Print this page Email this page | Users Online: 264
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 91-95

Trends and patterns of head-and-neck cancer among a cohort of bidi smokers: A clinical study

1 Department of Oral Pathology/Oral Medicine and Radiology, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India
2 Department of Periodontology, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India
3 Raj Bala Dental Center, B-90, Ramesh Vihar, Aligarh, Uttar Pradesh, India
4 Department of Periodontics and Community Dentistry, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Date of Submission13-Jun-2022
Date of Decision04-Aug-2022
Date of Acceptance08-Aug-2022
Date of Web Publication09-Sep-2022

Correspondence Address:
Dr. Juhi Gupta
Department of Oral Pathology/Oral Medicine and Radiology, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh, Uttar Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/srmjrds.srmjrds_84_22

Rights and Permissions

Background: In India, bidi smoking is prevalent among people of low socioeconomic status as it is cheaper than a cigarette. Aim: The aim of the current study was to analyze the pattern of distribution of oral and oropharyngeal cancer in bidi smokers in the Western Uttar Pradesh population. Materials and Methods: This unicentric cross-sectional study was conducted on patients having an exclusive habit of bidi smoking in the tertiary health care center from March 2019 to February 2022. Five hundred and eighty-five patients diagnosed with oropharyngeal or oral cancer, who were willing to share information related to the bidi smoking habit were enrolled. A Chi-square test and unpaired t-test were used for the statistical analysis. Results: The base of the tongue was found to be the most common site of oral cancer. It was our observation that 61.75% of men had cancer in the oropharynx, and about 34.8% had cancer in the oral cavity. Conclusion: Bidi smoke is dangerous and contains many carcinogenic agents. Bidi smokers have an increased risk of oropharyngeal cancer as compared to oral cancer.

Keywords: Bidi smoking, cigarette smoking, oral cancer, oropharyngeal cancer

How to cite this article:
Gupta J, Asadullah M, Mariam S, Jain V, Verma P, Agarwal N. Trends and patterns of head-and-neck cancer among a cohort of bidi smokers: A clinical study. SRM J Res Dent Sci 2022;13:91-5

How to cite this URL:
Gupta J, Asadullah M, Mariam S, Jain V, Verma P, Agarwal N. Trends and patterns of head-and-neck cancer among a cohort of bidi smokers: A clinical study. SRM J Res Dent Sci [serial online] 2022 [cited 2023 May 28];13:91-5. Available from:

  Introduction Top

Oral cancer is the sixth most common cancer worldwide.[1] Among all cancers, oral cancer is one of the most prevalent cancers in India and accounts for one-third of all oral cancer cases worldwide. A total of 77,000 new cases and 52,000 deaths are reported in India every year, which accounts for approximately one-fourth of global cases and deaths. Since oral cancer is one of the most common types of cancer in India, it is of great concern for community health.[2] Even though the oral cavity is the most accessible area of the body, the oral cancer diagnosis is usually delayed due to a lack of knowledge regarding the initial sign of the disease and individual negligence toward their oral health.

The overall 5-year survival rate for people with cancer is 85% if they are diagnosed at an early stage. About 28% of oral and oropharyngeal cancers are diagnosed at this stage. The overall 5-year survival rate is 68% if cancer has spread to nearby tissues, organs, or lymph nodes (meaning cancer has spread locally). In 50% of cases, oral or oropharyngeal cancers are diagnosed at this stage. There is a 40% 5-year survival rate when cancer spreads distantly to another part of the body (distant metastasis stage). About 18% of oral and oropharyngeal cancers are diagnosed at this stage.[3]

The etiological factors that may be related to oral or oropharyngeal cancer are nutritional deficiencies, use of smoke or smokeless tobacco, alcohol, and areca nut. It is common for Indians, particularly those from low socioeconomic backgrounds, to smoke bidis. Among this stratum of the population, bidi is considered a cheaper alternative to cigarettes. Studies done on the hazardous effects of smoking bidi have conclusively proven that bidi smoke is more hazardous.[4] The lack of general awareness of the harmful effects of bidi and the age-old belief that bidi smoking is safe may be behind the popularity of the practice.

Keeping these facts in mind, a study was conducted on the cohort of bidi smokers in the Aligarh population. The aim of the study was to analyze the pattern of occurrence of oral and oropharyngeal cancer in bidi smokers.

