What are the health risks associated with using smokeless tobacco. How does smokeless tobacco affect oral health. Can smokeless tobacco cause cancer. Why is smokeless tobacco addictive. How does smokeless tobacco impact cardiovascular health. What are the different types of smokeless tobacco products. How can users quit smokeless tobacco.

The Various Forms of Smokeless Tobacco

Smokeless tobacco comes in several forms, each with its own unique characteristics and methods of use. Understanding these different types is crucial for recognizing the potential risks associated with their consumption.

Chewing Tobacco

Chewing tobacco is available in three primary forms:

• Loose leaves
• Plugs
• Twists or rolls

Users typically place a piece of chewing tobacco, often referred to as a “plug,” “wad,” or “chew,” between their cheek and gum. They then chew on it for extended periods, sometimes up to several hours, while periodically spitting out the accumulated tobacco juices and saliva.

Snuff and Snus

Snuff and snus are finely ground tobacco products that come in two main varieties:

1. Moist snuff and snus: Sold in cans or sachets (small pouches resembling tea bags), users place a pinch of moist snuff or a sachet between their cheek or lip and gum.
2. Dry snuff: A powdered form sold in cans, which can be placed in the mouth or sniffed through the nose.

Dissolvable Tobacco Products

The newest additions to the smokeless tobacco market are dissolvable tobacco products. These are finely ground, flavored tobacco shaped into various forms:

• Sticks
• Pellets
• Strips

These products are designed to dissolve in the user’s mouth within 3 to 30 minutes, delivering nicotine directly into the bloodstream. It’s worth noting that some of these newer stick forms of smokeless tobacco contain up to three times more nicotine than an average cigarette, potentially increasing the risk of addiction.

The Addictive Nature of Smokeless Tobacco

Smokeless tobacco products contain nicotine, the primary addictive substance in all tobacco products. This chemical is responsible for the “buzz” users experience and plays a significant role in the difficulty many face when trying to quit.

Understanding Nicotine Addiction

How does nicotine addiction develop in smokeless tobacco users? The process typically involves two key factors:

1. Craving: With regular use, the body becomes accustomed to nicotine and begins to crave it. This craving is one of the primary signs of addiction.
2. Tolerance: As the body adjusts to the amount of tobacco needed to achieve the desired effect, users often find they need increasingly larger amounts to get the same “buzz.” This phenomenon is known as tolerance and is another clear indicator of addiction.

Many users report that quitting smokeless tobacco is even more challenging than quitting cigarettes. This difficulty is likely due to the higher nicotine content in some smokeless tobacco products, which can lead to stronger addiction.

Health Risks Associated with Smokeless Tobacco Use

While some may believe that smokeless tobacco is a safer alternative to smoking, it’s important to understand that these products carry their own set of significant health risks.

Oral Health Concerns

Smokeless tobacco can have severe and direct effects on oral health. What are some of the most common oral health issues associated with smokeless tobacco use?

• Bad breath: The use of smokeless tobacco often results in persistent bad breath and discolored teeth, which can negatively impact social interactions.
• Dental problems: The constant contact between smokeless tobacco and the gums can cause gum recession and disease, potentially leading to loose teeth. Many smokeless tobacco products also contain sugar, which combines with plaque to form acid that erodes tooth enamel, causing cavities and chronic painful sores.
• Leukoplakia: Users may develop leukoplakia, a condition characterized by white, leathery-like patches in the mouth. These patches can vary in size and shape and have the potential to become cancerous.

Cancer Risks

One of the most severe health risks associated with smokeless tobacco use is the increased risk of cancer. Which types of cancer are most commonly linked to smokeless tobacco use?

• Oral cancer: Cancer of the mouth, including the lip, tongue, and cheek, is often observed at the site where tobacco is held in the mouth.
• Throat cancer: The use of smokeless tobacco also increases the risk of developing throat cancer.

In severe cases, surgical removal of cancerous tissue may be necessary, potentially requiring the removal of parts of the face, tongue, cheek, or lip.

Cardiovascular Concerns

The continuous absorption of nicotine into the body from smokeless tobacco use can lead to various cardiovascular issues. What are some of the heart-related problems associated with smokeless tobacco use?

• Increased heart rate
• Elevated blood pressure
• Irregular heartbeats

These effects may increase the risk of sudden death from ventricular arrhythmias, a condition in which the heart does not beat properly.

The Rising Popularity of Smokeless Tobacco Among Youth

While smokeless tobacco use has traditionally been associated with adults, recent surveys from the Centers for Disease Control and Prevention (CDC) have shown a troubling trend: an increase in smokeless tobacco use among youth.

Factors Contributing to Youth Appeal

Several factors contribute to the growing popularity of smokeless tobacco among younger users:

• Attractive packaging: Many new forms of smokeless tobacco are designed to resemble candy or breath strips, making them visually appealing to younger users.
• Flavoring: Unlike traditional cigarettes, which have a bitter and unpleasant taste, many new smokeless tobacco products are minty and flavorful, increasing their appeal to younger users.
• Perceived safety: Some youth may believe that smokeless tobacco is a safer alternative to smoking, unaware of the significant health risks associated with its use.

Efforts to Curb Youth Usage

In response to the rising use of smokeless tobacco among youth, various organizations and governing bodies have proposed measures to discourage its use. What are some of the recommended strategies to reduce youth access to smokeless tobacco?

• Price increases: The American Academy of Pediatrics (AAP) recommends raising prices on tobacco products to discourage use by youth.
• Media restrictions: The AAP supports banning the use of tobacco products in media, including TV, movies, and video games.
• Sports-related bans: There is a movement to eliminate smokeless tobacco use by Major League Baseball players, with some cities already banning its use in their baseball parks.

Nicotine Poisoning: A Hidden Danger

The new forms of smokeless tobacco, particularly those designed to resemble candy or breath strips, pose an additional risk: nicotine poisoning. This danger is especially concerning for children who may mistake these products for harmless candy.

Symptoms of Nicotine Poisoning

What are the signs and symptoms of nicotine poisoning? Recognizing these symptoms is crucial for prompt medical intervention:

• Nausea and vomiting
• Abdominal pain
• Increased heart rate
• Elevated blood pressure
• Dizziness and confusion
• Seizures (in severe cases)

If nicotine poisoning is suspected, especially in children, immediate medical attention should be sought.

Strategies for Quitting Smokeless Tobacco

While quitting smokeless tobacco can be challenging due to its addictive nature, it is not impossible. Many users have successfully quit with the right approach and support.

Tips for Successful Cessation

How can users increase their chances of successfully quitting smokeless tobacco? Here are some effective strategies:

1. Set a quit date: Choose a specific date to stop using smokeless tobacco and commit to it.
2. Remove temptation: Throw away all smokeless tobacco products and related items.
3. Seek support: Inform friends and family about your decision to quit and ask for their support.
4. Consider nicotine replacement therapy: Consult with a healthcare provider about using nicotine gum, patches, or lozenges to manage cravings.
5. Stay busy: Engage in activities that keep your mind and hands occupied to distract from cravings.
6. Practice stress management: Learn and implement stress-reduction techniques such as deep breathing, meditation, or exercise.
7. Reward progress: Celebrate milestones in your quit journey to maintain motivation.

Professional Help and Resources

Where can users find additional support and resources for quitting smokeless tobacco?

• Healthcare providers: Consult with doctors or dentists for personalized advice and potential medication options.
• Quitlines: Many countries offer free telephone-based counseling services for tobacco users trying to quit.
• Support groups: Join local or online support groups for individuals quitting smokeless tobacco.
• Mobile apps: Utilize smartphone applications designed to help track progress and provide motivation during the quitting process.

The Importance of Education and Prevention

Addressing the issue of smokeless tobacco use requires a multifaceted approach that includes education, prevention, and policy measures. By raising awareness about the dangers of smokeless tobacco and implementing effective prevention strategies, we can work towards reducing its use and protecting public health.

Educational Initiatives

What are some effective educational strategies to inform the public about the risks of smokeless tobacco use?

• School-based programs: Implement comprehensive tobacco education programs in schools, focusing on the dangers of all forms of tobacco use, including smokeless tobacco.
• Public awareness campaigns: Develop and disseminate informative materials through various media channels to reach a wide audience.
• Healthcare provider education: Ensure that healthcare providers are well-informed about the risks of smokeless tobacco and can effectively counsel patients.

Policy Measures

How can policy measures contribute to reducing smokeless tobacco use?

• Taxation: Implement higher taxes on smokeless tobacco products to discourage use, particularly among youth.
• Marketing restrictions: Enforce strict regulations on the marketing and advertising of smokeless tobacco products.
• Access limitations: Implement and enforce age restrictions on the purchase of smokeless tobacco products.
• Warning labels: Require prominent health warning labels on all smokeless tobacco products.

By combining education, prevention efforts, and policy measures, we can work towards reducing the prevalence of smokeless tobacco use and its associated health risks. It’s crucial to continue research into the effects of smokeless tobacco and to adapt prevention and cessation strategies as new information becomes available.

Dangers of Smokeless Tobacco – HealthyChildren.org

What is Smokeless Tobacco?

Chewing tobacco, snuff, snus, and dissolvable tobacco in the shape of sticks, pellets, and strips are all types of tobacco products that are not smoked but used in other ways. All types of smokeless tobacco contain nicotine and chemicals that may cause cancer (carcinogens).

Chewing Tobacco

Chewing tobacco comes in 3 forms:

• Loose leaves
• Plugs
• Twists or rolls

A piece (plug, wad, or chew) of tobacco is placed between the cheek and gum. Users chew on it for several hours and spit out the tobacco juices and saliva as they build up.

Snuff and Snus

Snuff and snus are ground tobacco. Moist snuff and snus are sold in cans or sachets (pouches that look like tea bags). Users put a pinch  of moist snuff between the cheek or lip and gum. Sachets are placed between the cheek and gum. Dry snuff is a powdered form sold in cans. A pinch of dry snuff can be placed in the mouth or sniffed up the nose.

Other Forms of Smokeless Tobacco

The newest forms of smokeless tobacco are finely ground dissolvable tobacco that is flavored and shaped into sticks, pellets, or strips. These forms melt in the users’ mouth within 3 to 30 minutes, delivering nicotine. These new stick forms of smokeless tobacco contain 3 times more nicotine than an average cigarette. These forms of tobacco are not widely available as other types, and tobacco companies have been known to target specific areas to test these products out.

Smokeless Tobacco is Addictive

Nicotine in smokeless tobacco is what gives users a buzz. It also makes it very hard to quit.

Every time smokeless tobacco is used, the body gets used to the nicotine and starts to crave it. Craving is one of the signs of addiction. Another sign of addiction is called tolerance. This is when the body adjusts to the amount of tobacco needed to get a buzz. With continued use, more and more tobacco is needed to get the same feeling.

Many smokeless tobacco users say it is harder to quit smokeless tobacco than cigarettes.

Smokeless Tobacco is Not Safe

Some people believe smokeless tobacco is OK because it does not cause health problems from smoke and smoking. This does not make smokeless tobacco safe, however. Some smokeless tobacco delivers more nicotine than cigarettes, making addiction more likely. There are also direct effects of smokeless tobacco on the mouth.

• 
  Bad breath. Smokeless tobacco can give you really bad breath and discolored teeth. This will not help anyone’s social life.
• 
  Dental problems. Smokeless tobacco’s direct and repeated contact with the gums causes the gums to recede and become diseased, leading to loose teeth. Many forms of smokeless tobacco also contain sugar. This mixes with the plaque on the teeth to form acid that eats away at tooth enamel to cause cavities and chronic painful sores.
• 
  Cancer.  Cancer of the mouth (including the lip, tongue, and cheek) and throat can occur most often at the spot in the mouth where the tobacco is held. Surgical removal of cancer is often needed, and parts of the face, tongue, cheek, or lip must often be removed too.
• 
  Leukoplakia. A white, leathery-like patch called leukoplakia may form in the mouth. The patches vary in size and shape and can become cancerous. If you have a patch in your mouth, your doctor should examine it right away.

Other harmful effects:

• 
  Heart problems. The constant flow of nicotine into your body causes many side effects including increased heart rate, increased blood pressure, and sometimes irregular heartbeats, which may increase risk for sudden death from a condition (ventricular arrhythmias) in which the heart does not beat properly.
• 
  Nicotine poisoning. The new forms of smokeless tobacco look like candy or breath strips, making them attractive to all ages, even children. While tobacco from a cigarette tastes bitter and unpleasant, the new forms are minty and flavorful, increasing their potential for poisoning.

Smokeless Tobacco is Popular with Youth, Too
Smokeless tobacco is not used by adults alone—recent surveys from the Centers for Disease Control and Prevention (CDC) have shown that youth are using smokeless tobacco more frequently, and in addition to other types of tobacco products.

The American Academy of Pediatrics (AAP) recommends that prices for tobacco products be raised to discourage use by youth and that use of tobacco products in media (TV, movies, video games) be banned. The AAP supports a movement to


eliminate smokeless tobacco use by Major League Baseball players. A few cities have already banned smokeless tobacco from their baseball parks.

