EFFECTS OF MARAS POWDER (SMOKELESS TOBACCO) USAGE
Transkript
EFFECTS OF MARAS POWDER (SMOKELESS TOBACCO) USAGE
Acta Medica Mediterranea, 2015, 31: 291 EFFECTS OF MARAS POWDER (SMOKELESS TOBACCO) USAGE ON COGNITIVE FUNCTIONS IN MALES AGED ≥60 YEARS HAMIT SIRRI KETEN1, OGUZ ISIK2, HUSEYIN UCER2, UMIT ASLAN2, NAGIHAN SARI2, HAMZA SAHIN3, MUSTAFA CELIK2 1 Family Medicine, Onikisubat Community Health Center, Kahramanmaras - 2Family Medicine, Medical Faculty, Kahramanmaras Sutcu Imam University, Kahramanmaras - 3Neurology, Medical Faculty, Kahramanmaras Sutcu Imam University, Kahramanmaras, Turkey ABSTRACT Aim: This study investigated the effects of Maras powder usage on cognitive functions in males aged 60 or older. Materials and methods: The study was conducted with 140 male volunteers aged ≥60 years who attended four family health centers in Kahramanmaraş. Seventy volunteers with a comsuption of ¼ of a package of Maras powder daily for at least 10 years were assigned to the study group and 70 volunteers who reported no use of tobacco products were assigned to the control group. Data about socio-demographic characteristics and Maras powder usage were obtained through face-to-face interviews with all participants. The Standardized Mini Mental Test (SMMT) was also used for data collection. Results: The mean age of the participants was 63.69±6.01 years (min=60, max=85). The study and control groups did not differ significantly in age (p=0.156). SMMT mean scores were 22.78±5.36 in the study group and 23.92±4.22 in the control group; this difference was not significant (p=0.164). Participants with a primary school education had significantly lower test scores than those with higher education levels (p=0.001). Conclusion: Maras powder users and non-users in this study had similar cognitive functions. However, advanced age and low education levels were significantly related to decreased cognitive functions. Key words: Cognition, Geriatrics, Tobacco, Smokeless. Received June 18, 2014; Accepted October 02, 2014 Introduction The proportion of the world population aged ≥60 years has been increasing in recent years. It is expected to be 1.2 billion in 2025 and 1.9 billion in 2050(1). In Turkey, the proportion of people aged ≥60 years in the general population was 7.7% in 2013 and is expected to reach 20.8% in 2050 and 27.7% in 2075(2). According to data from the World Health Organization, there are over 1 billion tobacco users worldwide, and 4.9 million people die each year due to conditions related to tobacco usage (3) . Although the most frequently used tobacco product is cigarettes, the rate of smokeless tobacco usage is too high to overlook. It was reported to be 6.2% in males and 0.2% in females in the USA(4). In a study in Nigeria, 10.8% of males and 4.1% of females were found to use smokeless tobacco, and the rate of smokeless tobacco usage was reported to peak at the age of 60(5). There have been many studies on the effects of such commonly used tobacco products on human health. Some studies(6,7) have shown that active smoking is related to a decrease in cognitive functioning while others have not revealed such a relationship(8,9). Interestingly, several studies have reported preventive effects of smoking on cognitive function(10,11). Maras powder (MP) is a smokeless tobacco produced in Kahramanmaraş and commonly used in the eastern Mediterranean part of Turkey. To produce Maras powder, the leaves of the tobacco plant Nicotiana rustica linn are powdered and mixed with oak ashes in varying amounts(12). The mixture is wrapped in a special piece of paper and smoked or put in the inner side of the upper lip and sucked. In 292 a study performed in Kahramanmaras, the prevalence of Maras powder use was 25% in male adults and 1% in females(13). This study investigated the effects of MP on cognitive functioning in males aged 60 and older. Materials and methods This was a prospective study and included 140 male volunteers aged 60 or older who presented to four family health centers in Kahramanmaraş in Turkey between 01 January 2014 and 31 February 2014. The participants gave informed consent. Volunteers without at least a primary school education, and with