Global trends in the burden of tracheal, bronchus, and lung cancer attributable to household air pollution

Introduction

Household air pollution (HAP) is a leading environmental risk factor for chronic diseases, including tracheal, bronchial, and lung (TBL) cancer, particularly in low- and middle-income countries (LMICs), significantly contributing to global morbidity and mortality. Among the 3.2 million deaths attributed to HAP, 6% are due to lung cancer, with 11% of adult lung cancer deaths linked to exposure to carcinogenic pollutants from traditional fuels (1,2). Despite efforts to transition to cleaner energy sources, over 2.4 billion people worldwide continue to use polluting fuels, exacerbating health disparities, especially in regions with lower socio-economic development (3). The use of solid fuels, such as wood, coal, and agricultural waste, in poorly ventilated indoor environments exposes millions of individuals to high levels of harmful pollutants, including particulate matter (PM), carbon monoxide, and carcinogenic compounds such as benzene and formaldehyde.

However, the global, regional, and national epidemiological burden of TBL cancer due to HAP remains poorly understood. Most previous studies were limited to specific regions or periods and lacked comprehensive predictive models (4,5), which hinders the development of effective policy interventions. Given the rapid demographic and environmental changes expected in the coming decades, particularly in rapidly developing countries, there is an urgent need to provide a comprehensive assessment of the current and future burden of TBL cancer attributable to HAP.

International efforts spearheaded by agencies such as the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) have been implemented to reduce HAP exposure and improve household air quality (6). These initiatives include worldwide programs promoting the adoption of clean energy and advanced cookstove technologies, which are designed to curb the use of solid fuels and mitigate associated health risks. Such interventions are vital for attaining the health-oriented objectives of the 2030 Sustainable Development Goals (SDGs), especially SDG 3 (to ensure healthy lives and promote well-being for all at all ages) and SDG 7 (to ensure access to affordable, reliable, sustainable, and modern energy (7). Achieving progress in these areas is crucial for alleviating the global disease burden related to HAP and enhancing overall quality of life.

This study used data from the Global Burden of Disease (GBD) 2021 to assess the global burden of TBL cancer from HAP between 1990 and 2021. It projects future trends up to 2051 using Bayesian age-period-cohort (BAPC) models. The analysis examines demographic and geographic variations, persistent inequalities in low SDI regions like China, and trends related to gender and aging. The findings underscore the need for targeted interventions to address energy poverty, gender inequalities, and regional disparities, aligning with sustainable development goals. This work builds on recent advancements in pollution-cancer epidemiology and provides a framework to reduce HAP’s health risks amidst evolving environmental and demographic challenges. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1309/rc).

Methods

Data sources

The research leveraged data from the GBD 2021, conducted by the Institute for Health Metrics and Evaluation (IHME) (https://vizhub.healthdata.org/gbd) (4). The GBD 2021 provides comprehensive data on global health issues, including diseases, injuries, and risk factors, covering 204 countries and territories from 1990 to 2021. The study included 371 diseases and injuries, including TBL cancer (ICD-10 codes C33–C34) (8,9). This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The data utilized in the study are publicly accessible and did not require additional ethical approval.

Disability-adjusted life years (DALYs)

Data on deaths and DALYs for TBL cancer from the GBD 2021. DALYs, which combine the years of life lost due to premature death and the years lived with disability, serve as a key metric for assessing disease burden and the impact of healthcare interventions (9-11). This metric is essential for evaluating the impact of TBL cancer and the effectiveness of health interventions, particularly in disease prevention and control.

Socio-demographic index (SDI)

The SDI is a composite indicator of national development, incorporating factors such as educational attainment, per capita income, and fertility rates (12,13). Scaled between 0 and 1, higher SDI values indicate greater socio-economic development. In GBD 2021, countries were grouped into five SDI quintiles, allowing for analysis of the relationship between the burden of TBL cancer attributable to HAP and socio-economic progress (14). Adaptive Loess regression was used to assess the correlation between SDI and age-standardized rates (ASRs) of TBL cancer, including age-standardized mortality rates (ASMRs) and age-standardized disability rates (ASDRs).

