Articles

Disparities by province, age, and sex in site-specific cancer

burden attributable to 23 potentially modifiable risk factors
in China: a comparative risk assessment
Wanqing Chen*, Changfa Xia*, Rongshou Zheng, Maigeng Zhou, Chunqing Lin, Hongmei Zeng, Siwei Zhang, Lijun Wang, Zhixun Yang, Kexin Sun,
He Li, Matthew D Brown, Farhad Islami, Freddie Bray, Ahmedin Jemal, Jie He

Summary
Background Understanding disparities in the burden of cancer attributable to different risk factors is crucial to inform Lancet Glob Health 2019;
and improve cancer prevention and control. In this report, we estimate the site-specific population-attributable 7: e257–69

fractions (PAFs) for 23 potentially modifiable risk factors across all provinces in China. See Comment page e175
*Authors contributed equally
Methods In this comparative risk assessment study, we used 2014 cancer mortality data for adults from 978 county- National Cancer Center/
level surveillance points in 31 provinces of mainland China. Risk-factor prevalence estimates were obtained from National Clinical Research
Center for Cancer/Cancer
representative surveys. We used summary relative risks obtained from several recent large-scale pooled analyses or Hospital, Chinese Academy of
high-quality meta-analyses of studies in China. We calculated PAFs using multiple formulae incorporating exposure Medical Sciences and Peking
prevalence and relative risk data stratified by age, sex and province and then combined to create summary PAFs by Union Medical College, Beijing,
sex, cancer site, and risk factors. China (W Chen PhD, C Xia MPH,
R Zheng MPH, H Zeng PhD,
S Zhang BMedSc, Z Yang MPH,
Findings About 1 036 004 cancer deaths (45·2% of all cancer deaths [95% CI 44·0–46·4]) in China in 2014 in adults K Sun PhD, H Li MPH, J He MD);
aged 20 years or older were attributable to 23 evaluated risk factors. The PAF was higher in men (51·2% [95% CI National Center for Chronic
and Noncommunicable Disease
50·0–52·4]) than in women (34·9% [33·6–36·2]), with the leading risk factors being active smoking in men and low
Control and Prevention,
fruit intake in women. By province, the PAF in both sexes combined ranged from 35·2% in Shanghai to 52·9% in Chinese Center for Disease
Heilongjiang, while the PAF varied from 40·9% in Shanghai to 56·4% in Guangdong among men and from 26·9% in Control and Prevention,
Shanghai to 48·0% in Heilongjiang among women. The highest PAF among men was smoking in all 31 provinces, Beijing, China (M Zhou PhD,
L Wang MSc); Cancer
whereas among women it varied among low fruit intake (14 provinces), hepatitis B virus infection (seven provinces),
Surveillance Section,
smoking (six provinces), excess bodyweight (three provinces), and human papilloma virus infection (one province). International Agency for
Research on Cancer, Lyon,
Interpretation The PAFs of cancers attributable to potentially modifiable risk factors vary substantially across France (F Bray PhD);
International Agency for
provinces in China. Regional adoption of effective primary cancer prevention strategies has a vast potential to reduce
Research on Cancer, Lyon,
the burden of cancer and disparities in China. Smoking, poor diet, and infection warrant particular policy attention as France (C Lin PhD); Center for
they contributed a large proportion to the total cancer burden. Global Health, National Cancer
Institute, National Institutes of
Health, Bethesda, MD, USA
Funding National Science and Technology Basic Research Special Foundation of China.
(M D Brown PhD); and
Surveillance and Health
Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND Services Research, American
4.0 license. Cancer Society, Atlanta, GA,
USA (F Islami PhD, A Jemal PhD)

Introduction
Cancer is the leading cause of death in China, where
nearly 2·21 million individuals died from cancer in 2017,
accounting for 24·85% of all deaths in the country.1 This
number is projected to substantially increase in the
decades to come because of the aging and growth of the
population, as well as the adoption of unhealthy lifestyles
associated with rapid economic development, such as
physical inactivity and the consumption of high-calorie
foods.2,3
In high-income countries, a combination of early
diagnosis, screening, and treatment has been effective in
increasing the population-based survival for certain
cancers.4 However, limitations in the availability, access to,
and use of appropriate care for those cancers in China
and many other countries—including subpopulations in
very high-income countries—and the lack of potentially
curative treatments for other cancers, have limited the Correspondence to:
Dr Wanqing Chen, National
effect of clinical interventions on reducing cancer Cancer Center, Chaoyang District,
mortality.5 Progress in cancer control requires an equal Beijing 100021, China
focus on prevention activities, as illustrated by the chenwq@cicams.ac.cn
International Agency for Research on Cancer (IARC) or
Monographs, and the World Cancer Research Fund/ Dr Jie He, National Cancer Center,
American Institute for Cancer Research (WCRF/AICR) Chaoyang District, Beijing
100021, China
Continuous Update Project, in which the greatest effect hejie@cicams.ac.cn
on cancer mortality has been associated with the
modification of known environmental, lifestyle, and
infection-related factors.6,7
As such, primary prevention by reducing exposure to
potentially modifiable lifestyle and environmental risk
factors offers the best option for reducing the large and
increasing burden of cancer in China.8 A crucial step is
to quantify the proportion of cancer deaths that could
potentially be avoided if exposure to risk factors was

www.thelancet.com/lancetgh Vol 7 February 2019 257

 Articles
Research in context
Evidence before this study
The proportional reduction in population disease or mortality
that would occur if exposure to a risk factor were reduced to
an alternative ideal exposure scenario or the
population-attributable fraction (PAF) is a valuable metric to
inform cancer prevention and control. We searched PubMed,
Google Scholar, and China National Knowledge Infrastructure,
without language restrictions, for articles published before
June 4, 2018, using the terms “cancer burden”, “cancer death”,
“risk factor”, and “attributable fraction”. We found two studies
estimating the burden of cancer attributable to lifestyle
factors and infections in 2005, and 2013, in China at a
national level and we found several studies estimating the
burden of cancer attributable to individual risk factor alone,
either for one province or one cancer site. No study to date has
estimated the provincial-level cancer burden attributable to
potentially modifiable risk factors.
Added value of this study
This is the first comprehensive and systematic analysis of
site-specific cancer burden attributable to 23 potentially
modifiable risk factors for all 31 provinces in China. We
estimated that more than 1 million cancer deaths (45·2% of all
cancer deaths) in China could be prevented every year through
modified to minimise individual cancer risks, and a
data-driven framework to inform national and regional
cancer control plans was created to implement
more appropriate cancer prevention measures. Our
two previous studies provided estimates of population-
attributable fractions (PAFs) in China, but they included
only a small number of risk factors or cancer sites,
used data sources that might not have been nation­
ally representative, and employed outdated statistical
methods.9,10 Moreover, although there is substantial
geographic variation in cancer mortality and risk factor
exposures in China,11,12 PAFs at the subnational level are
not available. As such, estimates of attributable cancer
See Online for appendix burden at the province level are especially valuable for
local and national level policy makers in China in
mobilising public-sector resources to improve cancer
prevention and control.
In this study, we estimate the proportion of cancer
deaths attributable to modifiable risk factors in adults in
each of 31 provinces, autonomous regions, and munici­
palities (hereafter, provinces) in mainland China (Taiwan,
Hong Kong, and Macao are not included).
Methods
In this comparative risk assessment, we selected
modifiable risk factors for cancer based on scientific
literature searches from three sources: the IARC Mono­
graph series, the WCRF report,7 and recent umbrella
review of meta-analyses for diabetes.13,14 We further
258
primary cancer-control measures. For all cancers combined
and individual cancer sites, the overall PAFs varied
substantively by sex, age, and province. The leading risk
factors among men was active smoking for all 31 provinces,
whereas among women, it varied from low fruit intake to
smoking, excess bodyweight, and human papilloma virus
infection. The detailed exposition of the disparities in cancer
and risk exposure provide insights into both the magnitude of
cancer attributable to specific determinants and how
modification of risk exposure varied in impact across the
31 Chinese provinces.
Implications of all the available evidence
Evidence from this study should be used to focus primary
prevention efforts on reducing the number and proportions of
cancers attributable to modifiable risk factors in China.
Smoking, poor diet, and infection warrant particular policy
attention because of their large contribution to the total
cancer burden. Regional adoption of effective primary
cancer prevention strategies has a huge potential to mitigate
the growing cancer burden and associated disparities in China.
Local policy makers for each province should focus on the
major potentially modifiable cancer risk factors and tailored
programmes.
classified the selected 23 risk factors into five categories:
behavioural, dietary, metabolic, environ­mental, and of
infectious origin. Table 1 shows the full list of risk factors
and related cancer sites. We assumed 10–15 years lagged
exposure prevalence in estimating the attributable
burden for cancer death.10,15,16
Provincial cancer deaths estimation
We based province-level estimates of cancer deaths
in 2014 on data from cancer registries and disease
surveillance points, which covered 627 and 608 counties
(county is the subdivision of province, and a province
usually consists of numerous counties), respectively,
from all 31 provinces in mainland China (appendix).
After the elimination of duplicates, 978 of the
2859 counties in mainland China were included in the
analysis, covering 40·0% (425·8 million) of the adults
aged 20 years and older nationally and from 24·5% in
Tibet to 100% in Beijing (appendix).
First, we calculated the cancer mortality rate stratified by
sex, cancer site, and age group (20–24 years, 25–29 years,
30–34 years, 35–39 years, 40–44 years, 45–49 years,
50–54 years, 55–59 years, 60–64 years, 65–69 years, and
70 years and older) in each province. Next we extrapolated
the mortality with sex-specific, age-specific, and province-
specific populations in 2014 to estimate the number of
cancer deaths in each province. The total number of
cancer deaths in men and women was calculated by
summing cancer deaths over all age groups and cancer
www.thelancet.com/lancetgh Vol 7 February 2019
 Articles

sites across all 31 provinces to obtain national sex-

specific, site-specific, and age-specific cancer deaths as
well as total cancer deaths.
Exposure prevalence data
Age-specific, sex-specific, and province-specific
prevalence of behavioural factors, dietary factors, and
metabolic factors were obtained from the 2002 Chinese
National Nutrition and Health Survey (2002 NNHS),
which was a stratified multistage cluster sampling study
covering 132 sample sites from all 31 provinces (appendix
p 3).17,18 In this survey, information about behavioural
factors was obtained by well-trained staff using a
structured family interview with the predefined health
behaviour questionnaire; dietary consumptions were
collected from 24 h dietary self-recall recording on
3 consecutive days; weight and height were measured to
calculate body-mass index (BMI); and diabetes was
diagnosed by laboratory testing for a fasting blood
glucose (FDG) of 7·0 mmol/L or higher, or an oral
Cancer site (ICD-10)
Behavioural factors
Smoking Oral cavity, pharynx (C00–C14); oesophagus (C15); stomach (C16);
colorectum (C18–C20, C26·0); liver (C22); pancreas (C25); larynx (C32);
lung, bronchus, trachea (C33–C34); cervix (C53); kidney, renal pelvis,
ureter (C64–C66); urinary bladder (C67); acute myeloid leukaemia
(C92·0, C92·4–C92·5, C94·0, C94·2)
Second-hand smoking Lung, bronchus, trachea (C33–C34; only among never-smokers)
Alcohol drinking Oral cavity, pharynx (C00–C14); oesophagus (C15; squamous cell
carcinoma only); colorectum (C18–C20, C26·0); liver (C22); larynx (C32);
female breast (C50)
Physical inactivity Colon, excluding rectum (C18, C26·0); female breast (C50;
premenopausal cancers inversely associated with vigorous activity only,
postmenopausal cancers inversely associated with all types of physical
activity); corpus uteri (C54–C55)
Dietary factors
Low fruit intake Oral cavity, pharynx, larynx (C00–C14, C32); lung, bronchus, trachea
(C33-C34)
Low vegetable intake Oral cavity, pharynx, larynx (C00–C14, C32)
Low dietary fibre consumption Colorectum (C18–C20, C26·0)
Low dietary calcium consumption Colorectum (C18–C20, C26·0)

glucose tolerance test (OGTT) blood glucose of Red meat Colorectum (C18–C20, C26·0)

