Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
BMC Medicine
Published in: BMC Medicine 1/2020

01-12-2020 | Oral Cancer | Research article

Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries

Authors: Kamran Siddiqi, Scheherazade Husain, Aishwarya Vidyasagaran, Anne Readshaw, Masuma Pervin Mishu, Aziz Sheikh

Published in: BMC Medicine | Issue 1/2020

Login to get access

Abstract

Background

Smokeless tobacco (ST) is consumed by more than 300 million people worldwide. The distribution, determinants and health risks of ST differ from that of smoking; hence, there is a need to highlight its distinct health impact. We present the latest estimates of the global burden of disease due to ST use.

Methods

The ST-related disease burden was estimated for all countries reporting its use among adults. Using systematic searches, we first identified country-specific prevalence of ST use in men and women. We then revised our previously published disease risk estimates for oral, pharyngeal and oesophageal cancers and cardiovascular diseases by updating our systematic reviews and meta-analyses of observational studies. The updated country-specific prevalence of ST and disease risk estimates, including data up to 2019, allowed us to revise the population attributable fraction (PAF) for ST for each country. Finally, we estimated the disease burden attributable to ST for each country as a proportion of the DALYs lost and deaths reported in the 2017 Global Burden of Disease study.

Results

ST use in adults was reported in 127 countries; the highest rates of consumption were in South and Southeast Asia. The risk estimates for cancers were also highest in this region. In 2017, at least 2.5 million DALYs and 90,791 lives were lost across the globe due to oral, pharyngeal and oesophageal cancers that can be attributed to ST. Based on risk estimates obtained from the INTERHEART study, over 6 million DALYs and 258,006 lives were lost from ischaemic heart disease that can be attributed to ST. Three-quarters of the ST-related disease burden was among men. Geographically, > 85% of the ST-related burden was in South and Southeast Asia, India accounting for 70%, Pakistan for 7% and Bangladesh for 5% DALYs lost.

