The Influence of Smoking on Pulmonary Tuberculosis in Diabetic and Non-Diabetic Patients

BACKGROUND Both smoking and diabetes can increase the risk and influence the manifestations and outcomes of tuberculosis (TB). It is not clear whether the influence of smoking on pulmonary TB differs between non-diabetic and diabetic patients. Herein, we assessed the manifestations and outcomes of TB in relation to smoking in both diabetic and non-diabetic TB patients. METHODOLOGY/PRINCIPAL FINDINGS All diabetic culture-positive pulmonary TB patients notified from 2005-2010 at three teaching hospitals in Taiwan were enrolled. A culture-positive pulmonary TB patient without DM who was notified to the health authority immediately prior to each diabetic TB patient was selected for comparison. The 972 patients in this study cohort included 365 (37.6%) non-diabetic non-smokers, 149 (15.3%) non-diabetic smokers, 284 (29.2%) diabetic non-smokers, and 174 (17.9%) diabetic smokers. The adjusted relative risk of a pretreatment positive smear for a smoker compared with a non-smoker was 2.19 (95% CI 1.38-3.47) in non-diabetic patients and 2.23 (95% CI 1.29-3.87) in diabetic culture-positive pulmonary TB patients. The adjusted relative risk for a positive smear among diabetic smokers was 5.61 (95% CI 3.35-9.41) compared with non-diabetic non-smokers. Smoking was significantly associated with an increased frequency of bilateral lung parenchyma involvement (AdjOR 1.84, 95% CI 1.16-2.93), far-advanced pulmonary TB (AdjOR 1.91, 95% CI 1.04-3.50), cavitary lesions (AdjOR 2.03, 95% CI 1.29-3.20), and unfavorable outcomes of TB (AdjOR 2.35, 95% CI 1.02-5.41) in non-diabetic patients. However, smoking was not associated with cavitary lung parenchyma lesions regarding the location, number or size of the cavity in diabetic TB patients. CONCLUSIONS/SIGNIFICANCE Smoking and diabetes have joint effects on a pretreatment positive smear. Diabetic smokers had more than a 5-fold increased risk of a pretreatment positive smear than did non-diabetic non-smokers, indicating remarkable joint effects of diabetes and smoking on the risk of TB transmission.