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The global burden of chronic respiratory diseases attributable to tobacco from 1990 to 2021: a global burden of disease study 2021
樱花视频 volume听25, Article听number:听456 (2025)
Abstract
Background
Tobacco is a major risk factor for chronic respiratory diseases (CRDs), yet the global distribution and trends of tobacco-related CRD burdens remain inadequately explored.
Methods
This study extracted data on mortality, disability-adjusted life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized DALY rate (ASDR) related to tobacco-attributable CRDs from the 2021 Global Burden of Disease (GBD) study. Joinpoint regression was used to identify temporal trends in age-standardized rates (ASR), while autoregressive integrated moving average (ARIMA) forecasting was applied to project future trends in ASMR and ASDR for tobacco-related CRDs.
Results
In 2021, global tobacco-related CRD deaths and DALYs reached 1,545,686 (95% UI: 1,144,476-1,942,541) and 33,014,429 (95% UI: 24,275,462鈥夆垝鈥40,930,821), representing increases of 25.43% and 15.64%, respectively, since 1990. Elderly individuals and males showed a higher disease burden. Between 1990 and 2021, ASMR [average annual percentage change (AAPC) = -2.009 (95% CI: -1.8915 to -2.1263)] and ASDR [AAPC = -2.1057 (95% CI: -2.0123 to -2.199)] for tobacco-related CRDs showed a declining trend globally, with autoregressive integrated moving average forecasting suggesting continued declines in ASMR and ASDR in the future. Regionally, South Asia, East Asia, and Oceania had the highest CRD burdens, while country-specific data indicated that Nepal, Myanmar, Papua New Guinea, Kiribati, and the Democratic People鈥檚 Republic of Korea bore significant burdens. The ASMR and ASDR of tobacco-related CRDs were highest in regions and countries with Socio-Demographic Index values between 0.4 and 0.5.
Conclusion
Although global tobacco-related CRD deaths and DALYs have continued to increase, ASMR and ASDR are on the decline, with variations across geographic regions. Prevention and control strategies tailored to country-specific disease prevalence are essential to mitigate these burdens.
Introduction
Chronic respiratory diseases (CRDs) are a class of non-communicable diseases (NCDs) that profoundly impact global health and quality of life. In 2019, CRDs ranked as the third leading cause of death worldwide, responsible for around 4 million deaths each year [1]. Beyond the mortality risk, CRDs significantly contribute to disability, diminishing patients鈥 physical functioning and driving up healthcare costs, which places a substantial burden on families and society [1, 2]. The most common CRDs are chronic obstructive pulmonary disease (COPD) and asthma, with COPD being the primary cause of CRD-related deaths and asthma having the highest prevalence among CRDs [1]. Acknowledging the growing health challenge, the United Nations has set a target within the Sustainable Development Goals (SDG 3.4) to reduce premature NCD-related mortality, including that from CRDs, by one-third by 2030. Monitoring global trends in CRD burden is therefore essential to inform public health strategies and advance progress toward this ambitious goal.
Tobacco is widely recognized as a major risk factor, responsible for approximately 200 million deaths over the past three decades and imposing an estimated economic burden of $1 trillion [3, 4]. It remains a substantial contributor to CRDs, with approximately 70% of COPD cases in high-income countries attributed to smoking [5]. Additionally, a study conducted in China highlighted a history of smoking as a risk factor for the development of asthma and for airflow limitations in individuals with asthma [6].
In a comprehensive study utilizing data from the Global Burden of Diseases (GBD) database, findings revealed that from 1990 to 2019, the age-standardized prevalence, mortality, and disability-adjusted life year (DALY) rates for CRDs exhibited a downward trend [1]. CRDs are severe in different countries globally, with variations in their burden. In China, CRDs rank third in disease burden among the elderly population, with ASMR and ASDR in 2021 being 1540.21 and 8993.4, respectively [7]. In the United States, COPD caused 198 thousand deaths in 2021, with an ASDR of 778 [8]. In Brazil, the DALY for CRDs in 2017 was 2,146,048.00, which had increased by 34% compared to 1990 [9]. Furthermore, the highest deaths and DALYs from CRDs were attributed to smoking globally [1]. However, no research to date has specifically analyzed the burden of tobacco-related CRDs. This study thus aims to assess the trends in tobacco-attributable CRD mortality and DALYs from 1990 to 2021, with further examination of influencing factors such as sex, age, and the Socio-Demographic Index (SDI).
