EFFECTS OF MARAS POWDER (SMOKELESS TOBACCO) USAGE

EFFECTS OF MARAS POWDER (SMOKELESS TOBACCO) USAGE

Acta Medica Mediterranea, 2015, 31: 291
EFFECTS OF MARAS POWDER (SMOKELESS TOBACCO) USAGE ON COGNITIVE FUNCTIONS
IN MALES AGED ≥60 YEARS
HAMIT SIRRI KETEN1, OGUZ ISIK2, HUSEYIN UCER2, UMIT ASLAN2, NAGIHAN SARI2, HAMZA SAHIN3, MUSTAFA CELIK2
1
Family Medicine, Onikisubat Community Health Center, Kahramanmaras - 2Family Medicine, Medical Faculty, Kahramanmaras
Sutcu Imam University, Kahramanmaras - 3Neurology, Medical Faculty, Kahramanmaras Sutcu Imam University, Kahramanmaras,
Turkey
ABSTRACT
Aim: This study investigated the effects of Maras powder usage on cognitive functions in males aged 60 or older.
Materials and methods: The study was conducted with 140 male volunteers aged ≥60 years who attended four family health
centers in Kahramanmaraş. Seventy volunteers with a comsuption of ¼ of a package of Maras powder daily for at least 10 years
were assigned to the study group and 70 volunteers who reported no use of tobacco products were assigned to the control group.
Data about socio-demographic characteristics and Maras powder usage were obtained through face-to-face interviews with all participants. The Standardized Mini Mental Test (SMMT) was also used for data collection.
Results: The mean age of the participants was 63.69±6.01 years (min=60, max=85). The study and control groups did not differ significantly in age (p=0.156). SMMT mean scores were 22.78±5.36 in the study group and 23.92±4.22 in the control group; this
difference was not significant (p=0.164). Participants with a primary school education had significantly lower test scores than those
with higher education levels (p=0.001).
Conclusion: Maras powder users and non-users in this study had similar cognitive functions. However, advanced age and low
education levels were significantly related to decreased cognitive functions.
Key words: Cognition, Geriatrics, Tobacco, Smokeless.
Received June 18, 2014; Accepted October 02, 2014
Introduction
The proportion of the world population aged
≥60 years has been increasing in recent years. It is
expected to be 1.2 billion in 2025 and 1.9 billion in
2050(1). In Turkey, the proportion of people aged
≥60 years in the general population was 7.7% in
2013 and is expected to reach 20.8% in 2050 and
27.7% in 2075(2).
According to data from the World Health
Organization, there are over 1 billion tobacco users
worldwide, and 4.9 million people die each year
due to conditions related to tobacco usage (3) .
Although the most frequently used tobacco product
is cigarettes, the rate of smokeless tobacco usage is
too high to overlook. It was reported to be 6.2% in
males and 0.2% in females in the USA(4). In a study
in Nigeria, 10.8% of males and 4.1% of females
were found to use smokeless tobacco, and the rate
of smokeless tobacco usage was reported to peak at
the age of 60(5). There have been many studies on
the effects of such commonly used tobacco products on human health. Some studies(6,7) have shown
that active smoking is related to a decrease in cognitive functioning while others have not revealed
such a relationship(8,9). Interestingly, several studies
have reported preventive effects of smoking on
cognitive function(10,11).
Maras powder (MP) is a smokeless tobacco
produced in Kahramanmaraş and commonly used
in the eastern Mediterranean part of Turkey. To produce Maras powder, the leaves of the tobacco plant
Nicotiana rustica linn are powdered and mixed with
oak ashes in varying amounts(12). The mixture is
wrapped in a special piece of paper and smoked or
put in the inner side of the upper lip and sucked. In
292
a study performed in Kahramanmaras, the prevalence of Maras powder use was 25% in male adults
and 1% in females(13).
This study investigated the effects of MP on
cognitive functioning in males aged 60 and older.
