The disease burden attributable to tobacco use in China and its provinces from 1990-2023: an analysis from the Global Burden of Disease Study 2023

Background: As the world's leading producer and consumer of tobacco, China bears a significant health burden attributable to tobacco. This study aims to provide a precise, updated analysis of the demographic, temporal, and spatial dimensions of the tobacco-attributable disease burden across China. Methods: Using the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 comparative risk assessment framework and its hierarchical taxonomy, we analyzed tobacco use as a Level 2 (behavioral) risk. We estimated the national and provincial burdens of tobacco use in China from 1990 to 2023, quantifying deaths, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life years (DALYs) stratified by sex, age, cause, and the three Level 3 tobacco sub-categories: smoking, secondhand smoke (SHS), and chewing tobacco. Temporal trends were assessed via average annual percentage change (AAPC). Results: In 2023, tobacco use caused 2.38 million [95% uncertainty interval (UI) 2.02-2.83] deaths and 57.27 million (95% UI 48.28-60.82) DALYs, predominantly premature mortality [YLLs 49.45 million (95% UI 42.23-59.25)]. Direct smoking was the primary driver (2.01 million deaths), followed by SHS and chewing tobacco. A profound sex disparity existed in smoking burden, with the male age-standardized mortality rate (ASMR; 167.78/100,000) being 9.5-time higher than that of females, although females bore a greater SHS-attributable burden. From 1990 to 2023, absolute deaths and DALYs increased, but their age-standardized rates (ASRs) significantly declined (AAPC for mortality: -2.34%). The burden is concentrated in older adults, with the disease spectrum shifting from respiratory infections in youth to chronic diseases such as heart disease and lung cancer later in life. Geographically, northern provinces had the highest burden, whereas coastal areas had the lowest burden. Conclusions: Despite declining ASRs, China's tobacco attributable burden is concentrated among males, older adults, and northern provinces. In the context of rapid aging and the long-term harmful effects of tobacco smoking, more stringent and targeted policies should be implemented to address the challenges associated with tobacco use in China.