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Tobacco and Tuberculosis

Mini Lecture 1
Module: Tobacco effects on respiratory system
Objectives of the Mini Lecture
GOAL OF MINI LECTURE: Provide students with
knowledge on the harmful effects of tobacco on tuberculosis,
and skill to address smoking and to provide smoking
cessation counseling for tuberculosis
Learners will be able to:
Understand the burden of smoking among TB patients
Understand the association between smoking and TB,
and impact of smoking on TB
Conduct counseling to encourage TB patients to quit
Tobacco and tuberculosis
Mini Lecture 1
Module: Tobacco effects on respiratory system
Global Burden of TB
DOTS programmes (1995-2006): 31.8 million new and
relapse cases, and 15.5 million new smear-positive cases
In 2006: 9.2 million new cases (139 per 100 000), including
4.1 million new smear-positive cases and 0.7 million HIV-
positive cases
83% of the burden were in Africa (23%), South-East Asia
(35%) and Western Pacific (25%).
12 among the 15 countries with the highest estimated TB
incidence rates are in Africa, partly explained by the
relatively high rates of HIV co-infection.
(World Health Organization, 2007)
Tuberculosis in Indonesia
TB as the third leading cause of death in Indonesia
TB incidence decreased by 2.4% during 2004-2005 and
its prevalence also decreased in the last 30 years
Multidrug resistance new (1.6%), relapse cases (14%)
DOTS adopted in 1995 with coverage of 98% (2000-2005)
DOTS success rate treatment (90%), re-treatment (82%)
(WHO, 2008)
National Tuberculosis Programmes - Indonesia Stop TB
Initiative /Gerdunas (Gerakan Terpadu Nasional)
(Soemantri et al., 2007; MoH Indonesia, 2001)
Smoking: a risk factor for TB
Smoking increases the risk of TB infection, the RR
estimate for smokers is 1.73 (95% CI 1.46-2.04)
compared to non-smokers.
Smoking increases the risk of TB disease, the RR
estimate for smokers ranges from 2.3 to 2.7 compared to
Smoking increases the risk of TB mortality, the RR
estimate for smokers is 1.60 (95% CI 1.31-1.95)
compared to non-smokers.
The risk estimates for TB infection, disease, and mortality
are not independent.
(Bates et al., 2007)
Passive smoking and tuberculosis
Exposure to second-hand smoke increases the odds of
getting TB infection by 3.3 times than the non-smokers.
The risk of TB infection due to passive smoking exposure
is significantly higher among children than adults.
Evidence of dose-response relationship between
exposure intensity and the risk of TB infection
depends on the number of cigarettes consumed by family
member and the proximity of contact with smoking
(Lin et al., 2007)
Smoking and Respiratory Infection
the mechanisms
Structural changes
peribronchiolar inflammation and fibrosis
mucosal permeability and changes in pathogen adherence
impairment of the mucociliary clearance
disruption of the respiratory epithelium
Immunologic mechanisms
decreased immune response & circulating immunoglobulins
CD4 lymphopenia, CD8+ lympocyte counts
depressed phagocyte activity, and decreased release of
proinflammatory cytokines.
(Arcavi and Benowitz, 2004)
Smoking cessation for TB patients
q The clinical encounter is a teachable moment when the
patient may be more receptive to cessation messages
q The physicians should take advantage of the clinical
encounter to deliver cessation messages to all TB patients
who smoke
Engaging DOTS provider in
smoking cessation
In many countries with high TB prevalence, smoking
cessation is not integrated in the TB control programmes,
neither is DOTS provider involved.
(Siddiqi and Lee, 2008)
Smoking cessation should be integrated in TB management
program and guideline. Health professionals should be
provided appropriate knowledge and skills to provide
cessation counseling to TB patients.
(Slama et al., 2007)
Tobacco and tuberculosis
Mini Lecture 1
Module: Tobacco effects on respiratory system
Burden of TB in 5 countries with
highest number of TB patients
TB Estimates (2006)
India China
Incidence / 100,000 168 99 234 940 311
Prevalence / 100,000 299 201 253 998 615
Death / 100,000 28 15 38 218 81
Case Detection Rate (%) 64 79 73 71 20
DOTS treatment success (%) 86 94 91 71 75
(World Health Organization, 2007)
Smoking TB clinical manifestation,
conversion and relapses
TB smokers has higher possibility of experiencing
pulmonary TB, clinical manifestations, having cavitary
lesions, and to be smear-positive.
Smoking is not associated with sputum conversion two
months after treatment, but smoking prolongs the
conversion time among smokers than among non-smokers.
Smoking is an independent predictor of TB relapse
(OR=3.1), in addition to irregular treatment (OR=2.5) and
drug resistance (OR=4.8)
(Chiang et al., 2007)
Immunopathogenesis of smoking
and tuberculosis
Nicotine can reactivate latent mycobacterium tuberculosis
by down-regulation of TNF- by the macrophages in the
lungs lack of nitric oxide switch off the latent Tb state.
(Davies et al., 2006)
Iron, smoking and tuberculosis
Smoker inhales 1.1 g of iron from smoking 1 pack of
Iron levels in alveolar macrophages are higher in
asymptomatic TB smoker (2 fold) and symptomatic TB
smoker (4.6-7 fold) than in nonsmokers.
Iron loading promotes overgrowth of M.tuberculosis in
bronchoalveoral macrophages and decreases the
phagocytosis ability of macrophages.
(Boelaert et al., 2007)
Smoking among TB patients in
Predictors for smoking relapse: young, started smoking at
early age, perception that any level of smoking is harmless
(Ng et al., 2008)
Quitting among TB patients in
30% of TB patients in Indonesia were never asked about
their smoking behaviour or advised about quitting
60% relapsed smoker received only general health
messages and not TB-specific smoking messages.
(Ng et al., 2008)
Involving all health professionals in smoking cessation is