It’s time to end TB, and curbing tobacco use is one of the major first steps

Covid-19 has been declared a pandemic by the World Health Organisation. In South Africa, multiple cases and several deaths have been confirmed. While the fight to contain the pandemic continues, a major area of concern is the additional vulnerability of those with TB and HIV to Covid-19, particularly those who are not on treatment.


For the past 20 years, TB has consistently been one of the leading causes of death by communicable diseases in South Africa. An estimated 63,000 people died of TB in 2018, 42,000 of whom were also living with HIV.

The global 2020 theme for this past TB Month and for TB Day is “It’s time to end TB”, as part of the commitment to end the TB epidemic by 2030 in support of Goal 3 of the Sustainable Development Goals. Tobacco control policies are critical in the fight to end TB because reducing smoking prevalence and exposure to tobacco smoke will result in an improvement in TB cure rates, and treatment outcomes.


TB thrives where the body’s immune system is suppressed. When the immune system is strong, the body naturally fights off TB bacteria. Even when someone has the TB bacteria, as an estimated 80% of South Africans do, a strong immune system keeps the bacteria latent and therefore stops it from causing illness. At this stage, the TB is not infectious and one does not exhibit any symptoms.


The chemical components of tobacco smoke can trigger these latent infections of TB to become active. Even second-hand smoke increases the risk of contracting the disease and the development of active TB, especially in children. This should be reason enough not to start smoking cigarettes, e-cigarettes or hookah pipes, or to stop if you are already a smoker – and to avoid being exposed to second-hand smoke if you are not a smoker. Moreover, hookah pipes place users at risk of TB transmission if they share a single mouthpiece with someone who already has TB.


The lungs play a strategic role in fighting infections. Tobacco smoke undermines this function, damaging the lung’s defence system and impairing its response to viruses and bacteria. When inhaled, tobacco smoke disrupts the structures that sweep mucus and dirt out of the airways, allowing the toxic chemicals and substances in tobacco smoke to penetrate into the lungs more easily. The lung system is paralysed and it then fails to kill and clear out viruses, bacteria, infected cells and unhealthy cells.


Growing evidence also shows that e-cigarette use has similar effects on the lungs. The harmful chemicals in e-cigarettes also damage and disable the protective cells of the lungs. Studies have shown that using e-cigarettes for just three years can lead to the development of lung disease. A 2019 study done on mice by Matthew Madison, which was published in the American Journal of Clinical Investigation, found that after being exposed to e-cigarettes, lung immunity was disrupted which made the lungs unable to fight infections effectively.


Smoking accounts for one in every five cases of TB and people exposed to tobacco smoke have double the risk of developing TB, and are also more likely to have severe TB symptoms. Studies also show TB-related deaths are significantly higher in smokers than in never-smokers, up to nine times higher for smokers than for never-smokers

among individuals without a history of tuberculosis.


As such, stopping smoking and getting treatment is crucial for recovery from TB, it revives the lungs and body’s immunity. When a person stops smoking, these impaired immune cells are replaced by new ones, increasing the body’s capacity to fight all infections, including TB infections.


TB is curable, but smoking while on treatment has a negative impact on treatment, making the medication less effective or taking longer for the medication to improve the health of the person living with TB. Health outcomes are worse when a person infected with TB smokes tobacco and consumes alcohol in excessive quantities.

Even after TB treatment has been completed and the person has been cured, continuing to smoke doubles the chances of developing TB again, which is called recurrent TB. Smokers who stop smoking reduce the likelihood of being infected with TB and improve treatment outcomes for those with TB.


Studies done in South Africa and published in the European Respiratory Journal, and the International Journal of Tuberculosis and Lung Disorder have found high rates of smoking in patients with active TB, with a smoking prevalence of 56% in TB patients in Cape Town and a prevalence of 26% in patients from Soweto. These studies showed a smoking prevalence among TB patients to be much higher than among the population as a whole, which is about 21%.


Among people living with HIV or Aids, smoking triples the chances of developing TB and makes antiretroviral therapies less effective. Studies also show that smoking prevalence is higher in people living with HIV, again increasing their risk of developing TB. A 2018 study on the prevalence of smoking among people living with HIV in South Africa, published in the Nicotine and Tobacco Research journal, reported that smoking prevalence among adults living with HIV was above 30% (52% among men and 13% among women).


It is clear that the goal of ending TB cannot be met without also stopping the use of cigarettes, e-cigarettes and other tobacco products, including hookah pipes. For those with comorbidities like HIV, smoking increases mortality and morbidity exponentially. As such, tobacco control policies are an important tool in the fight against TB and HIV, and we urge the government to pass the Tobacco Bill to reduce TB as well as the outcomes of other respiratory diseases such as Covid-19.

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