Egyptian Journal of Chest Diseases and Tuberculosis (2015) 64, 929–932

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The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

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ORIGINAL ARTICLE

Pulmonary tuberculosis specificities in smokers

a,*
Rhanim Aziza , Hammi Sanae a, Kouismi Hatim a, Jamal Eddine Bourkadi b

a
Ibn Sina University Hospital Center, Department of Respiratory Medicine of Moulay Youssef Hospital, Morocco
b
Ibn Sina University Hospital Center, Department of Respiratory Medicine of Moulay Youssef Hospital, Rabat, Morocco

Available online 6 June 2015

KEYWORDS Abstract Background: Smoking and tuberculosis are two major challenges in public health
Clinic; system. The aim of our study is to identify the impact of smoking on clinical, radiological manifes-
Radiology; tations and evolutive pulmonary tuberculosis.
Bacteriology; Methods: This retrospective case–control study examined the files of 104 patients. The patients
Smoker; monitored for pulmonary tuberculosis were divided into 2 groups. We studied the clinical and
Tuberculosis radiological profile, and evolution in both groups.
Results: 104 patients were included, divided into two groups: Group I: 59 current smokers who
have tuberculosis (TB) and Group II: 45 TB patients who have never smoked. The mean age is
38 years. All patients in Group I are male while there is no predominance of one sex over the other
in group II. The time to diagnosis is delayed in patients who smoke. There is no significant differ-
ence in the clinical symptoms. Radiological lesions are diffuse among current smoker patients, as
they are mostly unilateral in group II. The clinical outcome was good in 91.1% of TB non smoking
patients with weight gain between 2 and 5 kg versus 35.3% in the group of smokers. Bacteriological
conversion in the second month was reached in 95.6% of patients in group II, while there was a
bacteriological negativity delay in group II patients. Three smoking patients died.
Conclusion: Our study raised the harmful impact of smoking on the clinical and radiological pre-
sentation of tuberculosis, and late bacteriological negativity, therefore we need to integrate smoking
control into the national TB control program.
ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest
Diseases and Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Background According to the World Health Organization (WHO), there

were 8.6 million cases of tuberculosis disease (TD), responsible
Smoking and tuberculosis (TB) represent two major issues of for 1.3 million deaths in 2012. Every year nearly 6 million
worldwide public health, especially in emerging countries. deaths are due to smoking among which over 600,000 are
non-smokers exposed to the smoke.
Abbreviations: TB, Tuberculosis; UK, United Kingdom; AFB, Acid- The incidence of tuberculosis remains strong despite the
Fast Bacilli effectiveness of antibacillary chemotherapy. Several factors
* Corresponding author at: 1305 Massira 1 CP, 10100 Rabat, are involved: promiscuity, low socioeconomical status, HIV
Morocco. Tel.: +212 675067168. infection and genetic susceptibility to tuberculosis. Often
E-mail address: aziza.rhanim@gmail.com (R. Aziza). neglected, the active and passive smoking is a risk factor for
Peer review under responsibility of The Egyptian Society of Chest pulmonary tuberculosis occurrence. Our study aims to
Diseases and Tuberculosis.
http://dx.doi.org/10.1016/j.ejcdt.2015.04.011
0422-7638 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
930 R. Aziza et al.

investigate the effects of smoking on the diagnosis period, clin-
ical, bacteriological, radiological and evolutive pulmonary
tuberculosis.
Methods
We made a retrospective case–control study with patients
monitored for pulmonary tuberculosis in a health center in
Rabat from January 2013 to April 2014. The center’s chief
doctor has given permission to conduct and publish this study.
The diagnosis is confirmed by two positive bacteriological
exams or a positive test and a positive culture or a radiological
environment compatible with tuberculosis. We excluded
patients in poor condition or malnourished, patients treated
with steroids or immunosuppressive therapy, those with a his-
tory of respiratory and wean smoking. All data were collected
on a pre-established form and data capture and analysis were
performed using SPSS version 10.0 software.
This manuscript does not include details, images, or video
relating to individual participants, therefore no consent was
requested.
Results
in group I, 44.2% of patients have a combination of several
radiological lesions (Figs. 4 and 2). These lesions are usually
extended in the group of smokers (71.2%), while they are
mostly unilateral in patients who have never smoked (77.1%)
with a statistically significant difference (p < 0.001) (Fig 3).
All patients were under the same therapeutic regimen: two
months of combined rifampicin, isoniazid, ethambutol and
pyrazinamide and four months of rifampicin and isoniazid
combined. In group I all patients (100%) were compliant,
while in group II, three patients discontinued treatment in
the second month, but there was no significant impact of
smoking on patient compliance.
In the second month of treatment, 91.1% of patients in
group II have evolved clinically gaining 2–5 kg weight, while
in the first group only 35.3% gained weight with a significant
difference (p < 0.001).
The AFB sputum in the second month of treatment was
systematic in all patients, it was negative in 95.6% of patients
in group II versus 66.1% of patients in group I, with a statis-
tically significant difference p < 0.001. Thus, smoking is linked
to a late negativity Koch’s bacillus in sputum smears in our
patients. Three patients died; they were active smokers. No
death was observed in group II, but there was no significant
difference between the 2 groups.

