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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(2):e168-e176LG

Abstract

BACKGROUND

Bidis are minimally regulated, inexpensive, hand-rolled tobacco products smoked in south Asia. We examined the effects of bidi smoking on baseline respiratory impairment, and prospectively collected data for all-cause mortality and cardiorespiratory events in men from this region.

METHODS

This substudy of the international, community-based Prospective Urban Rural Epidemiology (PURE) study was done in seven centres in India, Pakistan, and Bangladesh. Men aged 35-70 years completed spirometry testing and standardised questionnaires at baseline and were followed up yearly. We used multilevel regression to compare cross-sectional baseline cardiorespiratory symptoms, spirometry measurements, and follow-up events (all-cause mortality, cardiovascular events, respiratory events) adjusted for socioeconomic status and baseline risk factors between non-smokers, light smokers of bidis or cigarettes (≤10 pack-years), heavy smokers of cigarettes only (>10 pack-years), and heavy smokers of bidis (>10 pack-years).

FINDINGS

14 919 men from 158 communities were included in this substudy (8438 non-smokers, 3321 light smokers, 959 heavy cigarette smokers, and 2201 heavy bidi smokers). Mean duration of follow-up was 5·6 years (range 1-13). The adjusted prevalence of self-reported chronic wheeze, cough or sputum, dyspnoea, and chest pain at baseline increased across the categories of non-smokers, light smokers, heavy cigarette smokers, and heavy bidi smokers (p<0·0001 for association). Adjusted cross-sectional age-related changes in forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity (FVC) ratio were larger for heavy bidi smokers than for the other smoking categories. Hazard ratios (relative to non-smokers) showed increasing hazards for all-cause mortality (light smokers 1·28 [95% CI 1·02-1·62], heavy cigarette smokers 1·59 [1·13-2·24], heavy bidi smokers 1·56 [1·22-1·98]), cardiovascular events (1·45 [1·13-1·84], 1·47 [1·05-2·06], 1·55 [1·17-2·06], respectively) and respiratory events (1·30 [0·91-1·85], 1·21 [0·70-2·07], 1·73 [1·23-2·45], respectively) across the smoking categories.

INTERPRETATION

Bidi smoking is associated with severe baseline respiratory impairment, all-cause mortality, and cardiorespiratory outcomes. Stricter controls and regulation of bidis are needed to reduce the tobacco-related disease burden in south Asia.

FUNDING

Population Health Research Institute, Canadian Institutes of Health Research, and Heart and Stroke Foundation of Ontario.

Authors+Show Affiliations

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. Electronic address: duongmy@mcmaster.ca.Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.Division of Epidemiology and Population Health, St John's Research Institute, Bengaluru, India.Division of Epidemiology and Population Health, St John's Research Institute, Bengaluru, India.Division of Epidemiology and Population Health, St John's Research Institute, Bengaluru, India.Department of Pulmonary Medicine, Medical College, Thiruvananthapuram, Kerala, India; Health Action by People, Thiruvananthapuram, Kerala, India.Health Action by People, Thiruvananthapuram, Kerala, India; Dr Somervell Memorial CSI Medical College, Karakonam, Thiruvananthapuram, Kerala, India.Fortis Escorts Hospitals, JLN Marg, Jaipur, India.Fortis Escorts Hospitals, JLN Marg, Jaipur, India.Madras Diabetes Research Foundation, Chennai, India.Madras Diabetes Research Foundation, Chennai, India.Madras Diabetes Research Foundation, Chennai, India.Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan; Department of Medicine, Aga Khan University, Karachi, Pakistan.Department of Medicine, Aga Khan University, Karachi, Pakistan.Independent University, Dhaka, Bangladesh.Independent University, Dhaka, Bangladesh.Post Graduate Institute of Medical Education and Research (PGIMER) School of Public Health, Chandigarh, India.Post Graduate Institute of Medical Education and Research (PGIMER) School of Public Health, Chandigarh, India.Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada; Department of Medicine, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

