Use of smokeless tobacco and risk of myocardial infarction and stroke: systematic review with meta-analysis

Impact of Smokeless Tobacco on Cardiovascular Disease Risk in a Nigerian Metropolitan City

The use of smokeless tobacco products (STP) as a substitute for tobacco smoking is driving increasing consumption of these products especially in developing countries. The study sought to make comparison of cardiovascular risk profile between chronic STP users and suitably matched tobacco-naïve controls. This is a preliminary report from the cross sectional part of a two-arm prospective study of Smokeless Tobacco Products Composition and Exposure Outcome in Enugu metropolis, Nigeria. Consecutively recruited current Smokeless tobacco users, who had no history of cigarette smoking, aged 18 years and above, residing in selected communities in Enugu metropolis, Nigeria were recruited for the study from October 2022 to July 2023. Age and sex matched non-tobacco users from same localities as the study subjects served as controls. Written informed consent to participate in the study was obtained from all study participants. All participants were screened by the investigators, using the study case report forms, to obtain data on medical history, demographic, clinical, laboratory, and electrocardiographic evaluation. Data from 54 STP-users and 54 non-STP-users (mean age 56.58 ± 8.15 years) were analyzed. Anthropometric parameters were similar in both groups. Smokeless tobacco users had higher erect and supine blood pressure indices as well as greater postural drop in systolic blood pressure. The occurrence of diabetes mellitus (20.37% versus 5.56%) and hypertension (25.93%; 11.11%) was significantly higher in the STP-users than in the non-user population, (p = 0.02192 and 0.04751 respectively). Electrocardiographic evaluation showed significantly increased QTc and dispersions of P-wave, QRS and QT intervals as well as reduced PR interval in STP users. Electrocardiographic abnormalities observed in STP users include left ventricular hypertrophy, left atrial enlargement, ST-segment elevation, short PR interval and long QTc. Use of smokeless tobacco products is associated with increased risk burden of diabetes mellitus and hypertensive heart disease. Electrocardiographic findings linked to STP-use in this study are features consistent with arrhythmia, ventricular repolarization abnormality, myocardial hypertrophy and ischaemia, suggesting that smokeless tobacco products are not safe substitutes for tobacco smoking.

Evaluating the Impact of Tobacco Cessation Counseling on Oral Health-Related Quality of Life and Identifying Barriers to Quitting Among Tobacco Smokers

Introduction Tobacco addiction is widely recognized as the most significant menace to both systemic and oral diseases, resulting in around eight million fatalities worldwide annually. The current investigation was conducted to assess the influence of tobacco cessation counseling on the quality of life linked to oral health and to identify obstacles to quitting among those who use tobacco. Methods This observational, follow-up study was carried out among patients referred to the tobacco cessation unit for the cessation of their smoking tobacco habit. Data on the participants was collected in two phases. Oral health-related quality of life (OHRQoL) was assessed at baseline and again three months after quitting smoking habits in the second phase. The assessment of barriers to quitting was done by asking a few questions of all participants. A student t-test and a chi-square test were applied with a p-value <0.05 considering significance. Results The study comprised a total of 322 patients, ranging in age from 18 to 62, with a mean age of 32.58 ± 12.901 years. After three months of quitting tobacco, a comparison of the mean scores of the Oral Health Impact Profile (OHIP) domains revealed a significant reduction in the mean score across all domains. The reduction was statistically significant, with a p-value of 0.001. Upon investigating the association between obstacles to quitting tobacco and socioeconomic position, it was discovered that the expense of quitting aids or tobacco programs, as well as the likelihood of weight gain, were strongly linked to the socioeconomic status of the individuals involved in the study. Conclusion Based on the results, the present study concluded that oral health-related quality of life significantly improved after quitting.

Risk of acute coronary syndrome and relationship with the use of khat and tobacco products in the Jazan region, Saudi Arabia: A prospective case-control study

INTRODUCTION

Previous studies have identified several risk factors for acute coronary syndrome (ACS). This study was intended to examine the potential risk of ACS associated with khat and tobacco use.

METHODS

A case-control study of 344 people (172 cases and 172 controls) was conducted at Prince Mohammed Bin Nasser Hospital in Jazan, Saudi Arabia, from April to September 2019. The cases and controls were matched for age (±5 years) and gender. Data were analyzed using descriptive, inferential, and modeling analyses. We utilized the adjusted odds ratio (AOR) to express the results.

RESULTS

The prevalence of ever khat chewing among all study participants was 29.1%, significantly higher for the cases with ACS than for the control group (43.6% vs 14.5%, p<0.001). Cigarette smokers accounted for 33.4% of the study participants, and 22.1% were ACS cases, which is a significantly higher percentage than the control group. The prevalence of smokeless tobacco was 20.3% among ACS cases and 14.5% among controls, with no statistically significant differences (p>0.05). In the final model, tobacco use was more likely to be reported among cases with myocardial infarction (MI) (AOR=4.58; 95% CI: 1.01-4.73, p<0.05) as was khat chewing (AOR=3.4; 95% CI: 1.55-7.46, p<0.05), after controlling for other traditional risk factors.

CONCLUSIONS

Khat chewing was reported more by those who reported ACS. ACS cases were more likely to be frequent khat users with chewing sessions of five or more days per week. Regular tobacco use was also reported in those who reported ACS, and this increases with the amount of tobacco used. Implementing early intervention strategies can help mitigate the impact of khat chewing and smoking on the development of ACS.

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.

Documento de consenso sobre tabaquismo y riesgo vascular

Consensus statement on smoking and vascular risk About 22% of the Spanish population are daily smokers. Men are more likely to smoke than women. In Spain, women between 15-25 years of age smoke as much or more than men. Every smoker should be assessed for: physical dependence on nicotine (Fagerström test), social and psychological dependence (Glover Nilsson test), level of motivation to quit (Richmond test), probability of therapy success (Henri-Mondor and Michael-Fiore tests), and stage of behavioral change development (Prochaska and DiClementi). Advice on smoking cessation is highly cost-effective and should always be provided. Smoking is an enhancer of cardiovascular risk because it acts as a pathogen agent in the development of arteriosclerosis and is associated with ischemic heart disease, stroke, and peripheral artery disease. Smoking increases the risk of chronic lung diseases (COPD) and is related to cancers of the lung, female genitalia, larynx, oropharynx, bladder, mouth, esophagus, liver and biliary tract, and stomach, among others. Combined oral contraceptives should be avoided in women smokers older than 35 years of age due to the risk of thromboembolism. In smoking cessation, the involvement of physicians, nurses, psychologists, etc. is important, and their multidisciplinary collaboration is needed. Effective pharmacological treatments for smoking cessation are available. Combined treatments are recommended when smoker's dependence is high. For individuals who are unable to quit smoking, a strategy based on tobacco damage management with a total switch to smokeless products could be a less dangerous alternative for their health than continuing to smoke.

