





































Clinical Medicine Insights
Received 15 Sep 2021 | Revised 20 Oct 2020 | Accepted 25 Nov 2020| Published Online 15 Dec 2020

DOI: https://doi.org/10.52845/CMI/2020-1-1-06 
CMI JOURNAL 1 (1), 34−49 (2020) ISSN (O) 2694-4626 

REVIEW ARTICLE

Smoking and Non-Communicable Diseases: Part I Cardiovascular Diseases,
Respiratory Diseases, Obesity, Depression, Liver Diseases

Shashi K. Agarwal, MD ∗
 

12227 US Highway 1, #309 North
Brunswick, NJ 08902, USA

Abstract
Smoking tobacco is popular all over the world. It is however full of toxic
chemicals, with many of them being carcinogenic. These chemicals
affect every organ in the human body, leading to a wide array of
disorders. This results in considerable suffering. frequent disability,
and premature mortality. It is estimated that smokers lose several
years of healthy life. Smoking hookah or e-cigarettes is also harmful.
Smoking remains the number one preventable cause of several non-
communicable diseases.
Keywords: smoking, non-communicable diseases, cardiovascular dis-
eases, respiratory diseases, obesity, depression, liver diseases

Copyright : © 2021 The Authors. Published by Medical Editor and
Educational Research Publishers Ltd. This is an open access article
under the CC BY-NC-ND license
(https://creativecommons.org/licenses/by-nc-nd/4.0/).

1 INTRODUCTION

Tobacco smoking is a major modifiable risk
factor for a wide array of diseases1. Besides
nicotine, tobacco smoke also contains sev-

eral thousand chemical compounds, either gaseous
or particulate, and many of these are toxic2. In
addition to the major non-communicable diseases
discussed in this two-partmanuscript, tobacco smoke
has been associated with complications of pregnancy
and sudden infant death syndrome3. Infants exposed
to cigarette smoke either prenatal or after birth also
increase their risk of orofacial clefts, periodontal
disease, and dental caries4. Smoking increases the
risk of dental implant failure5. It also enhances aging,

causing premature wrinkles6. It is estimated that 16
million adults are currently living with smoking-
related diseases in the United States7.
Smoking cessation reduces the risk of major chronic
diseases8. Cessation also helps reduce the severity of

Supplementary information The online version of 
this article (10.52845/CMI/2020-1-1-06) contains 
supplementary material, which is available to autho-
rized users.

Corresponding Author: Shashi K. Agarwal, MD 
Shashi K. Agarwal, MD 2227 US Highway 1, #309 
North Brunswick, NJ 08902, USA
Email: usacardiologist@gmail.com

CMI JOURNAL 1 (1), 34−49 (2020) MEERP LTD 34

Open Access Journal

https://doi.org/10.52845/CMI/2021-2-3-12
https://orcid.org/0000-0003-0007-5582
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mailto:usacardiologist@gmail.com
https://medicineinsights.info/index.php/cmi/index


MEERP LTD
SHASHI K. AGARWAL, MD

the disease9, improves the quality of life10, increases
disease-free life11, and augments life expectancy12.
Smoking is the leading preventable cause of death
worldwide13.

