ORIGINAL ARTICLE

Cigarette smoking and health-promoting behaviours among

tuberculosis patients in rural areas
Shu-Lan Tsai, Chun-Liang Lai, Miao-Ching Chi and Mei-Yen Chen

Aims and objectives. To explore cigarette smoking and health-promoting beha-

viours among disadvantaged adults before their tuberculosis diagnosis and after What does this paper contribute
their tuberculosis treatment. to the wider global clinical
Background. Although tuberculosis infection is associated with impaired immune community?
function, healthy lifestyle habits can play a role in improving the immune system.  Malnutrition, cigarette smoking,
However, limited research has explored the health-promoting behaviours and and unhealthy habits were
cigarette smoking habits among tuberculosis patients in Taiwan. prevalent among tuberculosis
patients before their diagnosis.
Design. A cross-sectional retrospective study with a convenience sample.
 Body mass index and health-pro-
Methods. This study was conducted between May 2013–June 2014 with 123 moting behaviours improved sig-
patients at a rural district hospital in Chiayi County, Taiwan. Statistical analyses nificantly after treatment for
included descriptive statistics, univariate analysis and stepwise regression analysis. tuberculosis.
Results. Tuberculosis tended to be associated with less education, male sex, mal-  Cigarette smoking cessation and
nutrition, cigarette smoking and unhealthy lifestyle habits before the tuberculosis lifestyle modification pro-
grammes should be initiated for
diagnosis. The percentage of smoking decreased from 46
9% before to 30
2%
tuberculosis patients during their
after the tuberculosis diagnosis. Body mass index and health-promoting beha- treatment.
viours also significantly improved after tuberculosis treatment. After controlling
for potential confounding factors, multivariate analysis identified chronic disease
and completed treatment as significant factors that were associated with current
health-promoting behaviours.
Conclusions. A high prevalence of cigarette smoking and low levels of health-pro-
moting behaviours were observed before the diagnosis and during or after com-
pleting tuberculosis treatment.
Relevance to clinical practice. This study’s findings indicate the importance of
promoting healthy lifestyle changes among tuberculosis patients; aggressive mea-
sures should be implemented immediately after the first diagnosis of tuberculosis.
Furthermore, health promotion and smoking cessation programmes should be ini-
tiated in the general population to prevent activation of latent tuberculosis infec-
tion, and these programmes should specifically target men and rural residents.

Key words: cigarette smoking, health-promoting behaviours, rural, tuberculosis

Accepted for publication: 28 February 2016

Authors: Shu-Lan Tsai, RN, MSN, TB Case Manager, Dalin Tzu
Chi Hospital, Chiayi; Chun-Liang Lai, MD, Division of Pul-
monary and Critical Care, Dalin Tzu Chi Hospital, Chiayi;
Miao-Ching Chi, PhD, Assistant Professor, Department of Respi-
ratory Care, Chang Gung University of Science and Technology,
Chiayi; Mei-Yen Chen, RN, PhD, Professor, Graduate Institute
of Nursing, Chang Gung University of Science and Technology,
Chiayi County, Taiwan
Correspondence: Mei-Yen Chen, Professor, No. 2, Chiapu Road
West Sec., Putz City, Chiayi County 61363, Taiwan. Telephone:
+886 (5) 3628800 ext. 2201.
E-mail: meiyen@gw.cgust.edu.tw

