Second-hand smoke killed 325,600 people in India in 2023, Lancet finds

A global analysis in The Lancet Public Health estimates that 325,600 deaths in India in 2023 were attributable to second-hand smoke, up from 217,700 in 1990. That is a rise of almost 50% in the raw count. Age-standardised death rates moved the other way, falling from 46.1 to about 30 per 100,000, a drop of roughly 35%. More people died because more people lived in the exposed pool, not because each exposed person became more likely to die.

The exposed pool grew from 375 million in 1990 to 444 million in 2023, an 18.4% increase. Age-standardised prevalence of exposure fell from 43.2% to 30.6%. India had the second-largest number of exposed people after China’s 664 million. Indonesia was third at 142 million. Those three countries held nearly half of the 2.71 billion people the authors say were exposed worldwide in 2023, including 767 million children aged 0-14. Global prevalence was 33.9%.

Deaths among women in India rose from 113,400 to 156,900. Deaths among men rose from 104,300 to 168,700. Second-hand smoke accounted for 9.28 million disability-adjusted life-years in India in 2023. The paper links the exposure to ischaemic heart disease, stroke, lung cancer, chronic obstructive pulmonary disease, breast cancer, type 2 diabetes, asthma and lower respiratory infections. In children, lower respiratory infections drove most of the burden.

The pattern is a population-size story wearing a tobacco story’s clothes. Cotinine-measured exposure and household survey questions both show that a smaller share of Indians now live with a smoker’s plume. The absolute number still rose because the population rose. Homes remain the main room. COTPA restrictions cover many public places. They do not cover a kitchen in which someone else lights a bidi.

Dr G.C. Khilnani, chair of pulmonary and critical care at PSRI Hospital, told the Times of India that children and women carry extra risk because developing lungs and indoor time overlap. He said smoking should move outdoors and that public awareness still lags the statute book. That is a clinic sentence, not a finding in the Lancet tables. The tables already show women at 156,900 deaths in a country where female smoking rates are far lower than male rates. The smoke is arriving from someone else’s hand.

Southeast Asia, East Asia and Oceania had the highest age-standardised exposure prevalence at 48.4%. In some of those countries women were exposed at nearly 1.8 times the male rate. India sits inside that regional pattern even as its own prevalence number has come down. The policy implication is not a new slogan. It is enforcement inside homes, vehicles and shared housing, where the law is weakest and the minutes of exposure are longest.

The authors published in 2026 on 2023 data. The lag is normal for Global Burden work. What the 2023 snapshot gives a health ministry is a split: rates down, counts up, women still dying in six figures from smoke they did not buy. Any campaign that only talks to smokers about their own risk misses half the deaths in this paper. The other half belong to people who shared a room.