Tips to Quit

Trying to quit can be difficult, but it is not impossible. Here are some tips:

• Pick a quit date and throw out all of your smokeless tobacco products.
• Ask for help. You can successfully quit with help and support!
• Call your doctor.
• Go online to a smokeless tobacco quitting resource, such as
  
  http://mylastdip.com.
• Call a national toll-free telephone counseling resource, such as 1-800-QUIT-NOW.
• Ask your friends, family, teachers, and coaches for support and encouragement. Tell friends you are quitting and ask them to not offer you smokeless tobacco or other nicotine products. Ask a friend to quit with you.
• Chew on something else. A few good examples are sugarless gum, pumpkin or sunflower seeds, or apple slices.
• Stay busy with healthier activities. You could work on a hobby, listen to music, or volunteer your time. Exercise can help relieve any tension caused by quitting. Try biking, walking, running, or other sports.
• Everyone is different, so develop a personalized plan that works best for you. Set realistic goals so you will be more likely to achieve them.
• Reward yourself. Save the money that you would have spent on smokeless tobacco and use it for something special. Treat yourself to your favorite restaurant, a special purchase, or an event. Spend time with family and friends who are supportive.

Early Signs of Oral Cancer

Your chances of being cured are higher if oral cancer is found early. Check your mouth often, looking closely at the places where you hold the tobacco. See your doctor right away if you have any of the following:

• A sore that bleeds easily and does not heal
• A lump or thickening in your mouth or neck
• Soreness or swelling that does not go away
• A red or white patch that does not go away
• Trouble chewing, swallowing, or moving your tongue or jaw

If you use smokeless tobacco, your doctor and dentist should carefully examine your mouth at each checkup.

Additional Resources:

The information contained on this Web site should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Chew Tobacco – Get the Facts About Chew Tobacco, Including Ingredients and Risks

What You Need to Know

Here’s what we do know about the varieties of chew.

Chew is not a safe substitute for cigarettes.

• People who chew or dip ingest about the same amount of nicotine as regular smokers.²
• Chew and other smokeless tobacco products are linked to cancer and can be deadly. These products contain a variety of potentially harmful chemicals.³
• Because users suck on and sometimes swallow the juices, cancers and diseases of the mouth, esophagus and pancreas are common among chew users.⁴
• The most harmful cancer-causing substances in smokeless tobacco are tobacco-specific nitrosamines (TSNAs), which are formed during the curing and aging of tobacco. TSNA levels vary by product, but higher levels result in greater cancer risk.³
• Additional research is needed to examine long-term effects of newer smokeless tobacco products, such as snus.¹
• Chew and snuff are not a less harmful alternative to smoking; they are still linked to cancer and can be deadly.³

Swallowing chew can lead to nicotine poisoning.

Nicotine in any form is poisonous to children and pets. According to Poison Control, even swallowing just a small amount of chew in young people or adults can lead to nausea, vomiting, dizziness, tremors, sweating and seizures, as well as making the heart beat much faster than normal. Nicotine can poison through ingestion, skin, eye or mouth contact, so always properly store and dispose of all chew products. If you experience symptoms or suspect that a child has been exposed to nicotine or swallowed chew, immediately call Poison Control at 1-800-222-1222.&nbsp

Chew and snuff have not been proven to help cigarette smokers quit­­.

Cessation is the best option for those looking to lead a healthier lifestyle.³

Over 10 million Americans use smokeless tobacco, including over 6 percent of high school students. The highest concentration of users is in rural areas.

⁵

Harms of Cigarette Smoking and Health Benefits of Quitting

Smokeless Tobacco and Its Adverse Effects on Hematological Parameters: A Cross-Sectional Study

Background. Smokeless tobacco (SLT) as a drug substance has been used throughout the world although it has dangerous effects on human health. Among the 28 known carcinogens in SLT, tobacco-specific nitrosamines are considered to be the most potent. This has challenged the metabolic condition leading to a rise in the inflammatory status, increased apoptosis, and red blood cell (RBC) membrane damage. Therefore, the present study was undertaken to evaluate the adverse effects of SLT on hematological parameters and establish a correlation between them. Materials and Methods. A total of 100 subjects (50 SLT users and 50 nonusers) were selected for the study. Complete demographic data and history were taken and clinical examination was done to evaluate any oral mucosal changes. Venous blood samples were taken to analyze the hematological parameters. Results. Significant changes were observed in the complete blood profile in SLT users when compared to nonusers. All the hematological parameters had a negative correlation with form of SLT except for total leucocyte count which had a positive correlation. Conclusion. The current study confers an imperative role into SLT mediated effects on a complete hemogram and might be beneficial in spreading awareness against its usage. It also serves as a forewarning alarm among the population consuming SLT as an alternative to smoking tobacco.

1. Introduction

Oral cancer, a modern epidemic among the noncommunicable diseases, is a major problem in the Indian subcontinent where it ranks among the top three types of cancer in the country. 20 per 100,000 individuals are affected by oral cancer accounting for about 30% of all types of cancer in the country. The global burden of cancer continues to increase mostly because of increase in habits of tobacco, particularly smoke and smokeless forms [1].

Smokeless tobacco (SLT) is used in various forms in India such as pan (betel quid) with tobacco, zarda, pan masala, khaini, areca nut and slaked lime preparations, mawa, snuff, mishri, and gudakhu. In addition to the locally prepared products, recently many commercially packed products have been marketed at affordable prices and are easily accessible to everyone, particularly the young and poor [2]. The major tobacco alkaloid nicotine and its principal metabolite cotinine are metabolized to pyridine-N-glucuronides, nicotine-N-Gluc, and cotinine-N Gluc in the liver [3]. Besides the toxic chemicals like polycyclic aromatic hydrocarbons, nitrate, nitrite, nicotine, and acrolein, chemicals such as crotonaldehyde, formaldehyde, and acetaldehyde have also been reported in SLT [4].

According to the World Health Organization, nearly 1/3rd of the global adult populations are tobacco users. Global Adult Tobacco Survey-2 (GATS-2) reports that 28.6% of the population consumes tobacco in any form, 10.7% smoke, and 21.4% use SLT [5]. The prevalence of SLT use is higher among men (27%-37%) compared to women (10%-15%) [6]. As per GATS (2009-10), the prevalence of SLT in India ranges from 5% in Himachal Pradesh and Goa to nearly 50% in Bihar, Jharkhand, and Chhattisgarh [7].

Various pharmacological actions of nicotine and additives and their wide use in many regions and countries may affect the status of hematological parameters and further delineate the effects of tobacco use to systemic health. SLT products act locally on keratinocyte stem cells and are absorbed and act in many other tissues in the body. They produce DNA adducts, principally O-6-methyl-guanine and interfere with the accuracy of DNA replication and mutation, further contributing to the molecular chain of events leading to the malignant transformation of a cell. SLT products modulate the metabolic pattern in a robust way and escalate the risk of systemic inflammation such as RBC morphology modulation, polycythemia vera, and cardiovascular diseases. Indeed chromosomal instability resulting from SLT is most often studied in lymphocytes from peripheral blood [4, 8, 9].

Very few studies on the effect of the consumption of SLT on alteration in the levels of hematological parameters have been reported in the literature but no correlation has been established regarding the same. Considering the above background, the aim and objectives of the present study were to determine the effect of smokeless tobacco on hematological parameters in SLT users and nonusers and evaluate the correlation of smokeless tobacco form with complete blood profile.

2. Materials and Methods

A cross-sectional study was conducted at the Department of Oral Medicine and Radiology, Dental Institute, RIMS, Ranchi, on a total of 100 subjects (50 SLT users and 50 nonusers). The participants enrolled in the study belonged to the age group of 20-85 years and were selected through a simple random sampling technique. The refusal rate was found to be 7.4% (8 subjects refused to participate as they did not want to undergo any investigatory procedure) and these subjects were not included in the study. The study was explained to all the subjects and written informed consent was obtained. Demographic data (including occupation and socioeconomic status) was obtained for all individuals.

2.1. Inclusion Criteria

Healthy individuals with history of consumption of smokeless tobacco in any form and no history of any systemic illnesses were selected as SLT users (exposed). Age and sex matched healthy individuals with no history of tobacco consumption in any form and no history of any systemic illnesses were selected as nonusers.

2.2. Exclusion Criteria

Subjects with any systemic illness or immunocompromised conditions, those consuming alcohol and smoking tobacco in any form, and those not willing to participate were excluded from the study.

The armamentarium consisted of diagnostic instruments, a 5 ml syringe, vials containing ethylenediaminetetraacetic acid (EDTA), a tourniquet, sterile cotton, and surgical gloves. 5 ml of venous blood was collected from all subjects by using a routine venipuncture method and stored in vials containing EDTA. Complete blood count was analyzed using an automated blood cell counter by Horiba XL 80 at the hematology laboratory of the institution.

All the data obtained was noted in a proforma specially designed for the study. Comparison of the various parameters of complete blood profile in SLT users and nonusers was performed using the t-test and Spearman’s rank correlation coefficient with SPSS (Statistical Package for the Social Sciences) software version 16. 01. Significance level was considered at 1% (p value <0.01) and 5% (p value <0.05).

3. Results

A total of 100 subjects, 50 SLT users (48 males and 2 females) and 50 nonusers (46 males and 4 females) with mean ages of 40.2 years and 40.5 years, respectively, were selected for the study. Table 1 represents the detailed sociodemographic characteristics of SLT users and nonusers including occupation and socioeconomic status.

S. no. Variable Frequency SLT users Nonusers 1 No. of patients 50 50 2 Mean age (years) 40.2 40.5 Age range (20-85 years) 3 Gender      Male 48 46  Female 2 4 4 Occupation      Employed 13 14  Self-employed 19 16  Unemployed 18 20 5 Socioeconomic status      Upper 2 1  Upper middle 8 7  Lower middle 11 12  Upper lower 17 16  Lower 12 14

(: classified according to Kuppuswamy’s socioeconomic status scale 2018. )

In terms of exposure, consumption of SLT was described in terms of duration (number of months/years of consumption) and frequency (number of times of consumption per day). Among 50 SLT users (exposed), 29 subjects consumed khaini whereas 21 consumed gutkha. When duration of the habit was being compared, the majority of the subjects (24 SLT users) were reported with >10 years, followed by <5 years (15 SLT users) and 5-10 years (11 SLT users). The mean average of duration of khaini consumption was 16.14 years at a frequency of 11 times/day. The mean average duration of gutkha consumption was 6.24 years at a frequency of 6 times/day.

The various oral mucosal changes observed were white lesions (16 SLT users), proliferative/ulcerative growth (17 SLT users), and mixed red and white lesions (2 SLT users). No mucosal changes were observed in 15 SLT users and all the 50 nonusers. Table 2 shows the distribution of oral mucosal changes seen in SLT users according to duration of consumption. Burning sensation was noted in 26 SLT users.

3.1. Comparison of Hemoglobin (Hb ) in SLT Users (Exposed) and Nonusers

Mean serum Hb was lower in SLT users (13.74 g/dl) when compared to nonusers (14.12 g/dl) which was statistically nonsignificant with a t value of 1.18 and p value of 0.12 (Figure 1).

3.2. Comparison of Total Leucocyte Count (TLC) in SLT Users (Exposed) and Nonusers

Mean serum TLC was higher in SLT users (8277 cells/cu.mm) when compared to nonusers (7634 cells/cu.mm) which was statistically significant with a t value of -1.66 and p value of 0.04 (Figure 2).

3.3. Comparison of Total Red Blood Cells (TRBC) in SLT Users (Exposed) and Nonusers

Mean serum TRBC were lower in SLT users (4.88 mill/cu.mm) than nonusers (5.59 mill/cu.mm) which was highly statistically significant with a t value of 4.64 and p value of 0.00 (Figure 1).

3.4. Comparison of Total Platelet (PT) in SLT Users (Exposed) and Nonusers

Mean serum total PT was lower in SLT users (1.98 lakh/cu.mm) when compared to nonusers (3.02 lakh/cu.mm) which was highly statistically significant with a t value of 7.16 and p value of 0.00 (Figure 1).

3.5. Comparison of Mean Corpuscular Hemoglobin Concentration (MCHC) in SLT Users (Exposed) and Nonusers

Serum MCHC did not show much difference in SLT users (33.2 g/dl) and nonusers (33.9 g/dl) and was statistically nonsignificant with a t value of 2.26 and p value of 0.98 (Figure 3).

3.6. Comparison of Mean Corpuscular Hemoglobin (MCH) in SLT Users (Exposed) and Nonusers

Serum MCH was higher in SLT users (29.65 pg) when compared to nonusers (29.43 pg) which was statistically nonsignificant with a t value of -0.16 and p value of 0.43 (Figure 3).

3.7. Comparison of Mean Corpuscular Volume (MCV) in SLT Users (Exposed) and Nonusers

Serum MCV was lower in SLT users (83.24 fl) when compared to nonusers (87.16 fl) which was statistically significant with a t value of 2.18 and p value of < 0.01 (Figure 3).

3.8. Comparison of Packed Cell Volume (PCV) in SLT Users (Exposed) and Nonusers

Mean serum PCV was lower in SLT users (42.02%) when compared to nonusers (46.82%) which was statistically significant with a t value of 3.35 and p value of 0.00 (Figure 3).

