3.27 Health effects of smoking tobacco in other forms

Last updated:  August 2023

Suggested citation: Winnall, W, Bellew, B,  Hanley-Jones, S, Greenhalgh, EM, & Winstanley, MM. 3.27 Health effects of smoking tobacco in other forms. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 20231. Available from http://www.tobaccoinaustralia.org.au/3-27-health-effects-of-smoking-tobacco-in-other-fo


Data from the 2019 National Drug Strategy Household Survey1 show that while the vast majority of Australian smokers (84%) use manufactured cigarettes, a variety of other tobacco products are also used. Use of loose cigarette tobacco (commonly known as roll-your-own (RYO)) tobacco is common in Australia. Forty-five percent of Australian smokers over the age of 14 reported any use of roll-your-own tobacco in 2019, up from 26% in 2001. Some cigarette smokers use RYO tobacco exclusively (13.9% of smokers 14 years and over in 2019) and some use it in combination with manufactured (factory-made) cigarettes (32.7% in 2019). Some smokers report using unbranded roughly processed tobacco for rolling into cigarettes (also known as chop-chop). This tobacco is sold on the black market, without taxes and is illegal both to possess or supply—see Section 13.7 for further discussion. The proportion of smokers currently using unbranded loose tobacco has not changed significantly over six years to 2019. It was reported at 3.6% in 2013 and 4.9% in 2019.2

Other manufactured tobacco products smoked either regularly or occasionally in Australia (either exclusively or in addition to cigarettes) include cigars, traditional pipe tobacco and shisha tobacco used in waterpipes. In 2019, 5.4% of smokers use cigars, 2.2% reported using pipe tobacco, and 4.2% of current smokers used waterpipe tobacco.1

Kreteks and bidis are also used by small numbers of people in Australia, the former being a type of clove cigarette originating in Indonesia, and the later a small, thin, hand-rolled cigarette consisting of sun-dried and cured tobacco flakes rolled in tendu or temburni leaves, native to Asia. The proportion of smokers in Australia aged 14 years and over who had used bidis in the last 12 months was 1.1%.1 Consumption patterns for kreteks are unknown in Australia.

For more information on the extent to which tobacco products other than manufactured cigarettes are used in Australia, see Chapter 1, Section 1.12.

3.27.1 Manufactured loose tobacco

Manufactured loose tobacco, hand-rolled in cigarette paper and smoked with or without a filter, causes the same range of diseases as smoking manufactured cigarettes, contrary to some smokers’ misperception of roll-your-own (RYO) tobacco as less harmful than factory-made.3 Comparison of exposure to carcinogens among roll-your-own and factory-made cigarette smokers shows RYO to be no less harmful than factory-made cigarettes.4 Variations in the quantity of tobacco used per cigarette and filtration make measurements of individual exposure difficult to assess. But the directly comparable exposure to harmful constituents and method of consumption means that smokers of these products have at least an equivalent risk of developing disease as do smokers of conventional cigarettes. Several decades of research on the health effects of tobacco use have enabled comparisons between products with and without filters, and with high and low nicotine and tar yields. Overall, the incidence of lung cancer has not varied between the tobacco products used, nor have other health benefits become apparent.5 People who smoke roll-your-own tobacco have similar risks of many other types of cancer as people who smoke factory-made cigarettes, such as cancers of the mouth, pharynx (throat) and larynx (voice box).6

See Section 12.2.2 for information about the tobacco used in roll-your-own cigarettes.

3.27.2 Unbranded loose tobacco (‘chop-chop’)

Chop-chop is used by some as an alternative to manufactured cigarette tobaccos (either factory-made cigarettes or manufactured RYO tobacco) due to its comparative affordability, and common misapprehensions that it is less harmful to health since it is apparently more ‘natural’ and ‘unadulterated,’ not having been processed in the usual way.7-9 Research has shown that some batches of chop-chop contain bulking agents such as twigs, raw cotton and grass clippings. Fungal (mould) spores have also been detected. Fungal spores are of particular health concern since they give rise to mycotoxins, including aflatoxin, a known carcinogen. Inhalation of and contact with fungi and their mycotoxins can cause a range of adverse responses in the liver, kidneys and skin, and cause illnesses including allergic reactions, chronic bronchitis, asthma and lung diseases.10 Australian chop-chop users report significantly worse health than smokers of licit tobacco. In a comparison with licit-only tobacco smokers, current users of chop-chop had significantly greater odds of reporting below-average social functioning (OR 1.61; 95% CI, 1.06–2.44), measurable disability (OR 1.95; 95% CI, 1.08–3.51), below-average mental health (OR 1.61; 95% CI, 1.22–2.13) and above-average bodily pain (OR 1.40; 95% CI, 1.06–1.85).11

3.27.3 Cigar smoking       

A cigar is a roll of tobacco wrapped in tobacco leaf. Most cigars are made from a single type of tobacco that is air-cured and fermented.12 There are three main types available in Australia; large cigars, cigarillos and little cigars. Large cigars usually contain more than 5 g of tobacco with some containing as much as 20 g.13 Cigarillos are a smaller type of cigar that usually contain about 3 g of tobacco.13 Little cigars are the same size and shape as cigarettes and are often packaged like cigarettes, sometimes with a filter. The types of cigars and cigar tobacco are described in more detail in Section 12.2.1.

Unlike for cigarettes, most cigar smokers only allow the smoke into their mouth and throat. However, some smokers do inhale cigar smoke into their lungs, particular those who also smoke cigarettes or have switched from cigarettes to cigars.13, 14

Cigar smoke is at least as harmful and as carcinogenic as cigarette smoke and possibly more so. Cigars contain more tobacco per stick than cigarettes, take longer to smoke, and produce higher concentrations of a number of toxic chemicals including carbon monoxide, nitrogen oxides, carcinogenic N-nitrosamines and ammonia.14 In laboratory assays, particulate matter from cigarillos has a stronger cellular toxicity and genotoxicity (causing of mutations in DNA) than that from cigarettes.15 A 2016 symposium on cigar use, health effects and policy implications, noted that quantification of toxicant exposure from cigar smoke can be challenging as consumption behaviour varies. Some people inhale cigar smoke, others do not; some smoke only a portion of a cigar, returning to re-light the product later; while some people like to chew on their cigar, all of which have unique consequences on toxicant exposure.16

Cigar smoking carries many of the same health risks as cigarette smoking, with research showing an increased risk of all-cause mortality.17, 18 Cigar smoking increases the risk of oral, oesophageal, pharyngeal (throat), laryngeal (voice box), bladder, pancreatic and lung cancer,5, 17-26 as well as the risk of coronary heart disease, aortic aneurysm and stroke.18, 20

