Associations between tobacco use and poor TB treatment outcomes are well documented. However, for important outcomes such as TB recurrence or relapse and mortality during treatment, as well as for ...associations with smokeless tobacco (ST), the evidence is not summarized systematically.
Is tobacco use associated with risk of poor treatment outcomes among people with TB?
The MEDLINE, Embase, and Cumulative Index of Nursing and Allied Health Literature databases were searched on November 22, 2021. Epidemiologic studies reporting associations between tobacco use and at least one TB treatment outcome were eligible. Independent double-screening, extractions, and quality assessments were undertaken. Random effects meta-analyses were conducted for the two primary review outcomes (TB recurrence or relapse and mortality during treatment), and heterogeneity was explored using subgroups. Other outcomes were synthesized narratively.
Our searches identified 1,249 records, of which 28 were included in the meta-analyses. Based on 15 studies, higher risk of TB recurrence or relapse was found with ever using tobacco vs never using tobacco (risk ratio RR, 1.78; 95% CI, 1.31-2.43; I
= 85%), current tobacco use vs no tobacco use (RR, 1.95; 95% CI, 1.59-2.40; I
= 72%), and former tobacco use vs never using tobacco (RR, 1.84; 95% CI, 1.21-2.80; I
= 4%); heterogeneity arose from differences in study quality, design, and participant characteristics. Thirty-eight studies were identified for mortality, of which 13 reported mortality during treatment. Ever tobacco use (RR, 1.55; 95% CI, 1.32-1.81; I
= 0%) and current tobacco use (RR, 1.51; 95% CI, 1.09-2.10; I
= 87%) significantly increased the likelihood of mortality during treatment among people with TB compared with never using tobacco and not currently using tobacco, respectively; heterogeneity was explained largely by differences in study design. Almost all studies in the meta-analyses scored high or moderate on quality assessments. Narrative synthesis showed that tobacco use was a risk factor for other unfavorable TB treatment outcomes, as previously documented. Evidence on ST was limited, but identified studies suggested an increased risk for poor outcomes with its use compared with not using it.
Tobacco use significantly increases the risk of TB recurrence or relapse and mortality during treatment among people with TB, highlighting the need to address tobacco use to improve TB outcomes.
PROSPERO; No.: CRD42017060821; URL: https://www.crd.york.ac.uk/prospero/.
Provision of alternate livelihoods to smokeless tobacco (SLT) supply chain (SC) actors can help in curtailing SLT business and its consumption. We explored the reasons for SC actors' engagement in ...Naswar (SLT used in South Asia) business and their willingness to switch to other alternatives.
We conducted an equal-status concurrent mixed-methods study in four districts of Khyber Pakhtunkhwa province of Pakistan. We surveyed 286 general points of sale (GPOS) and exclusive Naswar (EN) vendors through multistage cluster sampling. Additionally, we interviewed 15 tobacco farmers interpretively, being distinct from other SC actors. We assessed the association between vendors' willingness to switch and their awareness about tobacco-harms, profit margin, Naswar as a family business, length of business, education-level and shop-type using logistic regression. Qualitative data assessed the farmer's viable alternatives to switch and was analyzed using deductive-inductive thematic analysis.
Product demand-77% and profit margins-75% were the main drivers for selling SLT by EN vendors. Half of the GPOS and 25% EN vendors expressed willingness to stop Naswar's sale. Vendors aware of tobacco-harms were more willing to switch, but less likely to switch if Naswar was perceived to bring "good-profit". Farmers were mainly cultivating tobacco because of profitability, family-run farm, and perceived land-suitability for tobacco. Lack of government support was main constraint for farmers looking to switch.
A considerable portion of Naswar SC actors in Pakistan are willing to switch to viable alternatives, with profitability of alternatives, support from authorities, and social obligations as key considerations in doing so.
