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  • Research article
  • Open Access
  • Open Peer Review

Factors associated with smoking among tuberculosis patients in Spain

  • 1, 2, 3Email author,
  • 2, 3, 4, 5,
  • 2, 3, 6,
  • 7,
  • 2, 5, 8,
  • 2, 9,
  • 2, 10,
  • 11,
  • 12, 13,
  • 2, 3, 4, 8, 14 and
BMC Infectious DiseasesBMC series – open, inclusive and trusted201616:486

https://doi.org/10.1186/s12879-016-1819-1

  • Received: 12 January 2016
  • Accepted: 8 September 2016
  • Published:
Open Peer Review reports

Abstract

Background

To determine the prevalence of smoking and analyze associated factors in a cohort of patients diagnosed with tuberculosis (TB) in Spain between 2006 and 2013.

Methods

Multicenter, cross-sectional, descriptive, observational study using a national database of TB patients, using logistic regression to calculate odds ratios (OR) and confidence intervals (CI).

Results

We analyzed 5,846 cases (62 % men, mean age 39 years, 33 % foreigners). 23.4 % were alcohol abuser, 1.3 % were injected drug users (IDU), 4.6 % were co-infected with HIV, and 7.5 % had a history of TB treatment. 6.6 % and 0.8 % showed resistance to one and multiple drugs, respectively. The predominant clinical presentation was pulmonary (71 %) with a cavitary radiological pattern in 32.8 % of cases. 82 % of cases were confirmed microbiologically, and 54 % were smear-positive microscopy.

2,300 (39.3 %) patients were smokers. The following factors were associated with smoking: male sex (OR = 2.26;CI:1.97;2.60), Spanish origin (OR = 2.79;CI:2.40–3.24), alcoholism (OR = 2.85;CI:2.46;3.31), IDU (OR = 2.78;CI:1.48;5.52), homelessness (OR = 1.99;CI:1.14–3.57), pulmonary TB (OR = 1.61;CI:1.16;2.24), cavitary radiological pattern (OR = 1.99;CI:1.43;2.79) and a smear-positive microscopy at the time of diagnosis (OR = 1.39;CI:1.14;1.17).

Conclusions

The prevalence of smoking among TB patients is high. Smokers with TB have a distinct sociodemographic, clinical, radiological and microbiological profile to non-smokers.

Keywords

  • Tuberculosis
  • Smoking
  • Predictors
  • Prevention

Background

Smoking and tuberculosis (TB) are two of the biggest public health problems worldwide [1]. Smoking is one of the leading preventable causes of premature death, producing 6 million deaths a year. At present, about 33 % of the world population smokes, mainly in countries with a high prevalence of TB. In turn, TB causes 9.6 million incident cases and 1.5 million deaths in 2014 [2, 3].

While, the relationship between smoking and TB has been recognized for almost a century, the impact of smoking on TB has only been demonstrated in last decade [47]: both active and passive exposure to smoke are independent risk factors for TB infection [8, 9], the progression of TB infection to disease [10, 11], greater disease severity, and increased risk of post-treatment relapse and mortality [1214].

A recent study based on mathematical modelling estimated that, between 2010 and 2050, smoking could raise the number of TB cases worldwide by 18 million, and substantially increase secondary mortality if current trends in tobacco consumption are maintained [15]. The World Health Organization and the International Union Against Tuberculosis and Lung Disease issued regulations in 2007 to control these two clearly related epidemics [1].

Smoking prevalence among TB patients could be higher than the objectified general population in many countries; in China a case-control study shows prevalence of 54.6 % [16], in South Africa found that 56 % of people with active TB were smokers [17], a study in rural India found that 81.5 % of TB cases had previously smoked at some time in their life [18] and in Georgia the prevalence of current smokers among the diagnoses of TB represents 45.9 % [19]. Currently, there are no reliable data on the prevalence of smoking among TB patients in Spain, with the exception of one study carried out in Catalonia between 1996 and 2002, which reported a smoking prevalence of 34.9 % [12].

The aim of our study was to determine the prevalence of smoking among patients diagnosed with TB in Spain between 2006 and 2013, and to identify factors associated with smoking in this population. The ultimate goal is to design assistance and support strategies for smoking cessation to improve clinical outcomes, reduce TB transmissibility, and improve prognosis and survival.

