Burden of COPD

The burden of COPD on patients and society

COPD affects 4% of the world’s population, and 3.2 million people die of it each year, which makes it the third leading cause of death worldwide [1] [2]. Currently, more than 36 million Europeans live with COPD [18] [3]. In Europe, the median prevalence of COPD is 3,230/100,000 in men and 2,202/100,000 in women, and overall mortality is 24/100,000 in men and 12/100,000 in women [4]. Although the prevalence of COPD varies greatly across countries, it has generally increased over the years (Figure 1). Notably, in the general population, the prevalence of COPD starts growing from the age of 35 and steadily increases with ageing (Figure 2). In the 19 European countries analysed, the prevalence of COPD across all age groups ranges from 3.6% in Turkey to 7.9% in Belgium. Its prevalence in the population over 40 years of age in Spain was estimated to be 11.8% [5]. However, these percentages do not reflect the real burden of the pathology, since COPD seems to be largely underdiagnosed. The diagnosis of COPD is often missed or delayed until the condition is at an advanced stage. It is estimated that the prevalence of non-diagnosed COPD ranges between 70% and 90% in Europe and North America, respectively [6]. In a study conducted in Northern France, 76.4% and 64.8% of patients with severe airway obstruction did not receive an appropriate diagnosis [7]. Similarly, in Sweden it was estimated that underdiagnosed cases reached 83.6% [6].

It is conceivable that underdiagnosis is due to a combination of factors:

Lack of public awareness about COPD, people tend to underestimate symptoms such as shortness of breath and may tend to associate them with smoking or ageing;
Lack of screening plans for lung health are a barrier to early detection of respiratory diseases in at-risk populations;
Spirometry, which is the key test for diagnosis, is often not available in primary care services. Therefore, a visit to a specialist is required to obtain a diagnosis.

Furthermore, as discussed in the Access to COPD Care section, the lack of dedicated primary care services as well as an uneven geographical distribution of pulmonary specialists in Europe is another barrier to diagnosis and to appropriate management of COPD.

Figure 1. 1990-2020 trends of prevalence of COPD, all ages

Source: Global Burden of Disease Study 2019 (GBD 2019) Results. Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2020.

Figure 2. Total prevalence of COPD, by age and sex in 2019

Modified from Safiri et al. 2022. Generated from Global Burden of Disease data. Creative Commons CC BY license.

“A European COPD Data Observatory is not just about numbers – it’s about understanding the true burden of this disease across our healthcare systems. Only through systematic monitoring can we develop targeted interventions and measure their real impact on patient outcomes.”

Prof. Alessandro Vatrella, COPD project Medical Advisor

“Research should look more to gender differences. ”

COPD patient, Italy

“The burden on the patient should be lightened up.”

COPD patient, France

“The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is concerned that COPD is not being taken seriously enough at any level, from individuals and communities, to national governments and international agencies.”

GOLD 2024

“Compared with cardiovascular disease, the gains made in COPD mortality in Europe are relatively modest”

Marshall et al., 2022

“The burden on the patient should be lightened up.”

COPD patient, France

Women are more prone to COPD development and worsening than men

COPD has always been considered a “male” disease. In fact, men used to have a higher COPD rate than women. However, in the last 10 years this trend has inverted: the prevalence of COPD in men is declining, while it is consistently increasing in women [4]. This may reflect the fact that smoking and exposure to poor air quality have increased among women in 10/16 countries (Table 1).

Furthermore, smoking habits have increased among women. Interestingly, some studies suggest that women are more susceptible than men to the effects of cigarette smoke. Furthermore, women are more prone to develop severe COPD with an accelerated decline in airflow and more severe symptoms than men (even if they are less exposed to cigarette smoke) and are at a higher risk of hospitalisation and death due to COPD [8] [9] [10].

COPD Patient Testimonial: Daniela, Italy (Italian)

Daniela suffered from chronic bronchitis from a young age, which worsened into a COPD diagnosis. Her smoking history further compromised her health, leading to severe breathing difficulties and mobility limitations. She advises others not to panic during respiratory crises and to seek support.

