Risk Parameters of Consuming Smokeless Tobacco “Madgha”: A Study in Aswan, Upper Egypt View PDF

^*Shaimaa S Abdlrheem
Department Of Public Health And Community Medicine, Faculty Of Medicine, Aswan University, Egypt

^*Corresponding Author:

Shaimaa S Abdlrheem
Department Of Public Health And Community Medicine, Faculty Of Medicine, Aswan University, Egypt
Email:dr_shimaasayed@yahoo.com

Published on: 2020-03-02

Abstract

Background: Smokeless tobacco (ST) use is a public practice in different places of the world. In Upper Egypt, Madgha is one of the chewable used tobacco consumed by individuals of different age groups. Being available and inexpensive has led to high consumption.
Objective: The current study aimed to examine the effect of Madgha on some hematological and biochemical parameters for Madgha users in Aswan.
Methods: We collected blood samples from 180 apparently healthy subjects, Madgha users (n=90) and their controls (n=90). Standard methods were used to examine the hematological and biochemical parameters.
Results: In a comparison of Madgha users with their controls, the results of hematological parameters showed a significant elevation in total white blood cell count, neutrophil and serum ESR, and a significant reduction in the percentage of lymphocytes and monocytes. Higher biochemical parameters like CRP, lipid contents, fasting blood glucose, and liver enzymes were observed in the blood samples of Madgha users. And a positive correlation between each of the white blood cell counts, platelet count, and CRP with the long duration of Madgha intake was reported in the study.
Conclusion: The study concluded that the consumption of Madgha might have harmed both hematological and biochemical parameters. Awareness is immensely needed to stop Madgha’s usage and safeguard people’s health in Aswan.

Keywords

Smokeless Tobacco; ST users; Madgha; Hematological and Biochemical parameters

Introduction

Over the years, the consumption of tobacco products remains animportant public health issue. Nicotine is present in different tobacco forms, including smoking and smokeless tobacco (ST) [1]. Smokeless tobacco (ST) use is a public practice in different places of the world. Smokeless tobacco (ST) is used without combustion and this obliterates the hazard of direct exposure to theburnedtoxic compounds to the users and the individuals around them [2]. There have been significant differences in the structure and manufacturing of ST products, the two main formsof which ST comes in are snuff and chewing tobacco. Smokelesstobacco products are called Shammain Saudi Arabia, Saot in Sudan, Tombak in Yamen, and Madgha in Egypt [3].

In Upper Egypt, Madgha is one of thechewable used tobacco consumed by individuals of different age groups, formed ofpowdered dried tobacco leaves mixed with Atron²a stony salty material coming from Sudanese mountains². Madghais sold in packs where each onecomposed of 12 pieces,each pieceis 3 grams, where it is used by placing a piece between lower labile mucosa and gum for 10 min, the user spits out or swallows it [4]. Being available and inexpensive has led to high consumption. Madgha is highly prevalent among individuals with a lowsocioeconomic standard. They believe that the health hazardsrelated to ST use are less than those related to smoked tobacco also they think ST has a curative effect on relieving pain and work-related stress [5].

Smokeless tobacco is easily anaddictive substance as it has a high amount of nicotineas well as numerous cancer-causing substances compared to smoking tobacco [6]. Using any form of ST is anextraordinary health incident for the body organs whichmainlylinked with systemic illnesses depending on the way of consuming Madgha and its nature of the toxic products.2 Earlier studies showed that ST has a durable association with a variety of oral, cardiovascular, respiratory, and renal diseases. ST seems to beinfluential in cellular and metabolic changes inside human bodies, particularly with long use duration [7,8]. By 2020, it is predicted that around 10 million deaths may arise if the continuous use pattern of ST is kept on [9]. The effect of ST use on some hematologic and biochemical parameters has been discussed by the earlier studies [10-12]. Still, evidence shows that persons are not well informed about the risks ofsmokeless tobacco. The monitoring of these parameters for ST users is entirely required to guide them about ST health hazards. This study aims to minimize the trend of Madgha consuming in Upper Egypt.

