Articles

Impact of changing the prevalence of smoking, alcohol

consumption and overweight/obesity on cancer incidence in
China from 2021 to 2050: a simulation modelling study
Song Song,a,c Lin Lei,b,c Han Liu,a Fan Yang,a Ni Li,a Wanqing Chen,a Ji Peng,b,∗∗ and Jiansong Rena,∗
a
Office of Cancer Screening, National Cancer Center / National Clinical Research Center for Cancer / Cancer Hospital, Chinese Academy
of Medical Sciences and Peking Union Medical College, Beijing 100021, China
b
Department of Cancer Control and Prevention, Shenzhen Center for Chronic Disease Control, Shenzhen 518000, China

Summary eClinicalMedicine
2023;63: 102163
Background Smoking, alcohol consumption and overweight/obesity are key cancer risk factors contributing to the
cancer burden in China. We aimed to quantify the cancer burden in China associated with smoking, alcohol con- Published Online xxx
https://doi.org/10.
sumption and overweight/obesity, and estimate the potential effect for cancer prevention interventions under
1016/j.eclinm.2023.
different scenarios. 102163

Methods We used a macro-simulation approach called Prevent Model to estimate for a 30-year study period
(2021–2050) numbers and proportions of future avoidable cancer cases under different scenarios of reducing the
prevalence of smoking, alcohol consumption and overweight/obesity in Chinese adults. Cancer incidence was
predicted under three scenarios: elimination, ambitious target (between elimination and manageable target) and
manageable target (from national policy or global action plan). Risk factor prevalence was obtained from China
Chronic Disease and Risk Factor Surveillance, and cancer incidence data were derived from the China Cancer
Registry Annual Report. Relative risks were obtained from several recent large-scale studies or high-quality meta-
analysis. Population data were extracted from the China Population & Employment Statistical Yearbook, China
Health Statistical Yearbook and World Population Prospects.

Findings Estimates of the avoidable cancer burden varied with different scenarios. In the theoretical maximum
intervention scenario, where the prevalence of smoking, alcohol consumption and overweight/obesity would be
eliminated, 9.17% (males: 13.50%; females: 1.47%) of smoking-related cancer cases, 7.06% (males: 11.49%; females:
1.00%) of cancer cases related to alcohol consumption and 8.22% (males: 7.91%; females: 8.52%) of overweight/
obesity-related cancer cases were estimated to be avoidable during 2021–2050. Other scenarios, with more
moderate goals in the exposure prevalence of smoking, alcohol use and overweight/obesity were also found to be
associated with substantial reductions in the future cancer burden.

Interpretation Our results suggested that a substantial number of future cancer cases could be avoided in Chinese
adults by reducing the prevalence of smoking, alcohol consumption and overweight/obesity.

Funding National Science & Technology Fundamental Resources Investigation Program of China; Sanming Project of
Medicine in Shenzhen.

Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Keywords: Cancer; Primary prevention; Risk factor; Potential impact fraction

Introduction cases and deaths in China will continue to increase

Cancer has become one of the major causes of death with aging and growth of population. Previous
in China, accounting for 25.43% of all deaths in 2020 studies showed that primary prevention, by reducing
in the country.1 Furthermore, the number of cancer exposure prevalence of related risk factors, is an

*Corresponding author.
**Corresponding author.
E-mail addresses: ren.js@cicams.ac.cn (J. Ren), pengji126@126.com (J. Peng).
c
These authors contributed equally to this work.