Methods

We performed a multicenter, cross-sectional, descriptive, analytical and observational study.

We included patients diagnosed with TB between 1 January 2006 and 31 December 2013 within the catchment area of the Integrated TB Research Program (PII TB) Working Group of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) in 60 centers in Spanish Autonomous Communities.

We included patients aged >18 years with a diagnosis of TB, as determined by: 1) positive smear, or negative smear with positive culture for Mycobacterium tuberculosis, or extra-pulmonary TB as demonstrated by granulomas tubercular on histology; 2) patients suspected TB (clinical, radiological, epidemiological and/or laboratory results) with a good response to TB treatment without other diagnosis.

Patients were considered to be smokers if they reported having smoked ≥1 cigarettes per day continuously during the year preceding the diagnosis of TB and no smoker the person who has smoked less than 100 cigarettes in his life [20].

The information is collected by clinical researcher from the interview and review of the history in three visits: at the time of diagnosis, the second month and the end of treatment. For all cases, we collected socio-demographic data, living status, origin (native or immigrant), place of diagnosis, alcohol consumption (men consuming over 280 g alcohol per week, an women over 168 gr, were considered alcoholics), use of intravenous heroin or/and cocaine drugs (IDU), delayed diagnosis (>50 days), TB localization, radiology, microbiology results and sensitivity study, history of TB, HIV infection, clinical progression, drug treatment, and treatment outcome (correct: cured, treatment completed; incorrect: therapeutic failure, moved away/transferred, lost to follow-up and death).

The information obtained from each patient was stored in an electronic data collection notebook (DCN) implemented in a software application available to each study investigator via a personal identifier and password.

The study was conducted according to the requirements of the Declaration of Helsinki and Spanish Data Protection Law 15/1999. All patients gave their informed consent to participate in this study, which was approved by the Clinical Research Ethics Committee of Vall d'Hebron University Hospital Foundation - Research Institute.

Statistical analysis

We performed a descriptive study of the prevalence of smoking among participants, and the frequency distribution of other variables. We performed bivariate analysis of factors potentially associated with smoking (yes/no) by comparing proportions between groups using the χ2 test. Results with p < 0.05 were considered statistically significant. For the multivariable analysis, we fit logistic regression models using the backward stepwise selection method to include variables that were relevant to the study, as well as those with p < 0.001 in the bivariate analysis, and to compute Odds Ratios (OR) and 95 % Confidence Intervals (CI). We used the Hosmer-Lemeshow test to evaluate the goodness of fit of each model. All analysis was performed using IBM SPSS Statistic19.

Results

We included 5,846 TB patients; with a mean age of 39 years (range 18–100 years), 3,626 (62 %) men, and 1,941 foreigners (33 %). 23.4 % were pathological alcohol drinkers, and 1.3 % were IDU. 4.6 % of cases were coinfected with HIV, 438 (7.5 %) had a history of TB treatment, and 49.5 % were diagnosed by hospital emergency services. 6.6 % of cases were found to be resistant to any drug, and 0.8 % to multiple drugs. The predominant clinical presentation was pulmonary tuberculosis (4,149 cases, 71 %), with a cavitary radiological pattern in 32.8 % of cases. 82 % of cases were confirmed microbiologically, of which 54 % were smear-positive.

A total of 2,300 (39.3 %) patients were smokers, and this proportion remained stable during the course of the study Fig. 1.
Fig. 1
Fig. 1

Trend in the prevalence of smoking in the general population and among smokers with tuberculosis 2006–2013

The bivariate analysis to detect factors associated with smoking (Table 1) indicated a higher prevalence of smoking among men, Spanish nationals, and individuals who live alone or in confinement, or who are homeless, regardless of age or employment status. Smoking was also associated with other harmful habits, such as alcoholism and the use of injected drugs. Smoking was more frequent in cases with coexisting HIV infection, and those with a history of TB treatment. The prevalence of delayed diagnosis was significantly higher in smokers than in non-smokers. Pulmonary forms of TB, radiological cavitation, and positive smear-test results were more common in smokers, as was therapeutic non-compliance, and the need for directly observed treatment (DOT) administration and poorer treatment outcome. In contrast, we observed no differences between smokers and non-smokers in terms of single or multi-drug resistance, prescribed treatment, or clinical or radiological progression (Table 1).
Table 1

