Poor people are most hard-hit by TB, COPD and tobacco

Tobacco use, tuberculosis (TB), and chronic obstructive pulmonary disease (COPD) are all burgeoning problems in resource poor settings. The evidence of their potentially devastating effects on global public health is increasing and they require a coordinated approach for control. These diseases all occur in predominantly resource-poor countries. They are perpetuated by poverty and inadequate resources, was the clear mandate from the consultative workshop organized by the TB and Poverty sub-working group of the Stop TB Partnership in India (29-30 October 2010). It is expected that the scientific deliberations at the 41st Union World Conference on Lung Health in Berlin, Germany (11-15 November 2010), will address these concerns on a well-coordinated response to these epidemics. Read more

The secretariat of the TB and poverty sub-working group of the Stop TB Partnership has now moved to India, housed at the South-East Asian office of the International Union Against Tuberculosis and Lung Disease (The Union) since August 2010.

Statistically, there is 1 TB-related death that takes place every 18 seconds, and 1 smoking-related death every 13 seconds. The enormous public challenge posed by the combined epidemics of tobacco smoking, TB and COPD, is undoubtedly alarming. In countries like India where the TB disease burden is the highest, the situation is only grimmer with majority of tobacco use happening in form of either leaf-rolled tobacco (beedi) or chewing tobacco.

But is there a link between TB, COPD and tobacco use? Do they increase the risk of each other?

"At the beginning of 21st century we really are facing convergence of several epidemics like TB, COPD and tobacco smoking among others" had said Richard N van Zyl-Smit to CNS at the 38th Union World Conference on Lung Health in 2007. Dr Richard  works with Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, South Africa.

"Tobacco smoking is unquestionably the primary risk factor for COPD. The importance of "total burden of inhaled particles" (occupational, household, environmental) is increasing" said Richard.

"Smokers have two fold higher risk of developing active TB disease" shared Dr Madhukar Pai from McGill University and Montreal Chest Institute in Canada. Dr Pai was referring to three meta-analysis studies from 2007/2008. "Tobacco smokers have 2 times more risk of dieing of TB" added Dr Pai, referring to the data from India. India has enormous tobacco use and COPD rates, and also the highest TB burden in the world.

There are studies to show that passive smoking escalates risk of developing active TB disease by three times.

Tobacco smoke increases the risk of pneumonia, influenza, menningococcal meningitis, among others. Evidence is accumulating that smoking is a risk factor for TB.

At least 15 more studies have been published since the three major meta-analyses in 2007/2008. All studies report a positive association between tuberculosis and tobacco smoking. Studies also show that current male smokers have a higher risk for active TB disease than former smokers. In a study conducted in India, 900 non-medical staff monitored 1.1 million people for 3 years for cause of death taking place in this population. TB was the biggest cause of death reported in this study in India, and 66% of those who died of TB during the study, were active smokers.

Mortality rates, particularly from Asian countries suggest that there is an urgent need to target TB patients for smoking cessation interventions.

The second edition of the International Standards of Tuberculosis Care (ISTC), which is an official component of the WHO Stop TB Strategy also mentions tobacco smoking cessation among other measures to improve TB treatment outcomes. The ISTC standard 17 says: "This plan should include assessment of and referrals for treatment of other illnesses with particular attention to those known to affect treatment outcome, for instance care for diabetes mellitus, drug and alcohol treatment programs, tobacco smoking cessation programs, and other psychosocial support services, or to such services as antenatal or well baby care.

Tobacco cessation is an important part of the comprehensive tobacco control programme, but not the only part. So all components of the comprehensive tobacco control measures should be implemented for improving public health outcomes. All countries should implement the global tobacco treaty formally known as the WHO Framework Convention on Tobacco Control (FCTC). Comprehensive tobacco control programmes can yield major public health outcomes, as 30% of male TB patients die of tobacco smoking.

According to PATH Canada factsheet, "For the poor, daily spending on tobacco represents a daily drain on scant family resources. Yet in many countries it is precisely the poor who use tobacco the most. In Bangladesh, smoking rates are twice as high in the lowest income group as in the highest."

According to the World Health Organization (WHO), "it is the poorer and the poorest who tend to smoke the most. Globally, 84% of smokers live in developing and transitional economy countries." The WHO further adds: "Together, tobacco and poverty create a vicious circle. In most countries, tobacco use tends to be higher among the poor. Poor families, in turn, spend a larger proportion of their income on tobacco. Money spent on tobacco cannot be spent on basic human needs such as food, shelter, education and healthcare. Tobacco can also worsen poverty among users and their families since tobacco users are at much higher risk of falling ill and dying prematurely of cancers, heart attacks, respiratory diseases or other tobacco-related diseases, depriving families of much-needed income and imposing additional costs for healthcare."

The risk to develop active TB disease is higher when tobacco smoking is combined with alcohol.

The poor people are undoubtedly most hard hit by TB, tobacco and COPD, and are least likely to have access to existing services. Collaboration between different single disease or other programmes that are addressing poverty in communities will be truly beneficial and have major public health outcomes.

Bobby Ramakant - CNS