my project on tobacco
tobacco use among adult patients in unth Enugu Nigeria
group members.
NNADI EMMANUEL DOUGLAS
OKORIE MARRY
ARONU IFEOMA
OGAZIECHI KENNETH
CHAPTER ONE
INTRODUCTION
Tobacco is the second major cause of death in the world and is currently responsible for the death of one in ten adults world wide. Tobacco use causes about 5 million deaths each year. If the current smoking pattern continues, it will cause some 10 million deaths each year by 20201, 2. Tobacco smoking, a form of tobacco use has been found to be the chief avoidable cause of death and ill health in the world 2. Out of all that die of tobacco use, WHO estimates that 3 million people worldwide die from smoking above every year at the current level of tobacco smoking. In 1990, WHO reported that Tobacco is the single largest preventable cause of morbidity in the world. It is also report that in the same year, 1.1 billion use tobacco, which represents one third of global adult population3. If one third of the global adult population use tobacco with it numerous devastating problems, the impact on the world economy cannot be over emphasized. A report from WHO Tobacco Free Initiative in 1994 estimated that, the use of tobacco results in annual global net loss of US$200 thousand million. A third of this was found to be in the developing countries1. While the incidence of tobacco use is increasing especially in the developing counties, males are still more likely to smoke and use tobacco than females. The exception is in the white adolescents in whom rates are same for males and females 3. National Institute on Drug Abuse USA reported that there is an increasing use of drugs by young people and the cause was attributed to increasing use of Marijuana. Between, 1995 and 1996, the cigarette use increased from 27.9 percent to 30.4 percent among 10th graders in the United States 4. In Nigeria, tobacco use was found to be more among University students. Here tobacco is the largest abused substance. About 66% of males and 36% of female smoked tobacco.5Among all the health problems associated with tobacco use, cardiovascular and respiratory diseases are well recognized (Source: Wikipedia Foundation). United States centre for Disease control and prevention reports that the main health risk of tobacco pertains to the disease of cardiovascular system. Smoking is the major risk factor for myocardial infarction worldwide. Obstructive pulmonary disease, emphysema and cancers of the lung, larynx and tongue have also been linked to tobacco use. A cross-sectional study done on 97586 construction workers in Sweden revealed that hypertension occur more among smokeless tobacco users7. From the above reports, it is evident that tobacco is a major health problem. It is also evident that lots of work has been done on tobacco in developed countries as compared to this part of the world where there is scanty information on the use of tobacco and its impact on the nation’s health and economy. This is why we have considered this project worthwhile so as to help and uncover the hidden harm tobacco has done and is still doing in our environment. We believe that this will go along way in informing health policy makers to reinforce their campaign against tobacco use in order to check the impending tobacco epidemics.
1.1 GOALS AND OBJECTIVES
General Objectives
To determine the prevalence of tobacco use and its variability with diagnosed disease among UNTH patients from January to June 2006.
Specific Objectives
(i) Determine prevalence of tobacco use among adults patients
(ii) Describe the variability of tobacco prevalence by patients age and sex distribution(iii) Describe the variability of prevalence of tobacco use with diagnosed disease and hospital unit.
(iv) Describe the variability of prevalence of tobacco with prognosis among the patients.
CHAPTER TWO
LITERATURE REVIEW
2.1 BRIEF HISTORY OF TOBACCO
Tobacco has been smoked thousands of years ago. Pipes and cigars were the common forms and were used in Native American Cultures, prior to arrival of European explorers. The practice is depicted in Early Mayan art dating from 1,500 year ago 11. Tobacco is a plant that grows natively in North and South America. It is in the same family as potato, pepper and poisonous night shade, a very deadly plant 10. The seed of tobacco plant is very small. A one once sample contain about 300,000 seeds. It is believed that tobacco began growing in Americas about 6000BC. The tobacco was believed to cure-all; for dressing wounds, painkiller and chewing of tobacco was believed to relieve the pain of toothache. Use of tobacco has grown in popularity over the centuries though not without oppositions and campaign against its use. The 19B, R.J Reynard’s began to market cigarette brand called Carmel10.2.2 FORMS OF TOBACCO
Tobacco can be used in smoking or smokeless forms. Tobacco Smoking is the act of burning the dried or cured leaves of tobacco plant, inhaling the smoke for pleasure, or ritual purposes, for self medication or out of habit and to satisfy addition 9. Smoking tobacco forms include cigarette, cigar, smoking pipes, and hookah. Cigarette smoking is by far the commonest form of tobacco use 11. Smokeless Forms of Tobacco include snuff, licking/sucking, chewing
2.3 CHEMICAL COMPOSITION OF TOBACCO
There are over 4000 chemical compounds that have been found in tobacco smoke which comprise the gaseous phase and the particulate phase11. Tobacco smoke contains the following gases among others Carbon monoxide, Ammonia, Dimethynitrosamine, Formaldehyde, Hydrogen cyanide and Acrolein. The Particulate contents of tobacco include Nicotine, Tar, benzene and Benzo (a) pyrene. Sixty substances are found mainly in the tar which has been found to be carcinogenic. Among all the chemicals, three are outstanding in causing diseases. These are Nicotine, tar and carbon monoxide.
