Tobacco smoking history and antibiotic-resistant infection: a systematic review and meta-analysis
Abstract
Background 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. Methods 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. Results Forty-three studies, comprising more than 35,000 participants and contributing 43 estimates, were included. Most studies examined tuberculosis…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 35,000 participants or records.
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