Effects of bidi smoking on all-cause mortality and cardiorespiratory outcomes in men from south Asia: an observational community-based substudy of the Prospective Urban Rural Epidemiology Study (PURE)

The global magnitude and temporal trend of rheumatoid arthritis burden attributable to smoking from 1990 to 2019

OBJECTIVES

The relationship between smoking and RA has been confirmed. Most nations have ratified the Framework Convention on Tobacco Control. However, there are considerable regional differences in how effectively tobacco control measures were implemented. This study was carried out to estimate the spatiotemporal trends of smoking-related RA burdens.

METHODS

Data were available from the Global Burden of Disease Study 2019 and were analysed by age, sex, year and region. Joinpoint regression analysis was applied to the analysis of temporal trends in the RA burden resulting from smoking over 30 years.

RESULTS

From 1990 to 2019, the number of global RA cases increased each year. The age-standardized prevalence, death and disability-adjusted life-year (DALY) rates also increased. However, there was a wave in the changing trend of the age-standardized death rate, with the lowest point in 2012 and the highest point in 1990. Smoking, in particular, was responsible for 11.9% of total RA deaths and 12.8% of total DALYs in 1990 but only 8.5% of total RA deaths and 9.6% of total DALYs in 2019. A greater burden from smoking exposure was borne by men, older adults and people living in high-middle and high sociodemographic index (SDI) countries and regions. Moreover, the UK demonstrated the highest reduction in age-standardized death and DALY rates over the three decades.

CONCLUSION

There were reductions in the age-standardized burdens of RA caused by smoking worldwide. Nevertheless, this continues to be an issue in some areas, and efforts to reduce smoking should be made to lessen this growing burden.

Death, Disability, and Premature Life Years Lost Due to Cigarettes, Bidis, and Smokeless Tobacco in India: A Comparative Assessment

BACKGROUND

Due to the staggering number of tobacco users in India, it is important to determine the exact mortality and morbidity rates due to tobacco use. This study aimed to estimate deaths, disability-adjusted life years (DALYs), and years of life lost (YLLs) attributable to cigarettes, bidis, and smokeless tobacco (SLT) in India.

METHODS

Data pooling and meta-analysis were done using case-control studies available on the three types of tobacco products. Health burden was estimated by applying the population attributable fraction (PAF) value to the total disease burden.

FINDINGS

A total of 33 studies were included. PAF was calculated for oral and lung cancer as well as ischemic heart disease (IHD) due to cigarettes, oral and lung cancer, IHD, and chronic obstructive pulmonary disease due to bidi, and oral and stomach cancer and IHD due to SLT. Cigarettes resulted in 8.4 million DALYs, 8.26 million YLLs, and 341 deaths; bidis led to 11.7 million DALYs, 10.7 million YLLs, and 478 thousand deaths, and SLTs accounted for 4.38 million DALYs, 4.3 million YLLs, and 171 thousand deaths annually.

CONCLUSION

Evidence of measurable health burden and methodology for calculation for individual states was provided in the study. The generated evidence could be utilized for policy recommendations and revision of the existing taxation norms.

Smokeless tobacco and cigarette smoking: chemical mechanisms and cancer prevention

Tobacco products present a deadly combination of nicotine addiction and carcinogen exposure resulting in millions of cancer deaths per year worldwide. A plethora of smokeless tobacco products lead to unacceptable exposure to multiple carcinogens, including the tobacco-specific nitrosamine N'-nitrosonornicotine, a likely cause of the commonly occurring oral cavity cancers observed particularly in South-East Asian countries. Cigarettes continue to deliver a large number of carcinogens, including tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons and volatile organic compounds. The multiple carcinogens in cigarette smoke are responsible for the complex mutations observed in critical cancer genes. The exposure of smokeless tobacco users and smokers to carcinogens and toxicants can now be monitored by urinary and DNA adduct biomarkers that may be able to identify those individuals at highest risk of cancer so that effective cancer prevention interventions can be initiated. Regulation of the levels of carcinogens, toxicants and nicotine in tobacco products and evidence-based tobacco control efforts are now recognized as established pathways to preventing tobacco related cancer.

