International Medical Journal Vol. 26, No. 4, pp. 282 - 287 , August 2019

PUBLIC HEALTH

Ill Health from Tobacco Cigarettes and Electronic Cigarettes: An Overview

Sachi Sri Kantha

ABSTRACTObjective: Among the more than thousands of papers, reviews, commentaries and editorials published on the theme of ill

health due to smoking tobacco products, I present an overview of the literature mostly published since 1980.Commentary: In 1908, less than 10 chemical compounds were identified from tobacco smoke. Now, this number has increased

to over 8,000. Literature on the reviews in 30 inter-related themes covering the pathophysiology of smoking and representative studies that had focused on the damage to reproductive and other sensory systems due to nicotine use and tobacco smoke inhala-tion are presented in two tables. Recent revelations on the tobacco industry's nefarious links to the Hollywood movie industry as well as the expose of the research funding offered by the tobacco industry to leading medical researchers Hans Selye and Ernst Wynder are also highlighted.

Conclusion: With the rising popularity of electronic cigarettes to a new generation of smokers in the past decade, services of specialty journals such as Tobacco Control, Tobacco Induced Diseases, as well as Nicotine and Tobacco Research becomes vital to combat the abuse of nicotine.

KEY WORDSepidemiology, nicotine, research funding, teenagers, tobacco addiction

Received on February 7, 2019 and accepted on April 21, 2019United Graduate School of Agricultural Sciences, Gifu University1-1 Yanagido, Gifu City 501-1193, JapanCorrespondence to: Sachi Sri Kantha(e-mail: sachisrikantha53@gmail.com)

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INTRODUCTION

In 1908, Dixon Mann's review with the caption, 'Some of the effects of excessive smoking' was published in the British Medical Journal1). It contained 27 references to papers published on this theme between 1871 to 1907. Among the then identified substances found in tobacco smoke, Dixon Mann listed only 7 ("nicotine, pyridine bases, ammonia, methyl-amine, hydrocyanic acid, carbon monoxide, sulphuretted hydrogen") and a group ("Oily tarry products, some of which are allied to phenol"). Sixty years later, this list of identified chemical components in cigarette smoke continued to expand to 1,200 in 1968, 3,000 in 1976, 4,000 in 1997 to 8,400 in 20091-5).

Table 1 provides a statistic on the prevalence percentage of smoking men and women globally, as published in a 2008 review on tobacco addiction, based on the databases of the WHO and American Cancer Society6). Nevertheless, Hatsukami et al6). provided a caveat for this assembled statistic, as follows: "These prevalence rates are not strictly comparable - samples might not be representative of the population of the country, they may refer to different time periods, the definitions of smoking might be different, and even age cut-offs might differ. Despite restrictions, they are the best data available." In the past ten years, smoking rates had fallen in Japan and USA, according to recently avail-able statistics; 17.9% adults (aged 20 and above) in Japan7) and around 14% adults in USA8). Though adult smoking population in countries like USA and Japan may be declining, big tobacco companies are constantly on prowl to trap teenagers by enticing them with slick promotions via social media and simultaneously blunting the anti-smoking campaigns through pro-smoking endorsements equated to life style choices.

Among the more than thousands of papers, reviews, commentaries and editorials published on the theme of ill health due to smoking tobac-co products, here I present an overview of the literature mostly pub-

lished since 1980.

C 2019 Japan Health Sciences University & Japan International Cultural Exchange Foundation

Table 1. Global Prevalence of Smoking in Men and WomenPercent of No. of Countries with Large PopulationsSmoking Countries (%) Population

Men> 55 24(16) Indonesia, Russia, Ukraine, Kenya44-55 28(19) China, Bangladesh, Japan, Philippines, Vietnam, Turkey35-45 39(27) Brazil, Pakistan, Germany, Egypt, Thailand, Myanmar25-35 30 (20) India, USA, France, UK, Italy, Colombia, Morocco< 25 26(18 Nigeria, Iran, Sudan, Tanzania, CanadaWomen> 24 33(22) Brazil, Germany, UK, Spain, Kenya14-24 43(29) USA, Bangladesh, Egypt, France, Italy Myanmar 4-14 37(25) Pakistan, Russia, Japan, Philippines, Turkey, Congo< 4 36(24) China, India, Indonesia, Nigeria, Vietnam, Iran, Thailand

adapted from Hatsukami et al.6

Kantha S. S. 283

COMMENTARY

Table 2 provides a random selection of reviews on 30 inter-related, specific themes covering the pathophysiology of smoking and smoking cessation; all except the first two were published in the last 30 years6,9-45). Ninety years had passed since the deleterious epidemiological evidence of tobacco smoking to the respiratory system was recognized for the first time in Weimar Republic of Germany46,47). However, smoking induced anomalies to other systems (especially excretory system and reproductive system) came to be recognized only lately. Table 3 cumu-lates representative studies that had focused on the damage to reproduc-

tive and other sensory systems due to nicotine and tobacco smoke inha-lation48-108).