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing, doi: 10.1111/jocn.13289 1
S-L Tsai et al.
Introduction
Tuberculosis (TB), which is a contagious, airborne disease,
is one of the top-ranking infectious diseases globally in
terms of mortality. In 2014, 9
6 million and 1
5 million
people worldwide were infected with or died from TB
respectively (WHO 2015). In addition, an estimated 1 mil-
lion and 140,000 children were infected with or died from
TB respectively (WHO 2015). Furthermore, many people
still die from multidrug-resistant TB, despite a 47%
decrease in the TB-related mortality rate and a treatment
success rate of 86% for newly diagnosed individuals (WHO
2015).
Although Mycobacterium tuberculosis is a pathogen that
has existed since ancient times, it remains a source of wide-
spread disease in many developing and developed countries.
In 2012, approximately 60% of all new TB cases occurred
in Asia (WHO 2014). In Taiwan, the incidence rate (54
5/
105) was higher than that in Singapore (44/105), Japan (27/
105) and the USA (4
8/105) (CDC 2014). In particular, the
rural regions of Yunlin and Chiayi Counties contain
increasingly ageing populations with TB rates of 70
3/105
(Yunlin) and 62
7/105 (Chiayi) (CDC 2014). Thankfully,
modern medicine has rendered TB curable and preventable.
Three important interrelated factors are generally associ-
ated with infectious diseases: the pathogen, environment
and host. Prevention strategies that address all three of
these factors are critical for reducing infections in all health
care settings. Host defenses may be strengthened by individ-
ual health-promoting behaviours that are related to nutri-
tion, immunisation, personal hygiene and regular exercise
(WHO 2010). These behaviours are often the result of pub-
lic health promotion strategies that motivate individuals to
take increased control over their health, which may
improve the society’s collective health status. Clinicians
play an important role in lifestyle modification for TB
patients, and many studies have demonstrated that health-
promoting behaviours are positively correlated with health
status (Chen et al. 2006, 2012). However, few studies
have examined health-promoting behaviours among TB
patients.
Background
The risk of developing TB depends on three interrelated
factors: a weakened host immune system, the presence of a
sufficient amount of M. tuberculosis, and an adequate
transmission environment (CDC 2014). Patients who have
latent TB infection have a 10% lifetime risk of developing
active TB, while the immune defense mechanism responsi-
2 Journal of Clinical Nursing
ble for protecting the other 90% does not activate (Horne
et al. 2012). During the incubation period, many people
develop latent TB infection, and endogenous reactivation
may occur when the individual’s health condition weakens
(Horne et al. 2012, WHO 2014). Approximately one-third
of the world’s population is infected with latent TB, which
is both noncommunicable and asymptomatic (Horne et al.
2012). Therefore, maintaining a healthy immune system is
critical for safeguarding against TB infection.
Epidemiological studies have indicated that certain char-
acteristics are associated with higher risks of acquiring TB
infection: older age, poverty, male sex, malnutrition,
unhealthy lifestyle, below normal weight (Cegielski et al.
2012, Dogar et al. 2012, Ladefoged et al. 2011, Jurcev-
Savicevic et al. 2013); cigarette smoking (Shang et al. 2011,
Li et al. 2014, and compromised immune systems and
specific chronic diseases, such as diabetes and HIV coinfec-
tion (Mupere et al. 2012, Hsu et al. 2013, Narasimhan
et al. 2013). Compared to nonsmokers, smokers have a 2–
3-fold higher risk of acquiring TB infection and progressing
from latent to active disease, even after completing treat-
ment (d’Arc Lyra et al. 2008, Ladefoged et al. 2011). In a
recent in vitro study from South Africa, van Zyl-Smit et al.
(2014) found that cigarette smoke moderated effector cyto-
kine response and compromised the macrophage contain-
ment of Mycobacteria in infected individuals.
Expert consensus indicates that ideal TB control involves
the following measures: (1) Bacillus Calmette-Guerin vacci-
nation in all eligible newborns; (2) early diagnosis; (3)
prompt treatment; (4) adherence to treatment, consisting
of regular chest radiography and directly observed treat-
ment programmes with a six to nine month course of 3–4
antimicrobial drugs and (5) enhanced individual immunity
through healthy lifestyle strategies, including smoking ces-
sation and adequate nutrition (Li et al. 2014, WHO
2014). However, enhancing immunity at the individual
level requires an understanding of the gaps in the adoption
of healthy behaviours at the different disease stages. Unfor-
tunately, most studies have focused on the side effects of
anti-TB drugs and adherence to TB treatments, and few
studies have investigated whether TB patients actually
adopt health-promoting behaviours and how these beha-
viours change between the pre-diagnosis and post-treat-
ment stages. Therefore, this study aimed to evaluate and
compare changes in cigarette smoking and health-promot-
ing behaviours reported before and after TB diagnosis
among adults in a disadvantaged region. This study used
previously reported risk factors associated with TB infec-
tion, based on the value of promoting healthy behaviours
in TB patients.
© 2016 John Wiley & Sons Ltd
Original article
Methods
Study design and setting
Retrospective and cross-sectional research designs were
implemented between May 2013–June 2014. Participants
were selected using convenience sampling from a TB outpa-
tient clinic in a local district hospital. All participants lived
near disadvantaged rural areas of central Taiwan. The inclu-
sion criteria were: (1) the first TB diagnosis was made by a
pulmonary physician using positive chest radiographs and
sputum smears, (2) infection was present either on the inside
or outside of the lung, and the patient (3) had received
greater than two weeks of (or completed) TB treatment
within the last six months, (4) was at least 20 years old and
was fully capable of living independently, (5) was able to
answer the questionnaire in Mandarin or Taiwanese dialects
via interview, (6) was able to walk to the community hospi-
tal and (7) provided their written informed consent. The
exclusion criteria were: (1) severe disease (e.g. diabetes with
leg amputation), (2) concurrent mental health condition (e.g.
dementia) and (3) an uncertain TB diagnosis.
Procedures and ethical considerations
Before data collection, this study was approved by the insti-
tutional review board of Tzu Chi Hospital. Participants
were invited to participate by the case manager. Informed
consent was obtained from all participants after the pur-
pose and procedures of this study had been explained, and
the covering letter that accompanied the questionnaire
emphasised that the responses would be kept confidential.
During the data analysis, confidentiality was maintained
using data coding. The interview was conducted with TB
patients who had received greater than two weeks of (or
completed) TB treatment within the last six months. All
participant interviews and data recording were performed
by a senior case manager working at the TB outpatient
clinic. To minimise any recall bias, we allowed one to
two minutes for the participants to recall and confirm their
information. In addition, our questions emphasised the dif-
ference between individual periods, such as ‘Now, let’s talk
about the habits you practiced before you were diagnosed
with TB’ or ‘Were you a smoker six months ago?’
Measures
Three measures were used to assess the treatment status
and practice of health-related behaviours during daily life
among TB patients. Before conducting the investigation,
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing
Smoking and health promoting behaviours
five experts (including two chest physicians, two nursing
supervisors and one member of a pulmonary nursing fac-
ulty) were invited to evaluate the questionnaire, including
the questions regarding participant characteristics and
cigarette smoking. Three three-point Likert scales were
established to rate the clarity, relevance, and importance of
each item. After each expert rated the items, the content
validity index was used to calculate the content validity
(0
93; range, 0
81–0
94).
1 Participant characteristics were obtained through medical
records and structured questions for sex, age, education
level, occupation, marital status, TB treatment status, TB
contact history, haemoglobin level (normal: men, 13
5–
17
5 g/dl; women, 12–16 g/dl), albumin level (3
5–
5
5 mg/dl) and comorbid diseases. Body mass index
(BMI) was calculated using weight and height, which
were measured during the interview.
2 Health-promoting behaviours were measured using the
Geriatric Health Promotion scale (GHPs). The GHPs is a
multidimensional instrument that attempts to evaluate the
lifestyle patterns of elderly Taiwanese people. This 22-item
scale was developed by Wang et al. (2015) and can be
administered in less than 10 minutes (Chang et al. 2013).
A four-point rating scale was used to score the frequency
of a behaviour, with the total possible scores ranging from
22–88. Responses were scored as ‘never’ (1), ‘sometimes’
(2), ‘usually’ (3) or ‘always’ (4). Higher scores indicate
more frequent practice of the health promoting beha-
viours. The GHPs contains six behaviour dimensions:
health habits (seven items with scores ranging from 7–28,
such as ‘I eat breakfast daily’), community participation
(five items with scores ranging from 5–20, such as ‘I par-
ticipate in a community program’), health responsibility
(three items with scores ranging from 3–12, such as ‘I
know the level of my blood pressure’), healthy diet (three
items with scores ranging from 3–12, such as ‘I eat a bal-
anced diet every day, including foods from five food
groups’), regular exercise (two items with scores ranging
from 2–8, such as ‘I exercise for at least 30 minutes each
day’), and oral health (two items with scores ranging from
2–8, such as ‘I brush my teeth three times per day’). We
found that this scale had acceptable content and construct
validity. The reliability coefficient for the total scale was
0
87, and the alpha coefficients for the subscales ranged
from 0
64–0
94 and explained 68% of the total variance.
3 Cigarette smoking information was obtained using a stan-
dardised personal interview. The participant was asked,
‘Did you smoke before you were diagnosed with TB
infection?’ and ‘Have you smoked recently, after having
been diagnosed with TB and receiving treatment?’
3
S-L Tsai et al.