Risk factors for chronic cough in adults: A systematic review and meta-analysis

Despite the challenges of diagnosing and managing adult patients with chronic cough, a systematic synthesis of evidence on aetiological risk factor is lacking. We systematically searched PubMed and EMBASE to synthesize the current evidence for longitudinal associations between a wide range of risk factors and chronic cough in the general adult population, following the meta-analysis of observational studies in epidemiology (MOOSE) guidelines. The Newcastle-Ottawa scale was used to assess the quality of the included studies. Fixed-effect meta-analysis was conducted where appropriate. Of 26 eligible articles, 16 domains of risk factors were assessed. There was consistent evidence that asthma (pooled adjusted OR [aOR] = 3.01; 95% CI: 2.33-3.70; I²  = 0%; number of articles [N] = 3) and low education levels/socioeconomic status (SES) (pooled aOR = 1.46; 95% CI: 1.20-1.72; I²  = 0%; N = 3) were associated with an increased risk of chronic cough after adjusting for smoking and other confounders. While continuous smoking was associated with chronic cough (aOR = 1.81; 95% CI: 1.36-2.26; I²  = 57%; N = 3), there was too little evidence to draw conclusions for occupational exposures, outdoor air pollution, early-life exposures, diet, snoring and other chronic conditions, including obesity, chronic obstructive pulmonary disease, gastro-oesophageal reflux disease and chronic pain. Asthma, persistent smoking and lower education/SES were associated with an increased risk of chronic cough. Longitudinal associations between other factors frequently mentioned empirically (i.e., occupational exposures, air pollution and chronic respiratory conditions) need further investigation, ideally with objective and standardized measurement.

District-level epidemiology, hot spots and sociodemographic determinants of tobacco use in Indian men and women: analysis of national family health survey-4 (2015-16)

OBJECTIVES

To map district-level tobacco hot spots and understand the Sociodemographic Indices (SDI) influencing tobacco consumption in Indian men and women.

STUDY DESIGN

Cross-sectional study.

METHODS

Tobacco use data from 640 districts of India were extracted from National Family Health Survey-4, carried out from 2015 to 2016 with a sample size of 103,411 men and 699,686 women. Geographic Information System was used to map the tobacco prevalence, and hot spots were identified by spatial statistics (Getis-OrdGi∗). SDI were studied by bivariate analyses and binary logistic regression.

RESULTS

India has two major tobacco hot spots; one comprising the districts of North-Eastern states, excluding Sikkim, and the second cluster is formed by the districts of Central-Eastern states. These hot spots coincide well with demographic determinants: North-East (adjusted odds ratio [aOR] men, 5.74; aOR women, 13.54) and Central India (aOR men, 4.5; aOR women, 3.5) have higher odds of Tobacco consumption. In men, respondents with no education (aOR 2.52; 95% confidence interval [CI]: 2.26-2.81) and Muslims (aOR 3.53; 95% CI: 2.93-4.26) have higher odds of tobacco consumption. The poorest (men aOR, 2.06; 95% CI: 1.87-2.27; women aOR, 3.36: 95% CI: 2.69-4.19) and ST women (aOR 1.89; 95% CI: 1.68-2.13) have higher odds of tobacco consumption.

CONCLUSIONS

We have identified tobacco hot spots and detailed the SDI affecting tobacco use separately in men and women to guide public health policies for targeted intervention of tobacco consumption.

Dyslipidemia and Cardiovascular Disease Prevention in South Asians: A Review and Discussion of Causes, Challenges and Management Strategies

BACKGROUND

South Asians are at a significantly increased risk of atherosclerotic cardiovascular disease (ASCVD). For a major portion of the South Asian population, the cardiovascular disease events occur at a relatively younger age, are associated with worse outcomes, and have potentially more severe socioeconomic implications compared to their western counterparts.