Lifestyle Medicine: An Antidote to Cardiovascular Diseases

Despite numerous advances in basic understanding of cardiovascular disease pathophysiology, pharmacology, therapeutic procedures, and systems improvement, there hasn't been much decline in heart disease related mortality in the US since 2010. Hypertension and diet induced risk continue to be the leading causes of cardiovascular morbidity. Even with the excessive mortality associated with the COVID-19 pandemic, in 2020, heart disease remained the leading cause of death. Given the degree of disease burden, morbidity, and mortality, there is an urgent need to redirect medical professionals' focus towards prevention through simple and cost effective lifestyle strategies. However, current practice paradigm and financial compensation systems are mainly centered disease management and not health promotion. For example, the financial value placed on 3-10 min smoking cessation counseling (.24RVUs) is 47-fold lower than an elective PCI (11.21 RVUs). The medical community seems to be enamored with the latest and greatest technology, new devices, and surgical procedures. What if the greatest technology of all was simply the way we live every day? Perhaps when this notion is known by enough, we will switch to this lifestyle medicine technology to prevent disease in the first place.

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.

Determination of nicotine content in locally produced smokeless tobacco (Shammah) samples from Jazan region of Saudi Arabia using a convenient HPLC-MS/MS method

Shammah is one of the forms of smokeless tobacco (SLT) prepared by mixing tobacco powder with other ingredients to increase its acceptability. Nicotine (NT) is the main alkaloid present in tobacco and is a precursor for carcinogenic metabolites including tobacco specific nitrosamines (TSNAs). In this study, eight varieties of Shammah samples, collected from Jazan region of Saudi Arabia, were analyzed for NT content by a validated high performance liquid chromatography-mass spectrometry/mass spectrometry method. Electrospray ionization was used with the multiple reaction monitoring in the positive mode for data acquisition. The method was fast and short retention times (RT) of 1.4 and 3.1 min were observed for NT and lapatinib used as internal standard (IS), respectively. The inter- and intra-day accuracy and precision results met the acceptance criteria of United States Food and Drug Administration and International Council for Harmonisation validation guidelines. The developed method was successfully applied for the detection of NT contents in various Shammah samples. NT concentration was found to be in the range of 6.94 ± 0.16 to 31.69 ± 0.79% with the maximum level detected in special Shammah from Ahad Al Masarihah and the lowest level in Khadrah Shammah from Samtah city. The results of this investigation have warranted further research to determine the minor Shammah contents including additive materials and assessment of associated health effects.

Effects of tobacco product use on oral health and the role of oral healthcare providers in cessation: A narrative review

Tobacco use has detrimental effects on health, including oral health. The emergence and increasing popularity of newer tobacco and nicotine products make tobacco use one of the major public health problems in the world. Tobacco use increases the risk of oral diseases such as oral cancer, oral mucosal lesions, periodontal disease, and dental caries, among many other oral diseases and conditions. The dental office is an excellent venue for providing cessation intervention. However, there is a lack of knowledge and training in tobacco use prevention among dental professionals. More efforts are needed for smoking cessation interventions in the dental office. Smoking cessation interventions provided by oral healthcare providers include brief educational, behavioral, and pharmacological interventions. This review provides an overview of the ill effects of tobacco use on oral health and the role of oral healthcare providers in managing and preventing tobacco dependence.

Impact of Chewing Bags, E-Cigarettes, and Combustible Cigarettes on Arterial Stiffness and Small Airway Function in Healthy Students

Several substitute products are discussed as a healthier alternative to smoking, thereunder e-cigarettes and smokeless tobacco products, e.g., chewing bags, which are increasingly used in this context. We investigated the acute effects of chewing bags compared to combustible cigarettes and e-cigarettes with and without nicotine on small airways and arterial stiffness in a head-to-head design. This single-center, four-arm cross-overstudy included 20 healthy occasional smokers (25 ± 0.6 years). On four test days, participants consumed one product per day. Before, during, and after consumption, peripheral and central hemodynamic as well as arterial stiffness parameters were measured by Mobil-O-Graph™ (I.E.M., Germany). Resistance and small airway function were assessed by tremoFlo® c-100 (THORASYS Thoracic Medical Systems Inc.). The combustible cigarette and the e-cigarettes with and without nicotine significantly increased the resistance of the small airways (p < 0.05), while chewing bags had no effect. All nicotine containing products (e-cigarette with nicotine, combustible cigarette, chewing bag) as well as the e-cigarette without nicotine significantly increased parameters of hemodynamic and arterial stiffness. Changes in blood pressure and arterial stiffness were similar after smoking, vaping, and using chewing bags. We conclude that e-cigarettes and combustible cigarettes have similar acute harmful effects on small airway dysfunction. All nicotine containing products are associated with an increased cardiovascular risk compared with no product use.

Awareness of health risks associated with smokeless tobacco use among users in Pretoria

BACKGROUND

Smokeless tobacco (ST) refers to all tobacco-containing products that are not smoked but rather consumed through other means. Contrary to the popular belief that ST products are safe, the use of such products exposes users to health risks. To assess the awareness of health risks associated with ST use among users in a Pretoria community, the study was conducted in Ramotse community, located in Tshwane region 2, Gauteng, South Africa.

METHODS

This was a cross-sectional design, using a piloted, structured and self-administered questionnaire.

RESULTS

Of 479 participants with a mean age of 43 years (ranging from 18 to 89 years), most were in the age group 30-39 years (148; 31.6%), followed by ≥ 50 years (138; 29.4%). There were more females (371; 77.5%), more unemployed (263; 54.9%), married (236; 49.7%), had reached the secondary level of education (270; 56.4%), did not have any chronic illness (274; 57.2%), used snuff by nose (338; 70.6%), and were unaware of health risks associated with ST use (452; 94.4%).

CONCLUSION

This study has demonstrated a poor awareness of health risks associated with ST use among the users in a Pretoria community. As a result, health education at various levels of the community (clinic, schools, ward-based outreach team or WBOT, etc.) could be one strategy for resolving the problem.

'95% less harmful'? Exploring reactions to quantitative modified risk claims for snus and e-cigarettes

OBJECTIVES

Studies examining perceptions of 'modified risk tobacco product' (MRTP) messages for e-cigarettes and smokeless tobacco have indicated consumers want statistics and quantification of harm reduction. However, limited research exists on reactions to quantitative MRTP messages.

DESIGN

We conducted 12 focus groups in the USA in 2019-6 focused on e-cigarette messages and 6 on snus messages. Eight groups were with current smokers (ages 21-66) and four with young adult (ages 18-25) non-smokers (n=57). Participants discussed messages stating that use of snus and vaping products have been estimated by scientists to be about 90% and 95% less harmful than smoking cigarettes, respectively.

RESULTS

Several participants agreed the messages strongly communicated that the products are less harmful than cigarettes, were attention getting and could be 'convincing'. However, participants expressed scepticism about the source and accuracy of the stated figures, and some noted the claims could be misleading and attractive to young people. Comments also reflected some claim misunderstandings (eg, that e-cigarettes only pose a 5% chance of harm). Participants also agreed that stating e-cigarette risks 'are unlikely to exceed 5% of cigarette smoking harms' was confusing and less impactful than the '95% less harmful' wording.