3.9. Correlation of Form of Smokeless Tobacco with Hematological Parameters

All the hematological parameters had a negative correlation with khaini and gutkha except TLC (positive correlation) and were statistically not significant (Table 3). This was suggestive of the fact that both khaini and gutkha had equally adverse systemic effects on the blood profile.

4. Discussion

Tobacco is the dried and processed leaves of the plant Nicotiana tobacum that is widely cultivated and commercially grown in many countries of the world [8]. SLT contains three to four times more nicotine than that delivered by a cigarette and it stays for a longer time in the bloodstream. Nicotine is a psychoactive ingredient, metabolically inactivated by CYP2A6 to cotinine, metabolized by the liver and detoxified [4].

SLT products commonly observed in our present study were khaini and gutkha. Khaini is prepared from sun-dried tobacco and slaked lime. Gutkha is a ready-to-eat SLT product comprised of areca nut, slaked lime, catechu, tobacco, flavoring agents, and sweeteners. Slaked lime is composed of calcium hydroxide obtained from limestone or sea shells. In addition, it also contains iron, magnesium, and a number of trace elements. The addition of slaked lime and other alkaline agents like magnesium carbonate boosts the pH of a product and results in increased availability of free nicotine, the form that is most easily absorbed. Toxic metals in SLT products include Pb, Cd, As, Cu, Hg, and Se [10].

SLT consumption is more prevalent among lower socioeconomic groups in India that include poor, semiskilled manual workers and unemployed people with meager education. It is believed that the usage of SLT relieves work related stress and has healing properties for curing toothaches, headaches, and stomachaches which forces many adults to accede to its usage. SLT products such as gutkha are considered a form of sweet candy by children and as a mouth freshener by some. Curiosity, peer pressure, and offering by friends and acquaintances contribute to the initiation of its use [11, 12]. Tobacco use is more common among males especially teenagers when compared with females [13]. Male predominance in the age group 30-40 yrs was seen in the present study. The majority of subjects (43 SLT users) were from low socioeconomic background.

The habit of chewing or holding of SLT in the oral cavity also allows absorption of nicotine and other carcinogens through the oral mucosa. This could be the reason behind injury to the oral epithelium caused by tobacco-related toxic products which in turn increases mucosal permeability and penetration of carcinogens. As an early sign of damage to the oral mucosa, chewers of SLT with or without tobacco often develop clinically visible whitish (leukoplakia) or reddish (erythroplakia) lesions and/or stiffening of the oral mucosa and oral submucous fibrosis which later transforms into malignancy. All these oral mucosal changes were observed in the present study [4, 14, 15].

The effects of SLT on physiological systems are also well known. SLT chewers have shown alteration in the morphology of RBCs. Scanning electron microscopy revealed change in RBC membranes with loss of their discoid shape with fine “bubble-like” protrusions. The ingredients of SLT perturb the cellular metabolism of the individuals leading to alteration in shape and size causing enormous consequences in the context of maintaining health [4].

The increase in total RBC count in SLT users seems to reflect that consuming tobacco may also stimulate erythropoiesis. Insufficient pulmonary function in SLT consumers may impart a necessity of stimulating erythropoiesis for fulfilling the oxygen demands of the body. Thus the increase in PCV and Hb levels following such increase in erythrocyte production is quite awaited [8]. Decreases in total RBC, PT, Hb, and PCV levels were seen in SLT users when compared to nonusers and were statistically significant in the present study. Similar decreases in total RBC count, PT, Hb, and PCV levels were seen in the study conducted by Metin et al. (2004) [16]. On the contrary, total RBC, Hb, and PCV levels were increased in the study conducted by Roan Mukherjee et al. (2013) [17].

Nicotine present in tobacco may influence the suprarenal glands to secrete more catecholamine which may affect leukocytosis causing damage to tissue and inflammation [18]. Higher TLC was observed in SLT users when compared to nonusers in the present study and was statistically significant. Similar increase in leukocyte count was also seen in studies conducted by P. Jaganmohan et al. (2011) and Saeed R et al. (2005) [19, 20].

Blood indices such as MCV, MCHC, and MCH relate to individual red blood cells and indicators of anemia. A decreased level of MCV relates to iron deficiency anemia and elevated levels are indicative of anemia of vitamin deficiency [21]. MCHC did not show much difference in SLT users and nonusers and was statistically significant. On the contrary, MCHC count was slightly increased in studies conducted by B. Purushottama Dass et al. (2013) and Biswas et al. (2015) [4, 22]. MCH level was increased in SLT users when compared with nonusers in the present study. Similar increase in MCH level was also present in the studies conducted by B. Purushottama Dass et al. (2013) and Biswas et al. (2015) [4, 22]. MCV level was decreased in the present study. Similar decrease in MCV level was seen in the study conducted by Purushottama Dass et al. (2013) and there was increase in the levels in the study by Biswas et al. (2015) [4, 22]. The altered hematological parameters in SLT users further suggest selective toxicity of SLT and its components.

The noxious components of khaini and gutkha might have an adverse effect on the blood profile. In the present study, all the hematological parameters had a negative correlation with khaini and gutkha and were statistically not significant, indicative of the fact that both khaini and gutkha had equally adverse systemic effects on the blood profile.

5. Limitations

Evaluation of all the toxic components present in khaini and gutkha and the differential dosage of these SLT products consumed were beyond the scope of the study. Further studies should be carried out to investigate the prevalence rates of different tobacco products separately along with detailed measures of tobacco consumption, as the economic and health effects of different products may vary considerably.

6. Conclusion and Recommendation

SLT use has severe adverse effects on hematological parameters. The present study might serve as an early diagnostic tool in any systemic diseases and be helpful in spreading awareness on the deleterious effect in the populace consuming SLT. Timely intervention among students can prevent the initial experimentations with tobacco from developing into addiction in adulthood. People should be counseled to avoid all habits of tobacco and undergo nicotine replacement therapy along with antioxidants. Knowledge and awareness about systemic and oral ill effects of tobacco should be spread through tobacco control programs in the pursuit for a tobacco-free world.

Data Availability

No data were used to support this study.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Acknowledgments

We would like to thank Dr. Ritika Jain, M.Sc., Ph.D. (economics), for her kind and valuable support in statistics.

6 Chewing Tobacco Risks – Comfort Dental

6 Chewing Tobacco Risks – Your Mouth, Teeth & Health

1. Stained Teeth & Bad Breath: Prolonged use of chewing tobacco can stain your teeth and tongue, as well as give you hard-to-cover foul breath…all very unattractive.
2. Dulled Sense of Taste and Smell: The harsh chemicals of chewing tobacco do more than impair your oral health; they also disrupt one’s sense of taste and smell.  
3. Increased Tooth Decay: The sugar and other agents in smokeless tobacco damage your tooth enamel and contribute to cavities.
4. Slowed Healing After Extraction or Other Surgery: The irritating agents in chewing tobacco reduces or impairs the body’s ability to heal.
5. Gum Recession: Having a small “pinch” of chewing tobacco next to your gums causes constant irritation. The effect is permanent damage to your gums and the surrounding bone. Damaged gum tissue pulls away from the teeth, causing sensitivity and additional exposure to tooth decay.  If bone surrounding the tooth erodes too much it can even result in permanent tooth loss.
6. Oral Cancer: Chewing tobacco with its 28-cancer causing agents leaves gums, cheeks, lips and throat in constant exposure to unhealthy juices. In addition, this tobacco use is also strongly associated with leukoplakia—a precancerous lesion of the soft tissue in the mouth that consists of a white patch or plaque that cannot be scraped off. This can result in cancer of the oral cavity, pharynx, larynx, and esophagus. (If you need visual proof, just search “Effects of Smokeless Tobacco” in Google images – then brace yourself.)

ORAL CANCER SCREENINGS
Oral cancer screenings are important for everyone and people with higher risk – such as tobacco users – are especially in need of monitoring. Click here for more information on this important screening at Comfort Dental. Early detection goes a long way in preventing problems in the future. Your oral and overall health is our number one concern.

Do you need a dental exam and cancer screening? Click here & visit us!

Hear more about the effects of tobacco use on your oral health:

WHAT‘S THE BEST ANSWER?
Quitting is the only way to decrease risks mentioned above and other tobacco-related health problems. The addictive quality of nicotine, found in cigarettes, cigars and chewing tobacco, can make this especially difficult. That’s why it’s important to have a plan and a support network of people to help you stick to your plan.

Talk to Dr. Randall Brucken, Dr. Lawrence Stubbs or your doctor to see if the medications available would help you to stop using tobacco. Living in a tobacco-free environment is healthier for you and for those around you. Make a plan to quit, stick to it and start living a healthier life.

If you have any additional questions about chewing tobacco or oral cancer, feel free to let us know. We are here to help! We strive for well-informed, healthy patients.

Overview, Uses, Side Effects, Precautions, Interactions, Dosing and Reviews

Backheet, E. Y. and Sayed, H. M. Two new chlorinated amides from Nicotiana glauca R. Graham. Pharmazie 2002;57(3):206-208. View abstract.

Barbieri, R., Gochberg, J., and Ryan, K. Nicotine, cotinine, and anabasine inhibit aromatase in human trophoblast in vitro. J Clin Invest 1986;77:1727-1733. View abstract.

Barbieri, R., York, C., Cherry, M., and Ryan, K. The effects of nicotine, cotinine and anabasine on rat adrenal 11 beta-hydroxylase and 21-hydroxylase. J Steroid Biochem 1987;28:25-28. View abstract.

Bunch, T. D., Panter, K. E., and James, L. F. Ultrasound studies of the effects of certain poisonous plants on uterine function and fetal development in livestock. J Anim Sci 1992;70(5):1639-1643. View abstract.

Castorena, J. L., Garriott, J. C., Barnhardt, F. E., and Shaw, R. F. A fatal poisoning from Nicotiana glauca. J Toxicol Clin Toxicol 1987;25(5):429-435. View abstract.

Dwosin, L., Teng, L., Buxton, S., Ravard, A., Deo, N., and Crooks, P. Minor alkaloids of tobacco release [3H]dopamine from superfused rat striatal slices. Eur J Pharmacol 1995;276:195-199. View abstract.

Furer V, Hersch M, Silvetzki N, Breuer GS, Zevin S. Nicotiana glauca (tree tobacco) intoxication–two cases in one family. J Med Toxicol 2011;7:47-51. View abstract.

Garcia C, Adams J. Healing with medicinal plants of the west – cultural and scientific basis for their use. La Crescenta, CA: Abedus Press; 2005.

Janakat, S. and Al Merie, H. Evaluation of hepatoprotective effect of Pistacia lentiscus, Phillyrea latifolia and Nicotiana glauca. J Ethnopharmacol 2002;83(1-2):135-138. View abstract.

Karadsheh, N., Kussie, P., and Linthicum, D. Inhibition of acetylcholinesterase by caffeine, anabasine, methyl pyrrolidine and their derivatives. Tox Lett 1991;55:335-342. View abstract.

Keeler, R. F. and Crowe, M. W. Congenital deformities in swine induced by wild tree tobacco, Nicotiana glauca. J Toxicol Clin Toxicol 1983;20(1):47-58. View abstract.

Keeler, R. F. and Crowe, M. W. Teratogenicity and toxicity of wild tree tobacco, Nicotiana glauca in sheep. Cornell Vet 1984;74(1):50-59. View abstract.

Keeler, R. F. Congenital defects in calves from maternal ingestion of Nicotiana glauca of high anabasine content. Clin Toxicol 1979;15(4):417-426. View abstract.

Keeler, R. F., Balls, L. D., and Panter, K. Teratogenic effects of Nicotiana glauca and concentration of anabasine, the suspect teratogen in plant parts. Cornell Vet 1981;71(1):47-53. View abstract.

Keeler, R. F., Crowe, M. W., and Lambert, E. A. Teratogenicity in swine of the tobacco alkaloid anabasine isolated from Nicotiana glauca. Teratology 1984;30(1):61-69. View abstract.

Keeler, R. F., Shupe, J. L., Crowe, M. W., Olson, A., and Balls, L. D. Nicotiana glauca-induced congenital deformities in calves: clinical and pathologic aspects. Am J Vet Res 1981;42(7):1231-1234. View abstract.

Khafagy, S. and Metwally, A. Phytochemical investigation of the polyphenolic constituents of Nicotiana glauca R Grah grown in Egypt. J Pharm Sci UAR 1968;9:117-126.

Leete, E. and Chedekel, M. Metabolism of nicotine in Nicotiana glauca. Phytochem 1974;13:1853-1859.

Leete, E. The metabolism of nicotine-2′-14C in Nicotiana Glauca. Tetrahedron Lett 1968;42:4433-4436. View abstract.

Maier, W., Schmidt, J., Nimtz, M., Wray, V., and Strack, D. Secondary products in mycorrhizal roots of tobacco and tomato. Phytochemistry 2000;54(5):473-479. View abstract.

Manoguerra, A. S. and Freeman, D. Acute poisoning from the ingestion of Nicotiana glauca. J Toxicol Clin Toxicol 1982;19(8):861-864. View abstract.

Mastropaolo, J., Rosse, R., and Deutsch, S. Anabasine, a selective nicotinic acetylcholine receptor agonist, antagonizes MK-801-elicited mouse popping behavior, an animal model of schizophrenia. Behav Brain Res 2004;153:419-422. View abstract.

