Smokeless tobacco and cardiovascular disease in low and middle income countries

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study

INTRODUCTION

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans.

METHODS

A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05.

RESULTS

Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates.

CONCLUSIONS

NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans.

IMPLICATIONS

A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

A cross-sectional study of attitudes and behaviors of snuff use and cessation among people with and without HIV in South Africa

Background

Despite a high (48%) prevalence of snuff use among women with HIV in South Africa, little is known of the attitudes and behaviors of use, strategies for cessation, and potential health risks.

Methods

In a cross-sectional study, a questionnaire was administered to adults (≥18 years) with (HIV+) and without HIV (HIV-) who self-reported current snuff use to collect information on demographics, snuff use and cessation attempts, preferred strategies for cessation, other substance use, history of respiratory illness, and mental health.

Results

150 (74 HIV+, 76 HIV-) participants were enrolled; 115 (77%) were daily snuff users, 6 (4%) were current smokers, and 17 (11%) former smokers. Top reasons for current snuff use included improving health (n = 48, 32%), reducing stress (n = 26, 16%), and "being a habit" (n = 38, 25%). Participants believed snuff use to have mostly positive (n = 68, 46%) or no (n = 54, 36%) health impacts, and 57 (38%) participants believed snuff cures headaches. 103 (69%) participants reported a previous quit attempt, and 110 (73%) indicated high interest in quitting snuff. Although 105 (70%) participants indicated that advice from a healthcare provider would aid them in quitting snuff, only 30 (20%) reported ever receiving that advice. A majority of participants (n = 141, 94%) suffer from moderate to high levels of perceived stress, and overall few differences were seen by HIV status.

Conclusions

Education on negative impacts of snuff, advice to quit from healthcare providers, and nicotine replacement therapy should be considered in the development of a snuff cessation program.

Burden of tobacco in Nepal: a systematic analysis from the Global Burden of Disease Study 1990-2017

OBJECTIVE

This study systematically reviews the data extracted from the Global Burden of Disease Study and sets out to assess the age-specific and sex-specific mortality and disability attributable to different forms of tobacco from 1990 to 2017, for Nepal.

DESIGN

This cross-sectional study extracted data from the Institute for Health Metrics and Evaluation's Global Burden of Disease database, then was quantitatively analysed to show the trends and patterns of prevalence of tobacco use, deaths and disability-adjusted life-years (DALYs) attributable to tobacco use from different diseases from the year 1990 to 2017 in Nepal.

SETTING

Nepal.

RESULTS

In between 1990 and 2015, the age-standardised prevalence of daily tobacco smoking decreased by 33% in males, 48% in females and 28% in both. By 2017, the age-standardised mortality rate and DALYs attributable to tobacco use, including any form, decreased by 34% and 41%, respectively, with tobacco smoking having the most contribution. However, the absolute number of deaths and DALYs increased by 39% and 3%, respectively. An increasing rate of deaths and DALYs attributable to tobacco was noted with an increase in age. Non-communicable diseases were responsible for most deaths and disabilities attributable to tobacco use.

CONCLUSION

The prevalence of smoking along with the age-standardised mortality rate and DALYs shows a decreasing trend. However, attention should be made to implement a strong plan to control all forms of tobacco including secondhand exposure.

Epidemiological Features of Cardiovascular Disease in Asia

Cardiovascular disease (CVD) is the leading cause of death in Asia. To combat the harmful impacts of CVD on public health in Asian countries with more effective strategies and actions, it is crucial to understand the current epidemiologic features of CVD in Asia. Through a systematic study and analysis of various timely data on CVD epidemiology in Asian countries from multiple sources, this state-of-the-art review provides an overview of the important epidemiologic features of CVD in Asia. Current and future challenges in CVD prevention implied by the epidemiologic features in Asian countries are highlighted and discussed in this review.

•

Comprehensive data for the current features of CVD epidemics in Asia are lacking.

•

This review provides an overview of the epidemiologic features of CVD in Asia.

•

Current and future challenges and requirements for CVD prevention in Asian countries are addressed.

Cardiovascular Risk Factors and Social Development Index

Cardiovascular diseases (CVD) are the leading causes of morbidity and mortality worldwide. The complex etiology of CVD is known to be significantly affected by environmental and social factors. There is, however, a lag in our understanding of how population level components may be related to the onset and severity of CVD, and how some indicators of unsatisfied basic needs might be related to known risk factors. Here, we present a cross-sectional study aimed to analyze the association between cardiovascular risk factors (CVRF) and Social Development Index (SDI) in adult individuals within a metropolitan urban environment. The six components of SDI as well as socioeconomic, anthropometric, clinical, biochemical, and risk behavior parameters were explored within the study population. As a result, several CVRF (waist circumference, waist-to-height ratio, body mass index, systolic blood pressure, glucose, lower high-density lipoprotein cholesterol, triglycerides, and sodium) were found in a higher proportion in the low or very low levels of the SDI, and this pattern occurs more in women than in men. Canonical analysis indicates a correlation between other socioeconomic features and anthropometric, clinical, and biochemical factors (canonical coefficient = 0.8030). Further studies along these lines are needed to fully establish how to insert such associations into the design of health policy and interventions with a view to lessen the burden of cardiovascular diseases, particularly in metropolitan urban environments.

