The Convergence of the Global Smoking, COPD, Tuberculosis, HIV, and Respiratory Infection Epidemics
Section snippets
Methodology and search strategy
We searched PubMed for peer-reviewed literature over the past 3 decades with a focus on studies that reported data on the associations among tuberculosis, smoking, HIV, influenza, pneumonia, and COPD. No language restrictions were imposed, although only English language studies were eventually included. In addition, we identified 3 systematic reviews7, 8, 9 on the association between tobacco and TB, 1 systematic review on the association between tobacco and HIV,10 and several narrative reviews5
Smoking and pulmonary immunity and disease
Current estimates of tobacco smoking rates are 49% for men and 8% for women in low- and middle-income countries, and 37% for men and 21% for women in high-income countries.7 Tobacco is the single most preventable cause of death in the world today. It kills more than 5 million people per year, with more than 80% of those deaths occurring in the developing world.19 There are a multitude of effects of tobacco smoke on the immune system, predisposing individuals to respiratory infections.15, 16, 17
Smoking and TB
The association between tobacco smoke and tuberculosis was suggested many years ago.2 Evidence of the impact of tobacco smoking on TB infection has been confounded by its almost universal association with poverty, overcrowding, and alcohol usage. Similar pathologic mechanisms induced by malnutrition, alcohol abuse, and smoking may indeed all predispose an individual to TB. There are now 3 comprehensive independent systematic reviews and meta-analyses that have synthesized the evidence for the
Smoking and pneumonia
Pneumonia occurs more frequently in individuals with impaired immunity. This is evident in the elderly and alcoholic individuals, and those who are malnourished, HIV-infected, and those with underlying COPD.26 In addition, tobacco smoking appears to be an independent risk factor for pneumonia.27, 28 It is evident from several studies that smoking is a particularly important risk factor for streptococcal pneumonia (OR 1.88 to 4.1).29, 30 Passive smokers and importantly children also have an
Smoking and influenza
With the prospect of an avian influenza epidemic ever increasing,3 multiple measures will be required to control the epidemics. Although not recognized as a risk factor in the 1918 pandemic (data not collected),2, 3 there is substantial evidence in both mouse and human models for a negative effect of smoking on influenza.44, 45, 46, 47, 48 The risk of infection is increased in smokers (OR 1.4–2.4),46, 47 as well as likelihood for severe disease and complications (OR 4.3; 95% CI 1.1–16.1).49 In
Smoking and HIV
Although both tobacco smoking and HIV infection may be associated through their common associations with poverty and high-risk behavior, tobacco smoking appears to be an independent and important risk factor for contracting HIV.58, 59, 60, 61 Other studies have demonstrated higher viral loads62 and rate of progression of HIV infection to AIDS in smokers,63, 64 but this association has not been observed in all studies.65, 66, 67, 68
Smoking further raises the extremely high risk of contracting TB
Smoking and COPD
Although the focus of this article is primarily on the convergence of respiratory infections, HIV, and tobacco smoking, the importance of COPD in the interactions needs to be stressed. The causal link between smoking and COPD is well described and the multitude of consequences well known.74 There is now a growing recognition of the importance of non-smoking causes for COPD.75 There are several studies examining respiratory infections (particularly TB) as a cause of COPD.76, 77, 78, 79, 80 The
Convergence of TB, HIV, COPD, pneumonia, and influenza
Tobacco smoking is undoubtedly at the center of convergence of the epidemics we are currently facing (not discounting the role of alcohol, malnutrition, poverty, indoor biomass fuel exposure, and outdoor air pollution).
As smoking increases the risk of TB and COPD, the long-term damage to pulmonary structures and respiratory function further increases the risk of bacterial pneumonia and influenza. Similarly, the increased susceptibility to influenza seen in smokers will magnify the risk of
Summary
At the beginning of the 21st century, the globe is facing an economic crisis in addition to the convergence of several potentially devastating infection epidemics. The emergence of H1N1 is adding to the burden on health care delivery systems, and is already diverting precious human and laboratory resources. This was clearly evident in countries such as Mexico and India. The final number of people who will succumb to TB, HIV, and influenza will depend on the combined efforts of governments,
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2020, Global Health JournalCitation Excerpt :This may ultimately lead to an increase in alcohol harm for a generation or more.112 The risk of respiratory tract infections in smokers may be increased through various mechanisms.113 Smoking impairs immune function and has been shown to almost double the risk of infection with tuberculosis114 and to increase the risk of several types of pneumonia infection 3–5 fold115 and of influenza approximately five fold.116
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R.V.Z.S. is supported by a Discovery Foundation fellowship and by the Fogarty International Clinical Research Scholars/Fellows Support Center National Institutes of Health grant R24TW007988. M.P. is supported by grants from the Canadian Institutes of Health Research (CIHR) and European Commission (TBSusgent; EU FP-7).