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SPECIAL SECTION: TOBACCO CONTROL
CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1324
Cecily S. Ray and Prakash C. Gupta are in the Healis–Sekhsaria Insti-
tute for Public Health, Belapur, Navi Mumbai 400 614, India.
*For correspondence. (e-mail: raycs@healis.org)
GENERAL ARTICLE
Bidis and smokeless tobacco
Cecily S. Ray* and Prakash C. Gupta
Bidis and smokeless tobacco are the cheapest, least taxed and most commonly used tobacco prod-
ucts in India. They are highly addictive and high in carcinogens. They cause a broad spectrum of
diseases; yet awareness about their ill-effects is low. Smokeless tobacco products containing are-
canut, e.g. gutka and mawa, are especially addictive and carcinogenic. The high incidences of oral
and lung cancers in India are mainly due to bidis and smokeless tobacco. Bidis bear no health
warnings, and smokeless products, only warnings in English in small print. The public favours
tobacco control policies and the Government tries to impose them, but the industry delays such
implementation. This article highlights the widespread use of bidis and smokeless tobacco in India,
reviews their harmful effects, documents public support for tobacco control policies, and provides
scientific evidence for the implementation of these policies.
Keywords: Bidi, disease consequences, gutka, tobacco use, youth.
Use of bidis and smokeless tobacco in India
Whereas in most countries cigarettes are the main form of
tobacco used, in India only less than one-fifth (19%) of
tobacco consumed (by weight) is in the form of cigarettes1.
The prevalence of cigarette smoking is also low: an analysis
of the National Sample Survey 55th Round (1999–2000)
showed that less than one-tenth of urban and less than 4%
of rural households consume cigarettes (Table 1)2.
On the other hand, over half of all tobacco consumed
in India is smoked as bidis (54%) and about one-fourth of
tobacco consumption is in smokeless form (nearly 27%)1.
In the country as a whole, 7–8 times more bidis are sold
than cigarettes3. The National Sample Survey of 1999–
2000 showed2 that:
(i) Bidis are smoked by at least one member of each
household in:
• Over one-third of households in rural areas.
• One-fifth of households in urban areas.
(ii) Smokeless tobacco is used by at least one member
of each household in:
• Almost one-third of households in rural areas.
• Almost one-sixth of households in urban areas.
It had been estimated in India that over a 100 million
people smoke bidis, about 25 million smoke cigarettes,
and the number of smokeless tobacco users is fairly close
to the total number of smokers1,4.
In the whole of India, one-third (33.3%) of the men and
1.6% of women aged 15–49 yrs smoke, while smokeless
tobacco use is found among more than one-third
(38.1%) of the men and around one-tenth (9.9% of the
women), according to the third round of the National
Family Health Survey (NFHS-3), conducted in 2005–06
(Figure 1)5.
In the NFHS-2 (1998–99), the states with the highest
prevalence of smokeless tobacco use among women of
reproductive age were Orissa (34.9%), the North East
States (16.5–60.7%), Maharashtra (18.5%), Karnataka
(14.9%) and Madhya Pradesh (14.8%), while the national
prevalence for women6 was 12.4%.
The question on smokeless tobacco in the NFHS-3
questionnaire also asked about the use of pan masala, an
arecanut product, some brands of which contain tobacco.
Pan masala is not supposed to contain tobacco, but is
generally sold with the same brand names and nearly
identical packaging as its counterpart containing tobacco
(labelled as gutka or mawa). The advertisement of these
plain pan masalas on television is surrogate advertising
for gutka, since the packaging looks the same and the
cost of these advertisements is much higher than that of
the sales of plain pan masala (nearly four times the sales
value). The sales of gutka (over Rs 160 crores for one
company in 2003–04) well exceed the cost of the adver-
tisements (over 6½ times7).
In a large survey in Uttar Pradesh, 10.6% of urban
and 7.9% of rural males (≥10 years) reported using
gutka or pan masala (80% of users <40 years), but
fewer than 4% of these used pan masala without
tobacco7.
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CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009 1325
Table 1. Proportion of households consuming tobacco products in India
Tobacco product Rural (%) Urban (%)
Bidis 36.5 19.8
Smokeless tobacco (tobacco leaf, snuff, chewing tobacco, others) 30.7 15.0
Cigarettes 3.7 9.6
Other smoking tobacco (hookah tobacco, cheroot) 3.6 1.0
None 37.4 60.3
Extracted from John2 (computed from the National Sample Survey (NSS-55th), 1999–2000).
Figure 1. Prevalence of tobacco use in India, National Family Health
Survey-3 (2005–06)5.
