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A study of dose dependant effect of cigarette smoking on lipid profile.

INTRODUCTION: Cigarette smoking is a habit which starts usually in teenage. Cigarette smoke is a heterogeneous aerosol produced by incomplete combustion of tobacco leaf. It contains many pharmacologically active, antigenic, cytotoxic, mutagenic and carcinogenic substances.

Indians are prone for CAD due to sedentary lifestyle, hypertension, obesity, hypercholesterolemia, Insulin resistance. (1) Dramatic increase in coronary artery disease in the next twenty years was predicted by Reddy K S in 1998. (2) Smoking produces adverse effects on lipid profile, therefore increasing the cardiovascular disease risk. The high prevalence of an atherogenic lipid profile in smokers makes them prone to develop premature atherosclerosis. (3)

All the ill effects are more with more number of cigarettes and for a prolonged period. Many researchers had already shown significant change of lipid profile in smokers. (4) The more the number of cigarettes smoked per day the greater is the risk of CAD. (5,6)

Passive smoking also produces similar effects but to a lesser extent.

Cessation of smoking brings down the lipid abnormalities and brings down the risk of CAD. (7) The World Health Report (8) (2003) concludes that consumption of tobacco products are the world's leading preventable cause of death, responsible for about 5 million deaths a year mostly in poor countries and poor populations. The toll will double in 20 years unless available and effective interventions are urgently and widely adopted.

AIMS:

1. To evaluate the variation in lipid profile with respect to number of cigarettes smoked (In packs) per day.

2. To evaluate the variation in lipid profile with respect to duration of cigarette smoking (In years).

MATERIALS AND METHODS: The study was conducted in the Department of Physiology, Biochemistry and PHC Ettumanoor of Government Medical College, Kottayam after obtaining clearance from Institutional Ethical Committee. Present study includes 240 healthy male subjects between age of 20-59 years, 120 non-smokers and 120 smokers. The smokers were grouped according to the average number of cigarettes in packs (each packet containing ten cigarettes) smoked per day and number of years of smoking.

The inclusion criteria are non-smokers and smokers between age 20 and 59 years, who are otherwise healthy.

The exclusion criteria includes subjects below 20 years and above 59 years, those with H/O Hypertension, Diabetes Mellitus, Endocrine disorders, Hyper-lipidemia and those on drugs like p blockers, Diuretics, Steroids and Anticonvulsants. Details such as name, age, address, occupation, history of smoking, dietary history, history of diabetes, hypertension, hyperlipidemia and use of any drugs were enquired and noted in the performa. Informed consent was obtained from subjects.

The subjects were asked to refrain from non-vegetarian diet for three days. Blood sample (5ml) was collected after an overnight fasting, using disposable syringe and needle under aseptic precautions. Samples were kept unshaken for half an hour, serum was separated by centrifuging at 3000 rpm for 5 minutes. Serum TC was done using kit AGAPPE diagnostics, TG using Enzyme calorimetric test and HDL-C using Phosphotungstic Acid method. Concentrations were measured colorimetrically.

LDL-C was calculated using Friede waldNs formula.

LDL cholesterol = Total cholesterol--(VLDL Cholesterol + HDL Cholesterol), where

VLDL cholesterol= Triglyceride/5

Ratio of TC/HDL-C and LDL-C/HDL-C was also calculated.

Statistical analysis was done using ANOVA test. The calculated F value is compared with that given in F table and level of significance was determined.

RESULTS: Table 1a shows Comparison of mean total cholesterol based on number of cigarettes (in packs) smoked per day. There is statistically significant increase in mean total cholesterol with increase in number of cigarettes smoked per day.

Table 1b shows comparison of mean total cholesterol based on duration of smoking. There is increase in mean cholesterol with increase in number of years of smoking and is statistically significant.

Table 2a shows Comparison of mean TG based on number of cigarettes (in packs) smoked per day. There is statistically significant increase in mean triglyceride with increase in number of cigarettes smoked per day.

Table 2b shows comparison of mean TG based on duration of smoking. There is increase in mean triglyceride with increase in number of years of smoking and is statistically significant.

