Vaping and Tuberculosis: An Overlooked Risk in High-Burden South Asian Countries

Tuberculosis (TB) is an infectious disease that remains one of the most pressing threats to public health, especially in South Asian countries. Despite being curable, it is a major cause of morbidity and mortality, driven by factors such as poverty, lack of nutrition, HIV infection, and overcrowding of individuals. Among modifiable risk factors, tobacco smoking has long been established as a major contributor to TB incidence. However, the increasing use of vapes/e-cigarettes, perceived as a safer alternative to traditional smoking, can pose as an underrecognized threat to TB control, particularly in high-burden regions. Vaping exposes individuals to nicotine, flavoring agents, and toxic substances that compromise lung immunity. Evidence shows that vaping impairs alveolar macrophage function, reduces cytokine signaling, and suppresses defense peptides in the host. All of these factors enhance Mycobacterium tuberculosis pathogenesis. Radiologically, vaping-induced injury can resemble features of military TB, such as ground-glass opacities, complicating diagnosis and eventually leading to misdiagnosis. Despite these concerns, South Asian countries fail to enforce strategies to ban the use of e-cigarettes. To address this important public health concern, vaping must be incorporated into TB risk assessments and recognized as a modifiable risk factor to strengthen public health efforts and accelerate progress towards TB elimination in South Asian countries.