While gutka continues to gain in popularity, unproc-
essed tobacco leaf is actually the most widely used form
of smokeless tobacco. As many as 19.4% of rural and
7.4% of urban households consume leaf tobacco2.
Adolescent tobacco use
Recent surveys on the prevalence of tobacco use among
adolescent students in India have measured bidi smoking
and smokeless tobacco use. These included a cross-
sectional study of sixth and eighth grade students in Delhi
and Chennai8. Two rounds of the nationwide Global
Youth Tobacco Survey (GYTS) on students in grades
8–10 were conducted in India during 2003 and 2006 re-
spectively9,10.
According to the GYTS of 2006, 7.2% (95% Confi-
dence Interval (CI): 6.0–8.6) students in grades 8–10
smoked tobacco in some form. Among these, 3.5% had
smoked bidis on one or more days in the past 30 days10.
Box 1 provides additional facts about adolescent bidi
smoking.
In the GYTS of 2006, current smokeless tobacco use
(8.1%) was not significantly different from overall smok-
ing (7.2%)10. Additional facts about smokeless tobacco
use by adolescents in India8,10,11 are given in Box 2. The
higher prevalence of smokeless tobacco use reported in
the round conducted in 2000–04 was higher, 14.6%
(13.1–16.1). It may be pointed out that in the earlier sur-
vey two states with low prevalence of smokeless tobacco
use (Kerala and Kashmir) were excluded6,12.
It is important to remember that tobacco use tends to
start early and is higher among non-student youth, such
as child labourers and street children. Since GYTS is
restricted to school-going children, such children are
excluded by design. These children are difficult to reach
even with household-based surveys.
Increasing tobacco use among youth due to
advertising
Even before the Cigarettes and Other Tobacco Products
(Prohibition of advertisement, and regulation of trade and
commerce, production, supply and distribution) Act, 2003
(COTPA)13 was notified in February 2004, surveys of
adolescent students in Mumbai (Maharashtra) and Anand
(Gujarat) indicated that surrogate advertising on televi-
sion for gutka with pan-masala brands was a major source
of information for them. It was found that noticing adverti-
sing was associated with increased gutka use14. In Punjab,
two-thirds of 100 adolescent school children studying in
the grades 6–10 in five villages reported using gutka
regularly, and one-third said they had been introduced to
the product through advertisements (on television, in
magazines and painted on buses)15.
After 1 May 2004, when the ban on tobacco advertis-
ing in all media went into force, direct advertising on
billboards was replaced by colourful point-of-sale adver-
tisements using brand names and logos, mostly for ciga-
rettes, but also for some smokeless tobacco products.
Indirect advertising also became important, with pan
masala advertising replacing gutka advertisements every-
where16. The packaging and branding of pan masala con-
tinued to be mostly identical to those of gutka or mawa,
then as now. Colourful strips of both these products hang
like banners at the points of sale. As in the case of direct
gutka advertising influencing youth earlier, it is likely
that the point of sale displays as well as indirect advertis-
ing in the media continue to influence them.
Children in grade 6 may be using tobacco at higher
rates than those in grade 8, according to a bi-centric study
in Delhi and Chennai conducted in the summer of 2004.
Ever use of tobacco was 24.8% among sixth graders (com-
pared to 9.3% among eighth graders). Ever chewing
was 19.0 and 6.8% among sixth and eighth graders
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respectively. Prevalence of ever smoking bidis was 11.9%
among sixth graders and 3.4% among eighth graders. Stu-
dents in grade 6 scored lower on all the 15 psycho-social
predictor variables measured (P < 0.01), including beliefs
about health effects, social effects and normative beliefs,
indicating they were at increased risk. In this study, expo-
sure to tobacco advertising was related to increased
tobacco use among students in the sixth grade, but not
among the eighth graders. The report offered a possible
explanation, based on the lack of awareness among the
sixth graders: ‘ . . . it may be that the 6th graders were
more receptive to the messages contained in recent
tobacco advertising campaigns, and thus more susceptible
to experimentation and regular use as a by-product of
exposure and their “risk profile” ’17.
A higher prevalence of ever or current tobacco use in
the younger group compared to the older group was an
indicator of increasing prevalence in the adolescent popu-
lation, since early use predicts greater likelihood of
addiction and lifetime use8.
Toxic constituents
Although nicotine is the main constituent of tobacco re-
sponsible for addiction, the user also gets exposed to all
the toxic and carcinogenic chemicals contained in smoke-
less tobacco and tobacco smoke.
Like an opiate that targets the reward pathway in the
brain, nicotine also produces feelings of pleasure
and well-being. Nicotine stimulates secretion from the
adrenaline glands, causing a sudden increase in blood
sugar, blood pressure, heart rate and respiration. These
rewarding and stimulating effects, coupled with the
unpleasant withdrawal syndrome contribute to tobacco
dependence18.
