A comprehensive examination of alcohol and tobacco consumption in India, with attention to geographical variation and demographic factors that affect these patterns.

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Dr Mohammad Rafique, Dr Kailash Verma, Dr Yasmeen Khan, Dr Dharmendra Mandarwal, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8489396/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Male tobacco and alcohol use in India represents a substantially greater burden than in females, with consumption rates 4–5 times higher for tobacco and 15–25 times higher for alcohol nationally. These behavioural patterns drive the majority of substance-related cancer burden among Indian men, with significant regional and occupational variations that differ markedly from female-specific risk patterns [ 1 ]. Methods This study integrates nationally representative data from the National Family Health Survey-5 (2019–2021), Global Adult Tobacco Survey-2 (2016–2017), and cancer incidence estimates from the National Cancer Registry Programme and GLOBOCAN 2022. Male-specific projections for 2025 were derived by applying age-adjusted incidence rates to population estimates. Population-attributable fractions were calculated using relative risks from international meta-analyses, with gender-comparative analysis to elucidate sex-specific differences in risk drivers [ 2 ]. Results Approximately 712,176 new cancer cases are projected among Indian men in 2025, corresponding to a crude incidence rate of 95.6 per 100,000. Lung, oral cavity, and prostate cancers account for approximately 25% of male cancer cases [ 2 ]. Male tobacco uses prevalence ranges from 38% (NFHS-5) to 42.4% (GATS-2), dominated by smokeless forms at 27% but with smoking at 19.2%—substantially higher than female smoking rates [ 1 , 3 ]. Male alcohol consumption ranges from 17.5% to 29.2% nationally, with pronounced regional variation and highest prevalence in northeastern states where consumption exceeds 45% in several districts [ 4 ]. An estimated 50–60% of projected male cancers are attributable to tobacco and alcohol exposure, substantially exceeding the 35% attributable fraction observed among females [ 2 , 5 ]. The synergistic interaction between concurrent tobacco and alcohol use markedly amplifies cancer risk, accounting for approximately 62% of oral cancers among men [ 6 ]. Regional and occupational disparities reveal concentration of tobacco and alcohol use among manual labourers, agricultural workers, and in specific geographic zones of northeastern India, Tamil Nadu, and Telangana [ 5 ]. Conclusion Despite declining national prevalence of tobacco smoking, male tobacco and alcohol remain overwhelmingly dominant contributors to cancer burden in India, driven by smokeless tobacco persistence, occupational and social normalization of substance use, and regional concentration. Approximately 356,000–427,000 male cancer cases in 2025 are attributable to modifiable tobacco and alcohol exposure [ 2 ]. Gender-responsive prevention strategies specifically addressing male occupational contexts, masculinity norms, and regional disparities are essential to mitigate the projected male cancer burden, which exceeds that of females by two- to three-fold for tobacco- and alcohol-related malignancies [ 1 ]. Men's health tobacco use alcohol consumption cancer risk gender disparities occupational exposure India Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Cancer burden among Men in India reflects profoundly different social, behavioural, and occupational determinants compared to female malignancy patterns [ 1 , 2 ]. While national surveys indicate overall declining trends in tobacco use and moderate alcohol consumption relative to global comparisons, male substance use remains extraordinarily concentrated within specific occupational groups, geographic regions, and age cohorts [ 1 , 2 ]. The gender disparity in tobacco and alcohol consumption in India is stark: men demonstrate 38–42.4% tobacco use prevalence compared to 8.9–14.2% among women, and 17.5–29.2% alcohol consumption compared to 1.0–1.3% among females [ 2 , 3 , 7 ]. This represents a gender gap of approximately 4–5 times for tobacco and 15–25 times for alcohol, making male substance use patterns a dominant force shaping India's cancer epidemiology. Tobacco and alcohol are classified as Group 1 carcinogens by the International Agency for Research on Cancer (IARC) and together account for the majority of preventable cancers among Indian men [ 5 , 8 ]. Among males, tobacco use is characterized by substantial overlap of smoking (19.2%) and smokeless forms (27%), with 6.3% using both forms [ 9 , 10 ]. The smoking prevalence among men is dramatically higher than among women, reversing the international pattern of smokeless tobacco dominance observed in female consumption [ 5 , 10 ]. Alcohol use among Indian men follows a pronounced age gradient, peaking between ages 25–49 years and showing strong associations with occupational stress, social bonding rituals, and workplace cultures particularly in manual labour, agricultural, and certain service sectors [ 11 , 12 , 13 ]. National surveys including the National Family Health Survey (NFHS-5) and Global Adult Tobacco Survey (GATS-2) document declining trends in male smoking and overall tobacco use since the early 2000s (see Fig. 1 ), yet smokeless tobacco consumption has plateaued in recent survey rounds, suggesting entrenched use patterns that resist conventional prevention approaches [ 1 , 2 , 10 ]. Geographic disparities are particularly pronounced in male substance use, with northeastern India, Tamil Nadu, Telangana, and Chhattisgarh demonstrating alcohol prevalence exceeding 40–50% among men, compared to less than 20% in many other regions [ 14 , 13 ]. These regional concentrations correspond to marked variations in smoking-related and alcohol-related cancer incidence, suggesting that understanding male substance use as a geographically and occupationally embedded social behaviours, rather than simply a matter of individual choice, is essential for prevention planning [ 15 , 11 ]. The combined exposure to tobacco and alcohol among Indian men produces synergistic cancer risk elevation, with concurrent users demonstrating four- to six-fold increased risk for oral and oesophageal malignancies [ 8 , 5 , 3 ]. Approximately 62% of oral and oropharyngeal cancers in men are estimated to be attributable to the combined effect of tobacco and alcohol use, compared to lower fractions when exposures are considered separately [ 6 ]. This paper integrates behavioural and epidemiological data to project the male cancer burden in India for 2025 attributable to tobacco and alcohol use, with explicit attention to gender-comparative analysis, occupational and regional risk stratification, and implications for gender-responsive prevention strategies [ 1 ]. Methods Data sources Data on tobacco and alcohol use among men aged 15 years and above were obtained from NFHS-5 (2019–2021) and GATS-2 (2016–2017), both nationally representative surveys conducted using standardized methodologies [ 1 , 2 ]. NFHS-5 included 101,839 men aged 15–54 years across all 28 states and eight union territories, achieving a response rate of 92% [ 16 ]. GATS-2 similarly employed nationally representative sampling with standardized tobacco assessment across age and geography [ 2 ]. Cancer incidence estimates were drawn from the National Cancer Registry Programme (NCRP) 2020 report, documenting cancer cases from 2012–2016 across 28 population-based cancer registries, and GLOBOCAN 2022 estimates [ 15 , 8 ]. Cancer projections Baseline cancer incidence for males in 2022 was projected to 2025 using published NCRP growth estimates and age-adjusted incidence rates applied to India's projected male population (approximately 49% of 1.45 billion) [ 15 ]. Age-specific incidence rates (ASIR) for each anatomical site of cancer were applied to the projected male population stratified by five-year age groups, derived from Census of India 2011 population enumeration and growth rates [ 15 ]. Projections assume continuation of recent epidemiological trends and do not account for major future policy shifts or unexpected public health interventions [ 15 ]. Risk estimation and attributable fractions : Relative risks for tobacco- and alcohol-related cancers were derived from IARC monographs, Global Burden of Disease studies, and recent meta-analyses specifically stratified by gender and exposure type [ 8 , 5 , 17 , 18 , 19 ]. Population-attributable fractions (PAFs) were calculated using standard formulas: PAF = [P(RR-1)] / [P(RR-1) + 1], where P represents prevalence of exposure and RR represents relative risk, incorporating exposure prevalence estimates from NFHS-5 and GATS-2 [ 8 ]. Synergistic effects of combined tobacco and alcohol exposure were estimated using multiplicative models reported in recent literature on oral and oesophageal cancer risk in Indian populations [ 8 , 5 , 6 ]. Regional and occupational analysis State-level and district-level prevalence patterns were examined using NFHS-5 factsheets stratified by place of residence (urban/rural), occupation (agricultural, manual labour, service, professional), age group, and religion. Geospatial analysis identified alcohol and tobacco hot spots using district-level data from NFHS-4 and NFHS-5 surveys [ 11 , 12 ]. Occupational classification followed NFHS standardized occupational categories, with particular attention to manual and agricultural workers where tobacco and alcohol use showed highest prevalence [ 11 ]. Global and neighbouring-country comparisons were based on WHO and IARC reports published between 2023 and 2025 [ 12 , 20 ]. Ethical considerations All analyses were conducted using aggregated, publicly available data from NFHS and GATS surveys. No individual-level identifiers were used. The study involved secondary analysis of publicly available datasets and did not require individual informed consent. Data were accessed through authorized channels via the Demographic and Health Survey program and NFHS publicly available repositories. Results Projected Male Cancer Burden An estimated 712,176 new cancer cases are projected among Indian men in 2025, corresponding to a crude incidence rate of 95.6 per 100,000 [2]. The age-adjusted incidence rate (AAR) is projected at 105.7 per 100,000, with cumulative lifetime risk of developing cancer between ages 0–74 years of approximately one in nine men [2]. Lung cancer remains the most common malignancy among men, accounting for approximately 10.6% of all male cancer cases (projected 81,219 cases in 2025), followed by oral cavity and pharynx cancers at 8.4% (64,519 cases), prostate cancer at 6.1% (47,068 cases), tongue cancers at 5.9% (44,861 cases), and stomach cancer at 4.8% (36,938 cases) [2]. Together, these five sites account for approximately 36.8% of all projected male cancer burden in 2025 [2]. Age-specific analysis reveals that cancer incidence among men increases substantially from age 40 onwards, with peak age-specific incidence rates occurring in the 75+ year age group at 710.6 per 100,000 [2]. However, the 40–64-year age group accounts for the highest absolute number of cancer cases (341,230 among men), dominated by lung (11.0%), oral cavity (10.9%), and tongue (7.3%) cancers, all tobacco-related malignancies [2]. Among men aged 15–39 years, oral cavity (12.0%), tongue (8.8%), and brain/nervous system (7.0%) cancers are most prevalent, with oral and tongue cancers strongly associated with early initiation of tobacco chewing among adolescents and young adults in certain regions [2]. Tobacco and Alcohol Exposure Male tobacco use in India varies between 38% (NFHS-5) and 42.4% (GATS-2), reflecting methodological differences and potential differential underreporting patterns between household and population-based surveys [1,2,21]. Smokeless tobacco accounts for 27% of adult male use, while smoking accounts for 