Smokeless tobacco and blood pressure

Association of Cardiovascular Disease Risk Factors with Exclusive Smokeless Tobacco Use among US Males: Cross-Sectional Analysis of NHANES Data 2003-2018

PURPOSE

To evaluate cardiovascular disease (CVD) risk factors among smokeless tobacco (ST) users. Exclusive ST users were compared to exclusive cigarette smokers and non-tobacco users.

DESIGN

Cross-sectional study.

SAMPLE

Data were used from 16,336 adult males who participated in one of the National Health and Nutrition Examination Surveys (NHANES) from 2003 to 2018.

MEASURES

Biochemically verified tobacco use, CVD risk factors (hypertension, cholesterol levels, BMI categories), physical activity, cotinine concentration, and sociodemographic variables.

ANALYSIS

Weighted analysis of the aggregate data was performed. ST users were compared with cigarette smokers and nontobacco users for their association with CVD risk factors. Associations were examined using univariate and multiple logistic regression with odds ratios (OR) and 95% confidence intervals (CI) reported.

RESULTS

Prevalence of exclusive ST use was 4.4% whereas, exclusive smoking was 22.2%. Among ST users, 36.2% were hypertensive, 24.5% had high cholesterol levels, and most of them were overweight (31.1%) or obese (52.6%). ST users were more likely to have hypertension compared to smokers (aOR = 1.48, 95%CI: 1.12, 1.95) and nontobacco users (aOR = 1.41, 95%CI: 1.09, 1.83) adjusted for other covariates. ST users were twice more likely to be obese than nontobacco users (aOR = 2.18, 95%CI: 1.52, 3.11). ST users had significantly higher cotinine concentration than smokers.

CONCLUSION

Study findings indicate substantial association of ST use among males with hypertension and obesity which are independent risk factors of CVD.

Missed opportunities for tobacco use screening and brief cessation advice in South African primary health care: a cross-sectional study

BACKGROUND

Primary health care (PHC) settings offer opportunities for tobacco use screening and brief cessation advice, but data on such activities in South Africa are limited. The aim of this study was to determine the extent to which participants were screened for and advised against tobacco use during consultations.

METHODS

This cross-sectional study involved 500 participants, 18 years and older, attended by doctors or PHC nurses. Using an exit-interview questionnaire, information was obtained on participants' tobacco use status, reason(s) for seeking medical care, whether participants had been screened for and advised about their tobacco use and patients' level of comfort about being asked about and advised to quit tobacco use. Main outcome measures included patients' self-reports on having been screened and advised about tobacco use during their current clinic visit and/or any other visit within the last year. Data analysis included the use of chi-square statistics, t-tests and multiple logistic regression analysis.

RESULTS

Of the 500 participants, 14.9% were current smokers and 12.1% were smokeless tobacco users. Only 12.9% of the participants were screened for tobacco use during their current visit, indicating the vast majority were not screened. Among the 134 tobacco users, 11.9% reported being advised against tobacco use during the current visit and 35.1% during any other visit within the last year. Of the participants not screened, 88% indicated they would be 'very comfortable' with being screened. A pregnancy-related clinic visit was the single most significant predictor for being screened during the current clinic visit (OR = 4.59; 95%CI = 2.13-9.88).

CONCLUSION

Opportunities for tobacco use screening and brief cessation advice were largely missed by clinicians. Incorporating tobacco use status into the clinical vital signs as is done for pregnant patients during antenatal care visits in South Africa has the potential to improve tobacco use screening rates and subsequent cessation.

Association of exclusive smokeless tobacco consumption with hypertension in an adult male rural population of India

Introduction

Tobacco consumption is a major source of mortality and morbidity in India . Prevalence of smokeless tobacco (ST) consumption in India is around 20%. Studies have shown increased prevalence of cardiovascular disease risk factors and an increased incidence of adverse cardiovascular events among the ST consumers. This is a cross-sectional study done to look into the association of exclusive smokeless tobacco consumption with hypertension, in an adult male rural population of north India.

Methods

All male residents of a village in north India above 15 years of age, who did not have any acute or chronic morbidity were included after taking an informed consent. Subjects were interviewed regarding their demographic profile, socioeconomic status and tobacco consuming habits. Current smokeless tobacco user was defined as one who has ever consumed tobacco orally in past 1 month. Blood pressure of the subjects was also recorded. Cut offs used for systolic and diastolic hypertension were 140 mm hg and 90 mm Hg respectively.