11·1 mmol/L or higher. Processed meat Colorectum (C18–C20, C26·0); stomach (C16·1–C16·6; non-cardia only)
The hourly data for particulate matter less than Salt-preserved vegetables Stomach (C16)
2·5 microns in diameter (PM2·5) was collected from the Metabolic factors
Ministry of Environmental Protection, which covered Excess bodyweight Oesophagus (C15; adenocarcinoma only); stomach (C16·0; cardia only);
colorectum (C18–C20, C26·0); liver (C22); gallbladder (C23); pancreas
970 monitoring points from 190 cities. The ultraviolet (C25); female breast (C50; postmenopausal cancers only); corpus uteri
radiation (UVR) data was obtained from the China (C54–C55); ovary (C56); kidney, renal pelvis (C64–C65); thyroid (C73)
Meteorological Administration. Hepatitis B virus (HBV) Diabetes Colorectum (C18–C20, C26·0); gallbladder (C23–C24); pancreas (C25);
and Hepatitis C virus (HCV) prevalence were estimated liver (C22); female breast (C50); corpus uteri (C54–C55)
mainly based on the incidence data from the infectious Environmental factors
diseases routine reporting system; the estimated PM2·5 Lung, bronchus, trachea (C33–C34)
prevalence rates were raked (ie, scaled along multiple Ultraviolet radiation Melanoma of the skin (C43)
dimensions) such that the sum across all provinces Infectious agents
equalled the national representative prevalence for HBV Helicobacter pylori Stomach (C16·1–C16·6; non-cardia only)
and HCV.19,20 We collected HIV prevalence data from Hepatitis B virus Liver (C22)
official national sentinel surveil­
lance sites,21 and used Hepatitis C virus Liver (C22); non-Hodgkin lymphoma (C82–C85, C96·3)
the methods recommended by the UNAIDS to esti­ Human immunodeficiency virus Anus (C21); Kaposi sarcoma (C46); cervix (C53); Hodgkin
mate the discovery rate and adjust HIV prevalence.22 lymphoma (C81); non-Hodgkin lymphoma (C82–C85, C96·3)
The prevalence of human papillomavirus (HPV) was Human papillomavirus Oral cavity (C02–C06); oropharynx, tonsils and base of tongue (C01,
estimated by systemic reviews of population-based C09–C10); anus (C21); cervix (C53); vulva (C51); vagina (C52); penis (C60)
studies related to HPV prevalence in China (appendix). Epstein-Barr virus Nasopharynx (C11), Hodgkin lymphoma (C81)
The prevalence of Helicobacter pylori for 19 provinces was Clonorchis sinensis Cholangiocarcinoma (C22·1)
estimated based on the data available from the Team of Human herpes virus type 8 Kaposi sarcoma (C46)
Collaboration of H pylori research in China,23 and for the ICD-10=International Classification of Diseases 10th revision. PM2·5=particulate matter less than 2·5 microns in diameter.
remaining 12 provinces, prevalence was estimated based Table 1: Potentially modifiable risk factors and related cancer site considered in the analysis
on systematic reviews of representative studies for each
province (appendix). Prevalence of Clonorchis sinensis was
extracted from a recently published study.24 We derived Attributable burden estimation For the data from the China
estimates for Epstein-Barr virus (EBV) prevalence among For our primary analysis, we used summary relative risks National Environmental
Monitoring Centre see
cases of nasopharyngeal carcinoma from a meta-analysis (RRs) obtained from several recent large-scale pooled http://www.cnemc.cn/
stratified by epidemic areas (high, intermediate, and low analyses or high-quality meta-analyses of studies in
For the data from the National
mortality; appendix).25 Except for HPV-related cervical China. When unavailable, we used RRs from pooled or Meteorological Information
cancer and EBV-related nasopharyngeal carcinoma, the meta-analyses of studies conducted in Asia or, tertiarily, Center see http://data.cma.cn/
provincial representative prevalence data for cancer from studies worldwide (appendix). When available, we
related to HPV, EBV, and human herpesvirus-8 (HHV8) used sex-specific relative risks.
were not available (accounting for 0·92% of total Most risk factors act proportionally to increase cancer
attributable cancer deaths). risk; therefore, we first calculated the proportional

www.thelancet.com/lancetgh Vol 7 February 2019 259

 Articles

reduction of cancer that would occur if exposure to the risk for each age group, sex, province, and cause according to
factor was reduced to theoretical minimum risk exposure, the following formula:26
as measured by the PAF. We calculated the burden m m

attributable to risk factors with categorical exposures

∫x=0 RR(x)P1(x)dx–∫x=0 RR(x)P2(x)dx
PAF= m
(behavioural factors, diabetes, H pylori, HBV, HCV, HIV, ∫x=0 RR(x)P1(x)dx
and HPV [ for cervical cancer]) for each province, sex, age,
and cause according to the following formula:26 where is the RR(x) at exposure level x, P1 (x) is the
n population distribution of exposure, P2 (x) is the
Σi=1 Pi(RRi–1) counterfactual distribution of the theoretical minimum
PAF= n
Σi=1 Pi(RRi–1)+1 risk exposure, and m the maximum exposure level.
As an alternative, the cancer burden attributable to
where Pi is the fraction of the population in exposure infectious agents can also be calculated retrospectively
category i, and is the RRi for exposure category i, and n is using the prevalence of cancer cases (Pc):27
the number of exposure categories.
(RR–1)
The burden attributable to continuous exposure PAF=Pc
RR
(dietary factors, excess bodyweight, PM2·5) was calculated

Men and women Men Women

Cancer Attributable Attributable pro­ Rank Cancer Attributable Attributable pro­ Rank Cancer Attributable Attributable pro­ Rank
deaths cancer portion of cancer deaths cancer portion of cancer deaths cancer portion of cancer
deaths deaths, % (95% CI) deaths deaths, % (95% CI) deaths deaths, % (95% CI)
Heilongjiang 70 854 37 516 52·9 (48·1–58·1) 1 42 994 24 152 56·2 (51·6–61·1) 2 27 860 13 365 48·0 (42·8–53·4) 1
Guangdong 136 448 67 863 49·7 (47·0–52·4) 2 91 287 51 456 56·4 (53·7–59·0) 1 45 161 16 407 36·3 (33·4–39·2) 9
Jilin 44 956 22 206 49·4 (44·5–54·5) 3 26 593 14 380 54·1 (49·4–59·0) 4 18 363 7826 42·6 (37·3–48·0) 2
Hubei 100 213 48 735 48·6 (45·4–51·9) 4 64 113 34 915 54·5 (51·3–57·6) 3 36 100 13 820 38·3 (34·8–41·7) 7
Inner 40 956 19 768 48·3 (42·6–54·2) 5 26 431 13 813 52·3 (46·8–57·8) 10 14 525 5955 41·0 (34·8–47·6) 4
Mongolia
Qinghai 7808 3739 47·9 (43·7–52·0) 6 4836 2566 53·1 (48·8–57·4) 8 2972 1173 39·5 (35·3–43·3) 6
Chongqing 61 478 29 105 47·3 (44·1–50·5) 7 40 426 21 785 53·9 (50·8–57·0) 6 21 052 7320 34·8 (31·3–38·0) 15
Guangxi 82 525 38 541 46·7 (43·5–49·9) 8 56 160 29 322 52·2 (49·0–55·4) 11 26 365 9219 35·0 (31·6–38·1) 13
Hainan 13 757 6403 46·5 (40·8–52·2) 9 8532 4599 53·9 (47·7–60·3) 5 5225 1803 34·5 (29·5–39·1) 17
Sichuan 172 081 79 164 46·0 (42·4–49·5) 10 112 816 58 170 51·6 (48·0–55·0) 13 59 265 20 994 35·4 (31·7–39·0) 11
Henan 180 694 82 879 45·9 (43·5–48·1) 11 109 269 58 412 53·5 (51·0–55·9) 7 71 425 24 467 34·3 (32·1–36·3) 19
Tianjin 16 548 7569 45·7 (41·3–50·4) 12 9709 4738 48·8 (44·2–53·6) 22 6839 2831 41·4 (37·1–45·9) 3
Hunan 104 625 47 788 45·7 (42·4–48·9) 13 69 601 35 488 51·0 (47·8–54·1) 16 35 024 12 300 35·1 (31·6–38·5) 12
Shandong 181 180 81 717 45·1 (42·0–48·2) 14 111 777 57 481 51·4 (48·3–54·6) 14 69 403 24 236 34·9 (31·8–37·9) 14
Ningxia 8559 3854 45·0 (39·5–50·4) 15 5199 2479 47·7 (42·3–53·0) 25 3360 1375 40·9 (35·3–46·3) 5
Jiangxi 68 436 30 766 45·0 (40·8–48·9) 16 44 864 23 209 51·7 (47·4–55·9) 12 23 572 7558 32·1 (28·3–35·6) 27
Anhui 124 160 55 727 44·9 (41·0–48·6) 17 79 695 40 637 51·0 (47·2–54·6) 15 44 464 15 091 33·9 (29·8–37·8) 22
Guizhou 53 905 24 189 44·9 (41·5–48·0) 18 33 753 16 922 50·1 (47·1–53·0) 18 20 152 7268 36·1 (32·2–39·7) 10
Liaoning 88 660 39 640 44·7 (41·8–47·7) 19 53 610 26 424 49·3 (46·4–52·2) 20 35 049 13 216 37·7 (34·7–40·9) 8
Fujian 57 063 25 493 44·7 (40·5–48·7) 20 37 380 19 556 52·3 (48·1–56·5) 9 19 684 5938 30·2 (26·2–34·0) 28
Shanxi 56 064 24 987 44·6 (41·7–47·3) 21 34 616 17 605 50·9 (48·1–53·6) 17 21 448 7382 34·4 (31·4–37·2) 18
Shaanxi 57 537 25 243 43·9 (40·8–46·8) 22 35 279 17 653 50·0 (46·8–53·1) 19 22 259 7589 34·1 (31·3–36·7) 20
Gansu 39 952 17 305 43·3 (40·5–46·2) 23 24 833 12 055 48·5 (45·8–51·4) 23 15 118 5250 34·7 (31·9–37·6) 16
Zhejiang 95 544 41 365 43·3 (38·9–47·5) 24 62 566 30 678 49·0 (44·6–53·3) 21 32 978 10 687 32·4 (28·1–36·5) 25
Beijing 26 178 10 810 41·3 (37·3–45·1) 25 15 685 7243 46·2 (42·5–49·7) 28 10 493 3566 34·0 (29·6–38·1) 21
Hebei 120 524 49 492 41·1 (38·1–43·9) 26 74 830 34 579 46·2 (43·3–49·1) 27 45 694 14 913 32·6 (29·6–35·5) 24
Jiangsu 162 894 66 820 41·0 (38·0–44·0) 27 101 098 48 295 47·8 (44·8–50·7) 24 61 796 18 524 30·0 (26·9–32·9) 29
Yunnan 53 276 21 500 40·4 (36·8–43·7) 28 33 131 15 533 46·9 (43·7–50·0) 26 20 145 5968 29·6 (25·6–33·3) 30
Xinjiang 21 775 8341 38·3 (33·0–43·2) 29 13 031 5425 41·6 (36·3–46·5) 30 8744 2916 33·3 (28·0–38·3) 23
Tibet 2322 873 37·6 (31·1–44·0) 30 1269 535 42·2 (35·5–49·1) 29 1053 338 32·1 (25·8–37·9) 26
Shanghai 39 567 13 921 35·2 (31·6–38·6) 31 23 372 9567 40·9 (37·1–44·6) 31 16 194 4355 26·9 (23·5–29·9) 31
China (total) 2 290 538 1 036 004 45·2 (44·0–46·4) ·· 1 448 757 742 082 51·2 (50·0–52·4) ·· 841 781 293 922 34·9 (33·6–36·2) ··

Table 2: Provincial–level cancer deaths attributable to potentially modifiable risk factors in adults 20 years and older, 2014

260 www.thelancet.com/lancetgh Vol 7 February 2019

 Articles

A Men

HL (2)

JL (4)

NM (10)
XJ (30) LN (20)

BJ (28)
GS (23) TJ (22)
HE (27)

NX SX (17)
(25) SD (14)
QH (8)

SN (19) HA (7) JS (24)

XZ (29) AH (15) SH (31)

HB (3)
SC (13)
CQ (6) ZJ (21)

HN (16) JX (12)
GZ (18) FJ (9)

YN (26) TW
GX (11) GD (1)
≥54·0%
HK 52·0–53·9%
MO 50·0–55·9%
48.0–49.9%
HI (5) 46·0–47·9%
<46·0%

B Women

HL (1)

JL (2)

NM (4) Figure 1: Rank and

XJ (23) LN (8) proportion of cancer deaths
attributable to modifiable
BJ (21)
GS (16) risk factors in men (A) and
TJ (3)
HE (24) women (B) aged 20 years
and older for 31 provinces in
NX SX (18)
SD (14) mainland China, 2014
QH (6) (5)
BJ=Beijing. TJ=Tianjin.
HE=Hebei. SX=Shanxi.
SN (20) HA (19) JS (29) NM=Inner Mongolia.
LN=Liaoning. JL=Jilin.
XZ (26) AH (22) SH (31)
HL=Heilongjiang.
HB (7)
SC (11) SH=Shanghai. JS=Jiangsu.
CQ (15) ZJ (25) ZJ=Zhejiang. AH=Anhui.
FJ=Fujian. JX=Jiangxi.
HN (12) JX (27)
SD=Shandong. HA=Henan.
GZ (10) FJ (28) HB=Hubei. HN=Hunan.
GD=Guangdong. GX=Guangxi.
YN (30) TW HI=Hainan. CQ=Chongqing.
GX (13) GD (9) ≥40·0% SC=Sichuan. GZ=Guizhou.
HK 38·0–39·9% YN=Yunnan. XZ=Tibet.
MO 36·0–37·9%
SN=Shaanxi. GS=Gansu.
34.0–35.9%
32·0–33·9% QH=Qinghai. NX=Ningxia.
HI (17) <32·0% XJ=Xinjiang. TW=Taiwan.
HK=Hong Kong. MO=Macao.

