ATVB in Focus
Tobacco-Related Cardiovascular Diseases in the 21st Century
Series Editor: Muredach Reilly
Epidemiology and Public Health Policy of Tobacco
Use and Cardiovascular Disorders in Low- and
Middle-Income Countries
Danish Saleheen, Wei Zhao, Asif Rasheed
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Abstract—All forms of tobacco lead to an increased risk of cardiovascular disorders. During the past few decades, the
number of people who consume tobacco has increased worldwide because of an overall increase in the global population.
It is estimated that close to 80% of the >1.3 billion people who smoke tobacco in the world are in low- and middleincome countries. Smokeless forms of tobacco are also widely consumed in low- and middle-income countries, including
chewable and snuffed forms. Lack of targeted and effective strategies to control tobacco consumption contributes to
a large burden of cardiovascular disorders in low- and middle-income countries, where cardiovascular disorders have
become the leading cause of morbidity and mortality. In this review, we evaluate the epidemiology of tobacco use in lowand middle-income countries and assess the public health policies needed to control tobacco use in such regions for the
prevention of cardiovascular disorders and other tobacco-related morbidities and mortality. (Arterioscler Thromb Vasc
Biol. 2014;34:00-00.)
Key Words: coronary disease ◼ smoking ◼ stroke ◼ tobacco
T
Tobacco Use in LMICs
obacco consumption is a causal but a modifiable risk factor for cardiovascular disorders (CVDs).1 Cigarette smoking, the predominant form of tobacco consumption globally,2
is one of the strongest lifestyle behaviors associated with the
risk of CVDs.3,4 Although the prevalence of tobacco smoking
has declined between 1980 and 2012, the number of people
who smoke tobacco worldwide has increased during this time
period because of an increase in the global population.5 The
burden of tobacco use remains stubbornly high worldwide.5
This is of particular concern for people in many low- and
middle-income countries (LMICs) who have limited social
and personal capacity to deal with the burden of wide-ranging
tobacco-associated diseases.6 In the year 2000 alone, ≈2.5 million people died because of tobacco consumption in LMICs,
which comprised half of all tobacco-related deaths globally.6 It
is estimated that by the year 2030 tobacco-related deaths will
rise to ≈6.6 million in LMICs if such rapid increases in tobacco
consumption are not curtailed effectively. One third of all
tobacco-related deaths will be because of CVDs.7 These numbers do not take into account cardiovascular morbidity because
of tobacco use in these regions. Effective and targeted public
health interventions are hence needed to control effectively the
growing increase of tobacco use in LMICs. In this review, we
evaluate the use of different forms of tobacco in LMICs and
their relevance in CVDs. We further assess the public health
policies needed to minimize tobacco use in these regions.
A wide variety of tobacco products are used in LMICs, which
could be broadly categorized into smoked tobacco products
and smokeless forms of tobacco.
Cigarette Smoking and Other
Smoked Tobacco Products
Smoking is the most common way tobacco is consumed worldwide.2,8 There are >1.3 billion smokers globally, 80% of which
live in LMICs.9,10 Manufactured cigarettes constitute a major
proportion of the tobacco sales in terms of value.2,8,10 Cigarette
smoke contains >7000 chemicals, including nicotine, reactive
oxygen species, reactive nitrogen species, carbon monoxide,
nitric oxides, cadmium, polycyclic hydrocarbons, cadmium, and
other metals and oxidants.11,12 Many of these constituents are well
established to be toxic and carcinogenic and are also known to
impact the cardiovascular system.12–15 Despite such knowledge,
cigarette sales continue to increase in LMICs.5,6 In parallel to an
increase in consumption of manufactured cigarettes, other forms
of smoked tobacco products, such as bidis, kreteks, cheroot,
pipes, cigars, and waterpipes are also widely prevalent in LMICs
(Table 1).16 These alternative forms of smoked tobacco products
often provide a cheaper alternative to manufactured cigarettes.
Bidis and Kreteks
Some of the smoked tobacco products are largely regionally specific. These products include bidis and kretes. Bidis are made of
Received on: November 25, 2013; final version accepted on: July 1, 2014.
From the Department of Biostatistics and Epidemiology (D.S., W.Z.) and Division of Translational Medicine and Human Genetics, Perelman School of
Medicine (D.S.), University of Pennsylvania, Philadelphia; and Center for Non-Communicable Diseases, Karachi, Pakistan (D.S., A.R.).
