Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019
Authors: Parkes J Kendrick, Marissa B Reitsma, Mohsen Abbasi-Kangevari, Amir Abdoli, Mohammad Abdollahi, Aidin Abedi, E S Abhilash, Victor Aboyans, Oladimeji M Adebayo, Shailesh M Advani, Bright Opoku Ahinkorah, Sohail Ahmad, Keivan Ahmadi, Haroon Ahmed, Budi Aji, Yonas Akalu, Chisom Joyqueenet Akunna, Fares Alahdab, Ziyad Al-Aly, Fahad Mashhour Alanezi, Turki M Alanzi, Khalid F Alhabib, Tilahun Ali, Sheikh Mohammad Alif, Vahid Alipour, Syed Mohamed Aljunid, Mahmoud A Alomari, Tarek Tawfik Amin, Saeed Amini, Hubert Amu, Robert Ancuceanu, Jason A Anderson, Catalina Liliana Andrei, Tudorel Andrei, Alireza Ansari-Moghaddam, Benny Antony, Davood Anvari, Jalal Arabloo, Nicholas D Arian, Monika Arora, Kurnia Dwi Artanti, Wondwossen Niguse Asmare, Desta Debalkie Atnafu, Marcel Ausloos, Asma Tahir Awan, Getinet Ayano, Getie Lake Aynalem, Samad Azari, Darshan B B, Ashish D Badiye, Atif Amin Baig, Maciej Banach, Srikanta K Banerjee, Suzanne Lyn Barker-Collo, Till Winfried Bärnighausen, Hiba Jawdat Barqawi, Sanjay Basu, Mohsen Bayati, Shahrzad Bazargan-Hejazi, Tariku Tesfaye Bekuma, Derrick A Bennett, Isabela M Bensenor, Habib Benzian, Catherine P Benziger, Adam E Berman, Akshaya Srikanth Bhagavathula, Neeraj Bhala, Nikha Bhardwaj, Pankaj Bhardwaj, Krittika Bhattacharyya, Sadia Bibi, Ali Bijani, Antonio Biondi, Dejana Braithwaite, Hermann Brenner, Andre R Brunoni, Katrin Burkart, Sharath Burugina Nagaraja, Zahid A Butt, Florentino Luciano Caetano dos Santos, Josip Car, Giulia Carreras, Joao Mauricio Castaldelli-Maia, Maria Sofia Sofia Cattaruzza, Jung-Chen Chang, Pankaj Chaturvedi, Simiao Chen, Onyema greg Chido-Amajuoyi, Dinh-Toi Chu, Sheng-Chia Chung, Liliana G Ciobanu, Vera Marisa Costa, Rosa A S Couto, Baye Dagnew, Xiaochen Dai, Albertino Antonio Moura Damasceno, Giovanni Damiani, Lalit Dandona, Rakhi Dandona, Parnaz Daneshpajouhnejad, Jiregna Darega Gela, Meseret Derbew Molla, Abebaw Alemayehu Desta, Samath Dhamminda Dharmaratne, Meghnath Dhimal, Arielle Wilder Eagan, Mohammad Ebrahimi Kalan, Kristina Edvardsson, Andem Effiong, Maha El Tantawi, Iffat Elbarazi, Saman Esmaeilnejad, Ibtihal Fadhil, Emerito Jose A Faraon, Medhat Farwati, Farshad Farzadfar, Mehdi Fazlzadeh, Valery L Feigin, Rachel Feldman, Irina Filip, Filippos Filippidis, Florian Fischer, Luisa Sorio Flor, Nataliya A Foigt, Morenike Oluwatoyin Folayan, Masoud Foroutan, Mohamed M Gad, Silvano Gallus, Biniyam Sahiledengle Geberemariyam, Birhan Gebresillassie Gebregiorgis, Lemma Getacher, Abera Getachew Obsa, Mansour Ghafourifard, Reza Ghanei Gheshlagh, Ahmad Ghashghaee, Nermin Ghith, Gabriela Fernanda Gil, Paramjit Singh Gill, Ibrahim Abdelmageed Ginawi, Salime Goharinezhad, Mahaveer Golechha, Sameer Vali Gopalani, Giuseppe Gorini, Michal Grivna, Avirup Guha, Rafael Alves Guimarães, Yuming Guo, Rajat Das Gupta, Rajeev Gupta, Tarun Gupta, Vin Gupta, Nima Hafezi-Nejad, Mohammad Rifat Haider, Randah R Hamadeh, Graeme J Hankey, Arief Hargono, Simon I Hay, Golnaz Heidari, Claudiu Herteliu, Kamal Hezam, Thomas R Hird, Ramesh Holla, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Mowafa Househ, Thomas Hsiao, Junjie Huang, Charles Ugochukwu Ibeneme, Segun Emmanuel Ibitoye, Irena M Ilic, Milena D Ilic, Leeberk Raja Inbaraj, Seyed Sina Naghibi Irvani, Jessica Y Islam, Rakibul M Islam, Sheikh Mohammed Shariful Islam, Farhad Islami, Hiroyasu Iso, Ramaiah Itumalla, Jalil Jaafari, Vardhmaan Jain, Mihajlo Jakovljevic, Sung-In Jang, Shubha Jayaram, Panniyammakal Jeemon, Ravi Prakash Jha, Jost B Jonas, Mikk Jürisson, Ali Kabir, Zubair Kabir, Leila R Kalankesh, Tanuj Kanchan, Himal Kandel, Neeti