www.thelancet.com Vol 63 September, 2023 1

 Articles
Research in context
Evidence before this study
We searched PubMed on 31 May 2023 with no date or
language restrictions using the search terms (“primary
prevention”) and (cancer) and (China) and (risk factor) and
(model). However, current cancer burden prediction studies in
China mostly focused on population attributable fraction
(PAF) of risk factors, and did not consider the future
demographic change and time dimensions of effects of risk
factor changes.
Added value of this study
To our knowledge, our study is the first analysis that has
systematically assessed the health effect on cancer incidence
of varying intervention scenarios with different prevalence of
smoking, alcohol consumption and overweight/obesity in
Chinese adults. Our results illustrated the estimated number
of future cancer cases that could be avoided in Chinese adults
by eliminating the prevalence of smoking, alcohol
important way for taking control of the cancer burden
in China.2
Cancer risk is determined by a range of risk factors,
including environmental/occupational factors, behav-
ioural factors, metabolic factors and so on. According to
the report of Global Burden of Diseases, Injuries, and
Risk Factors Study (GBD) 2019, 32.78 million cancer
DALYs (disability-adjusted life years) (48.52% [95% UI:
44.78–53.12] of all cancer DALYs) in China for both
sexes combined were attributable to the included 34 risk
factors. These risk factors at the most detailed level
contributing to China cancer burden defined by age-
standardized DALY rates were shown in
Supplementary Table S1, and the top three risk factors
that can be intervened at the individual level are smok-
ing, alcohol use and high body-mass index (BMI).3
Moreover, the prevalence of smoking, alcohol use and
high BMI are still high in China. The smoking rate of
Chinese adults in 2018 was 26.2%, which was lower
than previous surveys (28.3% in 2010), but still had a
large gap with the tobacco control goal of the outline for
the “Healthy China 2030” initiative.4 The alcohol con-
sumption rate among Chinese adults was 39.8% in
2018, 3.4% higher compared with 36.4% in 2010.4
In addition, overweight/obesity (high BMI) population
in Chinese adults is gradually increasing due to the
change of diet structure.5 Data showed that the over-
weight and obesity rates of people aged 18 years or older
in China were 34.3% and 16.4%, respectively.4 Assess-
ing the cancer burden, attributable to each modifiable
risk factor, helps optimize the resource allocation for
primary prevention. However, current cancer burden
prediction studies in China mostly focus on population
attributable fraction (PAF) of risk factors, and did not
consider the future demographic change and time
2 www.thelancet.com Vol 63 September, 2023
consumption and overweight/obesity. The estimations were
also conducted under different scenarios with more moderate
goals, which were also found to be associated with substantial
reductions in the future cancer burden.
Implications of all the available evidence
Cancer has become one of the major causes of death in China
and primary prevention is an important way for taking
control of the cancer burden in China. Our results can be used
to understand the potential impact and significance of
primary prevention interventions. This is especially important
because the connection between smoking, alcohol
consumption, overweight/obesity and cancer risk is not well
known among the public. Furthermore, our results should
motivate public health planners and policymakers to take
effective action against smoking, alcohol use and overweight/
obesity.
dimensions of effects of risk factor changes. In this
study, we therefore aimed to use a macro-simulation
model to quantify the cancer burden in China associ-
ated with smoking, alcohol consumption and over-
weight/obesity, and estimate the potential effect for
cancer prevention interventions under different sce-
narios over a 30-year period (2021–2050).
Methods
Model specification
In this paper, we used Prevent model (see
Supplementary materials), which had been applied in
several studies for estimating the impact of potential
interventions on the cancer burden, to estimate the
potential impact of smoking, alcohol consumption and
overweight/obesity intervention scenarios on future
cancer incidence in China.6–8 Data needed for applica-
tion of the Prevent model were risk factor prevalence,
cancer incidence rate, relative risk (RR) estimates, pop-
ulation data (projected population sizes), time effects
(Lag and latency time) and change in risk factor preva-
lence under different scenarios.
Exposure prevalence
The age-, area (urban/rural)- and sex-specific prevalence
of smoking, alcohol use and overweight/obesity in
Chinese adults (population aged 18+ years) was ob-
tained from China Chronic Disease and Risk Factor
Surveillance (CCDRFS) in 2018, which was a multistage
stratified cluster sampling study covering 298 sample
sites from all 31 provinces (Supplementary
Tables S2–S4).4,9
Current smokers referred to those who currently
smoke, including daily smokers and occasional
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smokers. Participants who consumed alcoholic beverage
in the past 12 months were defined as drinkers. Ac-
cording to the World Health Organization (WHO) In-
ternational Guide for Monitoring Alcohol Consumption
and Related Harm,10 alcohol use was divided into
moderate (male: 1–40 g, female: 1–20 g), hazardous
(male: 41–60 g, female: 21–40 g) and harmful (male:
61 + g, female: 41 + g) using average ethanol intake per
day. Based on the guidelines for the prevention and
control of overweight and obesity in adults in China,11
BMI was categorized as low weight (<18.50 kg/m2),
normal weight (18.5–23.9 kg/m2), overweight
(24.0–27.9 kg/m2) and obesity (≥28.0 kg/m2), with
overweight and obesity implying high BMI. Our study
combined low weight and normal weight into one group
called normal body weight.
Incidence rate and relative risks of related cancers
Cancer sites were chose based on reports by the World
Cancer Research Fund (WCRF) and the International
Agency for Research on Cancer (IARC) working group
(Table 1).12 We obtained China cancer incidence rates in
2017 by sex, area (urban/rural) and age group (0, 1–4
years, 5–84 years by 5 years and 85+ years) from the
China Cancer Registry Annual Report.13 To estimate the
incidences of oesophageal and gastric cancers by his-
tologic subtype, cancer cases by histology diagnosed in
the 2008–2012 from 35 cancer registries in China
included in the Cancer Incidence in Five Continents
database volume XI14 were integrated, where the urban-
rural division was based on the principle of the National
Bureau of Statistics (urban areas: prefecture-level and
above regions; rural areas: counties or county-level cit-
ies); sex-, area-, age-specific proportions by histology
were computed and then multiplied with the total
number of oesophageal cancer and gastric cancer cases
in 2017 database, to estimate the incidences of oeso-
phageal squamous cell carcinoma (SCC), oesophageal
adenocarcinoma (AC) and gastric cardia cancer. Be-
sides, we defined premenopausal breast cancer cases as
those diagnosed at age 49 years and below; post-
menopausal cases were those diagnosed at age ≥50
years.
For our study, we used summary relative risks (RRs)
of smoking/alcohol consumption/high BMI for specific
cancer sites obtained from recent studies of large-scale
pooled analyses or high-quality meta-analyses. When
possible, we used sex-specific relative risks
(Supplementary Table S5).
Population data
China’s population for 2021–2050 were projected by sex,
area (urban/rural) and 1-year age group. We used pa-
rameters from open-source publications or datasets. We
obtained China’s population data for 2020 by sex, area
(urban/rural) and age group (0–84 years by 1 year and
85+ years) from the China Population & Employment
Statistical Yearbook 2021.15 Mortality rate was extracted
from China Health Statistical Yearbook; and because of
relatively stable all-cause mortality rate from 2011 to
2020, ranging from 7.07‰ to 7.16‰, we used mortality
rate for 2020 as predictive parameters and assumed it
stable over 2021–2050.1,16–25 We extracted the projected
fertility rate and urbanization data for 2021–2050 from
the Population Division of United Nations.26
Lag and latency time
One of conditions of Prevent Model was the introduc-
tion of a time dimension, including lag (LAG) and la-
tency (LAT) time (Supplementary Fig. S1). LAT
expresses the time between the moment of cessation of
exposure and the moment that changes in risk factor
exposure are reflected in changes in cancer risk. LAG,
starting after LAT period, is the time taken for the RRs
to reach the risk of an unexposed person (RR = 1), where
the risk decreases linearly during the LAG time. For
smoking, according to previous studies, we defined the
LAT to be 5 years.27 For alcohol consumption and
overweight/obesity, this was set to be 1 year.27,28 As for
LAG, we set it to be 15 years for smoking, 4 years for
alcohol consumption, and 9 years for overweight/
obesity.27,28
Theoretical intervention scenarios
Smoking.
1. Elimination: An absolute elimination of tobacco
smoking by 2030.
2. Ambitious target: Overall prevalence of tobacco
smoking reduces to 10% by 2030.