NICOTINE is an important constituent of cigarette smoke. It is an alkaloid that readily crosses the blood-brain barrier12 was it stimulates nicotine receptors in the brain. It is also responsible for the acute pharmacological effects associated with tobacco use which are most likely mediated by catecholamine. The pharmacological effects are; increase in heart rate, blood pressure, coronary artery blood flow, cardiac contractility and out put. It also leads to mobilization of free fatty acids.
CARBON MONOXIDE is a colourless, odourless gas produced during incomplete combustion of fossil fuel or tobacco. It has 200 times more activity for haemoglobin than oxygen. It also binds to other hem-containing compounds such as myoglobin and cytochrome oxidase. It impairs oxygen delivery to peripheral issues12. Other substances such as polonium 210 are associated with cancer of the oral cavity.
2.4 PREVALENCE OF TOBACCO USE
Tobacco use is now a global threat. It is expected that by 2025, the total number of smoker in world will be 1.6 million12. Little wonder the World Health Organization (WHO) set aside. May 31st of every year as World No Tobacco Day. The theme for this year (2007) being “Tobacco, Deadly in any form of disgnise13. The largest number of users of tobacco is in Asia 15. A study done by WHO between 1970 and 1992 showed that while the practice of smoking has become more prevalent among men in low and middle income countries, there has been an overall decline in use among men in high income countries 14. There is a wide variation in regional pattern in smoking world wide. In 1997, data on the number of smokers in each region of the world was assessed by WHO in more than 80 separate studies. This showed a wide variation between regions and gender variability. Eastern Asia and Pacific had the highest number of smokers, a total of 401 million which represents 35% of all smokers world wide. The world wide sex prevalence is 59% males and 41% females. The Sub-Saharan African region has the least number of smokers; 67 million smokers, that is about 6% of smokers world wide. Sex prevalence gives a picture of 33% males and 10% females.14 The Global Youth Tobacco Survey was begun in 1999 as joint effort by WHO:, The US centre for disease control and prevention and the Canadian public health association. The CDC reports (2005) states that 17.3% of all respondents currently used some type of tobacco product. The overall rates of cigarette smoking and other tobacco use were, 8.9% and 11.2% respectively. Europe and America had the highest rates of smoking while South East Asia had the lowest at 4.3%. However, South East Asia had the highest rate of smokeless tobacco use.14 A study by the Department of General and Applied Psychology, University of Jos (Nigeria) put the overall prevalence of tobacco use (smoking cigarette, cigars/pipe and snuff) the Nigeria at 50.1% 19. Cigarette smokers accounted for 22.5% of the total prevalence while cigar/pipe tobacco and snuff users were 17.9% and 9.6% respectively 19. Generally females smoked less than males. In the second decade of life where smoking is more rampant, the prevalence of smoking among males is 21.5% as against 4.5% among females.2.5 RESPIRATORY DISEASES AND TOBACCO
Globally many diseases have been attributed to Tobacco use. In 1930, the lung cancer death rate for men was 4.9 per 100,000. In 1990 the rate had increased to 75.6 per 100,000 15. This income has been associated with increase in tobacco use during this period. Medical research has shown that smoking was a definite cause of cancer of the lungs, larynx and many others.16The world cancer reports indicates that the relative risk for cancer of oral cavity, pharynx and larynx etc is greater than six among smokers and that cancer of the lungs is 20-30 folds higher among smokers.17Chronic obstructive airway disease (COPD) is characterized by abnormalities in the lungs that make it difficult to exhale normally. Generally, two distinct diseases are involved: Emphysema and chronic bronchitis. According to the WHO, 75% of