Table 1. Prevalence of COPD in the countries surveyed in male and female. 2001 vs 2019*

	Female			Male
Country	2001	2019	Change (%)	2001	2019	Change (%)
Austria	2679	2816	5.1	3937	3485	-11.5
Belgium	3208	3588	11.9	4401	4345	-1.3
Bulgaria	1961	2318	18.2	3146	3098	-1.8
Czech Republic	1730	2141	23.7	3177	3160	-0.6
Finland	1590	1697	6.8	3471	2838	-18.2
France	1734	1650	-4.8	2940	2351	-20.1
Germany	2754	3213	16.7	3965	3684	-14.7
Ireland	4103	3687	-10.2	4248	3624	-14.7
Italy	1936	1878	-3.9	3422	2794	-18.4
Netherlands	3545	3990	12.6	4178	3743	-10.4
Poland	1798	1794	0.3	3390	2873	-15.2
Portugal	2456	2119	-13.7	4101	3396	-17.2
Spain	2433	2263	-7.0	4408	4051	-8.1
Sweden	3160	3371	6.7	3447	3055	-11.4
United Kingdom	3817	3900	2.2	4018	3903	-2.8

Box 3

COPD management and treatment should consider biological sex differences

The current guidelines lack consideration for sex-based differences in patient care, failing to address the need for distinct approaches tailored to biological sex. In recent years, numerous clinical and experimental studies have been conducted to understand the contribution of sex differences in the development of COPD. Some studies have indicated that sex hormones play a role in in the increased susceptibility of females to COPD. In addition, exposure to cigarette smoke in females appears to result in greater peripheral airway obstruction and airway remodelling than in male, due to the effect of oestrogens [11]. Furthermore, studies have shown that certain therapies have different effects on males and females. For example, considering the dual bronchodilator therapy, the flare risk was lower in men than in women treated with long-acting beta-agonist (LABA)/ long-acting muscarinic antagonists (LAMA) versus inhaled corticosteroids (ICS/LABA) [12]. Overall, further research should be conducted to better understand the mechanisms underlying sex differences in susceptibility to COPD, as well as in the response to available COPD therapies.

COPD Patient Testimonial: Patrick Diani, France (French)

Patrick Diani, President of ACMPA, describes COPD as a heavy burden and a harsh consequence of smoking, emphasising the severe physical and emotional toll of the disease. After 25 years of living with COPD, he now relies on oxygen almost 24/7.

COPD: A top cause of disability and death in Europe

COPD is still a major cause of death in European countries, and its burden on patients and on society as a whole is not significantly decreasing [4]. COPD represents 6% of all preventable deaths worldwide [13]. Considering all ages, COPD is among the top five causes of death in 13 out of the 19 countries surveyed (Austria, Belgium, Bulgaria, The Czech Republic, Germany, Iceland, Ireland, Italy, the Netherlands, Spain, Sweden, Switzerland, and Turkey), while it is between the sixth or eighth cause of death in the rest (Finland, France, Poland, Portugal, Serbia, UK). The age-adjusted mortality rates (per 100,000 people) ranged from 8% in Finland to 28% in Turkey, with great variability across countries (Figure 3). Mortality due to COPD is higher in people aged 80-84 years [14]. Interestingly, individuals with COPD older than 80 years of age are more vulnerable to the adverse effects of air pollution, accounting for the highest number of deaths caused by air pollution [14].

The improvement in COPD management programmes can effectively reduce mortality rates. In Finland, the 5% reduction in mortality due to COPD since 2010 is likely to be a long-term result of the 10-year Finnish COPD programme (1998-2007), which included multidisciplinary strategies and web-based guidelines available at nearly all primary healthcare centres around the country [15].

COPD is also the fourth cause of disability in Europe after cancer, cardiovascular and neuromuscular diseases [1]. In 2019, median disability-adjusted life year (DALYs) per 100,000 across Europe were 581/100,000 and 304/100,000 for males and females, respectively [4]. In France, COPD is the first cause of DALY in the advanced-age population. The total DALYs per 100,000 people were higher in Germany and the Netherlands, while they were the lowest in Switzerland and Finland (Figure 4). Between 2001 and 2019, DALYs due to COPD decreased in both men and women, but at a different magnitude. While the impact of disability due to COPD has remarkably decreased in men, this was not the case for women (−4.8% versus −25.7% median change) [4].

Box 4

Disability-adjusted life year

Disability-adjusted life year (DALYs): A time-based measure that combines years of life lost due to premature mortality (YLLs) and years of life lost due to time lived in states of less than full health, or years of healthy life lost due to disability (YLDs). One DALY represents the loss of the equivalent of one year of full health. This indicator can be used to assess the overall burden of a disease. Together with prevalence and death rate, DALY gives a picture of the burden of a disease.

Figure 3. Age-standardised death rate for COPD (per 100000 population)

Generated from Global Burden of Disease 2019 data.