www.thelancet.com/lancetgh Vol 7 February 2019 261

 Articles

A Men

ia
on ngol

Gu dong
Sha gjian

hua g
He ong

n
Jian hai
o
Jilin g

An ng

gqi

Yu u

g
Ha xi

Nin ai
Gu n

Ga xi
an

Xin ia
er M
in

gsu

jian
jing
njin

Sha i
Inn i

nan
ang
ang
ilon

nan
nd
ng

gx

nsu
gh
nx

an
hui
ian
jia

gx
ina

bei

ina
bei

izh
nn
on

et
Jian
Zhe
Sha

Sha

Qin
Tib
Bei
Tia

Fuj

Hu
Hu
Lia

Gu

Sic
He
He
Ch

Ch
Kaposi sarcoma 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0
Human herpes virus type 8 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0
HIV 15·2 22·0 14·6 2·5 14·4 9·9 9·9 4·8 2·0 4·7 26·6 10·9 7·2 2·9 18·2 6·7 4·5 13·3 35·4 7·4 13·7 16·6 49·2 2·3 5·9 59·2
Nasopharynx 96·8 95·1 95·7 95·6 95·5 95·3 95·4 95·2 95·8 94·3 95·6 95·5 95·3 97·1 97·3 96·0 95·3 95·0 97·0 98·1 98·0 96·9 95·0 95·3 97·5 96·2 97·2 95·0 96·1 95·8 95·0 95·7
Epstein-Barr virus 89·1 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 90·8 90·8 84·6 84·6 84·6 90·8 93·5 93·5 90·8 84·6 84·6 90·8 84·6 84·6 84·6 84·6 84·6 84·6 84·6
Smoking 33·8 32·8 31·4 33·8 36·3 37·4 33·3 33·3 33·4 29·5 35·5 31·9 33·9 35·9 33·6 32·4 33·5 32·8 34·8 35·6 29·4 28·7 35·3 30·7 39·1 38·3 28·8 30·8 36·4 32·4 28·5 25·9
Low vegetable intake 32·7 28·6 40·6 34·3 32·0 22·0 32·2 27·0 35·8 26·1 31·3 36·8 27·9 27·2 28·0 39·8 33·0 23·5 22·7 32·9 29·7 32·5 23·0 32·5 30·4 39·5 58·0 33·5 41·3 39·9 34·8 44·3
Low fruit intake 24·6 22·7 23·5 25·0 24·8 25·1 23·1 24·8 25·5 21·8 25·1 22·9 25·6 24·3 26·1 24·4 24·6 26·0 25·1 24·2 26·1 24·5 25·5 24·8 25·7 24·0 25·8 24·6 26·3 25·8 24·2 25·7
Alcohol drinking 12·0 15·1 10·9 11·3 9·5 15·7 13·2 13·8 14·9 10·2 13·4 12·4 13·3 9·7 15·7 14·5 8·5 14·2 12·7 8·9 15·7 7·6 13·0 12·8 15·2 13·6 16·4 5·7 8·7 9·4 8·1 8·7
Anus 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0
Human papillomavirus 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0
HIV 0·9 2·9 0·6 0·1 0·4 0·2 0·4 0·3 0·3 1·9 0·3 0·8 0·3 0·4 0·3 0·1 1·1 0·4 0·6 1·0 2·3 0·5 1·6 1·5 0·8 4·3 0·1 0·2 0·2 0·4 0·2 5·2
Oral cavity, pharynx 79·8 79·1 81·2 79·5 76·6 79·8 79·4 79·2 83·0 72·9 80·3 79·4 79·4 77·0 82·0 82·3 77·4 78·7 77·2 79·0 79·9 70·4 77·3 79·7 72·6 81·7 87·2 73·9 81·2 78·7 66·9 62·5
Low vegetable intake 33·5 29·7 40·5 34·9 31·9 21·7 32·3 28·2 36·2 25·8 31·8 36·6 28·9 27·5 29·3 40·6 33·7 24·6 23·6 34·0 29·5 27·6 23·7 33·4 24·0 38·1 58·8 34·2 42·5 38·0 27·5 30·3
Alcohol drinking 33·3 40·0 32·0 31·8 26·4 39·8 36·0 36·3 39·7 29·4 36·0 33·8 36·3 27·1 41·0 38·2 24·6 37·7 34·1 26·8 39·8 20·9 35·4 35·9 30·1 34·8 42·6 18·4 25·5 27·0 19·1 15·3
Smoking 32·7 31·0 32·4 32·7 34·2 35·8 32·4 31·4 32·3 27·5 34·4 30·1 33·0 35·0 33·1 31·3 32·7 32·2 33·6 34·7 28·6 25·0 33·7 29·4 29·2 35·7 26·8 30·0 35·3 30·3 23·5 16·0
Low fruit intake 24·6 22·5 23·3 25·0 24·0 24·1 23·0 24·1 25·5 21·7 25·2 23·1 25·6 23·9 26·1 24·4 24·5 25·9 24·7 24·1 25·5 21·0 25·4 24·7 19·6 22·6 25·7 24·7 26·1 24·0 19·2 17·1
Human papillomavirus 10·2 7·7 10·5 8·2 8·0 13·4 8·5 12·0 12·5 9·5 7·6 8·7 8·3 11·7 12·2 7·1 10·7 10·2 9·6 11·9 11·7 14·1 6·8 10·4 13·7 11·6 0·0 7·8 8·5 9·0 11·7 11·8
Liver 75·7 59·4 57·4 72·9 82·1 83·5 72·5 76·0 71·7 58·6 52·8 66·8 69·4 78·2 71·7 64·7 86·3 79·7 70·1 81·4 76·9 78·4 75·8 73·4 74·1 69·5 58·2 74·6 87·7 91·3 78·8 89·2
Hepatitis B virus 55·6 24·6 26·0 54·7 64·9 62·8 46·8 46·6 44·4 32·3 23·8 46·3 47·2 65·9 56·8 39·9 69·0 63·5 49·2 65·0 57·7 60·4 57·5 55·2 53·9 43·6 33·4 56·7 72·9 79·2 64·6 72·9
Hepatitis C virus 17·4 11·9 6·6 12·0 24·5 27·0 19·4 29·7 19·1 6·6 4·8 6·9 8·8 9·0 8·1 4·4 35·0 14·4 16·0 23·0 24·3 22·0 12·0 11·9 13·0 19·2 1·3 19·9 32·9 35·2 13·3 44·5
Smoking 15·7 14·6 15·0 15·7 17·2 18·0 15·4 15·1 15·5 13·1 17·0 14·8 16·0 17·1 15·7 14·9 15·7 15·2 16·2 16·8 13·3 13·2 16·7 13·9 19·0 18·6 13·1 14·0 17·2 15·8 13·1 11·9
Diabetes 10·9 15·2 18·9 5·8 10·2 12·2 13·9 13·4 11·5 16·9 9·4 10·3 12·5 6·0 1·1 15·2 11·1 10·5 5·6 8·4 2·1 9·3 10·8 10·4 7·0 5·6 9·1 7·9 9·4 14·9 11·0 5·8
Excess bodyweight 10·3 17·4 17·8 11·4 10·3 8·2 13·3 11·4 13·3 12·6 10·3 9·1 8·4 7·3 2·1 15·2 10·0 9·3 5·3 5·3 3·2 11·9 9·8 9·0 6·6 6·2 14·5 9·3 11·0 10·3 15·3 12·4
Alcohol drinking 10·3 12·9 9·5 9·6 7·9 13·5 11·3 11·7 13·0 8·6 11·8 10·6 11·6 8·2 13·6 12·4 7·2 12·2 10·7 7·6 13·5 6·6 11·2 11·0 13·0 11·7 14·4 4·8 7·3 8·7 6·6 7·6
Clonorchis sinensis 0·2 0·0 0·0 0·0 0·0 0·0 0·1 0·4 1·0 0·0 0·0 0·0 0·1 0·0 0·0 0·0 0·0 0·5 0·1 0·8 0·6 0·1 0·0 0·0 0·0 0·0 0·0 0·0 0·0 0·0 0·0 0·0
Larynx 75·5 74·5 76·7 75·8 74·9 75·8 75·2 75·0 78·8 66·1 76·6 75·3 75·5 73·0 76·9 78·9 73·6 74·5 73·1 74·8 76·1 71·8 73·7 75·3 78·6 80·2 71·7 79·6 77·5 69·7 75·2
Low vegetable intake 34·2 29·9 42·0 35·8 34·6 23·9 33·4 30·8 35·9 25·6 32·2 36·7 29·8 29·2 31·5 41·1 35·1 26·6 24·4 34·9 30·7 34·1 24·1 33·8 32·3 40·8 36·3 44·9 43·9 36·4 47·5
Smoking 31·9 30·0 29·9 31·5 34·3 35·8 30·9 30·8 32·9 24·1 34·1 29·5 32·6 35·1 31·5 30·5 32·0 31·8 33·5 34·0 29·2 28·4 33·7 28·8 37·5 37·2 28·7 35·0 29·8 25·2 21·2
Low fruit intake 24·6 22·4 23·1 25·1 24·9 25·0 23·3 24·6 25·5 21·7 25·2 23·2 25·6 24·5 26·2 24·4 24·6 26·1 24·9 24·0 26·1 24·4 25·5 24·7 25·6 23·7 25·0 26·4 25·8 24·6 26·1
Alcohol drinking 24·0 29·8 21·6 22·7 18·3 30·4 26·1 27·0 30·7 20·0 26·7 24·7 26·8 18·3 29·8 28·2 16·6 27·5 25·2 19·0 30·6 16·9 26·6 26·9 28·5 27·0 13·0 18·5 18·3 11·9 14·3
Human papillomavirus 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6
Lung 72·6 71·7 72·6 75·1 75·7 74·4 71·6 72·4 71·8 65·2 75·5 70·0 74·8 71·5 72·1 73·3 75·2 76·0 74·6 72·1 70·8 65·0 74·2 71·1 76·4 73·3 63·6 71·9 74·6 72·1 67·0 66·4
Smoking 55·1 52·5 52·1 54·6 58·7 60·0 52·8 53·9 53·0 46·3 57·8 51·5 55·6 58·8 55·7 53·1 55·6 55·8 56·4 57·8 52·1 49·2 56·9 51·8 62·1 61·4 45·6 52·7 59·0 52·8 47·2 41·9
Low fruit intake 27·1 24·6 25·6 27·7 27·5 27·7 25·7 27·1 27·9 23·9 27·8 25·7 28·2 26·9 28·9 26·9 27·2 28·7 27·2 26·5 28·8 26·9 28·0 27·2 28·2 26·2 28·2 27·4 29·0 28·3 26·9 28·5
PM2·5 14·4 19·2 20·5 22·6 16·9 9·6 15·8 14·6 13·1 12·4 17·9 13·6 20·2 3·9 10·4 20·1 21·5 22·1 18·1 8·0 13·1 2·0 15·5 15·8 11·8 4·9 2·1 17·0 10·9 16·8 11·5 14·0
Second-hand smoking 2·3 2·4 3·4 1·9 2·3 2·0 3·4 3·7 4·1 2·7 2·1 3·2 1·0 1·6 1·0 2·5 2·4 2·1 2·0 2·2 1·4 3·9 1·4 2·4 1·9 1·7 4·5 1·2 2·3 0·8 3·4 5·2
Hodgkin lymphoma 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0
Epstein-Barr virus 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0
HIV 0·5 1·8 0·3 0·1 0·2 0·1 0·2 0·2 0·1 0·8 0·2 0·5 0·2 0·3 0·1 0·1 0·5 0·2 0·3 0·7 1·6 0·2 0·7 0·9 0·2 1·7 0·1 0·1 0·2 1·2
Penile 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0
