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

GBD 2019 Chewing Tobacco Collaborators

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Abstract

Background: 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. Methods: 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. Findings: 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. Interpretation: 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. Funding: Bloomberg Philanthropies and the Bill & Melinda Gates Foundation.

Original languageEnglish
Pages (from-to)e482-e499
Number of pages18
JournalThe Lancet Public Health
Volume6
Issue number7
Early online date27 May 2021
DOIs
Publication statusPublished - Jul 2021
Externally publishedYes

Bibliographical note

Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license.

Funder

The authors alone are responsible for the views expressed in this Article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated or their funders. SheMA thanks the International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia and Department of Health Policy and Management, Faculty of Public Health, Kuwait University for the approval and support to participate in this research project. SKB received contributions from the Social Change Grant Program with Walden University. DAB receives support from the Oxford National Institute for Health Research (NIHR) Biomedical Research Centre (BRC). VMC acknowledges a grant (SFRH/BHD/110001/2015), through Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006. MEK was supported by University Graduate School Dissertation Year Fellowship at Florida International University. NG is employed as a postdoctoral researcher by the Technical University of Denmark and her salary is covered by a research grant from Novo Nordisk Foundation. CH, MarA, and AdP are partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation (CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084). CH and AdP are partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation (CNDS-UEFISCDI, project number PN-III-P2-2.1-SOL-2020-2-0351). JYI is supported by UNC's Cancer Care Quality Training 2T32CA116339-11. SMSI received funding from Deakin University, the National Heart Foundation of Australia, and the Australian National Health and Medical Research Council. MihJ has been co-funded through a grant from the Ministry of Science Education and Technological Development of the Republic of Serbia (OI 175 014). PJ was supported by the Wellcome Trust/DBT India Alliance Intermediate Fellowship 2015–21 (IA/CPHI/14/1/501497). MK has received funding from the Wellcome Trust (221854/Z/20/Z), the UK Medical Research Council (MRC S011676), and Helsinki Institute of Life Science (H970). SLKL acknowledges institutional support by Manipal Academy of Higher Education. KK is supported by UGC Centre of Advanced Study (CAS II), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. BL acknowledges support from UK Biobank, the NIHR Oxford BRC, and the BHF Oxford Centre of Research Excellence. IL is member of the Sistema Nacional de Investigación, which is supported by the Secretaría Nacional de Ciencia, Tecnología e Innovación, Panamá. MariM is supported by the NIHR BRC at Guy's and St Thomas' National Health Service Foundation Trust and King's College London. AMS acknowledges the support of the Egyptian Fulbright Mission Program. MMS-M acknowledges the support of the Ministry of Education, Science and Technological Development of the Republic of Serbia (contract number 175087). AzS acknowledges the support of the Health Data Research UK BREATHE Hub. JPS acknowledges support from the Applied Molecular Biosciences Unit (grant number UIDB/04378/2020), supported through Portuguese national funds via FCT/MCTES. AmbS is supported by the International Graduate Research Scholarship, University of Tasmania.