Mellick, L. B., Makowski, T., Mellick, G. A., and Borger, R. Neuromuscular blockade after ingestion of tree tobacco (Nicotiana glauca). Ann Emerg Med 1999;34(1):101-104. View abstract.

Mizrachi, N., Levy, S., and Goren, Z. Q. Fatal poisoning from Nicotiana glauca leaves: identification of anabasine by gas-chromatography/mass spectrometry. J Forensic Sci 2000;45(3):736-741. View abstract.

Ntelios D, Kargakis M, Topalis T, Drouzas A, Potolidis E. Acute respiratory failure due to Nicotiana glauca ingestion. Hippokratia 2013;17(2):183-4. View abstract.

Panter, K. E., Bunch, T. D., Keeler, R. F., Sisson, D. V., and Callan, R. J. Multiple congenital contractures (MCC) and cleft palate induced in goats by ingestion of piperidine alkaloid-containing plants: reduction in fetal movement as the probable cause. J Toxicol Clin Toxicol 1990;28(1):69-83. View abstract.

Panter, K. E., Keeler, R. F., Bunch, T. D., and Callan, R. J. Congenital skeletal malformations and cleft palate induced in goats by ingestion of Lupinus, Conium and Nicotiana species. . Toxicon 1990;28(12):1377-1385. View abstract.

Panter, K. E., Weinzweig, J., Gardner, D. R., Stegelmeier, B. L., and James, L. F. Comparison of cleft palate induction by Nicotiana glauca in goats and sheep. Teratology 2000;61(3):203-210. View abstract.

Plumlee, K. H., Holstege, D. M., Blanchard, P. C., Fiser, K. M., and Galey, F. D. Nicotiana glauca toxicosis of cattle. J Vet Diagn Invest 1993;5(3):498-499. View abstract.

Sims, D. N., James, R., and Christensen, T. Another death due to ingestion of Nicotiana glauca. J Forensic Sci 1999;44(2):447-449. View abstract.

Skliar, M., Curino, A., Milanesi, L., Benassati, S., and Boland, R. Nicotiana glauca: another plant species containing vitamin D(3) metabolites. Plant Sci 2000;156(2):193-199. View abstract.

Steenkamp, P. A., van Heerden, F. R., and van Wyk, B. E. Accidental fatal poisoning by Nicotiana glauca: identification of anabasine by high performance liquid chromatography/photodiode array/mass spectrometry. Forensic Sci Int 2002;127(3):208-217. View abstract.

Waka, M., Hopkins, R. J., and Curtis, C. Ethnobotanical survey and testing of plants traditionally used against hematophagous insects in Eritrea. J Ethnopharmacol 2004;95(1):95-101. View abstract.

Weinzweig, J., Panter, K. E., Pantaloni, M., Spangenberger, A., Harper, J. S., Lui, F., Gardner, D., Wierenga, T. L., and Edstrom, L. E. The fetal cleft palate: I. Characterization of a congenital model. Plast Reconstr Surg 1999;103(2):419-428. View abstract.

Weinzweig, J., Panter, K. E., Pantaloni, M., Spangenberger, A., Harper, J. S., Lui, F., James, L. F., and Edstrom, L. E. The fetal cleft palate: II. Scarless healing after in utero repair of a congenital model. Plast Reconstr Surg 1999;104(5):1356-1364. View abstract.

Weinzweig, J., Panter, K. E., Spangenberger, A., Harper, J. S., McRae, R., and Edstrom, L. E. The fetal cleft palate: III. Ultrastructural and functional analysis of palatal development following in utero repair of the congenital model. Plast Reconstr Surg 2002;109(7):2355-2362. View abstract.

Backheet, E. Y. and Sayed, H. M. Two new chlorinated amides from Nicotiana glauca R. Graham. Pharmazie 2002;57(3):206-208. View abstract.

Bardas SL. Short-term intubation after ingestion of Nicotiana glauca. Am J Health Syst Pharm. 2011;68(18):1678-9. View abstract.

Bunch, T. D., Panter, K. E., and James, L. F. Ultrasound studies of the effects of certain poisonous plants on uterine function and fetal development in livestock. J Anim Sci 1992;70(5):1639-1643. View abstract.

Castorena, J. L., Garriott, J. C., Barnhardt, F. E., and Shaw, R. F. A fatal poisoning from Nicotiana glauca. J Toxicol Clin Toxicol 1987;25(5):429-435. View abstract.

Dwosin, L., Teng, L., Buxton, S., Ravard, A., Deo, N., and Crooks, P. Minor alkaloids of tobacco release [3H]dopamine from superfused rat striatal slices. Eur J Pharmacol 1995;276:195-199. View abstract.

Furer V, Hersch M, Silvetzki N, Breuer GS, Zevin S. Nicotiana glauca (tree tobacco) intoxication–two cases in one family. J Med Toxicol 2011;7:47-51. View abstract.

Garcia C, Adams J. Healing with medicinal plants of the west – cultural and scientific basis for their use. La Crescenta, CA: Abedus Press; 2005.

Karadsheh, N., Kussie, P., and Linthicum, D. Inhibition of acetylcholinesterase by caffeine, anabasine, methyl pyrrolidine and their derivatives. Tox Lett 1991;55:335-342. View abstract.

Keeler, R. F. and Crowe, M. W. Congenital deformities in swine induced by wild tree tobacco, Nicotiana glauca. J Toxicol Clin Toxicol 1983;20(1):47-58. View abstract.

Keeler, R. F. and Crowe, M. W. Teratogenicity and toxicity of wild tree tobacco, Nicotiana glauca in sheep. Cornell Vet 1984;74(1):50-59. View abstract.

Keeler, R. F. Congenital defects in calves from maternal ingestion of Nicotiana glauca of high anabasine content. Clin Toxicol 1979;15(4):417-426. View abstract.

Keeler, R. F., Balls, L. D., and Panter, K. Teratogenic effects of Nicotiana glauca and concentration of anabasine, the suspect teratogen in plant parts. Cornell Vet 1981;71(1):47-53. View abstract.

Keeler, R. F., Crowe, M. W., and Lambert, E. A. Teratogenicity in swine of the tobacco alkaloid anabasine isolated from Nicotiana glauca. Teratology 1984;30(1):61-69. View abstract.

Keeler, R. F., Shupe, J. L., Crowe, M. W., Olson, A., and Balls, L. D. Nicotiana glauca-induced congenital deformities in calves: clinical and pathologic aspects. Am J Vet Res 1981;42(7):1231-1234. View abstract.

Khafagy, S. and Metwally, A. Phytochemical investigation of the polyphenolic constituents of Nicotiana glauca R Grah grown in Egypt. J Pharm Sci UAR 1968;9:117-126.

Leete, E. and Chedekel, M. Metabolism of nicotine in Nicotiana glauca. Phytochem 1974;13:1853-1859.

Leete, E. The metabolism of nicotine-2′-14C in Nicotiana Glauca. Tetrahedron Lett 1968;42:4433-4436. View abstract.

Maier, W., Schmidt, J., Nimtz, M., Wray, V., and Strack, D. Secondary products in mycorrhizal roots of tobacco and tomato. Phytochemistry 2000;54(5):473-479. View abstract.

Manoguerra, A. S. and Freeman, D. Acute poisoning from the ingestion of Nicotiana glauca. J Toxicol Clin Toxicol 1982;19(8):861-864. View abstract.

Mastropaolo, J., Rosse, R., and Deutsch, S. Anabasine, a selective nicotinic acetylcholine receptor agonist, antagonizes MK-801-elicited mouse popping behavior, an animal model of schizophrenia. Behav Brain Res 2004;153:419-422. View abstract.

Mellick, L. B., Makowski, T., Mellick, G. A., and Borger, R. Neuromuscular blockade after ingestion of tree tobacco (Nicotiana glauca). Ann Emerg Med 1999;34(1):101-104. View abstract.

Mizrachi, N., Levy, S., and Goren, Z. Q. Fatal poisoning from Nicotiana glauca leaves: identification of anabasine by gas-chromatography/mass spectrometry. J Forensic Sci 2000;45(3):736-741. View abstract.

Ntelios D, Kargakis M, Topalis T, Drouzas A, Potolidis E. Acute respiratory failure due to Nicotiana glauca ingestion. Hippokratia 2013;17(2):183-4. View abstract.

Panter, K. E., Bunch, T. D., Keeler, R. F., Sisson, D. V., and Callan, R. J. Multiple congenital contractures (MCC) and cleft palate induced in goats by ingestion of piperidine alkaloid-containing plants: reduction in fetal movement as the probable cause. J Toxicol Clin Toxicol 1990;28(1):69-83. View abstract.

Panter, K. E., Keeler, R. F., Bunch, T. D., and Callan, R. J. Congenital skeletal malformations and cleft palate induced in goats by ingestion of Lupinus, Conium and Nicotiana species. . Toxicon 1990;28(12):1377-1385. View abstract.

Panter, K. E., Weinzweig, J., Gardner, D. R., Stegelmeier, B. L., and James, L. F. Comparison of cleft palate induction by Nicotiana glauca in goats and sheep. Teratology 2000;61(3):203-210. View abstract.

Plumlee, K. H., Holstege, D. M., Blanchard, P. C., Fiser, K. M., and Galey, F. D. Nicotiana glauca toxicosis of cattle. J Vet Diagn Invest 1993;5(3):498-499. View abstract.

Sercan Y, Selahattin KG. Respiratory failure due to plant poisoning: Nicotiana glauca Graham. J Emerg Med. 2018;55(3):e61-e63. View abstract.

Sims, D. N., James, R., and Christensen, T. Another death due to ingestion of Nicotiana glauca. J Forensic Sci 1999;44(2):447-449. View abstract.

Skliar, M., Curino, A., Milanesi, L., Benassati, S., and Boland, R. Nicotiana glauca: another plant species containing vitamin D(3) metabolites. Plant Sci 2000;156(2):193-199. View abstract.

Steenkamp, P. A., van Heerden, F. R., and van Wyk, B. E. Accidental fatal poisoning by Nicotiana glauca: identification of anabasine by high performance liquid chromatography/photodiode array/mass spectrometry. Forensic Sci Int 2002;127(3):208-217. View abstract.

Waka, M., Hopkins, R. J., and Curtis, C. Ethnobotanical survey and testing of plants traditionally used against hematophagous insects in Eritrea. J Ethnopharmacol 2004;95(1):95-101. View abstract.

Weinzweig, J., Panter, K. E., Pantaloni, M., Spangenberger, A., Harper, J. S., Lui, F., Gardner, D., Wierenga, T. L., and Edstrom, L. E. The fetal cleft palate: I. Characterization of a congenital model. Plast Reconstr Surg 1999;103(2):419-428. View abstract.

Weinzweig, J., Panter, K. E., Pantaloni, M., Spangenberger, A., Harper, J. S., Lui, F., James, L. F., and Edstrom, L. E. The fetal cleft palate: II. Scarless healing after in utero repair of a congenital model. Plast Reconstr Surg 1999;104(5):1356-1364. View abstract.

Weinzweig, J., Panter, K. E., Spangenberger, A., Harper, J. S., McRae, R., and Edstrom, L. E. The fetal cleft palate: III. Ultrastructural and functional analysis of palatal development following in utero repair of the congenital model. Plast Reconstr Surg 2002;109(7):2355-2362. View abstract.

Effects of Tobacco on Health

Background

Tobacco is extracted from around 65 known species of the tobacco plant of which the one that is grown commercially and widely as a source of tobacco is Nicotiana tobaccum. Most of the tobacco from Northern India and Afghanistan comes from the species Nicotiana rustica. The growing use of tobacco is a cause of great concern around the world due to its serious effects on health.

Non-communicable diseases (NCDs) like ischemic heart diseases, cancers, diabetes, chronic respiratory diseases are the leading causes of death globally and associated with tobacco use. Available data from WHO demonstrate that thirty-eight million people die each year from NCDs, of which nearly 85% of NCD deaths occur in low- and middle-income countries.¹

According to WHO statistics for 2010 in India, NCDs are estimated to account for 53% of all deaths. Of these deaths, cardiovascular diseases and diabetes are the most common causes of deaths in India.² This huge burden of NCDs can be attributed to increasing use of tobacco. Tobacco is a major risk factor for a number of diseases affecting all age groups. WHO data shows that tobacco uses kill nearly six million people in a year. Around five million of those deaths are the result of direct tobacco use while more than 600,000 are the result of non-smokers being exposed to second-hand smoke. One person dies every six seconds due to tobacco. Up to half of current users will eventually die of a tobacco-related disease.³

The situation is equally bad in India with estimated number of tobacco users being 274.9 million where 163.7 million users of only smokeless tobacco, 68.9 million only smokers and 42.3 million users of both smoking and smokeless tobacco as per Global Adult Tobacco Survey India (GATS). It means around 35% of adults (47.9% males and 20.3% females) in India use tobacco in some form or the other. Use of smokeless tobacco is more prevalent in India (21%).⁴

Composition of tobacco

Tobacco products contains around 5000 toxic substances.⁵ Most important and dangerous constituents are:

1. 
   Nicotine
2. 
   Carbon Monoxide
3. 
   Tar

Nicotine is the major cause of the predominant behavioral effects of tobacco. It is a poisonous substance leads to addiction. Nicotine influences and reinforces all tobacco-use behavior. After absorption, nicotine travels rapidly to the brain, in a matter of seconds, therefore, the psycho-active rewards associated with smoking occur quickly and these rewards are highly reinforced. Nicotine binds to the receptors in the brain where it influences the cerebral metabolism. Nicotine is then distributed throughout the body, mostly to skeletal muscles. Development of tolerance to its own actions is similar to that produced by other addictive drugs.

