Smokeless tobacco use remains a difficult issue in tobacco control policy circles. These products are harmful by any measure, but the level of hazard they pose to users varies widely according to how the products are prepared and used.

Worldwide, the death toll from smokeless tobacco was 76,000 in 2017, but the death rate from smokeless tobacco use has increased 30% since 1991. Any consumer product that kills this many people, and disfigures many more, merits a serious policy response.

A new paper published in Lancet Oncology, “Smokeless tobacco control in 180 countries across the globe”  by Mehrotra and colleagues collects the largest volume of smokeless tobacco control policy data that we have ever seen in an effort to determine whether governments are meeting obligations in the FCTC to address all forms of tobacco use.

The policy solutions to control smokeless tobacco use are nearly identical to those used to control cigarette smoking, with the obvious exception that there is no need to protect bystanders from exposure to secondhand smokeless tobacco byproducts.

The Lancet Oncology paper collected policy data for many applicable FCTC provisions for smokeless tobacco use and found the application of such articles that are widely applied to cigarette use coming up short when applied to smokeless tobacco. The 180 countries in the paper cover FCTC signatories, so certain countries are left out of the count even though they might be (not) implementing some of the selected smokeless tobacco control policies and surveillance.

It is convenient to illustrate this divide by employing the MPOWER framework to analyze where countries are coming up short in applying their policies to curb smokeless tobacco use. The MPOWER framework can be thought of as the basic surveillance and policy steps that a country should take to confront a tobacco epidemic.



On the subject of surveillance, the Mehrotra et al study finds a severe deficit in the monitoring of smokeless tobacco use patterns compared to cigarette smoking.

According to the latest WHO Global Tobacco Control Report, 133 countries had performed a recent (since 2013) survey of adult smoking and 142 had performed a recent survey of youth smoking.  By contrast just 55 countries had performed a recent survey of smokeless tobacco use in adults and 70 had performed such a survey in youth.

Whereas only 4 FCTC countries failed to report the share of tax in the price of cigarettes in the latest WHO report, compared to 188 who reported some data, just 34 countries in total reported collecting any price or tax data on smokeless tobacco products.

On the policy front, while 37 countries had adopted the recommended comprehensive ban on the advertising promotion and sale of cigarettes, just 16 countries had passed such policies with regard to smokeless tobacco.

While 42 countries had engaged on mass media campaigns against smoking, just two countries dedicated any of their health education efforts to warn about the dangers of smokeless tobacco use and only India performed an evaluation of their campaign.

Finally, on the issue of package warning labels, only 14 countries had applied FCTC best practices of reserving 50% of a smokeless tobacco product package to a pictorial warning. This is dwarfed by the 78 countries who had adopted such large graphic health warnings on cigarette packaging in the last WHO report on the matter.

We would be remiss to point out one oversight made in this paper. In previous editions of The Tobacco Atlas, we made sure to point out that many countries had full or partial bans on the sale of smokeless tobacco. These bans derived from efforts beginning in the 1980s to contain what was then viewed as an effort to expand the tobacco market beyond what was viewed as the entrenched forms of tobacco use, namely cigarettes, pipe tobacco and cigars. By our count in 2015, some portion of 39 countries had a ban on some form of smokeless tobacco. This fact is not covered in the Mehrotra et al study. The consequence of such a policy is that policymakers may not have included smokeless tobacco products in the country’s law because their sale was not legal, leading to an overestimate of the true disparity in policy coverage between smokeless tobacco and cigarettes.

From the perspective of the Atlas team, the takeaway from this study is clear. Most countries could stand to be more comprehensive in the application of their tobacco policy and surveillance efforts. Worries about trying to implement a risk-proportionate regulatory framework on smokeless tobacco products are not going to be of much use when countries lack the most basic controls over a product. Countries should take the opportunity to determine whether their laws apply to all tobacco products. Such efforts seem worth pursuing.

By Alex Liber

Progress on Bans and Warnings

Percent of Global Population Covered by FCTC Marketing Policies (graphic health warnings (GHW) on packages, point-of-sale (POS) advertising ban, and internet marketing ban)

Smokeless Tobacco Warning Labels

Type of warning label mandated on smokeless tobacco products, 2018 or latest available from Mehrotra et al., 2019