An Overlooked Danger: Smokeless Tobacco and the Global Oral Cancer Epidemic
In this article
One of the world's most prestigious medical journals, New England Journal of Medicine (NEJM), drew attention to smokeless tobacco in its January 15, 2026 issue through a striking perspective article by Parascandola M., Nethan S.T., and Siddiqi K. While global efforts against smoking have achieved important successes, smokeless tobacco has reached more than 360 million users in 140 countries and become a silent force behind rising oral cancer. This is an urgent call to action for oncology and public health.
The Report's Critical Messages
- A Growing Threat: While smoking declines globally, smokeless tobacco use is rising, particularly in South Asia and the Pacific.
- Carcinogenic Effect: The International Agency for Research on Cancer (IARC) classifies smokeless tobacco products as "Group 1 Carcinogens" (definitely cancer-causing).
- Inequality: 77% of users live in low- and middle-income countries.
- Clinical Opportunity: A simple oral examination by a dentist or physician can create a teachable moment that encourages quitting.
🔍 Glossary: What Is Smokeless Tobacco?
Smokeless Tobacco (ST): A general term for products consumed without burning tobacco leaves, through chewing, sucking, or sniffing.
- Names Around the World: Snus, Gutka, Khaini, Toombak, Iqmik, Betel Quid.
- The Example in Türkiye: The most common form is "Maraş Otu".
1. The Global Crisis in Numbers
The report illustrates the scale of smokeless tobacco use with striking statistics. Across 140 countries, more than 360 million people use these products. Most users (77%) live in low- and middle-income countries.
Use is particularly high in Bangladesh, India, Pakistan, and Papua New Guinea. In India, smokeless tobacco accounts for 61% of all tobacco use and has become a multibillion-dollar industry.
2. Target Groups: Women and Young People
"Social Acceptance" Among Women
Unlike smoking, smokeless tobacco is considered socially acceptable for women in some societies. For example, in Burkina Faso, while 80% of men smoke, almost all women who use tobacco prefer smokeless products.
The Danger to Young People
Global Youth Tobacco Survey data show a 4.4% use rate among those aged 12-16. In Western Pacific islands, however, rates are alarming: 26.1% in the Marshall Islandsand 21.3% in Micronesia. Manufacturers directly target young people with flavored products and attractive packaging, such as nicotine pouches.
3. Oral Cancer: Preventable Devastation
According to 2022 data, worldwide there were 389,846 new oral cancer cases . Approximately 30% (120,000 cases) are directly attributed to smokeless tobacco and areca nut (betel nut). Areca nut is addictive and carcinogenic even when used alone.
Regional differences are striking. In South Asia, oral cancer is the most common head-and-neck cancer in men, and 87.8% of these cases are attributable to smokeless tobacco.
Proportion of Oral Cancers Attributable to Smokeless Tobacco (Regional Differences)
Source: Boffetta P, et al. Lancet Oncol 2008 & NEJM 2026.
4. A Roadmap for Healthcare Professionals
"Teachable Moment"
Physicians often ask about smoking while overlooking smokeless tobacco. Yet a simple oral examination in the dentist's or doctor's chair is an ideal opportunity to detect precancerous lesions such as leukoplakia . This is the right moment to encourage the patient to quit.
- Behavioral therapies (strongest evidence).
- Nicotine lozenges and varenicline (limited but promising evidence).
- Routine oral screening, particularly in high-risk groups.
Original Article
Parascandola M, Nethan ST, Siddiqi K. "Smokeless Tobacco and Oral Cancer in Global Perspective." N Engl J Med. 2026 Jan 15;394(3):209-211.
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