Results

443 subjects were included in the study. Prevalence of exclusive ST users was 21% while 19.4% consumed both forms and 26.6% did not take any form of tobacco. Mean systolic and diastolic BP were significantly higher in exclusive ST users(systolic BP=139.2+17.4,diastolic BP = 86.8+11.5)as compared to the non users(systolic BP= 135.7+18.8 , diastolic BP= 82.6 +11.5; p value < 0.05). The prevalence of diastolic hypertension was significantly higher in exclusive ST users as compared to non users ( 40.9%, 22.9% ;p value = 0.01) . The OR for diastolic hypertension in male ST users was 2.3( 95% C.I. = 1.3-4.3). Prevalence of systolic hypertension was higher in exclusive ST users too though this was not statistically significant (43%,36.4%;p value = 0.39.).

Conclusion

ST consumption is associated with increased prevalence of high BP in the adult male rural population.This is an indicator of increased predisposition to major adverse cardiac events later in their life time. Prevention of ST consumption could be an important intervention in preventing the ongoing upswing in prevalence of chronic heart disease.

Nicotine delivery capabilities of smokeless tobacco products and implications for control of tobacco dependence in South Africa

OBJECTIVES

Smokeless tobacco (SLT) use is popular among black South African women and children. The study sought to determine the nicotine delivery capability of popular industrialised and traditional SLT brands in South Africa, and to provide information for policy action by regulatory authorities.

DESIGN

Laboratory chemical analysis of four industrialised and one traditional SLT products commercially available, using previously published analytical methods. Potential for dependence was inferred from nicotine delivery capabilities determined by the percentage free base nicotine.

MEASUREMENTS

Moisture, pH, total nicotine, and percentage free base nicotine.

RESULTS

Total nicotine content was between 6-16 mg/g. The pH varied between 7-10 and this correlated with percentage free base nicotine, which ranged between 10-99%. The nicotine delivery capability of the traditional product was lower than that of the industrialised products except for the recently introduced portion bag snus, which had comparable total nicotine but the lowest pH and percentage free base nicotine. The most popular SLT brands showed the highest percentage free base nicotine ever reported for any industrialised SLT or cigarette brands. Small cans contained higher nicotine than the large cans of the same brand tested. Findings from the study support a potential for limited "product graduation" by users.

CONCLUSIONS

South African SLT users are mostly exposed to potentially very highly addictive levels of nicotine that may favour tobacco dependence and its consequent health risks. The increasing use of SLT by women of childbearing age support the need for intensified policy action to control its use.

Smokeless tobacco and cardiovascular disease

Various forms of smokeless tobacco (mainly snuff and chewing tobacco) cause an immediate increase in heart rate and blood pressure, but regular users of smokeless tobacco do not have permanent changes of heart rate or blood pressure when not exposed to tobacco. Cardiac output during workload and maximal working capacity are unaffected. Users of smokeless tobacco usually do not have the biochemical stigmata that regular smokers have. Thus, the scientific literature suggests that they are similar to non-tobacco users in terms of levels of hemoglobin/hematocrit, leukocytes, antioxidant vitamins, fibrinogen, components of the fibrinolytic system, C-reactive protein, and thromboxane A2 production. Two studies have found that snuff users, as opposed to smokers, do not have increased intima-media thickness or atherosclerotic lesions when investigated by ultrasound. Results on the risk for myocardial infarction have provided conflicting evidence, 2 case-control studies showing the same risks as in non-tobacco users and one cohort study showing an increased risk for cardiovascular death. In all, the use of smokeless tobacco (with snuff being the most studied variant) involves a much lower risk for adverse cardiovascular effects than smoking does. Whether or not the apparent risk reduction is a useful strategy to help inveterate smokers to quit is a matter of debate, as are the public health effects of a high prevalence of snuff use in some populations.

Systemic absorption and effects of nicotine from smokeless tobacco

Nicotine is absorbed in substantial quantities from smokeless tobacco and could contribute to the adverse consequences of smokeless tobacco use. Chronic systemic exposure to nicotine could contribute to accelerated coronary artery disease, acute cardiac ischemic events, and hypertension. Systemic absorption of sodium and mutagenic chemicals from smokeless tobacco could aggravate hypertension or cardiac failure, or contribute to cancer, respectively. Information concerning the potential hazards of nicotine and other systemically absorbed toxins may be incorporated into educational programs to discourage the use of smokeless tobacco.

Does corticosteroid metabolism in target organs affect the cardiovascular system?

