Epidemiologic Notes and Reports Illnesses Possibly Associated with Smoking Clove Cigarettes

Between March 1984 and May 1985, 12 cases of severe illnesses possibly associated with smoking clove cigarettes were reported to CDC. Signs and symptoms reported in the 11 hospitalized patients included pulmonary edema, bronchospasm, and hemoptysis. Milder symptoms reported with clove cigarette use included nausea and vomiting, angina, increased incidence of respiratory tract infections, exacerbations of chronic bronchitis, increased incidence and severity of asthma attacks, dyspnea, chronic cough, and epistaxis. Blood-streaked sputum and mild hemoptysis have been reported with particular frequency. Following are two examples of reported severe illnesses possibly resulting from smoking clove cigarettes.

Case 1: On August 4, 1984, a 19-year-old white male athlete was admitted to a California hospital after the sudden onset of acute respiratory distress. Three weeks before he was admitted, he had noted 7-10 days of cough and yellow sputum, but he had been feeling well for the week before admission. On the night before admission, he smoked two clove cigarettes and fell asleep for 3 hours. He awoke short of breath and noted a fever to 39.3C (102.8 F). Fourteen hours later, he was admitted to the hospital in acute respiratory distress, with a pulse of 144/minute, respiratory rate of 48/minute, temperature of 39.3 C (100.8 F), and blood pressure of 138/74). Chest examination revealed a few scattered rhonchi and basilar rales, diminished breath sounds at the lung bases, and no dullness to percussion. A chest roentgenogram showed diffuse interstitial pulmonary edema with a small amount of pleural fluid. His room air arterial pO((2)) was 56 mm Hg. His white blood count (WBC) was 21,500/cm((2)), with 88% neutrophils, 10% bands, 1% lymphocytes, and 1% monocytes. Blood and sputum cultures were negative. He responded rapidly to intravenous corticosteroids, diuretics, and bronchodilators. No antibiotics were given. He was discharged 2 days later with a near-normal chest roentgenogram and no apparent sequelae. He had previously smoked clove cigarettes without adverse consequences.

Case 2: On December 6, 1984, a 16-year-old black Ethiopian male living in the United States for the past 12 years was admitted to a California hospital. He had been in good health until the night before admission, when he developed symptoms of an upper respiratory tract infection, fever, and nonproductive cough. The next day, he noted increasing dyspnea, nausea, and vomiting. By early evening, he was admitted to the hospital in severe respiratory distress, with a pulse of 124/minute, respiratory rate of 40/minute; and temperature of 38.1 C (100.6 F). Chest examination revealed rare rhonchi but no rales or wheezing. Chest roentgenogram showed bilateral diffuse interstitial infiltrates without pleural effusions. His room air arterial pO((2)) was 47 mm Hg. His WBC was 30,200/cm((2)), with 91% neutrophils, 6% bands, 2% lymphocytes, and 2% monocytes. Blood and sputum cultures were negative. He was first treated with broad-spectrum antibiotics for presumed infectious pneumonia of unknown etiology. Bilateral pleural effusions developed over the ensuing 2 days, and diagnostic thoracentesis showed an exudative pleural fluid with a protein of 5.2 g/dl. The same day, it became known that he had smoked clove cigarettes the night before being hospitalized. Antibiotics were discontinued, and a course of intravenous corticosteroids was begun. He continued to improve and was discharged without sequelae. Both the pulmonary and infectious disease consultants believed the clinical course and laboratory findings were most consistent with a toxic rather than an infectious process. Reported by FG Schechter, MD, Presbyterian Intercommunity Hospital, Whittier, P Hackett, MD, Q Rodriguez, MD, Northern Inyo Hospital, Bishop, AD Dauer, MD, NA Sagle, MD, University of Southern California, DK Houston, MD, LW Wilson, MD, Brotman Hospital, Los Angeles, JA Kerley, MD, B Sanger, MD, Coronado Hospital, Coronado, HM Lee, MD, WT Nishigaya, MD, Humana Hospital, West Anaheim, RE Perez, MD, University of California at Irvine, Orange, JW Stratton, MD, Epidemiological Studies Section, California Dept of Health Svcs; TL Guidotti, MD, University of Alberta, Edmonton, Alberta, Canada; G Churchill, MD, Wayne State University, Detroit, Michigan; M Tafeen, MD, Plantation Pediatric Group, Plantation, SH King, MD, JJ Sacks, MD, Acting State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs; Div of Field Svcs, Epidemiology Program Office, Special Studies Br, Chronic Diseases Div, Center for Environmental Health, CDC.

