Skip to main content
NCBI home page
BMC Pulmonary Medicine logoLink to BMC Pulmonary Medicine
. 2025 Aug 25;25:403. doi: 10.1186/s12890-025-03811-w

Global trends and future projections of COPD burden under low-temperature risk: a 1990–2041 analysis based on GBD 2021

Xuyuan Wang 1,#, Aiping Gou 2,#, Jiangbo Wang 3,✉,#, Jing Li 4, Chunyan Gou 5,✉,#
PMCID: PMC12376480  PMID: 40855536

Abstract

Background

Low temperatures are an important risk factor for chronic obstructive pulmonary disease (COPD). However, trends and projections of the global burden of COPD at low temperatures are unclear.

Methods

Based on data from the 2021 Global Burden of Disease Study (GBD), this study assessed trends in the global and regional burden of death and disability-adjusted life years (DALYs) due to COPD from 1990 to 2021, and identified patterns of change in different regions. A Bayesian Age-Period-cohort (BAPC) model was used to predict the burden of COPD over the next 20 years.

Results

Although the number of COPD deaths worldwide in 2021 increased from 242,170 in 1990 to 300,849, and the number of DALYs increased from 4,749,734 to 4,981,981, the age-standardized deaths rate decreased from 7.04 to 3.69 per 100,000, and the DALYs rate decreased from 126.69 to 59.22 per 100,000. Up to 2021, men consistently bore a higher burden than women, though their age-standardized deaths rate declined more sharply (54.2% vs. 39.2%). COPD burden increased notably after age 45, with those aged 65 and older contributing most to the total and showing the steepest rise. By SDI level, middle and middle-high SDI regions had the highest burden but saw the fastest declines, while low and low-middle SDI areas carried heavier burdens with slower reductions. High SDI regions maintained low and stable burden levels. BAPC projections suggest a continued but slower decline in COPD mortality linked to low temperature by 2041, with a projected drop of 1.39 per 100,000, less than the 3.35 per 100,000 reduction observed from 1990 to 2021.

Conclusion

Global age-standardized mortality and DALYs for COPD at risk of low temperatures have declined over the past 30 years, with absolute burden numbers, BAPC predicting a slower rate of decline in the future, and persistent cross-country health inequalities. More precise interventions should be developed to target the resistance to low-temperature risk in older age groups and areas with low SDI.

Keywords: Global burden of disease (GBD), COPD, Extreme temperature, Low temperature risk, Public health policy

Introduction

Chronic obstructive pulmonary disease (COPD) is a major global driver of illness, death, and extensive healthcare resource consumption [1]. Its prevalence in the general population is approximately 12%, resulting in around 3 million deaths annually [2]. According to global estimates, chronic obstructive pulmonary disease has become the third leading cause of death worldwide [3, 4]. The etiology of COPD is multifactorial, with contributing factors including climatic conditions, environmental pollution, tobacco use, and occupational exposures [5–8].

Climate change–induced fluctuations in environmental temperature have become a critical global health concern [4, 9–11]. For individuals with chronic respiratory diseases, such fluctuations pose a substantial risk, particularly through their short-term physiological effects. High temperatures can exacerbate COPD symptoms by causing dehydration and thickening of airway mucus, leading to impaired mucociliary clearance and increased respiratory distress [12, 13]. In contrast, exposure to low temperatures is consistently linked to a heightened risk of acute exacerbations of COPD, primarily due to cold-induced airway inflammation [3]. Low temperatures impair pulmonary function by triggering bronchoconstriction, increasing mucus production, and disrupting local immune responses [14, 15]. These effects can promote secondary viral and bacterial infections, further intensifying airway inflammation and symptom severity [15–17]. Thus, cold air serves as a potent environmental trigger that aggravates COPD through synergistic inflammatory and infectious pathways.

Numerous studies have reported a strong association between cold exposure and increased rates of acute COPD episodes, hospitalizations, and mortality [18, 19]. Cold temperatures worsen COPD by triggering multiple pathways. For instance, cold can cause systemic vasoconstriction, increased cardiopulmonary workload, airway constriction, and intensified inflammatory responses, reducing lung function and acute exacerbations, ultimately raising mortality risk [12]. Studies indicate that overall mortality is higher in winter, with half of excess deaths during the cold season attributable to respiratory diseases [20], Moreover, lower temperatures are significantly associated with COPD mortality [21], Furthermore, viral and bacterial infections, such as influenza, are more prevalent during cold seasons, worsening COPD symptoms. This leads to acute exacerbations and increased hospitalization rates [5]. Existing studies are primarily focused on short-term effects or limited geographic areas, with little attention paid to long-term trends and global heterogeneity in low temperatures COPD burden [7]. This knowledge gap is particularly concerning given the increasing frequency of extreme cold events in certain regions, which may disproportionately affect vulnerable populations.

To address these limitations, the present study analyzes global and regional COPD-related mortality and DALYs data from 1990 to 2021, focusing on the long-term impact of low temperatures on COPD burden. In addition, we analyze trends in the variation of burden across different genders, age categories, and Socio-Demographic Index (SDI) regions. The Bayesian Age-Period-Cohort (BAPC) model is used to forecast global COPD burden trends over the next 20 years. This study aims to provide scientific evidence for researchers and policymakers to develop targeted interventions based on the specific circumstances of different regions. Furthermore, the findings offer guidance for the prevention of future extreme low-temperature events and encourage region-specific investigations into the relationship between low temperatures and COPD burden, ultimately contributing to effective strategies to reduce COPD mortality and burden.

Methods

Data sources and definitions

Overview

The global annual COPD case counts and their corresponding age-standardized rates (ASR), notably affected by low temperatures, were obtained from the GBD 2021 database. This version of the GBD represents the most extensive and systematic analysis of the global epidemiological burden to date, covering 369 diseases and injuries, as well as 87 risk factors, across 204 countries and territories. These entities are grouped into 21 regions and 7 super-regions, with results accessible through the GBD online platform (https://vizhub.healthdata.org/gbd-results/) and interactively visualized using the GBD Compare tool. Additionally, based on Socio-demographic Index (SDI) values, these 204 countries and territories are divided into five SDI regions [22].

COPD is characterized by a post-bronchodilation forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) ratio of less than 0.7. It also includes alternative diagnostic criteria, such as pre-bronchodilation GOLD, the lower limit of normal (LLN) for both post- and pre-bronchodilation measurements, and the guidelines set by the European Respiratory Society [23].

Mortality data related to chronic respiratory diseases (CRDs) were obtained from vital registration systems, verbal autopsy records (including household mortality surveys), and surveillance databases. The gathered information was then analyzed using the Cause of Death Ensemble Model (CODEm) to estimate COPD mortality rates, stratified by factors such as location, year, age, and sex [23]. Further details about the data sources can be found on the website. (Global Burden of Disease Study 2021 (GBD 2021) Burden and Strength of Evidence by Risk Factor 1990–2021| GHDx).

