The Effects of Smoking in Developing Hypertension in Pakistan: a Systematic Review

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The Effects of Smoking in Developing Hypertension in Pakistan: a Systematic Review South East Asia Journal Of Public Health ISSN: 2220-9476 ISSN: 2313-531X (Online) Review The effects of smoking in developing hypertension in Pakistan: a systematic review Qurrat ul Ain1, Krishna Regmi2 1PhD Research Scholar, Centre for Research in Primary and Community Care, University of Hertfordshire, UK. 2Principal Lecturer in Public Health, Faculty of Health and Social Sciences, Institute for Health Research, University of Bedfordshire, UK. Abstract Globally, hypertension is considered one of the most important preventable causes of morbidity and mortality. Several plausible factors have been assessed and identified in relation to high blood pressure but there have been limited studies carried out as to whether smoking can have any effect in developing high blood pressure in Pakistan. This paper aims to examine the effects of smoking in developing hypertension in Pakistan. This study employs a systematic review. A total of 1097 articles were identified (reduced to 61 once duplication was removed). Only six studies met the relevant quality appraisal criteria. Three major databases - Medline, EMBASE and Global Health - were searched using both ‘free terms’ and ‘index-terms’. All selected studies were quality appraised by critical appraisal tools and reviewed by two authors. The studies fell into three distinct themes – awareness, economic status and types of tobacco. Findings of the review indicated that an unhealthy relationship exists between hypertension and smoking, as incidences of hypertension were more prevalent in smokers as compared to non-smokers. In addition, both high systolic and diastolic blood pressure were more frequent in smokers compared to non-smokers. The present study suggests that a positive harmful relationship exists between blood pressure and smoking, and that smokers are more likely to develop high blood pressure compared to non-smokers. In addition, this review considers knowledge and lifestyle modification, their linkage with hypertension and compliance to the treatment regimen as important considerations to reduce unhealthy effects of smoking in developing hypertension. Keywords: Hypertension, High blood pressure, Smoking, Tobacco, Pakistan. Introduction Hypertension (HTN) is a global public health problem. It Practice Points is one of the most valuable preventable causes of premature morbidity and mortality in the world and its Hypertension is a global public health problem. management is one of the most common interventions in Smoking is considered one of main risk factors primary care. HTN affects over 26% of the adult of hypertension, and smoking with high or low population worldwide.1 Although smoking is considered nicotine cigarettes are particularly responsible one of main risk factors of hypertension,1-3 smoking with for an increase in high systolic blood pressure, high and low nicotine cigarettes are particularly heart rate and myocardial oxygen demand. responsible for an increase in high systolic blood pressure, heart rate and myocardial oxygen demand. The People in Pakistan often use tobacco products 4 World Health Organisation (WHO) estimated that there because of their affordability and because of a will be over 20 million cardiovascular deaths in 2015, widely held misconception that there use could which will account for 30% of deaths worldwide. HTN be beneficial in easing stomach aches, tooth- has earned the reputation as the ‘silent killer’ making it a aches and headaches. key priority for prevention, detection and control. High blood pressure is a major risk factor for strokes, heart Tobacco products and hypertension appear failure, chronic kidney disease, coronary artery disease independent of age, sex and area of residence. and cognitive decline that is ultimately responsible for Awareness does modify health behaviour and causing over 60% of deaths in developed countries and 80% in developing countries, including Pakistan.5,6 the findings of this review support the idea that better informed hypertensive subjects were less The WHO5 further reports that cardiovascular diseases likely to be involved in smoking habits. alone killed 2 million people in 2011 in low- and middle- to involvement in unhealthy behaviours and lifestyles.7 income countries. Morbidity associated with Smoking causes an acute increase in blood pressure; complications of hypertension account for 9.4 million heart rate has been associated with malignant deaths worldwide every year. Although hypertension can hypertension that causes a sudden rise in very high occur at any age, it is more common amongst adults due blood pressure.8 Nicotine chemicals in tobacco act as Correspondence: Dr Krishna Regmi, Faculty