Table 3a shows comparison of mean LDL cholesterol based on number of cigarettes (In packs) smoked per day. There is statistically significant increase in mean low density lipoprotein cholesterol with increase in number of cigarettes smoked per day.

Table 3b shows comparison of mean LDL Cholesterol based on duration of smoking. There is increase in mean low density lipoprotein cholesterol with increase in number of years of smoking and is statistically significant.

Table 4a shows comparison of mean HDL cholesterol based on number of cigarettes (In packs) smoked per day. There is statistically significant decrease in mean HDL cholesterol with increase in number of cigarettes smoked per day.

Table 4b shows comparison of mean HDL Cholesterol based on duration of smoking. There is decrease in mean HDL cholesterol with increase in number of years of smoking and is statistically significant.

Table 5a shows comparison of mean TC/HDL-C based on number of cigarettes (In packs) smoked per day. There is statistically significant increase in mean ratio of total cholesterol to high density lipoproteins with increase in number of cigarettes smoked per day.

Table 5 b shows comparison of mean TC/HDL-C based on duration of smoking. There is increase in mean ratio of total cholesterol to high density lipoproteins with increase in number of years of smoking and is statistically significant.

Table 6a shows comparison of mean LDL-C/HDL-C based on number of cigarettes (In packs) smoked per day. There is statistically significant increase in ratio of mean low density lipoprotein to high density lipoprotein cholesterol with increase in number of cigarettes smoked per day.

Table 6 b shows comparison of mean LDL-C/HDL-C based on duration of smoking. There is increase in mean ratio of low density lipoprotein to high density lipoprotein cholesterol with increase in number of years of smoking and is statistically significant.

DISCUSSION AND CONCLUSION: Smoking was not accepted as a bonafide hazard in the development of heart disease till Framingham study established smoking as an important risk factor of coronary artery disease. This factor could be modified to bring down occurrence of coronary artery disease. (9, 10) Risk of coronary artery disease and ischemic stroke increased by smoking. (11) There is a strong link between cigarette smoking and high rates of cardio vascular morbidity and mortality. (12,13) The risk was found to be fifteen times more in smokers. 14 In India smoking has also been correlated with increased mortality from pulmonary tuberculosis (15).

There is a dose dependant relation of increasing total cholesterol, triglycerides, low density lipoproteins and a decreasing high density lipoproteins with smoking. (16) No significant change was found with LDL-C by (17) Seidel. Increase in total Cholesterol and LDL-C increase were considered to be important risk factors for CAD. (18) Serum HDL-C levels were found to be low in smokers irrespective of the number of cigarettes smoked by Rosenson (19) and this is an independent risk prediction factor of CAD. (20)

The ratio of TC/HDL-C was found to be (> 3.5 ) and ratio of LDL-C/HDLC (>4.5) was found to be higher in smokers, (21) and the increase is more with more dose of smoking. Higher the value of the ratios, higher is the risk of CAD. (22)

Our findings of high levels of total cholesterol, triglycerides, low density lipoprotein & low levels of high density lipoproteins with increased number of cigarettes smoked per day and increased years of smoking are in accordance with several studies. (23,24,25 26)

Myocardial infarction rates are directly related to amount and duration of cigarettes smoking. (27) The rate of reinfarction and mortality due to coronary artery disease also has a direct relationship with dose. (28) Cessation of smoking brings down the cardiovascular risk by several years. (29) No other intervention for cardiovascular disease is likely to be as cost effective as smoking cessation and is included in the nondrug regime of Hypertension protocol. (30)

Thus from the present study it is inferred that higher the number of cigarettes smoked per day or longer the duration of smoking, higher is its influence on lipid profile values towards atherogenic side. It implies that more the number of cigarettes smoked per day or more the number of years of smoking, more will be the risk of coronary artery disease.

DOI: 10.14260/jemds/2015/169

ACKNOWLEDGEMENT: I sincerely thank Almighty, my family and friends for guiding me to present this research work. I am thankful to Dr. Balachandran. J for his support in the statistical analysis and final editing. My heartfelt regards to all the participants of the study whose co-operation has helped me to do this work possible.

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(1.) Rajeeve Guptha. Prevention of coronary heart disease among Indians--Focus on Primary Prevention. JIMA 2000; 98:703-09.

