Summary Background Understanding the magnitude of cancer burden attributable to potentially modifiable risk factors is crucial for development of effective prevention and mitigation strategies. We analysed results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 to inform cancer control planning efforts globally. Methods The GBD 2019 comparative risk assessment framework was used to estimate cancer burden attributable to behavioural, environmental and occupational, and metabolic risk factors. A total of 82 risk–outcome pairs were included on the basis of the World Cancer Research Fund criteria. Estimated cancer deaths and disability-adjusted life-years (DALYs) in 2019 and change in these measures between 2010 and 2019 are presented. Findings Globally, in 2019, the risk factors included in this analysis accounted for 4·45 million (95% uncertainty interval 4·01–4·94) deaths and 105 million (95·0–116) DALYs for both sexes combined, representing 44·4% (41·3–48·4) of all cancer deaths and 42·0% (39·1–45·6) of all DALYs. There were 2·88 million (2·60–3·18) risk-attributable cancer deaths in males (50·6% [47·8–54·1] of all male cancer deaths) and 1·58 million (1·36–1·84) risk-attributable cancer deaths in females (36·3% [32·5–41·3] of all female cancer deaths). The leading risk factors at the most detailed level globally for risk-attributable cancer deaths and DALYs in 2019 for both sexes combined were smoking, followed by alcohol use and high BMI. Risk-attributable cancer burden varied by world region and Socio-demographic Index (SDI), with smoking, unsafe sex, and alcohol use being the three leading risk factors for risk-attributable cancer DALYs in low SDI locations in 2019, whereas DALYs in high SDI locations mirrored the top three global risk factor rankings. From 2010 to 2019, global risk-attributable cancer deaths increased by 20·4% (12·6–28·4) and DALYs by 16·8% (8·8–25·0), with the greatest percentage increase in metabolic risks (34·7% [27·9–42·8] and 33·3% [25·8–42·0]). Interpretation The leading risk factors contributing to global cancer burden in 2019 were behavioural, whereas metabolic risk factors saw the largest increases between 2010 and 2019. Reducing exposure to these modifiable risk factors would decrease cancer mortality and DALY rates worldwide, and policies should be tailored appropriately to local cancer risk factor burden. Funding Bill & Melinda Gates Foundation.
Introduction 1 Kocarnik JM
Compton K
Dean FE
et al. Cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life years for 29 cancer groups from 2010 to 2019: a systematic analysis for the Global Burden of Disease Study 2019. , 2 Hecht SS Cigarette smoking and lung cancer: chemical mechanisms and approaches to prevention. , 3 Bianchini F
Kaaks R
Vainio H Overweight, obesity, and cancer risk. , 4 Lichtenstein P
Holm NV
Verkasalo PK
et al. Environmental and heritable factors in the causation of cancer—analyses of cohorts of twins from Sweden, Denmark, and Finland. 5 Richards M
Anderson M
Carter P
Ebert BL
Mossialos E The impact of the COVID-19 pandemic on cancer care. , 6 Sharpless NE COVID-19 and cancer. , 7 Maringe C
Spicer J
Morris M
et al. The impact of the COVID-19 pandemic on cancer deaths due to delays in diagnosis in England, UK: a national, population-based, modelling study. Cancer is the second leading cause of death worldwide, and exposure to risk factors plays an important role in the biology and burden of many cancer types.Understanding the relative contribution of modifiable risk factors to cancer burden and their trends over time is crucial to informing cancer control efforts both locally and globally. In 2015, the UN released the Sustainable Development Goals (SDGs), with SDG target 3.4 focusing on reducing global premature mortality by a third for non-communicable diseases, including cancer, by 2030. Effectively addressing the growing burden of cancer globally will require comprehensive measures that incorporate both curative and preventive interventions, particularly in light of the anticipated challenges that the COVID-19 pandemic will bring in progress towards SDG target 3.4. 8 Winn AN
Ekwueme DU
Guy Jr, GP
Neumann PJ Cost-utility analysis of cancer prevention, treatment, and control: a systematic review. 9 Doll R
Peto R The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. , 10 Evans J
van Donkelaar A
Martin RV
et al. Estimates of global mortality attributable to particulate air pollution using satellite imagery. , 11 Pukkala E
Martinsen JI
Lynge E
et al. Occupation and cancer—follow-up of 15 million people in five Nordic countries. , 12 Takala J Eliminating occupational cancer. , 13 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. , 14 Poirier AE
Ruan Y
Volesky KD
et al. The current and future burden of cancer attributable to modifiable risk factors in Canada: summary of results. , 15 Boffetta P
Tubiana M
Hill C
et al. The causes of cancer in France. , 16 Parkin DM
Boyd L
Walker LC 16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. , 17 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. , 18 Whiteman DC
Webb PM
Green AC
et al. Cancers in Australia in 2010 attributable to modifiable factors: summary and conclusions. , 19 Wang JB
Jiang Y
Liang H
et al. Attributable causes of cancer in China. , 20 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. 21 Arnold M
Pandeya N
Byrnes G
et al. Global burden of cancer attributable to high body-mass index in 2012: a population-based study. , 22 Rumgay H
Shield K
Charvat H
et al. Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study. , 23 de Martel C
Georges D
Bray F
Ferlay J
Clifford GM Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. , 24 Arnold M
de Vries E
Whiteman DC
et al. Global burden of cutaneous melanoma attributable to ultraviolet radiation in 2012. Although some cancer cases are not preventable, governments can work on a population level to support an environment that minimises exposure to known cancer risk factors. Primary prevention, or the prevention of a cancer developing, is a particularly cost-effective strategy,although it must be paired with more comprehensive efforts to address cancer burden, including secondary prevention initiatives, such as screening programmes, and ensuring effective capacity to diagnose and treat those with cancer. As part of cancer control strategies, prevention requires identification of causal risk factors, determination of contribution to local cancer burden, and development of effective strategies for their mitigation. Previous studies have quantified the burden of cancer attributable to individual risk factors globally or for several risk factors in select countries and regions,providing crucial location and risk-factor-specific information. However, comprehensive cancer risk factor estimates do not exist for many countries, leaving an important void as countries develop and update their cancer control plans. The Global Cancer Observatory from the International Agency for Research on Cancer provides estimates of global, regional, and national risk-attributable cancer burden for a subset of potentially modifiable risk factors (eg, obesity, alcohol consumption, infections, and ultraviolet radiation), but these estimates are not provided together in a comprehensive fashion across time, and some potentially modifiable risk factors are not estimated as part of this effort. Research in context Evidence before this study We identified previous work that primarily estimated the attributable cancer burden for single risk factors globally or multiple risk factors for single countries. The Global Cancer Observatory also provides estimates of cancer-attributable burden for select risk factor categories separately. One previous comparative risk assessment project estimated risk-attributable cancer mortality for nine risk factors. We searched titles and abstracts in PubMed for English-language research papers that were published between Jan 1, 2010, and June 1, 2021, using the search terms “cancer or neoplasm or tumor or malignancy” and “risk factor or attributable risk or population attributable fraction” and “global or international or worldwide or world” and “burden or metrics or incidence or mortality”, but did not identify additional informative studies. There is a gap in the literature on global estimates of risk-attributable cancer burden for a comprehensive list of risk factors that incorporate both cancer-related mortality and disability. Added value of this study We report, for the first time, the global cancer burden attributable to a comprehensive list of behavioural, metabolic, and environmental and occupational risk factors using Global Burden of Diseases, Injuries, and Risk Factors 2019 results. By estimating risk-attributable cancer burden nationally and globally using both mortality and disability-adjusted life-years (DALYs), this study provides a new perspective on attributable cancer burden. Globally, a large portion of cancer deaths and DALYs were attributable to the modifiable risk factors included, with behavioural risks representing the largest attributable burden. We identified substantial differences in attributable cancer death and DALY burden across Socio-demographic Index quintiles and between sexes. Risk-attributable cancer death and DALY burden increased globally from 2010 to 2019, with metabolic risk factors contributing to the largest percentage increases, most notably in low and low-middle Socio-demographic Index countries. Implications of all the available evidence The burden of cancer remains an important public health challenge that is growing in magnitude globally. Modifiable risk factors are important contributors to cancer mortality and DALYs globally, with contribution varying by setting. The results from this study highlight the need for context-specific policies aimed at reducing exposure to risk factors as part of comprehensive cancer control efforts. 25 Danaei G
Vander Hoorn S
Lopez AD
Murray CJ
Ezzati M Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. 26 GBD 2019 Risk Factors Collaborators
Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. To our knowledge, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) is the only study to date that quantifies cancer burden attributable to a broad set of modifiable risk factors for each GBD round, for all countries around the world, across age groups, for both sexes, and over time. GBD 2019, the most recent iteration of the GBD study, provides an opportunity to evaluate the global burden of cancer attributable to risk factors. A previous study used a similar comparative risk framework to estimate mortality from 12 cancer types and nine behavioural and environmental risk factors based on WHO cancer mortality data, but this analysis was limited to 2001 and has not been updated in a formal GBD analysis since.Herein, we present estimates of 82 risk–outcome pairs, including cancer deaths and disability-adjusted life-years (DALYs) attributable to risk factors at global, regional, and national levels in 2019, and assess the temporal trends from 2010 to 2019 of cancer burden attributable to environmental and occupational, behavioural, and metabolic risk factors to inform efforts to reduce exposure to cancer risk factors ( appendix pp 157–60 ).This manuscript was produced as part of the GBD Collaborator Network and in accordance with the GBD Protocol.
