Chewing Tobacco’s Deadliest Danger Isn’t the Cancer You’d Expect

Stroke, not mouth cancer, turns out to be the single biggest health consequence of chewing tobacco, according to a massive new global study that tracked the habit across 204 countries. Researchers estimate that in 2023 alone, chewing tobacco contributed to 251,000 deaths worldwide, with stroke responsible for more lost healthy years than any single cancer linked to the habit.

Published in The Lancet Global Health, the study found that 241 million people used chewing tobacco in 2023, a population roughly the size of Pakistan. That use fueled nearly 6.5 million years of healthy life lost to death and disability. Despite decades of global anti-tobacco campaigns, the share of people who chew tobacco has barely budged since 1990, even as the death toll has climbed sharply.

Those findings come from the Global Burden of Disease Study, a large international research project that tracks health trends across the world. Researchers behind the analysis say chewing tobacco has been treated as an afterthought compared to cigarettes, even though it delivers addictive nicotine and cancer-causing chemicals through the lining of the mouth rather than the lungs. The crisis is concentrated mostly in South Asia, but it reaches countries around the world, including the United States.

How Scientists Uncovered the Hidden Toll of Chewing Tobacco

To measure the size of the problem, researchers pulled together data from 799 surveys conducted worldwide, most of them from low- and middle-income countries. The surveys asked people directly whether they had used chewed tobacco products, as opposed to smoked ones, in the past 30 days. Because many surveys group chewing tobacco together with other smokeless products like dip or snuff, the team had to pull out the chewed products specifically, using criteria built from earlier rounds of the same global study.

Once they had solid numbers on who was using chewing tobacco, by country, age, and sex, the researchers needed to figure out how dangerous the habit actually is. They reviewed decades of medical research, from 1970 to 2023, looking for solid evidence linking chewing tobacco to specific diseases. They found more than 100 studies with enough data to calculate reliable risk estimates, which let them connect chewing tobacco to six health problems: stroke and five types of cancer affecting the mouth, throat, and food pipe. A link between chewing tobacco and heart disease didn’t hold up to scrutiny, so it was left out of the final calculations even though the researchers looked for it.

With exposure data and risk estimates in hand, the team then asked a simple question: how many deaths and how much disability would disappear if chewing tobacco vanished entirely? They ran that math separately for every age group, both sexes, and every country, for each year between 1990 and 2023.

Where Chewing Tobacco Use Is Concentrated

South Asia dominates the numbers. India alone accounts for 64.3% of all male chewing tobacco users worldwide and 54.8% of female users, with 105 million male users and 42.9 million female users in that country. Bangladesh is the next largest hotspot. There, the pattern reverses with age: among people over 80, women are far more likely to chew tobacco than men, with over half of elderly women using it compared to roughly a quarter of elderly men.

Globally, tobacco chewing tends to start around age 20 and rise from there, peaking among people aged 60 to 64. In South Asia, male use peaks at that same age range, hitting an unusually high rate of 27.3%, while female use keeps climbing even further, peaking after age 80.

Just ten countries account for more than 90% of all chewing tobacco-related deaths and lost healthy years worldwide, among them India, Bangladesh, Pakistan, China, and the United States. That concentration matters: focused efforts in a handful of countries could make a real dent in the global death toll.

Stroke, Not Cancer, Is Chewing Tobacco’s Biggest Killer

Perhaps the most surprising result is which disease causes the most harm. Many people associate chewing tobacco mainly with mouth cancer, and that risk is real: cancer of the lip and mouth was the second-largest contributor to the overall health damage, responsible for 17.4 lost healthy years per 100,000 people. But stroke topped the list, responsible for 55.9 lost healthy years per 100,000 people, more than three times the toll of the cancer.

In South Asia, the connection to stroke is especially pronounced. Chewing tobacco use accounts for 9.2% of all stroke-related health loss in that region, compared to just 2.4% worldwide. Researchers note the evidence linking chewing tobacco to stroke came from a small number of studies, just three, though those studies agreed closely with one another on the connection.

Between 1990 and 2023, deaths linked to chewing tobacco climbed by more than 133%, and the total measure of lost healthy years rose by over 116%. Yet the underlying rate of use, once adjusted for an aging population, barely moved, dropping by less than 8% worldwide.

A Policy Blind Spot With a Body Count

What’s most frustrating is how preventable the damage looks. Policies to curb cigarette smoking, like taxes, marketing restrictions, and public bans, have made real headway in many countries. Chewing tobacco hasn’t gotten the same treatment. In India, a ban on a popular chewing tobacco product called gutkha was introduced back in 2012, yet the product is still sold in alternative forms. Labeling and packaging rules in countries like India, Bangladesh, and Pakistan are frequently ignored.

Study authors describe chewing tobacco as “an understudied risk factor of public health concern” and argue that countries that signed onto the World Health Organization’s tobacco control treaty need to extend their efforts beyond cigarettes. Two hundred and forty-one million people are using a product tied to an estimated quarter million deaths in a single year, and the share using it has stayed nearly flat for more than three decades. That’s not a footnote to the global tobacco story. It’s the story that’s been missing from the headlines.

Disclaimer: This article summarizes modeled estimates from the Global Burden of Disease Study. The death and disability figures are statistical projections based on survey data and risk modeling, not directly counted cases, and come with wide uncertainty ranges. The study’s authors note that the underlying evidence linking chewing tobacco to these conditions ranges from moderate to weak. The findings describe population-level associations and attributable risk, not proof that chewing tobacco caused any individual’s illness or death.

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