Modeling framework

This study adopted the Global Burden of Disease (GBD) 2021 modeling framework, which integrates diverse data sources and advanced statistical tools to generate internally consistent estimates of disease burden by location, year, age, and sex. Mortality due to chronic respiratory diseases (CRDs), including COPD, was estimated using data from vital registration systems, verbal autopsies, household mortality surveys, and surveillance databases. These data were analyzed using the Cause of Death Ensemble model (CODEm)—a flexible platform that tests a wide array of statistical models and covariates to identify the best-fitting ensemble for each cause.

For non-fatal outcomes, including prevalence and incidence, the DisMod-MR 2.1 tool—a Bayesian meta-regression model—was used to synthesize heterogeneous epidemiological data, ensuring internal consistency across key parameters (incidence, prevalence, remission, and mortality). Following GBD conventions, remission and excess mortality for COPD were assumed to be zero, reflecting its chronic nature [24]. The 2021 iteration of the GBD study drew on extensive data sources, including household surveys, vital statistics, and administrative records [25].

To address potential biases in input data (e.g., differences in case definitions and survey methods), MR-BRT (meta-regression–Bayesian, regularized, trimmed) was applied to derive adjustment factors.

Uncertainty estimation and interpretation

All estimates in this study—such as mortality rates, DALYs, and EAPC—are presented with 95% uncertainty intervals (UIs) to quantify uncertainty. These UIs were generated through Bayesian simulation methods: for each parameter, the posterior distribution was obtained via 1,000 draws, incorporating uncertainty from sampling error, model structure, and covariate estimation. The 95% UI was then calculated as the range between the 2.5th and 97.5th percentiles of the ordered posterior draws. This process ensures probabilistic inference about the true value of the estimated quantity.

While similar in purpose to confidence intervals (CIs) used in frequentist statistics, UIs arise from a Bayesian framework and represent the most credible range within which the parameter is likely to fall, given the data and modeling assumptions. Unlike CIs, which represent the interval that would contain the true value in 95% of repeated samples, UIs reflect the degree of belief, given the data and model, that the true value lies within the specified range. Estimates were considered statistically significant if the 95% UI excluded zero.

Risk factor: low temperature

In GBD 2021, the daily average temperatures for each location were derived from the European Centre for Medium-Range Weather Forecasts data. The theoretical minimum risk exposure level for temperature (TMREL), which represents the temperature associated with the lowest mortality risk, was estimated annually for each location. Since TMREL can vary significantly across regions (e.g., higher in warmer climates compared to colder ones), years, and diseases [26, 27], the GBD 2021 standard aligns with that of GBD 2019, incorporating spatial and time-varying TMREL values [28]. In line with previous studies, low-temperature exposure in the GBD study was defined as temperatures below TMREL [29, 30].

Socio-demographic index

The SDI is an integrated metric used to assess the developmental level of countries or regions. It is calculated using indicators such as per capita income, average years of schooling, and fertility rates. The SDI scale ranges from 0 to 1, with higher values reflecting a more advanced developmental status. Globally, 204 countries or regions have corresponding SDI values. The GBD categorizes countries into five SDI levels: low SDI (41 countries), low-middle SDI (41 countries), middle SDI (40 countries), high-middle SDI (41 countries), and high SDI (41 countries). The SDI values range from 0 to 100, with higher scores indicating greater levels of development.

Geographic grouping: GBD regions and super-regions

In the GBD 2021 framework, estimates were reported for 204 countries and territories, encompassing all WHO member states and associate members. To facilitate meaningful cross-regional comparisons, these countries were first grouped into 21 GBD regions and further aggregated into seven super-regions, based on geographic proximity, socioeconomic development, and epidemiological patterns. The seven GBD super-regions are: (1) Central Europe, Eastern Europe, and Central Asia; (2) High-income; (3) Latin America and the Caribbean; (4) North Africa and the Middle East; (5) South Asia; (6) Southeast Asia, East Asia, and Oceania; and (7) Sub-Saharan Africa.

Study data

A total of 204 countries and regions, covering a range of socio-economic backgrounds, were included in the study from the GBD database. Populations were stratified by age, sex, and region to evaluate the differential impact of low temperatures on different groups, particularly across varying SDI levels. As COPD incidence among individuals under 20 years is significantly lower compared to other age groups, this study focused on populations aged 20 years and above, assuming that the disease burden related to low-temperature risk is negligible in those under 20 years. Following the GBD database’s age classification, the population over 20 years was divided into 16 groups. These age groups included: 20–24, 25–29, 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, 65–69, 70–74, 75–79, 80–84, 85–89, 90–94, and 95 years or older.

Statistical analysis

To evaluate the trends in ASR for COPD Deaths and DALYs, the study employed estimated annual percentage changes (EAPC). The ASR per 100,000 individuals was calculated using the following formula:

graphic file with name d33e393.gif 1

(ai: the ASR for the i-th age group; w: the number of individuals in the i-th age group of the standard population; A: the total number of individuals in the age group).

Cluster analysis

Estimated annual percentage changes (EAPC) were calculated using linear regression models applied to the natural logarithm of age-standardized rates (ASRs) over time [31]. The formula applied is Y = α + βx + e, where Y denotes the natural logarithm of the ASR, X indicates the calendar year, α is the intercept, β represents the slope or trend, and e stands for the error term. The EAPC is computed as 100 × [exp(β) − 1], reflecting the annual percentage change. A linear regression model was utilized to derive the 95% confidence interval (CI) for the EAPC. An increasing trend is defined when both the EAPC and the lower CI bound are positive; a decreasing trend is indicated if both the EAPC and the upper CI bound are negative. Otherwise, the ASR is considered stable. Hierarchical cluster analysis of EAPCs across the 21 GBD regions categorized them into four groups: significant increase, slight increase, stable/slight decrease, and significant decrease, to identify comparable trends in disease burden.

Bayesian Age-Period-Cohort analysis

To project the COPD burden attributable to low temperatures from 2020 to 2041, we used the Bayesian Age–Period–Cohort (BAPC) model with nested Laplace approximation [32, 33]. This model simultaneously estimates age, period, and cohort effects, offering a nuanced perspective on long-term epidemiological trends.

