Effects of Cigarette and Water-Pipe (Shisha) Smoking ...

Ministry of Higher Education and Scientific Research Al-Rafidain University College Faculty of Pharmacy

Effects of Cigarette and Water-Pipe (Shisha) Smoking on Blood cells, Body Mass Index and Blood Pressure in Healthy Iraqi Males Graduation Project Submitted to the Faculty of Pharmacy as a Partial Requirement for the BSc Degree in Pharmaceutical Sciences by

Ahmed Shaalan Deab, Jaafar Safaa Hussein and Natheer Yasir Kareem Supervised by Professor Saad A. Hussain (PhD)

March 2018

Certificate I certify that this graduation project, entitled ((Effects of Cigarette and Water-Pipe (Shisha) Smoking on Blood cells, Body Mass Index and Blood Pressure in Healthy Iraqi Males)) was prepared by the BSc candidates Ahmed Shaalan Deab, Jaafar Safaa Hussein and Natheer Yasir Kareem under my supervision at the Faculty of Pharmacy, Al-Rafidain University College, as a partial fulfillment of the requirements for the degree of BSc in Pharmaceutical Sciences (2017/2018).

Signature: Supervisor: Professor Saad A. Hussain (MSc, PhD) Address: Faculty of Pharmacy /Al-Rafidain University College Date:

/

/ 2018

Abstract The study was conducted in different locations within Baghdad City from September 2017 to January 2018. Seventy five male subjects participated in this study: cigarette smokers (n=25), water-pipe smokers (n=25) and nonsmokers (n=25). The cigarette smokers were regularly consuming ≥ 10 cigarettes/day for at least 1.0 year. Blood pressure, body mass index and complete hematological analysis were measured for all participants. Cigarette smokers showed significantly high systolic and diastolic pressure and high heart rate, they also demonstrated significantly low hematocrit, low RBC count and high WBC count. The results of our findings showed that continuous cigarette smoking has many adverse effects on blood pressure, heart rate and certain hematological parameters (hematocrit, WBC count, and RBC count) and these alterations might be associated with a greater risk for developing atherosclerosis, chronic obstructive pulmonary disease and/ or cardiovascular diseases.

Keywords: cigarette smoking, water-pipe smoking, shisha, blood cells, blood pressure, BMI

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1. INTRODUCTION 1.1. Effects of Smoking on Blood Tobacco smoke contains over 4000 compounds that have a more or a less adverse effect on human health, among which free radicals, the nicotine and the carbon monoxide are considered the most responsible for pharmacological effects. The nicotine induces formation of a clot in the coronary arteries, weakens the vascular activity, and increases endothelium dysfunction. Increase in the level of carboxyhaemoglobin may cause hypoxia, and it is also responsible for subendotheliaoedema considering that it alters the vascular permeability and accumulation of lipids [1]. Free radicals and peroxides from the tobacco smoke are clearly linked with physiological phenomenon such as synthesis of prostaglandins and thromboxane, and they are also involved in the pathogenesis of various diseases including atherosclerosis, carcinoma, and inflammatory processes. Effects of smoking on alterations of hemostatic and fibrinolythic system, antioxidant status and hematology parameters were extensively studied, but the studies presented inconsistent results. According to the data of the World Health Organization, approximately 5 million people die globally each year from the diseases caused by smoking, and if this trend continues, it is expected that by 2015, that number would be 10 million. Numerous studies indicated that smoking had adverse effects on human health and represented a predisposing factor for development of various pathological conditions and diseases, such as the chronic obstructive pulmonary disease [2], cancer [3], pancreatitis [4], gastrointestinal disorders [5], periodontal disease [6], metabolic syndrome [7], and some autoimmune diseases [8].

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Cigarette smoking is associated with an increased risk of cardiovascular diseases, including coronary artery disease, peripheral vascular disease [9], ischemic heart disease [10], atherosclerosis, myocardial infarction [11] and stroke [12]. The exact mechanisms of occurrence of these disorders in smokers are not known, but it is presumed that these effects are caused by abnormalities in the blood rheology, infection and inflammation, oxidative stress, and alterations of antithrombotic and fibrinolysis system. 1.2. Effects on the Pulmonary System Cigarette smoking is the most important risk factor for chronic obstructive pulmonary disease (COPD) [13]. However, only a proportion of all smokers, about 15-20%, will actually develop COPD, the so-called ‘susceptible’ smokers. It is still unclear which factors determine why these individuals are more sensitive to the detrimental effects of cigarette smoking compared with ‘non-susceptible’ smokers. To better understand how cigarette smoking leads to irreversible lung damage and chronic airflow obstruction, knowledge of the initial responses to cigarette smoking might be very useful. Several studies investigated the acute inflammatory and oxidative stress responses to cigarette smoking in animal and in vitro models, yet only a few studies investigated these responses in humans [14]. These studies focused generally on COPD patients and ‘healthy smokers’ without airway obstruction. However, aging and the cumulative amount of pack-years smoking may lead to changes in the airways and lung parenchyma in both groups, likely affecting their response to cigarette smoking. Particularly in COPD, the structural changes in the lung may lead to a different response to smoking. For this reason, it might be hypothesized that the very first responses to cigarette smoking in healthy young individuals with a low number of pack-years is an ideal model to investigate the induction and early progression towards COPD.

