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Comorbidities

Tobacco use significantly worsens other major health challenges such as tuberculosis, HIV infection and mental illness. Treatment of these other health conditions must address tobacco use, particularly by encouraging and supporting quitting.

In the last several years, research has shown that the negative impacts that smoking has on health go far beyond lung cancer, chronic obstructive pulmonary disease (COPD), heart disease, stroke and other well-known consequences of tobacco use. We now know that tobacco helps fuel the global epidemic of tuberculosis, and it worsens problems such as mental illness, HIV infection and alcohol abuse.

Tuberculosis (TB) is the leading cause of death due to a single infectious agent in the world, and is the 6th-leading cause of death in the world overall, killing 1.8 million people in 2015. Cigarette smoking increases the risk of developing TB, and it makes treatment for TB less effective. Worldwide TB rates could decline as much as 20% if we eliminated smoking.

Persons with mental illness are more likely to smoke than people without such disorders, and it is much more difficult for them to quit. The more psychiatric diagnoses an individual patient has (among disorders such as schizophrenia, attention deficit disorder, bipolar illness, and others), the more likely it is that a person will smoke. For certain illnesses such as anxiety disorders, schizophrenia and bipolar illness, smoking seems to exacerbate symptoms, perhaps by making psychiatric medications less effective, and quitting smoking may improve symptoms as much as adding additional psychotropic drugs. In the US state of California, more than half of persons with mental disorders die from tobacco-related illness.

The harmful effects of smoking are magnified and accelerated in patients with HIV infection because when these patients use tobacco, they develop lung cancer and airway diseases such as COPD at higher rates and at younger ages than HIV-infected non-smokers. In settings where primary treatment for HIV infection is widely available and the disease can be well-managed, continuing tobacco use threatens progress in controlling AIDS, whereas in low-resource settings, it undermines already challenging treatment efforts even more.

Alcohol abuse and tobacco dependence often coexist and have mutually-reinforcing harmful effects. A recent study in Russia demonstrated that although smoking was reported by “only” 14% of pregnant women, smoking prevalence was much higher (45%) among heavy drinkers and those at risk for an alcohol-exposed pregnancy. Thus, smoking and alcohol abuse co-occurred often and created a serious danger of dual prenatal exposure, with grave health consequences for offspring from those pregnancies.

Although links between tobacco and other serious medical conditions such as TB and HIV infection have been increasingly recognized, few TB or HIV clinics integrate smoking cessation programs into their routine services. This is an urgent need that must be addressed.


Tuberculosis and Tobacco

Percentage of tuberculosis-related deaths due to tobacco.

Tuberculosis Mortality and Smoking

Without smoking, Africa already has among the largest TB challenges of any region, but models predict that smoking will greatly exacerbate TB mortality trends for the foreseeable future

Smoking and HIV

As HIV-infected persons age, continued smoking robs them of more life than HIV-related factors

Effect of continued smoking on years of life lost in patients with HIV infection.

References

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Li XH, An FR, Ungvari GS, Ng CH, Chiu HFK, Wu PP, Jin X, Xiang YT. Prevalence of smoking in patients with bipolar disorder, major depressive disorder and schizophrenia and their relationships with quality of life. Sci Rep. 2017 Aug 16;7(1):8430.

Leung CC, Yew WW, Chan CK, Chang KC, Law WS, Lee SN, Tai LB, Leung EC, Au RK, Huang SS, Tam CM. Smoking adversely affects treatment response, outcome and relapse in tuberculosis. Eur Respir J. 2015 Mar;45(3):738-45.

Altet N, Latorre I, Jiménez-Fuentes MÁ, Maldonado J, Molina I, González-Díaz Y, Milà C, García-García E, Muriel B, Villar-Hernández R, Laabei M, Gómez AC, Godoy P, de Souza-Galvão ML, Solano S, Jiménez-Ruiz CA, Domínguez J; PII Smoking SEPAR Working Group. Assessment of the influence of direct tobacco smoke on infection and active TB management. PLoS One. 2017 Aug 24;12(8):e0182998.

Calvo M, Laguno M, Martínez M, Martínez E. Effects of tobacco smoking on HIV-infected individuals. AIDS Rev. 2015 Jan-Mar;17(1):47-55.

Helleberg M, May MT, Ingle SM, Dabis F, Reiss P, Fätkenheuer G, Costagliola D, d'Arminio A, Cavassini M, Smith C, Justice AC, Gill J, Sterne JA, Obel N. Smoking and life expectancy among HIV-infected individuals on antiretroviral therapy in Europe and North America. AIDS. 2015 Jan 14;29(2):221-9.