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Indian Journal of Community Medicine

Tobacco Use in a Rural Area of Bihar

Author(s): Dhirendra N. Sinha; Prakash C. Gupta; Mangesh S. Pednekar

Vol. 28, No. 4 (2003-10 - 2003-12)

Research question: What is the extent of tobacco use in a rural area of Bihar, India.

Objective: To study tobacco use in rural area of Bihar.

Study design:Cross-sectional.

Setting: A rural area in Bihar, India.

Participants: All the residents of Akhta village, Sitamarhi district of Bihar.

Study variables: Tobacco use, age, gender, socio-economic status.

Statistical analysis: Percentage, chi-square test.

Results: The response rate was 91%. The non-response was due to houses being locked during the period of survey. Among 3566 children (<15 years), smokeless tobacco use was 6.2% and smoking 0.3%. Most smokeless tobacco use was in the form of red toothpowder (77%). Smokeless tobacco use among adults (male 2910; female 2586) was 32.7% (42.6% males, 21.7% females). Khaini (57.1%) among males and tobacco toothpowder (41.3%) among females were the most commonly used smokeless tobacco products. Smoking prevalence was 27.7% (31.6% males, 23.4% females). The most prevalent form (>80%) was bidi smoking both in men and women.

Conclusion: Tobacco use among adult residents of Akhta village was quite high. Smoking prevalence among females was high even though smoking by women is considered as taboo in Indian society. Intervention measures need to be urgently explored.

Key Words: Khaini, Smokeless tobacco, Bidi, Smoking, Prevalence


Tobacco use is socially accepted in many segments of Indian society. Tobacco use in India is increasing but there are considerable changes in the types and methods by which it is used. According to WHO estimates, 194 million men and 45 million women use tobacco in smoked or smokeless form in India1. Only 20% of the tabacco consumed in India by weight is consumed as cigarettes, 40% consumed as bidi and the rest in smokeless forms 2. Information on prevalence of tobacco use is available from several studies, which shows a great deal of variation by area and gender3-5.

Tobacco use in Bihar has generally been reported to be high. One recent study showed a prevalence of 77% among school personnel in Bihar, almost identical among men and women6 . In an earlier study conducted during 1967 from a random sample of villages in Darabhanga district, the tobacco use was 78% among men and 52% among women.

This was a house-to-house survey in Akhta village (population about 10,000) in Sitamarhi district of Bihar.

Material and Methods:

The state of Bihar lies in the eastern part of India. The state has an area of 94,163 in sq. kms. and its population is 82,878,796 (census 2001), making it the third most populous state of India. The state is divided into 37 districts. Sitamarhi is adjacent to Darabhanga district and borders with Nepal.

Specially trained investigators visited all houses (1721) in Akhta village during June-July 2000. In a face-to-face interview, the investigators filled up a structured schedule first for the respondent and then for each member of the household on the basis of information provided by the respondent. The respondent could be either male or female head of the family.

Information was collected for 9097 persons, after a gap of 15 days one team of survey supervisors comprising one male and one female were sent back to check 10 randomly selected houses in each of the 16 areas (called tola) of the village.

Tobacco use definitions and criteria were based on standard WHO guidelines. Tobacco habit was broadly classified into four categories; non-user, smokeless, smoker and mixed (included smokeless tobacco users as well as smokers). Tobacco was mainly smoked as bidi, cigarette and hookah. It was used in smokeless form as gul (powdered form of pyrolysed tobacco), khaini (tobacco-lime mixtures), gutka (industrially manufactured and marketed tobacco product), and betel quid (consisting of fresh betel leaf, lime, catechu, areca nut and tobacco).

Ownership of the land (categorized as landless, having less than 5 acres of land and having more than 5 acres of land) was used as proxy for the socio-economic profile of the family.


Information on 9097 individuals (response rate 91%) was collected and due to some invalid responses, only 9062 were available for the analysis.

Table I: Sex-wise distribution (%age) of different types of tobacco habits among children (<15 years).

Tobbaco Use Girls Boys Total
Non-User 94.2 92.8 93.5
Smoker* 0.1 0.5 0.3
Smokeless 5.7 6.7 6.2
Tobacco Toothpowder 90.5 66.9 77.0
Others 9.5 33.1 23.0
  1,666 1,900 3,566

*may include smokeless tobacco users.

The tobacco use among children (below 15 years) was 6.5% of which 6.2% used tobacco in smokeless form and 0.3% were smokers. The most prevalent form was using tobacco as a dentifrice among both girls and boys.

Table II: Sex-wise distribution (%age) of different types of tobacco habits among adults (15 years or above).

Tobacco USe Female Male Total
Non-user 55.0 25.9 39.9
Smoker* 23.4 31.6 27.7
Bidi 84.1 82.0 82.9
Others 15.9 18.0 17.1
Smokeless 21.7 42.6 32.7
Tobacco Tooth powder 41.3 8.8 18.9
Pan Masala 20.0 7.5 11.4
Khaini 12.1 57.1 43.1
Others 26.6 26.6 26.6
Total 2,586 2,910 5,496

Table III: Prevalence of disease (as reported by respondent) according to tobacco use among adults (15 years or above).

  Non-User Smokeless Smoker
No. % No. % R.R.* No. % R.R.*
Male 29 3.85 111 8.96 2.22 104 11.33 2.74
Female 83 5.84 57 10.18 1.67 92 15.21 2,39
Total 112 5.15 168 9.34 1.74 196 12.87 2.33

*may include smokeless tobacco users.