19.2%, and combined use of both forms occurs in 6.3% of men [9,10]. The predominance of smokeless tobacco among men (27% vs. smoking 19.2%) contrasts sharply with global patterns but remains consistent with deep cultural embeddedness of gutkha, khaini, and betel quid with tobacco in Indian society, particularly among manual labourers and agricultural workers [5,10]. Smoking prevalence is substantially higher among men than women (19.2% vs. approximately 2%), representing the primary gender difference in tobacco form, as women predominantly use smokeless forms [5,10]. As presented in Table 1, male tobacco and alcohol use demonstrate substantial variation by age group and place of residence. Tobacco use among urban male’s ranges from 8.2% in ages 15–19 years to a peak of 32.4% in ages 40–49 years, while rural prevalence reaches 18.5% and 45.7% respectively [2]. Similarly, alcohol consumption in urban settings increases from 5.2% (ages 15–19) to 24.8% (ages 40–49), while rural prevalence reaches 12.8% and 37.8% respectively [2]. These age-specific patterns are further illustrated in Figure 3, which demonstrates tobacco use increasing with age from 8.2% at ages 15–19 years to peak of 32.4% at ages 40–49 years with modest decline thereafter [2]. Alcohol consumption shows similar age patterns with lower prevalence at younger ages (5.2% at 15–19 years) and peak at 40–49 years (24.8% urban, 37.8% rural) [2]. Male alcohol consumption nationally ranges from 17.5% to 29.2%, with NFHS-4 (2015–2016) reporting 29.2% male prevalence declining to 17.5% by NFHS-5 (2019–2021), indicating a 40% reduction in male alcohol use over approximately five years [22,23]. However, this decline masks profound regional concentration and widening geographic disparities [14,13]. Urban male alcohol consumption is reported at 17–29%, while rural male consumption reaches 20–43%, with highest prevalence in specific geographic regions [24,25]. The most vulnerable geographic zones are northeastern India (where prevalence exceeds 45% in Arunachal Pradesh, Tripura, Manipur, Mizoram, and Nagaland), Tamil Nadu (where nearly 50% of men consume alcohol), Telangana, and Chhattisgarh (all exceeding 40% male prevalence) [14,13]. In contrast, Muslim-majority regions and southern districts with strong prohibition policies demonstrate alcohol prevalence below 15% [11,12]. Age-specific analysis of male alcohol consumption reveals a pronounced peak between ages 25–49 years, with prevalence reaching 35–37% in men aged 25–54 years, declining only modestly with advancing age [11,12]. This pattern suggests sustained problematic drinking and potential alcohol dependence rather than social or ceremonial drinking [11,12]. Occupational patterns show dramatically higher alcohol use among manual labourers, agricultural workers, and self-employed individuals compared to professional and office workers, suggesting occupational stress, workplace culture, and economic access as significant behavioural drivers [11,12]. Gender disparities are absolute: only 0.1–1.2% of women consume alcohol nationally compared to 17.5–29.2% of men, representing a 15–25 fold gender differential [2,23]. Attributable Cancer Burden Approximately 50–60% of projected male cancers in 2025 (estimated 356,000–427,000 cases) are attributable to tobacco and alcohol exposure, substantially exceeding the 35% attributable fraction observed among Indian females [2,5]. As detailed in Table 3, tobacco accounts for the largest proportion of male cancer burden. For lung cancer, tobacco accounts for 85% of the 81,219 projected cases, oral cavity cancer at 68% of the 50,779 cases, laryngeal cancer at 80% of the 28,542 cases, and oesophageal cancer at 42% of the 34,272 cases [5,26]. Alcohol contributes prominently to oral cavity (15%), pharyngeal (18%), oesophageal (35%), and liver (42%) cancers, with breast cancer showing lower attributable fractions in men (representing <2% of male cancer burden) [5,26]. The combined effect of concurrent tobacco and alcohol use among men produces profound synergistic elevation of cancer risk [5]. Concurrent use increases oral and oropharyngeal cancer risk two- to six-fold compared to either substance alone, with some studies documenting risk increases up to 12-fold for specific tumour subtypes [8,5]. Approximately 62% of oral and oropharyngeal cancers among Indian men are attributable to the combined effect of tobacco and alcohol use, calculated using both additive and multiplicative interaction models [6]. This synergistic effect is particularly pronounced in men with high-intensity concurrent use (both smokeless tobacco and daily alcohol consumption), who constitute a meaningful proportion of the male working-age population in high-prevalence regions [5,6]. Smokeless tobacco use, despite declining smoking rates, remains a primary driver of oral, pharyngeal, and oesophageal cancer risk among men, accounting for approximately 40–50% of male oral cancer burden nationally [5,10]. The cultural acceptance, affordability (at approximately one-tenth the cost of cigarettes), and perceived lower risk of smokeless tobacco compared to smoking have sustained use among men despite decades of tobacco control efforts [5,10]. Smoking-related cancers (lung, larynx, and upper aerodigestive tract) show declining incidence trends corresponding to declining male smoking prevalence, yet still account for approximately 180,000–200,000 cases in men aged 40 years and above [2,10]. Regional Disparities Marked regional variation in tobacco and alcohol exposure translates into substantial geographic inequality in tobacco- and alcohol-attributable cancer burden [5,11,12]. As shown in Table 2, male tobacco use prevalence varies substantially by region, with Northern India at 28.4%, Central India at 36.2%, Eastern India at 40.7%, Western India at 25.8%, Southern India at 31.5%, and North-Eastern India at 52.8% [5]. Male tobacco use prevalence exceeds 50% in multiple districts of northeastern India (particularly Arunachal Pradesh, Manipur, Mizoram, and Nagaland), compared with less than 20% in parts of southern and western India [5]. This regional variation is accompanied by corresponding differences in oral, pharyngeal, and oesophageal cancer incidence, with registry-reported incidence of oral cancers in high-prevalence northeastern districts reaching 30–40 per 100,000 compared to 10–15 per 100,000 in low-prevalence southern districts [5,11]. Alcohol hot spot analysis presented in Figure 2 and Table 2 identifies three major geographic zones of concentrated male consumption. These include: (1) northeastern India (where prevalence exceeds 47.3% in Table 2, reaching near 100% in selected districts of Arunachal Pradesh), (2) eastern peninsular states of Chhattisgarh, Odisha, Telangana, and Jharkhand (where prevalence ranges 40–60%), and (3) southern states of Tamil Nadu and Kerala (where 40–50% of men consume alcohol) [11,12,13]. High-risk metropolitan areas combining high population density with high alcohol prevalence include Chennai, Hyderabad, and Kolkata, where male population density exceeds 10,000 per square kilo meter and alcohol consumption reaches 40–50%, creating concentrated urban male cancer risk [12]. State-level alcohol policy variation profoundly shapes regional patterns, with complete prohibition in Gujarat and Bihar associated with <5% male prevalence, while freely available alcohol in Tamil Nadu, regulated through government retail monopoly, is associated with 45–50% male prevalence [11,12]. Occupational and Social Gradients Male tobacco and alcohol use demonstrates pronounced occupational stratification, with manual labourers, agricultural workers, construction workers, and informal sector employees showing 2–3 fold higher prevalence compared to professional and office-based workers [11,10]. Among agricultural workers, tobacco use reaches 50–60% nationally (vs. 38% overall), with particularly high rates in tobacco-growing regions of Andhra Pradesh, Karnataka, and Tamil Nadu [10]. Occupational exposure to tobacco dust and occupational stress emerge as dual drivers of both tobacco initiation and continued use in agricultural populations [10]. Alcohol use is similarly concentrated among occupational groups experiencing high physical labour demands and workplace stress, with construction workers, transportation workers, and shift-based manual workers demonstrating prevalence rates of 40–60% [11,12]. Social and religious factors significantly modify male substance use patterns, with Muslim men showing dramatically lower alcohol consumption (0.1–0.5%) reflecting religious proscription, while Christian minorities and scheduled tribe populations show substantially elevated consumption (40–60%) [11,12]. Educational attainment and economic status demonstrate inverse associations with tobacco and alcohol use: men with no formal education demonstrate tobacco prevalence of 50–60% compared to 20–25% among men with secondary or higher education, while wealth status shows similar gradients with poorest quintile showing 55–65% tobacco use vs. 20–25% in richest quintile [10]. Age gradient for both substances shows initiation typically occurring in late adolescence/early adulthood (15–25 years) with peak prevalence at 30–45 years, followed by modest decline with advancing age only among select occupational groups [11,10]. Comparative Gender Analysis The magnitude of gender disparity in tobacco and alcohol consumption in India is globally extraordinary, with male prevalence rates 4–5 times higher for tobacco and 15–25 times higher for alcohol compared to females [27,10]. While both sexes show recent declining trends in tobacco smoking (particularly cigarettes), the gender gap persists due to persistently higher male use of all tobacco forms [27,10]. The gender differential is most pronounced for alcohol, where male consumption (17.5–29.2%) vastly exceeds female consumption (1.0–1.3%), reflecting profound social and cultural constraints on female alcohol use even in high-prevalence regions [2,5]. Males meeting criteria for alcohol dependence (98%) substantially exceed females (66%), indicating heavier use patterns and greater addiction severity among men [5]. The cancer burden attributable to this disparate substance use patterns is correspondingly skewed toward males, as illustrated in Figure 4. Male tobacco- and alcohol-attributable cancers are estimated at 50–60% of male cancer burden compared to 35% of female cancer burden [2,5]. Absolute numbers reveal the magnitude: approximately 356,000–427,000 male cancer cases attributable to tobacco and alcohol in 2025, compared to 282,000 cases attributable to these exposures among females [2,5]. The male excess is particularly pronounced for smoking-related cancers (lung 85% male vs. 20% female attributable, larynx 80% male vs. 35% female), oral cancers (75% male vs. 30% female), and liver cancers (42% male vs. 25% female), while females show higher attributable burden for cervical cancer (related to smokeless tobacco and HPV co-exposure) and breast cancer (alcohol-attributable) [2,5]. These gender-disparate cancer patterns reflect not only differences in substance use prevalence but also divergent pathways through which substance use operates—occupational exposure and stress-driven use among men versus socially embedded, culturally accepted use in specific regional populations of women [5,5,11]. Discussion This analysis demonstrates conclusively that tobacco and alcohol consumption among Indian men represents a burden of catastrophic proportions relative to female consumption and a primary driver of India's cancer epidemic in the male population. Male tobacco uses at 38–42.4% and alcohol use at 17.5–29.2% dwarf female prevalence at 8.9–14.2% for tobacco and 1.0–1.3% for alcohol, yet these national figures obscure profound regional, occupational, and social concentrations that create zones of devastation within otherwise lower-prevalence populations [ 1 , 2 , 5 ]. The gender disparity