Discussion Our analysis found that 44·4% (95% UI 41·3–48·4) of global cancer deaths and 42·0% (39·1–45·6) of global cancer DALYs were attributable to estimated risk factors in 2019. These findings highlight that a substantial proportion of cancer burden globally has potential for prevention through interventions aimed at reducing exposure to known cancer risk factors but also that a large proportion of cancer burden might not be avoidable through control of the risk factors currently estimated. Thus, cancer risk reduction efforts must be coupled with comprehensive cancer control strategies that include efforts to support early diagnosis and effective treatment. Most attributable cancer DALYs were accounted for by behavioural risk factors, such as tobacco use, alcohol use, unsafe sex, and dietary risks, suggesting a need for concerted efforts to address behavioural risk factors to effectively reduce cancer burden globally. Attributable cancer DALYs from each Level 1 risk factor group generally increased with increasing SDI, and although there were similarities in the leading risk factors across the SDI spectrum for both sexes combined (ie, smoking and alcohol use), there were differences in risk factor patterns following these leading risks, highlighting the need for cancer risk reduction efforts to be context specific. Between 2010 and 2019, age-standardised cancer DALYs attributable to all risk factors declined by 7·8% (1·4 to 14·0). Despite this decline, a global increase in age-standardised cancer DALYs (3·8% [–2·0 to 10·5]) attributable to metabolic risks was seen, largely driven by substantial increases in low and low-middle SDI countries. Furthermore, total risk-attributable cancer absolute DALY burden globally and in all SDI quintiles grew between 2010 and 2019, underscoring an expanding need for health systems around the world with capacity to comprehensively care for individuals with cancer, while developing and implementing cancer control efforts that consider risk reduction strategies. These estimates might help inform cancer control planning by identifying leading modifiable risk factors for cancer around the world, including for countries that might not have previous local research on cancer burden and cancer risk factor exposures. 9 Doll R
Peto R The causes of cancer: quantitative estimates of avoidable risks of cancer in the United States today. , 13 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. , 14 Poirier AE
Ruan Y
Volesky KD
et al. The current and future burden of cancer attributable to modifiable risk factors in Canada: summary of results. , 15 Boffetta P
Tubiana M
Hill C
et al. The causes of cancer in France. , 16 Parkin DM
Boyd L
Walker LC 16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. , 17 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. , 18 Whiteman DC
Webb PM
Green AC
et al. Cancers in Australia in 2010 attributable to modifiable factors: summary and conclusions. , 19 Wang JB
Jiang Y
Liang H
et al. Attributable causes of cancer in China. , 20 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. , 33 Schottenfeld D
Beebe-Dimmer JL
Buffler PA
Omenn GS Current perspective on the global and United States cancer burden attributable to lifestyle and environmental risk factors. , 34 Arriaga ME
Vajdic CM
Canfell K
et al. The burden of cancer attributable to modifiable risk factors: the Australian cancer—PAF cohort consortium. 35 Whiteman DC
Wilson LF The fractions of cancer attributable to modifiable factors: a global review. 21 Arnold M
Pandeya N
Byrnes G
et al. Global burden of cancer attributable to high body-mass index in 2012: a population-based study. , 22 Rumgay H
Shield K
Charvat H
et al. Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study. , 23 de Martel C
Georges D
Bray F
Ferlay J
Clifford GM Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. , 24 Arnold M
de Vries E
Whiteman DC
et al. Global burden of cutaneous melanoma attributable to ultraviolet radiation in 2012. , 25 Danaei G
Vander Hoorn S
Lopez AD
Murray CJ
Ezzati M Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. 13 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. , 14 Poirier AE
Ruan Y
Volesky KD
et al. The current and future burden of cancer attributable to modifiable risk factors in Canada: summary of results. , 15 Boffetta P
Tubiana M
Hill C
et al. The causes of cancer in France. , 16 Parkin DM
Boyd L
Walker LC 16. The fraction of cancer attributable to lifestyle and environmental factors in the UK in 2010. , 17 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. , 18 Whiteman DC
Webb PM
Green AC
et al. Cancers in Australia in 2010 attributable to modifiable factors: summary and conclusions. , 19 Wang JB
Jiang Y
Liang H
et al. Attributable causes of cancer in China. , 20 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. 25 Danaei G
Vander Hoorn S
Lopez AD
Murray CJ
Ezzati M Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. 21 Arnold M
Pandeya N
Byrnes G
et al. Global burden of cancer attributable to high body-mass index in 2012: a population-based study. , 22 Rumgay H
Shield K
Charvat H
et al. Global burden of cancer in 2020 attributable to alcohol consumption: a population-based study. 23 de Martel C
Georges D
Bray F
Ferlay J
Clifford GM Global burden of cancer attributable to infections in 2018: a worldwide incidence analysis. 24 Arnold M
de Vries E
Whiteman DC
et al. Global burden of cutaneous melanoma attributable to ultraviolet radiation in 2012. To our knowledge, this study represents the largest effort to date to determine the global burden of cancer attributable to risk factors, and it contributes to a growing body of evidence aimed at estimating the risk-attributable burden for specific cancers nationally,internationally,and globally.Our study builds on existing evidence by estimating both deaths and DALYs due to risk-attributable cancer burden, across a spectrum of cancer types and risk factors, for all countries, age groups, and sexes, over time. When comparing the results from this study with studies reporting national-level population attributable fraction estimates, GBD 2019 generally reported higher values for all risk factors combined. These comparisons are between cases and deaths for a subset of countries and differences might be due to a greater number of risk factors estimated and greater estimates for select risk factors, such as smoking, potentially due to differences in exposure definitions and risk–outcome pairs estimated.When compared with a previous effort to quantify the fatal burden of cancer attributable to risk factors globally, this study found a greater percentage of cancer deaths attributable to risk factors when estimating more risk factors (44·4% [95% UI 41·6–48·2] in 2001 in GBD 2019 compared with 35% in 2001 in the previous study), although both studies found leading contributions by smoking and alcohol use globally and unsafe sex in lower-income settings.Comparisons to comprehensive global risk-attributable cancer burden in the Global Cancer Observatory are not possible, as incidence estimates are provided only for individual risk categories, but for alcohol consumption and elevated BMI, risk factors estimated by both studies, similar estimates of risk-attributable cancer burden were noted (4·1% of new cancer cases in 2020 attributable to alcohol consumption in the Global Cancer Observatory and 4·9% [4·4–5·5] of cancer deaths in 2019 attributable to alcohol use in the GBD study; 3·6% of new cancer cases in 2012 attributable to high BMI in the Global Cancer Observatory and 4·6% [2·7–7·1] of cancer deaths in 2019 attributable to high BMI in the GBD study).For cancer risk factors not included in this study, estimates from the Global Cancer Observatory suggest that an additional approximately 8·9% of cancer cases would be attributable to infections appendix p 67 ) and an additional 1·2% of cancer cases would be attributable to ultraviolet radiation.These estimates should be interpreted with some caution given the different estimation approaches used, but might provide useful information for crucial remaining risk factors not yet included in the GBD study. 13 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. , 17 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. , 18 Whiteman DC
Webb PM
Green AC
et al. Cancers in Australia in 2010 attributable to modifiable factors: summary and conclusions. , 19 Wang JB
Jiang Y
Liang H
et al. Attributable causes of cancer in China. In GBD 2019, large all-age sex differences were seen in the global cancer burden attributable to all risk factors combined (48·0% [95% UI 45·3–51·5] of male cancer DALYs versus 34·3% [30·9–38·7] of female cancer DALYs). These sex differences are well documented, with several studies reporting higher attributable cancer burden in males compared with females.In this study, we identified sex differences across two primary risk factor groupings. For instance, there were disparities in cancer DALYs attributable to behavioural risk factors, such as smoking (33·2% [31·7–34·7] for males vs 8·9% [8·3–9·6] for females) and alcohol use (7·4% [6·7–8·2] for males vs 2·3% [2·0–2·6] for females), which might be driven by higher exposure to these behavioural risk factors among males than females. Similarly, for environmental and occupational risks, for example, the cancer DALYs attributable to occupational carcinogens were three times higher among males (3·9% [3·1–4·8]) than females (1·3% [1·0–1·6]), which might reflect that males are more likely than females to be employed in workplaces with higher risk of exposure to carcinogens. Between 2010 and 2019, the change in global age-standardised risk-attributable cancer DALY rates decreased slightly among females (–4·6% [–11·0 to 2·2]), whereas there was a more notable decline among males (–9·6% [–17·6 to –1·3]). This result might suggest inequities in our approach to cancer prevention by sex and a need for future sex-specific assessments of effective cancer risk factor interventions. 36 Monteiro CA
