Tobacco and CVD: a Historical Perspective

gOPINIONEDITORIAL VIEWPOINT Tobacco and CVD: A Historical Perspective

Manu Raj Mathur , Dorairaj Prabhakaran à,§ New Delhi, India

Tobacco consumption, in the past few decades brought with them tobacco leaves and seeds [7]. has arguably been established as one of the most From Europe, tobacco spread to other parts of the significant preventable causes of mortality and mor- world in the 16th century. In the early 16th century, bidity globally [1]. Recent projections estimate that tobacco was introduced in the Middle East by tobacco kills at least 6 million people globally every Egyptians [8]. Tobacco was introduced in China year, which is much higher than the combined and Japan between 1530 and 1600, and the Japa- mortality caused by diseases such as acquired nese army introduced tobacco in Korea in the last immunodeficiency syndrome, tuberculosis, and ma- decade of the 16th century [7]. During the same laria [2]. The low- and middle-income countries period, Portuguese and Spanish traders took tobac- (LMICs) are the worst affected by the tobacco epi- co to Africa during their voyages [7]. The Portu- demic [2]. It is estimated that by 2030, more than guese brought tobacco to India in early parts of 80% of the tobacco-related deaths will occur in the 17th century where they used tobacco leaves LMICs [3]. as barter for spices and textiles [1]. Tobacco use is a leading preventable risk factor The origin of the word tobacco is contested. of cardiovascular diseases (CVDs) [4]. About 1.62 Some people believe that it is derived from the Ara- billion deaths in the year 2000 (1 in every 10 car- bic word tabaq, which means ‘‘euphoria producing diovascular deaths) worldwide were due to smoking herb.’’ Some experts believe that tobacco comes tobacco in any form [5]. Approximately one-third from the Caribbean word tabaco, which is the name of deaths due to tobacco are likely to be attributed of the pipe from which tobacco was smoked. Some to CVDs by the year 2015 [6]. sources refer the origin of this word from the Understanding the historical evolution of tobac- Tabasco state in Mexico [9]. The tobacco plant co use and its association with CVDs may stimulate was botanically named by Swedish botanist Carolus as well as provide important inputs for future tobac- Linnaeus in 1753. He described 2 species of the to- co control and CVD prevention programs and bacco plant: nicotiana rustica and nicotiana tabacum. policies. He named the tobacco plant after French Diplomat Jean Nicot who introduced and popularized tobacco in France as a cure for migraine headaches [1]. TOBACCO’S JOURNEY ACROSS THE Historically, tobacco has been used for several WORLD purposes. These varied from time to time and region to region. Tobacco was mainly used by Native The story of the origin and spread of tobacco goes Americans for ceremonial purposes. They used to- back thousands of years. The tobacco plant is bacco for smoking, ingesting orally as syrup and mostly indigenous to the Americas, where its culti- chewing [8]. They even consumed tobacco through vation was started by the native Indians in the year rectal enemas in a spiritual ritual [8]. In Haiti, to- 6000 BCE [1]. Tobacco was introduced in Europe bacco was used as a medicine for cleaning nasal pas- in 1492 when Christopher Columbus and his crew sages and as an analgesic [1]. In the 16th century, returned from their first voyage of the Americas and European doctors used to recommend tobacco as

From the Public Health Foundation of India, New Delhi, India; àCentre for Cardiometabolic Risk Reduction in South Asia, Public Health Foundation of India, New Delhi, India; §Centre for Chronic Disease Control, Public Health Foundation of India, New Delhi, India. Correspondence: M.R. Mathur (manu.mathur@phﬁ.org). 108 Mathur and Prabhakaran GLOBAL HEART, VOL. 7, NO. 2, 2012 July 2012: 107–111 Tobacco and CVD