Carbon mono-oxide reduces the amount of oxygen blood can carry and causes shortness of breath. Tar is a sticky residue which contains benzopyrene, one of the deadliest cancer causing agents known. Other compounds are carbon dioxide, nitrogen oxides, ammonia, volatile nitrosamines, hydrogen cyanide, volatile sulfur containing compounds, volatile hydrocarbons, alcohols, aldehydes and ketones. Some of these compounds are known to cause cancers of various organs of the body.

Mechanism of action

Nicotine has structural similarity to a body neuro-transmitter acetylcholine (Ach) which conveys information from one neuron to another. Acetylcholine is an important neurotransmitter involved in systems concerned with mental and physical arousal, learning and memory, and several aspects of emotion. There are also other receptors for acetylcholine in the body, apart from the ones at synapses. They are also found at the junction of nerve and muscles and nerves and certain glands. Acetylcholine receptors throughout the body are traditionally classified as nicotine receptors (those that respond to nicotine) and muscarine receptors (those that respond to muscarine). The ability of nicotine to combine with acetylcholine-receptors means that it can exert actions like acetylcholine at all synapses where nicotine acetylcholine-receptors (nAChRs) are present and can trigger impulses.

Forms of tobacco intake

1. 
   Cigarette – Most common and most harmful
2. 
   Bidi – most commonly used form in India
3. 
   Cigar –
4. 
   Hookah (Hubble bubble)
5. 
   Sheesha
6. 
   Tobacco chewing
7. 
   Kreteks (clove cigarettes)
8. 
   Snuff – Moist & Dry
9. 
   E-cigarette – recent intruder in the list

When non-smokers are exposed to smoke containing nicotine and toxic chemicals emitted by smokers it is called passive smoking or exposure to second hand smoke.

Risk factors for tobacco initiation

Following factors influence the predilection for tobacco use:

1.Biological:

• 
  Developmental aspects of adolescent age group include (a) establishing independence and autonomy, (b) forming a coherent self-identity and (c) adjusting to psycho-social changes associated with physical maturation.
• 
  Gender: tobacco use is more common among males in India.

2.Psychological:

Low emotional stability and risk taking behavior are more common in tobacco users. Existence of some mental disorders also increases the risk of tobacco use.

3.Social and Environmental:

Parental influence, lower education status, attraction towards role models, cultural practices, etc.

Consequences of tobacco use

Various effects of tobacco use are as follows:

1. 
   Economic loss
2. 
   Health loss
3. 
   Environmental loss

Tobacco is considered as a major behavioral risk factor for non-communicable diseases one of the leading causes of death. Treatment of cardiovascular diseases and cancer imposes maximum financial burden on the individual and family. For cultivation of tobacco crop forests are destroyed. Burning of tobacco produces number of toxicants in environment. Manufacturing, packaging and transportation also cause environmental pollution.

Cancers associated with tobacco

Tobacco is also associated with cancer of respiratory tract, lung, upper gastrointestinal tract, liver, pancreas, kidney, urinary bladder, oral cavity, nasal cavity, cervix, etc. Smokeless tobacco (chew tobacco, snuff etc.) is a major cause of cancer of the oral cavity.

Risk of developing cancer increases with:

1. 
   Duration of use of tobacco
2. 
   Number of tobacco product use per day
3. 
   Degree of inhalation

Cardiovascular diseases

1. 
   Stroke is vascular disease of the brain where tobacco causes either constrict of blood vessels or rupture leading to loss of consciousness and paralysis.   
2. 
   Tobacco affects coronary vessels of the heart leading decrease of blood supply or death of heart muscles which is known as ischemic or coronary heart disease. This in turn causes cardiac arrest.
3. 
   Smoking acts synergistically with other risk factors like high cholesterol and blood pressure to increase the risk of Coronary Heart Diseases (CHD).

Respiratory Diseases

1. 
   Chronic Obstructive Pulmonary Disease: It includes chronic bronchitis and emphysema
2. 
   Asthma: Smoking is associated with acute attacks of asthma
3. 
   Tuberculosis

Effect on pregnancy and its outcome

1. 
   Bleeding during pregnancy
2. 
   Ectopic pregnancy
3. 
   Miscarriage/abortion
4. 
   Premature delivery of baby
5. 
   Stillbirth
6. 
   Abnormalities of the placenta

Effects on newborns and childhood

Maternal tobacco use during pregnancy and exposure of child to second hand smoke in childhood is known to be a risk factor for following conditions:

1. 
   Maternal smoking is associated with congenital malformations in baby like orofacial clefts, clubfoot and atrial-septal defects.
2. 
   Increased risk of allergies
3. 
   Higher blood pressure in childhood
4. 
   Increased likelihood of obesity
5. 
   Stunted growth
6. 
   Poorer lung function
7. 
   Increased likelihood of developing asthma

Miscellaneous

Following conditions are known to worsen if case of tobacco use:

1. 
   Rheumatologic conditions: Rheumatoid arthritis
2. 
   Kidney damage
3. 
   Eye Disease: Age-Related Macular Degeneration
4. 
   Dental Disease like caries
5. 
   Diabetes
6. 
   Inflammatory bowel diseases
7. 
   Erectile dysfunction

Figure 1: Risks form smoking- Smoking can damage every part of the body

Source:

Therapy for tobacco cessation at the individual level

Therapy for tobacco-cessation can be broadly classified into two types: a) pharmacological and b) non-pharmacological.

A.    Pharmacological:  

1. 
   Nicotine Replacement Therapy : The general principle of nicotine replacement therapy is to present the patient with a safer and more therapeutically manageable form of the nicotine that directly alleviates the signs and symptoms of withdrawal and craving. Nicotine chewing gum is a very common method. There are other nicotine delivery systems available:

• 
  Transdermal patches for delivery of nicotine through the skin.
• 
  Nasal nicotine solution
• 
  Nicotine vapour inhalers (smokeless tobacco).

           Nicotine lozenge and sub-lingual tablets are also available as a form of nicotine replacement therapy. These devices increase quitting rates by approximately 1.5 to 2 times, regardless of setting.

      2. Other Pharmacological Therapies: It includes anti depressants and symptomatic treatment. Pharmacological strategies have a useful role in alleviating withdrawal symptoms.

B. Behavioural treatment: There are number of techniques which can be used to manage the cessation of tobacco use.

1. 
   Psychoeducation is providing information about the tobacco and its effects on human body. Discussing about the changes occur due to nicotine use are also informed to the user. This helps the patient to accept the corrective method.
2. 
   Aversion therapy: Aversion procedures involve pairing of smoking with unpleasant imagery scripts with electric shock, or with the unpleasant effects produced by smoking itself. These techniques are designed to create aversions to cigarette smoke-effective reactions characterized by distaste, disgust, fear, or displeasure. Such reactions reduce the incentive to smoke.
3. 
   Social support: Spouses of the smokers are also included in smoking cessation program to teach them how to be supportive of clients’ quitting program.

Treating the Former Tobacco Users: Preventing Relapse to Tobacco Use

Effective relapse prevention treatment to all patients who have recently quit tobacco use needs to be provided. With the extraordinary high rate of relapse to smoking, patient’s decision to quit needs to be reinforced, benefits of quitting are reviewed, and the residual problems arising out of quitting need to be resolved. Minimal relapse prevention consists of congratulating success, encouraging continued abstinence, and discussing with the patient the benefits of quitting, the problems encountered during quitting and the anticipated challenges to staying abstinent

Tobacco control policies in India

Legislation

The Government of India enacted various legislations to control tobacco use. Recently the government enacted the Cigarettes and Other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act in 2003. The Act is applicable to all products containing tobacco in any form i.e. cigarettes, cigars, bidis, gutka, pan masala, khaini, snuff etc. The act has following sections:

Section 4: Bans Smoking in all “public places like Hotels restaurants, coffee houses, pubs, bars, airport lounges, and other such places visited by the general public, workplaces, shopping malls, cinema Halls, educational institutions and libraries, hospitals and auditorium, open auditorium, amusement centres, stadium, railway station, bus stop etc.

Section 5: It prohibits advertisement, promotion and sponsorship of all tobacco products; both direct and indirect advertisement of tobacco products is prohibited in all forms of audio, visual and print media. It imposes total ban on sponsoring of any sport and cultural events by cigarette and other tobacco product companies.

Section 6 (a): Prohibits sale of tobacco to minors (persons under the age of 18).

Section 6 (b): Prohibits sale of tobacco products near educational institutions. Sale of any tobacco product is prohibited in an area within radius of 100 yards of any educational institution

Section 7: Its calls for specified health warning labels on all tobacco products.

Section 7 (5): Every tobacco package must have nicotine and tar contents along with maximum permissible limits. Specified warning should be there depicted on tobacco package.⁷

Tobacco Free Initiative in India

One important initiative under this is setting up of Tobacco Cessation Clinics in India. During 2001-02, 13 Tobacco Cessation Clinics were set-up in 12 states across the country in settings such as cancer treatment hospitals, psychiatric hospitals, medical colleges, NGOs etc users to quit tobacco use.

National Guidelines for Treatment of Tobacco Dependence have also been developed and disseminated by the Government in 2011, to facilitate training of health professionals in tobacco cessation.⁸ Various interventions and research studies were also supported to develop community based tobacco cessation models.

National Tobacco Control Program

The National Tobacco Control Program was launched by Ministry of Health and Family Welfare, Government of India in 2007- 08 to bring about greater awareness about the harmful effects of tobacco use and tobacco Control Laws as well as to facilitate effective implementation of the tobacco Control Laws. The National Tobacco Control Cell (NTCC) is responsible for overall policy formulation, planning, monitoring and evaluation of the different activities. National level public awareness/mass media campaigns for awareness building and behavioural change are planned to be carried out.

The content of this module has been validated by Prof. Jugal Kishore, Department of Community Medicine, Maulana Azad Medical College on 27/10/2014

References

1. 
   WHO. Non-communicable Diseases Country Profiles.  2014. Available from  http://apps.who.int/iris/bitstream/10665/128038/1/9789241507509_eng.pdf. Accessed on 20th September 2014.
2. 
   WHO. NCDs country profile. 2010. Available from http://www.who.int/nmh/countries/ind_en.pdf. Accessed on 20th September 2014.
3. 
   WHO. Available from http://who.int/mediacentre/factsheets/fs339/en/. Accessed on 18th September 2014.
4. 
   GATS India Report 2009-2010. Available from http://mohfw.nic.in/WriteReadData/l892s/1455618937GATS%20India.pdf. Accessed on 18th September 2014.
5. 
   Talhout R, Schulz T, Florek E , Benthem J, Wester P, Opperhuizen A. Hazardous Compounds in Tobacco Smoke. Int. J. Environ. Res. Public Health 2011;8:613-28.
6. 
   Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014 [accessed 2014 Apr 24].
7. 
   Kishore J. National health programs of India: National Policies and legislation related to health. 11th Edn. 2014. New Delhi: Century Publications.
8. 
   Government of India. Ministry of Health & Family Welfare. Directorate General of Health Services. Tobacco Dependence Treatment Guidelines. 2011.

• PUBLISHED DATE : Apr 30, 2015
• PUBLISHED BY : NHP CC DC
• CREATED / VALIDATED BY : NHP Admin
• LAST UPDATED BY : Oct 13, 2015

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90,000 Side effects of the COVID-19 vaccine and which ones are the norm

Vaccines against coronavirus in the world are no longer only in the stage of active development, but also in the stage of application. However, many people are worried about their safety and the fact that there are news of deaths after vaccinations against COVID-19.

While the colors around the coronavirus vaccines are thickening. figured out what to really expect from the vaccine and what side effects are normal.

Severe case: what can happen after vaccination against coronavirus

At least 23 people who were vaccinated against coronavirus with the Pfizer / BioNTech vaccine died in Norway.The reasons for 13 of them have already been considered by experts, the Norwegian Medicines Agency (Legemiddelverk) reported.

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According to the agency’s chief physician, Sigurd Hortemu, the usual symptoms caused by the vaccine, such as nausea and fever, could lead to the death of elderly individuals in poor health. Indeed, vaccinations in Norway began at the end of December 2020. Residents of a nursing home in Oslo were the first to be vaccinated in the country.

In total, over 21,000 people received the first dose of Pfizer / BioNTech vaccine in Norway. In early 2021, three deaths of people who received the vaccine became known, but, according to authorities, the deaths are not related to the vaccine.

At the same time, 56-year-old obstetrician-gynecologist Gregory Michael died a few weeks after being vaccinated with a Pfizer drug in Florida, USA. According to the New York Post, the cause of death was a hemorrhagic stroke.

His wife told Facebook that a few days after the coronavirus vaccination, Gregory Michael noticed red spots on his body, which indicate the presence of internal bleeding.After he went to the hospital, where they found an acute shortage of platelets, Michael died two days before the operation.

