Trends in Smoking-Attributable Disease Burden in China, 1990–2021: Age, Sex, and Risk Factors in a Global Context

INTRODUCTION: Smoking remains one of the leading preventable causes of morbidity and mortality worldwide. Understanding long-term trends in smoking-related diseases is essential for evaluating policy effectiveness and guiding prevention efforts. This study assessed the burden of disease attributable to smoking in China from 1990 to 2021, comparing its trends with global and sociodemographic index (SDI) patterns to identify policy priorities. METHODS: Age-, sex-, and SDI-stratified analyses were conducted using mortality and disability-adjusted life years (DALYs) data from the Global Burden of Disease Study 2021. Temporal trends were evaluated with Joinpoint regression and multiple visualization methods. RESULTS: Globally, age-standardized smoking-attributable death rates declined, but China showed a steeper decline (average annual percent change = -2.00 vs. -1.77). However, China's absolute smoking-related deaths rose by 57.5% to 2.30 million in 2021, accounting for 37.3% of the global total. Males bore a disproportionately higher burden, with an age-standardized death rate nearly 10 times that of females. Burden peaked at ages 65-74 for death counts and at ages 90-94 for rates. Unlike the global pattern where cardiovascular diseases dominate, neoplasms were the leading cause in China. Age-standardized DALYs rates for diabetes and kidney diseases showed a rising trend. CONCLUSION: From 1990 to 2021, China experienced faster declines in standardized smoking burden than the global average, yet its absolute burden and global share increased substantially. Sustained, targeted tobacco control-especially among older males and for cancer prevention-is urgently needed.