eye sight problems, hearing problems and conditions likely to affect cognitive functioning (vascular, neurological, endocrinological, and psychiatric conditions and a history of drug abuse), smokers, and those using alcohol were not included in the study. All participants were examined by a family physician. Those diagnosed with or suspected conditions affecting cognitive functions (e.g., depression) were also excluded from the study. Data on socio-demographic features and MP usage were collected during face to face interviews with all participants. Seventy participants who had used at least ¼ of an MP packet a day for at least 10 years were assigned to the MP group and 70 participants who had never used any tobacco products were assigned to the control group. The Standardized Mini Mental Test (SMMT) was administered to all participant by family physicians; this took 10 minutes. The SMMT was developed by Foldstein et al. to screen cognitive functions(14) in older adult. The validity and reliability of the test for the Turkish population were established by Güngen et al.(15). The test requires that respondents be at least literate. It is composed of a total of 11 items and five parts: orientation (10 points), registration (3 points), attention and calculation (5 points), recall (3 points) and language (9 points). The total score that can be obtained from the test is 30 points and the cut-off score for mild and moderate dementia is 23/24 points. Statistical Analysis Data were analyzed using Statistical Package for the Social Sciences (SPSS); frequencies and standard deviations were calculated. The Kolmogorov–Smirnov test was used to determine whether the data were normally distributed. Socio- Hamit Sirri Keten, Oguz Isik et Al demographic data were analyzed using the Chisquare test. The t-test and Mann Whitney U test were used to reveal differences between the two groups, and analysis of variance (ANOVA) was used to show differences among three or more groups. Homogeneity of variance was evaluated using Levene’s test. When significant differences were found between groups, post-hoc pairwise comparisons were made using Tukey’s test. Relations among the variables were analyzed using the Pearson correlation test. p<0.05 was considered significant. Ethical approval was obtained from the ethical committee of the Medical Faculty of Kahramanmaras Sütçü İmam University in accordance with the Helsinki Declaration (Seoul, 2008). Results The study included 140 male participants, 70 were in the MP group and 70 were in the control group. The mean age of the participants was 63.69±6.01 (min=60, max=85) in the overall study sample, 62.97±5.50 in the MP group and 64.41±6.43 in the control group. There was no significant difference in age between the MP group and the control group (p=0.156). One hundred and twenty participants (85.7%) were married, 11 (7.9%) were widowers, 6 (4.3%) had never married and 3 (2.1%) were divorced. Marital status did not significantly differ between the MP group and the control group (p=0.469). One hundred and one participants (72.1%) were primary school graduates, 14 (10.0%) were middle school graduates, 10 (7.1%) were high school graduates and 15 (10.7%) were university graduates. The mean length of education was 6.80±3.32 years. The MP group and the control group did not differ significantly in terms of education (p=0.132) or income (p=0.451). The mean number of daily MP uses was 17.25±6.52 and the mean amount of MP consumption was 47.4±8.13 packages/year. One hundred and thirtyfive (96.4%) participants were right handed and 5 (3.6%) were left handed. Table 1 presents demographic features of the participants (Table 1). The mean SMMT score was 22.78±5.36 in the MP group and 23.92±4.22 in the control group; this difference was not significant (p=0.164). There was a significant negative correlation between age and SMMT score (p=0.001, r=-278), a significant positive correlation between length of education and SMMT score (p=0.00, r=333), and a significant Effects of Maras powder (smokeless tobacco) usage on cognitive function... negative correlation between the amount of MP consumed (package/year) and SMMT score in the MP group (p=0.002, r=-330). Socio-demographic features Age group 293 while the left handed participants’ mean score was 25.60±3.04; this difference was not significant (p=0.294). Total n(%) MP users n(%) Non-users of MP n(%) 60-64 96(68.6) 51(75.0) 45(66.2) 65-75 31(22.1) 14(20.6) 17(25.0) 75-84 9(6.4) 3(4.4) 6(8.8) Married 120(85.7) 62(88.6) 58(82.9) Widower 11(7.9) 5(7.1) 6(8.6) Single 6(4.3) 2(2.9) 4(5.7) Divorced 3(2.1) 1(1.4) 2(2.9) Retired 56(40.0) 22(31.4) 34(48.6) Worker 43(30.7) 28(40.0) 15(21.4) Tradesman 24(17.1) 17(24.3) 7(10.0) Government officer 10(7.1) 1(1.4) 9(12.9) Farmer 7(5.0) 2(2.9) 5(7.1) Primary school 101(72.1) 55(78.6) 46(65.7) Middle school 14(10.0) 10(14.3) 4(5.7) High School 10(7.1) 4(5.7) 6(8.6) University 15(10.7) 1(1.4) 14(20.0) <400 Dollars (<880 Turkish Liras) 69(49.3) 36(51.4) 33(47.1) 400-800 Dollars (8801760 Turkish Liras ) 32(22.9) 17(24.3) 15(21.4) Marital status Occupation p 0.435 0.469 Education Levels 0.864 0.132 Monthly income 0.451 801-1200 Dollars (1760-2640 Turkish Liras ) 33(23.6) 14(20.0) 19(27.1) >1200 Dollars (>2640 Turkish Liras ) 6(4.3) 3(4.3) 3(4.3) Table 1: Socio-demographic Features of the Participants. The mean SMMT score was significantly lower in primary school graduates than in participants with higher levels of education (p=0.001). It was also significantly lower in widowers than in married, never married and divorced participants (p=0.048). The mean SMMT score was 24.11±4.85 in participants aged 60-64, 21.67±4.63 in participants aged 65-74 and 20.77±4.43 in participants aged 75-85. Patients aged 75-80 had significantly lower SMMT scores than those in the other age groups (p=0.014). SMMT score was not significantly correlated with monthly income (p=0.107) and type of occupation (p=0.589). The right handed participants’ mean SMMT score was 23.27±4.88, Table 2 shows the distribution of SMMT scores across socio-demographic features. On the SMMT, 17 participants (12.1%) received scores <19, 64 participants (45.7%) received scores from 19-24 and 59 participants (42.1%) received scores from 25-30. Ten MP users (14.3%) and 7 non-users (10%) scored <19, 34 MP users (48.6%) and 30 non-users (42.9%) scored 1924 and 26 MP users (37.1%) and 33 non-users (47.1%) scored 25-30 on the SMMT. There was no significant difference between MP users and nonusers in terms of SMMT scores (p=0.447). The distribution of participants based on their SMMT scores is shown in Table 3. 294 Hamit Sirri Keten, Oguz Isik et Al Socio-demographic features Age group SMMT score Mean ±SD 60-64 24.11±4.85 65-74 21.67±4.63 75-85 20.77±4.43 Married 23.60±4.64 Widower 20.63±6.20 Single 23.16±6.52 Divorced 23.66±1.52 Retired 22.41±5.72 Worker 23.86±3.91 Tradesman 23.29±4.52 Government officer 25.50±4.24 Farmer 25.00±3.16 Primary school 22.32±5.03 Middle school 25.35±2.81 High school 26.10±2.92 University 26.60±3.33 <400 Dollars (<880 Turkish Liras) 22.44±5.32 400-800 Dollars (880-1760 Turkish Liras ) 24.90±3.58 801-1200 Dollars (1760-2640 Turkish Liras ) 23.54±4.72 >1200 Dollars (>2640 Turkish Liras ) 24.50±3.93 Marital status P 0.014 0.048 Occupation Education levels Monthly income Parameters Total Mean ±SD MP users Mean ±SD Non-users of MP Mean ±SD P SMMT 23.35±4.84 22.78±5.36 23.92±4.22 0.164 Orientation 9.29±1.6 9.11±2.01 9.46+1.12 0.216 Registration 2.66±0.82 2.61±0.92 2.71±0.72 0.477 Attention and Calculation 2.10±2.02 2.01±2.01 2.20±2.04 0.589 Recall 1.45±1.13 1.52±1.09 1.37±1.16 0.414 Language 7.85±1.80 7.51±2.11 8.18±1.37 0.028 Table 4: The Distribution of the Scores for SMMT and its Subscales by the MP Users and Non-users. Discussion 0.589 0.001 0.107 With respect to subscales of the SMMT, the Table 2: The distribution of the mean SMMT scores by Socio-demographic features. SMMT Score Total n(%) MP users n(%) Non-users of MP n(%) p <19 17(12.1) 10(14.3) 7(10.0) 0.447 19-24 64(45.7) 34(48.6) 30(42.9 ≥25 59(42.1) 26(37.1) 33(47.1) Table 3: The Distribution of the SMMT Scores by MP Users and Non-users. mean score for orientation was 9.11±2.01 for MP users and 9.46±1.12 for non-users; this difference was not significant (p=0.216). The mean score for language was 7.51±2.11 in MP users and 8.18±1.37 in non-users. The MP users had