Conclusions

ST is used across the globe and poses a major public health threat predominantly in South and Southeast Asia. While our disease risk estimates are based on a limited evidence of modest quality, the likely ST-related disease burden is substantial. In high-burden countries, ST use needs to be regulated through comprehensive implementation of the World Health Organization Framework Convention for Tobacco Control.
Appendix
Available only for authorised users
Literature
1.
2.
Moghbel N, Ryu B, Cabot PJ, Ratsch A, Steadman KJ. In vitro cytotoxicity of Nicotiana gossei leaves, used in the Australian Aboriginal smokeless tobacco known as pituri or mingkulpa. Toxicol Lett. 2016;254:45–51.PubMed
3.
Maki J. The incentives created by a harm reduction approach to smoking cessation: snus and smoking in Sweden and Finland. Int J Drug Policy. 2015;26:569–74.PubMed
4.
Palipudi K, Rizwan SA, Sinha DN, Andes LJ, Amarchand R, Krishnan A, et al. Prevalence and sociodemographic determinants of tobacco use in four countries of the World Health Organization: South-East Asia region: findings from the Global Adult Tobacco Survey. Indian J Cancer. 2014;51(Suppl 1):S24–32.PubMed
5.
6.
Stanfill SB, Connolly GN, Zhang L, Jia LT, Henningfield JE, Richter P, et al. Global surveillance of oral tobacco products: total nicotine, unionised nicotine and tobacco-specific N-nitrosamines. Tob Control. 2011;20:e2.PubMed
7.
Sankhla B, Kachhwaha K, Hussain SY, Saxena S, Sireesha SK, Bhargava A. Genotoxic and carcinogenic effect of gutkha: a fast-growing smokeless tobacco. Addict Health. 2018;10:52–63.PubMedPubMedCentral
8.
9.
Sinha DN, Suliankatchi RA, Gupta PC, Thamarangsi T, Agarwal N, Parascandola M, et al. Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: systematic review and meta-analysis. Tob Control. 2018;27:35–42.PubMed
10.
Zhou J, Michaud DS, Langevin SM, McClean MD, Eliot M, Kelsey KT. Smokeless tobacco and risk of head and neck cancer: evidence from a case-control study in New England. Int J Cancer. 2013;132:1911–7.PubMed
11.
Vidyasagaran AL, Siddiqi K, Kanaan M. Use of smokeless tobacco and risk of cardiovascular disease: a systematic review and meta-analysis. Eur J Prev Cardiol. 2016;23:1970–81.PubMed
12.
Inamdar AS, Croucher RE, Chokhandre MK, Mashyakhy MH, Marinho VCC. Maternal smokeless tobacco use in pregnancy and adverse health outcomes in newborns: a systematic review. Nicotine Tob Res. 2015;17:1058–66.PubMed
13.
Gupta PC, Subramoney S. Smokeless tobacco use and risk of stillbirth: a cohort study in Mumbai. India Epidemiology. 2006;17:47–51.PubMed
14.
Ezzati M, Lopez AD, Rodgers A, Vander Hoorn S, Murray CJL, Comparative Risk Assessment Collaborating Group. Selected major risk factors and global and regional burden of disease. Lancet. 2002;360:1347–60.PubMed
15.
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2224–60.PubMedPubMedCentral
16.
Siddiqi K, Shah S, Abbas SM, Vidyasagaran A, Jawad M, Dogar O, et al. Global burden of disease due to smokeless tobacco consumption in adults: analysis of data from 113 countries. BMC Med. 2015;13:194.PubMedPubMedCentral
17.
18.
Hearn BA, Renner CC, Ding YS, Vaughan-Watson C, Stanfill SB, Zhang L, et al. Chemical analysis of Alaskan Iq’mik smokeless tobacco. Nicotine Tob Res. 2013;15:1283–8.PubMed
19.
Lawler TS, Stanfill SB, Zhang L, Ashley DL, Watson CH. Chemical characterization of domestic oral tobacco products: total nicotine, pH, unprotonated nicotine and tobacco-specific N-nitrosamines. Food Chem Toxicol. 2013;57:380–6.PubMedPubMedCentral
20.
Stanfill SB, Oliveira da Silva AL, Lisko JG, Lawler TS, Kuklenyik P, Tyx RE, et al. Comprehensive chemical characterization of Rapé tobacco products: nicotine, un-ionized nicotine, tobacco-specific N’-nitrosamines, polycyclic aromatic hydrocarbons, and flavor constituents. Food Chem Toxicol. 2015;82:50–8.