The BAPC model assumes that age, period, and cohort effects evolve smoothly and additively over time. However, its predictive accuracy may be reduced in the presence of cohort drift, where successive birth cohorts experience unanticipated shifts in exposure or risk, or when abrupt structural changes (e.g., new interventions, policy shifts, or environmental disruptions) alter disease patterns in ways not captured by historical trends. Despite these limitations, BAPC has demonstrated superior performance in forecasting chronic disease burden compared to traditional models [34–36], making it appropriate for our analysis. Model implementation followed standard procedures using the BAPC package (version 0.0.36) and INLA (version 23.05.30), with all analyses and visualizations conducted in R (version 4.4.3) and the WHO’s Health Equity Assessment Toolkit.

Results

Trends in the burden of COPD at risk of low temperatures

Global and regional trends

From 1990 to 2021, the global burden of COPD attributable to low temperatures exhibited divergent trends between absolute numbers and age-standardized metrics. The number of deaths increased by 24.3%, from 242,170 (95% UI: 203,308.81–283,943.47) in 1990 to 300,849 (95% UI: 242,508.87–365,823.28) in 2021 (Table 1). However, the age-standardized death rate declined by 45.9%, from 7.04 (95% UI: 5.92–8.23) to 3.69 per 100,000 (95% UI: 2.97–4.48), with an estimated annual percentage change (EAPC) of −3.94% (95% CI: −5.54 to −87.59) (Table 1; Fig. 1).

Table 1.

The global number of deaths and the age-standardized death rate from low temperatures, COPD, and global trends from 1990 to 2021

graphic file with name 12890_2025_3811_Tab1_HTML.jpg

Open in a new tab

Abbreviations: SDI socio-demographic index, EAPC estimated annual percentage change, UI uncertainty intervals, CI confidence interval

Fig. 1.

Fig. 1

Open in a new tab

Global trends in age-standardized disability-adjusted life-year rates and mortality from COPD at risk of low temperatures, 1990–2021: A and B: sex, C, and D: age group

During the same period, the number of DALYs rose slightly by 4.9%, from 4,749,734.47 (95% UI: 3,974,572.85–5,601,837.82) in 1990 to 4,981,980.71 (95% UI: 3,996,216.58–6,090,816.43) in 2021. Nevertheless, the age-standardized DALY rate declined substantially by 50.2%, from 126.69 (95% UI: 106.18–149.22) to 59.22 (95% UI: 47.58–72.37) per 100,000 (Table 2; Fig. 1), indicating a reduced disease burden after adjusting for population aging and growth.

Table 2.

The global number of DALYS and age-standardized DALYS rate from low temperatures COPD and global trends from 1990 to 2021

graphic file with name 12890_2025_3811_Tab2_HTML.jpg

Open in a new tab

Abbreviations: SDI socio-demographic index, EAPC estimated annual percentage change, UI uncertainty intervals, CI confidence interval

Regionally, East Asia recorded the highest age-standardized DALY and mortality rates in 1990, followed by Oceania—both exceeding the global average (Fig. 2). By 2021, East Asia showed remarkable improvement, while South Asia and sub-Saharan Africa surpassed the global average, indicating a shift in disease burden. Some traditionally low-burden regions, including Central Asia, Eastern Europe, and Western Europe, remained relatively high despite being below the global average.

Fig. 2.

Fig. 2

Open in a new tab

Trends in age-standardised DALYs rates and deaths rates for COPD at risk of global low temperatures across GBD regions, 1990–2021

Cluster analysis (Fig. 3) revealed that mortality and DALY rates increased significantly in low- and low-middle-SDI regions, as well as in South Asia, high-income North America, Oceania, and sub-Saharan Africa. In contrast, middle- and high-middle-SDI regions, along with Eastern Europe and East Asia, demonstrated significant declines. High-SDI regions experienced only slight increases, while Tropical Latin America, high-income Asia-Pacific, and Central Asia showed slight declines. These patterns suggest that regions initially facing high burdens may have benefited from effective interventions, whereas resource-limited settings now face growing challenges in mitigating the cold-related burden of COPD.

Fig. 3.

Fig. 3

Open in a new tab

Results of cluster analysis of EAPCs under 21 GBD areas and SDI area classes for COPD at risk of low temperatures from 1990 to 2021

Sex differences in the burden of COPD

Both male and female COPD mortality and DALY rates showed a declining trend (Fig. 2A, B), but the burden on males remained significantly higher than among females. In particular, the absolute number of male deaths increased from 134,759.69 (95% UI: 112,080.91–157,646.46) in 1990 to 171,530.17 (95% UI: 135,476.96–209,088.62) in 2021, representing a 27.3% increase. However, the age-standardized death rate decreased by 54.2%, from 9.45 (95% UI: 7.91–10.96) per 100,000 to 4.99 (95% UI: 3.96–6.05) per 100,000. The number of female COPD deaths increased from 107,410.82 (95% UI: 81,052.84–129,979.29) in 1990 to 129,319.13 (95% UI: 99,341.71–163,346.09) in 2021, representing a 20.4% increase. Meanwhile, the age-standardized death rate decreased from 5.41 per 100,000 (95% UI: 4.11–6.54) to 2.75 per 100,000 (95% UI: 2.11–3.48), representing a 39.2% decrease, with an EAPC of −4.55%. The trend in daily changes is consistent with that of mortality. The total DALYs for males increased by 6.9%, from 2,753,608.67 to 2,943,139.06 (Table 2), but the age-standardized DALYs rate significantly decreased by 55.6%, from 167.41 per 100,000 (95% UI: 138.95–196.34) to 78.88 per 100,000 (95% UI: 61.78–96.64). In contrast, the total DALYs for females increased by only 2.1%, from 1,996,125.80 (95% UI: 1,508,814.53–2,438,871.98) to 2,038,841.65 (95% UI: 1,565,399.16–2,607,457.41), and their age-standardized DALYs rate decreased by 45.9%, from 95.9 per 100,000 (95% UI: 72.20–116.89) to 43.74 per 100,000 (95% UI: 33.56–55.94).

Age composition of the COPD burden

The burden of mortality and DALYs show distinct age stratification characteristics, with an increasing trend as age progresses (Fig. 2C-D). However, the rate of increase varies significantly (Tables 1 and 2). In the younger age group (20–45 years), both mortality and DALYS burdens are relatively low, with only a small decrease. For instance, the death rate in the 20–24 age group decreased from 0.06 per 100,000 (95% UI: 0.05–0.07) in 1990 to 0.02 per 100,000 (95% UI: 0.01–0.02) in 2021. The trend for DALYs is consistent with that of mortality (Fig. 1C, D), showing a gradual increase with age, although the overall burden remains relatively low.

