Chewing tobacco is responsible for 250,000 premature deaths worldwide in 2023.

A study published in The Lancet Global Health[1] The Global Burden of Disease Study 2023 estimates that 241 million people aged 15 and over worldwide used chewing tobacco in 2023, representing 3.9 million per 1,000 lifetimes (1/3,000 of the population). This consumption is estimated to be responsible for 251,000 preventable premature deaths and 6.48 million years of healthy life lost annually. The number of deaths has more than doubled since 1990, while the proportion of users in the population has remained roughly the same over thirty years. The burden is highly concentrated geographically: South Asia accounts for approximately 84 million per 1,000 lifetimes of deaths, and ten countries account for more than 90 million per 1,000 lifetimes.

Researchers at the Institute for Health Metrics and Evaluation (IHME, University of Washington) and their network of collaborators studied 204 countries and territories between 1990 and 2023, broken down by age and sex. To estimate the number of users, they used 799 national surveys in which individuals self-reported their smokeless tobacco use. Three-quarters of these surveys came from low- and middle-income countries. To assess health risks, the authors conducted a systematic review of the literature: 111 publications encompassing 103 studies were selected.

Consumption concentrated in South Asia

Chewing tobacco is more prevalent among men (5.4 per 100,000) than among women (2.5 per 100,000). It is used by 14.6 per 100,000 adults in South Asia. India alone accounts for 105 million male and 42.9 million female users, representing nearly two-thirds of male and more than half of female users worldwide. Next are Bangladesh (26.6 million people) and Pakistan (13.2 million). Nepal has the highest prevalence among men (30.6 per 100,000), followed by Palau, Bangladesh, and Bhutan. Similarly, among women, the highest rates are found in Bangladesh (26.3 per 100,000) and Palau (25.5 per 100,000). Consumption increases with age: it begins to rise around 20-24 years and reaches its peak between 60 and 64 years.

Cardiovascular and cancer risks

Chewing tobacco doesn't burn, but nicotine and carcinogenic substances called nitrosamines are absorbed directly into the body through the lining of the mouth. The study specifically links it to six diseases. The first is stroke: chewing tobacco raises blood pressure, damages the inner lining of blood vessels, and worsens metabolic disorders. Next are cancers of the lip and oral cavity, esophagus, larynx, and pharynx. Prolonged exposure to carcinogenic substances damages tissues and cell DNA. Chewing tobacco is responsible for 17.3 per 1,000 deaths from oral cancers worldwide, and 30.5 per 1,000 deaths in South Asia. It accounts for 2.4 per 1,000 deaths from strokes worldwide and 9.2 per 1,000 deaths in South Asia.

Of the 251,000 deaths, 152,000 were men and 99,700 were women. Since 1990, the number of deaths has increased by 134 per 100,000. Age-adjusted rates, however, have remained stable: this increase is mainly due to population growth and aging. Ten countries, including India, Bangladesh, Pakistan, and China, as well as the United States and Madagascar, account for more than 90 per 100,000 deaths. Health loss related to chewing tobacco is greater among women than men in 32 countries, including Cambodia and Bangladesh.

A blind spot in tobacco control policies

According to the authors, chewing tobacco has not seen the same progress as smoking tobacco under the WHO Framework Convention on Tobacco Control (FCTC). Yet, it accounts for more than 3% of total tobacco-related health loss worldwide. Measures adopted in the most affected countries are poorly implemented. In India, gutkha has been banned since 2012, but it remains available in other forms, such as separate pouches of tobacco and spices. Labeling rules are frequently violated in Bangladesh, India, and Pakistan. The authors point to industry interference in the drafting of laws and sales strategies designed to circumvent regulations. They also highlight the uneven enforcement of rules. According to them, these factors keep these products readily available and inexpensive. In some regions, the high level of social acceptance of chewing tobacco, including among women, also reduces the effectiveness of health warnings and advertising bans.

The study has several limitations, as noted by the authors. Consumption data are self-reported, and an underestimation of the situation is possible. The effect of products often associated with tobacco, such as areca nut, could not be isolated. The study also does not measure the additional risk to which people who use both chewing tobacco and smoked tobacco are exposed, a common situation in South Asia. Finally, studies specifically focused on chewing tobacco remain scarce, with most research grouping it with other smokeless products, which limits the level of evidence available for certain diseases.

©Generation Without Tobacco

AE

[1] Gil G, Anderson J, Dai X et al. Global, regional, and national burden of exposure to chewing tobacco, 1990–2023: a systematic analysis of the Global Burden of Disease Study 2023 The Lancet Global Health, 2026;