Smoking and BMI as a risk factor of cardiovascular disease at a doctors in Tuzla canton

Introduction: Cardiovascular diseases are becoming the leading social and medical problem of civilization, given the trend indicates an increase of morbidity, disability and mortality from this diseases. The aim of our study was to determine the frequency of smoking and increased BMI, as a risk factor for cardiovascular disease in doctors in the Tuzla Canton and correlate values of BMI by the doctor smokers and nonsmokers. Methods: The study was conducted in 13 medical centers in the area of Tuzla canton in the second quarter of 2009. Two groups were formed by randomization of 150 doctors non-smokers and 150 doctors smokers from a total of 366 doctors of both sexes, age over 25 years. The study involved doctors who smoke tobacco 5 or more years. The methods of anthropometric measurements and questionnaires were used in study. Results: The results showed that the total number of doctors surveyed, 44.81% were smokers, with more women smokers (28.7%) than men (21.3%) smokers (p=0.011). We found that there is a signifi cant statistical difference between subjects with BMI higher than 25 and subjects with normal weight, in the group of smokers (p = 0.0001). Conclusion: It can be concluded that the frequency of smoking in the total number of surveyed doctors, is signifi cant. The increased value of BMI (over 25) is present in large number of subjects (with the larger percentage subjects of smokers). © 2012 All rights reserved


Introduction
Chronic non-infectious diseases, including the cardiovascular and cerebrovascular diseases are the leading cause of morbidity and mortality, in addition to cancer (1).Th ey are a signifi cant cause of invalidity, loss of working ability, early death (before 65 years of age) and increasing health care costs, especially in countries where a high percentage of the population is represented by older people (2).For these the trend of increasing morbidity, mortality and invalidity from diseases of circulatory system, it is clear that these diseases are becoming major public health problem of civilization.According to the World Health Organization, cardiovascular diseases cause 16.7 million deaths annually (29% of all deaths), more than one third of cardiovascular deaths happens in persons of middle age (3).According to the reports of the Public Health Federation (4), in Bosnia and Herzegovina rates of mortality and morbidity of cardiovascular disease is rapidly growing from 60' of last century, and the indicators for year 2004 and 2005 show that in Bosnia and Herzegovina mortality rate from cardiovascular disease dominates about 50% of all causes of death and in women and men.During the 2008 diseases of circulatory system in Tuzla Canton, participate with 53.5% of total mortality.Th e mortality rate because of circulatory diseases in 2008 was 80.55 / 100.000 population younger than 65 years.Leading disease population of Tuzla Canton during 2002 to 2008 was headed the chronic non-infectious diseases, among which the fi rst are cardiovascular diseases (5).Harming eff ects of smoking for cardiovascular disease depends on the quantity of cigarettes smoked per day and duration of smoking habit (6).Th e risk for cardiovascular disease is higher if the start smoking before the age of 15.More cohort studies shows that smokers have two to three times higher risk for cardiovascular disease than non-smokers (7).Stopping smoking reduces the risk of cardiovascular disease by about 50% per year, and equal to the risk of nonsmokers aft er 5-15 years (8).From 50th to 90th year's 19th century in many European countries, the rate (%) doctors of smokers is constantly decreased (9).Fift ies of the 19th century in the U.S. is 55% of doctors smoked, while in 1993 rate doctors of smokers was only 5% (10).In England, since 1951th to 1994th rate doctors of smokers dropped from 68% to 7% (11).Northern European countries is characterized low frequency of smoking among doctors, on average 7-23% men and 3-15% women doctors of smokers, while the values in the general population ranged between 30-45%.Countries of Central Europe was characterized rate doctors of smokers some higher (20-28% men and 16-25% women), while the countries of eastern and north-eastern Europe have had even greater rate doctors of smokers, almost as general population (30-54% of men and 40% of women doctors smokers) (9).Masironi and Arciti (12) have showed, in studies, that 80-85% doctors who do not smoke or have stopped smoking, always give anti smoking advice to patients, while less than 50% doctors who smoke also, give advice.Overweight is one of the biggest public health problem in the 21 century, especially in some parts of the world, including the European Region of the World Health Organization.Th e risk of disease in all segments of the population increases progressively with increasing body mass index (BMI).Since the 1980, prevalence of obesity has increased in many European countries more than three times (13).Obesity is no more a problem only of the developed countries, it was become an increasing problem in developing countries.It is estimated that today the world's 1.1 billion adults and 10% of children have an increased body weight (14).Increased BMI is connected with increased risk of coronary heart disease (15) and hypertension (16).Aim of the study is determine frequency smoking among doctors in Tuzla Canton, and to determine the frequency of increased BMI as a risk factor of cardiovascular disease in smokers and nonsmokers doctors.

