Smokeless tobacco, while less harmful than combusted tobacco, is not harmless, and must be part of tobacco control efforts. In many countries, smokeless products are produced and sold on the informal market, demanding creative regulatory solutions.

More than 40 types of smokeless tobacco products (e.g. gutkha, pan masala, snus, chew, etc.) are consumed by nose or mouth, by more than 300 million people around the world, most of whom live in South Asia. In nearly two dozen countries, more women than men use smokeless tobacco, reflective of the differing norms in each culture of smokeless use.

Smokeless tobacco use definitively causes cancers of the head and neck. During the preparation of these products, an ongoing chain of chemical reactions between bacteria and tobacco leaves makes up the chemical-microbial dynamic, which influences the concentration in smokeless tobacco of the same deadly chemicals that cause disease in combustible tobacco users. The question of whether using smokeless tobacco changes the likelihood of a person using cigarettes is hotly debated.

The size of the smokeless tobacco market in high-income countries remains relatively stable. The 2014 European Union Tobacco Products Directive left a ban on snus sales in place in every EU country except Sweden. In recent years, the test marketing of dissolvable products failed in the United States, and

snus brand extensions were commercial failures in Canada and South Africa. By contrast, in 2012, the Indian Supreme Court disrupted the world’s largest smokeless tobacco market when it ruled that gutkha and pan masala were dangerous food products, the sale of which could be temporarily banned under Indian food safety laws. India’s manufacturers responded by producing smokeless tobacco products that are not classified as food. The reaction of India’s smokeless tobacco users to the bans remains unclear.

Bringing smokeless tobacco products into tobacco control regulatory frameworks is essential to managing the harms caused by these products. The research suggests a wide range in the levels of harm of these different products (none are “harmless”). Not surprisingly, there are challenges: for example, taxing smokeless products effectively in some countries has proven to be difficult because many of these products are produced and sold on the informal market. Research will inform future policy action on smokeless tobacco. There is more to learn about opportunities to regulate product flavorings, health warnings, and novel products.

Adult Use

Prevalence of Adult Smokeless Tobacco Use: 2016 or Most Recent

*55 countries have never collected smokeless tobacco use data, leaving them with an incomplete picture of tobacco use in their country. Such information needs to be collected in future tobacco surveillance efforts.

Smokeless Tobacco Health Burden

In 2016, there were approximately 315,000 deaths caused by smokeless tobacco products, most of which were in South Asia.

Source: Global Burden of Disease Collaborators, 2016.