Longer delay in accessing treatment among current smokers with new sputum smear-positive tuberculosis in Nepal

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.

Why tobacco control should be a priority agenda item of Joint External Monitoring Missions for TB control?

INTRODUCTION

Tobacco smoking is a significant risk factor for developing tuberculosis (TB), contributing to diagnostic delays, poor treatment outcomes and an increased risk of death and relapse. The World Health Organization (WHO) has reported that TB rates could decline by as much as 20% if smoking were eliminated. Tobacco smoking was a risk factor in at least 860,000 TB cases in 2018, and has been documented as one of the leading contributors to TB in India, Indonesia, Myanmar, Nepal and Philippines.

METHODS

Joint External Monitoring Missions (JEMM) are arranged by WHO to review the progress, challenges and plans for national TB control programs and provide guidance for improvement of policies, planning and implementation. During May and June 2021, JEMM reports from five South-East Asian countries that had a JEMM in 2019 and early 2020 were reviewed. Reports reviewed from India, Indonesia, Myanmar, Nepal and the Philippines. Any mention of the association of TB and smoking, TB and tobacco use, impact of tobacco use/smoking on TB outcomes, current practices and challenges of TB and tobacco in the TB control program and proposed actions were documented.

RESULTS

Of the five country JEMM, Myanmar's did not recognise the impact of smoking tobacco on TB at all, and only one of the five countries, India, identified a very limited number of current TB-Tobacco practises including that a collaborative framework for TB/tobacco was in place. Nepal's 2019 JEMM acknowledged that there was no smoking cessation within the TB Control program and health providers were not aware about the brief advice and smoking cessation program. The Philippines and Myanmar reported neither current practices nor challenges in implementing tobacco intervention in TB control programs.

CONCLUSION

Given the importance of tobacco smoking as a key risk factor for TB, assessing its burden on the national TB epidemic should be included as one of the key indicators in the JEMM framework. Key interventions include brief cessation support through regular TB services and the use of Nicotine Replacement Therapy (NRT) and other medications as part of a comprehensive package of care for people with TB to improve the quality of the services they receive. Multisectoral efforts to stop smoking also contribute the non-communicable disease agenda as well as protecting against poor outcomes for COVID-19. The support of TB programs to integrate tobacco control is critical and will contribute to national TB control program targets that support WHO's End TB Strategy.

Design, development and randomised controlled trial of a smartphone application, 'QinTB', for smoking cessation in tuberculosis patients: study protocol

INTRODUCTION

Providing smoking cessation treatment is an important intervention for tuberculosis (TB) patients. Mobile technologies, such as smartphone applications, have shown promising potential. However, there are few effective applications that could support TB patients in their efforts to quit smoking. To address this problem, we will develop a smartphone application 'QinTB' to help TB patients quit smoking, and we will evaluate the clinical efficacy of this application by using a randomised controlled trial (RCT).

METHODS AND ANALYSIS

This is a two-step study. In the first step, we will develop a smartphone application based on an interactive application of the transtheoretical model and protection motivation theory. Then, we will perform an RCT using a two-arm design; a total of 400 patients will be randomly assigned to the application group or the doctors' advice group; both treatments will be 6 months and follow-up will be 12 months; the primary outcome is the biochemically verified 6 month sustained abstinence rate; data will be analysed on an intention-to-treat basis.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of Beijing Research Institute for Tuberculosis Control and Prevention. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

This study was registered in the Chinese Clinical Trial Registry (ChiCTR1900022008) and the stage is Pre-results.

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.

Patient delay in the diagnosis and treatment of tuberculosis in China: findings of case detection projects

OBJECTIVE

1) To assess patient delay among new smear-positive pulmonary tuberculosis (PTB) patients in accessing health services in seven FIDELIS (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) projects from 2003 to 2008 in China; 2) to compare treatment delay by province; and 3) to assess factors associated with delay.

METHOD

Records of new smear-positive PTB patients were reviewed. Data sources were the consultation book, laboratory register, patient record, treatment card and the PWLAHS (people with limited access to health services) evaluation form. Data were collected using a standard questionnaire, cross-checked by staff from the sites and by the International Union Against Tuberculosis and Lung Disease (The Union) and analysed by The Union.

