Background: Smoking is implicated in ocular surface disease, but prospective case–control data from Indian coastal populations are limited. We evaluated the clinical profile and ocular surface alterations in chronic smokers versus non-smokers. Methods: Prospective, non-interventional case–control study at a tertiary centre in Mangalore (December 2015–August 2017). Male adults (20–65 years) included 80 chronic smokers (≥20 pack-years; beedi or cigarette) and 80 age-matched nonsmokers. Right eye data were analysed. Assessments included DEQ-5 symptom score, tear break-up time (TBUT), Schirmer’s I/II, tear meniscus height (TMH), corneal/conjunctival staining and corneal sensitivity. Results: Smokers showed significantly greater morbidity than controls: abnormal DEQ-5 (85.0% vs 12.5%, p<0.01), TBUT <10 s (52.5% vs 12.5%, p<0.001), Schirmer’s I <10 mm (20.0% vs 6.3%, p=0.01), Schirmer’s II <10 mm (23.8% vs 10.0%, p=0.02) and corneal staining (11.3% vs 0%, p<0.05). Reduced corneal sensitivity occurred in 12.5% of smokers. Abnormalities correlated with higher pack-years and were more frequent in cigarette than beedi smokers for TBUT, Schirmer’s II, TMH and sensitivity. Conclusions: Chronic smoking is associated with increased ocular surface symptoms, reduced tear stability and secretion, epithelial staining and reduced sensitivity, with stronger effects in heavier and cigarette smokers. Screening and cessation counselling are essential to reduce morbidity.