CONCLUSIONS

Quantitative claims suggesting high levels of reduced risk when comparing e-cigarettes or smokeless tobacco/snus relative to cigarettes may be successful in gaining attention and being persuasive for some audiences, particularly, if from more credible sources. However, message developers, users and evaluators should be mindful of message limitations and aim to mitigate unintended consequences.

Review with meta-analysis relating North American, European and Japanese snus or smokeless tobacco use to major smoking-related diseases

BACKGROUND

While extensive information exists relating cigarette smoking to the risk of lung cancer, chronic obstructive pulmonary disease (COPD), ischaemic heart disease (IHD) or acute myocardial infarction (AMI), and stroke, far less information is available on risks from moist snuff (“snus”) or smokeless tobacco (ST) in United States/Canada, Europe or Japan.

AIM

To summarize data from the selected countries on risks of the four diseases associated with current ST or snus use.

METHODS

Publications in English in 1990-2020 were considered that, based on epidemiological studies in North America, Europe or Japan, estimated risks of lung cancer, COPD, IHD/AMI, or stroke according to use of ST or snus. The studies should involve at least 100 cases of the disease considered, and not be restricted to those with specific other diseases. Medline literature searches were conducted, selecting papers initially from examination of titles and abstracts, and then from full texts. Further papers were sought from reference lists in selected papers, reviews and meta-analyses. For each disease, relative risk estimates adjusted at least for age were extracted relating ST or snus use to risk, and combined using random-effects meta-analysis. The estimates were mainly for current vs. never or non-current use, but results for ever vs never use were also considered.

RESULTS

Seven publications reported results for ST use from six United States studies. The most useful results came from four studies which provided results for current vs. never use. Random-effects meta-analyses of these results showed an increased risk for each disease, clearest for lung cancer (relative risk 1.59, 95% confidence interval 1.06-2.39, based on 4 estimates) and COPD (1.57, 1.09-2.26, n = 3), but also significant (at P < 0.05) for IHD (1.26, 1.10-1.45, n = 4) and stroke (1.27, 1.03-1.57, n = 4). Also including results for ever vs. never use from two other studies increased the lung cancer estimate to 1.80 (1.23-2.64, n = 6), but had little effect on the other estimates. For snus, 16 publications described results from 12 studies, one in Norway and the rest in Sweden. There were no results for COPD, and only three for lung cancer, with these reporting a relative risk of 0.80 (0.40-1.30) for current vs never use. More extensive data were available for IHD/AMI and stroke. Using the latest results from each study, combined estimates for current vs. never use were 1.00 (0.91-1.11, n = 5) for IHD/AMI and 1.05 (0.95-1.17, n = 2) for stroke, while for current vs. non-current use they were 1.10 (0.92-1.33, n = 9) for IHD/AMI and 1.12 (0.86-1.45, n = 9) for stroke. Meta-analyses including earlier results from some studies also showed no significant association between snus use and IHD/AMI or stroke. No relevant results were found for Japan.

CONCLUSION

Risks of smoking-related diseases from snus use in Scandinavia are not demonstrated, while those from ST use in the United States are less than from smoking.

Associations of Smokeless Tobacco Use With Cardiovascular Disease Risk: Insights From the Population Assessment of Tobacco and Health Study

INTRODUCTION

Cigarette smoking is strongly associated with the development of cardiovascular disease (CVD). However, evidence is limited as to whether smokeless tobacco (ST) use is associated with CVD.

AIMS AND METHODS

Using data from 4347 adults in the Population Assessment of Tobacco and Health Study (2013-2014), we compared geometric mean concentrations of CVD-related harm biomarkers and biomarkers of exposure among exclusive ST users and exclusive cigarette smokers-in relation to recent nicotine exposure-and never tobacco users, adjusting for age, sex, race/ethnicity, income, body mass index, and CVD. Biomarker levels among exclusive ST users who were former established cigarette smokers were compared with exclusive cigarette smokers.

RESULTS

Compared with cigarette smokers, ST users had significantly higher concentrations of total nicotine equivalents (TNE) but lower concentrations of inflammatory (high-sensitivity C-reactive protein, interleukin-6, intercellular adhesion molecule, fibrinogen) and oxidative stress (8-isoprostane) biomarkers (all p < .05). Biomarker levels among ST users were similar to never smokers. ST users who were former cigarette smokers had lower levels of inflammatory and oxidative stress biomarkers and biomarkers of exposure (cadmium, lead, 1-hydroxypyrene, acrylonitrile, and acrolein), compared with cigarettes smokers (p < .05), despite having higher TNE levels (p < .05). Among cigarette smokers, but not among ST users, inflammatory biomarkers and TNE were highly correlated.

CONCLUSIONS

ST use is not associated with increases in biomarkers of CVD-related harm and exposure, compared with never smokers, despite exposure to nicotine at levels higher than those observed among cigarette smokers. These findings support the concept that increases in CVD risk among cigarette smokers is caused primarily by constituents of tobacco smoke other than nicotine.

IMPLICATIONS

Despite having higher levels of nicotine and compared with exclusive cigarette smokers, exclusive ST users (including those who were former cigarette smokers) had significantly lower concentrations of inflammatory and oxidative stress biomarkers, comparable to levels observed among never tobacco users. These findings suggest that increases in CVD risk among cigarette smokers is caused primarily by tobacco constituents other than nicotine and that switching to ST is likely associated with lower CVD risk.

Chronic snus use in healthy males alters endothelial function and increases arterial stiffness

Background

Snus usage is commonly touted as a safer alternative to cigarette smoking. However, recent studies have demonstrated possible adverse cardiovascular effects in chronic snus users. The present study evaluates the effects of chronic snus use on vascular function by assessing central arterial stiffness and endothelial vasodilatory function in healthy chronic snus users as compared to matched non-users.

Methods and results

Fifty healthy males (24 snus users, 26 age-matched controls) with a mean age of 44 years were included in the study. Arterial stiffness was assessed employing both pulse wave velocity and pulse wave analysis. Endothelial vasodilatory function was measured by venous occlusion plethysmography, utilizing intra-arterial administration of acetylcholine, glyceryl trinitrate and bradykinin to further gauge endothelium-dependent and -independent vasodilatory function. Arterial stiffness was significantly higher in chronic snus users as compared to controls: pulse wave velocity [m/s]: 6.6±0.8 vs 7.1±0.9 resp. (p = 0.026), augmentation index corrected for heart rate [%]: 0.1±13.2 vs 7.3±7.8 resp. (p = 0.023). Endothelial independent vasodilation, i.e. the reaction to glyceryl trinitrate, was significantly lower in snus users as measured by venous occlusion plethysmography.

Conclusions

The results of this study show an increased arterial stiffness and an underlying endothelial dysfunction in daily snus users as compared to matched non-tobacco controls. These findings indicate that long-term use of snus may alter the function of the endothelium and therefore reinforces the assertion that chronic snus use is correlated to an increased risk of development of cardiovascular disease.

