Tuberculosis and smoking habits

World Tuberculosis Day (World TB Day) is celebrated every March 24th. The theme for commemorating World TB Day in 2023 is "Yes! We Can End TB". "Let's End TB Together, Indonesia Can." This theme is a form of optimism by all parties as well as a joint commitment to eliminate TB by 2030, which is contained in the global commitment to the End TB Strategy.

The Global TB Report released by WHO in 2022 shows that 10.6 million people suffer from tuberculosis in the world. TB is one of the deadliest infectious killers. The death rate from TB globally reaches 1.6 million, meaning that more than 4,300 people die from TB every day. The incidence of TB in Indonesia in 2021 will reach 969,000 cases, or 354 cases per 100,000 population, with a mortality rate of 144,000 people (52 per 100,000 population). This figure is still far from the target of RI Presidential Regulation Number 67 of 2021, which states that Indonesia is committed to reducing the incidence of tuberculosis cases to 65 per 100,000 people by 2030 and the target of reducing the death rate from TB to 6 per 100,000 people.

Another problem and challenge is the emergence of cases of drug-resistant tuberculosis (RO TB), child TB, TB-HIV, and TB with comorbidities, with an increasing incidence of cases. The bacteria Mycobacterium tuberculosis (M. tb.) contained in saliva or sputum splashes spread rapidly through the air from an active tuberculosis sufferer to someone who is healthy, either when talking, sneezing, or coughing. The high number of TB cases in Indonesia is inseparable from the risk factors that are closely related to daily habits, one of which is smoking. Several other risk factors for easy infection with tuberculosis are co-morbidities such as diabetes, hypertension, malnutrition, and people with HIV/AIDS (PLWHA).

Traditions And Trends Of Today's Cigarettes

As social beings, humans always interact and stay in touch, whether for economic transactions or just hanging out together over a cup of coffee. For some groups of people, smoking is a tradition that accompanies daily activities. No matter how much evidence there is about the dangers of cigarette smoke or vapor for health, they don't care.

If we examine cigarettes from the past to the present, they continue to innovate and adapt to meet the needs of all age groups. Conventionally, cigarettes are rolled tobacco wrapped in nipa leaves or paper, while smoking is the act of smoking cigarettes or the process of enjoying burned tobacco. Current technological developments cause the meaning of the word cigarettes to expand. There is an electric cigarette (E-Cigarette) in which the smoking activity includes the activity of inhaling chemical liquid vapors using a special tool called a vape.

The use of electronic cigarettes, commonly calledvaping, is increasing among teenagers and young adults. This electric cigarette is also known by various names, such as "e-cigs", "vapes", "mods", "tank systems", "e-hookahs", "vape pens", and "electronic nicotine delivery systems (ENDS). Some of the factors that support the rapid development of vaping are the perception of electronic cigarettes as a healthier alternative to conventional cigarettes because the levels of toxic substances and carcinogens tend to be lower. Apart from that, some communities also promote vaping as a tool for smoking cessation therapy. Massive and aggressive vape marketing opens up new business opportunities; shops selling vaping devices and refill liquids are mushrooming everywhere. Vaping is considered cooler for young people, becoming a new lifestyle and culture.

An electronic cigarette consists of several parts, namely a lithium battery, a heating component, and a container filled with liquid. Liquid will be converted into vapor for inhalation. Vape liquid contains solvents (propylene glycol, vegetable glycerin), flavors (fruits, mint, etc.), as well as the active ingredient nicotine. These substances cause symptoms similar to upper respiratory tract infections, have the potential to become cancer-causing substances, cause irritation to the eyes, lungs, and esophagus, and can cause a decrease in lung function capacity.

The Centers for Disease Control and Prevention (CDC) released a case of acute respiratory failure due to vaping, namely EVALI (e-cigarette or vaping, product use associated lung injury). The main cause of EVALI is thought to be due to vitamin E acetate, which contains tetrahydrocannabinol (THC), which enters the body when using vapes. EVALI complications include acute respiratory distress syndrome and respiratory failure, so some patients need intubation and mechanical ventilation.