Human papillomavirus 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0 51·0
Colorectum 45·1 45·8 47·1 43·3 41·5 45·8 45·8 45·9 51·1 43·1 44·0 42·5 45·5 42·7 44·0 47·4 40·3 47·3 44·6 47·1 48·0 48·4 48·0 46·6 48·4 48·0 40·4 39·1 46·5 45·0 45·5 38·4
Low dietary calcium consumption 16·6 14·5 17·2 18·0 17·0 18·8 16·0 16·4 21·0 11·7 14·5 12·8 14·8 16·5 17·6 17·2 16·9 16·8 16·8 16·6 17·7 16·5 17·3 17·3 17·3 17·7 12·3 17·8 21·0 18·2 18·7 12·9
Low dietary fibre consumption 12·7 10·0 12·5 11·7 11·4 9·8 12·6 14·1 15·4 11·5 11·7 11·8 14·1 11·6 12·1 13·1 10·5 15·3 12·3 14·7 14·3 14·9 13·9 14·3 14·6 14·6 10·6 10·8 13·7 14·1 11·4 8·0
Alcohol drinking 7·2 9·4 6·3 6·8 5·6 9·7 7·8 8·4 9·2 6·0 8·3 7·3 8·3 5·5 9·7 8·7 4·8 8·8 7·3 5·4 9·4 4·7 8·2 8·4 9·3 8·5 7·5 3·7 5·2 5·4 3·4 4·2
Excess bodyweight 6·0 10·0 10·3 6·2 5·8 4·4 8·2 6·4 7·7 7·4 5·6 5·2 4·8 4·5 0·7 9·0 5·8 5·2 3·1 3·0 1·3 7·0 6·4 5·3 3·7 3·2 6·8 5·3 6·5 6·4 9·3 6·2
Smoking 5·9 5·4 5·4 5·9 6·8 7·1 5·5 5·7 5·6 4·4 6·6 5·2 6·1 6·8 6·0 5·5 6·0 6·0 6·2 6·5 5·2 4·9 6·4 5·2 7·7 7·5 3·2 5·4 6·9 5·6 4·5 3·7
Diabetes 4·5 6·2 7·1 2·1 3·8 5·3 5·4 5·1 4·0 7·1 3·5 5·1 5·9 1·7 0·4 6·3 4·6 4·6 2·2 3·6 0·5 4·4 4·9 4·5 2·5 2·0 2·7 3·3 3·4 6·4 4·5 2·1
Red meat 4·4 4·8 2·8 1·4 1·4 2·4 3·0 3·9 2·2 5·0 4·5 5·3 3·6 4·3 5·9 3·1 2·1 3·4 5·2 7·2 10·6 8·7 5·2 5·4 6·2 7·3 3·8 1·1 1·3 3·1 4·9 6·7
Physical inactivity 3·0 2·8 4·2 3·1 2·3 3·9 4·2 2·5 4·9 5·9 3·6 3·5 2·7 3·3 1·8 3·1 2·0 3·7 2·2 4·1 2·5 2·0 2·0 1·5 1·0 2·1 5·5 2·6 3·7 2·6 4·8 5·0
Processed meat 1·0 1·4 1·2 0·5 0·2 0·1 0·8 0·5 0·6 1·7 0·6 0·7 1·2 0·4 0·1 0·9 0·6 0·4 2·7 1·7 0·1 3·7 2·2 1·6 1·9 0·6 1·1 0·1 0·0 0·2 0·2 0·0
Stomach 44·6 45·3 39·4 42·6 48·1 45·4 38·6 41·9 44·5 44·0 46·4 46·1 48·7 50·5 45·5 41·8 46·0 45·8 46·1 43·0 41·4 35·1 40·9 40·6 52·8 46·4 47·5 43·2 47·3 44·8 41·6 38·0
Helicobacter pylori 27·6 28·7 21·7 26·0 29·0 25·1 21·2 26·1 28·2 29·2 27·1 26·9 30·6 28·4 28·3 25·2 31·3 29·9 30·2 24·7 29·5 17·4 22·3 24·9 31·3 27·5 34·3 28·3 31·6 30·7 28·0 24·4
Smoking 17·2 15·9 16·0 17·1 19·4 20·2 16·1 16·6 16·3 12·9 18·7 15·3 17·5 19·4 17·5 16·2 17·5 17·5 18·0 18·7 15·5 14·5 18·3 15·3 21·6 21·1 13·2 15·9 19·6 16·8 13·3 11·8
Excess bodyweight 3·7 6·1 6·3 3·8 3·5 2·8 5·0 4·0 4·8 4·5 3·4 3·2 2·9 2·8 0·4 5·5 3·6 3·2 1·9 1·9 0·8 4·3 3·9 3·2 2·3 2·0 5·6 3·3 4·0 3·9 5·7 4·0
Salt-preserved vegetables 3·6 2·2 1·0 2·4 5·8 5·9 1·8 1·6 2·6 3·8 6·0 9·7 7·1 11·6 7·3 1·3 0·9 3·0 2·4 4·0 0·8 1·9 1·9 2·6 9·3 4·0 1·5 2·6 0·2 0·3 0·7 3·0
Processed meat 0·6 0·9 0·8 0·3 0·1 0·0 0·5 0·3 0·4 1·1 0·3 0·4 0·7 0·3 0·1 0·5 0·4 0·2 1·7 1·0 0·1 2·2 1·3 1·0 1·1 0·4 0·9 0·1 0·0 0·1 0·1 0·0
Oesophagus 35·3 39·4 33·6 34·7 34·1 42·0 36·8 37·3 38·5 30·5 38·2 34·3 37·1 34·0 38·9 37·7 30·7 38·2 36·1 33·1 37·3 28·5 37·7 35·7 41·8 40·3 37·5 26·9 33·5 30·9 24·0 24·6
Alcohol drinking 19·2 24·3 17·5 18·4 15·4 24·8 21·1 21·9 23·6 16·8 21·4 19·8 21·4 15·3 24·6 22·6 13·2 22·6 19·9 15·3 24·3 13·4 21·1 21·7 23·5 22·0 25·7 10·4 14·2 14·8 9·0 12·0
Smoking 18·6 17·6 17·3 18·6 20·9 22·0 18·2 18·2 17·9 14·8 20·2 16·9 18·9 21·1 18·9 17·5 18·8 18·9 19·6 20·3 16·8 15·7 19·6 16·6 23·0 22·7 13·9 17·1 21·0 17·5 14·3 13·0
Excess bodyweight 1·8 2·8 2·9 1·8 1·7 1·4 2·3 1·9 2·2 2·1 1·6 1·5 1·4 1·4 0·2 2·6 1·7 1·6 0·9 0·9 0·5 2·0 1·9 1·6 1·1 1·0 2·6 1·6 1·9 1·9 2·7 1·9
Bladder 30·3 28·4 27·4 29·1 34·0 35·2 27·1 29·1 28·0 21·9 32·8 26·6 31·0 34·2 31·1 28·3 31·2 31·9 31·4 33·1 28·5 27·8 32·0 27·8 38·0 36·9 21·9 29·0 34·8 28·7 24·0 19·0
Smoking 30·3 28·4 27·4 29·1 34·0 35·2 27·1 29·1 28·0 21·9 32·8 26·6 31·0 34·2 31·1 28·3 31·2 31·9 31·4 33·1 28·5 27·8 32·0 27·8 38·0 36·9 21·9 29·0 34·8 28·7 24·0 19·0
Melanoma of the skin 29·8 25·7 28·4 0·0 35·9 42·5 19·7 26·2 6·7 48·1 6·0 44·1 13·5 45·3 50·0 15·3 4·9 46·2 11·0 18·2 46·4 0·0 21·7 59·0 39·8 19·2 44·6 0·0 0·0 66·7
Ultraviolet radiation 29·8 25·7 28·4 0·0 35·9 42·5 19·7 26·2 6·7 48·1 6·0 44·1 13·5 45·3 50·0 15·3 4·9 46·2 11·0 18·2 46·4 0·0 21·7 59·0 39·8 19·2 44·6 0·0 0·0 66·7
Kidney 18·9 23·8 25·0 19·2 19·9 18·3 21·5 19·0 20·9 18·8 19·2 16·7 17·6 18·0 11·4 22·6 18·9 18·0 15·0 15·5 11·0 18·8 20·1 16·8 18·3 17·1 21·6 17·2 21·0 19·2 21·8 16·8
Smoking 10·1 9·2 9·6 10·0 11·4 11·9 9·5 9·5 9·5 7·7 11·1 9·0 10·5 11·5 10·2 9·4 10·3 10·2 10·5 11·0 8·9 8·6 10·8 8·8 12·9 12·5 8·1 9·2 11·6 9·8 7·9 6·8
Excess bodyweight 9·8 16·1 17·0 10·3 9·6 7·3 13·3 10·4 12·6 12·0 9·1 8·5 7·9 7·4 1·3 14·6 9·6 8·7 5·1 5·0 2·3 11·2 10·5 8·7 6·1 5·3 14·6 8·8 10·6 10·3 15·1 10·8
Pancreas 15·2 17·2 18·6 12·3 15·4 17·9 16·2 15·8 14·2 17·3 14·7 15·2 17·5 12·5 9·2 17·4 15·3 15·2 12·1 14·4 8·3 14·1 16·3 14·3 14·4 13·4 13·3 12·6 14·9 18·1 13·6 10·2
Smoking 8·1 7·5 7·7 8·1 9·2 9·7 7·7 7·8 7·7 6·3 9·0 7·3 8·4 9·2 8·3 7·6 8·3 8·2 8·5 8·9 7·1 6·8 8·7 7·1 10·4 10·1 6·2 7·4 9·3 7·9 6·2 5·5
Diabetes 7·6 10·3 11·8 3·7 6·7 8·8 9·1 8·6 7·0 11·7 6·2 8·2 9·8 3·1 0·7 10·5 7·7 7·6 3·8 6·0 1·0 7·3 8·3 7·6 4·4 3·5 6·5 5·5 6·0 10·9 7·5 3·9
Excess bodyweight 3·6 6·2 6·5 3·8 3·5 2·7 4·9 3·9 4·8 4·5 3·4 3·2 2·9 2·6 0·5 5·5 3·5 3·2 1·9 1·8 0·8 4·3 3·8 3·2 2·2 1·9 5·5 3·2 4·0 3·9 5·6 4·0
Acute myeloid leukaemia 12·9 11·9 12·4 12·7 14·8 15·2 12·7 12·8 12·9 9·9 13·8 12·1 13·2 14·1 12·2 12·3 13·3 12·5 13·7 13·6 10·9 10·3 13·8 11·8 16·0 15·6 12·1 15·1 15·0 10·4 10·5
Smoking 12·9 11·9 12·4 12·7 14·8 15·2 12·7 12·8 12·9 9·9 13·8 12·1 13·2 14·1 12·2 12·3 13·3 12·5 13·7 13·6 10·9 10·3 13·8 11·8 16·0 15·6 12·1 15·1 15·0 10·4 10·5
Gallbladder 7·9 13·3 13·8 8·0 7·7 6·6 10·8 8·5 10·1 9·7 7·3 7·2 7·7 6·0 1·3 11·9 7·7 6·9 4·1 4·4 1·9 9·1 8·6 7·1 5·1 4·4 11·0 7·1 8·7 8·7 12·5 8·5
Excess bodyweight 7·9 13·3 13·8 8·0 7·7 5·8 10·8 8·5 10·1 9·7 7·3 6·9 6·4 6·0 1·1 11·9 7·7 6·9 4·1 3·9 1·9 9·1 8·6 7·1 5·1 4·4 11·0 7·1 8·7 8·6 12·5 8·5
Diabetes 4·8 6·5 7·4 2·2 4·3 5·5 5·7 5·4 4·0 7·6 3·6 5·5 6·3 1·8 0·5 6·8 5·0 4·9 2·3 3·9 0·6 5·1 5·1 4·9 2·5 2·2 4·7 3·3 3·2 6·7 4·8 2·3
Thyroid 5·7 9·5 9·9 6·2 5·6 4·3 7·6 6·4 7·1 7·0 5·5 5·0 4·6 4·1 0·8 8·5 5·5 5·0 2·9 2·8 1·4 6·6 6·0 4·9 3·5 3·2 8·5 5·0 6·2 5·9 8·3 6·5
Excess bodyweight 5·7 9·5 9·9 6·2 5·6 4·3 7·6 6·4 7·1 7·0 5·5 5·0 4·6 4·1 0·8 8·5 5·5 5·0 2·9 2·8 1·4 6·6 6·0 4·9 3·5 3·2 8·5 5·0 6·2 5·9 8·3 6·5
Non-Hodgkin lymphoma 0·6 0·4 0·2 0·4 1·0 1·1 0·7 1·2 0·7 0·2 0·2 0·2 0·3 0·3 0·3 0·1 1·6 0·5 0·6 0·9 0·9 0·8 0·4 0·4 0·4 0·7 0·7 1·4 1·2 0·4 2·2
HIV 1·5 4·2 0·8 0·2 0·5 0·3 0·7 0·5 0·4 2·7 0·5 1·3 0·5 0·5 0·6 0·2 1·7 0·6 0·9 1·8 5·3 0·7 2·4 2·8 1·9 8·1 0·5 0·3 1·0 0·6 7·3
Hepatitis C virus 0·6 0·4 0·2 0·4 1·0 1·1 0·7 1·2 0·7 0·2 0·2 0·2 0·3 0·3 0·3 0·1 1·6 0·5 0·6 0·9 0·9 0·8 0·4 0·4 0·4 0·7 0·7 1·4 1·2 0·4 2·2