The study aims to examine the effect ofMadgha use on some hematological and biochemical parameters in Madgha users and to educate them about the health hazards of smokeless tobacco.

Methods

Study design and duration

A case-control study design was conducted over two months from August to September 2017.

Study subject and sampling

The study subjects included healthy individuals aged 18-50 years oldwho came to Aswan university hospital as visitors to their relatives who had been admitted to inpatient departments.

The sample size was calculated using G power program version 3.1.9.2. in order to detect a significance difference in mean value of Erythrocyte Sedimentation Rate (ESR) between two independent groups under the study, and based on the followinginput parameters being one tailed, with the effect size of0.49 as detected in Biswas et al. study8 and with analpha error of 0,05, power of 95%, and the allocation ratio between controls to cases was 1:1, thereforeninety subjects were included in each study group with total of 180 subjects. The required sample was collected by convenience sampling. The refusal rate was found to be 6.7%, (12 subjects refused to contribute as they did not want to go through any laboratory investigation), those subjects were not included in the study. Therecruited studied persons were divided into two groups:

i) Madgha-users, people who use only ST (n=90), not any other form of tobacco, regularly >20 times per week for at least 3 consecutive years.
ii) Non-users (n=90), persons who do not use any type of tobacco. The controls were age-and sex-matched for Madgha users. People who were taking any regular medication, and those with a recent history of infection (within the last month) and people of any vascular, systemic and metabolic diseases, or immunocompromised conditions, alcoholics, and women in pregnancy or inhormonal replacement therapy were excluded from this study.

Data collection

Our data was collected through direct interviews, clinical examinationand laboratory analyses. The direct interview was done to get complete demographicdata, clinical history and information on Madgha consumption. After the study participants completed their data with the interviewers, clinical and anthropometric examinations were done for allsubjects and blood pressure were measured twice in a sitting position, with 5 min apart.

In all the subjects 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. Each test procedure was carried out between 7-10 a.m. The subjects underwent the following tests: Blood pressure examination to rule out hypertension, estimation of the serum lipid profile, evaluation of the fasting and post prandial blood glucose levels to rule out diabetes, red blood cell count, total leukocyte count, differential leukocyte count, platelet count, packed cell volume, hemoglobin, serum urea and creatinine levels. Complete blood cell count was analyzed by CELL-DYN 3700 fully automatic haematological analyzer.

Regarding laboratory analyses,somehematological and biochemical parameterswere tested for ST-usersand non-users, and then compared. To examine the studied parameters, venous blood samples (7 ml) were drawn from each subject between 7-10 a.m. under strict aseptic conditions and after 12 hoursof overnight fasting. Each sample was divided into 3 parts;the first part (2 ml) was collected into tubes containing anticoagulant (K3 EDTA)used for CBC and differential count, the second part (2ml) was collected into tubescontaining (0.5 ml) 3.8% Sodium citrate anticoagulant used for ESR estimation, and the third part (3 ml) was allowed to clot in Wassermann tubes. Sera were obtained by centrifugation and divided into aliquots and used for liver enzymes, CRP, fasting blood glucose level, total lipid profile, serum creatinine, and ureaestimation. Hematological parameters such as hemoglobin, red blood cells, and leukocyte total and differential count were done on (Cell Dyne 3700, Abbott diag. USA) automated blood cellcounteract. ESR estimation by the Westergrenmethod.13The biochemical parameters including fasting blood glucose level, total lipid profile, serum creatinine, urea, serum AST, ALT, ALP levels were measured on an automated chemistry analyzer(APX pentra 400, Horiba diag.France). CRP estimation by rapid latex agglutination kit (AVITEX- CRP) (Omega Diag. Ltd 2015).In the end, every user was instructed by one of the authors for 10 minutes about health hazards of smokeless tobacco on body systems and possible links to oral diseases other cancers and cardiovascular disease.