significantly higher scores for language (p=0.028). MP users and nonusers did not differ significantly in registration (p=0.477), attention and calculation (p=0.589) and recall (p=0.414). Scores on the SMMT and its subscales are presented in Table 4. The results of the present study showed that the risk factors related to impaired cognitive functions were advanced age, low education levels and death of spouse. In addition, MP usage, income and types of occupation were not found to be related to impaired cognitive functions. In this study, the mean SMMT scores and the distribution of SMMT scores did not differ between MP users and nonusers. The MP users had a significantly higher mean score on the language subscale of the SMMT; however, both groups had similar mean scores on the other subscales of the SMMT. In addition, there was a significant negative correlation between SMMT scores and amount of MP (packet/year). Elwood et al., in their communitybased study in England, also found that the mean SMMT score was 26.2 in smokers aged 55-69 and 26.5 in non-smokers of the same age group, a nonsignificant difference(16). In a study by Launer et al., smokers made 20% more mistakes on the SMMT(17). Tekin et al., in their study of males aged over 40 in Ankara, Turkey, found that smoking did not affect SMMT scores, but the negative effects of smoking on low density lipoprotein (LDL) played an important role in the reduction of scores on the language subscale(18). In fact, while several studies have shown that active smoking was related to a reduction in cognitive functions(6,7), other studies have found no significant relation between smoking and deterioration of cognitive functions (8,9) . Interestingly, some studies have revealed that smoking had a protective effect on cognitive functions(10,11). It seems that there is conflicting evidence in the literature on the effects of smoking on cognitive functioning. In the present study, we found that MP usage did not have a direct effect on cognitive functioning, and it was striking that there was a negative Effects of Maras powder (smokeless tobacco) usage on cognitive function... correlation between the amount of MP used and SMMT scores. This suggests that long-term use of MP in higher amounts may affect cognitive function, making a case for clinical studies on larger samples. It should not be overlooked that tobacco usage damages health via various mechanisms and appropriate preventive measures should be taken. In the present study, the mean SMMT score was 23.35. With respect to the distribution of SMMT scores, 12.1% of the participants received <19, 45.7% of the participants received 19-24 and 42.1%% of the participants received 25-30. In a community based study in Kars, males aged over 60 had a mean SMMT score of 22.28, and the mean SMMT score was <19 for 23.4% of participants, 19-24 for 44.4% of participants and 25-3 for 32.0% of participants (19). In another community-based study, males over 65 years of age in Kocaeli, Turkey, received a mean SMMT score of 25.04 and 6.9% of males had a score of <19, 25.7% of males had a score of 20-24 and 67.4% of males had a score of 25-30(20). In a study on patients aged ≥65 and presenting to a state hospital in Ankara, 76.4% received scores ≥26 and 23.4% had a score of 24-26 on the SMMT(21). In studies from other parts of the world, the mean SMMT score was 25.92 for people aged ≥60 in China(22) and 22.4 in people aged ≥80 in Italy(23). The results of the present study were consistent with those of the study in Kars, Turkey, but found lower SMMT scores than those reported in the studies in Ankara, China and Italy. This can be attributed to differences in gender, education, marital status, age and socio-cultural features. In the current study, the mean SMMT score was 24.11 in the 60-64 age group, 21.67 in the 6574 age group and 20.77 in the 75-85 age group. The mean score was significantly lower in participants aged 75-85. There was a significant negative correlation between SMMT score and age. In a study on people aged ≥60 by Karatay et al., the SMMT score was 22.93 in participants aged 60-64, 22.75 in participants aged 65-74, 20.29 in participants aged 7584 and 18.14 in participants aged ≥85(19). Several similar studies have revealed a significant negative correlation between SMMT scores and age (18-22). Both the present study and other studies reported so far have shown advanced age is an important risk factor for cognitive functions. Naturally, aging cannot be prevented. However, healthy aging is not impossible and plays an important role in the preservation of cognitive functioning. 