METHODS

The term "South Asian" typically constitutes individuals from India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives, including expatriates as well as their families from these countries. Based on this, South Asians form approximately 25% of the world's population, with a high ASCVD burden in this group. In this review, we discuss the pathophysiological factors underlying ASCVD in South Asians, the dyslipidemia types and management, and discuss approaches to improve the overall ASCVD prevention efforts in this large subset population of the world. Although the pathophysiological mechanisms underlying the excess risk of cardiovascular disease in South Asians are multifactorial, dyslipidemia is a primary risk factor for the incidence and prevalence of this disease. The traditional "South Asian" dyslipidemia pattern includes levels of low-density lipoprotein cholesterol (LDL-C) in the normal range with a high concentration of LDL particles, elevated triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) with dysfunctional HDL particles, and high levels of lipoprotein(a).

CONCLUSION

While combined efforts to study the expatriate South Asians in western countries have been able to identify South Asian specific dyslipidemias, causal associations and optimal management remain relatively less explored. Larger scale studies are needed to better quantify the relationship of each lipid parameter with ASCVD risk among South Asians as well as optimal lipid targets and management strategies to reduce morbidity and mortality in this high-risk group.

Pathophysiological Mechanisms Underlying Excess Risk for Diabetes and Cardiovascular Disease in South Asians: The Perfect Storm

BACKGROUND

South Asians are at a significantly increased risk of type 2 diabetes (T2D) and cardiovascular disease (CVD), are diagnosed at relatively younger ages, and exhibit more severe disease phenotypes as compared with other ethnic groups. The pathophysiological mechanisms underlying T2D and CVD risk in South Asians are multifactorial and intricately related.

METHODS

A narrative review of the pathophysiology of excess risk of T2D and CVD in South Asians.

RESULTS

T2D and CVD have shared risk factors that encompass biological factors (early life influences, impaired glucose metabolism, and adverse body composition) as well as behavioral and environmental risk factors (diet, sedentary behavior, tobacco use, and social determinants of health). Genetics and epigenetics also play a role in explaining the increased risk of T2D and CVD among South Asians. Additionally, South Asians harbor several lipid abnormalities including high concentration of small-dense low-density lipoprotein (LDL) particles, elevated triglycerides, low high-density lipoprotein (HDL)- cholesterol levels, dysfunctional HDL particles, and elevated lipoprotein(a) that predispose them to CVD.

CONCLUSION

In this comprehensive review, we have discussed risk factors that provide insights into the pathophysiology of excess risk of T2D and CVD in South Asians.

The Association Between Participation in Mahatma Gandhi National Rural Employment Guarantee Program and Smoking in India

BACKGROUND

This paper examines whether participating in Mahatma Gandhi National Rural Employment Guarantee Program (NREGA) is associated with the likelihood of smoking among program participants in India.

METHODS

We use two-stage residual inclusion (2SRI) estimation method and two waves of India Human Development Surveys completed before (2005) and after (2012) NREGA implementation.

RESULTS

The likelihood of smoking increased with NREGA participation. For every 10% increase in NREGA income, the likelihood of smoking bidis (but not cigarettes) increased by 0.88 percentage point. A bidi, a stick of unprocessed tobacco wrapped in temburini leaves, is a significantly cheaper alternative to cigarettes. Nonparticipants who had a comparable increase in income between the two India Human Development Survey waves did not show an increase in likelihood of smoking. The heterogeneity in NREGA treatment effect shows that smoking tendency is not influenced by caste/religion or literacy.

CONCLUSIONS

NREGA, as the largest workfare program, most certainly has had a significantly positive influence on the rural poor in India. The findings highlight its small but meaningful influence of a negative health behavior, greater likelihood of uptake of smoking bidis/hookah among program participants.

