Smokeless tobacco use accelerates age-related loss of bone mineral density among older women in a multi-ethnic rural community

Smokeless tobacco use and public health nutrition: a global systematic review

OBJECTIVE

Tobacco consumption among low- and middle-income countries where food insecurity remains a challenge poses several concerns. This review examines the available global evidence linking smokeless tobacco (SLT) use with public health nutrition and its implications.

DESIGN

Systematic review of articles extracted from PubMed and Scopus from January 2000 to December 2020.

SETTING

Included studies that demonstrated the relationship between SLT and nutrition-related factors, that is, BMI, malnutrition, anaemia, poor birth outcomes and metabolic disorders. Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines have been followed to conduct the systematic evidence review.

PARTICIPANTS

A total of thirty-four studies were finally used in the systematic review, which included cross-sectional (thirty-one) and cohort (three).

RESULTS

SLT use has a huge impact on body weight, alteration in taste, poor oral health, and consumption of fruits and vegetables leading to malnutrition. Maternal use of SLT not only leads to anaemia but also hampers birth outcomes. Increased risk of metabolic syndrome and gallstone disease among SLT users are also well documented in the studies.

CONCLUSION

The review highlights the linkages between SLT usage and poor nutritional outcomes. Tobacco control efforts should be convergent with public health nutrition to achieve overall health benefits. Attention is also required to explore suitable mechanisms for SLT cessation combined with enhancing food and nutrition security at the community level in sync with investments in public health nutrition intervention.

Fractal Dimension and Radiomorphometric analysis of Orthopanoramic radiographs in patients with tobacco and areca nut associated oral mucosal lesions: A pilot in-vivo study in a North Indian cohort

OBJECTIVE

The aim of this study was to determine the fractal dimension (FD) and radiomorphometric indices (RMIs) in the mandible from orthopantomographic radiographs in patients with oral lesions associated with smokeless/smoking tobacco (SLT/ST) and areca nut habits in a North Indian cohort.

STUDY DESIGN

A prospective, cross-sectional, observational pilot study was conducted of 120 subjects, including controls and 3 study groups of 30 patients each with oral submucous fibrosis, tobacco pouch keratosis, and oral leukoplakia (OL). Two observers calculated FD and the RMIs of mandibular cortical thickness (MCT), panoramic mandibular index (PMI), and mandibular cortical index (MCI).

RESULTS

Mean FD was significantly reduced compared to controls with all oral lesions (P < .05) and with all habits in 3 of 4 regions of interest (P < .05). MCT was significantly reduced with OL (P < .005) and in ST users (P < .05). PMI did not differ regarding lesion status or habits. Compared to the controls, MCI C2 type was significantly more common in all oral lesions (P ≤ .005) and all types of habit (P < .005). Inter- and intraobserver agreement was strong to excellent.

CONCLUSIONS

FD and RMI values were significantly altered compared to controls in oral lesions associated with tobacco and areca nut habits and in the dominant type of habit.

Fractal dimension and lacunarity analysis of mandibular bone on digital panoramic radiographs of tobacco users

Background. This study aimed to evaluate and compare changes in the mandibular trabecular bone pattern using the fractal dimension (FD) and lacunarity analysis in tobacco users with healthy controls.

Methods. This study was carried out on digital panoramic radiographs of 225 subjects divided into three groups: smokeless tobacco users (SLTs), smokers, and control (n=75). ImageJ program with FracLac plugin was used to assess the FD and lacunarity of mandibular trabecular bone on the digital panoramic radiographs.

Results. The differences in the mean FD values of the study and control groups were statistically significant (P < 0.001). Mean FD was lower in the case groups than the control group, with SLTs having the least FD value. A significant difference in lacunarity was noted between SLTs and controls (P < 0.001). On the contrary, there was no significant difference in lacunarity between smokers and controls.

Conclusions. FD values were lower in tobacco users, suggesting that tobacco users have a less complex trabecular bone pattern than healthy controls. Higher lacunarity values in SLTs indicated a more heterogeneous bone pattern. These findings signify that FD and lacunarity analysis on digital panoramic radiographs can serve as promising predictive tools to assess bone quality for osteoporotic changes in tobacco users, thereby facilitating prompt referral for further management.

The influence of snuff and smoking on bone accretion in late adolescence. The Tromsø study, Fit Futures

Areal bone mineral density (aBMD) predicts future fracture risk. This study explores associations between use of tobacco and bone accretion in Norwegian adolescents. Our results indicate that use of snuff is negatively associated with accretion of aBMD in adolescence and may be a signal of increased future fracture risk.

PURPOSE

Bone mineral accrual in childhood and adolescence is a long-term primary preventive strategy of osteoporosis. Areal bone mineral density (aBMD) is a surrogate measure of bone strength and a predictor of fracture risk. The aim of this population-based 2-year follow-up cohort study was to explore associations between use of snuff and smoking and changes (∆) in aBMD in Norwegian girls and boys aged 15-17 years at baseline.

