonide and formoterol fumarate when the device was operated at airflow rate lower that 60 L/min. The aerosolizing performance of NEXThaler^® and Diskus^® was unaffected by the flow rate applied. Turbohaler^® proved to be the inhaler most sensitive to changes in flow rate in terms of fine particle fraction (FPF) for both components. Among the combinations tested, Foster NEXThaler^® was the only one capable to deliver around 50% of extra-fine particles relative to delivered dose.

Conclusions: NEXThaler^® and Diskus^® were substantially unaffected by flow rate through the inhaler in terms of both delivered dose and fine particle mass.

Impact of HIV infection and smoking on lung immunity and related disorders

HIV-infected persons not only have higher rates of smoking than the general population, but are also unusually vulnerable to the associated adverse health effects, both infective and noninfective in origin. Indeed, in the setting of well-organised care and availability of highly active antiretroviral therapy, HIV-infected smokers lose more life-years to smoking than to HIV infection per se, presenting a major challenge to healthcare providers. Not surprisingly, the respiratory system is particularly susceptible to the damaging interactive chronic inflammatory and immunosuppressive effects of HIV and smoking, intensifying the risk of the development of opportunistic infections, as well as lung cancer and obstructive lung disorders. The impact of smoking on the immunopathogenesis and frequencies of these respiratory conditions in the setting of HIV infection, as well as on the efficacy of antiretroviral therapy, represent the primary focus of this review.

Psychological distress and its relationship with non-adherence to TB treatment: a multicentre study

BACKGROUND

The successful cure of tuberculosis (TB) is dependent on adherence to treatment. Various factors influence adherence, however, few are easily modifiable. There are limited data regarding correlates of psychological distress and their association with non-adherence to anti-TB treatment.

METHODS

In a trial of a new TB test, we measured psychological distress (K-10 score), TB-related health literacy, and morbidity (TBscore), prior to diagnosis in 1502 patients with symptoms of pulmonary TB recruited from clinics in Cape Town (n = 419), Harare (n = 400), Lusaka (n = 400), Durban (n = 200), and Mbeya (n = 83). Socioeconomic, demographic, and alcohol usage-related data were captured. Patients initiated on treatment had their DOTS cards reviewed at two-and six-months.

RESULTS

22 %(95 % CI: 20 %, 25 %) of patients had severe psychological distress (K-10 ≥ 30). In a multivariable linear regression model, increased K-10 score was independently associated with previous TB [estimate (95 % CI) 0.98(0.09-1.87); p = 0.0304], increased TBscore [1(0.80, 1.20); p <0.0001], and heavy alcohol use [3.08(1.26, 4.91); p = 0.0010], whereas male gender was protective [-1.47(-2.28, -0.62); p = 0.0007]. 26 % (95 % CI: 21 %, 32 %) of 261 patients with culture-confirmed TB were non-adherent. In a multivariable logistic regression model for non-adherence, reduced TBscore [OR (95 % CI) 0.639 (0.497, 0.797); p = 0.0001], health literacy score [0.798(0.696, 0.906); p = 0.0008], and increased K-10 [1.082(1.033, 1.137); p = 0.0012], and heavy alcohol usage [14.83(2.083, 122.9); p = 0.0002], were independently associated. Culture-positive patients with a K-10 score ≥ 30 were more-likely to be non-adherent (OR = 2.290(1.033-5.126); p = 0.0416].

CONCLUSION

Severe psychological distress is frequent amongst TB patients in Southern Africa. Targeted interventions to alleviate psychological distress, alcohol use, and improve health literacy in newly-diagnosed TB patients could reduce non-adherence to treatment.

Statement on smoking cessation in COPD and other pulmonary diseases and in smokers with comorbidities who find it difficult to quit

Chronic obstructive pulmonary disease (COPD), lung cancer, asthma and pulmonary tuberculosis are common pulmonary diseases that are caused or worsened by tobacco smoking. Growing observational evidence suggests that symptoms and prognosis of these conditions improve upon smoking cessation. Despite increasing numbers of (small) randomised controlled trials suggesting intensive smoking cessation treatments work in people with pulmonary diseases many patients are not given specific advice on the benefits or referred for intensive cessation treatments and, therefore, continue smoking.This is a qualitative review regarding smoking cessation in patients with COPD and other pulmonary disorders, written by a group of European Respiratory Society experts. We describe the epidemiological links between smoking and pulmonary disorders, the evidence for benefits of stopping smoking, how best to assess tobacco dependence and what interventions currently work best to help pulmonary patients quit. Finally, we describe characteristics and management of any "hardcore" smoker who finds it difficult to quit with standard approaches.