Methods
Th e research was conducted in 13 health centers in Tuzla Canton in second quarter of 2009.From a total of 366 doctors of both sexes, aged over 25 years, method of free chose formed group from 150 doctors smokers and 150 doctors nonsmokers.In the study involved doctors who smoke tobacco 5 years and over, every day a certain number of cigarettes (at least 10 cigarettes a day), and excluded doctors who smoke tobacco occasionally, every second or third day, two to three cigarettes.Th e research was a prospective, cross-sectional.Risk factors were evaluated: smoking and overweight -obesity.It was processed with questionnaire and anthropometric measurements.Data on risk factors were obtained by the survey.A modifi ed questionnaire referred in part to general directories, and second part consisted of general information, general relation for smoking, smoking duration, number of cigarettes smoked per day (17,18).Body height (cm) was measured by anthropometry, three times and was calculated as the mean value.Body weight (kg) was measured by the decimal scale (100 grams of tolerance), which calibrated before the measurement.Th e measurement was done with minimum clothes, three times and calculated the mean value.Body mass index (BMI) was calculated based on the relation measured body mass (kg) and body height (cm), as follows: BMI = BW (kg) / TV (m) 2, whereby as the increased body weight taken BMI value equal to or greater than 25.0 according to the World Health Organization.Aft er the survey, made is appropriate encryption and controls to ensure proper data entry.Data were entered into the table in Excel, and then transported into the statistical soft ware package SPSS17.0.where the aft er defi nition of the variables were statistically processed data, and with the help program Arcus QuickStat completed.For testing the statistical signifi cance between groups, we used proportions, Chi square test, Student's t-test.Statistically signifi cant results we considered those in which the p <0.05.

Results
Of the total number of surveyed doctors (366) them 202 or 55.19% were non-smokers, and 164 or 44.81% were smokers, a sta-tistically signifi cant diff erence (p = 0.005).Method of random choice formed group from 150 doctors smokers and 150 doctors nonsmokers.In the sample from 150 smokers, was 86 or 28.7% women of smokers and 64 or 21.3% men of smokers, as shown in Table 1.Th e total number of observed subjects most of them in the age group between 46 and 55 years (98 or 32.7%), while the smallest number in the age group over 65 years (5 or 1.7%).Th e highest number doctors of smokers in the age group between 36 and 45, it is 49 or 16.3% of all respondents doctors of smokers, a statistically signifi cant diff erence compared to nonsmokers of the same age group (p = 0.0001) (Table 2) .Th e mean age of smokers is about 42 (+ -9) years.Th e youngest doctor is a smoker aged 25 years and the oldest 73 years.Th e total number subjects of smokers largest number of them is a smoker for 20 years and over, in the age group between 46 and 55 years (19 or 12.7%), while at the same age group of 3 or 2% smoked 5 years.Of the total number of smokers, 37 subjects or 24.7% is a smoker 10 years and 33 or 22% is smoke 20 or more years, no statistically signifi cant diff erence (p = 0.58).Th e total number subjects of smokers most of them women with smoking period of 10 years (30 or 20%), and the smallest number of men with smoking period of 10 years (7 or 4.7%), a statistically signifi cant diff erence (p = 0.0001).Of the total number women who smoke 20 or more years, 19    Mean values of BMI in both groups of patients were higher, but the test of signifi cance showed that there was no signifi cant diff erence among the groups.Correlating groups subjects of smokers and nonsmokers in relation to the value of BMI showed the existence of minor correlation (pc = 0.084).