deaths from COPD that occur in developed countries are directly related to smoking tobacco 22. There are an estimated 1.9 million people suffering with emphysema in United States. Of these 55.5% are men and 44.5% are women. Between 1982 and 1995 emphysema increased in women by 14.8% probably due to increase rate of smoking among women.22 Tobacco use is the number one risk factor for COPD and heavy smokers are at greater risk. Cigarette smokers are at greater risk than cigar and pipe smokers. All smokers are at greater risk than life long non smokers.22 Cigarette smoking is the most important cause of chronic bronchitis and it increases the risk of dying23. Studies show that cigarette smokers are 10 times more likely to develop emphysema than those who do not smoke. Smokers are also predisposed to pneumonia. A tobacco crippled heart cannot stand the extra strain that is placed upon it during any disease accompanied by high temperatures and high blood pressure. Pneumonia frequently weeds out those who possess some organic disease and it’s filed of operation affects mainly men due to their use of tobacco.23 Seven-tenths of those who became users of tobacco fall victim to tuberculosis. A report in 45 New York Elite Journal of Medicine (#14) 1539-1542 (15 July, 1945) states that smoking is a predisposing cause of tuberculosis of the lungs 23.
2.6 TOBACCO AND BONE HEALTH
There is evidence that tobacco use caused decrease in bone density and research studies have identified cigarette smoking as a risk factor for osteoporosis more than 20 years ago. In addition most studies on effect of smoking suggest that smoking increases the risk of having a fracture some of the statements from these studies are as follows:· The longer you smoke and the more cigarettes you consume, the greater your risk of fracture in old age.· That those who smoke and sustain fracture take a longer time to heal when compared to non-smokers.· There is also a significant loss of bone mass among men and women who smoke.· That exposure to second hand smoking increases the risk of developing low bone mass 23.A significant improvement was found in those who quit smoking.
2.7 TOBACCO AND EYE DISEASES
Many people are aware of the adverse health effect of tobacco but remain unaware of the effect on the eye. The eye diseases associated with tobacco use include; nuclear cataract, thyroid eye disease and eye related macular degeneration. A cross sectional study done in UK involving 12468 adults smokers and non smokers showed a few fold incurred age adjusted risk of age related macular degeneration compared to non-smokers. Studies have shown that current smokers and ex-smokers are more likely to develop acute macular degeneration (AMD) than people who never smoked.25 Some studies suggests that smoking may be linked to diabetic retinopathy or damage to blood vessels in the retina. Owen et al estimated 214000 UK residents to have visual impairment and 71000 individuals to be blind because of age related macular degeneration. Estimates showed that 53,900 UK residents older than 69 years may have visual impairment because of age elated macular degeneration attributable to tobacco smoking of which 17800 are blind.26
2.8 TOBACCO AND SKIN
Tobacco use did not spare the skin among the systems affected. Smoking more than triples the risk of developing Squamous cell carcinoma (Netherlands). Jan Nico Boumes Barink, states that most people are aware that exposure to sunlight is a risk factor for skin cancer but no one knows that smoking is an important and independent risk factor for skin cancer 26. His team of researchers compared the risk of smoking in 580 patients with different types of skin cancers, and in 386 people without skin cancer. It was discovered that smoking was only associated with development of squamous cell carcinoma. They concluded that smokers were 3.3 times more likely to develop skin cancer and the risk dropped to 1.9 in former smokers. There was also evidence in their research that the number of cigarettes smoked and cancer risk are related 26.
