Letter From the Japanese Respiratory Society

Chronic obstructive pulmonary disease (COPD) remains the world's fourth leading cause of death, responsible for approximately 3.5 million deaths in 2021, or about 5% of all deaths worldwide [1]. According to the World Health Organization (WHO), nearly 90% of COPD deaths among people under 70 years of age occur in low- and middle-income countries (LMICs), underscoring profound global inequities in chronic respiratory health. In contrast, in high-income countries such as Japan, tobacco control policies (including smoking restrictions, taxation, and cessation support), improvement in air quality, better healthcare access, appropriate medical interventions, infection control, and widespread vaccination have contributed to reductions in premature death from respiratory disease. However, rapid population aging and the recent stagnation in smoking reduction are expected to increase the burden of COPD, particularly among older adults. In Japan, approximately 5.3 million people are estimated to have COPD, yet only about 382,000 (7%) were receiving treatment in 2023, according to the Ministry of Health, Labour and Welfare (MHLW) Patient Survey [2]. It is presumed that many patients remain undiagnosed until the disease has advanced, and approximately 16,000 deaths occur annually, with a crude mortality rate of 13.3 per 100,000 population in 2021 [3]. These figures reveal a persistent gap between prevalence and care, highlighting the need to enhance public awareness and incorporate spirometry into routine health assessments. Recognising this, the MHLW designated COPD as one of the four major noncommunicable diseases (NCDs)—namely cancer, cardiovascular disease, diabetes, and chronic respiratory disease (COPD)—within its national health promotion framework Health Japan 21 (Phase III). This program represents the third phase (2024–2032) of Japan's long-term health initiative that originated from the National Health Promotion Movement, which was launched in 1978 and later formalised as Health Japan 21 in 2000. The goals are to extend healthy life expectancy and reduce health inequalities through multisectoral collaboration among government, healthcare providers and citizens [4]. Under this framework, the Japanese Respiratory Society (JRS) launched the COMORE-By2032 Project (Project for COPD Mortality Reduction By 2032) in 2023 to achieve the government's target of reducing COPD mortality from 13.3 to 10.0 per 100,000 population by 2032 [4]. The name COMORE-By (Komorebi), meaning ‘sunlight filtering through trees’, symbolises the collective light of small yet coordinated efforts to improve respiratory health. The COMORE-By 2032 Project aims to establish a sustainable, multi-layered framework integrating respiratory specialists, primary care physicians, health checkup institutions, and municipal health services to promote prevention, early detection, and appropriate treatment throughout the disease continuum. Although a large proportion of Japanese adults undergo annual health examinations, lung function testing is rarely included, leading to missed opportunities for early detection. In addition, while low-dose chest CT scans are increasingly performed as part of lung cancer screening or other health assessments, radiological findings suggestive of emphysema—a key feature of COPD—often receive little clinical attention. The COMORE-By2032 Project seeks to bridge these gaps by incorporating respiratory screening into standard checkups, creating efficient referral systems from general practitioners to respiratory specialists, and ensuring early initiation of smoking cessation support, inhaled pharmacotherapy, and exacerbation management. The natural history of COPD often involves prolonged periods of unrecognised disease, leading to a downward spiral of dyspnoea, inactivity, frailty, and disability, ultimately resulting in premature death. Conversely, early consultation, diagnosis, smoking cessation, inhaled therapy, and maintenance of physical activity can slow disease progression, preserve independence, and extend healthy life expectancy. To visualise this trajectory and the consequences of insufficient COPD control, the JRS COMORE-By2032 Working Group developed Figure 1. The figure illustrates that COPD can progress with few or no noticeable symptoms, and that as the disease advances, frailty, immobility, and long-term care dependency may impose cumulative burdens on both individuals and society. Furthermore, it demonstrates that implementing systematic COPD measures from the early stages of the disease can potentially mitigate or prevent these personal and societal disadvantages. The purpose of this figure is to raise awareness among non-medical audiences, policymakers, and healthcare administrators about the social impact of COPD and the need for comprehensive countermeasures. Natural history of COPD and the pathway toward mortality reduction through early detection and intervention (Conceptual framework of the COMORE-By2032 Project). This schematic diagram illustrates the natural course of chronic obstructive pulmonary disease (COPD) from the preclinical to the advanced stage and highlights the potential benefits of early detection and appropriate therapeutic intervention. Early identification of suspected cases through questionnaires and spirometry, followed by comprehensive management including smoking cessation support, pharmacological and non-pharmacological therapies and maintenance of physical activity, can slow disease progression, prevent exacerbations, and ultimately contribute to reducing COPD-related mortality. Conversely, when COPD is left unrecognised or inadequately managed, the disease progresses, leading not only to increased individual burdens such as frailty and disability but also to cumulative social and economic impacts. This diagram aims to enhance understanding of the natural history and societal consequences of COPD among policymakers, healthcare administrators, and the general public. It also represents the overall framework and objectives of the Japanese Respiratory Society's Project for COPD Mortality Reduction by 2032 (COMORE-By2032). Achieving meaningful progress in COPD control requires collaboration among diverse stakeholders—including respiratory specialists, primary care physicians, pharmacists, physiotherapists, public health nurses, local governments, and industry partners. Such collaborative efforts are essential to support nationwide activities for awareness, early diagnosis, timely intervention, and prevention of disease progression. Through the COMORE-By2032 Project, Japan aims not only to achieve a measurable reduction in COPD mortality by 2032 but also to serve as an example of a successful national NCD initiative, demonstrating coordinated multisectoral engagement in an aging society. The project's vision is consistent with the WHO's global noncommunicable disease (NCD) targets and aims to contribute to the shared goals of the Asia-Pacific respiratory community in reducing the burden of chronic respiratory diseases. Since its launch in 2023, the COMORE-By2032 Project has initiated several collaborative activities. In partnership with municipalities in Nara Prefecture, a process has been developed to encourage consultation and referral for people at high risk of COPD and to ensure timely specialist care. In addition, in collaboration with the Japanese Heart Failure Society, an educational document for cardiologists was prepared to enhance awareness of COPD among non-respiratory specialists [5]. It is expected that these efforts will contribute to more effective early detection and management of COPD in years to come. The author gratefully acknowledges the support and leadership of Professor Kazuhisa Takahashi, President of the Japanese Respiratory Society, and Professor Toyohiro Hirai, Immediate Past President. The author also thanks the members of the JRS COMORE-By2032 Working Group and the JRS Obstructive Lung Disease Assembly for their valuable contributions to the overall progress of the project. The author declares no conflicts of interest.