Chronic obstructive pulmonary disease (COPD) is one of the most prevalent chronic respiratory diseases worldwide. It has long ranked among the leading causes of death from chronic conditions, posing a heavy burden on both public health and socioeconomic systems (1, 2). In Asia, due to the combined effects of demographic structure and environmental exposures, the prevalence and mortality of COPD are significantly higher than the global average (3). For developing countries with limited health resources, this disparity underscores the importance of formulating region-specific prevention and control strategies (4, 5).

Patients with COPD commonly present with chronic cough, sputum production, and exertional dyspnea. Recurrent acute exacerbations accelerate disease progression and lead to persistent decline in lung function, thereby reducing quality of life and increasing healthcare burden (5). The major risk factors for COPD include smoking, outdoor air pollution, indoor solid fuel use, and occupational exposures, all of which are closely related to lifestyle and socioeconomic status (6). In Asia, widespread biomass fuel use in rural areas of South and Southeast Asia poses particular harm to women and children, while rapid urbanization and industrialization have led to sustained high levels of PM₂.₅ exposure and increased risks of occupational dust (7). The combination of these factors has substantially exacerbated the regional disease burden, highlighting the necessity of targeted research and intervention.

Although previous studies have systematically evaluated the long-term global trends and risk factors of COPD, research focusing on regional and inter-country differences in disease burden within Asia remains limited. Based on data from the Global Burden of Disease (GBD) 2021 study, this research assessed age-standardized rates (ASRs) and their temporal trends for COPD across Asian regions, age groups, sexes, and countries from 1990 to 2021. The analysis was further stratified by the Sociodemographic Index (SDI) to reveal disparities in disease burden across different levels of socioeconomic development. In addition, Joinpoint regression models were applied to calculate the annual percent change (APC) and average annual percent change (AAPC) for various periods. This study aims to systematically characterize the distribution and temporal evolution of the COPD burden in Asia, providing scientific evidence to guide public health interventions.

Based on GBD 2021 data, this study systematically analyzed the burden of COPD in Asia. In 2021, the number of new COPD cases exceeded 10 million (16), underscoring that COPD is not only a major chronic respiratory problem but also reflects the profound impact of demographic changes and combined environmental exposures on public health (17). Previous studies have provided a clear picture of the global burden of COPD and the attributable burdens of its major risk factors; however, Asia has often been treated as a single region, with limited characterization of within-region heterogeneity (18). Here, we refine the analytical scale to the country and subregional levels within Asia, identify high-burden hotspots in relation to major risk factors, and—through age- and sex-stratified analyses—delineate priority populations, thereby providing evidence to support region-specific prevention and resource allocation.

The main risk factors for COPD in Asia in 2021 included particulate matter (PM) pollution, smoking, and occupational exposure to particulate matter, gases, and fumes (OP-MGF), with varying contributions across regions. In South Asia, the use of biomass fuels in rural households has caused indoor air pollution that particularly harms women and children, significantly increasing COPD risk (19, 20). In addition, widespread tobacco consumption in India and several other Asian countries has further exacerbated the COPD burden (21). From 1990 to 2021, East Asia experienced a marked reduction in COPD burden. For example, in China, coal control policies, tobacco-control legislation, and the promotion of lung function screening collectively reduced exposures and improved disease management outcomes (22, 23). The East Asian experience demonstrates that comprehensive interventions are critical for COPD prevention and control, providing lessons for other regions (24).

Our 2021 analysis revealed a significant negative correlation between the Sociodemographic Index (SDI) and both ASMR and AS-DALYs in Asia. This trend highlights the importance of public health interventions such as smoking control, air pollution mitigation, and improvements in healthcare services in reducing disease burden (25, 26). However, despite relatively high SDI levels in some countries of East and South Asia, their COPD burden remained higher than expected, suggesting the combined effects of persistently high smoking prevalence, environmental particulate exposure, occupational hazards, and continued use of biomass fuels among certain populations (27). Further analyses showed that from 1990 to 2021, COPD burden in Asian countries was significantly negatively correlated with SDI, yet countries such as Nepal and India exhibited substantially higher burdens than predicted. This discrepancy reflects the critical roles of sociocultural factors, public health policy implementation, and healthcare accessibility in shaping disease burden in these regions (28, 29).

At the national level, the COPD burden in India and Nepal was particularly pronounced. In India, multiple factors, including high smoking prevalence, employment in high-risk industries, and limited public health awareness, have contributed to its leading COPD burden (30). In Nepal, 59.4% of COPD patients were current smokers, and 76.2% relied on traditional firewood for cooking; combined with poor ventilation in cold, high-altitude settings, this exacerbated indoor pollution alongside environmental PM₂.₅ exposure (31). Parallel promotion of tobacco control and clean energy alternatives, together with stronger occupational protections, is urgently required.