METHODS

The first wave of the Tromsø study, Fit Futures was conducted from 2010 to 2011. Femoral neck (FN), total hip (TH), and total body (TB) bone mineral content (BMC) and aBMD were measured by dual-energy X-ray absorptiometry. Information on use of snuff, smoking habits, and other lifestyle related variables were collected through self-administered questionnaires. Two years later, during 2012-2013, the measurements were repeated in the second wave. The present study included 349 girls and 281 boys and compared "non-users" (n = 243 girls, 184 boys) with "users" (n = 105 girls, 96 boys) of snuff and "non-smokers" (n = 327 girls, 249 boys) with "smokers" (n = 21 girls, 31 boys) using linear regression adjusted for age, baseline height and weight, change in height and weight, pubertal maturation, physical activity, ethnicity, alcohol consumption, diagnosis known to affect bone, and medication known to affect bone. The influence of "double use" on bone accretion was also explored.

RESULTS

In girls, no associations between use of snuff and ∆aBMD were found. In boys, use of snuff was associated with reduced bone accretion in all ∆aBMD models. Sensitivity analysis with exclusion of "sometimes" users of snuff strengthened associations at femoral sites in girls and attenuated all associations in boys. In girls, no associations between smoking and ∆aBMD were found. In boys, only the association with TB ∆aBMD was significant in the fully adjusted models. In girls, "double users" analyses showed similar association to smoking. In boys, nearly all models showed statistically significant associations with a difference of ~ 1-2% in ∆aBMD between "non-users" and "double users" during 2 years of follow-up.

CONCLUSIONS

Our results indicate that tobacco use in late adolescence could be detrimental to bone accretion and may be a signal of increased fracture risk in adult life.

Oral bisphosphonate use and lung cancer incidence among postmenopausal women

Background

Bisphosphonates are common medications for the treatment of osteoporosis in older populations. Several studies, including the Women’s Health Initiative (WHI), have found inverse associations of bisphosphonate use with risk of breast and endometrial cancer, but little is known about its association with other common malignancies. The objective of this study was to evaluate the association of bisphosphonate use on the incidence of lung cancer in the WHI.

Patients and methods

The association between oral bisphosphonate use and lung cancer risk was examined in 151 432 postmenopausal women enrolled into the WHI in 1993–1998. At baseline and during follow-up, participants completed an inventory of regularly used medications including bisphosphonates.

Results

After a mean follow-up of 13.3 years, 2511 women were diagnosed with incident lung cancer. There was no evidence of a difference in lung cancer incidence between oral bisphosphonate users and never users (adjusted hazard ratio = 0.91; 95% confidence intervals, 0.80–1.04; P = 0.16). However, an inverse association was observed among those who were never smokers (hazard ratio = 0.57, 95% confidence interval, 0.39–0.84; P < 0.01).

Conclusion

In this large prospective cohort of postmenopausal women, oral bisphosphonate use was associated with significantly lower lung cancer risk among never smokers, suggesting bisphosphonates may have a protective effect against lung cancer. Additional studies are needed to confirm our findings.

Estrogen receptor α and β gene polymorphism in relation to bone mineral density and lipid profile in Northeast Indian women

Estrogen regulates bone homeostasis and has a cardio-protective effect. Its physiological functions are mediated through receptors (ER) whose expression can be regulated by presence or absence of polymorphisms. However, the association between ER polymorphisms and BMD as well as lipids are inconsistent. The aim of the study was to investigate whether polymorphisms in ESR are associated with bone mineral density (BMD) and lipids in a cohort of Indian women. We studied PvuII, XbaI polymorphisms in ESR1 and AluI, RsaI polymorphisms in ESR2 genes and their association with bone mineral density (BMD) and lipids in premenopausal (n = 293, mean age: 33.01 ± 5.23 years) and postmenopausal (n = 145, mean age: 56.91 ± 7.1 years) women from Northeast India. AluI and RsaI polymorphisms in ESR2 gene were associated with BMD in postmenopausal women. Logistic regression analysis adjusted for age, BMI, tobacco and alcohol consumption revealed that xx genotype in XbaI polymorphism is associated with osteopenia at spine (OR = 3.3, 95% CI = 1.067-10.204) in postmenopausal women suggesting that allele X is protective (OR = 0.419, 95% CI = 0.177-0.991). Genotype aa in AluI polymorphism, seemed to be protective (OR = 0.092 for osteopenia; OR = 0.152 for osteoporosis) at spine whereas A allele was associated with osteopenia at femur (OR = 2.123, 95% CI = 1.079-4.166) in postmenopausal women. Allele r of RsaI polymorphism, was associated with osteoporosis at spine (OR = 3.222, 95% CI = 1.302-7.96). Thus, AIuI polymorphism of ESR2 gene was associated with spinal and femoral BMD whereas RsaI only with spinal BMD in postmenopausal women and ESR genotypes were not associated with lipids.