Statistical analysis

Data were analyzed using SPSS V. 23.0 and the mean ± standard deviation (SD) were calculated for the selected hematologic and biochemical parameters. The student t-test was used to test the significance of thevariance of the study parameters between Madgha users and controls. Qi squaretest and Pearson correlation were also used. In all cases, a P-value <0.05 was considered statistically significant.

Ethical consideration

The approval of the study was carried by the Ethical Review Committee of Aswan Faculty of Medicine before starting to work on the study. The study was in accord with the Second Declaration of Helsinki. We informed the study subjects with the details of the study procedures, and all subjects signed a written informed consent before their participation in the study.In case subjects were not able to read, an impartial witnesshad to be there at that time to explain accurately the content of the informed consent and sign it on the behalf of the subject in case of his\her approval.

Results

The baseline data of Madgha users and their controls are presented in table (1), there were statistically significant differences between the two groups regarding residence, education and working for cash in last 12 months,more than half percent of Madgha consumers (55.5%) were from rural areas. Illiterate/Read and write subjects represented approximately forty percent of Madgha consumers (37.8%) and about one-third of them (33.3%) were not working for cash in the last 12 months.

In comparison to the control group, it was found that Madgha consumers experienced a significant elevation in blood pressure either systolic or diastolic (P< 0.05), while the rest of the explanatoryvariables in this table were not significant (P> 0.05) (Table 1).

Table 1: Baseline characteristic of the study population.

Characteristics	Madgha -users (n= 90)		Non -users (n= 90)		P value
Characteristics	No.	%	No.	%	P value
Age in years:Mean ± SD (Range)	31.73 ± 7.44 (18 - 45)		31.47 ± 7.34 (19- 47)		0.194
Gender
Male	60	66.7	62	68.9	0.122
Female	30	33.3	28	31.1	0.122
Residence
Urban	40	44.4	60	66.7	0.011
Rural	50	55.5	30	33.3	0.011
Education					0.001
Illiterate / Read and write	34	37.8	14	15.6
Basic	26	28.9	22	24.4
Secondary or above	30	33.3	54	60.0
Working for cash in the last 12 months:
Yes	60	66.7	72	80.0	0.041
No	30	33.3	18	20.0	0.041
Daily vegetable intake:
Yes	12	13.3	18	20.0	0.094
No	78	86.7	72	80.0	0.094
Body mass index BMI: •	27.6±2		29.7±1.9		0.071
Waist circumference (cm)••
Male	0.89 ± 0.31		0.96 ± 0.05		0.064
Female	0.80 ± 0.12		0.82 ± 0.15		0.064
Pulse (beats/ min)	65±23		67±24		0.521
Systolic blood pressure (mmHg): •••	132±9		121±8		0.021
Diastolic blood pressure (mmHg): •••	82±9		74±6		0.011
Madgha use duration (year):			-		-
Mean ± SD (years) 10.3±5.4

Data presented are mean ± SD; NS: Non-Significant P < 0.05;chi square test; Student's t-test

BMI was calculated as body weight (kg) divided by body height (m) squared.
• Waist circumference was measured at the midpoint between the lowest rib and the iliac crest.
•• Blood pressure was measured with a mercury Sphygmomanometer and a standard stethoscope. Systolic blood pressure was recorded at the level when phase 1 Korotkoff sounds were first heard and diastolic blood pressure was recorded at the beginning of phase 5 with the disappearance of sounds.

From the data presented in table,the hematological profile of Madgha users differed from the controls group in the following: They had significantly higher total white cell count and ESR (Table 2). The results of the differential count showed that they had a significantly higher percentage of neutrophil while they had a significantly lower percentage of lymphocyte, monocyte in their blood. Moreover, the red cell count, hemoglobin level, hematocrit, eosinophils and basophils percentages in their blood did not significantly differ from the control group.

Table 2: Effect of Madgha on hematological and biochemical parameters.

