Cigarette Smoking and Health-Promoting Behaviours Among Tuberculosis Patients in Rural Areas
Cigarette Smoking and Health-Promoting Behaviours Among Tuberculosis Patients in Rural Areas
Cigarette Smoking and Health-Promoting Behaviours Among Tuberculosis Patients in Rural Areas
Authors: Shu-Lan Tsai, RN, MSN, TB Case Manager, Dalin Tzu of Nursing, Chang Gung University of Science and Technology,
Chi Hospital, Chiayi; Chun-Liang Lai, MD, Division of Pul- Chiayi County, Taiwan
monary and Critical Care, Dalin Tzu Chi Hospital, Chiayi; Correspondence: Mei-Yen Chen, Professor, No. 2, Chiapu Road
Miao-Ching Chi, PhD, Assistant Professor, Department of Respi- West Sec., Putz City, Chiayi County 61363, Taiwan. Telephone:
ratory Care, Chang Gung University of Science and Technology, +886 (5) 3628800 ext. 2201.
Chiayi; Mei-Yen Chen, RN, PhD, Professor, Graduate Institute E-mail: meiyen@gw.cgust.edu.tw
ble for protecting the other 90% does not activate (Horne
Introduction
et al. 2012). During the incubation period, many people
Tuberculosis (TB), which is a contagious, airborne disease, develop latent TB infection, and endogenous reactivation
is one of the top-ranking infectious diseases globally in may occur when the individual’s health condition weakens
terms of mortality. In 2014, 96 million and 15 million (Horne et al. 2012, WHO 2014). Approximately one-third
people worldwide were infected with or died from TB of the world’s population is infected with latent TB, which
respectively (WHO 2015). In addition, an estimated 1 mil- is both noncommunicable and asymptomatic (Horne et al.
lion and 140,000 children were infected with or died from 2012). Therefore, maintaining a healthy immune system is
TB respectively (WHO 2015). Furthermore, many people critical for safeguarding against TB infection.
still die from multidrug-resistant TB, despite a 47% Epidemiological studies have indicated that certain char-
decrease in the TB-related mortality rate and a treatment acteristics are associated with higher risks of acquiring TB
success rate of 86% for newly diagnosed individuals (WHO infection: older age, poverty, male sex, malnutrition,
2015). unhealthy lifestyle, below normal weight (Cegielski et al.
Although Mycobacterium tuberculosis is a pathogen that 2012, Dogar et al. 2012, Ladefoged et al. 2011, Jurcev-
has existed since ancient times, it remains a source of wide- Savicevic et al. 2013); cigarette smoking (Shang et al. 2011,
spread disease in many developing and developed countries. Li et al. 2014, and compromised immune systems and
In 2012, approximately 60% of all new TB cases occurred specific chronic diseases, such as diabetes and HIV coinfec-
in Asia (WHO 2014). In Taiwan, the incidence rate (545/ tion (Mupere et al. 2012, Hsu et al. 2013, Narasimhan
105) was higher than that in Singapore (44/105), Japan (27/ et al. 2013). Compared to nonsmokers, smokers have a 2–
105) and the USA (48/105) (CDC 2014). In particular, the 3-fold higher risk of acquiring TB infection and progressing
rural regions of Yunlin and Chiayi Counties contain from latent to active disease, even after completing treat-
increasingly ageing populations with TB rates of 703/105 ment (d’Arc Lyra et al. 2008, Ladefoged et al. 2011). In a
(Yunlin) and 627/105 (Chiayi) (CDC 2014). Thankfully, recent in vitro study from South Africa, van Zyl-Smit et al.
modern medicine has rendered TB curable and preventable. (2014) found that cigarette smoke moderated effector cyto-
Three important interrelated factors are generally associ- kine response and compromised the macrophage contain-
ated with infectious diseases: the pathogen, environment ment of Mycobacteria in infected individuals.