Modifiable risk Cancer site (ICD-10 code)

factor
Smoking Oral cavity, pharynx (C00–C14); oesophagus (C15); stomach (C16); colorectum (C18–C20); liver (C22); pancreas (C25); larynx (C32); lung, bronchus, trachea (C33–C34);
cervix (C53); kidney, renal pelvis, ureter (C64–C66); urinary bladder (C67); myeloid leukaemia (C92–C94, D45–D47)
Alcohol Oral cavity, pharynx (C00–C14); oesophagus (C15, SCC); stomach (C16); colorectum (C18–C20); liver (C22); larynx (C32); breast (C50, female, premenopausal); breast
consumption (C50, female, postmenopausal)
Overweight/obesity Oesophagus (C15, AC); stomach (C16.0, cardia); colorectum (C18–C20); liver (C22); gallbladder (C23–C24); pancreas (C25); breast (C50, female, postmenopausal);
corpus uteri (C54–C55); ovary (C56); kidney, renal pelvis (C64–C65); thyroid (C73)
SCC: squamous cell carcinoma; AC: adenocarcinoma.

Table 1: Smoking, alcohol consumption and overweight/obesity and related cancer site considered in the analysis.

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3. Manageable target: Overall prevalence of tobacco
smoking reduces to 20% by 2030.
Alcohol consumption.
1. Elimination: (a) An absolute elimination of alcohol
use by 2030; (b) An absolute elimination of
dangerous use and harmful use of alcohol by 2030;
(c) An absolute elimination of harmful use of
alcohol by 2030.
2. Ambitious target: A 50% relative reduction in
dangerous use and harmful use of alcohol by 2030.
3. Manageable target: A 20% relative reduction in
harmful use of alcohol by 2030.
Overweight/obesity.
1. Elimination: (a) An absolute elimination of over-
weight and obesity by 2030; (b) An absolute elimi-
nation of obesity by 2030
2. Ambitious target: A 50% relative reduction in
overweight and obesity by 2030.
3. Manageable target: Growth rate of obesity reduces to
0 by 2030. The growth rate is based on observed
prevalence trends between 2010 and 2018 in China.4,29
All scenarios were assumed to start in 2021. The
numbers of avoidable or extra number of cancer cases
under each scenario were calculated for the 30-year
period (2021–2050). Scenario 1 (Elimination) is com-
parable to estimates of the PAF in other studies. Sce-
nario 3 (Manageable target) is based on national policy
of China or Global action plan for the prevention and
control of non-communicable diseases.30,31 Scenario 2
(Ambitious target) falls between scenario 1 and scenario
3. It is assumed that interventions move individuals to
unexposed, so the decrease in any exposed group leads
to an increase in the group of unexposed persons.
Statistical analysis
Prevent Model was originally developed in 1988 to es-
timate the health effect of changes in risk factor preva-
lence for a population.7 It is based on the epidemiology
effect measure “potential impact fraction (PIF)”. PIF
means the incidence that is avoided by a preventive
intervention as a proportion of the incidence that would
have occurred in that population without the interven-
tion, and can be calculated by age, sex, area (urban/
rural) and cancer site using the following formula:
r,j=0,d,s,a,u
n
∑c=1 pc RRc,t −∑nc=1 p∗c RRc,t
PIF r,d,s,a,u
t = n r,j=0,d,s,a,u
∑c=1 pc RRc,t
Where pc is the prevalence of the risk factor in category c
and n is the number of exposure categories, RRc is the
4 www.thelancet.com Vol 63 September, 2023
relative risk for the category, an p∗c is the prevalence after
the intervention. t, r, d, s, a, u are indicators for time,
risk factor, cancer site, sex, age group and area (rural/
urban), respectively, and j is for reference if 0 and
intervention population if 1.
In our study, the reference scenario has no change
in both risk factor prevalence and cancer incidence
rate, which means the variations in numbers of future
incident cancer cases per year reflect population
changes. To estimate the site-specific cancer incidence
rate under different intervention scenarios for each
year, the cancer-specific PIF by age, sex and area (ur-
ban/rural) was applied to the reference cancer inci-
dence rate (Iref) (Iref*(1-PIF)). We estimated total
numbers of age-, sex-, area (urban/rural)- and site-
specific cancer cases for each year of the 30-year
period (2021–2050) by multiplying incidence rates for
each intervention scenario with the projected popula-
tion. The avoidable number of cases is the difference
between the reference scenario and each intervention
scenario.
In our sensitivity analyses, we examined the impact
of the uncertainty in the assumed LAT, LAG and the
cancer-specific relative risk estimates. We used varying
LAT and LAG, as well as the lower and upper limit of
the 95% confidence interval of the cancer-specific rela-
tive risk estimates, and then compared the numbers of
prevented cancer cases.
All statistical analyses were performed with R soft-
ware (version 4.2.1 R Foundation for Statistical
Computing, Vienna, Austria).
Ethical approval and informed consent
None applicable.
Role of the funding source
The funders were not involved in study design, data
collection, data analysis, interpretation of data, writing
of the report or decision to submit the paper for publi-
cation. All authors had full access to all the data in the
study and had final responsibility for the decision to
submit for publication.
Results
Smoking
The estimated numbers and percentages of avoidable
cases, due to smoking, were presented by sex, cancer
site and each intervention scenario (Table 2). Under the
most optimistic scenario (Scenario 1) where smoking
r,j=1,d,s,a,u
was eliminated in Chinese adults, we estimated 13.50%
and 1.47% of smoking-related cancers could be avoided
over the study period in males and females, respectively,
corresponding to approximately 10,724,214 and 655,045
cancer cases. Under the ambitious target scenario
(Scenario 2) in which prevalence of tobacco smoking
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Cancer site (ICD-10 code) Scenario 1a Scenario 2b Scenario 3c

