Tobacco Induced Diseases | 2021
The syndemic challenge of tuberculosis and tobacco use
Abstract
Published by European Publishing. © 2021 Siddiqi K. and Novotny T.E. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License. (https://creativecommons.org/licenses/by/4.0/) Tob. Induc. Dis. 2021;19(March):20 https://doi.org/10.18332/tid/133575 The term ‘syndemic’ describes linked health problems involving two or more conditions that act synergistically, causing an excess burden of disease in the population. These interacting conditions often cluster similarly by person, place, and time. Most importantly, interventions against them must address the underlying conditions that bind the problems together. The global incidence of tuberculosis (TB) has declined over the last few decades, albeit far slower than envisioned by the World Health Organization (WHO). For 2018–2019, TB incidence only declined by 2.3%, suggesting that WHO objectives for 2030 will not be met. Ten million persons were infected in 2019, but the burden of TB disease is highest in lowand middle-income countries (LMICs), where 95% of TB deaths occur. The high TB burden countries include India, Indonesia, China, Philippines, and Bangladesh, and these nations also rank among the top ten countries for daily smoking prevalence. Poverty, poor nutrition, and lack of comprehensive healthcare systems in these nations play into the TB and smoking syndemic. Smoking and secondhand smoke exposure are two of several conditions that exacerbate adverse TB outcomes such as recurrent disease, excess mortality, and treatment failure. These conditions include diabetes, poor nutrition, alcohol use, and HIV infection. Because there are over one billion smokers globally, it is not surprising that 17.6% (95% CI: 8.4–21.4) of new cases and 15.2% (95% CI: 1.8–31.9) of TB deaths are attributable to smoking in high burden countries, regardless of other risk factors. Given the syndemicity of TB and tobacco use, we might ask what would happen if the smoking prevalence among those infected with TB could be effectively reduced through consistent, integrated treatment for tobacco use. Unfortunately, and despite a higher prevalence of smoking in TB patients compared to the general population, the vast majority of TB patients are neither routinely asked about their smoking status nor advised to quit. Some progress has been made to meet the syndemic challenge of TB and smoking. There has been increased interest in policies to help TB patients quit smoking as well as recognition of the need for evidence-based smoking cessation interventions. The WHO and the Union were first to embrace this challenge in the 2007 Monograph on TB and Tobacco Control, which called for further research and the application of cessation assistance in TB programs. There are also a few large randomized-controlled trials (RCTs) conducted in high-TB burden countries, which highlight that face-to-face behavioral interventions can achieve high quit rates among TB patients. Those who quit smoking were shown to have better overall clinical outcomes. In these studies, TB staff were able to deliver behavioral interventions for smoking cessation. However, because of several health system barriers (e.g. cost, reach, sustainability), no high-TB burden country has so far integrated consistent face-to-face behavioral interventions for smoking cessation within its TB services. Recognizing the challenges of integrating and scaling AFFILIATION 1 Department of Health Sciences, University of York, York, United Kingdom 2 School of Public Health, San Diego State University, San Diego, United States