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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 17  |  Issue : 1  |  Page : 20-24

A study of the short-term cardiopulmonary effect of mawa chewing in rural India


1 Department of Physiology, Peoples Education Society Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
2 Department of Physiology, Basaveshwara Medical College, Chitradurga, Karnataka, India
3 Department of Anesthesiology, Basaveshwara Medical College, Chitradurga, Karnataka, India

Date of Web Publication7-Apr-2014

Correspondence Address:
Amrith Pakkala
40, SM Road 1st cross, T. Dasarahalli, Bangalore - 560 057
India
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DOI: 10.4103/1119-0388.130177

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  Abstract 

Background: Tobacco is consumed in smoking and smokeless forms all over the world. Smokeless tobacco has been advocated as a substitute for cigarette smoking. On the contrary, the use of smokeless tobacco is fraught with health risk and needs to be discouraged. Previous reports have described long-term harmful effects of nicotine on various body parameters, little is known about the acute effect of smokeless tobacco, such as mawa, consumed very rampantly in rural India, on cardiopulmonary parameters. Use of smokeless tobacco indeed represents a health concern of growing magnitude among these groups. As a consequence of its addictive qualities, the consumption of smokeless tobacco often becomes a lifelong habit with cumulative and deleterious effects on health. Very few studies have been undertaken on the acute effect of use of mawa, a common form of tobacco used in India, on cardiopulmonary parameters of youngsters. Materials and Methods: Treadmill Exercise Testing and Pulmonary Function Tests were done before and after maximal exercise testing to assess cardiopulmonary efficiency in two groups, namely, healthy sedentary controls and healthy mawa chewers. Results: On studying the differences in cardiopulmonary efficiency in the two groups, the resting heart rate was found to be statistically significantly higher in the study group and the delta heart rate was found to be statistically significantly lower among mawa chewers. There was no significant difference seen in parameters such as VO 2max , maximum oxygen pulse, MVV, VE max as an acute effect of mawa. Conclusion: In this study, it appears that mawa chewers are physically fit similar to the controls, but immediately after smoking a lesser delta HR suggests a higher risk for cardiovascular mortality. Stopping mawa at this juncture can be helpful in reverting back the risk, and parameters such as resting HR, recovery HR, and delta HR can be used as prognostic assessment tools for any intervention therapy to stop mawa chewing in asymptomatic individuals.

Keywords: Cardiopulmonary, delta HR, mawa chewing, MVV, resting HR, tobacco, VE max , VO 2max


How to cite this article:
Pakkala A, Ganashree CP, Raghavendra T. A study of the short-term cardiopulmonary effect of mawa chewing in rural India. Trop J Med Res 2014;17:20-4

How to cite this URL:
Pakkala A, Ganashree CP, Raghavendra T. A study of the short-term cardiopulmonary effect of mawa chewing in rural India. Trop J Med Res [serial online] 2014 [cited 2019 Mar 20];17:20-4. Available from: http://www.tjmrjournal.org/text.asp?2014/17/1/20/130177


  Introduction Top


Tobacco is consumed in smoking and smokeless forms all over the world. Tobacco has been used orally alone or in combination with other ingredients. In India, tobacco is taken in several other forms also, for example, Pan (betel quid), dried leaves (Patti), paste (Kiwan, Zarda), tobacco with lime (Khaini/Mawa). [1] There has been resurgence of tobacco use since 1970, [2] its use is common in various parts of the world, including India and central Asia. An increase in the consumption of tobacco has been noticed among high school students, college students, and sportspersons. [3],[4],[5] Use of smokeless tobacco indeed represents a health concern of growing magnitude among these groups. As a consequence of its addictive qualities, the consumption of smokeless tobacco often becomes a lifelong habit with cumulative and deleterious effects on health. [6],[7] Despite the known health consequences of tobacco, "chewing" is not viewed by users as particularly dangerous and is considered less of a "social evil" than smoking by much of the public. [8],[9] Previous reports have described long-term harmful effects of nicotine on various body parameters, little is known about the acute effect of tobacco smoking on cardiopulmonary parameters. [10] Very few studies have been undertaken on the acute effect of the use of mawa, a common form of smokeless tobacco consumption in rural India on cardiopulmonary parameters of youngsters.

