If you want to know about Consequences of Bidi Smoking, Lung Disease contact- Jindal Chest Clinic

1. Disease Consequences
of Bidi Smoking
Lung Disease
S. K. Jindal
Professor and Head
Department of Pulmonary Medicine
Postgraduate Institute of Medical Education & Research
Chandigarh, India

2. Global Burden of Disease Study (1997)
Specific causes of disability (DALY)
LRTI 1st
COPD 12th
Asthma 30th
Causes of death : LRTI, COPD
TB and Lung Cancer: 9.4 million death
(Top ten leading causes)

3. Tobacco Smoking and Lung Diseases
Established relationships since 1960s
• COPD (Chr. Obstructive Pulm. Disease)
• Respiratory infections
• Asthma and Bronchial hyper-responsiveness
• Impaired lung function
• Lung Cancer
• Others: TB, ILDs, Pneumonias

4. Smoking habits in rural areas
No. of Proportion Smoking product
subjects of smokers Cigarette Bidi Hookah
Men
Chandigarh 5333 40.48% 13.34% 81.47% 5.19%
Delhi 3933 41.42% 12.65% 78.21% 9.09%
Kanpur 3921 26.32% 6.30% 92.54% 0.78%
Bangalore 4111 34.71% 18.57% 81.43% 0.00%
Total 17298 36.11% 13.19% 82.44% 4.29%
Women
Chandigarh 4976 5.53% 8.00% 76.00% 16.00%
Delhi 3749 7.47% 3.21% 56.79% 40.00%
Kanpur 3278 1.59% 3.85% 96.15% 0.00%
Bangalore 4003 0.00% - - -
Total 16006 3.79% 5.44% 68.86% 25.70%

5. Smoking habits in urban areas
No. of Proportion Smoking product
subjects of smokers Cigarette Bidi Hookah
Men
Chandigarh 5717 20.01% 53.41% 45.45% 1.05%
Delhi 4033 17.85% 37.92% 60.97% 0.97%
Kanpur 6107 19.16% 40.17% 59.74% 0.09%
Bangalore 4527 32.58% 56.07% 43.93% 0.00%
Total 20384 22.12% 48.37% 51.14% 0.44%
Women
Chandigarh 5638 0.96% 20.37% 68.52% 11.11%
Delhi 3927 1.07% 11.90% 71.43% 16.67%
Kanpur 5552 0.65% 16.67% 80.56% 2.78%
Bangalore 4800 0.02% 100.00% 0.00% 0.00%
Total 19917 0.67% 17.29% 72.18% 10.53%

6. COPD (vs. Asthma)
• Chronic, progressive, irreversible narrowing
of airways  Chronic respiratory failure
• Includes: Chronic bronchitis and Emphysema
• Chronic cough, expectoration, breathlessness
• Chronic respiratory disability and early death
• Prevalence (Population > 30 yrs age)
M – 5%; F – 2.7%
Major cause of global disease and economic
burden

7. Smooth muscle hypertrophy
Inflammation and edema
Mucus gland hypertrophy
and hyperplasia
Airway narrowing
Mucus plugging
Airway wall
Smooth muscle
Airway lumen
Normal
airway
Airway of
a smoker
Mucus
glands

8. COPD and Smoking
• Recognized since 1950s
• Epidemiological, clinical and exptl. data
Royal College of Physicians, London 1962
• US Surg Gen reports 1964; 1984
• GOLD 2001

9. Authors Population No. of subjects COPD (%)
Smoker Non
smoker
Smoker Non
smoker
Wig et al9 Delhi Urban 302 276 0.7 5.8
Rural 115 181 2.6 12.1
Viswanathan30 Delhi- i. Textile mills 807 185 3.0 19.5
ii. Patients' attendants 174 43 3.5 13.3
iii. University staff 563 93 4.6 15.1
Viswanathan et al10 Patna area 14119 1686 1.1 7.3
Sikand et al6 Delhi 1052 449 2.8 16.9
Joshi et al5 Ludhiana (N.India) industrial workers 229 244 3.9 20.5
Bhattacharya et al13 Lucknow- rural 544 596* 4.2 7.0
Thiruvengadam et al23 Madras 762 55 1.2 7.4
Viswanathan & Singh7 Delhi Urban 788 205 3.9 15.6
Rural 770 231 1.4 13.4
Radha et al14 Delhi- Urban 436 338 4.3 8
Charan12 Punjab- rural 7132 0.7
* Including ex-smokers
A summary of studies from India and Nepal on prevalence
of COPD (Chronic Bronchitis and/or Emphysema) in male
subjects and its smoking associations

10. Authors Population No. of subjects COPD (%)
Smoker Non
smoker
Smoker Non
smoker
Malik & Singh31 Haryana- rural 81 197 0 21.6
Malik et al8 North India 810 334 4.0 19.0
Malik & Wahi32 North India, both urban and rural 1580 780 5.2 20.0
Shrestha & Pandey11 Kathmandu, Nepal-rural 1427 4.3 13.5
Malik et al33 Chandigarh city ,N.India 10061 444 1.0 9.9
Nigam et al34 Jhansi N. India-rural 115 660* 6.1 8.5
Pande et al27 Nepal, hills 2826 449 18.3* 16.9
Malik et al35 Himachal rural hills 120 184 5.8 32
Behera et al36 Chandigarh-Teachers 270 63 3 4.8
Jindal (follow up) 37 N. India** Urban 296 60 0.3 21.7
Rural 139 84 2.2 13.1
Ray et al38 Tamil Nadu South India 9946 3.3***
A summary of studies from India and Nepal on prevalence
of COPD (Chronic Bronchitis and/or Emphysema) in male
subjects and its smoking associations
* (incl. Ex-smokers
** Numbers restudied after 10 years of the original 1450 urban and 671 rural subjects studied in 1980
*** Of 198 male COPD subjects, 62% were smokers of whom 87% smoked bidis.

