Smoking Behaviour with Tuberculosis of Adults in the World: A Systematic

Review

Annisa Ayu Lestari (1711213009), Hanifatun Nabilah (1711212051), Iffah Afallah

(1711212053), Izzatul Mardiah Saini (1711211042), NindyFadhilla (1711212015), Ulfah
Winanda Putri (1711212035)
Faculty of Public Health, Andalas University, Padang, Indonesia

Abstract
Background: Tuberculosis is a disease that is concern to most of the world. Indonesia is the
third most burdened TB (Tuberculosis) country in the world. There are some various factors
caused tuberculosis, one of the main causes is a smoking behaviour.
Objectives: To determine the relationship of smoking behaviour with the occurrence of TB in
adults.
Method: The method of this research is a systematic review. We searched for articles trough the
PubMed and Science Direct database, included English-language articles from the 2014-2019
publication years. In result, we used 5 articles as research materials
Result: Based on 770 studies from the databases search, there are 5 studies that required being
included as research materials consist of 4 studies using a cross-sectional study design and 1
study using a case-control study design. The results of this study is indicate that TB diagnosis
rates are higher in people who smoke and lower in non-smokers
Conclusion: The five articles show that there is a significant relationship between smoking
behaviour and the incidence of TB in adults.

Keyword: Tuberculosis, Smoking, Adults

Background
Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. Transmission of
the disease is through patient sputum containing bacillus tuberculosis which time the patient
coughs or sneezes so that saliva containing bacillus will fly off, and then inhaled by healthy
people and get into the lungs, causing healthy people are infected with the disease (Thoracic,
2017).
 TB is a disease that concerns almost all over the world. TB has become one of the 10
leading causes of death in the world from a single infectious agent (beyond HIV / AIDS), where
every year there are millions of people who suffer from TB. In 2016, most cases of TB incidence
is estimated to occur in the region of Southeast Asia (45%), followed by Africa (25%) and the
Western Pacific region (17%) (WHO, 2017)
Globally, in 2017 is estimated at 10.0 million people have tuberculosis with distribution
as follows: 5.8 million men, 3.2 million women and 1.0 million children. The case was attacking
all countries and all age groups, but the overall 90% of sufferers are adults (aged ≥15 years).
Eight countries with the incidence of TB cases in 2017 are: India (27%), China (9%), Indonesia
(8%), Philippines (6%), Pakistan (5%), Nigeria (4%), Bangladesh (4 %) and South Africa (3%)
(WHO, 2018)
Currently, Indonesia is country with the third largest of TB burden in the world. It cannot
be taken lightly. In 2016-2017, number of new cases of TB in Indonesia as many as 420.994
cases (data as of May 17, 2018). By sex, the number of new TB cases in 2017, in men was 1.4
times greater than women, namely in women as many as 175.696 cases while in men as many as
245.298 cases. (Kemenkes, 2018)
The latest data from the Global Tuberculosis Report 2018 shows that the incidence of TB
in Indonesia is 842.000 people fell ill with TB, with 492,000 on the distribution of adult males,
349.000 occur in older women, the remaining approximately 49.000 occur in children. While the
death rate as much as 116,000 deaths, 9.400 of them occur in people who have HIV (WHO,
2018).
In West Sumatra province by the Health Profile of West Sumatra province in 2017 states
that the incidence rate of all types of TB cases and new cases of TB BTA positive can be seen
that the incidence of all types of TB was 131.65 per 100,000 population or approximately 6.852
cases of all type of TB, the incidence of new cases TB BTA positive at 4.597 per 100,000
population or approximately 5.258 new cases of smear-positive pulmonary TB (Dinkes Sumbar,
2017). In 2018, the prevalence of TB in West Sumatera has been under the national average
(0.42) is equal to 0.31 (Kemenkes, 2018). But that does not mean TB can already be resolved,
the case remains a concern government in West Sumatra, Indonesia, to the whole world in order
to complete the TB incidence in accordance with the target later SDGs 2030 (WHO, 2017).
 Based on the data above, it can be said that TB is still a problem in Indonesia, especially
in West Sumatra, and given the lack of treatment for TB is increasingly making it one of the
diseases that must be treated seriously from government to health workers and other relevant
parties.
Various efforts have been made by the government and related parties, especially in the
health sector to treat or at least reduce the incidence of tuberculosis. As DOTS strategy program
that is expected to provide healing and prevent infection. Through this strategy, Indonesia
managed to achieve the global targets for early detection and cure level in 2006 (Kemenkes,
2011). But the program does not run smoothly because there are several obstacles in its
implementation in the field as the patients dropped out treatment or the patient died before the
drugs produce maximum results. But if we look at the circumstances to date prove that the
treatment and prevention of TB disease is indeed something that is hard to do (Manalu, 2010).
According to tuberculosis prevalence surveys, prevalence in men 3 times higher than in
women. So is the case in other countries. This is likely due to men are more exposed to the risk
factors of TB such as smoking and lack of compliance with taking medication. The survey found
that of all male participants who smoke as much as 68.5% and only 3.7% of participants were
women who smoke (Kemenkes, 2018)
Looking for risk factors of TB is very important to formulate a plan of prevention of the
disease. Based on Minister of Health Regulation number 67 in 2016 referred to the TB control
are efforts that focuses on preventive and promotive, without neglecting aspects of curative and
rehabilitative services aimed at protecting public health, lowering morbidity rate, disability or
mortality, disconnect the transmission, prevent drug resistance and reduce the impact caused by
TB.
This systematic review was made with the aim of seeking relationships of smoking
behavior with the incidence of TB, especially in adults. This is due to the high incidence of TB
cases in Indonesia as well as in West Sumatra and based on the data presented on the background
mentioned the possibility of a person exposed to TB is one of them caused by smoking.

