Kamran Siddiqi

Clinical diagnosis of smear-negative pulmonary tuberculosis in low-income countries: the current evidence.

Sputum smear examination for acid-fast bacilli (AFB) can diagnose up to 50-60% of cases of pulmonary tuberculosis in well-equipped laboratories. In low-income countries, poor access to high-quality microscopy services contributes to even lower rates of AFB detection. Furthermore, in countries with high prevalence of both pulmonary tuberculosis and HIV infection, the detection rate is even lower owing to the paucibacillary nature of pulmonary tuberculosis in patients with HIV infection. In the absence of positive sputum smears for AFB, at primary care level, most cases of pulmonary tuberculosis are diagnosed on the basis of clinical and radiological indicators. This review aims to evaluate various criteria, algorithms, scoring systems, and clinical indicators used in low-income countries in the diagnosis of pulmonary tuberculosis in people with suspected tuberculosis but repeated negative sputum smears. Several algorithms and clinical scoring systems based on local epidemiology have been developed to predict smear-negative tuberculosis. Few of these have been validated within the local context. However, in areas where smear-negative tuberculosis poses a major public-health problem, these algorithms may be useful to national tuberculosis programmes by providing a starting point for development their own context-specific diagnostic guidelines.

Action to stop smoking in suspected tuberculosis (ASSIST) in Pakistan: a cluster randomized, controlled trial.

BACKGROUND Tobacco use is responsible for a large proportion of the total disease burden from tuberculosis. Pakistan is one of the 10 high-burden countries for both tuberculosis and tobacco use. OBJECTIVE To assess the effectiveness of a behavioral support intervention and bupropion in achieving 6-month continuous abstinence in adult smokers with suspected pulmonary tuberculosis. DESIGN Cluster randomized, controlled trial. (Current Controlled Trials: ISRCTN08829879) SETTING Health centers in the Jhang and Sargodha districts in Pakistan. PATIENTS 1955 adult smokers with suspected tuberculosis. INTERVENTION Health centers were randomly assigned to provide 2 brief behavioral support sessions (BSS), BSS plus 7 weeks of bupropion therapy (BSS+), or usual care. MEASUREMENTS The primary end point was continuous abstinence at 6 months after the quit date and was determined by carbon monoxide levels in patients. Secondary end points were point abstinence at 1 and 6 months. RESULTS Both treatments led to statistically significant relative risks (RRs) for abstinence compared with usual care (RR for BSS+, 8.2 [95% CI, 3.7 to 18.2]; RR for BSS, 7.4 [CI, 3.4 to 16.4]). Equivalence between the treatments could not be established. In the BSS+ group, 275 of 606 patients (45.4% [CI, 41.4% to 49.4%]) achieved continuous abstinence compared with 254 of 620 (41.0% [CI, 37.1% to 45.0%]) in the BSS group and 52 of 615 (8.5% [CI, 6.4% to 10.9%]) in the usual care group. There was substantial heterogeneity of program effects across clusters. LIMITATIONS Imbalances in the urban and rural proportions and smoking habits among treatment groups, and inability to confirm adherence to bupropion treatment and validate longer-term abstinence or the effect of smoking cessation on tuberculosis outcomes. CONCLUSION Behavioral support alone or in combination with bupropion is effective in promoting cessation in smokers with suspected tuberculosis. PRIMARY FUNDING SOURCE International Development Research Centre.

Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries

BackgroundSmokeless tobacco is consumed in most countries in the world. In view of its widespread use and increasing awareness of the associated risks, there is a need for a detailed assessment of its impact on health. We present the first global estimates of the burden of disease due to consumption of smokeless tobacco by adults.MethodsThe burden attributable to smokeless tobacco use in adults was estimated as a proportion of the disability-adjusted life-years (DALYs) lost and deaths reported in the 2010 Global Burden of Disease study. We used the comparative risk assessment method, which evaluates changes in population health that result from modifying a population’s exposure to a risk factor. Population exposure was extrapolated from country-specific prevalence of smokeless tobacco consumption, and changes in population health were estimated using disease-specific risk estimates (relative risks/odds ratios) associated with it. Country-specific prevalence estimates were obtained through systematically searching for all relevant studies. Disease-specific risks were estimated by conducting systematic reviews and meta-analyses based on epidemiological studies.ResultsWe found adult smokeless tobacco consumption figures for 115 countries and estimated burden of disease figures for 113 of these countries. Our estimates indicate that in 2010, smokeless tobacco use led to 1.7 million DALYs lost and 62,283 deaths due to cancers of mouth, pharynx and oesophagus and, based on data from the benchmark 52 country INTERHEART study, 4.7 million DALYs lost and 204,309 deaths from ischaemic heart disease. Over 85 % of this burden was in South-East Asia.ConclusionsSmokeless tobacco results in considerable, potentially preventable, global morbidity and mortality from cancer; estimates in relation to ischaemic heart disease need to be interpreted with more caution, but nonetheless suggest that the likely burden of disease is also substantial. The World Health Organization needs to consider incorporating regulation of smokeless tobacco into its Framework Convention for Tobacco Control.

An integrated approach to treat tobacco addiction in countries with high tuberculosis incidence

Communicable diseases as well as maternal and child health in low‐ and middle‐income countries continue to be the main focus of global attention. There are also rising trends in the prevalence of non‐communicable diseases and further increases are predicted. Several countries are facing this ‘dual burden of disease’. There is therefore a need to find ways to integrate the prevention and control of non‐communicable diseases into the current health agenda. Tobacco treatment interventions in patients suspected with tuberculosis (TB) offer one such opportunity for a linked healthcare response. Many countries with a high incidence of TB are doubly burdened by an epidemic of tobacco use and tobacco‐related diseases. Tobacco use increases the risk of TB infection and is associated with poor treatment compliance, increases in relapse rates and higher secondary mortality. In countries where TB is epidemic, this modest relative risk of infection leads to a significant attributable risk. Regular clinical contact with patients suspected with TB during the diagnosis and treatment phases provides considerable opportunity for health promotion to influence their tobacco‐related behaviour. Consequently, treating tobacco addiction in patients suspected with TB is likely to improve the control of TB and prevent tobacco‐related diseases. However, despite a high prevalence of tobacco use among TB patients, the treatment of tobacco addiction has not been a priority of TB control programmes. In countries with the dual epidemics of TB and tobacco use, considerable health and economic gains could potentially be made. If effective, such an approach would be highly desirable. We argue that further research assessing the cost‐effectiveness and feasibility of linking healthcare interventions such as the treatment of tobacco addiction among TB suspects should receive high priority.

Do electronic cigarettes increase cigarette smoking in UK adolescents? Evidence from a 12-month prospective study.

Background In cross-sectional surveys, increasing numbers of adolescents report using both electronic cigarettes (e-cigarettes) and cigarettes. This study assessed whether adolescent e-cigarette use was associated prospectively with initiation or escalation of cigarette use. Methods Data were from 2836 adolescents (aged 13–14 years at baseline) in 20 schools in England. At baseline, breath carbon monoxide levels, self-reported e-cigarette and cigarette use, sex, age, friends and family smoking, beliefs about cigarette use and percentage receiving free school meals (measure of socioeconomic status) were assessed. At 12-month follow-up, self-reported cigarette use was assessed and validated by breath carbon monoxide levels. Results At baseline, 34.2% of adolescents reported ever using e-cigarettes (16.0% used only e-cigarettes). Baseline ever use of e-cigarettes was strongly associated with subsequent initiation (n=1726; OR 5.38, 95% CI 4.02 to 7.22; controlling for covariates, OR 4.06, 95% CI 2.94 to 5.60) and escalation (n=318; OR 1.91, 95% CI 1.14 to 3.21; controlling for covariates, this effect became non-significant, OR 1.39, 95% CI 0.97 to 1.82) of cigarette use. Conclusions This is the first study to report prospective relationships between ever use of e-cigarettes and initiation and escalation of cigarette use among UK adolescents. Ever use of e-cigarettes was robustly associated with initiation but more modestly related to escalation of cigarette use. Further research with longer follow-up in a broader age range of adolescents is required.