The target organ metabolism of corticosteroids has been measured with biochemical and immunohistochemical techniques. Attention was focused on the key enzyme system 11 beta-hydroxysteroid oxidoreductase (11 beta-HSOR, EC 1.1.1.146). Several organs of rats, including kidney, colon, testis, pancreas, liver, lung and heart, express oxidative, as well as reductive activity, albeit with different ratios. The specific co-substrate preference in different organs points to the presence of isoforms of the enzyme, which can be inhibited by steroid compounds. In kidney tubules longitudinal heterogeneity of the enzyme distribution pattern has been reported. Inhibition of 11 beta-HSOR in transporting epithelia such as those of kidney and colon by liquorice, glycyrrhetinic acid and others leads to aldosterone-like effects of glucocorticosteroids. The mechanism of this effect is breakdown of the specific 11 beta-HSOR barrier for glucocorticosteroids which subsequently bind to mineralocorticosteroid receptors. Other possible mechanisms of interaction of the corticosteroid metabolism and the cardiovascular system are discussed.

Active and passive tobacco exposure: a serious pediatric health problem. A statement from the Committee on Atherosclerosis and Hypertension in Children, Council on Cardiovascular Disease in the Young, American Heart Association

This review defines the substantial pediatric morbidity from tobacco use, including health effects on the cardiovascular system, the respiratory system, the fetus and newborn, and risk-taking behaviors of adolescents. More recent research suggests effects may extend to other areas, including reports that cigarette smoking decreases breast milk production in mothers, byproducts of tobacco use are transmitted in breast milk, exposure to passive smoking may alter children's intelligence and behavior, and passive smoke exposure in childhood may be a risk factor for developing lung cancer as an adult. Primary prevention is the most effective strategy to decrease the prevalence of smoking. Those who never smoke never become addicted to nicotine and never have to quit. Secondary prevention must also be emphasized, because children whose parents smoke are exposed to health risks and are themselves more likely to smoke in the future. Parental health can be improved by smoking cessation. To accomplish the goals of primary and secondary prevention, the aggressive public health strategy directed at both parents and children should be expanded. This strategy requires the strong support of physicians, with emphasis on prevention in practice, support of public health initiatives, medical and public policy, and the conduct of high-quality research.

Tobacco and myocardial infarction: is snuff less dangerous than cigarettes?

OBJECTIVE

To estimate the risk of myocardial infarction in snuff users, cigarette smokers, and non-tobacco users in northern Sweden, where using snuff is traditional.

DESIGN

Case-control study.

SETTING

Northern Sweden.

SUBJECTS

All 35-64 year old men who had had a first myocardial infarction and a population based sample of 35-64 year old men who had not had an infarction in the same geographical area.

MAIN OUTCOME MEASURE

Tobacco consumption (regular snuff dipping, regular cigarette smoking, non-tobacco use) and risk of acute myocardial infarction.

RESULTS

59 of 585 (10%) patients who had a first myocardial infarction and 87 of 589 (15%) randomly selected men without myocardial infarction were non-smokers who used snuff daily. The age adjusted odds ratio for myocardial infarction was 0.89 (95% confidence interval 0.62 to 1.29) for exposure to snuff and 1.87 (1.40 to 2.48) for cigarette smoking compared with non-tobacco users, showing an increased risk in smokers but not in snuff dippers. Regular cigarette smokers had a significantly higher risk of myocardial infarction than regular snuff dippers (age adjusted odds ratio 2.09; 1.39 to 3.15). Smoking, but not snuff dipping, predicted myocardial infarction in a multiple logistic regression model that included age and level of education.

CONCLUSIONS

In middle aged men snuff dipping is associated with a lower risk of myocardial infarction than cigarette smoking.

Snuffing tobacco out of sport

Use of oral snuff has risen sharply among baseball players following a tobacco industry marketing campaign that linked smokeless tobacco with athletic performance and virility. Millions of adolescents have copied these professional role models and, today, are at risk of developing oral cancer and other mouth disorders. New policies and programs are needed to break the powerful grip that the tobacco industry has on professional sport. Health agencies, including the National Cancer Institute and the National Institute for Dental Research, have teamed up with major league baseball to help players quit and reduce public use of oral tobacco. If these efforts are successful, our national pastime will once again become America's classroom for teaching health and fitness, not nicotine addiction.