Nicotine content
Indian smokeless tobacco products (khaini, zarda and
unmanufactured tobacco) tend to contain more nicotine
(13.8–65.0 mg/g)19 than American smokeless tobacco
(chewing tobacco, dry snuff and moist snuff, 3.4–
39.7 mg/g)20. Various gutkas contain about 1.2–
11.4 mg/g tobacco19.
Bidi tobacco (sun-cured) has twice as much nicotine
(about 37.7 mg/g) as tobacco used in western-style ciga-
rettes (flue-cured Virginia (FCV) or Burley; about
16.5 mg/g)21.
Nicotine delivery
Smokeless tobacco use delivers as much or more nicotine
to the body as does cigarette smoking. Most smokeless
tobacco products in India contain alkalinizing agents like
calcium hydroxide. These can irritate the mucosa of the
mouth and esophagus and more importantly, promote
nicotine absorption by the oral mucosa into the blood-
stream, since their pH raising action dramatically
increases the proportion of unprotonated nicotine, the
most easily absorbed form20.
Bidi smoking delivers more nicotine to the user per
gram of tobacco than do cigarettes, despite containing
much less tobacco per stick (one-fifth to two-thirds the
amount found in one conventional cigarette) – this is due
Box 1. Bidi smoking among students in India8
–
10
Among students, bidi smoking typically begins in the mid to late teenage years.
1. Current bidi smoking prevalence in a survey of 11,642 students from grades 6 to 8 in 32 schools from Delhi and
Chennai:
• 2.0 and 0.9% respectively, currently smoked bidis (cigarette smoking was similar)8.
2. Current bidi-smoking prevalence among Indian youth in grades 8–10 in the GYTS (Conducted by the World Health
Organization (WHO) and the Centers for Disease Control and Prevention (CDC))9,10:
• 2.3% (2.1–2.6) (95% Confidence Interval (CI)) of students in 26 states (excluding Chhattisgarh, Kashmir and
Kerala) in 2000–04 (N = 62,399)9.
• 3.5% (2.7–4.6) of students in 2006 in 30 states (N = 12,086)10.
• 22% (± 7.3) in Manipur boys: highest all-India prevalence for boys9.
• 10.6% (± 10.2) (95% CI) in Chandigarh: highest all-India prevalence for girls9.
• Higher in the northeastern region of India9,10.
• Nearly four times higher among boys (5.1%) than girls (1.3%) nationwide10.
3. Other facts on bidi smoking9:
• More than two-thirds (69.2% ± 6.3) of current bidi smokers in grades 8–10 wanted to quit smoking, nationwide.
• More than half (57.4% ± 7.8) of the young bidi smokers were not refused purchase because of their age.
• Factors associated with current bidi smoking included: parental tobacco use (P < 0.001) and lack of curricular
teaching on the dangers of smoking (P < 0.001).
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CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009 1327
both to the type of tobacco used and to the non-porous
leaf wrapper, that does not permit much air dilution of the
smoke during puffing21.
Bidi smoking generates similar or slightly higher nico-
tine levels in the blood compared to conventional ciga-
rette smoking22.
Carcinogens
Smokeless tobacco is known to contain over 20 known
and potential carcinogens (Box 3)20.
Bidi smoke has been found to contain many of the
same chemicals found in cigarette smoke21 which con-
tains 69 carcinogens23.
Tobacco-specific nitrosamines
Tobacco-specific nitrosamines (TSNAs) are the major
and most abundant group of carcinogens in tobacco. Two
of the most common TSNAs are NNK (4-(methyl-
nitrosamino)-1-(3-pyridyl)-1-butanone) and NNN (N′-
nitrosonornicotine). Derived from nicotine and other alka-
loids present in tobacco, TSNAs are present in small
amounts in fresh green tobacco leaves. The major part of
TSNAs is formed in tobacco products during processing,
curing and fermentation. TSNAs may also form in the
mouth of smokeless tobacco users through the enzymatic
action of saliva on tobacco constituents20. TSNAs also
arise during smoking24.
Indian brands of smokeless tobacco (mainly khaini,
zarda and unprocessed tobacco) tend to contain higher
amounts of TSNAs than those marketed in Europe or
North America. For example, in 11 Indian products24,
NNN concentration ranged from 1.74 to 76.9 μg/g and
NNK from 0.08 to 28.4 μg/g. Testing of tuibur (hidakphu),
water through which tobacco smoke has been passed and
is used for gargling or sipping primarily by women20, has
yielded around 20 μg/g NNN.
