Avoidance of tobacco and smoking cessation represent the best method overcoming disease cases such as cancer, chronic obstructive pulmonary disease (COPD) and chronic heart disease (CHD). These approaches may not be successful for some smokers. It might be due to their attitude or self discipline to stop smoking. Supplementation of vitamins or minerals can be used as an alternative to increase the antioxidant levels and immune system in smokers. In this study, report the effect of a randomized single-blind placebo-controlled trial on the immune response of cigarette smokers after palmvitee supplementation. Supplementation of 200 mg/d palmvitee for 24 weeks to the smokers and nonsmokers increase total plasma vitamin E levels in plasma indicating compliance of the study subjects. When this total vitamin E was separated according to its type –tocopherol and tocotrienol, both were also increased with supplementation. The concentration of tocopherol was higher in plasma as compared to tocotrienol because of the action of hepatic α-tocopherol transfer protein (α-TTP). α-TTP selectively chooses α-tocopherol for enrichment of nascent very low density lipoproteins (VLDL)
. During VLDL catabolism in the circulation, α-tocopherol is transferred to all the other plasma lipoproteins. Although, the dose used in the study was 200 mg/d vitamin E, only 40% of palmvitee is α-tocopherol while 60% consisted of tocotrienols. Whereas tocotrienols are transported and distributed differently in different tissues according to their roles in cellular function
. For example, skin contained 15% tocotrienols and only 1% γ-tocopherol. Although, the accumulation of tocotrienols may be low, but they may exert substantial antioxidant effects
. Studied by Maniam et al. in rats showed that tocotrienol gives better protective effect against free radical damage in the femur compared to alpha-tocopherol. Reported by Saito et al. the uptake of alpha-tocotrienol in Jurkat cells was found to be 2.2 fold higher than alpha-tocopherol after incubation for 72 hours. Also, it was found that the initial rate of cellular uptake of alpha-tocotrienol was 70-fold higher than alpha-tocopherol
There was no significant difference in plasma vitamin E levels for tocopherol and tocotrienol between smokers and nonsmokers was observed. Previous study reported by Wallstrom et al. demonstrated that serum vitamin E levels (α-tocopherol) were similar in smokers vs. nonsmokers and only associated with dietary supplements, not with foods. Whereas when the smokers were grouped according to number of cigarettes smoked per day, it gave different result. Antioxidant vitamin intakes were significantly higher in nonsmokers than in light (1-20 cigarettes/day) and heavy smokers (>20 cigarettes/day)
. Exposure of human plasma in vivo to the gas phase of cigarette smoke will cause degradation of vitamin E
. Fractional disappearance rate of α-tocopherol in smokers were faster, and its half-lives were shorter than in nonsmokers
. This may lead to insufficient levels of vitamin E and was suggested to have an effect on the immune status of these individuals. Meydani et al. showed via a placebo-controlled, double-blind study using healthy elderly individuals for 235 days that after varying the dose of dl-α-tocopherol supplementation, it was found that a dose of 200 mg/d caused the highest percent increase in delayed type hypersensitivity, suggesting that 200 mg/d might be a threshold level for the immunostimulatory effect of vitamin E. It also supported by Lee and Man-Fan
 in supplementing healthy ethnic Chinese men and women with dl-α-tocopherol E (233 mg/d) for 28 days.
Comparison of lymphocyte proliferation measured as stimulation index induction with mitogen PHA and Con A did not show any differences between smokers and nonsmokers were also unaffected by supplementation of palmvitee (Tables
3). But lymphocyte response to the mitogen PHA also seemed to be increased with palmvitee supplementation. This observation differed from that reported by Meydani et al. where only Con A stimulated mitogenic response increased in the vitamin E supplemented group. Reported by Lee and Man-Fan Wan
 supplementation of vitamin E in healthy individual subjects increased lymphocyte proliferation both in the presence and absence of mitogen challenge and also the increasing of immunological subsets. But there was a confounding factor (gender) because hormonal changes play a role in the regulation of the immune response
 Studied by Radhakrishnan et al. in healthy human volunteers supplemented with 200 mg of tocotrienol-rich fraction or alpha-tocopherol showed no changes observed in the production of IL-4 or interferon-γ by Con A-stimulated lymphocytes. In this study, palmvitee supplementation also did not affect T-cell subsets and a similar finding was reported by Meydani et al.. Cigarette smoke is reported to contain many oxidising species
 and smokers incur a high and sustained free radical load. Smokers may need a higher dose of vitamin E than 200 mg/day to overcome the free radical load and increase the immune system. A study using monkeys have shown that a low dose cigarette smoke (human equivalent of 1 pack day) affect the response of spleens cells to either PHA or LPS whereas a heavy dose (human equivalent of 3 pack day) for 4-8 years caused a significant reduction in their natural NK-mediated lytic activity and a decreased response to Con A
. It is possible that the subjects were not heavy smokers to cause any changes to the lymphocytes proliferation activity. Studied by Thatcher et al. showed that at the higher dose of mainstream cigarette smoke (MSC) exposure (600 mg/m3 total suspended particulates (TSP) suppresses the antigen-specific proliferation and cytokine production by T-cell than low dose of MSC (77 mg/m3 TSP).