Correspondence to Danish Saleheen, MBBS, PhD, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA. E-mail
[email protected]
© 2014 American Heart Association, Inc.
Arterioscler Thromb Vasc Biol is available at http://atvb.ahajournals.org
1
DOI: 10.1161/ATVBAHA.114.303826
2 Arterioscler Thromb Vasc Biol September 2014
Nonstandard Abbreviations and Acronyms
CVD
FCTC
LMIC
SHS
WHO
cardiovascular disorder
Framework Convention on Tobacco Control
low- and middle-income countries
secondhand smoke
World Health Organization
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tobacco flakes wrapped in a nontobacco leaf (temburani or tendu)
and are widely used in South Asia.2 Flavoring ingredients are
sometime added to bidis. Majority of bidis are manufactured in
small cottage industries in South Asia.16 Bidi smoking in India is
more prevalent than manufactured cigarettes.17–19 Bidi sales have
not been subject to taxes and until recently they carried no health
warnings.20 Because of lower costs than manufactured cigarettes,
bids are frequently smoked by poor people who have less education and are usually unaware of the health hazards associated with
tobacco smoking.17 Kreteks are largely produced in Indonesia and
contain tobacco, clove buds, and a wide variety of additives (eg,
caca, flavors).21,22 Cloves contain eugenol, which acts as a local
anesthetic in airways inducing more intense smoking than manufactured cigarettes.23–25 Majority of kreteks have been machine
made since the mechanization of the industry in the 1970s.26 It
is estimated that >90% of all smokers in Indonesia use kreteks.27
Both bidis and kreteks are exported to other parts of the world
including Europe and North America.28 Studies examining smoking patterns, CO exposure, and nicotine delivery have found bidis
and kreteks to differ little from manufactured cigarettes.16,29–31
Waterpipes
There are various names by which waterpipes are known in different regions, including shisha, hookah, goza, and narghile.32
Table 1. Some Smoked Forms of Tobacco Prevalent in
Low- and Middle-Income Countries
Tobacco Type
Brief Description
Cigarettes
Roll of tobacco wrapped in paper or a substance not
containing tobacco.
Bidis
Tobacco flakes wrapped in a leaf (usually from tendu plant
but may from a different plan as well). Bidis are prevalent
in South Asia.
Kreteks
Made with a blend of tobacco, cloves, and other flavors.
Chillum
Straight conical pipe (made of clay or other substance)
for smoking tobacco. They are prevalent in South Asia,
especially in rural settings.
Hookah
A waterpipe instrument that consists of a water basin.
Vaporized or smoked tobacco is passed through the water
basin before inhalation.
Sheesha
A waterpipe similar to Hookah, most commonly used in
Middle East. Flavors (eg, apple and honey) are added to
enhance the taste.
Cigars
Roll of dried and fermented tobacco leaves that contain
shredded tobacco.
Pipes
Devise comprising of a bowl (for tobacco consumption) and
a thin hollow stem ending in a mouthpiece. Tobacco for
smoking in pipes is often blended with flavoring agents.
Cheroot
A low cost cylindrical cigar with both ends clipped during
manufacturing; common in Burma and India.
Typical waterpipes combust tobacco (usually with the help of
charcoal), and smoke is passed through a bowl of water before
being inhaled through a hose.32 A wide variety of products
may be added along with tobacco for combustion, including
hashish and other flavoring agents.22 Despite a common association of waterpipe tobacco consumption with the Eastern
Mediterranean region, waterpipe tobacco consumption is also
high in certain East Asian countries.33 In a recent survey, current prevalence of waterpipe tobacco consumption for men
was found higher in Vietnam (13%) than in Egypt (6.2%)
and Turkey (4.0%).33 There has also been a recent emergence
in the use of waterpipe tobacco consumption among young
adults and adolescents in many LMICs and developed countries.33–35 Several factors are responsible for the popularity of
waterpipe tobacco consumption among the youth, including
proliferation of cafes where waterpipes are available to consume tobacco in a communal setting.22,34,35 They are also often
consumed by adding different flavors (eg, apple, honey, and
strawberry) that are misconceived to have natural or cleansing effects.22,34,35 Waterpipes deliver most of the same toxic
compounds that are present in cigarette smoke.36 Behavioral
studies, however, suggest that intake of smoke and exposure
to nicotine through waterpipes are several folds higher than
cigarettes because waterpipe smoking sessions typically last
longer than the duration it takes to consume a cigarette.16,37,38
Cigars and Pipes
A cigar traditionally comprises of shredded tobacco in a rolled
tobacco leaf that has been dried and fermented.16 Cigars vary
in size ranging from cigarette-shaped little cigars (that often
have filters) to large cigars.39,40 A cigarillo is also a type of
small cigar that is larger than a cigarette but smaller than a
regular cigar. Pipe is a devise that comprises of a bowl (for
tobacco consumption) attached to thin hollow stem ending in
a mouthpiece. Tobacco for smoking in pipes is often blended
with flavoring agents.