Aims and objectives

The present study has been undertaken to study the acute effect of mawa chewing on cardiopulmonary efficiency tests in young healthy mawa chewers as compared with age- and sex-matched healthy controls.


  Materials and Methods Top


The present study was conducted in the Exercise Physiology lab of PESIMSR, Kuppam. Thirty apparently healthy sedentary male mawa chewers of age group 18-30 years were taken as subjects and equal number of age- and sex-matched healthy non-mawa chewers were taken as controls. Ethical clearance was obtained from institutional ethical committee.

The subjects for the study were selected based on the following criteria.

Inclusion criteria

  1. Males between 18 and 30 years of age
  2. Leading sedentary lifestyle
  3. Mawa chewing for 3-5 years duration of one or more packets per day.


Exclusion criteria

  1. Age more than 30 years
  2. Leading physically active lifestyle
  3. Suffering from cardiopulmonary or systemic illness such as diabetes, hypertension, and others
  4. Involved in any sports or exercise regimen
  5. Addicted (dependence) to any drugs.


The subjects for the control group were selected based on the following criteria.

Inclusion criteria

  1. Males between 18 and 30 years of age
  2. Leading sedentary lifestyle
  3. Not chewed even a single packet of mawa up to the time of the study.


Exclusion criteria

  1. Age more than 30 years
  2. Leading physically active lifestyle
  3. Suffering from cardiopulmonary or systemic illness such as diabetes, hypertension, and others
  4. Involved in any sports or exercise regimen
  5. Addicted (dependence) to any drugs.


Before starting the actual study, the subjects were briefed about the protocol and informed consent was obtained. A thorough history regarding suitability as per the above inclusion and exclusion criteria was elicited. Basic clinical examination was done to rule out any cardiopulmonary or other illness. Subjects were instructed to come to the lab and chew two mawa packs immediately before starting the recordings. Both controls and chewers were advised to refrain from consumption of coffee, tea, and heavy meals at least 2 h prior to the recordings.

Resting heart rate

Resting heart rate was measured in both nonchewing and mawa-chewing group, with the help of a single channel, 12 lead selection electrocardiograph, designed to record electrocardiograms. Measurement was carried out only after the subjects were thoroughly acquainted with the working of the corresponding instrument and the prescribed maneuver.

Special instructions

  1. The subject was made to rest for 15 min after the attachment of leads
  2. They were instructed to remain in sitting posture and completely relaxed.


The calibration (1 mv =10 mm deflection height) and paper speed (25 mm/s) were checked. Lead selection was switched to LEAD-II and electrocardiography (ECG) was taken. The resting heart rate was calculated and results were expressed as beats per minute.



Maximal voluntary ventilation

Maximal voluntary ventilation (MVV) was measured in both the study and the control group with the help of computerized spirolyzer.

Recording of MVV

The sensor was placed on the stand and then MVV key was pressed. The subject was instructed to keep the disposable mouthpiece attached to pneumotachograph half way in the mouth above the tongue. The nose clip was applied and the start button was pressed. The subject was asked to breathe as deeply and as quickly as possible for 12 s, at the end of which the test terminates automatically. Now the sensor is replaced back on the stand. The screen displays the values of MVV along with its graph. This test has no memory. The print key was pressed to obtain a print.

Maximal oxygen consumption (VO 2max )

VO 2max was indirectly assessed by the Astrand-Astrand nomogram method from submaximal exercise data obtained while running on a treadmill.

Submaximal exercise testing

Subject preparation


  1. Subjects had to appear for the test only after 2-3 h have lapsed after the last meal
  2. Contraindications to testing are ruled out
  3. A detailed explanation of the testing procedure was given outlining the risks and possible complications The subject was told how to perform the exercise test and the testing procedure was demonstrated
  4. All safety measures for the exercise testing were undertaken.


The treadmill was set to the elevation of 7°. The safety key was put in place and the mains switched ON. The subject was made to stand on the belt and support his arms by the side in the arm support provided. ECG limb leads were connected and the cables were securely tied to the legs. The ear pulse sensor was connected.