A 2015 systematic review found mortality risks from cigar smoking vary by number of cigars per day and inhalation level, but can be as high as, or exceed those, of cigarette smoking. Specifically, primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, oesophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease, and aortic aneurysm. Strong dose–response relationships were observed between the number of cigars smoked per day and inhalation level, and oral, oesophageal, laryngeal, and lung cancers. Among primary cigar smokers who reported that they did not inhale, relative mortality risk was still highly elevated for oral, oesophageal, and laryngeal cancers.18 These findings were later confirmed in a 2019 study, which also identified an increased prevalence of stroke, in addition to heart disease.20

A 2010 European longitudinal study involving more than 100,000 men found that, compared to never smokers, the risk of cancers of the lung, upper aerodigestive tract and bladder combined, was more than doubled (HR 2.2; 95% CI, 1.3–3.8) for exclusive cigar smokers. Effects were stronger in current than in ex-smokers and in inhalers than in non-inhalers. For ever smokers of both cigarettes and cigars there was more than a five-fold increase in the risk of these cancers (HR 5.7; 95% CI, 4.4–7.3) making the risk elevation as high as that among exclusive cigarette smokers.19

In 2018, a nationally representative US longitudinal study followed-up on 357,420 people who reported using cigars, pipes, or cigarettes from 1985 to the end of 2011. The results of this study showed that exclusive cigar smokers (HR, 1.20; 95% CI, 1.03-1.38) had higher all-cause mortality risks than never tobacco users, and had an elevated risk of dying from tobacco-related cancer (HR, 1.61; 95% CI, 1.11-2.32), including cancer of the bladder, oesophagus, larynx, lung, oral cavity, and pancreas.17

Regular cigar smokers who inhale the smoke into their lungs have an increased risk of chronic obstructive pulmonary disease and reduced lung function.14, 26

Cigar smokers also have a higher risk of periodontitis – an inflammatory gum disease that can lead to tooth loss (described in Section 3.11.1). Compared to non-smokers, people who smoked cigars only had a higher odds of periodontitis in multiple studies,26, 27 as well as tooth loss.28

Smoke drifting from the burning tip of a lit cigar contains most of the same harmful and carcinogenic compounds as cigarette smoke. As they are larger, cigars generate smoke for a longer period of time—as long as 90 minutes for a single large cigar. This is a health concern for those constantly exposed to indoor cigar smoke;14 some researchers have concluded that high passive exposure to smoke from cigars and pipes may be associated with lung cancer risk.21

3.27.4 Pipe smoking

Although pipe-smoking has a long history, it is now uncommon among Australian smokers. Pipe smoke is often tasted in the mouth rather than inhaled into the lungs.29 Smoke from pipe tobacco contains many of the same chemicals found in cigarette smoke.30 See Section 12.2.4 for more information about pipe tobacco.

Longitudinal research conducted in Norway has reported that pipe smoking is not safer than cigarette smoking. The study followed a cohort of more than 16,000 men for up to 13 years. Between pipe and cigarette smokers, no or only minor differences were found in mortality from any cause and the specified smoking-related diseases.31 Pipe smoking is associated with decreased lung function and increased odds of airflow obstruction, even in people who had never smoked cigarettes;32 it is associated with a significantly higher risk of dying from COPD, cerebrovascular disease and cardiovascular disease. Compared to never smokers, exclusive pipe smokers are estimated to have a three-fold increase in risk (HR 3.0; 95% CI, 2.1–4.5) for cancers of lung, upper aerodigestive tract and bladder combined,19 and an eight-fold risk (OR 8.7; 95% CI, 4.0–18.9) of all upper digestive tract cancers (including a 12-fold risk for oral and seven-fold risk for pharyngeal cancer).33 A review by the International Agency for Research on Cancer concluded that pipe smoking is strongly related to cancers of the mouth, pharynx (throat), larynx (voice box) and oesophagus, with the magnitude of risk being similar to cigarette smoking.25 Pipe smokers who are also heavy alcohol drinkers have a massive 38-fold increased risk of these cancers (OR 38.8; 95% CI, 13.6–110.9) as compared to never smokers and light drinkers, strongly suggesting that pipe smoking and heavy alcohol drinking may interact in a way that greatly increases the risks.33

A 2018 nationally representative US longitudinal study following 357,420 participants who reported using cigar, pipe, or cigarettes from 1985 to the end of 2011 showed exclusive current pipe smokers (HR, 1.58; 95% CI, 1.05-2.38) had an elevated risk of dying from a tobacco-related cancer than never-smokers, including bladder, oesophagus, larynx, lung, oral cavity, and pancreas.17

As with cigarette smoking, the risk of tobacco-caused mortality from pipe-smoking varies in a dose–response relationship. Mortality risk increases with the amount smoked, the depth to which it is inhaled and the duration of smoking. For most disease entities, the relative risk of mortality declines with quitting, increased length of time of cessation and younger age at quitting.34

Disease patterns differ from those observed in cigarette smokers because pipe smokers tend to inhale the smoke less deeply, taking up nicotine through the mucous membranes lining of the mouth instead of predominantly via the lungs. Some earlier studies suggested the possibility of some harm reduction benefits in switching from cigarette to pipe smoking.19 It was suggested that the magnitude of the extra risk was smaller if people had switched to cigars or pipes only (i.e. quit cigarettes) and had not compensated with greater smoking intensity. However, it should be noted that research has found men who switched from cigarettes-only to pipe-only had a risk that was not significantly different from the risk in sustained smokers of cigarettes only,31 so that the overall conclusion about pipe smoking is that it is hazardous and is certainly not a safe alternative to cigarette smoking.

3.27.5 Waterpipe smoking

Using a waterpipe to smoke tobacco is not a safe alternative to cigarette smoking.35 Names for waterpipes vary and include ‘narghile’, ‘arghile’, ‘shisha’, ‘goza’, ‘hubble bubble’ and ‘hookah’.36 Waterpipe use is common through the Middle East and Asia. Waterpipes were widely used in Turkey during the Ottoman Empire (15th century), Iran, Lebanon, Syria, Jordan, Greece, India, Pakistan, Palestine, Egypt and Saudi Arabia. As people immigrated to Europe from India, Pakistan, Northern Africa and the Middle East, hookahs and hookah cafes began appearing in European cities. Today, hookah bars and cafés are popular in many parts of Britain, France, Spain, Russia, India, Asia and throughout the Middle East, and are growing in popularity in the US.37 Epidemiological studies show an increase in the popularity of waterpipes since the year 1990s, particularly in younger people around the world. In countries that report data, prevalence was estimated at 6–34% of young people (13 to 15 years old).35

Waterpipe apparatus vary widely in design, but the method of use requires heating with burning charcoal of moist tobacco (usually sweetened and flavoured) to produce smoke. This is passed through water before being inhaled via a mouthpiece on the end of a hose (see a diagram in Section in Chapter 12).38, 39 Electronically heated systems have also been developed in recent years, but the effects of these on smokers and the environment have not been well-studied.40 See Section 12.2.5 for more about waterpipe tobacco.