Tobacco smoking and tuberculosis treatment outcomes: a prospective cohort study in Georgia

OBJECTIVE

To assess the effect of tobacco smoking on the outcome of tuberculosis treatment in Tbilisi, Georgia.

METHODS

We conducted a prospective cohort study of adults with laboratory-confirmed tuberculosis from May 2011 to November 2013. History of tobacco smoking was collected using a standardized questionnaire adapted from the global adult tobacco survey. We considered tuberculosis therapy to have a poor outcome if participants defaulted, failed treatment or died. We used multivariable regressions to estimate the risk of a poor treatment outcome.

FINDINGS

Of the 591 tuberculosis patients enrolled, 188 (31.8%) were past smokers and 271 (45.9%) were current smokers. Ninety (33.2%) of the current smokers and 24 (18.2%) of the participants who had never smoked had previously been treated for tuberculosis (P < 0.01). Treatment outcome data were available for 524 of the participants, of whom 128 (24.4%) - including 80 (32.9%) of the 243 current smokers and 21 (17.2%) of the 122 individuals who had never smoked - had a poor treatment outcome. Compared with those who had never smoked, current smokers had an increased risk of poor treatment outcome (adjusted relative risk, aRR: 1.70; 95% confidence interval, CI: 1.00-2.90). Those who had ceased smoking more than two months before enrolment did not have such an increased risk (aRR: 1.01; 95% CI: 0.51-1.99).

CONCLUSION

There is a high prevalence of smoking among patients with tuberculosis in Georgia and smoking increases the risk of a poor treatment outcome.

Dose-response association between salivary cotinine levels and Mycobacterium tuberculosis infection

SETTING

Tijuana, Mexico.

OBJECTIVE

To describe the association between salivary cotinine levels and interferon-gamma (IFN-γ) release assay results.

DESIGN

We conducted a cross-sectional study among injection drug users. Salivary cotinine levels were measured using NicAlert, a semi-quantitative dipstick assay. QuantiFERON©-TB Gold In-Tube (QFT-GIT) was used to determine Mycobacterium tuberculosis infection.

RESULTS

Among 234 participants, the prevalence of QFT-GIT positivity for NicAlert cotinine categories 0 (non-smoking), 1 (second-hand smoke exposure or low-level smoking) and 26 (regular smoking) were respectively 42.1%, 46.4% and 65.2% (Ptrend 0.012). We found increasing trends in QFT-GIT positivity (Ptrend 0.003) and IFN-γ concentrations (Spearman's r 0.200, P 0.002) across cotinine levels 0 to 6. In multivariable log-binomial regression models adjusted for education, cotinine levels were not associated with QFT-GIT positivity when included as smoking categories (1 and 26 vs. 0), but were independently associated with QFT-GIT positivity when included as an ordinal variable (prevalence ratio 1.09 per 1 cotinine level, 95%CI 1.021.16).

CONCLUSION

Our findings suggest that a dose-response relationship exists between tobacco smoke exposure and M. tuberculosis infection. Longitudinal studies that use biochemical measures for smoking status are needed to confirm our findings.

The Association between active and passive smoking and latent tuberculosis infection in adults and children in the united states: results from NHANES

BACKGROUND

Few studies assessing the relationship between active and passive smoking and tuberculosis have used biomarkers to measure smoke exposure. We sought to determine the association between active and passive smoking and LTBI in a representative sample of US adults and children.

METHODS

We used the 1999-2000 US National Health and Nutrition Examination Survey (NHANES) dataset with tuberculin skin test (TST) data to assess the association between cotinine-confirmed smoke exposure and latent tuberculosis infection (LTBI) among adults ages ≥20 years (n = 3598) and children 3-19 years (n = 2943) and estimate the prevalence of smoke exposure among those with LTBI. Weighted multivariate logistic regression was used to measure the associations between active and passive smoking and LTBI.

