Education And Debate

Should interventions to reduce respirable pollutants be linked to tuberculosis control programmes?

BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7474.1090 (Published 04 November 2004) Cite this as: BMJ 2004;329:1090
  1. Enis Baris, senior public health specialist1,
  2. Majid Ezzati (mezzati@hsph.harvard.edu), assistant professor of international health2
  1. 1 World Bank, Washington DC, USA
  2. 2 Department of Population and International Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
  1. Correspondence to: M Ezzati
  • Accepted 6 September 2004

The potential benefits of linking tuberculosis control programmes with interventions to reduce smoking and indoor air pollution make research to improve our understanding of their relation a high priority

Introduction

Tuberculosis, smoking, and indoor air pollution from solid fuels are among the leading global causes of death and burden of disease.1 2 Several studies have observed an increased risk of tuberculosis disease or mortality among smokers and those exposed to indoor air pollution, but our understanding of the strength and causal pathways of the risk remains uncertain Tuberculosis and exposure to respirable pollutants are often highest in the poorest socioeconomic groups, who are also those with the least access to interventions and health care. Thus, integrating interventions to reduce smoking and indoor air pollution with tuberculosis control programmes could in principle increase coverage and effectiveness. We discuss the arguments for linking the two public health measures and the scientific uncertainties that currently limit the potential for integration.

Current evidence and its limitations

Tuberculosis, indoor air pollution from solid fuels, and smoking each accounted for substantial mortality and disease burden in 2000, with a high proportion in developing countries (table). Epidemiological studies have found an increased risk of tuberculosis disease or mortality among smokers and those exposed to indoor air pollution, with relative risks or odds ratios varying between > 1 and nearly 5.410 Most published studies have used a retrospective, case-control design, generally with limited control for covariates (such as socioeconomic status, nutrition, alcohol consumption, housing, and crowding) or assessment of heterogeneity of risk. All studies have used self reported exposure for smoking and solid fuel use, and few have examined a dose-response relation.5 A few studies on smoking have considered increased risk of death from tuberculosis.4 6 8 All other studies have examined increased risk of tuberculosis disease in …

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