Children's exposure to second-hand smoke in the home: a household survey in the North of England.

Exposure of children to second-hand smoke (SHS) leads to increased risk of health and social problems and uptake of smoking in the future. We aimed to assess the prevalence of childrens exposure to SHS in their homes, in a deprived area in the North of England and identify what people thought would help them achieve a smoke-free home (SFH). We performed a cross-sectional survey of 318 households with at least one child aged under 16 years in Beeston Hill, a deprived locality in Leeds, England in June 2008. One hundred and seventy-three households [54%, 95% confidence interval (C.I.) 49-60] had at least one smoker in the house. In 42% (95% C.I. 35-50) of these households (n = 73), smoking took place in the presence of children. The odds of allowing smoking in front of children were 2.2 (95% C.I. 1.1-4.5) times greater in households whose head had less than A-level (national exams at 18 years) or equivalent qualification than in homes with a more qualified head of household. 92% of respondents were aware that SHS has negative effects on childrens health. However, 71% felt more information about health risks to children would help reduce exposure to SHS in the home. Smoking in the presence of children takes place in a relatively high proportion of households with smoker(s), despite media awareness campaigns regarding the dangers of passive smoking launched alongside the recently enforced smoke-free public and workplaces legislation. Specific promotion of SFHs is needed to protect the health of children.

Can a community-based ‘smoke-free homes’ intervention persuade families to apply smoking restrictions at homes?

BACKGROUND Children are commonly exposed to second-hand smoke (SHS). The aim of this study is to evaluate the feasibility, acceptability and outcome of Smoke-Free Homes (SFH), a community-based intervention; and assess potential evaluation methods. METHODS SFH, designed to encourage families to implement smoking restrictions at home, was delivered over a period of 6 months through schools, healthcare settings and community events in Beeston, South Leeds, UK. It was evaluated using baseline and post-implementation surveys, focus group discussions and promise forms follow-up. RESULTS We surveyed 318 households before, and 217 households after, the intervention. The proportion of all surveyed households reporting being completely smoke free significantly increased from 35% [95% confidence interval (CI) 30, 40] at baseline to 68% (95% CI: 61, 74) 6 months post-implementation (P < 0.0001). Ninety per cent of people, followed-up by telephone 3 months after signing SFH promise form, said they were still keeping their promise. Focus group discussions with children and parents conveyed acceptability of the intervention, in particular, the schools element, where children are encouraged to discuss the concept of SFH with the adults in their households. CONCLUSIONS Our study shows that SFH can be implemented effectively and has the potential to improve childrens health through preventing exposure to SHS in the home.

Clinical guidelines to diagnose smear‐negative pulmonary tuberculosis in Pakistan, a country with low‐HIV prevalence

Objectives  To develop and validate clinical guidelines for diagnosis of smear‐negative pulmonary tuberculosis (TB) in developing countries with low‐HIV prevalence.

Putting evidence into practice in low-resource settings

of at least two major steps: the first is to translate evidence into context-specific and user-friendly formats (such as algorithms, guidelines and desktop guides), requiring resources, support and specific skills; the second — which is perhaps even more challenging — is to ensure that clinical practitioners adopt the available evidence into practice. Knowledge on the effectiveness of various in terventions to influence clinical practice in low-resource settings is limited and is flawed because of weak research design (2). Moreover, a strong publication bias against reports from developing countries with negative results contributes to our lack of understanding of barriers to implementing such interventions (3). The effectiveness of a one-off training session is also questionable. Continuing medical education and formal training that focuses on local educational needs and barriers to implementing evidence are likely to be effective in influencing clinical practice, although more research is needed to demonstrate unequivocally the cost–effectiveness of continuing

Smokeless tobacco control policies in South Asia: a gap analysis and recommendations.

INTRODUCTION Almost a fifth of the worlds tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these. METHODS We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations. RESULTS We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit. CONCLUSIONS Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.