Tobacco Smoking and Smokeless Tobacco Use among Domestic and International Medical Students in Hungary

Medical students as future physicians will have an important role in tobacco control; therefore, their tobacco use behavior is of particular interest. Consumption of combustible tobacco (cigarettes, waterpipes, cigars, and pipes) is prevalent throughout Europe, whereas smokeless tobacco use is common mainly in the Nordic countries. Objectives: Aim of our study is to assess tobacco use among medical students from different countries studying in Hungary with special focus on students from Norway where smokeless tobacco is widely used. A self-administered questionnaire survey was carried out to measure current tobacco use. Results: The survey included 1337 students from Hungary, Norway, Germany, and from other countries (Multinational group). The lowest prevalence of cigarette smoking was found among students from Norway (13.0%) when compared with students from Hungary (21.5%), Germany (34.2%), or with students in the Multinational group (29.5%). Conversely, prevalence of smokeless tobacco use was the highest among students from Norway (40.9%) when compared with students from Hungary (1.4%), Germany (2.6%), or with students in the Multinational group (6.2%). Waterpipes, cigars, and pipes were rarely used, mostly only 1-3 times a month in all groups. More than half of Norwegian students used some form of tobacco (smokeless and/or combustible tobacco). Conclusions: Considering the impending role of medical students in tobacco control, faculties of medicine should sensitize their students on the topic of possible health risks associated with combustible and smokeless tobacco products. Culturally tailored tobacco cessation programs need to be offered to medical students coming from different cultural backgrounds.

Dyslipidemia and Cardiovascular Disease Prevention in South Asians: A Review and Discussion of Causes, Challenges and Management Strategies

BACKGROUND

South Asians are at a significantly increased risk of atherosclerotic cardiovascular disease (ASCVD). For a major portion of the South Asian population, the cardiovascular disease events occur at a relatively younger age, are associated with worse outcomes, and have potentially more severe socioeconomic implications compared to their western counterparts.

METHODS

The term "South Asian" typically constitutes individuals from India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives, including expatriates as well as their families from these countries. Based on this, South Asians form approximately 25% of the world's population, with a high ASCVD burden in this group. In this review, we discuss the pathophysiological factors underlying ASCVD in South Asians, the dyslipidemia types and management, and discuss approaches to improve the overall ASCVD prevention efforts in this large subset population of the world. Although the pathophysiological mechanisms underlying the excess risk of cardiovascular disease in South Asians are multifactorial, dyslipidemia is a primary risk factor for the incidence and prevalence of this disease. The traditional "South Asian" dyslipidemia pattern includes levels of low-density lipoprotein cholesterol (LDL-C) in the normal range with a high concentration of LDL particles, elevated triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) with dysfunctional HDL particles, and high levels of lipoprotein(a).

CONCLUSION

While combined efforts to study the expatriate South Asians in western countries have been able to identify South Asian specific dyslipidemias, causal associations and optimal management remain relatively less explored. Larger scale studies are needed to better quantify the relationship of each lipid parameter with ASCVD risk among South Asians as well as optimal lipid targets and management strategies to reduce morbidity and mortality in this high-risk group.

Pathophysiological Mechanisms Underlying Excess Risk for Diabetes and Cardiovascular Disease in South Asians: The Perfect Storm

BACKGROUND

South Asians are at a significantly increased risk of type 2 diabetes (T2D) and cardiovascular disease (CVD), are diagnosed at relatively younger ages, and exhibit more severe disease phenotypes as compared with other ethnic groups. The pathophysiological mechanisms underlying T2D and CVD risk in South Asians are multifactorial and intricately related.

METHODS

A narrative review of the pathophysiology of excess risk of T2D and CVD in South Asians.

RESULTS

T2D and CVD have shared risk factors that encompass biological factors (early life influences, impaired glucose metabolism, and adverse body composition) as well as behavioral and environmental risk factors (diet, sedentary behavior, tobacco use, and social determinants of health). Genetics and epigenetics also play a role in explaining the increased risk of T2D and CVD among South Asians. Additionally, South Asians harbor several lipid abnormalities including high concentration of small-dense low-density lipoprotein (LDL) particles, elevated triglycerides, low high-density lipoprotein (HDL)- cholesterol levels, dysfunctional HDL particles, and elevated lipoprotein(a) that predispose them to CVD.

CONCLUSION

In this comprehensive review, we have discussed risk factors that provide insights into the pathophysiology of excess risk of T2D and CVD in South Asians.

The impact of information about tobacco-related reproductive vs. general health risks on South Indian women's tobacco use decisions

Smokeless tobacco use among Indian women is increasing despite prevention efforts. Evolutionary theories suggest that reproductive-aged women should be more concerned about immediate threats to reproduction than threats to survival occurring late in life. This study therefore compared an anti-tobacco intervention that emphasized near-term reproductive harms to one involving general harms occurring later in life. Scheduled Tribal women (N = 92) from Karnataka, India participated in this study. At baseline, women reported tobacco use and knowledge of harms, provided a saliva sample to assess use, and randomly viewed either a general harms presentation (GHP) or reproductive harms presentation (RHP). At followup, women reported their use, knowledge of harms and intentions to quit, and provided another saliva sample. At baseline, participants were aware of general harms but not reproductive harms. Both interventions increased knowledge of harms. Women in the RHP condition did not list more harms than women in the GHP condition, however, and the RHP was not more effective in reducing tobacco use than the GHP. In the RHP condition fetal health was particularly salient. In the GHP condition, oral health was highly salient, aligning with the local disease ecology and research on tobacco use and attractiveness.

