Chewing tobacco was connected to 251,000 deaths worldwide in 2023, with South Asia accounting for about 84 per cent of the global death burden, according to a new study published in The Lancet Global Health.
The study, based on the Global Burden of Disease Study 2023, examined chewing tobacco use across 204 countries and territories from 1990 to 2023. Research by the Institute for Health Metrics and Evaluation (IHME) estimated that around 241 million people aged 15 years and older used chewing tobacco in 2023.
The study is significant since it examined chewing tobacco alone and not all types of smokeless tobacco. The number of chewing tobacco users worldwide has largely remained steady after decades of efforts to control tobacco.
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South Asia Accounts For Most Of The Global Burden
South Asia was the most affected region of chewing tobacco use. In 2023, 14.6 per cent of people aged 15 and above in the region used chewing tobacco.
The region accounted for approximately 210,000 chewing tobacco-related deaths, which represents about 84 per cent of the global total. In 2023, researchers found that nearly one in five men and one in 10 women in South Asia used chewing tobacco.
India is one of the major contributors to the region’s burden. According to a separate report in the study, about 104,000 deaths in India in 2023 are attributed to chewing tobacco, or 68 per cent of the total. Meanwhile, about 105 million people in India use chewing tobacco regularly, the study says.
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However, the highest prevalence does not necessarily correspond to the largest number of deaths. Countries with larger populations can account for a substantial absolute burden even when their population-level rates are lower.
The study found that more than 90 per cent of chewing tobacco-related burden among men was concentrated in 10 countries: India, Bangladesh, China, Pakistan, Myanmar, the United States, Nepal, Sri Lanka, the Philippines and Madagascar. For women, over 90 per cent of the burden was concentrated in India, Bangladesh, Pakistan, Indonesia, Myanmar, China, Thailand, Cambodia, Vietnam and Nepal.
Stroke and oral cancer are major health concerns
The researchers investigated the health burden of chewing tobacco in several conditions, including stroke, lip and oral cavity cancer, oesophageal cancer, laryngeal cancer, other pharyngeal cancers and nasopharyngeal cancer.
The research showed that stroke accounted for most of the chewing tobacco-related health loss worldwide. Lip and oral cavity cancer accounted for a substantial portion of the burden. Research estimates that chewing tobacco was responsible for 17.3 per cent of lip and oral cavity cancer disability-adjusted life years worldwide. The proportion was even higher in South Asia, at 30.5 per cent.
The study also measured the overall health loss using disability-adjusted life years, or DALYs. This measure involves years of life lost due to premature death and years lived with disability.
The researchers estimated that chewing tobacco was responsible for 6.48 million DALYs worldwide in 2023. About 6.17 million of those years were from premature deaths. DALYs related to chewing tobacco increased 116 per cent over 1990-2023.
241 Million People Used Chewing Tobacco In 2023
The study estimated that 241 million people aged 15 and above used chewing tobacco worldwide in 2023. That was a global prevalence of around 3.9 per cent and was more than twice as common among men as among women.
The researchers found chewing tobacco use to increase generally from early adulthood to the highest level among people aged 60 to 64. Use among older people in South Asia was particularly significant.
Bangladesh was one such example. Research conducted by the authors found that chewing tobacco use among people aged above 30 was higher among women than men in Bangladesh. This highlights the differences in tobacco-use patterns between countries and the need to consider age, sex, and local social factors in the health burden assessment.
The researchers also found that no country saw a significant decline in the number of chewing tobacco users between 1990 and 2023. At the same time, 24 countries saw significant increases in the number of users.
This is in contrast to cigarette smoking trends in several parts of the world and indicates that chewing tobacco is still a major public health problem.
Why is chewing tobacco still a concern?
Chewing tobacco is generally considered less health-threatening than smoking, as it does not involve inhaling cigarette smoke. Yet the new study tells us chewing tobacco can have bad effects.
The products studied in this study may be of different types of tobacco chewed or swallowed in the mouth. Products in South Asia such as chewing tobacco, gutkha and tobacco-containing paan are also commonly used.
The study found chewing tobacco to be less commonly used in tobacco control efforts than cigarettes. Cultural beliefs, misconceptions about its health effects, limited surveillance, and differences in access to cessation services might contribute to continued use in some populations.
The findings do not mean that every chewing tobacco user will develop a particular disease. Instead, the study estimates the population-level health burden attributable to exposure based on available evidence and disease modelling.
Researchers said better tobacco-control and cessation strategies are needed, especially in countries and communities where chewing tobacco use is prevalent. Prevention efforts also need to take into account differences in age, sex, local habits of use, and socioeconomic situations, they said.
As South Asia accounts for 84 per cent of chewing tobacco-related deaths worldwide in 2023, the region is still critical to reducing the global health burden of these products.
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