28104186

Citation

Duong, MyLinh, 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)." The Lancet. Global Health, vol. 5, no. 2, 2017, pp. e168-e176.
Duong M, Rangarajan S, Zhang X, 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(2):e168-e176.
Duong, M., Rangarajan, S., Zhang, X., Killian, K., Mony, P., Swaminathan, S., ... Yusuf, S. (2017). 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 Lancet. Global Health, 5(2), pp. e168-e176. doi:10.1016/S2214-109X(17)30004-9.
Duong M, 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(2):e168-e176. PubMed PMID: 28104186.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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). AU - Duong,MyLinh, AU - Rangarajan,Sumathy, AU - Zhang,Xiaohe, AU - Killian,Kieran, AU - Mony,Prem, AU - Swaminathan,Sumathi, AU - Bharathi,Ankalmadagu Venkatsubbareddy, AU - Nair,Sanjeev, AU - Vijayakumar,Krishnapillai, AU - Mohan,Indu, AU - Gupta,Rajeev, AU - Mohan,Deepa, AU - Rani,Shanthi, AU - Mohan,Viswanathan, AU - Iqbal,Romaina, AU - Kazmi,Khawar, AU - Rahman,Omar, AU - Yusuf,Rita, AU - Pinnaka,Lakshmi Venkata Maha, AU - Kumar,Rajesh, AU - O'Byrne,Paul, AU - Yusuf,Salim, PY - 2016/03/05/received PY - 2016/11/14/revised PY - 2016/12/14/accepted PY - 2017/1/21/entrez PY - 2017/1/21/pubmed PY - 2017/12/27/medline SP - e168 EP - e176 JF - The Lancet. Global health JO - Lancet Glob Health VL - 5 IS - 2 N2 - BACKGROUND: Bidis are minimally regulated, inexpensive, hand-rolled tobacco products smoked in south Asia. We examined the effects of bidi smoking on baseline respiratory impairment, and prospectively collected data for all-cause mortality and cardiorespiratory events in men from this region. METHODS: This substudy of the international, community-based Prospective Urban Rural Epidemiology (PURE) study was done in seven centres in India, Pakistan, and Bangladesh. Men aged 35-70 years completed spirometry testing and standardised questionnaires at baseline and were followed up yearly. We used multilevel regression to compare cross-sectional baseline cardiorespiratory symptoms, spirometry measurements, and follow-up events (all-cause mortality, cardiovascular events, respiratory events) adjusted for socioeconomic status and baseline risk factors between non-smokers, light smokers of bidis or cigarettes (≤10 pack-years), heavy smokers of cigarettes only (>10 pack-years), and heavy smokers of bidis (>10 pack-years). FINDINGS: 14 919 men from 158 communities were included in this substudy (8438 non-smokers, 3321 light smokers, 959 heavy cigarette smokers, and 2201 heavy bidi smokers). Mean duration of follow-up was 5·6 years (range 1-13). The adjusted prevalence of self-reported chronic wheeze, cough or sputum, dyspnoea, and chest pain at baseline increased across the categories of non-smokers, light smokers, heavy cigarette smokers, and heavy bidi smokers (p<0·0001 for association). Adjusted cross-sectional age-related changes in forced expiratory volume in 1 s (FEV1) and FEV1/forced vital capacity (FVC) ratio were larger for heavy bidi smokers than for the other smoking categories. Hazard ratios (relative to non-smokers) showed increasing hazards for all-cause mortality (light smokers 1·28 [95% CI 1·02-1·62], heavy cigarette smokers 1·59 [1·13-2·24], heavy bidi smokers 1·56 [1·22-1·98]), cardiovascular events (1·45 [1·13-1·84], 1·47 [1·05-2·06], 1·55 [1·17-2·06], respectively) and respiratory events (1·30 [0·91-1·85], 1·21 [0·70-2·07], 1·73 [1·23-2·45], respectively) across the smoking categories. INTERPRETATION: Bidi smoking is associated with severe baseline respiratory impairment, all-cause mortality, and cardiorespiratory outcomes. Stricter controls and regulation of bidis are needed to reduce the tobacco-related disease burden in south Asia. FUNDING: Population Health Research Institute, Canadian Institutes of Health Research, and Heart and Stroke Foundation of Ontario. SN - 2214-109X UR - https://www.unboundmedicine.com/medline/citation/28104186/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__ L2 - https://linkinghub.elsevier.com/retrieve/pii/S2214-109X(17)30004-9 DB - PRIME DP - Unbound Medicine ER -