a cure for headache, toothache, falling fingernails, found that almost 60% of patients with intermit- lockjaw, halitosis, worms, and cancer [10]. The rec- tent claudication were heavy smokers. Buerger reational use of tobacco started in the latter half of [15], in 1908, reported a rare form of peripheral the 16th century when pipe smoking was popular- vascular disease that leads to progressive inflamma- ized by Thomas Harriot (on his return from Vir- tion and thrombosis of arteries and veins of hand ginia, where he was sent to explore opportunities and feet and occurs mostly in smokers. This disease in the newly acquired colony) and his friend Sir was later named after him as Buerger’s disease Walter Raleigh (an English aristocrat, who devel- (thromboangiitis obliterans). His findings were sup- oped the art of curing tobacco leaves in a way that ported by Weber [16], Brown and Allen [17], popularized smoking among the British aristoc- and Allen et al. [18]. Hoffman was among the first racy) [10]. In the beginning of the 17th century, to show a statistical association between smoking pipe smoking became popular in the Netherlands and coronary thrombosis [19]. English et al. [20] and later in the 18th and 19th centuries, it spread compared 1,000 smokers matched with 1,000 non- across Europe and to the East Asian countries smokers in 1940 to show possible association be- [10]. In India and the Middle East, hookah or tween smoking and CVDs and concluded that water pipe smoking (where tobacco smoke was fil- there is ‘‘a more profound effect on younger indi- tered through water to overcome its purported ill viduals owing to the existence of relatively normal effects) was popular among noble and elite classes cardiovascular systems, influencing perhaps the ear- [11]. Oral and nasal forms of tobacco use became lier development of coronary disease.’’ The first popular in the 18th century [12]. In India, chewing U.S. Surgeon General’s Report on Smoking and of different flavors of tobacco flakes along with be- Health [21] provided evidence of higher death tel quid gained popularity especially among wo- rates among male smokers from coronary artery men. Women, in those times used to color their disease in comparison to male nonsmokers. This lips and mouth red by chewing tobacco with betel evidence was further strengthened in the U.S. Sur- quid for makeup. Sniffing tobacco was also widely geon General’s Report of 1971, which stated that accepted, which led to an increase in import of to- smoking not only is an independent risk factor, bacco in India during the Medieval Ages [11]. but also combines with other risk factors to affect During the Crimean War, the use of cigarettes cardiovascular health [22]. Hammond [23], in his started becoming popular [10]. Consumption of study on approximately 1 million people, showed cigarettes increased exponentially during World an increased mortality from coronary heart disease War I and by the end of World War II, cigarette among cigarette smokers. smoking was the most common form of tobacco The seminal British physicians cohort study by consumption in developed countries of the world Doll and Hill [24] showed that male cigarette- [10]. Cigarette smoking became deeply ingrained smoking doctors had a higher risk of death from in Western society after World War II. Cigarette coronary thrombosis (ratio of death rate for male smoking remains the most popular means of tobac- smokers in comparison to lifelong nonsmokers un- co consumption worldwide. der 70 years of age was 2:1 and for men over 70 years was 5:1). The Framingham Heart Study, which is one of the most important cohort studies for CVD TOBACCO CONSUMPTION AND CVDS: epidemiology, in the year 1960, provided evidence THE HISTORICAL EVIDENCE that cigarette smoking increased the risk of heart disease. The same cohort, in 1988, provided conclu- Huchard [13], in his article on diseases of the heart sive evidence for cigarette smoking being among the and blood vessels in the year 1893, provided some most important factors to cause stroke [25]. of the first evidence in scientific literature of a rela- tionship between tobacco consumption and heart diseases. He wrote: ‘‘The (unfavorable) influences ANTITOBACCO MOVEMENTS AND of nicotinism on the development of arteriosclero- SENTIMENTS: A HISTORICAL SNAPSHOT sis appear to have been demonstrated. And this is not surprising since nicotine produces most often During the time when tobacco consumption was arterial hypertension by vasoconstriction’’ [13]. gaining popularity worldwide the health, societal, Since the early 20th century, several physicians and economic harms of tobacco were also being and researchers have implicated tobacco in increas- highlighted by various scientists, thinkers, and ing the risk of several CVDs. Erb [14], in 1904, philosophers. GLOBAL HEART, VOL. 7, NO. 2, 2012 Mathur and Prabhakaran 109 July 2012: 107–111 Tobacco and CVD