Characteristics of 5,846 tuberculosis patients. Factors related to smoking at the time of tuberculosis diagnosis at bivariate level

 

Total

Non-smoker

Smoker

Bivariate analysis

 

N 5846

N 3546

61 %

N 2300

39 %

OR (95 % CI)

P-value

Sex

 Women

2082

1556

74,7

526

25,3

Ref

 

 Men

3626

1911

52,7

1715

47,3

2.65(2.36;2.99)

<0.001

 Unknown

138

79

57,2

59

42,8

2.21(1.55;3.14)

<0,001

Age

 Unknown

138

118

85,5

20

15,5

Ref

 

 18–30 years

1627

1077

66,2

550

33,8

2.99(1.88;5.01)

<0,001

 31–50 years

2405

1212

50,4

1193

49,6

5.77(3.65;9.61)

<0,001

  > 50 years

1676

1139

68

537

32

2.76(1.74;4.62)

<0,001

Origin

 Immigrant

1941

1408

72,5

533

27,5

Ref

 

 Native

3905

2138

54,8

1767

45,2

2,18(1,94;2.46)

<0,001

Cohabitation status

 Group

651

431

66,2

220

33,8

Ref

 

 Alone

554

276

49,8

278

50,2

1,97(1,56;2,49)

<0,001

 Homeless

100

25

25

75

75

5,84(3,65;9,63)

<0,001

 Confinement

80

38

47,5

42

52,5

2,16(1,35;3,47)

0,001

 With Family

4293

2683

62,5

1610

37,5

1,18(0,99;1,40)

0,067

 Unknown

168

93

55,4

75

44,6

1,58(1,12;2,23)

0,01

Employment status

 Retired

978

792

81

186

19

Ref

 

 Active

3026

1794

59,3

1232

40,7

2,92(2.46;3,95)

<0.001

 Unemployed

1481

730

49,3

751

50,7

4,38(3,63;5,30)

<0.001

 Incapacity

110

59

53,6

51

46,4

3,68(2,44;5,53)

<0.001

 Unknown

251

171

68,1

80

31,9

1,99(1,46;2,71)

<0.001

Alcohol

 No

4475

3079

68,8

1396

31,2

Ref

 

 Yes

1371

467

34,1

904

65,9

4,27(3.76;4,86)

<0,001

IDU

 No

5768

3532

61,2

2236

38,8

Ref

 

 Yes

78

14

17,9

64

82,1

7,15(4.12;13,4)

<0,001

HIV

 No

4547

2783

61,2

1764

38,8

1,10(0,96;1,27)

0,15

 Yes

269

108

40,1

161

59,9

2,60(1,97;3,92)

0,001

 Unknown

1030

655

63,5

375

36.4

Ref

 

Diagnosis

 Specialits service

898

602

67

296

33

Ref

 

 Hospital Emergency Room

2916

1691

58

1225

42

1,47(1,26;1,73)

<0,001

 Primere care

1106

660

59,7

446

40,3

1,37(1,14;1,65)

0,001

 Other

754

494

65,5

260

34,5

1,07(0,87;1,31)

0,515

 Unknown

172

99

57,6

73

42,4

1,5(1,07;2,09)

0,018

Prior Treatment

 No

5287

3245

61,4

2042

38,6

Ref

 

 Yes

438

224

51,1

214

48,9

1,52(1,25;1,85)

<0,001

Localization

 Extra-pulmonary

611

497

81,3

114

18,7

Ref

 

 Pulmonary

4149

2299

55,4

1850

44,6

3,50(2.84;4.35)

<0,001

 Disseminated

301

198

65,8

103

34,2

2,27(1,66;3,10)

<0,001

 Unknown

785

552

70,3

233

29,7

1,84(1,43;2,38)

<0,001

Radiology

 Normal

610

480

78,7

130

21,3

Ref

 

 Abnormal cavitary

1922

889

46,3

1033

53,7

4,28(3.47;5,32)

