European Journal of Cardiovascular Medicine

More than one-fourth of the TB (tuberculosis) associated death and cases across the globe are attributed by India alone. India has reported nearly 1.9 million cases of tuberculosis from 6.4 million total cases Worldwide following the data of year 2021. Following government data, 2.14 million cases of tuberculosis are reported in India in year 2021. Tobacco is being used by 1.3 billion population where every year 5.4 million deaths are reported globally from tobacco use alone which is expected to increase by 8.3 million by the end of year 2030. To consider the largely preventable TB epidemics and use of tobacco, in 2017, a national framework on TB–tobacco collaborative activities was released. The collaboration focusses on the need for including brief tobacco cessation advice in standard management of tuberculosis cases.¹

There is a high prevalence of smoking in subjects with pulmonary tuberculosis. There is an increase in the trend of using smokeless tobacco in India till year 2005 with a slight decrease seen in year 2017. However, the use of smokeless tobacco is tilla risk factor and increase the associated risk of death from respiratory diseases and tuberculosis in male subjects. Following GATS-2 (Global Adult Tobacco Survey second round), 35% of adult subjects from the age range of ≥15 years, 20% females and 48% male subjects use tobacco in either one form or other.²

India as a country is a predominant community having a habit of chewing tobacco with higher prevalence in under developed area. The prevalence of using smokeless tobacco is reported in 8-11% subjects that have been diagnosed newly for tuberculosis which is increased to 27% after 6 months of their treatment. The prevalence of using smokeless tobacco in few regions of India is reported to be 39%.³

Despite its ill-effects and adverse reactions, there is scarce knowledge concerning the evidence on the prevalence of smokeless tobacco use in  context.⁴ Hence, the present study was aimed to assess the predictors and prevalence of smokeless tobacco use and its awareness in  subjects having pulmonary tuberculosis.

The present descriptive cross-sectional study was aimed to assess the predictors and prevalence of smokeless tobacco use and its awareness in  subjects having pulmonary tuberculosis.. The study subjects were from Department of Medicine of the Institute. Verbal and written informed consent were taken from all the subjects and school authorities before study participation.

The study assessed 516 subjects that had drug-sensitive pulmonary TB and were selected randomly within the defined study period. The study included subjects aged >18 years having drug-sensitive pulmonary TB following data of 2019. Presumptive TB case were considered for microbiologically confirmed tuberculosis where a specimen was positive for acid-fast bacilli and Mycobacterium tuberculosis was isolated on a culture via rapid diagnostic molecular tests. Drug-sensitive tuberculosis was defined as tuberculosis caused by mycobacterium tuberculosis which had susceptibility to first-line anti-TB drugs such as rifampicin, isoniazid, pyrazinamide, and ethambutol.⁵ The exclusion criteria for the study were <18 years, declined to participate in the study, prescribed drug-resistant TB treatments, or diagnosed with extra-pulmonary TB.

All the study subjects were then personally met and a Global Adult Tobacco Survey questionnaire was used to collect the data from all the study subjects. Interviews of 0 packets per day or for >0 days for the past 6 months.^6,7,8 The questionnaire was translated in a language understood by all the study subjects and was also available in Hindi. The primary outcome variables assessed were dichotomous which indicates if patients consumed or did not consume smokeless tobacco. The variables’ considered predictors were socioeconomic status, occupation, tobacco smoking, literacy status, gender, age of the subjects.⁹

The gathered data were statistically analyzed using the chi-square test, Fisher’s exact test, Mann Whitney U test, and SPSS (Statistical Package for the Social Sciences) software version 24.0 (IBM Corp., Armonk. NY, USA) using ANOVA, chi-square test, and student's t-test. The significance level was considered at a p-value of <0.05.

The present descriptive cross-sectional study was aimed to assess the predictors and prevalence of smokeless tobacco use and its awareness in  subjects having pulmonary tuberculosis. The present study assessed 516 subjects that had drug-sensitive pulmonary TB and were selected randomly within the defined study period. The study included subjects aged >18 years having drug-sensitive pulmonary TB following data of 2019. There were 27% females and 73% males, 46% had literacy, 62% were from nuclear family, travelling was part of occupation in 40% subjects, and 66% study subjects were married. The mean age of the study subjects was 41.2±15.8 years and mean monthly income was 10288±8410 INR. The mean year for schooling in study subjects was 4 years with the range of 0-10 years (Table 1).