Participants were classified as ‘never smoked’ if they had
never smoked cigarettes before their TB diagnosis or after
TB treatment or as ‘have smoked at some time’ if they
were a smoker before their TB diagnosis or had smoked
during or after completing TB treatment.
Statistical analysis
SPSS software (version 17.0; SPSS Inc., Chicago, IL, USA)
was used for data analyses. All tests were two-sided, and
p-values of <0
05 were considered statistically significant.
The paired t-test, independent t-test, and chi-square test
were used for evaluating rates and equality of proportions
in the pre-diagnosis and post-treatment comparison of per-
sonal factors, health-related factors and health-promoting
behaviours. To investigate the factors that were associated
with health-promoting behaviours, stepwise linear regres-
sion analysis was conducted using variables that were sig-
nificant (p < 0
05) in the univariate analyses of occupation,
chronic disease, smoking habit and treatment status.
Results
majority of the remaining 123 participants were men
(n = 96, 78%), and the mean age was 61
4 years (standard
deviation, 16
5 years; range, 21–89 years). More than half
(n = 69, 56
1%) of the participants completed primary
school or less (≤6 years). The majority of participants were
married (n = 91, 74%), and more than half of the partici-
pants were currently working (n = 65, 52
8%) (Table 1).
Over half of the participants had completed TB treatment
(n = 72, 58
5%), and 41
5% (n = 51) were still undergoing
treatment. Positive contact history with family, relatives or
colleagues with TB was observed among 20
7% (n = 31) of
the participants, and 79
3% (n = 92) of the participants
stated that they had a negative TB contact history. Approx-
imately two-thirds (n = 84, 68
3%) of the participants
reported having one or more concurrent chronic diseases.
The most common concurrent chronic diseases were dia-
betes (27
5%), hepatitis (21
3%), and hypertension
(11
8%). Before their TB diagnosis, 13% (n = 16) of the
participants were classified as underweight (BMI < 18
5
kg/m2). Hospital medical records revealed that more than
half of the participants with available records had below-
average haemoglobin (57/105) and albumin (31/49) levels.