Waterpipe smoking usually occurs in a social setting with a number of participants seated around the waterpipe, taking it in turns to inhale. The availability of pre-moistened, shaped and flavoured tobacco made especially for waterpipe use (‘Maassel’) since the 1990s is likely to have contributed to a resurgence in waterpipe smoking in the Eastern Mediterranean Region, and its increased popularity.39, 41, 42 At least in some cultures, women and girls are more likely to use a waterpipe than to use other forms of tobacco, and it is popular among younger smokers.

As waterpipe smoke passes through a reservoir of water, waterpipe smoking may mistakenly43 be perceived as being less lethal than other methods of tobacco use.39, 44-46 However, many studies of waterpipe smoke that has passed through water have demonstrated the presence of nicotine, carbon monoxide, carcinogens (aldehydes, nitrosamines and polycyclic aromatic hydrocarbons) and other toxic chemicals.47-49 See Section for more information about the emissions from waterpipes.

Although the moist smoke produced by waterpipe smoking may be more palatable than cigarette smoke,38 many of the harmful gases and chemicals found in cigarette smoke are present in equal or even greater amounts in waterpipe smoke, including carbon monoxide, nicotine and heavy metals.39, 50 The harmful substances found in waterpipe smoke include carcinogens (that cause cancer), genotoxic chemicals (that mutate DNA sequences), heavy metals, so-called BTEX chemicals (benzene, toluene, ethylbenzene or xylene) and a range of pathogenic bacteria.51, 52  Smoking a waterpipe increases oxidative stress—a form of cell damage that underlies conditions such as inflammation and cardiovascular disease.53, 54 Waterpipe smoke increases the levels of many DNA damage markers and inhibits the production of DNA repair genes, that protect against cancer formation.51 Biomarkers of nicotine and carcinogens have been found in the blood, saliva, urine and hair of people exposed to waterpipe smoke.55

Waterpipe smokers are typically exposed to smoke over a longer period than cigarette smokers. A session lasts somewhere between 45 minutes to an hour, but some sessions may continue for many hours.38 Although waterpipe smokers do not usually smoke as frequently as do cigarette smokers,44, 56 it has been estimated that during a typical session, a waterpipe smoker inhales more than 100 times the volume of smoke produced by smoking a single cigarette.35 Relative to a single cigarette, a single waterpipe session exposes the smoker to 3–9 times the carbon monoxide and 1.7 times the nicotine.57

Waterpipe smoking is associated with features of dependence, such as drug-seeking behaviour, inability to quit despite repeated attempts, and abstinence-induced withdrawal that is suppressed by subsequent waterpipe use.58

Health effects associated with waterpipe smoking:

Research has shown tobacco waterpipe smoking to be significantly associated with a range of negative health effects, including, but not limited to; head and neck cancers,59, 60 oesophageal cancer,59, 61 lung cancer,59-62 cardiovascular60, 63 and respiratory diseases (COPD),60, 62, 64-66 periodontal disease,62 metabolic syndrome60 and obesity,67 low birthweight,60, 62 mental health problems60 and spreading of infectious diseases.68-70 Waterpipe smoking is also associated with injuries and other acute effects, such as burns, vomiting, fainting and severe carbon monoxide poisoning, particularly among young adults.71, 72

A 2010 systematic review found that waterpipe smoking of tobacco was significantly associated with double the risk of lung cancer (OR 2.12; 95% CI, 1.32– 3.42).62 Several systematic reviews and meta-analyses conducted in 2016 confirmed this finding.59-61 Cancers of the head and neck, including oral and oesophageal cancer, have also been found to be significantly associated with waterpipe tobacco smoking. However, while two 2016 meta-analyses found significant positive associations between waterpipe smoking and oesophageal cancer, another that same year did not find a significant association (OR=4.14, 95% CI=0.93,18.46).

Waterpipe tobacco smokers are significantly more likely to suffer the effects of metabolic syndrome, including hyper-triglyceridaemia (high blood fat levels), hyper-glycaemia (high blood sugar levels), hypertension (high blood pressure) and abdominal obesity.60, 73 A 2019 systematic review of five studies on the association between waterpipe smoking and higher risk of obesity, comprising of a total of 16,779 participants, found a higher prevalence of obesity and/or a higher association between obesity and waterpipe smoking than for non-smokers and cigarette smokers (when comparisons were available) regardless of gender, and among all ages.67

A Scientific Statement from the American Heart Association and a meta-analysis on waterpipe tobacco smoking and cardiovascular disease risk give an overview of the growing body of evidence that waterpipe tobacco smoking affects heart rate, blood pressure regulation, baroreflex sensitivity, tissue oxygenation, and vascular function over the short term.63, 74 Long-term waterpipe use is associated with increased risk of coronary artery disease.75 A 2016 systematic review and meta-analysis also found tobacco waterpipe smoking to be significantly associated with cardiovascular disease (OR = 1.67, 95% CI= 1.25,2.24).60  A study of over 200 people who had ‘first ever ischemic strokes’ found that, after controlling for numerous cofactors, waterpipe smoking was a strong risk factor for these stroke events.76

Systematic reviews have found that tobacco waterpipe smoking to be associated with several health indicators such as increased vascular resistance, increased heart rate, increased blood pressure, lower PFT scores, shortness of breath, chronic cough, and health conditions such as bronchitis and chronic bronchitis, COPD, nasal polyposis, cellular damage, low immunity, among other conditions already covered.64, 74 Even one session of waterpipe smoking can increase the heart rate and blood pressure.74

Another systematic review and meta-analysis of six cross-sectional studies was conducted to examine the effects of waterpipe tobacco smoking on lung function compared with no smoking. Despite methodological limitations in the reviewed studies, the authors were able to conclude that waterpipe smoking of tobacco negatively affects lung function, may be as harmful as cigarette smoking and is likely to be a cause of chronic obstructive pulmonary disease (COPD).66 Significant associations between waterpipe tobacco smoking and respiratory diseases (COPD odds ratio (OR)= 3.18, 95% CI= 1.25, 8.08; bronchitis odds ratio (OR)= 2.37, 95% CI= 1.49, 3.77; passive water-pipe smoking and wheezes odds ratio (OR)= 1.97, 95% CI= 1.28, 3.04) were later confirmed in a 2016 systematic review and meta-analysis on the effects of waterpipe tobacco smoking on a range of health outcomes.60

