In moving toward developing a comprehensive picture of tobacco use globally, in GBD 2016, we have for the first time included smokeless tobacco use as a risk factor. While the burden of smokeless tobacco is minimal in the majority of countries, it is of huge importance in south Asia, where the highest risk-weighted exposure is observed in Bangladesh (risk-weighted exposure of 0·75 [0·61–0·87]), Bhutan (0·53 [0·44–0·62]), Myanmar (0·50 [0·42–0·59]), Nepal (0·50 [0·42–0·58]), and India (0·45 [0·43–0·47]). In these countries more women use smokeless tobacco products than smoked tobacco products, and we find that use of any tobacco products, smoked or smokeless, continuously increases with age, a regional age pattern that differs from the global and male regional age pattern. The combination of high exposure and large population results in a majority of global deaths attributable to smokeless tobacco in 2016 occurring in India, where it is also the leading risk factor for oral cancer.
