BidiBidi SmokingSmoking andand PublicPublic HeHealthalth Editors Prakash C. Gupta Samira Asma Partners Ministry of Health and Family Welfare, Government of India World Health Organization Healis-Sekhsaria Institute for Public Health Centers for Disease Control and Prevention U.S. Department of Health and Human Services Bidi Smoking and Public Health Bidi Smoking and Public Health, March, 2008 Published by the Ministry of Health and Family Welfare, Nirman Bhawan, Maulana Azad Road, New Delhi 110011, India Disclaimer: The views expressed in this report are not necessarily those of the Ministry of Health and Family Welfare, Government of India; or the World Health Organization; or Healis-Sekhsaria Institute for Public Health, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Editors Prakash C. Gupta is the Director of Healis-Sekhsaria Institute for Public Health, Navi Mumbai. He is a long standing researcher on tobacco control issues and recepients of several awards. Samira Asma is the Associate Director for the Global Tobacco Control Program at the Office on Smoking and Health, Centers for Disease Control & Prevention. She provides strategic leadership & coordination on global tobacco research, surveillance & policy initiatives. Citation: Gupta PC, Asma S (eds.) Bidi Smoking and Public Health, New Delhi: Ministry of Health and Family Welfare, Government of India, 2008. Printed at Rakmo Press Pvt. Ltd., C-59, Okhla Industrial Area Phase-I, New Delhi - 110020, India ii Hkkjr ljdkj LokLF; ,oa ifjokj dY;k.k ea=ky; fuekZ.k Hkou] ubZ fnYyh - 110011 Government of India jk"V™h; xzkeh.k LokLF; fe'ku Ministry of Health & Family Welfare Nirman Bhavan, New Delhi-110011 Naresh Dayal Health & FW Secretary Tel.: 23061863 Fax : 23061252 e-mail : [email protected] Dated the 25th January 2008 [email protected] FOREWORD India is among the worlds largest tobacco consuming societies. Tobacco usage in India is also contrary to world trends since chewing tobacco and the bidi are the dominant forms of tobacco consumption, whereas internationally the cigarette is the most prominent form of tobacco use. About 19% of tobacco consumption in India is in the form of cigarettes, while 53% is smoked as bidis, the rest is used mainly in smokeless form. Bidis tend to be smoked by lower economic classes and have a level of social acceptance in different cultures. Available evidence indicates that tobacco consumption is the single most preventable cause of disease and death. It also imposes very high socio-economic costs on the society. Government of India has enacted “The Cigarettes and other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production Supply and Distribution) Act 2003”, with a view of protect public health by prohibiting smoking a public places, banning advertisement of tobacco products, banning sale of tobacco to minors and within 100 yards radius of educational institutions, prescribing pictorial health warnings etc. There are a number of studies, reports and reviews on cigarette use and its harmful effects. Similar studies on other tobacco forms, including bidi are very few. The bidi monograph bridges a very important gap in the area of public health as it provides a comprehensive review on impact of bidi consumption. The compilation of scientific studies on bidis provides a plethora of information on the consumption patterns and associated usage risks. Since the problem of bidi usage is unique to South Asia, the monograph would be extremely useful for public health managers both in India and neighboring countries, to promote effective initiatives for curbing bidi usage. The monograph has been prepared by the Healis-Sekhsaria Institute of Public Health, Navi Mumbai, in collaboration with the Centers for Disease Control and Prevention, Office on Smoking & Health, USA and with active support from Government of India and the World Health Organization. I congratulate the editors Dr. P.C. Gupta and Dr. Samira Asma, for the efforts put in by them and also acknowledge the valuable contributions made by individual experts. This monograph may be disseminated among all stakeholders, both within Government and outside to enable framing of positive public health policies. This monograph would also be useful in countering misinformation campaigns and propaganda regarding the health effects of bidi, as it is now clearly evident that bidi is as harmful as any other tobacco product. (NARESH DAYAL) Secretary to the Government of India iii Bidi Smoking and Public Health iv Preface Bidis are small hand-rolled cigarettes which are very common in India, seven or eight times more so than cigarettes. Although primarily an Indian product, bidis are exported abroad and have recently become popular in the United