Risk of Coronary Heart Disease Among Smokeless Tobacco Users: Results of Systematic Review and Meta-Analysis of Global Data

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.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

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.

Comprehensive Cardiovascular and Renal Protection in Patients with Type 2 Diabetes

Type 2 diabetes (T2DM) is one of the main public health care problems worldwide. It is associated with a marked increased risk of developing atherosclerotic vascular disease, heart failure, chronic kidney disease and death. It is essential to act during the early phases of the disease, through the intensification of lifestyle changes and the prescription of those drugs that have been shown to reduce these complications, with the aim not only of achieving an adequate metabolic control, but also a comprehensive vascular risk control. In this consensus document, developed by the different specialists that treat these patients (endocrinologists, primary care physicians, internists, nephrologists and cardiologists), a more appropriate approach in the management of patients with T2DM or its complications is provided. A particular focus is given to the global control of cardiovascular risk factors, the inclusion of weight within the therapeutic objectives, the education of patients, the deprescription of those drugs without cardiovascular benefit, and the inclusion of GLP-1 receptor agonists and SGLT2 inhibitors as cardiovascular protective drugs, at the same level as statins, acetylsalicylic acid, or renin angiotensin system inhibitors.

Effectiveness of brief counseling (5As): Antenatal tobacco cessation support program among pregnant women availing antenatal care

Introduction

It is likely that a pregnant woman is more motivated and receptive to accepting healthy habits and practices if talked about the benefits to the fetus. When explained about the harmful effects of tobacco on the health of the baby, the mother can be encouraged to modify her tobacco consumption habits and work toward quitting tobacco.

Aim

Our aim was to study the effectiveness of brief counseling (5As)-Antenatal Tobacco Cessation Support Program among pregnant women availing antenatal care (ANC).

Methodology

A quasi-randomized study design was used to conduct the study. The participants were identified by screening during ANC visits, and women consuming tobacco were subjected to detailed history taking and very brief counseling with the help of 5A's framework.

Results

We found that Mishri was the commonest form of tobacco consumed by these women. Around 93.33% of the women consume Mishri, followed by 6.66% of women consuming chewing tobacco. The method of brief counseling made an impact in the cessation of tobacco consumption in 13.37% of the study subjects.

Conclusion

We conclude that the use of brief counseling and motivational interviewing is feasible in most settings without inhibiting the other important aspects of ANC or disrupting the patient flow.

Evaluation of Receptor Activator of Nuclear Factor Kappa B Ligand, Osteoprotegerin, Osteopontin, and Tumor Necrosis Factor Alpha on Chronic Apical Periodontitis in Smokers

INTRODUCTION

Smoking can be considered a risk factor for chronic apical periodontitis (CAP). This study compared the immunoexpression of biomarkers receptor activator of nuclear factor kappa B ligand (RANKL), osteoprotegerin (OPG), osteopontin (OPN), and tumor necrosis factor alpha (TNF-α) in CAP in smokers and nonsmokers.

METHODS

Twelve smokers and 12 nonsmokers diagnosed with CAP and indicated for tooth extraction were selected. Exclusion factors were teeth with a diagnosis of root fracture, previous endodontic treatment, or endoperiodontal injury, in addition to individuals with systemic diseases, under 18 years of age, users of anti-inflammatory and/or antibiotics in the last 3 months, and drug users. Specimens were processed for histopathologic and immunohistochemical analysis.

RESULTS

Qualitative analysis of RANKL expression showed 66.66% weak/moderate and 33.33% strong in smokers and 100% weak/moderate in nonsmokers. OPG and OPN expressions were 100% negative to focal in the smoker group and 50% negative to focal and 50% weak/moderate in the nonsmoker group. TNF-α was 25% negative to focal and 75% weak/moderate in the smoker group and 33.33% negative to focal and 66.66% weak/moderate in the nonsmoker group. Quantitative analysis of the data using the Mann-Whitney U test showed that there was a significant difference in the immunoexpression of RANKL (P < .05), OPG (P < .05), and OPN (P < .05), but there was no statistical difference in the immunoexpression of TNF-α (P > .05) between the 2 groups.

