Bidi Use Among Urban Youth -- Massachusetts, March-April 1999

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.

TABLE 1. Percentage of middle and high school students surveyed who reported bidi
use, by sex, race/ethnicity, and grade -- Massachusetts, 1999
===============================================================================================
                               Lifetime*      Current+       Heavy&
                               ----------    -----------   ----------
Characteristic          No.    No.   (%)     No.    (%)    No.   (%)
---------------------------------------------------------------------
Sex
  Female                342    121   (35)     43    (12)    18   ( 5)
  Male                  282    127   (45)     54    (19)    32   (11)

Race/Ethnicity
  White, non-Hispanic    82     32   (39)      9    (11)     5   ( 6)
  Black, non-Hispanic   220     88   (40)     30    (14)    17   ( 8)
  Hispanic              232     95   (41)     49    (21)    21   ( 9)
  Other@                108     41   (38)     12    (11)     7   ( 6)

Grade
   7                     92     29   (31)     13    (14)     1   ( 1)
   8                    113     39   (34)     21    (19)    10   ( 9)
   9                    138     61   (44)     19    (14)    11   ( 8)
  10                    182     76   (42)     23    (13)    14   ( 8)
  11                     90     39   (43)     18    (20)    10   (11)
  12                     27     12   (44)      6    (22)     4   (15)

Overall                 642    256   (40)    100    (16)    50   ( 8)
---------------------------------------------------------------------
* Smoked at least once in lifetime (ever smoked, even one or two puffs).
+ Smoked one or more in the last 30 days.
& Smoked >=100 in lifetime.
@ When presented separately, numbers for other racial/ethnic groups were too small for mean-
  ingful analysis.
===============================================================================================

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