Tobacco-attributable mortality and disease burden in India: a descriptive analysis of Global Burden of Disease 2023 estimates for 1990 and 2023

Abstract

Objectives

Tobacco use remains a major contributor to mortality and disability in India. This study assessed tobacco-attributable mortality and disability-adjusted life-years (DALYs) in India in 1990 and 2023, with comparisons by sex, age group and type of tobacco exposure.

Design

Descriptive population-level analysis of secondary data from the Global Burden of Disease 2023 study.

Setting

India.

Methods

Tobacco-attributable deaths and DALYs were assessed by sex, age group and type of tobacco exposure, including smoking, chewing tobacco and secondhand smoke. Absolute numbers and age-standardised rates were compared between 1990 and 2023.

Results

Tobacco-attributable deaths increased by 54.7%, from 745.74 thousand in 1990 to 1 153.98 thousand in 2023, while DALYs increased by 15.1%, from 27.3 to 31.4 million. In contrast, age-standardised death and DALY rates declined by 39.8% and 47.8%, respectively. Smoking remained the leading contributor (738.8 thousand deaths; 19.78 million DALYs in 2023), particularly among males. Chewing tobacco showed the largest increase (deaths +153.7%; DALYs +124.8%). Secondhand smoke remained substantial, particularly among females (325.63 thousand deaths), though its DALY burden declined by 10.8%. The burden shifted towards non-communicable diseases, with chronic obstructive pulmonary disease, ischaemic heart disease and stroke as leading contributors in 2023.

Conclusion

Despite declines in age-standardised rates, the overall burden of tobacco in India remains substantial. The differing patterns across smoking, chewing tobacco and secondhand smoke highlight the need for comprehensive and targeted tobacco-control strategies.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study provides a detailed assessment of tobacco-attributable mortality and disease burden in India across smoking, smokeless tobacco and secondhand smoke using the latest Global Burden of Disease (GBD) 2023 estimates.

• The analysis is stratified by age and sex to characterise differences in tobacco-attributable mortality and disability-adjusted life-years across population groups.

• The use of both absolute numbers and age-standardised rates allows comparison of the tobacco-attributable burden between 1990 and 2023.

• This study analyses secondary GBD data and therefore has limitations inherent to the underlying estimates.

• Individual-level information on socioeconomic characteristics and detailed patterns, intensity and duration of tobacco exposure was not available.

Background

Tobacco use continues to be one of the leading preventable causes of death worldwide, claiming over 7 million lives each year, including around 1.6 million deaths from secondhand smoke (SHS) exposure.¹ Globally, approximately 1.3 billion people use tobacco, with about 80% living in low-income and middle-income countries.² Tobacco use involves a range of products with varying levels of health risk, sometimes referred to as a ‘continuum of risk’,³ which can lead to multiple adverse health outcomes, including cardiovascular diseases, cancers and chronic respiratory diseases, contributing substantially to premature mortality and reduced quality of life.^4–7 Globally, tobacco is also responsible for more than 200 million disability-adjusted life-years (DALYs) lost annually.⁸ Among the different forms of tobacco, smoked products remain the most widely used globally,^{9 10} while smokeless tobacco is more prevalent in specific regions such as South-East Asia.^11–13 SHS exposure continues to pose health risks for people who do not smoke, including women and children, contributing to cardiovascular and respiratory diseases.^14–16

India is the second-largest producer and consumer of tobacco globally, after China, accounting for a substantial share of the global tobacco burden. Approximately 267 million adults (about 29% of the adult population) use tobacco in various forms, including smoking (such as cigarettes and bidis), smokeless tobacco (such as gutka, khaini and chewing tobacco) and exposure to SHS.^{17 18} Notably, smokeless tobacco use (21.4%) exceeds smoking prevalence, distinguishing India’s tobacco epidemic from that of many other countries.¹⁹ The health consequences of tobacco use in India are substantial, with tobacco responsible for nearly 1.35 million deaths annually and contributing significantly to overall disease burden.^{20 21} In addition to its health impact, tobacco use imposes a significant economic burden through increased healthcare costs and loss of productivity; in India alone, it accounts for over 1% of GDP, with treatment of tobacco-related illnesses consuming about 5.3% of total health expenditures.^{22 23}

Alongside the substantial health and economic burden of tobacco use, India has undergone significant demographic and epidemiological changes, including population growth, increasing life expectancy and shifts in the overall mortality profile.^24–26 These transitions have altered both the number of individuals at risk and the distribution of health outcomes across the population.^{27 28} In this context, examining tobacco-attributable disease and mortality becomes particularly important, as changes in population structure and exposure patterns can influence the magnitude, distribution and trends of its impact. Understanding these dynamics is essential for accurately assessing the evolving burden of tobacco in India and for guiding public health priorities.