RESULTS

LTBI prevalence in 1999-2000 among cotinine-confirmed active, passive, and non-smoking adults and children was 6.0%, 5.2%, 3.3% and 0.3%, 1.0%, 1.5%, respectively. This corresponds to approximately 3,556,000 active and 3,379,000 passive smoking adults with LTBI in the US civilian non-institutionalized population in 1999-2000. Controlling for age, gender, socioeconomic status, race, birthplace (US vs. foreign-born), household size, and having ever lived with someone with TB, adult active smokers were significantly more likely to have LTBI than non-smoking adults (AOR = 2.31 95% CI 1.17-4.55). Adult passive smokers also had a greater odds of LTBI compared with non-smokers, but this association did not achieve statistical significance (AOR = 2.00 95% CI 0.87-4.60). Neither active or passive smoking was associated with LTBI among children. Among only the foreign-born adults, both active (AOR = 2.56 (95% CI 1.20-5.45) and passive smoking (AOR = 2.27 95% CI 1.09-4.72) were significantly associated with LTBI.

CONCLUSIONS

Active adult smokers and both foreign-born active and passive smokers in the United States are at elevated risk for LTBI. Targeted smoking prevention and cessation programs should be included in comprehensive national and international TB control efforts.

Serum level of plasminogen activator inhibitor type-1 in addicted patients with coronary artery disease

BACKGROUND

Plasminogen activator inhibitor-1 (PAI-1) is a glycoprotein with inhibitory effects on the formation of plasmin from plasminogen by plasminogen activator. Thus, it prevents clot lysis in vessel walls. Several evidences prove the relationship between coronary artery disease and response to fibrinolytic therapy in patients with myocardial infarction (MI) with PAI-1 level. Opium addiction is one of the most important factors in causing MI and cardiovascular events. This is due to it causing imbalance between coagulation and anticoagulation factors in the blood. This study was designed and implemented to determine the levels of PAI-I in opium-addicted patients with coronary artery disease in comparison with non addicts.

METHODS

In this case-control study, 160 patients with coronary heart disease (CHD), which was confirmed by angiography results, were enrolled. All of the patients had a medical history, their creatinine levels and lipid profile were evaluated, morphine urine test was performed, and after that a blood sample was taken to determine the levels of PAI-1. Thus, the 80 patients who had a positive morphine urine test result formed the case group, and the control group was constituted of the 80 patients with negative morphine test results. The two groups were matched.

FINDINGS

Average level of PAI-1 in the control group was 2.4 ± 2.6 and in the case group was 8.8 ± 9.1 and it was statistically significant (P < 0.001). The frequency of two vessel disease was higher in opium addicted patients than non-addicted patients and this was statistically significant (P = 0.030). However, the frequency of single vessel and three vessel disease was the same in the two groups. The two groups had no differences in age, lipid profile, and creatinine level. Moreover, females are at a higher risk of high PAI-1 levels.

CONCLUSION

PAI-1 levels in opium addicted patients with CHD are higher than other patients. In these patients, the risk of atherosclerosis and MI is higher than normal.

Tobacco use patterns in tuberculosis patients with high rates of human immunodeficiency virus co-infection in South Africa

BACKGROUND

Tuberculosis (TB) patients who smoke tobacco are at an increased risk for adverse TB treatment outcomes. This study describes tobacco use patterns among newly diagnosed TB patients, their readiness to quit, and their beliefs about tobacco-related health effects in a high HIV-burden setting in South Africa. Socio-economic and demographic factors associated with smoking were also determined.

METHODS

This was a cross-sectional analysis of baseline data collected for a smoking cessation study at six large tuberculosis clinics in a South African township (N = 1926). We collected information on current and past tobacco use, socio-economic and demographic status, beliefs regarding the harmful effects of smoking and quit behaviour, and motivation, using structured interviewer-administered questionnaires. TB- and HIV-related information was obtained from patient records. Data analysis entailed descriptive statistics, followed by multivariate logistic regression with backward elimination, adjusted for clustering by facility.

RESULTS

Just over one fifth of respondents (21.8%, 420/1924) reported currently smoking tobacco (males 37.6%, females 4.6%). By contrast, only 1.8% (35/1918) of all respondents reported being past smokers. Of the current smokers, about half (51.8%, 211/407) had previously attempted to quit, mainly for health reasons. The majority of respondents (89.3%, 1675/1875) believed tobacco smoking was harmful for their health and smokers were highly motivated to quit (median score 9, interquartile range 7-10). Smoking was less common among female respondents (Odds Ratio [OR] 0.10, 95% Confidence Interval [CI] 0.06-0.19) and respondents who had completed high school (OR 0.57, 95% CI 0.39-0.84), but was more common among respondents who do occasional work (OR 2.82, 95% CI 1.58-5.02), respondents who to bed hungry regularly (OR 4.19, 95% CI 2.42-7.25), those who have an alcohol problem (OR 5.79, 95% CI 3.24-10.34) and those who use illicit substances (OR 10.81, 95% CI 4.62-25.3).

