By Shobha Shukla & Bobby Ramakant
The epidemic-proportion diseases and untimely deaths caused by tobacco use are entirely preventable. Likewise, we have science-based tools and approaches to find all TB cases, treat all of them and prevent transmission of the disease. When even one TB or tobacco death is a death too many, how can one explain 1.25 million TB deaths and over 8 million tobacco-related deaths in 2023 alone? How can TB disease, that is entirely preventable (and curable), become the deadliest infectious disease worldwide?
Ahead of World No Tobacco Day 2025 as well as the World Conference on Tobacco Control 2025, Dr Tara Singh Bam, a noted and dedicated leader who has championed both #endTB and #endTobacco agenda – along with connecting more dots, like prevention and control of non-communicable diseases (NCDs), and invoking stronger local actions at sub-national levels to advance progress towards these goals- shared valuable insights on “TB and tobacco: A preventable tragedy, a shared responsibility.”
Dr Bam called for building result oriented political leadership that translates into effective TB and tobacco control legislation; accountability and sustainability of TB control and tobacco control programmes; and inclusion of smoking cessation through regular TB services at healthcare facilities. Dr Bam serves as Asia Pacific Director for Tobacco Control at Vital Strategies and earlier led the International Union Against Tuberculosis and Lung Disease (The Union) Asia Pacific as its Director. He also serves as a Board Director of Asia Pacific Cities Alliance for Health and Development (APCAT).
TB and tobacco both deadly by themselves and together become deadlier
TB if left untreated can be deadly. And as per the World Health Organization (WHO), one out of every two tobacco user dies of tobacco-related diseases prematurely. There is ZERO safe level of tobacco use, so tobacco use in all forms is deadly and dangerous for health as well as for the economy.
Health is a fundamental human right. So, ending tobacco use and ending TB are urgent priorities for not only global health but also for sustainable development. In addition, both tobacco use and TB jolt our economies. Tobacco causes a loss of US$ 1.4 trillion to the global economy every year. Hence investing in TB and tobacco control is a smart and necessary investment if governments want to deliver on SDGs. For example, every US$ 1invested in TB control yields a return of US$ 46.
Agrees Dr Vineet Bhatia, Regional Advisor for TB at the World Health Organization (WHO) in the Southeast Asian region: “If we must end TB, we must address its determinants – tobacco smoking is an important determinant of TB. WHO Southeast Asian region is the highest TB burden region globally accounting for nearly 5 million new TB patients and around 600,000 deaths in 2023.”
Tobacco (industry) fuels TB
TB is caused by bacteria but what about tobacco products? Every tobacco-related disease and death could have been averted. But the tobacco industry goes on deceiving us to fill up its bank coffers. Let us hope governments hold them to account and put people before profits.
“TB and tobacco both are big public health threats. Link between TB and tobacco smoking is strong. And well documented scientifically. Tobacco makes it harder to diagnose and treat TB, leads to more severe illness and raises the chances of TB recurrence and even TB death. According to the WHO if we eliminate tobacco use then we can reduce TB rates by up to 20%,” said Dr Gan Quan, who has made a distinguished contribution to tobacco and TB control at The Union earlier, and now serves at Vital Strategies.
Dr Vineet Bhatia agrees: “There is an increased risk of contracting TB as tobacco use impairs the immune system, making it easier for the TB bacteria to infect the lungs. Tobacco smoke impairs the immune response, including ciliary dysfunction, which impairs the clearance of TB bacteria from the respiratory tract. Tobacco smokers have a higher risk of recurrent TB. Smoking negatively influences the response to TB treatment and increases the likelihood of relapse. Smoking is also associated with more severe forms of TB, including cavitary disease and increases the risk of death from TB. Moreover, exposure to second-hand smoke (and third-hand smoke) also increases TB risk, especially in children.”
Dr Tara Singh Bam too emphasised: “Passive smoking (second-hand smoking) can increase the risk of TB too, especially the risk of TB infection and progression from latent TB infection to active TB disease as passive smoking impairs lung function and the immune response.”
Dr Elizabeth Cadena, the new President of The Union Asia Pacific said that “Tobacco smoking is a major risk factor for lung diseases including TB. There is also an association between tobacco smoking and drug-resistant TB. Rates of tobacco use prevalence are declining in all WHO regions, but the slowest decline is in the Western Pacific region where high TB burden countries are also located.”
The world is not on track to end TB or end tobacco: Why?