Smokeless Tobacco
Smokeless tobacco is a broad term encompassing tobacco
products that are used orally or nasally and are not burned
for consumption.41,42 They are used throughout the world;
however, their consumption is variable based on geography.
For instance, an estimated 258 million people use smokeless tobacco products in South Asia, in contrast to the United
States where an estimated 8.1 million people use such products.43 Some of the most widely used smokeless tobacco
products include betel quid or paan, gutka, zarda, toombak,
khaini, and dry snuff (Table 2). These tobacco products may
be chewed (eg, betel quid, gutka), sucked (eg, khaini), and
placed in the oral cavity (ie, in the space between gums and
the cheek) for variable time intervals (eg, naswar, toombak)
or snuffed nasally.41,42 Many of these products are handmade;
whereas some are produced commercially and require complex manufacturing process.41,44,45 The constituents of smokeless tobacco products range from simply cured tobacco to a
wide range of chemical ingredients and additives. Ingredients
for these tobacco products may contain plant material (eg,
betel leaf, areca nut), alkaline modifiers (eg, inorganic slats,
plant/fungi ashes, slaked lime), and other flavoring agents (eg,
Saleheen et al Epidemiology of Tobacco and CVDs in LMICs 3
Table 2. Some Smokeless Forms of Tobacco Prevalent in
Low- and Middle-Income Countries
Tobacco Type
Brief Description
Tobacco chewing
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Paan
Wrapped betel leaf containing betel quid made of
tobacco, areca nut, slaked lime, and other
flavoring agents.
Gutka
Chewable tobacco that consists of dry tobacco,
crushed betel nut and catechu, slaked lime, and
other flavoring agents.
Mawa
Mixture of thin shavings of tobacco, slaked lime, and
areca nut and is widely used in the Indian Gujarat.
Qiwam or khiwam
A paste containing mixture of tobacco extract,
spices, and other additives (eg, musk); used in
South Asia.
Zarda
Ingredient often used in betel quid and contains a
mixture of tobacco, lime, spices, vegetable dyes, and
areca nut.
Khaini
Sun-dried tobacco, slaked lime paste, sometimes
areca nut is added; commonly used in India (Gujarat
and Maharashtra).
Tobacco sucking
Naswar or nass
Moist and crushed tobacco. Tobacco is stuffed in the
floor of the mouth, under the lower lip, or inside the
cheek for extended periods of time.
Chimó
Crushed tobacco leafs containing sodium
bicarbonate, brown sugar, ashes from the Mamón
tree (Meliccoca bijuga), and other flavoring agents;
used in Venezuela Chimó is placed between the lip
or cheek and the gum and left there for some time
(usually half an hour).
Toombak
A moist tobacco product used primarily in Sudan
that consists of tobacco and sodium bicarbonate.
Tobacco leaves used in toombak are harvested and
dried followed by fermentation. They are then ground
and matured (≤1 y), followed by addition of sodium
bicarbonate. Toombak is rolled into a ball (called
saffa), which is slowly sucked by holding it in the
oral cavity.
Tobacco dentifrice
Masheri or mishri
Roasted tobacco flakes. Applied to gums and
teeth as a dentifrice but also kept inside mouth for
extended times because of addiction.
Gul or gudakhu
Paste containing tobacco powder, molasses, and
other ingredients; applied to the gums and teeth as
a dentifrice.
