Association between ECG Abnormalities and Hookah and Cigarette Smoking in the MASHAD Cohort Study Subjects

Articles in Press

Document Type : Research Paper

Authors

1 Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.

2 International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran.

3 Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

4 Clinical Research Development Unit, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

5 Department of Cardiovascular Diseases, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

6 Department of Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.

7 Social Determinants of Health Research center, Mashhad University of Medical Sciences, Mashhad, Iran.

8 Brighton and Sussex Medical School, Division of Medical Education, Brighton, UK.

9 Heart and Vascular Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.

10.22038/jctm.2025.79903.1486

Abstract

Introduction: Tobacco use, including cigarette and hookah smoking, is a major public health issue due to its association with cardiovascular disease (CVD). Cigarette and hookah smoking introduce harmful substances that lead to atherosclerosis, endothelial dysfunction, and myocardial ischemia, resulting in significant cardiovascular morbidity and mortality. In this study, we aimed to assess the association between hookah and cigarette smoking and ECG patterns using Minnesota Coding (MC) system in a large-scale population.
Methods: This study utilized data from the Mashhad Stroke and Heart Atherosclerotic Disorder (MASHAD) cohort, involving 9,704 participants aged 35-65 years. Demographic data, physical measurements, smoking habits, and medical histories were collected. Resting 12-lead ECGs were analyzed using the MC system to identify minor and major ECG abnormalities. Statistical analyses included binary logistic regression adjusted for sex, BMI, education, and employment status, as well as chi-squared tests.
Results: The final analysis included 8,821 participants. Cigarette users (92.3% male) had significantly lower BMI and higher employment rates compared to non-smokers, whereas hookah smokers (90.2% female) had higher BMIs and were predominantly retirees. Cigarette smokers exhibited a higher prevalence of minor ECG abnormalities (25.6% vs. 20.2%, p = 0.001), particularly ST-segment elevation, left axis deviation, sinus bradycardia, and high amplitude P-waves. Logistic regression confirmed significant associations for sinus bradycardia (OR: 1.600, 95% CI: 1.127-2.271, p = 0.009) and high amplitude P-waves (OR: 4.775, 95% CI: 1.771-12.880, p = 0.002). Hookah smokers had higher rates of left ventricular hypertrophy plus ST-T abnormalities (7.9% vs. 5.0%, p = 0.027) and a significantly lower prevalence of sinus tachycardia (0.3% vs. 1.6%, p = 0.042).
Conclusion: Cigarette and hookah smoking are associated with specific ECG abnormalities, suggesting significant cardiovascular effects. The persistence of certain abnormalities after adjustment underscores the long-term impact of smoking on cardiac function. Further research is needed to elucidate the mechanisms and mitigate the cardiovascular risks associated with various forms of tobacco use.