Difference between smokers and nonsmokers in baseline volumes of certain immune parameters measured were also observed these include higher total white cell counts, CD4+ cells and CD4+/CD8+ in smokers and lower number of natural killer cells. These differences in T-cells populations have also been reported in different studies in different countries. For example, the results obtained by Tollerud et al. have shown that CD4+ T-cells but not in CD8+ T-cells, CD3+ T-cells or CD19+ B-cells were higher in smokers compared to nonsmokers. Other T-cells subsets such as memory and naïve T-cells subpopulations were also increased in smokers
. The reduced NK cell observed in smokers is in agreement with another study by Moszczynski et al.. The reduction of NK cells in smokers correlated with a reduction in immune surveillance against tumors and viral infections
 and maybe a contributing factor to development of malignancy. Studied by Lu et al. in mice showed the consistent finding where that cigarette smoke suppressed NK activation and lead cell transformation and cancer formation. But other several studies reported that there were no changes in NK cells
[46, 47] and no significant differences in NK cell percentage but NK tumoricidal activity was significantly higher. Tanigawa et al. reported an increase in CD4+ cells in smokers compared with nonsmokers which was in agreement with the results obtained in this study. They also reported that the increase in the number of CD4 + CD29+ (helper inducer) T lymphocytes is responsible for the increase in total CD4+ T lymphocytes in smokers. This may be due to continuous local inflammation in the respiratory system induced by chronic smoking. Another possible explanation is that antigenic substances present such as glycoproteins present in some cigarettes may act as an antigen leading to an increase in CD4 + CD29+ T lymphocytes as the tobacco glycoprotein induces the production of interleukin (IL) 1 alpha and IL-1 beta by peripheral blood and adherent cells. Tobacco glycoprotein is a potent immunostimulatory compound that has been isolated from cigarette smoke
 where it has been shown to be antigenic in humans.
The B cells percentage was higher in smokers than nonsmokers and this was also reported by Mili et al. which was attributed to an increase in CD4+ in smokers. It is possible that in this study, CD4+ was induced by tobacco glycoprotein and provided a signal to B cells to produce antibodies. Palmvitee supplementation was found to increase B cells in nonsmokers only. This observation could be due to the immunoenhancing effect of vitamin E which acts by a reducing prostaglandins synthesis and or decreasing free radical formation
. This finding however differed with that of Meydani et al. who reported that vitamin E supplementation had no effect on immunoglobulin levels or levels of T and B cells in healthy elderly subjects. The difference observed could be due to the different age groups of the subjects and it is well established that the immune response is influenced by age. The increment of B cells and CD4+ cell correlated with the higher TWBC in smokers.
A similar pattern was observed when the immune parameters were measured in terms of packed years of exposure rather than cigarettes per day. Tanigawa et al. also reported higher CD4+ lymphocytes in smokers but no differences in CD8+, CD19+ B lymphocytes and CD16+ NK cells. The findings rather of the two parameters were however contrary to our present findings where B lymphocyte was raised while NK cells were decreased. However, Tanigawa et al. reported the results of only 8 male smokers whereas in this study other were 58 smokers which were also age-matched with the nonsmokers. Another studied by Moszczynski et al. who grouped the subjects in terms of less and over 10 years of smoking gave different pattern of result. CD4+, CD8+ and NK cells increased in smoked-group less than 10 years whereas reduced in smoked-group over 10 years. No changes were observed in B lymphocytes. The highly significant (p < 0.001) reduction in NK cells could also explain increased risk to cancer formation due to a decrease in cellular mediated immune protection/surveillance.
It was interesting to note that while supplementation had no effect on the lymphocyte proliferation as well as on total white cells, total lymphocytes, and total T-cells in both smokers and nonsmokers, palmvitee supplementation was observed to cause an increase (p < 0.05) in the number of B-cells in nonsmokers. This was --- betted to the response beneficial effect of palmvitee in enhancing immune response. However, in smokers B-cells numbers were unaffected by supplementation possibly because of the already raised basal values caused by smoking. This is the only immune parameter which was affected by palmvitee supplementation. Other parameter remained low with supplementation, whilst the high CD4+ and lower CD8+ percentage of cells remained unchanged with supplementation. This lack of effect could be due to the dosage used which was only 200 mg/d compared to 800 mg/d as reported by Meydani et al. in his study in the elderly population.
Urinary cotinine/creatinine standardized as μg/mg, a stable metabolite of nicotine, were increased significantly in smokers indicating the active smoking status of subjects compared to nonsmokers
. Obviously when smoking group divided into the number of cigarette smoked per day urinary cotinine increase accordingly to the number of cigarette smoked per day. Also serum α1-antitrypsin was significantly higher in smokers, again indicating the smoking status of these subjects. Elevations in α1-antitrypsin were significantly associated with the impairment of pulmonary function to smoking. Supplementation with palmvitee demonstrated no changes for both CCR and α1-antitrypsin concentration in smokers as compared to the placebo group. It showed that might be there were no interaction between CCR and α1-antitrypsin with palmvitee that can reduced their level in the blood.