The "ON" Switch is pressed to start the motor. The "FAST" Switch is pressed to increase the speed gradually up to 5 km/h and the subject is instructed to run at this speed. The running is continued till a heart rate between 125 and 170 beats per minute is obtained as shown on the liquid crystal display (LCD). A steady heart rate for a given work load is indicated by a variation of not more than 5 beats/min. On attaining this heart rate, the speed is gradually brought down by pressing the slow switch and the machine is switched OFF.

Lead II is selected in the ECG machine and ECG is recorded for a few complexes and submaximal heart rate is calculated.

The distance travelled and time taken is noted down from the LCD.

The power reached is calculated as follows:

X = sin α × B

Where X = vertical distance travelled; α = elevation in degrees; B = Distance travelled on treadmill (in km).

Work done = Weight of subject × ( X)

Power = Work done/Time.

The Astrand nomogram is used. The heart rate and the power reached are connected in the nomogram. VO 2max (in L/min) is read from the VO 2 scale.

Corresponding values of VO 2max in terms of body weight, height, and surface area are calculated.

Because the subjects in this study were not older than 25 years, age correction factor was not applied.

Maximal exercise testing

This is done after a rest period of 10 min. The LCD of the treadmill is reset to zero value.

The spirolyzer is switched ON, the subject's details entered, and the VC key is pressed and kept ready. The ECG limb leads are connected and the cables secured as before. The subject was suitably instructed about the test maneuver. Elevation was continued at 7°. The subject was asked to run till exhaustion and to stop only when he felt that he could no longer run.

With the subject on the belt, the treadmill was switched ON and the FAST key pressed. The speed was gradually raised to 10 km/h. When the subject could no longer continue running, the speed was gradually brought down and the treadmill switched OFF.

Lead II is selected in the ECG machine and ECG is recorded for a few complexes and Maximal Heart Rate is calculated.

Maximal heart rate

Simultaneously, the nose clip is applied; the disposable mouth piece on the pneumotachograph of the ready spirolyzer is placed on the subject's mouth over the tongue. The start switch is pressed in the VC Mode to record the respiration at VO 2max work load. After 50 s, the test terminates automatically. The sensor is placed back in its place. A print is obtained.

Delta heart rate

The delta heart rate (δHR) was the calculated difference between the maximal HR and the resting HR.

Minute volume at VO 2max (V Emax ) is calculated from the respiratory rate and the tidal volume recorded.

Breathing reserve (BR) at VO 2max is calculated using the formula:

BR at VO 2max = MVV − V Emax

Dyspnoeic index (DI) at VO 2max is calculated using the formula:

DI at VO 2max = BR at VO 2max /MVV.

Recovery heart rate

This is recorded after a period of 1 min from the cessation of maximal exercise. Lead II is selected in the ECG machine and ECG is recorded for 15 s.

Recovery heart rate is obtained by using the formula:

Recovery HR =15 sec- HR × 4

Maximum oxygen pulse

This is calculated by using the formula:



All these sets of recordings were done on both the study and control groups.

Statistical analysis was done by using unpaired Student's t test.


  Results Top


It is clear from [Table 1] that the study group and controls were anthropometrically similar. On comparing the various heart rates in [Table 2], it was found that mawa chewers had a significantly higher resting heart rate. There was no significant difference when parameters like delta heart rate and maximum oxygen pulse were compared in [Table 3]. The maximal oxygen consumption was similar in both the groups as shown in [Table 4]. The dynamic lung function parameters were also similar as shown in [Table 5].
Table 1: Anthropometric data of controls and mawa chewers (mean±SD)


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Table 2: Various heart rates of controls and mawa chewers (mean±SD)


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Table 3: Comparison of the differences between: 1. MHR-RHR, 2. Maximum heart rate and resting heart rate (äHR), and 3. Maximum oxygen pulse of controls and mawa chewers


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Table 4: Comparison of maximal oxygen consumption (VO2max) of controls and mawa chewers


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Table 5: Comparison of the differences between: 1. MVV, 2. VEmax, and 3. DI of controls and mawa chewers