Rank of population-attributable fration

1 5 10 15 20 25 30 32

(Figure 2 continues on next page)

262 www.thelancet.com/lancetgh Vol 7 February 2019

 Articles

B Women

a
on ngoli

Gu dong
Sha gjian

Sic qing
He ong
Jian hai
o
Jilin g

An ng

Yu u

g
Ha xi

Nin ai
Gu n

Ga xi
Tib n

Xin ia
er M
in

gsu

jian
jing
njin

Sha i
Inn i

nan

g
ang
ang
ilon

nan

hua

a
nd
ng

gx

nsu
gh
nx

an
hui
ian
jia

gx
ina

bei

ina
bei

izh
nn
on

et
Jian
Zhe
Sha

Sha

Qin
Bei
Tia

Fuj

Hu
Hu
Lia

Gu
He
He
Ch

Ch
Kaposi sarcoma 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0
Human herpes virus type 8 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0 100·0
HIV 4·7 7·2 2·0 0·4 2·6 1·2 1·2 1·9 3·3 0·5 5·2 11·9 6·7 8·5 6·7 46·1 1·2 1·2 8·2
Cervix 97·4 96·6 98·2 96·8 97·8 98·5 97·9 98·0 96·2 97·3 97·5 97·9 95·9 98·0 97·8 97·2 98·0 98·4 97·6 97·2 98·4 98·4 95·6 97·9 98·9 96·5 96·3 98·0 97·0 97·7 95·9 97·2
Human papillomavirus 97·4 96·6 98·2 96·8 97·8 98·5 97·9 98·0 96·1 97·3 97·5 97·9 95·9 98·0 97·8 97·2 98·0 98·4 97·6 97·2 98·4 98·4 95·6 97·9 98·9 96·5 96·3 98·0 97·0 97·7 95·9 97·2
HIV 0·2 0·9 0·2 0·0 0·1 0·1 0·1 0·1 0·1 0·5 0·1 0·2 0·1 0·1 0·1 0·0 0·3 0·1 0·2 0·3 0·8 0·1 0·4 0·5 0·3 1·2 0·1 0·1 0·0 0·1 0·1 1·1
Smoking 0·2 0·3 0·8 0·2 0·1 0·8 0·4 0·8 1·0 0·1 0·2 0·1 0·4 0·0 0·0 0·2 0·0 0·3 0·2 0·1 0·2 0·1 0·1 0·1 0·2 0·0 0·6 0·1 0·1 0·1 0·3 0·4
Nasopharynx 95·0 92·8 94·6 93·2 92·8 93·3 93·3 93·3 94·7 91·6 93·3 93·5 92·8 95·2 95·8 93·9 92·7 92·3 95·3 97·0 97·1 95·8 92·0 93·1 95·8 93·5 96·3 93·0 93·8 93·1 93·8 94·5
Epstein-Barr virus 88·7 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 84·6 90·8 90·8 84·6 84·6 84·6 90·8 93·5 93·5 90·8 84·6 84·6 90·8 84·6 84·6 84·6 84·6 84·6 84·6 84·6
Low vegetable intake 36·5 33·6 44·3 38·2 36·1 26·9 36·4 30·4 41·7 28·3 36·5 42·5 28·6 29·6 32·5 44·2 36·6 25·3 26·8 35·4 34·4 38·7 28·1 36·8 32·6 42·6 58·0 38·2 43·4 36·8 40·0 46·0
Low fruit intake 24·5 21·9 22·9 25·0 25·0 25·1 22·5 24·5 25·4 21·5 25·1 22·6 25·5 23·9 25·9 24·0 24·5 26·0 25·2 24·3 26·1 24·4 25·2 24·7 25·7 24·7 25·8 24·8 26·2 26·1 24·2 25·6
Smoking 5·5 7·1 18·3 4·5 1·9 19·0 10·5 17·2 19·6 1·9 5·9 2·4 9·6 1·2 0·4 6·1 1·0 7·3 4·8 3·3 5·2 1·9 2·3 3·4 4·6 1·3 12·7 1·8 3·0 3·3 11·1 8·9
Alcohol drinking 1·9 3·3 0·8 0·5 0·3 2·9 1·5 1·2 1·5 0·9 2·6 2·6 3·0 0·9 7·8 1·3 0·5 2·6 2·4 1·4 1·8 0·7 1·5 2·6 5·4 1·4 10·8 0·5 0·5 0·5 1·6 1·4
Anus 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0
Human papillomavirus 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0 88·0
HIV 0·3 0·8 0·1 0·0 0·1 0·1 0·1 0·1 0·1 0·4 0·1 0·2 0·1 0·1 0·1 0·0 0·3 0·1 0·2 0·3 0·7 0·2 0·4 0·4 0·3 1·4 0·1 0·0 0·1 0·1 2·4
Vaginal 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0
Human papillomavirus 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0 78·0
Oral cavity, pharynx 63·8 63·1 70·4 58·6 57·0 49·5 64·4 62·3 69·9 52·4 64·8 65·7 61·6 55·7 66·2 64·5 60·3 59·3 56·3 62·3 59·1 54·6 52·7 62·1 52·1 61·6 80·7 60·8 60·1 43·0 53·1 53·0
Low vegetable intake 38·6 35·5 46·5 38·4 36·5 17·6 38·3 32·4 40·6 28·4 38·4 44·5 28·6 31·4 36·1 44·1 39·3 26·7 27·7 37·5 32·8 34·2 27·0 37·2 23·8 43·1 57·5 40·9 37·9 27·0 27·6 34·3
Low fruit intake 24·6 22·3 22·5 23·6 24·2 14·8 23·0 24·4 24·1 21·6 25·3 23·0 25·2 23·7 25·9 23·0 24·6 24·9 23·1 23·9 23·3 19·9 22·7 23·8 18·1 24·1 25·9 25·1 21·5 19·3 15·8 18·3
Human papillomavirus 10·6 9·8 11·8 7·5 8·7 14·1 9·8 9·0 13·3 9·7 8·0 9·6 8·9 13·0 6·1 7·8 10·7 10·5 10·2 13·1 12·2 11·5 9·6 9·9 12·8 5·5 0·0 7·4 13·8 2·6 10·2 7·2
Alcohol drinking 6·8 12·0 2·9 1·1 0·7 6·0 6·5 3·7 5·4 3·8 10·5 8·1 10·9 1·8 23·7 4·7 1·7 9·1 8·0 4·9 4·4 2·5 5·0 8·2 13·5 4·8 30·5 1·9 1·0 1·5 5·2 1·6
Smoking 6·3 7·9 17·2 4·4 1·9 12·0 11·9 16·6 19·0 2·3 7·3 3·2 11·3 1·0 0·3 6·4 1·1 9·5 5·0 4·1 5·4 2·3 2·3 4·1 4·1 1·7 12·1 2·4 3·3 2·0 9·1 6·3
Liver 63·5 48·1 48·7 60·8 71·5 76·6 62·0 67·4 64·3 41·4 37·3 50·5 54·7 63·6 56·5 49·7 76·8 69·0 55·6 69·8 63·2 67·0 61·6 59·5 60·0 52·3 51·7 63·1 79·7 85·0 70·9 84·9
Hepatitis B virus 46·5 18·5 19·9 45·9 56·8 54·9 38·0 38·0 36·0 24·4 17·8 37·6 37·9 57·2 47·0 31·5 60·0 54·5 40·1 55·9 48·2 50·7 48·1 46·2 44·6 35·0 26·4 48·0 65·6 73·4 56·7 66·5
Hepatitis C virus 15·9 10·8 6·0 10·9 22·8 25·3 18·0 27·9 17·9 6·1 4·6 6·4 8·0 8·0 7·2 3·8 31·9 13·0 14·8 21·1 22·5 20·2 11·2 10·9 11·8 17·9 1·4 18·1 30·6 33·0 12·1 42·6
Excess bodyweight 13·0 21·3 20·1 15·6 13·0 10·5 16·3 14·5 15·5 15·3 13·6 11·4 10·5 6·5 3·7 18·7 13·5 12·3 6·9 7·5 1·7 13·6 13·8 10·7 9·6 5·8 19·4 11·4 12·0 12·9 14·0 14·5
Diabetes 8·8 14·4 13·8 7·6 5·4 11·5 9·8 10·9 12·6 11·6 8·8 7·5 5·7 5·1 3·1 10·8 9·9 9·9 3·7 5·9 0·1 7·8 11·4 8·4 1·8 6·6 1·1 5·1 8·2 9·6 9·1 6·8
Smoking 4·8 6·6 14·4 3·6 1·6 15·6 9·3 13·6 15·8 1·7 5·2 2·4 8·7 0·8 0·2 5·1 0·9 7·3 4·1 3·1 4·5 1·9 1·9 3·2 4·4 1·3 9·3 1·7 3·0 2·0 9·3 7·0
Alcohol drinking 1·6 2·9 0·6 0·3 0·2 2·4 1·5 0·9 1·3 0·8 2·4 2·0 2·6 0·5 6·6 1·1 0·4 2·3 2·1 1·2 1·2 0·7 1·3 2·0 4·9 1·1 9·0 0·4 0·3 0·4 1·3 0·8
Clonorchis sinensis 0·3 0·0 0·0 0·0 0·0 0·0 0·1 0·4 1·2 0·0 0·0 0·0 0·1 0·0 0·0 0·0 0·0 0·4 0·2 1·4 1·0 0·1 0·0 0·0 0·0 0·0 0·0 0·0 0·0 0·0 0·0 0·0
Larynx 60·6 62·1 68·7 61·5 56·6 63·4 63·2 61·4 69·8 49·5 62·6 64·9 59·8 49·0 62·9 65·6 57·2 57·8 54·0 58·6 59·2 58·0 53·1 61·0 62·4 60·8 61·1 61·9 56·0 68·3 69·2
Low vegetable intake 38·8 38·2 47·8 42·5 37·5 29·6 39·5 34·0 44·3 28·7 38·9 47·1 29·4 27·6 36·5 47·2 39·1 28·9 28·1 37·9 35·9 39·7 30·2 39·7 34·2 42·8 43·1 43·9 36·2 43·6 52·0
Low fruit intake 24·6 22·9 22·8 25·4 25·2 25·2 23·5 24·7 25·5 21·7 25·3 23·8 25·6 24·0 26·0 24·2 24·7 26·1 25·3 24·4 26·2 24·8 25·1 24·8 25·9 24·5 25·4 26·2 25·4 24·8 26·0
Smoking 6·4 8·8 17·0 5·2 2·2 21·6 12·7 16·3 20·5 2·6 7·7 3·9 13·2 1·5 0·4 6·9 1·1 10·6 4·7 4·1 6·1 1·7 2·4 5·5 6·0 1·4 2·8 2·9 1·7 16·4 7·9
Human papillomavirus 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6 4·6
Alcohol drinking 4·6 8·5 2·0 0·7 0·6 7·5 4·9 2·5 4·0 2·8 7·2 5·0 7·6 1·5 16·8 3·3 1·2 6·1 5·9 3·6 3·7 1·6 3·7 4·6 14·2 3·6 1·2 0·9 1·2 6·8 0·9
Hodgkin lymphoma 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0
Epstein-Barr virus 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0 56·0
HIV 0·1 0·5 0·1 0·0 0·1 0·0 0·1 0·1 0·0 0·3 0·0 0·1 0·0 0·0 0·1 0·0 0·2 0·1 0·1 0·3 0·8 0·1 0·1 0·2 0·1 0·5 0·1 0·1 0·1 0·1 0·4
Lung 51·1 53·7 62·7 54·8 50·0 61·6 56·5 61·0 63·0 42·5 54·3 47·6 59·0 37·8 41·4 54·1 50·1 59·3 53·1 45·0 49·9 40·3 48·7 49·4 51·7 42·4 50·9 47·0 49·8 48·4 55·6 53·1
Low fruit intake 27·2 24·9 25·2 27·8 27·8 27·7 25·5 27·3 28·0 23·9 27·8 25·7 28·2 26·7 28·6 26·6 27·4 28·8 27·8 27·0 28·8 27·5 27·7 27·4 28·5 27·2 28·5 27·7 28·9 28·6 27·0 28·2
PM2·5 14·4 19·2 20·5 22·6 16·9 9·6 15·8 14·6 13·1 12·4 17·9 13·6 20·2 3·9 10·4 20·1 21·5 22·1 18·1 8·0 13·1 2·0 15·5 15·8 11·8 4·9 2·1 17·0 10·9 16·8 11·5 14·0
Smoking 13·9 17·7 33·8 10·6 4·8 37·3 24·5 32·2 37·3 5·1 15·4 7·5 23·7 2·2 0·7 14·8 2·6 20·5 12·3 9·5 13·3 6·6 5·8 9·6 13·1 4·0 24·8 5·4 9·1 6·2 26·6 18·0
Second-hand smoking 8·8 7·2 5·4 9·5 12·5 6·2 8·1 7·3 5·7 9·0 8·7 11·6 6·1 9·7 7·7 8·0 10·0 7·7 9·5 9·5 6·5 10·0 10·8 8·5 11·8 13·2 6·6 6·6 12·8 7·3 5·9 7·2
Colorectum 41·4 42·3 46·4 40·7 36·1 46·3 42·9 45·7 51·1 38·9 40·7 37·7 40·5 37·6 39·6 42·8 37·5 44·1 40·0 43·0 41·8 45·0 43·0 42·0 41·1 40·7 34·9 36·6 41·4 40·1 45·9 39·9
Low dietary calcium consumption 17·8 15·3 17·6 19·6 18·3 19·6 17·7 17·8 21·3 12·8 16·6 15·1 16·1 17·5 19·5 18·8 18·6 17·5 18·0 17·8 18·5 18·2 18·3 18·3 17·5 17·8 10·4 19·2 21·7 18·8 19·9 16·1
Low dietary fibre consumption 14·2 12·3 14·2 14·0 12·9 12·2 14·2 15·0 16·8 12·8 13·5 13·3 14·3 12·8 13·1 14·8 12·7 16·3 13·6 15·8 15·0 16·7 15·5 15·7 15·0 15·0 9·0 13·4 15·2 13·8 14·3 10·5
Diabetes 5·5 9·2 8·9 4·4 3·0 7·8 5·9 6·6 8·1 7·1 5·4 4·5 3·2 3·1 2·1 6·4 6·2 6·3 2·3 3·7 0·1 5·2 7·3 5·3 0·9 4·2 0·2 3·2 4·9 6·6 5·6 4·3
Excess bodyweight 4·5 7·8 7·5 5·4 4·6 3·6 5·8 5·2 5·4 5·5 4·7 3·9 3·5 2·2 1·1 6·7 4·7 4·4 2·4 2·6 0·5 4·5 4·9 3·8 3·3 1·9 4·2 4·0 4·1 4·7 4·9 5·1
