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. 2025 Apr 5;405(10485):1167-1181.
doi: 10.1016/S0140-6736(24)02840-X. Epub 2025 Mar 18.

Global, regional, and national burden of household air pollution, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 HAP Collaborators
Collaborators

Global, regional, and national burden of household air pollution, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

GBD 2021 HAP Collaborators. Lancet. .

Abstract

Background: Despite a substantial reduction in the use of solid fuels for cooking worldwide, exposure to household air pollution (HAP) remains a leading global risk factor, contributing considerably to the burden of disease. We present a comprehensive analysis of spatial patterns and temporal trends in exposure and attributable disease from 1990 to 2021, featuring substantial methodological updates compared with previous iterations of the Global Burden of Diseases, Injuries, and Risk Factors Study, including improved exposure estimations accounting for specific fuel types.

Methods: We estimated HAP exposure and trends and attributable burden for cataract, chronic obstructive pulmonary disease, ischaemic heart disease, lower respiratory infections, tracheal cancer, bronchus cancer, lung cancer, stroke, type 2 diabetes, and causes mediated via adverse reproductive outcomes for 204 countries and territories from 1990 to 2021. We first estimated the mean fuel type-specific concentrations (in μg/m3) of fine particulate matter (PM2·5) pollution to which individuals using solid fuels for cooking were exposed, categorised by fuel type, location, year, age, and sex. Using a systematic review of the epidemiological literature and a newly developed meta-regression tool (meta-regression: Bayesian, regularised, trimmed), we derived disease-specific, non-parametric exposure-response curves to estimate relative risk as a function of PM2·5 concentration. We combined our exposure estimates and relative risks to estimate population attributable fractions and attributable burden for each cause by sex, age, location, and year.

Findings: In 2021, 2·67 billion (95% uncertainty interval [UI] 2·63-2·71) people, 33·8% (95% UI 33·2-34·3) of the global population, were exposed to HAP from all sources at a mean concentration of 84·2 μg/m3. Although these figures show a notable reduction in the percentage of the global population exposed in 1990 (56·7%, 56·4-57·1), in absolute terms, there has been only a decline of 0·35 billion (10%) from the 3·02 billion people exposed to HAP in 1990. In 2021, 111 million (95% UI 75·1-164) global disability-adjusted life-years (DALYs) were attributable to HAP, accounting for 3·9% (95% UI 2·6-5·7) of all DALYs. The rate of global, HAP-attributable DALYs in 2021 was 1500·3 (95% UI 1028·4-2195·6) age-standardised DALYs per 100 000 population, a decline of 63·8% since 1990, when HAP-attributable DALYs comprised 4147·7 (3101·4-5104·6) age-standardised DALYs per 100 000 population. HAP-attributable burden remained highest in sub-Saharan Africa and south Asia, with 4044·1 (3103·4-5219·7) and 3213·5 (2165·4-4409·4) age-standardised DALYs per 100 000 population, respectively. The rate of HAP-attributable DALYs was higher for males (1530·5, 1023·4-2263·6) than for females (1318·5, 866·1-1977·2). Approximately one-third of the HAP-attributable burden (518·1, 410·1-641·7) was mediated via short gestation and low birthweight. Decomposition of trends and drivers behind changes in the HAP-attributable burden highlighted that declines in exposures were counteracted by population growth in most regions of the world, especially sub-Saharan Africa.