IMPLICATIONS

Existing studies have found mixed evidence of an exogenous increase in income among low-income adults and its impact on smoking. No studies to date have tested the influence of workfare programs in rural areas of developing countries, where unemployment rates are higher and a substantial share of population in those areas is poor. Based on participation in employment guarantee programs as a proxy for exogenous increase in guaranteed income among rural population in India, we find that participants in the program were more likely to smoke bidis/hookah but not cigarettes.

The prevalence of depression symptoms after smoking cessation: a systematic review and meta-analysis

Objectives: Smoking cessation can have positive effects on people's health, especially mental health. This study aimed to address the prevalence of depression in the smoking cessation population. Methods: In the present meta-analysis study, PRISMA protocol was used. Two databases, PubMed and Scopus, were selected. Articles in these two databases in English were targeted and the search was limited to July 2020. First, the results related to the prevalence of depression were calculated. The results were pooled. Results: Forty-nine articles with different designs were eligible for meta-analysis. The prevalence of depression in the smoking cessation population was 18% and the confidence interval was 14-22%. The highest depression prevalence was in Asia and Europe, followed by America. The prevalence of major depression in the smoking cessation population was 15% and the prevalence of depressive symptoms was 17%. The smoking cessation population had a lower odds of depression than current smokers (OR= 0.63 CI = 0.54-0.75; I2 83.9%). There was little evidence for publication bias. Discussion: The status of depression in the smoking cessation population is different from that of nonsmokers and current smokers. Therefore, in terms of health policy and encouraging people to smoking cessation, the issue of its positive effects on mental health should be emphasized.

Patterns and predictors of mortality in a semi-urban population-based cohort in Sri Lanka: findings from the Ragama Health Study

OBJECTIVE

To describe patterns and predictors of mortality in a semi-urban population in Sri Lanka.

DESIGN

A prospective population-based cohort study.

SETTING

Ragama Medical Officer of Health area in the Gampaha district, Sri Lanka.

PARTICIPANTS

Adults between 35 and 64 years of age were recruited using an age stratified random sampling technique in 2007.

MEASURES

At baseline, we recorded socio-demographic, lifestyle, anthropometric, biochemical and clinical data of the participants. Over 10 years, we obtained the cause and date of death from the death registration documents of deceased participants. We determined the survival probability of the cohort over 10 years and estimated Hazard ratios (HRs) for all-cause mortality (ACM), cardiovascular mortality (CVM) and cancer-related mortality (CRM) using Cox's proportional hazards model. We also estimated the survival probabilities for men and women in each 10-year age group and standardised mortality ratio relative to the source population.

RESULTS

There were 169 deaths over 10 years with standardised mortality rates of 5.3 and 2.4 per 1000 years of follow-up for men and women, respectively. Independent predictors of: ACM were older age, lower income, smoking and diabetes mellitus while gender, education, occupation, harmful alcohol use, waist circumference and hypertension were not; CVM were older age, lower income, smoking, diabetes and hypertension while gender and harmful alcohol use were not; CRM was older age while gender, smoking and diabetes were not. Those engaged in clerical and technical occupations or unemployed had a lower risk of CRM as compared with those engaged in elementary occupations.

CONCLUSIONS

Older age, lower income, smoking, diabetes and hypertension strongly predict mortality in this cohort. Addressing the identified modifiable predictors through behavioural modification will improve longevity in similar populations.

Prevalence and predictors of hazardous alcohol use among tuberculosis patients: The need for a policy on joint tuberculosis-alcohol collaborative activities in India