21.
Al-Mukhaini NM, Ba-Omar TA, Eltayeb EA, Al-Shehi AH. Characterisation of nicotine and cancer-enhancing anions in the common smokeless tobacco Afzal in Oman. Sultan Qaboos Univ Med J. 2015;15:e469–76.PubMedPubMedCentral
22.
Al-Mukhaini N, Ba-Omar T, Eltayeb EA, Al-Shehi AA. Analysis of tobacco-specific nitrosamines in the common smokeless tobacco Afzal in Oman. Sultan Qaboos Univ Med J. 2016;16:e20–6.PubMedPubMedCentral
23.
Ratsch AM, Mason A, Rive L, Bogossian FE, Steadman KJ. The Pituri Learning Circle: central Australian Aboriginal women’s knowledge and practices around the use of Nicotiana spp. as a chewing tobacco. Rural Remote Health. 2017;17:4044.PubMed
24.
25.
World Health Organization WHO report on the global tobacco epidemic, 2017: Monitoring tobacco use and prevention policies. World Health Organization; 2017.
26.
27.
28.
Sreeramareddy CT, Pradhan PM, Sin S. Prevalence, distribution, and social determinants of tobacco use in 30 sub-Saharan African countries. BMC Med. 2014;12:243.PubMedPubMedCentral
29.
Ansara DL, Arnold F, Kishor S, Hsia J, Kaufmann R. Tobacco use by men and women in 49 countries with demographic and health surveys. ICF International; 2013.
30.
World Health Organization. WHO Report on the Global Tobacco Epidemic, 2013: Enforcing bans on tobacco advertising, promotion and sponsorship. World Health Organization; 2013.
31.
Health Canada. Canadian tobacco, alcohol and drugs survey (CTADS): summary of results for 2015. 2016.
32.
33.
Agaku IT, Filippidis FT, Vardavas CI, Odukoya OO, Awopegba AJ, Ayo-Yusuf OA, et al. Poly-tobacco use among adults in 44 countries during 2008-2012: evidence for an integrative and comprehensive approach in tobacco control. Drug Alcohol Depend. 2014;139:60–70.PubMed
34.
35.
Teo KK, Ounpuu S, Hawken S, Pandey MR, Valentin V, Hunt D, et al. Tobacco use and risk of myocardial infarction in 52 countries in the INTERHEART study: a case-control study. Lancet. 2006;368:1474–547X (Electronic):647–58.
36.
Anantharaman D, Chaubal PM, Kannan S, Bhisey RA, Mahimkar MB. Susceptibility to oral cancer by genetic polymorphisms at CYP1A1, GSTM1 and GSTT1 loci among Indians: tobacco exposure as a risk modulator. Carcinogenesis. 2007;28:1455–62.PubMed
37.
Balaram P, Sridhar H, Rajkumar T, Vaccarella S, Herrero R, Nandakumar A, et al. Oral cancer in southern India: the influence of smoking, drinking, paan-chewing and oral hygiene. Int J Cancer. 2002;98:440–5.PubMed
38.
Dikshit RP, Kanhere S. Tobacco habits and risk of lung, oropharyngeal and oral cavity cancer: a population-based case-control study in Bhopal, India. Int J Epidemiol. 2000;29:609–14.PubMed
39.
Goud ML, Mohapatra SC, Mohapatra P, Gaur SD, Pant GC, Knanna MN. Epidemiological correlates between consumption of Indian chewing tobacco and oral cancer. Eur J Epidemiol. 1990;6:219–22.PubMed
40.
Jayalekshmi PA, Gangadharan P, Akiba S, Nair RRK, Tsuji M, Rajan B. Tobacco chewing and female oral cavity cancer risk in Karunagappally cohort, India. Br J Cancer. 2009;100:848–52.PubMedPubMedCentral
41.
Jayalekshmi PA, Gangadharan P, Akiba S, Koriyama C, Nair RRK. Oral cavity cancer risk in relation to tobacco chewing and bidi smoking among men in Karunagappally, Kerala, India: Karunagappally cohort study. Cancer Sci. 2011;102:460–7.PubMed
42.
Jayant K, Balakrishnan V, Sanghvi LD, Jussawalla DJ. Quantification of the role of smoking and chewing tobacco in oral, pharyngeal, and oesophageal cancers. Br J Cancer. 1977;35:232–5.PubMedPubMedCentral
43.
Jussawalla DJ, Deshpande VA. Evaluation of cancer risk in tobacco chewers and smokers: an epidemiologic assessment. Cancer. 1971;28:244–52.PubMed
