Decades of failure to end TB and tobacco use

Shobha Shukla *

Despite strong scientific and community-based evidence to support tobacco and TB control, 1.1 million people died of TB in 2023 and over 8 million died of tobacco use in the same year. “Tobacco is an entirely preventable epidemic,” rightly said Dr Tara Singh Bam who is a force for change when it comes to stronger actions to prevent avoidable diseases and save lives in low- and middle-income countries.

TB too is preventable, and no one needs to die of it. We have the tools to find all TB, treat all and prevent all TB but the ground reality is that TB is neither preventable, not treatable for millions of people every year. In 2023, over 10.8 million people got infected with TB worldwide (and 1.1 million died of TB), said Dr Tara Singh Bam citing the recently released WHO Global TB Report 2024.

Dr Bam serves as Board Director of Asia Pacific Cities Alliance for Health and Development (APCAT), Asia Pacific Director for Tobacco Control at Vital Strategies, and till very recently served as Asia Pacific Director of International Union Against TB and Lung Disease (The Union). The Indonesian Ministry of Health had awarded Dr Bam in recognition of his nearly two decades of contribution to public health earlier this year.

TB and tobacco: dual pandemics

Tobacco smoking increases the risk of developing TB and makes TB treatment less effective – and – heightens risk of many other deadly diseases too.

Extensive scientific research underlines tobacco smoking’s substantial role in TB, amplifying the risk of infection, death, treatment relapse, heightened clinical severity, and delays in both: diagnosis and treatment, said Dr Tara Singh Bam. He was speaking at ‘Meet the Expert’ special session at the World Conference on Lung Health 2024 that was recently held in Bali, Indonesia.

Delayed diagnosis and treatment also mean that the person with TB suffers more, has a higher risk of TB death, while the infection spreads to potentially more people – all of this is so avoidable.

WHO lists tobacco use among the top 5 risk factors for TB – almost one in six TB deaths occur because of tobacco smoking. Tobacco use is also directly linked to dangerously increasing the risk of a range of life-threatening conditions, such as heart diseases and stroke, cancers, diabetes, chronic respiratory diseases, among others.

“Every single disease caused by tobacco is entirely preventable. Even one death is a death too many when it comes to tobacco and TB –because we have a range of evidence-based tools to save lives,” said Dr Bam.

As per the WHO Global TB Report 2024, globally 702,000 people suffered from active TB disease in 2023 because of tobacco use (out of 8 million). Almost half of them came from South-East Asian region (328,000). 191,000 people in Western Pacific region, and 89,000 people in Africa got TB disease due to tobacco use in 2023.

Dr Bam cited data from the latest Tobacco Atlas and said: “One in four TB deaths in China was because of tobacco use (25%). Nepal followed closely with 19.4% TB deaths occurring due to tobacco use. Next in line were Vietnam (17.8%), Philippines (17.5%), Indonesia (17%), Malaysia (16.7%), Myanmar (16.3%), Bangladesh (15.2%), Thailand (14.2%), and India (13%).

Tobacco delayed TB diagnosis and treatment in Nepal

Dr Donald Enarson who made lifetime and game-changing contribution to lung health worldwide, Dr Dirgha Singh Bam (former head of Nepal’s TB programme and former Health Secretary of Nepal government) and Dr Tara Singh Bam among others, did a study published in International Journal of TB and Lung Disease in 2016.

This study showed that delay in health seeking behaviour as well as TB diagnostic delay was alarmingly higher in those with tobacco use history.

Current smokers had the highest risk of long TB diagnostic delays (average: 133 days), followed by ex-smokers (103 days). Average delay in those who never smoked was 80 days.

There should be no delay in TB diagnosis. Early and accurate TB diagnosis is an entry-gate towards TB treatment, care pathway, reduces avoidable human suffering and risk of TB death. Early and accurate diagnosis of TB also stops the spread of infection.

Better TB treatment outcomes in those who quit tobacco use

A study published in 2022 in the reputed journal Thorax showed that TB treatment outcomes were significantly better among those patients who had quit tobacco use during the TB treatment in Pakistan and Bangladesh. More than 91% of TB patients who had quit tobacco use during TB treatment were successful in completing the therapy (compared to 80% who did not quit tobacco use).

TB relapse rates were also higher among those who did not quit tobacco use during TB treatment- 6% among those who had quit tobacco use and 14% among those who had not quit tobacco use during the treatment reported TB relapse.

Local actions for global goal to end TB and tobacco

Our leaders need to walk the talk on making health a fundamental human right for everyone.

Dr Tara Singh Bam calls for national laws that support this so that everyone is protected from the deadly impact of tobacco products as well as from TB.

“Break the siloes,” said Dr Bam as there is an urgent need for a range of health and development programmes to join forces at all levels – especially at sub-national level, so that the benefits of this convergence can reach the people most in need.

Once TB, tobacco and other programmes join hands to enhance public health outcomes and resource maximisation, we need to train healthcare workers on both: TB and tobacco. For example, everyone should get screened for TB in healthcare facilities and those with history of tobacco use, must be offered effective evidence-based tobacco quitting programmes and support. Quitting tobacco will help reduce burden of so many diseases, said Dr Bam.

Local leadership of sub-national leaders in advancing health and accountability has proven to make a major difference in over 80 cities of 12 countries where the Asia Pacific regional network consisting of Mayors, Members of Parliament, Governors, and other sub-national leaders and experts is active. This network is formally known as APCAT (Asia Pacific Cities Alliance for Health and Development).

In the context of addressing the dual pandemics of TB and tobacco, APCAT has made a huge difference in protecting the people from both – and more (such as NCDs).

There are a lot of doable science and evidence-based actions that must get implemented locally. Some of these are - raising awareness about “saying no to all forms of tobacco use”, screening people for both (tobacco use and TB), early and accurate TB detection and linkage to care, treatment adherence support, ending all forms of TB related stigma, engaging TB survivors meaningfully to make a difference, implementing the full package of evidence-based tobacco control interventions recommended by the WHO (including raising taxes and smokefree policies), ensuring that effective tobacco cessation services are functional across the healthcare facilities, and, most importantly, protecting public health from tobacco industry interference.

Tobacco industry interference in public health policy is the biggest obstacle in implementing tobacco control policies. That is why the legally binding global tobacco treaty, formally called the WHO Framework Convention on Tobacco Control, has an important Article 5.3 that was adopted by governments in 2008. Preamble of WHO FCTC Article 5.3 clearly states to protect public health policy from tobacco industry interference because there is a direct and irreconcilable conflict of interest between the two. WHO FCTC Article 19 calls to hold tobacco industries liable for the harm they cause.

“Break the chain of TB transmission and protect all people from tobacco use,” emphasises Dr Bam.

Science has proven that it is critically important to screen everyone in high TB burden settings (not just those with symptoms) for TB with WHO recommended tools and offer them upfront molecular testing and linkage to treatment, care and support. Not doing so is among the factors responsible for decades of failure in TB response.

Same goes for tobacco control. No one needs to suffer from diseases caused by tobacco use or die of them. Not implementing tobacco control policies effectively and protecting everyone from tobacco use worldwide is another major failure.

It is high time we course-correct and prioritise people over profits.