2.9 TOBACCO AND CARDIOVASCULAR DISEASES
The adverse effect of tobacco, use on the cardiovascular system cannot be over emphasized. Smoking is the single most preventable causes of heart diseases in the US.27 Smoking triples the risk of drying from heart disease.28 Studies have also shown that cigarette smoking is responsible for 40% of heart diseases in those under 65 years of age.27 According to the same report, tobacco was found to increase the risk of the following cardiovascular diseases. Atherosclerosis, Rheumatic heart disease, Hypertension, Ischemic heart disease, Cardiac arrest, cerebrovascular disease, Artic aneurysms and Coronary heart disease. About 30% of all heart disease deaths each year are caused by cigarette smoking 27. A similar report identifies that smoking is a major cause of coronary heart disease which leads to heart attack 28. As many as 30% of all coronary heart disease deaths in US each year are attributable to cigarette smoking with the risk being strongly dose related 29. Light smoking (1-4 cigarettes per day) caused an increase in coronary heart disease to 11% compared to only 3.7% for non-smokers. Tobacco smoke contains high levels of carbon monoxide. This affects the heart by reducing the amount of oxygen the blood is able to carry. This means that the heart and other vital organs don’t receive enough oxygen to perform every day function. People who use tobacco are more likely to have heart attacks, high blood pressure, blood clots, strokes, haemorrhages, aneurysms and other disorders of the cardiovascular system 27. Smoking increases the risk of cerebrovascular accidents by 40% in men and 60% in women 27.
2.10 TOBACCO AND THE DIGESTIVE SYSTEM
Tobacco use has a number of effects on the digestive system ranging from benign conditions through malignancies. Smoking increases the risk of gastric and duodenal ulcers. There is also higher risk of complications to heal on standard treatment regimen in smokers.30 Cigarette smoking increases the risk of developing oral cancers.31 The risk is higher among those that smoke pipes and cigars. Tobacco has also been implicated in pharyngeal, laryngeal and oesophageal, as well as cancers of the stomach and pancreas31, it is estimated that tobacco use causes most of the 12300 and 30,200 new cases of oesophageal and oropharyngeal malignancies respectively annually in the United States.31 Leukoplakia defined by WHO as any white patch or plague that cannot be characterized clinically or pathologically as any other disease. Tobacco use is a major etiologic factor of this condition.32 The incidence of the lesion among Indians 60 years of age who smoke or chew tobacco is 20% and only 1% in non-tobacco users of same age.32
2.11 TOBACCO USE AND URINARY SYSTEM
The kidneys are part of the vital organs in the body and is not excluded among the organs affected by tobacco use. A number of urinary system diseases traceable to tobacco use include; Renal Cell Carcinoma: renal failure, bladder cancer and diabetic nephropathy. The 2004 surgeon General’s report identifies smoking as a cause of carcinoma of the kidney and an estimated 11,900 people died from the disease.31 Cigarette smoke has been found to contain cadmium which can cause irreversible renal damage when an individual is exposed to a low dose for a long time 33. The presentation could be blood in urine. Smoking also increase the risk of end-stage renal failure in men with primary rend disease such as glomerulonephritis and adult polycystic kidney disease.34 Smoking has been identified as being responsible for increased incidence of bladder carcinoma in United States. An estimated 57900 people have the disease while 12500 persons have died from the disease in 2002 31. Tobacco smoking is a risk factor for onset and progression of diabetic nephropathy to end stage renal failure 34.
2.12 TOBACCO USE AND REPRODUCTION
Tobacco use also has effect on the reproductive system. It affects both the structures as well as the physiology of pregnancy and its out come. A study by Difranza and Lew showed that tobacco use is an important cause of abortions in pregnant mothers. Smoking has also been implicated in the incidence of low birth weight babies, infant morbidity and mortality as well as Sudden Infant Death Syndrome (SIDS)..35 Tobacco smoking increases the risk of erectile dysfunction by about 50% for men in their 30s and 40s.36 An estimated 120,000 men in the United Kingdom in their 30s and 40s are impotent as a direct consequence of smoking.36 Other effects of smoking on male sexual health include; reduces volume of ejaculate, low sperm count, abnormal sperm shape, and impaired sperm motility.36 Smoking is a recognized risk factor for malignancy of the cervix and the risk increases with duration of smoking.31
CHAPTER THREE
METHODOLOGY
3.1 BACKGROUND
University of Nigeria Teaching Hospital (UNTH) which is our selected place of study is a tertiary Health Institution Located in the capital city of Enugu State. The Hospital started early in the 20th century and became a teaching hospital in July 1, 1970. UNTH receives referrals from; Enugu, Anambra, Ebonyi, Abia, Imo, Cross River, Akwa Ibom, Bayelsa, Edo and Delta States. As at 2006 there were 24 wards and 702 beds in the Hospital. In 2006 a total 11,661 new patients visited the hospital for the first time. An additional 6259 were seen at the accident and emergency section of the hospital. In this same year 48,330 old patients visited the hospital giving a total of 59,991 for both freshly registered and old patients that were seen.