This study highlights that good profit margins in the Naswar business, lack of awareness of tobacco-related health harms, and absence of the Government's support are key detriments to switching to alternative businesses among Naswar supply chain actors in Pakistan. These findings are the first to come out in the context of both Pakistan and Naswar product, making a case for policy interventions focusing on tax increases, awareness campaigns about tobacco-harms, and a pro-active role by the government to provide support for the security of livelihoods to those tobacco supply chain actors who want to switch to other alternatives.
BackgroundConcerns about the magnitude of illicit cigarette trade have prevented the Government of Pakistan from increasing tobacco taxes. We estimated the proportion of illicit cigarettes sold in ...Pakistani cities. Moreover, we compared two methods for collecting cigarette packs and investigated if the illicit cigarette trade equates to tax evasion.MethodWe analysed cigarette packs collected from 10 cities of Pakistan using two methods: consumer survey based on a two-stage random sampling strategy to recruit adult smokers and photograph their cigarette packs and waste recycle store survey to purchase used cigarette packs. Cigarettes were considered illicit if any one of the following was absent from their packs: text and pictorial health warning, underage sale prohibition warning, retail price and manufacturer’s name. From the consumer survey, we also estimated the proportion of smokers who purchased loose cigarettes (illegal) and packs below the minimum retail price. Taxation officers (n=4) were consulted to assess their level of confidence in judging tax evasion using the above criteria.ResultsOut of 2416 cigarette packs in the consumer survey, 454 (17.8%; 95% CI 15.4% to 20.2%) were illicit. Similarly, out of 6213 packs from waste recycle shops, 1046 (16.8%; 95% CI 15.9% to 17.7%) were illicit; the difference was not statistically significant (p=0.473). Among consumers, 29.5% bought loose cigarettes and 13.8% paid less than the minimum retail price. The taxation officers considered the manufacturer’s name and retail price on cigarette packs as the most relevant criteria to detect tax evasion.ConclusionsOne in six cigarette packs consumed in Pakistan could be illicit. These figures are far less than those propagated by the tobacco industry. Collecting packs from waste recycle stores is an efficient and valid method to estimate illicit cigarette trade.
Background
Tuberculosis (TB) is a leading cause of mortality due to an infectious disease, with an estimated 1.6 million deaths due to TB in 2022. Approximately 25% of the global population has TB ...infection, giving rise to 10.6 million episodes of TB disease in 2022. Undernutrition is a key risk factor for TB and was linked to an estimated 2.2 million TB episodes in 2022, as outlined in the World Health Organization (WHO) Global Tuberculosis Report.
Objectives
To determine the prognostic value of undernutrition in the general population of adults, adolescents, and children for predicting tuberculosis disease over any time period.
Search methods
We searched the literature databases MEDLINE (via PubMed) and WHO Global Index Medicus, as well as the WHO International Clinical Trials Registry Platform (ICTRP) on 3 May 2023 (date of last search for all databases). We placed no restrictions on the language of publication.
Selection criteria
We included retrospective and prospective cohort studies, irrespective of publication status or language. The target population comprised adults, adolescents, and children from diverse settings, encompassing outpatient and inpatient cohorts, with varying comorbidities and risk of exposure to tuberculosis.
Data collection and analysis
We used standard Cochrane methodology and the Quality In Prognosis Studies (QUIPS) tool to assess the risk of bias of the studies. Prognostic factors included undernutrition, defined as wasting, stunting, and underweight, with specific measures such as body mass index (BMI) less than two standard deviations below the median for children and adolescents and low BMI scores (< 18.5) for adults and adolescents. Prognostication occurred at enrolment/baseline. The primary outcome was the incidence of TB disease. The secondary outcome was recurrent TB disease. We performed a random‐effects meta‐analysis for the adjusted hazard ratios (HR), risk ratios (RR), or odds ratios (OR), employing the restricted maximum likelihood estimation. We rated the certainty of the evidence using the GRADE approach.