295 In the present study, the primary school graduates obtained significantly lower SMMT scores than those with higher levels of education. In addition, there was a significant positive relation between length of education and SMMT score. Diker et al., in their study on people aged ≥65, also reported that SMMT scores were significantly lower in primary school graduates than in those with higher levels of education(20). In a study on people aged ≥60 in Mexico, low education levels were found to cause deterioration in cognitive functions(24). In addition, several other studies reported in the literature reported a significant positive correlation between length of education and SMMT score(18-20). In light of the results of the present study and the evidence from the literature, it is obvious that a shorter duration of education is a risk factor for low cognitive functioning. To enhance the educational activities in the childhood is important to attain a healthy society in terms of cognitive functions. The Ministry of Education should cooperate with the Ministry of Health in an attempt to enhance cognitive functions. In addition, education programs directed towards the middle-aged and elderly population should be designed to prevent the deterioration of cognitive functions. We found that people whose spouses had died had significantly lower scores on the SMMT than those with other types of marital status, which is consistent with the results of other studies with samples of the same age as those in the present study(19-25). It may be that the death of a spouse can weaken relationships with others. However, no significant relations were found between SMMT score and income and type of occupation, which is compatible with the literature. The non-significant effect of income on cognitive function in the present study can be explained by the fact that the participants had a similar financial status. The non-significant effect of occupation may be due to the fact that the elderly can be employed in posts that do not require much cognitive activity. Conclusion In the present study, both MP users and nonusers had similar cognitive functioning. However, it was striking that there was a significant positive relation between the amount of MP usage and SMMT score. Therefore, further studies with larger sample sizes are needed. Advanced age and low education levels were found to be associated with 296 Hamit Sirri Keten, Oguz Isik et Al deterioration of cognitive functions. Although aging is inevitable, healthy aging is of great importance in terms of preservation of cognitive functioning. The great role education plays in the maintenance of cognitive functions should not be disregarded, and education programs should be designed for all age groups. 14) 15) References 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) World Population Prospects: The 2002 Revision. United Nations Population Division. Available from: http://www.un.org/esa/population/publications/wpp200 2/WPP2002-HIGHLIGHTSrev1.PDF. Accessed 14.12.2014. Turkish Statistical Institute. Population Projections. Available from: http://www.tuik.gov.tr. Accessed:09.08.2014. De Beyer J, Waverley BL. Tobacco control policy: strategies, successes, and setbacks. A copublication of World Bank and Research for International Tobacco Control (RITC). Available from: http://siteresources.worldbank.org/INTPH/Resources/fr ont_matter.pdf. Accessed 09.08.2014 Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Results from the 2009 National Survey on Drug Use and Health: National Findings. Available from: http://www.samhsa.gov/data/2k9/2k9Resultsweb/web/2k9results.pdf. Accessed: 05.12.2013. Desalu OO, Iseh KR, Olokoba AB, Salawu FK, Danburam A. Smokeless tobacco use in adult Nigerian