SEATTLE, Wash. – Sept. 30, 2026 – A new study from the Institute for Health Metrics and Evaluation (IHME) finds that chewing tobacco use contributed to an estimated 251,000 deaths globally in 2023, with health loss overwhelmingly concentrated in South Asia.
The analysis, part of the Global Burden of Disease Study 2023 (GBD 2023) and published in The Lancet Global Health , is the most comprehensive assessment to date of chewing tobacco-related health burden, covering 204 countries and territories from 1990 to 2023. It distinguishes the burden of chewing tobacco from that of other forms of smokeless tobacco that are often grouped together.
Despite decades of progress in tobacco control, the global prevalence of chewing tobacco use has remained relatively unchanged. Researchers estimate that 241 million people aged 15 years and older used chewing tobacco in 2023, a prevalence of 3.9% globally and more than twice as high among males as females. No country recorded a significant decrease in the number of users between 1990 and 2023, while 24 countries saw significant increases.
South Asia remains the epicenter of chewing tobacco use.
South Asia had the highest concentration of chewing tobacco use, with 14.6% of people aged 15 years and older using chewing tobacco products in 2023. The region accounted for an estimated 210,000 chewing tobacco-related deaths, about 84% of the global total. At the country level, age-standardized prevalence was 24.4% in Palau, with Bangladesh (23.4%) and Nepal (17.5%) recording the next-highest prevalence rates.
The health burden extended beyond South Asia but remained concentrated in a relatively small number of countries. More than 90% of male chewing tobacco-related deaths and disability burden occurred in 10 countries: India, Bangladesh, China, Pakistan, Myanmar, the United States, Nepal, Sri Lanka, the Philippines, and Madagascar. Among females, more than 90% of the burden was concentrated in India, Bangladesh, Pakistan, Indonesia, Myanmar, China, Thailand, Cambodia, Vietnam, and Nepal. However, these figures reflect total deaths and disability, meaning countries with larger populations may account for a greater share of the burden even if their 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."
Chewing tobacco use differs sharply by age and sex.
Beyond geographic differences, patterns of chewing tobacco use also varied substantially by age and sex. Globally, chewing tobacco was more common among males than females, with use beginning to rise in early adulthood and continuing to increase with age before peaking among people ages 60 to 64.
These differences were especially pronounced in South Asia, where nearly one in five males and one in 10 females used chewing tobacco in 2023. Use among males peaked at ages 60 to 64, while use among females peaked among adults ages 80 and older. However, patterns differed considerably between countries. In Bangladesh, for example, the broader trend was reversed: chewing tobacco use was higher among females than males across all age groups older than 30, although chewing tobacco use remained common among both females and males.
"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."
Stroke and head and neck cancers contribute substantially to the health burden.
Using the Burden of Proof framework, researchers estimated the health risks associated with chewing tobacco and quantified attributable burden across six outcomes: stroke, lip and oral cavity cancer, esophageal cancer, other pharyngeal cancer, laryngeal cancer, and nasopharyngeal cancer. Among these conditions, 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. DALYs are a measure of total health loss that combines years lost to premature death and years lived with disability. Chewing tobacco was responsible for 17.3% of lip and oral cavity cancer DALYs worldwide, rising to 30.5% in South Asia.
The global burden is growing, driven largely by premature death.
The number of DALYs attributed to chewing tobacco increased by 116% between 1990 and 2023, reaching 6.48 million globally. Most of this burden came from premature death, accounting for 6.17 million years of life lost in 2023.
Despite this growing burden, chewing tobacco has historically received less attention than smoked tobacco in global tobacco control efforts. Across many settings, longstanding cultural and social practices, misconceptions about harm, limited surveillance, and higher use among some rural and lower-income populations may be contributing to continued use.
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. Targeted approaches that reflect differences by age, sex, local patterns of use, and socioeconomic context will be essential to reaching the populations most affected and reducing health loss.
