Highlights
- Mobile health (mHealth) interventions delivering tailored text messages significantly improve biochemically verified continuous tobacco abstinence in patients with tuberculosis (TB).
- The intervention leads to a threefold increase in smoking cessation at 6 months compared with usual care, demonstrating robust efficacy.
- Mortality in TB patients who receive mHealth support for smoking cessation is significantly reduced, highlighting potential survival benefits.
- mHealth is a feasible, scalable approach suitable for low-resource settings where TB burden and smoking prevalence are high.
Background
Tuberculosis remains a major global health issue, especially in low- and middle-income countries like Bangladesh and Pakistan. Smoking is a known risk factor that exacerbates TB morbidity and mortality by impairing immune response, reducing treatment efficacy, and increasing the risk of relapse and treatment failure. Quitting tobacco accelerates pulmonary recovery and improves TB outcomes. However, delivering effective cessation interventions integrated within TB programs in resource-limited settings presents major challenges. Mobile health (mHealth) technologies offer scalable, low-cost platforms for delivering behavioral interventions, but rigorous evidence in TB populations has been limited until now.
Key Content
Study Design and Population
Zahid and colleagues conducted a multicenter, cluster randomized clinical trial (RCT) from September 2023 to January 2025 across 27 TB clinics in Bangladesh and Pakistan. Clinics were randomized in a 2:1 ratio to receive an mHealth intervention or usual care. Eligible patients were 15 years and older, newly diagnosed with drug-sensitive pulmonary TB within 4 weeks, smoked daily, were motivated to quit, and had regular access to mobile phones. Among 9232 assessed, 1080 smokers met inclusion criteria and were enrolled (mHealth, n=720; usual care, n=360). The cohort was predominantly male (>95%) reflecting smoking demographics in these populations.
Intervention
The mHealth arm received a structured program of tobacco cessation text messages tailored to patients undergoing TB treatment; daily messages for the first 2 months followed by monthly messages for the subsequent 4 months. Messages included motivational content, cessation tips, and encouragements timed with TB treatment milestones. The control group received standard written information on tobacco cessation without additional follow-up.
Primary and Secondary Outcomes
The primary endpoint was self-reported continuous abstinence at 6 months, confirmed by carbon monoxide breath testing to biochemically verify smoking status. Secondary outcomes assessed were point prevalence abstinence at 9 weeks and 6 months, TB treatment adherence (duration of treatment days completed), treatment success (cure and treatment completion), treatment failure, defaults (≥2 months interruption), and mortality.
Principal Findings
At 6 months, 41.7% of patients in the mHealth group achieved continuous abstinence versus 15.3% in usual care (risk ratio 3.0, 95% CI 2.0-4.9), demonstrating a substantial and clinically meaningful effect. TB treatment adherence was similar between groups, with no statistically significant differences in days on treatment or treatment success rates (89.3% vs. 85.6%, risk ratio 1.2, 95% CI 0.9-1.6). Treatment failure and default rates were low and comparable. Importantly, mortality was significantly lower in the mHealth group (3.5%) compared to usual care (7.5%) with a hazard ratio of 0.4 (95% CI 0.2-0.9), indicating reduced risk of death associated with the intervention.
Comparative Evidence and Context
Prior meta-analyses of smoking cessation interventions in general populations show that text messaging programs increase quit rates by approximately 1.5 to 2-fold. The markedly enhanced efficacy observed in the TB population may reflect higher motivation due to TB diagnosis and the intensified intervention design. Earlier smaller studies in TB cohorts lacked biochemical verification and had shorter follow-up. This trial is among the largest and most rigorously conducted to date in TB patients, providing robust evidence of mHealth effectiveness.
Expert Commentary
This trial addresses a critical gap in TB care by integrating smoking cessation into routine management using scalable digital tools. The use of cluster randomization mitigates contamination, and biochemical verification strengthens outcome validity. The population, predominantly young males with recent TB diagnosis, represents the highest risk group for smoking-related TB morbidity. The non-significant difference in treatment adherence suggests cessation benefits are mediated through systemic and pulmonary improvements rather than altered TB treatment behavior.
Reduced mortality observed with the mHealth intervention may be attributable to diminished smoking-related inflammation, improved immune function, and better overall health. While causality warrants cautious interpretation, this finding is of high clinical and public health importance.
Implementation considerations include mobile phone ownership and literacy, which were eligibility criteria; adaptation in populations with lower access may be needed. The texting protocol can be enriched by interactive features or combined with pharmacotherapies. Ongoing monitoring and integration into national TB programs could enhance sustainability.
Conclusion
The cluster randomized trial by Zahid et al. provides compelling evidence that a structured mHealth text messaging intervention markedly improves smoking cessation rates and is associated with reduced mortality in patients undergoing treatment for pulmonary TB. This intervention represents a feasible, low-cost, and effective strategy to address the dual burden of tobacco use and TB disease, particularly in high-prevalence, resource-limited settings. Future work should explore integration with pharmacologic cessation aids, cost-effectiveness analyses, and adaptation for broader TB populations, including those with multidrug-resistant TB.
References
- Zahid M, Rahman F, Danaee M, et al. An mHealth (Mobile Health) Intervention for Smoking Cessation in People With Tuberculosis: A Cluster Randomized Clinical Trial. JAMA. 2025 Dec 22:e2520765. doi: 10.1001/jama.2025.20765. PMID: 41428342; PMCID: PMC12723593.
- World Health Organization. Global Tuberculosis Report 2023. Geneva: WHO; 2023.
- Guo B, Gao B, Chen P, et al. Efficacy of mobile phone text messaging for smoking cessation: A meta-analysis. Medicine (Baltimore). 2019;98(43):e17653. doi:10.1097/MD.0000000000017653.
- Chang JT, Wu LW, Chang CA, et al. Smoking and the risk of tuberculosis: a systematic review and meta-analysis. PLoS One. 2016;11(4):e0152163. doi:10.1371/journal.pone.0152163.
