Global burden of esophageal cancer attributable to tobacco, alcohol, and diet from 1990 to 2021, with projections to 2040

Background: Tobacco, alcohol, and unhealthy diet are modifiable hazards associated with esophageal cancer, but the global burden and future trends attributable to these risks are still uncertain. This study aimed to systematically analyze the dynamic changes, geographical and demographic variations in the global burden of esophageal cancer attributable to these modifiable behavioral risks. Methods: This study utilized the Global Burden of Diseases (GBD) 2021 to estimate the burden of esophageal cancer attributable to smoking, alcohol use, low vegetable intake, and chewing tobacco. Mortality and disability-adjusted life years (DALYs) were calculated by 21 regions, 204 countries and territories, sex, age, and socio-demographic index. The estimation of modifiable behavioral risks was relied on pre-attributed GBD data using comparative risk assessment framework. Joinpoint regression and Bayesian age-period-cohort models were used to analyze temporal trends and future projections. Results: In 2021, the numbers of esophageal cancer death and DALYs attributable to modifiable behavioral risks were 0.29 million and 7.10 million, respectively. From 1990 to 2021, although the age-standardized rates of death and DALYs decreased 1.41% and 1.73% per year, the number of deaths and DALYs increased by 40.84% and 24.12%, respectively. East Asia and Sub-Saharan Africa were the places with the highest burden attributable to modifiable behavioral risks. The male-to-female ratio for deaths and DALYs were 7.19 and 7.74, respectively. Smoking was the biggest modifiable behavioral risk factor for esophageal cancer globally. Until 2040, age-standardized death and DALY rates from esophageal cancer attributable to modifiable behavioral risks are projected to fall in both sexes, with men consistently bearing a heavier burden. Conclusions: Tobacco, alcohol, and low-vegetable diets significantly contribute to the global esophageal cancer burden. More than half of the deaths and DALYs were possibly preventable by changing those behaviors, highlighting the huge potential of lifestyle-based prevention against worse outcomes in patients with esophageal cancer.