Metabolomic signatures of cardiac remodelling and heart failure risk in the community

Aims

Heart failure (HF) is associated with several metabolic changes, but it is unknown whether distinct components of the circulating metabolome may be related to cardiac structure and function, and with incident HF in the community.

Methods and results

We assayed 217 circulating metabolites in 2336 Framingham Study participants (mean age 55 ± 10 years, 53% women) without HF at baseline. We used linear and Cox regression to relate concentrations of metabolites to left ventricular (LV) diastolic dimension, LV wall thickness, LV ejection fraction, left atrial dimension, LV ventricular mass, and aortic root size cross‐sectionally and to incident HF prospectively. Bonferroni‐adjusted P‐values <0.05 denoted statistical significance. Circulating concentrations of kynurenine [β = −0.12 cm per standard deviation (SD) increment in normalized residual of metabolite, P = 7.3 × 10⁻⁸] and aminoadipate (−0.11 cm per SD increment, P = 2.61 × 10⁻⁵) were associated with left ventricular diastolic dimension, phosphatidylcholine (carbon:double bound = 38:6) with left atrial dimension (0.10 cm per SD increment, P = 9.7 × 10⁻⁶), and cholesterol ester (carbon:double bound = 20:5) with left atrial dimension (0.10 cm per SD increment, P = 1.4 × 10⁻⁵) in multivariable‐adjusted models. During an average follow‐up of 15.8 (range 0.02–23.2) years, 113 participants (5%) were diagnosed with HF with reduced ejection fraction and 106 individuals (5%) with HF with preserved ejection fraction. In multivariable analyses, concentrations of phosphatidylcholine (hazard ratio 0.63, P = 1.3 × 10⁻⁵) and ornithine (hazard ratio 1.44, P = 0.00014) were associated with HF with reduced ejection fraction.

Conclusions

Several metabolites, including the vasoactive metabolite kynurenine, were related to cardiac structure and function in our sample. Additional research is warranted to confirm our observations and investigate if these metabolites can risk stratify ambulatory individuals.

Does menopausal status have an effect on body mass index and blood pressure?

Aim of the study was to understand the relationship of menopausal status with BMI and blood pressure. The study area was selected through multistage sampling technique covering six districts of West Bengal, a state located at the eastern part of India. 1400 participants were selected for the study. The participants were divided into four groups on the basis of menopausal status: early and late perimenopausal; early and late postmenopausal. Results shows that menopausal status was significantly associated with Body Mass Index (BMI) and Mean Arterial Pressure (MAP), after controlling the effect of covariates such as participants' age, reproductive behavior, diet and addiction to tobacco use.

Conveying hypertension message: An investigation into the language and content used in primary health clinics in South Africa

BACKGROUND

Hypertension is a global health burden affecting developed and developing countries, and South Africa is no exception.

AIM

This article aims to highlight the language and content used in health education on hypertension in primary healthcare (PHC) by health promoters and in pamphlets.

METHODS

The study design was quantitative descriptive. The population comprised a purposive selected sample of 12 health promoters in 12 PHC clinics and 50 pamphlets relating to health education on hypertension. An audio recorder was used to record health education provided by health promoters. Quantitative content analysis and frequency distribution was used to analyse the data.

RESULTS

The health promoters used various South African languages mixed with English (code switching). Patients were taught about lifestyle modifications and encouraged to adhere to management therapy. The switching in language usage may affect the understanding of those who do not speak the local language and that may explain the reason for lack of hypertension-suited life modification required by health education.

CONCLUSION

It is important that heath education on hypertension should be standardised so that the content of health education in clinic A is similar to that in clinic B. Information contained in pamphlets should be summarised and standardised to the content presented by health promoters.

Correlation of urinary cotinine with cardiovascular risk factors in pan masala tobacco users

BACKGROUND

Tobacco consumption is considered as one of the major risk factors for cardiovascular (CV) morbidity. However, the effect of paan masala tobacco (PMT) (a type of smokeless tobacco) consumption has not been well studied in our context. Our study is aimed to find an association of CV risk factors between PMT users and nonusers and to correlate those parameters with urinary cotinine level, a degradation product of nicotine occurring in tobacco.

METHODS

This comparative cross-sectional study was carried out among 200 participants. The effect of PMT use on CV risk factors such as blood pressure (BP), lipid profile, and body mass index was measured against urine cotinine level. Statistical tests used were χ2 test for categorical variable, independent t-test, Mann-Whitney U test, and Spearman's correlation applied for numerical variable, and multivariate regression analysis was performed as required. The level of significance was set at p < 0.05.

RESULT

Mean BP, total cholesterol, triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and median cotinine level were found to be significantly higher in PMT users than in controls (p < 0.001). Urinary cotinine level was positively correlated with mean BP, TC, TG, and LDL-C in PMT users (p < 0.001). Similarly, the odds of having hypercholesterolemia and increased diastolic BP was also significantly higher in PMT users (p < 0.001).

CONCLUSION

PMT use has an adverse effect on CV risk parameters and there is a rational of cotinine measurement for screening CV risk among PMT users.