Figure 4. COPD is a major cause of disability

Country ranking: COPD as cause of DALYs*

Belgium → 1231.46
United Kingdom → 1172.26

Sweden → 1231.46

Czech Republic → 929.37
Italy → 901.39
Spain → 842.88

Poland → 821.16

Germany → 1289.34

Austria → 958.15
Bulgaria → 1253.27
Iceland → 820.54
Ireland → 838.28
Netherlands → 1329.98

Serbia → 1071.88
Turkey → 789.50

Portugal → 850.63
Switzerland → 749.41

Finland → 631.76

Germany → 1289.34

Belgium → 1231.46
United Kingdom → 1172.26

Austria → 958.15
Bulgaria → 1253.27
Iceland → 820.54
Ireland → 838.28
Netherlands → 1329.98

Sweden → 1231.46

Serbia → 1071.88
Turkey → 789.50

Czech Republic → 929.37
Italy → 901.39
Spain → 842.88

Portugal → 850.63
Switzerland → 749.41

Poland → 821.16

Finland → 631.76

Comparison with other diseases was not available for France.
* DALYs per 100,000 population (all ages)
Source: https://data.who.int/countries/. Accessed November 2023.

Compared with cardiovascular disease, the gains made in COPD mortality in Europe are relatively modest [4]

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) is concerned that COPD is not being taken seriously enough at any level, from individuals and communities, to national governments and international agencies. [16]

COPD Ambassador (French)

Jean-Paul Vasseur, a COPD patient, shares how living with the condition inspired him to become an advocate for COPD patients.

Conclusion: Preventing COPD is critical to mitigate its present and future burden

COPD is one of the top leading causes of mortality and disability across European countries, yet it is preventable. The data available reveal a wide variability in terms of prevalence, mortality and DALYs attributed to COPD across the countries considered. These differences may be due to risk factors, such as affordable tobacco products and other exposures to risk factors (e.g., the indoor and outdoor air pollution) that vary significantly across countries.

Notwithstanding the efforts made, particularly in enforcing stricter tobacco control legislation, the prevalence of COPD remains high. Estimates suggest that 49 million people in Europe will suffer from COPD by 2050, corresponding to 9% of all diseases [3]. Given the ageing of the population worldwide, COPD must not be overlooked [17]. In fact, it is estimated that an increase of COPD due to ageing will result in increased costs, both for the patients and for the society (See “The cost of COPD in Europe”).

Despite the increasing prevalence, mortality slightly decreased in most countries. Nevertheless, COPD is still consistently among the top killer diseases. COPD high mortality rates may be due to delayed diagnosis and limitations in accessing therapies. In order to tackle this challenge, spirometry services for early detection of COPD should be made widely available to allow active case detection and access to appropriate treatments. In addition, access to affordable, high-quality pharmacological and non-pharmacological treatments is still not available to all patients [16].

Early diagnosis and the consequent early start of treatment, as well as the availability of new treatments, could increase the chances of survival of patients with COPD. Furthermore, increased awareness and health literacy regarding COPD among healthcare professionals can play a role in increasing survival rates, particularly in terms of early identification of the condition and management of comorbidities [14].

Continuous monitoring of the prevalence and mortality of COPD is of paramount importance in the assessment of the progress made by each country in terms of prevention, control, and treatment. It also helps to measure the efficacy of the actions taken to premature mortality from non-communicable diseases, including COPD, by one-third by 2030, which is one of the Sustainable Development Goals (SDG) of the United Nations 2030 agenda [2].

Recommendations

Strengthening National and European Efforts to Address COPD

Strengthening the capacity of national healthcare systems is crucial to effectively address the recurring gaps in Chronic Obstructive Pulmonary Disease (COPD) care. In order to do so, healthcare systems should enforce targeted prevention measures, improve coordination, and adopt a multidisciplinary approach to lung health.

At national level:

Establish national lung health plans: Develop comprehensive national lung health plans integrated in public health policies that encompass both early and accurate COPD diagnosis and optimal care management. These plans should prioritise prevention of COPD and should aim to enhance the overall quality of care.
Integrate COPD education across medical curricula: Promote training programmes on COPD for healthcare professionals, including for physicians, nurses, physiotherapists, and pharmacists. This training should emphasise early diagnosis, the administration of diagnostic procedures like spirometry testing, and effective management of COPD and its comorbidities.

At European level:

Promote COPD data collection and monitoring: Adopt systematic data collection and monitoring across Europe to better understand the impact of COPD on healthcare systems and its societal burden.