Demographic characteristics Cigarette smoking among participants with TB

Among the 134 candidates who were invited to participate The percentage of participants who smoked decreased from
in this study, 11 failed to complete the assessment. The the reported 46
9% (n = 45) before TB diagnosis to 30
2%

Table 1 Demographic characteristics and reported cigarette smoking behaviour changed before and after diagnosis of tuberculosis (n = 123)

Nonsmokers Stopped smoking

Variables before diagnosis after diagnosis Still smoking v2 p

Gender 19
96 <0
001

Male 51 (53
1) 16 (16
7) 29 (30
2)
Female 27 (100
0) 0 (0
0) 0 (0
0)
Age 12
97 0
002
<65 35 (55
6) 5 (7
9) 23 (36
5)
≧65 43 (71
7) 11 (18
3) 6 (10
0)
Education 7
53 0
023
≦Primary 50 (72
5) 9 (13
0) 10 (14
5)
≧Secondary 28 (51
9) 7 (13
0) 19 (35
2)
Occupation 18
51 <0
001
Unemployment 48 (82
8) 5 (8
6) 5 (8
6)
Employment 30 (46
2) 11 (16
9) 24 (36
9)
Marital status 8
93 0
012
Married 60 (65
9) 15 (16
5) 16 (17
6)
Others 18 (56
2) 1 (3
1) 13 (40
6)
Chronic Disease 7
43 0
024
Yes 57 (67
9) 13 (15
5) 14 (16
7)
No 21 (53
8) 3 (7
7) 15 (38
5)
Treatment status 0
88 0
644
Incomplete 30 (58
8) 7 (13
7) 14 (27
5)
Complete 48 (66
7) 9 (12
5) 15 (20
8)

© 2016 John Wiley & Sons Ltd

4 Journal of Clinical Nursing
Original article Smoking and health promoting behaviours

(n = 29) after receiving or completing TB treatment
(Table 1). Among the participants, male sex was signifi-
cantly associated with cigarette smoking habits (v2 = 19
96,
p < 0
001). Current smokers were significantly younger
(v2 = 12
97, p = 0
002), had a secondary school or greater
education (v2 = 7
53, p = 0
023), were currently employed
(v2 = 18
51, p < 0
001), were unmarried (v2 = 8
93,
p = 0
012), and had no concurrent chronic diseases
(v2 = 7
43, p = 0
024).
Factors associated with health-promoting behaviours
Table 2 shows that the three dimensions of the GHPs and
11 items of the health-promoting behaviours changed sig-
nificantly from reported behaviours before TB diagnosis to
after receiving or completing TB treatment. Significant
GHPs dimensions included health responsibility (t = –3
03,
p = 0
003), healthy diet (t = –3
48, p = 0
001), regular
exercise (t = –2
23, p = 0
028) and the total GHPs score
(t = –3
01, p = 0
003). Table 2 also shows that a significant
increase in BMI occurred after TB treatment (t = –6
13,
p < 0
001). Furthermore, 14 items of the health-promoting
behaviours occurred at frequencies of ‘sometimes’ or
‘never,’ especially for the community participation dimen-
sions (e.g. participation in community programmes, town-
ship or religious activities).
Table 3 shows the findings of the univariate analysis
regarding current health-promoting behaviours. Participants
who had never smoked or who had stopped smoking for
greater than one year had significantly higher scores, com-
pared to current smokers, in the dimensions of health
responsibility (p < 0
05), healthy diet (p < 0
01) and total
GHPs score (p < 0
05). Participants with chronic diseases
had significantly higher scores in health habits (p < 0
05),
health responsibility (p < 0
01), regular exercise (p < 0
05)
and total GHPs score (p < 0
01). Participants who were

Table 2 Reported health promoting behaviours and BMI changed before diagnosis and during or completing TB treatment (n = 123)