Genotoxicity of yellow shammah (smokeless tobacco) in murine bone marrow cells in vivo

Shammah is a traditional form of smokeless tobacco (ST) that is manufactured and used locally by people of Middle East with highest usage in Saudi Arabia, Yemen and Sudan. In Saudi Arabia, shammah comes in three variants: white, brown and yellow. In the present study, we investigated the genotoxicity of yellow shammah (YS) on bone marrow (BM) cells in vivo using mice. Bone marrow (BM) chromosomal aberration (CA) and micronucleus (MN) assay were performed and hepatic markers of oxidative stress were determined. Swiss albino mice were divided into five groups (n = 6) including negative control (NC) and positive control (PC) groups. The three treated groups included YS-100, 200 and 300 mg/kg, doses freshly prepared in 0.5% carboxymethyl cellulose (CMC) and administered orally once a day for 2 weeks. PC animals were administered cyclophosphamide (CP) at a dose of 40 mg/kg body weight, 24 h before termination. Two weeks continuous treatment of YS induced a dose dependent and significant increase in aberrant metaphases (AM), CA per cell and depression in mitotic activity. In micronucleus assay, YS treatment increased the percentage of micronucleated polychromatic erythrocytes (MNPCE) frequency and showed statistically significant reduction in polychromatic erythrocyte/normochromatic erythrocyte ratio at all doses, as compared to NC. YS also markedly inhibited the activities of superoxide dismutase, reduced glutathione and increased malondialdehyde content. CP was used as clastogen (positive control) and yielded the expected positive results. Therefore, it may be concluded that YS has genotoxic and cytotoxic effects for BM cells of mice in vivo.

Smoking Cessation Advisory Intervention in Patients with Cardiovascular Disease

Introduction:

Several studies have examined the efficacy of smoking cessation therapies in the general population. However little is known about the efficacy of these advisory methods in cardiovascular patients.

Aim:

The aim of the study is to determine the prevalence and the characteristics of smoking abstinence in cardiovascular patients, after a smoking intervention during hospitalization.

Methods:

The study involved 442 patients, smokers admitted for cardiovascular disease to the Department of Cardiology. During hospitalization patient’s data were collected and all patients were subjected to a 30-minutes long advisory session with drug administration in selected cases (varenicycline, bupropione, nocitine replacement therapy), according to standard protocol. After the discharge patients were asked about smoking abstinence at time intervals of 24 hours, 1 month, 3, 6 and 12 months.

Results:

After hospital discharge 11 patients (2.49%) could not be contacted after several attempts and 19 patients (4.3%) were died during follow up period. A total of 412 patients (218 men and 194 women, mean age 56.49+10.57 years) made up the final study population. Twenty four hours after hospital discharge 364 patients (88.35%) had quitted smoking. At 1, 3, 6 and 12 months the abstinence rates were 70.87%, 64.8%, 55.82% and 47.83% respectively. Patients with ischaemic cardiovascular diseases (angina – infarction) had a significantly higher probability of quitting smoking at 12 months (Hazard ratio: 0.64 – p=0.01).

Conclusion:

A smoking cessation program in cardiovascular patients during hospitalization was unlikely to result in success. These patients might benefit by following programs promoting smoking cessation in experienced specialized centers, involving a group of health professionals, such as psychologists and/or trained nurses.

Assessment of concentration and toxicological (Cancer) risk of lead, cadmium and chromium in tobacco products commonly available in Bangladesh

This study aimed to assess the concentrations of heavy metal ('lead (Pb)''cadmium (Cd)', and 'chromium (Cr)') in various brands of four types of tobacco products (zarda, gul, cigarettes, and bidi) as well as calculate toxicological risk as a lifetime cancer risk for Pb, Cd, and Cr. In smokeless tobacco products, the metal concentration ranged from 0.99 to 10.02 μg/g for Pb, 1.05-3.53 μg/g for Cd, and 1.23-7.29 μg/g for Cr, respectively. Metal concentrations in the smoke-based tobacco products ranged from 0.98 to 3.07 μg/g for Pb, 0.91-3.46 μg/g for Cd, 1.08-6.75 μg/g for Cr, respectively. When assuming a 100% transfer of these metals, the calculated lifetime cancer risk was found 'unacceptable' in 33 out of 35 tobacco samples which exceeded the U.S. Environmental Protection Agency (USEPA) benchmark of an 'acceptable' cancer risk range of 10E-4 to 10E-6. Our study demonstrated higher levels of Pb, Cd, and Cr in various tobacco products of Bangladesh compared to GOTHIATEK standard. This study shows the need for the development of industry standards and regulation for tobacco products to reduce the levels of heavy metals.

Nass use and associated factors among outpatients in northern Afghanistan: A cross-sectional study in Andkhoy City

INTRODUCTION

Tobacco use is one of the main risk factors for a number of chronic diseases, including cancer, lung diseases, and cardiovascular diseases. Nass is a form of smokeless tobacco. It is used most commonly in Central Asia, Afghanistan, Pakistan, and Iran, and is significantly associated with oral and oesophageal cancers. The aim of this study was to determine the prevalence of nass use and its associated factors among patients attending an outpatient clinic in Afghanistan.

METHODS

This cross-sectional study was performed in an outpatient clinic in Andkhoy, Afghanistan, from April to July 2017. The study included 387 consecutive patients. The data collection tool was a questionnaire, which includes three main items: demographic, physical, and biomedical measurements. We performed binary logistic regression to identify independent risk factors of nass use.