Tobacco sniffing
Dry snuff or tapkeer
Powdered form of tobacco that has been fire cured,
fermented, and processed is nasally snuffed; may
also be used orally for sucking. Known as tapkeer in
some parts of South Asia
saffron, eucalyptus).41,44,45 The amount and type of tobacco,
addition of plant ingredient and use of alkaline modifiers,
however, vary locally and regionally, resulting in a wide range
of smokeless tobacco products.41,43,45 Smokeless tobacco products contain many harmful and toxic constituents, including alkaloids (such as nicotine, cotinine, nornicotine), toxic
metals (mercury, lead, chromium and other trace elements),
aldehydes, lactones, radioactive metals, polycyclic aromatic
hydrocarbons, and tobacco-specific N-nitrosamines, many of
which are also known to have carcinogenic effects.46–49
Addiction Potential of Tobacco
Nicotine in tobacco is highly addictive and is primarily
responsible for the maintenance of tobacco consumption.50,51
Addiction to any tobacco product is largely dependent on the
amount of nicotine that is absorbed and the speed of nicotine
delivery.52,53 The amount and rate of nicotine absorption relate
to the pH of the tobacco product, route of administration, and
the overall nicotine content of the product. Cigarette smoking
provides the fastest mode of systemic delivery of nicotine.54 pH
of the tobacco product determines the amount of free or unionized nicotine. Unionized nicotine, compared with its ionized
form, is more rapidly absorbable in the blood, causing faster
spikes in blood nicotine levels;53 hence, tobacco products with
a higher fraction of unionized nicotine have a greater addiction potential than products with a lower fraction of unionized
nicotine.42 Different types of tobacco products have different
levels of unionized nicotine. Addition of alkaline modifiers in
smokeless tobacco products increases the pH of tobacco, converting a greater fraction of nicotine in the unionized form.41,45
Variability in Nicotine, pH, and Other
Constituents Among Tobacco Products
The concentration of nicotine, the pH of tobacco, and levels of carcinogens differ across various tobacco species and
across different tobacco products.41–43,45 The type of tobacco
and curing of tobacco can influence the nicotine content.46
For instance, tobacco products from many LMICs contain
Nicotiana rustica, a tobacco species that has higher nicotine
levels than found in tobacco cultivated in the United States.46
An estimated 35% to 40% of tobacco present in smokeless
tobacco products in India derive from N rustica.46,47 In a recent
survey conducted by Stanfill et al43 in 9 different countries
(many of which are LMICs), nicotine concentrations were
observed to vary substantially among different smokeless
tobacco products, ranging from 0.05 to 31.0 mg/g (a 620-fold
range of variation); products such as Bangladeshi gul powder, Indian zarda, and Sudani toombak were found to have the
highest nicotine levels (>27 mg/g product).43 Stanfill et al43
also observed that the pH of various smokeless tobacco products were variable ranging from 5.2 to 10.1, which equated to
0.2% to 99.1% of nicotine being in the free form. Gul powder
from Bangladesh and Venezuelan chimó was found to have
≥2-folds higher unioninized nicotine levels than all other
smokeless tobacco products studied across various countries.43
The results of their survey were also consistent with prior estimates that have suggested that roughly 40% of the moist snuff
products consumed in many LMICs have pH values exceeding
the highest value observed for any smokeless tobacco product in the United States.48 Some chewable forms of tobacco
(eg, pan, gutka, and mawa) manufactured in South Asia have
also been found to have high amounts of areca nut, which
has been classified as an International Agency for Research
group 1 carcinogen.47,49 The concentration of tobacco-specific
N-nitrosamine, the most potent classes of carcinogen, has
been observed to be several times higher in many smokeless
4 Arterioscler Thromb Vasc Biol September 2014
tobacco forms consumed in India, Bangladesh, and Sudan (eg,
tambook, gutka, and zarda) than the maximum concentration
observed for different smokeless forms of tobacco available in
the United States and the Sweden.43
Tobacco Consumption in Men and Women
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Patterns and choice of tobacco form consumed by men and
women vary across different regions.2,5,55 There is a higher
prevalence of tobacco smoking in men than in women globally.2,5 A recent study, that reviewed data on tobacco smoking
between 1980 and 2012 from 187 countries, estimated that
in the year 2012 age-standardized prevalence rates of daily
tobacco smoking in men and women were 31.1% and 6.2%,
respectively.5 Across various LMICs, the prevalence of daily
smoking in year 2012 was variable in men and women.5 Daily
smoking in men ranged from >50% (eg, Armenia, Indonesia,
Kiribati, Laos) to <10% (eg, Ghana, Niger, Sudan and
Ethiopia). Similarly in women, estimated prevalence of daily
smoking in 2012 across various LMICs ranged from >30%
(eg, Kiribati and Bulgaria) to 1% or lower (eg, Azerbaijan,
Algeria, Gambia, Sri Lanka, and Sudan).5 However, a weak
correlation was observed between daily smoking in men and
women in the year 2012 across different regions.5 Although
prevalence rates of daily tobacco smoking have decreased
between 1980 and 2012 globally, during this time period
prevalence of tobacco consumption increased in men living in some LMICs, including Cote d`Ivoire, Kazakhstan,
Mauritania, and Serbia.5 Similarly for women living in
LMICs, an increase in the prevalence of tobacco smoking
was observed in Tunisia, Kyrgyzstan, Costa Rica, Tonga, and
Bulgaria.5 In the year 2012, the prevalence rate of daily smoking in men living in LMICs increased sharply in the 15 to 19
year age group, reached its peak at the age 45 to 49 years, and
continuously dropped after the age of 50 years.5 In contrast,
the prevalence of daily smoking in women living in LMICs
continuously increased with age in the year 2012.5
In contrast to smoked forms of tobacco products, prevalence
of chewable forms of tobacco is higher or similar in men and
women across various regions within LMICs.2,55 The tendency
to use chewable forms of tobacco in combination with smoking
forms of tobacco, however, differs between the 2 sex groups.