While remarkable progress has been made in the fight against TB, mountainous challenges still remain towards #endTB: “More than 3.8 million people were put on TB treatment in 2023 in WHO Southeast Asian region – the highest ever reported in any single year. At the same time, the number of people who were being missed by the TB programmes in this region halved between 2020-2023 (from 44% in 2020 to 22% in 2023). TB deaths reduced too. “From 763,000 TB deaths in 2021 in WHO Southeast Asian region, the number came down to 583,000 in 2023,” said Dr Bhatia.
Undernutrition is the biggest TB risk factor globally
Undernutrition is not only the biggest TB risk factor worldwide but also in WHO Southeast Asian region.
As per the WHO Global TB Report 2024, globally, out of the estimated 10.8 million new TB cases in 2023 (however, only 8.2 million were reported by TB programmes worldwide, rest were missed), almost one million of them were attributed to undernutrition, 752,000 TB cases were attributed to alcohol, 702,000 TB cases were attributed to tobacco use, 681,000 TB cases were attributed to HIV, and 381,000 TB cases were attributed to diabetes.
In WHO Southeast Asian region, out of the estimated 4.9 million TB cases in 2023 (of which only 3.8 million cases were notified), over half a million (552,000) TB cases were attributed to undernutrition, followed by 328,000 attributed to tobacco use, 311,000 attributed to alcohol use, 173,000 attributed to diabetes and 92,000 attributed to HIV.
Tobacco is the biggest TB risk factor in Indonesia
Although undernutrition is overall the biggest TB risk factor globally as well as in the southeast Asian region, for Indonesia, tobacco smoking is the biggest risk factor (followed by undernutrition, diabetes, HIV and alcohol use), said Dr Bhatia.
Agrees Dr Gan Quan: “In Indonesia, one in three TB cases- over 300,000 people – get TB due to tobacco use. According to a few studies, up to 96% of male TB patients in the country smoke tobacco. It is a powerful reminder of how closely these two epidemics are intertwined. If we are serious about ending TB then we have to end tobacco use – that means, higher tobacco taxes, ending all forms of tobacco marketing, standardised health warnings on all tobacco packaging, making indoor spaces smoke- free, and offering support to tobacco users to quit.”
In addition, tobacco industry is the biggest threat to implementation of evidence-based tobacco control measures, as well as to the global tobacco treaty (formally called the WHO Framework Convention on Tobacco Control or WHO FCTC), that calls upon governments to stop tobacco industry interference in public policy (Article 5.3) and hold tobacco industry legally and financially liable for the harms they have knowingly caused to human race and our planet (Article 19).
Antimicrobial Resistance and tobacco use
Dr Vineet Bhatia shared that in 2024 he was part of WHO Indonesia Drug-Resistant TB Mission along with Dr Conradie Francesca of WHO HQ. They found that there were a significant number of patients who were started on individualised drug-resistant TB treatment regimens (but not on the WHO recommended shorter DR-TB treatment regimens) because of extensive lung lesions. The biggest probable causes for this were: late diagnosis, smoking (as a lot of these patients were smokers), undernutrition and other co-morbidities associated with TB.
#EndTB and #EndTobacco as enablers of progress towards SDGs
Strong science-based evidence shows how we can screen everyone (regardless of TB symptoms) in high burden settings and offer them upfront molecular testing to find ALL TB, link them to same-day-test-and-treat with best of TB regimens (after doing drug susceptibility testing), and implement the full cascade of TB prevention (like TB preventive therapy, ending malnutrition, ending tobacco and alcohol use, diabetes prevention and control, ensuring every person living with HIV has made undetectable equals untransmittable a reality, and addressing other TB risk factors).
But reality on how we find TB, treat TB or prevent TB is far away from this science-based approach. Let us bridge this gap.
Likewise, it is high time that governments fully implement science-based tobacco control measures (such as MPOWER measures recommended by WHO and WHO FCTC) and end tobacco use.
Dr Gan Quan said that in countries like India, Indonesia, Bangladesh and Pakistan, integrating tobacco smoking cessation programmes into routine TB services has led to more people quitting tobacco smoking.
Dr Tiffany Tiara Pakasi, Head of Indonesian government’s national TB programme, also stresses upon strengthening integration between TB programmes as well as tobacco control programmes to benefit the people even more.
Dr Bhatia of WHO calls for urgent need for targeted interventions to address the two co-epidemics of TB and tobacco use.
With only 67 months left to deliver on the promise of SDGs, it is high time accelerated action becomes a reality to end TB and end tobacco, along with enabling progress towards achieving all other SDGs.
(The writers co-lead the editorial at Citizen News Service and are on the governing board of award-winning Global Antimicrobial Resistance Media Alliance and Asia Pacific Media Alliance for Health and Development)