Materials and methods
This was a prospective study and included 140
male volunteers aged 60 or older who presented to
four family health centers in Kahramanmaraş in
Turkey between 01 January 2014 and 31 February
2014. The participants gave informed consent.
Volunteers without at least a primary school education, and with eye sight problems, hearing problems
and conditions likely to affect cognitive functioning
(vascular, neurological, endocrinological, and psychiatric conditions and a history of drug abuse),
smokers, and those using alcohol were not included
in the study. All participants were examined by a
family physician. Those diagnosed with or suspected conditions affecting cognitive functions (e.g.,
depression) were also excluded from the study.
Data on socio-demographic features and MP
usage were collected during face to face interviews
with all participants. Seventy participants who had
used at least ¼ of an MP packet a day for at least 10
years were assigned to the MP group and 70 participants who had never used any tobacco products
were assigned to the control group. The
Standardized Mini Mental Test (SMMT) was
administered to all participant by family physicians;
this took 10 minutes.
The SMMT was developed by Foldstein et al.
to screen cognitive functions(14) in older adult. The
validity and reliability of the test for the Turkish
population were established by Güngen et al.(15).
The test requires that respondents be at least literate. It is composed of a total of 11 items and five
parts: orientation (10 points), registration (3 points),
attention and calculation (5 points), recall (3 points)
and language (9 points). The total score that can be
obtained from the test is 30 points and the cut-off
score for mild and moderate dementia is 23/24
points.
Statistical Analysis
Data were analyzed using Statistical Package
for the Social Sciences (SPSS); frequencies and
standard deviations were calculated. The
Kolmogorov–Smirnov test was used to determine
whether the data were normally distributed. Socio-
Hamit Sirri Keten, Oguz Isik et Al
demographic data were analyzed using the Chisquare test. The t-test and Mann Whitney U test
were used to reveal differences between the two
groups, and analysis of variance (ANOVA) was
used to show differences among three or more
groups. Homogeneity of variance was evaluated
using Levene’s test. When significant differences
were found between groups, post-hoc pairwise
comparisons were made using Tukey’s test.
Relations among the variables were analyzed using
the Pearson correlation test. p<0.05 was considered
significant.
Ethical approval was obtained from the ethical
committee of the Medical Faculty of
Kahramanmaras Sütçü İmam University in accordance with the Helsinki Declaration (Seoul, 2008).
Results
The study included 140 male participants, 70
were in the MP group and 70 were in the control
group. The mean age of the participants was
63.69±6.01 (min=60, max=85) in the overall study
sample, 62.97±5.50 in the MP group and
64.41±6.43 in the control group. There was no significant difference in age between the MP group
and the control group (p=0.156). One hundred and
twenty participants (85.7%) were married, 11
(7.9%) were widowers, 6 (4.3%) had never married
and 3 (2.1%) were divorced. Marital status did not
significantly differ between the MP group and the
control group (p=0.469). One hundred and one participants (72.1%) were primary school graduates,
14 (10.0%) were middle school graduates, 10
(7.1%) were high school graduates and 15 (10.7%)
were university graduates. The mean length of education was 6.80±3.32 years. The MP group and the
control group did not differ significantly in terms of
education (p=0.132) or income (p=0.451). The
mean number of daily MP uses was 17.25±6.52 and
the mean amount of MP consumption was
47.4±8.13 packages/year. One hundred and thirtyfive (96.4%) participants were right handed and 5
(3.6%) were left handed. Table 1 presents demographic features of the participants (Table 1).
The mean SMMT score was 22.78±5.36 in the
MP group and 23.92±4.22 in the control group; this
difference was not significant (p=0.164). There was
a significant negative correlation between age and
SMMT score (p=0.001, r=-278), a significant positive correlation between length of education and
SMMT score (p=0.00, r=333), and a significant
Effects of Maras powder (smokeless tobacco) usage on cognitive function...
negative correlation between the amount of MP
consumed (package/year) and SMMT score in the
MP group (p=0.002, r=-330).
Socio-demographic features
Age group
293
while the left handed participants’ mean score was
25.60±3.04; this difference was not significant
(p=0.294).