Mainstream bidi smoke (MS) contains higher concen-
trations of TSNAs than flue-cured Virginia-style cigarettes
and about the same as those in the MS of conventional
cigarettes made in India25. TSNAs are found in the particu-
late portion of bidi smoke, also called ‘tar’, the thick,
sticky residue of tobacco smoke along with thousands of
other chemicals23. Bidi smoke delivers more ‘tar’ than
conventional cigarettes21.
Other harmful constituents
Tobacco leaves tend to have high levels of toxic inor-
ganic compounds, including heavy metals like arsenic,
Box 2. Smokeless tobacco use among students in India8,10,11
Among students, smokeless tobacco use typically begins in the mid to late teens.
1. A study of 11,642 students from grades 6 to 8 in 32 schools of Delhi and Chennai:
• 4.5 and 1.6% respectively, were currently using chewing tobacco8.
2. Prevalence of smokeless tobacco use among Indian youth in grades 8–10 according to GYTS (2000–04; Con-
ducted by WHO and CDC)10,11:
• 14.6% (13.1–16.1) (95% CI) of students in 2000–04 in 26 states (excluding Kashmir and Kerala)11.
• 8.1% (6.5–10.0) of students in 2006 (conducted in 30 states)10.
• Ranged from 2% in Himachal Pradesh to 55.6% in Bihar11 in 2000–04.
3. Prevalence of smokeless tobacco use regionwise in the GYTS of 2006 (N = 12,086)10:
• Equally prevalent among boys and girls in two regions:
Eastern region: 17.5% (14.3–21.2) boys; 16.4% (12.3–21.5) girls.
Northeastern region: 20.0% (14.9–26.4) boys; 21.5% (11.0–37.8) girls.
Box 3. Some harmful constituents of smokeless
tobacco and associated risks19,20
Toxic compounds Harm caused
Nicotine Addiction,
atherogenesis,
raised blood
pressure
Tobacco-specific nitrosamines Cancer
(e.g. NNN, NNK)
Poly-aromatic hydrocarbons Cancer
(e.g. benzo[
α
]pyrene)
Volatile aldehydes Cancer
Volatile N-nitrosamines Cancer
N-nitrosamino acids Cancer
Inorganic compounds Cancer
(e.g. cadmium, lead, nickel,
arsenic)
Radioelements (e.g. Polonium-210) Cancer
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cadmium and lead. Smokeless tobacco products made in
India have been found to contain these substances. Traces
of poly-aromatic hydrocarbons (PAHs) such as benzo(
α
)-
pyrene occur in some smokeless tobacco products in
appreciable amounts (≥ 0.5 μ/g)20.
Box 3 lists the harmful constituents in smokeless tobacco
and the harm they are associated with. Bidis deliver, when
machine smoked at two puffs per minute, at least 1.6
times higher concentration of several toxic compounds
than unfiltered American cigarettes, including carbon
monoxide, ammonia, hydrogen cyanide, phenol, o-cresol,
m- and p-cresol, 2,4-dimethylphenol and benzo[a]pyrene21.
Box 4 lists some of the well-known harmful constituents
in tobacco smoke.
Arecanut and its constituents
Arecanut is an ingredient of some popular smokeless to-
bacco products in India, including gutka and mawa. Are-
canut is the chief ingredient of pan (betel quid), a roll of betel
leaves, arecanut, slaked lime (aqueous CaOH) and catechu,
to which tobacco is commonly added. From pan, the con-
cept of pan masala was derived, which contains the same
ingredients except for the betel leaves. Arecanut contains
arecoline, the major arecanut-specific alkaloid. Arecoline
mimics acetylcholine and binds to muscarinic receptors26.
Arecanut as an ingredient in tobacco products confers
taste as well as harmful constituents. Arecoline and are-
canut-specific polyphenols lead to collagen damage in the
oral mucosa, probably underlying the development of the
painful and precancerous condition of oral submucous
fibrosis (OSF), in which the chewer has difficulty open-
ing the mouth.
Prevalence studies of OSF show that their incidence is
increasing dramatically at ages below 35 years in males
and females, and this is a harbinger of an increase in oral
cancer. The increase in OSF has been linked to use of
gutka, mawa and pan masala (Figure 2).
Arecanut products can also contain arecanut-derived
nitrosamines that form in the saliva during chewing, espe-
cially in the presence of nitrates24. Although evidence for
carcinogenicity of arecanut-derived nitrosamines is still
limited, the International Agency for Research on Cancer
has stated that there is now sufficient evidence for the
carcinogenicity of arecanut use in humans27.