The progression of the tobacco epidemic in India on the national and regional level, 1998-2016

BACKGROUND

Evidence regarding the progression of the tobacco epidemic remains fragmented in low- and middle-income countries. In India, most of the studies that examined tobacco consumption focused on one time point, on the country as a whole, and on men. Despite important gender differences in tobacco consumption, vast economic and cultural differences exist within India. We, therefore, assessed the progression of the tobacco epidemic in India on both the national and the regional level, by gender.

METHODS

We use information on current tobacco use among Indians aged 15-49 from three rounds of the National Family Health Survey (NFHS) (1998-99, 2005-06, 2015-16) to estimate the age-standardized sex specific smoking and smokeless tobacco prevalence across India and its states.

RESULTS

Age-standardized tobacco use prevalence in India increased between 1998-1999 and 2005-2006, and declined from 2005-2006 to 2015-2016, simultaneously for men and women. There are substantial spatial differences in the progression of the tobacco epidemic in India. While tobacco use declined in the majority of states, we observe high and increasing use for men in the north-eastern states of Manipur, Mizoram and Nagaland, and for women in the western state of Gujarat and north-eastern state of Manipur. We observed even more states with a recent increasing prevalence in either tobacco smoking or smokeless tobacco. Throughout, prevalence of tobacco use has been higher among men than women for all Indian regions, and remained higher than the national average in the north-eastern states.

CONCLUSIONS

Our results suggest that India and the majority of its states experienced a 'compressed tobacco epidemic' in which the prevalence of tobacco consumption increased and decreased simultaneously for women and men over a comparatively short period of time. Despite the overall progress India made in reducing tobacco use, further lowering tobacco consumption remains a public health priority, as the prevalence of smoking and/or smokeless tobacco use remains high in a number of states. We therefore conclude that tobacco regulations should be expanded with the aim of reducing the overall health burden associated with tobacco consumption across India.

Smokeless Tobacco Use and Prevalence of Cardiovascular Disease Among Males in the Population Assessment of Tobacco and Health (PATH) Study, Waves 1–4

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Oral smokeless tobacco (SLT) products are non-combusted forms of tobacco that can be dependence producing.

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SLT use may pose health risks to users such as cardiovascular disease (CVD) through various pathways including influencing hemodynamics, endothelial dysfunction, inflammation, insulin resistance, hyperlipidemia, and arrhythmogenesis.

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Past studies have suggested a small, elevated risk of CVD among SLT users compared to never tobacco users.

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This study advances the literature by exploring how the duration of regular SLT use relates to CVD prevalence.

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In this study of ≥ 40-year-old men only, we did not find a consistent dose–response trend for years of SLT use and prevalence of CVD.

The purpose of this period prevalence study is to compare the prevalence of cardiovascular disease (CVD) in current/former established smokeless tobacco (SLT) users (ever SLT users who have used the product fairly regularly) to those who were: 1) never established cigarette smokers and SLT users, and 2) current/former established exclusive cigarette smokers (have smoked at least a 100 or more cigarettes in lifetime) only, adjusting for known risk factors for CVD. Analyses included 4,703 men ≥ 40 years of age who participated in the Population Assessment of Tobacco and Health (PATH) Study, Waves: 1–4, conducted between 2013 and 2017. Current users were those using SLT products daily or on some days, whereas former users had not used SLT and/or cigarettes in the past 12 months. CVD prevalence was defined as a self-reported diagnosis of congestive heart failure, stroke, or myocardial infarction. Among current/former established SLT users, years of use defined exposure history, while pack-years defined exposure history for smokers. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were reported with trend tests to examine dose–response associations. Current/former established exclusive SLT users were not significantly more likely to have had any CVD compared to never established cigarette and SLT users (OR = 1.7 [0.8–3.7]), or current/former established exclusive cigarette smokers (OR = 0.9 [0.5–1.8]). Current/former established exclusive cigarette smokers were more likely to have had any CVD compared to those who were never established cigarette and SLT users (OR = 1.6 [1.1–2.3]).

Prevalence of the Usage of Smokeless Tobacco in Patients Presenting With Stroke in a Tertiary Care Hospital

Background Stroke is one of the leading causes of disability, long-term morbidity, and mortality. The key modifiable risk factors for stroke are largely driven by demographic changes and various social adaptations. Smokeless tobacco consumption is high in developing countries with less awareness of its potential health risks. Aim This study was designed to determine the prevalence of usage of smokeless tobacco in patients presenting with stroke in a tertiary care hospital in Karachi. Methods This is a cross-sectional study conducted at the Department of Neurology of Dr. Ruth K. M. Pfau Civil Hospital in Karachi. A total of 192 patients were enrolled during the study period of six months, from September 2018 to March 2019. All consenting patients were recruited who presented with stroke and fulfilled the inclusion criteria. All patients were assessed by a trained neurologist. Results A total of 192 patients with stroke were included. There were 146 (76%) males and 46 (24%) females with a mean age of 53 ± 6.1 years. The highest percentage (39%) of cases was illiterate. A majority (64%) of patients presented belonged to a lower socioeconomic background. Out of 192 stroke patients, 131 (68.2%) consumed smokeless tobacco.  Conclusion The frequency of smokeless tobacco consumption was found to be high in stroke patients who require the attention of the physician on modifiable risk factors.

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.

Association of smokeless tobacco and cerebrovascular accident: a systematic review and meta-analysis of global data

BACKGROUND

The association of smokeless tobacco (SLT) with stroke has been dealt with in only a few reviews. The present meta-analysis aims to present the updated comprehensive summary risk of stroke in adult SLT users along with sub group analysis.

METHODS

A systematic literature search for articles evaluating risk of stroke in SLT users was conducted. The study characteristics and risk estimates were extracted independently by two authors (RG and SG). Random-effect model was used to estimate the summary relative risks.

RESULTS

The overall risk of stroke in SLT users was found to be significantly higher (1.17, 95% CI 1.04–1.30) compared to non-users, especially for users in Southeast Asian region. The results remained unchanged even after strict adjustment for smoking (1.18, 95% CI 1.04–1.32). SLT users had 1.34 times or 13.4% higher risk of fatal stroke, though risk of nonfatal stroke was not enhanced. Significantly higher risk of stroke was seen in users of chewing tobacco (1.35, 95% CI 1.20–1.50) in comparison to non-chewers. Gender-based analysis showed enhanced risk of fatal stroke in both male and female users. SLT-attributable fraction of fatal stroke was highest for India at 14.8%.

CONCLUSION

The significant higher risk of stroke with SLT use, even after adjustment for smoking, emphasizes the imperative need to include SLT cessation advice for control and prevention of stroke.

Socioeconomic inequality in tobacco use in Kenya: a concentration analysis

This paper aims at assessing and exploring socioeconomic inequalities in tobacco use in Kenya. Using the theory of fundamental causes, and concentration index, we investigate the determinants of tobacco use, and whether it disproportionately affects the poor. All data used in this study emanated from the 2014 Global Adult Tobacco Survey implemented in Kenya on a nationally representative sample of men and women aged 15 years and older. Our results suggest a link between tobacco use and socioeconomic inequality. Overall, poorer households are more affected by tobacco use than richer households. This socioeconomic inequality is more evident among men and households living in urban areas. The decomposition of the concentration index indicates that the overall socioeconomic inequality for current tobacco smokers is explained by 69.11% of household wealth. To reduce the prevalence rate of smoking in Kenya, policymakers could design and implement tobacco control programs through the equity lens. Community health workers could be used to promote non-smoking behaviors among the poor.