A 2016 systematic review and meta-analysis also found waterpipe use to be significantly associated with poor mental health (OR 1.30-2.4 95% CI 1.20,2.80), and low birth weight (OR=2.39, 95% CI =1.32,4.32),60 and an earlier systematic review found that waterpipe smoking of tobacco was significantly associated with at least a trebling in the risk of periodontal disease.62

Waterpipe smoking in groups may also be increasing the transmission of infectious diseases. Sharing a waterpipe has been associated with increased risks of hepatitis,77 tuberculosis69, 70, 77 and mumps.68

Waterpipe smoking-related emissions can also cause harm to non-smokers. Secondhand smoke from waterpipe tobacco use produces a similar level of air pollutants as cigarettes. For more on the harms of secondhand smoke from sources other than cigarettes see Chapter 4, Section 4.2.1.  

3.27.6 Kreteks

Kreteks are cigarettes that contain a combination of cloves and clove oil, tobacco and other additives. Originating in Indonesia, where they account for about 90% of the market,78 a small number of brands are currently imported into Australia.

Although kreteks are smaller than typical cigarettes, they can deliver similar levels of nicotine and carbon monoxide to smokers.79 Gas chromatographic analysis of kreteks has revealed high levels of eugenol, anethole and coumarin compounds. The authors of one study noted that compounds such as eugenol are known to be hazardous to humans when inhaled in high concentrations, and pose significant health concerns. The researchers concluded that usage of such compounds in smoking products, particularly at high levels, should be discouraged pending the availability of detailed toxicity information.80 Another analysis found that the levels of these compounds found in kreteks are significantly higher than those typically found in commercial cigarette brands.81

Long-term research on the health effects of smoking kreteks is scant, but it can be reasonably assumed that they pose at least the same dangers to health as conventional cigarettes, due to a comparable exposure to harmful constituents and the method of consumption. Popular use of these cigarettes in the US commenced in about 1980. By the mid-1980s, warnings had begun to appear in the literature, notably so when 13 cases of severe illness with clove cigarette smoking were reported to the Centers for Disease Control and the California Department of Health Services. The effects of this illness on people included haemorrhagic pulmonary oedema (bleeding from the lungs), pneumonia, bronchitis and hemoptysis (spitting up or coughing up of blood).82

A systematic review of 32 Indonesian studies found that kretek-smoking was associated with oral cancer, cardiovascular disease, myocardial infarction, asthma, and oral diseases. However, the available studies were mostly low quality, reducing the strength the evidence for these health effects. The health effects associated with kretek in terms of oral cancer, cardiovascular disease and coronary heart diseases, were generally similar to those from regular cigarettes in studies that compared to two.78

Research from Indonesia has shown that regular high-dose kretek smokers have 13‒20 times the risk of abnormal lung function than non-smokers.83 Kretek use is associated with a higher risk of acute lung injury, particularly in susceptible individuals such as those with asthma or respiratory infections.84 There is also evidence that clove cigarettes are linked with a greatly increased risk of dental disease. In a longitudinal study of more than 1000 male bus drivers in Jakarta, 27% of those who had smoked for 10 years or less had dental caries. This proportion increased to 79.6% among those smoking for 11–15 years and rose to 89.3% among those smoking for more than 15 years. People who smoked 7–12 cigarettes a day were more than twice as likely (RR 2.66, p<0.0001) to develop dental caries compared to those smoking 0–6 cigarettes a day. Those categorised as smoking either 13–18 cigarettes a day (RR 3.19, p<0.0001) or more than 18 cigarettes a day (RR 2.96, p<0.0001) were three times more likely to do so.85 A small 2014 Indonesian study examining the association between kretek smoking and risk of oral cancer found those who smoked kreteks increased their risk of oral cancer by almost three-fold. Moreover, those who smoked kreteks were found to have almost double the risk of oral cancer compared to cigarette smokers.86

As previously noted, cloves contain a substance called eugenol, which when inhaled has the characteristics of a local anaesthetic. In the past this attribute has lent kreteks a reputation as soothing for sore throats and asthma,87 but in fact it can reduce the gag reflex, leading to pulmonary aspiration (when substances such as food or drink enter the lungs).84 The American Medical Association reviewed the medical evidence concerning clove cigarettes in 1988 and reached the following conclusions:

(i) clove cigarettes are tobacco products, therefore they possess all the harms associated with smoking tobacco cigarettes; and

(ii) inhaling clove cigarette smoke has been associated with severe lung injury in a few susceptible persons. People with asthma or with a throat or lung infection in its early stages may have an increased risk of harm from inhaling clove cigarette smoke.84

3.27.7 Bidis (beedis, beedies, biris)

Bidis are small, thin, hand-rolled cigarettes consisting of sun-dried and cured tobacco flakes rolled up in a piece of dried tendu or temburni leaf (from plants native to Asia). They may be flavoured with a variety of sweet or fruit essences (e.g. chocolate, cherry and mango) or unflavoured, and are secured at either end with colourful threads.88 See Sections 12.2.7 and for more information about bidi tobacco and bidi smoke.

Bidi use is most prevalent in India, Bangladesh, Nepal, Sri Lanka, Pakistan and the Maldives.89, 90 A paper published in 2000 estimated that 21% to 56% of men in South Asian countries smoke bidis.89

Smoke from a bidi contains 3–5 times the amount of nicotine as a regular cigarette and places users at risk of nicotine addiction.89, 91 A chemical analysis of bidi smoke found toxic gases such as carbon monoxide and nitric oxide, carcinogenic aldehydes (formaldehyde, acrolein, acetaldehyde), nicotine, phenol, polycyclic aromatic hydrocarbons and tobacco-specific nitrosamines.92 See Section 12.4.3 for more information about these toxic/addictive chemicals. The compounds added to provide flavouring (such as clove, cinnamon, vanilla, cardamom, strawberry, mango, grape, lemon-lime and chocolate) are also present in high levels and may contribute to long-term health damage, particularly in the case of cloves.93 Tobacco factory employees who hand-roll bidis are chronically exposed to potentially harmful levels of tobacco via inhalation of dust and flakes, and through the skin.89

Bidi smoking is associated with increased risk of oral cancer,94-96 pharyngeal (throat) and laryngeal (voice box) cancer,97 lung cancer,94, 98 stomach cancer, and oesophageal cancer.89, 99 It is also associated with a more than three-fold increased risk for coronary heart disease and acute myocardial infarction (heart attack);89 a nearly four-fold increased risk for chronic bronchitis;89 and with chronic obstructive pulmonary disease (COPD).100 Bidi use during pregnancy has been shown to be associated with perinatal mortality.88

Three studies have shown that people who smoke bidis have a higher risk of mortality from any cause.101-103 Excess mortality among bidi smokers in India was comparable to the excess mortality among cigarette smokers in Western countries.104

Relevant news and research

For recent news items and research on this topic, click  here. (Last updated June 2024)


1. Australian Institute of Health and Welfare. Data tables: National Drug Strategy Household Survey 2019 - 2. Tobacco smoking chapter, Supplementary data tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data.