Health-related consequences of smokeless
tobacco
It has been recognized internationally that smokeless
tobacco use is associated with early death, cancer and
adverse reproductive outcomes28. Epidemiological research
carried out in India has also found similar results. Higher
risk of cardiovascular disease due to smokeless tobacco
use is under investigation and some recent research re-
sults show an association.
Smokeless tobacco users have slightly higher risks
of early death than nonusers
In the Mumbai cohort study, where 97,244 residents aged
≥ 35 years were followed up for about five years, a
slightly elevated risk of premature death was found for
both men (relative risk (RR) = 1.16 (95% CI: 1.06–1.26))
and women (RR = 1.25 (95% CI: 1.15–1.35)), who used
smokeless tobacco. Among smokeless tobacco users,
women users of mishri only (a popular product in Maha-
rashtra) also had elevated relative risks of premature
death: RR = 1.2 (95% CI: 1.10–1.34)29.
Smokeless tobacco users have higher risks of
oral and pharyngeal cancers
India has some of the world’s highest incidence rates of
oral and pharyngeal cancers. For example, the estimated
Figure 2. Child patients of oral submucous fibrosis caused by gutka
chewing. (Source: Dr Pankaj Chaturvedi, Tata Memorial Hospital,
Mumbai.)
Box 4. Harmful constituents of bidi smoke and associ-
ated risks21,23
Toxic compounds Harm caused
Nicotine Addiction, atherogenesis,
raised blood pressure
Carbon monoxide Inhibits oxygen exchange,
stresses the heart
Ammonia Irritation to the respiratory tract
Hydrogen cyanide Toxic to cilia: inhibits lung
clearance
Phenol Tumour promoter
Nitrogen oxides Inflammation of the lung
Benz[
α
]anthracene Cancer
Benzo[
α
]pyrene Cancer
Tobacco-specific Cancer
nitrosamines
Acrolein Toxic to cilia: inhibits lung
clearance
Acetaldehyde DNA damage
Isoprene DNA damage
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age standardized (world) rate (ASR)30 for 2002 for males
in the entire country was 12.8 per 100,000 and for females
7.5 per 100,000. These cancers are highly related to to-
bacco use.
Numerous case-control studies carried out in India
have shown high odds ratios for smokeless tobacco use
and oral and pharyngeal cancers, and a trend of increas-
ing risk with increasing frequency of use per day31.
For example, chewers of pan with tobacco were six
times more likely than nonusers (OR = 6.1 (95% CI: 3.3–
11.4)) to have cancer of the tongue or floor of mouth, in a
case-control study in Thiruvananthapuram32.
Smokeless tobacco with arecanut can cause
esophageal cancer
Several case-control studies show that the risk of eso-
phageal cancer increased several fold in chewers of pan
with tobacco27,31.
Smokeless tobacco use in pregnancy can lead to
adverse outcomes
Many women in India use smokeless tobacco even
during pregnancy, and lack awareness about the adverse
effects33. A recent cohort study of 1217 pregnant women
in Mumbai found that smokeless tobacco users (17.1%
prevalence during pregnancy; 80% mishri users) had a
50% higher risk of giving birth to a low-birth-weight
baby if they used smokeless tobacco five times a day and
over 100% higher if they used it ten times per day, a risk
ratio of 2.1 (95% CI: 1.1–4.0)34. Users (N = 16) also had
an elevated risk ratio for stillbirth of 2.6 (95% CI: 1.4–
4.8), after adjustment for confounding variables. A dose
response relationship was found for frequency of mishri
use per day, the most common type of smokeless tobacco
use. Stratifying by type of smokeless tobacco used, gutka
users (N = 3) had a higher risk for stillbirth than mishri
users35.
Smokeless tobacco users may have higher risks of
cardiovascular disease
Emerging evidence points to smokeless tobacco as a
cause of cardiovascular diseas36. Even a small increase in
risk could have a large public health impact in countries
where smokeless tobacco use is widespread20. In a large
cohort of never-smoking men in Sweden (N = 118,465
men) followed up from 1978 to 2003, an increased risk
for fatal ischaemic stroke was associated with current
snuff use, with RR = 1.7 (95% CI: 1.1–2.8)37.
Recently in Rajasthan, prevalence of cardiovascular
risk factors was found to be similar among 200 tobacco
chewers and 200 smokers (except for obesity), in a popu-
lation-based case-control study also comprising 200 age
and gender-matched controls with no history of tobacco
use. Tobacco chewers had a significantly higher (P < 0.001)
systolic and diastolic blood pressure, resting heart rate,
total cholesterol, LDL cholesterol and triglycerides com-
pared to the controls and these values were similar to the
smoker group. There was also a significantly greater
(P < 0.01) prevalence of hypertension, positive stress test
and other risk factors in the tobacco chewer group com-
pared to the control group38.