Funding Information:
The authors alone are responsible for the views expressed in this Article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated or their funders. SheMA thanks the International Centre for Casemix and Clinical Coding, Faculty of Medicine, National University of Malaysia and Department of Health Policy and Management, Faculty of Public Health, Kuwait University for the approval and support to participate in this research project. SKB received contributions from the Social Change Grant Program with Walden University. DAB receives support from the Oxford National Institute for Health Research (NIHR) Biomedical Research Centre (BRC). VMC acknowledges a grant (SFRH/BHD/110001/2015), through Portuguese national funds through Fundação para a Ciência e Tecnologia (FCT), IP, under the Norma Transitória DL57/2016/CP1334/CT0006. MEK was supported by University Graduate School Dissertation Year Fellowship at Florida International University. NG is employed as a postdoctoral researcher by the Technical University of Denmark and her salary is covered by a research grant from Novo Nordisk Foundation. CH, MarA, and AdP are partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation (CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084). CH and AdP are partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation (CNDS-UEFISCDI, project number PN-III-P2-2.1-SOL-2020-2-0351). JYI is supported by UNC's Cancer Care Quality Training 2T32CA116339-11. SMSI received funding from Deakin University, the National Heart Foundation of Australia, and the Australian National Health and Medical Research Council. MihJ has been co-funded through a grant from the Ministry of Science Education and Technological Development of the Republic of Serbia (OI 175 014). PJ was supported by the Wellcome Trust/DBT India Alliance Intermediate Fellowship 2015–21 (IA/CPHI/14/1/501497). MK has received funding from the Wellcome Trust (221854/Z/20/Z), the UK Medical Research Council (MRC S011676), and Helsinki Institute of Life Science (H970). SLKL acknowledges institutional support by Manipal Academy of Higher Education. KK is supported by UGC Centre of Advanced Study (CAS II), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. BL acknowledges support from UK Biobank, the NIHR Oxford BRC, and the BHF Oxford Centre of Research Excellence. IL is member of the Sistema Nacional de Investigación, which is supported by the Secretaría Nacional de Ciencia, Tecnología e Innovación, Panamá. MariM is supported by the NIHR BRC at Guy's and St Thomas' National Health Service Foundation Trust and King's College London. AMS acknowledges the support of the Egyptian Fulbright Mission Program. MMS-M acknowledges the support of the Ministry of Education, Science and Technological Development of the Republic of Serbia (contract number 175087). AzS acknowledges the support of the Health Data Research UK BREATHE Hub. JPS acknowledges support from the Applied Molecular Biosciences Unit (grant number UIDB/04378/2020), supported through Portuguese national funds via FCT/MCTES. AmbS is supported by the International Graduate Research Scholarship, University of Tasmania. Editorial note: the Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.

Funding Information:
ViA reports personal fees from Bayer Healthcare, Boehringer Ingelheim/Lilly alliance, Bristol Myers Squibb/Pfizer alliance, and Novo Nordisk outside of the submitted work. RA reports consultancy and speakers' fees from UCB, Sandoz, AbbVie, Zentiva, Teva, Laropharm, Cegedim, Angelini, B Braun, Biessen Pharma, Hofigal, AstraZeneca, and Stada. BA reports personal fees from Australian Institute of Sports, grants and non-financial support from Natural Remedies, and non-financial support from Zydus Cadila outside of the submitted work. SI reports grants from National Heart Foundation of Australia, and Australian National Health and Medical Research Council outside the submitted work. KK reports non-financial support from UGC Centre of Advanced Study (CAS II), Department of Anthropology, Panjab University, Chandigarh, India, outside of the submitted work. TRM reports contracts from Gov't Plaintiff Lawyers, JUUL, outside of the submitted work. JAS reports consultancy fees from Crealta/Horizon, Medisys, Fidia, Two Labs Inc, Adept Field Solutions, Clinical Care Options, Clearview Healthcare Partners, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, UBM LLC, Trio Health, Medscape, WebMD, Practice Point Communications, and the National Institutes of Health and the American College of Rheumatology; receives payment for lectures as a member on the speaker's bureau of Simply Speaking; owns stock options in TPT Global Tech, Vaxart pharmaceuticals, and Charlotte's Web Holdings; previously owned stock options in Amarin, Viking, and Moderna pharmaceuticals; held a placement on the steering committee of OMERACT, an international organisation that develops measures for clinical trials and receives arm's length funding from 12 pharmaceutical companies; serves on the US Food and Drug Administration Arthritis Advisory Committee; is a member of the Veterans Affairs Rheumatology Field Advisory Committee; is the editor and is the Director of the University of Alabama at Birmingham Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis, all outside of the submitted work. JS reports ownership of companies providing services to Itrim, Amgen, Janssen, Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Bayer, Pfizer, and AstraZeneca outside of the submitted work. DJS reports personal fees from Lundbeck, Takeda, Johnson & Johnson, and Servier outside of the submitted work. SS reports grants from Edwards Lifesciences, Medtronic, Boston Scientific, and Abbott; and personal fees from Boston Scientific, Teleflex, and BTG outside of the submitted work. All other authors declare no competing interests.

Publisher Copyright:
© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license

ASJC Scopus subject areas

  • Public Health, Environmental and Occupational Health

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