The middle-aged group (45–65 age group) experienced a more pronounced decline in mortality compared to the younger group. For example, in the 60–64 age group, the death rate decreased from 12.86 per 100,000 (95% UI: 10.54–15.41) in 1990 to 4.77 per 100,000 (95% UI: 3.67–5.98) in 2021. Although mortality increases significantly with age, age-standardized death rates have decreased, and the curve typically remains within the middle range. The elderly group (≥ 65 years) bears the highest burden and is considered a high-risk population. The mortality curve remains in the high-value region, but there has been a significant decline compared to 1990. For example, in the 85–89 age group, the deaths rate decreased from 168.54 per 100,000 (95% UI: 141.16–195.76) in 1990 to 116.04 per 100,000 (95% UI: 93.25–138.57) in 2021.

SDI regional burdens and changes

In the high SDI regions, the burden of COPD has consistently remained at the highest level (Tables 1 and 2). In 1990, the number of COPD-related deaths in this region was 101,066.02 (83,950.63–118,386.24), with an age-standardized death rate of 13.05 (10.79–15.26) per 100,000. By 2021, the number of deaths had increased to 114,865.42 (92,136.40–140,529.93), although the standardized death rate had decreased to 5.16 (4.14–6.33) per 100,000. Despite this reduction, the absolute number of deaths remained the highest globally.

The high SDI regions demonstrated a notable shift in burden (Fig. 8A, B). In 1990, the number of deaths was 35,048.8 (31,051.4–38,458.36), with an age-standardized death rate of 3.09 (2.73–3.39) per 100,000. By 2021, the number of deaths had increased to 55,019.7 (47,810.05–60,408.62), but the standardized death rate decreased only to 2.28 (2.00–2.49) per 100,000, a 26.2% reduction, the smallest decline among all SDI groups. In contrast, the high-middle SDI and low-middle SDI regions showed a more balanced trend. In the high-middle SDI regions, the number of COPD-related deaths decreased from 80,122.53 (69,147.72–91,278.7) in 1990 to 76,852.03 (63,772.21–91,333.76) in 2021, with a 57.6% reduction in the standardized deaths rate.

Fig. 8.

Fig. 8

Open in a new tab

Deaths and DALYs in different regions and age groups, 1990–2021

In the low-middle SDI regions, the number of deaths increased from 19,318.18 (9,693.76–31,273.19) to 41,760.15 (19,265.72–66,590.35), and although the standardized death rate slightly declined, the absolute number of deaths increased significantly. The low SDI regions, while having the lowest COPD burden, experienced the most significant increase in deaths. In 1990, the number of deaths in these regions was 6,493.99 (3,744.33–9,587.01), and by 2021, it had risen to 12,222.38 (6,927.89–18,068.36), representing an 88.2% increase. Meanwhile, the standardized death rate decreased from 3.80 (2.23–5.63) per 100,000 to 3.28 (1.84–4.90) per 100,000, indicating a gradual shift towards an increasing number of absolute deaths.

Burden and trends at the national level

Globally, in 1990, the burden of COPD attributable to cold temperatures (Fig. 4) exhibited significant regional differences, with China, India, and the United States recording persistently high COPD DALYs and mortality. Sub-Saharan Africa and parts of South Asia also had relatively high DALYs. By 2021, China, India, and the United States continued to bear a significant COPD burden. Compared with 1990, some high-income countries, such as those in North America and Western Europe, experienced a decline in COPD deaths rates. However, in low-SDI (sociodemographic index) regions, such as sub-Saharan Africa and parts of South Asia, the burden remained severe.

Fig. 4.

Fig. 4

Open in a new tab

Global burden of disease for men and women in 204 countries and territories under COPD at risk of global low temperatures. A DALYS rates in 1990. B DALYS rates in 2021. C 1990 deaths rate. D Deaths rates in 2021

According to the global age-standardized COPD mortality and DALYs rates under low temperature risks (Fig. 5A, B), in 1990, China demonstrated particularly pronounced COPD mortality and DALYs rates, especially with respect to DALYs. In addition, Eastern Europe and Central Asia exhibited relatively high COPD burdens, whereas most regions in sub-Saharan Africa had lower mortality and DALYs rates. Low-SDI regions, such as sub-Saharan Africa and Southeast Asia, generally showed lighter burdens under low temperature risks, while high-SDI regions demonstrated heavier burdens. By 2021, China experienced a decline in DALYs rates (Fig. 5A-B), whereas Southeast Asia and parts of South Asia showed an increase in burden. In sub-Saharan Africa and other low-income countries, COPD mortality and DALYs rates also showed significant increases. These findings suggest that the COPD burden in low-SDI regions is increasing under the influence of cold temperatures, while public health interventions in high-income countries may have mitigated the COPD burden to some extent.

Fig. 5.

Fig. 5

Open in a new tab

Changes in the number of male and female cases under COPD at risk of low temperatures in 204 countries and territories globally, 1990–2021. A Changes in the number of cases of DALYs. B Changes in the number of fatal cases. C EAPC for DALYs. D EAPC for Deaths

From 1990 to 2021, the percentage changes in DALYs and mortality across countries revealed substantial geographic disparities (Fig. 5A, B). The decline in disease burden was predominantly observed in high-income regions and some middle-income countries. In Northern Europe, including nations such as Norway and Sweden, DALYs and mortality decreased significantly by 70-100%. Similarly, parts of Western Europe and North America, including Canada, exhibited a consistent reduction of 30-70%. In the Caribbean, countries like Cuba experienced a substantial reduction in DALYs, particularly within the range of 30-70%.Conversely, increases in disease burden were most pronounced in low- and middle-income countries, particularly in sub-Saharan Africa and South Asia. Sub-Saharan Africa recorded the most significant growth, with DALYs and mortality increasing by over 300%, indicating significant public health challenges and limited healthcare infrastructure in these regions. In South Asia, including countries like India and Pakistan, the disease burden rose by 100-300%, possibly driven by population growth, aging, and environmental and social determinants. In the Persian Gulf, nations such as Qatar and Bahrain experienced sharp increases in DALYs, ranging from 50 to 300%.

EAPC influencing factors

The relationship between the SDI and age-standardized DALYs rates across regions and countries (Fig. 6A, B), as well as expected levels based on SDI, revealed notable patterns. High-SDI regions, such as Australia and parts of Central Latin America, exhibited actual trends that closely aligned with expected levels throughout the study period. In contrast, middle- and low-SDI regions displayed substantial variability in patterns. For instance, certain high-income regions, including high-income Asia Pacific and North America, had DALYs rates significantly below expected levels, with relatively stable age-standardized rates. Conversely, East Asia, a middle-SDI region, had DALYs rates markedly above expected levels, although these rates showed a fluctuating or declining trend over time. In low-SDI regions such as sub-Saharan Africa and South Asia, DALYs rates remained disproportionately high, reflecting significant health burdens.

Fig. 6.

