Use of smokeless tobacco by patients with drug-sensitive pulmonary tuberculosis: The need for strengthening tuberculosis–tobacco collaborative in India

INTRODUCTION

India accounts for over one-quarter of the world’s tuberculosis (TB) cases and deaths.¹ India reported an estimated 1.9 million TB cases of the 6.4 million global incident cases in the year 2021.^1,2 As per government reports, India notified 2.14 million cases of TB in 2021.^2,3 Globally, 1.3 billion people use tobacco, and every year, tobacco use accounts for 5.4 million deaths worldwide and is estimated to rise to 8.3 million by 2030.^4–6 To address the largely preventable epidemics of TB and tobacco use, a national framework on TB–tobacco collaborative activities was released in 2017.⁷ The collaborative emphasizes the need for the inclusion of brief tobacco cessation advice in the standard TB case management.

The prevalence of smoking among patients with pulmonary TB is high.^8,9 There was a rising trend in smokeless tobacco use in India till 2005, followed by a slight decline in 2017.¹⁰ However, smokeless tobacco use is still a risk factor and increases the risk of death from TB and other respiratory diseases among men.¹¹ According to the Global Adult Tobacco Survey second round (GATS 2), 35% of adults aged ≥15 years, 48% of men, and 20% of women use tobacco in some form or other.¹²

Bhavnagar region is a predominant tobacco-chewing community in Gujarat (western India).^13,14 The prevalence of smokeless tobacco use has been reported to be 8%–11% among newly diagnosed TB patients, which increased to 27%, six months after the treatment.^15–17 The prevalence of smokeless tobacco use in Gujarat was reported to be as high as 39% among TB patients.¹⁸ However, evidence on the prevalence of smokeless tobacco use and knowledge regarding its hazards among patients with TB is scarce in the region. We estimated the prevalence and determined the predictors of smokeless tobacco use among patients with drug-sensitive pulmonary TB and assessed their knowledge and attitude towards smokeless tobacco use.

METHODS

We did a descriptive cross-sectional study in Bhavnagar city of Gujarat (western India) during April–October 2019. The city is situated 180 km southwest of Ahmedabad (the financial capital city of Gujarat state) and has a population of about 0.6 million.¹⁹ Approximately 750 cases of pulmonary TB are reported in Bhavnagar city every year.²⁰

RESULTS

DISCUSSION

We identified the prevalence and pattern of smokeless tobacco use and its predictors among patients with drug-sensitive pulmonary TB in Bhavnagar city. Almost 4 of 5 study participants knew about the adverse effects of tobacco on TB; however, almost half of the patients used smokeless tobacco. This highlights the need for strengthening the integration between the NTEP and the National Tobacco Control Programme through collaborative activities.⁷ Among South Asian countries, the efforts made by India to develop a TB–tobacco collaborative are well appreciated.^25,26 However, the researchers also highlighted the need for brief cessation support as part of the comprehensive care package for TB.^25,26 The collaboration needs to be cross-cutting across the cascade of care of TB,²⁷ with possible involvement of non-governmental organizations,²⁸ and with special attention to smokeless tobacco.²⁸

Similar to the high prevalence of smoking in India, the prevalence of smokeless tobacco use in our study population was high. A study from Puducherry reported a prevalence of smokeless tobacco use at the time of diagnosis at 10%, which remained so till completion of treatment.²⁹ A study from Karnataka reported that smokeless tobacco use during diagnosis was 40% and 26%, respectively, close to the prevalence reported in our study.^17,30 This difference was attributed to the fact that smokeless tobacco use among the general population was more prevalent in Karnataka compared to Puducherry (GATS survey 2009–2010).³¹ GATS-2 reported that 19% of people in Gujarat (28% men and 10% women) use smokeless tobacco.¹²