Pfizer said it is actively investigating the case and clarified that there is currently no evidence that the vaccine can cause a drop in platelet counts in the blood.

But there can be side effects. For example, in Poland, 37 undesirable side effects were recorded after vaccinations. Of these, 32 are mild side effects, 4 are moderate and 1 severe, said Polish Minister of Health Adam Nedzielski.

Most common side effects of coronavirus vaccines:

• pain at the injection site;
• fatigue;
• headaches;
• muscle pain;
• chills;
• joint pain;
• increase in body temperature;
• swelling at the injection site;
• redness at the injection site;
• nausea;
• general malaise;
• Swollen lymph nodes (lymphadenopathy).

No, this is normal: why side effects are not out of the ordinary

According to The Washington Post, a lot of people will feel tangible side effects from the coronavirus vaccine. But this only means that the human body gives an immune response. Indeed, a side effect can last from several hours to several days, but this does not mean that each case will become fatal. By the way, side effects also exist in other vaccines, such as influenza.

“Most vaccines have minor side effects. In fact, these are the body’s immune and inflammatory responses to the vaccine, ”says Yvonne Maldonado, an epidemiologist at Stanford University.

In some cases, vaccines do cause severe side effects, but in general they go through many stages of research and testing, making them safe and suitable for use.

For example, the vaccine from BioNTech and Pfizer has side effects: in some patients it caused a severe allergic reaction, in two – anaphylactic shock.In such cases, authorities warn of possible adverse reactions, especially in people with allergies.

Most common side effects from AstraZeneca vaccine are headache, swelling at the injection site. There was an allergic reaction from Moderna vaccine if it occurred during the first dose – the second dose was not given.

In addition to the issue of adverse reactions from vaccines, there is the issue of their effectiveness. For example, the Brazilian Institute of Butantan reported that the Chinese company Sinovac’s coronavirus vaccine is 50.38% effective.Brazil used to claim that the vaccine was 78% effective. By the way, according to the FDA recommendation, the effectiveness of 50% is enough to confirm the vaccine in medical regulators.

What will happen with vaccination in Ukraine

On December 30, 2020, Ukraine signed a contract with the Chinese company Sinovac on the supply of 1.9 million doses of vaccine at a price of UAH 504 per dose. Deliveries are expected in February-March 2021. The first batch will be delivered to Ukraine within 30 days after the vaccine is officially registered in China, or in one of the competent authorities of a number of other countries.It is planned to obtain a permit for use in January 2021. The vaccine against COVID-19 for Ukraine will be purchased by the British purchasing agency Crown Agents.

“We have taken serious steps with the countries that manufacture these vaccines. I think that in February, which will come in two weeks, we will really start mass vaccination in our country. And everything that you say about passports, about all other documents that will be received by citizens of the European Union, will also be received by citizens of Ukraine ”.

Maxim Stepanov

Minister of Health

Maxim Stepanov

Minister of Health

Prior to that, on December 22, 2020, the operational headquarters of the Ministry of Health for vaccine-preventable infections approved a plan for immunizing the population against COVID-19.It expects to cover at least 50% of the population of Ukraine (20 million people) with coronavirus vaccination during 2021-2022.

Planned 4 stages of vaccination:

• January-April 2021: people at high risk of infection and development of COVID-19 and those who perform critical functions in the fight against the COVID-19 pandemic will receive the vaccine; 90,028 90,027 April-June 2021: People at extremely high risk of infection and development of COVID-19 and those who provide medical services; 90,028 90,027 June-September 2021: people at high risk of infection and development of COVID-19 and those who perform functions of maintaining the security and life of the state; 90,028 90,027 September 2021 – March 2022: people at increased risk of infection and development of COVID-19 and those who perform functions to maintain the safety and life of the state.

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reduce side effects – Russian translation – Linguee

Anti-alarming efficiency of Atarax | Ryabokon I.V.

Anxiety is one of the most common mental disorders. Anxiety is manifested by an emotional, very painful experience of internal discomfort from the uncertainty of prospects.

Sometimes anxiety is natural, adequate, useful. Everyone feels anxious, anxious or stressed in certain situations, especially if they have to do something unusual or prepare for it. For example, giving a speech to an audience or taking an exam. A person may experience anxiety walking along an unlit street at night, or when he gets lost in a strange city. This type of anxiety is normal and even useful, as it encourages you to prepare a presentation, study the material before the exam, and think about whether you really need to go out at night all alone.In other cases, anxiety is unnatural, pathological, inadequate, harmful. It becomes chronic, constant and begins to appear not only in stressful situations, but also for no apparent reason. Then anxiety not only does not help the person, but, on the contrary, begins to interfere with his daily activities.
The line between a “normal” stress response and pathological anxiety disorder is often very blurred, making it difficult for a person to know when to seek professional help.These subsyndromally expressed anxiety disorders are the most difficult to diagnose, often remain untreated, while exerting an extremely negative impact on the quality of life of the patient and those around him. It is believed that treatment options should be considered when anxiety about routine events is beyond the patient’s control. Also, the reason for the appointment of therapy may be the following disorders: nervousness, fussiness, impaired concentration, irritability, sleep disturbance, symptoms of autonomic dysfunction.
The main approaches to the treatment of anxiety disorders are:
• psychotherapy
• pharmacotherapy
For the purpose of treatment, you can use simple relaxation methods (muscle relaxation, calm breathing, distraction). A friendly and encouraging conversation also contributes to the improvement of the condition.
Major drug groups for the treatment of anxiety disorders:
• Benzodiazepine tranquilizers
• Antidepressants:
– selective serotonin reuptake inhibitors,
– tricyclic antidepressants
• Antipsychotics
• Non-benzodiazepine tranquilizers
Benzodiazepines – quickly relieve sleep disturbances and symptoms of anxiety.Among the disadvantages of benzodiazepine treatment are the following: “recoil” syndrome (rapid resumption or transient increase in symptoms after drug withdrawal), the risk of addiction and drug dependence, impaired cognitive functions (attention, concentration, memory), impaired coordination. Therefore, drugs of the benzodiazepine group should not be taken for more than 2-4 weeks.
Tricyclic antidepressants are powerful drugs that relieve well all anxiety-depressive symptoms (acting on both bodily and mental manifestations of anxiety), sleep disturbances.Can be used for long-term treatment and prevention of anxiety. Tricyclic antidepressants have more pronounced side effects (dry mucous membranes, constipation, cardiovascular disorders, transient cognitive impairment). This worsens tolerance and increases the list of contraindications for their use in the treatment of anxiety, especially in patients with concomitant somatic diseases.
Selective serotonin reuptake inhibitors are relatively safe, have a minimal spectrum of side effects, are not addictive, and therefore can be used as a long-term maintenance treatment.Their relative disadvantage is the long period of “waiting” before the onset of the clinical effect of the drug (from 2 to 4 weeks). In addition, antidepressants in this group have side effects in the form of increased appetite and weight gain, nausea, loose stools, constipation, sweating, sleep disturbances, and sexual functions (libido and orgasm).
In some cases, a positive effect in the treatment of anxiety is achieved with the use of antipsychotics. Usually, small doses of these drugs are used.Nevertheless, when prescribing antipsychotics, weakness, lowering blood pressure, menstrual irregularities, weight gain, colostrum secretion, and decreased libido may occur.
Finally, international guidelines provide another drug for the treatment of anxiety – hydroxyzine (Atarax). It is distinguished by a rapid onset of the effect, lack of addiction and drug dependence, does not impair cognitive functions, has antipruritic and antiemetic effects.
Hydroxyzine does not belong to either the benzodiazepine group or the phenothiazine family.The non-benzodiazepine anxiolytic Atarax (hydroxyzine) is a derivative of diphenylmethane (Diphenylmetane), a histamine h2 receptor antagonist.
Hydroxyzine has been successfully used in various fields of medicine: as a means of controlling tobacco smoking [1]; in pediatric dentistry [2]; for its intended purpose – for the treatment of anxiety neurosis (even in the era of the existence of such a nosological form) and with “mild” depression [3]; for behavioral and learning disorders in children [4]. Due to its antihistaminic properties, hydroxyzine has been used in allergology, for the treatment of itching [5], with urticaria pigmentosa (mastocytosis) in children [6]; in oncology [7]; in burn patients [8], in narcology [9] and in many other conditions.
Recently, there has been an interest of researchers in the use of hydroxyzine in patients with generalized anxiety disorder (GAD). The prevalence of this pathology and the associated burden of social consequences in the modern scientific literature seem to be very significant. According to one review [E.G. Starostin. Generalized anxiety disorder and symptoms of anxiety in general medical practice. Rus. honey. zhurn. 2004; 12, 22 (222): 1277], with reference to numerous foreign works, “GAD is in the top ten diseases with the greatest temporary disability and, according to this indicator, is on a par with coronary artery disease, diabetes, joint diseases, peptic ulcer, and mental disorders – with depression or even ahead of it.
In a double-blind, placebo-controlled study for the treatment of generalized anxiety disorder [10], the anxiolytic activity of Atarax was shown at a dose of 50 mg (in 3 doses of 12.5 mg in the morning and in the afternoon plus 25 mg in the evening), which manifested itself in a statistically significant, rapid and a significant decrease in anxiety symptoms already at the end of the 1st week of treatment, which persisted for another 1 week after the cessation of treatment (n = 110; course duration 4 weeks; assessment on the Hamilton scale – A).At the same time, the phenomenon of “ricochet” or return of anxiety was not observed.
In another double-blind multicenter study [11], in which the benzodiazepine drug Bromazepam was also used along with placebo control, it was shown that hydroxyzine used for 3 months is statistically significantly different from placebo and is as effective as the reference drug … At the same time, against the background of benzodiazepine twice more often than with the use of hydroxyzine, there was observed side pronounced drowsiness (n = 334; dose of hydroxyzine 50 mg / day in 3 divided doses; bromazepam – 6 mg / day in 3 doses; improvement on the Hamilton-A scale> 50 %; p
Another study [12] showed the efficacy of Atarax (50 mg in 3 divided doses), comparable to that of the control buspirone (20 mg in 3 divided doses), with a statistically significant difference between Atarax and placebo on the 28th day of treatment (p
Another advantage of hydroxyzine is that, unlike benzodiazepines, it does not inhibit cognitive abilities [13] (triple crossover, double-blind clinical study; comparison of a single dose of 50 mg hydroxyzine with a single dose of 2 mg lorazepam and placebo; n = 9; healthy volunteers; 3-day interval before crossing; assessment of cognitive functions after 2-5 hours after taking the comparison drugs).
Several studies have shown a positive effect of hydroxyzine on cognitive function [14] (comparison with lorazepam; double-blind multicenter clinical trial; n = 30; GAD, Atarax 100 mg in 3 divided doses, lorazepam 4 mg in 3 doses; Beck score at 28 Day of treatment). Unlike lorazepam, with the same anxiolytic activity, hydroxyzine restored cognitive function to normal limits.
Similar results were obtained in another, less evidence-based study – an open RCT [A.E. Bobrov et al. Journal. neurol. and a psychiatrist. them. S.S. Korsakov. 1988; 2] outpatients with GAD; (n = 50). The course of treatment is 4 weeks, plus 2 weeks of follow-up.
Features of Atarax – fast onset of action, good tolerance, lack of dependence and depression of the central nervous system, make it an alternative drug to benzodiazepines in children and adolescents. In a study conducted at the Children’s Psychiatry Center [15], Atarax was prescribed for various forms of mental illness in children and adolescents with manifestations of anxiety, irritability and insomnia-type sleep disorders, and its effectiveness was assessed.The study included 50 patients aged 5 to 18 years with various forms of mental illness, who were on outpatient observation and treatment at the Center for Children’s Psychiatry. At the end of the 4th week of therapy, there was a decrease in the manifestations of anxiety and various fears noted earlier – falling asleep in the dark, staying at home in the absence of parents, fears of animals, noise of household appliances. In one case, a 5-year-old boy could stay at home with a nanny without parents – previously there was a pronounced affective reaction.In addition, in all patients, sleep improved already in the second week of therapy, tearfulness, moodiness, and irritability reduced. Simultaneously with the reduction of anxiety, mood improved in 7 patients with a mixed anxiety and depressive reaction caused by adjustment disorder and with a mixed anxiety and depressive disorder, which was associated not with the direct antidepressant effect of Atarax, but with the comorbid dependence of anxiety and depression: anxiety reduced – depression went away.
Hydroxyzine (Atarax) has its obvious advantages over benzodiazepine anxiolytics in the treatment of anxiety disorders, it does not cause “rebound” phenomena, does not inhibit cognitive function and does not cause pathological dependence.

