





































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

DOI: https://doi.org/10.52845/CMI/2020-1-1-7 
CMI JOURNAL 1 (1), 50−58 (2020) ISSN (O) 2694-4626 

REVIEW ARTICLE

Smoking and Non-communicable diseases. Part II Cancer, Diabetes
Mellitus, Kidney Diseases, Alzheimer’s Disease, Arthritis

Shashi K. Agarwal, MD ∗
 

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

Abstract
Tobacco smoking is responsible for significant global morbidity and
mortality. It has adverse effects on non-smokers exposed to second-
hand and third-hand smoke. E-cigarettes are also harmful to human
health. Smokeless tobacco also contains many toxic substances. Nico-
tine is the common addicting substance in all tobacco concoctions.
Several well done studies confirm that no amount of tobacco exposure is
safe. This second part of themanuscript discusses the deleterious effects
of smoking on five non-communicable diseases, viz., cancer, diabetes
mellitus, chronic kidney disease, Alzheimer’s disease, and arthritis.
Keywords: smoking, non-communicable diseases, cancer, diabetes
mellitus, chronic kidney disease, Alzheimer’s disease, arthritis

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

I t is estimated that over a billion people smoke
globally1. First-hand smoke is the smoke that
enters the smoker’s mouth directly and is

also known as mainstream smoke2. Side-stream
cigarette smoke emanates from the burning ends of a
cigarette. Environmental tobacco smoke or second-
hand smoke is a combination of side-stream smoke
(85%) and the exhaled main-stream smoke (15%)3.
Third-hand smoke is the gas and particulate residue
from tobacco products, including smoked cigarettes,
that cling to surfaces such as skin, hair, clothing,
and furniture4. These pollutants adhere strongly to

these surfaces, are difficult to removewith traditional
cleaning methods, and may persist for minutes to
months.

Supplementary information The online version of 
this article (10.52845/CMI/2020-1-1-7) 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), 50−58 MEERP LTD 50

Open Access Journal

https://doi.org/10.52845/CMI/2021-2-3-13
https://orcid.org/0000-0003-0007-5582
https://creativecommons.org/licenses/by-nc-nd/4.0/
mailto:usacardiologist@gmail.com
https://medicineinsights.info/index.php/cmi/index


MEERP LTD
SHASHI K. AGARWAL, MD

Smoked tobacco includes products like cigarettes, e-
cigarettes andwater pipes5. Smokeless tobacco prod-
ucts include loosely chewed tobacco leaves, tobacco
paste and tobacco-based concoctions such as snus,
naswar, gutka and snuffs6. Cigarette smoke has thou-
sands of gaseous and particulate substances, with
many being toxic and cancer provoking7. Water pipe
smoking is immensely popular in the Middle East
but has now become fashionable globally. Water
pipe (also known as hookah, narghila, argileh, hubble
bubble, goza, and sheesha in different countries)
smoking contains many of the same toxicants as
cigarette smoking.8. Water pipe smoking may result
in the inhalation of 50–100 times the smoke volume
during a single smoking session, when compared
to that inhaled from a single cigarette9. Electronic
cigarettes (e-cigarettes) are battery-powered devices
providing aerosol vapors for inhalation10. These va-
pors are usually produced by heating a liquid that has
propylene glycol and/or vegetable glycerin, nicotine
and flavoring. Though they are significantly lower
in carcinogens and toxins, they still cause harm11.
Smokeless tobacco provides nicotine like cigarettes,
with a slower absorption and still has more than 20
carcinogens12.
Of all the known constituents, nicotine is the ad-
dictive substance in tobacco, smoked or taken in
otherwise13. Toxic compounds in tobacco-derived
smoke are nitrosamines and polycyclic aromatic
hydrocarbons14,15. Other toxic materials found in
both tobacco cigarette/waterpipe smoke and e-
cigarette vapor are volatile organic compounds and
inorganic compounds such as metals and carbon
monoxide. Carbon monoxide is toxic to humans,
even at low concentrations16. E-cigarette liquid usu-
ally contains, propylene glycol, and glycerine, in
addition to nicotine. The inhaled e-cigarette vapor
contains toxic compounds derived from these three
ingredients17. Smokeless tobacco also contain harm-
ful substances like nitrosamines, polycyclic aromatic
hydrocarbons, and aldehydes18. In general, no to-
bacco product is safe.
The estimated economic cost associated with smok-
ing is 1.8% of global gross domestic product. In
2012, the world’s total medical expenditure for
smoking-attributable diseases reached 467 billion
US dollars, accounting for 5.7% of the global health

