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Estimated mortality and years of life lost attributed to tobacco use

1. Key messages

  • In 2020, more than 9000 deaths in Belgium were associated with cigarette smoking. This is 7.4% of all deaths in Belgium in that year.
  • Lung cancer, chronic obstructive pulmonary disease (COPD), and ischemic heart disease are the main causes of death associated with cigarette smoking.
  • Over time, there have been declining trends in the death rate, but regional disparities remain.
  • Belgium ranked fifth worst among EU-14 countries in terms of the number of deaths per 100,000 persons attributed to cigarette smoking

2. Tobacco-attributable mortality 

In 2020, cigarette smoking was responsible for 9413 deaths, accounting for 7.4% of all deaths in Belgium. 

Lung cancer, COPD, and ischemic heart disease are the main causes of tobacco-related mortality

Smoking is causally linked to the burden of 41 diseases including 19 types of cancer, 7 cardiovascular diseases, chronic obstructive pulmonary disease (COPD), and asthma. Lung cancer, COPD, and ischemic heart disease are the main causes of tobacco-related mortality, responsible for 3682, 1422, and 1305 deaths, respectively.

Overall, the main causes of tobacco-related mortality are similar across genders and regions. In the Flemish and Brussels-Capital regions, Alzheimer's and other dementias ranked eighth and sixth among smoking-related deaths, respectively. In the Walloon region, they ranked tenth. Women's rankings differed due to breast and cervical cancer, responsible for 49 and 53 deaths, respectively. For men, the ranking included aortic aneurysm, bladder, and liver cancer.

10 leading causes attributed to smoking, in number of deaths, both sexes, all ages combined, Belgium, 2020
Source: Own calculations based on data from Statbel [1]

Most tobacco-related deaths occur in males, and mainly in old age

Most of the smoking-related deaths occurred in people aged 45 and older, especially in people over 65. Most of these deaths were due to cancer (neoplasms, 51%), heart disease (cardiovascular diseases, 23%), and lung disease (chronic respiratory diseases, 18%). The disease burden related to smoking was higher in men than in women, regardless of their age.  

Distribution of smoking-related deaths, by age and sex, Belgium, 2020   
Source: Own calculations based on data from Statbel [1]

The death rates due to smoking are 50% higher in the Brussels Capital Region and Walloon Region compared to the Flemish Region 

There has been an overall declining trend in the smoking attributable deaths rate by region since 2013. Despite a decrease, regional differences persist. The rate of smoking-related deaths was the highest in the Brussels-Capital Region (115.07 per 100,000), followed by the Walloon Region (105.28 per 100,000), both of which are 50% higher compared to the Flemish Region (66.09 per 100,000).

Distribution of age-adjusted smoking-attributed deaths per 100,000 people by region, for both sexes, 2013-2020
Source: Own calculations based on data from Statbel [1]

Belgium ranks among the worst countries for smoking-related deaths in the EU-14 

In 2021, according to the Global Burden of Disease 2021 study (Institute for Health Metrics and Evaluation (IHME), 2024) the estimated death rate in Belgium was above the EU-14 countries mean, ranking the country fifth worst among the EU-14.

Age-adjusted mortality rates per 100,000, by country of residence (EU-14), 2021
Source: GBD 2021 study [2]

3. Read more

Belgian National Burden of Disease visualization tool
Belgian National Burden of Disease Study. Patterns of tobacco use and sales in Belgium: a critical appraisal of available data sources


We aimed to quantify the health impact of tobacco use in Belgium by using representative data from the Belgian Health Interview Survey (BHIS). This survey was selected as the best available data source as it provides detailed insights into smoking behaviour [3]. We then constructed a time series on the BHIS data to have annual estimates from 2013 to 2020, that offer comprehensive insights into smoking behaviour trends across causes by age, sex, and region. This enabled us to estimate the contribution of smoking to the burden of disease through the Population Attributable Fraction (PAF) equation. Combining PAF percentages with total burden estimates, we calculated the attributable burden for each disease by age group, sex, and region. Additionally, we computed rates per 100,000 individuals and age-standardized rates (BSP) using population estimates from Statbel.

We used the Comparative Risk Assessment (CRA) method to calculate smoking-related deaths. It allows for the estimation of population attributable fractions (PAFs), quantifying the disease burden caused by exposure. The attributable burden (for example deaths) represents the share of the burden that can be linked to specific risk factor exposure, such as tobacco use, and would not have occurred without past exposure [4].

We calculate the attributable burden of tobacco use estimates by age, sex, region, year, and cause. The complete set of estimates can be explored via


The EU-14 corresponds to all countries that belonged to the European Union between 1995 and 2004: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, and Sweden. We compare the Belgian health status to that of the EU-14 because these countries have similar socioeconomic conditions. Note: The United Kingdom is excluded as it is no longer a member of the EU.
Age-standardized mortality rate 
The age-standardization is a weighted average of age-specific mortality rates to remove variations arising from differences in age structure between population groups.


  1. Statistics Belgium (Statbel).
  2. Institute for Health Metrics and Evaluation (IHME). (2024). Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2021 (GBD 2021) Results.
  3.  Nayani, S., Guariguata, L., & Devleesschauwer, B. (2024). Belgian National Burden of Disease Study. Patterns of tobacco use and sales in Belgium: A critical appraisal of available data sources (D/2023.14.440/81; p. 30). Sciensano.
  4.  Plass, D., Hilderink, H., Lehtomäki, H. et al. Estimating risk factor attributable burden – challenges and potential solutions when using the comparative risk assessment methodology. Arch Public Health (2022).

Please cite this page as: Sciensano. Burden of disease: Risk factor attributable burden - Tobacco attributable burden, Health Status Report, 31 May 2024, Brussels, Belgium,