  Materials and Methods Top

Study design

It was a unicentric cross-sectional clinical, epidemiological study.

Study setting

The study was started in March 2019 and completed in February 2022. The study was conducted on cancer patients visiting tertiary health care center associated with medical college before radiation therapy. The study was approved by the Institutional Ethical Committee of Jawaharlal Nehru Medical College, AMU on February 10, 2019 with Ethical Approval Number IECJNMC/635. All the participants provided written informed consent for participation in the study. All procedures performed in the study were conducted in accordance with the ethical standards given in 1964 Declaration of Helsinki, as revised in 2013.

Study size

The sample size was determined using Cochran's formula (Z2pq/e2). According to this formula, the minimum sample size for an unknown large population should be 385.


The study participants had a histopathologically confirmed cancer diagnosis at the time of the study. Patients with habits other than smoking bidi, either alone or in combination with bidi, were excluded from the study. In addition, patients unwilling to participate in the study, with an inconclusive or doubtful diagnosis of lesion were excluded. History of bidi smoking, the amount, duration, and age of initiation of the habit were recorded. The socioeconomic status of the participants was calculated based on their occupation, monthly family income, and education status using Kuppuswamy socioeconomic status scale 2021.

Statistical analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 22 Armonk, NY, USA.. An unpaired t-test was used to compare the continuous data. A Chi-square goodness-of-fit test was performed to determine whether the cancers were equally distributed between oral cavity, oropharynx, and others. The level of significance was set at P < 0.05

  Results Top

The proportion of men and women in the study sample was found to be 94.7% (554) and 5.3% (31), respectively. The majority of the patients were farmers with monthly family income in the range of Rs. 6000–7000. The education status of most of the patients was below the middle school level. About 94.7% of the participants belonged to upper or lower class and 5.3% belonged to lower class socioeconomic status. The mean age of initiation of habit was found to be 22.45 ± 5.8 years for males and 20 ± 4.3 years for females (P = 0.004). The percentage of the study population with a frequency of smoking 10–20 bidi/day was 53.3% [Figure 1].
Figure 1: Distribution according to number of bidis smoked per day

Click here to view

It was found that the number of patients with cancers of the oropharynx (357) was more in number than cancers of the oral cavity (208) and other sites (20). This was statistically significant (P = 0.001). The most common site of occurrence of cancer was the base of the tongue. This is followed by other sites which included buccal mucosa, hard palate, lateral border of the tongue [Figure 2], and tonsil. Men and women did not differ significantly in the distribution of sites of oral and oropharyngeal cancer [Table 1]. Single site involvement (93.5%) was more common than concomitant lesions on two or more sites [Figure 3].
Figure 2: Carcinoma of left lateral border of tongue

Click here to view
Table 1: Distribution of sites of oral and oropharyngeal cancers between males and females

Click here to view
Figure 3: Frequency distribution of site of oral/oropharyngeal cancer

Click here to view

  Discussion Top

Tobacco contains many carcinogenic agents. Bidi and cigarettes are the two common types of smoked tobacco. Bidi comprises tobacco wrapped in a tendu or temburni leaf (plants native to Asia) and may be secured with a colorful string at one or both ends. Bidis can be flavored (e.g. chocolate, cherry, and mango) or unflavored. Bidis and kreteks have higher concentrations of nicotine, tar, and carbon monoxide than conventional cigarettes sold in the United States.[5]

Because of its low cost, bidi is popular as an alternative to cigarette smoking among people belonging to low socioeconomic status. In our study, all the patients belonged to a poor socioeconomic state and were using bidi as a cheaper alternative to cigarette smoking. The finding of our study is in agreement with the study conducted by Mbulo et al.[6]

It is a common misconception that these bidis are less harmful as it contains less tobacco. However, it is untrue. Despite the common misconception that hand-rolled bidi is safer to smoke than cigarettes because it contains fewer chemicals, it is just as harmful or even more dangerous. According to estimates, 53 million people used bidi in India and Bangladesh between 2003 and 2009.[7]