expenditure. Meanwhile, the total economic cost of
smoking (including medical expenditures and pro-
ductivity losses) in 2012was 1852 billionUS dollars,
accounting for 1.8% of the global gross domestic
product. Almost 40% of the economic cost occurs in
low-income or middle-income countries.

2 DISCUSSION

Noncommunicable diseases (NCDs) are the leading
cause of mortality, killing more than 36 million
people each year, globally19. They are responsible
for 63% of all annual deaths. Developing countries
bear the main brunt of this enormous mortality,
with almost 80% of NCD deaths occurring in low
and middle income countries20. Modifiable behav-
ioral health risk factors such as smoking tobacco,
inadequate vegetable and fruit consumption, high
alcohol consumption, physical inactivity and obesity
increase the risk of NCD morbidity and mortality21.
Tobacco smoking is a major player in this delete-
rious association. NCD diseases discussed in this
manuscript include cancer, diabetes, chronic kidney
diseases, Alzheimer’s disease, and arthritis.
Cancer is the second leading cause of death (after
cardiovascular disease) in 2017, accounting for 17%
of all global deaths31. Cancer related mortality ex-
ceeds that caused by communicable diseases such
as human immunodeficiency virus/acquired immun-
odeficiency syndrome, tuberculosis, and malaria.,
combined31.Cancer prevalence is rising and com-
monly involves the bladder, breast, colon, rectum,
lung, cervix and head and neck22. In 2018, GLOBO-
CAN estimated that 18.1 million people had been
diagnosed with cancer, with 9.6 million people dying
from it, worldwide23.
Diabetes is increasing in prevalence in several devel-
oped and in most developing countries45,46. Accord-
ing to the International Diabetes Federation there
are 451 million adults live with diabetes worldwide
in 2017 and this number is projected to increase to
693 million by 204547. Type 2 diabetes accounts for
90–95% of diabetes cases and is caused by insulin
resistance and progressive loss of β cell function
and mass. Diabetes is associated with an increase in

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SMOKING AND NON-COMMUNICABLE DISEASES. PART II CANCER, DIABETES MELLITUS,
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
mortality from several co-morbid conditions, such
as CVDs, chronic kidney disease, cancer and liver
diseases48. It also increases the risk of infections with
adverse outcomes. Diabetes is solely responsible for
1.5 million deaths worldwide. It also contributes
to an additional 17.5 million deaths each year49.
Type 2 diabetes invariably leads to the development
of several microvascular (retinopathy, nephropa-
thy, and neuropathy) and macrovascular (coronary
artery disease, stroke, peripheral artery disease)
complications24. Deaths from diabetes (DM) have
increased by more than 60% since 2000 and now
rank in the top 10 causes of death25.
The worldwide prevalence of chronic kidney dis-
ease (CKD) is estimated to be 8–16%58. CKD is
associated with a reduction in the glomerular fil-
tration rate (eGFR) <60 ml/min/1.73 m259. There
are usually structural renal abnormalities also noted.
Untreated CKD usually progresses to end-stage re-
nal disease (GFR<15 ml/min), requiring dialysis or
kidney transplant. CKD increases the risk of devel-
oping cardiovascular diseases, mineral and bone dis-
orders, and anemia. Worldwide, a 31.7% increase of
CKD mortality was observed over the last decade60.
Lifestyle factors, including smoking, alcohol, obe-
sity, and physical inactivity have been implicated in
the promotion of CKD.
Chronic kidney disease (CKD) affects over 10%
of the population worldwide. It was ranked 16th
among the leading causes of death in 2016 and is
expected to become the 5th leading cause of death by
204026. Diabetic kidney disease is the leading cause
of CKD27.
Cognition is involved in attention, memory, lan-
guage, orientation, performance, judgment and
problem-solving skills. A decline occurs with age
and is considered normal.Mild cognitive impairment
is a pre-dementia stage. Alzheimer’s disease (AD),
a progressive disease, accounts for 50–70% of
dementia cases66. According to theWHO, 44 million
had AD globally in 2016. This number is on the
increase and is projected to reach 82 million by 2030
and 152 million by 205067.
Alzheimer’s disease and other dementias afflict
nearly 44 million people worldwide28. The annual
healthcare expenditure for AD patients, was $277B