Editorial Note

Editorial Note: The passive reporting system through which these reports were received is useful for detecting rare and serious adverse effects occurring shortly after exposure to a possibly toxic substance, but it is not possible to establish the exact incidence or an etiologic relationship. In evaluating the relationship between common exposures and uncommon outcomes, clinicians and public health officials must maintain a high index of suspicion. With clove cigarettes, there is a disturbing pattern in the anecdotal reports of pulmonary illness in previously healthy young adults, temporally linked to clove cigarette smoking. This is especially true, since hemoptysis and pulmonary edema are biologically plausible effects of smoking clove cigarettes. Further toxicologic and epidemiologic data are needed to clarify the acute health effects, if any, of clove cigarettes in humans.

Since 1968, clove cigarettes have been imported into the United States from Indonesia. Sales in the United States have increased from 12 million in calendar year 1980 to 150 million in fiscal year 1984 (1). The cigarettes are sold throughout the United States. The majority of persons buying the cigarettes are between the ages of 17 and 30 years (2).

Clove cigarettes contain about 60%-70% tobacco and 30%-40% cloves. Exposure to tar, nicotine, and carbon monoxide is higher from clove cigarettes than from regular American cigarettes. In smoking machine tests, clove cigarettes averaged over twice as much tar, nicotine, and carbon monoxide delivery as moderate tar-containing American cigarettes (3). Also, in the United States, clove cigarette smoke is inhaled deeply and retained in the lungs.

Eugenol--the major active ingredient in cloves--has been used as a topical dental anesthetic for years. Although eugenol has caused dermal and mucosal hypersensitivity reactions in dental patients and occupationally exposed health-care workers (2), pulmonary toxicity has not been reported. Pharmacologic effects associated with eugenol include topical anesthesia, diminished smooth muscle activity, anticonvulsant activity, and cyclooxygenase inhibition. Although eugenol has not been shown to be mutagenic in the Ames assay or carcinogenic in laboratory animals, some of its metabolites are mutagenic.

Although a cause-and-effect relationship between clove cigarette smoking and the illnesses described in these patients is not proven, inhaling clove cigarette smoke may produce severe lung injury in a limited number of susceptible persons. Prodromal respiratory tract infections reported by persons who have become severely ill after smoking the cigarettes may contribute to the development of severe illness or may reflect repeated aspirations into an airway anesthetized by eugenol in clove cigarette smoke.

In addition to adverse health effects that may result from inhaled eugenol and pyrolyzed cloves, use of clove cigarettes may be changing the smoking patterns of American teenagers. Some researchers have suggested that eugenol, which is present in substantial quantities in clove cigarette smoke (4), anesthetizes the backs of smokers' throats and tracheas, permitting deeper inhalation and possibly encouraging smoking in persons who might otherwise be dissuaded by the harshness of regular cigarettes. Whether the higher tar and nicotine content of clove cigarettes leads clove cigarette smokers to smoke higher tar American cigarettes is unknown (2).

In Indonesia, clove cigarettes are smoked by most adult males (5); health effects have not been systematically studied. In the United States, despite publicity in the popular press and an apparently large number of smokers, relatively few cases of severe illness linked to clove cigarettes have been reported.

Cloves are only one of hundreds of ingredients currently being added to cigarettes to manipulate cigarette flavor, aroma, and burning quality. The inhalation toxicology of cigarette additives has been infrequently studied.

In April 1985, New Mexico outlawed sales of clove cigarettes; Michigan has introduced legislation to ban clove cigarettes.

Additional cases of illness possibly associated with smoking clove cigarettes should be reported to CDC through state and local health departments.

References

1. Bruce M, Bureau of Alcohol, Tobacco and Firearms, U.S. Department of the Treasury. Personal communication based on census data for imports for consumption.

2. Guidotti, TL. Possible risks to health associated with clove cigarettes. Chronic Diseases in Canada (in press).

3. White SK, Henderson GM, Jenkins RA. Selected constituents in the

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