Collaborative activities to address tobacco addiction among tuberculosis (TB) patients are in place in India. The research was carried out to estimate the prevalence and to determine the predictors of hazardous alcohol use among pulmonary TB patients, assessing the need for joint TB-alcohol collaborative activities. It was a cross-sectional study carried out among 200 drug-sensitive pulmonary TB patients of Bhavnagar city of Gujarat using the "Alcohol Use Disorder Identification Test" (AUDIT), with patients scoring ≥8 on AUDIT said to be having hazardous alcohol use. The prevalence of hazardous alcohol use among drug-sensitive pulmonary tuberculosis patients was found to be 20% (95% CI = 15%-26%). On applying multiple logistic regression, regular use of smokeless tobacco (adjusted Odds Ratio aOR = 5, 95% CI = 1.8-14.9, p = 0.002), history of alcohol use by father (aOR = 4, 95% CI = 1.7-10.2, p = 0.002), residing at a place where spurious liquor was being brewed (aOR = 4.8, 95% CI = 1.4-16.4, p = 0.012), and belonging to scheduled caste/scheduled tribe (SC/ST) (aOR = 2.7, 95% CI = 1.1-6.8, p = 0.034) were the significant predictors for hazardous alcohol use. It is concluded from the study that one-fifth of drug-sensitive pulmonary tuberculosis patients in Bhavnagar have hazardous alcohol use. The study calls for joint TB-alcohol collaborative activities in India.

How the Bidi Tobacco Industry Harms Child-workers: Results From a Walk-through and Quantitative Survey

Objective

Bidi is an inexpensive, low-processed, hand-rolled tobacco product. In Bangladesh, especially in Rangpur, tobacco farming and bidi processing are common. In this study, we aimed to evaluate the impact of bidi making on children working in bidi factories.

Methods

This qualitative(walk-through survey) and quantitative(questionnaire-based survey and a urine cotinine level quantitation) study was conducted in Rangpur, Bangladesh in 2017. Study population included child-workers aged ≤14 years who were regularly employed as bidi makers.

Findings

The results of the walk-through survey revealed hazardous working environments at bidi factories. For the quantitative survey, 171 child-workers were categorized into "less-working"(<5 hours/day) and "more-working"(≥5 hours/day) groups; additionally, "forced-working"(forced into work by parents) and "voluntary-working"(working voluntarily) groups were delineated within the same population. In the logistic regression analysis, odds ratios(ORs) of respiratory symptoms and unusual absence(absent ≥5 days/month) were higher in the "more-working" group than in the "less-working" group(unusual absence: OR, 2.91; 95% confidence interval[CI], 1.43-5.94), and this association became higher in the "forced-working" group with longer working hours(OR, 5.68, 95%CI 2.30-14.00).

Conclusions

Cheap, hand-rolled tobacco(bidi) is harmful to the health of bidi-making child-workers. Children in poverty bow to the demands of cheap labor and poverty and jeopardize their health and future prospects by working in bidi factories. Tobacco control policies should consider the social effects of tobacco beyond its biological effects.

Patterns and related factors of bidi smoking in India

INTRODUCTION

Bidis are the most commonly smoked tobacco product in India. Understanding bidi smoking is important to reducing overall tobacco smoking and health-related consequences in India. We analyzed 2009–2010 and 2016–2017 Global Adult Tobacco Survey (GATS) India data to examine bidi smoking and its associated sociodemographic correlates and perceptions of dangers of smoking.

METHODS

GATS is a nationally representative household survey of adults aged ≥15 years, designed to measure tobacco use and tobacco control indicators. Current bidi smoking was defined as current smoking of one or more bidis during a usual week. We computed bidi smoking prevalence estimates and relative change during 2009–2010 and 2016–2017. Used pooled multilevel logistic regression to identify individual-level determinants of bidi smoking and neighborhood-level and state-level variations.

RESULTS

Overall, 9.2% and 7.7% of adults smoked bidis in India during 2009–2010 and 2016–2017, respectively, reflecting 16.4% significant relative decline. In pooled analysis, male, older age, rural residence, lower education level, lower wealth index, less knowledge about harms of smoking, and survey year were associated with increased odds of bidi smoking. Results also showed variance in odds of smoking bidis is associated with neighborhood (15.9%) and state (31.8%) level.

CONCLUSIONS

Higher odds of bidi smoking were found among males, older age groups, and among those with lower socioeconomic status. Accordingly, health education interventions designed for these groups across India and other population-level interventions, such as WHO recommendation on increasing price on tobacco products, could help reduce bidi smoking. In addition, state/neighborhood-specific interventions could also help address differential bidi smoking across India.