(2.) Reddy KS, Yusuf. Emerging epidemic of CVD in the developing countries. Circulation. 1998; 97: 596-601.

(3.) Raya. K Al Bayati, Hassanian K, Al Bairanani, Zahra S, Al Garawi. Cigarette smoking And Accompanied Alterations in Lipid Profile in a group of students in Al-Mustansiriayh University. National Journal of Chemistry 2009; 35:521-27

(4.) Waheeb D M Alharbi.Influence of cigarette smoking on lipid profile in male university students. Pakisthan Journal of Pharmacology 2011; 28:45-49.

(5.) Doyle J T, Dawber J R, Kannel WB, Kinch SH Khan H A.The relationship of cigarette smoking to coronary heart disease. The second report of the combined experience of The Albany. New York and Framingham Massachusettes Studies. Journal of the American Medical Association 1964; 190: 886-90.

(6.) Khan H A. The Dorn study of smoking and mortality among U S veterans. Report on 8 % years observation in Haenszel W (Edition).Epidemiological Approaches to the study of cancer and other chronic diseases. National Cancer Institute of Health, National Cancer Institute 1966; January:1-125.

(7.) Hammond E C, Garfinkel L. Coronary Heart Disease, Stroke and aortic aneurysm. Archives of Environmental Health1969; 19(2):167-82.

(8.) World Health Report 2003. Neglected global epidemics: three growing threats. Geneva. World Health Organization 2003; 85-95.

(9.) Kannel WB. Am J Cardiol 1976; 38:46.

(10.) Krishna Swamy S, Richard J, Prasad MK. Association between cigarette smoking coronary artery disease in patients in India. How quantitative is it? An assessment by selective coronary arteriography. Intern J Cardiol 1991; 31:305-12.

(11.) Pias P Pogue, J Gerstein H. Risk factor for acute MI in Indians-a case control study. Lancet 1996; 348; 358-63.

(12.) Hammond E C, Horn D. Smoking and death rates-Report on forty four months follow up of 187, 783 men. JAMA 1968; 166:1294-1308.

(13.) Wilhelmsen L. Coronary Heart Disease, epidimiology of smoking and intervention studies of smoking. Am Heart J 1988; 115: 242-49.

(14.) Doll R and Peto R. Mortality in relation to smoking-20 years observation in male British Doctors.Br Med J1976;2(6051):1525-36.

(15.) Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43000 adult male deaths and 35000 controls. Lancet 2003; 362: 507-15.

(16.) Mero N et al. Decreased postprandial high density lipoprotein cholesterol and apolip-AI-E in normolipidemic smoking men: relation with lipid transfer proteins and LCAT activities. J Lipid Research 1998; 39: 1493-1502.

(17.) Seidel D, Cremer P, Elster H, Weise M, Wieland H. lnfluence of smoking on plasma lipoprotein profile. Kim Wochanschr 1989; 62 Suppl: 18-22.

(18.) Careton R A, Dwyer J, Finberg L. Report of the expert panel on population strategies for blood cholesterol reduction. A statement from the National Cholesterol Education Program. Circulation 1991; 83: 2154-232.

(19.) Rosenson R S. Low level of HDL-C. An approach to management. Arch Intern Med 1993; 153(13):1528-40.

(20.) Stamper M J, Sacks F M, Simonetta S.A prospective study of cholesterol, apolipoproteins and the risk of myocardial infarction. N Engl J Med 1991; 325: 373-80.

(21.) Bulliyya G. Blood pressure and serum lipid profile in smokers and non-smokers-a comparative study. The Indian Practitioner 2002; 55(6):363-8.

(22.) Manninen V, Tenkanen L, Koskinen P, Joint effects of triglycerides, LDL-C and HDL-C concentration on coronary heart disease risk in Helsinki Heart Study. Implication for treatment. Circulation1992; 85:37-45.

(23.) Rastogi R, Srivastava S, Mehrotra, Gupta M K. Lipid profile in smokers. JAPI 2001; 37(12):764-767.

(24.) Tiwari A K, Gode J D, Dubey G P.Effect of Cigarette smoking on serum total cholesterol and high density lipoproteins cholesterol in normal subjects and coronary heart patients. Indian Heart J. 2001; 41(2):92-94.

