Published Mar 10, 2026 | 8:00 AM ⚊ Updated Mar 10, 2026 | 8:00 AM
Cigarette smoking in Kerala dropped from 17.2% to 12.1% in villages and from 15.84% to 14.83% in urban areas.
Synopsis: Almost 1.35 million deaths in India can be attributed to tobacco annually. Approximately one in four Indians faces the risk of dying from a non-communicable disease before reaching the age of 70.
In a country where tobacco consumption is rising almost everywhere, one state stands apart. Kerala is the only state in India where overall tobacco use has declined across both rural and urban areas, from 27.4% to 19.0% in villages, and from 21.99% to 18.97% in cities.
Set this against the national picture, and the contrast is stark. Across India, rural tobacco-consuming households rose from 9.9 crore to 13.3 crore between 2011-12 and 2023-24, a 33% increase.
Urban tobacco-consuming households jumped by 59%, from 2.8 crore to 4.7 crore. Adjusted for inflation, per capita spending on tobacco rose 58% in rural India and 77% in urban areas. The country is moving decisively in one direction. Kerala is moving in the other.
A handful of other states show partial declines. Andhra Pradesh recorded a fall in rural overall tobacco consumption, from 41.9% to 37.6%, but urban tobacco use in the state actually rose, from 23.71% to 28.27%. Odisha tells a similar story: rural overall tobacco fell from 68.4% to 60.4%, but urban consumption nudged upward. Goa recorded a marginal rural decline but urban tobacco use more than doubled, from 6.50% to 16.54%.
Among Union Territories, Andaman and Nicobar Islands recorded declines in both rural and urban overall consumption, but as a small island territory, it is difficult to draw broader lessons from its numbers.
Chhattisgarh presents the most deceptive picture. Overall tobacco consumption declined in both rural and urban areas. The numbers suggest progress. But that headline decline masks a catastrophic shift underneath: gutkha consumption in rural Chhattisgarh exploded from 0.3% to 42.0%, as households moved away from traditional tobacco forms toward a far more dangerous packaged product. The overall number went down. The harm went up.
Kerala stands alone, not just in the direction of its numbers, but in the integrity of its decline.
What makes Kerala’s achievement genuinely remarkable is that the decline is not confined to one product or one geography. It runs across virtually every tobacco category, in both rural and urban areas.
Bidi consumption fell from 11.9% to 7.9% in rural Kerala and from 7.04% to 6.01% in cities. Cigarette use, often the last habit to fall even in health-conscious populations, dropped from 17.2% to 12.1% in villages and from 15.84% to 14.83% in urban areas. Leaf tobacco declined sharply, from 2.3% to just 0.3% rurally and from 0.71% to 0.37% in cities. Other tobacco products followed the same downward path.
Even gutkha, the product that has proved most resistant to control elsewhere in the country, has barely made an impression in Kerala. Rural gutkha crept up from zero to just 0.1%, and urban gutkha remained flat. In a country where rural gutkha consumption has risen six-fold nationally, Kerala’s near-zero penetration is not just good news. It is extraordinary.
The breadth of this decline matters. In many states where one product falls, another rises to take its place, bidi gives way to gutkha, or cigarettes replace leaf tobacco. In Kerala, there is no such substitution effect. Consumption has fallen across the board, suggesting a deeper cultural and behavioural shift rather than a simple product migration.
What explains it? The paper does not offer a definitive answer, but Kerala’s combination of high literacy, strong public health infrastructure, active civil society and decades of health awareness campaigns has clearly created conditions that no other state has fully replicated. It is a model the rest of India urgently needs to study, and the rest of southern India, in particular, needs to heed.
The scale of what is happening nationally puts Kerala’s achievement in sharp relief.
Between 2011-12 and 2023-24, tobacco consumption has not merely grown, it has spread into new geographies, new income groups and new product categories in ways that suggest deep structural change rather than a temporary blip.
The surge is not being driven by cigarettes or bidis, products with established regulatory frameworks and some degree of tax discipline. It is being driven overwhelmingly by gutkha, a smokeless tobacco product that causes oral cancer, oesophageal cancer and cardiovascular disease, and which has proved uniquely difficult to regulate.