Before diagnosis During/completing

Variables Mean (SD) Paired t p

Health habits 23
68 (2
95) 23
91 (2
75) 1
50 0
136

1. I eat breakfast daily 3
70 (0
78) 3
86 (0
53) 2
98 0
004
2. Regular diet schedule 3
40 (0
89) 3
58 (0
75) 3
23 0
002
3. Feel sleep enough 3
48 (0
88) 3
50 (0
92) 0
40 0
693
4. Good fitted shoes 3
78 (0
59) 3
78 (0
59) 0
00 1
000
5. Wear slipper resistant shoes 2
45 (1
37) 2
47 (1
38) 1
14 0
259
6. Familiar with village head 3
56 (1
04) 3
57 (1
03) 0
38 0
707
7. Interact with friends 3
32 (0
97) 3
15 (1
02) 2
81 0
006
Community participation 8
27 (3
05) 7
99 (2
94) 2
58 0
011
8. Participate in exercise 1
32 (0
84) 1
27 (0
80) 1
18 0
241
9. Participate community programme 1
14 (0
56) 1
14 (0
56) 0
00 1
000
10. Participate health education 1
24 (0
71) 1
22 (0
71) 0
63 0
529
11. Participate township activities 1
76 (1
13) 1
72 (1
10) 1
04 0
299
12. Participate religious activities 2
81 (1
26) 2
64 (1
26) 3
51 0
001
Health responsibility 7
63 (3
73) 8
19 (3
48) 3
03 0
003
13. Knowing my cholesterol level 2
22 (1
43) 2
29 (1
44) 1
32 0
190
14. Knowing blood pressure level 3
02 (1
32) 3
35 (1
16) 3
87 <0
001
15. Knowing blood sugar level 2
40 (1
46) 2
54 (1
47) 2
22 0
028
Healthy diet 8
29 (2
17) 8
67 (2
17) 3
48 0
001
16. A balanced diet (five groups) 3
30 (0
91) 3
51 (0
78) 3
51 0
001
17. 1.5 bowls of vegetable/day 2
59 (1
06) 2
75 (1
08) 3
07 0
003
18. Two fist-sized fruits/day 2
40 (0
91) 2
41 (0
92) 0
53 0
595
Regular exercise 4
19 (2
57) 4
50 (2
68) 2
23 0
028
19. Exercise 30 minutes/day 2
08 (1
28) 2
24 (1
34) 2
23 0
028
20. Exercise three times/day 2
11 (1
29) 2
26 (1
34) 2
23 0
028
Oral Health 4
12 (1
98) 4
15 (2
02) 1
14 0
259
21. Brush teeth before sleep 2
69 (1
46) 2
70 (1
47) 1
00 0
319
22. Brush teeth three times/day 1
43 (1
02) 1
45 (1
04) 0
82 0
416
Total score 56
19 (9
68) 57
41 (9
83) 3
01 0
003
Body mass index (BMI) 22
44 (3
41) 23
35 (3
18) 6
13 <0
001

© 2016 John Wiley & Sons Ltd

Journal of Clinical Nursing 5
S-L Tsai et al.

Table 3 Factors associated with present health promoting behaviours (n = 123)

HH CP HR HD Exercise OH Total score

Variables Mean (SD)

Gender
Male 23
9 (2
4) 8
1 (2
9) 8
4 (3
4) 8
5 (2
1) 4
7 (2
6) 4
0 (2
1) 57
6 (8
8)
Female 23
8 (3
6) 7
8 (2
9) 7
3 (3
8) 9
2 (2
3) 3
9 (2
8) 4
7 (1
8) 56
7 (12
9)
Age (years)
<65 23
9 (2
9) 7
7 (2
8) 7
8 (3
7) 9
0 (2
2) 4
2 (2
6) 4
3 (1
9) 56
9 (9
4)
≧65 23
9 (2
5) 8
3 (3
1) 8
6 (3
3) 8
3 (2
1) 4
8 (2
8) 3
9 (2
1) 57
9 (10
3)
Education
≦Primary 23
9 (2
5) 8
0 (2
8) 8
6 (3
4) 8
4 (2
1) 4
5 (2
8) 3
9 (2
1) 57
3 (9
4)
≧Secondary 23
9 (3
1) 7
9 (3
1) 7
7 93
6) 9
0 (2
2) 4
5 (2
5) 4
4 (1
9) 57
5 (10
4)
Occupation
Unemployment 24
1 (2
7) 8
5 (3
5) 8
1 (3
4) 8
7 (2
3) 5
3 (2
7)** 4
1 (1
9) 58
6 (10
9)
Employment 23
8 (2
8) 7
6 (2
2) 8
3 (3
6) 8
7 (2
1) 3
8 (2
5) 4
2 (2
1) 56
3 (8
60
Chronic disease
Yes 24
3 (2
6)* 8
3 (3
2) 8
9 (3
2)** 8
8 (2
2) 4
9 (2
7)* 4
0 (2
0) 59
2 (9
9)**
No 23
2 (3
0) 7
3 (2
1) 6
7 (3
7) 8
4 (1
9) 3
7 (2
5) 4
5 (1
9) 53
6 (8
6)
Smoking
Never/cessation 23
9 (2
7) 8
0 (3
1) 8
5 (3
5)* 8
9 (2
2)** 4
6 (2
7) 4
2 (2
0) 58
1 (10
0)*
Current user 23
7 (2
9) 7
8 (2
1) 6
3 (3
2) 7
3 (1
3) 3
9 (2
8) 3
9 (1
9) 52
7 (6
7)
Treatment status
Incomplete 23
3 (3
1) 7
2 (2
4) 7
3 (3
2) 8
6 (2
3) 4
1 (2
6) 4
1 (2
2) 54
5 (8
9)
Complete 24
4 (2
4)* 8
5 (3
2)* 8
9 (3
5)* 8
8 (2
1) 4
8 (2
7) 4
2 (1
9) 59
5 (9
9)**