population. Niger J Clin Pract 2010; 13(4): 382-387. Collins N, Sachs-Ericsson N, Preacher KJ, Sheffield KM, Markides K. Smoking increases risk for cognitive decline among community-dwelling older Mexican Americans. Am J Geriatr Psychiatry 2009;17(11): 934-942. Cataldo JK, Prochaska JJ, Glantz SA. Cigarette smoking is a risk factor for Alzheimer’s Disease: an analysis controlling for tobacco industry affiliation. J Alzheimers Dis 2010; 19(2): 465-80. Piguet O, Grayson DA, Creasey H, Bennett HP, Brooks WS, et al. Vascular risk factors, cognition and dementia incidence over 6 years in the Sydney Older Persons Study. Neuroepidemiology 2003; 22(3): 165-71. Ford AB, Mefrouche Z, Friedland RP, Debanne SM. Smoking and cognitive impairment: a population-based study. J Am Geriatr Soc 1996; 44(8): 905-9. Wang CC, Lu TH, Liao WC, Yuan SC, Kuo PC, et al. Cigarette smoking and cognitive impairment: a 10-year cohort study in Taiwan. Arch Gerontol Geriatr 2010; 51(2): 143-8. Murray KN, Abeles N. Nicotine’s effect on neural and cognitive functioning in an aging population. Aging Ment Health 2002; 6(2): 129-38. Aral M, Ekerbicer H, Celik M, Ciragil P, Gul M. Comparison of effects of smoking and smokeless tobacco “Maras powder” use on humoral immune system parameters. Mediators Inflamm 2006;2 006(3): 85019. Kafas A: Analysis of factors affecting cigarette smoking and Maras powder use among adults in the urban area of Kahramanmaras. Master’s Thesis, Institute of Science, Department of Agricultural Economics, 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) Kahramanmaras Sutcu Imam University, Turkey, 2011, https://tez.yok.gov.tr/UlusalTezMerkezi/ SearchTez (last accessed: 13.09.2014). Folstein MF, Folstein S, Mc Hugh PR. “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3): 189-98. Güngen C, Ertan T, Eker E, Yaşar R, Engin F. Reliability and validity of the standardized Mini Mental State Examination in the diagnosis of mild dementia in Turkish population. Turkish Journal of Psychiatry 2002; 13(4): 273-81. Elwood PC, Gallacher JE, Hopkinson CA, Pickering J, Rabbitt P, et al. Smoking, drinking, and other life style factors and cognitive function in men in the Caerphilly cohort. J Epidemiol Community Health 1999; 53(1): 914. Launer LJ, Feskens EJ, Kalmijn S, Kromhout D. Smoking, drinking and thinking. The Zutphen Elderly Study. Am J Epidemiol 1996; 143(3): 219-27. Tekin O, Özkara A, Yanık B, Yigitoglu MR, İlhan A, et al. Effects of plasma lipids and smoking on cognitive function. Turk J Med Sci 2011; 41 (2): 193-204. Karatay G, Aktaş B, Erdağı S. Screenıng of cognitive function in the population aged 60 years and over in kars: A field research. Turkish Journal of Geriatrics 2010; 13 (4) 261-269. Diker J, Etiler N, Yıldız M, Şeref B. Association between cognitive status and activities of daily living, life quality and some demographic variables in older than 65. Anatolian Journal of Psychiatry 2001; 2(2): 79-86. Onat ŞŞ. The effect of sociodemographic characteristics and cognitive functions on quality of life in elderly individuals. Turkish Journal of Osteoporosis 2013; 19: 69-73. Kwok T, Wong A, Chan G, Shiu Y , Lam KC, et al. Effectiveness of cognitive training for Chinese elderly in Hong Kong. Clin Interv Aging 2013; 8: 213-9. Lucca U, Garrì M, Recchia A, Logroscino G, Tiraboschi P, et al. A Population-based study of dementia in the oldest old: the Monzino 80-plus Study. BMC Neurol 2011; 11: 54. Ortiz GG, Arias-Merino ED, Flores-Saiffe ME, Velázquez-Brizuela IE, Macías-Islas MA, PachecoMoisés FP. Prevalence of cognitive impairment and depression among a population aged over 60 years in the Metropolitan Area of Guadalajara, Mexico. Curr Gerontol Geriatr Res 2012; 2012: 175019. Kavakcı Ö, Bilici M, Çam G, Ülgen M. Prevalence of depression and cognitive impairment in old age in Trabzon. Anatolian Journal of Psychiatry 2011; 12(4): 258-265. Acknowledgement This manuscript was presented as an oral presentation at the 13 th National Congress of Turkish Family Medicine, Antalya,Turkey, on 23-27 April 2014. _______ Correspoding author Dr. HAMIT SIRRI KETEN Onikisubat Community Health Center Department of Family Medicine TR-46050 Kahramanmaras (Turkey)