of Health and Social Sciences, Institute for Health Research, University of Bedfordshire, Putteridge Campus, Luton LU2 8LE, UK. Email: [email protected]. South East Asia Journal of Public Health 2015;5(1):4-11. © 2015 Ain & Regmi, publisher and licensee Public Health Foundation Bangladesh. This is an Open Access article which permits unrestricted non-commercial use, provided the original work is properly cited. DOI: http://dx.doi.org/10.3329/seajph.v5i1.24845 4 Ain & Regmi Effects of smoking in developing hypertension an adrenergic against local and systematic ing. 17 The Institute of Medicine,18 however, warns that it catecholamines, and mainly vasopressin, to increase may equally lead to incorrect conclusions, and pulse rate, followed by heart rate and blood pressure ultimately wrong decisions or recommendations if we simultaneously.7,9 The prothrombotic effect of ‘fail to acknowledge or address the risk of reporting continuous tobacco exposure causes alterations in blood biases, neglect to appraise the quality of individual cells, platelet function, antithrombotic and fibrinolytic studies included in the review, and are subject to errors factors.7,9,10 during the data extraction and analysis.’ Several studies have shown that there is an alteration in Search Strategy blood pressure and heart rate associated with those who To identify and highlight the primary research studies have stopped smoking tobacco.7-9 Any amount of and to determine the relationship between hypertension smoking, even occasional, damages the heart and blood and smoking in Pakistan, the three major electronic vessels, and chemicals in smoke form plaques within databases (MEDLINE, EMBASE, and CABI’s Global the arteries.1 Acute exposure to passive (environmental) Health) were searched focusing on smoking and smoking determines a gradual increase in blood hypertension in developing (low- and middle-income) pressure due to the combined effect of nicotine that acts countries in general and in Pakistan specifically. These by endothelial dysfunction and sympathetic stimulation. databases were considered the best known with Moreover, carbon monoxide in tobacco smoke exerts its international coverage for over 80 countries and about toxic effect directly.11 It is interesting to note that 15000 journals indexed, alongside the vast resources prevalence of smoking has been reported at 38% capturing the fields of medicine, international health and amongst 32 East Asian countries12 and 14-21% in ado- related disciplines. lescents and adults, and is more common in Pakistan.13 People in Pakistan often use tobacco products because Following the formulation of research questions, a of their affordability and because of a widely held research strategy was planned. An inclusion and misconception that the use of tobacco products could be exclusion criteria was set, and both free terms (text beneficial in easing stomach aches, toothaches and words) and index-terms (thesauruses) were established, headaches.14 The other reason for this high prevalence is identified and searched from research topics and that there is limited evidence and knowledge on relevant databases. These criteria stem from the PICO smoking hazards in Pakistan, such as its effect on health (population, intervention, context/comparison and out- and lifestyle modification in the general population.15 come) framework, defining the participants and the types of interventions to be studied and potentially also This study therefore aims to evaluate the role and use of limiting the type of study design.19 The search tool of smoking in the hypertensive population of Pakistan and these databases identified a total of 61 articles that to examine the effects of smoking in developing passed the title and abstract screening. To form a search hypertension. question, we broke down the search into two major Materials and Methods Table 1: Search terms used This study utilised a systematic review style - an Concept 1 Concept 2 approach which is considered a legitimate research Smoking Hypertension 16 methodology. Boland et al. argued that it is a valuable Tobacco High blood pressure form of research in terms of locating and appraising, as Cannabis smoking Blood pressure well as synthesising the best available evidence relating Cigar to a specific research question to provide ‘informative Cigarette and evidence-based’ answers. This approach is Hashish generally considered to be of a good standard as it aids Hookah in ‘synthesising the findings of several studies 16 Pipe investigating the same questions’ , thereby using high Waterpipe quality evidence to inform policy into decision mak- Note: All concepts combined with AND Table 2: Search terms using PICO Population Intervention/setting Comparatives/Issues Context Outcome Human Smoking control Hypertension Developing country* Control high
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