The overall tobacco use among adults (15 years or above) was 74.1 % for males and 45% for females. Among male tobacco users, 42.6% were only smokeless tobacco users and 31.6% were smokers (some used smokeless tobacco as well), whereas, among females 21.7% were smokeless tobacco users and 23.4% were smokers. Among female smokeless tobacco users; the dominating form was tobacco toothpowder (41.3%) followed by pan masala (20%), gul (18%, not shown in the table) and khaini (12.1%), whereas, among men it was khaini (57.1%) followed by tobacco toothpowder (8.8%) and pan masala (7.5%). Most smokers (over 80%) were bidi smokers both men as well as women (Table II).

Among children tobacco use was reported 2.0% for the age group 0-4, 6.1% for the age group 5-9 and 11.7% for the age group 10-14 years. Among adults, male tobacco users were higher than female users in all the age groups and the prevalence reached more than 80% by the age 30, whereas, among females it reached nearly 60% by the age of 40 years.

As per the respondents among the adults (5496) 8.7% (male 8.4%, female 9%) had some disease history of which 41% were reported to be suffering from chest disease, 22% abdominal, 9% high blood pressure and heart disease, 13% bone and joint disease and 16% other diseases. The relative risk for a smoker having history of suffering from a disease as compared to non-tobacco user was 2.33 and for a smokeless tobacco user 1.74 (p<0.01, Table III).

There was significantly strong association between the type of tobacco habit and socio-economic status for both men and women. As the socio-economic status increased, the prevalence of smokeless tobacco use increased and of smoking decreased.

Table IV: Comparison of 1967 survey and current survey (year 2000) for adults (age 15 years or above).

*Results based on current (year 2000) survey, +Results based on year 1967 survey.


High prevalence of tobacco use in Bihar is not unique to this study. A recent study of a representative sample of school personnel drawn from the selected schools of entire Bihar (Global School Personnel Survey, GSPS) showed tobacco use as 77.4% compared to 60.4% in this study 6. GSPS data showed the prevalence of smokeless tobacco use as 30.2% for men and 46.0% for women and in the present study, it was 42.6% for men and 21.7% for women. In GSPS, smoking was reported by 47.4% men and 31% women, whereas, in the present study it was 31.6% among men and 23.4% among women. Although school personnel of the State cannot be said to be similar to adult population of Akhta village, the prevalence of tobacco : use was very similar.

It is possible to get some idea about trend in the tobacco use by comparing results from this study to an older study conducted in adjoining Darabhanga district in 1967 7 . The prevalence of smokeless tobacco use in that study among men- was 27.5% (this study 42.6%) and among women 6.8% (this study 21.7%). Prevalence of smoking habit in older study was 24.3% among men (this study 4.0%) and among women 41.0% (this study 17.2%). It is clear that over the years, smoking has been replaced by smokeless tobacco use. It is also corroborated by the fact that average age of men as well as women smokeless tobacco users have decreased but those of smokers have increased (Table IV). It should be noted that almost all smoking was in the form of bidi and hookah and smokeless tobacco use in the form of khaini. Current smoking pattern largely consisted of bidi but hookah was considerably reduced. For smokeless tobacco, there are several new industrially manufactured products that are heavily advertised and intensely marketed. It appears that the advertising and marketing of smokeless tobacco products has played a key role in changing of tobacco use patterns.

In the present study among women smokeless tobacco users, the most common product was tobacco as a dentifrice (41.3%). It is interesting to recall that the Government of India had banned use of tobacco in toothpowder and toothpaste in 1992 and the Supreme Court of India upheld the decision of Government in 1997. These products however, continue to be available openly in the market, often without mentioning tobacco as one of the ingredient.

A limitation of the study was the surrogate respondent, one respondent giving information for all the members of the family. Despite this limitation the prevalence of smoking was high among women. This clearly shows that smoking among women members in the family has become a norm in that society. Because of surrogate respondent, the tobacco use among children might be underestimated. But it is noteworthy that 6.5% of children were reported to be tobacco users by the head of family. It is astonishing that 2% of children as young as 0-4 years were reported as tobacco users.

Male smoking is a social norm in India as everywhere else. It was well established that socio-economic status has a strong impact on tobacco use. In this study prevalence of smokeless tobacco use increased and smoking decreased with increase in the socio-economic status. This may seem paradoxical as smoking tobacco products are generally more expensive than smokeless tobacco. It turns out that the main smoking product, bidi, is more expensive than khaini (which is simply a mixture of tobacco and lime prepared by the user) but is less expensive compared to industrially manufactured smokeless tobacco products. In conformity, the prevalence of khaini decreased with increasing socio-economic status but that of other smokeless tobacco use increased. It is a well established fact that tobacco use causes a whole spectrum of diseases. It was interesting to note that the results demonstrated a strong positive association between tobacco use and disease history. This study re-emphasises the urgency of effective tobacco intervention policies in Bihar.


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  2. World Health Organization. Tobacco Health: A global status report, World Health Organization, Geneva, 1997 ( issue_situation.htm).
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  5. India 2002, Publication Division, Ministry of Information and Boradcasting, Government of India.
  6. Sinha DN, Gupta PC, Pednekar MS, Jones JT, Warren CW. Tobacco use among school personnel in Bihar, India. Tobacco Control 2002; 11: 82-3.
  7. Mehta FS, Pindborg JJ, Hamner JE. Oral cancer and precancerous condition in India, 1971, Tata Institute of Fundamental Research, Mumbai, Munksgaard, Copenhagen 1971; 113-26.

Dhirendra N. Sinha - School of Preventive Oncology, Patna
Prakash C. Gupta - Tata Institute of Fundamental Research,Mumbai
Mangesh S. Pednekar - Tata Memorial Centre, Mumbai

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