Tobacco Smoking as a risk factor for cardiovascular diseases
Tobacco Smoking as a risk factor for cardiovascular diseases
Cardiovascular diseases (CVD) remain to be one of the leading causes of mortality in both men and women worldwide, with an estimated of 18 million lives taken each year (Roth et al., 2020). CVD is a collective term which encompasses a range of heart and blood vessel disorders, such as coronary heart disease, cerebrovascular disease, rheumatic heart disease, and other various conditions (WHO, 2019a). Globally, more than four out of five CVD-related deaths result from heart attacks and strokes, and around 33% of these deaths occur prematurely in individuals under the age of 70 years old (Thiriet, 2018). In the United Arab Emirates (UAE), according to the most recent data from 2019, CVD emerges as the primary cause of mortality among both men and women, accountable for 40% of all deaths (WHO, 2019b). Notably, CVD prevalence in the UAE is higher among males compared to females, possibly influenced by the demographic distribution where 70% of the population is male, and only 30% are female (MOHAP, 2020).
The Framingham Heart Study, which began in 1948, aims to identify common factors or characteristics that contribute to the development of CVDs. It was during this study that the concept of cardiovascular risk factors was first created in 1961. (Mahmood et al., 2014). The term risk factor refers to something that can increase the likelihood of disease progression (Johansson et al., 2021). Cardiovascular risk factors can be divided into modifiable risk factors and non-modifiable risk factors. Modifiable cardiovascular risk factors are those that can be changed through lifestyle modifications including diet, physical activity, alcohol consumption, and smoking, whereas non-modifiable risk factors are those that cannot be changed such as age, male sex, and genetics (Johansson et al., 2021).
In 1960, researchers of the Framingham Heart Study officially declared smoking as a risk factor of CVDs (Mahmood et al., 2014). According to the World Health Organization (WHO), tobacco smoking is one of the most important modifiable risk factor to reduce the prevalence of CVD (WHO, 2019a). Tobacco smoking stands out as a primary and preventable contributor to CVD-related deaths. The goal of the INTER-HEART study was to investigate the primary risk factors for acute myocardial infarction (AMI) across 46 countries worldwide. These risk factors included alcohol consumption, smoking, ApoB/apoA1 levels, hypertension, daily intake of fruits and vegetables, psychosocial factors, physical activity, diabetes, and abdominal obesity. The results indicated that on a global scale, all nine risk factors showed significant associations with AMI, with smoking being the second most powerful predictor of risk. Additionally, the study revealed that smoking 1-5 cigarettes per day increases the risk of an AMI by 40% (unpuu et al., 2001).
As per the reports published by the World Heart Federation (WHF), tobacco use contributed to 3 million deaths globally in 2021 (WHF, 2023) . In 2020, the Ministry of Health and Prevention (MOHAP) in the UAE released an annual statistical report which showed that the prevalence rates for tobacco smoking in the UAE, amongst nationals and expatriates, were estimated to around 16% in men and 2% in women (MOHAP, 2020). These numbers are at risk of increasing due to the emerging smoking methods, such as vaping and E-cigarettes, which are notably popular among younger populations. In a study done by Ahmed et al., (2021), findings revealed that among university students in the UAE, with a mean age of 20 years old, 15% reported nicotine vaping, while 24% used E-cigarettes. Among nicotine vaping users, reasons for usage commonly included enjoyment of flavors and the vaporizing experience, and for some, it served as a tool to help them quit smoking (Ahmed et al., 2021).
Moreover, in the study done by Al-Shamsi et. al., (2019), where they examined the associated risk factors among Emirati men and women who experienced a major CVD event, the results showed that 34% of the male participants self-reported a history of smoking, whereas only 1.2% of the female participants self-reported a smoking history (Al-Shamsi et al., 2019). This study highlighted the need of implementing smoking cessation programs in the UAE, particularly targeting the male demographic. Additionally, when comparing smoking rates among the Middle East and North Africa (MENA) regions, the UAE exhibits lower prevalence rates compared to Egypt, Jordan, and Bahrain, where the smoking rates are higher (Alhuneafat et al., 2024).