Method
Before starting systematic review, the team conducted discussion to talk about goal of
systematic review. The formulated question is “can smoking habit affect Tuberculosis (TB) of
adults? In conducting the systematic review, we did some steps, they are determining keywords
to use, finding out the keyword on Pubmed, science direct and hand tool, evaluating abstract,
reading whole article context and putting the article to the appropriate table based on topic.
The First step is determining keyword. In accordance with our group’s research title, we
choose some keywords; they are smoking, tuberculosis and adult. After that we searched for
some articles which support our topic. We got 341 articles at PubMed, 438 articles at science
direct and 1 hand tool article in journal published 5 years ago and used cross sectional study and
case control study, written in English. So, after searching from those three databases, we got 770
articles.
The next stage is finding out duplication of articles we got manually. From the three
database mentioned above, we found 57 duplicated articles, so there are 713 articles remained.
Then, 1 article in Bahasa Indonesia is exluded and from those 712 articles, there are 694 articles
which do not use cross sectional study and case control.
The last step is conducting review or abstract research and reading full text. After reading
abstract we got 18 articles and we excluded 13 articles. Finally we only got 5 articles which
describe the relationship of smoking habit and tuberculosis (TB).
PRISMA Flow Diagram :

Additional records identified

PubMed Science Direct through other sources
n = 341 n = 438 (Hand Tool)
n=1

Topic based on article

n = 770

The Number Of Duplicated Articles

n = 57

Records after duplicates

removed
n = 713 Exclude
n=695
1 non English article
694 articles do not use
cross-sectional study
design and case
control
Topic based on abstract
n = 18
Exclude n=13
(Full Text) The articles
does not describe the
relationship of
smoking behavior
with the incidence of
Studies Included in tuberculosis
systematic review
n=5
Result
Based on the results of the screening of the 5 articles selected from 2015-2019, there
were 4 articles analyzed using a cross-sectional research design and 1 article analyzed using a
case control research design. In this study the object used is an adult. The results of several
articles indicate that smoking behavior can increase the incidence of tuberculosis (TB).
According to Shu-Lan Tsai, Chun-Liang Lai, Miao-Ching Chi and Mei-Yen Che in 2016 in 123
patients in rural district hospitals in Chiayi District, Taiwan about the effect of smoking behavior
with increased tuberculosis (TB). Although in the study the prevalence of smoking decreased
from 46.9% before to 30.2% after the diagnosis of TB, smoking remained a significant problem.
Likewise, according to a study conducted by V.G. Rao, J. Bhat, R. Yadav, M. Muniyandi, M.K.
Bhondeley, D.F. Wares, smokers and people who consume alcohol have an increased chance of
pulmonary TB compared to nonsmokers and non-alcoholics, respectively [(OR 3.2; 95% CI
516.4–1986.4; p = 0.003); (OR 3.2; 95% CI 480.8-2254.8; p = 0.009)]. Likewise, according to
research conducted by Liza Bronner Murrison, Neil Martinso, Rachael M. Moloney, Regina
Msandiwa, Mondiwana Mashabela, Jonathan M. Samet, Jonathan E. Golub, overall, 33% of
participants currently smoke, defined as smoking in 2 months (34% cases vs 32% controls, p =
0.27). The median CD4 cell count was lower (60 vs 81, p = 0.03) and the median viral load was
higher (173 vs 67, p <0.001) among cases versus controls. In the adjusted analysis, smoking
currently triples the chance of PTB (AOR 3.2; 95% CI: 1.3-7.7, P = 0.01) and former smoking
almost doubles the chance of PTB (AOR 1, 8; 95% CI 0.8-4.4, P = 0.18) compared to never
smoking.
This research is also supported by research conducted by M. Aryanpur, M. R. Masjedi,
M. Hosseini, E. Mortaz, P. Tabarsi, H. Soori, H. Emami, G. Heydari, M. Baikpour. (2015) in
1127 newly diagnosed PTB patients in Iran with an average age of 50.0 – 19.8 years said that
there were differences in the incidence of TB in people who smoke and who do not smoke where
smoking is caused due to addiction to nicotine which can affect the incidence of tuberculosis
(TB).
Other studies conducted by John O Opolot, Annette J Theron, Patrick MacPhail, Charles
Feldman, Ronald Anderson (2014) with samples of patients with pulmonary TB treated at Helen
Joseph Hospital (71 people) discussed the effects of smoking on acute phase reactants, hormonal
responses stress and vitamin C in pulmonary TB proves that the effect of smoking causes
depletion of vitamin C which is useful in preventing TB disease. Vitamin C is stored in the
adrenal glands not only needed for catecholamine synthesis, but also secreted in response to
adrenocorticotropic hormones, as an anti-oxidative, endogenous anti-inflammatory defense
mechanism. Findings from this study indicate that TB and smoking have an interactive effect on
depletion of vitamin C deposits..