RESULTS

The study included 387 participants, of whom 225 were males (58.1%) and 162 were females (41.9%). The overall prevalence of nass use was 48.8% (95% CI: 43.8–53.9%), with the Turkmen ethnic group having significantly higher prevalence than other ethnic groups (58.2%, 95% CI: 50.8–65.3% vs 41.8%, 95% CI: 34.7–49.2%). The mean and standard deviation of the age was 63.9 (17.2) years for nass users and 42.3 (17.4) years for non-users.

Based on a multivariate analysis, family history of nass use (OR=31.4, 95% CI: 12.5–78.5), illiteracy (OR=8.9, 95% CI: 2.5–31.2), rural residence (OR=2.0, 95% CI: 1.0–3.9), and unemployment (OR=5.4, 95% CI: 1.4–21.4) were associated with nass use.

CONCLUSIONS

Our results indicate that about half of the participants were nass users, and nass use associated factors were family history of nass use, illiteracy, unemployment, and rural residency in outpatient clinics in Afghanistan. More surveillance data are needed on a national level to inform the development of strategies for the prevention and control of nass consumption in Afghanistan.

Are e-cigarettes beneficial for public health: Hume's guillotine - The debate continues?

Cigarette smoking is the most common preventable cause of death which has led to a search for healthier alternatives to tobacco smoke. Electronic cigarettes are devoid of many harmful constituents found in cigarette smoke and are therefore being positioned as safer alternative to tobacco smoke. The carcinogenic potential may be of lower magnitude compared with cigarette smoke, but it is still there. The use of e-cigarettes, however, is fairly new, so its long-term effects are still unknown. Moreover, they continue to posses the cardiovascular side-effects and are certainly as addicting. Thus on one hand while their substitution could lead to reduction of some side-effects of tobacco smoke, its use may be just shifting the modality of addiction and will be unlikely to lead to total abstinence from tobacco products. On the other hand there is a fear that its use could lead to loosening of the taboo currently associated with use of tobacco products and so the benefits of years of advocacy to ban tobacco products might be lost. Thus currently the scientific community is divided about role of e-cigarettes.

Geographic and sociodemographic variation of cardiovascular disease risk in India: A cross-sectional study of 797,540 adults

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of mortality in India. Yet, evidence on the CVD risk of India's population is limited. To inform health system planning and effective targeting of interventions, this study aimed to determine how CVD risk-and the factors that determine risk-varies among states in India, by rural-urban location, and by individual-level sociodemographic characteristics.

METHODS AND FINDINGS

We used 2 large household surveys carried out between 2012 and 2014, which included a sample of 797,540 adults aged 30 to 74 years across India. The main outcome variable was the predicted 10-year risk of a CVD event as calculated with the Framingham risk score. The Harvard-NHANES, Globorisk, and WHO-ISH scores were used in secondary analyses. CVD risk and the prevalence of CVD risk factors were examined by state, rural-urban residence, age, sex, household wealth, and education. Mean CVD risk varied from 13.2% (95% CI: 12.7%-13.6%) in Jharkhand to 19.5% (95% CI: 19.1%-19.9%) in Kerala. CVD risk tended to be highest in North, Northeast, and South India. District-level wealth quintile (based on median household wealth in a district) and urbanization were both positively associated with CVD risk. Similarly, household wealth quintile and living in an urban area were positively associated with CVD risk among both sexes, but the associations were stronger among women than men. Smoking was more prevalent in poorer household wealth quintiles and in rural areas, whereas body mass index, high blood glucose, and systolic blood pressure were positively associated with household wealth and urban location. Men had a substantially higher (age-standardized) smoking prevalence (26.2% [95% CI: 25.7%-26.7%] versus 1.8% [95% CI: 1.7%-1.9%]) and mean systolic blood pressure (126.9 mm Hg [95% CI: 126.7-127.1] versus 124.3 mm Hg [95% CI: 124.1-124.5]) than women. Important limitations of this analysis are the high proportion of missing values (27.1%) in the main outcome variable, assessment of diabetes through a 1-time capillary blood glucose measurement, and the inability to exclude participants with a current or previous CVD event.

CONCLUSIONS

This study identified substantial variation in CVD risk among states and sociodemographic groups in India-findings that can facilitate effective targeting of CVD programs to those most at risk and most in need. While the CVD risk scores used have not been validated in South Asian populations, the patterns of variation in CVD risk among the Indian population were similar across all 4 risk scoring systems.

Metabolic Syndrome among Adults of Surendranagar District of Saurashtra, Gujarat: A Cross-Sectional Study

Background:

The metabolic syndrome (MetS) is a complex disorder and a major health concern in developing countries. Data on MetS in Indian population show multiplicity. There are no published reports about the prevalence of MetS in population of Saurashtra region, Gujarat. The aim of this study is to assess the prevalence of MetS and its components in adult population of this region.

Methods:

This cross-sectional observational study was carried out among 473 participants who attended free health checkup camps. Demographics, personal details along with anthropometric, clinical, and biochemical data were recorded. The MetS was diagnosed as per the definition provided by Joint Interim Statement 2009.

Results:

The overall prevalence of MetS among studied population was found to be 41.01% (females 44.21% and males 37.91%). Abdominal obesity (66.38%), low high-density lipoprotein-cholesterol (64.69%), and high blood pressure (40.59%) appeared as the most prevalent components. MetS showed a significant association with age, body mass index, total cholesterol, habit of chewing tobacco, and history of hypertension and hyperglycemia.