Parameters	Madgha -users (n= 90)	Non -users (n= 90)	P-value
Hematological parameters:
Red cell Count(×10¹²/L)	4.9 ± 0.3	4.5 ± 0.2	0.225 (NS)
Hemoglobin gm/dL	14.1 ± 2.0	13.1 ± 1.1	0.095 (NS)
Hematocrit (%)	44.6 ± 2.4	40.3 ± 3.0	0.054 (NS)
White cell count(×10⁹/L)	6.3 ± 1.2	5.4 ± 0.3	0.001
Neutrophils (%)	68.5 ± 5.8	56.4 ± 5.3	< 0.001
Lymphocytes (%)	30.7 ± 5.4	38 ± 4.7	< 0.001
Monocytes (%)	1.8 ±1.0	2.9 ± 1.3	< 0.001
Eosinophils (%)	1.9 ± 1.1	1.7 ± 0.8	0.991 (NS)
Basophils (%)	0.6 + 0.6	0.6 + 1.0	0.231 (NS)
Platelet count (×10⁹/L)	295 ± 54	279 ± 42	0.092 (NS)
ESR (mm/ hr) first hour	13.5±3.6	11.1±2.7	0.022 (NS)
PCV (%)	40.44 ± 5.66	41.46 ± 4.88	0.124 (NS)
MCV (fl)	81.97 ± 7.30	82.63 ± 4.70	0.333 (NS)
MCH (pg)	28.31 ± 2.64	27.83 ± 4.30	0.266 (NS)
MCHC (%)	33.70 ± 0.70	33.51 ± 0.66	0.211(NS)
Biochemical parameters:
CRP (mg/l)	2.9±0.42	0.91±0.31	0.041
Fasting blood glucose (mg/dl)	98±19	82±8	0.013
Total cholesterol (mg/dl)	200±33	179±35	<0.001
Triglycerides (mg/dl)	175±50	118±52	<0.001
HDL cholesterol (mg/dl)	38±4	45±7	<0.001
LDL cholesterol (mg/dl)	131±29	107±28	<0.001
Serum creatinine (mg/dl)	1.0 ± 0.2	0.9 ± 0.1	0.076 (NS)
Serum urea (mg/dl)	31.4 ± 6.8	28.8 ± 4.8	0.093 (NS)
AST (U/L)	21.4 ± 5.0	31.4 ± 7.1	<0.001
ALT (U/L)	20.8 ± 12.0	33.5 ± 10.1	<0.001
Alkaline phosphatase(U/L)	73.5 ± 18.6	69.7 ± 22.9	0.155 (NS)

Values represented in the table are the mean ± SD; Student's t-test; NS: Non-Significant; HDL: High-density lipoprotein. LDL: Low-density lipoprotein.

The mean and standard deviation of the studied biochemical parameters for Madgha users and their controls are also presented in table (2). On the contrary to our controls, Madgha consumers had significantly higher levels of C reactive protein, total serum cholesterol, triglycerides, HDL, LDL, and higher fasting blood glucose levels. In addition tohigher levels of serum AST and ALT. However,the other biochemical parameters as serum creatinine, serum urea, and alkaline phosphatase were not significantly different between Madgha consumers and their controls.

Nearly two-thirds of the users (64.4%) consumed Madgha for more than 6 years (Figure 1). And as shown in figure 2 there were 16 subjects consumed Madgha > 6 times per day.

Finding in the below table illustrated that there was a statistically significant positive correlation between duration of Madgha intake and each of the following: Total white cell count (P=0.001), platelet count (P= 0.008) and level of CRP in users' blood (P=0.0312). While there were no significant correlations between the duration of Madgha intake and the other assessed parameters in this table (Table 3).

Table 3: Pearson Correlation between duration of Madgha intake and some parameters.