In the past decade, conventional tobacco cigarette had morphed into electronic cigarette (e-cigarette). First patented internationally in 2007, e-cigarettes have gained a strong foothold among the adult smoking population as well as attracting the teenagers to nicotine addiction109-112). E-cigarettes are battery-powered, nicotine delivery systems, with a heat-ing element and a liquid solution containing nicotine in varying concen-trations and volatile flavor components. In an analysis of 28 e-cigarette liquids from 7 manufacturers, Hutzlet et al.95) reported the presence of 49 flavor compounds. The top five among these flavor compounds are vanillin, ethyl maltol, ethyl vanillin, menthol and piperonal. Deceptive

Table 2. A random selection of reviews on pathophysiology of smoking and smoking cessationTheme Authors* Journal Ref.

Tobacco and health Wynder and Hoffmann 1979 New Eng J Med. 9Animal studies on nicotine use Clarke 1987 Psychopharmacology 10Surveys on smoking Massey et al. 1987 Publ Health Rep. 11Smoking and cervical cancer Winkelstein 1990 Am J. Epidemiol. 12Antismoking products Gourlay and McNeil 1990 Med J Austr. 13Transdermal nicotine therapy Gourlay 1994 Med J Austr. 14Human costs of tobacco use Bartecchi et al. 1994 New Eng J Med. 15 MacKenzie et al. 1994 New Eng J Med. 16Smoking and male reproduction Vine 1996 Int J Androl. 17Women and smoking Kendrick and Merritt 1996 Am J Obst Gynecol. 18Cancer risk and tobacco leaf Kilthau 1996 Radiol Technol. 19Radioactivity Muggli et al. 2008 Am J Publ Health 20 New tobacco products Hoffmann et al. 1997 Prev. Med. 4 Couch et al. 2016 J. Am Dent Assoc. 21Cigarette smoking Bergen and Caporaso 1999 J Natl Cancer Inst. 22Tobacco smoke carcinogens Hecht 1999 J Nat Cancer Inst. 23and lung cancercigarette smoking and renal damage Orth 2002 Tob.Induced Dis. 24Tobacco smoking and periodontitis Mullally 2004 Tob.Induced Dis. 25Smoking and stroke Paul et al. 2004 Tob.Induced Dis. 26Genotoxicity of tobacco smoke De Marini 2004 Mutat Res. 27and tobacco smoke condensateSmoking and ovarian cancer Jordan et al. 2006 Gynecol. Oncol. 28 CGESOC 2012 Lancet Oncol. 29Acetaldehyde in tobacco smoke Talhout et al. 2007 Europ Neuropsy.pharmacol. 30addictionTobacco addiction Hatsukami et al. 2008 Lancet 6Smoking and suicide Hughes 2008 Drug Alcohol Depend. 31Tobacco use and bacterial infection Bagaitkar et al. 2008 Tob.Induced Dis. 32Tobacco smoke exposure and Meeker and Benedict 2013 Curr Women Health Rev. 33pregnancy lossElectronic cigarettes or Grana et al. 2014 Circulation 34Electronic Nicotine Delivery Bhatnagar et al. 2014 Circulation 35Systems (ENDS) Knorst et al. 2014 J Bras Pneumol. 36 Orellana-Barrios et al. 2015 Am J Med. 37 Dinakar and O'Connor 2016 New Eng J Med. 38Tobacco carcinogenesis research Hecht and Szabo, 2014 Cancer Prev Res 39Disease burden comparison: Oh and Kacker 2014 Laryngoscope 40tobacco smoke vs e-cigarettevaporEnvironmental tobacco smoke Javed et al. 2014 Environ Res. 41and periodontal diseasePathophysiology of tobacco Colombo et al. 2014 Mass Spectrometry Rev. 42smoke exposureNicotine carcinogenicity Sanner and Grimsrud 2015 Front Oncol. 43Tobacco specific nitrosamines Konstantinou et al. 2018 Food Chem Toxicol. 44Smoking and lung cancer de Groot et al. 2018 Transl.Lung Cancer Res. 45

*arranged chronologically from 1979 to 2018.

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Table 3. Reported Smoking Induced Health Anomalies other than Respiratory and Circulatory System DisordersHealth Anomalies Author(s) and Reference(s)

Reproductive System relatedInfertility and fetal loss Tokuhata48, Venners et al49, Farber50

Sperm abnormalities and reduced sperm quality Vine16, Evans et al.51, Kunzle et al.52

Neoplasia of uterine cervix Trevathan et al.53, Sasson et al.54

Anogenital cancer Daling et al.55

Cervical cancer Winkelstein11,56, Austin57

Delayed conception Baird & Wilcox58, Hull et al.59

Irreversible follicular depletion Westhoff et al.60

Menstrual disorders Sloss & Frerichs61, Hartz et al.62, Brown et al.63, Charlton & While66, Hornsby et al.65, Grossman & Nakajima66, Liu et al.67, Bertone-Johnson et al.68

Miscarriage Mishra et al.69

Premature natural menopause Hartz et al.62, Jick et al.70,

Other Recorded Negative AnomaliesBreast cancer Schechter et al.71, Chu et al.72, Palmer et al.73, Dimazio et al74, Callahan et al.75, Gram et al76