Total n(%)
MP users n(%)
Non-users of MP n(%)
60-64
96(68.6)
51(75.0)
45(66.2)
65-75
31(22.1)
14(20.6)
17(25.0)
75-84
9(6.4)
3(4.4)
6(8.8)
Married
120(85.7)
62(88.6)
58(82.9)
Widower
11(7.9)
5(7.1)
6(8.6)
Single
6(4.3)
2(2.9)
4(5.7)
Divorced
3(2.1)
1(1.4)
2(2.9)
Retired
56(40.0)
22(31.4)
34(48.6)
Worker
43(30.7)
28(40.0)
15(21.4)
Tradesman
24(17.1)
17(24.3)
7(10.0)
Government officer
10(7.1)
1(1.4)
9(12.9)
Farmer
7(5.0)
2(2.9)
5(7.1)
Primary school
101(72.1)
55(78.6)
46(65.7)
Middle school
14(10.0)
10(14.3)
4(5.7)
High School
10(7.1)
4(5.7)
6(8.6)
University
15(10.7)
1(1.4)
14(20.0)
<400 Dollars (<880
Turkish Liras)
69(49.3)
36(51.4)
33(47.1)
400-800 Dollars (8801760 Turkish Liras )
32(22.9)
17(24.3)
15(21.4)
Marital status
Occupation
p
0.435
0.469
Education Levels
0.864
0.132
Monthly income
0.451
801-1200 Dollars
(1760-2640 Turkish
Liras )
33(23.6)
14(20.0)
19(27.1)
>1200 Dollars (>2640
Turkish Liras )
6(4.3)
3(4.3)
3(4.3)
Table 1: Socio-demographic Features of the Participants.
The mean SMMT score was significantly
lower in primary school graduates than in participants with higher levels of education (p=0.001). It
was also significantly lower in widowers than in
married, never married and divorced participants
(p=0.048). The mean SMMT score was 24.11±4.85
in participants aged 60-64, 21.67±4.63 in participants aged 65-74 and 20.77±4.43 in participants
aged 75-85. Patients aged 75-80 had significantly
lower SMMT scores than those in the other age
groups (p=0.014). SMMT score was not significantly correlated with monthly income (p=0.107) and
type of occupation (p=0.589). The right handed participants’ mean SMMT score was 23.27±4.88,
Table 2 shows the distribution of SMMT
scores across socio-demographic features.
On the SMMT, 17 participants (12.1%)
received scores <19, 64 participants (45.7%)
received scores from 19-24 and 59 participants
(42.1%) received scores from 25-30. Ten MP users
(14.3%) and 7 non-users (10%) scored <19, 34 MP
users (48.6%) and 30 non-users (42.9%) scored 1924 and 26 MP users (37.1%) and 33 non-users
(47.1%) scored 25-30 on the SMMT. There was no
significant difference between MP users and nonusers in terms of SMMT scores (p=0.447). The distribution of participants based on their SMMT
scores is shown in Table 3.
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Hamit Sirri Keten, Oguz Isik et Al
Socio-demographic features
Age group
SMMT score Mean ±SD
60-64
24.11±4.85
65-74
21.67±4.63
75-85
20.77±4.43
Married
23.60±4.64
Widower
20.63±6.20
Single
23.16±6.52
Divorced
23.66±1.52
Retired
22.41±5.72
Worker
23.86±3.91
Tradesman
23.29±4.52
Government officer
25.50±4.24
Farmer
25.00±3.16
Primary school
22.32±5.03
Middle school
25.35±2.81
High school
26.10±2.92
University
26.60±3.33
<400 Dollars (<880
Turkish Liras)
22.44±5.32
400-800 Dollars
(880-1760 Turkish
Liras )
24.90±3.58
801-1200 Dollars
(1760-2640 Turkish
Liras )
23.54±4.72
>1200 Dollars
(>2640 Turkish
Liras )
24.50±3.93
Marital status
P
0.014
0.048
Occupation
Education levels
Monthly income
Parameters
Total
Mean ±SD
MP users
Mean ±SD
Non-users of MP
Mean ±SD
P
SMMT
23.35±4.84
22.78±5.36
23.92±4.22
0.164
Orientation
9.29±1.6
9.11±2.01
9.46+1.12
0.216
Registration
2.66±0.82
2.61±0.92
2.71±0.72
0.477
Attention and
Calculation
2.10±2.02
2.01±2.01
2.20±2.04
0.589
Recall
1.45±1.13
1.52±1.09
1.37±1.16
0.414
Language
7.85±1.80
7.51±2.11
8.18±1.37
0.028
Table 4: The Distribution of the Scores for SMMT and
its Subscales by the MP Users and Non-users.
