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Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: systematic review and meta-analysis
  1. Dhirendra N Sinha1,
  2. Rizwan A Suliankatchi2,
  3. Prakash C Gupta3,
  4. Thaksaphon Thamarangsi4,
  5. Naveen Agarwal4,
  6. Mark Parascandola5,
  7. Ravi Mehrotra6
  1. 1 Tobacco Free Initiative Unit, World Health Organization, New Delhi, India
  2. 2 Department of Community Medicine, Velammal Medical College Hospital and Research Institute, Madurai, Tamil Nadu, India
  3. 3 Healis—Sekhsaria Institute for Public Health, Mumbai, Maharashtra, India
  4. 4 Department of Noncommunicable Disease and Environmental Health, World Health Organization, New Delhi, India
  5. 5 Tobacco Control Research Branch, Behavioral Research Program, National Cancer Institute, Bethesda, Maryland, USA
  6. 6 Institute of Cytology and Preventive Oncology (ICMR), Noida, Uttar Pradesh, India
  1. Correspondence to Dr Dhirendra N Sinha, Regional Adviser, Surveillance (Tobacco Control), Tobacco Free Initiative Unit, World Health Organization, Regional Office for South-East Asia, I.P. Estate, New Delhi 110002, India; dhirendrasinha1{at}


Objectives To systematically review and meta-analyse the studies investigating the association between smokeless tobacco (SLT) use and all-cause mortality and cause-specific mortality outcomes among adult users of SLT and estimate the number of attributable deaths worldwide.

Methods Random-effects meta-analysis was used to estimate the pooled risk of death due to SLT use. Population attributable fractions were derived and used to calculate the number of attributable deaths. Observational studies published upto 2015 were identified through MEDLINE, IndMED, Google Scholar and other databases. Data on the prevalence of SLT use was obtained from latest reports or national surveys. Data on the disease burden were obtained from the Global Burden of Disease Study. Hospital-based or community-based case–control and cohort studies that adjusted for the smoking status were included.

Results 16 studies that provided estimates for mortality due to all cause, all cancer, upper aerodigestive tract (UADT) cancer, stomach cancer, cervical cancer, ischaemic heart disease (IHD) and stroke were included. A significant association was found for mortality due to all cause (1.22; 1.11–1.34), all cancer (1.31; 1.16–1.47), UADT cancer (2.17; 1.47–3.22), stomach cancer (1.33; 1.12–1.59), cervical cancer (2.07; 1.64–2.61), IHD (1.10; 1.04–1.17) and stroke (1.37; 1.24–1.51). Subgroup analysis showed major regional differences. Globally, the number of attributable deaths from all-cause mortality was 652 494 (234 008–1 081 437), of which 88% was borne by the South-East Asian region.

Conclusions SLT is responsible for a large number of deaths worldwide with the South-East Asian region bearing a substantial share of the burden.

  • Prevention
  • Non-cigarette tobacco products
  • Low/Middle income country
  • Global health
  • Advocacy

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  • Twitter Follow Rizwan Suliankatchi Abdulkader at @sarizwan1986

  • Contributors RAS, DNS and PCG developed the concept and study protocol. RAS and DNS carried out the literature review and PCG served as the arbitrator. NA carried out prevalence data extraction. Analysis plan was developed by all authors and carried out by RAS. RAS wrote the first draft and DNS, PCG, TT, MP and RM provided critical inputs to the analysis plan, interpretation and manuscript writing. All authors read and approved the final manuscript.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Data of this study are available to anyone who wishes to perform additional analysis with any objective, from RAS, by sending an email to