Disparities in smokeless tobacco use in Bangladesh, India, and Pakistan: Findings from the Global Adult Tobacco Survey, 2014-2017

BACKGROUND

Smokeless tobacco (SLT) use is associated with multiple adverse health effects. It is prominent in Bangladesh, India, and Pakistan, but disparities in use within and across these countries are not well documented or understood. This study assessed the prevalence, patterns, and correlates of SLT use in these three countries.

METHOD

Data came from the Global Adult Tobacco Survey, a household survey of adults aged ≥15 years. Data were collected in 2014 (Pakistan), 2017 (Bangladesh), and India (2016-2017). Current SLT use (nasal or oral use) was defined as reported SLT use daily or less than daily at the time of the survey. Prevalence of both overall and specific SLT types were assessed. Multivariate logistic regression was used to assess correlates of SLT use.

RESULTS

Overall, SLT use among adults ≥15 years of age was 20.6% in Bangladesh, 21.4% in India, and 7.7% in Pakistan, corresponding to 22.0 million SLT users in Bangladesh, 199.4 million in India, and 9.6 million in Pakistan. Among current tobacco users overall, the percentage of those who used SLT was 58.4% (CI: 56.0-60.7) in Bangladesh, 74.7% (CI: 73.4-76.0) in India, and 40.3% (CI: 36.2-44.5) in Pakistan. The most commonly used oral SLT product was Zarda (14.5%) in Bangladesh, Khaini (11.2%) in India, and Naswar (5.1%) in Pakistan. Females had greater odds of SLT use than males in Bangladesh, but lower odds of SLT use than males in India and Pakistan. In all three countries, the odds of SLT use was higher among those 25 years and older, lower education, lower wealth index, and greater exposure to SLT marketing.

CONCLUSION

An estimated 231 million adults aged 15 years or older currently use SLT in Bangladesh, India, and Pakistan, comprising 40.3%-74.7% of overall tobacco product use in these countries. Moreover, marked variations in SLT use exist by population groups. Furthermore, exposure to pro-SLT marketing was found to be associated with higher SLT use compared to non-exposed. It is important that tobacco control strategies address all forms of tobacco product use, including SLT.

Identifying co-occurrence and clustering of chronic diseases using latent class analysis: cross-sectional findings from SAGE South Africa Wave 2

OBJECTIVES

To classify South African adults with chronic health conditions for multimorbidity (MM) risk, and to determine sociodemographic, anthropometric and behavioural factors associated with identified patterns of MM, using data from the WHO's Study on global AGEing and adult health South Africa Wave 2.

DESIGN

Nationally representative (for ≥50-year-old adults) cross-sectional study.

SETTING

Adults in South Africa between 2014 and 2015.

PARTICIPANTS

1967 individuals (men: 623 and women: 1344) aged ≥45 years for whom data on all seven health conditions and socioeconomic, demographic, behavioural, and anthropological information were available.

MEASURES

MM latent classes.

RESULTS

The prevalence of MM (coexistence of two or more non-communicable diseases (NCDs)) was 21%. The latent class analysis identified three groups namely: minimal MM risk (83%), concordant (hypertension and diabetes) MM (11%) and discordant (angina, asthma, chronic lung disease, arthritis and depression) MM (6%). Using the minimal MM risk group as the reference, female (relative risk ratio (RRR)=4.57; 95% CI (1.64 to 12.75); p =0.004) and older (RRR=1.08; 95% CI (1.04 to 1.12); p<0.001) participants were more likely to belong to the concordant MM group, while tobacco users (RRR=8.41; 95% CI (1.93 to 36.69); p=0.005) and older (RRR=1.09; 95% CI (1.03 to 1.15); p=0.002) participants had a high likelihood of belonging to the discordant MM group.

CONCLUSION

NCDs with similar pathophysiological risk profiles tend to cluster together in older people. Risk factors for MM in South African adults include sex, age and tobacco use.

Vaping Instead of Cigarette Smoking: A Panacea or Just Another Form of Cardiovascular Risk?

Since 2007, the electronic cigarette (EC), with its increasingly diverse array of device options, has gained popularity both among long-term tobacco cigarette (TC) smokers and among never-smoking youth. The absence of a number of known toxic by-products of TC smoking has helped cultivate the perception that ECs are healthy. However, an expanding literature has provided concerning evidence that a number of EC constituents, including nicotine, and their thermal degradation by-products may have adverse effects, including cardiovascular effects. In this review, we discuss the cardiovascular risks associated with EC vaping and compare this risk profile with TC smoking. Acknowledging the dynamic nature of EC vaping, we will focus on the latest developments, including the introduction of the pod-like device, which is the most popular EC device used today. We discuss the implications of a new, unique, nicotine chemistry that mimics the efficient and addictive nicotine delivery of TCs. Furthermore, we touch on the outbreak of the lethal lung disease associated with ECs, which exposed the lack of quality control in the EC industry. Along the way, we will identify the limitations of current knowledge and provide suggestions for future research. Overall, we conclude that although ECs may once have held promise as part of a harm-reduction strategy in people who smoke lethal TCs, this role has been largely offset by the unconscionable marketing to our youth, in addition to a failure of regulation and enforcement, leading to significant harm, especially in never-smokers who use them.

Tobacco harm reduction: Past history, current controversies and a proposed approach for the future

Tobacco harm reduction remains a controversial topic in tobacco control. Tobacco harm reduction involves providing tobacco users who are unwilling or unable to quit using nicotine products with less harmful nicotine-containing products for continued use. The skepticism towards harm reduction is based in part on the experience with low-yield tar/nicotine cigarettes, which were presumed to be associated with lower health risks than higher yield cigarettes and marketed as such by cigarette manufacturers. Only later did the field learn that these cigarettes were a deceptive way for cigarette manufacturers to allay the health concerns over cigarette smoking. Since this experience, there has been a proliferation of tobacco products that might potentially serve as a means to reduce tobacco harm. Some members of the tobacco control community believe that these products have great potential to reduce mortality and morbidity among smokers who completely switch to them. Others believe that we will be addicting another generation to tobacco products. This paper reviews the past history, the current tobacco landscape and controversies, and an approach that might rapidly reduce the yearly half-million deaths associated with cigarette smoking in the U.S.

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.