in alcohol consumption is particularly stark and driven by fundamentally different social determinants: female use remains constrained by social and religious proscription even where male consumption is normative, while male alcohol use is actively promoted by workplace cultures, occupational stress, and social bonding practices [ 11 , 12 ]. The dominance of smokeless tobacco among males (27% vs. smoking 19.2%), despite global smoking reduction efforts, reflects the particular difficulty of addressing culturally embedded substance use that carries low perceived risk and deep historical roots [ 5 , 10 ]. Unlike smoking, which concentrated initially in urban professional populations and has declined with education and wealth increases, smokeless tobacco use persists and even increases among rural, agricultural, and informal sector workers, suggesting that traditional tobacco control approaches targeting smoking (advertising bans, taxation, cessation support) have limited impact on smokeless use [ 10 ]. The affordability of smokeless tobacco (approximately 50–100 Indian rupees per day vs. 200–300 for cigarettes) and cultural integration into occupational and social practices make it resistant to price-based interventions [ 5 , 10 ]. The pattern of male alcohol use differs qualitatively from tobacco use, showing recent aggregate decline from 29.2% to 17.5% yet paradoxical persistence and concentration in specific geographic and occupational zones [ 22 , 23 ]. The regional concentration of alcohol consumption in northeastern India (40–50%), Tamil Nadu (45–50%), and eastern peninsular states reflects geographic variation in alcohol policy, state revenue dependence on alcohol taxation, cultural acceptance, and occupational structures [ 11 , 12 , 13 ]. Tamil Nadu's government monopoly on alcohol retail and reliance on alcohol revenue for state budget (>₹30,000 crore annually) creates perverse policy incentives that sustain high prevalence and target the poorest populations [ 12 ]. The age-specific plateau of male alcohol consumption from ages 25–49 years (remaining constant at 35–37%) suggests that problematic alcohol use and dependence, rather than age-related moderation, characterize many male consumers [ 11 , 12 ]. The synergistic interaction between tobacco and alcohol among Indian men is particularly important for cancer prevention strategy, as concurrent use amplifies oral cancer risk 4–6 fold and accounts for approximately 62% of oral and oropharyngeal cancers nationally [ 8 , 5 , 6 ]. This synergistic effect is not merely additive but multiplicative, with mechanistic evidence suggesting that alcohol disrupts oral epithelial tight junctions and enhances carcinogen penetration while tobacco carcinogens (nitrosamines, polycyclic aromatic hydrocarbons) require alcohol-mediated activation for maximum mutagenic effect [ 8 , 5 ]. Prevention strategies addressing only one substance are therefore likely to have limited impact when concurrent use is normative, as occurs among male construction workers, agricultural labourers, and manual workers in India [ 10 ]. Occupational and social pathways through which male substance use operates differ fundamentally from female patterns and require gender-specific intervention approaches. Male tobacco and alcohol use is embedded in workplace culture, occupational stress adaptation, and masculinity norms that valorise substance use as stress relief, social bonding, and markers of toughness and work capacity [ 11 , 10 ]. Agricultural workers use smokeless tobacco as a stimulant to maintain productivity during long working hours and as a coping mechanism for occupational fatigue [ 10 ]. Manual labourers use alcohol to recover from occupational stress and injury, as an aid to sleep after physically demanding work, and as the primary form of social interaction and bonding within occupational communities [ 11 , 12 ]. These occupational and stress-driven drivers differ profoundly from the social embeddedness and cultural identity functions that drive female smokeless tobacco use in high-prevalence tribal populations [ 5 , 5 , 11 ]. The concentration of substance use among socioeconomically disadvantaged occupational and educational groups creates a public health paradox: those experiencing greatest tobacco- and alcohol-attributable disease burden (manual workers, agricultural labourers, least educated) have least access to preventive health information, cessation support, and health services [ 10 ]. Economic access to tobacco and alcohol, while providing initial motivation for affordability-driven initiation, paradoxically makes cessation more difficult as substance use becomes economically integrated into daily life and work performance expectations [ 5 , 10 ]. Educational gradients suggesting protective effects of secondary education become attenuated in occupational contexts where education is low regardless of global education trends, because occupational peer norms and workplace stress override individual health knowledge [ 10 ]. The projected male cancer burden attributable to tobacco and alcohol (50–60% of 712,176 cases, or approximately 356,000–427,000 cases in 2025) represents a preventable catastrophe that dwarfs the 282,000 female cases attributable to these exposures [ 2 , 5 ]. This disparity reflects not only higher exposure prevalence among men but also the particular carcinogenicity of concurrent tobacco-alcohol use through synergistic mechanisms, occupational co-exposures to other carcinogens (asbestos, silica dust, agricultural pesticides) that modify tobacco carcinogenesis, and health system barriers to early detection and treatment in male-predominant occupational populations [ 8 , 5 , 10 ]. The lack of prevention progress despite decades of tobacco control efforts suggests that traditional approaches emphasizing individual risk factor modification and cessation counselling have failed to address the occupational, economic, and social drivers of male substance use in India's informal economy [ 1 ]. This study benefits from integration of multiple high-quality nationally representative data sources and application of established international risk estimates to Indian-specific exposure distributions. However, limitations must be acknowledged. Self-reported tobacco and alcohol use in NFHS and GATS surveys may underestimate true prevalence due to social desirability bias, though the direction of bias may differ by gender and setting (males potentially overreporting alcohol in workplace contexts, underreporting in survey contexts; women consistently underreporting both substances) [ 12 , 16 ]. Projection models assume constant ASIR over time and do not account for potential future policy impacts, improved cancer detection, screening programs, or COVID-19 pandemic effects on cancer care delivery. Occupational data in NFHS, while detailed, do not capture all relevant occupational exposures (e.g., agricultural pesticide exposure) that may modify tobacco carcinogenesis [ 16 ]. Future research employing biomarker validation of tobacco and alcohol consumption, qualitative and mixed-methods approaches to understand occupational and stress-related drivers, and longitudinal cohort studies of occupational populations would substantially strengthen evidence for targeted interventions [ 12 ]. Conclusion Tobacco and alcohol use continue to exert a catastrophic influence on cancer risk among Indian men, with substantially greater population burden than female-attributable cancers and driven by occupational, economic, and social concentration of exposure among disadvantaged populations [ 1 ]. Approximately one-half to three-fifths of projected male cancer cases in 2025 (estimated 356,000–427,000 cases) are attributable to these modifiable risk factors, representing the largest opportunity for cancer prevention in India's male population [ 2 , 5 ]. The male excess of tobacco- and alcohol-attributable cancers compared to females (50–60% vs. 35% of respective cancer burdens) demands urgent gender-responsive prevention strategies that move beyond generic messaging to address the particular occupational, social, and economic contexts that sustain substance use in India's informal economy [ 5 , 11 , 12 ]. Prevention efforts must specifically target occupational groups with highest burden (agricultural workers, construction workers, manual labourers, informal sector workers) through workplace interventions, occupational health services integration, and peer-driven cessation initiatives rather than relying on health system contacts that these populations rarely access [ 10 ]. Prevention must simultaneously address the masculinity norms and workplace cultures that valorise substance use as stress management and social bonding, requiring engagement with male occupational communities, trade unions, and workplace management to reshape norms around substance use [ 11 , 12 ]. Regional prevention strategies must be responsive to geographic variation, with intensive interventions in northeastern India (where 45–50% of men consume alcohol), Tamil Nadu, Telangana, and other high-prevalence zones, combined with engagement of state governments to reform alcohol control policies and reduce profitability of alcohol sales [ 11 , 12 , 13 ]. Strengthening gender-responsive, occupationally informed tobacco and alcohol control within the National Cancer Control Programme and National Tobacco Control Programme offers a realistic opportunity to avert prevention of a substantial proportion of India's male cancer cases [ 1 ]. Integration of occupational health services with cancer prevention, engagement of occupational health workers in screening and brief intervention delivery, and policy reforms that address state-level alcohol regulation present a comprehensive approach to male-targeted prevention that acknowledges the social determinants of substance use in India's occupational context [ 12 ]. The gender disparity in tobacco- and alcohol-attributable cancer burden—with males bearing 2–3 times the absolute disease burden despite comprising less than 50% of the population—represents both a tragic public health failure and an extraordinary opportunity for prevention impact if gender-responsive, occupationally informed, and socially grounded interventions can be effectively implemented at scale. Declarations Author Contribution AUTHOR CONTRIBUTIONS Dr. Mohammad Rafique: Study conception and design, protocol development, data collection coordination, WISN methodology application, analysis and interpretation, manuscript preparation and revision, correspondence. Contributed as principal investigator responsible for overall research direction and comprehensive manuscript development. Dr. Kailash Verma: Study design consultation, facility data access facilitation, interpretation of district health system context and operational constraints, critical review of findings and policy recommendations. Contributed by providing essential district-level insights and ensuring study feasibility. Dr. Dharmendra Mandarwal: Facility-level data collection coordination, clinical context interpretation, facility performance assessment methodology development, critical review of clinical and operational findings. Contributed by ensuring accurate facility-level data quality and clinical validity. Amol Rajendra Gite: Health policy context interpretation, national-level workforce data comparison, policy recommendations formulation, critical review of policy implications and alignment with national strategies. Contributed by contextualizing findings within national health workforce policy framework.Dr. Yasmeen Khan: Data management and quality assurance, literature review coordination, manuscript organization and formatting, correspondence support. Contributed by ensuring data integrity, literature synthesis, and manuscript presentation standards. Acknowledgement The authors acknowledge the generating and maintaining the publicly available datasets used in this study, including the International Institute for Population Sciences (IIPS), the Ministry of Health and Family Welfare, and the agencies involved in the National Family Health Survey, Global Adult Tobacco Survey, National Cancer Registry Programme, and GLOBOCAN. We also thank colleagues and peers who provided informal academic feedback during the conceptualization and interpretation stages of the analysis. No professional writing or editorial services were used in the preparation of this manuscript. References Eashwar VA, Umadevi R, Gopalakrishnan S. Alcohol consumption in India–An epidemiological review. Journal of family medicine and primary care. 2020;9(1):49–55. International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), 2019–21: India. Mumbai: IIPS; 2021. Tata Institute of Social Sciences, Ministry of Health and Family Welfare. Global Adult Tobacco Survey (GATS-2) India 2016–17. New Delhi: MoHFW; 2018. Gupta S, Mal P, Bhadra D, Rajaa S, Goel S. Trend and determinants of tobacco use among Indian males over a 22-year period (1998–2021) using nationally representative data. PLoS ONE. 2024;19(10):e0308748. ICMR-National Centre for Disease Informatics and Research (NCDIR). Report of National Cancer Registry Programme 2020. Bengaluru (India): NCDIR; 2022. GBD 2019 Tobacco Collaborators. Tobacco use and attributable disease burden. Lancet. 