Interpretation: Although the burden attributable to HAP has decreased considerably, HAP remains a substantial risk factor, especially in sub-Saharan Africa and south Asia. Our comprehensive estimates of HAP exposure and attributable burden offer a robust and reliable resource for health policy makers and practitioners to precisely target and tailor health interventions. Given the persistent and substantial impact of HAP in many regions and countries, it is imperative to accelerate efforts to transition under-resourced communities to cleaner household energy sources. Such initiatives are crucial for mitigating health risks and promoting sustainable development, ultimately improving the quality of life and health outcomes for millions of people.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests S Afzal reports support for the present manuscript from King Edward Medical University for providing study material, research articles, valid data sources and authentic real time information. S Afzal reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from King Edward Medical University and collaborative partners including University of Johns Hopkins, University of California, University of Massachusetts, KEMCAANA, KEMCA UK; support for attending meetings and/or travel from King Edward Medical University; participation on a Data Safety Monitoring Board or Advisory Board with National Bioethics Committee Pakistan, King Edward Medical University Ethical Review Board, Ethical Review Board Fatima Jinnah Medical University and Sir Ganga Ram Hospital, and Member Technical Working Group on Infectious Diseases to formulate guidelines; leadership or fiduciary roles in board, society, committee or advocacy groups, paid or unpaid with Pakistan Association of Medical Editors, Faculty of Public Health Royal Colleges UK (FFPH) as Fellow, Society of Prevention, Advocacy And Research, King Edward Medical University (SPARK), and Pakistan Society of Infectious Diseases as a member; other support from King Edward Medical University as Dean of Public Health and Preventative Medicine and Director of Quality Enhancement Cell, Annals of King Edward Medical University as Chief Editor since 2014, Faculty of Public Health United Kingdom as Fellow, KEMCA-UK as Advisory Board Member and Chair Scientific Session, KEMCAANA as Chairperson International Scientific Conference, Research and Publications Higher Education Commission, HEC Pakistan as Member, Research and Journals Committee Paki-stan Medical and Dental Council, Pakistan as Member, National Bioethics Committee, Pakistan as Member, Punjab Corona Experts Advisory Group as Member, Technical Working Group on Infectious Diseases as Member, Dengue Experts Advisory Group as Member, Punjab Residency Program Research Committee as Chair; all outside the submitted work. S M Alif reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Victoria University Online; support for attending meetings and/or travel from University of Melbourne; leadership or fiduciary roles in board, society, committee or advocacy groups, paid or unpaid with Thoracic Society of Australia and New Zealand; all outside the submitted work. S Barteit reports grants from Carl-Zeiss Foundation and German Research Foundation (DFG); stock or stock options in CHEERS company, a for-profit company focusing on climate change and health evaluation and response systems; all outside the submitted work. A Beloukas reports grants or sponsorships from Gilead and GSK/ViiV paid to the University of West Attica; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Gilead and GSK/ViiV paid to the University of West Attica; support for attending meetings and/or travel from Gilead and GSK/ViiV; receipt of equipment, materials, drugs, medical writing, gifts or other services from Cepheid for FOC reagents provided for a research project; all outside the submitted work. S Bhaskar reports grant or contracts from Japan Society for the Promotion of Science (JSPS), Japanese Ministry of Education, Culture, Sports, Science and Technology (MEXT) for a Grant-in-Aid for Scientific Research (KAKENHI) (23KF0126) and from JSPS and the Australian Academy of Science for the JSPS International Fellowship (P23712); leadership or fiduciary roles in board, society, committee or advocacy groups, paid or unpaid with Rotary District 9675, Sydney, Australia as District Chair, Diversity, Equity & Inclusion, Global Health & Migration Hub Community, Global Health Hub Germany, Berlin, Germany as Chair, Founding Member and Manager, PLOS One, BMC Neurology, Frontiers in Neurology, Frontiers in Stroke, Frontiers in Public Health, Journal of Aging Research & BMC Medical Research Methodology as Editorial Board Member, College of Reviewers, Canadian Institutes of Health Research (CIHR), Government of Canada as Member, World Headache Society, Bengaluru, India as Director of Research; Cariplo Foundation, Milan, Italy as Expert Adviser/Reviewer, National Cerebral and Cardiovascular Center, Department of Neurology, Division of Cerebrovascular Medicine and Neurology, Suita, Osaka, Japan as Visiting Director, and Cardiff University Biobank, Cardiff, UK as Member, Scientific Review Committee; all outside the submitted work. T C Ekundayo reports grants or contracts from University of South Africa via a PDF research fellowship payment, outside the submitted work. N Ghith reports a grant from Novo Nordisk Foundation (NNF16OC0021856) via a salary during her employment at the Technical University of Denmark between 2019-2022; support for attending meetings and/or travel from Danish Data Science Institute at the Technical University of Denmark in 2023; all outside the submitted work. C Hu reports support for the present manuscript from the National Social Science Fund of China (grant number: 24CSH106). R M Islam reports other support from International Meno-pause Society (IMS) for serving as an Associate Editor of Climacteric, the official journal of the International Menopause Society (IMS), and as a member of the IMS Publication Steering Committee, outside the submitted work. K Krishan reports non-financial support from the UGC Centre of Advanced Study, CAS II, awarded to the Department of Anthropology, Panjab University, Chandigarh, India, outside the submitted work. M Lee reports support for the present manuscript from the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF-2023S1A3A2A05095298). S A Meo reports grants or contracts from Researchers Supporting Project, King Saud University, Riyadh, Saudi Arabia (RSP-2025 R47), outside the submitted work. B Oancea reports grants or contracts from the MRID (project PNRR-I8 no 842027778, contract no 760096), outside the submitted work. F Thienemann reports grants or contracts from Gates MRI, EDCTP, CRDF Global for studies at the University of Cape Town, EDCTP2 programme supported by the European Union (grant number RIA2017T-2004-StatinTB), CRDF Global (G-202303-69943); outside the submitted work.

Figures

Figure 1
Figure 1
Percentage of global population exposed to HAP from solid cooking fuels, 2021 HAP=household air pollution.
Figure 2
Figure 2
Percentages of population exposed to solid fuel types, globally and by super-region, 1990–2021
Figure 3
Figure 3
Exposure–response relationships for PM2·5 concentration and outcomes except for cataract Risk curves were calculated on the basis of epidemiological data characterising exposure to ambient PM2·5 air pollution, and household air pollution. Shading indicates 95% uncertainty interval; x-axis truncated at 600 μg/m3 to provide more detail at lower concentrations. COPD=chronic obstructive pulmonary disease.
Figure 4
Figure 4
Population attributable fraction of DALYs attributable to HAP (A) and age-standardised rate per 100 000 population of DALYs attributable to HAP (B), by location, 2021 DALY=disability-adjusted life-years. HAP=household air pollution.
Figure 5
Figure 5
Composition of global, HAP-attributable Level 3 DALYs (A), deaths (B), YLLs (C), and YLDs (D) by disease, 2021 Non-communicable diseases are in blue; communicable, maternal, neonatal, and nutritional diseases are in red. COPD=chronic obstructive pulmonary disease. DALYs=disability-adjusted life-years. HAP=household air pollution. YLD=years lived with disability. YLL=years of life lost.
Figure 6
Figure 6
Decomposition of all-cause HAP-attributable DALYs into percent change driven by population growth, population ageing, exposure, or risk-deleted DALY rate, globally and by super-region, 1990–2021 DALYs=disability-adjusted life-years. HAP=household air pollution.
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