BACKGROUND: Chewing tobacco is both harmful and common globally. It is essential to understand both the current state and temporal patterns of chewing tobacco use to inform goal setting and policy implementation.
METHODS: In the Global Burden of Disease (GBD) Study 2023, we used spatiotemporal Gaussian process regression to estimate the prevalence of chewing tobacco use among males and females across 204 countries and territories, from 1990 through 2023. Models utilized 811 nationally or sub-nationally representative surveys. The burden of proof approach was used to estimate the relative risks between chewing tobacco and stroke, as well as cancers of the lip and oral cavity, esophagus, larynx, pharynx, and nasopharynx, from which the burden of disease was derived.
RESULTS: Globally, 241.3 million people (95% uncertainty interval 164.1, 353.1) 15 years and above used chewing tobacco in 2023. The age-standardized prevalence of current use was 4.0% (2.2, 6.7): 5.4% (3.9, 7.5) among males and 2.6% (1.4, 4.3) among females. Prevalence has not significantly changed since 1990 (3.4% increase [-48.6, 94.3]). Most current users resided in South Asia (80.1% [71.5, 87.2]), with the majority in India (61.8% [54.0, 68.5] of global users). Of the ten countries with highest prevalence, only two – Nepal and India – showed a decline since 1990, though neither was significant. We estimated 255.9 thousand (157.4, 384.1) chewing tobacco-attributable deaths and 6.61 million (4.14, 9.89) disability-adjusted life-years lost in 2023. For both males (0.5% [0.3, 0.7]) and females (0.4% [0.2, 0.6]), chewing tobacco was attributable for around one in two hundred deaths.
CONCLUSIONS: Chewing tobacco poses a significant health burden yet has not received the attention of smoking. Subsequently, the prevalence of chewing tobacco use remains unchanged since 1990. Reducing stroke and cancers of the head and neck attributable to chewing tobacco will require policies targeting adoption and use, especially in South Asia.