Physical inactivity 4·3 4·0 6·1 5·8 3·6 4·9 5·8 5·5 6·7 7·1 4·6 4·6 3·2 5·8 3·4 4·8 3·7 4·4 2·7 6·0 4·2 5·0 3·1 3·7 1·7 3·3 7·5 3·4 3·9 3·6 6·7 5·2
Red meat 3·3 3·7 2·0 1·3 0·8 2·0 1·9 3·3 2·1 3·9 3·0 3·3 2·9 3·9 3·5 2·3 1·3 3·6 4·9 5·1 8·8 6·6 3·8 2·4 4·5 5·5 2·4 0·7 0·6 2·8 3·3 6·2
Smoking 2·7 3·6 8·3 1·9 0·8 9·4 5·3 7·5 9·3 1·0 3·1 1·4 5·1 0·4 0·1 2·9 0·4 4·3 2·3 1·8 2·5 1·3 1·0 2·0 2·6 0·7 2·8 1·0 1·6 1·2 5·7 3·7
Alcohol drinking 1·2 2·2 0·5 0·2 0·1 1·8 1·2 0·7 1·0 0·6 1·9 1·4 2·0 0·3 4·9 0·9 0·3 1·7 1·6 0·8 0·8 0·6 1·0 1·8 3·9 0·8 3·8 0·3 0·2 0·2 1·2 0·5
Processed meat 0·9 1·5 0·7 0·4 0·4 0·2 0·5 0·5 0·3 1·6 0·8 0·7 1·7 0·3 0·1 0·8 0·2 0·2 2·1 1·3 0·1 1·3 2·3 1·5 1·2 1·3 1·4 0·3 0·0 0·2 0·4 0·5
Melanoma of the skin 34·9 23·6 46·6 17·0 36·3 53·9 11·2 48·0 16·7 41·2 22·5 33·6 25·9 47·5 46·7 24·0 14·4 22·8 23·7 33·2 46·2 95·9 0·0 47·5 37·7 20·7 56·4 89·0 65·2
Ultraviolet radiation 34·9 23·6 46·6 17·0 36·3 53·9 11·2 48·0 16·7 41·2 22·5 33·6 25·9 47·5 46·7 24·0 14·4 22·8 23·7 33·2 46·2 95·9 0·0 47·5 37·7 20·7 56·4 89·0 65·2
Stomach 32·7 36·7 27·6 30·8 35·2 32·2 27·5 30·2 35·1 34·6 32·1 33·1 38·2 37·6 30·6 30·7 33·6 31·1 33·0 30·0 29·6 23·1 28·4 30·0 42·7 32·5 40·9 31·4 33·6 33·9 33·0 31·3
Helicobacter pylori 25·6 27·2 18·3 24·5 27·6 25·0 19·6 22·9 26·7 27·8 23·3 21·9 29·1 26·8 26·7 23·7 29·7 24·1 28·6 23·3 28·0 17·4 22·0 23·5 29·7 26·0 33·0 26·8 30·1 30·0 26·5 24·0
Excess bodyweight 4·6 7·7 7·3 5·5 4·6 3·6 5·8 5·2 5·4 5·5 4·7 4·0 3·6 2·2 1·2 6·7 4·7 4·4 2·5 2·7 0·6 4·7 5·0 3·8 3·4 2·0 7·1 4·0 4·2 4·7 5·0 5·2
Salt-preserved vegetables 3·7 3·7 1·0 2·1 5·7 2·6 2·1 1·3 2·8 3·0 5·6 9·9 6·9 12·4 3·9 1·2 0·6 3·4 1·6 4·9 0·7 1·0 1·7 2·9 14·2 6·0 1·9 1·8 0·2 0·2 1·7 3·2
Smoking 0·9 1·2 3·0 0·7 0·3 3·5 1·9 2·9 3·4 0·3 1·1 0·5 1·9 0·1 0·0 1·0 0·2 1·6 0·8 0·6 0·9 0·4 0·4 1·4 0·9 0·2 1·9 0·3 0·6 0·4 2·2 1·3
Processed meat 0·6 0·9 0·4 0·3 0·3 0·1 0·3 0·3 0·2 0·9 0·5 0·4 1·0 0·2 0·1 0·5 0·1 0·1 1·3 0·8 0·1 0·8 1·4 0·6 0·7 0·8 1·4 0·2 0·0 0·1 0·2 0·3
Corpus uteri 28·0 37·0 36·6 35·0 28·7 29·8 33·7 30·7 38·0 31·5 29·4 27·7 23·3 22·2 15·4 36·6 28·9 28·6 18·2 21·1 8·6 30·2 29·9 25·2 21·0 20·5 35·9 24·0 28·4 25·8 30·0 30·9
Excess bodyweight 20·8 32·8 30·4 25·6 21·3 17·8 26·0 22·3 25·0 23·3 21·5 18·3 17·3 10·8 6·9 29·5 21·7 19·3 11·1 12·3 3·4 21·3 21·0 17·2 15·8 10·7 28·8 18·5 20·4 18·5 22·1 23·3
Diabetes 16·4 26·2 24·3 15·8 12·2 18·4 19·1 19·9 22·4 22·4 16·8 14·8 12·2 10·6 5·2 20·8 17·8 17·8 7·1 11·0 0·4 14·0 20·4 15·2 4·6 11·4 3·0 9·1 13·9 12·8 15·8 12·5
Physical inactivity 8·8 6·2 9·0 12·5 8·8 7·5 10·3 9·3 13·6 10·2 9·3 11·1 7·2 11·1 6·8 10·0 7·3 9·9 7·6 8·2 5·3 10·2 8·8 7·9 6·2 7·0 9·8 6·7 8·4 7·2 9·9 9·9
Vulvar 24·1 19·2 20·3 28·7 21·6 37·5 24·3 24·0 27·2 19·8 19·1 15·0 20·3 15·0 25·0 26·9 19·4 28·6 25·3 24·1 29·6 29·0 24·5 15·0 29·5 26·2 21·1 32·8 29·2 22·7
Human papillomavirus 24·1 19·2 20·3 28·7 21·6 37·5 24·3 24·0 27·2 19·8 19·1 15·0 20·3 15·0 25·0 26·9 19·4 28·6 25·3 24·1 29·6 29·0 24·5 15·0 29·5 26·2 21·1 32·8 29·2 22·7
Breast 23·2 29·7 31·4 29·7 23·8 20·6 28·5 24·4 30·8 28·4 24·7 25·0 19·0 20·1 12·8 29·8 22·6 23·5 15·6 17·3 8·0 25·8 23·3 19·8 16·6 15·2 30·2 19·7 20·7 20·9 23·9 23·6
Excess bodyweight 16·4 25·8 24·3 20·1 16·6 13·6 20·8 17·9 20·2 18·3 17·2 14·3 13·8 8·6 4·8 23·5 17·3 15·0 8·5 9·5 2·3 18·1 16·7 13·4 12·6 7·8 25·4 14·3 15·9 16·2 18·1 18·3
Physical inactivity 11·6 8·9 12·1 15·9 12·0 9·2 13·3 11·5 16·8 13·5 12·2 15·0 9·1 14·3 9·0 13·0 10·1 12·8 9·6 10·6 6·4 13·6 11·6 10·5 8·2 9·0 12·5 9·5 10·9 10·6 13·0 12·7
Diabetes 7·0 12·1 11·7 6·7 5·1 7·8 8·5 8·5 9·6 10·5 7·4 6·3 5·3 4·3 2·0 9·3 7·7 7·5 3·0 4·5 0·2 5·7 8·8 6·2 2·0 4·7 1·7 3·6 5·6 6·9 7·0 5·0
Kidney 13·3 21·6 23·0 14·8 12·3 14·4 17·6 17·5 18·8 14·9 13·9 11·3 12·2 6·0 3·1 18·6 12·4 13·9 7·8 8·1 2·8 12·8 13·5 11·0 10·2 5·5 19·8 10·8 11·6 12·8 16·0 14·9 Figure 2: Provincial-level
Excess bodyweight 11·9 19·9 19·0 13·9 11·9 9·1 14·9 13·7 13·9 14·4 12·3 10·5 9·4 5·8 3·0 17·2 12·2 11·6 6·5 7·1 1·4 12·1 13·0 10·0 8·9 5·1 17·6 10·3 10·7 12·3 12·7 13·1
Smoking 1·6 2·1 4·9 1·2 0·5 5·9 3·2 4·4 5·6 0·6 1·8 0·8 3·1 0·2 0·1 1·7 0·3 2·6 1·4 1·1 1·5 0·8 0·6 1·1 1·5 0·4 2·7 0·5 1·0 0·6 3·8 2·1 population-attributable
Gallbladder 10·9 18·1 17·2 13·1 10·9 10·6 13·8 12·4 12·3 13·1 11·2 9·5 8·6 5·4 3·9 15·6 11·2 10·6 5·9 6·5 1·3 10·9 11·8 9·0 8·1 5·9 19·6 9·6 10·1 11·5 12·1 12·1 fraction of each cancer site
Excess bodyweight 10·9 18·1 17·2 13·1 10·9 8·6 13·8 12·4 12·3 13·1 11·2 9·5 8·6 5·4 3·3 15·6 11·2 10·6 5·9 6·5 1·3 10·9 11·8 9·0 8·1 5·0 19·6 9·6 10·1 11·5 12·1 12·1
Diabetes 5·4 8·9 8·4 4·5 3·1 7·4 5·9 6·5 8·4 6·9 5·3 4·4 3·2 3·1 1·8 6·3 6·3 6·3 2·2 3·8 0·1 4·5 7·1 5·2 1·0 3·9 3·3 3·1 5·3 7·1 5·5 3·7 and related risk factors in
Pancreas 8·8 13·1 19·5 8·5 5·9 20·0 13·8 16·9 20·3 7·1 9·6 6·3 11·4 3·2 2·2 11·2 6·1 11·7 6·2 5·9 4·7 6·9 7·4 7·2 7·4 4·6 15·1 5·5 7·3 7·6 13·6 10·6
men and women aged
Excess bodyweight 4·6 7·9 7·5 5·5 4·5 3·6 5·9 5·2 5·5 5·6 4·7 4·0 3·6 2·2 1·2 6·8 4·7 4·4 2·4 2·7 0·5 4·7 5·0 3·9 3·3 1·9 7·6 4·0 4·1 4·8 5·2 5·1
Smoking 4·4 5·6 13·0 3·2 1·4 14·5 8·4 12·1 14·3 1·5 5·0 2·3 8·1 0·7 0·2 4·7 0·7 7·0 3·8 2·9 4·3 2·0 1·7 3·8 4·2 1·2 8·1 1·6 2·8 2·0 8·9 5·8 20 years and older, 2014
Diabetes 4·1 6·7 6·3 3·4 2·3 5·7 4·4 5·0 6·0 5·3 4·0 3·4 2·4 2·3 1·5 4·9 4·6 4·7 1·7 2·8 0·0 3·8 5·4 2·9 0·7 3·1 0·3 2·4 3·7 5·0 4·3 3·2
The provinces are arranged
Oesophagus 7·1 11·7 9·1 3·9 2·8 13·1 9·3 8·7 10·8 5·0 9·9 6·7 10·7 1·9 14·1 7·1 3·1 9·8 7·3 4·8 4·0 4·4 5·7 7·1 14·3 3·7 22·7 3·3 3·3 3·5 9·8 5·0
Alcohol drinking 3·6 6·8 1·5 0·5 0·3 5·8 3·8 2·0 3·1 2·1 6·1 4·1 6·2 0·7 13·6 2·7 0·9 5·2 4·9 2·6 2·2 1·8 3·0 4·5 11·5 2·5 17·6 1·0 0·5 0·6 4·1 0·8 left-to-right by administrative
Excess bodyweight 1·9 3·1 2·9 2·2 1·9 1·5 2·3 2·2 2·2 2·3 2·0 1·7 1·5 1·0 0·5 2·7 2·0 1·9 1·1 1·2 0·2 1·9 2·1 1·6 1·4 0·8 2·9 1·7 1·7 2·1 2·0 2·1
Smoking 1·7 2·2 4·9 1·3 0·5 6·3 3·5 4·8 5·9 0·6 2·1 1·0 3·4 0·3 0·1 1·9 0·3 2·9 1·5 1·2 1·7 0·8 0·7 1·2 1·8 0·5 3·4 0·7 1·2 0·8 4·0 2·2 area code; the colour of each
Thyroid 6·3 10·6 10·3 7·8 6·4 5·3 8·2 6·8 7·6 7·5 6·6 5·5 5·0 3·0 1·8 9·4 6·6 5·9 3·3 3·6 0·9 6·9 6·6 5·2 4·6 3·0 9·8 5·4 5·7 5·9 6·7 7·2 cell shows the rankings of
Excess bodyweight 6·3 10·6 10·3 7·8 6·4 5·3 8·2 6·8 7·6 7·5 6·6 5·5 5·0 3·0 1·8 9·4 6·6 5·9 3·3 3·6 0·9 6·9 6·6 5·2 4·6 3·0 9·8 5·4 5·7 5·9 6·7 7·2
Ovary 2·9 5·0 4·6 3·8 3·0 2·5 3·8 3·2 3·6 3·3 3·1 2·5 2·4 1·5 0·9 4·4 3·1 2·6 1·5 1·6 0·5 3·1 2·9 2·4 2·1 1·5 4·3 2·6 2·9 2·6 3·0 3·3 population-attributable
Excess bodyweight 2·9 5·0 4·6 3·8 3·0 2·5 3·8 3·2 3·6 3·3 3·1 2·5 2·4 1·5 0·9 4·4 3·1 2·6 1·5 1·6 0·5 3·1 2·9 2·4 2·1 1·5 4·3 2·6 2·9 2·6 3·0 3·3 fractions in each row. The
Bladder 2·9 3·7 7·9 2·0 0·9 10·8 5·7 7·3 9·9 1·1 3·6 1·8 5·8 0·3 0·1 3·1 0·5 5·3 2·6 2·0 2·7 1·5 1·1 2·0 3·0 0·8 5·0 1·1 1·9 1·1 6·1 3·5
Smoking 2·9 3·7 7·9 2·0 0·9 10·8 5·7 7·3 9·9 1·1 3·6 1·8 5·8 0·3 0·1 3·1 0·5 5·3 2·6 2·0 2·7 1·5 1·1 2·0 3·0 0·8 5·0 1·1 1·9 1·1 6·1 3·5 numbers shown in rows
Acute myeloid leukaemia 1·6 2·4 5·8 0·9 0·5 6·3 3·5 4·9 6·0 0·6 1·9 0·8 3·3 0·3 0·1 1·7 0·3 2·3 1·1 1·1 1·6 0·1 0·6 1·1 1·4 0·3 0·6 1·1 3·0 1·9
represent the proportions of
Smoking 1·6 2·4 5·8 0·9 0·5 6·3 3·5 4·9 6·0 0·6 1·9 0·8 3·3 0·3 0·1 1·7 0·3 2·3 1·1 1·1 1·6 0·1 0·6 1·1 1·4 0·3 0·6 1·1 3·0 1·9
Non-Hodgkin lymphoma 0·5 0·3 0·2 0·4 0·8 1·0 0·6 1·1 0·6 0·2 0·1 0·2 0·2 0·2 0·2 0·1 1·3 0·4 0·5 0·8 0·8 0·7 0·3 0·3 0·3 0·6 0·0 0·6 1·2 1·6 0·4 2·1 the corresponding cancer site
Hepatitis C virus 0·5 0·3 0·2 0·4 0·8 1·0 0·6 1·1 0·6 0·2 0·1 0·2 0·2 0·2 0·2 0·1 1·3 0·4 0·5 0·8 0·8 0·7 0·3 0·7 0·3 0·6 0·0 0·6 1·2 1·6 0·4 2·1
attributable to evaluated risk
HIV 0·4 1·1 0·2 0·1 0·2 0·1 0·2 0·1 0·1 0·7 0·1 0·3 0·1 0·2 0·2 0·1 0·5 0·2 0·3 0·5 1·4 0·2 0·7 0·3 0·7 2·3 0·1 0·1 0·1 0·1 0·2 1·7
factors. The cells without a
Rank of population-attributable fraction
1 5 10 15 20 25 30 32 number indicate cancers that
were sparse in that province.