HH, health habits; CP, community participation; HR, health responsibility; HD, healthy diet; exercise, regular exercise; OH, oral health.
Independent t-test, *p < 0
05; **p < 0
01.

currently not working had significantly higher scores in reg-
ular exercise (p < 0
01), compared to working participants.
Participants who had completed TB treatment scored signif-
icantly higher in health-promoting behaviours, compared to
participants who had not completed TB treatment, for
health habits (p < 0
05), community participation
(p < 0
05), health responsibility (p < 0
05) and total GHPs
score (p < 0
01).
After adjusting for potential confounding variables, our
stepwise linear regression analysis (Table 4) revealed that
the determinants for current health-promoting behaviours
were chronic disease (b = –0
25, p = 0
005) and completion
of TB treatment (b = 0
23, p = 0
007).
Discussion
This study aimed to investigate the changes in health-pro-
moting behaviours and smoking habits among adults
between reported behaviours before TB diagnosis and dur-
ing or after completing TB treatment in a disadvantaged
geographical area. There was a high prevalence of cigarette
smoking and a low rate of health-promoting behaviours
among the participants, both before TB diagnosis and dur-
ing or after TB treatment.
Similar to previous studies of TB (Olson et al. 2012,
WHO 2014), we found that male sex, lower socioeconomic
status and smoking habits were important characteristics
among TB patients. Nicotine has the ability to impair the
uptake of Mycobacteria via monocyte-derived or alveolar
macrophages, and this macrophage impairment may
weaken the host immune response and increase the risk of
latent TB infection (Dogar et al. 2012, Horne et al. 2012,
Louwagie & Ayo-Yusuf 2013). One mathematical mod-
elling analysis by Basu et al. (2011) predicted that tobacco
smoking could substantially increase the number of TB
cases and deaths worldwide in the coming years. Notably,
in this study, no one started to smoke after the diagnosis.
Although the prevalence of cigarette smoking decreased
from 46
9% before to 30
2% after the diagnosis of TB,
smoking remains a significant problem. Therefore, if TB-
related public health goals include reducing TB relapse and
multidrug-resistant TB, smoking cessation should be aggres-
sively addressed in TB treatment protocols and in coun-
selling environments, especially for individuals who are
more likely to smoke (e.g. men).
Previous studies revealed that malnutrition is a risk factor
for TB infection and relapse after treatment (Karyadi et al.
2000, Pakasi et al. 2009, Lonnroth et al. 2010, Choi et al.

