1. Tuberculosis (TB) causes estimated 2 million deaths per year and is a serious public health problem in many low- and middle-income countries, particularly in densely populated areas such as Rio de Janeiro: High TB incidence 7,000 new cases/year Typical smoking prevalence (20%) Free access to NRT 52% smokers among TB patients Despite the fact that a very high percentage of tuberculosis patients smoke, smoking cessation interventions in TB patients have not been reported. 1,2 Background Smoking Cessation in DOTS Clinics in Rio de Janeiro Enhancing tuberculosis treatment through smoking cessation Nick K. Schneider, MD,[1] José R. Lapa e Silva, MD PhD,[2] Betina Durovni, MD,[3] Sabrina Presman,[3] Alberto J. de Araújo, MD,[4] Stella Aguinaga Bialous, RN PhD,[5] Andrea B. Sereno, MD,[2] Thomas E. Novotny, MD MPH[1] [1] Center for Tobacco Control Research and Education, University of California, San Francisco, [2] Federal University of Rio de Janeiro, [3] Rio de Janeiro City Health Department [4] NETT, Federal University of Rio de Janeiro, [5] Tobacco Policy International, San Francisco Nick K. Schneider, Center for Tobacco Control Research and Education, University of California, San Francisco, email: nick.schneider@ucsf.edu Literature review: ”tuberculosis”, “smoking”, “immunology”, “smoking cessation”, “pathogenesis” Study Design Qualitative pilot study (2007-2008) –Feasibility (2 DOTS clinics) Randomized Clinical Trial (2008-2009) –Effectiveness (18 DOTS clinics) Multicenter Study (2009 - 2014) –Generalizability (several countries) Methods Conclusion Smoking cessation should be included in local, national, and international TB treatment programs. Additional research is needed to fully evaluate the benefit of this transdisciplinary intervention in communicable and non-communicable disease control. References 1 Slama K, Chiang CY, Enarson DA. Introducing brief advice in tuberculosis services. Int J Tuberc Lung Dis 2007;11(5):496-9 2 Enarson DA, Slama K, Chiang CY. Providing and monitoring quality service for smoking cessation in tuberculosis care. Int J Tuberc Lung Dis 2007;11(8):838-47. 3 Lin HH, Ezzati M, Murray M. Tobacco Smoke, Indoor Air Pollution and Tuberculosis: A Systematic Review and Meta-Analysis. PLoS Med 2007;4(1):e20 4 Bates MN, Khalakdina A, Pai M, Chang L, Lessa F, Smith KR. Risk of Tuberculosis From Exposure to Tobacco Smoke: A Systematic Review and Meta-analysis. Arch Intern Med 2007;167(4):335-42 5 Davies PD, Yew WW, Ganguly D, Davidow AL, Reichman LB, Dheda K, et al. Smoking and tuberculosis: the epidemiological association and immunopathogenesis. Trans R Soc Trop Med Hyg 2006;100(4):291-8 6 Houtmeyers E, Gosselink R, Gayan-Ramirez G, et al. Regulation of mucociliary clearance in health and disease. Eur Respir J 1999;13:1177-1188 7 Sopori M. Effects of cigarette smoke on the immune system. Nat Rev Immunol 2002;2:372-377 8 Arcavi L, Benowitz NL. Cigarette smoking and infection. Arch Intern Med 2004;164(20):2206-16 Discussion Directly Observed Therapy Short Course (DOTS) Frequent patient-provider interaction (several times a week over at least 6 months) Smoking cessation counseling for TB patients theoretically feasible and cost-effective An ideal and novel setting for smoking cessation counseling, NRT, and evaluation Addition of cessation counseling and NRT to DOTS: May improve TB treatment outcomes May improve general health of TB patients May reduce treatment failure and relapse May reduce household spread We expect Increased smoking cessation rates Earlier sputum smear conversion time Shortened infectivity and earlier hospital discharge We need More interaction between TB treatment providers and smoking cessation programs Well-designed research, including randomized controlled trials, to evaluate efficacy and cost effectiveness OutcomePredictorOdds Ratio / Relative RiskStudy designStudiesSource TB infectionever smokingRR 1.73 ( 95% CI 1.46-2.04)Systematic review and meta-analysis 5 Bates MN, Khalakdina A, Pai M, Chang L, Lessa F, Smith KR. Arch Intern Med 2007;167(4):335-42 TB morbidityever smokingRR 2.33 (95% CI 1.93-2.71)Systematic review and meta-analysis 16 Bates MN, Khalakdina A, Pai M, Chang L, Lessa F, Smith KR. Arch Intern Med 2007;167(4):335-42 current smokingRR 2.66 (95% CI 2.15-3.28)Systematic review and meta-analysis 7 Bates MN, Khalakdina A, Pai M, Chang L, Lessa F, Smith KR. Arch Intern Med 2007;167(4):335-42 Latent TB infectionpassive smokingOR 2.68 (95% CI 1.52-4.71)Systematic review and meta-analysis 1 Singh M, Mynak ML, Kumar L, Mathew JL, Jindal SK. Arch Dis Child 2005;90(6):624-8. Dose responsepassive smoking close contact aOR 9.31 (95% CI 3.14-27.58)Case control1 Tipayamongkholgul M, Podhipak A, Chearskul S, Sunakorn P. Southeast Asian J Trop Med Public Health 2005;36(1):145-50. passive smoking distant contact aOR 0.54 (95% CI 0.25-1.16)Case control1 Tipayamongkholgul M, Podhipak A, Chearskul S, Sunakorn P. Southeast Asian J Trop Med Public Health 2005;36(1):145-50. “Smokers are twice as likely as non-smokers to die of tuberculosis” Fig.1: Cartoon and text from the Bangladesh Anti-Tobacco Alliance, BATA (warning sticker, http://bata.globalink.org/image/materials/tuberculosis.jpg) Mural by John Lewis, 1810 North 16th Street, Philadelphia Results Smoking and TB Increased risk for TB infection, morbidity, infectivity, and mortality (table 1) 3-5 High smoking prevalence among TB patients Rio de Janeiro: 52% The effects of tobacco smoking on the immune system may explain increased TB risks 6-8 Most immunologic abnormalities due to tobacco smoke are reversible within 6 weeks of smoking cessation 8 Directly Observed Therapy Short Course (DOTS) Frequent patient-provider interaction – several times a week – at least 6 months Smoking cessation counseling – theoretically feasible – cost-effective Ideal and novel setting Table 1: Association between active and passive smoking with TB infection and morbidity