<0,001

 Abnormal non cavitary

3114

2042

65,6

1072

33,4

1,94(1,58;2,39)

<0,001

 Unknown

200

135

67,5

65

32,5

1,78(1,24;2,53)

0,002

Microbiology

 Culture (−)

1055

779

73,8

276

26,2

Ref

 

 Microscopy smear (+)

3144

1636

52

1508

48

2,60(2,23;3,04)

<0,001

 Microscopy smear (+), culture (−)

1647

1131

68,7

516

31,3

1,29(1,08;1,53)

0,004

Single-drug resistance

 No

5458

3311

60,7

2147

39,3

Ref

 

 Yes

388

235

60,6

153

39,4

1,00(0,81;1,24)

0,968

Multi-drug resistance

 No

5797

3517

60,7

2280

39,3

Ref

 

 Yes

49

29

59,2

20

40,8

1,07(0,59;1,88)

0,827

Delayed diagnosis

 Unknown

343

226

65,9

117

34,1

Ref

 

  < 50 days

2777

1680

60,5

1097

39,5

1,26(1,00;1,60)

0,052

  > 50 days

2726

1640

60,2

1086

39,8

1,28(1,01;1,62)

0,04

Treatment indicated

 Unknown

197

132

67

65

33

Ref

 

 3 drugs

2566

1521

59,3

1045

40,7

1,39(1,03;1,91)

0,032

 4 drugs

2819

1732

61,4

1087

38,6

1,27(0,94;1,74)

0,119

 Others

264

161

61

103

39

1,30(0,88;1,92)

0,186

Need for DOT

 Unknown

597

373

62,5

224

37,5

Ref

 

 No

4629

2834

61,2

1795

38,8

1,05(0,89;1,26)

0,555

 Yes

620

339

54,7

281

45,3

1,38(1,10;1,74)

0,006

Clinical progression

 Unknown

569

354

62,2

215

37,8

Ref

 

 Improved

4860

2936

60,4

1924

39,6

1,08(0,90;1,19)

0,406

 Stable

368

226

61,4

142

38,6

1,03(0,79;1,35)

0,805

 Progressed

49

30

61,2

19

38,8

1,05(0,56;1,89)

0,884

Radiological progression

 Stable

981

626

63,8

355

36,2

Ref

 

 Improved

3750

2238

59,7

1512

40,3

1,19(1,03;1,38)

0,018

 Progressed

36

17

47,2

19

52,8

1,97(1,00;3,89)

0,049

 Unknown

1079

665

61,6

414

38,4

1,10(0,92;1,31)

0,307

Treatment outcome

 Unknown

520

324

62,3

196

37,7

Ref

 

 Correct

5079

3123

61,5

1956

38,5

1,04(0,86;1,25)

0,717

 Incorrect

247

99

40,1

148

59,9

2,47(1,81;3,37)

<0,001

OR odds ratio

CI confidence interval

IDU injecten drug users

HVI humanimmunodeficiency virus

The multivariate analysis (Table 2) showed that the following factors were associated with smoking at the time of diagnosis in this cohort of TB patients: male gender (OR = 2.26,CI 1.97–2.60), being native Spanish (OR = 2.79,CI 2.40–3.24), alcohol consumption (OR = 2.85,CI 2.46–3.31), IDU (OR = 2.78,CI 1.48–5.52), poverty (OR = 1.99,CI 1.14–3.57), pulmonary forms of TB (OR = 1.61,CI 1.16–2.24), cavitary radiological patterns (OR = 1.99,CI 1.43–2.79) and positive smear-test results (OR = 1.39, CI 1.14–1.71).
Table 2

Characteristics of 5,846 tuberculosis patients. Factors related to smoking at the time of tuberculosis diagnosis at multivariate level

 

Total

Non-smoker

Smoker

Multi-variate analysis.