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  Discussion Top


The greatest concern for nicotine-related effects is acceleration or aggravation of cardiovascular disease. [11] In a study of the cardiovascular effects of daily cigarette use, the prominent effects of nicotine use, namely, heart rate acceleration and increased urinary catecholamine excretion were similar throughout the day in people smoking cigarettes and those using smokeless tobacco. [10]

In the present study, the resting heart rate was found to be statistically significantly higher in the study group. This is attributable to the lower vagal tone in mawa chewers as a result of nicotine use even in the short term of 3-5 years, which becomes apparent as an acute effect. This finding is in agreement with other studies. [12]

The delta heart rate was found to be statistically significantly lower among chewers. Delta HR is a long-term predictor of cardiovascular mortality independent of age, physical fitness, and conventional coronary risk factors. [13] The lower delta HR suggests that chewers are at a higher risk for cardiovascular mortality.

There was no significant difference seen in parameters such as VO 2max , maximum oxygen pulse, MVV, and VE max as an acute effect of mawa. Most of the workers had attributed decreased VO 2max among chewers to the carbon monoxide saturation and less hemoglobin availability to carry oxygen.

In this study, it appears that tobacco chewers are physically fit similar to the controls, but immediately after chewing, lesser delta HR suggests a higher risk for cardiovascular mortality.

Respiratory parameters show marginal increase in values. This could be because of bronchodilatation due to the release of epinephrine or stimulation of sympathetic system or both.

Stopping mawa use at this juncture can be helpful in reverting back the risk and parameters such as resting HR, recovery HR, and delta HR can be used as prognostic assessment tools for any intervention therapy to stop mawa use in asymptomatic individuals.

 
  References Top

1.Health effects of smokeless tobacco. Council on scientific affairs. JAMA 1986;255:1038-44.  Back to cited text no. 1
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2.Gupta R, Gurm H, Bartholomew JR. Smokeless tobacco and cardiovascular risk. Arch Intern Med 2004;164:1845-9.  Back to cited text no. 2
    
3.Sankaranarayanan R, Duffy SW, Padmakumary G, Dey NE, Padmanabhan TK. Tobacco chewing, alcohol and nasal snuff in cancer of the gingival in Kerala, India. Br J Cancer 1989;60:638-43.  Back to cited text no. 3
    
4.Jones RB. Use of smokeless tobacco in the 1986 world series. N Engl J Med 1987;316:952.  Back to cited text no. 4
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5.Hunter SM, Croft JB, Burke GL, Parker FC, Webber LS, Berenson GS. Longitudinal patterns of cigarette smoking and smokeless tobacco use in youth: The Bogalusa heart study. Am J Public Health 1986;76:193-5.  Back to cited text no. 5
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6.Schroeder KL, Chen MS Jr. Smokeless tobacco and blood pressure. N Engl J Med 1985;312:919.  Back to cited text no. 6
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7.Tomar SL, Giovino GA. Incidence and predictors of smokeless tobacco use among US youth. Am J Public Health 1998;88:20-6.  Back to cited text no. 7
    
8.Rothman KJ. Tobacco habits. Am J Public Health 1986;76:133.  Back to cited text no. 8
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9.Marty PJ, McDermott RJ, Williams T. Pattern of smokeless tobacco use in a population of high school students. Am J Public Health 1986;76:190-2.  Back to cited text no. 9
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10.Siegel D, Benowitz N, Ernster VL, Grady DG, Hauck WW. Smokeless tobacco, cardiovascular risk factors, and nicotine and cotinine levels in professional baseball players. Am J Public Health 1992;82:417-21.  Back to cited text no. 10
    
11.Benowitz NL. Systemic absorption and effects of nicotine from smokeless tobacco. Adv Dent Res 1997;11:336-41.  Back to cited text no. 11
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12.Bolinder GM, Ahlborg BO, Lindell JH. Use of smokeless tobacco: Blood pressure elevation and other health hazards found in a large-scale population survey. J Intern Med 1992:232:327-34.  Back to cited text no. 12
    
13.Sandvik L, Erikssen J, Ellestad M, Erikssen G, Thaulow E, Mundal R, et al. Heart rate increase and maximal heart rate during exercise as predictors of cardiovascular mortality: A 16-year follow-up study of 1960 healthy men. Coron Artery Dis 1995;6:667-79.  Back to cited text no. 13
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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