However, most existing studies in India have focused on tobacco use patterns, with comparatively limited emphasis on its contribution to mortality and overall disease burden. To our knowledge, no studies have comprehensively examined the differences in health outcomes associated with different forms of tobacco use and exposure, such as smoking, smokeless tobacco and SHS, particularly with sex-specific analyses over time. Earlier research has also often relied on older datasets and does not reflect the most recent evidence. Given India’s large and diverse population and the growing pressure on its healthcare system, an updated and comprehensive assessment of tobacco-attributable deaths and disease burden is essential for informing effective public health policies and resource allocation.

To address these gaps, the present study evaluates death and DALY attributable to tobacco, including smoking, SHS and chewing tobacco, by sex in India for 1990 and 2023. It further examines the leading cause of tobacco-attributable death at these two time points, providing insight into changing patterns and supporting more targeted tobacco-control strategies in the country.

Data and methods

Study design

This study used a descriptive, population-level analysis of secondary data from the Global Burden of Disease (GBD) 2023 study. We assessed tobacco-attributable deaths and DALYs in India by sex (male and female), age group (<15, 15–49, 50–74 and ≥75 years) and type of tobacco exposure (smoking, chewing tobacco and SHS), comparing estimates between 1990 and 2023.

Data source

This study used data from the 2023 GBD study, the most comprehensive and systematic effort to quantify levels and trends in population health worldwide. Coordinated by the Institute for Health Metrics and Evaluation at the University of Washington, the GBD represents a large-scale international collaboration covering 204 countries and territories and provides a comparative estimate of diseases, injuries and risk factors across demographic groups, geographic locations and years. The GBD estimates are derived from multiple data sources, including population-based surveys and censuses, civil registration and vital statistics, disease surveillance systems, cancer registries, health system records and published epidemiological studies. These data are systematically assessed, harmonised, and synthesised using standardised statistical modelling methods to generate estimates of mortality, morbidity and risk-attributable burden. The GBD 2023 study assessed 88 modifiable risk factors and 375 diseases and injuries, generating estimates of incidence, prevalence, years lived with disability (YLDs), years of life lost (YLLs), DALYs and risk-attributable DALYs for the period 1990–2023.²⁹ Detailed methodological descriptions and data from GBD 2023 are available through the official GBD platform (dataset) (https://ghdx.healthdata.org/gbd-results-tool).³⁰

Risk factors in the GBD 2023 are structured within a four-level hierarchical framework (online supplemental appendix table A1). Within this hierarchy, tobacco use is classified as a level 2 risk factor comprising three components: smoking, chewing tobacco and SHS.^31–33 These components are defined at level 3, with smoking further characterised by detailed exposure measures such as intensity and duration. Detailed operational definitions of tobacco-related risk factors and exposure measures are provided in online supplemental appendix table A2. Furthermore, hierarchical classification of disease and injuries is presented in online supplemental appendix table A3.

Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

Data extraction method

Data was extracted using the GBD results tool. The ‘Risk factor’ category was selected, and tobacco-related risks including tobacco use, smoking, chewing tobacco and SHS were included. Measures considered were deaths, DALYs, YLLs and YLDs. Metrics included number, per cent and age-standardised rates (ASRs). Causes were selected at level 3 of the GBD cause hierarchy and analysed individually. The geographic location was restricted to India, and data were extracted for the period 1990–2023. The analysis included estimation of annual numbers and ASRs of deaths and DALYs attributable to each tobacco-related risk factor. Additionally, the burden was examined across age groups (<15, 15–49, 50–74 and ≥75 years) and by sex (both sexes, males and females).

Statistical analysis

Tobacco-attributable deaths and DALYs were summarised by sex, age group and type of tobacco exposure for 1990 and 2023. These years were selected as the earliest and most recent years of the GBD 2023 study period, respectively. Because the analysis was stratified by sex, age group and type of tobacco exposure, comparisons were limited to these 2 years. Estimates were reported with 95% uncertainty intervals (UIs) as provided by the GBD 2023 Results Tool. Percentage changes in deaths and DALYs between 1990 and 2023 were calculated to quantify changes in the tobacco-attributable burden over the study period. ASRs were used to facilitate comparisons across years and population groups. All analyses were conducted using Microsoft Excel 2021.