Kapoor, André Karch, Salah Eddin Karimi, Kindie Mitiku Kebede, Bayew Kelkay, Ryan David Kennedy, Yousef Saleh Khader, Ejaz Ahmad Khan, Maryam Khayamzadeh, Gyu Ri Kim, Ruth W Kimokoti, Mika Kivimäki, Soewarta Kosen, Sindhura Lakshmi Koulmane Laxminarayana, Ai Koyanagi, Kewal Krishan, Nuworza Kugbey, G Anil Kumar, Nithin Kumar, Om P Kurmi, Dian Kusuma, Ben Lacey, Iván Landires, Savita Lasrado, Paolo Lauriola, Doo Woong Lee, Yo Han Lee, Janni Leung, Shanshan Li, Hualiang Lin, Wei Liu, Alessandra Lugo, Shilpashree Madhava Kunjathur, Azeem Majeed, Afshin Maleki, Reza Malekzadeh, Deborah Carvalho Malta, Abdullah A Mamun, Narayana Manjunatha, Borhan Mansouri, Mohammad Ali Mansournia, Santi Martini, Manu Raj Mathur, Prashant Mathur, Mohsen Mazidi, Martin McKee, Carlo Eduardo Medina-Solís, Suresh Mehata, Walter Mendoza, Ritesh G Menezes, Bartosz Miazgowski, Irmina Maria Michalek, Ted R Miller, GK Mini, Andreea Mirica, Erkin M Mirrakhimov, Hamed Mirzaei, Sanjeev Misra, Yousef Mohammad, Abdollah Mohammadian-Hafshejani, Shafiu Mohammed, Ali H Mokdad, Mariam Molokhia, Lorenzo Monasta, Mohammad Ali Moni, Rahmatollah Moradzadeh, Shane Douglas Morrison, Tilahun Belete Mossie, Sumaira Mubarik, Erin C Mullany, Christopher J L Murray, Shankar Prasad Nagaraju, Mohsen Naghavi, Nitish Naik, Mahdi Nalini, Vinay Nangia, Atta Abbas Naqvi, Sreenivas Narasimha Swamy, Muhammad Naveed, Javad Nazari, Sabina O Nduaguba, Ruxandra Irina Negoi, Sandhya Neupane Kandel, Huong Lan Thi Nguyen, Yeshambel T Nigatu, Molly R Nixon, Chukwudi A Nnaji, Jean Jacques Noubiap, Christoph Nowak, Virginia Nuñez-Samudio, Felix Akpojene Ogbo, Ayodipupo Sikiru Oguntade, In-Hwan Oh, Andrew T Olagunju, Mayowa O Owolabi, Mahesh P A, Keyvan Pakshir, Adrian Pana, Demosthenes Panagiotakos, Songhomitra Panda-Jonas, Ashok Pandey, Utsav Parekh, Eun-Cheol Park, Eun-Kee Park, Fatemeh Pashazadeh Kan, Mona Pathak, Shrikant Pawar, Richard G Pestell, Hai Quang Pham, Marina Pinheiro, Khem Narayan Pokhrel, Akram Pourshams, Akila Prashant, Amir Radfar, Vafa Rahimi-Movaghar, Mohammad Hifz Ur Rahman, Muhammad Aziz Rahman, Amir Masoud Rahmani, Pradhum Ram, Juwel Rana, Chhabi Lal Ranabhat, Priya Rathi, David Laith Rawaf, Salman Rawaf, Reza Rawassizadeh, Andre M N Renzaho, Aziz Rezapour, Mavra A Riaz, Leonardo Roever, Luca Ronfani, Gholamreza Roshandel, Ambuj Roy, Bedanta Roy, Basema Saddik, Amirhossein Sahebkar, Sana Salehi, Hamideh Salimzadeh, Abdallah M Samy, Juan Sanabria, Milena M Santric-Milicevic, Bruno Piassi Sao Jose, Brijesh Sathian, Monika Sawhney, Ganesh Kumar Saya, Falk Schwendicke, Abdul-Aziz Seidu, Nachimuthu Senthil Kumar, Sadaf G Sepanlou, Omid Shafaat, Syed Mahboob Shah, Masood Ali Shaikh, Mohammed Shannawaz, Kiomars Sharafi, Aziz Sheikh, Sara Sheikhbahaei, Mika Shigematsu, Rahman Shiri, Kawkab Shishani, K M Shivakumar, Siddharudha Shivalli, Roman Shrestha, Soraya Siabani, Negussie Boti Sidemo, Inga Dora Sigfusdottir, Rannveig Sigurvinsdottir, João Pedro Silva, Ambrish Singh, Jasvinder A Singh, Virendra Singh, Dhirendra Narain Sinha, Valentin Yurievich Skryabin, Anna Aleksandrovna Skryabina, Ali Soroush, Ireneous N Soyiri, Chandrashekhar T Sreeramareddy, Dan J Stein, Paschalis Steiropoulos, Stefan Stortecky, Kurt Straif, Rizwan Suliankatchi Abdulkader, Gerhard Sulo, Johan Sundström, Takahiro Tabuchi, Eyayou Girma Tadesse, Animut Tagele Tamiru, Minale Tareke, Md Ismail Tareque, Ingan Ukur Tarigan, Bhaskar Thakur, Kavumpurathu Raman Thankappan, Rekha Thapar, Musliu Adetola Tolani, Marcos Roberto Tovani-Palone, Bach Xuan Tran, Jaya Prasad Tripathy, Gebiyaw Wudie Tsegaye, Hayley D Tymeson, Saif Ullah, Brigid Unim, Rachel L Updike, Olalekan A