and host. Prevention strategies that address all three of Expert consensus indicates that ideal TB control involves
these factors are critical for reducing infections in all health the following measures: (1) Bacillus Calmette-Guerin vacci-
care settings. Host defenses may be strengthened by individ- nation in all eligible newborns; (2) early diagnosis; (3)
ual health-promoting behaviours that are related to nutri- prompt treatment; (4) adherence to treatment, consisting
tion, immunisation, personal hygiene and regular exercise of regular chest radiography and directly observed treat-
(WHO 2010). These behaviours are often the result of pub- ment programmes with a six to nine month course of 3–4
lic health promotion strategies that motivate individuals to antimicrobial drugs and (5) enhanced individual immunity
take increased control over their health, which may through healthy lifestyle strategies, including smoking ces-
improve the society’s collective health status. Clinicians sation and adequate nutrition (Li et al. 2014, WHO
play an important role in lifestyle modification for TB 2014). However, enhancing immunity at the individual
patients, and many studies have demonstrated that health- level requires an understanding of the gaps in the adoption
promoting behaviours are positively correlated with health of healthy behaviours at the different disease stages. Unfor-
status (Chen et al. 2006, 2012). However, few studies tunately, most studies have focused on the side effects of
have examined health-promoting behaviours among TB anti-TB drugs and adherence to TB treatments, and few
patients. studies have investigated whether TB patients actually
adopt health-promoting behaviours and how these beha-
viours change between the pre-diagnosis and post-treat-
Background
ment stages. Therefore, this study aimed to evaluate and
The risk of developing TB depends on three interrelated compare changes in cigarette smoking and health-promot-
factors: a weakened host immune system, the presence of a ing behaviours reported before and after TB diagnosis
sufficient amount of M. tuberculosis, and an adequate among adults in a disadvantaged region. This study used
transmission environment (CDC 2014). Patients who have previously reported risk factors associated with TB infec-
latent TB infection have a 10% lifetime risk of developing tion, based on the value of promoting healthy behaviours
active TB, while the immune defense mechanism responsi- in TB patients.
Participants were classified as ‘never smoked’ if they had majority of the remaining 123 participants were men
never smoked cigarettes before their TB diagnosis or after (n = 96, 78%), and the mean age was 614 years (standard
TB treatment or as ‘have smoked at some time’ if they deviation, 165 years; range, 21–89 years). More than half
were a smoker before their TB diagnosis or had smoked (n = 69, 561%) of the participants completed primary
during or after completing TB treatment. school or less (≤6 years). The majority of participants were
married (n = 91, 74%), and more than half of the partici-
pants were currently working (n = 65, 528%) (Table 1).
Statistical analysis
Over half of the participants had completed TB treatment
SPSS software (version 17.0; SPSS Inc., Chicago, IL, USA) (n = 72, 585%), and 415% (n = 51) were still undergoing
was used for data analyses. All tests were two-sided, and treatment. Positive contact history with family, relatives or
p-values of <005 were considered statistically significant. colleagues with TB was observed among 207% (n = 31) of
The paired t-test, independent t-test, and chi-square test the participants, and 793% (n = 92) of the participants
were used for evaluating rates and equality of proportions stated that they had a negative TB contact history. Approx-
in the pre-diagnosis and post-treatment comparison of per- imately two-thirds (n = 84, 683%) of the participants
sonal factors, health-related factors and health-promoting reported having one or more concurrent chronic diseases.
behaviours. To investigate the factors that were associated The most common concurrent chronic diseases were dia-
with health-promoting behaviours, stepwise linear regres- betes (275%), hepatitis (213%), and hypertension
sion analysis was conducted using variables that were sig- (118%). Before their TB diagnosis, 13% (n = 16) of the
nificant (p < 005) in the univariate analyses of occupation, participants were classified as underweight (BMI < 185
chronic disease, smoking habit and treatment status. kg/m2). Hospital medical records revealed that more than
half of the participants with available records had below-
average haemoglobin (57/105) and albumin (31/49) levels.
Results
Among the 134 candidates who were invited to participate The percentage of participants who smoked decreased from
in this study, 11 failed to complete the assessment. The the reported 469% (n = 45) before TB diagnosis to 302%
Table 1 Demographic characteristics and reported cigarette smoking behaviour changed before and after diagnosis of tuberculosis (n = 123)
(n = 29) after receiving or completing TB treatment exercise (t = –223, p = 0028) and the total GHPs score
(Table 1). Among the participants, male sex was signifi- (t = –301, p = 0003). Table 2 also shows that a significant
cantly associated with cigarette smoking habits (v2 = 1996, increase in BMI occurred after TB treatment (t = –613,
p < 0001). Current smokers were significantly younger p < 0001). Furthermore, 14 items of the health-promoting
(v2 = 1297, p = 0002), had a secondary school or greater behaviours occurred at frequencies of ‘sometimes’ or
education (v2 = 753, p = 0023), were currently employed ‘never,’ especially for the community participation dimen-
(v2 = 1851, p < 0001), were unmarried (v2 = 893, sions (e.g. participation in community programmes, town-
p = 0012), and had no concurrent chronic diseases ship or religious activities).
