Action to Stop Smoking in Suspected Tuberculosis (ASSIST) in Pakistan

Action to Stop Smoking in Suspected Tuberculosis (ASSIST) in Pakistan

This study, funded by International Development Research Council (IDRC), Canada, was done in partnership with; Directorate General of Health Services, Punjab; and Nuffield Centre for International Health and Development, University of Leeds, UK; Bradford Health Authority; and World Health Organization (WHO).

Background: Tobacco use is responsible for a large proportion of the total disease burden from tuberculosis. Pakistan is one of the 10 high-burden countries for both tuberculosis and tobacco use.

Objective: To assess the effectiveness of a behavioral support intervention and bupropion in achieving 6-month continuous abstinence in adult smokers with suspected pulmonary tuberculosis.

Design: Cluster randomized, controlled trial. (Current Controlled Trials: ISRCTN08829879)

Setting: Health centers in the Jhang and Sargodha districts in Pakistan.

 Patients: 1955 adult smokers with suspected tuberculosis.

Intervention: Health centers were randomly assigned to provide 2 brief behavioral support sessions (BSS), BSS plus 7 weeks of bupropion therapy (BSS_), or usual care.

Measurements: The primary end point was continuous abstinence at 6 months after the quit date and was determined by carbon monoxide levels in patients. Secondary end points were point abstinence at 1 and 6 months.

Results: Both treatments led to statistically significant relative risks (RRs) for abstinence compared with usual care (RR for BSS_, 8.2 [95% CI, 3.7 to 18.2]; RR for BSS, 7.4 [CI, 3.4 to 16.4]). Equivalence between the treatments could not be established. In the BSS_ group, 275 of 606 patients (45.4% [CI, 41.4% to 49.4%]) achieved continuous abstinence compared with 254 of 620 (41.0% [CI, 37.1% to 45.0%]) in the BSS group and 52 of 615 (8.5% [CI, 6.4% to 10.9%]) in the usual care group. There was substantial heterogeneity of program effects across clusters.

Limitations: Imbalances in the urban and rural proportions and smoking habits among treatment groups, and inability to confirm adherence to bupropion treatment and validate longer-term abstinence or the effect of smoking cessation on tuberculosis outcomes.

 Conclusion: Behavioral support alone or in combination with bupropion is effective in promoting cessation in smokers with suspected tuberculosis.