Mortality Fractions Attributable to Smoking and Smokeless and Mixed Tobacco Use Among Men and Women Across India,...

Evidence on the mortality burden of tobacco use remains fragmented for low- and middle-income countries like India, and does not fully use Indian-specific datasets. We estimated mortality fractions attributable to different tobacco types (smoked, smokeless, and mixed tobacco use) for India by sex and state-and-union territories over time.

We applied a direct prevalence approach to estimate mortality fractions attributable to tobacco types among men (35-54 years) and women (35-49 years) over time across 36 Indian states. We used national- and state-level prevalence estimates from the National Family Health Survey (1998-1999, 2005-2006, 2015-2016, and 2019-2021) and estimated Indian-specific relative risks (RRs) of all-cause mortality by tobacco type and sex by applying Cox proportional hazards models to data from the Mumbai Cohort Study.

RRs and sex differences therein differed by tobacco use type. Smoking exhibited the highest RR among men, while mixed tobacco use was highest among women. In 2019-2021, 45.7% and 2.5% of all deaths among Indian men and women, respectively, were related to tobacco use, driven by smoking-attributable mortality among men (28%) and smokeless tobacco-attributable mortality among women (2.1%). Tobacco-attributable mortality shares declined between 1998-1999 and 2019-2021, more strongly for women than men, with an increase in different tobacco types for men and in smoking for women until 2005-2008. State differences in tobacco-attributable mortality shares varied by sex and tobacco types, with higher shares for smoking in the Northeast region, and for smokeless tobacco in East India.

Levels, sex and state differences, and time trends in mortality fractions attributable to tobacco use in India differed substantially by tobacco type.

Our findings highlight the importance of further strengthening tobacco control initiatives by shifting to a target-oriented approach comprising different actions for each tobacco use type, aimed particularly at men and the Northeast Indian states, to enable India to achieve its Sustainable Development Goals by 2030.