Chewing Tobacco Tied to 251,000 Deaths Worldwide as Burden Concentrates in Just 10 Countries

Chewing tobacco contributed to an estimated 251,000 deaths worldwide in 2023, according to the most comprehensive assessment of smokeless tobacco harm ever conducted, and the overwhelming majority of that health loss was concentrated in a small group of countries, with South Asia alone accounting for roughly 84 percent of the global death toll. The findings, published in The Lancet Global Health as part of the Global Burden of Disease Study 2023, come from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington School of Medicine and cover 204 countries and territories across a 33-year span from 1990 to 2023. Unlike earlier analyses that lumped all smokeless tobacco products together, the new study deliberately separates chewing tobacco from other non-smoked forms, allowing researchers for the first time to isolate the specific contribution of products that are held in the mouth and chewed, sucked, or placed between the gum and cheek.

The scale of exposure is striking. Researchers estimate that 241 million people aged 15 years and older were chewing tobacco users in 2023, a global prevalence of 3.9 percent, with use more than twice as common among males as among females. Despite decades of progress in tobacco control that has driven down smoking rates in many parts of the world, the global prevalence of chewing tobacco use has remained essentially unchanged. No country recorded a significant decrease in the number of users between 1990 and 2023, while 24 countries saw significant increases in the size of their chewing tobacco populations. That stagnation stands in sharp contrast to the trajectory of smoked tobacco and suggests that chewing products have largely escaped the taxation, advertising bans, and public awareness campaigns that have reshaped cigarette consumption.

Geographically, the burden maps onto a narrow band of the planet. South Asia had the highest regional concentration of use, with 14.6 percent of people aged 15 and older using chewing tobacco in 2023, and the region accounted for an estimated 210,000 chewing tobacco-related deaths, about 84 percent of the global total. At the country level, age-standardized prevalence reached 24.4 percent in Palau, followed by Bangladesh at 23.4 percent and Nepal at 17.5 percent. More than 90 percent of male chewing tobacco-related deaths and disability occurred in just ten countries: India, Bangladesh, China, Pakistan, Myanmar, the United States, Nepal, Sri Lanka, the Philippines, and Madagascar. Among females, more than 90 percent of the burden was concentrated in India, Bangladesh, Pakistan, Indonesia, Myanmar, China, Thailand, Cambodia, Vietnam, and Nepal. The researchers caution that these figures reflect absolute numbers of deaths and disability, so countries with larger populations can account for a greater share of the burden even when their per-capita rates are not the highest.

“Chewing tobacco is not a uniform public health problem, and our findings show that a relatively small number of countries bear an overwhelming share of its health burden,” said Gabriela Gil, lead author and Research Scientist at IHME. “Understanding how patterns of use differ within these populations is critical to designing more effective prevention and tobacco control strategies.” Her point underscores a methodological strength of the new analysis: by disaggregating chewing tobacco from other smokeless products and estimating exposure country by country, the study gives policymakers a far more granular picture of where interventions are likely to yield the greatest returns.

The demographic architecture of chewing tobacco use differs sharply by age and sex, and those differences vary by setting in ways that complicate prevention. Globally, use was more common among males, rising through early adulthood and continuing to climb with age before peaking among people aged 60 to 64. In South Asia, nearly one in five males and one in ten females used chewing tobacco in 2023. Male use in the region peaked at ages 60 to 64, while female use peaked among adults aged 80 and older, a pattern consistent with long-duration, lifelong habits established decades earlier. Bangladesh, however, reverses the broader trend: chewing tobacco use was higher among females than males across all age groups older than 30, even though the products remained common among both sexes. “These findings show why chewing tobacco control cannot take a one-size-fits-all approach,” said Dr. Emmanuela Gakidou, senior author and Professor in the Department of Health Metrics Sciences at IHME. “Prevention and cessation strategies need to reflect how patterns of use differ by country, age, and sex, as well as the cultural and social factors that shape tobacco use in each setting.”

On the health outcomes side, the study employed the Burden of Proof framework, a systematic approach for quantifying the risks associated with a given exposure, to estimate the burden attributable to chewing tobacco across six outcomes: stroke, lip and oral cavity cancer, esophageal cancer, other pharyngeal cancer, laryngeal cancer, and nasopharyngeal cancer. The results challenge the common perception that chewing tobacco is primarily an oral cancer risk. Stroke accounted for the largest share of chewing tobacco-related health loss globally, at 55.9 disability-adjusted life-years, or DALYs, per 100,000 people, followed by lip and oral cavity cancer at 17.4 per 100,000. DALYs are a composite metric that combines years of life lost to premature death with years lived in disability, providing a single measure of total health loss. The prominence of stroke indicates that the cardiovascular consequences of chewing tobacco, likely driven by nicotine absorption and its effects on blood pressure and vascular function, may be as consequential as, or more consequential than, the cancers that dominate public perception of the habit.

The cancer burden remains substantial nonetheless. Chewing tobacco was responsible for 17.3 percent of lip and oral cavity cancer DALYs worldwide, a figure that rose to 30.5 percent in South Asia, where products such as betel quid with tobacco are deeply embedded in social and cultural practice. The concentration of oral cancer risk in the same region that dominates overall chewing tobacco mortality creates a compounding public health challenge: health systems in Bangladesh, India, Nepal, and neighboring countries face elevated rates of both cardiovascular disease and head and neck cancers attributable to a single exposure, straining diagnostic, surgical, and oncology services that are often already under-resourced.

The trajectory of the burden is also alarming. The number of DALYs attributed to chewing tobacco increased by 116 percent between 1990 and 2023, reaching 6.48 million globally. Most of that burden came from premature death, accounting for 6.17 million years of life lost in 2023, a signal that chewing tobacco is killing users early rather than merely adding years of chronic illness. Population growth and aging in high-prevalence countries help explain part of the increase, since even stable prevalence rates translate into more users and more deaths as populations expand, but the finding that no country achieved a significant decline in user numbers means the growth in burden has been met with essentially no counteracting progress in exposure reduction.

Why has chewing tobacco escaped the attention devoted to cigarettes? The study points to a convergence of factors: longstanding cultural and social practices that normalize the habit, widespread misconceptions that chewing products are less harmful than smoking, limited surveillance systems that fail to track smokeless tobacco use separately, and higher rates of use among rural and lower-income populations who may have less access to cessation services and health information. These dynamics have left a gap in global tobacco control, in which smokeless products are frequently absent from taxation schemes, graphic warning requirements, and cessation programs designed around cigarettes.

The authors argue that reducing chewing tobacco-related deaths and disability will require stronger integration of smokeless tobacco prevention and cessation into national tobacco control and noncommunicable disease strategies, with approaches tailored to differences by age, sex, local patterns of use, and socioeconomic context. Given that more than 90 percent of the burden clusters in ten countries for each sex, even modest, well-targeted interventions in those settings could avert a disproportionate share of the global toll. As the GBD 2023 analysis makes clear, the world’s progress against tobacco will remain incomplete until the products tucked in the cheeks of 241 million users receive the same scrutiny as the cigarette.

Subject of Research: The global, regional, and national burden of chewing tobacco use and its attributable deaths and disability from 1990 to 2023

Article Title: Chewing tobacco linked to 251,000 deaths worldwide, with more than 90% of health loss concentrated in 10 countries

Article References: Chewing tobacco linked to 251,000 deaths worldwide, with more than 90% of health loss concentrated in 10 countries. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: chewing tobacco, Global Burden of Disease, smokeless tobacco, stroke, oral cavity cancer, South Asia, DALYs, tobacco control, IHME, public health, prevalence, The Lancet Global Health