Smoke and Heart Should Stay Apart: A Look at E Cigarettes and Other Alternatives to Conventional Cigarettes, and Their Impact on Cardiovascular Health

The leading cause of preventable death in the world is smoking; leading to 7 million deaths attributable to tobacco use per year worldwide and 480,000 deaths per year in the United States. Though the actual rates of smoking in the United States have been on the decline, the advent of electronic cigarettes (E cigs) in 2007 was met with immense reception especially among the youth. Though initially thought to be a means to facilitate smoking cessation, recent evidence and the E cigs epidemic suggest its implications in significant morbidity and mortality. The other alternatives for conventional tobacco cigarettes have also been implicated in cardiovascular diseases. This manuscript aims to review E cigarettes and other alternatives to conventional cigarettes, and their impact on cardiovascular health. We conducted a Medline search using various combinations of "Cigarettes," "E cigarettes," "Smokeless tobacco," "hookah", and "cardiovascular risk" to identify pivotal trials published before May 10, 2020, for inclusion in this review. Concurrently, major practice guidelines, trial bibliographies, and pertinent reviews were examined to ensure inclusion of relevant trials. A consensus among the authors was used to choose items for narrative inclusion. The following section reviews data from pivotal trials to review the effects of E cigarettes, smokeless tobacco, hookah, nicotine replacement therapy on cardiovascular mortality and morbidity. There are many alternatives to conventional tobacco cigarette smoking, but none can be attributed as absolutely safe from a cardiovascular health perspective. The abundance of evidence regarding its impact on cardiovascular mortality and morbidity does not position it as a safe alternative, but an alternative means of smoking nicotine. The humongous rise in popularity and its gain in favor among the younger population poses a serious threat to the cardiovascular well-being of the exposed. Thus, E cigs and other alternatives of cigarette smoking do impart differing risks in cardiovascular mortality and morbidity, with the possible exception of nicotine replacement therapy.

Prevalence and Correlates of Cultural Smokeless Tobacco Products among South Asian Americans in New York City

Despite the high prevalence of smokeless tobacco (SLT) use in South Asia, little is known about the use of cultural smokeless tobacco among South Asians in the United States (US). This study examines the prevalence and correlates of SLT products among South Asians living in New York City (NYC). A total of 602 South Asians living in NYC completed a community health needs and resource assessment and answered questions about the use of SLT. Multivariable logistic regression models were run to examine predictors of SLT use (ever and current use). A total of 28.2% South Asian individuals reported ever use of SLT (35.9% among men and 21.5% among women) and a total of 12.9% reported current use of SLT (16.5% among men and 9.7% among women). Logistic regression models were stratified by sex. Among men, factors associated with ever or current use included: Bangladeshi and Himalayan ethnic subgroup, speaking English very well, attending a religious service a few times a year (ever use only), and current or former cigarette smoking. Among women, factors associated with ever use included: Bangladeshi ethnic subgroup, self-reporting condition of mouth and teeth as fair/poor, and at risk for depression. No factors were significant among women for current use. Overall, prevalence of current and ever use of SLT is high, and important differences exist by sex. Future studies are needed to better understand SLT use patterns in South Asian communities in the US and to inform culturally relevant interventions aiming to decrease overall tobacco use.

Evaluation of the effect of smokeless tobacco (Maras powder) on choroidal and retinal blood flow: an optical coherence tomography angiography study

ABSRTACT

PURPOSE: To investigate the acute and chronic effects of the use of smokeless tobacco (Maras powder) on macular and choroidal blood flow, via optical coherence tomography angiography (OCTA).

METHODS

The study included 30 eyes of 30 patients using smokeless tobacco (ST) as the study group and 30 eyes of 30 healthy individuals as the control group. All subjects underwent a full ophthalmological examination, and baseline OCTA measurements were taken. Flow area in superficial capillary plexus (SCP), in deep capillary plexus (DCP), in choriocapillaris (mm²⁾ and mean vascular density (VD) and foveal avascular zone in SCP and in DCP were assessed. Subfoveal choroidal thickness (SFCT) and central macular thickness were measured as well.

RESULTS

The SFCT measurements were determined to be significantly low in the study group (p < 0.001). In the comparison of the study group measurements at 5 m, 30 m and 1 h after using ST compared to the baseline measurements, SCP and DCP flow area, VD, CC flow area and SFCT were determined to have significantly decreased, statistically (p < 0.001).

CONCLUSION

OCTA could be important in showing that choroidal microvascular structures have been affected before occurence of the apparent clinical signs associated with acute and chronic ST use.

Prevalence and Correlates of Snuff Use, and its Association With Tuberculosis, Among Women Living With HIV in South Africa

INTRODUCTION

A higher proportion of people living with HIV (PLWH) smoke compared to the general population, but little information exists about the prevalence and correlates of smokeless tobacco use among PLWH. In South Africa, dry powdered tobacco is inhaled nasally as snuff.

METHODS

A cross-sectional survey among PLWH attending three HIV clinics was conducted. Snuff use was assessed via self-report and urine cotinine.

RESULTS

Given the low (3%) prevalence of snuff use among men, analysis was restricted to n = 606 nonsmoking women living with HIV. Half (n = 298, 49%) were snuff users, the majority of whom (n = 244, 84%) had a positive urine cotinine test. In adjusted analysis, snuff use was negatively associated with higher education (relative risk [RR] 0.55; 95% confidence interval [CI]: 0.39, 0.77) and mobile phone ownership (RR 0.83; 95% CI: 0.71, 0.98), and positively associated with ever having tuberculosis (TB) (RR 1.22; 95% CI: 1.03, 1.45). In adjusted analysis, with current TB as the outcome, snuff use was marginally statistically significantly associated with a twofold increase in odds of a current TB diagnosis (odds ratio [OR] 1.99; 95% CI: 0.98, 4.15).

DISCUSSION

A high proportion of nonsmoking South African women living with HIV use snuff, which was a risk factor for TB. Additional research is needed to understand the relationship between snuff, TB, and other potential health risks.

IMPLICATIONS

PLWH have a higher prevalence of smoking than their seronegative peers, but there is a paucity of research on smokeless tobacco use in this population, especially in low-resource settings. TB is the leading cause of death among PLWH, and with improvements to HIV treatment and care, PLWH are at greater risk of tobacco-related diseases. We report an extremely high prevalence of snuff use among women living with HIV in South Africa. Further, in this population snuff use is positively associated with ever having a TB diagnosis, as well as currently having TB.

Effect of a Responsiveness-Based Support Intervention on Smokeless Tobacco Cessation: The UCare-ChewFree Randomized Clinical Trial

INTRODUCTION

Partner behaviors and attitudes can motivate or undermine a tobacco user's cessation efforts. We developed a multimedia intervention, UCare (Understanding-CAring-REspect) for women who wanted their male partner to quit smokeless tobacco (ST), based on perceived partner responsiveness-the empirically based theory that support is best received when the supporter conveys respect, understanding, and caring.

METHODS

One thousand one hundred three women were randomized to receive either immediate access to the UCare website and printed booklet (Intervention; N = 552), or a Delayed Treatment control (N = 551). We assessed supportive behaviors and attitudes at baseline and 6-week follow-up, and the ST-using partner's abstinence at 6 weeks and 7.5 months (surrogate report).

RESULTS

For partners of women assigned to Intervention, 7.0% had quit all tobacco at 7.5 months, compared with 6.6% for control (χ2 (1, n = 1088) = .058, p = .810). For partners of women completing the intervention, 12.4% had quit all tobacco at 7.5 months, compared with 6.6% for Delayed Treatment (χ2 (1, n = 753) = 6.775, p = .009). A previously reported change in responsiveness-based behaviors and instrumental behaviors at 6 weeks mediated 7.5-month cessation, and change in responsiveness-based attitudes mediated the change in responsiveness-based behaviors, indirectly increasing cessation.