CONCLUSIONS

These findings suggest that smoking is capable of altering the inflammatory response, influencing the evolution of CAP.

Smokeless tobacco industry's brand stretching through FM radio: A study from Delhi National Capital Region, India

Smokeless tobacco (SLT) consumption is associated with multiple adverse health effects and mortality, with the highest burden in India. The WHO FCTC has banned tobacco advertisement, promotion and sponsorship via Article 13. Indian laws also prohibit any kind of direct or indirect advertisements in all forms of audio, visual, and print media; brand promotion; and sponsorship of tobacco products. However, the tobacco industry continues to find aggressive marketing ways to advertise their products. This study aims to assess the extent of surrogate advertisement of smokeless tobacco products through frequency modulation (FM) radio stations in the city of Delhi (National Capital Territory of India). In this study, the advertisements broadcasted over FM radio across different channels (private and government owned) in total 162 h were analyzed. The time duration was spread evenly over morning peak hours, off hours, and evening peak hours. It was found that multiple brands including Vimal, Kamla Pasand, and Rajshree have used surrogate advertising to market their brands that are commonly associated with smokeless tobacco products. However, no such advertisement was found to be aired on government-owned FM channels. The total surrogate advertisements broadcasted were over 286 times, where no significant difference was found in distribution among peak and non-peak hours. The study indicated that the tobacco industry is making its way to sell the products through indirect advertisements. The need of the hour is to not only enforce tobacco advertising ban laws in all forms of advertising media but also to strictly regulate smokeless tobacco products.

2022 Prevention of chronic non-communicable diseases in Of the Russian Federation. National guidelines

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The health impact of smokeless tobacco products: a systematic review

INTRODUCTION

The objective was to systematically review studies on health outcomes from smokeless tobacco (SLT) products.

METHODS

We analysed published literature on the health outcomes from SLT use between 01/01/2015 to 01/02/2020, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol using PubMed, Embase, Scopus, and Google Scholar.

RESULTS

Of 53 studies included, six were global, 32 from Asia, Middle East and Africa (AMEA), nine from USA and six from Europe. 'Poor'-rated studies predominated (23;43%), in particular, for global (4;66%) and AMEA (16;50%). Health outcomes differed between SLT-products and regions; those in AMEA were associated with higher mortality (overall, cancer, Coronary heart disease (CHD), respiratory but not cardiovascular disease (CVD)), and morbidity (CVD, oral and head and neck cancers), with odds ratios up to 38.7. European studies showed no excess mortality (overall, CVD, from cancers) or morbidity (ischemic heart disease (IHD), stroke, oral, head and neck, pancreatic or colon cancers) from several meta-analyses; single studies reported elevated risk of rectal cancer and respiratory disorders. Pooled study data showed protection against developing Parkinson's disease. US studies showed mixed results for mortality (raised overall, CHD, cancer and smoking-related cancer mortality; no excess risk of respiratory or CVD mortality). Morbidity outcomes were also mixed, with some evidence of increased IHD, stroke and cancer risk (oral, head and neck). No studies reported on switching from cigarettes to SLT-products.

CONCLUSION

Our review demonstrates stark differences between different SLT-products in different regions, ranging from zero harm from European snus to greatly increased health risks in AMEA. The literature on the safety profile for SLT-products for harm reduction is incomplete and potentially misinforming policy and regulation.

Nicotine causes alternative polarization of macrophages via Src-mediated STAT3 activation: Potential pathobiological implications