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Several family studies have provided evidence that a genetic predisposition is involved in the smoking-related development of COPD. Silverman et al. showed that smoking or ex-smoking in first degree relatives of early-onset COPD probands associates significantly with lower forced expiratory volume in one second (FEV1) values compared to relatives of control subjects [15]. Several other studies have demonstrated that the combination of smoking and familial clustering of COPD strongly associates with a higher risk for COPD [16-18]. Although a history of familial COPD may help to identify smokers who are susceptible to develop COPD themselves, a more discriminative biomarker would be welcome in the field of

preventive

medicine.

Additionally,

elucidating

the

smoking-induced

pathogenesis of COPD in susceptible individuals may ultimately lead to the identification of new drug targets. 1.3. Health Effects of Water-Pipe (Shisha) Smoking Water-pipe smoking (WPS), commonly known as hookah smoking, is a growing worldwide social phenomenon practiced in group settings such as hookah bars or cafés in which patrons purchase water-pipe (WP) tobacco and then share it during smoking sessions. WPS is a symbol of social sharing and cultural identity [19]. The unregulated social aspect of smoking WP, combined with the myth that WPS is less harmful than smoking cigarettes, makes it difficult for those newly exposed to WPS to recognize the potential harmful effects, particularly when evidence is still being established. WPS sessions vary in length, ranging from 30 to 90 minutes [20] depending on the number of those sharing or the number of tobacco pouches used during a smoking session. A single WPS session may involve 50 to 100 times the smoke volume inhaled from a single cigarette [21,22]. In one study, once-a-day WP smokers were found to have levels of plasma nicotine concentration comparable to those of 10 cigarettes/day smokers [23] and evidence suggests that

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WP use is associated with health risks comparable to those caused due to cigarette smoking [24]. WPS is also associated with nicotine addiction and includes negative health consequences from secondhand smoke exposure [25]. Despite the evidence, most WP users are misinformed about the risks of use. Of particular concern is WP use in the Eastern Mediterranean Region (which includes Middle Eastern and North African countries). Prevalence of WPS in this region is the highest in the world, ranging between 20% and 70%.6 WPS appears to be on the rise, especially among youth and college-age young adults [26,27]. Research focused on WPS and WP secondhand smoke is garnering attention in the US and across the globe; however, there continues to remain a gap in knowledge about WPS and WP secondhand smoke in the US in comparison to other countries such as those in the Middle East. The World Health Organization’s (WHO) report on research for universal health coverage notes that smoking is responsible for about six million deaths annually worldwide; more than five million of these deaths occur in primary smokers, and the remainders die as a result of secondhand smoke exposure [28,29]. Despite the remarkable success of public health policies in regulating and reducing cigarette smoking, WPS has been flourishing worldwide, thus emphasizing the importance of strict tobacco control policies and regulations that are also WP oriented. Monitoring and regulating tobacco use should target not only cigarette smoking but also all forms of tobacco in order to combat the worldwide spread of WPS and the misconception that it is less harmful than other forms of tobacco. Two systematic reviews conducted by Akl et al. [30] and El-Zaatari et al. [31] did an excellent job of summarizing the health effects of WPS on multiple organ systems. The systematic review presented here offers additional evidence by extending the search to include CINAHL, Science Direct, PMC, and Cochrane

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Library databases. Additionally, our systematic review adds five additional studies to the previously published systematic review [31] and includes a comprehensive focus and inclusion of studies reporting cardiovascular and respiratory health outcomes as well as on oxidative stress, immunity, and cell cycle interference health outcomes. This review is important in order to compel evidence about the direct association between cardiovascular, respiratory illness, and WPS. In addition, this review is important to develop scientifically based regulatory policies with regard to WPS and WP secondhand smoke exposure, as tobacco control policy makers need reliable up-to-date scientific evidence to inform concerns aimed at: 1) establishing health warning campaigns and label packaging that identifies the known risks of WPS, 2) prevention of the sale of WP tobacco to minors, and 3) targeting prevention control and taxation similar to those used to combat cigarette smoking. 1.4. Aim of the Study The present study was conducted to compare the effects of cigarette and water-pipe smoking on body weight, blood pressure and hematological parameters between smokers and age-matched non-smoker controls.