In Central Asia, countries such as Kyrgyzstan and Tajikistan—among the poorest and highest-altitude nations in Asia—showed COPD burdens above the regional median. Reviews of high-altitude populations have demonstrated that solid-fuel heating during cold seasons, combined with unfavorable meteorological conditions, leads to persistently elevated indoor PM₂.₅ levels, which are strongly associated with increased COPD risk (32, 33). Regarding occupational factors, a meta-analysis in Central Asia revealed a significant association between exposure to vapors, gases, dusts, and fumes and COPD risk, with a stronger effect observed in Kazakhstan (34, 35). Although Kazakhstan ranks only 25th in Asia by population, this study showed that its COPD burden is among the highest. During the heating season, PM₂.₅ concentrations in Almaty frequently reach extreme levels, with daily AQI values ranking among the world’s highest (36). Combined with emissions from mining and oil, and gas industries, urban air pollution has worsened (37). Given the difficulty of avoiding short-term high pollution events, emission reduction from biomass fuels, adoption of clean heating alternatives, industrial emission control, and enhanced public risk communication are essential.

In Southeast Asia, Indonesia, the world’s fourth most populous country, had 62.9% of men and 4.8% of women aged 15 years or older using tobacco (38). In addition to smoking, indoor air pollution from household biomass fuel use and occupational dust/fume exposures were also linked to increased COPD risk and should be prioritized in national-level interventions (39). In East Asia, North Korea has become a high-burden region due to severe carbon monoxide and aerosol pollution, highlighting the importance of energy structure and environmental governance (40). By contrast, Singapore achieved remarkable success in COPD prevention and control. From 1990 to 2021, its COPD burden declined significantly, benefiting from early diagnosis, tobacco-control legislation, comprehensive management strategies, and optimized healthcare resources (41, 42). These achievements not only highlight the effectiveness of systemic interventions but also provide transferable lessons for other countries.

Overall, the COPD burden in Asia shows striking heterogeneity. In South Asia, smoking and biomass fuel use dominate; in Central Asia, high altitude and occupational exposures are key drivers; in Southeast Asia, risks reflect both urban–rural disparities and environmental challenges linked to rapid urbanization; and in some regions, sustained declines have been observed due to early diagnosis, tobacco-control policies, and integrated disease management. Future prevention and control efforts should be tailored to local contexts, focusing on modifiable key risk factors to reduce regional burdens.

Analyses by sex and age demonstrated that COPD burden increased substantially with age, particularly after 45 years. Natural declines in lung function with aging, combined with chronic airway inflammation and parenchymal destruction, are the main contributors to increased burden among older adults (43, 44). Men bear a heavier burden due to historically higher smoking prevalence, whereas women are emerging as a potential high-risk group in countries where female smoking prevalence is rising (45, 46). These findings are consistent with a previous study on young COPD, which indicated that early-onset COPD already poses a public health threat and projected a continued increase in burden through 2050, suggesting a cumulative effect across the life course (47) Building upon this evidence, our study extends the analysis to middle-aged and older populations, confirming the significant increase in burden in the context of population aging and revealing divergent trends between men and women. Therefore, future prevention strategies should particularly target middle-aged and older men, as well as women, in settings with increasing smoking prevalence, to achieve more precise stratified interventions.

Joinpoint regression analysis showed that the COPD burden in Asia declined markedly between 2004 and 2007. This change was closely linked to the implementation of comprehensive interventions. Measures such as higher tobacco taxes, comprehensive smoke-free legislation, and improvements in air quality effectively reduced the COPD burden (48, 49). In addition, strengthening healthcare systems and optimizing chronic disease management promoted screening and early diagnosis, further reducing disease burden (50). Looking forward, continued intensification of tobacco control, optimization of healthcare services, and air quality improvements are essential to further mitigate the COPD burden in Asia.

In summary, this study demonstrates that COPD remains a substantial burden in Asia, with significant regional disparities driven by smoking, biomass fuel use, occupational exposures, and population aging. Clinically, early identification of high-risk populations and management of comorbidities should be prioritized, with special attention to rural and resource-limited populations and smokers. From a public health perspective, dual-track strategies are needed: strengthening tobacco control (taxation, smoke-free policies, cessation services) and systematically advancing air pollution control. Specifically, low-income countries should prioritize tobacco control and the adoption of clean energy and stoves; rapidly urbanizing countries should focus on PM₂.₅ control and tailored interventions for urban–rural differences; and high-SDI regions should continue optimizing early diagnosis and integrated chronic disease management. Although the relative contribution of occupational dust exposure may decline with industrial mechanization, population aging and persistent air pollution will remain major drivers of COPD burden, necessitating ongoing monitoring and dynamic policy adjustments.

This study has limitations. Data quality and availability were limited in some countries, which may affect the precision of estimates. Future work should rely on higher-quality epidemiological data and high spatiotemporal resolution exposure monitoring to support policy evaluation and effectiveness verification.