No. (%) avoided No. (%) avoided No. (%) avoided
Males
Oral cavity, pharynx (C00–C14) 390,770 14.41 237,722 8.76 84,675 3.12
Oesophagus (C15) 699,153 8.56 425,320 5.21 151,488 1.85
Stomach (C16) 936,396 7.98 569,639 4.85 202,882 1.73
Colorectum (C18–C20) 289,905 2.75 176,356 1.67 62,807 0.59
Liver (C22) 724,945 6.63 441,014 4.03 157,084 1.44
Pancreas (C25) 96,173 3.74 58,504 2.28 20,835 0.81
Larynx (C32) 149,481 14.69 90,934 8.94 32,387 3.18
Lung, bronchus, trachea (C33–C34) 6,814,668 26.47 4,145,537 16.1 1,476,406 5.73
Kidney, renal pelvis, ureter (C64–C66) 88,996 4.63 54,139 2.82 19,282 1.00
Urinary bladder (C67) 479,855 15.36 291,902 9.34 103,950 3.33
Myeloid leukaemia (C92–C94, D45–D47) 53,873 5.67 32,772 3.45 11,672 1.23
Total (2021–2050) 10,724,214 13.50 6,523,841 8.21 2,323,469 2.92
Females
Oral cavity, pharynx (C00–C14) 16,226 1.35 9871 0.82 3516 0.29
Oesophagus (C15) 13,910 0.42 8462 0.26 3014 0.09
Stomach (C16) 12,019 0.23 7311 0.14 2604 0.05
Colorectum (C18–C20) 48,115 0.62 29,269 0.37 10,423 0.13
Liver (C22) 54,255 1.19 33,005 0.72 11,754 0.26
Pancreas (C25) 21,968 1.04 13,364 0.64 4759 0.23
Larynx (C32) 1667 1.56 1014 0.95 361 0.34
Lung, bronchus, trachea (C33–C34) 472,141 3.45 287,213 2.10 102,285 0.75
Cervix (C53) 1763 0.05 1073 0.03 382 0.01
Kidney, renal pelvis, ureter (C64–C66) 4050 0.34 2464 0.21 877 0.07
Urinary bladder (C67) 5908 0.67 3594 0.41 1280 0.14
Myeloid leukaemia (C92–C94, D45–D47) 3022 0.40 1839 0.24 655 0.09
Total (2021–2050) 655,045 1.47 398,478 0.89 141,910 0.32
Males and females
Oral cavity, pharynx (C00–C14) 406,995 10.39 247,593 6.32 88,190 2.25
Oesophagus (C15) 713,063 6.23 433,782 3.79 154,501 1.35
Stomach (C16) 948,415 5.57 576,950 3.39 205,486 1.21
Colorectum (C18–C20) 338,020 1.84 205,626 1.12 73,231 0.4
Liver (C22) 779,200 5.03 474,019 3.06 168,838 1.09
Pancreas (C25) 118,141 2.53 71,868 1.54 25,594 0.55
Larynx (C32) 151,148 13.44 91,948 8.18 32,748 2.91
Lung, bronchus, trachea (C33–C34) 7,286,810 18.48 4,432,751 11.24 1,578,692 4.00
Cervix (C53) 1763 0.05 1073 0.03 382 0.01
Kidney, renal pelvis, ureter (C64–C66) 93,046 2.98 56,603 1.81 20,159 0.65
Urinary bladder (C67) 485,763 12.11 295,496 7.37 105,230 2.62
Myeloid leukaemia (C92–C94, D45–D47) 56,895 3.34 34,611 2.03 12,327 0.72
Total (2021–2050) 11,379,259 9.17 6,922,319 5.58 2,465,379 1.99
a
Scenario 1: Elimination: a total elimination of tobacco smoking by 2030. bScenario 2: Ambitious target: overall prevalence of tobacco smoking reduces to 10% by 2030.
c
Scenario 3: Manageable target: overall prevalence of tobacco smoking reduces to 20% by 2030.

Table 2: Estimated number and proportion of avoidable smoking-related cancers 2021–2050 (30 years) under different scenarios in China, compared
with constant levels.

would be reduced to 10% between 2021 and 2030, about
6,523,841 (8.21%) and 398,478 (0.89%) of smoking-
related cancer cases could be prevented in males and
females, respectively. Under a more manageable target
(Scenario 3), in which the proportion of smoking was
reduced to 20% by 2030, the proportion of avoidable
smoking-related cancer cases would be 2.92%
(2,323,469) for males and 0.32% (141,910) for females.
The cancer with the largest absolute numbers and
highest proportion of potentially preventable cancer
cases was lung cancer.
The annual number of prevented cancer cases under
different scenarios was explicitly shown in Fig. 1A and
B. In the scenario of an elimination of smoking in
Chinese adults, approximately 810,000 and 50,000 can-
cer cases in males and females, respectively, were

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Fig. 1: Total number of annually prevented cancer cases over a 30-year period (2021–2050) for different scenarios of smoking (A and B), alcohol
consumption (C and D) and overweight/obesity (E and F) in the Chinese adults, stratified by sex. A and B: Scenario 1: Elimination: An absolute
elimination of tobacco smoking by 2030; Scenario 2: Ambitious target: Overall prevalence of tobacco smoking reduces to 10% by 2030;
Scenario 3: Manageable target: Overall prevalence of tobacco smoking reduces to 20% by 2030. C and D: Scenario 1: Elimination: (a) An absolute
elimination of alcohol use by 2030; (b) An absolute elimination of dangerous use and harmful use of alcohol by 2030; (c) An absolute
elimination of harmful use of alcohol by 2030; Scenario 2: Ambitious target: A 50% relative reduction in dangerous use and harmful use of
alcohol by 2030; Scenario 3: Manageable target: A 20% relative reduction in harmful use of alcohol by 2030. E and F: Scenario 1: Elimination: (a)
A total elimination of overweight and obesity by 2030; (b) A total elimination of obesity by 2030; Scenario 2: Ambitious target: A 50% relative
reduction in overweight and obesity by 2030; Scenario 3: Manageable target: Growth rate of obesity reduces to 0 by 2030.

