India's Passive Smoking Paradox: Exposure Falls, Deaths Keep Rising

By: Shreya Maheshwari

A new Lancet Public Health study estimates that 444 million people in India were exposed to passive smoking in 2023, while deaths linked to second-hand smoke rose from 217,700 in 1990 to 325,600 in 2023.

India's passive smoking burden has grown even as the share of people exposed has declined. A new Lancet Public Health study estimates that 444 million Indians were exposed to tobacco smoke from others in 2023, while deaths linked to passive smoking increased from 217,700 in 1990 to 325,600 in 2023.

The study reveals a striking contradiction. Over the past three decades, India's age-standardised exposure prevalence declined from 43.2% in 1990 to 30.6% in 2023, indicating that a smaller proportion of the population is exposed today than it was three decades ago. Yet the total number of people exposed increased from 375 million to 444 million during the same period, an increase of 18.4%. The findings suggest that population growth has offset improvements in exposure rates, leaving millions more Indians vulnerable to the health risks associated with second-hand smoke.

The rising exposure burden has translated into a substantial increase in mortality. Deaths attributable to passive smoking have risen by nearly 50% over the last 33 years. The increase has been recorded across both genders, with annual deaths among women rising from 113,400 to 156,900, while deaths among men increased from 104,300 to 168,700 between 1990 and 2023. At the same time, the age-adjusted death rate fell from 46.1 to 30 deaths per 100,000 people, a decline of 35%, showing that lower rates have not prevented the overall number of deaths from increasing.

The health burden extends well beyond mortality. In 2023, second-hand smoke accounted for an estimated 9.28 million disability-adjusted life years (DALYs) in India, reflecting healthy years lost because of premature death, illness and disability. The study associates passive smoking with several serious health conditions, including ischaemic heart disease, stroke, lung cancer, chronic obstructive pulmonary disease, breast cancer, type 2 diabetes, asthma and lower respiratory infections.

Children emerge as one of the most vulnerable groups. Because their lungs and immune systems are still developing, exposure to tobacco smoke carries a particularly high health burden. The study identifies lower respiratory infections as the leading contributor to the disease burden among children exposed to second-hand smoke. Globally, children accounted for more than 12% of the disease burden linked to passive smoking.

India also recorded the second-highest number of people exposed to second-hand smoke globally in 2023, behind China. The study estimates that China had 664 million people exposed, compared with 444 million in India and 142 million in Indonesia. Together, these three countries accounted for nearly half of the world's exposed population.

The scale of the challenge extends far beyond India. Globally, an estimated 2.71 billion people were exposed to second-hand smoke in 2023, including 767 million children aged 0–14 years. The exposure was associated with approximately 1.66 million deaths and 44.8 million DALYs worldwide.

The study underscores an important public health paradox. While India has reduced the proportion of its population exposed to second-hand smoke over time, the country's growing population has expanded the number of people living with its health risks. The result is that hundreds of thousands of deaths and millions of healthy years are lost each year not to smoking itself, but to breathing in someone else's tobacco smoke.