11. Summary of studies on COPD
Prevalence in Bidi smokers
Total COPD Prevalence (%)
number Non
smoker
Cig.
smoker
Bidi
smoker
Mixed
smoker
Bhattacharya et al 1140 4.2 - 3.1* -
Radha et al 774 4.35 6.02 8.33 15.7
Malik & Wahi 2360 5.2 13.3 17.2 19.6
Malik et al 2816 1.0 8.8 9.0 8.5
Nigam et al 775 6.1 4.3* 4.6* -
Jindal et al 1473 2.2 21.7 13.1 -
* Excludes the high prevalence of 25% seen in ex-smokers (mostly bidis)

12. COPD and Bidi Smoking (Males)
Initial Study
(1977-1980)
Follow up
Study (1990)
No. of subjects 4372 1475 (33.7%)
Smokers:
Cigarettes (U)
Bidis (R )
444
286
60 (13.5%)
84 (29.4%)
COPD Prevalence:
Nonsmokers
Smokers:
Cigarettes (U)
Bidis (R )
25 (1.8%)
44 (0.9%)
47 (16.4%)
4 (0.9%)
14 (21.7%)
11 (13.1%)
Total 91 (12.5%) 25 (15.2%)
(Malik 1986; Jindal SK 1993)

13. Odds of having chronic bronchitis
for different smoking products
Chandigarh Delhi Kanpur Bangalore
Cigarette 2.446
(1.602-3.734)
3.517
(2.293-5.395)
1.072
(0.619-1.856)
1.781
(1.330-2.385)
Bidi 3.003
(2.262-3.987)
3.853
(2.988-4.970)
2.425
(1.906-3.084)
2.793
(2.306-3.381)
Hookah 9.472
(5.902-15.20)
3.167
(1.881-5.333)
9.619
(1.931-47.91)
-

14. Bidi Smoking and Asthma
• Triggering of asthma (Cig vs. bidi ?)
• Symptomatic prevalence of asthma in
smokers (vs nonsmokers)
Total No. 73605 O.R. 95% CI
Cig. smoking 2.12 1.76-2.55
Bidi smoking 1.97 1.73-2.23

15. Odds of having bronchial asthma
for different smoking products
Chandigarh Delhi Kanpur Bangalore
Cigarette 2.540
(1.843-3.501)
2.988
(1.866-4.785)
1.641
(0.985-2.733)
1.515
(1.123-2.042)
Bidi 1.742
(1.366-2.223)
2.104
(1.550-2.857)
2.207
(1.688-2.885)
2.025
(1.632-2.511)
Hookah 7.809
(4.972-12.26)
2.125
(1.036-4.359)
6.005
(0.758-47.54)
-

16. Bidi Smoking: BHR
BHR increased in bidi smokers
Asymptomatic 54.5%
Symptomatic 83.3%
Greater the Smoking Index, lower the
baseline FEV1 & PD20 i.e. greater the BHR.
Jindal et al 1985, 1987

17. Bidi Smoking and Lung Function
Evidence of airflow obstruction
• Malik and Wahi, 1978
• Swaroop & Agnihotri, 1998
• Khan et al, 2002
• Chhabra et al, 2001
• Dhand et al, 1985

18. A summary of reports from India on
tobacco association of Lung cancer
Smoking association
Total no. N:S ratio
Viswanathan et al, 196256 95 2.1
Shankar et al, 196757 20 5.7
Nagrath et al, 197058 35 1.9
Guleria et al, 197159 120 2.0
Basu et al, 197160 24 5.0
Jha et al, 197261 25 5.3
Nafae et al, 197362 25 7.3
Malik et al, 197663 136 3.5
Narang et al, 197764 58 4.8
Jindal et al, 197965 150 2.4
Notani et al, 197466 520 3.9
Malhotra 198667 70 4.8
Jindal et al, 198768 480 3.0
Jindal et al, 199069 1009 2.7

19. Lung Ca and Bidi Smoking
• Mumbai RR (Bidis) 3.38
(Notani et al 1977)
• Chandigarh O.R. 95% CI
(Gupta et al 2001) Bidi 5.76 3.42-9.7
Cig. 5.64 3.15-10.1
Total No.: Lung Ca 265
Controls 525

20. SUMMARY
1. Bidi smoking is causally associated with
• Increased incidence of COPD
• Impaired lung function tests
• Increased BHR
• Increased ORs for asthma
• Higher incidence of lung cancer
2. The risks for smoking of bidis are at least
similar to those of cigarettes