India's tobacco burden: 267 million users, 1.35 million deaths a year, and the law trying to catch up

The scale of use: 267 million adults

The most authoritative picture comes from the Global Adult Tobacco Survey, known as GATS-2, conducted in 2016-17. It found that 28.6 percent of Indian adults aged 15 and above use tobacco in some form, about 266.8 million people, of whom 24.9 percent are daily users and 3.7 percent use tobacco occasionally. That is a decline from 34.6 percent in GATS-1 in 2009-10, a real but slow improvement, and the next round of the survey, GATS-3, surveyed in 2025, is still awaited, so these remain the latest national figures available. India is the world's second-largest consumer and producer of tobacco after China, and consumes an estimated 821,000 tonnes of tobacco a year through smoking and smokeless products.

The headline number hides a crucial split. Only about 10.7 percent of adults smoke, while 21.4 percent use smokeless tobacco, and among all users roughly 26 percent consume smoked products while 74 percent use smokeless ones. The single most common product is khaini, a mixture of tobacco and lime, used by 11.2 percent of adults, followed by bidi at 7.7 percent, with gutkha and betel quid with tobacco next. Smokers average 6.8 cigarettes a day, while bidi smokers average 15.1 bidis, and nearly half of male smokers consume five or more cigarettes or bidis a day. Any policy that only thinks about cigarettes misses most of the Indian tobacco problem, which is chewed, sucked and tucked into the cheek rather than lit.

Who uses what, and where

Tobacco use in India is sharply divided by gender, place and region. Men use tobacco at 42.4 percent against 14.2 percent for women, which works out to around 198 million men and 53 million women. Rural use, at 32.5 percent, is much higher than urban use at 21.2 percent, and the product mix differs too: rural areas favour khaini and bidi, while urban users lean towards khaini and gutkha. Among men the most common forms are khaini and bidi, while women predominantly use smokeless products such as betel quid with tobacco and khaini, a pattern that matters because smokeless products are often wrongly seen as safer than smoking.

Regional variation is extreme. Smokeless tobacco use ranges from 48.5 percent of adults in Tripura to just 3.1 percent in Himachal Pradesh. National Family Health Survey data puts Mizoram at the top overall, with 73 percent of men and 62 percent of women aged 15 and above reporting tobacco use, followed by the Andaman and Nicobar Islands and Manipur for men and Tripura and Manipur for women. Large Hindi-belt states also record high use: Odisha reports 48.3 percent among men and 22.8 percent among women, Bihar 45.8 percent among men against only 4 percent among women, and Uttar Pradesh 45.2 percent among men and 9.6 percent among women. A national campaign that works in Himachal Pradesh will not automatically work in Mizoram, which is one reason tobacco control in India is run substantially through state and district machinery rather than from Delhi alone.

What tobacco does to the body

Tobacco smoke contains thousands of chemicals, including tar and carbon monoxide, and it damages nearly every organ it touches. In the lungs it causes chronic obstructive pulmonary disease, chronic bronchitis, emphysema and lung cancer by injuring lung cells and airways. In the cardiovascular system it accelerates atherosclerosis and raises the risk of coronary artery disease, heart attacks, angina and stroke. Beyond lung cancer, smoking raises the risk of cancers of the mouth, throat, larynx, oesophagus, pancreas, bladder, kidney and cervix, and smokeless tobacco in particular heightens the risk of oral cancer, which is why India's smokeless-heavy pattern produces an oral cancer burden that smoking-dominated countries do not see to the same degree.

The damage extends further. Smoking increases the risk of type 2 diabetes, age-related macular degeneration and osteoporosis, reduces fertility in men, and raises the risk of miscarriage, preterm birth, low birth weight and sudden infant death syndrome in pregnancy. It weakens immune defences by impairing macrophages, neutrophils and lymphocytes, leaving smokers more vulnerable to respiratory infections, pneumonia, influenza and tuberculosis, and worsening outcomes for people who already have tuberculosis. Second-hand smoke carries its own toll, causing respiratory infections, asthma attacks and cardiovascular disease, particularly in children and pregnant women; globally, more than 1.6 million non-smokers die each year from second-hand smoke exposure. Nicotine is also harmful to children, adolescents and young adults whose brains are still developing, which is the scientific basis for the youth focus of modern tobacco campaigns.

The death toll and the economic bill

The World Health Organization attributes around 1.35 million deaths in India every year to tobacco use, a figure that makes tobacco one of the country's largest single preventable causes of death. To put the human cost in economic terms, a major study of 2017-18 estimated the total cost of tobacco-related diseases and deaths among people aged 35 and above at 1,773.4 billion rupees, about 27.5 billion dollars, or roughly 1.04 percent of India's GDP in that year. Only 22 percent of that cost was direct medical and non-medical spending; the remaining 78 percent was indirect, meaning lost productivity from illness and premature death. Men bore 91 percent of the total cost, smoking accounted for 74 percent and smokeless tobacco for 26 percent, and direct medical costs alone amounted to about 5.3 percent of India's total health expenditure.

Set against that bill, tobacco tax revenue looks small. Excise revenue from tobacco in 2016-17 was only 12.2 percent of the economic cost, and one widely cited comparison puts it starkly: for every 100 rupees collected through excise taxes on tobacco products, the economy incurs an estimated cost of 816 rupees. The household picture is just as telling. An average tobacco user spends around 350 to 400 rupees a month on tobacco products, and tobacco accounts for roughly 1.5 to 3.8 percent of monthly household expenditure in rural areas in several states, and 1 to 2.4 percent in urban areas. In some states, spending on tobacco exceeds spending on pulses and fruits. Tobacco therefore impoverishes twice over: it drains household budgets that could buy food and schooling, and then it imposes treatment costs and lost earnings when disease arrives.