A large majority of women who chew tobacco do not smoke;
whereas men who chew tobacco also tend to smoke tobacco.55
The snuffed forms of tobacco are mostly used by men and few
women report snuffing tobacco within LMICs.2,44,55
Tobacco and CVDs
Tobacco smoking is causally associated with increased risk
of CVDs.55–59 The impact of tobacco smoking on the risk of
CVDs is similar across various regions globally.55,58 There is
a strong dose–response relationship between the amount of
cigarettes consumed and risk of CVDs.55,58 It was previously
suggested such a dose-related increase in CHD risk persists
up to ≈25 cigarettes per day60–62; more recent analyses of data
from 5 contemporary cohorts, however, show a significant
increasing trend between cigarettes per day and CHD risk for
both men and women for ≤40 cigarettes per day.63 Association
between cigarette consumption and CHD risk is stronger
in younger participants compared with their older counterparts.55,57,59 This is particularly relevant in LMICs where initiation to smoking addiction begins at childhood. The Global
Youth Tobacco Survey, a worldwide collaboration that used a
uniform methodology to assess prevalence of smoking among
school-going children (13–15 years) in 43 countries, found
that among many schools in LMICs, including Chile, Peru,
Indonesia, and India, prevalence of ever use of any tobacco
product was >30%.64 Similar trends have been observed by
other studies in LMICs including Bangladesh, Pakistan,
Indonesia, and many countries in Africa.65–69 Many studies
have demonstrated that risk of CHD is lower in former smokers than current smokers55,63,70–72; however, compared with
nonsmokers, the risk of CHD is higher in former smokers.55,63
In both men and women, risk of CHD has been found to be
lower among former smokers than current smokers, and risk
of CHD has been shown to decrease progressively with time
after smoking cessation.11,12,55
Other forms of smoked tobacco products are also associated with increased CVD risk.55 Data from the INTERHEART
study found the risk of smoking bidis alone to be similar to
that of current cigarette smoking. The risk of CHD progressively increases with an increasing number of bidis smoked
per day.55 Similarly, in the absence of current cigarette or bidi
smoking, use of pipes, cigars, or waterpipes is also associated
with an increased CHD risk.55
All smokeless forms of tobacco lead to an increased risk
of CHD.55 Participants who smoke tobacco and chew tobacco
have a higher CHD risk than those who only consume tobacco
using either way.55 There are, however, many uncertainties
that still persist, including the relative quantitative impact of
the various smokeless forms of tobacco on the risk of various
CVD subtypes, whether the impact of various smokeless forms
of tobacco differ across various clinical groups, the shapes of
the association for the amount of smokeless tobacco on risk
of CVDs, and the biological mechanisms through which
these alternative forms of tobacco lead to CVDs. In addition,
as noted above smokeless tobacco products from different
regions vary in terms of their nicotine content, pH, ionization
fraction, and levels of harmful substances.41–43,45 Larger and
detailed studies specific to each region, than currently available, are, therefore, needed. Many ongoing studies in LMICs
in the coming years may be able to answer some of the uncertainties outlined above. Among these studies, the Pakistan
Risk of Myocardial Infarction Study (PROMIS)73 and the
Risk Assessment of Cerebrovascular Events Study (RACE)74
are 2 ongoing studies in Pakistan that have already enrolled
close to 57 000 participants, including 17 000 cases with myocardial infarction and 6000 stroke cases, and have recorded
detailed lifestyle information (including habits related to different types of tobacco consumption). The Kadoorie biobank
is a large prospective study in China that has recorded detailed
information on lifestyle factors and is accruing participants
for various incident diseases, including CVDs.75 Findings
from such studies would help better understand the prevalence
of different smokeless forms of tobacco (in men and women,
across various age groups and other relevant categories, eg,
socioeconomic groups), determinants of smokeless forms
Saleheen et al Epidemiology of Tobacco and CVDs in LMICs 5
of tobacco, their relative quantitative impact on the risk of
CVDs, and biological mechanisms that link different smokeless forms of tobacco with increased risk of CVDs. Such data
would be particularly important to help devise effective public
health strategies to control the growing burden of tobacco use
in LMICs.