6 www.thelancet.com Vol 63 September, 2023

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Cancer site (ICD-10 code) Scenario 1 (a)a Scenario 1 (b)a Scenario 1 (c)a Scenario 2b Scenario 3c
No. (%) avoided No. (%) avoided No. (%) avoided No. (%) avoided No. (%) avoided
Males
Oral cavity, pharynx (C00–C14) 338,508 12.48 195,823 7.22 145,830 5.38 98,028 3.61 29,320 1.08
Oesophagus (C15, SCC) 2,443,849 34.47 1,753,880 24.74 1,399,572 19.74 877,957 12.38 281,331 3.97
Stomach (C16) 187,611 1.60 187,611 1.60 136,620 1.16 93,909 0.80 27,459 0.23
Colorectum (C18–C20) 739,460 7.00 739,460 7.00 549,414 5.20 370,120 3.51 110,403 1.05
Liver (C22) 1,222,165 11.17 1,222,165 11.17 924,191 8.45 611,805 5.59 185,806 1.70
Larynx (C32) 128,622 12.64 76,946 7.56 57,409 5.64 38,515 3.78 11,539 1.13
Total (2021–2050) 5,060,215 11.49 4,175,885 9.48 3,213,035 7.29 2,090,334 4.75 645,857 1.47
Females
Oral cavity, pharynx (C00–C14) 53,617 4.45 15,050 1.25 10,677 0.89 7533 0.62 2146 0.18
Oesophagus (C15, SCC) 106,162 3.79 37,713 1.35 26,921 0.96 18,876 0.67 5410 0.19
Stomach (C16) 2451 0.05 2451 0.05 2451 0.05 1227 0.02 492 0.01
Colorectum (C18–C20) 10,435 0.13 10,435 0.13 6985 0.09 5223 0.07 1403 0.02
Liver (C22) 15,312 0.34 15,312 0.34 15,312 0.34 7665 0.17 3077 0.07
Larynx (C32) 3597 3.36 1078 1.01 764 0.71 539 0.50 153 0.14
Breast (C50, female, premenopausal) 23,303 0.88 2737 0.10 1518 0.06 1370 0.05 306 0.01
Breast (C50, female, postmenopausal) 107,576 1.39 23,018 0.30 15,561 0.20 11,522 0.15 3128 0.04
Total (2021–2050) 322,453 1.00 107,793 0.33 80,189 0.25 53,956 0.17 16,116 0.05
Males and females
Oral cavity, pharynx (C00–C14) 392,125 10.01 210,873 5.38 156,506 3.99 105,561 2.69 31,466 0.80
Oesophagus (C15, SCC) 2,550,011 25.78 1,791,593 18.11 1,426,494 14.42 896,834 9.07 286,741 2.90
Stomach (C16) 190,062 1.12 190,062 1.12 139,070 0.82 95,136 0.56 27,952 0.16
Colorectum (C18–C20) 749,896 4.08 749,896 4.08 556,399 3.03 375,343 2.04 111,806 0.61
Liver (C22) 1,237,477 7.98 1,237,477 7.98 939,503 6.06 619,470 4.00 188,883 1.22
Larynx (C32) 132,219 11.76 78,023 6.94 58,173 5.17 39,055 3.47 11,692 1.04
Breast (C50, female, premenopausal) 23,303 0.88 2737 0.10 1518 0.06 1370 0.05 306 0.01
Breast (C50, female, postmenopausal) 107,576 1.39 23,018 0.30 15,561 0.20 11,522 0.15 3128 0.04
Total (2021–2050) 5,382,669 7.06 4,283,678 5.62 3,293,224 4.32 2,144,290 2.81 661,974 0.87
SCC: squamous cell carcinoma. aScenario 1: Elimination: (a) An absolute elimination of alcohol use by 2030; (b) An absolute elimination of dangerous use and harmful use of
alcohol by 2030; (c) An absolute elimination of harmful use of alcohol by 2030. bScenario 2: Ambitious target: a 50% relative reduction in dangerous use and harmful use of
alcohol by 2030. cScenario 3: Manageable target: a 20% relative reduction in harmful use of alcohol by 2030.

Table 3: Estimated number and proportion of avoidable alcohol-related cancers 2021–2050 (30 years) under different scenarios in China, compared
with constant levels.

estimated to be avoided annually, when the impact of
the intervention scenarios has reached their full effect.
Alcohol consumption
Table 3 showed the number and proportion of ex-
pected avoidable alcohol-related cancer cases accord-
ing to gender under various scenarios. An absolute
elimination of alcohol (Scenario 1 (a)) or dangerous
use and harmful use of alcohol (Scenario 1 (b)) or
harmful use of alcohol (Scenario 1 (c)) by 2030 in the
total Chinese adults would lead to a reduction of
about 5,060,215 (11.49%), 4,175,885 (9.48%) or
3,213,035 (7.29%) incident cancer cases in males. For
females, analogous estimates amount to about
322,453 (1.00%), 107,793 (0.33%) or 80,189 (0.25%)
prevented cancers for the respective intervention
scenarios. Compared to the reference scenario of
constant levels of alcohol consumption, approxi-
mately 2,090,334 (4.75%) and 53,956 (0.17%) alcohol-
related cancer cases in males and females,
respectively, can be avoided over the 30-year period if
there is a 50% relative reduction in dangerous use
and harmful use of alcohol by 2030 in the total Chi-
nese adults (Scenario 2). Under the manageable target
(Scenario 3), in which the proportion of harmful use
of alcohol was reduced by 20% by 2030, we estimated
645,857 (1.47%) and 16,116 (0.05%) of alcohol-related
cancers would be avoided among males and females
respectively.
By cancer site, under no consumption scenario
(Scenario 1 (a)), cancers with the highest proportion of
potentially preventable were oesophageal SCC and can-
cers of larynx and liver among males and females.
Cancers with the largest absolute numbers of potentially
avoidable cancer cases were oesophageal SCC, cancers
of liver and colorectum among males, and post-
menopausal breast cancer, oesophageal SCC and can-
cers of oral cavity and pharynx among females (Table 3).
Fig. 1C and D demonstrated the impact of different
intervention scenarios by presenting the total number of