Nationally, the share of rural households consuming gutkha has risen more than six-fold, from 5.3% to 30.4%. Today, 41% of all rural tobacco expenditure goes towards gutkha, making it the single largest tobacco product by value. The central belt has been most severely affected: in rural Madhya Pradesh, more than six in ten households now consume gutkha; Uttar Pradesh has crossed the 50% mark. Bihar, Chhattisgarh and Rajasthan are not far behind.
The health consequences are not abstract. As the paper notes, “smokeless tobacco products like gutkha, khaini, and zarda cause oral, oesophageal, pancreatic cancers, dental, and cardiovascular diseases.”
According to WHO estimates cited in the paper, almost 1.35 million deaths in India can be attributed to tobacco annually. Approximately one in four Indians faces the risk of dying from a non-communicable disease before reaching the age of 70.
The paper’s authors are unsparing in their overall assessment: “the increase is not confined to specific regions or income groups; rather, it reflects a broad-based expansion cutting across states, consumption classes, and product categories, signalling changing consumption preferences and the growing penetration of commercial tobacco markets.”
Until recently, southern India appeared to be holding the line. Kerala, Tamil Nadu and Andhra Pradesh continued to record gutkha rates that barely registered, under 2% of households in most cases.
This gave credence to a narrative that the south was structurally different: better educated, more health-conscious, less susceptible to the aggressive marketing that had swept the central belt.
Karnataka has shattered that narrative.
In 2011-12, just 1.1% of rural Karnataka households consumed gutkha. By 2023-24, that figure had risen to 25.5%, a roughly 23-fold increase in just over a decade. Urban Karnataka tells an equally alarming story: gutkha consumption climbed from 0.88% to 16.3%, a nearly 19-fold increase, suggesting the product has penetrated the state comprehensively, from its villages to its cities.
These numbers place Karnataka not in the company of southern laggards but squarely alongside states like Rajasthan and West Bengal in terms of gutkha prevalence.
What makes this particularly difficult to explain away is Karnataka’s profile. This is not a remote, impoverished state with limited health information. It is home to Bengaluru, one of India’s most educated and economically dynamic cities. The gutkha surge here is not a story of poverty and ignorance, it is a story of a commercially aggressive product successfully penetrating new markets regardless of income or literacy.
The paper identifies the mechanism with uncomfortable clarity. “Gutkha advertisement goes unabated and big Bollywood stars promote gutkha under the fig leaf of ‘silver coated cardamom’. Cricket is the most widely watched sport event in India and gutkha products dominate in the ad breaks. These subtle steps go a big way in normalising tobacco consumption. This is alarming.”
The paper further flags the “twin sachet method of selling tobacco-less pan masala and tobacco sachet together to circumvent the gutkha ban”, a practice that has hollowed out enforcement across the country, including in states that once prided themselves on stricter compliance.
In Karnataka, normalisation has clearly reached a tipping point.
Karnataka is not alone. Telangana has seen rural gutkha consumption rise from 1.0% to 10.4%, a tenfold increase. In urban areas, the numbers move from 1.33% to 7.46%, a nearly sixfold rise, indicating that gutkha is spreading across Telangana’s cities just as steadily as its countryside.
Telangana’s numbers are lower than Karnataka’s in absolute terms, but the trajectory is arguably more instructive. A tenfold increase over a single survey period is the signature of a product in its active penetration phase, not yet entrenched, but moving fast.
If the pattern seen in Karnataka, or in the central belt states before it, is any guide, Telangana’s numbers could look very different again by the next survey.
Taken together, Karnataka and Telangana represent a meaningful breach in what was once southern India’s relative immunity. The paper’s conclusion is unambiguous about what drives this: “particularly notable is the sharp rise in packaged and branded tobacco products such as gutkha and cigarettes, signalling changing consumption preferences and the growing penetration of commercial tobacco markets.”