Discussion
Analyzing, in our study, the frequency of smoking and increased BMI values as risk factors for cardiovascular disease in 366 doctors in primary care, both sexes, aged over 25 years, we have found that smoking among doctors is present in a significant percentage (44.81%).By Masironu ( 9) from 50's to 90's of the 19th century in many European countries, the rate (%) doctors of smokers has constantly decreased.In the study group of health workers in the department of pediatrics, gynecology, community health services, and home treatment in Belgrade, smokers were more than in the our study (58.5%), and 23% nonsmokers (19).In the total investigated sample of smokers in our study, it was found that there are more women smokers (28.7%) than men (21.3%) smokers (p = 0.011), the larger the percentage of survey frequency of smoking in late last century in the northern countries of Europe (9).In this study characterized the low frequency of smoking among doctors, an average of 7-23% men and 3-15% women doctors of smokers, while the values in the general population ranged between 30-45%.By the same study, the countries of Central Europe is characterized by the rate doctors of smokers slightly higher (20-28% men and women 16-25%), which is close to our study, while the countries of eastern and north-eastern Europe have had higher rate doctors of smokers, which is greater than our study and was 30-54% men and 40% women doctors of smokers.According to statistical data British Heart Foundation (20) in England in 2004 were 26% men and 23% of women aged 16 years and over who  smoke cigarettes, which is also similar to our results.Testing that was done in Croatia, in the general population group, it was found that smoking is more frequent among men than in women, which is diff erent from our study where a larger percentage of smokers among women (21).Results of our study confi rm that most patients who smoke, with smoking period of 10 years (24.7%),including more women than men, less is subjects with smoking period of 20 years and over (20 %).From the aspect of the amount of cigarettes smoked per day, we found that most subjects smokers (42%) smoked 10 cigarettes a day, signifi cantly more women, slightly less (38%) smoked 20 cigarettes a day, and 1.3% of those smoking 40 or more cigarettes a day , which is worrying from the aspect unwanted eff ects on cardiovascular disease, which depends on the amount of cigarettes and smoking period, as showed De Backe et al ( 6) Manson and colleagues (22).Among subjects who smoked 20 cigarettes a day slightly leading men than women, which was not statistically signifi cant diff erence (p = 0.85), and is risk of negative eff ects is present for both population groups.Our study shows that the largest number of smokers in the older age group between 36 and 45 years, which is diff erent from research Kovacic and colleagues (21) which was carried in Croatia in which smoking is most common in the younger age group between 18 and 25 years.
Results of ATTICA study, conducted in Greece, confi rmed earlier research that obesity is connected with various cardiovascular risk factors such as diabetes, hypertension and hipercholesteronemia (23), and we have the purpose of estimating potential risk to our subjects wanted to look and value BMI.In our study, the increased values of BMI (over 25) are present in a signifi cant number subjects (56.7%).In the study in Slovenia, Zaletel-Kragelj and Fras (24) showed that among the subjects was 40.1% overweight and 38.5% were normal weight, which is slightly smaller than our results.Increased levels of BMI in the subjects were smokers in the percentage of 30% and in nonsmokers 26.7%, which is not a signifi cant diff erence between groups.Th ere was no connection between the frequency of obesity-BMI (CHI2 = 0.86, p = 0.35) in the investigated group.Values of BMI over 30, in our study had 13% subjects, which is less than the research was conducted in Croatia by Heim and colleagues (25).In their study showed that in the adult population has more than 1/5 subjects in whom there a BMI over 30.In our study the subjects of smokers was measured by higher BMI values in the range of 25-30, in the highest percentage (22.3%),while the value the subjects of nonsmokers the BMI range of 25-30 is similar, with slightly smaller percentage (21.3%).
Th is diff ers from large epidemiological studies that show an inverse relationship between smoking and body mass -smokers are less heavy than nonsmokers (26).From study conducted in Slovenia, it is clear that among smokers less obesity than nonsmokers.Th is diff erence is statistically signifi cant (27), which diff ers from the results of our research.In this research found that there is a signifi cant statistical diff erence among to subjects with higher BMI and those who had a BMI lower than 25, in the group of smokers (p = 0.0001).While in the group nonsmokers we no found statistically signifi cant diff erence among to subjects with higher BMI and less than 25 (p = 0.0781).Towards WHO data in Europe have obesity 1/3 of adults.Th e average BMI is 26.5, while the index in Croatia in 2003.totaled 29.9 (25), and in our study the mean BMI is 26.3 in the group of smokers and 25.6 in the group nonsmokers.Primary prevention and early detection of risk factors for cardiovascular diseases and their control are essential.Health workers need to, not only quit smoking, than to be a major health educators, obliged to actively publish the risk of harmful eff ects of smoking and other risk factors, and to transfer knowledge about keeping and improving health, still from the earliest youth.

Conclusions
Th is study has shown that the frequency of smoking in the total number of surveyed doctors (N = 366) present in a signifi cant percentage.Smoking is frequently in women than in men, the majority of doctors smokers in the age group of 36-55 years.Increased levels of BMI (over 25) are present in a signifi cant number subjects of both groups (56.7%), of which in most percentage of subjects smokers.In relation to BMI in the group of smokers there is a signifi cant statistical diff erence between those who have an increased BMI and a satisfactory weight.Th ere was no con-nection between the frequency of obesity-BMI (CHI2 = 0.86, p = 0.35) in the investigated group.

Confl ict of interest
Authors declare no confl ict of interest.

TABLE 1 .
The gender structure of subjects in the sample of smokers and nonsmokers

TABLE 3 .
Distribution of cigarettes smoked per day by sex subjects

TABLE 2 .
Age structure in a sample of smokers and nonsmokers

TABLE 4 .
BMI values of doctors smokers and doctors of non-smokers (According to WHO BMI over25 = obesity)