44.
Madani AH, Jahromi AS, Madhurima D, Debanshu B, et al. Risk assessment of tobacco types and oral cancer. Am J Pharmacol Toxicol. 2010;5:9–13.
45.
Muwonge R, Ramadas K, Sankila R, Thara S, Thomas G, Vinoda J, et al. Role of tobacco smoking, chewing and alcohol drinking in the risk of oral cancer in Trivandrum, India: a nested case-control design using incident cancer cases. Oral Oncol. 2008;44:446–54.PubMed
46.
Nandakumar A, Thimmasetty KT, Sreeramareddy NM, Venugopal TC, Rajanna, Vinutha AT, et al. A population-based case-control investigation on cancers of the oral cavity in Bangalore, India. Br J Cancer. 1990;62:847–51.PubMedPubMedCentral
47.
Rao DN, Ganesh B, Rao RS, Desai PB. Risk assessment of tobacco, alcohol and diet in oral cancer—a case-control study. Int J Cancer. 1994;58:469–73.PubMed
48.
Sanghvi LD, Rao KC, Khanolkar VR. Smoking and chewing of tobacco in relation to cancer of the upper alimentary tract. Br Med J. 1955;1:1111–4.PubMedPubMedCentral
49.
Sankaranarayanan R, Duffy SW, Padmakumary G, Day NE, Krishan NM. Risk factors for cancer of the buccal and labial mucosa in Kerala, southern India. J Epidemiol Community Health. 1990;44:286–92.PubMedPubMedCentral
50.
Wasnik KS, Ughade SN, Zodpey SP, Ingole DL. Tobacco consumption practices and risk of oro-pharyngeal cancer: a case-control study in Central India. Southeast Asian J Trop Med Public Health. 1998;29:827–34.PubMed
51.
Subapriya R, Thangavelu A, Mathavan B, Ramachandran CR, Nagini S. Assessment of risk factors for oral squamous cell carcinoma in Chidambaram, Southern India: a case–control study. Eur J Cancer Prev. 2007;16:251.PubMed
52.
Wahi PN, Kehar U, Lahiri B. Factors influencing oral and oropharyngeal cancers in India. Br J Cancer. 1965;19:642–60.PubMedPubMedCentral
53.
Merchant A, Husain SS, Hosain M, Fikree FF, Pitiphat W, Siddiqui AR, et al. Paan without tobacco: an independent risk factor for oral cancer. Int J Cancer. 2000;86:128–31.PubMed
54.
Roosaar A, Johansson ALV, Sandborgh-Englund G, Axéll T, Nyrén O. Cancer and mortality among users and nonusers of snus. Int J Cancer. 2008;123:168–73.PubMed
55.
Znaor A, Brennan P, Gajalakshmi V, Mathew A, Shanta V, Varghese C, et al. Independent and combined effects of tobacco smoking, chewing and alcohol drinking on the risk of oral, pharyngeal and esophageal cancers in Indian men. Int J Cancer. 2003;105:681–6.PubMed
56.
Boffetta P, Aagnes B, Weiderpass E, Andersen A. Smokeless tobacco use and risk of cancer of the pancreas and other organs. Int J Cancer. 2005;114:992–5.PubMed
57.
Lewin F, Norell SE, Johansson H, Gustavsson P, Wennerberg J, Biörklund A, et al. Smoking tobacco, oral snuff, and alcohol in the etiology of squamous cell carcinoma of the head and neck: a population-based case-referent study in Sweden. Cancer. 1998;82:1367–75.PubMed
58.
Luo J, Ye W, Zendehdel K, Adami J, Adami H-O, Boffetta P, et al. Oral use of Swedish moist snuff (snus) and risk for cancer of the mouth, lung, and pancreas in male construction workers: a retrospective cohort study. Lancet. 2007;369:2015–20.PubMed
59.
Rosenquist K, Wennerberg J, Schildt E-B, Bladström A, Hansson BG, Andersson G. Use of Swedish moist snuff, smoking and alcohol consumption in the aetiology of oral and oropharyngeal squamous cell carcinoma. A population-based case-control study in southern Sweden. Acta Otolaryngol. 2005;125:991–8.PubMed
60.
Schildt E-B, Eriksson M, Hardell L, Magnuson A. Oral snuff, smoking habits and alcohol consumption in relation to oral cancer in a Swedish case-control study. Int J Cancer. 1998;77:341–6.PubMed
61.
Mashberg A, Boffetta P, Winkelman R, Garfinkel L. Tobacco smoking, alcohol drinking, and cancer of the oral cavity and oropharynx among U.S. veterans. Cancer. 1993;72:1369–75.PubMed
