Tobacco use is the leading preventable
cause of death in the United States.
Bidis are small, brown, hand-rolled
cigarettes primarily made in India and
other southeast Asian countries (1)
consisting of tobacco wrapped in a
tendu or temburni leaf (Diospyros
melanoxylon). In the United States,
bidis are purchased for $1.50-$4.00
for one package of 20 and are
available in different flavors (e.g.,
cherry, chocolate, and mango).
Anecdotal reports indicate that bidi use
was first observed during the mid-
1990s and seems to be widespread among
youth and racial/ethnic minority
adolescents. This report summarizes
preliminary data collected from a
convenience sample of adolescents
surveyed during March and early April
1999 in Massachusetts on the
prevalence of bidi use among urban
youth; these data indicate that of
642 youth surveyed, 40% had smoked
bidis at least once during their
lifetimes and 16% were current bidi
smokers.
The Massachusetts Tobacco Control Program
conducted a pilot study to assess
adolescents' knowledge and use of
bidis. A convenience sample
included a school- and community-based
survey of youth from a large
metropolitan area in Massachusetts.
Peer leaders from a local tobacco-use
prevention program and their adult
advisors were granted access to three
middle schools and seven high schools
through professional networks (e.g.,
contact with the principal, health
teacher, and nurse). Participants were
given a set of standardized
instructions and informed consent was
obtained.
Students surveyed in school were from
health, science (e.g., biology,
chemistry, and computer science),
language (e.g., English or English as
a second language), and history
classes. After completing the surveys,
participants were briefed about the
intent of the survey. Peer leaders
also assessed youth who attended local
schools in several community
neighborhoods. Data gathered in the
community were from areas frequented
by students (i.e., neighborhood
stores, after-school programs, and bus
and subway stations).
Community respondents were compared with
school respondents. A greater
proportion of community respondents
reported heavy and past-month bidi use
than school respondents. Community
respondents also were more likely to
be Hispanic and less likely to be
white than school respondents.
Analyses conducted by grade and
race/ethnicity on two results (current
and heavy bidi use) indicated no
significant differences.
A total of 822 respondents participated in
the study; 108 surveys with incomplete
or inconsistent responses were
eliminated. Of those 642 participants
whose self-reported grade was seven
through 12 (Table 1), 342 (55%) girls
and 282 (45%) boys completed surveys
(18 respondents did not report sex);
341 (53%) were surveyed in schools and
299 (47%) were surveyed in the
community (two surveys were missing
setting information); 232 (36%)
were Hispanic, 220 (34%) were black
(non-Hispanic), 82 (13%) were white
(non-Hispanic), and 108 (17%) were
other.*
Current bidi users were defined as having
"smoked more than one bidi in
the last 30 days." Lifetime bidi
smokers were defined as having "smoked
a bidi, even just one or two puffs."
Heavy bidi smokers were defined as
having "smoked more than 100 bidis in
their lifetime." Data were analyzed
using Statistical Package for the
Social Sciences (SPSS) version 7.5.
Prevalence of bidi use was compared by
sex, race/ethnicity, grade, and
overall (Table 1).
Two hundred fifty-six (40%) of the
respondents had ever smoked bidis,
100 (16%) were current bidi users, and
50 (8%) were heavy bidi users. There
were no significant differences in
bidi use by sex, grade, or
race/ethnicity. Responses (n=280) to
the question why bidis were smoked
instead of cigarettes included bidis
tasted better (63 [23%]), were cheaper
(49 [18%]), were safer (37 [13%]), and
were easier to buy (33 [12%]). Other
reasons included "just to try it" (20
[7%]), "to improve my mood" (17 [6%]),
"it makes me look cool" (16 [6%]), "my
friends smoke them" (four [1%]),
"smoke them in place of cigarettes or
marijuana" (four [1%]), "like the
flavor" (three [1%]), and other (34
[12%]).
Reported by: C Celebucki, PhD, DM
Turner-Bowker, PhD, G Connolly, DMD,
HK Koh, MD, Massachusetts Dept of
Public Health; Tobacco Control
Program, Boston, Massachusetts. Office
on Smoking and Health, National Center
for Chronic Disease Prevention and
Health Promotion, CDC.
Editorial Note: When tested on a
standard smoking machine, bidis
produced higher levels of carbon
monoxide, nicotine, and tar than
cigarettes (1-3); one study found that
bidis produced approximately three
times the amount of carbon monoxide
and nicotine and approximately five
times the amount of tar than
cigarettes (4). Because of low
combustibility of the tendu leaf
wrapper, bidi smokers inhale more
often and more deeply, breathing in
greater quantities of tar and other
toxins than cigarette smokers (2-6).