Keywords

References

  1. Chen C, Wei J, AlBadri A, Zarrini P, Merz CN. Coronary microvascular dysfunction―epidemiology, pathogenesis, prognosis, diagnosis, risk factors and therapy―. Circulation Journal. 2016 Dec 22;81(1):3-11.
  2. Banks E, Joshy G, Korda RJ, Stavreski B, Soga K, Egger S, et al. Tobacco smoking and risk of 36 cardiovascular disease subtypes: fatal and non-fatal outcomes in a large prospective Australian study. BMC medicine. 2019 Dec;17:1-8.
  3. Camici PG, Crea F. Coronary microvascular dysfunction. New England Journal of Medicine. 2007 Feb 22;356(8):830-40.
  4. BaHammam AS. Hookah and Cigarette Smoking: Two Sides of the Same Coin. Journal of Nature and Science of Medicine. 2020 Jan 1;3(1):1-2.
  5. Al-Sadat N, Misau AY, Zarihah Z, Maznah D, Su TT. Adolescent tobacco use and health in Southeast Asia. Asia Pacific Journal of Public Health. 2010 Jul;22(3_suppl):175S-80S.
  6. Schroll M, Hagerup L. Relationship of fasting blood glucose to prevalence of ECG abnormalities and 10 yr risk of mortality from cardiovascular diseases in men born in 1914: from the Glostrup population studies. Journal of Chronic Diseases. 1979 Jan 1;32(11-12):699-707.
  7. Omare MO, Kibet JK, Cherutoi JK, Kengara FO. A review of tobacco abuse and its epidemiological consequences. Journal of public health. 2021 Jan 6:1-6.
  8. Abrams DB, Glasser AM, Pearson JL, Villanti AC, Collins LK, Niaura RS. Harm minimization and tobacco control: reframing societal views of nicotine use to rapidly save lives. Annual review of public health. 2018 Apr 1;39(1):193-213.
  9. Wang JL, Yin WJ, Zhou LY, Wang YF, Zuo XC. Association between initiation, intensity, and cessation of smoking and mortality risk in patients with cardiovascular disease: a cohort study. Frontiers in cardiovascular medicine. 2021 Dec 15;8:728217.
  10.  Wang TW. Tobacco product use among adults—United States, 2017. MMWR. Morbidity and mortality weekly report. 2018;67.
  11. Duncan MS, Freiberg MS, Greevy RA, Kundu S, Vasan RS, Tindle HA. Association of smoking cessation with subsequent risk of cardiovascular disease. Jama. 2019 Aug 20;322(7):642-50.
  12. Klonizakis M, Gumber A, McIntosh E, Brose LS. Medium-and longer-term cardiovascular effects of e-cigarettes in adults making a stop-smoking attempt: a randomized controlled trial. BMC medicine. 2022 Aug 16;20(1):276.
  13. Paudel KR, Panth N, Manandhar B, Singh SK, Gupta G, Wich PR, et al. Attenuation of cigarette-smoke-induced oxidative stress, senescence, and inflammation by berberine-loaded liquid crystalline nanoparticles: in vitro study in 16HBE and RAW264. 7 cells. Antioxidants. 2022 May;11(5):873.
  14. Addissouky TA, El Sayed IE, Ali MM, Wang Y, El Baz A, Elarabany N, et al. Oxidative stress and inflammation: elucidating mechanisms of smoking-attributable pathology for therapeutic targeting. Bulletin of the National Research Centre. 2024 Jan 22;48(1):16.
  15. Hu T, Mu C, Li Y, Hao W, Yu X, Wang Y, et al. GPS2 ameliorates cigarette smoking-induced pulmonary vascular remodeling by modulating the ras-Raf-ERK axis. Respiratory Research. 2024 May 16;25(1):210.
  16. Lu Y, Wang Z, Zheng L. Association of smoking with coronary artery disease and myocardial infarction: a Mendelian randomization study. European journal of preventive cardiology. 2021 Nov 1;28(12):e11-2.
  17. Luo J, Tang X, Li F, Wen H, Wang L, Ge S, et al. Cigarette smoking and risk of different pathologic types of stroke: a systematic review and dose-response meta-analysis. Frontiers in Neurology. 2022 Jan 25;12:772373.
  18. Momayyezi M, Jambarsang S, Fallahzadeh H, Sefidkar R. Association between lipid profiles and cigarette smoke among adults in the Persian cohort (Shahedieh) study. BMC public health. 2024 May 7;24(1):1256.
  19. Yadav A, Mala M, Yadav GA, Kumar LN. Effect of cigarette smoking on blood levels of lipid and atherogenic lipid ratios. Natl J Lab Med. 2020;9:1-3.
