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Background/Aims The relationship between overall obesity, as measured by body mass index (BMI), and risk of esophageal squamous cell carcinoma (ESCC) has been reported, and it has a negative correlation. However, the relationship with abdominal obesity, as measured by waist circumference, may be different. We investigated the association between abdominal obesity and ESCC. Methods Retrospective cohort study with 22,809,722 individuals who had undergone regular health check-ups provided by the National Health Insurance Corporation between 2009 and 2012 (median follow-up period was 6.4 years) in South Korea. Abdominal obesity was defined as a waist circumference over 90 cm for men and 85 cm for women. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) using chi-square test and Cox proportional hazard model adjusted for confounding factors. Primary outcome was newly developed esophageal cancer. Results After adjusting for BMI, abdominal obesity increased the risk of ESCC (HR, 1.29; 95% CI, 1.23 to 1.36). Waist circumference is associated with increased risk of ESCC in a dose-dependent manner (p for trend <0.0001). We analyzed individuals divided into five categories of BMI. Among individuals with overweight (BMI, 23 to 24.9 kg/m2) and obese I (BMI, 25 to 29.9 kg/m2), abdominal obesity was a risk factor associated with developing ESCC (HR, 1.22; 95% CI, 1.11 to 1.34 and HR, 1.28; 95% CI, 1.18 to 1.39, respectively). Conclusions Abdominal obesity, not BMI itself, is associated with an increased risk for ESCC. Therefore, reducing abdominal obesity may affect decreasing the development of ESCC. [ABSTRACT FROM AUTHOR]