Moura EC
Conde WL
Popkin BM Socioeconomic status and obesity in adult populations of developing countries: a review. , 37 Katzmarzyk PT
Mason C The physical activity transition. Our results show a gradient across the sociodemographic spectrum in 2019, with the risk-attributable cancer age-standardised DALY rates generally increasing with higher SDI quintiles. However, from 2010 to 2019, age-standardised cancer DALY rates attributable to all risks combined declined in high, high-middle, and middle SDI countries, whereas these values increased in low-middle SDI countries or were approximately stable in low SDI countries. This increase was largely due to metabolic risks, which include risk factors such as high BMI. The growth in metabolic risk-attributable cancer burden might be the result of these countries experiencing an epidemiological transition in which improvements in country-level developmental status are related to increasing obesity levels. 38 Flor LS
Reitsma MB
Gupta V
Ng M
Gakidou E The effects of tobacco control policies on global smoking prevalence. , 39 GBD 2019 Tobacco Collaborators
Spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990–2019: a systematic analysis from the Global Burden of Disease Study 2019. 38 Flor LS
Reitsma MB
Gupta V
Ng M
Gakidou E The effects of tobacco control policies on global smoking prevalence. , 40 Brundtland GH Achieving worldwide tobacco control. 41 WHO
Tackling NCDs: ‘best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. , 42 WHO
Global status report on alcohol and health 2018. , 43 WHO
The SAFER initiative: a world free from alcohol related harm. 44 Szreter S The population health approach in historical perspective. 45 Braveman P
Gottlieb L The social determinants of health: it's time to consider the causes of the causes. , 46 Marmot M
Allen J
Bell R
Bloomer E
Goldblatt P WHO European review of social determinants of health and the health divide. Globally, there has been substantial progress in reducing exposure to tobacco that can be linked to coordinated international and national prevention efforts.Interventions through taxation and regulatory policies for tobacco smoking, including smoke-free policies, increased tobacco taxes, and advertisement bans guided by the WHO Framework Convention on Tobacco Control, have played a major role in these efforts.Similar efforts, including taxation and advertisement bans, have been recommended to help reduce the harmful use of alcohol.Behavioural risk factors are strongly influenced by the environment in which people live and individuals with cancer should not be blamed for their disease. Future research is needed to investigate the effect of population health approaches to cancer risk factor reduction that go beyond individual-oriented prevention and might be more effective long-term strategies than placing the onus on individuals to modify exposures to prevent cancer.Many risk factors for cancer have been well established for decades, but greater political commitment to implementing policies addressing cancer prevention is needed. Improving social determinants of health, such as access to education and reduction of poverty, might be a feasible approach to reducing exposure to certain risks across populations.Population-based approaches aimed at improving social determinants of health might provide an equitable cancer control approach to overcome the systemic barriers promoting disproportionate risk-attributable cancer burden growth in some regions, countries, and subpopulations within countries. For these reasons, future research should not overlook the importance of context-specific interventions that are guided or led by those with an understanding of local cultural and behavioural patterns. Finally, cancers remain fundamentally linked to genetics and ageing, and although addressing contributing risk factors is crucial for cancer prevention, this will never eliminate cancer burden. As a result, countries should continue to invest in comprehensive cancer control strategies beyond risk factor reduction, which include health-care systems capable of early diagnosis, detection through screening for select cancers, and effective treatment options for those diagnosed with cancer. 47 IARC monographs on the evaluation of carcinogenic risks to humans
Solar and ultraviolet radiation. , 48 Polk DB
Peek Jr, RM Helicobacter pylori: gastric cancer and beyond. Although GBD 2019 is the largest effort to date to estimate the global burden of cancer attributable to risk factors, there remain opportunities for improvement. First, some limitations are inherent in the data sources available. For instance, some countries do not have population-based cancer registries, which are an important data source for estimating cancer burden. As is apparent in the relative uncertainty of risk-attributable cancer burden estimated by GBD 2019 ( appendix p 171 ), there is greater uncertainty relative to point estimates in many lower SDI countries as compared with higher SDI countries. GBD study models rely on available data, and estimates should not supplant but rather complement the ongoing crucial work to expand and improve directly observed data around the world. Cancer registry development and support are integral in cancer control efforts and should be considered in broader cancer control planning initiatives. Delays are inherent with the release of cancer registry and vital statistics reports, which result in more recent cancer mortality estimates often relying on historical data. The data used to estimate risk factor exposure is at times sparse and many data sources do not provide sufficient information to assess for potential measurement error or bias. Where there is information available, the GBD study aims to correct for systematic bias in risk exposure data by establishing a reference definition of each risk exposure and adjusting acceptable alternative exposure measurements on the basis of studies with observed data pairs of the two different definitions. However, after these adjustments, residual measurement bias is likely to persist and might vary around the world, over time, and by risk factor. Formal assessments of exposure model performance would be beneficial in future GBD iterations. Second, the risk factors included in this study are based on current knowledge of risk factors for cancer, but as knowledge expands there might be additional risk factors important to incorporate in future iterations of the GBD study. In addition, there are known risk factors for cancer, such as sunlight exposure (ie, ultraviolet radiation), and infectious agents, such as Helicobacter pylori, which are not included in the GBD study.Unsafe sex is estimated as a risk factor, but human papillomavirus, a known risk factor for several cancer types, is not explicitly estimated; and although liver cancer burden due to hepatitis B and C is estimated within the GBD cause hierarchy, these viral infections are not estimated as risk factors, making their inclusion in robust risk-attributable cancer burden estimation challenging. Infection-associated cancers are more notable in lower SDI settings, so addressing these will be important to producing comprehensive global assessments of cancer-attributable risk and disparities. Third, second-order measures of cancer-relevant risk factors, including aspects such as income inequality and racism, would be challenging to comprehensively account for, but could add important context for future health policy work. Finally, GBD 2019 results were estimated before the COVID-19 pandemic. Evaluating the effect of the COVID-19 pandemic on risk-attributable cancer burden is an important area for future research. However, several leading risk factors identified in this study are also linked to an increase in the severity of illness in individuals with COVID-19 and to burden of other non-communicable diseases besides cancer. Thus, reducing exposure to these harmful risk factors might not only have a positive effect on cancer burden reduction efforts, but synergistically improve population health more broadly. Worldwide, a large percentage of cancer deaths and DALYs were attributable to risk factors in 2019, with most being attributable to behavioural risks. Smoking continues to be the leading cancer risk factor globally, with other substantial contributors to cancer burden varying around the world. Targeting leading location-specific cancer risk factors might help countries make progress towards reducing non-communicable disease premature mortality by a third by 2030, as highlighted in SDG target 3.4. Although progress has been seen in high and high-middle SDI countries for behavioural and environmental and occupational risk-attributable cancer age-standardised DALY rates between 2010 and 2019, in low and low-middle SDI countries, metabolic risk-attributable cancer burden has grown considerably. Considerable cancer burden is not avoidable through the currently estimated risk factors, and, as such, countries should continue to simultaneously invest in risk reduction strategies while strengthening health systems to support early diagnosis and effective treatment of those with cancer. Given the increasing burden of cancer worldwide, this study can help policy makers and researchers identify important modifiable risk factors that could be targeted in efforts to reduce cancer burden globally, regionally, and nationally.