Main results
We included 51 cohort studies with over 27 million participants from the six WHO regions. Sixteen large population‐based studies were conducted in China, Singapore, South Korea, and the USA, and 25 studies focused on people living with HIV, which were mainly conducted in the African region. Most studies were in adults, four in children, and three in children and adults. Undernutrition as an exposure was usually defined according to standard criteria; however, the diagnosis of TB did not include a confirmatory culture or molecular diagnosis using a WHO‐approved rapid diagnostic test in eight studies. The median follow‐up time was 3.5 years, and the studies primarily reported an adjusted hazard ratio from a multivariable Cox‐proportional hazard model.
Hazard ratios (HR)
The HR estimates represent the highest certainty of the evidence, explored through sensitivity analyses and excluding studies at high risk of bias. We present 95% confidence intervals (CI) and prediction intervals, which present between‐study heterogeneity represented in a measurement of the variability of effect sizes (i.e. the interval within which the effect size of a new study would fall considering the same population of studies included in the meta‐analysis).
Undernutrition may increase the risk of TB disease (HR 2.23, 95% CI 1.83 to 2.72; prediction interval 0.98 to 5.05; 23 studies; 2,883,266 participants). The certainty of the evidence is low due to a moderate risk of bias across studies and inconsistency.
When stratified by follow‐up time, the results are more consistent across < 10 years follow‐up (HR 2.02, 95% CI 1.74 to 2.34; prediction interval 1.20 to 3.39; 22 studies; 2,869,077 participants). This results in a moderate certainty of evidence due to a moderate risk of bias across studies.
However, at 10 or more years of follow‐up, we found only one study with a wider CI and higher HR (HR 12.43, 95% CI 5.74 to 26.91; 14,189 participants). The certainty of the evidence is low due to the moderate risk of bias and indirectness.
Odds ratio (OR)
Undernutrition may increase the odds of TB disease, but the results are uncertain (OR 1.56, 95% CI 1.13 to 2.17; prediction interval 0.61 to 3.99; 8 studies; 173,497 participants). Stratification by follow‐up was not possible as all studies had a follow‐up of < 10 years. The certainty of the evidence is very low due to the high risk of bias and inconsistency. Contour‐enhanced funnel plots were not reported due to the few studies included.
Risk ratio (RR)
Undernutrition may increase the risk of TB disease (RR 1.95, 95% CI 1.72 to 2.20; prediction interval 1.49 to 2.55; 4 studies; 1,475,867 participants). Stratification by follow‐up was not possible as all studies had a follow‐up of < 10 years. The certainty of the evidence is low due to the high risk of bias. Contour‐enhanced funnel plots were not reported due to the few studies included.
Authors' conclusions
Undernutrition probably increases the risk of TB two‐fold in the short term (< 10 years) and may also increase the risk in the long term (> 10 years). Policies targeted towards the reduction of the burden of undernutrition are not only needed to alleviate human suffering due to undernutrition and its many adverse consequences, but are also an important part of the critical measures for ending the TB epidemic by 2030. Large population‐based cohorts, including those derived from high‐quality national registries of exposures (undernutrition) and outcomes (TB disease), are needed to provide high‐certainty estimates of this risk across different settings and populations, including low and middle‐income countries from different WHO regions. Moreover, studies including children and adolescents and state‐of‐the‐art methods for diagnosing TB would provide more up‐to‐date information relevant to practice and policy.
Funding
World Health Organization (203256442).
Registration
PROSPERO registration: CRD42023408807
Protocol: https://doi.org/10.1002/14651858.CD015890
Smoking prevalence in Germany remains high at approximately 28%. We assessed public support for tobacco legislation and associations between level of support and smoking and socio-demographic ...characteristics. Data from 2087 people were collected as part of the German Study on Tobacco Use ("DEBRA"): a nationally representative, face-to-face household survey. Public support was measured on total ban of sale, raising the minimum age for sales, taxation of tobacco industry sales, research into e-cigarettes, and ban of smoking in cars when children are present. Associations were assessed with multivariate logistic regression. Over 50% of the German population support taxing industry profits (57.3%) and assessing e-cigarettes as an aid to quit smoking (55.5%). Over 40% support raising the legal age of sale (43.1%), and 22.9% support a total ban on tobacco sales. A smoking ban in cars when children are present was most popular (71.5%), even among current smokers (67.0%). There is public support for stricter tobacco control measures in Germany. A smoking ban in cars when children are present could be a feasible policy to implement.