Nicotine addiction

Smoking is a fun activity because, in several cycles of friendship, smoking is socially considered a symbol of friendship and intimacy, while personally smoking is addictive.

Conventional cigarettes contain substances such as tar, nicotine, carbon monoxide, etc., as well as e-cigarettes. Nicotine in cigarettes, when inhaled, reaches the brain within seven seconds and binds to the nicotinic acetylcholine receptors (nAChR). Activation of these nerves causes the production of dopamine. Dopamine is able to strengthen brain stimulation and activate reward pathways, namely the regulation of feelings and behavior, through certain mechanisms in the brain. Dopamine is a chemical compound that is responsible for feelings of pleasure, calm, motivation, and pain relief. The release of dopamine is only temporary, so smokers will repeat their smoking habit to get the same sensation but with an increased dose or number of cigarettes. A person can be said to be suffering from nicotine addiction if they experience symptoms of tolerance and withdrawal symptoms after quitting smoking.

Impact of cigarettes

Cigarette smoke consists of more than 7,000 chemical compounds, and there are 69 carcinogenic substances that cause cancer. The Central Statistics Agency (BPS) in 2022 noted that the percentage of smokers aged 15 years in Indonesia was 28.6% and smokers aged 18 years was 3.44%. Most children become passive smokers. The 2018 Riskesdas recorded 39 million children aged 0-14 years who were exposed to cigarette smoke at home, 13 million of whom were toddlers. Not only passive smokers or secondhand smokers who inhale cigarette smoke directly are third-hand smokers, our children, who inhale cigarette smoke particles or vape vapor particles that stick to surrounding objects (such as hair, clothes, walls, etc.) and carpet.

If the activity of smoking freely is left alone without clear rules, then we have the potential to destroy the child's future. The tradition of smoking weakens all aspects of life. Because cigarette toxins not only damage the body's defense system, they are susceptible to disease. Even socio-economically, smoking is very detrimental to the family budget when it comes to meeting basic needs.

Smokers are more vulnerable to suffering from TB.

One of the studies conducted by Roya Alavi-Naini et al. in Iran proved that smokers have a three times higher risk of suffering from tuberculosis than non-smokers in the control samples. A cross-sectional study conducted by Altet-Gomez found that M. tuberculosis replicated more quickly in smokers because smokers had more cavitary lesions and positive smear results were obtained from sputum microscopy more often.

Smoking damages the structure and function of the airways and reduces the activity of the immune system. The occurrence of TB has been shown to be associated with an altered immune response and several defects in immune cells such as macrophages, monocytes, and CD-4 lymphocytes. Other mechanisms, such as mechanical disturbance of ciliary function and hormonal effects, may also occur secondary to smoking. Furthermore, smokers have a lower ability of alveolar macrophage phagocytosis, which increases the risk of pathogenic germs being active. A study by Qiu et al. in 2017 said that smoking stimulates macrophages to produce more IL-8, which causes excessive inflammation. Results of research by Kalra et al. also found that exposure to cigarette smoke can affect T-cell responsiveness, decrease T-cell proliferation, and decrease antibody response.

The effect of e-cigarettes on the risk of tuberculosis is the same as that of conventional cigarettes. Andromeda-Celeste Go´mez In the publication of her research results, "E-cigarettes: Effects in Phagocytosis and Cytokines Response against Mycobacterium tuberculosis, she states that electronic cigarettes stimulate pro-inflammatory cytokine responses and interfere with phagocyte function and cytokine responses to M. tuberculosis.

Therefore, all of these factors can contribute to increasing the susceptibility of individual smokers to suffering from TB disease, accelerating the onset of active TB, increasing the risk of TB recurrence, and reducing the effectiveness of TB treatment.

Let's stop smoking from now on; together, we can end TB. Indonesia can!