Age-period-cohort (APC) model and BAPC model

The APC model was employed to assess the independent effects of age, period, and cohort on the burden of TBL cancer attributable to HAP (14). Based on the Poisson distribution, this model estimates mortality or DALYs rates using the equation: log(λ_ij) = µ + α_i + β_j + γ_k, where λ_ij was the value for TBL cancer attributable to HAP, and µ, α_i, β_j, and γ_k were the mean effect, age, period, and cohort effects, respectively (15). Risk ratios (RRs) were calculated for period and cohort effects relative to a reference. The National Cancer Institute’s APC network tool was used to estimate these parameters. Additionally, the BAPC model, combined with Integrated Nested Laplace Approximations (INLA), was applied to project future trends in ASMR and ASDR for TBL cancer attributable to HAP over the next 30 years (16).

Data analysis

Temporal patterns and trends in TBL cancer attributable to HAP were assessed using annual percentage change and estimated annual percentage change (EAPC) from 1990 to 2021 (5). ASRs per 100,000 people were calculated using the formula (17).

ASR=∑i=1Aaiwi∑i=1Awi×100000[1]

Where a_i represents the age-specific rate for the ith age group, W_i denotes the number of individuals within the corresponding age group, and A indicates the total number of distinct age groups.

The EAPC, derived from a regression model, represents the annual percentage change in ASR and is calculated as 100 × [exp(β) − 1]. An increasing trend was indicated when the EAPC and its 95% uncertainty interval (UI) lower bound were positive, while a decreasing trend was identified when the EAPC and its 95% UI upper bound were negative. If neither condition was met, the ASR was considered stable (18).

Data analysis was conducted using R software (version 4.4.1), with visualizations created using the ggplot2 package. Final figure modifications were completed using Adobe Illustrator.

Results

Global burden of TBL cancer attributable to HAP

From 1990 to 2021, there was a notable decline in the global burden of TBL cancer attributable to HAP. Mortality due to TBL cancer decreased by 39.2%, from 125,844 [95% uncertainty interval (UI): 77,843 to 177,114] to 76,482 (95% UI: 28,604 to 187,340). Concurrently, the ASMR fell by 71.97%, from 3.14 (95% UI: 1.94 to 4.43) to 0.88 (95% UI: 0.33 to 2.16) per 100,000 people (Table 1). Similarly, the number of DALYs decreased by 44.1%, from 3,517,878 (95% UI: 2,180,370 to 4,954,257) to 1,966,426 (95% UI: 758,405 to 4,632,387), with the ASDR declining by 73.37%, from 84.14 (95% UI: 52.12 to 118.39) to 22.41 (95% UI: 8.64 to 52.88) per 100,000 people (Table 2).

The high SDI regions reported the lowest ASMR and ASDR in 2021, with 0.01 (95% UI: 0 to 0.1) and 0.24 (95% UI: 0 to 2.25), respectively. These regions also experienced the most significant reductions in ASMR and ASDR from 1990 to 2021, with decreases of 94.12% and 97.36%, respectively.

In 21 GBD regions, the Oceania region saw a sharp increase in TBL cancer-related deaths and DALYs, with mortality rising by 141.1%, from 141 to 340, and the number of DALYs increasing by 140.3%, from 4,008 to 9,632. Western sub-Saharan Africa experienced a slight increase in both ASMR, from 1.11 to 1.18 per 100,000, and ASDR, from 27.09 to 27.68 per 100,000.

The burden of TBL cancer due to HAP in 204 countries and territories

The ASMR of EAPC from 1990 to 2021 revealed significant regional variations. The Northern Mariana Islands experienced the highest annual increase in ASMR, with an EAPC of 7.1 (95% CI: 5.57 to 8.65), while the Republic of the Niger showed the smallest increase, with an EAPC of 0.28 (95% CI: 0.05 to 0.5). The Republic of Equatorial Guinea saw the largest decrease in ASMR, with an EAPC of −17.38 (95% CI: −19.3 to −15.42) (Figure 1A). For China, the EAPC of ASMR decreased by −4.2 (95% CI: −5.03 to −3.37).

Figure 1 ASMR (A) and ASDR (B) of the burden of TBL cancer due to HAP in 204 countries and territories, 1990–2021. The study is based on GBD 2021, in which Taiwan is treated as a province of China and its data are separately calculated and statistically analyzed. Therefore, there are differences in the raw data for the disease burden between Taiwan and mainland China, which is reflected in the color variations on the map. ASDR, age-standardized disability rate; ASMR, age-standardized mortality rate; EAPC, estimated annual percentage change; HAP, household air pollution; TBL, tracheal, bronchial, and lung.