(v2 = 743, p = 0024). Table 3 shows the findings of the univariate analysis
regarding current health-promoting behaviours. Participants
who had never smoked or who had stopped smoking for
Factors associated with health-promoting behaviours
greater than one year had significantly higher scores, com-
Table 2 shows that the three dimensions of the GHPs and pared to current smokers, in the dimensions of health
11 items of the health-promoting behaviours changed sig- responsibility (p < 005), healthy diet (p < 001) and total
nificantly from reported behaviours before TB diagnosis to GHPs score (p < 005). Participants with chronic diseases
after receiving or completing TB treatment. Significant had significantly higher scores in health habits (p < 005),
GHPs dimensions included health responsibility (t = –303, health responsibility (p < 001), regular exercise (p < 005)
p = 0003), healthy diet (t = –348, p = 0001), regular and total GHPs score (p < 001). Participants who were
Table 2 Reported health promoting behaviours and BMI changed before diagnosis and during or completing TB treatment (n = 123)
Gender
Male 239 (24) 81 (29) 84 (34) 85 (21) 47 (26) 40 (21) 576 (88)
Female 238 (36) 78 (29) 73 (38) 92 (23) 39 (28) 47 (18) 567 (129)
Age (years)
<65 239 (29) 77 (28) 78 (37) 90 (22) 42 (26) 43 (19) 569 (94)
≧65 239 (25) 83 (31) 86 (33) 83 (21) 48 (28) 39 (21) 579 (103)
Education
≦Primary 239 (25) 80 (28) 86 (34) 84 (21) 45 (28) 39 (21) 573 (94)
≧Secondary 239 (31) 79 (31) 77 936) 90 (22) 45 (25) 44 (19) 575 (104)
Occupation
Unemployment 241 (27) 85 (35) 81 (34) 87 (23) 53 (27)** 41 (19) 586 (109)
Employment 238 (28) 76 (22) 83 (36) 87 (21) 38 (25) 42 (21) 563 (860
Chronic disease
Yes 243 (26)* 83 (32) 89 (32)** 88 (22) 49 (27)* 40 (20) 592 (99)**
No 232 (30) 73 (21) 67 (37) 84 (19) 37 (25) 45 (19) 536 (86)
Smoking
Never/cessation 239 (27) 80 (31) 85 (35)* 89 (22)** 46 (27) 42 (20) 581 (100)*
Current user 237 (29) 78 (21) 63 (32) 73 (13) 39 (28) 39 (19) 527 (67)
Treatment status
Incomplete 233 (31) 72 (24) 73 (32) 86 (23) 41 (26) 41 (22) 545 (89)
Complete 244 (24)* 85 (32)* 89 (35)* 88 (21) 48 (27) 42 (19) 595 (99)**
HH, health habits; CP, community participation; HR, health responsibility; HD, healthy diet; exercise, regular exercise; OH, oral health.
Independent t-test, *p < 005; **p < 001.
currently not working had significantly higher scores in reg- Similar to previous studies of TB (Olson et al. 2012,
ular exercise (p < 001), compared to working participants. WHO 2014), we found that male sex, lower socioeconomic
Participants who had completed TB treatment scored signif- status and smoking habits were important characteristics
icantly higher in health-promoting behaviours, compared to among TB patients. Nicotine has the ability to impair the
participants who had not completed TB treatment, for uptake of Mycobacteria via monocyte-derived or alveolar
health habits (p < 005), community participation macrophages, and this macrophage impairment may
(p < 005), health responsibility (p < 005) and total GHPs weaken the host immune response and increase the risk of
score (p < 001). latent TB infection (Dogar et al. 2012, Horne et al. 2012,
After adjusting for potential confounding variables, our Louwagie & Ayo-Yusuf 2013). One mathematical mod-
stepwise linear regression analysis (Table 4) revealed that elling analysis by Basu et al. (2011) predicted that tobacco
the determinants for current health-promoting behaviours smoking could substantially increase the number of TB
were chronic disease (b = –025, p = 0005) and completion cases and deaths worldwide in the coming years. Notably,
of TB treatment (b = 023, p = 0007). in this study, no one started to smoke after the diagnosis.
Although the prevalence of cigarette smoking decreased
from 469% before to 302% after the diagnosis of TB,
Discussion
smoking remains a significant problem. Therefore, if TB-
This study aimed to investigate the changes in health-pro- related public health goals include reducing TB relapse and
moting behaviours and smoking habits among adults multidrug-resistant TB, smoking cessation should be aggres-
between reported behaviours before TB diagnosis and dur- sively addressed in TB treatment protocols and in coun-
ing or after completing TB treatment in a disadvantaged selling environments, especially for individuals who are
geographical area. There was a high prevalence of cigarette more likely to smoke (e.g. men).
smoking and a low rate of health-promoting behaviours Previous studies revealed that malnutrition is a risk factor
among the participants, both before TB diagnosis and dur- for TB infection and relapse after treatment (Karyadi et al.
ing or after TB treatment. 2000, Pakasi et al. 2009, Lonnroth et al. 2010, Choi et al.