GBD 2019 Cancer Risk Factors Collaborators
† Co-first authors † Co-first authors ‡ Co-senior authors ‡ Co-senior authors Khanh Bao Tran, Justin J Lang, Kelly Compton, Rixing Xu, Alistair R Acheson, Hannah Jacqueline Henrikson, Jonathan M Kocarnik, Louise Penberthy, Amirali Aali, Qamar Abbas, Behzad Abbasi, Mohsen Abbasi-Kangevari, Zeinab Abbasi-Kangevari, Hedayat Abbastabar, Michael Abdelmasseh, Sherief Abd-Elsalam, Ahmed Abdelwahab Abdelwahab, Gholamreza Abdoli, Hanan Abdulkadir Abdulkadir, Aidin Abedi, Kedir Hussein Abegaz, Hassan Abidi, Richard Gyan Aboagye, Hassan Abolhassani, Abdorrahim Absalan, Yonas Derso Abtew, Hiwa Abubaker Ali, Eman Abu-Gharbieh, Basavaprabhu Achappa, Juan Manuel Acuna, Daniel Addison, Isaac Yeboah Addo, Oyelola A Adegboye, Miracle Ayomikun Adesina, Mohammad Adnan, Qorinah Estiningtyas Sakilah Adnani, Shailesh M Advani, Sumia Afrin, Muhammad Sohail Afzal, Manik Aggarwal, Bright Opoku Ahinkorah, Araz Ramazan Ahmad, Rizwan Ahmad, Sajjad Ahmad, Sohail Ahmad, Sepideh Ahmadi, Haroon Ahmed, Luai A Ahmed, Muktar Beshir Ahmed, Tarik Ahmed Rashid, Wajeeha Aiman, Marjan Ajami, Gizachew Taddesse Akalu, Mostafa Akbarzadeh-Khiavi, Addis Aklilu, Maxwell Akonde, Chisom Joyqueenet Akunna, Hanadi Al Hamad, Fares Alahdab, Fahad Mashhour Alanezi, Turki M Alanzi, Saleh Ali Alessy, Abdelazeem M Algammal, Mohammed Khaled Al-Hanawi, Robert Kaba Alhassan, Beriwan Abdulqadir Ali, Liaqat Ali, Syed Shujait Ali, Yousef Alimohamadi, Vahid Alipour, Syed Mohamed Aljunid, Motasem Alkhayyat, Sadeq Ali Ali Al-Maweri, Sami Almustanyir, Nivaldo Alonso, Shehabaldin Alqalyoobi, Rajaa M Al-Raddadi, Rami H Hani Al-Rifai, Salman Khalifah Al-Sabah, Ala’a B Al-Tammemi, Haya Altawalah, Nelson Alvis-Guzman, Firehiwot Amare, Edward Kwabena Ameyaw, Javad Javad Aminian Dehkordi, Mohammad Hosein Amirzade-Iranaq, Hubert Amu, Ganiyu Adeniyi Amusa, Robert Ancuceanu, Jason A Anderson, Yaregal Animut Animut, Amir Anoushiravani, Ali Arash Anoushirvani, Alireza Ansari-Moghaddam, Mustafa Geleto Ansha, Benny Antony, Maxwell Hubert Antwi, Sumadi Lukman Anwar, Razique Anwer, Anayochukwu Edward Anyasodor, Jalal Arabloo, Morteza Arab-Zozani, Olatunde Aremu, Ayele Mamo Argaw, Hany Ariffin, Timur Aripov, Muhammad Arshad, Al Artaman, Judie Arulappan, Raphael Taiwo Aruleba, Armin Aryannejad, Malke Asaad, Mulusew A Asemahagn, Zatollah Asemi, Mohammad Asghari-Jafarabadi, Tahira Ashraf, Reza Assadi, Mohammad Athar, Seyyed Shamsadin Athari, Maha Moh’d Wahbi Atout, Sameh Attia, Avinash Aujayeb, Marcel Ausloos, Leticia Avila-Burgos, Atalel Fentahun Awedew, Mamaru Ayenew Awoke, Tewachew Awoke, Beatriz Paulina Ayala Quintanilla, Tegegn Mulatu Ayana, Solomon Shitu Ayen, Davood Azadi, Sina Azadnajafabad, Saber Azami-Aghdash, Melkalem Mamuye Azanaw, Mohammadreza Azangou-Khyavy, Amirhossein Azari Jafari, Hosein Azizi, Ahmed Y Y Azzam, Amirhesam Babajani, Muhammad Badar, Ashish D Badiye, Nayereh Baghcheghi, Nader Bagheri, Sara Bagherieh, Saeed Bahadory, Atif Amin Baig, Jennifer L Baker, Ahad Bakhtiari, Ravleen Kaur Bakshi, Maciej Banach, Indrajit Banerjee, Mainak Bardhan, Francesco Barone-Adesi, Fabio Barra, Amadou Barrow, Nasir Z Bashir, Azadeh Bashiri, Saurav Basu, Abdul-Monim Mohammad Batiha, Aeysha Begum, Alehegn Bekele Bekele, Alemayehu Sayih Belay, Melaku Ashagrie Belete, Uzma Iqbal Belgaumi, Arielle Wilder Bell, Luis Belo, Habib Benzian, Alemshet Yirga Berhie, Amiel Nazer C Bermudez, Eduardo Bernabe, Akshaya Srikanth Bhagavathula, Neeraj Bhala, Bharti Bhandari Bhandari, Nikha Bhardwaj, Pankaj Bhardwaj, Krittika Bhattacharyya, Vijayalakshmi S Bhojaraja, Soumitra S Bhuyan, Sadia Bibi, Awraris Hailu Bilchut, Bagas Suryo Bintoro, Antonio Biondi, Mesfin Geremaw Birega Birega, Habitu Eshetu Birhan, Tone Bjørge, Oleg Blyuss, Belay Boda Abule Bodicha, Srinivasa Rao Bolla, Archith Boloor, Cristina Bosetti, Dejana Braithwaite, Michael Brauer, Hermann Brenner, Andrey Nikolaevich Briko, Nikolay Ivanovich Briko, Christina Maree Buchanan, Norma B Bulamu, Maria Teresa Bustamante-Teixeira, Muhammad Hammad Butt, Nadeem Shafique Butt, Zahid A Butt, Florentino Luciano Caetano dos Santos, Luis Alberto Cámera, Chao Cao, Yin Cao, Giulia Carreras, Márcia Carvalho, Francieli Cembranel, Ester Cerin, Promit Ananyo Chakraborty, Periklis Charalampous, Vijay Kumar Chattu, Odgerel Chimed-Ochir, Jesus Lorenzo Chirinos-Caceres, Daniel Youngwhan Cho, William C S Cho, Devasahayam J Christopher, Dinh-Toi Chu, Isaac Sunday Chukwu, Aaron J Cohen, Joao Conde, Sandra Cortés, Vera Marisa Costa, Natália Cruz-Martins, Garland T Culbreth, Omid Dadras, Fentaw Teshome Dagnaw, Saad M A Dahlawi, Xiaochen Dai, Lalit Dandona, Rakhi Dandona, Parnaz Daneshpajouhnejad, Anna Danielewicz, An Thi Minh Dao, Reza Darvishi Cheshmeh Soltani, Aso Mohammad Darwesh, Saswati Das, Dragos Virgil Davitoiu, Elham Davtalab Esmaeili, Fernando Pio De la Hoz, Sisay Abebe Debela, Azizallah Dehghan, Biniyam Demisse, Fitsum Wolde Demisse, Edgar Denova-Gutiérrez, Afshin Derakhshani, Meseret Derbew Molla, Diriba Dereje, Kalkidan Solomon Deribe, Rupak Desai, Markos Desalegn Desalegn, Fikadu Nugusu Dessalegn, Samuel Abebe A Dessalegni, Gashaw Dessie, Abebaw Alemayehu Desta, Syed Masudur Rahman Dewan, Samath Dhamminda Dharmaratne, Meghnath Dhimal, Mostafa Dianatinasab, Nancy Diao, Daniel Diaz, Lankamo Ena Digesa, Shilpi Gupta Dixit, Saeid Doaei, Linh Phuong Doan, Paul Narh Doku, Deepa Dongarwar, Wendel Mombaque dos Santos, Tim Robert Driscoll, Haneil Larson Dsouza, Oyewole Christopher Durojaiye, Sareh Edalati, Fatemeh Eghbalian, Elham Ehsani-Chimeh, Ebrahim Eini, Michael Ekholuenetale, Temitope Cyrus Ekundayo, Donatus U Ekwueme, Maha El Tantawi, Mostafa Ahmed Elbahnasawy, Iffat Elbarazi, Hesham Elghazaly, Muhammed Elhadi, Waseem El-Huneidi, Mohammad Hassan Emamian, Luchuo Engelbert Bain, Daniel Berhanie Enyew, Ryenchindorj Erkhembayar, Tegegne Eshetu, Babak Eshrati, Sharareh Eskandarieh, Juan Espinosa-Montero, Farshid Etaee, Azin Etemadimanesh, Tahir Eyayu, Ifeanyi Jude Ezeonwumelu, Sayeh Ezzikouri, Adeniyi Francis Fagbamigbe, Saman Fahimi, Ildar Ravisovich Fakhradiyev, Emerito Jose A Faraon, Jawad Fares, Abbas Farmany, Umar Farooque, Hossein Farrokhpour, Abidemi Omolara Fasanmi, Ali Fatehizadeh, Wafa Fatima, Hamed Fattahi, Ginenus Fekadu, Berhanu Elfu Feleke, Allegra Allegra Ferrari, Simone Ferrero, Lorenzo Ferro Desideri, Irina Filip, Florian Fischer, Roham Foroumadi, Masoud Foroutan, Takeshi