in 2018 and expected to go up to $1100B annually
by 2050.
The two main kinds are osteoarthritis and rheuma-
toid arthritis. Osteoarthritis (OA) is leading cause
of pain and disability among adults all over the
world. It affects almost 1 in 3 people over age 6575.
Osteo-arthritis exhibits cartilage loss while rheuma-
toid arthritis affects the synovial joints resulting in
synovitis, joint erosion, and cartilage damage.
Arthritis is of over 100 types, the most common
being rheumatoid arthritis, osteoarthritis, psoriatic
arthritis and inflammatory arthritis29. These diseases
result in considerable functional disability in the
sufferers, especially with increasing age.
All these diseases are not only non-communicable
but usually chronic. CDC30 defines chronic diseases
as “conditions that last 1 year or more and re-
quire ongoing medical attention or limit activities
of daily living or both.” Noncommunicable diseases
are gradually replacing infectious diseases as the
major health burden in the developing countries.
Deaths from noncommunicable diseases are also on
the rise, globally. As discussed in the previous part of
this 2 part manuscript, smoking is one lifestyle that
plays an important adverse role in the genesis and
progression of these diseases.
Cancer
Smoking is strongly associated with cancer, account-
ing for 19% of all cancer cases32. Tobacco smoke
is full of carcinogens33. Active smoking has been
associated with cancer of lamost every organ of
the human body. It is estimated that smoking ac-
counts for 81.7% of lung cancers, 73.8% of lar-
ynx cancers, 50% of esophageal cancers, 46.9% of
bladder cancers and 28.8% of all cancer deaths32.
Other methods of smoking tobacco, such as water
pipe smoking34. Electronic Nicotine Delivery Sys-
tem (ENDS) smoking35, and Heat-not-Burn (HNB)
smoking36 have also been implicated in increasing
the cancer risk. Second-hand smoke also increases
the risk of cancer37. Smokeless tobacco also poses
a risk, causing cancers of the oral cavity, esoph-
agus, and pancreas38. Smoking after the diagnosis
of cancer demonstrate a poor treatment response
and enhanced treatment-related toxic effects39. They
risk getting recurrrences40 and are more likely to

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SHASHI K. AGARWAL, MD

develop a primary second cancer41, compared to
non-smokers. They are also subject to an increased
mortality42. This mortality risk is reduced by 30%
to 40% with smoking cessation43. Overall, smok-
ing cessation after cancer diagnosis may have ben-
efits that equal or exceed those achieved by can-
cer treatments44. Smoking cessation is difficult with
almost 80% of smokers relapsing within the first
month of abstinence, and only about 5% achieve
long-term abstinence.
Diabetes Mellitus
Any kind of tobacco smoke exposure increase the
risk of Type 2 diabetes50. It is estimated that 11.7%
of diabetes cases among men and 2.4% of diabetes
cases among women are probably connected with
active smoking51. This association appears to be
dose-response related. In 2014, the Surgen General
reported that active smoking increases the risk of
T2D by 30–40% in active smokers compared to
non-smokers52. In a meta-analysis of 88 prospective
studies of almost 6 million participants, Pan and
group found that passive smoking was associated
with a 22% increased risk of incident type 2 diabetes
in never smokers compared to never smokers not ex-
posed to passive smoke51. Alternate tobacco smok-
ing methods and smokeless tobacco products also
appear to impact diabetes development53. Smoking
during pregnancy increases the risk of gestational
diabetes mellitus54 and may also increase the risk
of future diabetes in the offspring55. Infants exposed
to secondhand cigarette smoke also experience an
increased risk for T2D development.
Active smoking has been associated with reduced
appetite and weight loss. On the other hand, smoking
cessation is often associated with weight gain. Sev-
eral studies reported that diabetes risk was increased
in individuals who had recently quit smoking, raising
a concern about elevated diabetes risk with smok-
ing cessation56. This phenomenon occurs more fre-
quently during the first 3 years post-cessation and
appears to be related to an increase in body weight
upon withdrawal of nicotine56.
Smoking appears to acutely worsen glucose toler-
ance, alter peripheral insulin signally and impair beta
cell function57.
Chronic Kidney Disease