Conclusion:

The high prevalence of MetS shows that population of Saurashtra is at an increased risk of cardiovascular disease (CVD) and diabetes. This highlights the need for extensive diabetes and CVD prevention and control program in this region.

The Risk of Hypertension and Other Chronic Diseases: Comparing Smokeless Tobacco with Smoking

BACKGROUND

In the past, studies have compared smokeless tobacco and non-tobacco users for the risk of various chronic diseases. The differences in the risk of chronic diseases between smokeless tobacco user and smokers have not been explored. The objective of this study is to estimate the risk of chronic diseases among smokeless tobacco users compared to smokers.

METHODS

The data were used from the Study on Global Ageing and Adult Health (SAGE) Wave-1, conducted in 2007-2008 in India. The study sample is the respondents who reported consuming any form of tobacco in last 1 month. The total sample size was 4,038 respondents. The odds ratio of chronic morbidities was estimated taking smokers as the reference category.

RESULTS

The odds ratios for (self-reported) diabetes, asthma, and hypertension were not significant for smokeless tobacco user compared to smoked tobacco users. The odds ratio of chronic lung diseases (CLDs) was significantly lower among smokeless tobacco users compared to smoked tobacco users. The odds ratio of hypertension (measured) combined with low education and belonging to lowest wealth quintiles were not significant for smokeless tobacco users compared to smoked tobacco users. Duration of the use of smokeless tobacco and quantity of use was found to have no significant relation with risk of chronic diseases as compared to smoking.

CONCLUSION

This study did not find the significantly higher risk of chronic morbidities except for CLD for smokeless tobacco users compared to smoked tobacco users. The study suggests that the use of any form of tobacco may have a similar risk of chronic diseases.

An examination of the effectiveness of health warning labels on smokeless tobacco products in four states in India: findings from the TCP India cohort survey

BACKGROUND

In 2009, after many delays and changes, India introduced a single pictorial health warning label (HWL) on smokeless tobacco (SLT) packing-a symbolic image of a scorpion covering 40% of the front surface. In 2011, the scorpion was replaced with 4 graphic images. This paper tested the effectiveness of SLT HWLs in India and whether the 2011 change from symbolic to graphic images increased their effectiveness.

METHODS

Data were from a cohort of 4733 adult SLT users (age15+) of the Tobacco Control Project (TCP) India Survey from 4 states. The surveys included key indicators of health warning effectiveness, including warning salience, and cognitive, emotional, and behavioral responses to the warnings.

RESULTS

The HWL change from symbolic to graphic did not result in significant increases on any of the HWL outcome indicators. A substantial minority of SLT users were unaware that SLT packages contained HWLs (27% at both waves). Noticing the warnings was also remarkably low at both waves (W1 = 34.3%, W2 = 28.1%). These effects carried over to the cognitive and behavioural measures, where among those who noticed HWLs, about one-third reported forgoing SLT at least once because of the HWLs, and fewer than 20% reported that HWLs made them think about SLT risks or about quitting SLT. Even fewer reported avoiding HWLs (8.1 to 11.6%). Among those who quit using SLT by post-policy, awareness that SLT packaging contained HWLs was significantly greater at post-policy (86.8%) compared to pre-policy (77.8%, p = 0.02). Quitters were also significantly more aware of the post-policy HWLs compared to those who continued to use SLT (p < 0.001).

CONCLUSIONS

Health warnings on SLT packages in India are low in effectiveness, and the change from the symbolic warning (pre-policy) to graphic HWLs (post-policy) did not lead to significant increases of effectiveness on any of the HWL indicators among those who continued to use SLT products, thus suggesting that changing an image alone is not enough to have an impact. There is a critical need to implement SLT HWLs in India that are more salient (large in size and on the front and back of the package) and impactful, which following from studies of HWLs on cigarette packaging, would have strong potential to increase awareness of the harms of SLT and to motivate quitting.

Management standards for stable coronary artery disease in India

Coronary artery disease (CAD) is one of the important causes of cardiovascular morbidity and mortality globally, giving rise to more than 7 million deaths annually. An increasing burden of CAD in India is a major cause of concern with angina being the leading manifestation. Stable coronary artery disease (SCAD) is characterised by episodes of transient central chest pain (angina pectoris), often triggered by exercise, emotion or other forms of stress, generally triggered by a reversible mismatch between myocardial oxygen demand and supply resulting in myocardial ischemia or hypoxia. A stabilised, frequently asymptomatic phase following an acute coronary syndrome (ACS) is also classified as SCAD. This definition of SCAD also encompasses vasospastic and microvascular angina under the common umbrella.

