Chewing tobacco was tied to 251,000 deaths in 2023, a growing, understudied toll

Global tobacco control has a blind spot, and a Global Burden of Disease (GBD) 2023 analysis published in The Lancet Global Health on 30 September sets out to fill it. Smoking dominates the research literature and the policy agenda; chewing tobacco — betel quid with tobacco, gutka, and related smokeless products chewed or held in the mouth — has been tracked far less closely, even though it is a known carcinogen. The new paper estimates its prevalence and attributable harm across 204 countries and territories for people aged 15 years and older, drawing on self-reported survey data on smokeless tobacco use spanning 188 countries [s1].

What the numbers say

To build the estimates, the team combined self-reported survey data on smokeless tobacco use from 188 countries with a systematic review and meta-analysis that used GBD's "burden of proof" methodology to derive the relative risks linking chewing tobacco to specific diseases [s1]. Those inputs then fed cause-, location-, age-, sex-, and year-specific population-attributable fractions — the standard GBD machinery for turning exposure into attributable death and disability [s1].

In 2023 the authors estimate 241 million users of chewing tobacco worldwide (95% uncertainty interval 165–355 million), a prevalence of 3.9% (2.7–5.8) among people aged 15 and over [s1]. The habit is heavily concentrated in south Asia. India alone accounts for 64.3% of all male chewing tobacco users and 54.8% of all female users; Bangladesh follows, with 7.6% of male users and 19.0% of female users [s1]. Use rises with age, peaking at a prevalence of 5.1% among people aged 60–64 [s1].

The attributable harm is substantial and, unlike prevalence, it is climbing. Chewing tobacco was linked to 251,000 deaths in 2023 (149,000–389,000), of which 152,000 (96,200–235,000) were in males and 99,700 (53,200–164,000) in females [s1]. Counting years lost to early death together with years lived with disability, the total came to 6.48 million disability-adjusted life-years, or DALYs (3.96–9.91 million) [s1]. That works out to 133.5 DALYs per 100,000 males (85.8–201.8) and 66.9 per 100,000 females (35.6–109.9) [s1].

The burden was tied to six health outcomes. The largest was stroke, at 55.9 DALYs per 100,000 people (29.0–92.9), followed by lip and oral cavity cancer at 17.4 (11.3–24.3) [s1]. The authors are candid about the evidence underneath these figures: the epidemiological base linking chewing tobacco to specific diseases ranges, in their words, from moderate to weak, which is part of why the uncertainty intervals are so wide [s1].

Why a flat prevalence still means a growing toll

The headline tension in the paper is that prevalence has changed little over the three decades studied, yet the associated death and disability have grown [s1]. That pattern is what demographers expect when populations are both expanding and ageing: a stable share of a larger, older population translates into more cases and more harm, because the cancers and strokes involved cluster in later life. The result is a risk factor that looks static on a prevalence chart while its real-world consequences mount [s1].

A separate GBD 2023 analysis published in BMJ Open the same week, focused on India, shows the same dynamic from the ground. Tobacco-attributable deaths in India rose 54.7%, from 745,740 in 1990 to 1,153,980 in 2023, and DALYs rose 15.1%, from 27.3 million to 31.4 million — even as age-standardised death and DALY rates fell by 39.8% and 47.8% respectively [s2]. Within that total, chewing tobacco showed the steepest increase of any exposure type, with deaths up 153.7% and DALYs up 124.8%, while second-hand smoke still accounted for 325,630 deaths, concentrated among women [s2]. Rates per head are improving; absolute counts are not.

The policy reading

The authors frame chewing tobacco as an understudied risk factor of genuine public health concern, and they direct their recommendation at signatories of the WHO Framework Convention on Tobacco Control, calling for the effort spent on cigarettes to be extended to smokeless products [s1]. The World Health Organization's own tobacco materials make the stakes plain, describing tobacco in all its forms as a leading preventable cause of death [s3]. The study was funded by Bloomberg Philanthropies and the Gates Foundation [s1].

Two cautions belong with the figures. The first is the evidence quality the authors flag themselves: the wide intervals around every estimate mean the central numbers should be read as best guesses, not precise counts [s1]. The second is that the data lean on self-report, which tends to understate stigmatised behaviours and varies in quality across the 188 countries surveyed [s1]. What the analysis establishes is not a single exact toll but a direction of travel — a product used by hundreds of millions, barely touched by three decades of tobacco policy, carrying a rising burden of stroke and head and neck cancer that falls most heavily on south Asia [s1].

Sources

• [s1] 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. https://doi.org/10.1016/j.langlo.2026.104043
• [s2] Tobacco-attributable mortality and disease burden in India: a descriptive analysis of Global Burden of Disease 2023 estimates for 1990 and 2023. BMJ Open. https://doi.org/10.1136/bmjopen-2026-123483
• [s3] Tobacco (fact sheet). World Health Organization. https://www.who.int/news-room/fact-sheets/detail/tobacco