www.thelancet.com/lancetgh Vol 7 February 2019 263

 Articles
With an increase in RR, the PAF becomes approximately
equal to infection prevalence in cancer cases: PAF=Pc.
Except for HPV-related cervical cancer and EBV-related
naso­pharyngeal carcinoma, we applied national PAFs
for calculation of PAFs for HPV and EBV-related cancers
in provinces, because representative prevalence data for
provinces were not available and a substantial geo­
graphical variation was unlikely.27,28 Human herpes virus
type 8 (HHV8) is a causal factor for the development of
Kaposi sarcomas, and, similar to previous studies, we
attributed all Kaposi sarcomas to HHV8 infection.15,28
C sinensis infections have been reported in 27 provinces
in mainland China, while no cases have been identified
in Inner Mongolia, Qinghai, Ningxia, and Tibet.29 Thus,
we estimated the number of attributable deaths taking
the four non-exposed provinces as the reference using
the following formula:30
AD=PiM(RR–1)
Where Pi represents the prevalence of C sinensis in the
province i and is the mortality of the cholangiocarcinoma
among non-exposed.
It is difficult to accurately measure historical individual
UVR exposure; thus, the melanoma of the skin burden
attributable to UVR exposure is usually estimated by
comparing the mortality from melanoma of the skin in
populations having high ambient UVR exposure to that
in populations with low exposure (either in low ambient
locations or in deeply pigmented populations).15,31–33 In
China, there are few deeply pigmented populations, and
yet there are remarkable geographical variations in
ambient UVR, with Chongqing (located in a sub-tropical
climate zone 244 meters high) having a much lower UVR
than other provinces.34,35 Thus, we calculated excess
deaths of skin melanoma for the rest of the 30 provinces
using Chongqing as minimally exposed population.
We assumed that risk factors are independent except
high BMI and diabetes. To calculate the combined PAF
for BMI and diabetes, we adopted the conservative
method introduced by Pearson-Stuttard and colleagues.14
A combined PAF for all risk factors by cancer site was
calculated according to the following formula:36
R carcinoma, and anal and vaginal cancers among women
PAF=1–Π (1–PAFr)
r=1
Where r is each individual risk factor, and R is the total
number of risk factors for the corresponding risk factor
and cancer site. HIV has been shown to increase cancer
risk only in combination with other infectious agents,
therefore, we did not include HIV in the calculation of
the combined PAFs.28
The 95% CIs for the PAFs were estimated using a
bootstrap simulation method with 5000 simulations.
After the PAF calculations, we calculated the number
and corresponding 95% CI for attributable cancer deaths
264
in each age and sex group and for every cancer site in
31 provinces by multiplying the age-specific, sex-specific,
site-specific, and province-specific PAFs by the
corresponding estimated cancer deaths in 2014. The total
number and 95% CI for each cancer site and province
were then calculated by summing across all age groups.
Finally, the overall PAFs and the corresponding 95% CI
for each cancer site by province was calculated by dividing
the number of estimated attributable cancer deaths by
the total number of cancer deaths among adults 20 years
and older in each province.
Role of the funding source
The funder of the study had no role in study design, data
collection, data analysis, data interpretation or writing of
the report. The corresponding author had full access to
all data in the study and had final responsibility for the
decision to submit for publication.
Results
In 2014, 1 036 004 cancer deaths (45·2% of all cancer
deaths [95% CI 44·0–46·4]) in adults aged 20 years or
older in China were attributable to potentially modifiable
risk factors, with 742 082 of these deaths occurring in
1 448 757 men (51·2%, 95% CI 50·0–52·4) and 293 922 in
841 781 women (34·9%, 33·6–36·2; table 2). The PAFs
were highest in Heilongjiang, following by Guangdong,
Jilin, and Hubei, and lowest in Shanghai, Tibet, and
Xinjiang (table 2). Among men, there were four provinces
(Guangdong, Heilongjiang, Hubei, and Jilin) with PAFs
over 54·0%, while in another three provinces (Shanghai,
Xinjiang, and Tibet) the PAF was lower than 43·0%.
Among women, the PAFs ranged from 26·9% in
Shanghai to 48·0% in Heilongjiang, with the top
five provinces being Heilongjiang, Jilin, Tianjin, Inner
Mongolia, and Ningxia, and the five provinces with the
lowest PAFs being Shanghai, Yunnan, Jiangsu, Fujian,
and Jiangxi (figure 1 and table 2).
By cancer site, cancers with the highest PAFs (>70%)
for all risk factors combined were Kaposi sarcoma,
nasopharyngeal carcinoma, and cancers of the anus, oral
cavity and pharynx, liver, larynx, and lung among men
and Kaposi sarcoma, cervical cancer, nasopharyngeal
(figure 2). However, there were substantial variations in
PAFs by cancer site across provinces. For example, the
proportion for liver cancer deaths attributable to
modifiable risk factors was 91·3% among men and
85·0% among women in Qinghai, while it was
52·8% among men and 37·3% among women in Jiangsu.
PAFs for most cancer sites were similar in men and
women, especially for infection dominating cancers, such
as liver cancer and nasopharyngeal carcinoma, whereas
Figure 3: Provincial-level proportion of attributable cancer deaths for each
risk factor in men and women aged 20 years and older, 2014
www.thelancet.com/lancetgh Vol 7 February 2019
 Articles

A Men
China Physical inactivity
Beijing Second-hand smoking
Tianjin Alcohol drinking
Hebei Smoking
Processed meat
Shanxi
Red meat
Inner Mongolia
Salt-preserved vegetables
Liaoning Low dietary fibre consumption
Jilin Low vegetable intake
Heilongjiang Low dietary calcium consumption
Shanghai Low fruit intake
Jiangsu Diabetes
Zhejiang Excess bodyweight
Ultraviolet radiation
Anhui
PM2·5
Fujian Human herpes virus type 8
Jiangxi HIV
Shandong Clonorchis sinensis
Henan Human papillomavirus
Hubei Epstein-Barr virus
Hunan Hepatitis C virus
Guangdong Helicobacter pylori
Hepatitis B virus
Guangxi
Hainan
Chongqing
Sichuan
Guizhou
Yunnan
Tibet
Shaanxi
Gansu
Qinghai
Ningxia
Xinjiang

B Women
China
Beijing
Tianjin
Hebei
Shanxi
Inner Mongolia
Liaoning
Jilin
Heilongjiang
Shanghai
Jiangsu
Zhejiang
Anhui
Fujian
Jiangxi
Shandong
Henan
Hubei
Hunan
Guangdong
Guangxi
Hainan
Chongqing
Sichuan
Guizhou
Yunnan
Tibet
Shaanxi
Gansu
Qinghai
Ningxia
Xinjiang
0 20 40 60 80 100
Proportion of cancer deaths attributable to modifiable risk factors (%)

www.thelancet.com/lancetgh Vol 7 February 2019 265

 Articles
Behavioural factors Metabolic factors Infectious agents Men
Dietary factors Environmental factors Women
35
30
25
Population attributable fraction (%)
20
15
10
5 exposure estimate for all age groups and both sexes
0 using more recent cancer mortality data and an increased
20–24 25–29 30–34 35–39 40–44 45–49 50–54 55–59 60–64 65–69
Age group
Figure 4: Age-specific proportion of cancer deaths attributable to potentially modifiable risk factors in
mainland China for men and women, 2014
PAFs were substantially higher among men for smoking-
related cancers, notably lung and oesophageal cancer.
By individual risk factors, the highest PAFs nationally
were for smoking, HBV infection, low fruit intake,
alcohol drinking, and exposure to PM2·5 among men,
whereas they were low fruit intake, HBV infection,
smoking, excess bodyweight, and HPV infection in
women (figure 3). The top five risk factors at the
provinces level showed substantial heterogeneity, except
for active smoking among men, which had the highest
PAF in all 31 provinces. The leading risk factor among
women varied by province, with smoking as the leading
risk factor in six provinces (Heilongjiang, Tianjin, Inner
Mongolia, Jilin, Liaoning, and Anhui); excess bodyweight
in three provinces (Tibet, Shanghai, and Beijing), HBV
infection in seven provinces (Qinghai, Fujian, Gansu,
Henan, Ningxia, Hubei, and Xinjiang); HPV infection in
Shanxi, and low fruit intake in the remaining
14 provinces.
The patterns for age-specific PAFs were generally
different between sex and risk-factor groups (figure 4).
The PAFs for behavioural factors were higher at older
age groups, and were highest in men aged 50–54 years,
and in women aged 65–69 years. For infectious agents,
we recorded higher PAFs in men and women aged
30–54 years with the peak among those aged 35–39 years.
PAFs for dietary factors and environmental factors
increased with age. The PAF for metabolic factors was
highest in the 40–44 years age group in men and the
50–54 years age group in women; before the age of
266
50 years, this PAF was higher in men than in women,
but this pattern was reversed after about age 50 years.
Discussion
In 2014, more than 1 million cancer deaths in adults
20 years and older in China were attributable to
potentially modifiable risk factors. Of these, about
71·6% occurred in men and 28·4% in women. Nationally,
the leading preventable cause of cancer death was active
smoking in men and low fruit intake in women,
accounting for 35·9% and 15·6% of the total attributable
cancer deaths in men and women, respectively. At
provincial level, PAFs for various risk factors and cancer
sites showed substantial differences in both men and
women.
In our two previous studies, we quantified the
contribution of modifiable risk factors to cancer deaths
in China at the national level only.9,10 Further, the analyses
were based on limited data sources or used single
combined, despite variations across these demographic
strata. In this study, we updated national level PAFs
≥70
number of evaluated risk factors, and also provided
estimates at the provincial level. Our PAFs for several
risk factors at the national levels were similar to our
previous estimates.9,10 However, the reported PAF for
smoking among men was 32·7% in 2005, which was
driven from much extreme RRs (5·9 for men and 5·0 for
women) from a case-control study in Shanghai.9,37,38 The
reported PAFs for 2013 are similar to the results in this
study;10 however, this study considered a broader array of
potentially modifiable risk factors and dose-response
effects of applicable exposure factors. Moreover, we used
more representative exposure and cancer occurrence
data than previous studies. For example, the population
coverage of cancer occurrence data used in our study was
about 2·4 times higher than that used in the most recent
publication (40% vs 17% of total Chinese population),10
which allowed us to examine provincial-level PAFs for
the first time.
The current PAF of cancer deaths associated with
modifiable risk factors in China is higher than that in the
UK (37·7%),16 Italy (37·9%),39 and Australia (38·0%),32
but is similar to the overall PAF in the USA (45·1%),15
and Japan (46·2%).40 The differences seem to be a result
of multiple factors. First, high prevalence of smoking
and alcohol drinking in men, high prevalence of HBV
infection, low fruit intake, excess bodyweight and
diabetes, combined with high PM2·5 concentrations,
contribute to the higher PAFs in China.19,41–44 Second, the
cancer profiles in China differ substantially from other
countries, with deaths from cancers of the lung, liver,
stomach, oesophagus and colorectum accounting for
27·3%, 13·9%, 12·8%, 8·4%, and 7·8% of all cancer
deaths, respectively.45 Of these, two-thirds of lung cancer
deaths occur in men, more than 55% of which are
www.thelancet.com/lancetgh Vol 7 February 2019

