Background: Population based prevalence of statin use indicates accessibility to health care for cardiovascular diseases. This study assessed current statin use among those with diabetes and/or coronary heart disease in Tamil Nadu, India and trends in use among rural diabetics four years later. Methods: A community based WHO STEPS cross sectional survey was conducted in rural and urban Vellore, Tamil Nadu among 6196 adults aged 30 to 64 years, in 2010-12. A randomly selected sample of 245 diabetics from the rural cohort of diabetics was re-surveyed in 2016 and their medication history updated. Results In 2010-12, 61 with diagnosed coronary heart disease and 348 with diabetes (on diabetic medication or fasting blood sugar â‰¥ 126 mg/dl) were identified. Among those with coronary heart disease, 40% of urban and 33% of rural subjects were on statins. Statin use among urban diabetics aged â‰¥ 40 years with LDL â‰¥ 70 mg/dl was 12%, while it was 7.5% among rural diabetics. Adjusting for age and sex, urban residence and education (â‰¥ 8th grade) were significantly associated with use of statins. The proportion of rural diabetics aged â‰¥ 40 years on statins increased from 7.5% in 2010-12 to 17.0% in 2016. Conclusions Statin use for coronary heart disease was below 50%, but higher than the use for primary prevention among diabetics, which however, is rising slowly. Reasons for low statin use need to be explored to improve access to preventive measures, especially in rural areas, to decrease cardiovascular mortality. Key words: chronic disease management and prevention, cardiovascular disease prevention Key messages: 1. Prevalence of statin use for secondary prevention of heart disease was below 50% in this large population based study in an area with comparatively good healthcare. 2. Statin use for primary prevention (among diabetics with LDL â‰¥ 70 mg/dl) was lower (7.5%-12%). 3. Although there was a rise in statin use for primary prevention among diabetics, the overall low rate indicates a need to evaluate the reasons, in order to reduce cardiovascular mortality among high risk groups.