62.
Sapkota A, Gajalakshmi V, Jetly DH, Roychowdhury S, Dikshit RP, Brennan P, et al. Smokeless tobacco and increased risk of hypopharyngeal and laryngeal cancers: a multicentric case–control study from India. Int J Cancer. 2007;121:1793–8.PubMed
63.
Akhtar S, Sheikh AA, Qureshi HU. Chewing areca nut, betel quid, oral snuff, cigarette smoking and the risk of oesophageal squamous-cell carcinoma in South Asians: a multicentre case–control study. Eur J Cancer. 2012;48:655–61.PubMed
64.
Dar NA, Bhat GA, Shah IA, Iqbal B, Makhdoomi MA, Nisar I, et al. Hookah smoking, nass chewing, and oesophageal squamous cell carcinoma in Kashmir, India. Br J Cancer. 2012;107:1618–23.PubMedPubMedCentral
65.
Sehgal S, Kaul S, Gupta BB, Dhar MK. Risk factors and survival analysis of the esophageal cancer in the population of Jammu, India. Indian J Cancer. 2012;49:245–50.PubMed
66.
Talukdar FR, Ghosh SK, Laskar RS, Mondal R. Epigenetic, genetic and environmental interactions in esophageal squamous cell carcinoma from northeast India. PLoS One. 2013;8:e60996.PubMedPubMedCentral
67.
Lagergren J, Bergström R, Lindgren A, Nyrén O. The role of tobacco, snuff and alcohol use in the aetiology of cancer of the oesophagus and gastric cardia. Int J Cancer. 2000;85:340–6.PubMed
68.
Zendehdel K, Nyrén O, Luo J, Dickman PW, Boffetta P, Englund A, et al. Risk of gastroesophageal cancer among smokers and users of Scandinavian moist snuff. Int J Cancer. 2008;122:1095–9.PubMed
69.
Bolinder G, Alfredsson L, Englund A, de Faire U. Smokeless tobacco use and increased cardiovascular mortality among Swedish construction workers. Am J Public Health. 1994;84:399–404.PubMedPubMedCentral
70.
Sasco AJ, Merrill RM, Dari I, Benhaïm-Luzon V, Carriot F, Cann CI, et al. A case--control study of lung cancer in Casablanca, Morocco. Cancer Causes Control. 2002;13:609–16.PubMed
71.
Brown LM, Blot WJ, Schuman SH, Smith VM, Ershow AG, Marks RD, et al. Environmental factors and high risk of esophageal cancer among men in coastal South Carolina. J Natl Cancer Inst. 1988;80:1620–5.PubMed
72.
Alguacil J, Silverman DT. Smokeless and other noncigarette tobacco use and pancreatic cancer: a case-control study based on direct interviews. Cancer Epidemiol Biomark Prev. 2004;13:55–8.
73.
Hassan MM, Abbruzzese JL, Bondy ML, Wolff RA, Vauthey J-N, Pisters PW, et al. Passive smoking and the use of noncigarette tobacco products in association with risk for pancreatic cancer: a case-control study. Cancer. 2007;109:2547–56.PubMedPubMedCentral
74.
Khan Z, Dreger S, Shah SMH, Pohlabeln H, Khan S, Ullah Z, et al. Oral cancer via the bargain bin: the risk of oral cancer associated with a smokeless tobacco product (Naswar). PLoS One. 2017;12:e0180445.PubMedPubMedCentral
75.
Mahapatra S, Kamath R, Shetty BK, Binu VS. Risk of oral cancer associated with gutka and other tobacco products: a hospital-based case-control study. J Cancer Res Ther. 2015;11:199–203.PubMed
76.
Merchant AT, Pitiphat W. Total, direct, and indirect effects of paan on oral cancer. Cancer Causes Control. 2015;26:487–91.PubMed
77.
78.
Rahman MA, Zaman MM. Smoking and smokeless tobacco consumption: possible risk factors for coronary heart disease among young patients attending a tertiary care cardiac hospital in Bangladesh. Public Health. 2008;122:1331–8.PubMed
79.
Rahman MA, Spurrier N, Mahmood MA, Rahman M, Choudhury SR, Leeder S. Is there any association between use of smokeless tobacco products and coronary heart disease in Bangladesh? PLoS One. 2012;7:e30584.PubMedPubMedCentral
80.
Agashe A, Gawde N. Stroke and the use of smokeless tobacco--a case-control study. Healthline. 2013;4:13–8.
81.