RESULTS

Of the 75 401 new smear-positive PTB patients included in the study, 63-89% were PWLAHS. The average gross domestic product of the project sites and at national level were respectively US$557 and US$998. The median patient delay was 93 days (range 68-128). Delays were longer among females, older patients, rural residents and PWLAHS. Delayed access to health services was significantly associated with a greater number of symptoms.

CONCLUSION

Patient delay in accessing health care in China was lengthy; TB care and control needs to be improved.

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.

Smoking cessation and smokefree environments for tuberculosis patients in Indonesia-a cohort study

Background

Research indicates that smoking substantially increases the risk of tuberculosis (TB), delay in diagnosis, failure of TB treatment and death from TB. Quitting smoking is one of the best ways to prevent unwanted outcomes. Exposure to secondhand smoke increases the risks of both TB infection and development of active TB disease among children and adults. TB patients who smoke in the home are also placing their families at a greater risk of TB infection. It is very important to keep homes smokefree. The present study assessed the implementation and effectiveness of an intervention that promotes smoking cessation and smokefree environments for TB patients.

Methods

All consecutive new sputum smear-positive TB patients (aged ≥15 years old) diagnosed and registered in 17 health centres between 1 January 2011 and 31 December 2012 were enrolled. The ABC (A=ask, B=brief advice, C=cessation support) intervention was offered for 5 to 10 minutes within DOTS services at each visit. Smoking status and smokefree environments at home were assessed at the first visit, each monthly follow up and at month six. Factors associated with quitting were analysed by univariable and multivariable analysis

Results

Of the 750 TB patients registered, 582 (77.6 %) were current smokers, 40 (5.3 %) were ex-smokers and 128 (17.1 %) were never smokers. Of the 582 current smokers, 66.8 % had quit smoking at month six. A time from waking to first cigarette of >30 minutes, having a smokefree home and the display of “no smoking” signage at home at month six were significantly associated with quitting. Of the 750 TB patients, 86.1 % had created a smokefree home at six month follow-up compared with 18.5 % at baseline. All 80 health facilities were 100 % tobacco-free at the end of 2012 compared with only 52 (65 %) when the intervention began in March 2011.

Conclusions

Brief advice of 5–10 minutes with minimal cessation support at every visit of TB patients resulted in high quit rates and higher awareness of adverse health effects of secondhand smoke exposure, which led patients to make their homes smokefree and health providers to make health care tobacco-free.

Delay in the diagnosis and treatment of pulmonary tuberculosis in Uzbekistan: a cross-sectional study

Background

Early diagnosis and prompt effective therapy are crucial for the prevention of tuberculosis (TB) transmission, particularly in regions with high levels of multi-drug resistant TB. This study aimed to evaluate the extent of delay in diagnosis and treatment of TB in Uzbekistan and identify associated risk factors.

Methods

A cross-sectional study was performed on hospital patients with newly diagnosed TB. The time between the onset of respiratory symptoms and initiation of anti-TB treatment was assessed and delays were divided into patient, health system and total delays. Univariable and multivariable logistic regression analysis was used to evaluate determinants of diagnostic and treatment delay.

Results

Among 538 patients enrolled, the median delay from onset of symptoms until treatment with anti-TB drugs was 50 days. Analysis of the factors affecting health-seeking behaviour and timely treatment showed the presence of the patient factor. Self-medication was the first health-seeking action for 231 (43%) patients and proved to be a significant predictor of delay (p = 0.005), as well as coughing (p = 0.009), loss of weight (p = 0.001), and visiting private and primary healthcare facilities (p = 0.03 and p = 0.02, respectively).

Conclusion

TB diagnostic and treatment delay was mainly contributed to by patient delay and should be reduced through increasing public awareness of TB symptoms and improving public health-seeking behaviour for timely initiation of anti-TB treatment. Efforts should be made to minimise irrational use of antibiotics and support interventions to restrict over-the-counter availability of antibiotics.