title: Smokeless tobacco use: a meta-analysis of risk and attributable mortality estimates for India.
abstract: BACKGROUND
  Use of smokeless tobacco (SLT) is widely prevalent in India and Indian subcontinent. Cohort and case-control studies in India and elsewhere report excess mortality due to its use.
  
  
  OBJECTIVE
  The aim was to estimate the SLT use-attributable deaths in males and females, aged 35 years and older, in India.
  
  
  METHODS
  Prevalence of SLT use in persons aged 35 years and older was obtained from the Global Adult Tobacco Survey in India and population size and deaths in the relevant age-sex groups were obtained from UN estimates (2010 revision) for 2008. A meta-relative risk (RR) based population attributable fraction was used to estimate attributable deaths in persons aged 35 years and older. A random effects model was used in the meta-analysis on all-cause mortality from SLT use in India including four cohort and one case-control study. The studies included in the meta-analysis were adjusted for smoking, age and education.
  
  
  RESULTS
  The prevalence of SLT use in India was 25.2% for men and 24.5% for women aged 35 years and older. RRs for females and males were 1.34 (1.27-1.42) and 1.17 (1.05-1.42), respectively. The number of deaths attributable to SLT use in India is estimated to be 368127 (217,076 women and 151,051 men), with nearly three-fifth (60%) of these deaths occurring among women.
  
  
  CONCLUSIONS
  SLT use caused over 350,000 deaths in India in 2010, and nearly three-fifth of SLT use-attributable deaths were among women in India. This calls for targeted public health intervention focusing on SLT products especially among women.
authors.affiliation: World Health Organization, Regional Office for South-East Asia, New Delhi, India.
authors.forename: D N
authors.initials: DN
authors.lastname: Sinha
authors.forename: K M
authors.initials: KM
authors.lastname: Palipudi
authors.forename: P C
authors.initials: PC
authors.lastname: Gupta
authors.forename: S
authors.initials: S
authors.lastname: Singhal
authors.forename: C
authors.initials: C
authors.lastname: Ramasundarahettige
authors.forename: P
authors.initials: P
authors.lastname: Jha
authors.forename: A
authors.initials: A
authors.lastname: Indrayan
authors.forename: S
authors.initials: S
authors.lastname: Asma
authors.forename: G
authors.initials: G
authors.lastname: Vendhan
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016022:Case-Control Studies; D005260:Female; D006801:Humans; D007194:India; D008297:Male; D008875:Middle Aged; D011634:Public Health; D018570:Risk Assessment; D012907:Smoking / Q000401:mortality*; D014029:Tobacco Use Disorder / Q000401:mortality*; D014030:Tobacco, Smokeless / Q000009:adverse effects*