Nasal Mucociliary Clearance in Smokers: A Systematic Review

Introduction  Smoking is one of the most important causes of mortality and morbidity in the world, as it is related to the risk factor and etiology of respiratory-tract diseases. Long-term smoking causes both structural and functional damage in the respiratory airways, leading to changes in nasal mucociliary clearance (NMC). Objectives  The aim of the present study was to look systematically into the current literature and carefully collect and analyze results to explore NMC in smokers. Data Synthesis  Two independent reviewers conducted a literature search on some Electronic database: Pubmed, Medline, Ebsco, Springer Link, Science Direct, Scopus, and Proquest searching for articles fulfilling the inclusion and exclusion criteria. The lead author independently assessed the risk of bias of each of the included studies and discussed their assessments with the other two authors to achieve consensus. Of the 1,654 articles identified in the database search, 16 met the criteria for this review. Most of the articles (15 out of 16) showed the impairment of NMC in smokers. Conclusion  The present systematic review suggests that there is an impairment of NMC in smokers. The impairment is not only observed in cigarette smoking, but also in passive smoking, bidi smoking, electronic smoking, and hookah smoking. The impairment of NMC in chronic exposure to smoking is caused by the ciliotoxic effect, hypersecretion and viscoelastic change of mucous, airway surface liquid depletion, increased oxidative stress, and deteriorations in the inflammatory and immune systems.

Analysis of chemical constituents in mainstream bidi smoke

Bidi, an indigenous form of cigarette in South Asian countries, is popular because of its low cost and multi-flavored variants. Although recent studies have shown that bidi smokers suffer from various adverse health effects including cancer, research on bidi smoke composition and exposure levels is still very limited. In this research, the vapor and particulate phases of bidi were characterized using gas chromatography coupled with mass spectrometry (GC–MS) and Fourier-transform infrared spectrometry (FTIR). The amounts of nicotine, cotinine, indole, substituted phenols, substituted pyridines, and phytol found in different size fractions of the particulate matter collected using a cascade impactor were reported. Due to the low combustibility of the tendu leaf in bidi, a six-second puff interval was used to sample the smoke constituents for analysis. Significant levels of carbon monoxide, hydrogen cyanide, and hydrocarbons like ethylene, methane and 1, 3-butadiene were detected in the mainstream bidi smoke. In addition, 3-methylpyridine, cotinine, α-amyrin, and β-amyrin were also present at high levels in bidi smoke. Despite having less tobacco compared to conventional cigarette, bidi smokers are potentially exposed to significantly higher concentrations of nicotine due to the greater puffing frequency. The non-porous nature and higher moisture content of tendu leaf in bidis compared to cigarette wrapping paper led to higher levels of carbon monoxide and tar in bidi smoke compared to regular cigarette smoke. Results of this study indicate the presence of harmful and carcinogenic chemicals in the mainstream bidi smoke that could be harmful to human health.

Assessing health-seeking behavior among Asthma and COPD patients in urban South India

CONTEXT

Health-seeking behavior of patients with chronic obstructive pulmonary disease (COPD) and asthma and the diagnosis told to them by doctors before they reach tertiary care is not well documented.

AIMS

This study aimed at describing the health-seeking behavior of asthma and COPD patients before they present to a tertiary care hospital in Trivandrum in South India.

METHODS AND MATERIALS

The hospital-based cross-sectional study was done at one government and one private tertiary care hospital in Trivandrum, Kerala, including diagnosed COPD and asthma patients. Data were collected using a pretested semistructured questionnaire paired with the results of clinical evaluation and spirometry.