3.2 STUDY DESIGN
A retrospective study design was used in this work.
3.3 SAMPLING PLAN
Our target population was the adult patients seen in UNTH between January and June 2006. The study population included all the adult patients who visited the hospital for the first time in the following clinics.(i) Dental Clinic(ii) Ear-Nose – and Throat (ENT)(iii) Chest ClinicA total of 1500 patients visited the hospital during this period (Jan – June) 2006 among these 1960 were under 18 years of age, while 540 were 18 year and above. We studied a total of 540 patients how were 18 years and above.
3.4 SURVEY INSTRUMENT AND DATA COLLECTION
We used a study proforma, a copy of which is attached at the end of this work. Data was collected from the case notes of these patients. From the case notes, we obtained the following data:
1. Folder number
2. Date of registration (Date first seen)
3. Hospital Section (Unit)
4. Age
5. Sex
6. Use or nor-use of tobacco
7. Diagnosed disease
8. Method of diagnosis of disease; Clinical, Microbiological, Biochemical, Histological, Radiological.
9. Prognosis
10. Date when last seen.
3.5 METHOD OF DATA ANALYSIS
This was done with the use of computer using the EPI INFO 3.3.2 Version 2005 software. Data were presented by means of tables, bar charts and pie charts.
3.6 DEFINITION OF KEY VARIABLES
(1) Adult Any patient who is 18 years and above.
(2) Diagnosed Disease The definitive diagnosis male by a medical consultant as confirmed by clinical, radiological microbiological, histological or biochemical tests.
(3) Tobacco use was classified as
(a) Current Tobacco UserTobacco use at the onset of the illness.
(b)Ex-User: Had stopped tobacco use before the onset of illness.
©Non-User: Those who have never used tobacco before.
(4) Disease Classification: This is based on the system involved.
(5) Prognosis: Each patient will be classified as alive or dead when last seen by the hospital health team.
3.7 PLANS FOR RELIABILITY OF DATA
(1) The data collected were as recorded in the patients’ case notes.
(2) These data were cross-checked with patients’ records kept in the clinics and the Ward.
3.8 ETHICAL CONSIDERATIONS(1) We handled the folders carefully to avoid destruction or loss of the contents.(2) Names of patients and other confidential information about the patients were handled as such. We did not disclose this information to any person outside the research group.
CHAPTER FOUR
RESULTS
A total of 540 adult patients were studied. Two hundred and sixty nine (59.8%) were females and 271(50.2%) males. Within this period ENT unit had the highest number of adult patients 370 (68.5%) while the Dental unit had the lowest 76(14.1%) number of cases. See table.
TABLE 1: PATIENTS BY SE X AND HOSPITAL UNIT
| CLINIC | MALENo | FEMALENo | TOTALNo (%) |
| CHEST | 49 | 45 | 94 |
| ENT | 187 | 183 | 370 |
| DENTAL | 35 | 41 | 76 |
| TOTAL | 271 | 269 | 540 |
TABLE 2: TOBACCO USE BY PATIENTS SEX
| TOBACCO USE | MALENo (%) | FEMALE No (%) | TOTALNo (%) |
| CURRENT USER | 18 (6.6) | 2 (0.7) | 20(3.7) |
| EX-USER | 20 (7.4) | 3 (1.4) | 23 (4.3) |
| NON-USER | 93 (34.3) | 96 (35.7) | 189 (35.0) |
| UNKNOWN | 140(51.7) | 168 (62.5) | 308 (51.6) |
| TOTAL | 271 (100) | 269 (100) | 540 (100) |
There was no documentation about use of tobacco for 308(51.6%) of these patients. Among those that were documented, 23 (4.3%) were ex-tobacco users while 20 (3.7%) were current tobacco users. The males had higher rate of tobacco use with 38 cases 14.0%) while females had 5 cases (2.1%). See Table 2.
TABLE 3: PREVALENCE OF TOBACCO USE BY AGE
| Age group(years) | Ever usersNo (%) | Non usersNo (%) | Unknown statusNo (%) | TotalNo (%) |
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