www.thelancet.com Vol 63 September, 2023 7

 Articles
annually prevented cancer cases from 2021 to 2050. In
the scenario of an elimination of alcohol consumption
in Chinese adults, approximately 220,000 cases and
14,000 cases in males and females, respectively, were
estimated to be avoided annually, starting from the
point in time when the impact of the hypothetical
intervention would have completely indicated in cancer
risk.
Overweight/obesity
Table 4 showed the estimated total numbers and pro-
portion of avoidable cancer cases under different sce-
narios of changing the proportion of overweight/obesity
in Chinese adults. In the ideal scenario (Scenario 1(a)),
where overweight and obesity were eradicated in Chi-
nese adults by 2030, 2,772,792 (7.91%) and 3,093,623
(8.52%) overweight/obesity-related cancer cases in
males and females, respectively, can be prevented over
the 30-year period. An absolute elimination of obesity
(Scenario 1 (b)) by 2030 in the total Chinese adults
would lead to a reduction of about 1,227,222 (3.50%)
incident cancer cases in males and 1,535,492 (4.23%)
cases in females. Approximately 1,388,799 (3.96%) and
1,548,171 (4.26%) alcohol-related cancer cases in males
and females, respectively, can be avoided over the 30-
year period if there is a 50% relative reduction in over-
weight and obesity by 2030 in the total Chinese adults
(Scenario 2). If the prevalence of obesity continued to
rise and the growth rate reduced to 0 over the period
2021–2030 (Scenario 3), we estimated a 0.81% (283,079)
increase in obesity-related cancers in males and 0.97%
(353,994) in females over the 30-year period.
Under the ideal scenario (Scenario 1(a)), the cancer
sites with the highest proportion of potentially avoidable
cases were oesophageal (adenocarcinoma (AC)), kidney,
renal pelvis and liver cancers among males, and oeso-
phageal (AC), corpus uteri and breast (female, post-
menopausal) cancers among females. The cancer sites
with the highest numbers of potentially avoidable cases
were liver, colorectum and stomach cancers among
males, and breast (female, postmenopausal), liver and
corpus uteri cancers among females.
Total number of annually prevented cancer cases
over a 30-year period (2021–2050) for different scenarios
of overweight/obesity in the Chinese adults stratified by
sex was explicitly shown in Fig. 1E and F. In the most
ideal scenario (Scenario 1(a)), where overweight and
obesity were eliminated in Chinese adults by 2030,
approximately 140,000 and 156,000 cancer cases in
males and females, respectively, were estimated to be
avoided annually, when the impact of the intervention
scenarios has reached their full effect.
Sensitivity analyses
In our sensitivity analyses, we used varying LAT and
LAG, as well as the lower and upper limit of the 95%
confidence interval of the cancer-specific relative risk
8 www.thelancet.com Vol 63 September, 2023
estimates, and then compared the numbers of pre-
vented cancers (Supplementary Figs. S2–S7 and
Tables S6–S8). Results from the sensitivity analyses
showed that the number of avoidable cancers differed
somewhat between the different analyses, but the per-
centage of avoidable cancers was fairly robust.
Assuming different LAT for the scenario of eliminating
smoking led to more total avoidable cancer cases, from
11,379,259 cases to 13,426,042 cases for both sexes
combined. In the sensitivity analyses, when used lower
and upper confidence limits of the relative risk, esti-
mates of cumulative prevented incident cancer cases by
eliminating smoking over the 30-year study period
ranged from 6,972,529 cases to 14,418,076 cases for
males, and from 297,404 cases to 1,258,526 cases for
females.
Using varying LAG and LAT, estimates of total pre-
vented cancer cases by eliminating alcohol use were
from 3,242,661 cases to 5,382,668 cases for both sexes
combined over the 30-year study period (2021–2050).
Further sensitivity analyses using lower and upper
confidence limits of the relative risk estimates resulted
in total avoidable cancer cases in the range from
2,400,948 cases to 7,676,279 cases for males, and from
177,371 cases to 506,048 cases for females.
Assuming diverse LAG and LAT for the scenario of
eliminating overweight and obesity, estimates of total
prevented overweight/obesity-related cancer cases went
from 3,957,806 cases to 5,866,415 cases for both sexes
combined. Sensitivity analyses, using the lower and
upper limit of the 95% confidence interval of the cancer-
specific relative risk estimates, estimates of cumulative
avoidable cancer cases over the 30-year study period
ranged from 1,445,003 cases to 4,196,084 cases for
males, and from 1,881,443 cases to 4,271,586 cases for
females.
Discussion
Based on a macro-simulation modelling approach, we
illustrated the health effect of different scenarios of
changing the prevalence of smoking, alcohol use and
overweight/obesity. We found that approximately
13.50% and 1.47% cancer cases in males and females,
respectively, were estimated to be avoided over a 30-year
period (2021–2050) if smoking was eliminated in Chi-
nese adults by 2030. Up to 11.49% of alcohol-related
cancers among males and 1.00% among females could
be prevented over a 30-year period if alcohol was elim-
inated from Chinese adults by 2030. An estimated
7.91% of overweight/obesity-related cancers in males
and 8.52% in females could be avoided over a 30-year
period if everyone could have normal weight by 2030.
Other scenarios, with more moderate goals in the
exposure prevalence of smoking, alcohol use and over-
weight/obesity were also found to be associated with
substantial reductions in the future cancer burden.
 Articles

