Tobacco dependence treatment to help achieve Millennium Development Goal of reducing tuberculosis deaths

In several low- and middle-income countries (LMICs), including China, India, Indonesia, Pakistan and South Africa, tuberculosis (TB) disease outcomes are likely to be substantially impacted by patterns of tobacco use.  In particular, it has been projected that tobacco use will lead to an extra 18 million tuberculosis cases and 40 million tuberculosis deaths between 2010 and 2050 (Basu et al., 2011). Already, as of 2012, there were 8.6 million new cases and nearly 1.3 million deaths worldwide from TB (WHO 2013).

Active and passive tobacco smoking is an established risk factor for TB disease in children and adults (WHO, 2007). It is pertinent to note that about 70% of those with TB are estimated to also be HIV positive, and tobacco smoking would be particularly more harmful for HIV/TB co-infected patients who carry additional risk of mortality and morbidity due to HIV infection. TB is indeed one of the main opportunistic infections associated with HIV/AIDS, which is disproportionately prevalent in the Sub-Saharan African region.

All regions, except Africa and Europe, are reportedly on track to achieve the UN’s Millennium Development Goals (MDG) target of 50% decline in TB deaths by 2015. It has been estimated that 20% of TB deaths are attributable to tobacco smoking (WHO 2007). The elimination of tobacco smoking is therefore likely to reduce TB mortality by at least 20% or almost half the MDG target. In fact, a recent study from Taiwan showed that mortality from TB decreased by up to 65% in smokers who quit (Wen et al., 2010).

To further highlight the potential role of treatment for tobacco dependence in achieving the MDG target for TB reduction, a 2007 WHO/UNION report based on an extensive review of the literature also emphasized the need to integrate tobacco cessation in TB treatment programmes. This report specifically recommended the addition of brief counselling and close support for smoking cessation with or without pharmacologic therapy in treatment programs for TB (WHO, 2007). These interventions are consistent with the recommendations for implementing Article 14 of the WHO Framework Convention on Tobacco Control (WHO, 2010). This guideline calls for the engagement of both professional and non-professional care-givers in providing cessation support using existing health systems infrastructure.

It has been demonstrated that non-physicians can be trained to provide effective smoking cessation among TB patients (Awaisu et al., 2010), and  a number of other recent studies, mainly from LMICs, have demonstrated that behavioural support, with or without medication, are cost-effective smoking cessation interventions for patients with TB (Saddiqi et al., 2013; Baral et al., 2013).There is therefore enough evidence to support the integration of treatment for tobacco use and dependence in TB treatment programmes. However, it would appear that this is not happening on a large scale, if it is happening at all. This brief therefore calls on all policy makers, particularly in LMICs where the burden of TB is most felt, to make a commitment to train their healthcare workers including directly observed treatment supervisors and community health workers to provide cessation support to all patients, but particularly TB patients.

About the Author: Lekan Ayo-Yusuf, currently a Professor and Dean of School of Oral Health Sciences, University of Limpopo MEDUNSA campus, Pretoria , is also the Regional Director for Global Bridges in the AFRO region.

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