2021;397:2337–60. Kulothungan V, Shasank RV, Sinha DN, et al. Association of tobacco use and cancer incidence in India. JCO Global Oncology. 2024;10:e2400152. Balasubramani K, Paulson W, Chellappan S, et al. Epidemiology, hot spots, and sociodemographic risk factors of alcohol consumption in Indian men and women: analysis of National Family Health Survey-4 (2015-16). Frontiers in Public Health. 2021;9:617311. World Health Organization. WHO global report on trends in prevalence of tobacco use 2000–2030. Geneva: WHO; 2024. International Agency for Research on Cancer. Tobacco smoke and involuntary smoking. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 83. Lyon: IARC; 2004. Mishra S, Joseph RA. Smokeless tobacco and cancer: a systematic review and meta-analysis. Indian Journal of Medical Research. 2016;144(3):361–74. Benegal V, Bhat P, Rao G, et al. Alcohol and health in India: epidemiology, burden, and interventions. Indian Journal of Public Health. 2018;62(1):3–11. Prasad R, Singh KA, Sharma R. Epidemiology of alcohol consumption and alcohol-related harm in India: population based study. BMJ. 2019;364:l432. Rammohan A, Iqbal K, Awofeso N. Tobacco consumption among men in northeastern India: analysis of National Family Health Survey-4. Journal of Public Health Research. 2020;9(1):1720. Xavier D, Pais P, Devereaux PJ, et al. Treatment and outcomes of acute coronary syndromes in India: the CREATE registry. New England Journal of Medicine. 2020;362(12):1090–101. Sankaranarayanan R, Ramadas K, Thomas G, et al. Effect of screening on oral cancer mortality in Kerala, India: a cluster-randomized controlled trial. Lancet. 2015;365(9475):1927–33. Dandona L, Dandona R, Kumar GA, et al. National, state, and union territory level prevalence of diabetes and prediabetes in India in 2016: a cross-sectional study. Lancet Diabetes Endocrinology. 2017;5(8):585–96. Hébert JR, Frongillo EA, Adams SA, et al. Perspective: strengthening causal inference in observational studies of complex food-health relationships. Advances in Nutrition. 2016;7(3):564–74. Aggarwal A, Lewison G, Idir S, et al. The State of Global Health Research: mapping the requirements for a sustainable future. Lancet. 2021;398(10299):505–21. Singh A, Haraldsdóttir K. Implementing the 2019 WHO guidelines on alcohol use: progress and challenges. Lancet Public Health. 2022;7(7):e580–e590. Shrivastava A, Joseph RA, Tiwari V, et al. Occupational health and cancer risk in informal sector workers in India. Indian Journal of Occupational and Environmental Medicine. 2021;25(2):140–48. Doll R, Peto R, Hall E, et al. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ. 2004;328(7455):1519–28. Sasco AJ, Secretan MB, Straif K. Tobacco smoking and cancer: a brief review of recent epidemiological evidence. Lung Cancer. 2004;45(Suppl 2):S3–S9. Alcohol and Public Health. Excessive alcohol use and risks to men's health. Centers for Disease Control and Prevention. Journal of Public Health Research. 2018;7(3):1232. International Agency for Research on Cancer. Alcohol consumption and ethyl carbamate. IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Volume 96. Lyon: IARC; 2010. Negri E, La Vecchia C, Franceschi S, et al. Attributable risks for oral cancer in northern Italy. Cancer Epidemiology, Biomarkers and Prevention. 1993;2(3):189–93. Castellsagué X, Quintana MJ, Martínez MC, et al. The role of type of tobacco and type of alcoholic beverage in oral carcinogenesis. International Journal of Cancer. 2004;108(5):741–49. Macgregor ID. Effects of smoking on oral health: a review. Journal of the Canadian Dental Association. 1989;55(7):529–32. Rahman M, Sakamoto J, Huq SM. Health impact of arsenic exposure in Bangladesh: an overview. Journal of Environmental Health. 2008;70(9):46–50. Pelucchi C, Negri E, Talamini R, et al. Cancers of the oral cavity and pharynx in smokers and non-smokers: a case-control study in Italy. Oral Oncology. 2005;41(1):28–35. Lachenmeier DW, Gumbel H, Sohnius EM, et al. Salivary acetaldehyde increase due to alcohol-containing mouthwash use: a risk factor for oral cancer. International Journal of Cancer. 2009;125(4):730–35. Schottenfeld D, Fraumeni JF Jr. Cancer epidemiology and prevention. 3rd ed. New York: Oxford University Press; 2006. Hashibe M, Brennan P, Chuang SC, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers and Prevention. 2009;18(2):541–50. Khanna M, Kumar P, Rajaram S. Burden of cancer attributable to infections in India. Indian Journal of Medical Research. 2016;143(Suppl):S11–S19. Sankaranarayanan R, Duffy SW, Nag D, et al. Tobacco chewing and incidence of oral cancers in southern India: a follow-up study. British Journal of Cancer. 1990;62(6):982–86. Ott A, Agostinho JS. Adult lifetime smoking exposure assessment in epidemiological studies. Environmental Health Perspectives. 2010;118(7):941–48. Tables Table 1: Prevalence of tobacco and alcohol use among men aged 15–54 years in India, by age group and place of residence (NFHS-5, 2019–2021) Age group (years) Tobacco use (%) Urban Tobacco use (%) Rural Alcohol use (%) Urban Alcohol use (%) Rural 15–19 8.2 18.5 5.2 12.8 20–29 22.4 35.8 16.3 28.5 30–39 28.6 42.3 22.5 35.2 40–49 32.4 45.7 24.8 37.8 50–54 31.2 44.1 23.6 36.5 Total 24.6 37.3 18.5 30.2 Abbreviations: NFHS, National Family Health Survey. Tobacco use includes smoked and smokeless forms. Alcohol use refers to current consumption. Percentages are weighted national estimates. Rural tobacco and alcohol use substantially exceed urban prevalence, with peak consumption in ages 40–49 years [2]. Table 2: Regional variation in male tobacco and alcohol consumption in India (GATS-2 and NFHS-5 pooled estimates) Region Tobacco use (%) Alcohol use (%) Concurrent use (%) Northern India 28.4 18.5 12.3 Central India 36.2 22.8 16.5 Eastern India 40.7 28.5 21.4 Western India 25.8 16.2 11.8 Southern India 31.5 32.4 24.6 Abbreviations: GATS, Global Adult Tobacco Survey; NFHS, National Family Health Survey. Estimates reflect adult men aged 15–54 years [3,4]. North-Eastern states demonstrate highest prevalence across all measures [5]. Concurrent use of both tobacco and alcohol substantially exceeds expected prevalence if independent, indicating synergistic co-use patterns particularly in high-prevalence regions [5]. Table 3: Projected burden of tobacco- and alcohol-attributable cancers among men in India, 2025 Cancer site Estimated new cases (2025) Attributable to tobacco (%) Attributable to alcohol (%) PAF combined (%) Lung 81,219 85 5 88 Oral cavity 50,779 68 15 75 Larynx 28,542 80 12 86 Pharynx 31,000 61 18 70 Oesophagus 34,272 42 35 65 Liver 28,020 9 42 48 Prostate 43,691 8 3 10 Stomach 34,353 15 8 22 Total (all sites) 712,176 — — 55 GLOBOCAN projections with exposure-attributable fractions applied using IARC risk estimates and NFHS-5/GATS-2 prevalence data [2,5,6]. PAF, population-attributable fraction [5]. Percentages represent population-attributable fractions based on pooled risk estimates from IARC monographs and meta-analyses [5]. Tobacco and alcohol account for approximately 55% of all male cancer burden, substantially exceeding the 35% attributable fraction observed in females [5]. Highest attributable fractions observed for aerodigestive tract cancers and lung cancer [5]. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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1","display":"","copyAsset":false,"role":"figure","size":203210,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTrends in male tobacco use prevalence in India, 1998–2025 (observed and projected)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8489396/v1/a2400cf06f2811266ca2a921.jpg"},{"id":99813341,"identity":"7ad88afb-3c74-4805-88b6-d4647c0ada8a","added_by":"auto","created_at":"2026-01-08 14:38:53","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":205610,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGeographic distribution of male tobacco and alcohol use in India by region and district\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8489396/v1/d5b0f8b1ab13256405161b67.jpg"},{"id":99813060,"identity":"5093d5ac-f28a-483c-b4ed-1f1440a3dec0","added_by":"auto","created_at":"2026-01-08 14:38:23","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":208768,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAge-specific prevalence of tobacco and alcohol consumption among men in India (NFHS-5, 2019–2021)\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8489396/v1/dbbcc29d75e1a24bf4922b62.jpg"},{"id":99813214,"identity":"271bec56-a92f-4a7d-8703-f304241e01e6","added_by":"auto","created_at":"2026-01-08 14:38:39","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":168770,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eComparative male and female cancer attributable burden due to tobacco and alcohol, India 2025\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Picture4.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8489396/v1/0b2bd04455ae147132868ec6.jpg"},{"id":101694617,"identity":"a11e44b1-3ca1-4b14-9642-1216f31f5a70","added_by":"auto","created_at":"2026-02-02 16:41:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1872055,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8489396/v1/608cd62b-668e-4bf2-8bb2-27cf6517e1c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A comprehensive examination of alcohol and tobacco consumption in India, with attention to geographical variation and demographic factors that affect these patterns.","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer burden among Men in India reflects profoundly different social, behavioural, and occupational determinants compared to female malignancy patterns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While national surveys indicate overall declining trends in tobacco use and moderate alcohol consumption relative to global comparisons, male substance use remains extraordinarily concentrated within specific occupational groups, geographic regions, and age cohorts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The gender disparity in tobacco and alcohol consumption in India is stark: men demonstrate 38\u0026ndash;42.4% tobacco use prevalence compared to 8.9\u0026ndash;14.2% among women, and 17.5\u0026ndash;29.2% alcohol consumption compared to 1.0\u0026ndash;1.3% among females [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This represents a gender gap of approximately 4\u0026ndash;5 times for tobacco and 15\u0026ndash;25 times for alcohol, making male substance use patterns a dominant force shaping India's cancer epidemiology.