Objectives. To estimate the burden of respiratory ill health in South African children and adults in 2000 from exposure to indoor air pollution associated with household use of solid fuels. Design. World Health Organization comparative risk assessment (CRA) methodology was followed. The South African Census 2001 was used to derive the proportion of households using solid fuels for cooking and heating by population group. Exposure estimates were adjusted by a ventilation factor taking into account the general level of ventilation in the households. Population-attributable fractions were calculated and applied to revised burden of disease estimates for each population group. Monte Carlo simulation-modelling techniques were used for uncertainty analysis. Setting. South Africa. Subjects. Black African, coloured, white and Indian children under 5 years of age and adults aged 30 years and older. Outcome measures. Mortality and disability-adjusted life years (DALYs) from acute lower respiratory infections in children under 5 years, and chronic obstructive pulmonary disease and lung cancer in adults 30 years and older. Results. An estimated 20% of South African households were exposed to indoor smoke from solid fuels, with marked variation by population group. This exposure was estimated to have caused 2 489 deaths (95% uncertainty interval 1 672 - 3 324) or 0.5% (95% uncertainty interval 0.3 - 0.6%) of all deaths in South Africa in 2000. The loss of healthy life years comprised a slightly smaller proportion of the total: 60 934 DALYs (95% uncertainty interval 41 170 - 81 246) or 0.4% of all DALYs (95% uncertainty interval 0.3 - 0.5%) in South Africa in 2000. Almost 99% of this burden occurred in the black African population. Conclusions. The most important interventions to reduce this impact include access to cleaner household fuels, improved stoves, and better ventilation.