Chandigarh-27.05.2026

The Silent Killer You Put in Your Mouth: Smokeless Tobacco
Questions & Answers

*Q1. How serious is India's smokeless tobacco problem?

Answer:

India is home to approximately 27 crore tobacco users — the second largest tobacco-using population in the world. Of these, a staggering 20 crore adults (21.4% of all adults) use smokeless forms of tobacco. The scale of India's burden is further underscored by a 2024 analysis in The Lancet Oncology, which found that of the 120,200 oral cancer cases globally attributable to smokeless tobacco and areca nut use in 2022, as many as 83,400 — nearly 70% — occurred in India alone, the highest of any country in the world.

Source: GATS-2 India 2016–17; Goel S et al., 2022, 2025; Siddiqi K, Husain S, Vidyasagaran A et al., BMC Medicine, 2020; Rumgay H, Nethan ST, Shah R et al., Lancet Oncol, 2024;25(11):1413–1423

*Q2. What is smokeless tobacco (SLT) and what forms does it take in India?

Answer:

Smokeless tobacco (SLT) refers to all tobacco products used without burning. They are chewed, sucked, held in the mouth, applied to the gums, or inhaled. India possesses diversity of tobacco products. Common forms include:- Chewed or held in the mouth: Khaini, Zarda, Gutkha, Pan masala with tobacco, Betel quid with tobacco; Applied to gums or teeth: Mishri, Gul, Gudakhu, Tobacco toothpaste and inhaled / dry snuff: Naswar, Dry snuff

As per the GATS-2 report, of all the individual products, khaini is by far the most used (11.2% — used by 1 in every 9 adults), followed by gutkha (6.8%), betel quid with tobacco (5.8%), oral tobacco products including mishri/gul/gudakhu (3.8%), paan masala with tobacco (2.8%), and snuff (0.6%).

Sources: Goel S, Walia D, Kumar R. J Family Med Prim Care, 2024; GATS-2 India 2016–17

*Q3. Is smokeless tobacco safer than Smoking?

Answer:

No — emphatically not. Smokeless tobacco delivers nicotine directly through the oral mucosa.According to the study by Digard et al. published in Nicotine & Tobacco Research, nicotine from cigarettes entered the body faster, but the total amount of nicotine absorbed was similar to that from smokeless tobacco products (AUC for SLT = 14.8 ng.h/ml; Cmax for SLT = 12.8 ng.h/ml). This suggests that the amount of nicotine absorbed depends more on the quantity of tobacco and total nicotine content than on the form of the product.

SLT users are 1.22 times more likely to die from any cause, 1.31 times more likely to die from any cancer, and face more than double the risk of dying from cancers of the upper aerodigestive tract (2.17 times). The risk of death from stomach cancer is 1.33 times higher, while cervical cancer mortality is more than doubled (2.07 times) among SLT users compared to non-users. The cardiovascular burden is equally alarming — SLT use increases the risk of death from ischaemic heart disease 1.10 times and from stroke 1.37 times, underscoring that the harm of smokeless tobacco extends far beyond the mouth and throat to the heart, the gut, and the entire body.

Source: Goel S et al., Int J Noncommunicable Dis, 2022; Bhatt G,Digard H et al., Nicotine Tob Res, 2013;15(suppl):S89–S98 PMC3524070;Sinha DN, Suliankatchi RA, Gupta PC et al., Tob Control, 2018;27(1):35–42

*Q4. What is the impact of smokeless tobacco on women? And does smokeless tobacco during pregnancy only harms the mother?

Answer:

Among women, the crisis is growing fast and demands urgent attention. GATS 2016–17 reports 14.2% ofIndian women use some form oftobacco. Women are more vulnerable to tobacco dependence due to unique physiological characteristics. Their bodies are more sensitive to tobacco's harmful effects, which increases their risk of toxicity.

Smokeless tobacco use during pregnancy poses serious health risks for both the mother and her child. A systematic review of 9 studies found that maternal smokeless tobacco use was significantly associated with low birth weight (LBW) in 5 out of 7 studies, preterm birth in 3 out of 6 studies, and most strikingly, stillbirth in all 4 studies that examined this outcome, with small for gestational age (SGA) reported in 1 out of 2 studies. The harmful effects of smokeless tobacco — driven by nicotine-induced reduction in blood flow to the placenta and exposure to toxic carcinogens — deprive the growing baby of oxygen and essential nutrients, resulting in babies born too small (LBW, <2.5 kg), too early (<37 weeks), or not born alive at all. These perinatal complications are not merely birth-time events; they set the stage for a lifetime of poor health in the child, including increased susceptibility to infections, impaired neurodevelopment, and chronic diseases in later life. This evidence, though limited by heterogeneity between studies (I² = 44–87%) and potential confounding, consistently points in one direction — smokeless tobacco is unsafe at any stage of pregnancy, and its use must be identified and addressed at every antenatal contact.

