National and subnational burden of non-cancer health outcomes related to bidi consumption in India

Abstract Introduction Bidi is the most prevalent form of smoked tobacco in India and is often perceived as less harmful than cigarettes. While evidence on bidi-related cancers is growing, the burden of non-cancer health outcomes remains poorly quantified and largely dependent on secondary estimates. This study aimed to generate national and subnational estimates of mortality and disability attributable to bidi consumption for major non-cancer diseases in India. Methods A two-phase methodology was employed. First, a meta-analysis of Indian studies published between 2000 and 2022 was conducted to estimate pooled odds ratios and population attributable fractions (PAFs) for major diseases resulting from bidi consumption. These PAFs were applied to state-wise mortality and disability-adjusted life years (DALYs) from the Global Burden of Disease 2021 database. Next, a country-wide cross-sectional hospital-based survey was conducted across 21 healthcare facilities in 11 states/UTs, enrolling patients diagnosed with the selected diseases to estimate disease-specific bidi exposure and derive primary burden estimates. Results The highest PAF was observed for TB (0.21), followed by COPD (0.19), IHD (0.17), and CVD (0.03). Secondary analysis estimated 568,453 annual deaths and 14.8 million DALYs attributable to bidi consumption. Primary data indicated a higher burden, with 757,590 annual deaths and 20.2 million DALYs lost. Uttar Pradesh, Maharashtra, Tamil Nadu, Gujarat, and West Bengal, accounted for nearly half of the national burden. Conclusion Bidi consumption contributes substantially to non-cancer mortality and disability in India, highlighting the urgent need for strengthened surveillance, non-cancer registries, and targeted tobacco control interventions.