Fukumoto, Peter Andras Gaal, Mohamed M Gad, Muktar A Gadanya, Abduzhappar Gaipov, Nasrin Galehdar, Silvano Gallus, Tushar Garg, Mariana Gaspar Fonseca, Yosef Haile Gebremariam, Teferi Gebru Gebremeskel, Mathewos Alemu Gebremichael, Yohannes Fikadu Geda, Yibeltal Yismaw Gela, Belete Negese Belete Gemeda, Melaku Getachew, Motuma Erena Getachew, Kazem Ghaffari, Mansour Ghafourifard, Seyyed-Hadi Ghamari, Mohammad Ghasemi Nour, Fariba Ghassemi, Ajnish Ghimire, Nermin Ghith, Maryam Gholamalizadeh, Jamshid Gholizadeh Navashenaq, Sherief Ghozy, Syed Amir Gilani, Paramjit Singh Gill, Themba G Ginindza, Abraham Tamirat T Gizaw, James C Glasbey, Justyna Godos, Amit Goel, Mahaveer Golechha, Pouya Goleij, Davide Golinelli, Mohamad Golitaleb, Giuseppe Gorini, Bárbara Niegia Garcia Goulart, Giuseppe Grosso, Habtamu Alganeh Guadie, Mohammed Ibrahim Mohialdeen Gubari, Temesgen Worku Gudayu, Maximiliano Ribeiro Guerra, Damitha Asanga Gunawardane, Bhawna Gupta, Sapna Gupta, Veer Bala Gupta, Vivek Kumar Gupta, Mekdes Kondale Gurara, Alemu Guta, Parham Habibzadeh, Atlas Haddadi Avval, Nima Hafezi-Nejad, Adel Hajj Ali, Arvin Haj-Mirzaian, Esam S Halboub, Aram Halimi, Rabih Halwani, Randah R Hamadeh, Sajid Hameed, Samer Hamidi, Asif Hanif, Sanam Hariri, Netanja I Harlianto, Josep Maria Haro, Risky Kusuma Hartono, Ahmed I Hasaballah, S M Mahmudul Hasan, Hamidreza Hasani, Seyedeh Melika Hashemi, Abbas M Hassan, Soheil Hassanipour, Khezar Hayat, Golnaz Heidari, Mohammad Heidari, Zahra Heidarymeybodi, Brenda Yuliana Herrera-Serna, Claudiu Herteliu, Kamal Hezam, Yuta Hiraike, Mbuzeleni Mbuzeleni Hlongwa, Ramesh Holla, Marianne Holm, Nobuyuki Horita, Mohammad Hoseini, Md Mahbub Hossain, Mohammad Bellal Hossain Hossain, Mohammad-Salar Hosseini, Ali Hosseinzadeh, Mehdi Hosseinzadeh, Mihaela Hostiuc, Sorin Hostiuc, Mowafa Househ, Junjie Huang, Fernando N Hugo, Ayesha Humayun, Salman Hussain, Nawfal R Hussein, Bing-Fang Hwang, Segun Emmanuel Ibitoye, Pulwasha Maria Iftikhar, Kevin S Ikuta, Olayinka Stephen Ilesanmi, Irena M Ilic, Milena D Ilic, Mustapha Immurana, Kaire Innos, Pooya Iranpour, Lalu Muhammad Irham, Md Shariful Islam, Rakibul M Islam, Farhad Islami, Nahlah Elkudssiah Ismail, Gaetano Isola, Masao Iwagami, Linda Merin J, Abhishek Jaiswal, Mihajlo Jakovljevic, Mahsa Jalili, Shahram Jalilian, Elham Jamshidi, Sung-In Jang, Chinmay T Jani, Tahereh Javaheri, Umesh Umesh Jayarajah, Shubha Jayaram, Seyed Behzad Jazayeri, Rime Jebai, Bedru Jemal, Wonjeong Jeong, Ravi Prakash Jha, Har Ashish Jindal, Yetunde O John-Akinola, Jost B Jonas, Tamas Joo, Nitin Joseph, Farahnaz Joukar, Jacek Jerzy Jozwiak, Mikk Jürisson, Ali Kabir, Salah Eddine Oussama Kacimi, Vidya Kadashetti, Farima Kahe, Pradnya Vishal Kakodkar, Laleh R Kalankesh, Leila R Kalankesh, Rohollah Kalhor, Vineet Kumar Kamal, Farin Kamangar, Ashwin Kamath, Tanuj Kanchan, Eswar Kandaswamy, Himal Kandel, HyeJung Kang, Girum Gebremeskel Kanno, Neeti Kapoor, Sitanshu Sekhar Kar, Shama D Karanth, Ibraheem M Karaye, André Karch, Amirali Karimi, Bekalu Getnet Kassa, Patrick DMC Katoto, Joonas H Kauppila, Harkiran Kaur, Abinet Gebremickael Kebede, Leila Keikavoosi-Arani, Gemechu Gemechu Kejela, Phillip M Kemp Bohan, Maryam Keramati, Mohammad Keykhaei, Himanshu Khajuria, Abbas Khan, Abdul Aziz Khan Khan, Ejaz Ahmad Khan, Gulfaraz Khan, Md Nuruzzaman Khan, Moien AB Khan, Javad Khanali, Khaled Khatab, Moawiah Mohammad Khatatbeh, Mahalaqua Nazli Khatib, Maryam Khayamzadeh, Hamid Reza Khayat Kashani, Mohammad Amin Khazeei Tabari, Mehdi Khezeli, Mahmoud Khodadost, Min Seo Kim, Yun Jin Kim, Adnan Kisa, Sezer Kisa, Miloslav Klugar, Jitka Klugarová, Ali-Asghar Kolahi, Pavel Kolkhir, Farzad Kompani, Parvaiz A Koul, Sindhura Lakshmi Koulmane Laxminarayana, Ai Koyanagi, Kewal Krishan, Yuvaraj Krishnamoorthy, Burcu Kucuk Bicer, Nuworza Kugbey, Mukhtar Kulimbet, Akshay Kumar, G Anil Kumar, Narinder Kumar, Om P Kurmi, Ambily Kuttikkattu, Carlo La Vecchia, Arista Lahiri, Dharmesh Kumar Lal, Judit Lám, Qing Lan, Iván Landires, Bagher Larijani, Savita Lasrado, Jerrald Lau, Paolo Lauriola, Caterina Ledda, Sang-woong Lee, Shaun Wen Huey Lee, Wei-Chen Lee, Yeong Yeh Lee, Yo Han Lee, Samson Mideksa Legesse, James Leigh, Elvynna Leong, Ming-Chieh Li, Stephen S Lim, Gang Liu, Jue Liu, Chun-Han Lo, Ayush Lohiya, Platon D Lopukhov, László Lorenzovici, Mojgan Lotfi, Joana A Loureiro, Raimundas Lunevicius, Farzan Madadizadeh, Ahmad R Mafi, Sameh Magdeldin, Soleiman Mahjoub, Ata Mahmoodpoor, Morteza Mahmoudi, Marzieh Mahmoudimanesh, Rashidul Alam Mahumud, Azeem Majeed, Jamal Majidpoor, Alaa Makki, Konstantinos Christos Makris, Elaheh Malakan Rad, Mohammad-Reza Malekpour, Reza Malekzadeh, Ahmad Azam Malik, Tauqeer Hussain Mallhi, Sneha Deepak Mallya, Mohammed A Mamun, Ana Laura Manda, Fariborz Mansour-Ghanaei, Borhan Mansouri, Mohammad Ali Mansournia, Lorenzo Giovanni Mantovani, Santi Martini, Miquel Martorell, Sahar Masoudi, Seyedeh Zahra Masoumi, Clara N Matei, Elezebeth Mathews, Manu Raj Mathur, Vasundhara Mathur, Martin McKee, Jitendra Kumar Meena, Khalid Mehmood, Entezar Mehrabi Nasab, Ravi Mehrotra, Addisu Melese, Walter Mendoza, Ritesh G Menezes, SIsay Derso Mengesha, Laverne G Mensah, Alexios-Fotios A Mentis, Andry Yasmid Mera Mera-Mamián, Tuomo J Meretoja, Mehari Woldemariam Merid, Amanual Getnet Mersha, Belsity Temesgen Meselu, Mahboobeh Meshkat, Tomislav Mestrovic, Junmei Miao Jonasson, Tomasz Miazgowski, Irmina Maria Michalek, Gelana Fekadu Worku Mijena, Ted R Miller, Shabir Ahmad Mir, Seyed Kazem Mirinezhad, Seyyedmohammadsadeq Mirmoeeni, Mohammad Mirza-Aghazadeh-Attari, Hamed Mirzaei, Hamid Reza Mirzaei, Abay Sisay Misganaw, Sanjeev Misra, Karzan Abdulmuhsin Mohammad, Esmaeil Mohammadi, Mokhtar Mohammadi, Abdollah Mohammadian-Hafshejani, Reza Mohammadpourhodki, Arif Mohammed, Shafiu Mohammed, Syam Mohan, Mohammad Mohseni, Nagabhishek Moka, Ali H Mokdad, Alex Molassiotis, Mariam Molokhia, Kaveh Momenzadeh, Sara Momtazmanesh, Lorenzo Monasta, Ute Mons, Ahmed Al Montasir, Fateme Montazeri, Arnulfo Montero, Mohammad Amin Moosavi, Abdolvahab Moradi, Yousef Moradi, Mostafa Moradi Sarabi, Paula Moraga, Lidia Morawska, Shane Douglas Morrison, Jakub Morze, Abbas Mosapour, Ebrahim Mostafavi, Seyyed Meysam Mousavi, Haleh Mousavi Isfahani, Amin Mousavi Khaneghah, Christine Mpundu-Kaambwa, Sumaira Mubarik, Francesk Mulita, Daniel Munblit, Sandra B Munro, Efrén Murillo-Zamora, Jonah Musa, Ashraf