Health-related consequences of bidi smoking
Cigarette smoking has been widely studied in many coun-
tries and is known to cause higher early mortality,
ischaemic heart disease, stroke, chronic obstructive pul-
monary disease, lung cancer and numerous other can-
cers39. A cigarette is generally defined as a smoking
device in which tobacco is wrapped in a non-tobacco
material. The bidi is a burning device containing tobacco,
but with a non-tobacco wrapper. Hence, by definition,
bidi smoking is a type of cigarette. Epidemiological stud-
ies in India have confirmed that bidi smoking carries
similar types of health risks as cigarette smoking. Major
results of such studies are described below.
Bidi smoking is associated with early death
Several studies carried out in different parts of India have
demonstrated a risk of early deaths, at least 50% higher in
bidi smokers than in never-smokers40.
For example, a recent nationwide population-based
case-control study in 1.1 million homes, has estimated
that each year about 930,000 adult deaths in the country
are due to smoking. Also, in the age group 30–69 years,
one in five male deaths and one in 20 female deaths in
ages are due to smoking. Most male smokers in the study
smoked only bidis and a dose response relationship was
found for death with the number of bidis smoked per day.
Even among men who smoked the fewest bidis – from
one to seven (mean 4) per day – the smoking associated
excess deaths accounted for a quarter of all deaths41.
Another example is the Mumbai cohort study. The rela-
tive risk of death in the case of men who smoked bidis
was found to be at least 60% higher than for non-smokers
(RR = 1.6; 95% CI: 1.5–1.8), with increasing risk for
higher number of bidis smoked per day (RR for 1–5
bidis = 1.42; 95% CI: 1.20–1.68, going up to RR for ≥ 16
bidis = 1.78; 95% CI: 1.57–2.02)29.
Bidi smoking is associated with cardiovascular
disease, at least tripling the risks
A causal relationship has been established between smok-
ing and coronary heart disease, cerebro-vascular disease
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1330
(stroke) and abdominal aortic aneurysm38. Tobacco
smoke adversely affects the heart and the circulatory sys-
tem in several ways through nicotine, carbon monoxide
and free radicals: by increasing heart rate and blood pres-
sure, reducing oxygen supply (hypoxia) to the heart and
clogging of the arteries due to altered blood lipids and
enhanced platelet aggregation (blood clotting)42. Arterial
stiffening also occurs due to tissue oxidation by free
radicals43. Epidemiological studies have confirmed the
association of bidi smoking with cardiovascular disease
(CVD).
For example, in a case-control study in Bangalore, with
300 cases with first heart attack and 300 age-matched
controls, smoking ten or more bidis or cigarettes imparted
a four-fold higher risk of acute MI compared to not
smoking. The odds ratio of acute MI for smoking ≥ 10
bidis per day was 4.36 (P < 0.0001) and somewhat higher
than that for smoking the same number of cigarettes
(OR = 3.58; (P < 0.0001)). Bidi smoking was thus found
to be an independent risk factor for heart attack, at least
as important as cigarette smoking44.
Thromboangitis obliterans is another disease found
among smokers. It mainly affects the legs, leading to
poor mobility and sometimes gangrene and the need for
amputation. It is a disease that typically develops in bidi
smokers who start smoking in childhood42.
In the Mumbai cohort study, the RR for deaths from
CVD (ICD10 codes – I61-64,66,67) among smokers was
1.54 (95% CI: 1.09–2.19)29.
Bidi smoking is associated with tuberculosis
Prevalence of tuberculosis (TB) is about three times greater
among ever-smokers compared to never-smokers, and mor-
tality from TB is about four times greater. This has been re-
ported from epidemiological studies in rural and urban
Tamil Nadu and urban Maharashtra (Mumbai cohort study).
Furthermore, bidi smoking was found to confer higher RR
than cigarette smoking in causing deaths due to TB45.
In the Mumbai cohort study, men who smoked had
more than twice the risk of death due to TB29. Among
bidi smokers, the adjusted relative risk was 2.6 (95% CI:
2.0–3.3). The risk of self-reported TB among bidi smok-
ers was five times higher than never-smokers. It was es-
timated from the results of this study that in India nearly
one-third of TB deaths (32%) could be attributed to bidi
smoking46.
