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Editor's Correspondence
October 8, 2007

Smoking and Risk of Tuberculosis

Arch Intern Med. 2007;167(18):2008. doi:10.1001/archinte.167.18.2008-a

The excellent study by Bates and colleagues1 found evidence that smoking is a risk factor for tuberculosis (TB) infection and TB disease. The authors state that it has long been suggested that tobacco smoking may affect the risk of developing TB and cite a single study by Lowe2 in 1956 that drew this conclusion. However, history reveals much earlier observations of this relationship. A signer of the Declaration of Independence, Dr Benjamin Rush, attributed pulmonary consumption in a 17-year old male patient to “intemperate use of cigars.”3 Statistical reports were made in the early 1900s.4,5 The fourth (1907) and fifth (1908) reports of the Phipps Institute of Philadelphia for the study and treatment of TB countered the “preposterous claim” that tobacco prevented TB, suggesting that “the increase of tuberculosis in man runs parallel with the increase of the consumption of tobacco.”4(p53) Approximately 75% of male patients were tobacco users; the majority smoked. Mortality was higher in those who used tobacco (18.6%) than in those who did not (5.2%). It was suggested that the effects of tobacco on the development and mortality of TB might be caused by tobacco's adverse influence on circulation and nutrition. Studies of World War I soldiers suggested that chronic airway “irritation” predisposed individuals to TB. An immunologic mechanism was suggested from studies of the effects of nicotine on lowering the tuberculo-opsonic index, “one of the most delicate means of measuring the resistance of the body to the tubercle bacillus.”4(p55) Although most of this early literature is anecdotal and the research methods archaic by modern standards, the myriad of observations by astute clinicians and researchers of this era leave no question about the weight of opinion favoring a link between development and progression of tuberculosis and tobacco smoking.

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