F Nabhan, Ahamarshan Jayaraman Nagarajan, Shankar Prasad Nagaraju, Gabriele Nagel, Mohammadreza Naghipour, Mukhammad David Naimzada, Tapas Sadasivan Nair, Atta Abbas Naqvi, Sreenivas Narasimha Swamy, Aparna Ichalangod Narayana, Hasan Nassereldine, Zuhair S Natto, Biswa Prakash Nayak, Rawlance Ndejjo, Sabina Onyinye Nduaguba, Wogene Wogene Negash, Seyed Aria Nejadghaderi, Kazem Nejati, Sandhya Neupane Kandel, Huy Van Nguyen Nguyen, Robina Khan Niazi, Nurulamin M Noor, Maryam Noori, Nafise Noroozi, Hasti Nouraei, Ali Nowroozi, Virginia Nuñez-Samudio, Chimezie Igwegbe Nzoputam, Ogochukwu Janet Nzoputam, Bogdan Oancea, Oluwakemi Ololade Odukoya, Onome Bright Oghenetega, Ropo Ebenezer Ogunsakin, Ayodipupo Sikiru Oguntade, In-Hwan Oh, Hassan Okati-Aliabad, Akinkunmi Paul Okekunle, Andrew T Olagunju, Tinuke O Olagunju, Babayemi Oluwaseun Olakunde, Isaac Iyinoluwa Olufadewa, Emad Omer, Abidemi E Emmanuel Omonisi, Sokking Ong, Obinna E Onwujekwe, Hans Orru, Stanislav S Otstavnov, Abderrahim Oulhaj, Bilcha Oumer, Oluwatomi Funbi Owopetu, Babatunji Emmanuel Oyinloye, Mahesh P A, Alicia Padron-Monedero, Jagadish Rao Padubidri, Babak Pakbin, Keyvan Pakshir, Reza Pakzad, Tamás Palicz, Adrian Pana, Anamika Pandey, Ashok Pandey, Suman Pant, Shahina Pardhan, Eun-Cheol Park, Eun-Kee Park, Seoyeon Park, Jay Patel, Siddhartha Pati, Rajan Paudel, Uttam Paudel, Mihaela Paun, Hamidreza Pazoki Toroudi, Minjin Peng, Jeevan Pereira, Renato B Pereira, Simone Perna, Navaraj Perumalsamy, Richard G Pestell, Raffaele Pezzani, Cristiano Piccinelli, Julian David Pillay, Zahra Zahid Piracha, Tobias Pischon, Maarten J Postma, Ashkan Pourabhari Langroudi, Akram Pourshams, Naeimeh Pourtaheri, Akila Prashant, Mirza Muhammad Fahd Qadir, Zahiruddin Quazi Syed, Mohammad Rabiee, Navid Rabiee, Amir Radfar, Raghu Anekal Radhakrishnan, Venkatraman Radhakrishnan, Mojtaba Raeisi, Ata Rafiee, Alireza Rafiei, Nasiru Raheem, Fakher Rahim, Md Obaidur Rahman, Mosiur Rahman, Muhammad Aziz Rahman, Amir Masoud Rahmani, Shayan Rahmani, Vahid Rahmanian, Nazanin Rajai, Aashish Rajesh, Pradhum Ram, Kiana Ramezanzadeh, Juwel Rana, Kamal Ranabhat, Priyanga Ranasinghe, Chythra R Rao, Sowmya J Rao, Sina Rashedi, Amirfarzan Rashidi, Mahsa Rashidi, Mohammad-Mahdi Rashidi, Zubair Ahmed Ratan, David Laith Rawaf, Salman Rawaf, Lal Rawal, Reza Rawassizadeh, Mohammad Sadegh Razeghinia, Ashfaq Ur Rehman, Inayat ur Rehman, Marissa B Reitsma, Andre M N Renzaho, Maryam Rezaei, Nazila Rezaei, Negar Rezaei, Nima Rezaei, Saeid Rezaei, Mohsen Rezaeian, Aziz Rezapour, Abanoub Riad, Reza Rikhtegar, Maria Rios-Blancas, Thomas J Roberts, Peter Rohloff, Esperanza Romero-Rodríguez, Gholamreza Roshandel, Godfrey M Rwegerera, Manjula S, Maha Mohamed Saber-Ayad, Bahar Saberzadeh-Ardestani, Siamak Sabour, Basema Saddik, Erfan Sadeghi, Mohammad Reza Saeb, Umar Saeed, Mohsen Safaei, Azam Safary, Maryam Sahebazzamani, Amirhossein Sahebkar, Harihar Sahoo, Mirza Rizwan Sajid, Hedayat Salari, Sana Salehi, Marwa Rashad Salem, Hamideh Salimzadeh, Yoseph Leonardo Samodra, Abdallah M Samy, Juan Sanabria, Senthilkumar Sankararaman, Francesco Sanmarchi, Milena M Santric-Milicevic, Muhammad Arif Nadeem Saqib, Arash Sarveazad, Fatemeh Sarvi, Brijesh Sathian, Maheswar Satpathy, Nicolas Sayegh, Ione Jayce Ceola Schneider, Michaël Schwarzinger, Mario Šekerija, Subramanian Senthilkumaran, Sadaf G Sepanlou, Allen Seylani, Kenbon Seyoum, Feng Sha, Omid Shafaat, Pritik A Shah, Saeed Shahabi, Izza Shahid, Mohammad Amin Shahrbaf, Hamid R Shahsavari, Masood Ali Shaikh, Mohammed Feyisso Shaka, Elaheh Shaker, Mohammed Shannawaz, Mequannent Melaku Sharew Sharew, Azam Sharifi, Javad Sharifi-Rad, Purva Sharma, Bereket Beyene Shashamo, Aziz Sheikh, Mahdi Sheikh, Sara Sheikhbahaei, Rahim Ali Sheikhi, Ali Sheikhy, Peter Robin Shepherd, Adithi Shetty, Jeevan K Shetty, Ranjitha S Shetty, Kenji Shibuya, Reza Shirkoohi, Hesamaddin Shirzad-Aski, K M Shivakumar, Siddharudha Shivalli, Velizar Shivarov, Parnian Shobeiri, Zahra Shokri Varniab, Seyed Afshin Shorofi, Sunil Shrestha, Migbar Mekonnen Sibhat, Sudeep K Siddappa Malleshappa, Negussie Boti Sidemo, Diego Augusto Santos Silva, Luís Manuel Lopes Rodrigues Silva, Guilherme Silva Julian, Nicola Silvestris, Wudneh Simegn, Achintya Dinesh Singh, Ambrish Singh, Garima Singh, Harpreet Singh, Jasvinder A Singh, Jitendra Kumar Singh, Paramdeep Singh, Surjit Singh, Dhirendra Narain Sinha, Abiy H Sinke, Md Shahjahan Siraj, Freddy Sitas, Samarjeet Singh Siwal, Valentin Yurievich Skryabin, Anna Aleksandrovna Skryabina, Bogdan Socea, Matthew J Soeberg, Ahmad Sofi-Mahmudi, Yonatan Solomon, Mohammad Sadegh Soltani-Zangbar, Suhang Song, Yimeng Song, Reed J D Sorensen, Sergey Soshnikov, Houman Sotoudeh, Alieu Sowe, Mu’awiyyah Babale Sufiyan, Ryan Suk, Muhammad Suleman, Rizwan Suliankatchi Abdulkader, Saima Sultana, Daniel Sur, Miklós Szócska, Seidamir Pasha Tabaeian, Rafael Tabarés-Seisdedos, Seyyed Mohammad Tabatabaei, Takahiro Tabuchi, Hooman Tadbiri, Ensiyeh Taheri, Majid Taheri, Moslem Taheri Soodejani, Ken Takahashi, Iman M Talaat, Mircea Tampa, Ker-Kan Tan, Nathan Y Tat, Vivian Y Tat, Ahmad Tavakoli, Arash Tavakoli, Arash Tehrani-Banihashemi, Yohannes Tekalegn, Fisaha Haile Tesfay, Rekha Thapar, Aravind Thavamani, Viveksandeep Thoguluva Chandrasekar, Nihal Thomas, Nikhil Kenny Thomas, Jansje Henny Vera Ticoalu, Amir Tiyuri, Daniel Nigusse Tollosa, Roman Topor-Madry, Mathilde Touvier, Marcos Roberto Tovani-Palone, Eugenio Traini, Mai Thi Ngoc Tran, Jaya Prasad Tripathy, Gebresilasea Gendisha Ukke, Irfan Ullah, Saif Ullah, Sana Ullah, Bhaskaran Unnikrishnan, Marco Vacante, Maryam Vaezi, Sahel Valadan Tahbaz, Pascual R Valdez, Constantine Vardavas, Shoban Babu Varthya, Siavash Vaziri, Diana Zuleika Velazquez, Massimiliano Veroux, Paul J Villeneuve, Francesco S Violante, Sergey Konstantinovitch Vladimirov, Vasily Vlassov, Bay Vo, Linh Gia Vu, Abdul Wadood Wadood, Yasir Waheed, Mandaras Tariku Walde, Richard G Wamai, Cong Wang, Fang Wang, Ning Wang, Yu Wang, Paul Ward, Abdul Waris, Ronny Westerman, Nuwan Darshana Wickramasinghe, Melat Woldemariam, Berhanu Woldu, Hong Xiao, Suowen Xu, Xiaoyue Xu, Lalit Yadav, Seyed Hossein Yahyazadeh Jabbari, Lin Yang, Fereshteh Yazdanpanah, Yigizie Yeshaw, Yazachew Yismaw, Naohiro Yonemoto, Mustafa Z Younis, Zabihollah Yousefi, Fatemeh Yousefian, Chuanhua Yu, Yong Yu, Ismaeel Yunusa, Mazyar Zahir, Nazar Zaki, Burhan Abdullah Zaman, Moein Zangiabadian, Fariba Zare, Iman Zare, Zahra Zareshahrabadi, Armin Zarrintan, Mikhail Sergeevich Zastrozhin, Mohammad A Zeineddine, Dongyu Zhang, Jianrong Zhang, Yunquan Zhang, Zhi-Jiang Zhang, Linghui Zhou, Sanjay Zodpey, Mohammad Zoladl, Theo Vos, Simon I Hay, Lisa M Force, Christopher J L Murray