A total of 104 patients were included and divided into two
groups: Group I represents 59 current smokers with tuberculo-
sis, and Group II represents 45 TB who have never smoked.
The mean age of our patients is 38 ± 15 years. The age of the
patients in group I (current smokers TB) ranges between 21
and 73 years; while the number of patients in group II ranges
from 15 to 67 years. The mean age of patients in group I was
higher than that in group II: 42.9 versus 31.6 years. All patients
in group I were male while there was no significant gender pre-
dominance in Group II: 51.1% men versus 48.9% women.
Contact with tuberculosis was noticed in 37.3% of patients
in group I versus only 4.4% in group II, with a statistically sig-
nificant difference (p < 0.001). The degree of smoking intoxi-
cation in the smoker group was estimated between 14 and 33
pack-years with a mean of 20 pack-years.
Discussion
The relationship between smoking and pulmonary tuberculosis
was suspected since 1918 and it is only recently that the effect
of smoking on TB has been identified [1]. Indeed smoking is
not only a major cause of morbidity and mortality, but also
one of the risk factors for the occurrence of tuberculosis.
Nodules + Excavaon
alveolar lesions+ Pleuresy
Nodules + Pleuresy
alveolar lesions+ hilar opacity

In group I the diagnosis confirmation period is from 30 to Excavaons

Non smokers
120 days with an average of 60 days, while in the second group alveolar lesions smokers
the period is between 15 and 60 days with an average of
Nodules
30 days. The difference between the two groups was statisti-
cally significant p < 0.001. Clinical symptoms were not differ- 0 5 10 15 20 25 30 35
ent between the two groups (Fig. 1).
Figure 2 Radiological lesions in the studied groups.
Regarding the type of radiological lesions, 89% of group II
patients have only one type of radiological lesions. Meanwhile

80.00%
100 70.00%
60.00%
50 50.00%
40.00%
0 30.00% smokers
smokers 20.00% Non smokers
non smokers 10.00%
0.00%
unilateral
localized bilateral
localized bilateral
lesions diffuse unilateral
lesions diffuse
lesions
lesions

Figure 1 Comparison of clinical signs between the two groups. Figure 3 Extension of the radiological lesions in the two groups.
Pulmonary tuberculosis specificities in smokers
smokers
isolated radiological lesions 33 (55,9%)
multiple radiological lesions 26(44,1%)
Figure 4 Comparison of isolated and multiple radiological lesions between the 2 groups.
In developing countries, where TB incidence is high, the
increase in the prevalence of smoking can have a significant
impact on the endemic tuberculosis. In 1956, Lowe had noted
in a study in the UK, a higher prevalence of smoking (smok-
ing_20 c/d) among patients with tuberculosis (50.1% in men
and 11.4% in women) than in controls (43.4% in men and
2.4% in women) [2]. In a review of the literature, Davies
et al. have also shown that the incidence of TB increases with
the consumption of tobacco, the risk is multiplied by 2 or 4 if
the number of cigarettes smoked per day is over 20 [3].
Clinical signs in tuberculosis are more important when
associated with smoking [4–5]. Cough and dyspnea are more
common in smokers [6]. But other studies have not shown
any significant difference [7].
The time to diagnosis is longer in the smoker group, the
main reasons for this delay are divided into system factors
and patient factors: Alcoholism, smoking, other intoxications,
mild symptoms, absence of hemoptysis and existence of a
chronic respiratory disease [8]. The majority of Moroccan
pneumologists believe that there is a consultation delay in
smoking-related TB patients most likely explained by the link
that the patient has between respiratory symptoms and smok-
ing chronic bronchitis [9].
Initial radiological lesions of tuberculosis are larger and
more frequent in smokers than in non smokers [7].
According to the study of H. Racil in Tunisia, lesions (nodules,
infiltrates and excavations) are more important in smokers
compared to non smokers (85% of cases versus 47%,
p < 0.001) [1]. Other published data have shown that the
lesions are more diffuse in smokers with tuberculosis com-
pared with non smoking population, with more cavitary
lesions, nodular and miliary aspects [4–5]. These results cor-
roborate those found in our series. These extension radiologi-
cal lesions can be explained by a poor cellular immunity in the
local inflammatory site related to lymphopenia (CD4),
impaired function of macrophages secondary to smoking,
which are the cause of an increase in the disease [10].
Among the risk factors for poor compliance among TB
patients, Chang et al. demonstrated in their study that smok-
ing is one of these factors (OR = 3.00; 95% CI 1.41–6.39)
[11]. The study by Wang et al. performed in Taiwan in 523
new TB patients also showed there was a positive association
between smoking (current or former) and poor adherence to
treatment [5].
The response to treatment is estimated by improved clinical
symptoms, weight gain and bacteriological conversion. The
smoking impact on the clinical course of such patients’ weight
gain has not been evaluated in the literature, our study has
clearly emphasized this aspect. Regarding the bacteriological
conversion, Metanat showed that smoking is significantly
associated with negativity delay of sputum smear p < 0.001
(negativation retardation in 53% of smokers versus 10% of
non-smokers) [12].
931
Non smokers
40 (88,9%) p < 0,001
5(11,1%) p < 0,001
Finally, smoking is linked to an increased risk of tuberculo-
sis mortality among smokers. A case–control study realized by
Sitas et al. in South Africa, showed a positive association
between smoking (current and former) and mortality from
tuberculosis disease (pulmonary and extrapulmonary) with
an odds ratio of 1.61 (95% confidence intervals: 1.23–2.11).
The fraction of TB deaths related to smoking was 20% [13].
The meta-analysis of Bates et al. including five studies, has also
found a positive association between smoking and tuberculosis
mortality with a RR of 2.15 [14].
Conclusions
Increase in smoking in developing countries is an additional
risk factor for developing TB. The smoked tobacco delays
the time for the diagnosis of TB, aggravates radiological dam-
age and delays clinical improvement and bacteriological nega-
tivity, thus it is important to integrate smoking control in the
national TB program.
Conflicts of interest
The authors declare no conflict of interest.
Acknowledgements
AR conducted the study and drafted the article and did not use
funding.
We thank HK who conducted the statistical analysis with
SPSS tools. He did not use funding.
We thank JED and SH who performed proofreading and cor-
rection of the article. They did not use funding.
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