Changes in Cardiovascular system among smokeless tobacco users attending tertiary care hospital in Andhra Pradesh, India

Changes in Cardiovascular system among smokeless tobacco users attending tertiary care hospital in Andhra Pradesh, India Annaji B1, Sreedevi P.2*, Sudheer K.3 DOI: https://doi.org/10.17511/ijmrr.2020.i04.07 1 Annaji B, Assistant Professor, Department of General Medicine, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India. 2* Sreedevi P, Assistant Professor, Department of General Medicine, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India. 3 Sudheer K, Professor, Department of General Medicine, Great Eastern Medical School and Hospital, Srikakulam, Andhra Pradesh, India.


Introduction
An estimated 600 million people worldwide, 300 million use smokeless tobacco [1]. Smokeless tobacco use is a significant part of the overall world tobacco problem. Nearly six million people die each year as a result of tobacco use, accounting for 12% of global adult mortality [2]. If current tobacco use patterns continue, it will cause some 10 million deaths each year by 2020. Unlike cigarettes and other forms of tobacco, smokeless tobacco is consumed without combustion. Instead, it is placed in contact with mucous membranes in the mouth or nose, through which nicotine is absorbed into the body. The term smokeless tobacco refers to more than 30 different products, broadly categorized as 'spit tobacco' or 'chewing tobacco [3,4]. In North America, smokeless tobacco use typically consists of the oral use of snuff (moist or dry). In Central, South, and Southeast Asia, smokeless tobacco is usually chewed with another substance, such as ash, lime, cotton, sesame, or betel quid (a mixture of nut, lime, and leaves) [ . Nicotine raises blood pressure by constricting blood vessels. This occurs because nicotine directly stimulates the production of a hormone, epinephrine (also known as adrenaline), in the adrenal gland. Epinephrine raises blood pressure by constricting blood vessels [12]. It is important to note that some ST products, such as loose snuff and chewing tobacco, contain large amounts of sodium as part of the sodium bicarbonate alkaline buffer that is necessary to Facilitate nicotine absorption; the sodium load (30 to 40 excess MEq sodium per day) could aggravate hypertension, as well as cardiac failure [13].
Furthermore, some ST products contain as a flavorant a large amount of licorice, which contains glycyrrhizinic acid that has mineralocorticoid activity, which can also aggravate hypertension and produce potassium wasting [14]. Smokeless Tobacco also contains more nicotine than cigarettes.
That's what makes smokeless tobacco even more addicting than smoking cigarettes [15]. Smokeless tobacco is also a source of exposure to trace levels of some heavy metals, some of which, such as arsenic or manganese, may increase the risk of hypertension. It appears to be related to elevated homocysteine, a risk factor for heart disease [16,17].
Association of smokeless tobacco consumption with the occurrence of adverse cardiovascular events like myocardial infarction, stroke, and ischemic heart disease has been studied in detail in the western population. [18] There are limited prospective studies that assessed the role of smokeless tobacco on CVD outcomes or mortality.
Further rigorous studies are needed to determine more clearly the cardiovascular risks potentially associated with smokeless tobacco use [19].

Results
In the present study of 50 smokeless tobacco users, the mean (± SD) of age was 52.90±8.4 years.

Discussion
Smokeless tobacco affects the cardiovascular system and is associated with heart disease, stroke, and high blood pressure [20]. In the present study,  [22].
Hypertension was most common in smokeless tobacco users. These findings indicate that increased cardiovascular risk is also associated with the use of smokeless tobacco [23]. Hypertension is a strong predictor of future CV events such as MI and stroke and, therefore, determination of the impact of ST product use on the development of hypertension is important [24]. In one study at the 15-year follow-up time point, and after adjustment for age and body mass index only, there was a modest increase in the relative risk for developing hypertension in current snuff users [25]. In another study (case-control), the prevalence of hypertension (systolic BP ≥170/diastolic BP ≥95 mm Hg) was 35% in current snuff users. In this study, higher blood pressure in the smokeless tobacco users corroborates with findings in previous studies [26].
Association of smokeless tobacco consumption with the occurrence of adverse cardiovascular events like myocardial infarction, stroke, and ischemic heart disease has been studied in detail in the western population. Results from these studies paint a mixed picture with some showing increased incidence of these adverse events [27] while others showing no such association. Similarly, contradictory results have been seen in studies evaluating increased risk factors for cardiovascular diseases in the smokeless tobacco consuming population [28,29].

Limitations
However, the present study has several limitations such as small sample size, not being able to extrapolate to all tobacco users due to exclusion criteria, not being able to generalize the result since the study subjects were from a single tertiary care center.

Conclusion
It is concluded from the present study that among smokeless tobacco users, the mean systolic and diastolic blood pressure were higher than normal.
But the mean pulse rate was within the normal range.
What does the study add to the existing knowledge  [Crossref] International Journal of Medical Research and Review 2020;8(4)