(25.) Tilwani, Mjos D O, Norway T, Lipid effects of smoking. Am Heart J 2003; 115: 272-75.

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(28.) Johansson S, Bergstrand R, Pennert K. Cessation of smoking after Myocardial infarction in women, effects on mortality and reinfarction. Am J Epidemol 1985; 121: 823-31.

(29.) Rosenberg L, Kaufman D W, Helmrich S P. The risk of myocardial infarction after quitting smoking in men under 55 years of age. N England J of Medicine1985;313(24):1511-4.

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Beenakumari R [1], Balachandran J [2]

AUTHORS:

[1.] Beenakumari R.

[2.] Balachandran J.

PARTICULARS OF CONTRIBUTORS:

[1.] Associate Professor, Department of Physiology, Sree Gokulam Medical College and Research Foundation, Venjarammodu, Trivandrum.

[2.] Associate Professor, Department of Pulmonary Medicine, Travancore Medical College, Kollam.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Beenakumari R, MRA-5, Bappuji Gardens Lane 1, Kulathoor House, Mannanthala, P. O, Trivandrum-15.

E-mail: dr.beenakumari@yahoo.co.in

Date of Submission: 30/12/2014.

Date of Peer Review: 31/12/2014.

Date of Acceptance: 13/01/2015.

Date of Publishing: 21/01/2015.
Table 1a: Comparison of mean Total Cholesterol based on number
of cigarettes (in packs) smoked per day

                               Smokers Number of cigarettes
                                   smoked per day

                  Non
                smokers  <1 pack  1 pack  2 packs  >2 packs   Total

No. of persons    120      21       36      40        23       240
Mean TC         183.49   2218.94  213.95  223.07    232.31    202.44
Std. Deviation   31.99    38.16   36.64    37.57    30.82     39.08
F Value                                                       19.54
Significance                                                 .0001 **

Table 1b: Comparison of mean Total Cholesterol based on duration
of smoking

                              Smokers Duration of
                                smoking in years

                   Non
                 smokers    1 -5     6-10    11-15

No. of persons     120       17       19       23
Mean TC          183.49    181.38   195.33   221.70
Std. Devn         31.99    18.78    25.33    42.83
F Value
Significance

                      Smokers
                    Duration of
                 smoking in years

                 16-20     >20      Total

No. of persons     20       41       240
Mean TC          235.78   242.83    202.43
Std. Devn        27.72    23.22     39.08
F Value                             32.37
Significance                       .0001 **

Table 2a: Comparison of mean Triglycerides based on number of
cigarettes (in packs) smoked per day

                                         Smokers
                           Number of cigarettes smoked per day

                  Non
                smokers  <1 pack  1 pack  2 packs  >2 packs  Total

No. of persons    120      21       36      40        23      240
Mean TG         149.06   165.29   162.40  176.09    168.28   158.92
Std. Deviation   38.09    43.21   37.78    26.75    54.84    39.92
F Value                                                       4.47
Significance                                                 .002 *

Table 2 b: Comparison of mean Triglycerides based on duration
of smoking

                              Smokers Duration of
                                smoking in years

                   Non
                 smokers    1 -5     6-10    11-15

No. of persons     120       17       19       23
Mean TG          149.06    138.22   150.06   172.38
Std. Deviation    38.09    25.51    35.95    36.90
F Value
Significance

                 Smokers Duration
                   of smoking in
                       years

                 16-20     >20      Total

No. of persons     20       41       240
Mean TG          178.44   183.41    158.92
Std. Deviation   32.60    41.14     39.93
F Value                              8.2
Significance                       .0001 **

Table 3 a: Comparison of mean Low density lipoprotein levels
based on number of cigarettes (in packs) smoked per day

                                       Smokers
                           Number of cigarettes smoked per day

                  Non
                smokers  <1 pack  1 pack  2 packs  >2 packs   Total

No. of persons    120      21       36      40        23       240
Mean LDL-C      108.92   145.14   142.49  150.74    163.66    129.34
Std. Devn         29      37.11   41.82    38.17    27.51     39.33
F Value                                                       23.91
Significance                                                 .0001 **