Results

Changes in tobacco-attributable deaths and disease burden in India by sex, 1990–2023

Table 1 presents the total numbers and percentage changes in tobacco-attributable deaths and disease burden between 1990 to 2023. Overall, tobacco-attributable deaths increased by approximately 54.7%, rising from 745.74 thousand (95% UI 592.26 to 892.12) in 1990 to 1153.98 thousand (95% UI 957.30 to 1391.93) in 2023. Among different forms of tobacco use, smoking accounted for the highest number of deaths, followed by SHS and chewing tobacco. Deaths attributable to smoking increased from 508.50 thousand (95% UI 377.80 to 639.58) in 1990 to 738.80 thousand (95% UI 557.62 to 965.01) in 2023, deaths due to chewing tobacco rose from 64.34 thousand (95% UI 34.52 to 103.98) to 163.22 thousand (95% UI 97.60 to 254.66), while deaths attributable to SHS increased from 217.71 thousand (95% UI 169.65 to 276.11) to 325.63 thousand (95% UI 261.12 to 410.39) over the same period. Notably, deaths due to chewing tobacco showed the largest relative increase (153.7%) among all forms of tobacco use.

Table 1.

Trends and percentage changes in tobacco-attributable deaths and disease burden by risk factors in India, 1990–2023

	1990 (95% UI)	2023 (95% UI)	1990–2023 (% change)
All age deaths (in thousands)
Tobacco	745.74 (592.26 to 892.12)	1153.98 (957.3 to 1391.93)	54.7
Smoking	508.5 (377.8 to 639.58)	738.8 (557.62 to 965.01)	45.3
Chewing tobacco	64.34 (34.52 to 103.98)	163.22 (97.6 to 254.66)	153.7
SHS	217.71 (169.65 to 276.11)	325.63 (261.12 to 410.39)	49.6
All age death rate per 100 000
Tobacco	88.22 (70.06 to 105.53)	79.95 (66.32 to 96.43)	−9.4
Smoking	60.15 (44.69 to 75.66)	51.19 (38.63 to 66.86)	−14.9
Chewing tobacco	7.61 (4.08 to 12.3)	11.31 (6.76 to 17.64)	48.6
SHS	25.75 (20.07 to 32.66)	22.56 (18.09 to 28.43)	−12.4
Age-standardised death rate per 100 000
Tobacco	170.77 (132.88 to 205.43)	102.84 (84.96 to 125)	−39.8
Smoking	120.55 (88.68 to 154.03)	65.38 (49.26 to 86.14)	−45.8
Chewing tobacco	15.48 (8.35 to 25.3)	14.08 (8.37 to 21.96)	−9.0
SHS	46.11 (34.78 to 59.76)	29.99 (24.16 to 37.97)	−35.0
All age YLL rate per 100 000
Tobacco	2984.06 (2428.95 to 3573.2)	1941.64 (1601.22 to 2322.67)	−34.9
Smoking	1733.87 (1287.16 to 2175.6)	1206.7 (929.62 to 1605.94)	−30.4
Chewing tobacco	210.75 (115.75 to 336.7)	277.32 (167.61 to 421.83)	31.6
SHS	1179.24 (880.32 to 1541.86)	574.54 (461.69 to 720.03)	−51.3
Age-standardised YLL rate per 100 000
Tobacco	4429.48 (3572.51 to 5297.18)	2256.22 (1883.67 to 2715.98)	−49.1
Smoking	2921.33 (2166.36 to 3684.01)	1384.86 (1073 to 1831.7)	−52.6
Chewing tobacco	364.18 (195.63 to 586)	312.86 (187.61 to 479.87)	−14.1
SHS	1396.48 (1086.65 to 1786.48)	694.32 (558.22 to 869.28)	−50.3
All age YLD rate per 100 000
Tobacco	245.82 (162.4 to 333.86)	234.82 (159.53 to 317.38)	−4.5
Smoking	194.46 (124.58 to 270.38)	163.71 (100.39 to 238.54)	−15.8
Chewing tobacco	9.18 (4.23 to 16.67)	12.21 (6.9 to 20.77)	33.0
SHS	52.13 (35.07 to 70.14)	68.68 (45.88 to 94.3)	31.7
Age-standardised YLD rate per 100 000
Tobacco	397.66 (265.7 to 527.29)	262.65 (179.63 to 351.53)	−34.0
Smoking	315.54 (203.18 to 430.54)	183.99 (113.41 to 262.3)	−41.7
Chewing tobacco	14.8 (6.78 to 26.74)	13.61 (7.7 to 23.31)	−8.1
SHS	85.14 (56.96 to 113.19)	76.44 (51.04 to 104.96)	−10.2
All age DALYs (in thousands)
Tobacco	27 303.94 (22181.11 to 32574.25)	31 414.72 (25875.15 to 38203.38)	15.1
Smoking	16 301.24 (12142.34 to 20446.65)	19 780.28 (15050.44 to 25902.74)	21.3
Chewing tobacco	1859.2 (1011.66 to 2965.62)	4179.13 (2516.9 to 6397.03)	124.8
SHS	10 409.46 (7881.07 to 13548.55)	9284.13 (7390.35 to 11594.38)	−10.8
All age DALY rate per 100 000
Tobacco	3229.88 (2623.88 to 3853.32)	2176.46 (1792.67 to 2646.79)	−32.6
Smoking	1928.33 (1436.36 to 2418.7)	1370.41 (1042.72 to 1794.58)	−28.9
Chewing tobacco	219.93 (119.67 to 350.81)	289.54 (174.37 to 443.2)	31.6
SHS	1231.37 (932.28 to 1602.7)	643.22 (512.02 to 803.28)	−47.8
Age-standardised DALY rate per 100 000
Tobacco	4827.14 (3866.87 to 5732.71)	2518.87 (2104.66 to 3075.18)	−47.8
Smoking	3236.87 (2386.94 to 4059.55)	1568.85 (1190.94 to 2058.29)	−51.5
Chewing tobacco	378.98 (202.45 to 609.4)	326.47 (194.97 to 503.89)	−13.9
SHS	1481.63 (1159.25 to 1890.53)	770.76 (613.34 to 955.12)	−48.0