© 2016 John Wiley & Sons Ltd

6 Journal of Clinical Nursing
Original article
Table 4 Determinant factors associated with present health promoting behaviours (n = 123)
Variables Unstandardised B
Constant 56
34
Chronic disease (1 = no) 5
20
Treatment status (1 = complete) 4
63
Model summary F = 8
40 (p < 0
001), R2 = 0
12.
Dependent variables – total score of health promoting behaviour; Independent variables – Chronic disease, smoking, treatment status,
occupation.
2014). Our study also revealed similar findings, as many
participants were underweight, with abnormal haemoglobin
and albumin levels, before their TB diagnosis. Our findings
appear to indicate that not all health care providers evalu-
ate these nutritional elements before a TB diagnosis or after
TB treatment. National data from the US (Cegielski et al.
2012) and South Korea (Choi et al. 2014) indicate that
individuals who are underweight (BMI < 18
5 kg/m2) and
have low serum albumin levels are at an increased risk of
developing TB infection and having poor TB treatment out-
comes. Therefore, future treatment plans should consider
nutritional assessment and provide nutritional counselling
during the identification and treatment of TB.
The present findings also demonstrate that having a con-
current chronic disease (especially type 2 diabetes) and
completing TB treatment were associated with health-
promoting behaviours. These patients might have received
general health promotion messages from their health care
providers. For example, protocols for standardised diabetes
care in Taiwan encourage patients to adopt better exercise
habits and a balanced diet that includes food from the five
food groups. Although emphasising lifestyle improvements
during TB treatment is not a health promotion strategy in
Taiwan, this strategy could potentially significantly improve
the physical condition of patients who complete TB
treatment (e.g. by reducing unwanted side effects after TB
treatment) and motivate these patients to continue their
health-promotion behaviours. Therefore, we conclude that
participants who completed TB treatment had improved
health behaviours. Nevertheless, although significant
improvements were identified in these patients, healthy
habits were practiced at a frequency below “usually” dur-
ing daily life. Therefore, to continue building up the host
immune system and avoid activation of latent TB, it is nec-
essary to establish standardised counselling that encourages
TB patients to adopt healthier behaviours.
Limitations
There are several limitations in this study. First, because the
participants were recruited using a convenient sample from
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing
Smoking and health promoting behaviours
SE b t value p 95% CI
1
45 38
95 <0
001 53
45 to 59
21
1
80 0
25 2
88 0
005 8
76 to 1
63
1
70 0
23 2
72 0
007 1
26 to 8
00
a rural hospital with relatively uneducated patients, the
generalisability of these findings may be limited. Second,
the cross-sectional and retrospective data only reflect
associations and do not indicate causal relationships. Third,
self-reporting may have caused underestimation or overesti-
mation of certain health-related behaviours, such as the
amount and frequency of cigarette use or personal dietary
habits. Fourth, recall bias may have occurred, as current
smoking status was not determined using a carbon monox-
ide monitor. Fifth, although the mean age of the partici-
pants was 61 years, the GHPs was used, which might have
resulted in measurement error. Moreover, recall bias is of
concern. The potential inaccuracy of the recall measure
would lead to the biases in memory, which are produced
by factors outside consciousness, such as primacy, recency,
and demand characteristics of the experiment. To achieve
more conclusive results, future research should use more
robust methods, such as a prospective study of health beha-
viours from the time of diagnosis.
Conclusion
Our findings revealed that the majority of participants
exhibited low levels of health-promoting behaviours, both
before their TB diagnosis and during or after completing
TB treatment. Therefore, Taiwanese TB programmes and
future research should utilise strategies that incorporate
healthy lifestyle promotion to eliminate TB. Although the
presence of M. tuberculosis is necessary, but not sufficient,
to cause TB (Jurcev-Savicevic et al. 2013), poor health con-
ditions, concurrent chronic diseases and unhealthy lifestyle
choices are also important host immunity factors that can
play roles in susceptibility to TB.
Relevance to clinical practice
Nurses are expected to provide evidence-based care, and
nursing leaders have an obligation to support and enable
nurses to meet that expectation. According to the present
findings, malnutrition, cigarette smoking and unhealthy
habits were prevalent among TB patients. Therefore, it is
7
S-L Tsai et al.

necessary to enhance the promotion of a healthy lifestyle,
and cigarette smoking and healthy eating should be assessed
and evaluated immediately after the first diagnosis of TB in
the hospital. Furthermore, health promotion-related lifestyle
modification and smoking cessation programmes should
receive continued attention for TB patients during their
treatment.
Acknowledgements
The study was supported by a grant from the Buddhist
Dalin Tzu Chi Hospital, Chiayi County (NO: B10204019).
The authors would like to thank Dr. Chia-Ho Chang for
his statistics support. The authors would like to thank the
patients who participated in this study for their support in
making this study possible. In addition, we would like to
acknowledge the nursing staffs and chest physicians at the
outpatient clinic of the Dalin Tzu Chi Hospital for provid-
ing administrative support.
Contributions
Study design: SLT, MYC, CLL; data analysis and interpreta-
tion: MCC. All authors read and approved the final article.
Conflict of interest
The authors declare that they have no conflict of interests.