Secondhand Smoke and Risk of CVDs
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Passive exposure to tobacco smoke or secondhand smoke
(SHS) increases the risk of both CHD and stroke independent
of established CVD risk factors.76–78 The impact of SHS on
CVD risk is similar in men and women.78,79 Several studies
have shown a dose–response relationship between exposure to
SHS and risk of CHD.55,79–81 Compared with nonsmokers not
exposed to SHS, nonsmokers exposed to 1 to 19 cigarettes/d
and to >20 cigarettes/d have been observed to have relative
risks of CHD of 1.23 and 1.31, respectively.81 There is also
strong evidence linking SHS with secondary CVD events.82,83
In patients with ACS, exposure to SHS has been found to
increase risk of repeat cardiac events by ≈61% during the first
30 days in comparison with those patients with ACS who are
not exposed to SHS.82 There is also a dose-related increase
in the risk of secondary CVD events in patients with ACS
exposed to SHS.83
Studies quantifying cotinine levels, a metabolite of nicotine
and a well-established biomarker for measuring exposure to
smoking,84–86 have, however, suggested that SHS may have
a stronger impact on CHD risk than observed through studies using questionnaire based data.87–90 In a study conducted
in 2105 male nonsmokers, relative risks for CHD in participants with mild (cotinine levels: 0.8–1.4 ng/mL), moderate
(cotinine levels: 1.5–2.7 ng/mL), and high (cotinine levels:
2.8–14 ng/mL) exposures to SHS were observed to be 1.45,
1.49, and 1.57, respectively.90 Similarly, relative risks for allcause mortality in patients with ACS exposed to SHS have
been shown to increase from 1.66 in those with mild cotinine
levels (0.1–0.3 ng/mL) to 3.79 in those with cotinine levels
>0.9 ng/mL.83 These data suggest that assessment of SHS
through objective methods is less prone to biases compared
with data obtained through self-report only, thereby encouraging the use of biomarkers in quantifying the risk of SHS
on CVD and other tobacco related diseases. Cotinine levels
(blood, saliva, or urine), however, have an average half-life of
16 hours and are not able to reflect exposure to chronic smoking.91 The average half-life of cotinine levels in the toe nail or
urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol on the
other contrary is ≈3 weeks91; however, the relationship of such
biomarkers that are reflective of chronic exposure to smoking with CVD status remains poorly understood.91,92 More
detailed studies on biomarkers that are reflective of both acute
and chronic SHS are needed to quantify the impact of SHS on
the risk of CVDs.
Tobacco Control Policies in LMICs
There is an urgent need to implement wide-ranging
approaches for reducing the growing epidemic of tobacco use
in LMICs.8,93–95 Local governments, nongovernmental organizations, and private sectors need to act together to implement
strategies that will introduce (1) smoke-free legislations; (2)
tobacco taxation policies; (3) bans on direct and indirect ways
of tobacco promotion; (4) limiting the influence of the tobacco
industry on tobacco control policies; and (5) implementation
of UN treaties, agreements, and recommendations such as the
World Health Organization (WHO) Framework Convention
on Tobacco Control (FCTC)94 and the MPOWER.93 Adopting a
multifaceted strategy at all levels of the society will be needed
to deal with the growing epidemic of tobacco in LMICs.