Resveratrol and pterostilbene attenuated smokeless tobacco induced cardiovascular aberrations in estrogen deficient female rats

This study evaluated the impact of resveratrol (RSV) and pterostilbene (PT) on the aqueous extract of smokeless tobacco (AEST) induced cardiovascular aberrations in estrogen deficient female Sprague-Dawley rats. Exposure to 4-vinylcyclohexene diepoxide (VCD) (80 mg kg-1, i.p.) for 30 days induces estrogen deficiency. The rats were administered AEST alone or AEST along with resveratrol and/or pterostilbene. Several markers of cardiovascular health were estimated to evaluate the repercussion of the exposures. RSV and PT per se and in combination significantly reversed the derangements caused by AEST. RSV decreased the atherogenic index and systolic blood pressure and normalized ECG. RSV and PT treatment markedly decreased aortic collagen, cardiac-carbonylated proteins, serum creatine-kinase, cholesterol, LDH, LDL, VLDL, CRP and TNF-α levels. Conversely, they increased serum nitrate-nitrite and HDL levels. The drugs improved the gene expression of SIRT1, PGC-1α, PPAR-α, TFAM, NRF-1 and mtDNA in the cardiac tissue. However, the expression of SIRT1 was not modified by PT. These favorable effects were comparable to those of estradiol therapy. Histopathological outcomes also corroborated these benefits. Thus, resveratrol and pterostilbene abrogated the deleterious effects of AEST on cardiovascular parameters in estrogen deficient female rats.

Determinants of Smokeless Tobacco Consumption and its Cessation among its Current Users in India

INTRODUCTION

Global Smokeless Tobacco (SLT) consumption is on the rise and constitutes a major Public Health problem. Controlling SLT intake is central to containing the increasing tobacco menace.

AIM

The present study was undertaken to comprehensively explore various factors involved in SLT consumption and its cessation among current SLT users.

MATERIALS AND METHODS

Present study was conducted among current SLT users visiting Department of Oral Medicine and Radiology, Manipal College of Dental Sciences (MCODS), Manipal University, Mangalore, Karnataka, India. A structured, pretested and self-administered questionnaire was employed for the present study. Knowledge, attitude, behaviour, worksite practices of respondents towards SLT consumption and its cessation, barriers to SLT cessation were explored. Information about socio-demographic variables was also collected.

RESULTS

Overall, 170 current SLT users participated in the present study. Results revealed that the mean knowledge, attitude, worksite related practices and barrier scores were 9.96(55.33%), 48.89(81.48%), 2.70(33.75%) and 54.25(60.27%) respectively. Correlation analysis revealed significant association of socio-demographic factors with knowledge, attitude and worksite related practices (p<0.05). SLT cessation related practices revealed that majority wished to quit (90%) and significant associations were noted amongst wish to quit with higher attitude scores; actual quit attempts with higher attitude, lower barrier scores and difficulty to quit with higher barrier scores (p<0.05).

CONCLUSION

The present study draws attention towards involvement of complex interactions of various parameters including socio-demographic factors in SLT consumption and its cessation. Hence, it is imperative to implement multifactorial SLT control approach in order to contain tobacco menace spread across the globe.

25 by 25: Achieving Global Reduction in Cardiovascular Mortality

Four non-communicable diseases-cardiovascular disease, chronic respiratory disease, diabetes mellitus, and cancer-account for over 60 % of all deaths globally. In recognition of this significant epidemic, the United Nations set forth a target of reducing the four major NCDs by 25 % by 2025. Cardiovascular disease alone represents half of these deaths and is the leading cause of death globally, representing as much as 60 % of all deaths in regions such as Eastern Europe. In response, the WHO set specific targets on conditions and risk factors and changes in the health systems structure in order to achieve the goals. The focus was set on lifestyle risk factors-physical activity, salt-intake, and tobacco-and established conditions-obesity, hypertension, and diabetes mellitus. Health system efforts to improve medical treatment of high risk are encouraged. Efforts to achieve the goal are being promoted by leading international CVD organizations.

Understanding implementation and feasibility of tobacco cessation in routine primary care in Nepal: a mixed methods study

Background

By 2030, 80 % of the annual 8.3 million deaths attributable to tobacco will be in low-income countries (LICs). Yet, services to support people to quit tobacco are not part of routine primary care in LICs. This study explored the challenges to implementing a behavioural support (BS) intervention to promote tobacco cessation within primary care in Nepal.

Methods

The study used qualitative and quantitative methods within an action research approach in three primary health care centres (PHCCs) in two districts of Nepal. Before implementation, 21 patient interviews and two focus groups with health workers informed intervention design. Over a 6-month period, two researchers facilitated action research meetings with staff and observed implementation, recording the process and their reflections in diaries. Patients were followed up 3 months after BS to determine tobacco use (verified biochemically) and gain feedback on the intervention. A further five interviews with managers provided reflections on the process. The qualitative analysis used Normalisation Process Theory (NPT) to understand implementation.

Results

Only 2 % of out-patient appointments identified the patient as a smoker. Qualitative findings highlight patients’ unwillingness to admit their smoking status and limited motivation among health workers to offer the intervention. Patient-centred skills needed for BS were new to staff, who found them challenging particularly with low-literacy patients (skill set workability). Heath workers saw cessation advice and BS as an addition to their existing workload (relational integration). While there was strong policy buy-in, operationalising this through reporting and supervision was limited (contextual integration). Of the 44 patients receiving the intervention, 27 were successfully followed up after 3 months; 37 % of these had quit (verified biochemically).

Conclusions

Traditionally, primary health care in LICs has focused on acute care; with increasing recognition of the need for lifestyle change, health workers must develop new skills and relationships with patients. Appropriate and regular recording, reporting, supervision and clear leadership are needed if health workers are to take responsibility for smoking cessation. The consistent implementation of these health system activities is a requirement if cessation services are to be normalised within routine primary care.

