More than a quarter of a million people die each year that are linked to using smokeless tobacco, say scholars who believe that governments need to consider incorporating the regulation of smokeless tobacco into policy frameworks.

A paper funded by Leeds City Council and the Medical Research Council links smokeless tobacco to more than 62,000 deaths due to cancers of the mouth, pharynx and oesophagus and accounted for more than 200,00 deaths from heart disease in 2010.

Researchers compiled the figures using data from 113 countries and extracted from the 2010 Global Burden of Disease Study and surveys such as Global Adult Tobacco Survey. The team says that more research is needed in countries with high levels of consumption but where figures for the relative risk of acquiring smoking-related cancers are not available.

They would also need to figure out how many of those people would not have gotten cancer without chewing tobacco, a much trickier proposition that has been used by tobacco companies to defuse smoking critics as well; half of lung cancer patients never smoked and only about 10 percent of smokers get lung cancer, while no study can successfully link second-hand smoke to any deaths. 

Despite concerns about the validity of surveys and mapping them to epidemiology, Dr. Kamran Siddiqi, senior lecturer in epidemiology and public health at the Department of Health Sciences/Hull York Medical School, believes his results are actually conservative "and future studies may reveal that the impact is even bigger. We need a global effort to try and address and control smokeless tobacco."

Sweden disagrees. Their tobacco-related death rate is 25 percent of the rest of Europe because more people use "snus" rather than smoking. 

Instead, the results may be confounded by other factors. They found that South-East Asia was a hotspot and India which accounted for 74 percent of the global disease burden, which means that it may not be the product at all. "Smokeless tobacco is used by almost a quarter of tobacco users and most of them live in South-East Asia. But even in this country there are communities in east London, Leicester, Birmingham, Leeds, Bradford and Birmingham using it.

"We have got no international policy on how to regulate the production, composition, sale, labelling, packaging and marketing of smokeless tobacco products. "The international framework to control tobacco doesn't seem to work to control smokeless tobacco. It doesn't get the same regulation as cigarettes. There is a need to build on the insights obtained from efforts to reduce cigarette smoking and to investigate strategies to reduce the use of smokeless tobacco."

Gross, yes, but smokeless tobacco has nowhere near the disease burden of cigarettes.