Fig. 6

Open in a new tab

Age-standardized deaths and DALYs for COPD due to low temperatures by SDI for 21 GBD regions (A) and 204 countries and territories (B), 1990–2021, with expected values based on socio-demographic indices and incidence rates for all locations shown as black lines. Abbreviations: DALYS, disability-adjusted life year

At the national level, DALYs rates and mortality were positively correlated with SDI in low- and middle-SDI regions (Fig. 6C, D). Countries such as Afghanistan and Madagascar stood out in the middle-SDI category, while Nepal and Lesotho showed significant trends in the lower-middle-SDI group. Among countries with higher SDI values, COPD burdens and mortality exhibited oscillating trends. For instance, China and Kazakhstan, in the upper-middle-SDI category, reported higher burdens, while high-SDI countries generally had lower overall burdens, though Denmark and Hungary experienced slightly higher burdens compared to other high-SDI nations.

Future forecasts of COPD

Between 1990 and 2021, the global DALYs of COPD under low-temperature risk significantly decreased (Fig. 7A, F), from 1.266 million in 1990 to 592,000 in 2021, with an average annual decline of approximately 2.1%. Projections indicate that DALYs will further decrease to 363,000 by 2041, maintaining a downward trend. COPD mortality declined from 7.04 per 100,000 in 1990 to 3.69 per 100,000 in 2021, reflecting an overall reduction of 47.6%, and is projected to continue declining to 2.30 per 100,000 by 2041.

Fig. 7.

Fig. 7

Open in a new tab

BAPC model projections of age-standardized DALYs and mortality sums for global low temperatures risk, 1990–2041. Abbreviations: BAPC, Bayesian age-period-cohort

The DALYs of COPD under low-temperature risk among males decreased from 1.674 million in 1990 to 789,000 in 2021 and are projected to decline further to 489,600 by 2041. Similarly, the DALYs for females decreased from 958,000 in 1990 to 440,000 in 2021, with a further reduction to 331,000 expected by 2041. The decline rate among males was slightly faster, with an average annual decrease of 2.3%, compared to 1.9% for females. However, male mortality remained higher than that of females throughout the study period (9.45 per 100,000 vs. 5.41 per 100,000 in 1990). Although the gender gap in mortality is expected to narrow in the future, it will persist. Female mortality decreased from 5.41 per 100,000 in 1990 to 2.78 per 100,000 in 2021, representing a 48.6%.

Discussion

This study comprehensively evaluated the burden and trends of COPD under low-temperature risk from 1990 to 2021, revealing that low-temperature risk continues to exert significant impacts on various age groups, regions, and SDI groups. The analysis systematically identified high-risk regions and susceptible populations from a multidimensional perspective and projected COPD trends over the next 20 years. These findings provide scientific evidence and guidance for global efforts to address COPD under low-temperature risk.

Global COPD burden trends and risk groups at risk of low temperatures

By 2021, global age-standardized COPD mortality and DALYs attributable to cold exposure showed a marked decline, largely driven by strengthened public health interventions—such as improved indoor air quality, tobacco control, and expanded healthcare access [37]. However, the increasing total case numbers highlight that the burden of cold-related COPD remains significant in the context of population growth and aging.

Sex-specific patterns show that men consistently experienced a higher cold-related COPD burden, primarily due to higher smoking rates and occupational exposures [38]. Nevertheless, the male burden declined more rapidly, narrowing the gender gap, likely due to stricter tobacco and occupational health regulations [39]. In contrast, women remain more physiologically sensitive to cold exposure, exhibiting earlier thermogenic responses [40], and are disproportionately exposed to indoor air pollution from solid fuel use, especially in low-resource settings [24].

Cold-related COPD burden shows a clear age gradient, with low risk in individuals aged 20–45, intermediate risk in those 45–65, and highest risk in adults aged 65 and above. This pattern reflects the increased physiological vulnerability of older adults, including impaired thermoregulation, reduced mucociliary clearance, diminished lung elasticity, and weakened immunity [41]. These changes heighten the impact of cold exposure, leading to bronchoconstriction, increased mucus secretion, and a higher susceptibility to respiratory infections [40, 42, 43].

While these vulnerabilities are biologically universal, their impact is significantly amplified in socioeconomically disadvantaged settings. In high-burden regions such as sub-Saharan Africa, the cold-related COPD DALY burden among individuals aged 45–79 remains substantial. This is driven by poverty, rapid urbanization, widespread reliance on polluting fuels, inadequate housing, and poor indoor air quality [44]. Limited access to healthcare and weak chronic disease management further compound the risks among elderly populations [23].

Geographic and socio-economic factors of COPD burden

The burden of COPD shows an inverse relationship with socio-demographic development when measured by age-standardized rates. Age-standardized COPD mortality and DALYs have declined markedly in high-SDI regions, whereas reductions in low and low-middle SDI regions remain limited or stagnant. This trend suggests that socioeconomic development plays a critical role in mitigating COPD burden, largely through improvements in environmental quality, behavioral risk factor control, and health system performance. High-SDI regions typically maintain low DALYs and age-standardized death rates (ASDR), due to advanced medical technologies [6], broad healthcare coverage, enhanced early diagnosis, and efficient indoor climate control and disease management strategies [7, 45].

This disparity highlights the critical role of socioeconomic development in modifying environmental and behavioral risk exposures. In under-resourced settings, the impact of low temperature is not merely additive but compounding: socio-economic disadvantages (e.g., poor housing [8], lack of heating [6], limited healthcare [46]) amplify the biological vulnerability of COPD patients to cold exposure. These conditions increase the frequency and severity of cold-induced physiological responses—bronchoconstriction, impaired mucociliary clearance, airway inflammation, vasoconstriction, and immune suppression—which jointly elevate the risk of infection and exacerbations [15, 47].

This compound risk effect is particularly evident in older adults in low-SDI regions, where both adaptive capacity and healthcare responsiveness are limited (Fig. 8A-B). In regions such as East Asia, South Asia, Southeast Asia, and sub-Saharan Africa, this interplay of environmental exposure and systemic inadequacy has resulted in persistently high cold-related COPD DALYs and mortality [48].

Most COPD patients in these settings face limited access to diagnosis and treatment, low spirometry use, and ineffective public health policies [49]. For instance, Malawi’s single spirometer and unequal access to COPD medications illustrate these systemic gaps. Recent studies reinforce these findings. Kumar et al. identified significant regional disparities in India using GBD data and emphasized the urgency of strengthening spirometry-based diagnosis in primary care [50]. Li et al. also highlighted that in younger populations across LMICs, exposure to air pollution and occupational hazards remains a key modifiable factor [51]. Countries such as Afghanistan, Madagascar, Papua New Guinea, Bhutan, and Sudan demonstrate slow declines in COPD burden due to insufficient medical infrastructure, persistent use of polluting fuels, and limited climate adaptation capacity [6, 46].