Table 3b: Comparison of mean Low density lipoprotein levels
based on duration of smoking

                                Smokers Duration
                              of smoking in years

                   Non
                 smokers    1-5      6-10    11-15

No. of persons     120       17       19       23
MeanLDL-C        108.92    111.75   121.99   147.79
Std. Devn         29.05    20.55    23.12    41.59
F Value
Significance

                 Smokers Duration
                   of smoking in
                      years

                 16-20     >20      Total

No. of persons     20       41       240
MeanLDL-C        164.34   172.39    129.34
Std. Devn        37.43    24.26     39.33
F Value                             37.59
Significance                       .0001 **

Table 4a: Comparison of mean High density lipoproteins levels
based on number of cigarettes (in packs) smoked per day

                                Smokers
                               Number of
                               cigarettes
                             smoked per day
                   Non
                 smokers   <1 pack   1 pack

No. of persons     120       21        36
Mean HDL-C        44.81     42.09    41.60
Std. Devn         6.45      6.33      4.01
F Value
Significance

                       Smokers
                      Number of
                      cigarettes
                    smoked per day

                 2 packs   >2 packs    Total

No. of persons     40         23        240
Mean HDL-C        37.68     35.01      41.96
Std. Devn         5.31       5.69       6.77
F Value                                20.44
Significance                          .0001 **

Table 4b: Comparison of mean High density lipoprotein levels
based on duration of smoking

                           Smokers Duration of smoking in years

                  Non
                smokers   1-5   6-10   11-15  16-20   >20    Total

No. of persons    120     17     19     23     20     41      240
Mean HDL-C       44.81   43.73  43.25  39.48  40.15  34.58   41.96
Std. Devn        6.45    3.48   3.11   5.27   4.31   5.39     6.77
F Value                                                      22.02
Significance                                                .0001 **

Table 5a: Comparison of mean TC/HDL-C based on number of
cigarettes (in packs) smoked per day

                                  Smokers
                           Number of cigarettes smoked per day

                  Non
                smokers  <1 pack  1 pack  2 packs  >2 packs   Total

No. of persons    120      21       36      40        23       240
Mean TC/HDL-C    4.22     5.38     5.21    6.08      6.81      5.00
Std. Devn        1.13     1.50     1.12    1.53      1.42      1.55
F Value                                                       30.99
Significance                                                 .0001 **

Table 5b: Comparison of mean TC/HDL-C based on duration of smoking

                               Smokers Duration of
                                  smoking in years

                  Non
                smokers  1-5   6-10  11-15  16-20  >20    Total

No. of persons    120     17    19    23     20     41     240
Mean TC/HDL-C    4.22    4.16  4.53  5.69   5.93   7.19    5.03
Std. Devn        1.130   0.41  0.55  1.24   0.88   1.18    1.54
F Value                                                   54.77
Significance                                             .0001 **

Table 6 a: Comparison of mean LDL-C/HDL-C based on number of
cigarettes (in packs) smoked per day

                                        Smokers
                            Number of cigarettes smoked per day

                    Non
                  smokers  <1 pack  1 pack  2 packs  >2 packs   Total

No. of persons      120      21       36      40        23       240
Mean LDL-C/HDL-C   2.53     3.59     3.49    4.15      4.82      3.26
Std. Devn          0.92     1.26     1.20    1.45      1.19      1.37
F Value                                                         30.79
Significance                                                   .0001 **

**--Highly significant *--Significant

TC-Total Cholesterol, TG-Tri Glycerides,

Table 6 b: Comparison of mean LDL-C/HDL-C
based on duration of smoking
                                      Smokers
                              Duration of smoking in years
                    Non
                  smokers  1-5   6-10  11-15  16-20  >20    Total

No. of persons      120     17    19    23     20     41     240
Mean LDL-C/HDL-C   2.53    2.56  2.83  3.82   4.15   5.11    3.26
Std. Devn          0.92    0.44  0.52  1.20   1.09   1.10    1.37
F Value                                                     52.90
Significance                                               .0001 **
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Title Annotation:ORIGINAL ARTICLE
Author:Beenakumari, R.; Balachandran, J.
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Jan 22, 2015
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