Association of high-density lipoprotein, triglycerides, and homocysteine with bone mineral density in young Indian tribal women

This study investigated association between lipids and homocysteine (Hcy) with bone mineral density (BMD) in young women as opposed to previous studies on elderly women. HDL, triglyceride, and Hcy are significantly associated with BMD in young women and tobacco and alcohol consumption have no effect on this association.

PURPOSE

The present study investigates whether the association of serum lipids and homocysteine (Hcy) with bone mineral density (BMD) reported mostly in elderly population can be generalized to young or premenopausal women, consequently suggesting screening of young women with low BMD for dyslipidemia or any cardiovascular events and vice versa.

METHODS

Women (n = 293, aged 20-47 years) from Northeast India belonging to Tibeto-Burman origin were enrolled. Information about their physical and clinical attributes were collected by a structured questionnaire. Their BMDs at lumbar spine and femur were measured by dual-energy X-ray absorptiometry (DXA) and sera were profiled for lipid parameters and Hcy by auto-analyzer and ELISA, respectively. Women consuming tobacco and/or alcohol were grouped as consumers and others as non-consumers for the analysis.

RESULTS

Positive correlation of BMD with HDL (spine and femur r = 0.38, p < 0.0001) and triglyceride (spine r = 0.534, p < 0.0001; femur r = 0.423, p < 0.0001) was observed, whereas Hcy correlated negatively with BMD (spine r = - 0.189, p = 0.0026; femur r = - 0.273, p < 0.0001). LDL showed a weak negative correlation with BMD (spine r = - 0.128, p = 0.0283; femur r = - 0.199, p = 0.0006). However, after adjusting for age, BMI, and consumption, HDL, triglyceride, and Hcy continued to show significant correlation with BMD at both the sites. Logistic regression analyses indicated that HDL, triglyceride, and Hcy were significant predictors of osteopenia and osteoporosis in our study cohort; however, consumption did not contribute to its prediction.

CONCLUSION

Low levels of HDL and triglyceride and high levels of Hcy are significantly associated with osteopenia and osteoporosis in young Northeast Indian women.

Behaviour change intervention for smokeless tobacco cessation: its development, feasibility and fidelity testing in Pakistan and in the UK

BACKGROUND

People of South Asian-origin are responsible for more than three-quarters of all the smokeless tobacco (SLT) consumption worldwide; yet there is little evidence on the effect of SLT cessation interventions in this population. South Asians use highly addictive and hazardous SLT products that have a strong socio-cultural dimension. We designed a bespoke behaviour change intervention (BCI) to support South Asians in quitting SLT and then evaluated its feasibility in Pakistan and in the UK.

METHODS

We conducted two literature reviews to identify determinants of SLT use among South Asians and behaviour change techniques (BCTs) likely to modify these, respectively. Iterative consensus development workshops helped in selecting potent BCTs for BCI and designing activities and materials to deliver these. We piloted the BCI in 32 SLT users. All BCI sessions were audiotaped and analysed for adherence to intervention content and the quality of interaction (fidelity index). In-depth interviews with16 participants and five advisors assessed acceptability and feasibility of delivering the BCI, respectively. Quit success was assessed at 6 months by saliva/urine cotinine.

RESULTS

The BCI included 23 activities and an interactive pictorial resource that supported these. Activities included raising awareness of the harms of SLT use and benefits of quitting, boosting clients' motivation and self-efficacy, and developing strategies to manage their triggers, withdrawal symptoms, and relapse should that occur. Betel quid and Guthka were the common forms of SLT used. Pakistani clients were more SLT dependent than those in the UK. Out of 32, four participants had undetectable cotinine at 6 months. Fidelity scores for each site varied between 11.2 and 42.6 for adherence to content - maximum score achievable 44; and between 1.4 and 14 for the quality of interaction - maximum score achievable was 14. Interviews with advisors highlighted the need for additional training on BCTs, integrating nicotine replacement and reducing duration of the pre-quit session. Clients were receptive to health messages but most reported SLT reduction rather than complete cessation.

CONCLUSION

We developed a theory-based BCI that was also acceptable and feasible to deliver with moderate fidelity scores. It now needs to be evaluated in an effectiveness trial.

Body composition in the Study of Women Entering and in Endocrine Transition (SWEET): A perspective of African women who have a high prevalence of obesity and HIV infection

OBJECTIVES

Little data are available for sub-Saharan African women on changes in body composition in menopause transition (MT). The study aimed to determine whether there are differences in body adiposity, lean muscle mass, and bone mineral density (BMD) across MT groups in urban African women, who have a high prevalence of obesity and HIV infection, and if this is related to an altered hormonal milieu.