Bidi smoking increases the risk of chronic
obstructive pulmonary disease
In a large study of 35,295 adults aged 35 years and above
in India47, bidi smokers had a nearly threefold higher risk
of chronic obstructive pulmonary disease (COPD) (OR =
2.7 (95% CI: 2.3–3.1)) compared to non-smokers. This
was found in a multicentric cross-sectional study in both
urban and rural areas of Bangalore, Chandigarh, Delhi
and Kanpur. Cigarette smokers had a twofold higher risk
of COPD (OR = 2.0 (95% CI: 1.6–2.4)). Prevalence48
among bidi smokers was 8.2% and among cigarette
smokers 5.9%.
In the Mumbai cohort study, the RR for respiratory
diseases (ICD 10 codes J00–J99) among smokers was
2.12 (95% CI: 1.57–2.87)29.
Lung cancer is another major risk faced by bidi
smokers
Few studies have reported results on lung cancer risk for
bidi smokers49. In one case-control study of 235 male
lung cancer patients in Chandigarh, bidi smoking carried
a nearly sixfold higher risk of lung cancer (RR = 5.8;
95% CI: 3.4–9.7)50.
In a cohort of 65,829 men aged 30–84 years followed
up for eight years with 212 newly diagnosed lung cancers
in Karunagapally, Kerala, current bidi smokers had
more than a fourfold relative risk for lung cancer com-
pared to never-smokers (RR = 4.6 (95% CI: 2.5–8.5;
P < 0.001))51.
Oral and pharyngeal cancers are strongly
associated with bidi smoking
Bidi smoking is causally related to oral cancer in India52.
A review of six case-control studies on oral cancer
showed that bidi smokers had at least a twofold higher
risk of oral cancer than non-smokers49.
Smokers had nearly 20 times higher risk of death due
to oral and pharyngeal cancers than non-smokers in the
Mumbai cohort study (RR = 19.7 (2.7–146.1)). About equal
numbers smoked bidis as cigarettes29.
Several other cancers are also associated with
bidi smoking
Cancers of the hypopharynx, larynx, esophagus and stom-
ach are also found to be associated with bidi smoking in
case control studies in India49.
Tobacco-related policies and their
implementation
There is a clear need for urgent tobacco control measures
in India. Several tobacco-related policies are currently in
place, but some are geared to promote tobacco, while
others meant to control tobacco are getting delayed in
implementation.
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CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009 1331
Export policy
The Indian Government views tobacco as a foreign
exchange earner and a generator of tax revenue. During
most years, the Indian Government sets targets for
tobacco exports. Total tobacco exports represent 4% of
total agro exports. Exported unmanufactured tobacco is
mainly of the varieties used in cigarette manufacture53.
Manufactured tobacco products contribute 15% of the
quantity and 27% of the value of total tobacco exports.
Of the total value of tobacco products (Rs 544.27 crores)
exported in 2007–08, chewing tobacco represented 46.5%
(Rs 253 crores), bidis 8.1% and snuff 0.3%, while the rest
consisted of cigarettes 26.6%, cut tobacco 10.1% (mostly
used for making cigarettes), and lastly54, hookah paste
8.4%.
As far as the quantity of exported tobacco products is
concerned, out of a total of 30,657 t, chewing tobacco
represents over one-fourth (27% or 8338 t), bidis only 3%
and snuff less than 1%, while hookah paste constitutes
over one-third (34.7% or 10,656 t), cigarettes almost one-
fifth (19%) and cut tobacco almost one-sixth (15%)54.
The quantity of exported chewing tobacco – which in-
cludes gutka – has increased over 19 times since 1995–
96, while bidi exports have increased by only about one-
third1,54. These increases have some obvious implications
for international public health.
Taxation and control policies
Tobacco products provide about 10% of the total excise
revenue in India. Of total tobacco revenue, smokeless
tobacco contributes less than 15% and bidis only 5%,
while cigarettes generate around 80% (Figure 3)1.
An economic analysis has found that raising the excise
duty on bidis to a point where their price equals that of
the lowest priced cigarettes would not reduce excise
revenue, but would help curb tobacco use55.
Figure 3. Break-up of total excise revenue (Rs 81,823.50) from
tobacco products in India, 2000–01. (Source: Panchamukhi et al.1.)
A lobbying argument of the bidi industry for keeping
the excise tax low, is that it will affect the jobs of the
workers in the bidi industry and tobacco-related trades,
and that all these constitute a powerful vote-bank. It is
also to be noted that some high-level politicians are
directly involved in the bidi industry56. Keeping taxes
low on smokeless tobacco would have similar considera-
tions, except that the workforce is much smaller.