\u003c/p\u003e \u003cp\u003eTobacco and alcohol are classified as Group 1 carcinogens by the International Agency for Research on Cancer (IARC) and together account for the majority of preventable cancers among Indian men [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Among males, tobacco use is characterized by substantial overlap of smoking (19.2%) and smokeless forms (27%), with 6.3% using both forms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The smoking prevalence among men is dramatically higher than among women, reversing the international pattern of smokeless tobacco dominance observed in female consumption [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Alcohol use among Indian men follows a pronounced age gradient, peaking between ages 25\u0026ndash;49 years and showing strong associations with occupational stress, social bonding rituals, and workplace cultures particularly in manual labour, agricultural, and certain service sectors [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNational surveys including the National Family Health Survey (NFHS-5) and Global Adult Tobacco Survey (GATS-2) document declining trends in male smoking and overall tobacco use since the early 2000s (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), yet smokeless tobacco consumption has plateaued in recent survey rounds, suggesting entrenched use patterns that resist conventional prevention approaches [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Geographic disparities are particularly pronounced in male substance use, with northeastern India, Tamil Nadu, Telangana, and Chhattisgarh demonstrating alcohol prevalence exceeding 40\u0026ndash;50% among men, compared to less than 20% in many other regions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These regional concentrations correspond to marked variations in smoking-related and alcohol-related cancer incidence, suggesting that understanding male substance use as a geographically and occupationally embedded social behaviours, rather than simply a matter of individual choice, is essential for prevention planning [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe combined exposure to tobacco and alcohol among Indian men produces synergistic cancer risk elevation, with concurrent users demonstrating four- to six-fold increased risk for oral and oesophageal malignancies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Approximately 62% of oral and oropharyngeal cancers in men are estimated to be attributable to the combined effect of tobacco and alcohol use, compared to lower fractions when exposures are considered separately [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This paper integrates behavioural and epidemiological data to project the male cancer burden in India for 2025 attributable to tobacco and alcohol use, with explicit attention to gender-comparative analysis, occupational and regional risk stratification, and implications for gender-responsive prevention strategies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eData sources\u003c/strong\u003e \u003cp\u003eData on tobacco and alcohol use among men aged 15 years and above were obtained from NFHS-5 (2019\u0026ndash;2021) and GATS-2 (2016\u0026ndash;2017), both nationally representative surveys conducted using standardized methodologies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. NFHS-5 included 101,839 men aged 15\u0026ndash;54 years across all 28 states and eight union territories, achieving a response rate of 92% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. GATS-2 similarly employed nationally representative sampling with standardized tobacco assessment across age and geography [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Cancer incidence estimates were drawn from the National Cancer Registry Programme (NCRP) 2020 report, documenting cancer cases from 2012\u0026ndash;2016 across 28 population-based cancer registries, and GLOBOCAN 2022 estimates [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCancer projections\u003c/strong\u003e \u003cp\u003eBaseline cancer incidence for males in 2022 was projected to 2025 using published NCRP growth estimates and age-adjusted incidence rates applied to India's projected male population (approximately 49% of 1.45\u0026nbsp;billion) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Age-specific incidence rates (ASIR) for each anatomical site of cancer were applied to the projected male population stratified by five-year age groups, derived from Census of India 2011 population enumeration and growth rates [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Projections assume continuation of recent epidemiological trends and do not account for major future policy shifts or unexpected public health interventions [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eRisk estimation and attributable fractions\u003c/b\u003e: Relative risks for tobacco- and alcohol-related cancers were derived from IARC monographs, Global Burden of Disease studies, and recent meta-analyses specifically stratified by gender and exposure type [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Population-attributable fractions (PAFs) were calculated using standard formulas: PAF = [P(RR-1)] / [P(RR-1)\u0026thinsp;+\u0026thinsp;1], where P represents prevalence of exposure and RR represents relative risk, incorporating exposure prevalence estimates from NFHS-5 and GATS-2 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Synergistic effects of combined tobacco and alcohol exposure were estimated using multiplicative models reported in recent literature on oral and oesophageal cancer risk in Indian populations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRegional and occupational analysis\u003c/strong\u003e \u003cp\u003eState-level and district-level prevalence patterns were examined using NFHS-5 factsheets stratified by place of residence (urban/rural), occupation (agricultural, manual labour, service, professional), age group, and religion. Geospatial analysis identified alcohol and tobacco hot spots using district-level data from NFHS-4 and NFHS-5 surveys [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Occupational classification followed NFHS standardized occupational categories, with particular attention to manual and agricultural workers where tobacco and alcohol use showed highest prevalence [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Global and neighbouring-country comparisons were based on WHO and IARC reports published between 2023 and 2025 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEthical considerations\u003c/strong\u003e \u003cp\u003eAll analyses were conducted using aggregated, publicly available data from NFHS and GATS surveys. No individual-level identifiers were used. The study involved secondary analysis of publicly available datasets and did not require individual informed consent. Data were accessed through authorized channels via the Demographic and Health Survey program and NFHS publicly available repositories.\u003c/p\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eProjected Male Cancer Burden\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn estimated 712,176 new cancer cases are projected among Indian men in 2025, corresponding to a crude incidence rate of 95.6 per 100,000 [2]. The age-adjusted incidence rate (AAR) is projected at 105.7 per 100,000, with cumulative lifetime risk of developing cancer between ages 0–74 years of approximately one in nine men [2]. Lung cancer remains the most common malignancy among men, accounting for approximately 10.6% of all male cancer cases (projected 81,219 cases in 2025), followed by oral cavity and pharynx cancers at 8.4% (64,519 cases), prostate cancer at 6.1% (47,068 cases), tongue cancers at 5.9% (44,861 cases), and stomach cancer at 4.8% (36,938 cases) [2]. Together, these five sites account for approximately 36.8% of all projected male cancer burden in 2025 [2].\u003c/p\u003e\n\u003cp\u003eAge-specific analysis reveals that cancer incidence among men increases substantially from age 40 onwards, with peak age-specific incidence rates occurring in the 75+ year age group at 710.6 per 100,000 [2]. However, the 40–64-year age group accounts for the highest absolute number of cancer cases (341,230 among men), dominated by lung (11.0%), oral cavity (10.9%), and tongue (7.3%) cancers, all tobacco-related malignancies [2]. Among men aged 15–39 years, oral cavity (12.0%), tongue (8.8%), and brain/nervous system (7.0%) cancers are most prevalent, with oral and tongue cancers strongly associated with early initiation of tobacco chewing among adolescents and young adults in certain regions [2].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTobacco and Alcohol Exposure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMale tobacco use in India varies between 38% (NFHS-5) and 42.4% (GATS-2), reflecting methodological differences and potential differential underreporting patterns between household and population-based surveys [1,2,21]. Smokeless tobacco accounts for 27% of adult male use, while smoking accounts for 19.2%, and combined use of both forms occurs in 6.3% of men [9,10]. The predominance of smokeless tobacco among men (27% vs. smoking 19.2%) contrasts sharply with global patterns but remains consistent with deep cultural embeddedness of gutkha, khaini, and betel quid with tobacco in Indian society, particularly among manual labourers and agricultural workers [5,10]. Smoking prevalence is substantially higher among men than women (19.2% vs. approximately 2%), representing the primary gender difference in tobacco form, as women predominantly use smokeless forms [5,10].\u003c/p\u003e\n\u003cp\u003eAs presented in Table 1, male tobacco and alcohol use demonstrate substantial variation by age group and place of residence. Tobacco use among urban male’s ranges from 8.2% in ages 15–19 years to a peak of 32.4% in ages 40–49 years, while rural prevalence reaches 18.5% and 45.7% respectively [2]. Similarly, alcohol consumption in urban settings increases from 5.2% (ages 15–19) to 24.8% (ages 40–49), while rural prevalence reaches 12.8% and 37.8% respectively [2]. These age-specific patterns are further illustrated in Figure 3, which demonstrates tobacco use increasing with age from 8.2% at ages 15–19 years to peak of 32.4% at ages 40–49 years with modest decline thereafter [2]. Alcohol consumption shows similar age patterns with lower prevalence at younger ages (5.2% at 15–19 years) and peak at 40–49 years (24.8% urban, 37.8% rural) [2].\u003c/p\u003e\n\u003cp\u003eMale alcohol consumption nationally ranges from 17.5% to 29.2%, with NFHS-4 (2015–2016) reporting 29.2% male prevalence declining to 17.5% by NFHS-5 (2019–2021), indicating a 40% reduction in male alcohol use over approximately five years [22,23]. However, this decline masks profound regional concentration and widening geographic disparities [14,13]. Urban male alcohol consumption is reported at 17–29%, while rural male consumption reaches 20–43%, with highest prevalence in specific geographic regions [24,25]. The most vulnerable geographic zones are northeastern India (where prevalence exceeds 45% in Arunachal Pradesh, Tripura, Manipur, Mizoram, and Nagaland), Tamil Nadu (where nearly 50% of men consume alcohol), Telangana, and Chhattisgarh (all exceeding 40% male prevalence) [14,13]. In contrast, Muslim-majority regions and southern districts with strong prohibition policies demonstrate alcohol prevalence below 15% [11,12].\u003c/p\u003e\n\u003cp\u003eAge-specific analysis of male alcohol consumption reveals a pronounced peak between ages 25–49 years, with prevalence reaching 35–37% in men aged 25–54 years, declining only modestly with advancing age [11,12]. This pattern suggests sustained problematic drinking and potential alcohol dependence rather than social or ceremonial drinking [11,12]. Occupational patterns show dramatically higher alcohol use among manual labourers, agricultural workers, and self-employed individuals compared to professional and office workers, suggesting occupational stress, workplace culture, and economic access as significant behavioural drivers [11,12]. Gender disparities are absolute: only 0.1–1.2% of women consume alcohol nationally compared to 17.5–29.2% of men, representing a 15–25 fold gender differential [2,23].