References
d’Arc Lyra BJ, de Fatima Pessoa Militao
de Albuquerque M, de Alencar Xime-
nes RA & Rodrigues LC (2008)
Smoking increases the risk of relapse
after successful tuberculosis treatment.
American Journal of Epidemiology 37,
841–851.
Basu S, Stuckler D, Bitton A & Glantz SA
(2011) Projected effects of tobacco
smoking on worldwide tuberculosis
control: mathematical modeling analy-
sis. British Medical Journal 343,
d5506.
Cegielski JP, Arab L & Cornoni-Huntley J
(2012) Nutritional risk factors for
tuberculosis among adults in the Uni-
ted States, 1971–1992. American Jour-
nal of Epidemiology 176, 409–422.
Center for Disease Control, ROC, Taiwan
(2014) Tuberculosis. Available at: http:
//www.cdc.gov.tw/english/page.aspx?
treeid=E79C7A9E1E9B1CDF&now-
treeid=9EB5EA29D4CCC2D5 (ac-
cessed 20 April 2014).
Chang CF, Lin MS, Chou LN, Wang J,
Fan JY & Chen MY (2013) The rela-
tionship between health promoting
behaviors and geriatric depression
among community seniors. The Jour-
nal of Nursing Research 21, 75–82.
Chen MY, Wang EK & Cheng YI (2006)
Adequate sleep among adolescents is
positively associated with health status
and health-related behaviors. BioMed
Central Public Health 6, 59.
Chen HC, Chen HM, Chen ML, Chiang
CM & Chen MY (2012) The relation-
ship between adolescent body size and
health promoting behavior and bio-
chemical indicator. Journal of Nursing
59, 51–60.
Choi H, Lee M, Chen RY, Kim Y, Yoon S,
Joh JS, Park SK, Dodd LE, Lee J, Song
T & Cho SN (2014) Predictors of
pulmonary tuberculosis treatment
outcomes in South Korea: a Risk factors for tuberculosis in Green-
prospective cohort study, 2005–2012.
BioMed Central Infectious Diseases
14, 360.
Dogar OF, Shah SK, Chughtai AA &
Qadeer E (2012) Gender disparity in
tuberculosis cases in eastern and west-
ern provinces of Pakistan. BioMed
Central Infectious Disease 12, 244.
Horne DJ, Campo M, Ortiz JR, Oren E,
Arent M, Crothers K & Narita M
(2012) Association between smoking
and latent tuberculosis in the U.S.
population: an analysis of the national
health and nutrition examination
survey. PLoS One 7, e49050.
Hsu AH, Lee JJ, Chiang CY, Li YH, Chen
LK & Lin CB (2013) Diabetes is asso-
ciated with drug-resistant tuberculosis
in Eastern Taiwan. The International
Journal of Tuberculosis and Lung
Disease 17, 354–356.
Jurcev-Savicevic A, Mulic R, Ban B, Kozul
K, Bacun-Ivcek L, Valic J, Popijac-
Cesar G, Marinovic-Dunatov S, Goto-
vac M & Simunovic A (2013) Risk fac-
tors for pulmonary tuberculosis in
Croatia: a matched case-control study.
BioMed Central Public Health 13, 991.
Karyadi E, Schultink W, Nelwan RH,
Gross R, Amin Z, Dolmans WM &
West CE (2000) Poor micronutrient
status of active pulmonary tuberculo-
sis patients in Indonesia. The Journal
of Nutrition 130, 2953–2958.
Ladefoged K, Rendal T, Skifte T, Ander-
sson M, Soborg B & Koch A (2011)
land: case-control study. The Interna-
tional Journal of Tuberculosis and
Lung Disease 15, 44–49.
Li Y, Ehiri J, Hu D, Zhang Y, Wang Q,
Zhang S & Cao J (2014) Framework
of behavioral indicators for outcome
evaluation of TB health promotion: a
Delphi study of TB suspects and TB
patients. BioMed Central Infectious
Disease 14, 268.
Lonnroth K, Williams BG, Cegielski P & Dye
C (2010) A consistent log-linear rela-
tionship between tuberculosis incidence
and body mass index. International
Journal of Epidemiology 39, 149–155.
Louwagie GM & Ayo-Yusuf OA (2013)
Tobacco use patterns in tuberculosis
patients with high rates of human
immunodeficiency virus co-infection in
South Africa. BioMed Central Public
Health 13, 1031.
Mupere E, Parraga IM, Tisch DJ, Mayanja
HK & Whalen CC (2012) Low nutri-
ent intake among adult women and
patients with severe tuberculosis dis-
ease in Uganda: a cross-sectional
study. BioMed Central Public Health
12, 1050.

© 2016 John Wiley & Sons Ltd

8 Journal of Clinical Nursing
Original article
Narasimhan P, Wood J, Macintyre CR &
Mathai D (2013) Risk factors for
tuberculosis. Pulmonary Medicine 12,
828939.
Olson NA, Davidow AL, Winston CA,
Chen MP, Gazmararian JA & Katz DJ
(2012) A national study of socioeco-
nomic status and tuberculosis rates by
country of birth, United States, 1996–
2005. BioMed Central Public Health
12, 365.
Pakasi TA, Karyadi E, Dolmans WM, van
der Meer JW & van der Velden K
(2009) Malnutrition and socio-demo-
graphic factors associated with pul-
© 2016 John Wiley & Sons Ltd
Journal of Clinical Nursing
monary tuberculosis in Timor and
Rote Islands, Indonesia. The Interna-
tional Journal of Tuberculosis and
Lung Disease 13, 755–759.
Shang S, Ordway D, Henao-Tamayo M,
Bai X & Oberley-Deegan R (2011)
Cigarette smoke increases susceptibil-
ity to tuberculosis – evidence from
in vivo and in vitro models. Journal of
Infectious Disease 203, 1240–1248.
Wang J, Li CM, Chang CF, Jane SW &
Chen MY (2015) Psychometric testing
of the geriatric health promotion
scale. The Journal of Nursing
Research 23, 56–64.
Smoking and health promoting behaviours
World Health Organization (2010) Mile-
stones in Health Promotion: Statements
from Global Conferences. Available at:
http://www.who.int/entity/healthpromo-
tion/Milestones_Health_Promotion_050
22010.pdf (accessed 15 May 2014).
World Health Organization (2014) Global
Tuberculosis Control. Available at:
http://apps.who.int/iris/bitstream/1066
5/75938/1/9789241564502_eng.pdf
(accessed 1 May 2015).
World Health Organization (2015) Tuber-
culosis: Global Tuberculosis Report
2015. Available at: http://www.who.
int/tb/en/ (accessed 1 January 2016).
9