Variable	rho	P-value
RBCs Count (10¹²/L)	0.083	0.063 (NS)
Hemoglobin gm/dL	-0.177	0.311 (NS)
WBCs (10⁹/L)	0.712	0.001
Platelet Count (10⁹/L)	0.477	0.008
PCV (%)	-0.073	0.841 (NS)
MCV (fl)	-0.062	0.743 (NS)
MCH (pg)	-0.271	0.062 (NS)
MCHC (%)	-0.221	0.071 (NS)
CRP (mg/l)	0.526	0.0312
Fasting Blood Glucose (mg/dL)	-0.161	0.352 (NS)
Total cholesterol (mg/dl)	0.331	0.075 (NS)
Triglycerides (mg/dl)	0.531	0.055 (NS)
AST (U/L)	0.322	0.062 (NS)
ALT (U/L)	0.431	0.078 (NS)
ALP (U/L)	-0.158	0.361 (NS)
Serum Urea (mg/dl)	0.546	0.065 (NS)
Serum Creatinine (mg/dl)	0.246	0.152 (NS)

NS: Non-Significant.

Discussion

Smokeless tobacco is adeep-rootedhuman practice like smoking tobacco. The adverse effect of tobacco products on human systems has been well known for long-lasting years. We conducted the present study to find out whether Madgha causedunfavourable effects on selected hematological and biochemical parameters or not in a group of apparently healthy individuals.

Similar tothe previous studies, the present study observed an increase in total leukocyte count among Madgha users, especially with the long use duration, such an increase might take in consideration the occurrence of tissues inflammation and damages, alsothe nicotine present in smokeless tobacco products speeds up the occurrence of leucocytosis [13-17]. The tobacco-specific nitrosamines present in ST (The most potent carcinogen among the known 28 carcinogens) altered the metabolicstat gradually leading to an increase in the tissue inflammation, apoptosis, and differentblood cell damage.

Like what detected in Mukherjee R, et al.(2013) study, ST usershad higher levels of neutrophils and lower levels of lymphocytes and monocytes in their blood, the observed increase in neutrophil count indicated the initiation of the inflammatory reactions [15].

C-reactive protein (CRP) is one of the primary acute-phase proteins promptly elevated in responseto human tissue inflammations. A high-level of CRP refers to the occurrence of an acute infection. It is measured to monitor the disease progress. 18 Our study agrees with other studies that reported ST is accompanied by higher CRP, and other inflammatory markers [19,20].

The undesirable effects of Madgha intake on lipid profile were seenamong ourST users, the total serum cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol levels were found high in the ST-users group compared to the non -users group. Studies on the use of Gutka conducted among the Indian population showed a similar negative effect on serum cholesterol and fat metabolism [21]. Nicotine released from non-smoked tobacco consumptionstimulates catecholamine secretion that may have raised blood cholesterol levels and increased the risk of expanding lipid-related disorders [22].

A significant increase in the mean value of fasting blood glucose levels was noted among the user participants, and this result is accepted by Jaganmohan P, et al. (2011) study [21]. Our findings supported the fact that nicotine in tobacco may contribute in reducing insulin sensitivity in human tissue [23,24].

Smokeless tobacco products have high fatal systemic toxicity.8 So, the prevention of ST lowers many causes of non-communicable morbidity and mortality.

Study limitations

The small sample size of the current study may have had an impact on the clarityof the results, so theresultscould not be generalized to the total population of the study site.No measurement of the quantity of nicotine or its metabolitewas done for the users due to the unavailability of lab resources at the time of the study.

Conclusion

The consumption of Madgha might have harmed both hematological (viz. increase in white cell count, neutrophil percentages, ESR, and a decrease in the percentage of lymphocytes and monocytes) and biochemical parameters (viz. increase in CRP levels, total lipid profile, and blood glucose levels). A significant positive correlation was detected between the duration of Madgha intake and each of the following parameters: Total white cell count, platelet count, and level of CRP. Awareness is immensely needed to stop Madgha's usage and safeguard people's health in Aswan. Our findings might help in theconduction of an awareness campaign that covers the health hazards of ST products to the users in Upper Egypt, who consumeMadgha as an inexpensive alternative to tobacco smoking. Long-term follow-up studiesare required with detailed measures of tobacco use to determine whether Madgha is a risk factor for most of non-communicabledisorders.