A loophole exists to prevent a number of companies
from paying excise and providing the special cess for
welfare of the bidi workers. It is the exemption for com-
panies manufacturing ≤ 20 lakh beedis (2 million) per
year57. This leads to evasion in payment of excise tax and
cess58, as well as evasion of legal responsibility to pro-
vide social and welfare services to bidi workers59. While
the average size of bidi factories is 200–300 workers, the
number of workers needed to make 20 lakh bidis a year is
only 6–10. Hence declaring the manufacture of less than
20 lakh bidis a year is in most cases only an attempt to
exploit the loophole for tax evasion58.
According to the Indian Budget of 2007–08, excise
duty (excluding cess) on bidis, which was last fixed in
2001, was raised from Rs 7 to 11 per thousand for non-
machine-made bidis and from Rs 17 to 24 per thousand
for machine-made bidis60. Yet these modest increases are
nowhere near the levels suggested for curbing bidi smok-
ing (Rs 100–168 per 1000 sticks)55,57.
Bidis have been exempted from the special levy on
tobacco products created to generate revenue for the
National Rural Health Mission1. Yet bidis are most
probably causing most of the disease and deaths due to
tobacco in India. Thus, there is a need to question the
favoured status of the bidi.
As taxation to raise the price is considered the most
effective type of control policy for tobacco use61, it cer-
tainly would make sense to raise taxes much higher on
both bidis and smokeless tobacco.
Other policies
India, a party to the FCTC, had incorporated several
effective tobacco control policies in the COTPA. This law
includes five important policies: ban on smoking in pub-
lic places, ban on tobacco advertising and sponsorship,
ban on sale to minors and within 100 yards of educational
institutions, the requirement of health-warning labels, and
regulation of contents. Rules for the first four of these
have so far been notified.
Even before the COTPA was passed in the parliament,
a survey determined that the first three of these policies,
as well as increased taxation, all enjoy strong public sup-
port (Box 5)9,62,63.
Despite public support for tobacco control policies,
lobbying from the tobacco industry has delayed imple-
mentation of the COTPA. The bidi industry has often
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CURRENT SCIENCE, VOL. 96, NO. 10, 25 MAY 2009
1332
cited the purported difficulty in enforcing policy regula-
tion in a cottage industry64 and fear of job loss65.
Creation of alternate forms of employment
Creation of alternative livelyhoods for workers connected
with the bidi industry is another necessary policy62 for the
sake of justice and human rights, and is required by he
FCTC (Art. 4).
It can be also argued that economic dependence on
tobacco represents a poor model of development, because
it gives rise addiction that leads to death and disease.
Summary and conclusion
Bidi smoking and smokeless tobacco use continue to be
practised by a large percentage of the population in India.
Smokeless tobacco use is twice as high as bidi smoking
among adolescents. Initiation into use of these products
among youth leads to lifelong adult use. Bidis are respon-
sible for most of the one million or more yearly smoking-
related deaths in the country. Political will has been lack-
ing for the implementation of the tobacco control policies
already adopted in the law. Lack of political will is also
responsible for low taxes on bidis and smokeless tobacco
products. To protect health and promote healthy eco-
nomic development in the country, the lobbying power of
the industry needs to be countered. To accomplish this,
public support is a must.
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Box 5. Public support for tobacco control policies
Sentinel Survey62
A survey of nearly 30,000 persons 10 years and above in both Karnataka and Uttar Pradesh revealed that there was
high acceptance of four control measures about which opinion was sought:
1. Increase in the prices of tobacco products;
2. Discontinuation of tobacco advertising and sponsorship;
3. Banning smoking in public places, and
4. Banning sale of tobacco to minors.
Even a high proportion of tobacco users supported implementation of these measures.
The maximum opposition was by tobacco users for an increase in prices of tobacco products (3.2% in Karnataka and
11.2% in Uttar Pradesh). While male tobacco users were somewhat more supportive of tobacco control measures than
females, there was not much variation in the socio-demographic variables of residence, economic strata or religion.
Among very young users, 10–14 years, the maximum opposition was found in Uttar Pradesh against raising the price
(16.1%) and against banning sale to minors (11.3%). A high overall percentage for approval of these measures sug-
gests a scenario conducive for social acceptance.
Surveys of school personnel63
Global school personnel surveys conducted in Bihar, Orissa and four North East States showed that the great majority
of school personnel, including tobacco users, supported the following policies:
1. Higher taxation to increase the price of tobacco products,
2. School policies prohibiting tobacco use in school premises and
3. Other tobacco control policies.
Survey of adolescent students9
Three-fourths of students in the GYTS India (2000–04) favoured a ban on smoking in public places.
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ACKNOWLEDGEMENTS. This work was supported by Physicians
for Smoke-free Canada, Ontario, Canada. We thank Dr Pankaj
Chaturvedi for permission to reproduce the photographs of oral submu-
cous fibrosis patients.