Table 1: Demographic and disease data in study subjects with tuberculosis

It was seen that for pattern and prevalence of using smokeless tobacco, in 516 subjects, 52% subjects used smokeless tobacco in either additive to smoking or as exclusive form. History of using tobacco in their lifetime was positive in 69% study subjects. There were 46% (n=237) subjects that exclusively used smokeless tobacco, 6% (n=31) used both forms of the tobacco, and 13% (n=67) subjects were smokers. There were 4% (n=10) subjects that quitted the tobacco habit after they were diagnosed with tuberculosis. In subjects that used smokeless tobacco, 8% subjects used tobacco occasionally and 44% used smokeless tobacco. The mean age of initiating tobacco use tobacco use was 20 years with the range of 16-23 years and mean duration of use was 15 years with the range of 4-23 years. The most common form of tobacco used by study subjects was mawa used in 82% subjects.

The study results showed that Smokeless tobacco use history was positive in 52% of study subjects 8% using tobacco occasionally and 44% used it daily. The significant predictors of TB identified in study subjects were monthly income of 3-6 thousand, 9-12 thousand, and >12000, occupation that required travelling, and male gender. In 98% subjects, they were aware of the harmful effects of smokeless tobacco on the health (Table 2).

Table 2: Predictors of using smokeless tobacco in subjects with drug-sensitive pulmonary tuberculosis

Concerning attitude and knowledge of study subjects towards the use of smokeless tobacco, it was seen that nearly all subjects with 98% subjects reported that use of smokeless tobacco is harmful for the health of its users. However, in 79% of the study subjects, it was known that smokeless tobacco has harmful effects on tuberculosis (Table 3). It was seen that in all the subjects were agreed that the sales of tobacco must be restricted and banned to subjects aged less than 18 years.

Table 3: Attitude and knowledge of smokeless tobacco use in subjects with drug sensitive pulmonary tuberculosis

The present study assessed 516 subjects that had drug-sensitive pulmonary TB and were selected randomly within the defined study period. The study included subjects aged >18 years having drug-sensitive pulmonary TB following data of 2019. There were 27% females and 73% males, 46% had literacy, 62% were from nuclear family, travelling was part of occupation in 40% subjects, and 66% study subjects were married. The mean age of the study subjects was 41.2±15.8 years and mean monthly income was 10288±8410 INR. The mean year for schooling in study subjects was 4 years with the range of 0-10 years. These data were comparable to the previous studies of Awaisu A et al¹⁰ in 2011 and Ng N et al¹¹ in 2008 where authors assessed subjects with demographic data comparable to the present study in their respective studies.

The study results showed that for pattern and prevalence of using smokeless tobacco, in 516 subjects, 52% subjects used smokeless tobacco in either additive to smoking or as exclusive form. History of using tobacco in their lifetime was positive in 69% study subjects. There were 46% (n=237) subjects that exclusively used smokeless tobacco, 6% (n=31) used both forms of the tobacco, and 13% (n=67) subjects were smokers. There were 4% (n=10) subjects that quitted the tobacco habit after they were diagnosed with tuberculosis. In subjects that used smokeless tobacco, 8% subjects used tobacco occasionally and 44% used smokeless tobacco. The mean age of initiating tobacco use tobacco use was 20 years with the range of 16-23 years and mean duration of use was 15 years with the range of 4-23 years. The most common form of tobacco used by study subjects was mawa used in 82% subjects. These results were consistent with the findings of Tiwari RV et al¹² in 2014 and Warren CW et al¹³ in 2000 where results of for pattern and prevalence of using smokeless tobacco reported by the authors were comparable to the present study.

It was seen that Smokeless tobacco use history was positive in 52% of study subjects 8% using tobacco occasionally and 44% used it daily. The significant predictors of TB identified in study subjects were monthly income of 3-6 thousand, 9-12 thousand, and >12000, occupation that required travelling, and male gender. In 98% subjects, they were aware of the harmful effects of smokeless tobacco on the health. These findings were in agreement with the results of Nyi Latt N et al¹⁴ in 2018 and Htin Aung Myint MN et al¹⁵ in 2019 where results for predictors of tuberculosis in subjects using smokeless tobacco comparable to the present study were also reported by the authors in their studies.

On evaluating the attitude and knowledge of study subjects towards the use of smokeless tobacco, it was seen that nearly all subjects with 98% subjects reported that use of smokeless tobacco is harmful for the health of its users. However, in 79% of the study subjects, it was known that smokeless tobacco has harmful effects on tuberculosis (Table 3). It was seen that in all the subjects were agreed that the sales of tobacco must be restricted and banned to subjects aged less than 18 years. These results correlated with the findings of Tiwari RV et al¹⁶ in 2014 and Das Shukla A et al¹⁷ in 2017 where results reported by the authors for attitude and knowledge towards the use of smokeless tobacco reported by the authors were similar to the present study.

Within its limitations, the present study concludes that smokeless tobacco is used by more than half subjects with pulmonary tuberculosis. The collaborative framework of TB and tobacco needs to be further strengthen using brief counselling sessions in subjects with tuberculosis that use smokeless tobacco for collateral benefit attainment to control tuberculosis in India