Cancer site (ICD-10 code) Scenario 1 (a)a Scenario 1 (b)a Scenario 2b Scenario 3c
No. (%) avoided No. (%) avoided No. (%) avoided No. (%) avoided
Males
Oesophagus (C15, AC) 113,661 16.19 50,316 7.17 56,928 8.11 −11,570 −1.65
Stomach (C16.0, cardia) 427,474 7.43 179,767 3.13 214,183 3.72 −41,462 −0.72
Colorectum (C18–C20) 657,477 6.23 283,883 2.69 329,358 3.12 −65,309 −0.62
Liver (C22) 1,102,400 10.08 498,459 4.56 552,079 5.05 −115,191 −1.05
Gallbladder (C23–C24) 99,000 8.13 42,684 3.50 49,593 4.07 −9810 −0.81
Pancreas (C25) 95,981 3.74 40,468 1.57 48,088 1.87 −9305 −0.36
Kidney, renal pelvis (C64–C65) 176,564 10.29 80,372 4.68 88,417 5.15 −18,531 −1.08
Thyroid (C73) 100,236 6.19 51,273 3.17 50,152 3.10 −11,901 −0.74
Total (2021–2050) 2,772,792 7.91 1,227,222 3.50 1,388,799 3.96 −283,079 −0.81
Females
Oesophagus (C15, AC) 49,384 16.25 24,805 8.16 24,710 8.13 −5688 −1.87
Stomach (C16.0, cardia) 177,886 8.42 85,993 4.07 89,039 4.21 −19,815 −0.94
Colorectum (C18–C20) 323,528 4.14 155,131 1.99 161,945 2.07 −35,621 −0.46
Liver (C22) 507,279 11.11 250,937 5.50 253,864 5.56 −57,672 −1.26
Gallbladder (C23–C24) 142,936 9.75 70,340 4.80 71,533 4.88 −16,129 −1.10
Pancreas (C25) 88,133 4.19 42,217 2.01 44,115 2.10 −9678 −0.46
Breast (C50, female, postmenopausal) 1,030,379 13.29 518,828 6.69 515,588 6.65 −119,725 −1.54
Corpus uteri (C54–C55) 392,462 16.14 201,402 8.28 196,358 8.07 −46,651 −1.92
Ovary (C56) 45,226 2.36 21,528 1.12 22,641 1.18 −4977 −0.26
Kidney, renal pelvis (C64–C65) 105,355 10.54 52,310 5.23 52,723 5.27 −12,033 −1.20
Thyroid (C73) 231,054 4.76 111,999 2.31 115,656 2.38 −26,004 −0.54
Total (2021–2050) 3,093,623 8.52 1,535,492 4.23 1,548,171 4.26 −353,994 −0.97
Males and females
Oesophagus (C15, AC) 163,045 16.21 75,122 7.47 81,638 8.12 −17,257 −1.72
Stomach (C16.0, cardia) 605,360 7.70 265,760 3.38 303,222 3.86 −61,277 −0.78
Colorectum (C18–C20) 981,005 5.34 439,013 2.39 491,303 2.67 −100,930 −0.55
Liver (C22) 1,609,679 10.38 749,396 4.83 805,943 5.20 −172,863 −1.11
Gallbladder (C23–C24) 241,935 9.01 113,025 4.21 121,126 4.51 −25,939 −0.97
pancreas (C25) 184,113 3.94 82,685 1.77 92,204 1.97 −18,984 −0.41
Breast (C50, female, postmenopausal) 1,030,379 13.29 518,828 6.69 515,588 6.65 −119,725 −1.54
Corpus uteri (C54–C55) 392,462 16.14 201,402 8.28 196,358 8.07 −46,651 −1.92
Ovary (C56) 45,226 2.36 21,528 1.12 22,641 1.18 −4977 −0.26
Kidney, renal pelvis (C64–C65) 281,919 10.38 132,682 4.89 141,140 5.20 −30,564 −1.13
Thyroid (C73) 331,290 5.12 163,272 2.52 165,808 2.56 −37,904 −0.59
Total (2021–2050) 5,866,415 8.22 2,762,713 3.87 2,936,970 4.11 −637,072 −0.89
a b
AC: adenocarcinoma. Scenario 1: Elimination: (a) An absolute elimination of overweight and obesity by 2030; (b) An absolute elimination of obesity by 2030. Scenario 2:
Ambitious target: a 50% relative reduction in overweight and obesity by 2030. cScenario 3: Manageable target: growth rate of obesity reduces to 0 by 2030.

Table 4: Estimated number and proportion of avoidable overweight/obesity-related cancers 2021–2050 (30 years) under different scenarios in China,
compared with constant levels.

Very few studies have used the same approaches to
model the potential impact of smoking, alcohol use and
overweight/obesity interventions on cancer incidence in
China. It was estimated that 19.3% smoking-related
cancer cases in the Nordic countries could be avoided
during 2016–2045 if smoking was eliminated from 2016
onwards.32 A study of Australia reported that over a 30-
year period, 3.90% (males: 6.40%; females: 2.5%) of
alcohol-related cancers could be prevented if alcohol
consumption was eliminated in the population.33
Another study of Nordic countries28 estimated that
9.50% of overweight/obesity related cancers in the
population could be prevented over a 30-year study
(2016–2045) period if they obtained normal weight from
2016 onwards. Our results of the theoretical maximum
intervention (13.50% males, 1.47% females, for smok-
ing; 11.49% males, 1.00% females, for alcohol con-
sumption; 7.91% males, 8.52% females, for overweight/
obesity) were discrepant from these results, though we
using similar parameters and timeframe. One possible
explanation is the difference in the prevalence of
smoking, alcohol use and overweight/obesity between
regions. For example, 66% of males and 49% of females
were defined as drinkers in Australia,33 while there were
60.3% of males and 19.1% of females consuming
alcohol in China.4 Another possible reason is that the

