IntroductionThe World Health Organization and the International Union Against Tuberculosis and Lung Disease recognizing the association between tuberculosis (TB) and the tobacco epidemic, recommended joint initiatives by national TB and tobacco control programs . Tobacco is an important risk factor for TB infection and TB disease . Identifying tobacco users and providing tobacco cessation services is expected to reduce the burden of TB 1, 2. In India, 40% of the TB burden is attributed to tobacco use and hence it is important to identify simple cost-effective strategies to combat this risk factor . The World Health Organization recommends the assessment of tobacco use and tobacco cessation services routinely for all diagnosed TB patients . Although this strategy improves the clinical outcomes of TB patients, its role in reducing the burden of TB seems minimal as intervention is directed only for TB patients. Efforts in tobacco control in general are expected to reduce the number of incident TB cases. Since community-based tobacco control strategies are resource intensive and India's National Tobacco Control Program is at infant stage, identifying tobacco users in a health facility will be a short-term alternate option. In this context, a national TB program (NTP) with its well established organizational setup can assist in tobacco control . In a designated microscopy center (DMC) under NTP, we aimed to assess the burden of tobacco use among presumptive TB patients and their willingness to avail of tobacco cessation services at a tertiary care hospital.
2.1 Study design and settingA cross-sectional study was conducted among presumptive TB patients attending a DMC of a tertiary hospital in South India. The tertiary hospital is part of a medical institute, which is an institute of national importance under the Ministry of Health and Family Welfare, Government of India. People from most states of South India seek care from the tertiary hospital and all the medical services are provided free of cost.The DMC was functioning under the supervision of the Department of Pulmonary Medicine at JIPMER (Jawaharlal Institute of Postgraduate Medical Education & Research), Pondicherry, India. The presumptive TB patients (suspects) from all the departments in the hospital were referred to DMC for diagnosis of TB. On average, 30 presumptive TB patients were referred each day. DMC functions on all the working days from 9.00 AM to 12.30 PM. The presumptive TB patients referred to DMC were tested for TB using Revised National Tuberculosis Control Program guidelines.
2.2 Study population and sample sizeAll presumptive TB patients aged ≥ 18 years attending the DMC during the month of July in 2014 were eligible for the present study. The sample size was calculated assuming the prevalence of tobacco use among presumptive TB patients was the same as that in the adult population of the neighboring state of Tamil Nadu. The sample size was calculated using OpenEpi software (Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version 3.01), with a 16% prevalence of tobacco use as per the NFHS-3 survey , with an absolute precision of 4% and a 95% confidence interval. The minimum number of presumptive TB patients to be included in the study was 336.
2.3 SamplingOn average, around 500 presumptive TB patients availed of DMC services. All the adult (age, ≥ 18 years) presumptive TB patients who attended the DMC during the month of August in 2015, were included in the study.
2.4 Study variables and study toolData on presumptive TB patient's age, sex, tobacco use and forms of tobacco, attempts to quit tobacco since 1 year, and willingness to attend the smoking cessation clinic in the tertiary hospital were captured. Tobacco use history in any form in the last month was considered as “tobacco use,”. A pretested, semistructured interview schedule was used to extract information. After obtaining informed consent from the presumptive TB patients, the interview was conducted by a Bachelor of Medicine/Bachelor of Surgery student.
2.5 Data entry and analysisData were entered and analyzed using EpiData (EpiData Association, Odense, Denmark). Frequencies and percentages were used to summarize tobacco use. Relative risk with 95% confidence interval was calculated to assess the possible association of age, sex, and education with tobacco use. The number needed to identify a presumptive TB patient with tobacco use was calculated for the above mentioned variables.
2.6 Ethical considerationThe study was approved by the Human Institute Ethics Committee of Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. After completing the interview, presumptive TB patients with “tobacco use” were given a brief intervention by the interviewer to quit tobacco.
ResultsA total of 424 presumptive TB patients were interviewed. The mean (standard deviation) age of presumptive TB patients was 44 (16) years; 248 (58.5%) were men and three-quarters had some formal education. Tobacco use in previous 1 month was reported by 176 (41.5%, 95% confidence interval: 36.9–46.3%) presumptive TB patients; 75% of them reporting tobacco use in smoke form and the rest (25%) in a smokeless form (Figure 1). Among presumptive TB patients using tobacco in smoke form, all except one were daily users. Of the 132 smokers, 83 (62.9%) had attempted to quit in past 1 year. Of the 132 smokers, 70 (53%) were willing to avail of tobacco cessation services, if provided. In total, 78 out of 424 presumptive TB patients were eventually diagnosed with smear-positive pulmonary TB, of them 63 (80%) were tobacco users.Table 1 shows the relationship between socio-demographic variables and tobacco use. Age, sex, and educational level were significantly associated with tobacco use. The number needed to identify a tobacco user was low for presumptive TB patients aged ≥ 30 years, male sex, and schooling for < 10 years.
DiscussionThis is the first study from India on tobacco use among presumptive TB patients. Four out of 10 presumptive TB patients reported tobacco use in past 1 month, which is nearly double compared with that of general population reported in The Global Adult Tobacco Survey . A similar finding has been reported among presumptive TB patients from Cape Town, South Africa (57%) . This high level was expected as tobacco smoke is known to cause respiratory morbidity mainly manifesting as a cough for a long duration. In developing countries like India where TB is a common provisional diagnosis, evaluating presumptive TB patients with a cough at DMCs provides an opportunity to screen for tobacco use and counsel for further cessation services.More than half of tobacco smokers had reported their willingness to use cessation services if provided at the same study setting. The willingness was even higher among those who had attempted to quit and failed in the past 1 year. However, community-based studies from India reported low levels (11% and 20%) of “intention to quit” tobacco 8, 9. Possibly, the former presumptive TB patients could have related the present symptoms to their smoking behavior.The study has few implications for TB and tobacco control programs. Firstly, as tobacco smoking is associated with TB, identifying the tobacco smokers and initiating control measures will help the TB program in the long run. Secondly, since the national tobacco control programs are in their infancy, opportunistic screening for tobacco use using the existing manpower within the NTP and simple screening questions might be cost-effective compared with community-based screening. Thirdly, as screening takes place at health care facilities where patients seek care for their perceived severe symptoms, tobacco users will be more receptive for cessation measures. In developing countries, deaddiction services are almost only available tertiary care hospitals and hence linking to these services will be easier at tertiary hospitals.This operational research was conducted within the existing program personnel and infrastructure. We followed sound ethics principles and Strengthening the Reporting of Observational Studies in Epidemiology guidelines for the conduct and reporting of this observational study 10, 11. Responses related to willingness to attend cessation clinics could have been influenced by social desirability. Also, willingness was assessed only among tobacco smokers.In conclusion, tobacco use among presumptive TB patients was high. Considering the high willingness to quit among smokers, proven brief interventions to help quit smoking can be tried. This will not only benefit the TB control program but also prevent a wide array of morbidities related to tobacco use.