The UAE Healthy Future Study (UAEHFS) aims to examine the Emirati nationals to understand the factors that contributes to the prevalence of non-communicable diseases, especially diabetes, CVD, and obesity. As part of their study, they used biochemical assessments to verify self-reported data of tobacco use through cotinine testing, among Emirati adults aged between 18 and 40 years old. During the survey, 36% of the male participants self-reported tobacco use and 3% of the female participants self-reported tobacco use. However, when the researchers examined smoking status through biochemical assessment, 42% of men and 9% of women tested positive for cotinine, suggesting potential recent tobacco consumption. The study also found that dual and poly-use of tobacco products was relatively common. Cigarettes were the most common form of tobacco use among men and women, followed by dokha/midwakh (tobacco mixed with herbs) as the second most common choice among men, and shisha (water pipe) among women (Al-Houqani et al., 2018). This study highlighted the significance of not solely relying on self-reported tobacco use data, as it can be prone to inaccuracies.
Apart from causing cancer, tobacco smoking affects nearly all body organs, including the heart, blood vessels, eyes, mouth, lungs, reproductive organs, bladder, bones, and digestive organs (Gallucci et al., 2020). In relation to the cardiovascular system, tobacco smoking has a direct impact on the endothelium cells that lines the walls of the blood vessels. The endothelium has anti-inflammatory, antithrombotic, and vasomotor properties which are crucial in regulating and maintaining vascular tone and hemostasis. Therefore, a compromised endothelium loses its natural anti-clotting properties, leading to poor platelet aggregation which results in clot formation. This makes tobacco smoking the leading factor for acute coronary thrombosis, thereby increasing the risk of sudden cardiac death in chronic smokers (Gallucci et al., 2020). In addition, tobacco smoking leads to arterial stiffness which in turn increases the blood pressure (Gallucci et al., 2020).
Tobacco smoking is highly addictive due to the presence of nicotine. This addiction results in intensive cravings for tobacco use in order to alleviate the negative mood and physical symptoms experienced during periods of abstinence (Widysanto et al., 2023). The process of smoking cessation is challenging for many individuals due to the withdrawal symptoms they encounter. These symptoms include irritability, anxiety, depression, difficulty in socializing, increased appetite, and insomnia (Widysanto et al., 2023). When nicotine withdrawal is not treated among chronic smokers, the symptoms can manifest with intensities comparable to those seen in psychiatric disorders (Widysanto et al., 2023). Therefore, individuals seeking to quit tobacco smoking often require multiple interventions to aid in their cessation efforts. Nicotine replacement therapies (NRT), such as nicotine skin patches or chewing gums, as well as nicotine replacement medications, such as Bupropion or Varenicline, has been shown to be effective in helping individuals quit smoking (Widysanto et al., 2023). In addition to NRT, behavioral support is needed.
According to a 2015 report by the Centers for Disease Control and Prevention (CDC), 68% of adult smokers in the United States wanted to quit smoking, with 55% having attempted to do so within the past year. However, only 7% were able to successfully quit (Babb et al., 2017). The transtheoretical model, also known as the stages of change model, suggests that smokers progress through distinct stages before successfully quitting. These stages include precontemplation (individual has no intention to quit), contemplation (individual considering quitting), preparation (individual planning to quit within the next 30 days), action (individual successfully quit for up to 6 months), and maintenance (individual has sustained abstinence for more than 6 months) (Sharma et al., 2017).
To aid countries in reducing tobacco consumption, the WHO introduced the MPOWER measures in 2008. These measures include: (a) Monitoring tobacco use and prevention policies, (b) Protecting people from tobacco smoke, (c) Offering help to quit tobacco use, (d) Warning about the dangers of tobacco, (e) Enforcing bans on tobacco advertising, promotion, and sponsorship, and (f) Raising taxes on tobacco. According to the WHO, full implementation of the MPOWER measures in the Eastern Mediterranean regions could potentially reduce the prevalence of smoking from 24% to 13% by the year 2030.
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