Literature
1. Turle G. An investigation into the therapeutic action of hydroxyzine / Atarax in the treatment of nervous disorders and the control of tobacco – habit. Brit J Psychiat 1958; 104: 82 p. 33.
2. Lang L. An evaluation of the efficacy of hydroxyzine (atarax – vistaril) in controlling the behavior of child patients.J – Dent – ​​Child 1965; 32, 4: 253-8)
3.R. Middlefell, K. Edwards Hydroxyzine / Atarax in the relief of tension associated with anxiety neurosis and mild depressive states.Brit J Psychiat 1959; 105: 792-4.
4. Segal L, Tansley A. A clinical trial with Hydroxyzine (Atarax) on a group of maladjusted educationally subnormal children. J Mental – Science; Br J Psychiat from 1963; 1957; 103: 677-81.
5. Rhoades R, Leifer K, Cohan R, Wittig H. Suppression of histamine – induced pruritus by three antihistaminic drugs. J Allergy Clin Immunol, 1975 Mar .; 55, 3: 180-5.
6. Kettelhut B, Berkebile C, Bradley D, Metcalfe D. A double-blind, placebo-controlled, crossover trial of ketotifen versus hydroxyzine in the treatment of pediatric mastocytosis.J Allergy ClinImmunol 1989 May; 83, 5: 866-70)
7. Broder L, Lean N, Hilsenbeck S. A randomized blinded clinical trial comparing delta – 9 – tetrahydrocannabinol (THC) and hydroxizine (HZ) as antiemetics (AE) for cancer chemotherapy (CT). PROC – AM – ASSOC – CANCER – RES; 1982; 23: 514.
8. Vitale M, Fields-Blache C, Luterman. A Severe itching in the patient with burns. J burn care & rehabilitat 1991; 12, 4: 330-3.
9. Kaim S, Klett C, B. Rothfeld. Treatment of the acute alcohol withdrawal state: a comparison of four drugs.Agressologie: revue internationale de physio-biologie et de pharmacologieappliquees aux effets de l’agression, 1968; 9, 2: 305-8.
10. Ferreri M, Hantouche T, M. Billardon. Interet de l’hydroxizynedans des trouble d’anxietegeneralisee: etude controlee en double aveugle versus placebo. L’encephale 1994; 20: 785-91.
11. Llorka P. et al. Efficasy and safety of hydroxisyne in the treatment of generalized anxiety disorder: a 3-month double-blind study. J Clin Psychiatry 2002; 63: 1020-7.
12. Lader Scotto J. A multicenter double – blind comparison of hydroxizine, buspirone and placebo in patient with generalized anxiety disorder. Psychopharmacology 1998; 139: 402-6.
13. De Brabander A, Deberdt W. Effect of hydroxizyne on attentijn and memory. Human Psychopharmacology 1990; 357-62.
14. Samuelian J, Billardon M, Guillou N. Retentissmentsur les functions cognitives de deuxtraitmentsanxiolitiques chez des patients souffrantd’anxietegeneralisee. L’encephale 1995; 21: 147
15.A.A. Rezakov Experience of using hydroxyzine (atarax) in children’s and adolescent practice. “PHARMindex-Praktik” issue 10; 2006, pp. 37–39

.

Science: Science and Technology: Lenta.ru

Scientists at the University of California tested the tobacco heating system produced by Philip Morris International to find out if it is actually safer than conventional cigarettes, as claimed by the manufacturer. It is assumed that the absence of the combustion process does not lead to the release of carcinogenic substances, but the conclusions of the specialists were disappointing.”Lenta.ru” writes about a study published in the journal BMJ.

Heat-not-burn tobacco product (HNB) systems use a temperature lower than that at which the contents of conventional cigarettes are burned. This produces smoke containing nicotine and other chemicals. The first HNB products appeared in 1988, but initially did not have commercial success. Interest in her arose against the background of frustration with electronic cigarettes, which could not provide the desired effect from the puff.Currently, tobacco heating systems are manufactured by large tobacco manufacturers.

Although tobacco companies claim that HNB is safer than conventional cigarettes, there is no hard and reliable scientific evidence to support this. Much of the research on this topic has been funded by manufacturers themselves, so their conclusions are questionable due to conflicts of interest. Independent medical professionals claim that tobacco heating systems do the same harm as regular smoking, but they admit that there is little scientific work devoted to this problem.

In 1998, one of the largest tobacco companies, Philip Morris International, launched a heating device inside which a cigarette was inserted. It became the forerunner of the iQOS system. This name is an abbreviation for the slogan I quit original smoking. According to the company, HNB will completely replace tobacco cigarettes and vapes in the future, but industry analysts doubt that this will ever happen.

iQOS consists of a phone-sized charger and a holder resembling a ballpoint pen.A tobacco stick is inserted into it, which is then heated to a temperature of 350 degrees Celsius. The stick is impregnated with glycerin so that, in the absence of combustion, an aerosol containing tobacco particles can be released.

This design assumes that the user will not be exposed to the high toxic and carcinogenic substances that are usually formed when tobacco is burned. IQOS works for six minutes and then shuts down by itself. As the researchers noted in their article published in the journal BMJ, claims about harm reduction are released in scientific journals with a low level of peer review.

Image: Department of Molecular, Cell and Systems Biology, University of California, Riverside, California, USA

Unused and used sticks

In the course of the study, scientists purchased four iQOS kits that met quality requirements. They also bought Marlboro sticks from the same manufacturer. The holders have been tested in two cleaning modes. In the first variant, they were thoroughly cleaned of residual liquid and tobacco particles after each heating.In the second, cleaning was carried out according to the instructions, according to which dirt was removed from the holder every 20 heatings using a cleaning hook.

Parameters such as the pressure drop inside the holder, the density of the aerosol, the amount of solid particles in it and the number of possible puffs were measured. The pressure drops during each puff are determined using a peristaltic pump connected to a U-shaped water pressure gauge. Aerosols were captured in glass cuvettes, which were inserted into a spectrophotometer and irradiated with 420 nanometer wavelengths.

Five operating modes have been tested. During a 2-second or 4-second puff, a volumetric air flow of 7 milliliters per second was created, in both cases a total of 14 puffs were made. In the case of six 2-second puffs, the volumetric flow reached 17.5 milliliters per second, and with 12 puffs of the same duration, 27.5 milliliters per second. Finally, the fifth mode was similar to the fourth, but the holders were cleaned according to the instructions.

Scientists assessed the state of the heating element in the holder visually using a microscope and a camera.Some of the sticks were cut into pieces to estimate the amount of particles generated by pyrolysis of the heater and melting of the polymer film in the filters. Gas chromatography and mass spectrometry were performed to assess aerosol levels.

Image: Department of Molecular, Cell and Systems Biology, University of California, Riverside, California, USA

Condition of the heating element under various operating conditions

Cleaning was not able to completely remove combustion products from the heating element.If the holder is not properly maintained, droplets of brown liquid and dirt will remain in the device and grow in volume with each use. During operation, the pressure drop became less pronounced with each puff, and the density of particles in the aerosol increased, although after 7-9 puffs it began to fall. Signs of charring were also found in the sticks, although regular cleaning prevented the burning area from increasing. In addition, the temperature of the emitted aerosol was sufficient to melt the filter, which as a result becomes a source of potentially harmful substances.

The results of gas chromatography and mass spectrometry showed that the filter contains lactide, ε-caprolactone and 1,2-diacetin, which are used in the manufacture of plastic and do not have a harmful effect. However, the toxic formaldehyde cyanohydrin, used in rubber production, was also discovered. This compound, entering the body, is deposited in the liver, where it is broken down into formaldehyde and cyanide. It is known that relatively low doses of the substance are fatal to mice.

Researchers believe that limiting smoking times to six minutes will force users to take as many puffs as possible and reduce the interval between puffs.As a result, they will be exposed to large volumes of aerosol. Despite the manufacturer’s claims, scientists have found no evidence that the tobacco heating system minimizes the amount of potentially hazardous volatile pollutants, including polycyclic aromatic hydrocarbons and carbon and nitrogen oxides.

The official representative of Philip Morris International in Russia told Lente.ru that “the conclusions of the authors of the study that the polymer film of the filter of tobacco sticks under normal conditions of use begins to melt and release a chemical substance” do not correspond to the results of the company’s research.

Thus, the polymer filter does not melt during consumption. When using tobacco sticks with IQOS, the biopolymer film in the filter hardens, this is a normal reaction to the temperature of the aerosol. The components of the aerosol trapped by the filter can cause changes in its color, this is also a normal process.

In addition, hardening and discoloration of the filter are not indicative of the release of any chemicals.

According to the representative of Philip Morris International in Russia, the polymer filter in tobacco sticks is made from corn starch.The substance discovered by the authors of the study is not used at any stage of the production process. It was also not detected in emission analyzes conducted by scientists at Philip Morris International under realistic conditions of use and using measurement methods similar to those used by the authors of this study.

Studies in the most diverse modes of use of the product did not reveal an increase in the content of toxic substances. In addition, clinical studies in which participants were able to use IQOS without restriction showed a reduction in exposure to harmful substances at about 95 percent of the reduction observed in smokers who quit tobacco altogether during the study period.

“The results of IQOS scientific research, which we have to date, collectively indicate that IQOS is potentially less harmful than conventional cigarettes,” summed up the representative of Philip Morris International.

90,000 Smokeless tobacco use and cancer risk

Highlights

Various studies have shown that people who use smokeless tobacco products are at high risk of developing various types of cancer, including head and neck cancers, in particular oral cancer, pharyngeal cancer, laryngeal cancer, esophageal cancer; and pancreatic cancer.Smokeless tobacco is not a safer alternative to smoking cigarettes. Regardless of the type, form and route of consumption, all tobacco products (alone or with betel leaf, areca / betel nuts and hydrated lime) should be considered harmful and their use should be strongly discouraged to reduce the risk of cancer.

Tobacco use is one of the main causes of cancer. According to the World Health Organization, tobacco consumption kills over 8 million people a year worldwide.There are about 1.3 billion tobacco users worldwide, over 80% of whom live in low- and middle-income countries. People commonly use tobacco products because of nicotine, a highly addictive chemical found in the tobacco plant.

In addition to nicotine, tobacco smoke also contains over 7000 chemicals, including 70 carcinogens that can lead to cancer, many of which damage DNA. Some of these chemicals include hydrogen cyanide, formaldehyde, lead, arsenic, ammonia, benzene, carbon monoxide, nitrosamines, and polycyclic aromatic hydrocarbons (PAHs).Tobacco leaves also contain certain radioactive substances such as uranium, polonium-210 and lead-210, which are absorbed from high phosphate fertilizers, soil and air. Tobacco use can lead to many types of cancer, including cancer of the lung, larynx, mouth, esophagus, throat, bladder, kidney, liver, stomach, pancreas, colon, rectum, and cervix, and acute myeloid leukemia.

This leads to the question of whether smokeless tobacco use is a safer alternative to smoking cigarettes and other tobacco products? Let’s find out!

What is smokeless tobacco?

Smokeless tobacco and tobacco products are consumed orally or through the nasal cavity without burning the product.There are many types of smokeless tobacco products, including chewing tobacco, snuff, snus, and instant tobacco.

Chewing, oral or spitting tobacco

These are inserts, corks or curls of dried tobacco, possibly flavored, that are chewed or placed between the cheek and gum or teeth, and the resulting brown saliva is spat out or swallowed. The nicotine in tobacco is absorbed by the tissues of the mouth.

Snuff or dipping tobacco

This is a finely cut tobacco sold dry or wet with added flavors.Dry snuff, available in powder form, is inhaled or inhaled through the nasal cavity. Wet snuff is placed between the lower lip or cheek and the gum and the nicotine is absorbed through the tissues of the mouth.

Snus

A type of wet snuff flavored with spices or fruits that is placed between the gums and the tissues of the mouth and swallowed.

Instant tobacco

This is a flavored, instant, compressed powdery tobacco that dissolves in the mouth and does not require spitting out the tobacco juice.

Like cigarettes, cigars and other tobacco products, smokeless tobacco use is also addictive due to its nicotine content.

Are there any cancer-causing chemicals in smokeless tobacco products?

Many of us also mistakenly believe that smokeless tobacco is a safer alternative to smoking cigarettes because it cannot be associated with lung cancer. However, the risk of developing cancer is not limited to those who smoke tobacco. People who use smokeless tobacco products are also prone to developing various types of cancer.In fact, there is no safe form of tobacco or a safe level of tobacco use.

There are 28 different cancer-causing agents or carcinogens found in smokeless tobacco products. Of these, the most harmful carcinogenic substances are tobacco-specific nitrosamines (TSNA). Besides TSNA, other carcinogens present in smokeless tobacco include N-nitrosoamino acids, volatile N-nitrosamines, volatile aldehydes, polynuclear aromatic hydrocarbons (PAHs), and radioactive substances such as polonium-210 and uranium-235 and -238.(International Agency for Research on Cancer (IARC), World Health Organization)

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Health hazards from smokeless tobacco

Due to the presence of harmful chemicals and carcinogens, the use of smokeless tobacco products is also associated with many health problems.Some of them are listed below:

• Risk of various types of cancer
• Increased exposure to nicotine because smokeless tobacco products are typically used more consistently than tobacco smoking, which occurs intermittently throughout the day.
• Risk of Heart Disease
• Propensity for gum disease, tooth decay, tooth loss, drooping gums, abrasion of teeth, bad breath, loss of bone mass around the roots and tooth staining.
• Precancerous oral lesions such as leukoplakia
• Certain candy-like smokeless tobacco products can attract children and lead to nicotine poisoning.

Smokeless tobacco use and cancer risk

Researchers around the world have conducted various studies and systematic reviews to assess the link between smokeless tobacco use and cancer. The results of some of these studies are summarized below.