2 DISCUSSION

CDC defines chronic diseases as “conditions that
last 1 year or more and require ongoing medical
attention or limit activities of daily living or both”14.
Most chronic diseases are noncommunicable. The
five major diseases discussed in this part are cardio-
vascular diseases (CVD), respiratory diseases, obe-
sity, depression, and liver diseases. CVDs include
coronary heart disease, high blood pressure (BP),
stroke, heart failure, cardiac arrhythmias (includ-
ing sudden cardiac death), peripheral arterial dis-
ease, deep vein thrombosis, and vasculogenic erec-
tile dysfunction. They are a leading cause of mor-
bidity and mortality, globally15. Smoking remains
the main modifiable lifestyle factor responsible for
most of these diseases16. Even low-tar cigarettes and
smokeless tobacco have been shown to increase the
risk of cardiovascular events in comparison to non-
smokers17. The main respiratory diseases are chronic
obstructive pulmonary disease (COPD), asthma, res-
piratory infections, and cancer. COPD is a progres-
sive and debilitating disease that causes a decline in
lung function leading to cor-pulmonale, respiratory
failure, and premature death18. It is responsible for
over 3 million deaths annually19. The World Health
Organization (WHO) predicts that COPD will be the
third leading cause of death, worldwide, in 203020.
Obesity is a pandemic and is associated with in-
creased morbidity and mortality21. Bodyweight clas-
sification is generally based on the calculation of
body mass index (BMI)22. Normal BMI is 18.5–
24.9 kg/m2, overweight is a BMI 25 to 29.9 kg/m2,
and obesity is a BMI >30 kg/m223. Central obesity
(visceral or abdominal obesity) often confers worse
health effects, even with a normal BMI24. This type
of obesity can be determined by waist circumfer-
ence, waist hip-ratio, or waist-height ratio25,26. De-
pression is characterized by sadness, loss of interest
and pleasure, feelings of guilt, feeling of worthless-
ness, low appetite, fatigue, and poor concentration27.

It is estimated that it affects 350 million people
worldwide28. Depression increases the risk of phys-
ical ailments, especially cardiovascular diseases29.
The Global Burden of Disease Study 2016 reported
that depression is a major cause of disability30. It also
increases suicide and all-cause mortality31. Liver
diseases are on the rise worldwide and are respon-
sible for a considerable amount of morbidity and
mortality32. They include non-alcoholic fatty liver
(NAFLD), alcoholic liver disease, cirrhosis, and liver
cancer33. Hepatocellular carcinoma is highly lethal,
with less than 10% living beyond 5 years34.
Cardiovascular Diseases

Cigarette smoking is a major cause of CVDs35. Most
CVDs are due to atherosclerosis36. Smoking accel-
erates this process by several mechanisms, including
activation of inflammatory factors, dysregulation of
the lipid metabolism, an increase in oxidative stress,
and causing endothelial dysfunction37−39. Smoking
acutely elevates blood pressure40 through the stim-
ulation of the sympathetic nervous system41. It also
increases the risk of renovascular42, malignant43, and
masked hypertension44. The causal impact of smok-
ing on chronic hypertension is however unclear45.
Passive smoking has been associated with an in-
creased risk of hypertension among adults46. Several
epidemiologic studies have indicated that there is an
increase in the incidence of myocardial infarction
and fatal coronary artery disease with smoking47,48.
Smoking raises the risk of coronary plaque rup-
ture47, and this generates thrombosis at the site48.
Smoking is also associated with an increase in coro-
nary spasms49,50. Passive smoking also increases
the risk of coronary artery disease51. In a meta-
analysis of 29 prospective cohort studies, Aune et
al. found that smoking increased the relative risk
of heart failure by 44%52. Lu et al. confirmed this
increased propensity in a recent Mendelian ran-
domization analysis study53. Cigarette smoking is
causally connected with 12.4% of acute strokes54.
Pre-stroke smoking also appears to worsen its prog-
nosis when compared to never smokers55. Smoking
is also directly associated with a more than a two-
fold increased risk of atrial fibrillation56. Smoking
cessation lowers this risk56. Sudden cardiac death