Nicotine is an addictive ingredient of tobacco products and other noncigarette substitutes, including those being used for smoking cessation to relieve withdrawal symptoms. Earlier research, however, has associated nicotine with the risk and poorer outcome of several diseases, including cancer. Macrophages are an important component of the innate immune system and can have both pro-and anti-inflammatory functions depending upon their polarization state. Here, we investigated the effect of nicotine on macrophage polarization, growth, and invasion to understand its role in human physiology. We observed that nicotine induced M2 polarization of RAW264.7 and THP-1-derived macrophages in a dose-dependent manner. Cytokine profiling suggested a mixed M2a/d phenotype of nicotine-polarized macrophages associated with tissue repair and pro-angiogenic functions. Moreover, nicotine treatment also enhanced the growth, motility, and invasion of macrophages. Mechanistic studies revealed increased phosphorylation of STAT3 in nicotine-treated macrophages that was mediated through Src activation. Importantly, pretreatment of macrophages with either Src or STAT3 inhibitor abrogated nicotine-induced macrophage polarization, growth, and motility, suggesting a functional role of the Src-STAT3 signaling axis. Together, our findings reveal a novel role of nicotine in immunosuppression via causing M2 polarization of macrophages that could be implicated in the pathogenesis of various diseases.

Smokeless Tobacco and Its Ill-Effects: Recent Literature Update

According to the Global Adult Tobacco Survey part 2 (GATS-2), approximately 200 million adult Indians consume smokeless tobacco (SLT). Circumvention of SLT product ban has been observed. We conducted a review of the literature to summarize the ill effects of tobacco for the articles published from 2019 to 2020. A systematic search of the databases PubMed (2019 onward) and Web of Science (2019 onward), through February 2021 was done. Search yielded 1,061 articles and after excluding articles based on the inclusion criteria, 37 articles were taken in to consideration. The review shows that differential SLT product has specific odds of oral carcinogenesis. Review also indicates the emerging data of cardiovascular risk due to higher use of SLT products along with its known cause of oral cancer. It also cautions about the adverse consequences of pregnancy associated with SLT use.

Prevalence, duration of exposure and predicting factors for snus use among young Finnish men: a cross-sectional study

OBJECTIVE

The health hazards of tobacco products depend on the level of exposure, but little is known about the characteristics of snus use. The aim of this study was to investigate the duration of daily exposure to snus among occasional and daily users and its associated predictive factors among young Finnish men.

DESIGN

Cross-sectional questionnaire study.

SETTING

Three out of 16 Finnish Defence Forces units.

PARTICIPANTS

1280 young Finnish male conscripts starting their military service in 2016 chosen by simple random sampling.

PRIMARY AND SECONDARY MEASURES

The prevalence, duration of use and the amount of daily usage of snus and cigarettes were investigated. The attitudes towards perceived harmfulness of snus and the predictive factors affecting the total time of snus consumption were examined.

RESULTS

Almost a fifth (19.5%) of the conscripts reported daily snus use, and a further 16% reported occasional use. Daily snus use was associated with an earlier starting age, longer duration of use and higher daily exposure time compared with occasional use. On average, daily snus users consumed 10 portions and occasional users three portions per day (p<0.001). The daily total exposure time for daily users was 372 min (95% CI 344 to 401) and for occasional users 139 min (95% CI 106 to 171). Respondents with an upper secondary education had significantly less daily total exposure than those with basic comprehensive education (p=0.036). Perceptions of snus as a harmful substance resulted in a significantly lower duration of exposure.

CONCLUSION

Snus use was very common among young Finnish men. High snus exposure duration was associated with an earlier starting age, a longer history of use and a careless attitude to its health hazards. A higher education level was a protective factor for total exposure time. Studies of the long-term health effects and dependency profile of snus use are needed.

Smokeless Tobacco Point of Sale Advertising, Placement and Promotion: Associations With Store and Neighborhood Characteristics

Introduction: Objectives of this study were to determine retail and neighborhood characteristics associated with smokeless tobacco (ST) product promotion, price promotion, and storefront advertising among retailers in Oklahoma.

Methods: In this statewide point-of-sale study, we collected data from 1,354 ST retailers. Using store characteristics and census tract information, we estimated summary statistics and adjusted prevalence ratios during 2019–2020.