Like all tobacco products, bidis are
mutagenic and carcinogenic (6). Bidi
smokers risk coronary heart disease
(7), cancers of the oral cavity,
pharynx, larynx (1), lung (8,9),
esophagus, stomach, and liver (1).
Perinatal mortality is also associated
with bidi use during pregnancy (10).
The findings in this report are subject
to at least five limitations.
First, the external validity of this
study may be limited by convenience
sampling and may not represent the
prevalence of bidi use among all
students in these schools and
communities. More representative
surveys are needed to develop precise
estimates of bidi use and to monitor
trends over time.
Second, participants surveyed in the
community may have been subject to
selection bias; peer leaders may have
been more likely to approach those
similar to them in age and
race/ethnicity. Because most peer
leaders were racial/ethnic minorities
aged less than 16 years, the
convenience sample surveyed in the
community reflects these demographics.
Third, the extent of underreporting and
overreporting of bidi use cannot be
determined.
Fourth, the number or characteristics
of students who refused to participate
is not known. Finally, the sample was
drawn from one large metropolitan area
and may not represent persons from
other urban areas in Massachusetts or
the rest of the United States.
This investigation was the first in
the United States to estimate the
prevalence of bidi smoking among
students in grades seven through 12.
Preliminary findings from this study
support the need for additional
research on bidis, particularly on
smoking prevalence among youth from
differing geographic, educational, and
socioeconomic backgrounds. The
knowledge, attitudes, and behavioral
patterns of bidi smokers also must be
assessed to understand this phenomenon
and to curtail use. Research should
assess the psychosocial and contextual
factors affecting bidi use, the
influence of peer pressure, how bidis
are smoked (as an initiation to
smoking or following cigarette
smoking), and whether bidis are smoked
instead of cigarettes or to mask the
use of other substances.
Adolescents in this study reported
their preference for the taste of
bidis over cigarettes and their belief
that bidis are less expensive, easier
to buy, and safer than cigarettes. The
findings on prevalence, knowledge,
and attitudes, especially if they are
replicated in other communities, may
demonstrate the need for actions to
curtail youth access to bidis similar
to measures for limiting access to
cigarettes and smokeless tobacco.
Adolescents should be alerted to the
high toxicity of bidis to dispel the
notion that bidis are safer to smoke
than cigarettes. Additional research
is needed to assess other factors
affecting the use of novel tobacco
products such as bidis, including how
restrictions on access and advertising
are being enforced, how pricing
affects use of these products, the
application of federal and state
excise taxes, and appropriate labeling
of these products with the Surgeon
General's health warnings regarding
tobacco use.
References
1. Gupta PC, Hamner JE III, Murti PR, eds.
Control of tobacco-related cancers and
other diseases; proceedings of an
international symposium.
Bombay, India: Tata Institute of
Fundamental Research, Oxford
University Press, 1992.
2. Jayant K, Pakhale SS. Toxic
constituents in bidi smoke. In:
Sanghvi LD, Notani P, eds. Tobacco and
health: the Indian scene. Bombay,
India: Tata Memorial Center, 1989.
3. Pakhale SS, Maru GB. Distribution of
major and minor alkaloids in
tobacco, mainstream and sidestream
smoke of popular Indian smoking
products. Food Chemical Toxicol
1998;36:1131.
4. Rickert WS. Determination of yields
of "tar", nicotine and carbon
monoxide from bidi cigarettes: final
report. Ontario, Canada: Labstat
International, Inc., 1999.
5. Hoffman D, Sanghvi LD, Wynder EL.
Comparative chemical analysis of
Indian bidi and American cigarette
smoke. Int J Cancer 1974;1:49-53.
6. Sanghvi LD. Cancer epidemiology: the
Indian scene. J Cancer Res Clin
Oncol 1981;91:1-14.
7. Pais P, Pogue J, Gerstein H, et al.
Risk factors for acute myocardial
infarction in Indians: a case-control
study. Lancet 1996;348:358.
8. Jussawala DJ, Jain DK. Lung cancer
in greater Bombay: correlations with
religion and smoking habits. Br J
Cancer 1979;40:437-48.
9. Notani PN, Rao DN, Sirsat MV,
Sanghvi LD. A study of lung cancer in
relation to bidi smoking in different
religious communities. Indian J Cancer
1977;14:115.
10. Coleman S, Piotrow PT, Rinehart W.
Tobacco hazards to health and human
reproduction. Popul Rep L 1979;L1:1-37.
* When presented separately, numbers
for other racial/ethnic groups were
too small for meaningful analysis.
Bidi Related Links
Smoking & Health Action Coalition (SHAC), Rochester, New York