In an analysis of 15 prospective cohort studies
involving 65,064 incident CKD cases, Xia et al.
found an increased risk of CKD in smokers vs
nonsmoker61. Smoking enhances its progression62.
It is also associated with a higher incidence of death
from end-stage renal disease (ESRD) in both males
and females63. Smoking cessation reduces the risk of
incident CKD64.
Smoking is an independent risk factor for the de-
velopment of CKD. Previous studies have demon-
strated that nicotine causes tubule-interstitial injury
and plays a central role in smoking-mediated renal
dysfunction65.
Alzheimer’s Disease
Smoking has been linked to increased cognitive
decline Several studies reported that smokers were
1.9–4.3 times more likely to develop AD than non-
smokers68. Nicotine has short-term enhancing ef-
fects, and this may help explain the high rate of
smoking in individuals with psychiatric disorders
and the difficulty in quitting in this population69.
However, in the long run smoking harms cognitive
function and may lead to the development of neu-
rodegenerative disorders including AD70. Second-
hand smoke is also harmful to cognition with an
increase in cognitive impairment of 24% noted in
older adults with such an exposure71. Smoking dur-
ing pregnancy can harm fetal brain development,
while cigarette smoking at an earlier age is associated
with future cognitive impairment72.
Smoking in AD patients is associated with ox-
idative stress, neuroinflammation, and impaired
neuroprotection73. Structural abnormalities such as
a thinner anterior cingulum and prefrontal lobe have
also been noted in these patients74.
Arthritis
Smoking is a risk factor in knee and hip OA, caus-
ing an increased proliferation of chondrocytes76. It
increases pain and cartilage loss in these patients.
However, ameta-analysis of 48 observational studies
and data from the 5th KNHANES study of individ-
uals over the age of 50 suggest the smoking and
osteoarthritis may not be significantly associated77.
Some studies have shown that CS intensity and
duration are causally related to the risk of RA

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SMOKING AND NON-COMMUNICABLE DISEASES. PART II CANCER, DIABETES MELLITUS,
KIDNEY DISEASES, ALZHEIMER’S DISEASE, ARTHRITIS
development78. This increased risk appears to persist
even after CS cessation

3 CONCLUSION

Tobacco use, especially cigarette smoking, is an
important cause of global morbidity and mortality.
Tobacco consumption in any form harms nearly ev-
ery organ of the human body. It is adversely involved
in the genesis and progression of all major non-
communicable chronic diseases. Smoking remains
the leading preventable cause of death in the world.
No amount of exposure to tobacco is safe. Absti-
nence from smoking is therefore an important step
in the prevention and management of the world’s
deadliest non-communicable diseases.
Acknowledgement: None
Funding: None
Conflict of interest: None
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How to cite this article: Agarwal S.K, MD Smok-
ing and Non-communicable diseases. Part II 
Cancer, Diabetes Mellitus, Kidney Dis-eases, 
Alzheimer’s Disease, Arthritis. Clinical Medicine 
Insights. 2020; 34−42. https://doi.org/10.5284 5/
CMI/2020-1-1-7

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	Introduction
	Discussion
	Conclusion



