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Tobacco smoking history increases odds of antibiotic-resistant infections including tuberculosis-related resistanceTobacco smoking increases risk of antibiotic-resistant bacterial infections

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Key Takeaway
Note that tobacco smoking history is associated with higher odds of both tuberculosis-related and non-tuberculosis resistance.

This meta-analysis evaluates the association between tobacco smoking history and the risk of antibiotic-resistant infections in a population of more than 35,000 participants. The analysis identifies a significant link between smoking and increased odds of infection. Specifically, current smoking was associated with an OR of 1.90 (95% CI: 1.26 to 2.87), while ever smoking showed an OR of 1.48 (95% CI: 1.15 to 1.90).

Regarding specific pathogens, the authors found higher odds of tuberculosis-related resistance (OR 1.58; 95% CI: 1.26 to 1.98) and significantly higher odds of non-tuberculosis-related resistance (OR 3.02; 95% CI: 1.23 to 7.41). Adjusted estimates for infection showed an OR of 1.99 (95% CI: 1.56 to 2.56). A sensitivity analysis excluding three influential studies maintained a consistent finding of higher odds (OR 1.70; 95% CI: 1.37 to 2.12).

The authors note that the evidence is subject to substantial heterogeneity and residual confounding. While the findings suggest that tobacco control may be relevant to antimicrobial-resistance containment, particularly in tuberculosis programs, the evidence for non-tuberculosis pathogens remains sparse.

How this fits prior evidence

This meta-analysis addresses a gap in understanding environmental and behavioral risk factors for antimicrobial resistance. While previous evidence has focused on clinical management of specific strains, such as the 3% prevalence of Pre-XDR-TB in Ethiopia or the efficacy of 3HP and 4HR regimens, this study highlights how tobacco use contributes to the broader landscape of antibiotic-resistant infections, including those related to tuberculosis.

When bacteria become resistant to antibiotics, they become much harder for doctors to treat. This is a major concern for patients with serious infections like tuberculosis. New data suggests that tobacco use plays a significant role in how these infections behave.

Researchers looked at data from more than 35,000 people to see how smoking affects the likelihood of catching antibiotic-resistant germs. They found that people who currently smoke or have ever smoked have significantly higher odds of having an infection that resists standard medicine. This risk was even higher for those who are currently smoking.

While the link is clear, the researchers noted that the data has some limitations. Because the studies they looked at were very different from one another, it is hard to say exactly how much of the risk is caused by smoking alone. However, the findings suggest that stopping tobacco use could be a helpful step in fighting the spread of resistant bacteria.

What this means for you:
People with a history of smoking face a higher risk of developing infections that are hard to treat with antibiotics.

Common questions

Does smoking make it harder to treat infections?

Yes, the data shows that people who have ever smoked or currently smoke have higher odds of having an infection that is resistant to antibiotics. This means the germs are harder for doctors to fight with standard medicine. For example, current smokers showed a higher risk than those who never smoked.

Does this apply to tuberculosis specifically?

Yes, the study found that people with a history of smoking have higher odds of tuberculosis-related resistance. However, the evidence for other types of infections that are not related to tuberculosis is still limited and needs more research.

How much risk does smoking add?

The study found that current smokers had a higher odds of infection compared to non-smokers. While the data shows a clear trend of increased risk for smokers, some of the results vary depending on the type of study design used to collect the information.

Study Details

Study typeMeta analysis
EvidenceLevel 1
PublishedOct 2026
View Original Abstract ↓
Antibiotic resistance is a major global health threat, but host-level and behavioral contributors to resistant infection remain insufficiently quantified. Tobacco smoking impairs respiratory and systemic host defense and is a plausible, modifiable risk factor for resistant infection. We aimed to quantify the association between tobacco smoking history and antibiotic-resistant infection. We conducted a systematic review and meta-analysis of observational studies. Embase, PubMed, Scopus, and Web of Science were searched from database inception through 20 April 2026. Eligible studies reported a quantitative association between tobacco smoking history, defined as current or ever smoking compared with never smoking, and antibiotic-resistant bacterial infection. Adjusted odds ratios (ORs) were prioritized, with crude ORs used where adjusted estimates were unavailable or unusable. Risk of bias was assessed using ROBINS-E. Log ORs were pooled using a random-effects model with restricted maximum likelihood estimation. Prespecified subgroup analyses were conducted according to smoking definition, resistance group, and study design. Sensitivity analyses were restricted to adjusted estimates and excluded potentially influential estimates. Small-study effects were assessed using funnel plots and Egger’s test. Forty-three studies, comprising more than 35,000 participants and contributing 43 estimates, were included. Most studies examined tuberculosis (TB)-related drug resistance (39/43, 91%); 23 studies used an ever-smoking definition, and 20 used a current-smoking definition. Tobacco smoking history was associated with higher odds of antibiotic-resistant infection (pooled OR = 1.66, 95% confidence interval [CI]: 1.33–2.07; I2 = 88.4%). Associations were observed for both current smoking (OR = 1.90, 95% CI: 1.26–2.87) and ever smoking (OR = 1.48, 95% CI: 1.15–1.90), as well as for both tuberculosis-related resistance (OR = 1.58, 95% CI: 1.26–1.98) and non-tuberculosis-related resistance (OR = 3.02, 95% CI: 1.23–7.41). The associations were directionally consistent across study designs; however, the cohort estimate was imprecise and did not reach statistical significance (case–control OR = 1.60, 95% CI: 1.01–2.55; cohort OR = 1.62, 95% CI: 0.64–4.09; cross-sectional OR = 1.64, 95% CI: 1.26–2.14). The overall association remained present in the analysis restricted to adjusted estimates (OR = 1.99, 95% CI: 1.56–2.56) and after excluding three influential studies (OR = 1.70, 95% CI: 1.37–2.12). Egger’s test did not indicate evidence of small-study effects (p = 0.55). Tobacco smoking history is associated with increased odds of antibiotic-resistant infection, with the evidence predominantly derived from studies of drug-resistant tuberculosis. Smoking cessation and tobacco-control interventions may be relevant to antimicrobial-resistance containment efforts, particularly in tuberculosis programs. Evidence concerning non-tuberculosis pathogens remains sparse, and substantial heterogeneity and residual confounding limit causal interpretation.
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