www.thelancet.com Vol 63 September, 2023 9

 Articles
cancer burden distribution in China was substantially
different from other countries. In China, lung cancer
was the most common cancer in cancer, followed by
female breast cancer, colorectal cancer, stomach cancer,
liver cancer and oesophageal cancer.13 Taking oesopha-
geal SCC and alcohol consumption for example, in our
study, alcohol-related cancers with the largest absolute
numbers and the highest proportion of potentially pre-
ventable were oesophageal SCC, which is obviously
distinct from western countries. Finally, the variation in
RR values in different studies might partly account for
the differences.
Like all such modelling studies, the accuracy of our
model is heavily dependent on a number of assump-
tions and the input data. Our exposure prevalence of
smoking, alcohol consumption and overweight/obesity
were from a nationally representative survey4,9; however,
we did not have detailed data so that we cannot treated
alcohol use and BMI as continuous covariate or divide
alcohol use into more groups. Our reference scenario
has no change in cancer incidence rate over a 30-year
period, with the variations in numbers of future can-
cer cases per year resulting from population changes. It
can provide a stable base for comparing across cancers
and acquire the full impact of the modelled intervention
scenarios versus the reference scenario, as the only
difference between the two scenarios are due to differ-
ences in the prevalence of the exposure. This approach
may underestimate future cancer incidence, but it does
not require assumptions to be made about projected
trends in cancer incidence by sex, age, area (urban/ru-
ral) and cancer type, and thus avoiding uncertainty to
these current projections. When choosing cancer caus-
ally associated with smoking, alcohol consumption and
overweight/obesity, we followed the reports by the
World Cancer Research Fund (WCRF) and the Inter-
national Agency for Research on Cancer (IARC) work-
ing group (Table 1).12 Moreover, summary relative risks
(RRs) came from recent large-scale pooled analyses or
high-quality meta-analyses of studies, providing the best
estimates of the etiology effect of the risk factors.
We tested a number of assumptions in sensitivity
analyses. Sensitivity analyses were conducted by using
varying LAT and LAG, as well as the lower and upper
limit of the 95% confidence interval of the cancer-
specific relative risk estimates. These sensitivity ana-
lyses showed that the proportions of prevented cancer
cases were fairly robust to changes in those modelling
parameters and indicated a substantial public health
impact. Even so, the results should be treated carefully
as the main purpose of the model is not to accurately
predict future cancer burden, but rather show the dif-
ference in the number of cases under different exposure
prevalence. Furthermore, our study did not consider the
lag time between specific interventions and consequent
changes in risk factor prevalence. Actually, risk factor
prevalence is influenced by many kinds of interventions.
10
Therefore, to avoid uncertainty, our study assumed that
risk factor prevalence changes from start according to
different scenarios, and our study did not cover which
kind of intervention would be more effective and how
long it would take for the interventions to have an effect.
One of the advantages of our modelling approach
introduced a time dimension, including LAG and LAT
reflecting delayed changes in risk after the cessation of
exposure. Moreover, we incorporated the changes in
population size and structure into the projection.
To our knowledge, our study is the first analysis that
has systematically assessed the health effect of varying
intervention scenarios with different prevalence of
smoking, alcohol consumption and overweight/obesity
in Chinese adults. However, our study has some limi-
tations. Firstly, due to the lack of data, we could not
consider interactions between smoking, alcohol con-
sumption and overweight/obesity in our models. How-
ever, etiologic effects used in our study were from
multivariate models adjusting for related risk factors.
Secondly, some etiological effects of risk factors used in
this study were from western populations. Future esti-
mations among Chinese populations are warranted
when data become available.
The results from our simulation modelling study can
be used to understand the potential impact and signifi-
cance of primary prevention interventions aiming to
reduce the prevalence of smoking, alcohol consumption
and overweight/obesity in Chinese adults. This is
especially important because the connection between
smoking, alcohol consumption, overweight/obesity and
cancer risk is not well known among the public. For
example, only about 60% of population know that
smoking can cause many malignancies other than lung
cancer.34 Furthermore, our results should motivate
public health planners and policymakers to take effec-
tive action, especially given that smoking, alcohol use
and overweight/obesity have also been causally associ-
ated with other diseases.
Contributors
Jiansong Ren contributed to funding acquisition of the study. Song
Song, Lin Lei, Ji Peng and Jiansong Ren co-designed the study. Song
Song, Lin Lei, Ji Peng and Jiansong Ren accessed and verified the un-
derlying data reported in the manuscript. Song Song and Fan Yang
contributed to the analysis and visualization of the study. Song Song
drafted the manuscript. Lin Lei, Han Liu, Fan Yang, Ni Li, Wanqing
Chen, Ji Peng and Jiansong Ren contributed to the validation of the
analysis and study findings, and critically revised the manuscript for
intellectual content. All authors approved the final version of the
manuscript. All authors had full access to all the data in the study and
had final responsibility for the decision to submit for publication.
Data sharing statement
This study does not involve any patient data or participant data. Readers
can access the data used in this study from the links to public domain
resources provided in the Manuscript and Supplementary materials.
Declaration of interests
All authors declare no conflict of interest.
www.thelancet.com Vol 63 September, 2023

Acknowledgements
We acknowledge funding from the National Science & Technology
Fundamental Resources Investigation Program of China
(2019FY101105); Sanming Project of Medicine in Shenzhen (SZSM
201911015).
Appendix A. Supplementary data
Supplementary data related to this article can be found at https://doi.
org/10.1016/j.eclinm.2023.102163.
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