The sixth nationwide epidemiological survey of chronic pancreatitis in Japan: What about tobacco?

Abstract

We enjoyed reading the article from Dr. Morihisa Hirota et al. titled “The sixth nationwide epidemiological survey of chronic pancreatitis in Japan” [Pancreatology 12 (2012) 79–84]. They reported that the incidence and prevalence of chronic pancreatitis (CP) has increased in Japan. The methodology and results investigated causes of CP. In their discussion, an increase of alcohol consumption and improvement of the sensitivity of diagnostic tests are mentioned as factors likely causing this change [1]. Nevertheless, we noticed that there was no mention on the influence of tobacco during the first or second surveys reported in this paper. Over the last decade or so, our awareness has increased on the influence of chemicals in tobacco not only worsening the evolution, but also as an etiologic factor in CP [2,3]. The effects of smoking include exposure to nicotine andmany of the toxins in tar, which can not only cause acute and chronic inflammation in the pancreas independently from alcohol, but also synergistic with alcohol [4]. Rodent studies showed multiple mechanisms of inflammation due to exposure to cigarette smoke leading to aggravation of pancreatic damage in a short period of time after inhalation. They found acinar cell destruction with reorganization of circumscribed areas of exocrine pancreas to connective tissue, reduction of protective anti-protease activity and increased turnover of pancreatic digestive enzymes among other pathogenic mechanisms [5]. Epidemiologic studies performed in Asia reported that up to 75% of patients with alcoholic CP also smoked [6]. It is very encouraging to realize that tobacco use is decreasing in Japan. Many reports indicate that trend in different sectors of society. Adolescents and women, who are most vulnerable, as well as rural population, are among those groups [7-9]. Oncologists, a very influential group have reduced their smoking rate from 9% to 5.3% between 2006 and 2012 [10]. Even with those positive indicators, WHO reports that smoking occurs in 38.2% of adult males and 10% of adult women in Japan in 2010 [11]. This fact contrasts with a very long life expectancy in this country [12] and leads to the discussion of tobacco as a factor in many illnesses, including CP. Based on these considerations, we would like to respectfully suggest to the authors of this article to consider the inclusion of questions about tobacco consumption both first and second hand on future surveys on CP. We hypothesize that tobacco may account for many of the cases with unknown etiology as well as contributing to those from alcohol.