Results: Of ST retailers audited, 11.0% demonstrated ST youth promotion, 43.0% ST price promotions, and 19.6% ST storefront advertising. The adjusted prevalence ratio (aPR) for convenience stores was higher for all three ST strategies: youth promotion (aPR = 3.4, 95% CI 1.9, 6.2), price promotion (aPR = 3.8, 95% CI 2.9, 5.0), and storefront advertising (aPR=16.4, 95% CI 6.7, 40.3) compared to other store types. Metropolitan tobacco retailers had higher aPRs for youth promotion (aPR = 1.7, 95% CI 1.12 2.6) and storefront advertising (aPR = 1.5, 95% CI 1.2, 1.9).

Conclusions: Findings of this study suggest there are currently ample opportunities for youth and adults at risk for tobacco initiation to be exposed to ST products in the retail environment. Convenience stores, more likely to be found and utilized in rural areas compared to metropolitan areas, are disproportionately more likely to engage in marketing strategies that could lure youth into trying smokeless tobacco.

Does tobacco smoking predispose to apical periodontitis and endodontic treatment need? A systematic review and meta-analysis

BACKGROUND

Controversial findings exist in the literature regarding the association between tobacco smoking and development of apical periodontitis or need for root canal treatment, with some studies reporting an increase in the prevalence of these outcomes in smokers, whilst others reporting no association.

AIM

To evaluate if there is scientific evidence to support an association between tobacco smoking and a greater prevalence of apical periodontitis and/or root canal treatments.

DATA SOURCES

A systematic search was performed using MeSH terms and free terms in the PubMed, Scopus, Virtual Health Library (VHL), Cochrane library and Open Gray databases.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS AND INTERVENTIONS

Observational studies that evaluated the association between smoking and the development or healing of periapical lesion and/or the prevalence of root canal treatment in humans were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

A quality assessment of included studies was performed, and the relevant information and findings were evaluated. A meta-analysis using nine included studies was performed through RevMan software, and the certainty of evidence was evaluated through GRADE.

RESULTS

Fifteen studies were included, of which 10 were classified as low risk of bias, 4 were considered as moderate risk of bias and 1 as high risk of bias. Ten studies reported that smoking was associated with a greater prevalence of periapical periodontitis and/or root canal treatment. Five studies reported no association. Nine studies were included in the pooled meta-analysis, comprising two subgroups: apical periodontitis and root canal treatment. From these nine studies, eight studies were included in the apical periodontitis subgroup meta-analysis and demonstrated that this condition was significantly more prevalent in smokers when compared to the nonsmokers (odds ratio = 2.78[CI: 1.60, 4.85], P < 0.001; I²  = 79%; no adjusted odds ratio). Three studies were included in the root canal treatment subgroup meta-analysis and demonstrated an increased prevalence in smokers when compared to the nonsmokers (odds ratio = 2.73 [CI: 1.06, 2.83], P < 0.001; I²  = 72%; no adjusted odds ratio). The pooled meta-analysis demonstrated that smokers had twice the chance of having apical periodontitis and/or root canal treatment when compared to nonsmokers (odds ratio of 2.42 [CI: 1.59, 3.68], P < 0.01; I²  = 85%). The GRADE analysis demonstrated moderate certainty of evidence.

LIMITATIONS

Several confounding factors were identified such as misinformation regarding the period of time subjects had smoked, as well as the frequency of smoking and the number of cigarettes consumed. No adjustment in odds ratio data for confounding was performed.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

This systematic review and meta-analysis indicate that tobacco smokers have an increased prevalence of periapical periodontitis and root canal treatments with moderate certainty of evidence.

Identification of volatile constituents released from IQOS heat-not-burn tobacco HeatSticks using a direct sampling method

OBJECTIVES

To identify the chemicals released in I Quit Ordinary Smoking (IQOS) heat-not-burn tobacco aerosol and to assess their potential human health toxicity.

METHODS

The heating temperature window of the IQOS heat-not-burn device was determined using a thermographic camera over a period of 100 s. Qualitative studies were performed using a novel real-time gas chromatograph-mass spectrometer set-up. Aerosols from six tobacco-flavoured IQOS HeatSticks (Amber, Blue, Bronze, Sienna, Turquoise and Yellow) were collected in a 1 mL loop via a manual syringe attached to the sample-out port of the valve. The gas transport line was heated to 200°C in order to prevent the condensation of volatile species. Compound identification was performed using the NIST11 mass spectrometry database library (US National Institute of Standards and Technology), where only chemicals with a match of 70% and above were listed as identifiable.