Similarly, the EAPC for ASDR showed a significant increase in the Northern Mariana Islands (6.64, 95% CI: 5.14 to 8.17), while the People’s Republic of Vanuatu had the smallest increase (0.3, 95% CI: 0.19 to 0.42). The Republic of Equatorial Guinea experienced the largest decrease in ASDR, with an EAPC of −17.47 (95% CI: −19.41 to −15.49) (Figure 1B). In China, the EAPC for ASDR also showed a decreasing trend, with an EAPC of −4.73 (95% CI: −5.56 to −3.9).

The burden of TBL cancer due to HAP by SDI

A significant negative correlation was observed between both ASMR and ASDR and the SDI. Regions with an SDI below 0.4 showed relatively stable ASMR and ASDR, whereas regions with SDI values above 0.4 exhibited more pronounced declines in both indicators. Notably, East Asia, Southeast Asia, and Oceania regions, though showing similar trends, consistently reported higher levels of ASMR and ASDR at comparable SDI levels compared to other regions (Figure 2A). Additionally, the burden of TBL cancer attributable to HAP was notably lower in countries with higher SDI, where both ASMR and ASDR remained low and stable. However, despite China’s SDI approximating 0.7, its ASMR and ASDR for TBL cancer attributable to HAP remained higher than those of other countries with similar SDI levels, suggesting that, despite socio-economic development, China continues to face a disproportionately high burden (Figure 2B).

Figure 2 The burden of TBL cancer due to HAP in the 21 GBD regions and 204 countries and territories by SDI, 1990–2021. (A) ASMR (B) ASDR. ASDR, age-standardized disability rate; ASMR, age-standardized mortality rate; GBD, Global Burden of Disease; HAP, household air pollution; SDI, socio-demographic index; TBL, tracheal, bronchial, and lung.

The burden of TBL cancer due to HAP by age and sex

Globally, the burden of TBL cancer due to HAP varied significantly by sex, with ASMR and ASDR consistently higher in males than in females. In the 85–89 years age group, the ASMR for males was 10.51 per 100,000 (95% UI: 3.10 to 30.97), which was twice the rate in females (5.03 per 100,000; 95% UI: 1.42 to 13.84) (Figure 3A). In the 70–74 years age group, the ASDR was substantially higher in males (166.85 per 100,000; 95% UI: 56.79 to 427.96) than in females (81.44 per 100,000; 95% UI: 28.77 to 205.78) (Figure 3B). The ASMR and ASDR for TBL cancer due to HAP generally increased with age before declining. In males, ASMR peaked in the 85–89 years age group, while in females, it peaked in the 80–84 years age group at 5.12 per 100,000 (95% UI: 1.61 to 13.53). The lowest ASMR and ASDR were observed in the 25–29 years age group, with males showing an ASMR of 0.04 per 100,000 (95% UI: 0.02 to 0.08) and an ASDR of 2.41 per 100,000 (95% UI: 1.12 to 4.82), and females having an ASMR of 0.03 per 100,000 (95% UI: 0.02 to 0.06) and an ASDR of 2.00 per 100,000 (95% UI: 0.99 to 3.67) (Figure 3).

Figure 3 Trends in ASMR (A) and ASDR (B) for TBL cancer due to HAP by age and sex in 2021. ASDR, age-standardized disability rate; ASMR, age-standardized mortality rate; DALYs, disability-adjusted life years; HAP, household air pollution; TBL, tracheal, bronchial, and lung.

APC model

The APC model revealed distinct patterns in age effects on mortality and DALYs rates for TBL cancer due to HAP. Globally, mortality peaked at around 70 years of age, while DALYs rates peaked at approximately 60 years (Figure 4A, Figure S1A). This pattern was consistent across all SDI regions, although with regional variations. In low and middle SDI regions, mortality rates peaked at approximately 90 years, while DALYs rates peaked around 70 years. In high SDI regions, mortality peaked between 40 and 55 years, while DALYs peaked at 50 years. Period effects showed a general decline in RRs globally, except in low SDI regions, where a decrease was observed until 2015, followed by a slight increase thereafter (Figure 4B, Figure S1B). Cohort effects revealed a general decline in TBL cancer mortality and DALYs rates in high SDI regions, while low SDI regions experienced an upward trend for individuals born between 1900 and 1920, followed by a decline for later birth cohorts (Figure 4C, Figure S1C).