In the year 1604, King James I of England EVOLUTION OF ANTITOBACCO wrote ‘‘A Counterblaste to Tobacco’’ in which he POLICIES IN THE MODERN ERA said: ‘‘Smoking is a custom loathsome to the eye, hateful to the nose, harmful to the brain, dangerous Countries worldwide are now cognizant of the to the lungs, and in the black, stinking fume there- harmful effects of tobacco, and the ever-powerful of nearest resembling the horrible Stygian smoke of tobacco industry, and are trying to put in place the pit that is bottomless’’ [10]. comprehensive legislations to reduce tobacco The first recorded legislation against tobacco consumption as well as to prevent people who are use dates back to 1575, when the Roman Catholic nonsmokers from secondhand smoke. California Church passed a law prohibiting smoking in any was the first U.S. state to pass legislation against place of worship throughout the Spanish colonies smoking in public places, including bars and res- [26]. In the year 1624, Pope Urban VIII issued a taurants, in the year 1998 [28]. This was followed worldwide ban on using or carrying tobacco prod- by South Africa, where a law was passed making ucts in any place of worship. He also issued a warn- public places smoke-free but this law exempted ing to excommunicate those who violated this law. bars and restaurants from being smoke-free [28]. However, the law was abolished by Pope Benedict Ireland was the first country to adopt a comprehen- XIII in the late 17th century who was a tobacco sive smoking ban in indoor workplaces, including user himself [10]. bars, pubs, and restaurants. This ban was strength- From the 17th century onward, different rulers ened by overwhelming public support and was seen and religious leaders worldwide have imposed some as a societal revolution in a country known for its form of tobacco ban in their regimes or among smoke-filled pubs and restaurants [29]. New their followers. Sultan Murad IV of the Ottoman Zealand followed the Irish model of a smoking Empire and Czar Michael of Russia issued smok- ban and became smoke-free in 2005 [28]. Soon ing bans with violators being treated as criminals after, a number of European countries such as and issued a death penalty [7]. In 1891, Iranians, Scotland, England, France, and Italy adopted the led by the Grand Ayatollah Haji Mirza Hasan legislation of smoke-free indoor areas [8]. The Shirazi, banned the trading of any tobacco prod- smoking bans were not confined to European na- ucts [7]. Cigarette trading was also banned for tions and recently Canada and Australia have also about 26 years in North Dakota [8]. In the latter put into effect legislations banning smoking in in- half of the 20th century, the tobacco industry be- door areas [8]. India has also been a world leader in came so powerful financially that it started provid- tobacco control. On October 2, 2008, the Indian ing financial assistance to the governments and so government implemented Section 4 of the Ciga- all the existing smoking bans either were made very rette and Other Tobacco Products Act (COTPA), weak or were abolished. which banned smoking any form of tobacco in One of the most successful antitobacco cam- public places [30]. Although COTPA-2003 is paigns took place in Germany and was led by the comprehensive tobacco control legislation, its Association against Tobacco for the protection of implementation has been weak. This has been Non Smokers (Deutscher Tabakgegnerverein zum mainly due to lack of human resources at the state Schutze fur Nichtraucher), which was formed in level, lack of infrastructure and training to imple- 1904 and rose to strength with the National Socia- ment the law, and absence of a strategic media list Party of Germany coming to power in the and communication plan to effectively disseminate 1930s [27]. Hitler was strongly against the use of the law. tobacco and made education about the harmful ef- Given the importance of tobacco control in fects of tobacco compulsory in junior schools [27]. reducing CVD burden, the World Health Organi- The government printed pamphlets warning peo- zation (WHO) proposed one of the most rapidly ple against the harms of tobacco and doctors orga- embraced treaties of all time known as the Frame- nized mass meetings to raise public awareness. work Convention of Tobacco Control (FCTC). Smoking by uniformed police officers, persons un- This was the world’s first global public health der 18 years of age, and in buses and trains was treaty, and it came into effect on February 27, banned [27]. However, this campaign against to- 2005 (Table 1). To date, 170 of the 192 members bacco was short-lived and had very little impact of WHO have signed and ratified this treaty [8]. on the per capita consumption of cigarettes, which The treaty has been immensely successful in rose year after year. mobilizing resources; it has rallied hundreds of 110 Mathur and Prabhakaran GLOBAL HEART, VOL. 7, NO. 2, 2012 July 2012: 107–111 Tobacco and CVD