RESULTS

The temperature profile of the IQOS device revealed a non-combustive process employed in generating the tobacco aerosol. Real-time qualitative analysis revealed 62 compounds encompassing a broad spectrum of chemicals such as carbonyls, furans and phthalates, which are highly toxic.

DISCUSSION

Our findings complement the qualitative studies previously performed by Philip Morris International and others via indirect sampling methods. By analysing the aerosols in real time, we have identified a total of 62 compounds, from which only 10 were in common with previous studies. Several identified species such as diacetyl, 2,3-pentanedione, hydroxymethylfurfural and diethylhexyl phthalate are classified as highly toxic, with the latter considered carcinogenic.

Smokeless tobacco use: its prevalence and relationships with dental symptoms, nutritional status and blood pressure among rural women in Burkina Faso

BACKGROUND

Sub-Saharan women use smokeless tobacco (SLT) more than smoked tobacco. Among Western African countries, the estimated weighted prevalence of SLT use in rural women was found to be the highest in Burkina Faso (after Sierra Leone). This study aimed to assess the prevalence of SLT use and its associated factors among rural women in Burkina Faso by using nationally representative data.

METHODS

We used data from the 2013 STEPwise approach to Surveillance (STEPS) study, which provided sociodemographic, clinical (anthropometric, systolic blood pressure [SBP], diastolic blood pressure [DBP] and dental symptoms), biological (total and high-density lipoprotein cholesterol and fasting blood sugar), and tobacco and alcohol consumption data. Data for 1730 rural women were used, and we performed Student's chi-squared and logistic regression analyses.

RESULTS

The prevalence of current SLT use was 13.8% (95% CI: 12.2-15.5). Significant risks for SLT use were the presence of dental symptoms (adjusted odds ratio [aOR] = 2.59; p < 0.001), undernourishment (aOR = 1.78; p < 0.01), decreased waist circumference (aOR = 0.98; p < 0.05), decreased DBP (aOR = 0.97; p < 0.01), increased SBP (aOR = 1.01; p < 0.05), and increased differential blood pressure (aOR = 1.01; p < 0.05). The co-use of alcohol was also a significant risk factor (aOR = 2.80; p < 0.001).

CONCLUSION

The prevalence of current SLT use was high among rural women in Burkina Faso, and significant concerns for users included alcohol co-use, the occurrence of dental symptoms, undernourishment, and an increase in differential blood pressure. National Public Health interventions are needed to reduce SLT use and its health-related concerns.

In vivo assessment of genotoxic potential of brown shammah (smokeless tobacco) in bone marrow cells of mice

This study was aimed to assess the genotoxicity of brown shammah (BS), a local form of smokeless tobacco, popular in Middle East countries including Yemen, Saudi Arabia and Sudan. The genotoxicity was explored using in vivo chromosomal aberration (CA), micronucleus (MN) and sperm abnormality (SA) assays. In addition, oxidative stress was also determined using various hepatic markers. Swiss albino mice were selected for the study, which were divided in to 5 groups of six animals each. They include, negative control (NC, received only vehicle) as well as positive control group (PC, received vehicle for 2 weeks followed by administration of cyclophosphamide, CP). Depending upon their dose, three BS treated animal groups were BS-100, 300 and 900 mg/kg. Doses of BS were obtained by suspending BS in 0.5% CMC (carboxy methyl cellulose) and orally administered once a day for 2 weeks. Significant augmentation of the average percentage of aberrant metaphase (AM), CA per cells and suppressed mitotic activity was observed on post administration of BS. In addition, BS increased the occurrence of MNPCEs (micronucleated polychromatic erythrocytes) formation, induced cytotoxicity and increased percentage of abnormal sperms as compared to NC. Moreover, BS also induced oxidative stress as the activities of hepatic superoxide dismutase (SOD) and glutathione (GSH) were reduced and malondialdehyde (MDA) content were increased by BS. Cyclophosphamide was utilized as clastogen, showed anticipated positive results and confirmed the sensitivity of test system. Therefore, it may be deduced from the study that the BS possesses genotoxic effects on mice bone marrow and germ cells in vivo.