 

N 5846

N 3546

61 %

N 2300

39 %

OR (95 % CI)

P-value

Sex

 Women

2082

1556

74,7

526

25,3

Ref

 

 Men

3626

1911

52,7

1715

47,3

2.26(1.97;2.60)

<0.001

 Unknown

138

79

57,2

59

42,8

2.19(1.46;3.28)

<0.001

Age

 Unknown

138

118

85,5

20

15,5

Ref

 

 18–30 years

1627

1077

66,2

550

33,8

2.39(1.44;4,13)

<0.001

 31–50 years

2405

1212

50,4

1193

49,6

3.45(2.09;5,94

<0.001

  > 50 years

1676

1139

68

537

32

2.52(1.50;4.42

<0.001

Origin

 Immigrant

1941

1408

72,5

533

27,5

Ref

 

 Native

3905

2138

54,8

1767

45,2

2,79(2,40;3,24)

<0,001

Cohabitation status

 Group

651

431

66,2

220

33,8

Ref

 

 Alone

554

276

49,8

278

50,2

1,21(0,91;1,60)

0,174

 Homeless

100

25

25

75

75

1,99(1,14;3,57)

<0.001

 Confinement

80

38

47,5

42

52,5

1,70(0,98;2,97)

0,056

 With Family

4293

2683

62,5

1610

37,5

0,89(0,72;1,11)

0,317

 Unknown

168

93

55,4

75

44,6

1,35(0,89;2,04)

0,147

Alcohol

 No

4475

3079

68,8

1396

31,2

Ref

 

 Yes

1371

467

34,1

904

65,9

2,85(2,46;3,31)

<0,001

IDU

 No

5768

3532

61,2

2236

38,8

  

 Yes

78

14

17,9

64

82,1

2.78(1.48;5.52)

<0,001

HIV

 No

4547

2783

61,2

1764

38,8

0,81(0,34;2,07)

0,646

 Yes

269

108

40,1

161

59,9

1,48(0,59;3,94)

0,412

 Unknown

1030

655

63,5

375

36.4

Ref

 

Prior Treatment

 No

5287

3245

61,4

2042

38,6

Ref

 

 Yes

438

224

51,1

214

48,9

1,12(0,89;2,04)

0,314

Localization

 Extra-pulmonary

611

497

81,3

114

18,7

Ref

 

 Pulmonary

4149

2299

55,4

1850

44,6

1,61(1,16;2,24)

<0,001

 Disseminated

301

198

65,8

103

34,2

1,12(0,73;1,70)

0,59

 Unknown

785

552

70,3

233

29,7

1,14(0,80;1,63)

0,458

Radiology

 Normal

610

480

78,7

130

21,3

Ref

 

 Abnormall cavitary

1922

889

46,3

1033

53,7

1,99(1,43;2,79)

<0,001

 Abnormal non cavitary

3114

2042

65,6

1072

33,4

1,24(0,91;1,70)

0,167

 Unknown

200

135

67,5

65

32,5

1,21(0,77;1,89)

0,4

Microbiology

 Culture (−)

1055

779

73,8

276

26,2

Ref

 

 Microscopy smear (+)

3144

1636

52

1508

48

1,39(1,14;1,71)

<0,001

 Microscopy smear (+), culture (−)

1647

1131

68,7

516

31,3

1,01(0,82;1,24)

0,896

OR odds ratio

CI confidence interval

IDU injecten drug users

HVI humanimmunodeficiency virus

Discussion

We observed a high prevalence of smoking among individuals diagnosed with TB in Spain between 2006 and 2013. Smoking was associated with male gender, being native Spanish, the consumption of other drugs, a precarious social position, more severe and more developed lung disease, and poorer treatment outcome than in non-smoking TB patients.

In this study, we found that 39.3 % of TB patients were regular smokers at the time of diagnosis, a much higher figure than that reported for the general population in Spain, 23.95 %, according to data from the National Health Survey 2011–2013 and it remained well above this value, and with little annual variation (Fig. 1); this level was similar to that published for Catalonia in 2002 (34.9 %) [12]. However, during the period of this study, we observed a steady decline in smoking prevalence in Spain, 26.44 % in 2006 to 23.95 % in 2013 [21], as a result of legislative changes and prevention programs [22]. Thus, the TB patients smokers may be resistant to general anti-smoking measures, possibly for social reasons or because of differences in its level of addiction to nicotine. This hinders smoking cessation in this group, and highlights the need for a different set of cessation strategies to those used in the general population.