Table 1. Main provisions of WHO Framework Convention of Tobacco Control

Regulation of: Contents, packaging, and labeling of tobacco products Sales to and by minors Illicit trade in tobacco products Smoking at work and public places

Reduction in consumer demand by: Price and tax measures Comprehensive ban on tobacco advertising, promotion, and sponsorship Education, training, raising public awareness, and assistance with quitting

Protection of environment and health of tobacco workers: Support for economically viable alternative activities Research, surveillance, and exchange of information Support for legislative action to deal with liability

Adapted, with permission, from Shafey et al. [8]. WHO, World Health Organization.

nongovernmental organizations, encouraged gov- CONCLUSIONS ernment action, and raised tobacco control awareness. In a further addition to its tobacco-control The use of tobacco became omnipresent worldwide efforts, WHO published the MPOWER report within 150 years of Columbus being introduced to on the global tobacco epidemic in 2008. The it in the Americas. Tobacco was successfully able to MPOWER report elaborates 6 strategies, recom- percolate through the social and cultural texture of mended by WHO as an entry point to implemen- communities in many continents. This assimilation tation of the WHO FCTC (Table 2) [31]. The was facilitated by the perceived medicinal attributes report is evidence-based and is shown to reduce of tobacco and its ability to suppress hunger and the burden of noncommunicable diseases in coun- provide mild intoxication. Myriad varieties of to- tries that have successfully implemented them. bacco products and methods in which they can be The MPOWER report serves as a guiding docu- used made it popular across the globe. Although ment especially for LMICs to help them plan there were many controversies against tobacco use effective tobacco-control strategies. and concerns about health effects of its use, the The historical evidence stated herein clearly demand for tobacco kept expanding across the points to the fact that leaders across the globe be- world and provided the thrust to tobacco compa- lieved that by formulating and effectively imple- nies for increased production of tobacco. The ready menting antismoking policies, health can be revenues that strengthened the economy along with promoted and premature losses of lives and disabil- ease of export and employment opportunities pro- ity can be prevented. vided a rationale for bringing tobacco to center stage both as a crop and as an industry. It is this amalgamation of international linkages, strong economic forces, and distinctive sociocultural inﬂu- ences that make the history of tobacco a very Table 2. WHO MPOWER strategy fascinating study. Learning from history, a concerted action is Monitor tobacco use and prevention policies Protect people from tobacco smoke needed at the international, the national, and the Offer help to quit tobacco use community levels to curb the tobacco epidemic, Warn about the dangers of tobacco which in turn will help in reducing the burden of Enforce bans on tobacco advertising, promotion, and CVDs. The tobacco industry, over the years, has sponsorship worked to assimilate tobacco use in culture, political Raise taxes on tobacco structures, local and national economies, and Adapted, with permission, from WHO [31]. personal behaviors. Therefore, sustainable tobac- WHO, World Health Organization. co-control efforts require not only government GLOBAL HEART, VOL. 7, NO. 2, 2012 Mathur and Prabhakaran 111 July 2012: 107–111 Tobacco and CVD

support, ﬁnancing, and community empowerment, rise and fall of tobacco consumption worldwide. but also effective global health governance to control The history of tobacco provides a tool for discus- the multinational marketing, trade agreements, and sion and a move forward for effective tobacco-con- information asymmetry that supports tobacco use. trol policies to realize the dream of a tobacco-free The history of tobacco helps us to observe mul- world. tiple factors and events that have contributed to the

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