According to the study conducted by Reddy and Shaik, compared with unfiltered cigarettes, filtered cigarettes averaged 802.3 mg, while unfiltered cigarettes averaged 800.4 mg. 712.2 and 728 mg of tobacco were found in filtered and unfiltered cigarettes, respectively. Smokers who smoked filtered cigarettes had an average nicotine concentration of 14.5 mg/g, whereas those who smoked unfiltered cigarettes had an average nicotine concentration of 15.6 mg/g. 399.4 mg was the average weight of the bidis. Each bidi contained an average of 187.5 mg of tobacco. Forty-seven percentage of the bidi weight was made up of tendu leaf wrapping. There was an average nicotine concentration of 26.9 mg/g in bidis, while it was 15 mg/g in cigarettes; this was a significant finding.[8] Apart from that, the study conducted by Malson et al. also found that bidi tobacco had a nicotine content of 21.2 mg/g, which was considerably higher than that of commercial, filtered (16.3 mg/g), and unfiltered cigarettes (13.5 mg/g).[9]

Tobacco smoke from conventional cigarettes is a highly complex and dynamic mixture of more than 6500 constituents with 150 harmful or potentially harmful substances and more than 50 known carcinogens. While mainstream cigarette smoke is very complex, bidi smoke may have additional compounds due to the unconventional ingredients used in manufacturing.[4] When total consumption of cigarette/bidi was more than 5 packs/year, the average breath CO level was significantly higher for bidi smokers (18.9 ppm × 7.7 ppm) than cigarette smokers (13.6 ppm × 5.8 ppm) (P = 0.002).[8] Due to the fact that bidis are typically unfiltered, they may be able to deliver a higher amount of these carcinogens to the oral cavity when smoked.[10]

Tendu leaves are not very flammable, so bidi smokers tend to smoke with more force. Bidi requires multiple relights since they self-extinguish after a few puffs. This also leads to an increased level of tar and carbon monoxide level in bidi smoke as compared to cigarettes.[4] Bidi smoke contains more carbon monoxide, nicotine, and other components than cigarette smoke. As a result, the health risks associated with nicotine and other elements of bidi smoke are multiplied many folds, making it more dangerous than cigarette smoking.[11],[12]

Cancer of the mouth is a multifactorial disease. Smoking or using smokeless tobacco, areca nut, and alcohol separately or in combination may lead to oropharyngeal or oral cancer. Oral and oropharyngeal cancer are almost twice as common in men as compared to women.[3] It is estimated that men have a lifetime risk of developing oral cavity and oropharyngeal cancer of 1 in 60 (1.7%), while women have a lifetime risk of 1 in 140 (0.71%).[13] However, the ratio is very much high in men as compared to women in our study group (17.87:1). It may be due to the underreporting of oral and oropharyngeal cancer cases in females. The most common frequency of bidi smoking in our study was found to be 10–20 bidi/day. The finding of our study is consistent with the study conducted by Prasad et al.[14] In our study, it was also observed that the age of initiation of habit was at a much younger age in women than in men and it was found to be significant. It was difficult to determine the exact reason, but it was evident during history taking that either the spouse smoked bidi or there was a family history of the habit.

The clastogenic and genotoxic effect of bidi smoke on human beings is a well-established fact.[15] A study conducted by Rao and Desai[16] found that the base of the tongue was the most common site of cancer. Our findings corroborate their findings that bidi smoking increases the risks of carcinoma of the base of the tongue. Bidi smokers have an increased risk of oropharyngeal cancer as compared to oral cancer. The finding of our study is in agreement with the study conducted by Dikshit and Kanhere.[17] The authors have observed that both bidi and cigarette smokers had an increased risk for oropharyngeal and lung cancer but only a marginally increased risk for oral cancer.[17]

Rahman et al. conducted a study and concluded that bidi smokers have a higher risk of oral cancer as compared to nonsmokers.[18] The findings of our study are in partial disagreement with the current study because we have done the study on the pattern of distribution of cancer sites among bidi smokers alone. We had excluded nonsmokers and subject with any other oral habits.

Patients who reported for radiotherapy were included in our study. This could be considered selection bias which also contributed to the increased prevalence of oropharyngeal cancer in our study group compared to oral cancer.

  Conclusion Top

Bidis are an affordable alternative to manufactured cigarettes and are readily available in India. However, since bidis are readily available and affordable, it has become a significant health threat, particularly among people of low socioeconomic status.

