Intensive Smoking-cessation Versus Basic Smoking-cessation Advice in Smear-positive Patients With Pulmonary Tuberculosis

The aim of the study is to determine the impact of a package of smoking-cessation interventions on a composite measure of Tuberculosis (TB) treatment-related outcomes.

Given the lack of objective clinical data/evidence about the impact of smoking-cessation on TB-related outcomes, yet subjective expert opinion that smoking cessation is highly likely to be beneficial particularly in patients with TB, this study proposes to determine what the impact is of an intensive package of smoking-cessation interventions aimed to promote smoking-cessation (counseling plus nicotine replacement therapy, NRT), on patient response to anti-tuberculosis therapy. This is to be compared with the conventional/standard, basic smoking-cessation advice that is recommended to be routinely provided by health care workers to all patients who are smokers. If the results prove that such a smoking-cessation PI indeed improves outcomes in TB patients, such information would strongly motivate for the institution of more intensive smoking-cessation interventions in TB clinics than is currently being employed for TB patients

No clinical trials have been done to determine if the cessation of smoking has any influence on outcome in tuberculosis patients. In particular, if smoking cessation leads to a higher rate of sputum culture-conversion at 2 months, TB transmission rates should be reduced. Such targeted smoking-cessation intervention may be more successful than general public education strategies in reducing the spread of TB in high-incidence countries Tuberculosis (TB) is a major health concern. The WHO has estimated that approximately a third of the world's population is infected with Mycobacterium tuberculosis, and approximately 2 million die from TB every year. Tobacco smoking, which is the single most preventable cause of death in the world today, appears to be an important risk factor for TB disease and mortality, especially in countries such as India. The smoking-TB association has major public health implications because in many of the developing countries where there is a high prevalence of TB, smoking is also a common practice. Smoking is widespread, with approximately a third of the global population aged 15 years or above being smokers, but has reached epidemic proportions in countries such as India, China and Russia. For example, in India more than half of the rural male population is estimated to smoke and India accounts for 1.85 million TB cases each year. Therefore in India, as for other developing countries, the co-existence of a high TB and smoking burden is a major health concern, and further underscores the importance of promoting smoking cessation to the general public. In India, studies have shown a strong association between tobacco and TB mortality. An estimated third of male TB deaths in India may be due to smoking. However, there is concern that many of the published studies did not adequately control for bias and confounding (that may have caused spurious associations).

Study participants will be selected from group of sputum smear positive category-I or Category-II patients who self report to smoke more than 10 cigarette/bidis per day.

• Control arm
  control arm patients will receive basic smoking advise along with routine DOTS treatment
  Intervention: Drug: nicotine replacement therapy
• Cessation arm
  cessation arm patients will receive basic smoking advise along and nicotine replacement therapy(NRT)with routine DOTS treatment

Inclusion Criteria:

• any adult (> 18 years)
• newly-diagnosed smear-positive TB patient who self-reports to smoke at least 10 whole cigarettes or bidis (rolled tobacco leaf) per day, every day

Exclusion Criteria:

• patients will be excluded from recruitment to the study if they fall into any one or more of these exclusion categories:

  • Inability to give consent or < 18 years
  • Patients who self-report to smoke less than 10 whole cigarettes/bidis per day
  • TB patients who have already started anti-tuberculosis therapy for more than 1 week.
  • Patients with known multidrug-resistant TB (or XDR) (information provided by patient or the information is available in the clinic folder). However no new testing for resistant TB will be performed as part of the study protocol.
  • Known HIV-positive patients
  • Contra-indications to NRT (patients with a history of severe cardiovascular disease including arrhythmias, recent myocardial infarction (within the last 6 months), recent cerebrovascular incident (6 months), and/ or history of peripheral vascular disease, phaeochromocytoma, poorly controlled diabetes mellitus, hyperthyroidism, renal/hepatic impairment or gastritis/peptic ulcers). Patients with asthma or depression will also be excluded, as quitting may have an effect on medications used for these conditions. Patients with severe skin disorders (such as psoriasis or eczema) will also be excluded.

• University of Cape Town
• Sri Venkateswara Institute of Medical Sciences University