DESIGN

Participants were 702 black urban women. Menopause stage was defined using STRAW+10 criteria. Levels of follicle stimulating hormone (FSH), estradiol (E2), dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), testosterone (T) and sex hormone blinding globulin (SHBG) were measured. Body composition was measured with dual-energy X-ray absorptiometry (DXA) and ultrasound scans.

RESULTS

Whole body lean mass (p=0.002) and BMD (p<0.0005) were significantly lower in postmenopausal compared to premenopausal groups. Estradiol (p<0.0005), SHBG (p<0.0005) and DHEAS (p=0007) were significantly lower in post- than premenopausal groups, while FSH was higher (p<0.0005). FSH correlated negatively (β=-2.06, p<0.0005) with total lean mass while E2 correlated positively (β=20.0, p=0.002) with BMD. Use of antiretroviral therapy (ART) correlated negatively with total fat mass (β=-2.92, p=0.008) and total bone mineral content (BMC; β=-78.8, p=0.003).

CONCLUSIONS

The MT in this population is characterized by lower whole body lean mass and BMD in post- compared to premenopausal subjects but there are minimal differences in fat mass. Lower lean mass and BMD were associated with higher FSH and lower E2 serum levels, respectively. Use of ART was associated with lower fat mass and BMC.

Patterns and predictors of smokeless tobacco use among adults in Bangladesh: findings from the International Tobacco Control (ITC) Bangladesh survey

BACKGROUND

Although smokeless tobacco (SLT) use is prevalent in South Asian countries including Bangladesh, information about the pattern and correlates of SLT use is scarce. This study described the pattern and predictors of SLT use among Bangladeshi adults.

METHODS

The data for this study were derived from the International Tobacco Control Policy Evaluation Bangladesh (ITC BD) Survey, a prospective cohort survey of a nationally representative sample of smokers and non-smokers, conducted during November 2011 and May 2012. The study included 5522 adults aged 15 or above. We used multiple logistic regression models to identify predictors of SLT use.

RESULTS

Of the respondents (N = 5522), 20% were SLT users. In general, SLT use was significantly higher among women, the illiterate and residents of the Dhaka slums or non-tribal/non-border areas outside Dhaka; SLT use increased with age. Several attitudinal factors were also associated with SLT use. Multivariable logistic regression analyses revealed several predictors of SLT use: being female (OR = 1.96, 95% confidence interval, CI: 1.18-3.24), an increasing age, being a resident of a Dhaka slum (OR = 5.86; 95% CI: 3.73-9.21) or non-tribal/non-border areas outside Dhaka (OR = 3.42; 95% CI: 1.94-6.03), being illiterate (OR = 3.37; 95% CI: 1.99-5.71), holding positive opinion towards societal approval of SLT use (OR = 5.84; 95% CI: 3.38-10.09), holding positive opinion towards SLT use by women (OR = 2.63; 95% CI: 1.53-4.54), believing that SLT is addictive (OR = 2.96; 95% CI: 1.51-5.81), and believing SLT is less harmful than bidi (OR = 2.22; 95% CI: 1.36-3.62).

CONCLUSION

The findings suggest that coordinated efforts of governmental and non-governmental organizations, targeting both smoked tobacco and SLT use reduction and cessation, could be modified to reach each level of population including those who are marginalized, female, less educated and elderly. As most tobacco control programs in Bangladesh target mainly cigarette or bidi smoking, coordinated programs are needed that will also include SLT use within the tobacco control policy and prevention strategies.

Translation, cultural adaptation and validation of the WHO fracture risk assessment tool (FRAX(®) ) into Bengali

AIM

To develop a translated and culturally adapted Bengali version of the WHO Fracture Risk Assessment Tool (FRAX(®) ) and to test its feasibility, content validity and reliability.

METHOD

The English FRAX was translated and culturally adapted for use in Bangladeshi populations following established forward-backward translation methods and being extensively field-tested. The final version was interviewer-administered to 130 consecutive osteoporotic patients between 40 and 90 years of age. For test-retest reliability, the questionnaire was re-administered after 14 days in 60 odd serial-numbered patients.

RESULTS

To better match with the Bengali culture, several adaptations were made to the FRAX items, including replacements and additions for tobacco, prednisolone and alcohol use. The response rate of the pre-final Bengali version of FRAX was 100% and all patients could understand the questions. Test-retest reliability (Pearson's r) in osteoporotic patients was > 0.93 for all items.

CONCLUSION

The culturally adapted Bengali version of the FRAX appears to be an acceptable and reliable instrument. Further studies are needed to confirm the ability of the tool to accurately predict the 10-year probability of hip and major osteoporotic fractures in the Bengali population.