Methods
Data source
Data were obtained from the GBD Results Tool (), a publicly accessible database offering attributable burden data for diverse risk factors across all countries, estimated via standardized methodologies. The GBD 2021 study evaluated the age- and sex-specific global burden of 371 diseases and injuries across 204 countries and territories from 1990 to 2021, quantifying health losses due to both premature mortality and non-fatal disability [10,11,12].
Estimated CRD burden due to tobacco
In GBD 2021, CRDs encompassed a range of diseases classified under the International Classification of Diseases (ICD) 10th and 11th Revisions (codes J40-J47 and CA20-CA27, respectively). Among these, only COPD and asthma were attributed to tobacco exposure in the GBD 2021 assessment. Per GBD 2021 definitions, tobacco includes all forms of use, encompassing smoking, chewing, and exposure to secondhand smoke.
The burden of tobacco-related CRDs was assessed by calculating attributable deaths and disability-adjusted life years (DALYs). DALYs, a comprehensive health metric, gauges the overall impact of diseases and injuries within a population by combining years of life lost (YLL) due to premature mortality with years lived with disability (YLD). YLL is determined by subtracting the age at death from the standard life expectancy, while YLD accounts for years lived with disability, adjusted by severity-specific disability weights. Higher DALY values signify a greater health impact, facilitating cross-disease, regional, and temporal comparisons to guide public health strategies and assess intervention effectiveness. Uncertainty was addressed by sampling 1,000 draws at each computational stage, incorporating uncertainties from sources such as input data, adjustments for measurement errors, and estimations of residual non-sampling error. Uncertainty intervals were delineated as the 25th and 975th values among the ordered draws. When calculating age-standardized rates, the reference population commonly used is the World Standard Population recommended by the WHO. This population is derived from a weighted average based on the age structure of different regions, aiming to eliminate the influence of differences in population age structures across regions on rate comparisons.
The association between the burden of tobacco-related CRDs and the SDI across 21 regions and 204 countries and territories was examined using smoothing spline models. SDI is a composite metric quantifying development levels in a country or region based on socioeconomic indicators. It integrates three dimensions: per capita income (including gross domestic product smoothed over the past decade), the average educational attainment for individuals aged 15 and above, and the fertility rate for those under age 25. Each component is normalized on a scale from 0 to 1, and these are geometrically averaged to derive a final SDI score for a country or region, ranging from 0 (lowest development) to 1 (highest development). This index facilitates comparison of health metrics, such as disease burden and life expectancy, across countries or regions with similar development levels.
Statistical analyses
The autoregressive integrated moving average (ARIMA) model is widely utilized in demographic and epidemiological trend analysis, leveraging historical time series data to project future patterns [13]. An ARIMA model was developed based on the 2021 GBD data, with differencing applied until the series achieved stationarity. The model displaying the lowest Akaike Information Criterion (AIC) value was selected as the optimal predictor via the 鈥渁uto.arima()鈥 function. Model reliability was confirmed through a white noise test, with residuals passing the test (P鈥>鈥0.05). Using the 鈥渇orecast鈥 package, the age-standardized mortality rate (ASMR) and age-standardized disability-adjusted life years (ASDR) for tobacco-related CRDs were projected, setting the significance level at 伪鈥=鈥0.05.
The estimated annual percentage change (EAPC) is a widely used metric for analyzing trends in age-specific incidence rates over a defined time period. It assesses changes in the age-specific incidence rate (ASR) of tobacco-related CRD burden based on GBD 2021 data from 1992 to 2021. Linear regression was performed on the logarithmic values of ASR, using the year as the independent variable in the model: 饾懄=饾憥+饾憦饾懃+饾憭, where y鈥=鈥塴n(ASR) and 饾懃= year. The EAPC was calculated from the estimated values using the formula: EAPC鈥=鈥100脳(exp(b)鈥夆垝鈥1). A positive EAPC indicates an annual increase in ASR, while a negative EAPC reflects a year-on-year decrease.