2. Australian Institute of Health and Welfare. Table 2.55 Use of unbranded tobacco: National Drug Strategy Household Survey 2019 - 2. Tobacco smoking chapter, Supplementary data tables. Canberra: AIHW, 2020. Available from: https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/data.

3. Filippidis FT, Driezen P, Kyriakos CN, Katsaounou P, Petroulia I, et al. Transitions from and to roll-your-own tobacco, perceptions and health beliefs among smokers: findings from the EUREST-PLUS ITC Europe Surveys. European Journal of Public Health, 2020; 30(Suppl_3):iii18-iii25. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32267933

4. Shahab L, West R, and McNeill A. A comparison of exposure to carcinogens among roll-your-own and factory-made cigarette smokers. Addiction Biology, 2009; 14(3):315-20. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19523045

5. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. Available from: https://www.cdc.gov/tobacco/data_statistics/sgr/2004/complete_report/index.htm.

6. De Stefani E, Oreggia F, Rivero S, and Fierro L. Hand-rolled cigarette smoking and risk of cancer of the mouth, pharynx, and larynx. Cancer, 1992; 70(3):679-82. Available from: https://pubmed.ncbi.nlm.nih.gov/1623483/

7. Aitken C, Fry TR, Grahlmann L, and Masters T. Health perceptions of home-grown tobacco (chop-chop) smokers. Nicotine and Tobacco Research, 2008; 10(3):413-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18324558

8. Bittoun R. 'Chop chop' tobacco smoking [Letter]. Medical Journal of Australia, 2002; 177(2):686-7. Available from: https://www.mja.com.au/journal/2002/177/11/chop-chop-tobacco-smoking

9. Lindorff K. Tobacco–time for action. National Aboriginal and Torres Strait Islander Tobacco Control Project. Final report. Canberra: National Aboriginal Community Controlled Health Organisation, 2002. Available from: https://trove.nla.gov.au/work/12890239?selectedversion=NBD23740852.

10. Bittoun R. The medical consequences of smoking 'chop chop' tobacco.  Report prepared for the Commonwealth Department of Health and Ageing. Canberra: Department of Health and Ageing, 2004. Available from: https://web.archive.org/web/20110602194636/http://www.health.gov.au/internet/main/publishing.nsf/Content/927F4224C3D9E1A6CA25700D0018284B/$File/chopchop.pdf.

11. Aitken CK, Fry TR, Farrell L, and Pellegrini B. Smokers of illicit tobacco report significantly worse health than other smokers. Nicotine and Tobacco Research, 2009; 11(8):996-1001. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19541950

12. Centers for Disease Control and Prevention. Cigars. CDC, 2020. Available from: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/tobacco_industry/cigars/index.htm.

13. National Cancer Institute. Cigar smoking and cancer.: NIH, 2010. Available from: https://www.cancer.gov/about-cancer/causes-prevention/risk/tobacco/cigars-fact-sheet.

14. National Cancer Institute. Cigars: Health effects and trends. Smoking and Tobacco Control Monographs, no. 9.Rockville, MD: National Cancer Institute, US National Institutes of Health, 1998. Available from: https://cancercontrol.cancer.gov/brp/tcrb/monographs/9/index.html.

15. Crosby L, Yucesoy B, Leggett C, Tu Z, Belinsky SA, et al. Smoke chemistry, in vitro cytotoxicity, and genotoxicity demonstrates enhanced toxicity of cigarillos compared with cigarettes. Toxicological Sciences, 2021; 180(1):122-35. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33021639

16. Pickworth WB and Thanner MH. Cigar use symposium: Epidemiology, toxicant exposure, health and policy implications. Tobacco Regulatory Science, 2017; 3(Suppl 1):S3-S7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28983497

17. Christensen CH, Rostron B, Cosgrove C, Altekruse SF, Hartman AM, et al. Association of cigarette, cigar, and pipe use with mortality risk in the US population. JAMA Internal Medicine, 2018; 178(4):469-76. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29459935

18. Chang CM, Corey CG, Rostron BL, and Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health, 2015; 15(1):390. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25907101

19. McCormack VA, Agudo A, Dahm CC, Overvad K, Olsen A, et al. Cigar and pipe smoking and cancer risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). International Journal of Cancer, 2010; 127(10):2402-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20162568

20. Rostron BL, Corey CG, and Gindi RM. Cigar smoking prevalence and morbidity among US adults, 2000-2015. Preventative Medicine Reports, 2019; 14:100821. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30815336

21. Boffetta P, Nyberg F, Agudo A, Benhamou E, Jockel KH, et al. Risk of lung cancer from exposure to environmental tobacco smoke from cigars, cigarillos and pipes. International Journal of Cancer, 1999; 83(6):805-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10597199

22. Higgins IT, Mahan CM, and Wynder EL. Lung cancer among cigar and pipe smokers. Preventive Medicine, 1988; 17(1):116-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/3362797

23. Iodice S, Gandini S, Maisonneuve P, and Lowenfels AB. Tobacco and the risk of pancreatic cancer: a review and meta-analysis. Langenbeck's Archives of Surgery, 2008; 393(4):535-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18193270

24. Bertuccio P, La Vecchia C, Silverman D, Petersen G, Bracci P, et al. Cigar and pipe smoking, smokeless tobacco use and pancreatic cancer: an analysis from the International Pancreatic Cancer Case-Control Consortium (PanC4). Annals of Oncology, 2011; 22(6):1420-6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21245160

25. International Agency for Research on Cancer Working Group on the Evaluation of Carcinogenic Risks to Humans. Tobacco smoke and involuntary smoking.  IARC monographs on the evaluation of the carcinogenic risk of chemicals to humans. Volume 83. Lyon: International Agency for Research on Cancer, 2004. Available from: https://publications.iarc.fr/Book-And-Report-Series/Iarc-Monographs-On-The-Identification-Of-Carcinogenic-Hazards-To-Humans/Tobacco-Smoke-And-Involuntary-Smoking-2004.

