The Commission, co-chaired by Professor Christopher JL Murray, Director of the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, and Dr. Natalia Kanem, former Executive Director of the United Nations Population Fund, drew on the expertise of 35 leaders from health, economics, security, governance and technology. The authors examined hundreds of possible threats, using historical evidence and new risk analysis covering 204 countries and territories from IHME. From that long list, they identified seventeen threats that pose the greatest danger to human health and survival between 2025 and 2100, and for which governments, funders and industry have a realistic route to act through policy change, funding decisions and innovation.

The methodology behind the selection is deliberately rigorous. A threat was classified as catastrophic if it met three key criteria: it could account for at least one billion disability-adjusted life years, or DALYs, by 2100; there is sufficient data available to model the threat; and there is sufficient scope for policy action. DALYs measure the number of years in good health lost to sickness, disability or premature mortality that could be avoided with targeted action. For each of the seventeen threats, the Commission modelled a plausible best-case and worst-case future, and the gap between them, measured in amenable DALYs, shows decision-makers exactly where investment and innovation can make the greatest difference.

Two of the seventeen threats stand apart because of their extinction potential: the malicious use of artificial intelligence and nuclear conflict. While the likelihood of either remains comparatively low, their consequences are so severe that the Commission treats them as consequential threats demanding urgent preventive action. Accounting for both potential impact and probability, the assessment finds that action to prevent nuclear conflict could avert an estimated 133 million deaths and 9.35 billion DALYs by 2100, while action to reduce the risk of malicious AI could avert an estimated 10.4 billion DALYs. These figures underline the Commission’s central argument that low-probability, high-consequence events cannot be excluded from rational long-term health planning.

The remaining fifteen catastrophic threats read like a catalogue of the century’s most pressing challenges: air pollution, antimicrobial resistance, childhood malnutrition, climate change, conventional conflict, declining development assistance for health, high alcohol use, high blood pressure, income inequality, low educational attainment, naturally occurring pandemics, obesity, poor mental health, smoking and unhealthy ageing. Several of these are already imposing substantial health burdens today, while others carry a real danger if they materialize. Crucially, the Commission emphasizes that all seventeen threats are interconnected, which is why the authors insist they must be addressed together rather than in isolation. Climate change, for example, intensifies other risks such as migration pressures in ways not yet reflected in the current numbers.

Some of the quantified findings are striking. Climate change is described as already a catastrophic and urgent threat to health and human survival. The Commission finds that limiting global warming to around 1.8 degrees Celsius, rather than letting it reach 4.4 degrees, could prevent 1.89 billion years of healthy life from being lost to causes like extreme heat and air pollution. The true burden is likely even greater, because this estimate captures only direct harms that can be measured today, excluding harder-to-quantify effects such as displacement, drought and mental health impacts. Without sharp cuts to emissions, these losses will continue to compound beyond 2100.

Socioeconomic factors emerge as enormous levers of health. The Commission calculates that 16.1 billion DALYs are amenable to improvements in educational attainment, with women and children in sub-Saharan Africa facing the greatest potential burden of associated health loss. Faster progress on education would substantially improve health outcomes and reduce mortality rates among the children of educated mothers, while indirectly contributing to slower population growth over the longer term. Income inequality, meanwhile, could impose an amenable health burden equivalent to twenty-five COVID-19 pandemics by 2100, accounting for an estimated 13.8 billion DALYs. Obesity is forecast to compound over time, contributing 23.1 billion potential DALYs by 2100 that could be avoided through policies to reduce obesity risk. Sub-Saharan Africa is forecast to bear around seventy percent of the amenable health burden linked to a collapse in development assistance for health.

If current trends continue, the seventeen catastrophic threats collectively could account for tens of billions of years of lost health. While the scale varies by threat and region, every country faces significant risks, and within each country the harms will be distributed unequally, with people in resource-limited settings and marginalized communities bearing the greatest burden, compounded by existing inequalities. Professor Murray notes that the striking finding is not only the scale of these threats but that humanity still has the agency to act, warning that delaying action will only serve to shift and increase the costs into the future. Dr. Kanem adds that recent global events show how quickly stability can give way to crisis, and how costly it is to respond only after disaster strikes, yet the future is not inevitable.

To convert analysis into action, the Commission proposes a three-part agenda: build, back and track. Building readiness means creating and funding threat-ready health systems with dedicated teams for foresight, prevention, preparedness and protection across a wide range of risks, embedded in how health systems are funded and delivered, supported by durable financing rather than ad hoc crisis responses, and designed to reach lower-resource settings and marginalized communities. Backing breakthroughs means increasing investment in innovation where existing tools are insufficient, including new vaccines, antibiotics, obesity treatments and climate technologies, alongside appropriate governance and equitable access. Tracking threats means regular and independent reassessment so that evidence keeps pace with emerging risks and reaches decision-makers in finance and security as well as health, including the creation of a Lancet Monitor of 21st Century Global Threats to Health as an institutionalized tracking mechanism.

The Commission does not present a fixed ranking of threats or policy priorities. As an accompanying Lancet Editorial makes clear, the report’s analysis should be seen as a dynamic process whose findings will probably change as new evidence and data are accrued. Lancet Editor-in-Chief Dr. Richard Horton describes the work as a radical conceptual shift in how humanity thinks about future threats to survival, inviting a move from single issues to a broader and more complex landscape of dangers that demands a much more extensive framework for coordinated action. The report’s authors hope the framework will catalyze international, regional and national action, helping leaders identify opportunities for collaborative, cross-sectoral responses that build societies resilient to global threats, protect economies and security, and secure a fairer and more peaceful future for coming generations.

Subject of Research: Global catastrophic threats to human health and survival, including climate change, nuclear conflict, malicious AI and socioeconomic risks, and policy strategies to mitigate them by 2100

Article Title: The Lancet: New Commission provides roadmap to protect economies, security and global stability from catastrophic threats to health and human survival

Article References: The Lancet: New Commission provides roadmap to protect economies, security and global stability from catastrophic threats to health and human survival. (n.d.). Original publication

Image Credits: AI Generated

DOI: Not provided

Keywords: The Lancet, global health, catastrophic threats, DALYs, climate change, nuclear conflict, artificial intelligence, IHME, health policy, pandemics, income inequality, obesity

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