attributable to active smoking, and more than half of
liver cancer deaths are caused by HBV.45 Finally, the
variation in RR values and the number of risk factors in
different studies might partly explain the differences. For
example, we included air pollution in our study while
most previous studies did not.
Disparities in PAFs by sex and province for each
evaluated risk factor and related cancer site seem to be
primarily driven by the variations in exposure prevalence,
which is related to differences in various factors,
including socioeconomic status and demographic,
cultural, and other environmental factors. For example,
both the PAF for smoking and smoking prevalence are
relatively high compared with the national average
among men in Yunnan, Hunan, and Guizhou, where
there is much more economic reliance on the production
of tobacco than many other provinces.12,46 Lower socio­
economic status and poor health literacy are also
associated with lower levels of fruit consumption47 and
higher prevalence of many infectious agents, including
H pylori and HBV, in China.48,49 As people of higher
socioeconomic groups in China have experienced a
remarkable shift toward a western lifestyle along with the
rapid economic development during the last 40 years,
differences in the metabolic status and related cancer
burden between urban and rural populations and eastern
and western areas in China have widened.50 Environ­
mental factors also vary between provinces; their cancer
burden mainly correlates with geographical variations in
PM2·5 concentration and UVR. 34,51
The age-specific PAFs for the five risk factor groups
were mainly driven by the joint effects of exposures at
each birth cohort. For example, the prevalence of
smoking peaked in men born in the 1950s and 1960s,37,38
and correspondingly, PAFs for behavioural factors in this
study were higher in men aged 45-64 years in 2014 (born
about 1950–1969).
Our study is the first analysis that has systematically
assessed sex-specific, age-specific, and site-specific
cancer burden attributable to potentially modifiable risk
factors in all 31 provinces in mainland China using
representative exposure and cancer death data. However,
our study has some limitations. First, because of a lack of
provincial-level representative exposure data on several
potentially modifiable risk factors, such as indoor air
pollution, occupational risks, and aflatoxins, we were not
able to include them in our analysis, which could have
led to underestimation of overall PAFs. Second, the RRs
for all evaluated risk factors and related cancers can vary
across subpopulations and regions, but specific RRs are
not available for each province and age group; thus, we
used the same RR values in all provinces and age groups,
which could attenuate disparities in PAFs for cancer
deaths across provinces. Third, interactions of multiple
risk factors (except for high BMI and diabetes) were not
taken into consideration in our study because of a lack of
prevalence data on coinfection or overlapping exposures.
www.thelancet.com/lancetgh Vol 7 February 2019
Articles
To avoid overestimating the joint PAFs, we used the RR
estimates for HBV-positive/HCV-negative and HCV-
positive/HBV-megative rather than the RRs for
coinfection of hepatitis B and C (appendix). Finally,
although the cancer data used in this study delivered
unprecedented population coverage in China, the
precision of attributable cancer burden estimates in each
province might be affected by disproportionate disparities
on data quality (appendix), particularly in Tibet and
Xinjiang.
Population ageing in China is happening at a faster
rate than in almost any other country in recent history.52,53
Further, cancer burden related to some risk factors,
notably tobacco smoking, metabolic factors, and air
pollution, are emerging in China.37,54 This increase is
expected to continue in the coming decades. National
and local political leadership in concert with public
health professionals must fund and implement wide­
spread and targeted cancer prevention and control
programmes.3 Our findings emphasise the need for
primary prevention through specific lifestyle and
environ­ mental interventions, as well as an increased
coverage of vaccines and ecological improvement, to
mitigate the growing cancer burden in China. Achieving
the goals of Healthy China 203055 requires increasing
public sector resources for planning and implementing
comprehensive cancer control programmes, for ensuring
access to quality care to all, and for intensified public
campaigns to increase awareness about the health hazard
of major risk factors and preventive measures. It should
also be noted that, as indicated by the heterogeneity in
the results presented here, there are substantial variations
in socioeconomic status, health resources, and lifestyles
across the 31 provinces in mainland China.1,56 Therefore,
adopting a “one size fits all” for primary cancer prevention
is unlikely to provide the best results. A provincial-level
approach that focuses on the major potentially modifiable
cancer risk factors and tailored programmes that can
realistically modify behavioural and environmental
factors could substantially reduce the burden of cancer
and associated disparities in China. In addition to the
45·2% cancer deaths that are potentially preventable by
primary prevention in China, cancer deaths could be
prevented through broad application of cancer screening
and palliative care services, particularly in rural areas and
western China. Since 2005, China has launched the
Cancer Early Diagnosis and Early Treatment Programme
in rural areas. However, the population coverage is highly
varied across provinces and the screening services are
only available in several selected counties.57 A
comprehensive approach to risk factor intervention,
cancer screening and care management of cancer should
be further strengthened in China.
In summary, more than 1 million cancer deaths in
China are attributed to potentially modifiable risk factors
in 2014, with the attributable fraction by province ranging
from 35·2% in Shanghai to 52·9% in Heilongjiang.
267
 Articles
Smoking, infections, and poor diet were the largest
contributors to the total cancer burden. The province-
specific, sex-specific, and age-specific findings in this
report can serve as a useful reference for informing
policies and programmes to plan for primary prevention
of cancer in each province of China more effectively.
Local policy makers for each province should focus on
the major potentially modifiable cancer risk factors and
tailored programmes. Regional adoption of effective
primary cancer prevention strategies could generate
significant returns, because policies that support healthy
activities not only have the considerable potential to
mitigate the growing cancer burden and associated
disparities in the country, but also contribute towards
achieving many of the Healthy China 2030 goals.
Contributors
WC, CX, and JH contributed to the conception and design of the study.
CX led the data analysis with support from FI. WC, RZ, MZ, SZ, HZ,
and LW contributed to the cancer data collection and data quality
control. CX, WC, and JH contributed to the exposure data collection.
CX, CL, and ZY contributed to literature review. KS and HL supervised
the analysis and generating of results. CX drafted and finalised the
paper with input from FI, FB, AJ, MDB, and WC. All authors
contributed to data interpretation, and reviewed and approved the final
version manuscript. JH and WC had full access to all the data in the
study and had final responsibility for the decision to submit for
publication.
Declaration of interests
We declare no competing interests.
Acknowledgments
This study was funded by the Ministry of Science and Technology of
China (grant number 2014FY121100). We thank all staff from the
contributing cancer registries and disease surveillance points who have
made a great contribution to the data collection, supplements, auditing,
and database management.
References
1 National Health Commission. China Health Statistics Yearbook,
2018. Beijing: Peking Union Medical College Press, 2018.
2 National Bureau of Statistics of China. China Statistical Yearbook,
2017. Beijing: China Statistics Press, 2017.
3 Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015.
CA Cancer J Clin 2016; 66: 115–32.
4 Allemani C, Matsuda T, Di Carlo V, et al. Global surveillance of
trends in cancer survival 2000-14 (CONCORD-3): analysis of
individual records for 37 513 025 patients diagnosed with one of
18 cancers from 322 population-based registries in 71 countries.
Lancet 2018; 391: 1023–75.
5 Chalkidou K, Marquez P, Dhillon PK, et al. Evidence-informed
frameworks for cost-effective cancer care and prevention in low,
middle, and high-income countries. Lancet Oncol 2014; 15: e119–31.
6 Cogliano VJ, Baan R, Straif K, et al. Preventable exposures
associated with human cancers. J Natl Cancer Inst 2011;
103: 1827–39.
7 World Cancer Research Fund/American Institute for Cancer
Research. Diet, nutrition, physical activity and cancer:
a global perspective. Continuous Update Project Expert Report
2018. Washington DC: World Cancer Research Fund/American
Institute for Cancer Research, 2018.
8 Bray F, Jemal A, Torre LA, Forman D, Vineis P. Long-term realism
and cost-effectiveness: primary prevention in combatting cancer
and associated inequalities worldwide. J Natl Cancer Inst 2015;
107: djv273.
9 Wang JB, Jiang Y, Liang H, et al. Attributable causes of cancer in
China. Ann Oncol 2012; 23: 2983–89.
10 Islami F, Chen W, Yu XQ, et al. Cancer deaths and cases
attributable to lifestyle factors and infections in China, 2013.
Ann Oncol 2017; 28: 2567–74.
268
11 The Editoral Committee for the Atlas of Cancer Mortality in the
People’s Republic of China. Atlas of cancer mortality in the People’s
Republic of China. Beijing: China Map Press, 1979.
12 Astell-Burt T, Zhang M, Feng X, et al. Geographical inequality in
tobacco control in China: multilevel evidence from
98 058 participants. Nicotine Tob Res 2017; 20: 755–65.
13 Tsilidis KK, Kasimis JC, Lopez DS, Ntzani EE, Ioannidis JP. Type 2
diabetes and cancer: umbrella review of meta-analyses of
observational studies. BMJ 2015; 350: g7607.
14 Pearson-Stuttard J, Zhou B, Kontis V, Bentham J, Gunter MJ,
Ezzati M. Worldwide burden of cancer attributable to diabetes and
high body-mass index: a comparative risk assessment.
Lancet Diabetes Endocrinol 2017; 6: 95–104.
15 Islami F, Goding Sauer A, Miller KD, et al. Proportion and number
of cancer cases and deaths attributable to potentially modifiable risk
factors in the United States. CA Cancer J Clin 2018; 68: 31–54.
16 Brown KF, Rumgay H, Dunlop C, et al. The fraction of cancer
attributable to modifiable risk factors in England, Wales, Scotland,
Northern Ireland, and the United Kingdom in 2015. Br J Cancer
2018; 118: 1130–41.
17 Wu Y, Huxley R, Li L, et al. Prevalence, awareness, treatment, and
control of hypertension in China: data from the China National
Nutrition and Health Survey 2002. Circulation 2008; 118: 2679–86.
18 Wang L. Summary report of China Nutrition and Health Survey
2002. Beijing: People’s Medical Publishing House, 2005.
19 Schweitzer A, Horn J, Mikolajczyk RT, Krause G, Ott JJ.
Estimations of worldwide prevalence of chronic hepatitis B virus
infection: a systematic review of data published between 1965 and
2013. Lancet 2015; 386: 1546–55.
20 Chen YS, Li L, Cui FQ, et al. A sero-epidemiological study on
hepatitis C in China. Chinese Journal of Epidemiology 2011;
32: 888–91.
21 Zhang L, Chow EP, Jing J, et al. HIV prevalence in China:
integration of surveillance data and a systematic review.
Lancet Infect Dis 2013; 13: 955–63.
22 National Health and Family Planning Commission of the People’s
Republic of China. 2015 China AIDS response progress report.
Beijing China: UNAIDS, 2015.
23 China Ttocohpri. Prevalence of Helicobacter pylori infection in
China. Mod Dig Interv 2010; 15: 265–70.
24 Lai YS, Zhou XN, Pan ZH, Utzinger J, Vounatsou P. Risk mapping
of clonorchiasis in the People’s Republic of China: a systematic
review and Bayesian geostatistical analysis. PLoS Negl Trop Dis 2017;
11: e0005239.
25 Xia C, Yu XQ, Zheng R, et al. Spatial and temporal patterns of
nasopharyngeal carcinoma mortality in China, 1973–2005.
Cancer Lett 2017; 401: 33–38.
26 Barendregt JJ, Veerman JL. Categorical versus continuous risk
factors and the calculation of potential impact fractions.
J Epidemiol Community Health 2010; 64: 209–12.
27 de Martel C, Ferlay J, Franceschi S, et al. Global burden of cancers
attributable to infections in 2008: a review and synthetic analysis.
Lancet Oncol 2012; 13: 607–15.
28 Plummer M, de Martel C, Vignat J, Ferlay J, Bray F, Franceschi S.
Global burden of cancers attributable to infections in 2012:
a synthetic analysis. Lancet Glob Health 2016; 4: e609–16.
29 Kim TS, Pak JH, Kim JB, Bahk YY. Clonorchis sinensis, an oriental
liver fluke, as a human biological agent of cholangiocarcinoma:
a brief review. BMB Rep 2016; 49: 590–97.
30 Parkin DM. The global health burden of infection-associated
cancers in the year 2002. Int J Cancer 2006; 118: 3030–44.
31 Lucas R, McMichael T, Smith W, Armstrong B. Solar ultraviolet
radiation: global burden of disease from solar ultraviolet radiation.
Geneva: World Health Organization, 2006.
32 Wilson LF, Antonsson A, Green AC, et al. How many cancer cases
and deaths are potentially preventable? Estimates for Australia in
2013. Int J Cancer 2018; 142: 691–701.
33 Parkin DM, Mesher D, Sasieni P. 13. Cancers attributable to solar
(ultraviolet) radiation exposure in the UK in 2010. Br J Cancer 2011;
105 (suppl 2): S66–69.
34 Liu H, Hu B, Zhang L, et al. Ultraviolet radiation over China:
Spatial distribution and trends.
Renewable and Sustainable Energy Reviews 2017; 76: 1371–83.
www.thelancet.com/lancetgh Vol 7 February 2019

35 He G, Kammen DM. Where, when and how much solar is
available? A provincial-scale solar resource assessment for China.
Renewable Energy 2016; 85: 74–82.
36 Ezzati M, Hoorn SV, Rodgers A, Lopez AD, Mathers CD,
Murray CJ. Estimates of global and regional potential health gains
from reducing multiple major risk factors. Lancet 2003; 362: 271–80.
37 Chen ZM, Peto R, Iona A, et al. Emerging tobacco-related cancer
risks in China: a nationwide, prospective study of 0.5 million adults.
Cancer 2015; 121 (suppl 17): 3097–106.
38 Chen Z, Peto R, Zhou M, et al. Contrasting male and female trends
in tobacco-attributed mortality in China: evidence from successive
nationwide prospective cohort studies. Lancet 2015; 386: 1447–56.
39 Battisti F, Carreras G, Grassi T, Chellini E, Gorini G. Estimates of
cancer deaths attributable to behavioural risk factors in Italy, 2013.
Epidemiol Prev 2017; 41: 61–67.
40 Inoue M, Sawada N, Matsuda T, et al. Attributable causes of cancer
in Japan in 2005—systematic assessment to estimate current
burden of cancer attributable to known preventable risk factors in
Japan. Ann Oncol 2012; 23: 1362–69.
41 GBD 2015 Tobacco Collaborators. Smoking prevalence and
attributable disease burden in 195 countries and territories,
1990–2015: a systematic analysis from the Global Burden of Disease
Study 2015. Lancet 2017; 389: 1885–906.
42 Wang L, Gao P, Zhang M, et al. Prevalence and ethnic pattern of
diabetes and prediabetes in China in 2013. JAMA 2017; 317: 2515–23.
43 Cohen AJ, Brauer M, Burnett R, et al. Estimates and 25-year trends
of the global burden of disease attributable to ambient air pollution:
an analysis of data from the Global Burden of Diseases Study 2015.
Lancet 2017; 389: 1907–18.
44 GBD 2016 Risk Factors Collaborators. Global, regional, and national
comparative risk assessment of 84 behavioural, environmental and
occupational, and metabolic risks or clusters of risks, 1990–2016:
a systematic analysis for the Global Burden of Disease Study 2016.
Lancet 2017; 390: 1345–422.
45 Chen W, Sun K, Zheng R, et al. Cancer incidence and mortality in
China, 2014. Chin J Cancer Res 2018; 30: 1–12.
www.thelancet.com/lancetgh Vol 7 February 2019
Articles
46 Yang T, Barnett R, Rockett IR, et al. The impact of regional
economic reliance on the tobacco industry on current smoking in
China. Health Place 2015; 33: 159–71.
47 Li YC, Jiang B, Zhang M, et al. Vegetable and fruit consumption
among Chinese adults and associated factors: a nationally
representative study of 170,847 adults. Biomed Environ Sci 2017;
30: 863–74.
48 Shi R, Xu S, Zhang H, et al. Prevalence and risk factors for
Helicobacter pylori infection in Chinese populations. Helicobacter
2008; 13: 157–65.
49 Yan YP, Su HX, Ji ZH, Shao ZJ, Pu ZS. Epidemiology of hepatitis B
virus infection in China: current status and challenges.
J Clin Transl Hepatol 2014; 2: 15–22.
50 Li Y, Wang DD, Ley SH, et al. Time trends of dietary and lifestyle
factors and their potential impact on diabetes burden in China.
Diabetes Care 2017; 40: 1685–94.
51 Song C, He J, Wu L, et al. Health burden attributable to ambient
PM2.5 in China. Environ Pollut 2017; 223: 575–86.
52 Fang EF, Scheibye-Knudsen M, Jahn HJ, et al. A research agenda
for aging in China in the 21st century. Ageing Res Rev 2015;
24: 197–205.
53 Zhao Y, Smith JP, Strauss J. Can China age healthily? Lancet 2014;
384: 723–24.
54 Maji KJ, Dikshit AK, Arora M, Deshpande A. Estimating premature
mortality attributable to PM2.5 exposure and benefit of air pollution
control policies in China for 2020. Sci Total Environ 2018;
612: 683–93.
55 The Lancet. The best science for achieving Healthy China 2030.
Lancet 2016; 388: 1851.
56 National Bureau of Statistics of China. National data. 2018.
http://data.stats.gov.cn/ (accessed March 29, 2018).
57 Zou XN. Epidemic trend, screening, and early detection and
treatment of cancer in Chinese population. Cancer Biol Med 2017;
14: 50–59.
269