Chewing tobacco contributed to an estimated 251,000 deaths worldwide in 2023, according to a Global Burden of Disease study from the Institute for Health Metrics and Evaluation published September 30, 2026, in The Lancet Global Health. South Asia accounted for about 210,000 of those deaths, and global use has not meaningfully declined since 1990.
Key Takeaways
- An estimated 241 million people aged 15 and older used chewing tobacco in 2023, a global prevalence of 3.9%.
- No country recorded a significant decrease in the number of chewing tobacco users between 1990 and 2023, while 24 countries saw significant increases.
- More than 90% of male chewing tobacco-related health loss occurred in 10 countries: India, Bangladesh, China, Pakistan, Myanmar, the United States, Nepal, Sri Lanka, the Philippines, and Madagascar.
- Health loss attributed to chewing tobacco rose 116% between 1990 and 2023, reaching 6.48 million disability-adjusted life-years.
- Chewing tobacco accounted for 17.3% of lip and oral cavity cancer health loss worldwide and 30.5% in South Asia.
- Palau recorded the highest age-standardized prevalence at 24.4%, followed by Bangladesh at 23.4% and Nepal at 17.5%.
IHME Study Separates Chewing Tobacco From Broader Smokeless Categories
The Institute for Health Metrics and Evaluation (IHME) study, part of the Global Burden of Disease Study 2023, covers 204 countries and territories from 1990 to 2023. Its main methodological contribution is that it measures chewing tobacco on its own rather than combining it with other smokeless tobacco forms, as many earlier global estimates did. That separation makes it possible to see where chewing tobacco specifically causes harm and how that harm has changed over three decades.
Researchers used IHME’s Burden of Proof framework to estimate risk across six health outcomes: stroke, lip and oral cavity cancer, esophageal cancer, other pharyngeal cancer, laryngeal cancer, and nasopharyngeal cancer. Stroke accounted for the largest share of chewing tobacco-related health loss globally, at 55.9 disability-adjusted life-years (DALYs) per 100,000 people, followed by lip and oral cavity cancer at 17.4 per 100,000.
The stroke finding may surprise many readers. Public awareness of chewing tobacco’s harms has tended to center on oral cancer, but the IHME data shows cardiovascular damage accounts for the larger share of health loss at the population level.
Global Tobacco Control Progress Has Largely Bypassed Chewing Tobacco
The most important finding in the IHME study may be how little has changed. Over the past three decades, international tobacco control efforts have reduced smoking in many countries through taxation, advertising restrictions, warning labels, and smoke-free laws. Chewing tobacco has not followed that path. Global prevalence has stayed roughly flat since 1990, and the overall burden has more than doubled.
The IHME team points to several reasons. Chewing tobacco has historically received less attention than smoked tobacco in global control efforts. In many settings, long-standing cultural and social practices, misconceptions about harm, weak surveillance systems, and higher use in some rural and lower-income communities help keep use steady.
Most tobacco control frameworks were built around smoking, and that is part of the problem. Measures like smoke-free indoor laws do nothing to reduce chewing tobacco use, and public campaigns focused on lung disease may lead people to believe smokeless products are a lower-risk choice. The IHME findings challenge that belief directly.
South Asia Remains the Center of the Global Chewing Tobacco Burden
South Asia’s numbers are high by any measure. In 2023, 14.6% of people aged 15 and older in the region used chewing tobacco, compared with 3.9% globally. Nearly one in five men and one in ten women in South Asia used it, and the region accounted for about 84% of all chewing tobacco-related deaths worldwide.
The 10-country concentration needs some context. The more-than-90% figure applies to male health loss. For women, the countries carrying most of the burden were India, Bangladesh, Pakistan, Indonesia, Myanmar, China, Thailand, Cambodia, Vietnam, and Nepal. The IHME team also notes that these rankings reflect total deaths and disability, so countries with large populations such as India and China rank high even where their per-person rates are not the highest.
The United States appears on the male list, which shows that chewing tobacco’s health burden is not limited to low- and middle-income countries, even though most of it falls there.
Age and Sex Patterns Complicate Prevention Strategies
Chewing tobacco use rises through adulthood and peaks among people aged 60 to 64, which runs against the common assumption that tobacco prevention mainly means reaching young people. In South Asia, male use peaked at 60 to 64, while female use peaked among adults 80 and older.
Bangladesh reverses the global pattern. Women there used chewing tobacco at higher rates than men in every age group over 30. Gabriela Gil, the study’s lead author and an IHME research scientist, said chewing tobacco is not a uniform public health problem
and that understanding how patterns of use differ is critical to designing effective prevention. Senior author Dr. Emmanuela Gakidou made a similar point, arguing that control strategies must reflect differences by country, age, and sex, along with the cultural factors that shape use.
Researchers Call for Integration Into National Health Strategies
The IHME team recommends building smokeless tobacco prevention and cessation into national tobacco control and noncommunicable disease strategies rather than treating it as a separate concern. The researchers say targeted approaches based on age, sex, local patterns of use, and socioeconomic conditions will be needed to reach the people most affected.
Because most of the burden comes from premature death, which accounted for 6.17 million of the 6.48 million DALYs in 2023, the study suggests that each year of limited action adds to a death toll that could be reduced through prevention and earlier detection.
Disclaimer: This article summarizes findings from a scientific study published in The Lancet Global Health and based on estimates from the Institute for Health Metrics and Evaluation’s Global Burden of Disease Study 2023. The reported deaths, prevalence, and disability-adjusted life-years are modeled estimates and should not be interpreted as exact counts. The findings describe population-level associations and health burden estimates and do not determine an individual’s personal health risk. Readers should consult qualified health professionals for advice about tobacco use, cessation, or individual medical concerns.
FAQs
How many deaths are linked to chewing tobacco worldwide?
The IHME study estimates that chewing tobacco contributed to about 251,000 deaths globally in 2023, with roughly 210,000 of those in South Asia.
Which countries have the highest chewing tobacco burden?
More than 90% of male chewing tobacco-related health loss occurred in India, Bangladesh, China, Pakistan, Myanmar, the United States, Nepal, Sri Lanka, the Philippines, and Madagascar. By prevalence, Palau, Bangladesh, and Nepal recorded the highest rates.
What health conditions does chewing tobacco contribute to?
The study measured six outcomes: stroke, lip and oral cavity cancer, esophageal cancer, other pharyngeal cancer, laryngeal cancer, and nasopharyngeal cancer. Stroke accounted for the largest share of health loss globally.
How many people use chewing tobacco globally?
An estimated 241 million people aged 15 and older used chewing tobacco in 2023, a global prevalence of 3.9%, and use was more than twice as common among men as among women.
Where was the chewing tobacco study published?
The study was published in The Lancet Global Health on September 30, 2026, as part of the Global Burden of Disease Study 2023 led by the Institute for Health Metrics and Evaluation.