Patterns of tobacco use among smokers prior to hospitalization for an acute cardiac event: Use of combusted and non-combusted products

Use of tobacco products before or after a cardiac event increases risk of morbidity and mortality. Unlike cigarette smoking, which is generally screened in the healthcare system, identifying the use of other tobacco products remains virtually unexplored. This study aimed at characterizing the use of other non-combusted tobacco products in addition to combusted products among cardiac patients and identifying a profile of patients who are more likely to use non-combusted products. Patients (N = 168) hospitalized for a coronary event who reported being current cigarette smokers completed a survey querying sociodemographics, cardiac diagnoses, use of other tobacco products, and perceptions towards these products. Classification and regression tree (CART) analysis was used to identify which interrelationships of participants characteristics led to profiles of smoking cardiac patients more likely to also be using non-combusted tobacco products. Results showed that non-combusted tobacco product use ranged from 0% to 47% depending on patient characteristic combinations. Younger age and lower perception that cigarette smoking is responsible for their cardiac condition were the strongest predictive factors for use of non-combusted products. Tobacco product use among cardiac patients extends beyond combusted products (13.7% non-combusted product use), and consequently, screening in health care settings should be expanded to encompass other tobacco product use. This study also characterizes patients likely to be using non-combusted products in addition to combusted, a group at high-risk due to their multiple product use, but also a group that may be amenable to harm reduction approaches and evidence-based tobacco treatment strategies.

The cardiovascular effects of electronic cigarettes: A systematic review of experimental studies

BACKGROUND

Smoking is responsible for substantial cardiovascular morbidity and mortality. Electronic cigarettes have been advocated as a means to reduce this disease burden; by reducing exposure to harmful substances in smokers who are unable to quit. Concerns have been raised however, about cardiovascular effects of their use, with inhalants containing carbonyls and fine particulate matter. We systematically reviewed experimental studies of in vitro, animal, and human cardiovascular effects associated with electronic cigarette use.

METHODS

A literature search was conducted using Ovid MEDLINE & Embase databases, identifying experimental studies investigating cardiovascular effects of electronic cigarette use. Subsequently, Cochrane Risk of Bias tools were used to assess study quality. Any differences in outcomes by conflict of interest and risk of bias status were sought.

RESULTS

38 studies were included, investigating animals (n=6), humans (n=24) and human cardiovascular cells in vitro (n=8). 74.3% of studies found potentially harmful effects. Increased sympathetic nerve activity was observed in human studies, whilst platelet haemostatic processes, reactive oxygen species production and endothelial dysfunction were reported across all study types. Studies with conflicts of interest or median-high risk of bias were less likely to identify potentially harmful effects (p=0.0007, p=0.04 respectively).

DISCUSSION

Most studies suggest potential for cardiovascular harm from electronic cigarette use, through mechanisms that increase risk of thrombosis and atherosclerosis. Notably, studies with conflicts of interest are significantly less likely to identify concerning cardiovascular effects. Included studies examine healthy, adult participants, limiting generalisation to potential high-risk groups including individuals with established cardiovascular disease or young, non-smokers.

Smokeless tobacco control in 180 countries across the globe: call to action for full implementation of WHO FCTC measures