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SMOKING AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES,
RESPIRATORY DISEASES, OBESITY, DEPRESSION, LIVER DISEASES
is usually due to ventricular arrhythmias57, and this
is also increased in smokers58. Smoking has been
linked with an increase in the risk of peripheral artery
disease59,60 and abdominal aortic aneurysms61,62.
Smoking cessation is associated with a reduced rate
of aneurysmal growth63. Smoking can induce erec-
tile dysfunction64 through multiple pathways, with
disturbed nitric oxide signal transduction pathway
being the main one65−68. Smokers are also at an
increased risk of venous thromboembolism69. This
risk is partially increased by physical inactivity70 and
the occurrence of smoking-related diseases in these
patients71.
Smoking cessation reduces cardiovascular events72.
It reduces these risks and mortality even if cessa-
tion happens after the development of a CVD73.
Smoking promotes atherosclerosis via vasomotor
dysfunction, increased inflammation, and modifica-
tion of lipids74. It also enhances thrombosis, via
prothrombotic alterations in platelet function, an-
tithrombotic/prothrombotic activity, and fibrinolytic
factors75.
Respiratory Diseases
Cigarette smoking is a major cause of COPD76,77.
COPD is one of the most common and dangerous
noncommunicable health disorders78. The lifetime
risk for smokers getting COPD is estimated to be
over 20%79, with one recent study estimating the
risk to be as high as 50%80. Passive smokers are
also at an increased risk of developing COPD81.
COPD smokers, both current and past, exhibit an
increased risk for lung cancer, CVDs, and diabetes
mellitus82−84. Smoking cessation, especially at an
early age, greatly helps reduce the symptoms and
the rate of pulmonary function decline in these
patients85,86. Their quality of life also improves87,
and mortality is reduced88. Besides COPD, asthma is
also a major disease affecting the respiratory tract89.
Smoking increases the risk of developing asthma
by 33% to 81%, when compared to nonsmokers90.
Continued smoking also increases the incidence of
exacerbations and poor control in these patients91. It
can also lead to a more severe pulmonary disease
like COPD92. Second-hand smoke exposure, espe-
cially in children, also exacerbates asthma-related
hospitalizations93,94. Smoking has also been associ-
ated with chronic bronchitis and several interstitial

lung diseases85,96. It is estimated that almost 90% of
lung cancers are related to smoking97. Secondhand
smoke exposure also increases the risk of lung cancer
in non-smokers98. Smokers are alsomore susceptible
to bacterial and viral pulmonary infections99−101.

These include viral influenza and tuberculosis99,100.
Smoking also increases the risk of acute respiratory
distress syndrome in COVID infections101.
Tobacco smoke affects the lungs in several ways
– it induces oxidative stress and apoptosis102−104,
increases secretions from mucous glands105,106, and
alters the histologic alveolar histology107,108. Epige-
netic factors may also be involved109.
Obesity
The relationship between smoking and obesity is
complex and published reports provide conflicting
results110−112. While some studies have shown no
significant association between smoking status and
BMI110, others have suggested that smoking may be
associated with lower BMI111 and smoking cessation
with an increased BMI112. Most individuals believe
that smoking helps weight loss113−115, and fear of
weight gain is often a cause of relapse among former
smokers116. Both smokers and nonsmokers believe
that smoking is an efficient way to control body
weight117. Most scientific studies confirm that lower
adiposity is common among active smokers118,119.
Nicotine acutely increases energy expenditure120 and
may also help reduce appetite121,122. Further, scien-
tific studies find that former smokers have a higher
level of obesity123, mainly due to an increase in BMI
following smoking cessation124−126, thereby validat-
ing the smokers’ bias. However, current smokers
tend to have a higher visceral (abdominal) obesity
than non-smokers127−129. CAT scans reveal higher
levels of visceral adiposity to subcutaneous adipose
tissue ratio in smokers130. Second-hand smoke expo-
sure also increases obesity, with adolescents having
an increased 1.19 odds of obesity than those with
no exposure to secondhand smoke131. In a study
includingmore than 10million participants from 239
prospective studies, all-cause mortality was minimal
for persons with BMI between 20 and 25; however,
each 5-unit increase in BMI above 25 was associated
with a 49%, 38%, and 19% higher risk of mortality,
respectively132. Therefore, there is a concern that