In many developed countries, implementation of smokefree legislations has resulted in rapid reductions in prevalence
of smokers and hospitalizations.96–99 For instance in New York
City, a comprehensive ban on smoking in all public spaces
was implemented in 2002, which resulted in a 15% reduction in the prevalence of adult smoking.100 Similar smoke-free
legislations covering all sections of the society need to be
aggressively pursued in LMICs that will ensure establishing
public areas, work places, and restaurants that are tobacco-free,
thereby reducing the social acceptability of tobacco use and
encouraging current tobacco users to quit. In parallel, tobacco
excise taxes need to be increased. Implementing tobacco taxation policy has been shown one of the most effective ways of
reducing prevalence of smoking, especially among children
and adolescents.100 A 10% increase in pricing has been shown
to reduce cigarette consumption by 3% to 5%.101 Although
many regions within LMICs have implemented a partial ban
on tobacco sponsorship, such partial restrictions have not been
proven effective in reducing the burden of tobacco in these
regions, necessitating the need for aggressively banning all
indirect or alternative forms of tobacco marketing.93 Exposure
to tobacco marketing has been associated with a doubling
of the probability of initiation of smoking in youth.102,103
Health warning labels should be placed on tobacco products.
Sustained mass media campaigns with graphic depictions of
the health consequences of smoking should be implemented;
such efforts incorporated in tobacco control programs have
been shown to reduce tobacco use in developed countries.102,103
Tobacco Industry—the Vector of the Tobacco
Epidemic
Tobacco control policies cannot be effectively implemented
without targeting the tobacco industry which is the vector
of tobacco epidemic. The tobacco industry has been implementing several strategies to promote and create a demand
of tobacco use in LIMIC’s. Weak tobacco control policies
and low awareness about the wide-ranging hazardous effects
of tobacco use in LMICs have allowed and resulted into the
global expansion of various multinational tobacco companies.93,104–106 The tobacco industry has used direct investment
in many LMICs (eg, Philippines, Indonesia, Cambodia) where
it was perceived and often welcomed as a source of economic
development.107–109 In many LMICs where such direct economic access was restricted because of bans imposed by
the government (eg, Malawi and Uganda) or complexity in
bureaucracy (eg, China),110–112 smuggling was used an alternative route to create demand and set a foothold; it was further
used as a leverage for negotiations with the government for
tax concessions and licensing permissions. Such economic
6 Arterioscler Thromb Vasc Biol September 2014
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interventions were coupled with marketing and promotion of
tobacco products to create demand in LMICs. Both direct and
indirect ways of advertisement have been used by the tobacco
industry in many LMICs.104,109,113 Products such as mild,
light, and low-tar cigarettes have been introduced especially
to attract young adults and women.107,113,114 Marketing strategies such as associating tobacco use with youth and glamor
have been used to attract young people who have never used
tobacco previously. Political lobbying, public relation campaigns, and voluntary self-regulatory advertising codes are
some of the ways that the tobacco industry has pursued to produce a favorable environment facilitating growth of tobacco
use in LMICs.104,115–117 Manipulation of the scientific evidence
and partnering with third party allies have also been adopted
by the tobacco industry to oppose implementation of tobacco
control policies.104,118,119 For instance, by working with local
trade associations (eg, restaurants and hospitality) which acted
as third parties, Accommodation Programs and Courtesy of
Choice programs were enforced, allowing creation of smoking and no-smoking sections; thereby opposing laws that
could enforce 100% smoke-free environment at work places
and public places.104,118–120 Many of the above fraudulent acts
have been used by the tobacco industry in developed countries as well. The conviction of major multinational tobacco
companies under the United States Racketeer Influenced and
Corrupt Organizations Act is a historical verdict which not
only holds the tobacco industry liable for fraudulently covering up the health risks associated with smoking and for unlawfully marketing their products to children, but the verdict also
highlights the need to change substantially the manner in
which tobacco industry is overseen without which the tobacco
industry is likely to continue its unlawful activities.121
The WHO FCTC and MPOWER: 2 Global
Public Health Programs for Combatting the
Tobacco Epidemic
The WHO FCTC, a policy that has been ratified by 177 countries to date (including most LMICs), is an important step
toward combatting the epidemic of tobacco internationally.94
The WHO FCTC pinpointed the factors that are responsible
for the spread of the tobacco epidemic globally, including
trade liberalization, direct foreign investment, global marketing, transnational tobacco advertising, promotion and sponsorship, and the international movement of counterfeit cigarettes.