Despite having a lower tobacco content than filtered or unfiltered cigarettes, bidi contains higher levels of nicotine and cancer-causing chemicals such as carbon monoxide, ammonia, hydrogen cyanide, phenol, and volatile phenols. Awareness regarding the harmful effect of bidi among the general population is low as compared to cigarettes. To control and monitor the availability of bidi in India, the sale and price of it must be regulated.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Dhanuthai K, Rojanawatsirivej S, Thosaporn W, Kintarak S, Subarnbhesaj A, Darling M, et al. Oral cancer: A multicenter study. Med Oral Patol Oral Cir Bucal 2018;23:e23-9.  Back to cited text no. 1
Borse V, Konwar AN, Buragohain P. Oral cancer diagnosis and perspectives in India. Sens Int 2020;1:100046.  Back to cited text no. 2
Risk Factors for Oral Cavity and Oropharyngeal Cancers. Available from: oral cavity and oropharyngeal cancer/causes risks prevention/ risk factors.html. USA, American Cancer Society. 2021.  Back to cited text no. 3
Oladipupo OA, Dutta D, Chong NS. Analysis of chemical constituents in mainstream bidi smoke. BMC Chem 2019;13:93.  Back to cited text no. 4
Malson JL, Lee EM, Murty R, Moolchan ET, Pickworth WB. Clove cigarette smoking: biochemical, physiological, and subjective effects. Pharmacol Biochem Behav. 2003 Feb;74(3).  Back to cited text no. 5
Mbulo L, Palipudi KM, Smith T, Yin S, Munish VG, Sinha DN, et al. Patterns and related factors of bidi smoking in India. Tob Prev Cessat 2020;6:28.  Back to cited text no. 6
Duong M, Rangarajan S, Zhang X, Killian K, Mony P, Swaminathan S, et al. 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). Lancet Glob Health 2017;5:e168-76.  Back to cited text no. 7
Reddy SS, Shaik HA. Estimation of nicotine content in popular Indian brands of smoking and chewing tobacco products. Indian J Dent Res 2008;19:88-91.  Back to cited text no. 8
[PUBMED]  [Full text]  
Malson JL, Sims K, Murty R, Pickworth WB. Comparison of the nicotine content of tobacco used in bidis and conventional cigarettes. Tob Control 2001;10:181-3.  Back to cited text no. 9
Khan A, Ongole R, Baptist J, Srikant N, Lukmani F. Patterns of tobacco use and its relation to oral precancers and cancers among individuals visiting a tertiary hospital in South India. J Contemp Dent Pract 2020;21:304-9.  Back to cited text no. 10
Kumar R, Prakash S, Kushwah AS, Vijayan VK. Breath carbon monoxide concentration in cigarette and bidi smokers in India. Indian J Chest Dis Allied Sci 2010;52:19-24.  Back to cited text no. 11
Watson CH, Polzin GM, Calafat AM, Ashley DL. Determination of tar, nicotine, and carbon monoxide yields in the smoke of bidi cigarettes. Nicotine Tob Res 2003;5:747-53.  Back to cited text no. 12
Oral and Oropharyngeal Cancer: Statistics. Available from: https:// statistics. USA, American Society of Clinical Oncology (ASCO); March 2022.  Back to cited text no. 13
Prasad R, Ahuja RC, Singhal S, Srivastava AN, James P, Kesarwani V, et al. A case-control study of bidi smoking and bronchogenic carcinoma. Ann Thorac Med 2010;5:238-41.  Back to cited text no. 14
[PUBMED]  [Full text]  
Yadav JS, Thakur S. Cytogenetic damage in bidi smokers. Nicotine Tob Res 2000;2:97-103.  Back to cited text no. 15
Rao DN, Desai PB. Risk assessment of tobacco, alcohol and diet in cancers of base tongue and oral tongue – A case control study. Indian J Cancer 1998;35:65-72.  Back to cited text no. 16
Dikshit RP, Kanhere S. Tobacco habits and risk of lung, oropharyngeal and oral cavity cancer: A population-based case-control study in Bhopal, India. Int J Epidemiol 2000;29:609-14.  Back to cited text no. 17
Rahman M, Sakamoto J, Fukui T. Bidi smoking and oral cancer: A meta-analysis. Int J Cancer 2003;106:600-4.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded155    
    Comments [Add]    

Recommend this journal