Discussion
Tuberculosis or TB is an infectious disease caused by micro tuberculosis bacteria that can
be transmitted through sputum splash. Tuberculosis is not a hereditary disease or a curse and can
be cured with regular medication, supervised by the Drugs Supervision (PMO). Tuberculosis is a
direct infectious disease caused by TB germs. Most TB germs attack the lungs but can also other
organs.
One of the factors that influence the increase in TB cases is smoking. Smoking can
increase the risk of TB, because cigarettes contain nicotine, which on average, a cigarette
provides 4mg of nicotine absorbed in the body. This compound makes smokers become
addicted. Nicotine has the ability to impair the absorption of Mycobacterium through
macrophages derived from monocytes or alveolar, and these macrophage disorders can weaken
the host's immune response and increase the risk of TB infection.
Judging from the existing theories, smoking has an important role in the occurrence of
pulmonary TB. The particle size of cigarettes and other chemicals have a role in the emergence
of airway inflammation. According to Ozturk in 2014, several studies mentioned that Tumour
Factor Alpha Necrosis (TNF-α), Interleukin-6 (IL-6), IL-8 cytokines, activation of Nuclear
Factors (NF-κβ) and cellular lipid per oxidation were effective as pro-inflammatory and
oxidative damage to the lungs. According to Chuang et al in 2015 that smoking can cause
structural changes in Mycobacterium exposure. The function of pulmonary fluid production will
increase both for normal people and those affected by pulmonary TB. Cigarettes also cause
changes in natural and acquired cell immunity which can result in macrophages and leukocytes.
Furthermore smoking can also cause depletion of vitamin C, where vitamin C is able to
prevent the occurrence of TB. Vitamin C also acts as an anti-oxidative and anti-inflammatory
defence. If there is depletion of vitamin C, it will cause a decrease in anti-inflammatory stress
hormone response, especially epinephrine production, and have a tendency in lung damage that
causes inflammation.
The 5 articles analyzed showed that there was a relationship between smoking behavior
and an increased incidence of tuberculosis (TB).According to an article written by Shu-Lan Tsai,
Chun-Liang Lai, Miao-Ching Chi and Mei-Yen Che in 2016 about the effect of smoking
behavior with an increase in tuberculosis (TB) explains that there is a relationship between
smoking behavior and TB despite the prevalence of smoking in his study decreased from 46.9%
before to 30.2% after TB diagnosis. Likewise, according to a study conducted by V.G. Rao, J.
Bhat, R. Yadav, M. Muniyandi, M.K. Bhondeley, D.F. Wares, smokers and people who consume
alcohol have an increased chance of pulmonary TB compared to nonsmokers and non-alcoholics.
Because people who smoke may involve structural changes that affect lung function and changes
in immune response, and people who drink alcohol have an increased risk of infection. Likewise,
according to research conducted by Liza Bronner Murrison, Neil Martinso, Rachael M. Moloney,
Regina Msandiwa, Mondiwana Mashabela, Jonathan M. Samet, and Jonathan E. Golub, in an
adjusted analysis, smoking currently triples the chances of PTB and former smoking almost
doubles the chance of PTB compared to never smoking. Because smoking has a bad impact on
the immune system and makes people more susceptible to TB disease.
This research is also supported by research conducted by M. Aryanpur, MR Masjedi, M.
Hosseini, E. Mortaz, P. Tabarsi, H. Soori, H. Emami, G. Heydari, M. Baikpour (2015), said that
there are differences in the incidence of TB in people who smoke and who don't smoke, where
smoking is caused by the addiction to nicotine which can affect the incidence of tuberculosis
(TB). Other research conducted by John O Opolot, Annette J Theron, Patrick MacPhail, Charles
Feldman, Ronald Anderson (2014), discusses the effects of smoking on acute phase reactants, the
response of stress hormones and vitamin C to pulmonary TB proving that the effect of smoking
causes depletion of vitamin C which is useful in the prevention of TB.

Conclusion and Suggestion

Based on the discussion above, it can be concluded that there is a relationship between
smoking behaviour and the incidence of tuberculosis. Suggestions that researchers can give are
for the community, the role of the community is very important in avoiding smoking behaviour,
reducing the intensity of smoking, and changing the view that smoking is a negative attitude that
must be avoided. For health workers, to further enhance promotive and preventive efforts
regarding the dangers of smoking in the community.

Acknowledgment
The researcher would like to thank Ms. Arinil Haq as a lecturer in Systematic and
Metaaanalysis Study Subjects for his guidance to researchers, so researchers can complete this
research properly. Furthermore, thanks to epidemiology classmate for their support and input as
well as their suggestions in perfecting this research.

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