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SHASHI K. AGARWAL, MD

weight gain after smoking cessation could increase
the risk of chronic diseases and potentially attenuate
the benefits of quitting smoking133. However, given
the serious deterioration of health from smoking, the
net effect is still better health outcomes after smoking
cessation134.
Depression
Individuals with mental health conditions smoke
more heavily135 and experience up to 18 years
of reduced life expectancy when compared with
the general population136. This major decrease in
longevity is primarily due to premature mortal-
ity from smoking-related diseases137. Depression is
strongly linked with smoking – and this relation-
ship is bidirectional138. In the National Longitudi-
nal Study of Adolescent Health from the United
States, Goodman and Capitman found that smoking
in adolescents resulted in a higher risk of develop-
ing depressive symptoms139. In an Australian case-
control study, the age-adjusted odds ratio (OR) for
smoking more than 20 cigarettes per day and de-
veloping depression, was 2.18140. In a multinational
study (WHO’s Study on Global Ageing and Adult
Health), the OR for smoking associated with incident
depression was 2.06141. In another study, current
smokers who smokedmore than 20 cigarettes per day
had the highest risk of developing depression142. A
more recent systematic review of 148 studies, also
found a positive association between smoking and
depression143. Another recent large study involving
10,036 individuals (Gutenberg Health Study), found
that current smoking was predictive of new-onset de-
pression, with an OR of 1.35144. Secondhand smoke
also increases the risk of depression, in children145,
adolescents146, and adults147−149. This relationship
is dose dependent150. Depressed people also smoke
more151−154.
It is estimated that in the United Kingdom, up to 31%
of individuals with depression smoke151 while only
14% of the general population does152. Depressed
patients are more likely to increase their smoking
over time153, and those who continue to smoke expe-
rience worse depressive symptoms compared to their
abstinent counterparts154.
Liver Diseases

Smoking is associated with worse outcomes in
patients with NAFLD155,156. They are more apt
to develop liver fibrosis155 and primary biliary
cirrhosis156. Patients with Hepatitis B (HBV) who
smoke increase their risk for hepatocellular cancer
(HCC)157. Smoking is also harmful to individu-
als with hepatitis C (HCV), increasing the risk of
steatosis, fibrosis, and HCC158,159.Tobacco smoking
has been shown to delay wound healing post-liver
transplant160 and to significantly increase vascular
complications in these patients161.
HCC is also more common in smokers162. Lee et al.
calculated that the relative risk ratio was 1.51 for
this increased incidence, after conducting a meta-
analysis of 38 cohort studies and 58 case-control
studies, and after adjusting for HBV infection, HCV
infection, and alcohol consumption163. Smoking also
increases HCC related mortality164. Besides the mul-
titude of carcinogens found in cigarette smoke, one
chemical, 4-Aminobiphenyl, has been specifically
shown to increase the risk of HCC165. Tobacco
smoking has also been implicated in the reduction
of p53, a tumor-suppressing gene and a common
pathway of oncogenesis for many neoplasms166. Al-
cohol is extremely harmful to the liver167. Almost
90% of alcoholics smoke and most of them smoke
at least one pack of cigarettes per day168. Chronic
smokers are also more likely to consume alcohol
in excess169. Smoking is also harmful in patients
needing liver transplantation – a poor lung function
often precludes liver transplantation170. Following
transplantation, smoking increases the risk of de
novo malignancy171, vascular complications172, and
non-graft-associated mortality173.

3 CONCLUSION

Tobacco is highly addictive and extremely harmful.
It increases the risk of developing and worsening the
progression of several non-communicable diseases,
including cardiovascular, respiratory, and liver dis-
eases. It is also detrimentally associated with obesity
and depression. There is no safe level of tobacco
exposure including second-hand and third-hand ex-
posure. Smoking cessation can be achieved and is
associated with alleviation of symptoms, decrease in

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SMOKING AND NON-COMMUNICABLE DISEASES: PART I CARDIOVASCULAR DISEASES,
RESPIRATORY DISEASES, OBESITY, DEPRESSION, LIVER DISEASES
disease progression, a better quality of life, and an
increased life expectancy.
Acknowledgment: None
Funding: None
Conflict of interest: None
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MEERP LTD
SHASHI K. AGARWAL, MD

How to cite this article: Agarwal S.K, MD 
Smoking and Non-Communicable Diseases: 
Part I Car-diovascular Diseases, Respiratory 
Diseases, Obesity, Depression, Liver Diseases. 
Clinical Medicine Insights. 2020;268−283. 
https://doi.org/ 10.52845/CMI/2020-1-1-06

MEERP LTD CMI JOURNAL 1 (1), 34−49 (2020) 49


	Introduction
	Discussion
	Conclusion