The unit for DALYs to YLLs and YLDs is person-years.

DALY, disability-adjusted life-year; SHS, secondhand smoke; UI, uncertainty interval; YLD, year lived with disability; YLL, year of life lost.

On the other hand, tobacco-attributable DALYs increased by approximately 15%, rising from 27.3 million (95% UI 22.2 to 32.6) in 1990 to 31.4 million (95% UI 25.9 to 38.2) in 2023. Similar to mortality patterns, DALYs were highest for smoking, increasing from 16.3 million (95% UI 12.1 to 20.4) in 1990 to 19.8 million (95% UI 15.1 to 25.9) in 2023, while DALYs due to chewing tobacco rose from 1.9 million (95% UI 1.0 to 3.0) to 4.2 million (95% UI 2.5 to 6.4), and DALYs attributable to SHS changed from 10.4 million (95% UI 7.9 to 13.5) to 9.3 million (95% UI 7.4 to 11.6) over the same period. Notably, DALYs due to chewing tobacco increased by 124.8%, while those attributable to SHS decreased by 10.8%. The distribution of DALYs further indicates that the overall burden is largely driven by YLLs rather than YLD. The YLL rate declined substantially from 2984.06 per 100 000 in 1990 to 1941.64 in 2023 (−34.9%), reflecting a reduction in premature mortality. In contrast, the YLD rate showed only a marginal decline from 245.82 to 234.82 per 100 000 (−4.5%), suggesting a relatively stable burden of non-fatal health outcomes.

The distribution of the tobacco-attributable burden indicates that it was largely driven by YLLs rather than YLDs. The YLL rate declined substantially from 2984.06 per 100 000 in 1990 to 1941.64 in 2023 (−34.9%), reflecting a reduction in premature mortality, whereas the YLD rate showed only a marginal decline from 245.82 to 234.82 per 100 000 (−4.5%), suggesting a relatively stable burden of non-fatal health outcomes. Despite these declines in rates, tobacco-attributable DALYs increased by approximately 15%, rising from 27.3 million (95% UI 22.2 to 32.6) in 1990 to 31.4 million (95% UI 25.9 to 38.2) in 2023. Similar to mortality patterns, DALYs were highest for smoking, increasing from 16.3 million (95% UI 12.1 to 20.4) in 1990 to 19.8 million (95% UI 15.1 to 25.9) in 2023, while DALYs due to chewing tobacco rose from 1.9 million (95% UI 1.0 to 3.0) to 4.2 million (95% UI 2.5 to 6.4), and those attributable to SHS changed from 10.4 million (95% UI 7.9 to 13.5) to 9.3 million (95% UI 7.4 to 11.6) over the same period. Notably, DALYs due to chewing tobacco increased by 124.8%, whereas those attributable to SHS decreased by 10.8%.

Sex-specific analyses show the distinct patterns in tobacco-attributable mortality and disease burden in India (online supplemental appendix table A4 and A5). Among males, tobacco-attributable deaths increased by 49.0%, from 565.25 thousand (95% UI 448.61 to 692.57) in 1990 to 842.10 thousand (95% UI 681.74 to 1048.89) in 2023, with smoking remaining the leading contributor. Chewing tobacco showed the largest relative increase in deaths (154.0%). Despite increases in absolute burden, age-standardised death rates declined by 38.9%, indicating improvements after accounting for population ageing. The tobacco-attributable burden among males was primarily driven by YLLs, with the YLL rate declining by 31.0%, whereas changes in YLDs were relatively modest. DALYs increased, with chewing tobacco showing the largest relative increase (128.0%).