2. METHODS 2.1. Subjects Present study was carried out to investigate the effects of cigarette and water-pipe (Shisha) smoking on body weight, blood pressure, and hematological parameters in a group of clinically healthy volunteers. A total of 75 subjects were enrolled in the study, 25 cigarette smokers, 25 shisha smokers and 25 non-smokers in the age range 19-40 years. The subjects were recruited from different locations including University campus. The smokers were regularly consuming 10-20 cigarettes per

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day for at least 1.0 year. Each subject gave an informed consent and study protocol was approved by the Research Ethical Review Committee, Faculty of Pharmacy, Al-Rafidain University College. Data on smoking habits and the amount of tobacco consumed were collected by a self-administered questionnaire to be filled in by the participants. Subjects included in this study were free of evidence of active liver and kidney disease, chronic pancreatitis, and hormonal therapy. 2.2. Anthropometric and biochemical measurements In all participants, arterial blood pressure, blood pressure and anthropometric data (height, weight and waist circumference) were measured. Waist circumference was measured at the midpoint between the lowest rib and the iliac crest. BMI was calculated as body weight (kg) divided by body height (m) squared. Blood pressure of each subject was measured with a mercury Sphygmomanometer and a standard stethoscope. Blood samples were drawn after an overnight fast. The participants underwent the following tests: Blood pressure examination to rule out hypertension. Estimation of the red blood cell count, total leukocyte count, differential leukocyte count, platelet count, packed cell volume, and hemoglobin was performed utilizing automated hematometer. 2.3. Statistical analysis Statistical analysis was performed using Graph Pad Prism software version 5.1. Before statistical analysis, normal distribution and homogeneity of the variances were tested using Kolmogorov-Smirnov test respectively. Groups were compared using Students unpaired t-test and ANOVA supported by Bonferroni’s post hoc analysis for parameters with normal distribution or Chi-Square test for parameters with non-normal distribution. Correlations between parameters were analyzed

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using the Pearson test for variables with normal distribution. Data are expressed as percentages or mean ± standard deviation. P 0.05).

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Table 1: Demographic characteristics of the surveyed subjects Variable Gender n (%) Male Age (Year), mean±S.D BMI (kg/m2), mean±S.D Waist Circumference (Cm), mean±S.D Education status n (%) None Primary Secondary College Smoking duration (Year), mean±S.D Smoking rate mean±S.D Medical History n (%) Arthritis Allergy IBS Hypertension Asthma Infections Drug History n (%) Anti-inflammatory drugs Antibiotics Analgesics Supplements Antihypertensive agents Antihistamines

Control n=25

Cigarette Smokers n=25

Shisha Smokers n=25

25 (100) 23.5±3.9 26.4±5.1 91.8±14.2

25 (100) 28.2±6.6 27.6±7.2 97.4±20.9

25 (100) 23.3±4.1 25.5±4.5 90.2±22.6

0 (0) 4 (16) 5 (20) 16 (64) 0 0

2 (8) 1 (4) 13 (52) 9 (36) 6.8±6.2 Cigarette/day 20.3±7.3

2 (8) 7 (28) 9 (36) 7 (28) 3.4±2.5* Session/day 1.7±0.9

0 (0) 1 (4) 2 (8) 1 (4) 1 (0) 2 (8)

0 (0) 1 (4) 6 (24) 1 (4) 1 (0) 2 (8)

1 (4) 2 (8) 0 (0) 0 (0) 0 (0) 1 (8)

1 (4) 1 (4) 1 (4) 2 (8) 0 (0) 0 (0)

1 (4) 1 (4) 1 (4) 0 (0) 1 (4) 1 (4)

1 (4) 1 (4) 1 (4) 5 (20) 0 (0) 1 (4)

n: number of subjects, BMI: body mass index, IBS: irritable bowel syndrome;* significant difference (P0.05)

Table 3 indicated that systolic and diastolic blood pressure and heart rate in cigarette smokers were significantly elevated compared with non-smokers, while those reported in shisha smokers were not significantly differ compared with control group. However, the changes reported in cigarette smokers were not significantly differ from that of shisha smokers, except for heart rate, where the value reported in cigarette smokers was significantly higher. In table 4, cigarette smoking significantly decreased hematocrit value and RBC count and increased WBC count compared with non-smokers, while shisha smoking did not significantly change these markers. Correlation study between the duration and rate of smoking with blood pressure and heart rate (Figures 1-3) indicated that systolic pressure was poorly and nonsignificantly correlated with these two variables. Meanwhile, diastolic blood pressure demonstrates low positive, but not significant, correlation only with the duration of smoking in shisha smokers (r= 0.3). However, heart rate was found to be negatively, but non-significantly, correlated with duration and rate of smoking (relatively low r values) in both cigarette and shisha smokers (Figure 3). In figure

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4, hematocrit demonstrates weak negative and non-significant correlation with both duration and rate of cigarette smoking (r value around – 0.2). Meanwhile, figure 5 showed that RBC count demonstrates relatively low positive correlation with the duration of smoking in shisha smokers (r= 0.3, P= 0.17). In figure 6, WBC count showed similar pattern of correlation in shisha smokers, where duration of shisha smoking demonstrate weak negative and non-significant correlation with WBC count.

Table 3: Effects of cigarette and shisha smoking on the blood pressure and heart rate of the smokers compared with non-smokers. Hemodynamic marker

Control n=25

Systolic pressure (mmHg) Diastolic pressure (mmHg) Heart rate (beat/min)

119.4±9.4 77.7±8.2 75.6±8.7a

Cigarette smoker n=25 131.2±18.8* 85.2±13.2* 84.0±11.5*b

Shisha smoker n=25 121.5±14.6 79.0±12.6 75.0±11.8a

Values are presented as mean±SD; n: number of subjects; * significantly different compared with control (unpaired t-test, P