States, especially among young people. This is a cause for public health concern both in the U.S. and globally. Just like cigarette smoking, bidi smoking causes vascular disease, lung disease and cancers. On standard smoking machines bidis produce equal or higher levels of nicotine, tar and other toxic chemicals, when compared to cigarettes. Although many studies have been reported in the scientific literature, until now there had been no attempt by any national or international agency to consolidate information about bidi smoking. For this reason, a collaborative project was proposed between the Centers for Disease Control and Prevention, Office on Smoking and Health, USA and the Healis-Sekhsaria Institute of Public Health, Navi Mumbai, India, to bring together comprehensive information on bidi smoking in one single publication. Scientists who have made original contributions towards understanding bidi smoking, mainly in the USA and India, were asked to contribute a state-of-the-art paper in their specific area of expertise. The resulting papers fell into six broad categories, which form the main sections of this publication: Product Description; Prevalence of Bidi Smoking; Chemistry, Toxicology, Pharmacology and Abuse Potential; Disease Consequences; Economics; and Public Health Policy Strategies. Drafts of papers were subjected for peer review and authors were given the opportunity to revise their papers based on reviewers’ comments. Then each paper was presented by the authors during a three-day workshop in New Delhi in August 2004. In addition to authors and reviewers from the USA and India, the workshop was attended by representatives from the Indian Council of Medical Research; Ministry of Health and Family Welfare, Government of India; and the World Health Organization’s India Office and South East Asian Regional Office. After the authors summarized their papers, considerable time was dedicated to discussion, questions and comments. Lead authors were then able to modify their papers in light of the discussion that emanated from the workshop. The final papers were peer reviewed once more before being returned to their authors for finalization. The introductory section on Product Description has two papers. Chapter 1.1: History and Culture of Bidis in India: Production, Employment, Marketing and Regulations provides an overview of the bidi industry in India and suggests areas for future action, research and policy change towards safeguarding bidi smokers and finding alternate employment for bidi workers. Chapter 1.2: Marketing, Promotion and Availability of Bidis in the United States examines what is currently known about the presence, perceptions, marketing and promotion of bidis in the United States, with special attention to risk factors that lead to bidi smoking and popular perceptions about the relative risk of bidis compared to Western-style cigarettes, and v Bidi Smoking and Public Health marketing strategies of bidi distributors and the extent to which overt advertising messages may mislead American youth into thinking bidis are a safe alternative to cigarettes. Three papers address the Prevalence of Bidi Smoking. Chapter 2.1: Prevalence of Bidi Smoking among Youth in India summarizes the issues on the prevalence of bidi smoking among youth in India and the knowledge, attitudes and behavioral aspects of bidi smoking among youth, which should be useful for interventions aimed at curtailing their bidi smoking habits. Chapter 2.2: Prevalence and Patterns of Bidi Smoking in India paints a picture of the prevalence of bidi smoking among adults in different parts of India relative to other competing tobacco products and identifies patterns and trends, through a review of large-scale surveys from the 1960s onwards, including country-wide prevalence and state-wide consumption data from the National Sample Survey. Chapter 2.3: Prevalence of Bidi Cigarette Use in the United States, 2000 to 2004 describes the epidemiology of bidi use in the USA from 2000 to 2004, based on data from the National Youth Tobacco Survey (NYTS) and the Behavioral Risk Factor Surveillance System (BRFSS). This information should encourage further monitoring of bidis in vulnerable populations and the development and implementation of evidence-based policies to prevent their use. The Chemistry, Toxicology, Pharmacology and Abuse Potential of Bidis is discussed in two papers. Chapter 3.1: Chemistry and Toxicology outlines product characteristics, from curing and processing to wrapping and additives. It describes protocols to machine measure bidi smoke, in vitro studies of the toxicology of bidi smoke and chemical constituents, and studies of product modifications to reduce the tar and nicotine. Greater detail