Burden of chronic obstructive pulmonary disease attributable to ambient ozone pollution across China and its provinces, 1990–2021: An analysis for the Global Burden of Disease Study 2021

Abstract Background: Epidemiological studies have demonstrated a causal relationship between ambient ozone (O 3 ) and mortality from chronic obstructive pulmonary disease (COPD), which is the only outcome considered in the Global Burden of Disease Study 2021 for O 3 . This study aims to evaluate the temporal trend and spatial distribution of the COPD burden attributable to O 3 across China from 1990 to 2021. Methods: The ambient O 3 concentrations in China were estimated. Based on the methodology framework and standard analytical methods applied in the Global Burden of Disease Study 2021, we estimated the annual number, age-standardized rate, and percentage of deaths and disability-adjusted life-years (DALYs) from COPD attributable to O 3 pollution during 1990–2021 at the national and provincial levels in China. Results: In 2021, a total of 125.7 (95% uncertainty interval [UI], 26.4–228.3) thousand deaths and 1917.5 (95% UI, 398.7–3504.6) thousand DALYs from COPD were attributable to ambient O 3 pollution in China, accounting for 9.8% (95% UI, 2.1–17.0%) and 8.1% (95% UI, 1.8–14.1%) of the total COPD deaths and DALYs, respectively. Generally, a higher burden was observed among males, the elderly, and the population residing in regions with worse health conditions. The age-standardized rates of COPD deaths and DALYs per 100,000 populations ranged from 0.5 (95% UI, 0–1.4) and 8.1 (95% UI, 0.7–20.9) in Hong Kong to 22.8 (95% UI, 3.9–43.5) and 396.6 (95% UI, 68.9–763.7) in Xizang. From 1990 to 2021, there was a notable decrease in the age-standardized rates of COPD deaths (68.2%, 95% UI, 60.1–74.9%) and DALYs (71.5%, 95% UI, 63.7–77.6%), especially in regions with poor health conditions. However, the attributable numbers and percentages changed relatively marginally. Conclusions: Ambient O 3 pollution is a major contributor to the COPD burden in China. Our findings highlight the significant spatial heterogeneity across different provinces and underscore the implementation of geographically tailored policies to effectively reduce O 3 pollution and alleviate the associated disease burden.