Discussion
0.589
0.001
0.107
With respect to subscales of the SMMT, the
Table 2: The distribution of the mean SMMT scores by
Socio-demographic features.
SMMT Score
Total n(%)
MP users n(%)
Non-users of MP n(%)
p
<19
17(12.1)
10(14.3)
7(10.0)
0.447
19-24
64(45.7)
34(48.6)
30(42.9
≥25
59(42.1)
26(37.1)
33(47.1)
Table 3: The Distribution of the SMMT Scores by MP
Users and Non-users.
mean score for orientation was 9.11±2.01 for MP
users and 9.46±1.12 for non-users; this difference
was not significant (p=0.216). The mean score for
language was 7.51±2.11 in MP users and 8.18±1.37
in non-users. The MP users had significantly higher
scores for language (p=0.028). MP users and nonusers did not differ significantly in registration
(p=0.477), attention and calculation (p=0.589) and
recall (p=0.414). Scores on the SMMT and its subscales are presented in Table 4.
The results of the present study showed that
the risk factors related to impaired cognitive functions were advanced age, low education levels and
death of spouse. In addition, MP usage, income and
types of occupation were not found to be related to
impaired cognitive functions.
In this study, the mean SMMT scores and the
distribution of SMMT scores did not differ between
MP users and nonusers. The MP users had a significantly higher mean score on the language subscale
of the SMMT; however, both groups had similar
mean scores on the other subscales of the SMMT.
In addition, there was a significant negative correlation between SMMT scores and amount of MP
(packet/year). Elwood et al., in their communitybased study in England, also found that the mean
SMMT score was 26.2 in smokers aged 55-69 and
26.5 in non-smokers of the same age group, a nonsignificant difference(16). In a study by Launer et al.,
smokers made 20% more mistakes on the
SMMT(17). Tekin et al., in their study of males aged
over 40 in Ankara, Turkey, found that smoking did
not affect SMMT scores, but the negative effects of
smoking on low density lipoprotein (LDL) played
an important role in the reduction of scores on the
language subscale(18). In fact, while several studies
have shown that active smoking was related to a
reduction in cognitive functions(6,7), other studies
have found no significant relation between smoking
and deterioration of cognitive functions (8,9) .
Interestingly, some studies have revealed that
smoking had a protective effect on cognitive functions(10,11).
It seems that there is conflicting evidence in
the literature on the effects of smoking on cognitive
functioning. In the present study, we found that MP
usage did not have a direct effect on cognitive functioning, and it was striking that there was a negative
Effects of Maras powder (smokeless tobacco) usage on cognitive function...
correlation between the amount of MP used and
SMMT scores. This suggests that long-term use of
MP in higher amounts may affect cognitive function, making a case for clinical studies on larger
samples. It should not be overlooked that tobacco
usage damages health via various mechanisms and
appropriate preventive measures should be taken.