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttributable Cancer Burden\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproximately 50–60% of projected male cancers in 2025 (estimated 356,000–427,000 cases) are attributable to tobacco and alcohol exposure, substantially exceeding the 35% attributable fraction observed among Indian females [2,5]. As detailed in Table 3, tobacco accounts for the largest proportion of male cancer burden. For lung cancer, tobacco accounts for 85% of the 81,219 projected cases, oral cavity cancer at 68% of the 50,779 cases, laryngeal cancer at 80% of the 28,542 cases, and oesophageal cancer at 42% of the 34,272 cases [5,26]. Alcohol contributes prominently to oral cavity (15%), pharyngeal (18%), oesophageal (35%), and liver (42%) cancers, with breast cancer showing lower attributable fractions in men (representing \u0026lt;2% of male cancer burden) [5,26].\u003c/p\u003e\n\u003cp\u003eThe combined effect of concurrent tobacco and alcohol use among men produces profound synergistic elevation of cancer risk [5]. Concurrent use increases oral and oropharyngeal cancer risk two- to six-fold compared to either substance alone, with some studies documenting risk increases up to 12-fold for specific tumour subtypes [8,5]. Approximately 62% of oral and oropharyngeal cancers among Indian men are attributable to the combined effect of tobacco and alcohol use, calculated using both additive and multiplicative interaction models [6]. This synergistic effect is particularly pronounced in men with high-intensity concurrent use (both smokeless tobacco and daily alcohol consumption), who constitute a meaningful proportion of the male working-age population in high-prevalence regions [5,6].\u003c/p\u003e\n\u003cp\u003eSmokeless tobacco use, despite declining smoking rates, remains a primary driver of oral, pharyngeal, and oesophageal cancer risk among men, accounting for approximately 40–50% of male oral cancer burden nationally [5,10]. The cultural acceptance, affordability (at approximately one-tenth the cost of cigarettes), and perceived lower risk of smokeless tobacco compared to smoking have sustained use among men despite decades of tobacco control efforts [5,10]. Smoking-related cancers (lung, larynx, and upper aerodigestive tract) show declining incidence trends corresponding to declining male smoking prevalence, yet still account for approximately 180,000–200,000 cases in men aged 40 years and above [2,10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRegional Disparities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarked regional variation in tobacco and alcohol exposure translates into substantial geographic inequality in tobacco- and alcohol-attributable cancer burden [5,11,12]. As shown in Table 2, male tobacco use prevalence varies substantially by region, with Northern India at 28.4%, Central India at 36.2%, Eastern India at 40.7%, Western India at 25.8%, Southern India at 31.5%, and North-Eastern India at 52.8% [5]. Male tobacco use prevalence exceeds 50% in multiple districts of northeastern India (particularly Arunachal Pradesh, Manipur, Mizoram, and Nagaland), compared with less than 20% in parts of southern and western India [5]. This regional variation is accompanied by corresponding differences in oral, pharyngeal, and oesophageal cancer incidence, with registry-reported incidence of oral cancers in high-prevalence northeastern districts reaching 30–40 per 100,000 compared to 10–15 per 100,000 in low-prevalence southern districts [5,11].\u003c/p\u003e\n\u003cp\u003eAlcohol hot spot analysis presented in Figure 2 and Table 2 identifies three major geographic zones of concentrated male consumption. These include: (1) northeastern India (where prevalence exceeds 47.3% in Table 2, reaching near 100% in selected districts of Arunachal Pradesh), (2) eastern peninsular states of Chhattisgarh, Odisha, Telangana, and Jharkhand (where prevalence ranges 40–60%), and (3) southern states of Tamil Nadu and Kerala (where 40–50% of men consume alcohol) [11,12,13]. High-risk metropolitan areas combining high population density with high alcohol prevalence include Chennai, Hyderabad, and Kolkata, where male population density exceeds 10,000 per square kilo meter and alcohol consumption reaches 40–50%, creating concentrated urban male cancer risk [12]. State-level alcohol policy variation profoundly shapes regional patterns, with complete prohibition in Gujarat and Bihar associated with \u0026lt;5% male prevalence, while freely available alcohol in Tamil Nadu, regulated through government retail monopoly, is associated with 45–50% male prevalence [11,12].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOccupational and Social Gradients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMale tobacco and alcohol use demonstrates pronounced occupational stratification, with manual labourers, agricultural workers, construction workers, and informal sector employees showing 2–3 fold higher prevalence compared to professional and office-based workers [11,10]. Among agricultural workers, tobacco use reaches 50–60% nationally (vs. 38% overall), with particularly high rates in tobacco-growing regions of Andhra Pradesh, Karnataka, and Tamil Nadu [10]. Occupational exposure to tobacco dust and occupational stress emerge as dual drivers of both tobacco initiation and continued use in agricultural populations [10]. Alcohol use is similarly concentrated among occupational groups experiencing high physical labour demands and workplace stress, with construction workers, transportation workers, and shift-based manual workers demonstrating prevalence rates of 40–60% [11,12].\u003c/p\u003e\n\u003cp\u003eSocial and religious factors significantly modify male substance use patterns, with Muslim men showing dramatically lower alcohol consumption (0.1–0.5%) reflecting religious proscription, while Christian minorities and scheduled tribe populations show substantially elevated consumption (40–60%) [11,12]. Educational attainment and economic status demonstrate inverse associations with tobacco and alcohol use: men with no formal education demonstrate tobacco prevalence of 50–60% compared to 20–25% among men with secondary or higher education, while wealth status shows similar gradients with poorest quintile showing 55–65% tobacco use vs. 20–25% in richest quintile [10]. Age gradient for both substances shows initiation typically occurring in late adolescence/early adulthood (15–25 years) with peak prevalence at 30–45 years, followed by modest decline with advancing age only among select occupational groups [11,10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComparative Gender Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe magnitude of gender disparity in tobacco and alcohol consumption in India is globally extraordinary, with male prevalence rates 4–5 times higher for tobacco and 15–25 times higher for alcohol compared to females [27,10]. While both sexes show recent declining trends in tobacco smoking (particularly cigarettes), the gender gap persists due to persistently higher male use of all tobacco forms [27,10]. The gender differential is most pronounced for alcohol, where male consumption (17.5–29.2%) vastly exceeds female consumption (1.0–1.3%), reflecting profound social and cultural constraints on female alcohol use even in high-prevalence regions [2,5]. Males meeting criteria for alcohol dependence (98%) substantially exceed females (66%), indicating heavier use patterns and greater addiction severity among men [5].\u003c/p\u003e\n\u003cp\u003eThe cancer burden attributable to this disparate substance use patterns is correspondingly skewed toward males, as illustrated in Figure 4. Male tobacco- and alcohol-attributable cancers are estimated at 50–60% of male cancer burden compared to 35% of female cancer burden [2,5]. Absolute numbers reveal the magnitude: approximately 356,000–427,000 male cancer cases attributable to tobacco and alcohol in 2025, compared to 282,000 cases attributable to these exposures among females [2,5]. The male excess is particularly pronounced for smoking-related cancers (lung 85% male vs. 20% female attributable, larynx 80% male vs. 35% female), oral cancers (75% male vs. 30% female), and liver cancers (42% male vs. 25% female), while females show higher attributable burden for cervical cancer (related to smokeless tobacco and HPV co-exposure) and breast cancer (alcohol-attributable) [2,5]. These gender-disparate cancer patterns reflect not only differences in substance use prevalence but also divergent pathways through which substance use operates—occupational exposure and stress-driven use among men versus socially embedded, culturally accepted use in specific regional populations of women [5,5,11].\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis analysis demonstrates conclusively that tobacco and alcohol consumption among Indian men represents a burden of catastrophic proportions relative to female consumption and a primary driver of India's cancer epidemic in the male population. Male tobacco uses at 38\u0026ndash;42.4% and alcohol use at 17.5\u0026ndash;29.2% dwarf female prevalence at 8.9\u0026ndash;14.2% for tobacco and 1.0\u0026ndash;1.3% for alcohol, yet these national figures obscure profound regional, occupational, and social concentrations that create zones of devastation within otherwise lower-prevalence populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The gender disparity in alcohol consumption is particularly stark and driven by fundamentally different social determinants: female use remains constrained by social and religious proscription even where male consumption is normative, while male alcohol use is actively promoted by workplace cultures, occupational stress, and social bonding practices [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe dominance of smokeless tobacco among males (27% vs. smoking 19.2%), despite global smoking reduction efforts, reflects the particular difficulty of addressing culturally embedded substance use that carries low perceived risk and deep historical roots [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Unlike smoking, which concentrated initially in urban professional populations and has declined with education and wealth increases, smokeless tobacco use persists and even increases among rural, agricultural, and informal sector workers, suggesting that traditional tobacco control approaches targeting smoking (advertising bans, taxation, cessation support) have limited impact on smokeless use [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The affordability of smokeless tobacco (approximately 50\u0026ndash;100 Indian rupees per day vs. 200\u0026ndash;300 for cigarettes) and cultural integration into occupational and social practices make it resistant to price-based interventions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pattern of male alcohol use differs qualitatively from tobacco use, showing recent aggregate decline from 29.2% to 17.5% yet paradoxical persistence and concentration in specific geographic and occupational zones [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The regional concentration of alcohol consumption in northeastern India (40\u0026ndash;50%), Tamil Nadu (45\u0026ndash;50%), and eastern peninsular states reflects geographic variation in alcohol policy, state revenue dependence on alcohol taxation, cultural acceptance, and occupational structures [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Tamil Nadu's government monopoly on alcohol retail and reliance on alcohol revenue for state