Source: Global Adult Tobacco Survey India 2016–17 (GATS-2); Goel S, Walia D, Kumar R. J Family Med Prim Care, 2024,Inamdar AS et al. Nicotine & Tobacco Research. 2015;17(9):1058–1066. Oxford University Press

*Q5. 'Khaini is natural — it comes from leaves, so it can't be that harmful.' Is this true?

Answer:

FALSE. Tobacco leaves contain nicotine, nitrosamines, and polycyclic aromatic hydrocarbons — all of which are established carcinogens. 'Natural' origin does not reduce harm in any way. SLT raises blood pressure, causes oral cancer, and is highly addictive.

Source: Goel S et al., Int J Noncommunicable Dis, 2022

*Q6. There is a belief that quitting smokeless tobacco (SLT) leads to weight gain. Is that true?

Answer:

Based on the study by Rodu and colleagues published in the Journal of Internal Medicine (2004), which followed nearly 3,000 men in Sweden over more than a decade, men who quit smokeless tobacco gained 0.70% of their body weight per year after quitting, compared to 0.44% per year among men who never used tobacco at all. To put this in plain terms — if you weigh 70 kg, quitting smokeless tobacco may cause you to gain around 490 grams per year, while a person who never used tobacco gains around 308 grams per year. The difference between the two is just 182 grams per year — roughly the weight of one medium banana. Over five years, that adds up to less than 1 kg of extra weight. So yes, quitting smokeless tobacco can cause a small amount of weight gain, but it is modest, gradual, and far outweighed by the serious health risks — including oral cancer, high blood pressure, and heart disease — that come with continuing to use it. The fear of gaining weight should never be a reason to keep using tobacco.

Source: Rodu et.al., Journal of Internal Medicine (2004)

*Q7. What harmfull chemicals are present in Smokeless Tobacco?

Answer:

According to the Centers for Disease Control and Prevention (CDC) (Smokeless Tobacco and Public Health: A Global Perspective, 2014), smokeless tobacco contains a mix of 4,000 chemicals, of which at least 30 are directly linked to cancer. The most dangerous are Tobacco-Specific Nitrosamines (TSNAs) — chemicals that form inside the tobacco leaf during growing and curing, enter your body through the mouth lining, damage DNA inside your cells, and directly cause oral, throat, oesophageal, and pancreatic cancers. Alongside these, smokeless tobacco also contains arsenic — the same chemical used in insecticides; cadmium — found in batteries; lead — the toxic metal once used in house paint; formaldehyde — the chemical used to preserve dead bodies in mortuaries; and polonium-210 — a genuinely radioactive element. Every time a person places khaini, gutkha, or any smokeless tobacco product in their mouth, all of these chemicals are absorbed directly into the bloodstream within minutes, travelling to the throat, oesophagus, pancreas, and every organ in the body. As the FDA states clearly — because all tobacco products contain the addictive chemical nicotine, no tobacco product can be considered safe.

Sources: CDC/NCI — Smokeless Tobacco and Public Health: A Global Perspective, NIH Publication No. 14-7983, 2014.

*Q8. What support is available in India for people trying to quit Smokeless Tobacco?

Answer:

In India, individuals trying to quit tobacco or nicotine products can seek support through several government-backed cessation services. The Ministry of Health and Family Welfare operates the National Tobacco Quitline Services, which provides counselling and quitting support through the toll-free number 1800-11-2356. India’s mCessation Programme, a flagship mobile health initiative of the Ministry of Health and Family Welfare, also helps users quit tobacco through free mobile-based support. By simply giving a missed call to 011-22901701, users can register to receive tailored behavioural support messages via SMS in Hindi or English. India also has more than 2,000 Tobacco Cessation Centres (TCCs) across the country. These centres, located in District Hospitals, Medical Colleges, and Dental Institutes, provide counselling and pharmacological therapies, including nicotine replacement therapy (NRT), to support individuals trying to quit tobacco and nicotine addiction. Additionally, the World Health Organization (WHO) has launched the “Quit Tobacco App” to support people in quitting tobacco and nicotine products, including cigarettes, smokeless tobacco, and newer products such as e-cigarettes and vapes .