RESULTS

Among the studied population, about half (53%) of the patients in this study sought initial treatment from government facilities and most patients continued the same pattern of government care or private providers till the final level. Most of them (91%) were likely to have a history of first care from modern medicine system. High proportion of patients (89%) did not have a diagnosis known after the initial consultations, among patients with asthma only 3.4% were given a correct diagnosis and only one person was given a correct diagnosis of COPD out of 129 patients with COPD as the final diagnosis. Out of 739 patients, only 135 patients had done pulmonary functtion test as investigation.

CONCLUSIONS

High proportions of patients do not know the diagnosis of their disease when they reached tertiary care. Patients tended to follow the same sector of health care (private/government) where they sought initial care.

Impact of Normal Weight Central Obesity on Clinical Outcomes in Male Patients With Premature Acute Coronary Syndrome

There is a lack of studies that evaluate the association between normal weight central obesity and subsequent outcomes in patients with premature acute coronary syndrome (ACS). We evaluated 338 consecutive male patients (aged ≤ 55 years) with premature ACS. The primary outcomes were all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE). We compared the hazard ratios (HRs) in patients with and without normal weight central obesity using multivariable Cox proportional hazard models. All-cause mortality (16.8%) of patients with normal weight central obesity was much higher than those (7.1%) without normal weight central obesity (P = .008). The incidence of MACCE in patients with and without normal weight central obesity were 40.7 and 23.6% (P = .001), respectively. After multivariable adjustment, the risks of all-cause mortality and MACCE were significantly higher in patients with normal weight central obesity than those without normal weight central obesity (adjusted HR: 1.83; 95% confidence interval [CI]: 1.04-3.31; P = .004 and adjusted HR: 1.62; 95% CI: 1.18-2.27; P = .017, respectively). In conclusion, the risks of all-cause mortality and MACCE were significantly higher in male patients with premature ACS with normal weight central obesity than in those without normal weight central obesity.

Economic costs of diseases and deaths attributable to bidi smoking in India, 2017

Objective

To estimate the economic burden of diseases and deaths attributable to bidi smoking in India for persons aged 30–69 years.

Methods

The National Sample Survey data on healthcare expenditures, data on bidi smoking prevalence from the Global Adult Tobacco Survey and relative risks of all-cause mortality from bidi smoking are used to estimate the economic burden of diseases and deaths attributable to bidi smoking in India using a prevalence-based attributable-risk approach. Costs are estimated under the following heads: (1) direct medical expenditure of treating diseases; (2) indirect morbidity costs and (3) indirect mortality costs of premature deaths.

Findings

The total economic costs attributable to bidi smoking from all diseases and deaths in India in the year 2017 for persons aged 30–69 years amount to INR805.5 billion (US$12.4 billion), of which 20.9% is direct and 79.1% is indirect cost. Men bear 93.7% of the total costs.

Conclusion

The total annual economic costs of bidi smoking amount to approximately 0.5% of India’s gross domestic product, while the excise tax revenue from bidi is only half a per cent of its economic costs. The direct medical costs of bidi smoking amount to 2.24% of total health expenditure. Since the poor bear a disproportionately large share of the economic costs of bidi smoking, the unregulated use of bidi would potentially push more households in India, which incur heavy out-of-pocket expenditures on healthcare, into poverty.

Epidemiologic studies targeting primary cardiovascular disease prevention in South Asia

South Asia has experienced a 73% increase in healthy life years lost due to ischemic heart disease between 1990 and 2010. There is a lack of quality data relating to cardiovascular risk factors and disease from this region. Several observational and prospective cohorts in South Asia have been established in recent times to evaluate the burden of cardiovascular disease and their risk factors. The Prospective Rural Urban Epidemiology (PURE) study is the largest of these studies that has provided data on social, environmental, behavioral and biologic risk factors that influence heart disease and diabetes. Some studies have also borrowed data from large datasets to provide meaningful insights. These studies have allowed a better understanding of cardiovascular disease risk factors indigenous to the South Asian population along with conventional risk factors. Culturally sensitive interventions geared towards treating risk factors identified in these studies are needed to fully realize the true potential of these epidemiologic studies.