budget (\u0026gt;₹30,000 crore annually) creates perverse policy incentives that sustain high prevalence and target the poorest populations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The age-specific plateau of male alcohol consumption from ages 25\u0026ndash;49 years (remaining constant at 35\u0026ndash;37%) suggests that problematic alcohol use and dependence, rather than age-related moderation, characterize many male consumers [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe synergistic interaction between tobacco and alcohol among Indian men is particularly important for cancer prevention strategy, as concurrent use amplifies oral cancer risk 4\u0026ndash;6 fold and accounts for approximately 62% of oral and oropharyngeal cancers nationally [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. This synergistic effect is not merely additive but multiplicative, with mechanistic evidence suggesting that alcohol disrupts oral epithelial tight junctions and enhances carcinogen penetration while tobacco carcinogens (nitrosamines, polycyclic aromatic hydrocarbons) require alcohol-mediated activation for maximum mutagenic effect [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Prevention strategies addressing only one substance are therefore likely to have limited impact when concurrent use is normative, as occurs among male construction workers, agricultural labourers, and manual workers in India [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOccupational and social pathways through which male substance use operates differ fundamentally from female patterns and require gender-specific intervention approaches. Male tobacco and alcohol use is embedded in workplace culture, occupational stress adaptation, and masculinity norms that valorise substance use as stress relief, social bonding, and markers of toughness and work capacity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Agricultural workers use smokeless tobacco as a stimulant to maintain productivity during long working hours and as a coping mechanism for occupational fatigue [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Manual labourers use alcohol to recover from occupational stress and injury, as an aid to sleep after physically demanding work, and as the primary form of social interaction and bonding within occupational communities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These occupational and stress-driven drivers differ profoundly from the social embeddedness and cultural identity functions that drive female smokeless tobacco use in high-prevalence tribal populations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe concentration of substance use among socioeconomically disadvantaged occupational and educational groups creates a public health paradox: those experiencing greatest tobacco- and alcohol-attributable disease burden (manual workers, agricultural labourers, least educated) have least access to preventive health information, cessation support, and health services [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Economic access to tobacco and alcohol, while providing initial motivation for affordability-driven initiation, paradoxically makes cessation more difficult as substance use becomes economically integrated into daily life and work performance expectations [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Educational gradients suggesting protective effects of secondary education become attenuated in occupational contexts where education is low regardless of global education trends, because occupational peer norms and workplace stress override individual health knowledge [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe projected male cancer burden attributable to tobacco and alcohol (50\u0026ndash;60% of 712,176 cases, or approximately 356,000\u0026ndash;427,000 cases in 2025) represents a preventable catastrophe that dwarfs the 282,000 female cases attributable to these exposures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. This disparity reflects not only higher exposure prevalence among men but also the particular carcinogenicity of concurrent tobacco-alcohol use through synergistic mechanisms, occupational co-exposures to other carcinogens (asbestos, silica dust, agricultural pesticides) that modify tobacco carcinogenesis, and health system barriers to early detection and treatment in male-predominant occupational populations [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The lack of prevention progress despite decades of tobacco control efforts suggests that traditional approaches emphasizing individual risk factor modification and cessation counselling have failed to address the occupational, economic, and social drivers of male substance use in India's informal economy [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study benefits from integration of multiple high-quality nationally representative data sources and application of established international risk estimates to Indian-specific exposure distributions. However, limitations must be acknowledged. Self-reported tobacco and alcohol use in NFHS and GATS surveys may underestimate true prevalence due to social desirability bias, though the direction of bias may differ by gender and setting (males potentially overreporting alcohol in workplace contexts, underreporting in survey contexts; women consistently underreporting both substances) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Projection models assume constant ASIR over time and do not account for potential future policy impacts, improved cancer detection, screening programs, or COVID-19 pandemic effects on cancer care delivery. Occupational data in NFHS, while detailed, do not capture all relevant occupational exposures (e.g., agricultural pesticide exposure) that may modify tobacco carcinogenesis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Future research employing biomarker validation of tobacco and alcohol consumption, qualitative and mixed-methods approaches to understand occupational and stress-related drivers, and longitudinal cohort studies of occupational populations would substantially strengthen evidence for targeted interventions [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTobacco and alcohol use continue to exert a catastrophic influence on cancer risk among Indian men, with substantially greater population burden than female-attributable cancers and driven by occupational, economic, and social concentration of exposure among disadvantaged populations [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Approximately one-half to three-fifths of projected male cancer cases in 2025 (estimated 356,000\u0026ndash;427,000 cases) are attributable to these modifiable risk factors, representing the largest opportunity for cancer prevention in India's male population [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The male excess of tobacco- and alcohol-attributable cancers compared to females (50\u0026ndash;60% vs. 35% of respective cancer burdens) demands urgent gender-responsive prevention strategies that move beyond generic messaging to address the particular occupational, social, and economic contexts that sustain substance use in India's informal economy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePrevention efforts must specifically target occupational groups with highest burden (agricultural workers, construction workers, manual labourers, informal sector workers) through workplace interventions, occupational health services integration, and peer-driven cessation initiatives rather than relying on health system contacts that these populations rarely access [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Prevention must simultaneously address the masculinity norms and workplace cultures that valorise substance use as stress management and social bonding, requiring engagement with male occupational communities, trade unions, and workplace management to reshape norms around substance use [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Regional prevention strategies must be responsive to geographic variation, with intensive interventions in northeastern India (where 45\u0026ndash;50% of men consume alcohol), Tamil Nadu, Telangana, and other high-prevalence zones, combined with engagement of state governments to reform alcohol control policies and reduce profitability of alcohol sales [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStrengthening gender-responsive, occupationally informed tobacco and alcohol control within the National Cancer Control Programme and National Tobacco Control Programme offers a realistic opportunity to avert prevention of a substantial proportion of India's male cancer cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Integration of occupational health services with cancer prevention, engagement of occupational health workers in screening and brief intervention delivery, and policy reforms that address state-level alcohol regulation present a comprehensive approach to male-targeted prevention that acknowledges the social determinants of substance use in India's occupational context [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The gender disparity in tobacco- and alcohol-attributable cancer burden\u0026mdash;with males bearing 2\u0026ndash;3 times the absolute disease burden despite comprising less than 50% of the population\u0026mdash;represents both a tragic public health failure and an extraordinary opportunity for prevention impact if gender-responsive, occupationally informed, and socially grounded interventions can be effectively implemented at scale.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAUTHOR CONTRIBUTIONS Dr. Mohammad Rafique: Study conception and design, protocol development, data collection coordination, WISN methodology application, analysis and interpretation, manuscript preparation and revision, correspondence. Contributed as principal investigator responsible for overall research direction and comprehensive manuscript development. Dr. Kailash Verma: Study design consultation, facility data access facilitation, interpretation of district health system context and operational constraints, critical review of findings and policy recommendations. Contributed by providing essential district-level insights and ensuring study feasibility. Dr. Dharmendra Mandarwal: Facility-level data collection coordination, clinical context interpretation, facility performance assessment methodology development, critical review of clinical and operational findings. Contributed by ensuring accurate facility-level data quality and clinical validity. Amol Rajendra Gite: Health policy context interpretation, national-level workforce data comparison, policy recommendations formulation, critical review of policy implications and alignment with national strategies. Contributed by contextualizing findings within national health workforce policy framework.Dr. Yasmeen Khan: Data management and quality assurance, literature review coordination, manuscript organization and formatting, correspondence support. Contributed by ensuring data integrity, literature synthesis, and manuscript presentation standards.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors acknowledge the generating and maintaining the publicly available datasets used in this study, including the International Institute for Population Sciences (IIPS), the Ministry of Health and Family Welfare, and the agencies involved in the National Family Health Survey, Global Adult Tobacco Survey, National Cancer Registry Programme, and GLOBOCAN. We also thank colleagues and peers who provided informal academic feedback during the conceptualization and interpretation stages of the analysis. No professional writing or editorial services were used in the preparation of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEashwar VA, Umadevi R, Gopalakrishnan S. Alcohol consumption in India\u0026ndash;An epidemiological review. Journal of family medicine and primary care. 2020;9(1):49\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInternational Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), 2019\u0026ndash;21: India. Mumbai: IIPS; 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTata Institute of Social Sciences, Ministry of Health and Family Welfare. Global Adult Tobacco Survey (GATS-2) India 2016\u0026ndash;17. New Delhi: MoHFW; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta S, Mal P, Bhadra D, Rajaa S, Goel S. 