26. National Academies of Sciences Engineering and Medicine, Premium cigars: Patterns of use, marketing, and health effects Washington, DC: The National Academies Press; 2022. Available from: https://nap.nationalacademies.org/catalog/26421/premium-cigars-patterns-of-use-marketing-and-health-effects.

27. Albandar JM, Streckfus CF, Adesanya MR, and Winn DM. Cigar, pipe, and cigarette smoking as risk factors for periodontal disease and tooth loss. Journal of Periodontology, 2000; 71(12):1874-81. Available from: https://pubmed.ncbi.nlm.nih.gov/11156044/

28. Krall EA, Garvey AJ, and Garcia RI. Alveolar bone loss and tooth loss in male cigar and pipe smokers. Journal of the American Dental Association, 1999; 130(1):57-64. Available from: https://jada.ada.org/article/S0002-8177(14)65673-7/pdf

29. Watson S. Effects of smoking pipes and cigars.  2020. Available from: https://www.webmd.com/smoking-cessation/effects-of-smoking-pipes-and-cigars.

30. US Department of Health and Human Services. The Health Consequences of Smoking: 1977-1978. DHEW Publication No. (PHS) 79-50065, Atlanta: US Department of Health, Education and Welfare, Public Health Service, Office of the Assistant Secretary for Health, Office on Smoking and Health, 1977. Available from: https://profiles.nlm.nih.gov/101584932X284.

31. Tverdal A and Bjartveit K. Health consequences of pipe versus cigarette smoking. Tobacco Control, 2011; 20(2):123-30. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20952559

32. Rodriguez J, Jiang R, Johnson WC, MacKenzie BA, Smith LJ, et al. The association of pipe and cigar use with cotinine levels, lung function, and airflow obstruction: a cross-sectional study. Annals of Internal Medicine, 2010; 152(4):201-10. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20157134

33. Randi G, Scotti L, Bosetti C, Talamini R, Negri E, et al. Pipe smoking and cancers of the upper digestive tract. International Journal of Cancer, 2007; 121(9):2049-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17631642

34. Henley S, Thun M, Chao A, and Calle E. Association between exclusive pipe smoking and mortality from cancer and other diseases. Journal of the National Cancer Institute, 2004; 96(11):853-61. Available from: http://jnci.oxfordjournals.org/cgi/reprint/96/11/853

35. World Health Organization Study Group on Tobacco Product Regulation. Advisory note.  Waterpipe tobacco smoking:  health effects, research needs and recommended actions by regulators. Geneva: WHO, 2005. Available from: http://www.who.int/tobacco/global_interaction/tobreg/Waterpipe%20recommendation_Final.pdf.

36. Maziak W, Ward KD, and Eissenberg T. Interventions for waterpipe smoking cessation. Cochrane Database of Systematic Reviews, 2007; (4):CD005549. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17943865

37. Salloum RG, Thrasher JF, Getz KR, Barnett TE, Asfar T, et al. Patterns of waterpipe tobacco smoking among U.S. young adults, 2013-2014. American Journal of Preventive Medicine, 2017; 52(4):507-12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27890515

38. Knishkowy B and Amitai Y. Water-pipe (narghile) smoking: an emerging health risk behaviour. Pediatrics, 2005; 116(1):113-19. Available from: http://pediatrics.aappublications.org/cgi/reprint/116/1/e113.pdf

39. Maziak W, Ward KD, Afifi Soweid RA, and Eissenberg T. Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic. Tobacco Control, 2004; 13(4):327−33. Available from: https://pubmed.ncbi.nlm.nih.gov/15564614/

40. US Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: https://www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf.

41. Maziak W. The waterpipe: time for action. Addiction, 2008; 103(11):1763-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18778388

42. Rastam S, Ward KD, Eissenberg T, and Maziak W. Estimating the beginning of the waterpipe epidemic in Syria. BMC Public Health, 2004; 4(32):32. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15294023

43. Chan A and Murin S. Up in smoke: the fallacy of the harmless Hookah. Chest, 2011; 139(4):737-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21467052

44. Asfar T, Ward K, Eissenberg T, and Maziak W. Comparison of patterns of use, beliefs, and attitudes related to waterpipe between beginning and established smokers. BMC Public Health, 2005; 5(19):doi:10.1186/471-2458-5-19. Available from: http://www.biomedcentral.com/1471-2458/5/19

45. Maziak W, Ben Taleb Z, Jawad M, Afifi R, Nakkash R, et al. Consensus statement on assessment of waterpipe smoking in epidemiological studies. Tobacco Control, 2017; 26(3):338-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27165995

46. Maziak W, Osibogun O, and Asfar T. Waterpipe smoking: the pressing need for risk communication. Expert Review of Respiratory Medicine, 2019; 13(11):1109-19. Available from: https://www.ncbi.nlm.nih.gov/pubmed/31519113

47. Shihadeh A, Schubert J, Klaiany J, El Sabban M, Luch A, et al. Toxicant content, physical properties and biological activity of waterpipe tobacco smoke and its tobacco-free alternatives. Tobacco Control, 2015; 24 Suppl 1(Suppl 1):i22-i30. Available from: https://pubmed.ncbi.nlm.nih.gov/25666550/

48. Al Rashidi M, Shihadeh A, and Saliba NA. Volatile aldehydes in the mainstream smoke of the narghile waterpipe. Food and Chemical Toxicology, 2008; 46(11):3546-9. Available from: https://pubmed.ncbi.nlm.nih.gov/18834915/

49. Sepetdjian E, Shihadeh A, and Saliba NA. Measurement of 16 polycyclic aromatic hydrocarbons in narghile waterpipe tobacco smoke. Food and Chemical Toxicology, 2008; 46(5):1582-90. Available from: https://pubmed.ncbi.nlm.nih.gov/18308445/

50. Shihadeh A and Saleh R. Polycyclic aromatic hydrocarbons, carbon monoxide, "tar", and nicotine in the mainstream smoke aerosol of the narghile water pipe. Food and Chemical Toxicology, 2005; 43(5):655-61. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15778004

51. Aljadani RH, Algabbani AM, Alamir JA, Alqahtani AS, and BinDhim NF. Waterpipe tobacco chemical content, microbial contamination, and genotoxic effects: A systematic review. International Journal of Toxicology, 2020; 39(3):256-62. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32054347