How the law works: COTPA and the web around it

India never banned tobacco. Instead it built a web of laws around it, centred on the Cigarettes and Other Tobacco Products Act of 2003, known as COTPA. Its full name explains its ambition: it covers cigarettes, cigars, cheroots, bidis, pipe and hookah tobacco, chewing tobacco, snuff, pan masala or any chewing material containing tobacco, gutkha and tooth powder containing tobacco. Section 4 prohibits smoking in public places, Section 5 prohibits direct and indirect advertising, promotion and sponsorship, Section 6(a) bans sales to under-18s, Section 6(b) bans sales within 100 yards of educational institutions, and Sections 7 to 10 require specified health warnings on every pack. The smoke-free rules took effect on 2 October 2008, and pictorial warnings appeared from 31 May 2009 at 40 percent of the front panel before rising to 85 percent of both main faces of every pack from 1 April 2016, with 60 percent picture and 25 percent text.

Around COTPA sits a set of laws that each closed a gap the main Act could not reach. Gutkha was not banned by COTPA at all: the Food Safety and Standards Regulations of 2011 barred tobacco and nicotine as ingredients in any food product, and states began issuing gutkha bans from 2012, although twin packs of pan masala and chewing tobacco sold separately remain a major loophole. Tobacco imagery on screens is regulated too: film and television rules from 2012 require health spots, disclaimers and on-screen warnings during tobacco scenes, and the 2023 rules extended those requirements to streaming platforms, making India among the first countries to apply tobacco-imagery rules to online content. On price, tobacco moved to 40 percent GST from 1 February 2026, with bidis at 18 percent, plus a new excise duty, and Karnataka raised its tobacco purchase age to 21 in 2025. A draft amendment that would raise the national age to 21, ban loose cigarette sales and designated smoking areas and raise fines has been circulated but not enacted, which is why enforcement still depends heavily on fines as low as 200 rupees for several COTPA offences.

The e-cigarette exception: banned, not regulated

E-cigarettes are the one product India chose to prohibit rather than regulate. The Prohibition of Electronic Cigarettes Act, 2019, enacted on 5 December 2019 and in force from 18 September 2019, bans the production, manufacture, import, export, transport, sale, distribution, storage and advertisement of e-cigarettes, including heat-not-burn products and e-hookahs. The penalties are far harsher than COTPA's: a first offence can bring up to one year in prison or a fine of up to one lakh rupees or both, a repeat offence up to three years or five lakh rupees, and even storing e-cigarettes can attract up to six months in prison or a fine of fifty thousand rupees. Authorities often treat possession as evidence of storage or transport, so even travellers and individual users can face legal trouble if found with the devices.

The policy logic, as the government presented it, was preventive: it is easier to stop a new product before it spreads than to control it afterwards, and officials pointed to rising youth vaping elsewhere and to the uncertain long-term health effects of inhaled nicotine liquids. Critics have argued the opposite, saying the ban protects the cigarette market and denies smokers a less harmful alternative, a debate that continues in public health circles worldwide. What is not in dispute is the asymmetry it creates: an adult can legally buy cigarettes and khaini under COTPA's restrictions, but cannot legally buy, sell or store a vape at all. That asymmetry is deliberate, and it reveals the philosophy of Indian tobacco control in miniature: regulate the entrenched product, prohibit the new one before it becomes entrenched, and use price, packaging and place restrictions to squeeze the old market slowly rather than outlawing it overnight.

Why youth campaigns exist, and what quitting takes

Youth-focused campaigns exist because initiation happens young and addiction then does the rest. GATS-2 found that among daily tobacco users aged 20 to 34, 12.2 percent had started before age 15 and 35.8 percent before age 18, and a majority of daily users consume tobacco within 30 minutes of waking, a classic marker of dependence. There is one encouraging trend: the average age of initiation rose from 17.9 years in GATS-1 to 18.9 years in GATS-2, suggesting that age limits, school buffers and advertising bans may be delaying first use even where they have not prevented it. Early adulthood is the critical window because nicotine dependence can take hold quickly, peer influence is strong, and cheap small sachets of khaini and gutkha keep the entry price low even as taxes rise. Campaigns that turn college and university students into ambassadors for tobacco-free campuses are aimed squarely at that window, combining peer influence with enforcement of tobacco-free institution rules.

For people who already use tobacco, the evidence points to a combination of approaches rather than willpower alone. Reviews of cessation strategies emphasise counselling integrated with medication, quitlines such as the national tobacco quitline number printed on packs, and increasingly digital support through mobile apps, alongside the policy levers of taxation, smoke-free laws and advertising restrictions that make quitting easier and relapse harder. Progress is real but slow: adult use fell from 34.6 percent to 28.6 percent between the two GATS rounds, yet more than a quarter of adults still use tobacco, smokeless products remain deeply embedded in daily life in many states, and enforcement of even basic rules such as the 100-yard school buffer is uneven. The honest conclusion is that India has built one of the world's more comprehensive tobacco-control frameworks on paper, and that the gap between that framework and the 267 million users is now mostly a gap of enforcement, price, and reaching young people before dependence sets in. This article is general educational information only, not personal medical advice; anyone seeking help to quit tobacco should consult a qualified healthcare professional or an authorised cessation service.

Editorial disclosure

This article was researched with AI assistance and reviewed by the publisher before publication. Report factual errors through our contact page.