Among females, tobacco-attributable deaths increased by 72.8%, from 180.49 thousand (95% UI 136.52 to 227.74) in 1990 to 311.88 thousand (95% UI 244.32 to 389.98) in 2023. In contrast to males, SHS was the leading contributor. The tobacco-attributable burden was again primarily driven by YLLs, with the YLL rate declining by 43.0%, while changes in YLDs were relatively modest. DALYs increased modestly by 4.8%, from 7.6 million (95% UI 5.6 to 9.9) to 8.0 million (95% UI 6.3 to 10.1), while chewing tobacco showed the largest proportional increase (118.3%). Age-standardised DALY rates declined substantially by 48.2%, suggesting improved population-level outcomes. Overall, across both sexes, the larger decline in YLL rates compared with YLD rates indicates a greater reduction in premature mortality than in non-fatal health outcomes (online supplemental appendix table A4 and A5).

Age-specific and sex-specific tobacco-attributable deaths and DALY in India, 1990–2023

Tobacco-attributable death and DALY rates in India showed substantial declines across all age groups between 1990 and 2023. SHS remained the major contributor among children aged <15 years, while smoking was the predominant contributor among older age groups. Despite considerable reductions over time, the burden remained highest among individuals aged ≥75 years. Similar age-specific patterns were observed among both males and females, although exposure profiles differed by sex, with smoking predominating among males and SHS contributing substantially among females. Detailed age-specific and sex-specific estimates for tobacco-attributable deaths and DALYs are presented in online supplemental appendix table A6 and A7.

Proportional distribution of tobacco-attributable deaths and DALYs to the total disease burden

The contribution of tobacco-attributable deaths and DALYs to the overall disease burden in India increased between 1990 and 2023. Smoking remained the leading contributor to both deaths and DALYs, while the contributions from SHS and chewing tobacco also increased over time. Males consistently experienced a higher tobacco-attributable burden compared with females, although increasing trends were observed in both sexes. Detailed sex-specific and risk factor-specific trends are presented in online supplemental figure A1a and A1b and online supplemental appendix table A8 in the online supplemental appendix.

Tobacco-attributable deaths and DALYs in 1990 were concentrated in tuberculosis and chronic obstructive pulmonary disease (COPD), with tuberculosis accounting for the largest share (deaths: 66.7%; DALYs: 67.0%), followed by COPD (deaths: 53.7%; DALYs: 52.4%). Stroke (deaths: 27.8%; DALYs: 29.2%), ischaemic heart disease (deaths: 26.3%; DALYs: 28.4%) and lower respiratory infections (deaths: 19.0%; DALYs: 16.8%) also contributed substantially, whereas diabetes mellitus accounted for a smaller proportion (deaths: 10.2%). By 2023, the distribution had shifted, with COPD representing the largest share of both deaths and DALYs (deaths: 42.2%; DALYs: 41.4%). Stroke, ischaemic heart disease and lower respiratory infections continued to account for notable proportions, while diabetes mellitus contributed less (deaths: 7.9%). Road injuries (deaths: 1.1%; DALYs: 0.8%) and falls (DALYs: 1.7%) remained minor contributors (tables 2 and 3).

Table 2.

Proportion of tobacco-attributable deaths to total deaths for the top 10 causes of death among both sexes, 1990 and 2023

Sl. no.	Top 10 death causes in 1990	Total deaths	Tobacco-attributable deaths	%	Sl. no.	Top 10 death causes in 2023	Total deaths	Tobacco-attributable deaths	%
1	Diarrhoeal diseases	1 393 843.4	0.0	0.0	1	Ischaemic heart disease	1 361 664.4	253 131.6	18.6
2	Neonatal disorders	866 131.0	0.0	0.0	2	Stroke	889 523.8	194 803.4	21.9
3	Ischaemic heart disease	563 073.3	147 958.6	26.3	3	Chronic obstructive pulmonary disease	820 106.8	346 285.4	42.2
4	Lower respiratory infections	529 639.2	100 519.2	19.0	4	Diabetes mellitus	594 830.3	47 241.8	7.9
5	Stroke	358 120.3	99 736.3	27.8	5	Diarrhoeal diseases	385 147.2	0.0	0.0
6	Chronic obstructive pulmonary disease	325 138.1	174 482.1	53.7	6	Neonatal disorders	273 801.1	0.0	0.0
7	Measles	211 653.8	0.0	0.0	7	Lower respiratory infections	273 398.0	61 127.6	22.4
8	Tuberculosis	169 890.8	113 353.8	66.7	8	Hypertensive heart disease	245 787.6	0.0	0.0
9	Diabetes mellitus	106 372.1	10 823.9	10.2	9	Road injuries	126 924.3	1 365.4	1.1
10	Protein-energy malnutrition	96 349.8	0.0	0.0	10	Chronic kidney disease	120 700.3	0.0	0.0
	Total (including other causes)	5 291 965.5	745 741.3	14.1		Total (including other causes)	6 139 393.2	1 153 978.1	18.8

Table 3.