52. Jafari AJ, Asl YA, and Momeniha F. Determination of metals and BTEX in different components of waterpipe: charcoal, tobacco, smoke and water. Journal of Environmental Health Science and Engineering, 2020; 18(1):243-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32399236

53. Jebai R, Ebrahimi Kalan M, Vargas-Rivera M, Osibogun O, Li W, et al. Markers of oxidative stress and toxicant exposure among young waterpipe smokers in the USA. Environmental Science and Pollution Research, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33491143

54. Badran M and Laher I. Waterpipe (shisha, hookah) smoking, oxidative stress and hidden disease potential. Redox Biology, 2020; 34:101455. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32086009

55. Moon KA, Rule AM, Magid HS, Ferguson J, Susan J, et al. Biomarkers of secondhand smoke exposure in waterpipe tobacco venue employees in Istanbul, Moscow, and Cairo. Nicotine and Tobacco Research, 2017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28582531

56. World Health Organization Regional Office for the Eastern Mediterranean. Tobacco use in shisha: studies on waterpipe smoking in Egypt., Cairo: WHO Regional Office for the Eastern Mediterranean, Egyptian Smoking Prevention Research Institute, 2006. Available from: https://apps.who.int/iris/handle/10665/119837?show=full.

57. Eissenberg T and Shihadeh A. Waterpipe tobacco and cigarette smoking: direct comparison of toxicant exposure. American Journal of Preventive Medicine, 2009; 37(6):518-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19944918

58. Maziak W, Rastam S, Ibrahim I, Ward KD, Shihadeh A, et al. CO exposure, puff topography, and subjective effects in waterpipe tobacco smokers. Nicotine and Tobacco Research, 2009; 11(7):806-11. Available from: https://www.ncbi.nlm.nih.gov/pubmed/19420278

59. Mamtani R, Cheema S, Sheikh J, Al Mulla A, Lowenfels A, et al. Cancer risk in waterpipe smokers: a meta-analysis. International Journal of Public Health, 2017; 62(1):73-83. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27421466

60. Waziry R, Jawad M, Ballout RA, Al Akel M, and Akl EA. The effects of waterpipe tobacco smoking on health outcomes: an updated systematic review and meta-analysis. International Journal of Epidemiology, 2017; 46(1):32-43. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27075769

61. Montazeri Z, Nyiraneza C, El-Katerji H, and Little J. Waterpipe smoking and cancer: systematic review and meta-analysis. Tobacco Control, 2017; 26(1):92-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27165994

62. Akl EA, Gaddam S, Gunukula SK, Honeine R, Jaoude PA, et al. The effects of waterpipe tobacco smoking on health outcomes: a systematic review. International Journal of Epidemiology, 2010; 39(3):834-57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20207606

63. Bhatnagar A, Maziak W, Eissenberg T, Ward KD, Thurston G, et al. Water pipe (hookah) smoking and cardiovascular disease risk: A scientific statement from the American Heart Association. Circulation, 2019; 139(19):e917-e36. Available from: https://www.ncbi.nlm.nih.gov/pubmed/30845826

64. Haddad L, Kelly DL, Weglicki LS, Barnett TE, Ferrell AV, et al. A systematic review of effects of waterpipe smoking on cardiovascular and respiratory health outcomes. Tobacco Use Insights, 2016; 9:13-28. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27398028

65. Hakim F, Hellou E, Goldbart A, Katz R, Bentur Y, et al. The acute effects of water-pipe smoking on the cardiorespiratory system. Chest, 2011; 139(4):775-81. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21030492

66. Raad D, Gaddam S, Schunemann HJ, Irani J, Abou Jaoude P, et al. Effects of water-pipe smoking on lung function: a systematic review and meta-analysis. Chest, 2011; 139(4):764-74. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20671057

67. Baalbaki R, Itani L, El Kebbi L, Dehni R, Abbas N, et al. Association between smoking hookahs (shishas) and higher risk of obesity: A systematic review of population-based studies. Journal of Cardiovascular Development and Disease, 2019; 6(2). Available from: https://www.ncbi.nlm.nih.gov/pubmed/31208138

68. Aragon A, Velasco MJ, Gavilan AM, Fernandez-Garcia A, and Sanz JC. Mumps virus outbreak related to a water pipe (narghile) shared smoking. Enfermedades Infecciosas y Microbiologia Clinica, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33059946

69. Marchetti AU, Boss OL, Schenker CM, and Kalin K. Water-pipe smoking as a risk factor for transmitting mycobacterium tuberculosis. European Journal of Case Reports in Internal Medicine, 2020; 7(1):001342. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32015968

70. Steentoft J, Wittendorf J, and Andersen JR. [Tuberculosis and water pipes as source of infection]. Ugeskrift for Laeger, 2006; 168(9):904-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/16513054

71. Inyang NA, Chang JT, and Wang B. National estimates of hospital emergency department visits due to acute injuries associated with hookah smoking, United States, 2011-2019. Injyry Epidemiology, 2020; 7(1):41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32772919

72. Nguyen V, Salama M, Fernandez D, Sperling JD, Regina A, et al. Comparison between carbon monoxide poisoning from hookah smoking versus other sources. Clinical Toxicology, 2020; 58(12):1320-5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32253946

73. Shafique K, Mirza SS, Mughal MK, Arain ZI, Khan NA, et al. Water-pipe smoking and metabolic syndrome: a population-based study. PLoS ONE, 2012; 7(7):e39734. Available from: https://www.ncbi.nlm.nih.gov/pubmed/22848361

74. Al Ali R, Vukadinovic D, Maziak W, Katmeh L, Schwarz V, et al. Cardiovascular effects of waterpipe smoking: a systematic review and meta-analysis. Reviews in Cardiovascular Medicine, 2020; 21(3):453-68. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33070549

75. Morovatdar N, Poorzand H, Bondarsahebi Y, Hozhabrossadati SA, Montazeri S, et al. Water pipe tobacco smoking and risk of Coronary Artery Disease: A systematic review and meta-analyses. Current Molecular Pharmacology, 2020. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33357208

76. Tabrizi R, Borhani-Haghighi A, Lankarani KB, Heydari ST, Bayat M, et al. Hookah smoking: A potentially risk factor for first-ever ischemic stroke. Journal of Stroke and Cerebrovascular Diseases, 2020; 29(10):105138. Available from: https://www.ncbi.nlm.nih.gov/pubmed/32912523

77. Kadhum M, Sweidan A, Jaffery AE, Al-Saadi A, and Madden B. A review of the health effects of smoking shisha. Clinical Medicine, 2015; 15(3):263-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26031977