  20. Kalan ME, Rahman A, Gautam P, Taleb ZB. Hookah home delivery: an emerging public health issue. Tobacco Control. 2021 Jan 1;30(1):114-5.
  21. Ansari H. Hookah Use Among Youth and Young Adults: A Public Health Challenge. Health Scope. 2014;3(3):e20632.
  22. Cobb C, Ward KD, Maziak W, Shihadeh AL, Eissenberg T. Waterpipe tobacco smoking: an emerging health crisis in the United States. American journal of health behavior. 2010 May 1;34(3):275-85.
  23. Smith SY, Curbow B, Stillman FA. Harm perception of nicotine products in college freshmen. Nicotine & Tobacco Research. 2007 Sep 1;9(9):977-82.
  24. Münzel T, Hahad O, Kuntic M, Keaney Jr JF, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes. European heart journal. 2020 Nov 1;41(41):4057-70.
  25. Sharma NK, Jaiswal KK, Meena SR, Chandel R, Chittora S, Goga PS, et al. ECG Changes in Young Healthy Smokers: A Simple and Cost-Effective Method to Assess Cardiovascular Risk According to Pack-Years of Smoking. The Journal of the Association of Physicians of India. 2017 Jun 1;65(6):26-30.
  26. Ibrahim UF, Olamat A, Akan A. Analyses of changes in electrocardiogram signals during Hookah Smoking. In2017 Medical Technologies National Congress (TIPTEKNO) 2017 Oct 12 (pp. 1-4). IEEE.
  27. Gupta V, Mittal M, Mittal V, Saxena NK. A critical review of feature extraction techniques for ECG signal analysis. Journal of The Institution of Engineers (India): Series B. 2021 Oct;102:1049-60.
  28. Tseng KK, Li J, Tang YJ, Yang CW, Lin FY. Healthcare knowledge of relationship between time series electrocardiogram and cigarette smoking using clinical records. BMC Medical Informatics and Decision Making. 2020 Jul;20:1-1.
  29. Blackburn H. Electrocardiographic classification for population comparisons: The Minnesota code. Journal of electrocardiology. 1969 Jan 1;2(1):5-9.
  30. Ghayour-Mobarhan M, Moohebati M, Esmaily H, Ebrahimi M, Parizadeh SM, Heidari-Bakavoli AR, et al. Mashhad stroke and heart atherosclerotic disorder (MASHAD) study: design, baseline characteristics and 10-year cardiovascular risk estimation. International journal of public health. 2015 Jul;60:561-72.
  31. Saffar Soflaei S, Ebrahimi M, Rahimi HR, Moodi Ghalibaf A, Jafari M, Alimi H, et al. A large population‐based study on the prevalence of electrocardiographic abnormalities: A result of Mashhad stroke and heart atherosclerotic disorder cohort study. Annals of Noninvasive Electrocardiology. 2023 Nov;28(6):e13086.
  32. Prineas RJ, Crow RS, Zhang ZM. The Minnesota code manual of electrocardiographic findings. Springer Science & Business Media; 2009 Oct 26.
  33. Rautaharju PM, Warren JW, Calhoun HP. Estimation of QT prolongation: a persistent, avoidable error in computer electrocardiography. Journal of electrocardiology. 1990 Jan 1;23:111-7.
  34. Auer R, Bauer DC, Marques-Vidal P, Butler J, Min LJ, Cornuz J, et al. Association of major and minor ECG abnormalities with coronary heart disease events. Jama. 2012 Apr 11;307(14):1497-505.
  35. Chao AM, Wadden TA, Ashare RL, Loughead J, Schmidt HD. Tobacco smoking, eating behaviors, and body weight: a review. Current addiction reports. 2019 Sep 15;6:191-9.
  36. Plurphanswat N, Rodu B. The association of smoking and demographic characteristics on body mass index and obesity among adults in the US, 1999–2012. BMC obesity. 2014 Dec;1:1-9.
  37. Chiolero A, Faeh D, Paccaud F, Cornuz J. Consequences of smoking for body weight, body fat distribution, and insulin resistance. The American journal of clinical nutrition. 2008 Apr 1;87(4):801-9.
  38. Munafò MR, Tilling K, Ben-Shlomo Y. Smoking status and body mass index: a longitudinal study. Nicotine & Tobacco Research. 2009 Jun 1;11(6):765-71.