CONCLUSIONS

A responsiveness-based intervention with female partners of male ST users improved supportive attitudes and behaviors, leading to higher cessation rates among tobacco users not actively seeking to quit. The study demonstrates the potential for responsiveness as a basis for effective intervention with supporters. This approach may reach tobacco users who would not directly seek help.

IMPLICATIONS

This study demonstrates the value of a responsiveness-based intervention (showing respect, understanding, and caring) in training partners to provide support for a loved one to quit ST. In a randomized clinical trial, 1,103 women married to or living with a ST user were randomized to receive the UCare-ChewFree intervention (website + booklet) or a Delayed Treatment control. Women completing the intervention were more likely to improve their behaviors and attitudes, and change in behaviors and attitudes mediated cessation outcomes for their partners, who had not enrolled in the study and may not have been seeking to quit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01885221.

Heart Disease and Stroke Statistics-2020 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports on the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2020 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, metrics to assess and monitor healthy diets, an enhanced focus on social determinants of health, a focus on the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors, implementation strategies, and implications of the American Heart Association's 2020 Impact Goals.

RESULTS

Each of the 26 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, healthcare administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

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

Background

Use of smokeless tobacco (SLT) products has been linked to multiple adverse effects, especially precancer and cancer of oral cavity. However, the association of SLT use with risk of coronary heart disease (CHD) is shrouded with controversy due to conflicting results in the literature. The present meta-analysis aimed to evaluate the risk of CHD among adult ever-users of SLT products along with sub-group analysis.

Methods

The analysis included studies retrieved from a systematic literature search for published articles assessing risk of CHD with SLT use. Two authors independently extracted risk estimates and study characteristics of the included studies. Summary relative risks were estimated using the random-effect model.

Results

Twenty studies from four WHO regions were included in the analysis. The summary risk of CHD in SLT users was not significantly positive (1.05, 95% CI = 0.96 to 1.15) although a higher risk of fatal CHD was seen (1.10, 95% CI = 1.00 to 1.20). The risk was significant for users in European Region (1.30, 95% CI = 1.14 to 1.47). The results remained unchanged even after strict adjustment for smoking. Product-wise analysis revealed a significant positive association of fatal CHD with snus/snuff use (1.37, 95% CI = 1.14 to 1.61). The SLT-attributable fraction of fatal CHD was calculated to be 0.3%, highest being for European region (5%).

Conclusion

A significant positive association was detected between SLT use and risk of fatal CHD, especially for European users and those consuming snus/snuff. In view of the positive association even after strict adjustment for smoking, these results underscore the need for inclusion of cessation efforts for smokeless tobacco in addition to smoking for control of fatal cardiovascular diseases.

Implications

The present meta-analysis demonstrates a global perspective of association between coronary heart disease (CHD) and use of smokeless tobacco (SLT), especially for fatal cardiac events, even with strict adjustment for smoking. There appears to be some difference in this effect based on the type of SLT product used. These results highlight the independent deleterious effect of SLT products on the outcome of CHD and might help to resolve the long-standing controversy regarding the association of SLT with the risk of CHD. Hence, we propose that in addition to smoking, cessation efforts should be directed towards SLT products as well, for control of cardiovascular diseases.

Systemic Toxicity of Smokeless Tobacco Products in Mice

Introduction

Smokeless tobacco products such as snuff and snus are used worldwide. However, little is known about the systemic and cardiovascular toxicity of smokeless tobacco exposure.

Methods

Biomarkers of endothelial activation and injury, immune functions, platelet activation and insulin resistance were measured in 8-week old male C57BL/6 mice exposed to commercial snuff, CRP-2 reference snuff, commercial snus, CRP-1 reference snus, and nicotine in drinking water (100 µg/mL) for 4, 12, and 24 weeks.

Results

Twenty-four weeks of exposure to smokeless tobacco products or nicotine significantly decreased the levels of circulating Flk+/Sca+ endothelial progenitor cells. Twelve and 24 weeks of exposure to all the smokeless tobacco products and nicotine significantly decreased the levels of circulating CD19+ B cells, CD4+ T cells, CD8+ T cells, and CD11b+ monocytes, whereas 4 weeks of exposure to Camel snus and Copenhagen snuff significantly depleted the levels of peripheral blood CD19+ B cells and CD11b+ monocytes. Twenty-four weeks of exposure to smokeless tobacco products or nicotine significantly decreased plasma IFNγ levels. However, plasma TNFα levels were significantly increased in mice exposed to Copenhagen snuff or nicotine for 24 weeks. This was accompanied by a five to sevenfold increase in the hepatic expression of TNFα. Neither smokeless products nor nicotine affected plasma lipoproteins, platelet activation, or systemic insulin sensitivity.

Conclusions

Chronic exposure to snuff and snus suppresses circulating levels of EPCs, endothelial microparticles and immune cells, but increases plasma TNF-α levels. These effects of smokeless tobacco products are attributable, at least in part, to nicotine.

Implications

Exposure to smokeless tobacco products results in the depletion of endothelial progenitor cells, which may impair the endothelium repair. Suppression of the circulating levels of immune cells upon exposure to smokeless tobacco products may increase the susceptibility to secondary infection. Increased formation of proinflammatory cytokines such as TNFα by nicotine or Copenhagen snuff may lead to vascular inflammation and thereby exacerbate atherogenesis.

Electronic cigarettes and cardiovascular health: what do we know so far?

While tobacco cigarette (TC) smoking has continued to drop to all-time lows, the use of electronic cigarettes (ECs), introduced in the US in 2007, has been rising dramatically, especially among youth. In EC emissions, nicotine is the major biologically active element, while levels of carcinogens and harmful combustion products that typify TC smoke are very low or even undetectable. TCs cause cardiovascular harm by activation of inflammatory pathways and oxidative damage, leading to atherogenesis and thrombosis, as well as through sympathetic activation triggering ischemia and arrhythmia. While ECs are generally believed to be safer than TCs, there remain many uncertainties regarding the overall cardiovascular health effects of EC usage. In this review, we discuss the various components of EC smoke and review the potential mechanisms of cardiovascular injury caused by EC use. We also discuss the controversy regarding the increasing epidemic of youth EC use weighed against the use of ECs as a smoking-cessation aid.

LC-MS/MS Analysis of Sugars, Alditols, and Humectants in Smokeless Tobacco Products

Globally, smokeless tobacco (ST) includes a wide array of chemically diverse products generally used in the oral cavity. Although ST has been widely investigated, this study was undertaken to determine the levels of sugars (mono- and di-saccharides), alditols, and humectants present in major ST categories/subcategories by using high performance liquid chromatography coupled with a triple quadrupole mass spectrometer (HPLC-MS/MS). The products studied included chewing tobacco (loose leaf, plug, twist), US moist snuff, Swedish snus, creamy snuff, dry snuff, dissolvable tobacco products, and tobacco-coated toothpicks. The highest mean sugar level was detected in chewing tobacco (9.3-27.5%, w/w), followed by dissolvable tobacco (2.1%); all other products were lower than 1%. Creamy snuff had the highest mean alditol levels (22.6%), followed by dissolvable tobacco (15.4%); all others had levels lower than 1%. The detected mean humectant levels ranged from non-detectable to 5.9%. This study demonstrates the broad chemical diversity among ST. This research may aid researchers and public health advocates investigating the exposures and risks of ST. [Beitr. Tabakforsch. Int. 28 (2019) 203-213].