78. Nuryunarsih D, Lewis S, and Langley T. Health risks of kretek cigarettes: A systematic review. Nicotine and Tobacco Research, 2021. Available from: https://www.ncbi.nlm.nih.gov/pubmed/33503247

79. Malson JL, Lee EM, Murty R, Moolchan ET, and Pickworth WB. Clove cigarette smoking: biochemical, physiological, and subjective effects. Pharmacology, Biochemistry and Behavior, 2003; 74(3):739-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12543240

80. Stanfill SB, Brown CR, Yan XJ, Watson CH, and Ashley DL. Quantification of flavor-related compounds in the unburned contents of bidi and clove cigarettes. Journal of Agricultural and Food Chemistry, 2006; 54(22):8580-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17061837

81. Polzin GM, Stanfill SB, Brown CR, Ashley DL, and Watson CH. Determination of eugenol, anethole, and coumarin in the mainstream cigarette smoke of Indonesian clove cigarettes. Food and Chemical Toxicology, 2007; 45(10):1948-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17583404

82. Guidotti TL, Laing L, and Prakash UB. Clove cigarettes. The basis for concern regarding health effects. Western Journal of Medicine, 1989; 151(2):220-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/2773482

83. Mangunnegoro H and Sutoyo DK. Environmental and occupational lung diseases in Indonesia. Respirology, 1996; 1(2):85-93. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9434323

84. American Medical Association Council on Scientific Affairs. Council report: evaluation of the health hazard of clove cigarettes. Journal of the American Medical Association, 1988; 260:3641-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3057254

85. Soetiarto F. The relationship between habitual clove cigarette smoking and a specific pattern of dental decay in male bus drivers in Jakarta, Indonesia. Caries Research, 1999; 33(3):248-50. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10207202

86. Amtha R, Razak IA, Basuki B, Roeslan BO, Gautama W, et al. Tobacco (kretek) smoking, betel quid chewing and risk of oral cancer in a selected jakarta population. Asian Pacific Journal of Cancer Prevention, 2014; 15(20):8673-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25374188

87. Lawrence S and Collin J. Competing with kreteks: transnational tobacco companies, globalisation, and Indonesia. Tobacco Control, 2004; 13 Suppl 2(suppl. 2):ii96-103. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15564227

88. Centers for Disease Control and Prevention. Bidi use among urban youth-Massachusetts. Morbidity and Mortality Weekly Reports, 1999; March-April 1999(48):796-9. Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm4836a2.htm

89. Rahman M and Fukui T. Bidi smoking and health. Public Health, 2000; 114(2):123-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10800151

90. Rahman M, Nurullah Awal AS, Fukui T, and Sakamoto J. Prevalence of cigarette and bidi smoking among rickshaw pullers in Dhaka city. Preventive Medicine, 2007; 44(3):218-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17173963

91. Watson CH, Polzin GM, Calafat AM, and Ashley DL. Determination of tar, nicotine, and carbon monoxide yields in the smoke of bidi cigarettes. Nicotine and Tobacco Research, 2003; 5(5):747-53. Available from: https://www.ncbi.nlm.nih.gov/pubmed/14577991

92. Ahamad T and Alshehri SM. TG-FTIR-MS (Evolved Gas Analysis) of bidi tobacco powder during combustion and pyrolysis. Journal of Hazardous Materials, 2012; 199-200:200-8. Available from: https://pubmed.ncbi.nlm.nih.gov/22119196/

93. Stanfill SB, Calafat AM, Brown CR, Polzin GM, Chiang JM, et al. Concentrations of nine alkenylbenzenes, coumarin, piperonal and pulegone in Indian bidi cigarette tobacco. Food and Chemical Toxicology, 2003; 41(2):303-17. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12480305

94. Jayalekshmy PA AS, Nair MK, Gangadharan P, Rajan B, Nair RK, et al. . Bidi smoking and lung cancer incidence among males in Karunagappally cohort in Kerala, India. International Journal of Cancer, 2008; 123(6):1390-7. Available from: http://onlinelibrary.wiley.com/doi/10.1002/ijc.23618/pdf

95. Pednekar MS, Gupta PC, Yeole BB, and Hebert JR. Association of tobacco habits, including bidi smoking, with overall and site-specific cancer incidence: results from the Mumbai cohort study. Cancer Causes and Control, 2011; 22(6):859-68. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21431915

96. Rahman M, Sakamoto J, and Fukui T. Calculation of population attributable risk for bidi smoking and oral cancer in south Asia. Preventive Medicine, 2005; 40(5):510-4. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15749132

97. Rao DN, Desai PB, and Ganesh B. Alcohol as an additional risk factor in laryngopharyngeal cancer in Mumbai--a case-control study. Cancer Detection and Prevention, 1999; 23(1):37-44. Available from: https://pubmed.ncbi.nlm.nih.gov/9892989/

98. Prasad R, Ahuja RC, Singhal S, Srivastava AN, James P, et al. A case-control study of bidi smoking and bronchogenic carcinoma. Annals of Thoracic Medicine, 2010; 5(4):238-41. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20981185

99. Sankaranarayanan R, Duffy SW, Padmakumary G, Nair SM, Day NE, et al. Risk factors for cancer of the oesophagus in Kerala, India. International Journal of Cancer, 1991; 49(4):485-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/1917146

100. Ministry of Health and Family Welfare. Bidi smoking and public health., New Delhi, India: Ministry of Health and Family Welfare, 2008. Available from: https://dphodisha.nic.in/sites/default/files/Download/Bidi%20Smoking%20and%20Public%20Health.pdf.

101. Gupta PC and Mehta HC. Cohort study of all-cause mortality among tobacco users in Mumbai, India. Bulletin of the World Health Organization, 2000; 78(7):877-83. Available from: https://pubmed.ncbi.nlm.nih.gov/10994260/

102. Gajalakshmi V, Peto R, Kanaka TS, and Jha P. Smoking and mortality from tuberculosis and other diseases in India: retrospective study of 43000 adult male deaths and 35000 controls. Lancet, 2003; 362(9383):507-15. Available from: https://www.ncbi.nlm.nih.gov/pubmed/12932381

103. Duong M, Rangarajan S, Zhang X, Killian K, Mony P, 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 Global Health, 2017; 5(2):e168-e76. Available from: https://pubmed.ncbi.nlm.nih.gov/28104186/

104. Gupta PC, Bhonsle RB, Mehta FS, and Pindborg JJ. Mortality experience in relation to tobacco chewing and smoking habits from a 10-year follow-up study in Ernakulam District, Kerala. International Journal of Epidemiology, 1984; 13(2):184-7. Available from: https://pubmed.ncbi.nlm.nih.gov/6735563/