To analyze trends in tobacco-related CRD burden, we employed the Age-Period-Cohort (APC) model, represented by the expression log(饾憖)=饾渿+饾浖饾憱+饾浗饾宪+饾浘饾憳+饾湒. Here,
饾憖 represents the expected mortality rate, while 饾浖, 饾浗, and 饾浘 denote age, period, and cohort effects, respectively. The constant 饾渿 serves as the baseline level of risk across these three dimensions (饾浖, 饾浗, and 饾浘), and 饾湒 captures random error [14]. In this model, cohort equals period minus age. We utilized five parameters to examine trends in mortality, age, period, and cohort effects. Among these, net drift is most pivotal, indicating the overall temporal trend in mortality while accounting for period and cohort influences. Local drift highlights birth cohort effects on temporal trends, suggesting that a single age-standardized rate curve or EAPC may not fully capture age-group-specific trend variations.
The longitudinal age curve provides a smoothed representation of expected age-specific rates based on a reference cohort, adjusting for period effect variations. Period or cohort rate ratios above 1 indicate a higher relative mortality risk for that period or cohort compared to the reference, while values below 1 imply a reduced risk [15]. Due to limited data in GBD 2021, tobacco-related CRD data for individuals under 30 years were unavailable, preventing analysis of those age groups. For analysis, data were segmented into 5-year age, period, and cohort intervals, with statistical analyses conducted using R (version 4.4.1). Statistical significance was set at 饾憙<0.05.
Results
Global CRD burden attributable to tobacco
Between 1990 and 2021, tobacco-related CRD deaths rose by 25.43%, increasing from 1,232,294 (95% CI: 944,898-1,504,174) to 1,545,686 (95% CI: 1,144,476-1,942,541) (Table 1). Concurrently, tobacco-related DALYs saw a 15.64% increase, rising from 28,548,355 (95% CI: 21,512,965鈥夆垝鈥35,165,341) to 33,014,429 (95% CI: 24,275,462鈥夆垝鈥40,930,821). Tobacco-related YLLs grew from 25,194,846 (95% CI: 19,312,844鈥夆垝鈥30,791,400) to 27,512,827 (95% CI: 20,430,102鈥夆垝鈥34,454,851), and YLDs escalated from 3,353,509 (95% CI: 2,078,110-4,702,459) to 5,501,602 (95% CI: 3,714,264-7,457,320). In contrast, age-standardized mortality (ASMR) and DALY rates (ASDR) in 2021 were 18.67 (95% CI: 13.83鈥23.49) and 386.82 (95% CI: 283.97-480.11) per 100,000 population, respectively, showing a clear downward trend since 1990. This decline is illustrated by the negative annual percent change (Figure S1), with the average annual percent change (AAPC) for deaths and DALYs at -2.009 (95% CI: -1.8915 to -2.1263) and 鈭掆2.1057 (95% CI: -2.0123 to -2.199), respectively, over this period.
The primary CRDs, COPD and asthma, followed distinct trends. Similar to CRDs overall, COPD-related deaths, DALYs, YLLs, and YLDs linked to tobacco increased in 2021 compared to 1990, while ASMR and ASDR for COPD decreased. Asthma, however, displayed a different trend: all metrics-tobacco-related deaths, DALYs, YLLs, YLDs, ASMR, and ASDR-decreased in 2021 relative to 1990. Detailed data for tobacco-associated COPD and asthma can be found in Table 1.
Age-sex pattern of CRD burden attributable to tobacco
In both 1990 and 2021, tobacco-related CRD deaths and DALYs were consistently higher in males across all age groups compared to females (Fig. 1). A similar pattern is evident for tobacco-related COPD and asthma (Figures S2 and S3).
Age-sex pattern of CRD attributable to tobacco. (A) The number of death in CRD attributable to tobacco in 2021; (B) The rate of death in CRD attributable to tobacco in 2021; (C) The number of DALY in CRD attributable to tobacco in 2021; (D) The rate of DALY in CRD attributable to tobacco in 2021; (E) The number of death in CRD attributable to tobacco in 2021; (F) The rate of death in CRD attributable to tobacco in 2021; (G) The number of DALY in CRD attributable to tobacco in 2021; (H) The rate of DALY in CRD attributable to tobacco in 2021. CRD, chronic respiratory disease; DALY, disability-adjusted life years
As age increases, mortality and DALY rates for tobacco-related CRD and COPD rise progressively, with individuals aged 85 and older exhibiting the highest mortality and DALY rates (Fig. 1 and S2). However, while deaths and DALYs for tobacco-related CRD and COPD initially increase with age, they decline after reaching a peak. In 1990, the highest mortality was observed in the 75鈥79 age group, with the 70鈥74 age group having the highest DALYs. By 2021, peak mortality shifted to the 80鈥84 age group, though the 70鈥74 age group remained highest for DALYs.