CONCLUSIONS

Despite documented evidence of its harmful effects, smoking is prevalent among male TB patients in this high HIV-prevalence population. Few patients have managed to quit smoking on their own. However, patients are highly motivated to stop smoking. We recommend implementing and evaluating a smoking cessation programme in tandem with TB services.

The prevalence of smoking and the knowledge of smoking hazards and smoking cessation strategies among HIV- positive patients in Johannesburg, South Africa

BACKGROUND

While the detrimental effects of smoking among HIV-positive patients have been well documented, there is a paucity of data regarding cigarette smoking prevalence among these patients in South Africa (SA).

OBJECTIVES

To establish the frequency, demographics, knowledge of harmful effects, and knowledge of smoking cessation strategies among HIV-positive patients in Johannesburg, SA.

METHODS

We conducted a prospective cross-sectional survey using a structured questionnaire to interview HIV-positive patients attending the HIV Clinic at the Charlotte Maxeke Johannesburg Academic Hospital between 1 July and 31 October 2011.

RESULTS

Of 207 HIV-positive patients attending an antiretroviral therapy (ART) roll-out clinic, 31 (15%) were current smokers (23.2% of males and 7.4% of females) and a further 45 (21.7%) were ex-smokers. Most of the current smokers (30/31 patients) indicated their wish to quit smoking, and among the group as a whole, most patients were aware of the general (82.1%) and HIV-related (77.8%) risks of smoking and of methods for quitting smoking. Despite this, however, most (62.3%) were not aware of who they could approach for assistance and advice.

CONCLUSIONS

Given the relatively high prevalence of current and ex-smokers among HIV-positive patients, there is a need for the introduction of smoking-cessation strategies and assistance at ART roll-out clinics in SA.

Cigarette smoking and mechanisms of susceptibility to infections of the respiratory tract and other organ systems

The predisposition of cigarette smokers for development of oral and respiratory infections caused by microbial pathogens is well recognised, with those infected with the human immunodeficiency virus (HIV) at particularly high risk. Smoking cigarettes has a suppressive effect on the protective functions of airway epithelium, alveolar macrophages, dendritic cells, natural killer (NK) cells and adaptive immune mechanisms, in the setting of chronic systemic activation of neutrophils. Cigarette smoke also has a direct effect on microbial pathogens to promote the likelihood of infective disease, specifically promotion of microbial virulence and antibiotic resistance. In addition to interactions between smoking and HIV infection, a number of specific infections/clinical syndromes have been associated epidemiologically with cigarette smoking, including those of the upper and lower respiratory tract, gastrointestinal tract, central nervous and other organ systems. Smoking cessation benefits patients in many ways, including reduction of the risk of infectious disease.

Association between smoking and latent tuberculosis in the U.S. population: an analysis of the National Health and Nutrition Examination Survey

BACKGROUND

Evidence of an association between cigarette smoking and latent tuberculosis infection (LTBI) is based on studies in special populations and/or from high prevalence settings. We sought to evaluate the association between LTBI and smoking in a low prevalence TB setting using population-based data from the National Health and Nutrition Examination Survey (NHANES).

METHODS

In 1999-2000, NHANES assessed LTBI (defined as a tuberculin skin test measurement ≥10 mm) in participants, and those ≥20 years of age were queried regarding their tobacco use and serum cotinine was measured. We evaluated the association of LTBI with self-reported smoking history and smoking intensity in multivariable logistic regression models that adjusted for known confounders (gender, age, birthplace, race/ethnicity, poverty, education, history of BCG vaccination, and history of household exposure to tuberculosis disease).

RESULTS

Estimated LTBI prevalence was 5.3% among those ≥20 years of age. The LTBI prevalence among never smokers, current smokers, and former smokers was 4.1%, 6.6%, and 6.2%, respectively. In a multivariable model, current smoking was associated with LTBI (OR 1.8; 95% CI, 1.1-2.9). The association between smoking and LTBI was strongest for Mexican-American and black individuals. In multivariate analysis stratified by race/ethnicity, cigarette packs per day among Mexican-American smokers and cotinine levels among black smokers, were significantly associated with LTBI.

CONCLUSIONS

In the large, representative, population-based NHANES sample, smoking was independently associated with significantly increased risks of LTBI. In certain populations, a greater risk of LTBI corresponded with increased smoking exposure.