Contemporary Associations of Exclusive Cigarette, Cigar, Pipe, and Smokeless Tobacco Use With Overall and Cause-Specific Mortality in the United States

Background

A growing proportion of tobacco users in the United States use non-cigarette products including cigars, pipes, and smokeless tobacco. Studies examining the disease and mortality risks of these products are urgently needed.

Methods

We harmonized tobacco use data from 165 335 adults in the 1991, 1992, 1998, 2000, 2005, and 2010 National Health Interview Surveys. Hazard ratios (HRs) and 95% confidence intervals (CIs) for overall and cause-specific mortality occurring through December 31, 2015, were estimated by exclusive use of cigarettes, cigars, pipes, or smokeless tobacco using Cox proportional hazards regression with age as the underlying time metric and never tobacco users as the referent group.

Results

Current use of cigarettes (HR = 2.23, 95% CI = 2.13 to 2.33) and smokeless tobacco (HR = 1.36, 95% CI = 1.17 to 1.59) were each associated with overall mortality. Relative to never tobacco users, higher risks were observed both in daily (HR = 2.34, 95% CI = 2.24 to 2.44) and nondaily (HR = 1.69, 95% CI = 1.54 to 1.86) cigarette smokers, with associations also observed across major smoking-related causes of death. Daily use of smokeless tobacco was also associated with overall mortality (HR = 1.41, 95% CI = 1.20 to 1.66) as was daily use of cigars (HR = 1.52, 95% CI = 1.12 to 2.08). Current smokeless tobacco use was associated with a higher risk of mortality from heart disease and smoking-related cancer, with strong associations observed for cancers of the oral cavity and bladder.

Conclusions

Exclusive daily use of cigarettes, cigars, and smokeless tobacco was associated with higher mortality risk. Tobacco control efforts should include cigars and smokeless tobacco.

SLTChemDB: A database of chemical compounds present in Smokeless tobacco products

Smokeless tobacco (SLT), a cause of potentially preventable diseases, has a diverse chemical composition encompassing toxicants as well as potent carcinogens. Though the chemical profile of SLT products has been analyzed earlier, this information is not available in a comprehensive and easily accessible format. Hence, there is an imperative felt need to develop a one-stop information source providing inclusive information on SLT products. SLTChemDB is the first such database that makes available detailed information on various properties of chemical compounds identified across different brands of SLT products. The primary information for the database was extracted through extensive literature search, which was further curated from popular chemical web servers and databases. At present, SLTChemDB contains comprehensive information on 233 unique chemical compounds and 82 SLT products. The database has been made user-friendly with facility for systematic search and filters. SLTChemDB would provide the initial data on chemical compounds in SLT products to various tobacco testing laboratories. The database also highlights research gaps and thus, would be a guide for researchers interested in chemistry and toxicology of SLT products. With regular update of information in the database, it shall be a valuable evidence base for policymakers to formulate stringent policies for SLT control.

Smokers' perceptions of risks and harm from snus relative to cigarettes: A latent profile analysis study

INTRODUCTION

Certain types of smokeless tobacco (SLT) products, particularly snus, carry fewer health risks than cigarette smoking and might be able to serve as harm-reduction products for smokers. However, studies frequently find that smokers misperceive SLT and snus to be as or more harmful than smoking. This perception is often measured with a single general harm question, and research on underlying risk perceptions is limited.

METHODS

Using a sample of 256 current smokers, we utilized Latent Profile Analysis to examine response profiles to items that assessed perceived risk of specific health outcomes (lung cancer, heart disease, oral cancer) from snus relative to cigarettes, along with the typical single item measure of overall harm from snus compared to cigarettes.

RESULTS

Three smoker response profiles emerged. Almost half (44.9%) of smokers perceived snus to be as or more risky than cigarettes for all three specific health outcomes (group 1), while over one third (38.3%) had an elevated perceived risk for oral cancer only (group 2). About 17% of smokers perceived snus to have lower risks for lung cancer only (group 3). Across each profile, perceived risk was highest for oral cancer.

CONCLUSIONS

If smokers are to consider snus for harm-reduction, efforts may be needed to better inform smokers about their lower relative risks, including for particular health outcomes of interest. This study also suggests that smokers may vary in their level of need for information to correct their relative risk misperceptions.

The Impact of Smokeless Tobacco Risk Information on Smokers' Risk Perceptions and Use Intentions: A News Media Experiment

Little research exists on the impact of risk information comparing smokeless tobacco (SLT) use, particularly snus, to cigarette smoking. This study explored this topic using a communication channel where smokers may be exposed to such information-the news media. We randomly assigned 1008 current smokers to read one of three constructed news stories or to a control group (no article). The "favorable" story framed snus as a "safer" smoking alternative while the "cautious" story described snus risks. The "mixed" version described potential risks and harm-reduction benefits. Participants completed a post-article survey with snus risk and harm perception and use intention measures. Article condition was significantly associated with perceived harm of daily snus use relative to smoking (1 = a lot less harmful - 5 = a lot more harmful; p < .0001), and mean ratings of snus harm in the favorable (2.46) and mixed conditions (2.66) were significantly lower than those of the cautious (2.96) and control conditions (2.98). Mean interest in trying snus in the next 6 months was low, but significantly higher for those in the favorable (1.55) and mixed conditions (1.32) versus those in the cautious (1.17) and control conditions (1.16)(1 = not at all - 5 = extremely interested, p < .0001). There were no significant differences by group in terms of the story's perceived interestingness, importance, or relevance. Exposure to reduced-risk news messages about SLT and snus relative to cigarettes may impact smokers' SLT harm perceptions and use intentions. Tobacco control professionals and FDA officials should consider the potential impact of the news media when communicating about tobacco risks.

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.

Prevention and Treatment of Tobacco Use: JACC Health Promotion Series

Tobacco use is the leading preventable cause of death worldwide and is a major risk factor for cardiovascular disease (CVD). Both prevention of smoking initiation among youth and smoking cessation among established smokers are key for reducing smoking prevalence and the associated negative health consequences. Proven tobacco cessation treatment includes pharmacotherapy and behavioral support, which are most effective when provided together. First-line medications (varenicline, bupropion, and nicotine replacement) are effective and safe for patients with CVD. Clinicians who care for patients with CVD should give as high a priority to treating tobacco use as to managing other CVD risk factors. Broader tobacco control efforts to raise tobacco taxes, adopt smoke-free laws, conduct mass media campaigns, and restrict tobacco marketing enhance clinicians' actions working with individual smokers.