For tobacco-related asthma, mortality and DALY rates also increase with age, following a similar trajectory of initial rise followed by decline. However, unlike CRD and COPD, peak mortality and DALY rates in asthma occur at younger ages. In 2021, the 70鈥75 age group had the highest mortality, while the 55鈥59 age group had the highest DALYs (Figure S3).
The APC analysis of CRD attributable to tobacco
Using the APC model, we analyzed age-specific rates and rate ratios for the period and cohort effects of tobacco-attributable CRD (Fig. 2). Our findings indicate a progressive increase in mortality and DALY rates for tobacco-related CRD with advancing age. This pattern is also reflected in tobacco-attributable COPD. Conversely, for asthma attributable to tobacco, mortality rates increased with age, but the peak DALY rates were noted in the 60鈥65 age group (Fig. 2).
The age-period-cohort analysis of CRD burden attributable to tobacco. (A) The age-period-cohort analysis of CRD attributable to tobacco in death and DALY; (B) The age-period-cohort analysis of COPD attributable to tobacco in death and DALY; (C) The age-period-cohort analysis of asthma attributable to tobacco in death and DALY. The red curve re DALYs, disability-adjusted life years presents the relationship between longitudinal age and rate, the blue curve illustrates the relationship between period and rate ratio, and the green curve depicts the relationship between cohort and rate ratio. CRD, chronic respiratory disease
From 1992 to 2021, mortality and DALY rate ratios for tobacco-attributable CRD, COPD, and asthma exhibited a gradual decline over time (Fig. 2). Additionally, rate ratios for mortality and DALYs across birth cohorts from 1897 to 1992 demonstrated a consistent downward trend (Fig. 2). These results suggest that the global disease burden of CRD, COPD, and asthma attributable to tobacco is gradually diminishing over time.
Regional trends of CRD attributable to tobacco
Using data from the GBD database, we analyzed the burden of CRD attributable to tobacco across 21 regions (Table 2). Findings reveal that in each of these regions, the ASMR and ASDR for tobacco-related CRD in 2021 were significantly lower than in 1990. The most substantial decrease was observed in East Asia, where ASMR and ASDR fell by 68% in 2021 relative to 1990. In contrast, the Caribbean showed the smallest reduction, with ASMR and ASDR declining by only 9% and 11%, respectively, since 1990.
In 1990, the three regions with the highest ASMR for tobacco-related CRD were East Asia, South Asia, and Oceania, while East Asia, Oceania, and South Asia led in ASDR. By 2021, the regions with the highest ASMR had shifted to South Asia, Oceania, and East Asia, while the highest ASDR rates were observed in Oceania, South Asia, and East Asia.
Countries and territories trends of CRD attributable to tobacco
We analyzed the burden of tobacco-attributable CRD across 204 countries and territories (Fig. 3). In the majority of these locations, the burden of tobacco-related CRD in 2021 showed a reduction compared to 1990, with Singapore demonstrating the most significant decrease in ASMR and ASDR, dropping by 90% and 86%, respectively. However, ASMR increased in 12 countries and ASDR rose in 9 countries during the same period.
Age-standardized burden of CRD attributable to tobacco in 204 countries and territories in 1990 and 2021. (A) World map of ASMR for CRD attributable to tobacco in 1990. (B) World map of ASMR for CRD attributable to tobacco in 2021. (C) World map of ASDR for CRD attributable to tobacco in 1990. (D) World map of ASDR for CRD attributable to tobacco in 2021. CRD, chronic respiratory disease; DALYs, disability-adjusted life years; ASDR, age-standardized rate of DALYs; ASMR, age-standardized rates of mortality
Tables 3 and 4 display the top 10 and bottom 10 countries and territories with the highest and lowest CRD burdens in 2021, along with the respective changes in disease burden. In 2021, Nepal, Myanmar, and Papua New Guinea exhibited the highest ASMR, while Nepal, Kiribati, and Papua New Guinea recorded the highest ASDR. Conversely, Kuwait, Nigeria, and Peru showed the lowest ASMR, while Peru, Nigeria, and Barbados had the lowest ASDR.