Future projections

The BAPC model projects a continued global decline in COPD-related deaths and DALYs for both sexes by 2041, indicating gradual mitigation of disease burden despite persistent cold-related risks. This trend likely reflects improvements in healthcare resources and winter-specific disease management. Low temperatures exacerbate COPD primarily by intensifying air pollution. During colder months, PM2.5 concentrations rise due to increased fuel combustion and meteorological phenomena such as temperature inversions [47], which trap pollutants near the surface. Studies indicate that over 90% of severe air pollution days—mostly in winter—are linked to inversion events [52]. Such pollution significantly worsens COPD symptoms and increases mortality [53].

Projections also show that DALYs and mortality will decline more rapidly among men. This may be attributed to their higher baseline burden and the stronger impact of tobacco control and climate adaptation policies targeting high-risk male behaviors and occupations. However, women remain physiologically more sensitive to cold and air pollution exposures [21], and are particularly vulnerable in settings with poor indoor air quality and inadequate heating [54]. The slower burden reduction observed in women may reflect their lower baseline but also insufficient targeted protection.

Public health implications and adaptation strategies

In light of the growing burden of cold-related COPD—particularly in low- and middle-SDI regions—a practical, regionally tailored public health response is urgently needed. Based on our findings, we propose the following four strategic priorities:

  1. Improve environmental and thermal protection

Extreme low temperatures intensify COPD risks by both direct physiological stress and indirect mechanisms such as increased indoor air pollution. In underdeveloped regions, improving access to clean heating fuels, enhancing home insulation, and ensuring adequate ventilation are key to reducing cold-season vulnerability.

  • (2)

    Expand basic diagnostic capacity and service coverage

In many cold-affected, resource-limited areas, limited access to diagnostic equipment contributes to delayed diagnosis and poorer outcomes. Strengthening COPD detection through the deployment of basic spirometry devices in primary care and promoting routine seasonal health check-ups for high-risk individuals can facilitate early management. Additionally, expanding clinic coverage in cold-prone regions—through fixed or outreach-based models—can improve access to essential medications and follow-up care during the winter months.

  • (3)

    Protect highly vulnerable populations

Older adults with COPD face compounding risks due to physiological decline and poor housing or healthcare access. Targeted winter interventions, such as vaccination campaigns, home visits, and heating assistance, should be prioritized.

  • (4)

    Gender-specific strategies are also important:

For women, promoting clean cooking fuels and improving indoor air quality can reduce cold-related COPD risks. For men, particularly those engaged in outdoor labor, strengthening cold-weather occupational protections is critical.

Collectively, these strategies offer a framework for climate-resilient COPD prevention, with the potential to reduce health inequities, enhance cold-season preparedness, and lower long-term respiratory disease burden—especially in structurally disadvantaged regions.

Conclusion

In 2021, the global burden of COPD attributable to low temperatures declined significantly compared to 1990. However, substantial disparities remain across sex, age, and socio-demographic levels. Men and older adults (≥ 65 years) remain the most affected, and low- and lower-middle SDI regions continue to experience the highest burden with the slowest decline.

Although forecasts suggest a continued global reduction in COPD mortality, the pace of improvement may decelerate, especially in resource-limited settings. The interplay between cold exposure and poor infrastructure, limited diagnostic access, and low healthcare investment disproportionately amplifies risks in these regions.

This underscores the urgent need for context-specific adaptation strategies, including improved thermal protection, expanded access to early diagnosis and essential care, targeted support for vulnerable populations (especially the elderly), and gender-sensitive interventions. These measures are essential to mitigate cold-related COPD burden, reduce global health inequities, and enhance resilience in the face of ongoing climate change.

Limitation

There are some limitations to this study: (1) Data quality and modeling bias: The accuracy of estimates depends on the quality and availability of data across regions. In low- and middle-income areas where primary data are sparse, the GBD relies more heavily on modeling assumptions, which may introduce bias and affect the reliability of the results. In addition, inherent assumptions and complexities in the GBD modeling framework can add further uncertainty. While robust statistical approaches are applied to reduce these issues, the findings should be viewed as the best available estimates based on current data. (2) Impact of climate change: This study did not account for the potential amplification of hypothermia risk caused by climate variability and extreme weather events. (3) Limited range of risk factors: While hypothermia represents a key risk factor for COPD, this study did not comprehensively analyze other critical factors such as air pollution, smoking, occupational exposures, and comorbidities, potentially underestimating their interaction with hypothermia risk.(4) Policy and financial constraints: While this study highlighted the insufficiency of policy and financial support in certain regions, it did not delve into the root causes of these issues or provide actionable recommendations for their resolution. (5) Public health and policy differences: Substantial disparities exist in public health interventions and policy responses to climate change among countries. The absence of country-specific, context-sensitive climate policies and analyses of their impacts limits the practical applicability of the findings.

Acknowledgements

We would like to express our sincere gratitude to the National Natural Science Foundation of China for supporting this work. We also thank the Chongqing Municipal Hospital of Traditional Chinese Medicine and the Chongqing Municipal Health Commission for their institutional and financial support through the Chongqing Medical Leading Talent Project. In addition, we acknowledge the GBD 2021 collaborators whose outstanding contributions enabled us to complete this study.

Authors’ contributions

Xuyuan Wang: Writing – review & editing, Writing – original draft, Software, Visualization, Project administration, Formal analysis, Data curation, Validation, Methodology. Aiping Gou: Writing – original draft, Supervision, Resources, Investigation, Funding acquisition. Jiangbo Wang: Conceptualization, Writing – review & editing, Supervision. Jing Li: Supervision, Project administration, Resources. Chunyan Gou: Supervision, Project administration, Funding acquisition, Resources.

Funding

This study was supported by the National Natural Science Foundation of China [Grant numbers 51778364, 51978329], and the Chongqing Medical Leading Talent Project [Grant number YXLJ202418].

Data availability

The datasets generated and/or analyzed during the current study are included in this published article. To download the data used in these analyses, please visit the Global Health Data Exchange GBD 2021 website (https://ghdx.healthdata.org/gbd-2021).

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Xuyuan Wang and Aiping Gou contributed equally to this work and should be considered co-first authors.

Jiangbo Wang and Chunyan Gou co-corresponding authors.

Contributor Information

Jiangbo Wang, Email: jumbo@njtech.edu.cn.

Chunyan Gou, Email: 335719554@qq.com.