They made evidence-based recommendations to counter these
factors (Table 3). Specific recommendations were also made
to reduce the influence of tobacco industry on tobacco control
policies, including (1) creating awareness about the interference of the tobacco industry in the implementation of tobacco
control policies; (2) limiting interactions with the tobacco
industry; (3) rejecting partnerships with the tobacco industry;
(4) avoiding conflicts of interest for government representatives; (5) mandating that information shared by the tobacco
industry is transparent and accurate; (6) regulating corporate
social activities by the tobacco industry; (7) no preferential
treatment to the tobacco industry; and (8) treatment of any
state-owned tobacco industry in a manner similar to other
tobacco industries.94
Table 3. Main Provisions in the WHO FCTC
Provisions
Reduction and regulation
Demand for tobacco through price and tax
measures
Tobacco advertising, promotion, and sponsorship
Illicit trade in tobacco products
Sales to and by minors
Measures concerning tobacco dependence and
cessation
Regulation
Packaging and labeling of tobacco products
Regulation of tobacco product disclosures
Regulation of the contents of tobacco products
Protection from exposure to tobacco smoke
especially smoking in work and public areas
Provision and support
Education, communication, training, and public
awareness
Support for economically viable alternative
activities
Research, surveillance and exchange of
information
Legislative actions to prevent the influence and
interference of the tobacco industry on public
health policy
FCTC indicates Framework Convention on Tobacco Control; and WHO, World
Health Organization.
To support further the FCTC, the WHO in 2008 devised
a 6-point evidence-based strategy, called MPOWER.93 The
MPOWER strategy includes (1) monitoring tobacco use
and prevention policies; (2) protecting people from tobacco
smoke by establishing smoke-free public areas; (3) offer
help to those who would like to quit tobacco; (4) warn people about the dangers of tobacco, including the smokeless
forms that are commonly used by women and being increasing used in younger generations; (5) enforcing bans that
cover all types of tobacco advertising, promotion, and sponsorship activities; and (6) raising the price of all tobaccorelated products through taxation. Such a program has been
either fully or partially implemented in many parts of the
world and is already proving to be effective. For instance,
the MPOWER measures implemented in Turkey resulted in
a 13% relative decline in smoking prevalence between 2008
and 2012.93
Implementation of tobacco control programs, such as FCTC
and MPOWER, is clearly important, and a wider reach of such
programs in LMICs should be ensured. One of the key limitations, however, in all such programs is the lack of advocacy
for eradication tobacco at its source. Curtailing tobacco cultivation gradually and offering tobacco farmers with incentives
(eg, providing seeds for alternative crops, monitory assistance
in the initial few years) should be made part of tobacco eradication policies. Tobacco farmers need to be educated about
both acute and chronic effects of tobacco farming and harmful effects of tobacco use in general. It has been reported that
≤55% of the tobacco farmers and their families experienced
green tobacco sickness, an acute toxicity syndrome associated
with tobacco exposure.122 A large proportion of the effected
Saleheen et al Epidemiology of Tobacco and CVDs in LMICs 7
are children.123 In rural settings that currently rely on tobacco
farming, community-based initiatives should be placed that
can discourage families from cultivating tobacco and offer
help to grow alternative crops. Governments can further intervene by making other alternative healthier crops as profitable
as tobacco farming. Such wider initiatives that can help in
reducing tobacco cultivation along with tobacco control programs that restrict the use of tobacco will ultimately help in
creating a tobacco-free society.
Conclusions
Downloaded from http://atvb.ahajournals.org/ by guest on June 15, 2017
Despite availability of overwhelming evidence that all forms of
tobacco lead to a higher risk of CVDs, the burden of tobacco
consumption remains high in LIMICs. Comprehensive and
multilevel public health strategies are needed to control the burden of tobacco in LMICs, including smoke-free legislations,
tobacco taxation policies, limiting the influence of the tobacco
industry on public health policies, bans on direct and indirect
ways of tobacco promotion, and implementation of international treaties such as the WHO FCTC and the MPOWER.
Sources of Funding
Dr Saleheen has received funding from the National Institutes of
Health, the Fogarty International, the Wellcome Trust, the British
Heart Foundation, and Pfizer.
Disclosures
None.
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Significance
Despite extensive efforts for the past several decades, prevalence of tobacco use remains stubbornly high in low- and middle-income countries.
Various forms of smoked and smokeless tobacco products are consumed in low- and middle-income countries. Cardiovascular disorders are a
major group of diseases that result because of consumption of any form of smoked or smokeless tobacco. We have reviewed the epidemiology of
various forms of tobacco consumption in low- and middle-income countries and their impact on the risk of cardiovascular disorders. We have further summarized the public health strategies that are needed to control the epidemic of tobacco consumption in low- and middle-income countries.
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Epidemiology and Public Health Policy of Tobacco Use and Cardiovascular Disorders in
Low- and Middle-Income Countries
Danish Saleheen, Wei Zhao and Asif Rasheed
Arterioscler Thromb Vasc Biol. published online July 17, 2014;
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