SDI trends of CRD attributable to tobacco
An inverted 鈥淰鈥 curve illustrates the relationship between SDI and ASMR or ASDR across 204 countries and territories, as well as in 21 regions (Fig. 4). Among the 21 GBD regions, despite differences in SDI, all regions exhibited a consistent decline in ASMR and ASDR from 1990 to 2021 (Fig. 4A and C). When SDI was below 0.4, ASMR and ASDR progressively increased across the 204 countries and 21 regions. However, with an SDI exceeding 0.5, both ASMR and ASDR gradually declined. These results indicate that countries with moderate SDI values bear the highest burden of tobacco-attributable CRD.
The correlation between SDI and burden of CRD attributable to tobacco. (A) The correlation between SDI and ASMR of CRD attributable to tobacco in 21 GBD regions; (B) The correlation between SDI and ASMR of CRD attributable to tobacco in 204 countries and territories in 2021; (C) The correlation between SDI and ASDR of CRD attributable to tobacco in 21 GBD regions; (D) The correlation between SDI and ASDR of CRD attributable to tobacco in 204 countries and territories in 2021. CRD, chronic respiratory disease; DALYs: disability-adjusted life-years; ASDR, age-standardized rate of DALYs; ASMR, age-standardized rates of mortality
Trend of CRD attributable to tobacco from 2022 to 2036
As illustrated in Fig. 5, the projected global ASMR (Fig. 5A) and ASDR (Fig. 5D) of tobacco-attributable CRD are expected to decrease steadily from 2022 to 2036. By 2036, the global ASMR for tobacco-related CRD is projected to decline to 11.59 per 100,000 population, marking a 37.9% reduction from 18.67 per 100,000 in 2021. Similarly, the global ASDR is anticipated to reach 236.78 per 100,000 by 2036, representing a 38.8% decrease from 386.82 per 100,000 in 2021. Tobacco-related COPD (Fig. 5B and E) and asthma (Fig. 5C and F) are also forecasted to exhibit a gradual decline over the same period, from 2022 to 2036.
Prediction of CRD burden attributable to tobacco from 2021 to 2036. (A) Trend of ASMR from 2021 to 2036 in CRD attributable to tobacco; (B) Trend of ASMR from 2021 to 2036 in COPD attributable to tobacco; (C) Trend of ASMR from 2021 to 2036 in asthma attributable to tobacco; (D) Trend of ASDR from 2021 to 2036 in CRD attributable to tobacco; (E) Trend of ASDR from 2021 to 2036 in COPD attributable to tobacco; (F) Trend of ASDR from 2021 to 2036 in asthma attributable to tobacco. The white hollow circle represents the predicted trend, and the yellow-shaded area represents the 95% confidence interval of the predicted values; the vertical line divides the data into real values (1990鈥2021) and predicted values (2021鈥2036). CRD, chronic respiratory disease; ASMR, age-standardized rates of mortality; ASDR, age-standardized rate of disability-adjusted life years (DALYs)
Discussion
Using the latest GBD 2021 data, this study provides a comprehensive summary of the global epidemiological profile of tobacco-related CRD burden. The findings reveal that while the number of deaths and DALYs from tobacco-attributable CRDs rose in 2021 compared to 1990, both ASMR and ASDR have shown a decline, largely driven by factors such as population aging and growth. From 1990 to 2021, the global ASMR and ASDR of tobacco-related CRDs displayed a consistent downward trend, although some countries or regions recorded increases in ASMR and ASDR in 2021 relative to 1990. A deeper stratified analysis showed that the burden of tobacco-related CRDs was higher in males than females, with ASMR and ASDR rising progressively with age. The SDI-ASMR/ASDR relationship demonstrated an inverted 鈥淰鈥 curve, indicating that countries with an SDI between 0.4 and 0.5 experienced a greater disease burden. This study underscores the evolving burden of tobacco-related CRDs over the past three decades, offering a theoretical foundation for formulating future health strategies focused on preventing and reducing CRD burden.