Short-term acute effects of gutkha chewing on heart rate variability among young adults: A cross-sectional study

BACKGROUND AND OBJECTIVES

An increase in the consumption of smokeless tobacco has been noticed among high school, college students, and adults. Despite the antiquity and popularity of chewing tobacco in India, its effects have not been investigated systematically in humans. The aim of this study was to investigate acute effects of gutkha chewing on heart rate variability (HRV) among healthy young adults.

MATERIALS AND METHODS

A total of 60 young adult males were included in the study. Each individual was asked to chew tobacco and subjected to HRV analysis. HRV analysis using short-term electrocardiogram recording was used to measure HRV parameters before gutkha chewing and at 5, 15, and 30 min after chewing tobacco. One-way analysis of variance and paired t-test was used to assess changes over time.

RESULTS

There was a significant increase in heart rate (HR) during tobacco chewing. Mean HR at baseline measured 73.0 ± 6.2 bpm. There was a rise in mean HR to 83.7 ± 9.1 bpm at 5 min during tobacco chewing and gradual reduction to baseline observed after 15 min followed by no significant change till 30 min. The normalized low-frequency power and LF/high-frequency (HF) power ratio were elevated after 5 min; however, normalized HF power was reduced after 5 min tobacco chewing.

CONCLUSION

Gutkha is closely associated with traditional cardiovascular risk factors as detected by a transient enhancing sympathetic activity during tobacco chewing in the form of increased HRV parameters or an imbalance between sympathetic and parasympathetic neural activity among healthy young adults.

Patterns of Use and Perceptions of Harm of Smokeless Tobacco in Navi Mumbai, India and Dhaka, Bangladesh

Background:

Globally, smokeless tobacco use is disproportionately concentrated in low-income and middle-income countries like India and Bangladesh.

Objectives:

The current study examined comparative patterns of use and perceptions of harm for different smokeless tobacco products among adults and youth in Navi Mumbai, India, and Dhaka, Bangladesh.

Methods:

Face-to-face interviews were conducted on tablets with adult (19 years and older) smokeless tobacco users and youth (16–18 years) users and non-users in Navi Mumbai (n = 1002), and Dhaka (n = 1081).

Results:

A majority (88.9%) of smokeless tobacco users reported daily use. Approximately one-fifth (20.4%) of the sample were mixed-users (used both smoked and smokeless tobacco), of which about half (54.4%) reported that they primarily used smokeless over smoked forms like cigarettes or bidis. The proportion of users planning to quit was higher in India than in Bangladesh (75.7% vs. 49.8%, p < 0.001). Gutkha was the most commonly used smokeless product in India, and pan masala in Bangladesh. Among users in Bangladesh, the most commonly reported reason for using their usual product was the belief that it was “less harmful” than other types. Perceptions of harm also differed with respect to a respondent's usual product. Bangladeshi respondents reported more negative attitudes toward smokeless tobacco compared to Indian respondents.

Conclusions:

The findings highlight the high daily use of smokeless tobacco, and the high prevalence of false beliefs about its harms. This set of findings reinforces the need to implement effective tobacco control strategies in low and middle-income countries like India and Bangladesh.

Rapid emergence of atherosclerosis in Asia: a systematic review of coronary atherosclerotic heart disease epidemiology and implications for prevention and control strategies

PURPOSE OF REVIEW

There is a global epidemic of coronary heart disease (CHD) caused by atherosclerosis. We discussed its emergence, underlying reasons, and implications for prevention and control strategies in Asia.

RECENT FINDINGS

Most countries in Asia are experiencing the challenges from CHD, with the mortality rate varying from 103 to 366 per 100 000 adult populations, reported by recently published studies. Raised population cholesterol levels played a pivotal role. Men, older adults, and those with dyslipidemia, hypertension, and diabetes were high-risk individuals. During the past decade, there was a marked rising trend of atherosclerosis-related burden particularly in Eastern Asia where an alarming increase of 117.2 and 115.3% of total deaths and disability adjusted life-years, respectively, were observed. The rise of CHD could be attributed to unhealthy lifestyles, clinical-risk factors, psychosocial factors, and public health transitions. Ageing, urbanization, and increase in prosperity may serve as underlying key drivers.

SUMMARY

The burden of CHD is substantial, whereas contributors are multifactorial. This grand challenge should be a top priority for injecting healthcare resources. The formulation of public health measures will need to adopt an integrated and life-course approach, based on the need and risks of different population subgroups in Asia.

The Burden of Cardiovascular Disease in Low- and Middle-Income Countries: Epidemiology and Management

Cardiovascular disease (CVD) is the second leading cause of mortality worldwide, accounting for 17 million deaths in 2013. More than 80% of these cases were in low- and middle-income countries (LMICs). Although the risk factors for the development of CVD are similar throughout the world, the evolving change in lifestyle and health behaviours in LMICs-including tobacco use, decreased physical activity, and obesity-are contributing to the escalating presence of CVD and mortality. Although CVD mortality is falling in high-income settings because of more effective preventive and management programs, access to evidence-based interventions for combating CVD in resource-limited settings is variable. The existing pressures on both human and financial resources impact the efforts of controlling CVD. The implementation of emerging innovative interventions to improve medication adherence, introducing m-health programs, and decentralizing the management of chronic diseases are promising methods to reduce the burden of chronic disease management on such fragile health care systems.