Bladder cancer Brennan et al.77, Castelao et al78, Quirk et al.79

Facial wrinkling Kadunce et al.80, Kottke81, Aizen & Gilhar82

α-radiation exposure to 210Po and 210Pb Winters & DiFranza83, DiFranza & Winters84, Cohen85, Hill86, Hoffmann & Wynder87, Martell88, Ravenholt89, Wagner90, Cohen & Harley91, Papastefanou92, Nagamatsu et al.93

Hirsutism Hartz et al.62

depleted oral health Javed et al.41, Reibel94, Chemical hazards Hutzler et al.95

Explosion injuries Brownson et al.96

Autism spectrum disorder James97, Jung et al.98

Hearing difficulties Palmer et al.99

Free flap failure in breast reconstruction Krishnan et al.100

Sleep disturbance Bale & White101, Wetter & Young102

Reduced longevity Pearl103, Basavaraj104, Goldman105

Suicide Hemenway et al.106, Tanskanen et al.107, Scherrer et al.108

Figure 1. 1st page (of a 4 page advertisement spread) of a decep-tive advertisement for the Chelsea cigarette by R.J. Reynolds, in 1989. Note the 'Scratch 'n Sniff' box, which suggests four flavors, one of which is 'a new cigarette's aroma'. In this page, the name of the cigarette is not mentioned. 2nd and 3rd pages (not shown here), have a caption: 'Guess again. Introducing the first cigarette that smells good'. The message in the 2nd page also instructs the viewer, "CALL 1-800-CHELSEA AND GET A FREE T-SHIRT. Just say 'Chelsea smells good.' You must be a smoker and 21 years of age or older." At the lower end of 2nd page, in a white box, surgeon general's warning was included as follows: "SURGEON GENERAL'S WARNING: Quitting Smoking Now Greatly Reduces Serious Risks to Your Health." Also mentioned is the data: "11 mg. 'tar', 0.9 mg nico-tine av. per cigarette by FTC method." The 3rd page provides a pop-out advertisement for a box of Chelsea cigarette and a Chelsea-tagged T-shirt. About the T-shirt, there was this description: 'One size fits all with this stylish, 100% cotton T-shirt with padded shoulders."

Kantha S. S. 285

labeling on the "absence of nicotine" was also recorded. According to Hutzler et al95)., "Ten out of 28 products had been declared 'free-of-nico-tine' by the manufacturer. Among these ten, seven liquids were identi-fied containing nicotine in the range of 0.1 - 15 μg/ml."

Though the merits of e-cigarettes were promoted by its advocates in that, (1) it contains lesser number of dangerous chemicals compared to those released from burning tobacco, (2) it don't release tar of conven-tional cigarettes, and (3) it has a lower potential disease burden than conventional tobacco cigarettes40), the demerits of e-cigarette use have also come to prominence lately96,113-120).

Tobacco Industry's Devious Methods

Tobacco industry's devious methods in promoting tobacco use are numerous. Among these, deceptive advertisement to capture the hearts of young women is one. As samples, Figures 1 and 2 present scanned images of an advertisement in blue and light green colors for Chelsea cigarette by R.J. Reynolds in an American magazine, in 1989. Fig.3 present a scanned image of the advertisement for another cigarette Merit Ultra Lights by Philip Morris in an American magazine in 1989. That the big players in the tobacco industry like R.J. Reynolds and Philip Morris, have deep pockets for cigarette advertising in social media is an open secret. In a special report to the New England Journal of Medicine in 1985, Warner opined that, "As long as cigarette advertising remains legal and widespread, its influence on editorial coverage of smoking and health is likely to persist"121). Tobacco industry's nefarious links with the Hollywood movie industry122-124) and muting the anti-tobacco messages by sports events sponsorships, publishing life style magazines for tobac-co marketing125,126) and offering research funding to prominent medical researchers127,128) have been reviewed as well. Covering the first 25 year period of 'talkies', from 1927 to 1951, Lum et al.123) had inferred "Nearly 200 movie actors are known to have simultaneously promoted a tobacco brand and their studios' releases from 1927-51". In one table, Lum et al.123) provided the names of 40 actors (men and women), who were paid for endorsing one particular brand 'Lucky Strike' in 1937-38.

Analysis of tobacco industry documents had proved that the funding tentacles of the tobacco industry had trapped Ernst Wynder127) and Hans Selye128) to tarnish their integrity and reputations, after their death.

CONCLUSION

Other than leading medical journals like the Lancet, British Medical Journal and New England Journal of Medicine, that had promoted anti-smoking messages and published significant number of original research reports and reviews against the prevailing popularity of nico-tine inhalation via e-cigarettes, the services of specialty journals such as Tobacco Control (volume 1 appeared in 1992), Tobacco Induced Diseases (volume 1 appeared in 2003) as well as Nicotine and Tobacco Research (volume 1 appeared in 1999) appears vital to combat the abuse of nicotine.

COMPETING INTEREST

I declare that I have no competing interests, other than the fact that my father's death due to bladder cancer in 2003, at the age of 80, was hastened by his passion to munch smoked tobacco for stress relief.

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