Smokeless tobacco is consumed by 356 million people globally and is a leading cause of head and neck cancers. However, global efforts to control smokeless tobacco use trail behind the progress made in curbing cigarette consumption. In this Policy Review, we describe the extent of the policy implementation gap in smokeless tobacco control, discuss key reasons on why it exists, and make recommendations on how to bridge this gap. Although 180 countries have agreed that the WHO Framework Convention on Tobacco Control is the best approach to control the demand and supply of smokeless tobacco, only 138 (77%) Parties define smokeless tobacco in their statutes. Only 34 (19%) Parties tax or report taxing smokeless tobacco products, six (3%) measure content and emissions of smokeless tobacco products, and 41 (23%) mandate pictorial health warnings on these products. Although awareness of the harms related to smokeless tobacco is growing in many parts of the world, few Parties collect or present data on smokeless tobacco use under global or national surveillance mechanisms (eg, Global Tobacco Surveillance System and WHO STEPwise). Only 16 (9%) Parties have implemented a comprehensive ban on smokeless tobacco advertisement, promotion, and sponsorships. Globally, a smaller proportion of smokeless tobacco users are advised to quit the use of smokeless tobacco products compared to tobacco users. Use of smokeless tobacco is becoming a global cause of concern, requiring a greater commitment on the full implementation of the WHO Framework Convention on Tobacco Control measures.

Acupuncture combined with Buyang Huanwu decoction in treatment of patients with ischemic stroke

OBJECTIVE

This study was performed to investigate the effect of acupuncture combined with Buyang Huanwu decoction in patients with ischemic stroke.

METHODS

In total, 115 patients with ischemic stroke were recruited and divided into 3 groups. The control group received normal treatment, the acupuncture group received additional acupuncture treatment, and the combined group received additional acupuncture combined with Buyang Huanwu decoction treatment. The National Institutes of Health Stroke Scale (NIHSS) and Chinese Stroke Scale (CSS) were used to evaluate the stroke condition, and the Barthel index (BI) was used to measure life quality. Blood lipids and recurrence were also analyzed.

RESULTS

The CSS and NIHSS scores were significantly lower in the acupuncture group and combined group than in the control group; however, the BI score was significantly higher in the acupuncture group and combined group. Similarly, the levels of cholesterol, triglycerides, and low-density lipoprotein were all significantly increased, while the level of high-density lipoprotein showed no significant difference in all groups. The recurrence rate was significantly lower in the combined group than in the other two groups.

CONCLUSION

Acupuncture combined with Buyang Huanwu decoction could improve the clinical outcomes and reduce the recurrence rates in patients with ischemic stroke.

Setting research priorities in smokeless tobacco control: A retrospective review

Background & objectives

Smokeless tobacco (SLT) has become a global menace; India being one of the high-burden countries contributes about 67 per cent of its users. Although research is ongoing on various aspects of SLT use and its effects, there is a need to identify the still under-researched areas in this field. This study was aimed at delineating the quantum of research on various topics of SLT, with intent to delineate research gaps for guiding future research priorities.

Methods

Data about research in SLT were collected from PubMed database using 'smokeless tobacco' as a keyword and applying Medical Subject Headings (MeSH) terms filter. Data were extracted in XML (Extensible Markup Language) format and parsed into database to extract necessary fields such as PubMed IDs, authors' names, affiliations and MeSH terms. Quantum of research in various aspects of SLT was identified for individual MeSH terms and compared for global and Indian data.

Results

Data analysis of 2857 records revealed that maximum number of articles was devoted to adverse effects (35.6%) followed by epidemiology (32.4%). In comparison, India contributed only 11.7 per cent of records with maximum number of articles on the topics of epidemiology (26%) and adverse effects (45.8%). Higher proportion of research was published on epidemiology, aetiology and prevention and control at global level, while adverse effects of SLT were researched more in Indian studies as compared to global data.

Interpretation & conclusions

The present analysis highlighted the paucity of research studies on important topics such as economics and alternative strategies of SLT control, both on the global and regional levels.

School-based behavioral intervention to reduce the habit of smokeless tobacco and betel quid use in high-risk youth in Karachi: A randomized controlled trial