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Smokeless tobacco use and the risk of oral cancer

1. Researchers at ICMR – National Institute for Cancer Prevention and Research, India, analyzed 37 studies published between 1960 and 2016 to assess the relationship between smokeless tobacco use and oral cancer.The studies were obtained through literature searches on databases / search engines Pubmed, Indmed, EMBASE and Google Scholar. Researchers found that smokeless tobacco use was associated with a significantly increased risk of oral cancer, especially in the Southeast Asia, Eastern Mediterranean regions and among female consumers. (Smita Astana et al., Nicotine Tob Res., 2019)

2. In a meta-analysis of 25 studies conducted by scientists from India, they found that smokeless tobacco use was associated with a significant increase in the incidence of oral, pharyngeal, laryngeal, esophagus and stomach.They also found that, compared to men, women had a higher risk of oral cancer but a lower risk of esophageal cancer. (Dhirendra N. Sinha et al., Int J Cancer., 2016)

3. Researchers from the Institute for Preventive Research and Epidemiology. Leibniz (BIPS) in Germany and Khyber Medical University in Pakistan conducted a systematic review of 21 publications to assess the risk of oral cancer associated with the use of various forms of smokeless tobacco. Data were obtained through literature searches on Medline and the ISI Web of Knowledge for observational studies published in South Asia from 1984 to 2013.They found that chewing tobacco and using paan with tobacco were associated with an increased risk of oral cancer. (Zohaib Khan et al., J. Cancer Epidemiol., 2014)

4. Scientists at Griffith University in Australia conducted a meta-analysis of 15 studies to assess the link between oral smokeless tobacco use in any form, betel quid (containing betel leaf, areca nut / betel nut and slaked lime) without tobacco and areca nut with oral cancer incidence in South Asia and the Pacific.The studies were obtained through literature searches in Pubmed, CINAHL and Cochrane databases up to June 2013. Research has shown that chewing tobacco is significantly associated with an increased risk of squamous cell carcinoma of the mouth. The study also found that tobacco-free consumption of betel nut (containing betel leaf, areca nut / betel nut and hydrated lime) also increased the risk of oral cancer, possibly due to the carcinogenicity of areca nut.

These studies show a strong association between the use of various forms of smokeless tobacco (with and without betel leaves, areca / betel nuts) and an increased risk of oral cancer.

Smokeless tobacco use and the risk of head and neck cancer

Researchers at the National Institute of Environmental Sciences, North Carolina analyzed data from 11 US case-control studies (1981-2006) on oral, pharyngeal and laryngeal cancers involving 6,772 cases and 8,375 controls in the International Epidemiology of Head Cancer and Neck (INHANCE) Consortium. They found that people who never smoked cigarettes but used snuff were strongly associated with an increased risk of head and neck cancer, especially oral cancer.In addition, they found that tobacco chewing was also strongly associated with an increased risk of oral cancer, although this association was found to be weak when all other head and neck cancers were assessed together. (Anna B. Wyss et al., Am J Epidemiol., 2016)

The study concluded that smokeless tobacco may be associated with an increased risk of head and neck cancer, especially oral cancer, with the risk being higher with snuff than with chewing tobacco.

Chewing alcohol and tobacco and the risk of HPV infection in patients with head and neck cancer

Investigators in India analyzed samples from 106 head and neck cancer patients from the Head and Neck Cancer Surgery Unit, Dr.Bhubaneshwar Borooa Cancer Institute (BBCI), Regional Cancer Center, Guwahati, India, to study high-risk HPV ( hr -HPV) infection and its association with lifestyle habits, including tobacco and alcohol use.Patients were enrolled between October 2011 and September 2013 (Rupesh Kumar et al., PLoS One., 2015)

High-risk HPV infections were found in 31.13% of patients with head and neck cancer. The study found that alcohol consumption and tobacco chewing were significantly associated with an increased risk of HPV infection in head and neck cancers. They also added that compared to HPV-18 infection, HPV-16 was found to be more significantly associated with tobacco chewing.

Smokeless tobacco use and risk of esophageal cancer

In a study by scientists at the University of Kuwait, they assessed the association between chewing areca nut, betel nut (containing betel leaf, areca nut / betel nut and slaked lime), oral snuff, cigarette smoking, and the risk of squamous cell disease in the esophagus.carcinoma / cancer in South Asians. The study used data from 91 cases of squamous cell carcinoma of the esophagus and 364 control patients from 3 tertiary hospitals in Karachi, Pakistan.

Their analysis showed that people who chewed areca nut, chewed betel quid (containing betel leaf, areca nut / betel nut and slaked lime) with tobacco, practiced snuff dipping, or smoked cigarettes were associated with an increased risk of squamous cell / esophageal cancer … … The risk of squamous cell carcinoma / esophageal cancer was further increased in those who smoked cigarettes and chewed betel quid (containing betel leaf, areca / betel nut and slaked lime) with tobacco, or in those who smoked cigarettes and also practiced snuff …(Said Akhtar et al., Eur J Cancer., 2012)

Smokeless tobacco use and risk of pancreatic cancer

Researchers from ICMR – National Institute for Cancer Prevention and Research, Noida and the School of Preventive Oncology, Patna, India, studied the relationship between smokeless tobacco and the risk of various types of cancer. They used data from 80 studies that included 121 risk assessments for various types of cancer, derived from literature searches in PubMed and Google Scholar, based on smokeless tobacco and cancer studies published from 1985 to January 2018.(Sanjay Gupta et al., Indian J Med Res., 2018)

Study found that smokeless tobacco use was associated with an increased risk of oral, esophageal and pancreatic cancer; however, the risk of oral and esophageal cancer is higher in the South-East Asia and Eastern Mediterranean Region, and pancreatic cancer in the European Region.

Conclusion

Various studies have shown that people who use smokeless tobacco products are also at high risk of developing various types of cancer, including head and neck cancers, in particular oral cancer, pharyngeal cancer, laryngeal cancer, esophageal cancer; and pancreatic cancer.This suggests that regardless of the type, form and route of consumption, all tobacco products (taken alone or with betel leaf, areca nut / betel nut and slaked mucus) are harmful and can cause various types of cancer and other health problems. Therefore, the use of all tobacco products, including smokeless tobacco, is discouraged.

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Investor Profile INVEST_WAY | Tinkoff Investments Pulse

Investments in semiconductors.Great overview. Part 2
We continue our large review of semiconductor companies, who have not read the first part, I recommend that you familiarize yourself with it.

1. Qualcomm $ QCOM
A species is a company that does not have its own factories.

Segments:
• Processors;
• Chips for IoT;
• Automotive chips and electronics.

The company divides its revenue into 2 segments:
1. QCT – this includes the famous Snapdragon mobile processors, which are found in most smartphones based on android and modems that are used in almost all smartphones and other devices – about 80%.2. QTL is a kind of passive income that they receive through the use of their intellectual property by other companies, in other words, patents – about 20%.
Despite the fact that the QCT segment generates 4 times more revenue, it brings the company only 1.5 times more profit than QTL.
Qualcomm Strategic Investments – This includes various new lines of business. One of these areas, for example, is the development of processors for autonomous vehicles.

Speaking of autonomous transport, Qualcomm has signed an agreement with the American automaker GM $ GM to supply chips for smart cars.Qualcomm has developed a close to a monopoly position due to its patents, which is why, according to many of the company’s partners, they inflate the prices of their products and licenses. Apple $ AAPL tried to sue, looked for an alternative, but in the end they had to capitulate, conclude a licensing agreement for 6 years and pay compensation. I think everyone has also heard about Huawei.

2. Texas Instruments $ TXN
The type of the company is an independent development and production of chips, however, the company gives part of the orders to outsourcing to other manufacturers.Segments:
• Industrial chips;
• Analog chips;
• Processors;
• Chips for IoT.

Texas Instruments is the leader in revenue in 2 segments: Industrial and analog chips. Often it can be the same product, but still.
Especially the company will list one of the best profitability in the industry.

3. Infineon Technologies $ IFX @ DE
The type of company is a hybrid company, some of the products are produced by themselves, and some are outsourced to other manufacturers.

Segments:
• Industrial chips
• Analog chips
• Processors
• Automotive chips and electronics.• Chips for IoT.
• Chips for programmable solutions (FPGA, ASIC, etc.).

Company advantages:
1. The company is one of the 10 largest suppliers of semiconductor products in the world.
2. Is the largest supplier of power semiconductors.
3. The third largest supplier of microcontrollers in the world.

Disadvantages of the company:
1. One of the lowest profitability in the industry
2. Dear multipliers

4. Broadcom $ AVGO
The type of the company is hybrid, some of the products are produced by themselves, some are given to other companies, mainly TSMC.Segments:
• Industrial chips
• Processors
• Automotive chips and electronics.
• Chips for IoT.

Semiconductor solutions bring 72% of the company’s revenue, the remaining 28% is infrastructure software.

Advantages:
1. Good revenue growth
2. Dividend yield of almost 3%
Disadvantages:
1. High debt load
2. Payout Ratio 154%

Conclusion on part 2
All of the companies reviewed still look too expensive despite the recent correction.
I selected 2 companies for myself, which I will select if good prices are provided:
• Infineon Technologies – the company is located in Germany, and it is highly likely that it will become the main beneficiary of automation in the European Union.Moreover, their business is quite well diversified.
• Texas Instruments – benchmark marginality and leading position in its segment.
A more complete overview can be found at the link in the profile, unfortunately, the size of posts in the pulse is limited. 90,000 Medical Myths: Is Alcohol Compatible with Antibiotics?

• Claudia Hammond
• BBC Fututre

1st June 2015

Medical research shows that alcohol does not block the action of most medications and usually does not cause side effects when combined with drugs.But there are a few other important points to keep in mind, warns BBC Future.

Women in the early stages of pregnancy, who are not yet ready to share this good news with others, know very well that those around them can easily guess everything themselves if the expectant mother refuses to drink at a party.

But there is a good excuse: you can tell colleagues and friends that you are being treated with antibiotics, and all questions will disappear. Even overly curious acquaintances are unlikely to ask what the medicine was prescribed for.

But is it really necessary to abstain from alcohol in combination with a course of antibiotics?

Some believe that alcohol can interfere with the drug’s desired effect, some are convinced that this combination has side effects.

The staff of one of the urogenital clinics in London interviewed 300 patients – it turned out that 81% of them adhered to the first point of view, and 71% – the second.

But in the case of most antibiotics, neither the first nor the second is true.From the point of view of doctors, it is much more dangerous when a patient who believes in one of these myths decides not to take the medicine by drinking a glass of wine.

Any factor that causes a dose to be skipped exacerbates the serious global problem of antibiotic resistance in bacteria.

In fact, alcohol does not in any way interfere with the action of most commonly used antibiotics.

But there are exceptions: for example, the drug of the cephalosporin group, cefocetan, slows down the process of alcohol breakdown, as a result of which the level of acetaldehyde in the body rises.

And this can lead to undesirable consequences in the form of dizziness, vomiting, flushing of the face, headaches, shortness of breath and chest pains.

Similar side effects are caused by the drug disulfiram, sometimes used in the treatment of alcohol dependence. The idea is that the patient being treated starts to feel bad about drinking – which, in theory, should make him stop drinking further.

These sensations are unpleasant, therefore, during the treatment with cefocetan and disulfiram (and for several days after the end of the course), one should refrain from alcohol.

Another antibiotic that is poorly compatible with alcohol is metronidazole. It is used to treat oral infections, infected leg ulcers, and pressure sores. It is believed that in combination with alcohol, it gives the same side effects as the cephalosporins already mentioned.

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Pidpis to the photo,

Antibiotics, of course, are different. But most of them are not affected by alcohol in any way

However, this point of view was questioned after an analysis of pharmacological studies conducted in 2003.In addition, an experiment was conducted on a small control group of Finnish men, during which they consumed alcohol with metronidazole for five days without any unpleasant consequences.

However, the authors of this study admit that the likelihood of unwanted effects cannot be completely ruled out, and now doctors still do not recommend combining alcohol with metronidazole.

There are several other antibiotics that may be better off drinking when taking, such as tinedazole, linezolid, and erythromycin.But this incongruity is well known, and doctors specifically warn patients about it by prescribing a medicine.

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Thus, there remains an extensive list of other antibiotics, when taken, it is not dangerous to drink. Of course, alcohol is unlikely to help cure a disease: it can make your body dehydrated and sluggish, but this has nothing to do with medications.

Perhaps the myth about the incompatibility of antibiotics and alcohol appeared after some unpleasant cases, but there are two more interesting theories.

One is that antibiotics are used to treat common sexually transmitted diseases, and doctors allegedly punished patients for promiscuous behavior by forbidding them to drink a glass or two.

There is another explanation given by James Bingham, one of the authors of the above-mentioned survey of patients at the London Urogenital Clinic.

He met with retired Brigadier General Ian Fraser, who during World War II began using penicillin to treat wounded soldiers in North Africa.

At that time, there was so little penicillin that after taking the medicine by mouth, urine was taken from patients and the drug was again isolated from it.

The military who were on treatment were allowed to drink beer, but this led to an increase in the volume of urine produced by the body and, as a result, made it difficult to obtain the medicine. According to General Fraser, therefore, the command decided to ban beer.

Agree, a good story, regardless of whether it influenced the spread of the myth about the incompatibility of alcohol and antibiotics.

But debunking myths is a double-edged sword.