CRDs rank among the leading causes of global disability and mortality, with tobacco use recognized as a principal risk factor for CRDs and other chronic NCDs [16, 17]. Tobacco-related CRDs primarily encompass COPD and asthma. Smoking plays a significant role in COPD pathogenesis, with research showing that cigarette smoke contributes by inducing alveolar macrophage polarization, oxidative stress in bronchial epithelial cells, and disruptions in autophagy processes [18, 19]. Furthermore, a smoking history is a notable risk factor for asthma development and airflow limitation [6]. Smoking damages the innate immune response mediated by epithelial cells, alveolar macrophages, dendritic cells, and natural killer cells, making susceptible individuals more prone to airway allergic reactions. When patients are exposed to allergens, epithelial cells are more likely to release alarm signals such as IL-33, TSLP, and IL-25, which initiate T2 immunity. This activates eosinophils and mast cells, leading to the release of pro-inflammatory mediators such as IL-13, resulting in the development of asthma [20]. Between 1990 and 2019, previous studies reported a gradual decrease in the ASMR and ASDR for CRDs, although absolute deaths and DALYs have risen [1]. These trends align with our findings on the burden of tobacco-related CRDs. Unlike earlier studies, the GBD database also includes pneumoconiosis and interstitial lung disease in CRDs; however, this study focused specifically on tobacco-related CRDs, namely COPD and asthma. Additionally, the proportion of tobacco-related disease burden from COPD and asthma is notably higher than their overall contribution to total CRDs. For instance, in 2021, the ASMR and ASDR for tobacco-related COPD and asthma were 18.26/0.41 and 370.64/16.19, respectively, significantly surpassing the values in 2019, where COPD and asthma ASMR and ASDR were 42.5/5.8 and 926.1/273.6 [1]. This discrepancy likely stems from the greater influence of tobacco as a risk factor for COPD compared to asthma. Besides, compared to 1990, the number of deaths, DALYs, YLLs, and YLDs in COPD patients increased in 2021, while the age-standardized rates decreased. In contrast, the number of disease burden and age-standardized rates in asthma patients both decreased. The main reason for this difference is the variation in disease control between COPD and asthma patients over the past 30 years. Asthma patients benefit from regular inhaled corticosteroid treatment, and the majority of patients can achieve good disease control. However, in COPD patients, despite regular use of medications such as anticholinergics, the disease continues to progress, primarily due to the unclear inflammatory mechanisms of COPD. However, with the application of anti-inflammatory drugs such as Dupilumab in COPD [21], disease control in COPD patients is expected to improve and reach levels similar to asthma in the future.
Our analysis revealed that both the mortality and DALY counts, along with age-standardized rates of tobacco-related CRDs, were markedly higher in men than in women-a trend also mirrored in tobacco-related COPD and asthma. These findings align with prior research indicating a heavier CRD burden in the male population compared to females [22]. This disparity likely stems from significantly higher smoking rates among men, with studies indicating that male smoking prevalence is nearly eight times that of females [23]. Interestingly, previous study has shown that women displayed higher levels of smoking-induced bulky/hydrophobic DNA adducts, which might be related to an increased expression of CYP1A1 in their lung adenocarcinoma cells, compared to men [24]. Although women might metabolize certain components of tobacco smoke differently than men [25], whether these differences could explain the gender disparities in smoking-induced decline in lung function and the onset of CRDs remained to be further explored. This could mean that the proportion of tobacco-related CRDs in women may increase relative to men in the future. Additionally, our study identified that the mortality and DALY rates for tobacco-related CRDs rise with age, a trend supported by previous research [26]. This increase is likely due to prolonged exposure to cigarette use, which progressively exacerbates its impact on airflow obstruction over time [27]. These findings underscore the importance of focusing on sex-specific risk factors in tobacco-related diseases and recognizing the cumulative, long-term effects of smoking.
In 2021, most regions and countries saw reductions in ASMR and ASDR for tobacco-related CRDs compared to 1990, reflecting global trends. These findings underscore the significant impact of the WHO Framework Convention on Tobacco Control and the WHO MPOWER initiatives efforts that include demand reduction strategies, advertising regulations, product labeling guidelines, and tobacco taxation-in driving global smoking reduction. Regionally, South Asia, Oceania, and East Asia recorded the highest ASMR and ASDR for tobacco-related CRDs in both 1990 and 2021. Notably, East Asia experienced a substantial decrease, moving from the highest-ranked region in 1990 to third in 2021, a trend that aligns closely with the region鈥檚 economic growth and the vigorous implementation of tobacco control measures. Specifically, China鈥檚 Healthy China 2030 initiative, which aims to reduce the smoking rate to 20%, likely played a significant role in lowering the tobacco-attributable burden in this region [28]. At the country level, nations such as Nepal, Myanmar, Papua New Guinea, Kiribati, and the Democratic People鈥檚 Republic of Korea reported the highest ASMR and ASDR for tobacco-related CRDs in 2021. Despite their geographic diversity, these countries face common challenges of lower economic development and limited healthcare resources. Therefore, prioritizing tobacco control and CRD management in these regions is essential for international health organizations. Effective measures include implementing national restrictions and public smoking bans, increasing tobacco taxes to deter usage, and prohibiting tobacco marketing and advertising-all proven methods for reducing smoking rates and decreasing exposure to secondhand smoke [29, 30].