In our sample, we found that men smoke significantly more than women; 62 % of men with TB were smokers, compared to 27.87 % of males in the general population during the same period. In comparison, the prevalence of smoking among female TB patients (25.3 %) was only 5 percentage points higher than in the general population (20.2 %). Worldwide, TB is known to be more common in men than in women. A study conducted in 22 countries with a high burden of TB found that smoking was a predictor of increased reporting of TB in males [23], suggesting that the differences in disease rates between sexes could be due to the higher prevalence of smoking in men, a pattern that persists in virtually all ethnic groups and countries [2].

While a third of the cases included in this study were foreigners, the prevalence of smoking was much lower in this group (27.5 %) than in native Spanish patients (45.2 %). Previous studies carried out in Spain show that the intensity of drug and alcohol consumption is lower in the immigrant population than in natives. This pattern has been attributed to cultural differences and economic difficulties that reduce consumption, and is maintained in immigrants with TB [24].

Smoking was also associated with situations of social precariousness, and its prevalence was significantly higher among individuals who live alone, in poverty, or in confinement, regardless of their age or employment status. Smoking was also associated with pathological alcohol consumption (65.9 %) and injected drug use (82.1 %). These risk factors are classically associated with TB in people at risk of social marginalization, as previously described in our setting [12, 24, 25]. The proportion of HIV co-infection was low in this sample (4.6 %), and HIV was associated with tobacco use in the bivariate but not multivariate analysis, possibly because of the low number of co-infected cases. The clinical presentation of TB in smokers was mainly pulmonary and disseminated, while isolated extra-pulmonary TB was rare in smokers. Radiologically, we also observed more extensive lesions in these patients, with more frequent cavitation and positive smear results at the time of diagnosis. These findings are similar to those reported by other authors, mentioned above, and reflect generally more serious and advanced disease [12, 13]. Several studies in animal models and humans have shown that exposure to tobacco smoke causes immunological changes, acting on alveolar macrophages by decreasing the production of TNF-α, IFN-γ, and mucociliary clearance, promoting disease progression [2628], delaying sputum conversion and thereby extending the period of transmissibility [29]. In this sense, and in contrast to other studies [12], the observed delay in diagnosis was also higher in smokers, possibly because cough is a common symptom in these patients, and it may be difficult to perceive changes that alert the subject and motivate them to seek medical advice.

We did not find any significant differences between smokers and non-smokers in the presence of single or multi-drug resistance, or in the treatment initially indicated, although directly observed therapy was indicated more frequently in smokers than in non-smokers. Poorer treatment outcome was also more common among smokers. Therefore, smokers require closer monitoring and greater resources to ensure therapeutic compliance and the ultimate success of treatment, leading to increased healthcare spending. Other studies have also found a greater need for hospitalization, longer stays [12], and increased risk of relapse following treatment. A study in Taiwan found that people who smoke more than 10 cigarettes per day have twice the risk of relapse of non-smokers after proper treatment [14]. In our series, 7.5 % of patients had a history of previous illness, which was significantly with smoking.

Our study has some limitations. Our work can only show association between smoking and tuberculosis from an epidemiological point of view, and cannot show causality.

We did not quantify daily tobacco consumption, the number of years of smoking, type of tobacco used, or the intensity of passive smoking, which prevents us from evaluating a possible dose-response relationship. Only smoking status at the time of diagnosis was recorded, and we cannot determine if this persisted throughout the patient’s follow-up. Thus, it was not possible to assess the impact of smoking cessation on disease progression or the treatment outcome.

We could not collect systematic information on smoking cessation interventions by health professionals, since this survey depended solely on routine clinical practice and the experience of the individual medical teams in each of the participating centers. Some centers gave brief anti-smoking counseling, along with basic health education during each visit. This type of intervention has previously proven useful and feasible in other TB treatment programs [30], but is not included in local or national recommendations or regulations in our setting. The introduction of drug therapy for smoking cessation in patients with TB is still a pending task, given the limited clinical experience available [31]; few professionals feel prepared to advise their TB patients on smoking cessation [32], and cessation drugs are not widely accessible due to their high price because Spain are not subsidized by the National Health System and makes it impossible the access groups with economic difficulties as they are often patients with TB.