In the present study, the mean SMMT score
was 23.35. With respect to the distribution of
SMMT scores, 12.1% of the participants received
<19, 45.7% of the participants received 19-24 and
42.1%% of the participants received 25-30. In a
community based study in Kars, males aged over
60 had a mean SMMT score of 22.28, and the mean
SMMT score was <19 for 23.4% of participants,
19-24 for 44.4% of participants and 25-3 for 32.0%
of participants (19). In another community-based
study, males over 65 years of age in Kocaeli,
Turkey, received a mean SMMT score of 25.04 and
6.9% of males had a score of <19, 25.7% of males
had a score of 20-24 and 67.4% of males had a
score of 25-30(20). In a study on patients aged ≥65
and presenting to a state hospital in Ankara, 76.4%
received scores ≥26 and 23.4% had a score of 24-26
on the SMMT(21). In studies from other parts of
the world, the mean SMMT score was 25.92 for
people aged ≥60 in China(22) and 22.4 in people
aged ≥80 in Italy(23). The results of the present study
were consistent with those of the study in Kars,
Turkey, but found lower SMMT scores than those
reported in the studies in Ankara, China and Italy.
This can be attributed to differences in gender, education, marital status, age and socio-cultural features.
In the current study, the mean SMMT score
was 24.11 in the 60-64 age group, 21.67 in the 6574 age group and 20.77 in the 75-85 age group. The
mean score was significantly lower in participants
aged 75-85. There was a significant negative correlation between SMMT score and age. In a study on
people aged ≥60 by Karatay et al., the SMMT score
was 22.93 in participants aged 60-64, 22.75 in participants aged 65-74, 20.29 in participants aged 7584 and 18.14 in participants aged ≥85(19). Several
similar studies have revealed a significant negative
correlation between SMMT scores and age (18-22).
Both the present study and other studies reported so
far have shown advanced age is an important risk
factor for cognitive functions. Naturally, aging cannot be prevented. However, healthy aging is not
impossible and plays an important role in the
preservation of cognitive functioning.
295
In the present study, the primary school graduates obtained significantly lower SMMT scores
than those with higher levels of education. In addition, there was a significant positive relation
between length of education and SMMT score.
Diker et al., in their study on people aged ≥65, also
reported that SMMT scores were significantly
lower in primary school graduates than in those
with higher levels of education(20). In a study on
people aged ≥60 in Mexico, low education levels
were found to cause deterioration in cognitive functions(24). In addition, several other studies reported
in the literature reported a significant positive correlation between length of education and SMMT
score(18-20). In light of the results of the present study
and the evidence from the literature, it is obvious
that a shorter duration of education is a risk factor
for low cognitive functioning. To enhance the educational activities in the childhood is important to
attain a healthy society in terms of cognitive functions. The Ministry of Education should cooperate
with the Ministry of Health in an attempt to
enhance cognitive functions. In addition, education
programs directed towards the middle-aged and
elderly population should be designed to prevent
the deterioration of cognitive functions.
We found that people whose spouses had died
had significantly lower scores on the SMMT than
those with other types of marital status, which is
consistent with the results of other studies with
samples of the same age as those in the present
study(19-25). It may be that the death of a spouse
can weaken relationships with others. However, no
significant relations were found between SMMT
score and income and type of occupation, which is
compatible with the literature. The non-significant
effect of income on cognitive function in the present study can be explained by the fact that the participants had a similar financial status. The non-significant effect of occupation may be due to the fact
that the elderly can be employed in posts that do
not require much cognitive activity.
Conclusion
In the present study, both MP users and nonusers had similar cognitive functioning. However, it
was striking that there was a significant positive
relation between the amount of MP usage and
SMMT score. Therefore, further studies with larger
sample sizes are needed. Advanced age and low
education levels were found to be associated with
296
Hamit Sirri Keten, Oguz Isik et Al
deterioration of cognitive functions. Although aging
is inevitable, healthy aging is of great importance in
terms of preservation of cognitive functioning. The
great role education plays in the maintenance of
cognitive functions should not be disregarded, and
education programs should be designed for all age
groups.
14)
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Acknowledgement
This manuscript was presented as an oral presentation at the
13 th National Congress of Turkish Family Medicine,
Antalya,Turkey, on 23-27 April 2014.
_______
Correspoding author
Dr. HAMIT SIRRI KETEN
Onikisubat Community Health Center
Department of Family Medicine
TR-46050 Kahramanmaras
(Turkey)