# Comparative burden and projections of chewing tobacco-attributable lip/oral cavity and esophageal cancers: global and China-specific trends, 2000–2036

## TL;DR

Chewing tobacco is causing rising cancer rates globally and in China, especially for lip/oral cavity cancers, with males and working-age groups most affected.

## Contribution

This study quantifies the growing burden of chewing tobacco-related cancers in China and projects future trends using global and China-specific data.

## Key findings

- Chewing tobacco–attributable lip and oral cavity cancer deaths and DALYs nearly doubled globally and in China from 2000 to 2021.
- China experienced a steeper rise in lip/oral cavity cancer burden among males and a larger decline in esophageal cancer burden among females.
- Projections suggest continued increases in lip/oral cavity cancer burden and further declines in esophageal cancer burden.

## Abstract

Smokeless tobacco (SLT), particularly chewing tobacco, is an underrecognized public health concern. Its long-term burden and trends, especially in China, remain incompletely quantified.

Using Global Burden of Disease (GBD) 2021 data, we estimated chewing tobacco–attributable deaths, disability-adjusted life years (DALYs), and age-standardized mortality and DALY rates for lip and oral cavity cancer and esophageal cancer (2000–2021), globally and in China. Analyses were stratified by year, sex, and age. Decomposition, age–period–cohort (APC), and Bayesian age–period–cohort (BAPC) models assessed drivers and project trends.

From 2000 to 2021, chewing tobacco–attributable lip and oral cavity cancer deaths and DALYs nearly doubled globally and in China, with modest rises in age-standardized rates. Esophageal cancer showed slight absolute increases but declining standardized rates. For both cancers, DALYs peaked earlier than deaths. Compared with global patterns, China experienced a steeper increase in age-standardized lip and oral cavity cancer burden, particularly among males, and a larger decline in esophageal cancer burden, especially among females, leading to increasing male predominance. Globally, changes mainly reflected population growth and aging, whereas population growth predominated in China. Projections indicate continued increases in lip and oral cavity cancer burden and further declines in esophageal cancer burden.

Chewing tobacco–attributable lip and oral cavity cancer burden in China has risen markedly and is projected to increase further, particularly among males and working-age populations, whereas esophageal cancer burden continues to decline. Integrated prevention strategies are needed to sustain progress and reduce the growing burden.