References

1. WHO. Global Health Estimates 2019: Disease burden by Cause, Age, Sex, by Country and by Region, 2000-2019. 2020. ↩

2. Momtazmanesh S, Moghaddam SS, Ghamari S-H, Rad EM, Rezaei N, Shobeiri P, et al. Global burden of chronic respiratory diseases and risk factors, 1990–2019: an update from the Global Burden of Disease Study 2019. eClinicalMedicine. 2023;59. ↩

3. Benjafield A, Tellez D, Barrett M, Gondalia R, Nunez C, Wedzicha J, et al. An estimate of the European prevalence of COPD in 2050. European Respiratory Journal. 2021;58 suppl 65. ↩

4. Marshall DC, Al Omari O, Goodall R, Shalhoub J, Adcock IM, Chung KF, et al. Trends in prevalence, mortality, and disability-adjusted life-years relating to chronic obstructive pulmonary disease in Europe: an observational study of the global burden of disease database, 2001–2019. ↩

5. Soriano JB, Alfageme I, Miravitlles M, de Lucas P, Soler-Cataluña JJ, García-Río F, et al. Prevalence and Determinants of COPD in Spain: EPISCAN II. Arch Bronconeumol (Engl Ed). 2021;57:61–9. ↩

6. Axelsson M, Backman H, Nwaru BI, Stridsman C, Vanfleteren L, Hedman L, et al. Underdiagnosis and misclassification of COPD in Sweden – A Nordic Epilung study. Respir Med. 2023;217:107347. ↩

7. Quach A, Giovannelli J, Chérot-Kornobis N, Ciuchete A, Clément G, Matran R, et al. Prevalence and underdiagnosis of airway obstruction among middle-aged adults in northern France: The ELISABET study 2011-2013. Respir Med. 2015;109:1553–61. ↩

8. Prescott E, Bjerg AM, Andersen PK, Lange P, Vestbo J. Gender difference in smoking effects on lung function and risk of hospitalization for COPD: results from a Danish longitudinal population study. European Respiratory Journal. 1997;10:822–7. ↩

9. Gan WQ, Man SFP, Postma DS, Camp P, Sin DD. Female smokers beyond the perimenopausal period are at increased risk of chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respir Res. 2006;7:52. ↩

10. Sørheim I-C, Johannessen A, Gulsvik A, Bakke PS, Silverman EK, DeMeo DL. Gender differences in COPD: are women more susceptible to smoking effects than men? Thorax. 2010;65:480–5. ↩

11. Tam A, Morrish D, Wadsworth S, Dorscheid D, Man SFP, Sin DD. The role of female hormones on lung function in chronic lung diseases. BMC Womens Health. 2011;11:24. ↩

12. Kirkpatrick deNay P, Dransfield MT. Racial and sex differences in chronic obstructive pulmonary disease susceptibility, diagnosis, and treatment. Curr Opin Pulm Med. 2009;15:100–4. ↩

13. OECD. Realising the Potential of Primary Health Care. 2020. ↩

14. Safiri S, Carson-Chahhoud K, Noori M, Nejadghaderi SA, Sullman MJM, Heris JA, 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;378:e069679. ↩

15. Kinnula VL, Vasankari T, Kontula E, Sovijarvi A, Saynajakangas O, Pietinalho A. The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality. Prim Care Respir J. 2011;20:178–83. ↩

16. GOLD. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2024 Report). 2024. ↩

17. Forum of International Respiratory Societies. The global impact of respiratory disease. Third Edition. 2021. ↩

18. Data based on World Bank population projections and Global Burden of Disease data for COPD in 39 European countries. ↩

Previous chapter

What is COPD

Next chapter

Cost of COPD

Burden of COPD

Burden of COPD

The burden of COPD on patients and society

Women are more prone to COPD development and worsening than men

COPD Patient Testimonial: Daniela, Italy (Italian)

Box 3

COPD management and treatment should consider biological sex differences

COPD Patient Testimonial: Patrick Diani, France (French)

COPD: A top cause of disability and death in Europe

Box 4

Disability-adjusted life year

COPD Ambassador (French)

Conclusion: Preventing COPD is critical to mitigate its present and future burden

Recommendations

Strengthening National and European Efforts to Address COPD

At national level:

At European level:

References

About

What is copd

Burden of copd

Cost of COPD

Disease awareness

COPD Prevention

COPD Early Diagnosis

COPD Care Acces

Quality of Life with COPD

Digital Health for COPD

The Impact of COVID-19 on COPD Care

Recommendations