Figure 4 Age, period, and birth cohort effects of the APC model on mortality in the TBL cancer due to HAP by SDI. (A) Age effects. (B) Period effects. (C) Birth cohort effects. APC, age-period-cohort; HAP, household air pollution; RR, risk ratio; SDI, socio-demographic index; TBL, tracheal, bronchial, and lung.

Future projections of the BAPC model

The BAPC model projections indicated that, despite significant declines in ASMR and ASDR from 1990 to 2021, both are expected to increase over the next 30 years (Figure 5). A gender disparity is projected, with females experiencing a greater burden of TBL cancer due to HAP than males. By 2051, the projected ASMR and ASDR for males are 3.97 (95% UI: −3.35 to 11.30) and 92.32 (95% UI: −75.67 to 260.31), respectively. For females, the projections are 4.08 (95% UI: −3.76 to 11.92) and 116.66 (95% UI: −112.38 to 345.69), respectively.

Figure 5 Global trends in the burden of TBL cancer due to HAP by sex over the next 30 years as predicted by the BAPC model. (A) ASMR. (B) ASDR. ASDR, age-standardized disability rate; ASMR, age-standardized mortality rate; BAPC, Bayesian age-period-cohort; HAP, household air pollution; TBL, tracheal, bronchial, and lung.

Discussion

Our analysis utilizing the GBD 2021 data demonstrated a notable decrease in the global burden of TBL cancer attributable to HAP between 1990 and 2021. A study by Lu et al. (19) accentuated the escalating cancer burden linked to ambient particulate matter pollution (APMP) and the declining trend in HAP-related cancer burden on a global scale. This research underscored the imperative for targeted interventions to mitigate HAP in low SDI regions, where the burden persists at elevated levels.

Specifically, there was a 39.2% reduction in global deaths and a 44.1% decrease in DALYs cases due to HAP-related TBL cancer. This trend mirrors the heightened global awareness of HAP’s health risks and the efficacy of interventions designed to curb indoor air pollution exposure. Nonetheless, this general decline masks considerable regional disparities. High SDI regions, including North America and Western Europe, witnessed substantial declines in ASMR and ASDR, whereas low SDI regions, especially sub-Saharan Africa and Oceania, experienced rises in mortality and DALYs rates. These increases highlight the persistent challenges faced by these regions in adopting cleaner energy sources, compounded by economic limitations, restricted access to clean cooking technologies, and a dependence on traditional biomass fuels for cooking, which sustain high levels of HAP exposure (20,21).

Importantly, indoor air quality in these regions is shaped not only by fuel combustion but also by additional sources of pollution, such as tobacco smoking, which further compound overall exposure and health risks (22). Moreover, inadequate household ventilation exacerbates the accumulation of multiple pollutants, intensifying harmful emissions and worsening respiratory health outcomes (23). Effective interventions must therefore adopt an integrated approach that simultaneously addresses cleaner fuel adoption, ventilation improvements, and broader household air quality management.

Our findings align with previous studies showing significant reductions in HAP-related TBL cancer in high SDI regions, where clean cooking technologies and policies to reduce PM have been effective (24). In contrast, low SDI regions continued to face considerable barriers in reducing HAP exposure, particularly in sub-Saharan Africa, where solid fuels for cooking remained widely used, contributing to higher levels of indoor air pollution and, consequently, higher cancer burden (25). A particularly striking finding in our study was the situation in China. Despite rapid socio-economic development and a high SDI, the burden of TBL cancer attributable to HAP remained disproportionately high compared to other countries with similar SDI levels (26-28). This aligned with previous research suggesting that China’s reliance on coal for domestic heating and cooking, particularly in rural areas, had continued to contribute significantly to HAP-related cancer risks. This observation highlighted the need for targeted, region-specific interventions to address the persistent challenge of HAP in even the most economically advanced nations.

Our study also highlighted significant sex disparities in the burden of TBL cancer attributable to HAP. Males consistently experienced higher ASMR and ASDR compared to females, with the highest rates occurring in the 85–89 years age group for men and the 80–84 years age group for women. This finding was in line with existing literature, which attributed higher exposure levels among men to a combination of HAP and other risk factors such as smoking and occupational exposures to carcinogens (29). However, our data also revealed a higher EAPC for women, suggesting a more pronounced upward trend in cancer burden among females, particularly in older age groups. This increasing burden among women could be attributed to several factors. First, women were often more likely to be responsible for cooking in households relying on solid fuels, leading to prolonged exposure to HAP (30,31). Second, sociocultural factors in many LMICs, such as gendered roles in household chores, exacerbated women’s exposure to indoor air pollution (32,33). Additionally, the increased life expectancy among women in many regions may have contributed to the higher burden observed in older age groups.