Proportion of tobacco-attributable DALYs to total DALYs for the top 10 causes of DALYs among both sexes, 1990 and 2023

Sl. no.	Top 10 DALY causes in 1990	Total DALYs	Tobacco-attributable DALYs	%	Sl. no.	Top 10 DALY causes in 2023	Total DALYs	Tobacco-attributable DALYs	%
1	Neonatal disorders	80 456 851.0	0.0	0.0	1	Ischaemic heart disease	34 609 017.4	6 909 859.4	20.0
2	Diarrhoeal diseases	78 373 728.3	0.0	0.0	2	Neonatal disorders	30 729 869.8	0.0	0.0
3	Lower respiratory infections	41 494 011.7	6 973 546.8	16.8	3	Diabetes mellitus	22 108 661.4	1 770 104.3	8.0
4	Measles	18 640 585.1	0.0	0.0	4	Stroke	21 842 051.2	4 893 634.5	22.4
5	Ischaemic heart disease	16 489 791.8	4 680 248.0	28.4	5	Chronic obstructive pulmonary disease	18 589 361.6	7 694 623.9	41.4
6	Dietary iron deficiency	10 914 061.7	0.0	0.0	6	Lower respiratory infections	14 770 783.7	2 306 570.2	15.6
7	Stroke	9 851 030.9	2 874 862.6	29.2	7	Dietary iron deficiency	13 406 513.8	0.0	0.0
8	Protein-energy malnutrition	9 748 260.5	0.0	0.0	8	Diarrhoeal diseases	12 906 318.1	0.0	0.0
9	Chronic obstructive pulmonary disease	8 388 044.8	4 396 972.4	52.4	9	Road injuries	6 628 581.0	51 538.3	0.8
10	Tuberculosis	6 249 086.4	4 189 938.4	67.0	10	Falls	5 835 088.0	99 565.1	1.7
	Total (including other causes)	324 624 378.2	27 303 944.5	8.4		Total (including other causes)	241 421 984.9	31 414 717.4	13.0

DALYs, disability-adjusted life-years.

Among males, tuberculosis and COPD together accounted for the majority of tobacco-attributable deaths and DALYs in 1990 (tuberculosis—deaths: 70.2%; DALYs: 69.6%; COPD deaths: 63.4%; DALYs: 62.2%). Stroke and ischaemic heart disease followed, with lower respiratory infections and diabetes mellitus contributing smaller shares, and road injuries remaining minimal (deaths: 1.3%; DALYs: 0.9%). By 2023, COPD became the primary contributor (deaths: 55.0%; DALYs: 53.9%), with stroke, ischaemic heart disease and lower respiratory infections forming the next largest components. Diabetes mellitus contributed a smaller proportion (deaths and DALYs: 10.3%), whereas falls (DALYs: 2.0%) and road injuries (deaths: 1.3%; DALYs: 0.8%) remained limited (online supplemental appendix table A9 and A10).

Among females, COPD accounted for the largest share of tobacco-attributable deaths and DALYs in 1990 (deaths: 32.2%; DALYs: 31.8%), followed by stroke, lower respiratory infections and ischaemic heart disease. Diabetes mellitus and cervical cancer also contributed to the overall burden. By 2023, COPD remained the leading contributor (deaths: 26.4%; DALYs: 25.3%), while lower respiratory infections, stroke and ischaemic heart disease continued to represent substantial proportions. The contribution of diabetes mellitus declined (deaths and DALYs: 5.2%), as did cervical cancer (deaths: 1.6%), and falls emerged as an additional contributor (deaths: 1.6%) (online supplemental appendix table A11 and A12).

Cause-specific tobacco-attributable burden, 1990–2023

Figures 1 and 2 present the leading causes of tobacco-attributable deaths and DALYs for both sexes and their changes over time. COPD remained the leading cause in 2023, with deaths increasing from 174.48 thousand in 1990 to 346.29 thousand and DALYs reaching 7.7 million. Ischaemic heart disease also showed a substantial rise (deaths: 147.96 thousand to 253.13 thousand; DALYs: 6.9 million), followed by stroke (deaths: 194.8 thousand; DALYs: 4.9 million), lower respiratory infections (deaths: 61.13 thousand; DALYs: 2.3 million) and diabetes mellitus (deaths: 47.24 thousand; DALYs: 1.8 million). Other contributors included tracheal, bronchus and lung cancer, tuberculosis, lip and oral cavity cancer, oesophageal cancer, larynx cancer, other pharynx cancers and asthma, with smaller contributions from breast cancer, stomach cancer, upper digestive system diseases and low back pain (DALYs). ASRs declined for most causes, with increases concentrated in oesophageal cancer, diabetes mellitus, breast cancer, other pharynx cancers and tracheal, bronchus and lung cancer across deaths and DALYs, suggesting persistent elevation in risk for a limited set of conditions despite overall improvements elsewhere.