The other southern states, and why they cannot be complacent
Tamil Nadu and Andhra Pradesh continue to record gutkha rates well below the national average, 1.1% and 2.1% of rural households respectively. But overall tobacco use is rising in Tamil Nadu (30.3% to 36.3% rural) and cigarette consumption is climbing across most southern states. The south’s advantage rests on an increasingly fragile base.
Puducherry offers a cautionary tale of how quickly the picture can change. Overall tobacco consumption in the union territory leapt from 15.6% to 55.1% in rural areas, with cigarette use alone hitting 41.9%, among the highest in the country. From being one of India’s lowest-consumption territories, Puducherry has effectively collapsed into the national average within a decade.
No southern state should take its current numbers for granted.
The burden of this epidemic falls most heavily on those least equipped to bear it. In rural India, more than 70% of households in the bottom 40% of the income distribution consume tobacco. In states like Uttar Pradesh, Madhya Pradesh and Bihar, this figure exceeds 85%.
Poorer rural households spend a larger share of their monthly per capita expenditure on tobacco (1.7%) than the wealthiest 20% (1.2%).
The paper draws a comparison that should give any policymaker pause: “In rural India, bottom-40 households spend just 2.5% of MPCE on education, while spending 4% on pan, tobacco and intoxicants. A welfare state cannot credibly champion human capital development while allowing addictive products to crowd out spending on education, nutrition and health.”
This collision between rising tobacco use and expanding public healthcare creates what the paper describes as a classic moral hazard problem. As of October 2025, over 42 crore Ayushman Bharat cards have been issued, covering nearly 12 crore families. Government health expenditure as a share of total health spending rose from 29% to 48% between FY2015 and FY2022.
“At the time when out-of-pocket expenditure on healthcare is constantly declining, consumption on tobacco products specially cigarettes, gutkha, chewing tobacco are rising,” the paper warns.
The fiscal arithmetic is stark. For every ₹100 received as excise taxes from tobacco, ₹816 of costs is imposed on society through its consumption.
The paper does not spare the current regulatory framework. On advertising, it demands action that goes beyond existing law: “We need clearly worded act to stop any kind of advertising, including surrogate advertising and prevent manufacturers from exploiting loopholes. There need to be public consensus to call out big celebrities who mindlessly promote tobacco products.”
Enforcement on the ground is equally weak. The paper flags near-total failure to restrict sales near schools: “Sight of small tobacco shops adjacent to school premises are quite common. Strict enforcement of the act and penal provisions, random checks with flying squads can help reducing young person’s exposure and accessibility of tobacco products.”
On taxation, the recently amended Central Excise (Amendment) Bill 2025 proposes raising duty on chewing tobacco to 100% and on gutkha to 40%. The paper supports this direction but argues bidi, currently taxed at just 18% under GST compared to 40% for other tobacco products, must also be revisited. “There is medical research that proves bidi is even more harmful than commercial cigarettes… bidi has poor combustibility, leading to frequent puffs and deeper inhalation which are relatively more damaging.”
For high-consumption states, the paper proposes linking union government fund disbursements under Ayushman Bharat to outcomes in tobacco control programmes, using fiscal incentives to push states toward meaningful action.
The paper’s conclusion frames the stakes plainly: “Rising consumption today implies higher morbidity, premature mortality, and greater long-term healthcare demand in the years ahead… tobacco control must be viewed not only as a health priority but also as a fiscal and developmental imperative.”
Karnataka has already crossed a threshold from which recovery is difficult. Telangana is approaching one. The rest of the south retains an advantage, but the forces eroding it are well-funded, well-organised and increasingly effective.
“India’s progress toward universal health coverage will be incomplete if preventable risk factors continue to expand unchecked,” the authors conclude. “Curbing tobacco consumption is therefore central to safeguarding both population health and the long-term sustainability of public finance.”
For southern India, the window to act is narrowing. Kerala has shown that the trajectory can be reversed, comprehensively, across every product, in both villages and cities. The question is whether any other state is willing to do what it takes to follow. The gutkha sachet has found its way past the gates, and in Karnataka at least, it is no longer knocking at the door. It has moved in.
(Edited by Majnu Babu).
