More than 300 million people in at least 70 countries use smokeless tobacco

The first-ever report on the global use and public health impact of smokeless tobacco finds that more than 300 million people in at least 70 countries use these harmful products. The report, Smokeless Tobacco and Public Health: A Global Perspective, is being released today by the CDC and the National Cancer Institute at the National Conference on Smoking or Health in Mumbai, India. Thirty-two leading experts from around the world contributed to the report.

The serious health effects of smokeless tobacco have been documented. As the report explains, there is sufficient evidence to conclude that smokeless tobacco causes oral cancer, esophageal cancer, and pancreatic cancer in humans. More than 30 carcinogens have been identified in smokeless tobacco products. Smokeless tobacco use also causes adverse oral health outcomes, including oral mucosal lesions, leukoplakia, and periodontal disease. Additionally, smokeless tobacco products contain nicotine, and users of these products demonstrate signs of dependence similar to those of cigarette smokers, including tolerance with repeated use and symptoms of withdrawal upon cessation of use.

In addition to detailing the serious and well-documented health effects of smokeless tobacco products, the report also examines the distinct challenges and policy solutions in reducing the burden of smokeless tobacco use. For example, a wide range of smokeless tobacco products with different characteristics are in use around the world, yet limited data are available detailing the contents of these products, how they’re used, and their prevalence within different population groups. Additionally, the ways in which smokeless tobacco products are produced, sold, used, and regulated differ widely across counties and regions.

“Making smokeless tobacco prevention and control a top priority in South Asia is critical to saving lives from tobacco-related death and disease,” said Samira Asma, D.D.S., M.P.H., chief of the Global Tobacco Control Branch in CDC’s Office on Smoking and Health. “Urgent action is needed in countries where smokeless tobacco use is most prevalent. Reduction of smokeless tobacco use should be an integral component of national tobacco prevention and control strategies.”

The report finds the majority of smokeless tobacco users (89 percent) are in Southeast Asia, which also has the highest oral cancer rates in the world. Users in India and Bangladesh make up 80 percent of total smokeless tobacco users in the world. Prevalence among men is high across most of the region, varying between 25 percent and 51percent in five countries. However, use by adult women is similar to or greater than use by men in some low-and middle-income countries. Among youth aged 13 to 15 years, prevalence is also high across the region, equivalent to that of cigarettes.

“While the adverse health effects of smokeless tobacco use are well documented, expanded research and surveillance efforts are critically needed to support effective action to reduce the burden of smokeless tobacco worldwide,” said Mark Parascandola, Ph.D., M.P.H., epidemiologist in the Tobacco Control Research Branch at the National Cancer Institute.

In countries with the highest prevalence of smokeless tobacco use, smokeless tobacco prices are lower, warning labels are weaker, surveillance is less developed, fewer evidence-based cessation interventions are available, and fewer resources are devoted to prevention and control programs, when compared with cigarettes and other smoked tobacco products. Developing and implementing effective strategies will require increased public health capacity, particularly in low- and middle-income countries where the smokeless tobacco burden is high.

Use of smokeless tobacco can lead to nicotine addiction, which can make cessation more difficult. In addition to causing cancer, smokeless tobacco products cause adverse reproductive and developmental effects, including stillbirth, preterm birth, and low birth weight. Some, but not all, smokeless tobacco products are associated with increased risk of fatal ischemic heart disease, type 2 diabetes, and fatal stroke.