Our findings suggested that the burden of TBL cancer attributable to HAP increased with age, with mortality rates peaking in the 85–89 years age group for men and 80–84 years for women. This pattern reflected the natural progression of cancer risk as individuals aged, compounded by cumulative exposure to risk factors such as HAP. The APC reveals higher mortality peaks in low SDI regions compared to high SDI regions, suggesting that chronic HAP exposure in low SDI regions significantly exacerbates the cancer burden among older adults. This suggested the need for targeted interventions to reduce HAP exposure in low SDI regions, including transitioning to cleaner fuels and improving indoor air quality (34). Enhancing healthcare services and promoting cancer prevention programs are also essential to mitigate the high cancer burden in these vulnerable populations.

Projections from the BAPC model indicated that the global burden of TBL cancer due to HAP was expected to rise over the next 30 years, particularly among women. These projections underscored the need for continued efforts to mitigate HAP exposure, especially in low SDI regions, where the burden remained high and was projected to increase in the coming decades. Given the sex disparities in burden and projections, public health policies needed to focus on reducing HAP exposure in a gender-sensitive manner.

The research outcomes highlight a pressing demand for tailored public health strategies in low SDI regions, which continue to grapple with substantial TBL cancer rates associated with HAP. There is an urgent call for localized approaches to manage these issues, including the promotion of eco-friendly cooking solutions, broader access to cleaner energy sources, and public awareness initiatives to inform about HAP risks (35,36). Although high-income nations have successfully reduced HAP exposure, ongoing vigilance and action are required, particularly for rural and indigenous communities that are often overlooked. The study also signals the importance of gender-responsive policies in light of the rising TBL cancer rates due to HAP, predominantly affecting women. It is vital for ongoing research to explore the interplay among HAP, socio-economic conditions, gender, and age to craft more precise interventions for high-risk groups (37). There is a clear need for both national and global health entities to focus on interventions that tackle the socio-economic and cultural aspects contributing to HAP-linked cancer risks, especially in areas where the disease burden is growing.

This study provided important insights into the global burden of TBL cancer attributable to HAP, but limitations include reliance on model-based estimates, particularly in regions with limited data (38). Future research should focus on improving exposure assessments and integrating more granular data on fuel use and health disparities. Longitudinal studies on the long-term effects of HAP on cancer incidence and mortality are also needed to enhance understanding of disease progression.

In addition to policy-level strategies, household-level actions play a pivotal role in reducing exposure to HAP and its associated cancer burden. A central priority is the gradual transition from solid fuels, such as wood, coal, and agricultural residues, to cleaner energy sources, including liquefied petroleum gas, electricity, and biogas, which markedly lower the emission of carcinogenic pollutants. Equally important is improving ventilation in cooking and living spaces; the installation of chimneys, the use of exhaust fans, or relocating cooking to semi-open areas can substantially diminish the accumulation of harmful indoor pollutants. Reducing secondary sources of exposure, particularly indoor tobacco use and the burning of incense or candles, further lessens overall pollutant load. Regular inspection and maintenance of cooking stoves and ventilation devices are also essential to ensure optimal performance and pollutant removal. Finally, raising awareness of the health risks of HAP, particularly among women and children, who often bear the highest exposure burden, can foster sustainable behavioral changes and community-level adoption of safer practices. Collectively, these practical recommendations, while relatively low-cost and feasible, can complement structural clean-energy policies and accelerate progress toward reducing the global burden of tracheal, bronchial, and lung cancers attributable to HAP.

Conclusions

In conclusion, our study highlights the significant reductions in the global burden of TBL cancer attributable to HAP in high SDI regions, while emphasizing the continued challenges faced by low SDI regions. The projected rise in TBL cancer burden, particularly among women, underscores the urgent need for targeted, gender-sensitive interventions to reduce HAP and its associated health impacts. Addressing these disparities through region-specific policies and interventions is essential to achieving global reductions in the burden of HAP-related TBL cancer.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1309/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1309/prf

Funding: This study was supported by Natural Science Foundation of Guangdong Province, China (grant No. 2024A1515013161).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1309/coif). H.L. serves as an unpaid editorial board member of Journal of Thoracic Disease. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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