One of this study’s strong points is the large number of cases recruited representing 12 % of total cases reported in the regions that are part of the Spanish state during the study period [33] and the quality of the information, which allowed us to analyze trends in prevalence during the study period and to evaluate factors associated with smoking among TB patients.

Conclusion

The prevalence of smoking among TB patients in Spain is high. Smokers with TB have a distinct sociodemographic, clinical, radiological and microbiological profile to non-smokers. A detailed understanding of the prevalence of smoking in our setting, as well as sociodemographic, clinical and developmental factors associated with smoking among TB patients is the first step towards designing effective strategies for control and monitoring, with the aim of improving the care of these patients, their clinical progression, and the treatment outcome.

Declarations

Smoking and tuberculosis research working group

R. Agüero (H Marqués de Valdecilla, Santander); J.L. Alcázar (Instituto Nacional de Silicosis, Oviedo); N. Altet (Hospital Universitari Vall d’Hebrón Barcelona); L. Altube (H Galdakao, Galdakao); F. Álvarez Navascués (H San Agustín, Avilés, Asturias); L. Anibarro (Unidad de Tuberculosis de Pontevedra, Vigo); M. Barrón (H San Millán-San Pedro, Logroño); P. Bermúdez (Hospital Universitario Carlos Haya, Málaga), R. Blanquer (H. Dr. Peset, Valencia); L. Borderías (H San Jorge, Huesca); A. Bustamante (H Sierrallana, Torrelavega); J.L. Calpe (H La Marina Baixa, Villajoyosa); J.A. Caminero (Complejo Hospitalario Dr. Negrín, Las Palmas de Gran Canaria); F. Cañas (H. Insular de Gran Canaria, Las Palmas de Gran Canaria); F. Casas (Hospital Clínico San Cecilio, Granada), X. Casas (Hospital de Sant Boi, Llobregat), E. Cases (H Universitario La Fe, Valencia); R. Castrodeza (H El Bierzo Ponferrada-León, Ponferrada); J.J. Cebrián (H Costa del Sol, Marbella); J. E. Ciruelos (Hospital de Cruces, Guetxo); A.E. Delgado (Hospital Santa Ana, Motril), M.L. De Souza (Hospital Universitari Vall d´Hebrón. Barcelona); D. Díaz (Complejo Hospitalario Juan Canalejo, La Coruña); M Dominguez Alvarez (Hospital del Mar, Barcelona); B. Fernández (H de Navarra, Pamplona); A. Fernández (H Río Carrión, Palencia); J. Gallardo (H Universitario de Guadalajara, Guadalajara); M. Gallego (Corporación Sanitaria Parc Taulí, Sabadell); M.M. García Clemente (Hospital Central de Asturias, Oviedo), C. García (H General Isla Fuerteventura, Puerto del Rosario); F.J. García (H Universitario de la Princesa, Madrid); F.J. Garros (Hospital Santa Marina, Bilbao), A. Guerediaga (Hospital Santa Marina, Bilbao), J.A. Gullón (H San Agustín, Avilés, Asturias); C. Hidalgo (Hospital Universitario Virgen de las Nieves, Granada), M. Iglesias (H Marqués de Valdecilla, Santander); G. Jiménez (Hospital de Jaén), M.A. Jiménez-Fuentes (Hospital Universitari Vall d´Hebrón, Barcelona); J.M. Kindelan (H Universitario Reina Sofía, Córdoba); J. Laparra (H Donostia-San Sebastián, San Sebastián); R. Lera (H. Dr. Peset, Valencia); T. Lloret (H General Universitario de Valencia, Valencia); M. Marín (H General de Castellón, Castellón); J.T. Martínez (H Mutua de Terrasa, Tarrasa); E. Martínez (H de Sagunto, Sagunto); A. Martínez (H de La Marina Baixa, Villajoyosa); J.F. Medina (H Universitario Virgen del Rocío, Sevilla); C. Melero (H 12 de Octubre, Madrid); C. Milà (Hospital Universitari Vall d´Hebrón, Barcelona); I. Mir (H Son Llatzer, Palma de Mallorca); C. Morales (Hospital Universitario Virgen de las Nieves, Granada), M.A. Morales (Hospital Cruz Roja Inglesa, Ceuta); V. Moreno (H Carlos III, Madrid); A. Muñoz (Hospital Universitario Carlos Haya, Málaga), L. Muñoz (H Reina Sofía, Córdoba); C. Muñoz (H Clínico Universitario de Valencia, Valencia); J.A. Muñoz (H Universitario Central, Oviedo); I. Parra (H Universitario Virgen de la Arrixaca, El Palmar); A. Penas (Complejo Hospitalario Xeral-Calde, Lugo); J.A. Pérez (H Arnau de Vilanova, Valencia); P. Rivas (H Virgen Blanca, León); J. Rodríguez (Hospital Universitario Virgen de las Nieves, Granada), J. Ruiz-Manzano (H. Universitario Germans Trías i Pujol, Badalona); J. Sala (H Universitario Joan XXIII, Tarragona); M. Sánchez (Unidad Tuberculosis Distrito Poniente, Almería); P. Sánchez (H del Mar, Barcelona); F. Sanz (H. General Universitario de Valencia, Valencia); M. Somoza (Consorcio Sanitario de Tarrasa, Barcelona), E. Trujillo (Complejo Hospitalario de Ávila, Ávila); E. Valencia (H Carlos III, Madrid); A. Vargas (H Universitario Puerto Real, Cádiz); I. Vidal (Complejo Hospitalario Juan Canalejo, La Coruña); R. Vidal (H. VallD’Hebrón, Barcelona); M.A. Villanueva (Hospital San Agustín, Avilés, Asturias); A. Villar (H. VallD’Hebrón, Barcelona); M. Vizcaya (Complejo Hospitalario Universitario de Albacete, Albacete); M. Zabaleta (H de Laredo, Laredo); G. Zubillaga (H Donostia-San Sebastián, San Sebastián).

