To understand the changing trends in the burden of chronic obstructive pulmonary disease (COPD) and the main risk factors for death in major countries participating in the Belt and Road Initiative (BRI) from 1990 to 2021, and to provide a reference for formulating COPD prevention and control strategies for these countries.

Data on age-standardized incidence rate (ASIR), age-standardized mortality rate (ASMR), age-standardized disability-adjusted life years (DALY) rate, and the attributable fraction of COPD death risk factors from 1990 to 2021 were extracted from the Global Burden of Disease Study 2021 (GBD 2021) database for 13 major BRI participating countries: China, Egypt, Pakistan, Russia, the Philippines, Bangladesh, Myanmar, Thailand, Turkey, Iran, India, Indonesia, and Vietnam. Estimated annual percentage change (EAPC) was used to describe the trends in ASIR, ASMR, and age-standardized DALY rate in each country. Butterfly charts were used to compare the attributable fractions of COPD death risk factors by sex in 2021.

From 1990 to 2021, the ASIR of COPD generally showed an upward trend in Egypt, Turkey, Iran, Indonesia, and Vietnam, increasing from 129.68/100 000, 199.53/100 000, 114.36/100 000, 155.06/100 000, and 159.48/100 000 in 1990 to 177.45/100 000, 225.79/100 000, 152.05/100 000, 176.01/100 000, and 179.64/100 000 in 2021, respectively. The corresponding EAPCs (95%CI) were 0.92% (0.90–0.95), 0.38% (0.34–0.42), 0.96% (0.94–0.98), 0.36% (0.33–0.38), and 0.28% (0.24–0.33). The ASIR of COPD generally showed a downward trend in China, Pakistan, Russia, the Philippines, Bangladesh, Myanmar, Thailand, and India, decreasing from 271.22/100 000, 243.66/100 000, 162.10/100 000, 191.76/100 000, 260.88/100 000, 241.21/100 000, 164.34/100 000, and 275.49/100 000 in 1990 to 215.62/100 000, 231.91/100 000, 144.19/100 000, 165.78/100 000, 238.94/100 000, 234.81/100 000, 125.47/100 000, and 262.45/100 000 in 2021, respectively. The corresponding EAPCs (95%CI) were –0.84% (–0.88– –0.81), –0.18% (–0.22– –0.14), –0.53% (–0.59– –0.46), –0.14% (–0.16– –0.12), –0.29% (–0.35– –0.23), –0.91% (–0.94– –0.88), –0.67% (–0.74– –0.59), and –0.18% (–0.19– –0.17). From 1990 to 2021, the ASMR of COPD generally showed a downward trend in China, Egypt, Pakistan, Russia, the Philippines, Bangladesh, Myanmar, Thailand, Turkey, Iran, Indonesia, and Vietnam, decreasing from 231.78/100 000, 48.30/100 000, 83.97/100 000, 29.81/100 000, 46.58/100 000, 101.94/100 000, 135.53/100 000, 55.13/100 000, 57.54/100 000, 21.01/100 000, 53.00/100 000, and 54.29/100 000 in 1990 to 73.23/100 000, 25.87/100 000, 73.80/100 000, 13.04/100 000, 32.81/100 000, 59.65/100 000, 104.53/100 000, 19.80/100 000, 40.77/100 000, 17.44/100 000, 49.53/100 000, and 43.96/100 000 in 2021, respectively. The corresponding EAPCs (95%CI) were –4.25% (–4.48– –4.02), –0.32% (–0.44– –0.19), –0.66% (–0.92– –0.40), –3.23% (–3.60– –2.86), –1.11% (–1.22– –1.00), –1.97% (–2.33– –1.61), –4.05% (–4.36– –3.75), –0.92% (–1.01– –0.84), –0.72% (–1.11– –0.33), –2.12% (–2.32– –1.92), –0.19% (–0.31– –0.06), and –0.66% (–0.76– –0.55). From 1990 to 2021, the age-standardized DALY rate of COPD generally showed a downward trend in all 13 major BRI participating countries. Attributable death risk factor analysis for COPD deaths showed significant sex differences in the proportions of deaths attributed to ambient particulate matter pollution, household air pollution from solid fuels, and occupational risks, with males generally having higher proportions than females.

From 1990 to 2021, the burden of COPD generally showed a downward trend in the 13 major BRI participating countries, with significant differences among countries. The proportions of COPD deaths attributed to ambient particulate matter pollution, household air pollution from solid fuels, and occupational risks were higher in males than in females.