Divergent Trajectories and Risk Factor Attribution of Chronic Obstructive Pulmonary Disease Burden in China and the United States, 1990–2023: An Age-Period-Cohort Analysis with Projections to 2035 Based on the Global Burden of Disease Study

Yunfei Deng,1 Yimin Zhu,2 Chong Chen,3 Wenhui Xu,2 Wenbing Yao1 1International Pharmaceutical Business School, China Pharmaceutical University, Nanjing, Jiangsu, 211198, People’s Republic of China; 2Department of Respiration, the Second Affiliated Hospital of Nanjing University of Traditional Chinese Medicine (Jiangsu Second Hospital of Traditional Chinese Medicine), Nanjing, Jiangsu, 210017, People’s Republic of China; 3Nanjing Municipal Medical Insurance Bureau, Nanjing, Jiangsu, 210017, People’s Republic of ChinaCorrespondence: Wenbing Yao, International Pharmaceutical Business School, China Pharmaceutical University, Nanjing, Jiangsu, 211198, People’s Republic of China, Email [email protected]: Chronic obstructive pulmonary disease (COPD) remains a leading cause of global mortality. China and the United States, the world’s two largest economies accounting for 40% of global COPD burden, lack comprehensive comparative analyses of long-term trends and risk factor attribution.Objective: This study aimed to compare COPD burden trends, decompose age-period-cohort effects, quantify risk factor contributions, and project future trajectories in China and the United States from 1990 to 2023 with forecasts to 2035.Methods: We analyzed Global Burden of Disease Study 2023 data for China and the United States, examining incidence, prevalence, mortality, and disability-adjusted life years (DALYs) stratified by sex and 17 age groups. Joinpoint regression identified temporal inflection points. Age-period-cohort models decomposed burden into independent effects. Risk factor attribution analyzed eight major exposures. Bayesian methods projected burden to 2035.Results: China demonstrated remarkable declines in age-standardized mortality (58.68% decrease to 46.60 per 100,000) and DALY rates (61.12% decrease to 777.86 per 100,000), with dramatic risk factor reductions: particulate matter pollution declined 82.21%, smoking 68.48%. Conversely, the United States exhibited increasing age-standardized mortality (8.90% increase to 28.89 per 100,000), with female mortality rising 45.64% and smoking-attributable burden declining only 14.09%. Period effects deteriorated in the United States (relative risk: 0.67 to 1.34) while improving in China (1.20 to 0.83). Projections indicated Chinese deaths would surge 135.9% by 2035 despite declining age-standardized rates, while American deaths would increase 30.1% with rising age-standardized rates.Conclusion: Substantial COPD burden reductions are achievable through comprehensive risk factor control as demonstrated by China’s success, while persistent deterioration in the United States highlights critical prevention gaps requiring urgent intervention to avert projected burden escalation.Keywords: chronic obstructive pulmonary disease, global burden of disease, age-period-cohort analysis, risk factors, epidemiological trends