Funding

This work was made possible by a grant from the Spanish Society of Pneumology and Thoracic Surgery, SEPAR 2011.

Availability of data and materials

The dataset supporting the conclusions of this article is available by request to Integrated TB Research Program (PII TB) Working Group of the Spanish Society of Pneumology and Thoracic Surgery (PII_TB_Teresa_Rodrigo@separ.es).

Authors’ contributions

MJF conceived of the study, and participated in its design and coordination, acquisition of data, interpreted data analysis and drafted the manuscript. TR, MNA, CJR, AP, IM, SSR, JRM, JAC and The Smoking and Tuberculosis Research Working Group in Spain participated in the acquisition of data and have been involved in revising the manuscript. MC participated in the design of the study and performed the statistical analysis. JAC and TR participated in its design and coordination, interpreted data analysis and helped to draft the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not applicable.

Ethics approval and consent to participate

Approved by the Clinical Research Ethics Committee of Vall d'Hebron University Hospital Foundation - Research Institute. All patients gave their informed consent to participate in this study.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Unidad de Tuberculosis Valle de Hebrón-Drassanes. Programa Especial de Enfermedades Infecciosas, Hospital Universitario Valle de Hebrón, Av Drassanes, 17-21, 08001 Barcelona, Spain
(2)
Programa Integrado de Investigación en Tuberculosis (PII TB) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), Barcelona, Spain
(3)
Unidad de Investigación de Tuberculosis de Barcelona, Barcelona, Spain
(4)
Fundación Respira de la SEPAR, Barcelona, Spain
(5)
Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
(6)
Serveis Clínics S.A., Barcelona, Spain
(7)
Unidad Especializada de Tabaquismo de la Comunidad de Madrid, Madrid, Spain
(8)
Servicio de Epidemiología de la Agencia de Salud Pública de Barcelona, Barcelona, Spain
(9)
Hospital Lucus Augusti, Lugo, Spain
(10)
Hospital Son Llàtzer, Palma de Mallorca, Spain
(11)
Hospital Gregorio Marañón, Madrid, Spain
(12)
Complejo Hospitalario de Cáceres, Cáceres, Spain
(13)
Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
(14)
Departamento de Salud Pública, Universitat Autónoma de Barcelona, Barcelona, Spain

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Copyright

© The Author(s). 2016

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