References

  • 1.Christenson SA, Smith BM, Bafadhel M, Putcha N. Chronic obstructive pulmonary disease. Lancet. 2022;399:2227–42. [DOI] [PubMed] [Google Scholar]
  • 2.Vukoja M, Kopitovic I, Lazic Z, Milenkovic B, Stankovic I, Zvezdin B, et al. Diagnosis and management of chronic obstructive pulmonary disease in serbia: an expert group position statement. Int J Chronic Obstr Pulm Dis. 2019;14:1993–2002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Tran HM, Chuang TW, Chuang HC, Tsai FJ. Climate change and mortality rates of COPD and asthma: a global analysis from 2000 to 2018. Environ Res. 2023;233:116448. [DOI] [PubMed] [Google Scholar]
  • 4.Tran HM, Tsai FJ, Lee KY, Wang YH, Yang FM, Ho SC, et al. Extreme temperature increases the risk of COPD morbimortality: a systematic review and meta-analysis. Sci Total Environ. 2025;958:178087. [DOI] [PubMed] [Google Scholar]
  • 5.Fu J, Liu Y, Zhao Y, Chen Y, Chang Z, Xu KF, Huang C, Fan Z. Association between the temperature difference and acute exacerbations of chronic obstructive pulmonary disease: a time-series analysis with 143,318 hospital admissions in Beijing, China. Front Public Health. 2023;11:1112926. [DOI] [PMC free article] [PubMed]
  • 6.Awokola BI, Amusa GA, Jewell CP, Okello G, Stobrink M, Finney LJ, et al. Chronic obstructive pulmonary disease in sub-Saharan Africa. Int J Tuberc Lung Dis. 2022;26:232–42. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Zou J, Sun T, Song X, Liu Y-M, Lei F, Chen M-M, et al. Distributions and trends of the global burden of COPD attributable to risk factors by SDI, age, and sex from 1990 to 2019: a systematic analysis of GBD 2019 data. Respir Res. 2022;23:90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.McAllister DA, Morling JR, Fischbacher CM, MacNee W, Wild SH. Socioeconomic deprivation increases the effect of winter on admissions to hospital with COPD: retrospective analysis of 10 years of National hospitalisation data. Prim Care Respir J. 2013;22:296–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Shi C, Zhu J, Wu Q, Liu Y, Hao Y. Effects of ambient temperature and humidity on COPD mortality in Ganzhou city, China. Int J Biometeorol. 2024;68:1789–98. [DOI] [PubMed] [Google Scholar]
  • 10.Shi Z, Shao J, Dong C, Song G, Hu Y, Niu Q, et al. Burden of chronic obstructive pulmonary disease attributable to non-optimal temperature, 1990–2044: six countries on the same isotherm. BMC Public Health. 2024;24:3407. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Tran HM, Tsai F-J, Wang Y-H, Lee K-Y, Chang J-H, Chung C-L, et al. Joint effects of temperature and humidity with PM2.5 on COPD. BMC Public Health. 2025;25:424. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Donaldson GC, Wedzicha JA. The causes and consequences of seasonal variation in COPD exacerbations. COPD. 2014;9:1101–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Hansel NN, McCormack MC, Kim V. The effects of air pollution and temperature on COPD. COPD. 2016;13:372–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Rau A, Tarr GAM, Baldomero AK, Wendt CH, Alexander BH, Berman JD. Heat and cold Wave–Related mortality risk among united States veterans with chronic obstructive pulmonary disease: A Case-Crossover study. Environ Health Perspect. 2024;132:027004. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Xu J, Xu G, Liu Z, Hou R, Ji JS, Huang C. COPD risk due to extreme temperature exposure: combining epidemiological evidence with pathophysiological mechanisms. Time Series. 2025;116. [DOI] [PMC free article] [PubMed]
  • 16.Ran D, Chen L, Xie W, Xu Q, Han Z, Huang H, et al. Cold-inducible RNA binding protein regulates mucin expression induced by cold temperatures in human airway epithelial cells. Arch Biochem Biophys. 2016;603:81–90. [DOI] [PubMed] [Google Scholar]
  • 17.Mekhuri S, Quach S, Barakat C, Sun W, Nonoyama ML. A cross-sectional survey on the effects of ambient temperature and humidity on health outcomes in individuals with chronic respiratory disease. Can J Respir Ther. 2023;59:256–69. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 18.Konstantinoudis G, Minelli C, Vicedo-Cabrera AM, Ballester J, Gasparrini A, Blangiardo M. Ambient heat exposure and COPD hospitalisations in england: a nationwide case-crossover study during 2007–2018. Thorax. 2022;77:1098–104. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Witt CC, Liebers U, Essler AK. Inhalative treatment induces vulnerability to heat-related exacerbations in COPD - a prospective study in the Metropolitan Area of Berlin, Germany. In: C24. Disparities in the health effects of climate change and pollutants. American Thoracic Society; 2023. p. A4609–A4609.
  • 20.McCormack MC, Paulin LM, Gummerson CE, Peng RD, Diette GB, Hansel NN. Colder temperature is associated with increased COPD morbidity. Eur Respir J. 2017;49:1601501. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Chung CY, Yang J, Yang X, He J. Effects of ambient temperature on chronic obstructive pulmonary disease (COPD) mortality in highly polluted region. Urban Clim. 2024;58:102163. [Google Scholar]
  • 22.Xie J, Wang M, Long Z, Ning H, Li J, Cao Y, Liao Y, Liu G, Wang F, Pan A. Global burden of type 2 diabetes in adolescents and young adults, 1990–2019: systematic analysis of the Global Burden of Disease Study 2019. BMJ. 2022;2022(379):e072385. 10.1136/bmj-2022-072385. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23.GBD 2019 Chronic Respiratory Diseases Collaborators. Global burden of chronic respiratory diseases and risk factors, 1990–2019: an update from the global burden of disease study 2019. EClinicalMedicine. 2023;59:101936. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. Lancet. 2020;396:1204–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25.Hu W, Yang J. Effect of ambient Ozone pollution on disease burden globally: A systematic analysis for the global burden of disease study 2019. Sci Total Environ. 2024;926:171739. [DOI] [PubMed] [Google Scholar]
  • 26.Moghadamnia MT, Ardalan A, Mesdaghinia A, Keshtkar A, Naddafi K, Yekaninejad MS. Ambient temperature and cardiovascular mortality: a systematic review and meta-analysis. PeerJ. 2017;5:e3574. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 27.Yin Q, Wang J, Ren Z, Li J, Guo Y. Mapping the increased minimum mortality temperatures in the context of global climate change. Nat Commun. 2019;10:4640. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 28.GBD 2021 Risk Factors Collaborators. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021: a systematic analysis for the global burden of disease study 2021. Lancet. 2024;403:2162–203. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Chen R, Yin P, Wang L, Liu C, Niu Y, Wang W, Jiang Y, Liu Y, Liu J, Qi J, You J, Kan H, Zhou M. Association between ambient temperature and mortality risk and burden: time series study in 272 main Chinese cities. BMJ. 2018;2018(363):k4306. 10.1136/bmj.k4306. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Song J, Qin W, Pan R, Yi W, Song S, Cheng J, et al. A global comprehensive analysis of ambient low temperature and non-communicable diseases burden during 1990–2019. Environ Sci Pollut Res. 2022;29:66136–47. [DOI] [PubMed] [Google Scholar]