  39. Driva S, Korkontzelou A, Tonstad S, Tentolouris N, Katsaounou P. The effect of smoking cessation on body weight and other metabolic parameters with focus on people with type 2 diabetes mellitus. International Journal of Environmental Research and Public Health. 2022 Oct 14;19(20):13222.
  40. Baalbaki R, Itani L, El Kebbi L, Dehni R, Abbas N, Farsakouri R, et al. Association between smoking hookahs (shishas) and higher risk of obesity: A systematic review of population-based studies. Journal of cardiovascular development and disease. 2019 Jun 16;6(2):23.
  41. Payne JR, Eleftheriou KI, James LE, Hawe E, Mann J, Stronge A, et al. Left ventricular growth response to exercise and cigarette smoking: data from LARGE Heart. Heart. 2006 Dec 1;92(12):1784-8.
  42. Benowitz NL. The role of nicotine in smoking-related cardiovascular disease. Preventive medicine. 1997 Jul 1;26(4):412-7.
  43. Lee AJ, Crombie IK, Smith WC, Tunstall-Pedoe HD. Cigarette smoking and employment status. Social science & medicine. 1991 Jan 1;33(11):1309-12.
  44. Beard E, Brown J, Jackson SE, West R, Kock L, Boniface S, et al. Independent associations between different measures of socioeconomic position and smoking status: a cross-sectional study of adults in England. Nicotine and Tobacco Research. 2021 Jan 1;23(1):107-14.
  45. Kouvonen A, Kivimäki M, Virtanen M, Pentti J, Vahtera J. Work stress, smoking status, and smoking intensity: an observational study of 46 190 employees. Journal of Epidemiology & Community Health. 2005 Jan 1;59(1):63-9.
  46. Hummel K, van den Putte B, Mons U, Willemsen MC, Fong GT, Andler R, et al. The role of income and psychological distress in the relationship between work loss and smoking cessation: Findings from three International Tobacco Control (ITC) Europe countries. Tobacco prevention & cessation. 2019 Nov 19;5:42.
  47. Sadeghi R, Gerayllo S, Khanjani N, Hanna F, Yoshany N. Factors Related to Hookah Smoking Among the Iranian Population: A Systematic Review. Tobacco and Health. 2023 Sep 1;2(3):107-16.
  48. Tomioka K, Kurumatani N, Saeki K. The association between education and smoking prevalence, independent of occupation: a nationally representative survey in Japan. Journal of epidemiology. 2020 Mar 5;30(3):136-42.
  49. Ruokolainen O, Härkänen T, Lahti J, Haukkala A, Heliövaara M, Rahkonen O. Association between educational level and smoking cessation in an 11-year follow-up study of a national health survey. Scandinavian Journal of Public Health. 2021 Dec;49(8):951-60.
  50. Maralani V. Understanding the links between education and smoking. Social science research. 2014 Nov 1;48:20-34.
  51. Alborzi S, Movahed M, Mozafari R. A Sociological Study on Hookah Consumption Among the Youth of Shiraz. Tobacco and Health. 2022 Jan 30;1(1):36-41.
  52. Sethi P, Murtaza G, Sharma A, Paul T. ST segment elevation with normal coronaries. Case reports in medicine. 2016;2016(1):3132654.
  53. Caliri AW, Tommasi S, Besaratinia A. Relationships among smoking, oxidative stress, inflammation, macromolecular damage, and cancer. Mutat Res Rev Mutat Res. 2021;787:108365-.
  54. Isik B, Ceylan A, Isik R. Oxidative stress in smokers and non-smokers. Inhalation toxicology. 2007 Jan 1;19(9):767-9.
  55. Emma R, Caruso M, Campagna D, Pulvirenti R, Li Volti G. The impact of tobacco cigarettes, vaping products and tobacco heating products on oxidative stress. Antioxidants. 2022 Sep 16;11(9):1829.
  56. Messner B, Bernhard D. Smoking and cardiovascular disease: mechanisms of endothelial dysfunction and early atherogenesis. Arteriosclerosis, thrombosis, and vascular biology. 2014 Mar;34(3):509-15.
  57. Benowitz NL. Cigarette smoking and cardiovascular disease: pathophysiology and implications for treatment. Progress in cardiovascular diseases. 2003 Jul 1;46(1):91-111.
  58. Park SK, Ryoo JH, Kang JG, Jung JY. Smoking status, intensity of smoking, and their relation to left ventricular hypertrophy in working aged Korean men. Nicotine and Tobacco Research. 2021 Jul 1;23(7):1176-82.