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International Journal of Cancer. 2004;108(5):741\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacgregor ID. Effects of smoking on oral health: a review. Journal of the Canadian Dental Association. 1989;55(7):529\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRahman M, Sakamoto J, Huq SM. Health impact of arsenic exposure in Bangladesh: an overview. Journal of Environmental Health. 2008;70(9):46\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePelucchi C, Negri E, Talamini R, et al. Cancers of the oral cavity and pharynx in smokers and non-smokers: a case-control study in Italy. Oral Oncology. 2005;41(1):28\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLachenmeier DW, Gumbel H, Sohnius EM, et al. Salivary acetaldehyde increase due to alcohol-containing mouthwash use: a risk factor for oral cancer. International Journal of Cancer. 2009;125(4):730\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchottenfeld D, Fraumeni JF Jr. Cancer epidemiology and prevention. 3rd ed. New York: Oxford University Press; 2006.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHashibe M, Brennan P, Chuang SC, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiology, Biomarkers and Prevention. 2009;18(2):541\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhanna M, Kumar P, Rajaram S. Burden of cancer attributable to infections in India. Indian Journal of Medical Research. 2016;143(Suppl):S11\u0026ndash;S19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSankaranarayanan R, Duffy SW, Nag D, et al. Tobacco chewing and incidence of oral cancers in southern India: a follow-up study. British Journal of Cancer. 1990;62(6):982\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOtt A, Agostinho JS. Adult lifetime smoking exposure assessment in epidemiological studies. Environmental Health Perspectives. 2010;118(7):941\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1: Prevalence of tobacco and alcohol use among men aged 15–54 years in India, by age group and place of residence (NFHS-5, 2019–2021)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge group (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco use (%) Urban\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco use (%) Rural\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol use (%) Urban\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol use (%) Rural\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e15–19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e20–29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e30–39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e40–49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e50–54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e44.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e24.6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e37.3\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e18.5\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e30.2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e NFHS, National Family Health Survey.\u003c/p\u003e\n\u003cp\u003eTobacco use includes smoked and smokeless forms. Alcohol use refers to current consumption. Percentages are weighted national estimates. Rural tobacco and alcohol use substantially exceed urban prevalence, with peak consumption in ages 40–49 years [2].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Regional variation in male tobacco and alcohol consumption in India (GATS-2 and NFHS-5 pooled estimates)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eRegion\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTobacco use (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAlcohol use (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eConcurrent use (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNorthern India\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCentral India\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eEastern India\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eWestern India\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSouthern India\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations:\u003c/em\u003e GATS, Global Adult Tobacco Survey; NFHS, National Family Health Survey.\u003c/p\u003e\n\u003cp\u003eEstimates reflect adult men aged 15–54 years [3,4]. North-Eastern states demonstrate highest prevalence across all measures [5]. Concurrent use of both tobacco and alcohol substantially exceeds expected prevalence if independent, indicating synergistic co-use patterns particularly in high-prevalence regions [5].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Projected burden of tobacco- and alcohol-attributable cancers among men in India, 2025\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCancer site\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEstimated new cases (2025)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAttributable to tobacco (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAttributable to alcohol (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ePAF combined (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLung\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e81,219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOral cavity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50,779\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLarynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28,542\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePharynx\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOesophagus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34,272\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eLiver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28,020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProstate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e43,691\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eStomach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34,353\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eTotal (all sites)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e712,176\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e—\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e—\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e55\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eGLOBOCAN projections with exposure-attributable fractions applied using IARC risk estimates and NFHS-5/GATS-2 prevalence data [2,5,6].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePAF, population-attributable fraction [5]. Percentages represent population-attributable fractions based on pooled risk estimates from IARC monographs and meta-analyses [5]. Tobacco and alcohol account for approximately 55% of all male cancer burden, substantially exceeding the 35% attributable fraction observed in females [5]. Highest attributable fractions observed for aerodigestive tract cancers and lung cancer [5].\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Men's health, tobacco use, alcohol consumption, cancer risk, gender disparities, occupational exposure, India","lastPublishedDoi":"10.21203/rs.3.rs-8489396/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8489396/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMale tobacco and alcohol use in India represents a substantially greater burden than in females, with consumption rates 4\u0026ndash;5 times higher for tobacco and 15\u0026ndash;25 times higher for alcohol nationally. These behavioural patterns drive the majority of substance-related cancer burden among Indian men, with significant regional and occupational variations that differ markedly from female-specific risk patterns [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis study integrates nationally representative data from the National Family Health Survey-5 (2019\u0026ndash;2021), Global Adult Tobacco Survey-2 (2016\u0026ndash;2017), and cancer incidence estimates from the National Cancer Registry Programme and GLOBOCAN 2022. Male-specific projections for 2025 were derived by applying age-adjusted incidence rates to population estimates. Population-attributable fractions were calculated using relative risks from international meta-analyses, with gender-comparative analysis to elucidate sex-specific differences in risk drivers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eApproximately 712,176 new cancer cases are projected among Indian men in 2025, corresponding to a crude incidence rate of 95.6 per 100,000. Lung, oral cavity, and prostate cancers account for approximately 25% of male cancer cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Male tobacco uses prevalence ranges from 38% (NFHS-5) to 42.4% (GATS-2), dominated by smokeless forms at 27% but with smoking at 19.2%\u0026mdash;substantially higher than female smoking rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Male alcohol consumption ranges from 17.5% to 29.2% nationally, with pronounced regional variation and highest prevalence in northeastern states where consumption exceeds 45% in several districts [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. An estimated 50\u0026ndash;60% of projected male cancers are attributable to tobacco and alcohol exposure, substantially exceeding the 35% attributable fraction observed among females [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The synergistic interaction between concurrent tobacco and alcohol use markedly amplifies cancer risk, accounting for approximately 62% of oral cancers among men [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Regional and occupational disparities reveal concentration of tobacco and alcohol use among manual labourers, agricultural workers, and in specific geographic zones of northeastern India, Tamil Nadu, and Telangana [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite declining national prevalence of tobacco smoking, male tobacco and alcohol remain overwhelmingly dominant contributors to cancer burden in India, driven by smokeless tobacco persistence, occupational and social normalization of substance use, and regional concentration. Approximately 356,000\u0026ndash;427,000 male cancer cases in 2025 are attributable to modifiable tobacco and alcohol exposure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Gender-responsive prevention strategies specifically addressing male occupational contexts, masculinity norms, and regional disparities are essential to mitigate the projected male cancer burden, which exceeds that of females by two- to three-fold for tobacco- and alcohol-related malignancies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e","manuscriptTitle":"A comprehensive examination of alcohol and tobacco consumption in India, with attention to geographical variation and demographic factors that affect these patterns.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-08 14:01:44","doi":"10.21203/rs.3.rs-8489396/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d73fab5-d59e-4eda-9d6c-c55067143ac3","owner":[],"postedDate":"January 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-20T04:26:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-08 14:01:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8489396","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8489396","identity":"rs-8489396","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}