Table 4 Determinant factors associated with present health promoting behaviours (n = 123)
2014). Our study also revealed similar findings, as many a rural hospital with relatively uneducated patients, the
participants were underweight, with abnormal haemoglobin generalisability of these findings may be limited. Second,
and albumin levels, before their TB diagnosis. Our findings the cross-sectional and retrospective data only reflect
appear to indicate that not all health care providers evalu- associations and do not indicate causal relationships. Third,
ate these nutritional elements before a TB diagnosis or after self-reporting may have caused underestimation or overesti-
TB treatment. National data from the US (Cegielski et al. mation of certain health-related behaviours, such as the
2012) and South Korea (Choi et al. 2014) indicate that amount and frequency of cigarette use or personal dietary
individuals who are underweight (BMI < 185 kg/m2) and habits. Fourth, recall bias may have occurred, as current
have low serum albumin levels are at an increased risk of smoking status was not determined using a carbon monox-
developing TB infection and having poor TB treatment out- ide monitor. Fifth, although the mean age of the partici-
comes. Therefore, future treatment plans should consider pants was 61 years, the GHPs was used, which might have
nutritional assessment and provide nutritional counselling resulted in measurement error. Moreover, recall bias is of
during the identification and treatment of TB. concern. The potential inaccuracy of the recall measure
The present findings also demonstrate that having a con- would lead to the biases in memory, which are produced
current chronic disease (especially type 2 diabetes) and by factors outside consciousness, such as primacy, recency,
completing TB treatment were associated with health- and demand characteristics of the experiment. To achieve
promoting behaviours. These patients might have received more conclusive results, future research should use more
general health promotion messages from their health care robust methods, such as a prospective study of health beha-
providers. For example, protocols for standardised diabetes viours from the time of diagnosis.
care in Taiwan encourage patients to adopt better exercise
habits and a balanced diet that includes food from the five
Conclusion
food groups. Although emphasising lifestyle improvements
during TB treatment is not a health promotion strategy in Our findings revealed that the majority of participants
Taiwan, this strategy could potentially significantly improve exhibited low levels of health-promoting behaviours, both
the physical condition of patients who complete TB before their TB diagnosis and during or after completing
treatment (e.g. by reducing unwanted side effects after TB TB treatment. Therefore, Taiwanese TB programmes and
treatment) and motivate these patients to continue their future research should utilise strategies that incorporate
health-promotion behaviours. Therefore, we conclude that healthy lifestyle promotion to eliminate TB. Although the
participants who completed TB treatment had improved presence of M. tuberculosis is necessary, but not sufficient,
health behaviours. Nevertheless, although significant to cause TB (Jurcev-Savicevic et al. 2013), poor health con-
improvements were identified in these patients, healthy ditions, concurrent chronic diseases and unhealthy lifestyle
habits were practiced at a frequency below “usually” dur- choices are also important host immunity factors that can
ing daily life. Therefore, to continue building up the host play roles in susceptibility to TB.
immune system and avoid activation of latent TB, it is nec-
essary to establish standardised counselling that encourages
Relevance to clinical practice
TB patients to adopt healthier behaviours.
Nurses are expected to provide evidence-based care, and
nursing leaders have an obligation to support and enable
Limitations
nurses to meet that expectation. According to the present
There are several limitations in this study. First, because the findings, malnutrition, cigarette smoking and unhealthy
participants were recruited using a convenient sample from habits were prevalent among TB patients. Therefore, it is
necessary to enhance the promotion of a healthy lifestyle, patients who participated in this study for their support in
and cigarette smoking and healthy eating should be assessed making this study possible. In addition, we would like to
and evaluated immediately after the first diagnosis of TB in acknowledge the nursing staffs and chest physicians at the
the hospital. Furthermore, health promotion-related lifestyle outpatient clinic of the Dalin Tzu Chi Hospital for provid-
modification and smoking cessation programmes should ing administrative support.
receive continued attention for TB patients during their
treatment.
Contributions
Study design: SLT, MYC, CLL; data analysis and interpreta-
Acknowledgements
tion: MCC. All authors read and approved the final article.
The study was supported by a grant from the Buddhist
Dalin Tzu Chi Hospital, Chiayi County (NO: B10204019).
Conflict of interest
The authors would like to thank Dr. Chia-Ho Chang for
his statistics support. The authors would like to thank the The authors declare that they have no conflict of interests.
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