Global burden of esophageal cancer attributable to smoking and alcohol, 1990–2021, with projections to 2040: a population-based analysis of the global burden of disease study 2021

BACKGROUND: Esophageal cancer is a major health burden, with smoking and alcohol as preventable risk factors. Comprehensive assessments of long-term trends, disparities, and future projections remain insufficient. METHODS: Using data from the Global Burden of Disease Study 2021, this observational study evaluated the burden of esophageal cancer attributable to smoking and alcohol-attributable esophageal cancer burden across 204 countries (1990-2021). Metrics included disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized DALY rate (ASDR). Temporal trends were assessed using estimated annual percentage change, decomposition analysis quantified drivers of burden changes, and a Bayesian age-period-cohort model projected burden to 2040. RESULTS: From 1990 to 2021, global deaths and DALYs increased, while ASMR and ASDR declined. Burden was uneven ; males had higher burden than females and peak burden occurring in the 65-79 age group. Geographically, ASRs declined notably in Central Asia and Latin America but rose sharply in West Africa. Middle SDI regions had the highest absolute burden; low-middle SDI regions showed increasing alcohol-attributable ASRs. Population growth and aging were primary drivers of absolute burden increases. Projections indicate continued declines in age-standardized rates, but male burden will remain higher. CONCLUSIONS: Despite declining age-standardized risks, smoking and alcohol remain major drivers of the global burden of esophageal cancer. Population growth and aging will further increase absolute case numbers. Projections to 2040 show continued declines in age-standardized mortality and DALY rates, yet male burden will remain substantially higher. Prevention should prioritize tobacco/alcohol control and targeted strategies for high-burden regions, males, and the elderly.