There have been recent surges in the use of smokeless tobacco (SLT) and betel quid (BQ) chew among adolescents in South East Asian countries, with an increase, on average, of 7% to 15% between 2004 and 2013, necessitating interventional investigations to modify this behavior. The current intervention was aimed towards changing adolescents' perceptions regarding the harmful effects of SLT and BQ use and encouraging them to quit. This randomized control trial involved 2140 adolescents from 26 private and public-sector schools in Karachi, Pakistan. After randomization, 1185 individuals were placed in the intervention group and administered a behavior changing intervention (BCI), while 955 individuals constituted the control group. A generalized estimating equation was employed to measure differences in repeated measures for both groups. The beta coefficients were reported after adjusting the covariates with the 95% confidence interval, and the p-value was considered significant at <0.050. Cohen's d was employed to report the effect size of the intervention. The BCI resulted in a 0.176-unit (95% CI 0.078-0.274, p-value <0.001) increase in knowledge scores regarding the health hazards of SLT and BQ, a 0.141-unit (95% CI 0.090-0.192, p-value <0.001) increase in use perception scores, and a 0.067-unit (95% CI 0.006-0.129, p-value 0.031) increase in quit perception scores in the intervention group compared with those in the control group. A knowledge related module (p-value 0.024) and quit preparation module (p-value 0.005) were found to be helpful by adolescents in either changing their perceptions regarding SLT and/or BQ chew use or in quitting. The role of BCI is promising in improving adolescents' knowledge and changing their perceptions in a positive manner regarding their harmful SLT and BQ use. Convincing results may be achieved if interventions are tailored, with an emphasis on the identification of the products that are used by adolescents in addition to highlighting their ill effects and how students may manage to quit them. If included in the schools' curricula, this BCI method may help in developing schools that are free of SLT and BQ use. Trial registration: ClinicalTrials.gov NCT03488095.

Smokeless tobacco use and circulatory disease risk: a systematic review and meta-analysis

Objective

Smokeless tobacco use is a public health issue throughout the world, but reviews and analyses of circulatory disease risks associated with smokeless tobacco use may be outdated or incomplete. This study provides a thorough and comprehensive review and meta-analysis of circulatory disease risks in high-income countries, including recently published study estimates.

Methods

We conducted a systematic review of studies of circulatory disease risks associated with smokeless tobacco use in Europe and North America that were identified from electronic databases and reference lists. Study estimates were extracted by region, smokeless tobacco use status, cigarette smoking status, and circulatory condition and combined in meta-analysis using a random-effects model. We used the Newcastle-Ottawa scale to assess study quality and risk of bias.

Results

We identified 17 relevant cohort studies, two pooled analyses, five case-control studies and one cross-sectional analysis. We found increased risk of heart disease (relative risk (RR) 1.17, 95% CI 1.09 to 1.27) and stroke (RR 1.28, 95% CI 1.01 to 1.62) among US smokeless tobacco users compared with non-users. Increased circulatory disease risk was not observed among Swedish smokeless tobacco users.

Conclusion

US smokeless tobacco users were found to have increased risk of heart disease and stroke.

A systematic review on association between smokeless tobacco & cardiovascular diseases

BACKGROUND & OBJECTIVES

The association of smokeless tobacco (SLT) with cardiovascular diseases has remained controversial due to conflicting reports from various countries. Earlier meta-analyses have shown significantly higher risk of fatal myocardial infarction and stroke in SLT users. However, the risk of hypertension (HTN) with SLT products has not been reviewed earlier. This systematic review was undertaken to summarize the evidence available from global literature on the association of SLT with cardiovascular outcomes - heart disease, stroke and HTN.

METHODS

A systematic literature search was performed in PubMed and Google Scholar since their inception till October 2017 using pre-decided search terms and inclusion/exclusion criteria. Data were extracted from studies included independently by two authors and reviewed.

RESULTS

The review included 50 studies - 23 on heart disease, 14 on stroke and 14 on HTN. Majority of the studies evaluating heart disease or stroke were conducted in the European Region and most of these did not find a significant association between SLT use and either of these outcomes. On the other hand, 70 per cent of the studies on HTN were reported from South-East Asian Region and about half of the studies found a higher risk of HTN in SLT users.

INTERPRETATION & CONCLUSIONS

Current available evidence is insufficient to conclusively support the association of cardiovascular diseases with SLT use due to variability in results and methodological constraints in most of the studies. Region and product-specific well-designed studies are required to provide this evidence to the policymakers. However, advice on cessation of SLT products should be offered to patients presenting with cardiovascular diseases.