Smoking and Esophageal Cancer Risk Factors
SMOKING emerged as the strongest modifiable driver of esophageal squamous cell carcinoma in a large Johannesburg analysis.
A case control analysis from the Johannesburg Cancer Study assessed 939 histologically confirmed esophageal squamous cell carcinoma cases against 3,089 cancer controls to clarify which lifestyle and environmental exposures most strongly shaped risk in a high burden setting. The findings pointed most clearly to tobacco, while alcohol showed a smaller independent effect that was largely confined to very high intake.
Current smoking carried the highest observed association with esophageal squamous cell carcinoma, with an adjusted odds ratio of 6.71, while ex smoking was also strongly associated with risk, with an adjusted odds ratio of 2.82. By comparison, very high alcohol intake of at least 840 g ethanol per week was linked to a more modest adjusted odds ratio of 1.56. The pattern was also notable across exposure groups: among never smokers, alcohol showed little clear dose response, and among smokers, risk remained high across alcohol categories without a consistent rise at higher intake.
Tobacco Outweighs Alcohol
These findings sharpen the prevention message for clinicians. In this cohort, tobacco stood out as the principal modifiable risk factor for esophageal squamous cell carcinoma, suggesting that smoking cessation is likely to have the greatest impact on prevention efforts. Alcohol still mattered, but the signal was weaker than may be assumed from broader cancer messaging and appeared most relevant at the highest consumption levels.
The analysis also showed that risk clustered with disadvantage. Rural origin or residence, lower educational attainment, and the use of biomass or other household fuels were all associated with increased odds of esophageal squamous cell carcinoma. Fuel exposure carried an adjusted odds ratio of 1.50, reinforcing the idea that household environment may contribute meaningfully to risk alongside behavioral factors.
A Syndemic Prevention Message
Taken together, the results support viewing esophageal squamous cell carcinoma through a syndemic lens, in which smoking, hazardous alcohol use, socioeconomic disadvantage, and environmental exposures do not occur in isolation. For physicians and public health teams, that means prevention strategies should extend beyond individual counseling alone.
Smoking cessation remains central, but the data also support efforts to reduce hazardous drinking patterns and address harmful household exposures, particularly in vulnerable communities. The study adds greater exposure detail to earlier Johannesburg findings and helps clarify where the strongest modifiable opportunities for prevention may lie.
Reference
Chen WC et al. Lifestyle and Environmental Risk Factors for Esophageal Squamous Cell Carcinoma: Evidence From the Johannesburg Cancer Study. JCO Glob Oncol. 2026;12(4):e2500669.
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