Figure 1.

Top 15 causes of tobacco-attributable deaths among both sexes in 1990 and 2023.

Figure 2.

Top 15 causes of tobacco-attributable disability-adjusted life-years (DALYs) among both sexes in 1990 and 2023.

Among males, COPD remained the leading contributor to tobacco-attributable deaths and DALYs, followed by ischaemic heart disease and stroke. Tobacco-related cancers and metabolic conditions such as diabetes mellitus also contributed substantially, with increasing ASRs observed for diabetes and selected cancers. Among females, the leading causes shifted from lower respiratory infections in 1990 to COPD in 2023, while stroke and ischaemic heart disease remained major contributors throughout the study period. Increasing trends were also observed for tobacco-related cancers and diabetes mellitus among females. Detailed cause-specific patterns and trends are presented in online supplemental appendix figures A2-A5.

Discussion

This study analysed tobacco-related deaths and DALYs in India in 1990 and 2023 representing the beginning and most recent years of the GBD 2023 study period, respectively, with a focus on differences by sex, age, and type of exposure to identify the most affected population groups. Tobacco-attributable deaths and DALYs showed a substantial increase in absolute terms over the study period, despite variation across exposure types and between males and females. This pattern is consistent with previous studies reporting rising absolute burden alongside declining ASRs and largely explained by population growth and demographic ageing.^34–36 As the population structure shifted toward older age groups, the cumulative effects of long-term tobacco exposure became more evident in mortality and DALY estimates.³⁷ Age-specific patterns showed a decline in tobacco-attributable burden across all age groups, consistent with earlier findings and likely reflecting improvements in prevention and control efforts.³⁸ However, the burden remained substantially higher among older adults, indicating accumulated lifetime exposure.³⁹ While lower burden among younger populations may reflect increased awareness, delayed initiation and policy measures,⁴⁰ the higher burden among older adults reflects the delayed manifestation of disease following prolonged exposure.⁴¹ Taken together, these patterns point to a dual health-system requirement: preventing initiation and promoting cessation earlier in life while maintaining adequate capacity for the long-term treatment and management of tobacco-related chronic diseases among older adults.

Smoking remained the leading contributor to both deaths and DALYs across the study period, particularly among males.6 8 21 34 42 Evidence from India and similar settings consistently shows higher smoking prevalence among men, often linked to occupational environments, peer influence, and stress-related coping behaviours.^43–46 In contrast, the disease burden due to smokeless tobacco increased more rapidly than other forms of tobacco, reflecting its widespread use in rural India, low cost, easy availability and strong cultural acceptance, particularly among females.^47–50 Its discreet use in occupational settings, weaker regulatory enforcement and misconceptions regarding relative safety, especially among socioeconomically disadvantaged groups, may have further contributed to sustained use.^51–56 The faster growth in smokeless-tobacco-attributable burden shows that the tobacco epidemic in India is changing in composition, rather than simply declining. Tobacco-control efforts therefore need to address smokeless products alongside smoking, with measures such as taxation, restrictions on availability and marketing, standardised packaging, stricter licensing, prominent health warnings and public education to improve recognition of tobacco-containing products and support cessation.

While DALYs due to smoking and smokeless tobacco increased in line with mortality trends, those attributable to SHS remained stable or declined, suggesting partial improvement in exposure reduction, although this pattern has not been uniform across settings.⁵⁷ Across outcomes, the burden was predominantly driven by the year of life lost, indicating substantial premature mortality, while YLDs contributed a smaller but gradually increasing proportion, reflecting the growing chronic disease burden associated with tobacco use.⁸ The predominance of YLLs underscores the importance of preventing exposure before tobacco-related disease develops, while the increasing contribution of YLDs points to a growing need for sustained care for chronic conditions. Although the decline in SHS burden may reflect smoke-free policies, awareness campaigns and behavioural changes, continued exposure among women within households due to indoor smoking and limited ventilation remains a concern.^58–65 Reducing this residual exposure requires stronger smoke-free household norms, cessation support for people who smoke and counselling through primary healthcare and community health workers, together with efforts to reduce exposure to solid-fuel smoke.