  • 31.Clegg LX, Hankey BF, Tiwari R, Feuer EJ, Edwards BK. Estimating average annual per cent change in trend analysis. Stat Med. 2009;28:3670–82. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Chen J, Chen H, Zhang T, Yin X, Man J, Yang X, et al. Burden of pancreatic cancer along with attributable risk factors in China from 1990 to 2019, and projections until 2030. Pancreatology. 2022;22:608–18. [DOI] [PubMed] [Google Scholar]
  • 33.Du Z, Chen W, Xia Q, Shi O, Chen Q. Trends and projections of kidney cancer incidence at the global and National levels, 1990–2030: a bayesian age-period-cohort modeling study. Biomark Res. 2020;8:16. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Knoll M, Furkel J, Debus J, Abdollahi A, Karch A, Stock C. An R package for an integrated evaluation of statistical approaches to cancer incidence projection. BMC Med Res Methodol. 2020;20:257. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Li S, Chen H, Man J, Zhang T, Yin X, He Q, et al. Changing trends in the disease burden of esophageal cancer in China from 1990 to 2017 and its predicted level in 25 years. Cancer Med. 2021;10:1889–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 36.Wu B, Li Y, Shi B, Zhang X, Lai Y, Cui F, et al. Temporal trends of breast cancer burden in the Western Pacific region from 1990 to 2044: implications from the global burden of disease study 2019. J Adv Res. 2024;59:189–99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Salvi S, Kumar GA, Dhaliwal RS, Paulson K, Agrawal A, Koul PA, et al. The burden of chronic respiratory diseases and their heterogeneity across the States of india: the global burden of disease study 1990–2016. Lancet Global Health. 2018;6:e1363–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 38.Safiri S, Carson-Chahhoud K, Noori M, Nejadghaderi SA, Sullman MJM, Ahmadian Heris J, et al. Burden of chronic obstructive pulmonary disease and its attributable risk factors in 204 countries and territories, 1990–2019: results from the global burden of disease study 2019. BMJ. 2022:e069679. [DOI] [PMC free article] [PubMed]
  • 39.Flor LS, Reitsma MB, Gupta V, Ng M, Gakidou E. The effects of tobacco control policies on global smoking prevalence. Nat Med. 2021;27:239–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Zhang Y, Liu X, Kong D, Fu J, Liu Y, Zhao Y, et al. Effects of ambient temperature on acute exacerbations of chronic obstructive pulmonary disease: results from a Time-Series analysis of 143318 hospitalizations. Int J Chron Obstruct Pulmon Dis. 2020;15:213–23. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 41.Wang C, Xu J, Yang L, Xu Y, Zhang X, Bai C, et al. Prevalence and risk factors of chronic obstructive pulmonary disease in China (the China pulmonary health [CPH] study): a National cross-sectional study. Lancet. 2018;391:1706–17. [DOI] [PubMed] [Google Scholar]
  • 42.Koskela HO. Cold air-provoked respiratory symptoms: the mechanisms and management. Int J Circumpolar Health. 2007;66:91–100. [DOI] [PubMed] [Google Scholar]
  • 43.Qi Y, Yan Y, Tang D, Han J, Zhu X, Cui M, et al. Inflammatory and immune mechanisms in COPD: current status and therapeutic prospects. J Inflamm Res. 2024;17:6603–18. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Halpin DMG, Celli BR, Criner GJ, Frith P, López Varela MV, Salvi S, et al. The GOLD summit on chronic obstructive pulmonary disease in low- and middle-income countries. Int J Tuberc Lung Dis. 2019;23:1131–41. [DOI] [PubMed] [Google Scholar]
  • 45.Chen S, Kuhn M, Prettner K, Yu F, Yang T, Bärnighausen T, et al. The global economic burden of chronic obstructive pulmonary disease for 204 countries and territories in 2020–50: a health-augmented macroeconomic modelling study. Lancet Global Health. 2023;11:e1183–93. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Perret JL, Dharmage SC. COPD-related incidence, mortality, and disability: an illustrative summary of the GBD study (1990–2019). Respirology. 2023;28:11–2. [DOI] [PubMed] [Google Scholar]
  • 47.Xu T, Song Y, Liu M, Cai X, Zhang H, Guo J, Zhu T. Temperature inversions in severe polluted days derived from radiosonde data in North China from 2011 to 2016. Sci Total Environ. 2019;647:1011–20. 10.1016/j.scitotenv.2018.08.088. [DOI] [PubMed] [Google Scholar]
  • 48.Zhou M, Wang H, Zeng X, Yin P, Zhu J, Chen W, et al. Mortality, morbidity, and risk factors in China and its provinces, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2019;394:1145–58. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Halpin DMG, Celli BR, Criner GJ, Frith P, López Varela MV, Salvi S, et al. It is time for the world to take COPD seriously: a statement from the GOLD board of directors. Eur Respir J. 2019;54:1900914. [DOI] [PubMed] [Google Scholar]
  • 50.Kumar V, Singh M, Khatib MN, Balaraman AK, Roopashree R, Kaur M, et al. Burden and regional disparities of chronic obstructive pulmonary disease in india: insights from the global burden of disease data and projections for future incidence. Expert Rev Respir Med. 2025;19:269–77. [DOI] [PubMed] [Google Scholar]
  • 51.Li X, Kong X, Yang C, Cheng Z, Lv J, Guo H, et al. Global, regional, and National burden of ischemic stroke, 1990–2021: an analysis of data from the global burden of disease study 2021. eClinicalMedicine. 2024;75:102758. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.Chung CY, Yang J, He J, Yang X, Hubbard R, Ji D. An investigation into the impact of variations of ambient air pollution and meteorological factors on lung cancer mortality in Yangtze river delta. Sci Total Environ. 2021;779:146427. 10.1016/j.scitotenv.2021.146427. [DOI] [PubMed] [Google Scholar]
  • 53.Hansel NN, McCormack MC, Kim V. The effects of air pollution and temperature on COPD. COPD. 2016;13:372–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Son JY, Lane KJ, Lee JT, Bell ML. Urban vegetation and heat-related mortality in Seoul, Korea. Environ Res. 2016;151:728–33. 10.1016/j.envres.2016.09.001. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets generated and/or analyzed during the current study are included in this published article. To download the data used in these analyses, please visit the Global Health Data Exchange GBD 2021 website (https://ghdx.healthdata.org/gbd-2021).

Articles from BMC Pulmonary Medicine are provided here courtesy of BMC

RESOURCES