Smokeless tobacco is marketed in India in various forms and attractive packaging with easy availability, low cost and injudicious publicity, under little supervision,³² which contributes to its widespread use in all age groups. The Global Youth Tobacco Survey (GYTS) 2009 reported a prevalence of smokeless tobacco use of 9%, while in 2006, it was 9.4%.³³ Comparable to the findings of GYTS 2009 and 2006, our study showed a similar age-wise distribution of smokeless tobacco use.³³ In our study, being a male was significantly associated with smokeless tobacco use. In contrast, a study in urban Puducherry found a male with a lower education level using smoked tobacco products, whereas a female with a lower education level used smokeless tobacco.²⁹ This difference in association could be due to behavioural and cultural differences between females in Gujarat and Puducherry. Conventionally, women have poorer access to money, education, information and health.^34–36 The decision-making regarding a woman’s treatment is made by the husband or senior members of the family.^34–36 Women had to depend on men for their treatment-related expenses and mobility.^34–36

We found that almost all (98%) the participants knew the harmful effects of tobacco use. However, a smaller proportion (79%) of participants knew about the hazardous effects of tobacco on TB. In a study in Malaysia using a 58-item validated questionnaire, 43% of participants believed that smokeless tobacco was a safe and harmless product.⁹ More than half the patients in our study believed that tobacco chewing was fun (60%), helped make more friends (52%) and relieved stress (61%). Studies from Myanmar have reported that similar to our study, tobacco users, including smokeless tobacco users, were significantly associated with a low level of attitude towards tobacco but not with the level of knowledge.^37,38 Evidence suggests that a lower prevalence of smoking was related to being taught about the dangers of smoking.³⁹ A study of 1500 schoolchildren in India suggested an inverse relationship between knowledge about tobacco and the prevalence of smoking.⁴⁰ The authors argued that teaching about the dangers of smoking was highly effective and influenced the smoking habits of students and proposed that the laws on tobacco products and the financial and health hazards should be taught as a part of the school curriculum.⁴⁰ However, the findings of our study were contrary to these findings, where the number of smokeless tobacco users was high despite adequate knowledge of the ill-effects.

The enhanced use of smokeless tobacco products across India is a common practice. Understanding the tobacco use knowledge, attitudes and behaviours of patients with TB is of importance in the provision of behavioural therapy for the cessation of tobacco use. In a cross-sectional study of former patients with TB in Indonesia, over 30% reported that they were never asked about their smoking behaviour or advised about quitting.⁴¹ Hence, necessary health information against the use of nicotine in the form of smokeless tobacco among patients with pulmonary TB must be provided. The attitude towards tobacco use is believed to influence the usage pattern of tobacco. Therefore, to stop the use of tobacco, awareness of the harmful effects of tobacco must be conveyed.³⁷

We found that participants who travel for their occupation had higher chances of using smokeless tobacco. Focused counselling about smokeless tobacco use among patients with pulmonary TB needs to be implemented to prevent its increased usage. Such information will also be of value in designing effective educational intervention programmes to motivate tobacco users to quit and urge non-users to avoid it. The educational programmes can have an impact on the control and prevention of TB and its adverse outcomes such as treatment failure, relapse and poor prognosis.⁴²

Our study being cross-sectional in nature, could not establish causal associations. Furthermore, we did not visit any facility catering to tobacco users to check the status of referrals to the NTEP. Finally, we used self-reported smokeless tobacco use as a measure, rather than relying on biological cotinine levels.

We conclude that the prevalence of smokeless tobacco use was high among patients with drug-sensitive pulmonary TB in Bhavnagar. Despite high awareness about the harms of smokeless tobacco use, patients with TB continued to use tobacco. The existing TB–tobacco collaborative framework needs to be strengthened with brief counselling interventions for patients with TB using smokeless tobacco. The collaborative framework needs to be monitored for its effective implementation and coordination between NTEP and NTCP, linking cessation programmes with a bi-directional screening of tobacco users for TB symptoms. Awareness generation, follow-up, and scale-up of digital initiatives such as telephonic counselling of smokeless tobacco users willing to quit and evidence-based behavioural change text messages on their mobile phones would close the existing gaps in the collaborative framework.