ObjectiveTo obtain insights into the perceptions of barriers and facilitators to implementation of the WHO Framework Convention on Tobacco Control (FCTC) among smokeless tobacco (SLT) supply chain ...actors in the Khyber Pakhtunkhwa province of Pakistan.MethodsWe conducted a qualitative study to investigate the perceptions about SLT control policy formulation and implementation among exclusive Naswar sellers and point of sale vendors. We conducted five focus group discussions in three districts of Khyber Pakhtunkhwa using combined deductive-inductive thematic analyses.ResultsWe identified three central themes that potentially impact policy formulation, its implementation and application. The first theme examines the role of children in the Naswar business: as potential customers, and as potential heirs to a Naswar-selling business. A second theme targets the ‘business of Naswar’, which includes a specific identity of Naswar sellers, its potential to generate profits and the special case of Naswar regulation as a socially accepted and culturally rooted product. The third theme addresses the unusual ingredients of Naswar and its production process, making Naswar a health risk for consumers and producers. We also report conflicting views regarding SLT control among the supply chain actors.ConclusionsThis study provides insights into the perceptions of important SLT supply-side stakeholders regarding various SLT control policy options based on the FCTC. While there is some opposition to policy approaches like taxation and switching of business, implementing a ban on selling SLT to minors may be a viable option for policymakers in the short term.
Climate change will likely have impacts on disease vector distribution. Posing a significant health threat in the 21st century, risk of tick-borne diseases may increase with higher annual mean ...temperatures and changes in precipitation. We modeled the current and future potential distribution of the Ixodes ricinus tick species in Europe. The Genetic Algorithm for Rule-set Prediction (GARP) was utilized to predict potential distributions of I. ricinus based on current (1990–2010 averages) and future (2040–2060 averages) environmental variables. A ten model best subset was created out of a possible 200 models based on omission and commission criteria. Our results show that under the A2 climate change scenario the potential habitat range for the I. ricinus tick in Europe will expand into higher elevations and latitudes (e.g., Scandinavia, the Baltics, and Belarus), while contracting in other areas (e.g., Alps, Pyrenees, interior Italy, and northwestern Poland). Overall, a potential habitat expansion of 3.8% in all of Europe is possible. Our results may be used to inform climate change adaptation efforts in Europe.
•We modeled current and future potential Ixodes ricinus tick distribution in Europe.•Tick habitat range was predicted to expand into higher elevations and latitudes.•Overall, habitats are predicted to expand by 3.8% from their current range.•Results can inform climate change adaptation efforts in Europe.
Links between heat exposure and congenital anomalies have not been explored in detail despite animal data and other strands of evidence that indicate such links are likely. We reviewed articles on ...heat and congenital anomalies from PubMed and Web of Science, screening 14,880 titles and abstracts in duplicate for articles on environmental heat exposure during pregnancy and congenital anomalies. Thirteen studies were included. Most studies were in North America (8) or the Middle East (3). Methodological diversity was considerable, including in temperature measurement, gestational windows of exposure, and range of defects studied. Associations were detected between heat exposure and congenital cardiac anomalies in three of six studies, with point estimates highest for atrial septal defects. Two studies with null findings used self-reported temperature exposures. Hypospadias, congenital cataracts, renal agenesis/hypoplasia, spina bifida, and craniofacial defects were also linked with heat exposure. Effects generally increased with duration and intensity of heat exposure. However, some neural tube defects, gastroschisis, anopthalmia/microphthalmia and congenital hypothyroidism were less frequent at higher temperatures. While findings are heterogenous, the evidence raises important concerns about heat exposure and birth defects. Some heterogeneity may be explained by biases in reproductive epidemiology. Pooled analyses of heat impacts using registers of congenital anomalies are a high priority.
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