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Incorporating Tobacco Cessation into TB services

By Asaf Bitton | 25 Mar, 2009 Last edited by Sophie Beauvais on 04 May 2010

There is an emerging consensus around the evidence that tobacco use increases a person's risk of having a positive tuberculin skin test, developing active TB, and of dying from TB by a factor of 1.5-3. In India and South Africa as many as 20-40% of TB deaths may also be related to concurrent tobacco use (see Jha et al., NEJM, March 13, 2008, Number 11, A Nationally Representative Case–Control Study of Smoking and Death in India, full text available here: http://content.nejm.org/cgi/content/full/358/11/1137, and Groenewald et al, SAMJ, August 2007, #8 Part 2, Estimating the burden of disease attributable to smoking in South Africa in 2000, abstract here:

In response to this convincing evidence, many members of the tobacco control field (of which I am one) are working to find ways to incorporate tobacco cessation into TB services in low-resource settings around the world. Strong evidence exists that brief, repeated, and direct counseling by health providers can increase the odds of a tobacco user quitting by at least two-fold. Thus, one of the more intriguing proposals out there is to incorporate brief, evidence-based counseling techniques into DOTS community health worker training. Preliminary work suggests that a 1-2 hour training is probably enough to get the basics down, and that providing 1 minute of advice by a CHW to a DOTS patient is feasible.

At the recent 14th World Conference on Tobacco or Health earlier this month in Mumbai, I co-led a session with Dr. KR Thankappan, director of the Achutha Menon Centre for Health Science Studies in Kerala, India, and a leader in this emerging field. We had a high level of interest and participation in this work group by members of the tobacco control community from around the world. They almost uniformly identified a need to move forward with this integration of services, but also a lack of existing models on how to do so.

Dr. Thankappan presented on his group's recent study of 215 patients on DOTS who were given a tobacco use questionnaire at 8 time points throughout their treatment. At baseline, while overall tobacco use in Kerala is 30%, his group found that tobacco use in their TB patients was a staggering 85%. As soon as TB was diagnosed, current tobacco use went down to 10% in the first week after diagnosis. During the intense phase of treatment within the first 2 months, tobacco use increased to 20%, and finally up to 38% once treatment neared completion. Why did a high level of tobacco relapse occur even though all patients were counseled about tobacco use? He reported that the following factors were significant in association with tobacco use relapse: lack of respiratory symptoms, high previous tobacco use, low provider training on tobacco cessation, and non-specific or non-direct cessation messages.

I presented a summary of one of the most promising trials to date that was conducted by El Sony et al (IJTLD 2007) in 24 health centers in Sudan that provide TB treatment. The purpose of the study was to examine the feasibility of introducing a tobacco cessation intervention into TB treatment programs. 16 intervention clinics and 8 controls were studied to see if tobacco cessation training would be accepted by health staff and the impact on TB treatment outcomes. A secondary assessment looked at rate of stopping tobacco use among those enrolled in the intervention. Staff members did not differ in personal use of tobacco, in enforcing rules banning the use of tobacco at health centres, or in rates of recruitment into the study. There was a high degree of acceptance of tobacco cessation services into their TB work. A total of 83% of patients in the intervention clinics compared to 59% in the control clinics were cured or completed TB treatment. Of identified tobacco users undergoing the cessation intervention, 66% reported abstinence at the end of their TB treatment compared to a much lower percent in the control clinics. Of note, this was not a randomized trial and differences existed between patients enrolled or not enrolled. However, the intervention was demonstrated to be feasible to implement and effective for those enrolled within routine TB services.

Thus, the questions I have for this group are:

1. Does anyone have experience incorporating tobacco cessation into existing TB services?

2. Is there interest in doing so?

3. What might be the best way to approach this issue?

4. Are their members/groups interested in working with our tobacco cessation group in Boston to train CHWs to incorporate brief tobacco cessation into their work?

Thank you for your input.

Asaf Bitton, MD
Brigham and Women's Hospital
Boston, USA

Attached resource:
  • A WHO / The Union Monograph on TB and Tobacco Control: Joining efforts to control two related global epidemics. (download, 1.5 MB)

    Summary: Associations between tobacco use and tuberculosis (TB) outcomes have long been suspected, but until recently the predominant view was that existing studies were not adequate to provide confirmation of any link. However, more recent studies and some recent reviews of existing studies have seemed to provide a better-evidenced link between active and passive tobacco smoking and a range of TB outcomes including infection, response to treatment, relapse rates and mortality.
    This monograph was jointly prepared by WHO and The Union. A large number of international experts from various institutions and agencies were involved as contributors.

    Source: International Union Against Tuberculosis and Lung Disease (The Union)

    Publication Date: January 1, 2007

    Language: English

    Keywords: Publications & Research, tobacco



Julia Fischer-Mackey Replied at 1:33 PM, 26 Mar 2010

An interesting study was just announced in BMC Public Health: "An intervention to stop smoking among patients suspected of TB - evaluation of an integrated approach" http://www.biomedcentral.com/1471-2458/10/160.

The research will be embedded within Pakistan's national tobacco control and TB control programs so that a relevant, integrated, and scalable intervention can emerge from the research.

Is anyone in the community incorporating smoking cessation into TB treatment? If so, it would be great to hear about your experiences.

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