Affiliations
Department of Molecular Medicine and Pathology (K B Tran MD, C M Buchanan PhD, Prof P R Shepherd PhD), University of Auckland, Auckland, New Zealand; Department of Clinical Hematology and Toxicology (K B Tran MD), Maurice Wilkins Centre, Auckland, New Zealand; Centre for Surveillance and Applied Research (J J Lang PhD), Public Health Agency of Canada, Ottawa, ON, Canada; Institute for Health Metrics and Evaluation (K Compton BS, R Xu BS, A R Acheson BA, J M Kocarnik PhD, L Penberthy MS, J A Anderson BS, Prof M Brauer DSc, A J Cohen DSc, G T Culbreth PhD, X Dai PhD, Prof L Dandona MD, Prof R Dandona PhD, Prof S D Dharmaratne MD, H J Henrikson BA, K S Ikuta MD, Prof S S Lim PhD, T Mestrovic PhD, A H Mokdad PhD, H Nassereldine MD, M B Reitsma BS, R J D Sorensen PhD, Prof T Vos PhD, Prof S I Hay FMedSci, L M Force MD, Prof C J L Murray DPhil), Department of Health Metrics Sciences, School of Medicine (X Dai PhD, Prof R Dandona PhD, Prof S D Dharmaratne MD, Prof S S Lim PhD, A H Mokdad PhD, Prof T Vos PhD, Prof S I Hay FMedSci, L M Force MD, Prof C J L Murray DPhil), Division of Allergy and Infectious Diseases (K S Ikuta MD), Division of Plastic and Reconstructive Surgery (S D Morrison MD), Department of Global Health (R J D Sorensen PhD), Division of Pediatric Hematology-Oncology (L M Force MD), University of Washington, Seattle, WA, USA; Health Informatic Lab (T Javaheri PhD), Department of Computer Science (R Rawassizadeh PhD), Boston University, Boston, MA, USA; Department of Medicine (H J Henrikson BA), Brigham and Women's Hospital, Boston, MA, USA; Faculty of Medicine (A Aali MD), Education Development Center (R Assadi PhD), E-Learning Center (M Ghasemi Nour MD), School of Medicine (A Haddadi Avval), Department of Nursing (R Mohammadpourhodki PhD), Applied Biomedical Research Center (A Sahebkar PhD), Biotechnology Research Center (A Sahebkar PhD), Department of Medical Informatics (S Tabatabaei PhD), Clinical Research Development Unit (S Tabatabaei PhD), Mashhad University of Medical Sciences, Mashhad, Iran (M Keramati MD); Health Policy Research Center (A Aali MD, S Shahabi PhD), Health Information Management (A Bashiri PhD), Department of Epidemiology (M Dianatinasab MSc), Research Center for Health Sciences (P Habibzadeh MD, M Hoseini PhD), Department of Environmental Health (M Hoseini PhD), Department of Radiology (P Iranpour MD), Non-communicable Disease Research Center (Prof R Malekzadeh MD, S G Sepanlou MD), Department of Medical Mycology and Parasitology (H Nouraei MSc, Prof K Pakshir PhD, Z Zareshahrabadi PhD), Shiraz University of Medical Sciences, Shiraz, Iran; Department of Biology (Q Abbas PhD), University of Bahrain, Manama, Bahrain; Uro-oncology Research Center (B Abbasi MD), Non-communicable Diseases Research Center (Z Abbasi-Kangevari BSc, A Aryannejad MD, S Azadnajafabad MD, M Azangou-Khyavy MD, S Ghamari MD, J Khanali MD, M Keykhaei MD, M Malekpour MD, S Momtazmanesh MD, F Montazeri MD, A Pourabhari Langroudi MD, S Rahmani MD, M Rashidi MD, N Rezaei MD, N Rezaei PhD, Z Shokri Varniab MD), Advanced Diagnostic and Interventional Radiology Research Center (H Abbastabar PhD), Research Center for Immunodeficiencies (H Abolhassani PhD, Prof N Rezaei PhD), Department of Epidemiology and Biostatistics (Y Alimohamadi PhD, H Azizi PhD, M Mansournia PhD), Universal Scientific Education and Research Network (USERN) (M Amirzade-Iranaq DDS), Digestive Diseases Research Institute (A Anoushiravani MD, S Fahimi MD, xiri MD, Prof R Malekzadeh MD, S Masoudi MSc, Prof A Pourshams MD, H Salimzadeh PhD, S G Sepanlou MD, M Sheikh PhD), Experimental Medicine Research Center (A Aryannejad MD), Department of Health Policy, Management, and Economics (A Bakhtiari PhD), National Institute for Health Research (E Ehsani-Chimeh PhD), Multiple Sclerosis Research Center (S Eskandarieh PhD), Department of Pathology (A Etemadimanesh MD), School of Medicine (H Farrokhpour MD, N Hafezi-Nejad MD, S Hashemi MD, A Karimi MD, S Momtazmanesh MD, A Nowroozi BMedSc), Endocrinology and Metabolism Research Institute (R Foroumadi MD, Prof B Larijani FACE, N Rezaei PhD), Department of Surgery (R Foroumadi MD), Ophthalmology Department (Prof F Ghassemi MD), Digestive Oncology Research Center (Prof F Kamangar MD), Students’ Scientific Research Center (SSRC) (M Keykhaei MD), Children's Medical Center (F Kompani MD), Department of Pediatrics and Pediatric Cardiology (Prof E Malakan Rad MD), Tehran Heart Center (E Mehrabi Nasab MD), Department of Medical Immunology (H Mirzaei PhD), Faculty of Medicine (E Mohammadi MD, E Shaker MD, P Shobeiri MD), Department of Pharmacology (N Noroozi DVM, M Zahir MD), Metabolomics and Genomics Research Center (F Rahim PhD), Department of Cardiology (S Rashedi MD), Department of Gastroenterology (B Saberzadeh-Ardestani MD), Cancer Research Center (R Shirkoohi PhD), Cancer Biology Research Center (R Shirkoohi PhD), Department of Pediatric Allergy and Immunology (F Yazdanpanah MD), Department of Environmental Health (F Yousefian PhD), Tehran University of Medical Sciences, Tehran, Iran; Reproductive Biomedicine Research Center (B Abbasi MD), Royan Institution, Isfahan, Iran; Social Determinants of Health Research Center (M Abbasi-Kangevari MD, Z Abbasi-Kangevari BSc, M Azangou-Khyavy MD, S Ghamari MD, J Khanali MD, A Kolahi MD, M Rashidi MD), School of Advanced Technologies in Medicine (S Ahmadi PhD), Department of Pharmacology (A Babajani MD, A Haj-Mirzaian MD, K Ramezanzadeh PharmD), Department of Community Nutrition (S Doaei PhD, S Edalati PhD), Cancer Research Center (M Gholamalizadeh PhD), Obesity Research Center (A Haj-Mirzaian MD), Research Institute for Endocrine Sciences (A Halimi BSc), Functional Neurosurgery Research Center (E Jamshidi PharmD), Department of Neurosurgery (H Khayat Kashani MD), Department of Health & Community Medicine (A Kolahi MD), Department of Clinical Oncology (A R Mafi MD), School of Medicine (F Montazeri MD, S Nejadghaderi MD, M Zangiabadian MD), Student Research Committee (S Rahmani MD), Department of Epidemiology (S Sabour