Huhtasaari F, Asplund K, Lundberg V, Stegmayr B, Wester PO. Tobacco and myocardial infarction: is snuff less dangerous than cigarettes? BMJ. 1992;305:1252–6.PubMedPubMedCentral
82.
Huhtasaari F, Lundberg V, Eliasson M, Janlert U, Asplund K. Smokeless tobacco as a possible risk factor for myocardial infarction: a population-based study in middle-aged men. J Am Coll Cardiol. 1999;34:1784–90.PubMed
83.
Asplund K, Nasic S, Janlert U, Stegmayr B. Smokeless tobacco as a possible risk factor for stroke in men: a nested case-control study. Stroke. 2003;34:1754–9.PubMed
84.
Hergens M-P, Ahlbom A, Andersson T, Pershagen G. Swedish moist snuff and myocardial infarction among men. Epidemiology. 2005;16:12–6.PubMed
85.
Haglund B, Eliasson M, Stenbeck M, Rosén M. Is moist snuff use associated with excess risk of IHD or stroke? A longitudinal follow-up of snuff users in Sweden. Scand J Public Health. 2007;35:618–22.PubMed
86.
Hergens M-P, Alfredsson L, Bolinder G, Lambe M, Pershagen G, Ye W. Long-term use of Swedish moist snuff and the risk of myocardial infarction amongst men. J Intern Med. 2007;262:351–9.PubMed
87.
Wennberg P, Eliasson M, Hallmans G, Johansson L, Boman K, Jansson J-H. The risk of myocardial infarction and sudden cardiac death amongst snuff users with or without a previous history of smoking. J Intern Med. 2007;262:360–7.PubMed
88.
Hergens M-P, Lambe M, Pershagen G, Terent A, Ye W. Smokeless tobacco and the risk of stroke. Epidemiology. 2008;19:794–9.PubMed
89.
Hansson J, Pedersen NL, Galanti MR, Andersson T, Ahlbom A, Hallqvist J, et al. Use of snus and risk for cardiovascular disease: results from the Swedish Twin Registry. J Intern Med. 2009;265:717–24.PubMed
90.
Janzon E, Hedblad B. Swedish snuff and incidence of cardiovascular disease. A population-based cohort study BMC Cardiovasc Disord. 2009;9:21.PubMed
91.
92.
Singh PK, Yadav A, Lal P, Sinha DN, Gupta PC, Swasticharan L, et al. Dual burden of smoked and smokeless tobacco use in India, 2009–2017: a repeated cross-sectional analysis based on global adult tobacco survey. Nicotine Tobacco Research. 2020. https://​doi.​org/​10.​1093/​ntr/​ntaa033.
93.
Mehrotra R, Yadav A, Sinha DN, Parascandola M, John RM, Ayo-Yusuf O, et al. Smokeless tobacco control in 180 countries across the globe: call to action for full implementation of WHO FCTC measures. Lancet Oncol. 2019;20:e208–17.PubMed
94.
95.
Mehrotra R, Kaushik N, Kaushik R. Why smokeless tobacco control needs to be strengthened? Cancer Control. 2020;27:1073274820914659.PubMedPubMedCentral
Metadata
Title
Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries
Authors
Kamran Siddiqi
Scheherazade Husain
Aishwarya Vidyasagaran
Anne Readshaw
Masuma Pervin Mishu
Aziz Sheikh
Publication date
01-12-2020
Publisher
BioMed Central
Published in
BMC Medicine / Issue 1/2020
Electronic ISSN: 1741-7015
DOI
https://doi.org/10.1186/s12916-020-01677-9

Other articles of this Issue 1/2020

BMC Medicine 1/2020 Go to the issue

Research article

Increased frequency of intentional weight loss associated with reduced mortality: a prospective cohort analysis

Research article

Development and validation of an artificial intelligence system for grading colposcopic impressions and guiding biopsies

Research article

Mendelian randomization study of inflammatory bowel disease and bone mineral density

Research article

Aspirin and other non-steroidal anti-inflammatory drugs and depression, anxiety, and stress-related disorders following a cancer diagnosis: a nationwide register-based cohort study

Commentary

Systems and implementation science should be part of the COVID-19 response in low resource settings

Research article

C-reactive protein as a potential biomarker for disease progression in dengue: a multi-country observational study