Over the study period, a clear epidemiological transition was observed, with tobacco-related deaths and DALYs increasingly concentrated in non-communicable diseases such as COPD, cardiovascular diseases, stroke and cancers, reflecting the long-term cumulative effects of exposure.⁸ This shift is driven both by the long induction period of tobacco-related diseases and by improvements in the control of infectious diseases, allowing chronic conditions to emerge as dominant contributors.⁶⁶ COPD remained a leading cause, highlighting the sustained impact of smoking and its interaction with other risk factors such as household air pollution.^67–69 Cardiovascular diseases and stroke also contributed substantially to both mortality and DALYs,^70–72 illustrating tobacco’s systemic effects beyond respiratory outcomes. In contrast, the declining contribution of infectious diseases such as tuberculosis suggests improvements in public health interventions.⁷³ This changing disease profile reflects India’s broader transition towards non-communicable diseases, which is shaped by multiple demographic, environmental, behavioural and metabolic factors, with tobacco remaining an important modifiable contributor. Addressing this broader burden requires stronger primary healthcare capacity for population-level prevention, healthy lifestyle promotion, early detection, risk factor management, appropriate treatment and continuity of care. Within this broader non communicable disease response, incorporating tobacco screening and cessation support into routine chronic disease services could help reduce continued exposure while addressing the conditions associated with it.

Importantly, while ASRs declined for most causes, increases were observed for selected conditions, including oesophageal cancer, diabetes mellitus, breast cancer, other pharyngeal cancers and tracheal, bronchus and lung cancer, indicating that risk reduction has not been uniform across all tobacco-related outcomes.^74–78 These increases may reflect heterogeneous exposure patterns, changes in tobacco products and intensity of use, and improved diagnostic capacity leading to better detection of specific conditions.⁷⁹ This divergence between overall declines and cause-specific increases in age-standardised death rates, alongside shifts in DALY distribution, suggests uneven epidemiological progress across disease categories.^{80 81} These findings reinforce the value of maintaining and strengthening tobacco-control measures, as cessation can reduce the risk of tobacco-related disease and mortality, while population-level measures such as taxation and comprehensive tobacco-control policies can reduce tobacco use. India has established a national tobacco-control framework through COTPA and the National Tobacco Control Programme; however, the persistence of substantial tobacco-attributable burden and the increasing contribution of smokeless tobacco point to the need for stronger implementation, wider access to cessation support and product-specific measures. Such efforts are particularly important where declines in overall ASRs have not been accompanied by comparable reductions in specific tobacco-related diseases.

Limitation

Although this study provides a comprehensive assessment of tobacco-attributable mortality and disease burden in India using the latest GBD 2023 estimates, certain limitations should be considered when interpreting the findings. First, GBD estimates are derived from multiple data sources, and differences in the availability, quality and coverage of underlying data across populations may contribute to uncertainty in the estimates. Some estimates had wide 95% UIs, reflecting greater uncertainty in the underlying data and modelled estimates. Second, as a secondary analysis of GBD data, detailed individual-level information on socioeconomic characteristics, education, occupation and specific patterns, intensity and duration of tobacco exposure was not available. Furthermore, the use of population-level estimates limits the assessment of individual-level causal relationships and may mask important geographical and socioeconomic differences in tobacco exposure and attributable burden within India. Finally, although GBD provides annual estimates for 1990–2023, our analysis primarily compared the two endpoint years and therefore does not formally characterise year-to-year or non-linear changes across the full period. In addition, different tobacco-related outcomes have different latency periods, and the burden observed in a given year may reflect exposure accumulated over previous years. Future studies incorporating individual-level and subnational data and longitudinal analytical approaches could provide further insight into the determinants and changing patterns of tobacco-attributable burden in India.

Conclusion

This study demonstrates that tobacco remains a substantial contributor to mortality and disease burden in India. Although progress in reducing tobacco-related burden is evident, the continuing health impact highlights the need for sustained and comprehensive tobacco control. The findings support a shift from a predominantly smoking-focused approach towards a broader strategy that addresses all major forms of tobacco exposure and the different populations affected by them. Tobacco control should be integrated more closely with India’s broader non-communicable disease prevention and health-system strategies, combining population-level measures with accessible prevention and cessation services. Strengthening taxation and regulatory measures, improving enforcement of existing tobacco-control policies and ensuring clear public communication about tobacco-containing products are important components of this approach. Greater emphasis should also be placed on reducing involuntary exposure to SHS, particularly within households, while strengthening primary healthcare capacity for tobacco prevention, cessation and management of related chronic diseases. A coordinated approach that combines regulation, public awareness, cessation support and long-term clinical care will be essential to reduce the continuing health consequences of tobacco exposure in India.

Data availability statement

Data are available in a public, open access repository. The data used in this study are publicly available from the Global Burden of Disease (GBD) 2023 study, coordinated by the Institute for Health Metrics and Evaluation (IHME), University of Washington. GBD provides comprehensive, standardised estimates of diseases, injuries and risk factors across countries and time periods. The datasets generated and/or analysed during the current study can be accessed through the IHME GBD Results Tool and related resources available at: http://www.healthdata.org/gbd/. No primary data were collected for this study.

Ethics statements

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Ethics approval

This study used publicly available Global Burden of Disease 2023 estimates and did not involve direct interaction with human participants or access to identifiable individual-level data.