PhD), Faculty of Medicine (M Shahrbaf MD), Medical Ethics and Law Research Center (M Taheri PhD), Shahid Beheshti University of Medical Sciences, Tehran, Iran (M Khayamzadeh MD); Department of Surgery (M Abdelmasseh MD, Prof J Sanabria MD), Marshall University, Huntington, WV, USA; Tropical Medicine Department (S Abd-Elsalam PhD), Tanta University, Tanta, Egypt; Department of Internal Medicine (A A Abdelwahab MD), Baylor College of Medicine, Houston, TX, USA; Department of Epidemiology (G Abdoli PhD), Social Development and Health Promotion Research Center (M Khezeli PhD), Substance Abuse Prevention Research Center (B Mansouri PhD), Advanced Dental Sciences Research Center (M Safaei PhD), Department of Infectious Disease (Prof S Vaziri MD), Kermanshah University of Medical Sciences, Kermanshah, Iran; Department of Public Health (H A Abdulkadir MPH, Y H Gebremariam MPH), Department of Biomedical Science (Y D Abtew MSc, B B A Bodicha MSc), Department of Medical Laboratory Sciences (A Aklilu MSc), School of Nursing (T M Ayana MSc), Department of Medical Anatomy (A B Bekele MSc), Department of Nursing (B Demisse MSc, B B Shashamo MSc), Department of Midwifery (F W Demisse MSc, S A A Dessalegni MSc, B Oumer MPH, G G Ukke MSc), Department of Comprehensive Nursing (L E Digesa MSc), Department of Epidemiology and Biostatistics (M A Gebremichael MPH), School of Public Health (M K Gurara MPH, N B Sidemo MPH), Department of Anatomy (A G Kebede MA), Department of Medical Laboratory Science (M Woldemariam MSc), Arba Minch University, Arba Minch, Ethiopia; Department of Neurosurgery (A Abedi MD), Keck School of Medicine (A Abedi MD), Mark and Mary Stevens Neuroimaging and Informatics Institute (S Salehi MD), University of Southern California, Los Angeles, CA, USA; Department of Biostatistics (K H Abegaz MSc), Near East University, Nicosia, Cyprus; Department of Biostatistics and Health Informatics (K H Abegaz MSc), Department of Public Health (Y Tekalegn MPH), Madda Walabu University, Bale Robe, Ethiopia; Laboratory Technology Sciences Department (H Abidi PhD), Department of Nursing (M Zoladl PhD), Yasuj University of Medical Sciences, Yasuj, Iran; Department of Family and Community Health (R G Aboagye MPH), Institute of Health Research (R K Alhassan PhD, M Immurana PhD), Department of Population and Behavioural Sciences (H Amu PhD), University of Health and Allied Sciences, Ho, Ghana; Department of Biosciences and Nutrition (H Abolhassani PhD), Karolinska University Hospital, Huddinge, Sweden; Medical Laboratory Sciences (A Absalan PhD), Department of Laboratory Sciences (K Ghaffari MSc), Khomein University of Medical Sciences, Khomein, Iran; Research and Development (A Absalan PhD), Satras Biotechnology Company, Tehran, Iran; University of Human Development (Prof H Abubaker Ali PhD), Department of Information Technology (A M Darwesh PhD), Department of Computer Science (M Hosseinzadeh PhD), University of Human Development, Sulaymaniyah, Iraq; Clinical Sciences Department (E Abu-Gharbieh PhD, Prof R Halwani PhD, Prof I M Talaat PhD), Department of Basic Medical Sciences (W El-Huneidi PhD), College of Medicine (Prof R Halwani PhD), Mass Communication Department (A Makki PhD), Department of Clinical Sciences (M M Saber-Ayad MD), Sharjah Institute for Medical Research (B Saddik PhD), University of Sharjah, Sharjah, United Arab Emirates; Department of Internal Medicine (B Achappa MD, A Boloor MD), Department of Forensic Medicine and Toxicology (H L Dsouza MD), Department of Community Medicine (N Joseph MD, R Thapar MD), Department of Obstetrics and Gynaecology (A Shetty MS), Kasturba Medical College (Prof B Unnikrishnan MD), Manipal Academy of Higher Education, Mangalore, India; Department of Epidemiology and Population Health (Prof J M Acuna MD, A Oulhaj PhD), Khalifa University, Abu Dhabi, United Arab Emirates; Robert Stempel College of Public Health & Social Work (Prof J M Acuna MD), Department of Epidemiology (R Jebai MPH), Florida International University, Miami, FL, USA; Department of Internal Medicine (D Addison MD), Ohio State University, Columbus, OH, USA; Centre for Social Research in Health (I Y Addo PhD), Centre for Primary Health Care and Equity (CPHCE) (F Sitas PhD), School of Population Health (X Xu PhD), University of New South Wales, Sydney, NSW, Australia; Quality and Systems Performance Unit (I Y Addo PhD), Cancer Institute NSW, Sydney, NSW, Australia; Public Health and Tropical Medicine (O A Adegboye PhD), James Cook University, Towsville, QLD, Australia; Slum and Rural Health Initiative Research Academy (M A Adesina BS, I I Olufadewa MHS), Slum and Rural Health Initiative, Ibadan, Nigeria; Department of Physiotherapy (M A Adesina BS), Department of Epidemiology and Medical Statistics (M Ekholuenetale MSc, A F Fagbamigbe PhD), Faculty of Public Health (M Ekholuenetale MSc, I I Olufadewa MHS), Department of Health Promotion and Education (S E Ibitoye MPH, Y O John-Akinola PhD), Department of Community Medicine (O S Ilesanmi PhD), Department of Obstetrics and Gynecology (O B Oghenetega MSc), College of Medicine (A P Okekunle PhD), University of Ibadan, Ibadan, Nigeria; Department of Neonatology (M Adnan MD), Indiana University Health Ball Memorial Hospital, Muncie, IN, USA; Faculty of Medicine (Q E S Adnani PhD), Universitas Padjadjaran (Padjadjaran University), Bandung, Indonesia; Terasaki Institute for Biomedical Innovation, Los Angeles, CA, USA (S M Advani PhD); School of Medicine (S M Advani PhD), Department of Oncology (D Zhang PhD), Georgetown University, Washington, DC, USA; Department of Conservative Dentistry (S Afrin DDS), Department of Population Sciences (Prof M B H Hossain PhD), University of Dhaka, Dhaka, Bangladesh; Department of Life Sciences (M S Afzal PhD, I Ullah PhD), School of Sciences (M N Saqib PhD), University of Management and Technology, Lahore, Pakistan; Department of Internal Medicine (M Aggarwal MD, M Alkhayyat MD, A D Singh MD), Department of Cardiovascular Medicine (M M Gad MD), Heart, Vascular, Thoracic Institute (A Hajj Ali MD), Cleveland Clinic, Cleveland, OH, USA; The Australian Centre for Public and Population Health Research (ACPPHR) (B O Ahinkorah MPH, E K Ameyaw MPhil), University of Technology Sydney, Sydney, NSW, Australia; College of Nursing (A R Ahmad PhD), International Relations & Diplomacy, Ranya, Iraq; International Relations & Diploma