Tobacco use, tobacco cessation and tuberculosis treatment outcomes: Need to connect the DOTS?

Tuberculosis (TB) and tobacco use are currently two formidable public health concerns and independently pose a considerable threat to global health, and India in particular. With nearly 2.6 million TB patients annually, India is the highest tuberculosis burden-country accounting for one-fourth (26 percent) of the global incidence. Every year, around a quarter of a million people die due to TB in India. That is 2 deaths due to TB every 5 minutes. Also, with over 260 million tobacco users, India has over a quarter of the world’s tobacco consumers. Tobacco use kills nearly a million users annually in India.

TB and tobacco use are intricately linked. Almost 38 percent of tuberculosis deaths are associated with tobacco use. It is proven that exposure to tobacco smoke increases the risk of both tuberculosis infection and disease. Tobacco smokers have twice the risk of developing tuberculosis disease when compared to non-smokers. Patients with TB who smoke have twice the risk of death during tuberculosis treatment. There is substantial evidence to link smoking with tuberculosis disease and poor treatment outcomes.

Smoking damages the lungs and makes them more susceptible to TB. Tobacco use also interacts at an immunologic and cellular level to reduce antitubercular treatment efficacy. Although similar data are not available for Indian forms of oral smokeless tobacco products (gutkha, zarda), those products also contain carcinogens and are known to adversely impact the users’ immunity.

Tobacco cessation improves the respiratory tract’s ciliary function and local immunological responses, thereby improving cure rates in people with TB. This TB-tobacco connection is not known or practised by those delivering the DOTS treatment- thus missing out on an opportunistic win-win. E.g. The section for tobacco use history in the medical records of TB patients is more often than not left blank.

Proactively enabling tobacco cessation is essential for improving treatment outcomes in TB patients as well as reducing population-level TB incidence in the long run. India has set an ambitious target to achieve “END TB” goals of 80 percent reduction in incidence and 90 percent reduction in deaths by 2025, which is 5 years earlier than the stipulated timeline. India rebranded its RNTCP (Revised national TB control programme) to NTEP (National TB Elimination Programme) in 2020, to underscore this ambition. Currently, NTEP is well resourced and funded, with treatment centres spread across the country and community, and a strict protocol for administering WHO prescribed DOTS treatment. DOTS consists of a combination of key anti-tuberculosis drugs for six months under observation and adherence monitoring.

India has made great strides in the NTEP. During 2018, among patients with drug-sensitive tuberculosis initiated on antitubercular treatment, an overall success rate of 81 percent was recorded in India. The successful implementation of the DOTS regime is a public health win. However, the present annual rate of decline of TB incidence is around 3 percent, and needs to be accelerated to 11 percent to achieve the desired target. Addressing tobacco use and achieving tobacco cessation among TB patients may hold the key to open the door to another public health success for India.

The latest round of national tobacco use survey for India (GATS 2017) has evidenced that 8.4 percent of the current smokers had intended to quit smoking in the next one month and 38.5 percent of the tobacco users made a quit attempt in the previous 12 months, among whom 71.7 percent attempted without any assistance. As a result, less than 1/4th of all those who attempted to quit sustained abstinence for at least 3 months. A disturbing fact is that among 4.1 percent of the smokers who attempted to quit, switching to smokeless forms of tobacco was mistakenly perceived as a form of cessation. Besides, only 4.1 percent and 8.6 percent of them used pharmacotherapy and counselling advice respectively.

Quitting tobacco use without support is proven to be ineffective and unsustainable for most users. Over the past few decades, clinical research into cessation treatments has given us medications proven to manage the nicotine cravings during quitting. These include nicotine replacement therapy (NRT) products such as nicotine gums, patches and lozenges, and medicines such as bupropion and varenicline. Nicotine replacement therapy products are even on the WHO’s model essential list of medicines, thus underscoring the need to have them available and affordable for treating tobacco addiction globally. A range of behavioural counselling techniques have also been developed and proven to address the habit. A combination of these treatments, tailored to individual needs, and delivered by trained healthcare professionals, has the highest proven likelihood of success to quit tobacco and not relapse.

Improving cessation rates requires the practical implementation of the recommendations of Article 14 of the WHO’s Framework Convention on Tobacco Control (FCTC), to which India is a signatory. The Article states that all parties “shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.” ‘Offer to help quit tobacco use is also one of the six MPOWER strategies (the ‘O’ in the MPOWER) for tobacco control advocated by WHO.

However, the implementation of Article 14 has been sluggish, placing nearly a billion would-be quitters at risk of premature death, globally. In India, the infrastructure is now put in place at each district level in the form of tobacco control cells and cessation rates should see an improvement if the necessary tools and services are available. That may still be a bottleneck.

The cost of nicotine replacement therapy remains unacceptably high, and the availability of the products is limited. Healthcare practitioners do not get any or adequate training in prescribing cessation medications or providing cessation support to their patients. Myths persist among healthcare practitioners on nicotine itself, and many wrongly consider nicotine to be carcinogenic. This leads to poor support to patients for quitting tobacco, sub-optimal cessation outcomes, more failed attempts to quit, and a large residual population of tobacco users who face premature death due to continued tobacco use.

The proven success of DOTS for tuberculosis patients can have its mirror-image for tobacco cessation. Brief advice, accompanied by NRT and/or pharmacotherapy, should be considered as the first line of treatment for tobacco cessation. This would be possible only with adequate training to healthcare professionals across various levels including primary care doctors a DOTS centre staff and secondary or tertiary level of specialists such as psychiatrists and general physicians. Refresher training courses on tobacco cessation are needed on a regular basis for healthcare professionals. The training should also focus on motivating government as well as private sectors to record the use of tobacco products for all patients and offer appropriate and comprehensive support for quitting tobacco.

The journey from tobacco use to the prompt self-reporting of tobacco use, to intention to quit, to seeking appropriate intervention for cessation, and to finally quit smoking seems to have a long hiatus between every pitstop. This leakage in the efficiency of tobacco cessation is impacting outcomes of tuberculosis treatments in terms of higher default rates, poor microbiological conversion, and finally, higher case fatality rates among tuberculosis patients who are also tobacco users. The connection of these widely gapped dots could be a key to achieving the goals of tuberculosis elimination in India by 2025.

Since these two public health problems are under the ambit of their respective national health programmes, a coordinated effort is essential in all the components of the programme deliverables such as training of healthcare personnel on tobacco cessation, use of effective and appropriate technology for tobacco cessation, robust data monitoring, making tobacco cessation medications accessible and affordable, providing behavioural support appropriate for each tobacco user and audits conducted to monitor the effectiveness of these interventions. Designing an effective tobacco cessation programme for tuberculosis patients is the need of the hour in India. These initiatives shall pave the way for effective tobacco cessation interventions that enable improved quit rates among TB patients leading to better TB treatment as well as overall health outcomes.