The relationship between the SDI and the ASMR or ASDR of tobacco-related CRDs follows a nonlinear pattern. Both high and low SDI regions exhibit relatively low tobacco-attributable CRD burdens, while regions with an SDI between 0.4 and 0.5 experience the highest burden. Higher SDI regions often benefit from increased government investment in smoking prevention and CRD management initiatives [31, 32], as well as improved healthcare infrastructure and greater public health awareness. In contrast, low to medium SDI regions-primarily developing countries such as China, Brazil, India, and Indonesia-report the highest tobacco-related CRD burden [33], as they rank among the leading tobacco producers and consumers worldwide. Interestingly, low SDI regions do not display the anticipated SDI gradient, with a CRD burden lower than that in medium-low and medium SDI regions. This may stem from limited universal health coverage, shortages in healthcare personnel, and delays in diagnosis, resulting in underreporting and potential underestimation of the true CRD burden in low SDI areas [34].
The most important strength of this study is providing a comprehensive summary of the global epidemiological profile of tobacco-related CRD burden, which includes the disease burden of tobacco-related COPD and tobacco-related asthma. Additionally, we analyzed the relationship between tobacco-related CRD burden and factors such as region and SDI, providing some basis for the development of targeted CRD prevention and control strategies in the future. However, this study has certain limitations. Firstly, although GBD 2021 serves as our primary data source with extensive global coverage, variations in mortality data collection across countries-including reliance on vital registration systems and verbal autopsies-may introduce diagnostic biases. Secondly, the database includes only publicly accessible data, thus omitting unpublished sources. Additionally, as a secondary analysis of GBD data, we lack detailed covariates such as race, education level, and occupation, which could aid in bias control. The accuracy and robustness of GBD estimates are largely dependent on the quality and scope of the data used in modeling. Lastly, since this study utilizes aggregated data rather than individual-level data, causal relationships cannot be inferred.
Conclusion
Despite substantial improvements in reducing the global burden of tobacco-related CRDs over the past three decades, significant gender and regional disparities remain. Tobacco-related CRDs continue to pose severe challenges for elderly populations, men, and individuals in low- to middle-SDI regions. Given the tobacco industry鈥檚 role as an economic foundation in many developing countries, tobacco control initiatives face substantial obstacles. Health strategies should prioritize high-risk areas, particularly in South Asia, East Asia, and Oceania, where robust policy support is critical to alleviating the tobacco-attributable burden of CRDs.
Data availability
Data were publicly available at .
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Acknowledgements
We sincerely appreciate all the participants of the GBD 2021 for their contribution.
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This work was supported by the National Science and Technology Major Project of the Ministry of Science and Technology of China (2023ZD0506402), General Program of Department of Education of Liaoning Province (JYTMS20230091), Basic Application Program of Department of Science and Technology of Liaoning Province (2023JH2/101700211), Natural Science Foundation of Liaoning Province (2023-BS-096) and 345 Talent Project of Shengjing Hospital.
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R.Z. and H.F. conceptualized the study; H.F. drafted the initial manuscript; H.F., Z.L., and R.Z. conducted data collection and analysis. Z.L. and R.Z. undertook comprehensive revisions and editing. R.Z. and H.F. acquired funding. All authors have reviewed and endorsed the manuscript.
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Feng, H., Li, Z. & Zheng, R. The global burden of chronic respiratory diseases attributable to tobacco from 1990 to 2021: a global burden of disease study 2021. 樱花视频 25, 456 (2025). https://doi.org/10.1186/s12889-025-21680-0
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DOI: https://doi.org/10.1186/s12889-025-21680-0