Cardiovascular risk factors in young snuff-users and cigarette smokers

We studied cardiovascular risk factors in 21 young men who were habitual snuff-users, and compared them with the same risk factors in 18 non-tobacco-users and 19 cigarette smokers of the same age and body mass index. Both snuff-users and smokers showed increased levels of alcohol and coffee consumption and a decreased level of physical exercise compared to non-users. Both groups of tobacco-users showed increased serum insulin levels compared to the control group at similar blood glucose concentrations. In contrast to the smokers, snuff-users showed no significant elevation of diastolic blood pressure, haemoglobin concentrations, white cell count, serum cholesterol or triglyceride levels. Snuff users had higher plasma fibrinogen levels than non-users (P = 0.07). The use of snuff by young men appears to have less impact than smoking on cardiovascular risk factors, with the possible exception of elevated serum insulin and plasma fibrinogen levels.

Oral leukoplakia and adolescent smokeless tobacco use

The recent increase in smokeless tobacco (ST) use has prompted investigators to assess the health effects of ST use. This study attempted to evaluate the prevalence of oral leukoplakia among adolescent users and to determine factors associated with its presence. During their annual physical examination, 1116 teenaged football players (567 black, 546 white) answered a 34-question survey and received an oral screening examination. Results indicated that 0.5% of nonusers, 1.5% of previous users, and 13% of current users had clinically evident oral leukoplakia. Factors statistically associated with higher leukoplakia rates included history of ST use, regular ST use, years of ST use, and the weekly quantity consumed. Factors not associated included use of alcohol, use of cigarettes, type of ST used, and hours of ST use. One brand of snuff was found to be associated with a relative risk of leukoplakia higher than that of another brand of snuff. Overall, in ST users oral leukoplakia was six times more likely to develop than in nonusers. Earlier ages of ST use may lead to greater periods of use (in years) and to possible increases in deleterious long-term health effects in current adolescents.

An interpretative review of smokeless tobacco research in the United States: Part II

This is the second part of a two-part series reviewing the published literature of smokeless tobacco in the United States. The article explores smokeless tobacco as a pharmacologically addicting substance, educational interventions designed to prevent use or help users quit, and outlines areas of future research.

An interpretative review of smokeless tobacco research in the United States: Part I

The first part of a two-part series reviewing the published literature of smokeless tobacco in the United States and concomitant health effects associated with its use. This article delineates the current status of its prevalence, behavioral psychosocial factors associated with use, and review of the negative health effects associated with regular use.

Screening for smokeless tobacco-associated lesions: recommendations for the dental practitioner

The increasing use of smokeless tobacco and the accumulating list of associated health hazards including cancer and cardiovascular effects should be of concern to the dentist. This study documents both concern from patients' perceptions and clinical examinations of their smokeless tobacco-associated lesions. Implications for the dentists' practice among adolescents and young adults are discussed.

Learner characteristics associated with responses to film and interactive video lessons on smokeless tobacco

To determine college students' cognitive and affective responses to alternative technologies for presenting a lesson on smokeless tobacco, and to learn if responses to experimental conditions were associated with gender, ethnicity, tobacco-use practices, and the practices of significant others, 162 undergraduate students were randomly assigned to either a control group (questionnaire only) or one of two experimental groups. Experimental subjects viewed a videotape or an interactive video version of the lesson and then completed a questionnaire to ascertain knowledge and attitude. Each main effect was significant for knowledge about smokeless tobacco [experimental condition (P less than 0.001); gender (P less than 0.024); and ethnicity (P less than 0.003)]. The interactive video group demonstrated the most accurate and comprehensive recall. Neither gender nor ethnicity interacted significantly with experimental condition, indicating that the effect of experimental condition is constant across gender and ethnicity. Attitudes to instructional formats did not vary significantly as a function of experimental condition or gender, but were associated with ethnicity (P less than 0.034). Again, neither gender nor ethnicity interacted significantly with experimental condition, suggesting that attitudes reflect a generalized view toward content irrespective of presentation mode. Responses to both experimental conditions were quite favorable. Items about present and past experiences with tobacco, with the exception of the "Do you smoke?" item, were not associated with total cognitive score or attitude.

Prevalence and patterns of smokeless tobacco use in a southeastern university

The purpose of this study was to determine prevalence and patterns of use for tobacco products, especially, the use of smokeless tobacco among students at a university in the Southeastern United States. Six-hundred and thirty-two students, representing both sexes, participated in the survey, which elicited information regarding current and former use of tobacco products. Smokeless tobacco use was considerably more prevalent among male students than among female students; the reverse was true for cigarette smoking. Overall, the prevalence of tobacco use in this study indicates a need to begin health education programs regarding the adverse health effects of smokeless tobacco use with males and to revise smoking education programs to place more emphasis on female usage.