  59. Puvvada DLM, Patel DAT, Sachdeo DRT, Thakkar DM. Electrocardiographic Changes in Young Healthy Male Smokers. International Journal Of Medical Science And Clinical Research Studies. 2022;2(12) :1421-4.
  60. Gepner AD, Piper ME, Leal MA, Asthana A, Fiore MC, Baker TB, et al. Electrocardiographic changes associated with smoking and smoking cessation: outcomes from a randomized controlled trial. PLoS One. 2013 Apr 23;8(4):e62311..
  61. Barutcu I, Esen AM, Kaya D, Turkmen M, Karakaya O, Melek M, et al. Cigarette smoking and heart rate variability: dynamic influence of parasympathetic and sympathetic maneuvers. Annals of noninvasive electrocardiology. 2005 Jul;10(3):324-9.
  62. Ashare RL, Sinha R, Lampert R, Weinberger AH, Anderson GM, Lavery ME, et al. Blunted vagal reactivity predicts stress-precipitated tobacco smoking. Psychopharmacology. 2012 Mar;220:259-68.
  63. Paik JH, Kang S, Durey A, Kim JH, Kim AJ. Symptomatic bradycardia due to nicotine intoxication. Revista Brasileira de terapia intensiva. 2018 Jan;30:121-6.
  64. Oakes JM, Xu J, Morris TM, Fried ND, Pearson CS, Lobell TD, et al. Effects of chronic nicotine inhalation on systemic and pulmonary blood pressure and right ventricular remodeling in mice. Hypertension. 2020 May;75(5):1305-14.
  65. Frost AE, Zhao C, Farber HW, Benza R, Yen J, Selej M, et al. Smoking history and pulmonary arterial hypertension: demographics, onset, and outcomes. The Journal of Heart and Lung Transplantation. 2023 Mar 1;42(3):377-89.
  66. Cobb CO, Shihadeh A, Weaver MF, Eissenberg T. Waterpipe tobacco smoking and cigarette smoking: a direct comparison of toxicant exposure and subjective effects. Nicotine & Tobacco Research. 2011 Feb 1;13(2):78-87.
  67. Eissenberg T, Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. American journal of preventive medicine. 2009 Dec 1;37(6):518-23.
  68. Primack BA, Sidani J, Agarwal AA, Shadel WG, Donny EC, Eissenberg TE. Prevalence of and associations with waterpipe tobacco smoking among US university students. Annals of behavioral medicine. 2008 Aug 1;36(1):81-6.
  69. Vinyoles E, Soldevila N, Torras J, Olona N, de la Figuera M. Prognostic value of non-specific ST-T changes and left ventricular hypertrophy electrocardiographic criteria in hypertensive patients: 16-year follow-up results from the MINACOR cohort. BMC Cardiovascular Disorders. 2015 Dec;15:1-7.
  70. Ali S, Goodman SG, Yan RT, Budaj A, Fox KA, Gore JM, et al. Prognostic significance of electrocardiographic-determined left ventricular hypertrophy and associated ST-segment depression in patients with non–ST-elevation acute coronary syndromes. American Heart Journal. 2011 May 1;161(5):878-85.
  71. Coppola G, Carità P, Corrado E, Borrelli A, Rotolo A, Guglielmo M, et al. ST segment elevations: always a marker of acute myocardial infarction?. Indian heart journal. 2013 Jul 1;65(4):412-23.
  72. Mutikainen S, Ortega‐Alonso A, Alen M, Kaprio J, Karjalainen J, Rantanen T, et al. Electrocardiographic indices of left ventricular hypertrophy and repolarization phase share the same genetic influences: a twin study. Annals of Noninvasive Electrocardiology. 2009 Oct;14(4):346-54.
  73. Devi MR, Arvind T, Kumar PS. ECG changes in smokers and non smokers-a comparative study. Journal of clinical and diagnostic research: JCDR. 2013 Mar 6;7(5):824.
  74. Ramakrishnan S, Bhatt K, Dubey AK, Roy A, Singh S, Naik N, et al. Acute electrocardiographic changes during smoking: an observational study. BMJ open. 2013 Jan 1;3(4):e002486.
  75. Ondrejka J, Giorgio G. Type 1 Brugada pattern associated with nicotine toxicity. The Journal of Emergency Medicine. 2015 Dec 1;49(6):e183-6.
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Available Online from 17 March 2025

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