Uthman, Marco Vacante, Constantine Vardavas, Narayanaswamy Venketasubramanian, Madhur Verma, Simone Vidale, Bay Vo, Giang Thu Vu, Yasir Waheed, Yanzhong Wang, Kevin Welding, Andrea Werdecker, Joanna L Whisnant, Nuwan Darshana Wickramasinghe, Befikadu Legesse Wubishet, Kazumasa Yamagishi, Yuichiro Yano, Vahid Yazdi-Feyzabadi, Yigizie Yeshaw, Mohammed Zewdu Yimmer, Naohiro Yonemoto, Zabihollah Yousefi, Chuanhua Yu, Ismaeel Yunusa, Hasan Yusefzadeh, Muhammed Shahriar Zaman, Mohammad Zamani, Maryam Zamanian, Mikhail Sergeevich Zastrozhin, Anasthasia Zastrozhina, Jianrong Zhang, Zhi-Jiang Zhang, Chenwen Zhong, Yves Miel H Zuniga, Emmanuela Gakidou
Journal: The Lancet Public Health (2021)

<h2>Summary</h2><h3>Background</h3> Chewing tobacco and other types of smokeless tobacco use have had less attention from the global health community than smoked tobacco use. However, the practice is popular in many parts of the world and has been linked to several adverse health outcomes. Understanding trends in prevalence with age, over time, and by location and sex is important for policy setting and in relation to monitoring and assessing commitment to the WHO Framework Convention on Tobacco Control. <h3>Methods</h3> We estimated prevalence of chewing tobacco use as part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2019 using a modelling strategy that used information on multiple types of smokeless tobacco products. We generated a time series of prevalence of chewing tobacco use among individuals aged 15 years and older from 1990 to 2019 in 204 countries and territories, including age-sex specific estimates. We also compared these trends to those of smoked tobacco over the same time period. <h3>Findings</h3> In 2019, 273·9 million (95% uncertainty interval 258·5 to 290·9) people aged 15 years and older used chewing tobacco, and the global age-standardised prevalence of chewing tobacco use was 4·72% (4·46 to 5·01). 228·2 million (213·6 to 244·7; 83·29% [82·15 to 84·42]) chewing tobacco users lived in the south Asia region. Prevalence among young people aged 15–19 years was over 10% in seven locations in 2019. Although global age-standardised prevalence of smoking tobacco use decreased significantly between 1990 and 2019 (annualised rate of change: –1·21% [–1·26 to –1·16]), similar progress was not observed for chewing tobacco (0·46% [0·13 to 0·79]). Among the 12 highest prevalence countries (Bangladesh, Bhutan, Cambodia, India, Madagascar, Marshall Islands, Myanmar, Nepal, Pakistan, Palau, Sri Lanka, and Yemen), only Yemen had a significant decrease in the prevalence of chewing tobacco use, which was among males between 1990 and 2019 (−0·94% [–1·72 to –0·14]), compared with nine of 12 countries that had significant decreases in the prevalence of smoking tobacco. Among females, none of these 12 countries had significant decreases in prevalence of chewing tobacco use, whereas seven of 12 countries had a significant decrease in the prevalence of tobacco smoking use for the period. <h3>Interpretation</h3> Chewing tobacco remains a substantial public health problem in several regions of the world, and predominantly in south Asia. We found little change in the prevalence of chewing tobacco use between 1990 and 2019, and that control efforts have had much larger effects on the prevalence of smoking tobacco use than on chewing tobacco use in some countries. Mitigating the health effects of chewing tobacco requires stronger regulations and policies that specifically target use of chewing tobacco, especially in countries with high prevalence. <h3>Funding</h3> Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.