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 Table of Contents  
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 184-188

Factors associated with Chronic Obstructive Pulmonary Disease burden in India

Department of Pediatrics, Safdarjung Hospital, New Delhi, India

Date of Submission21-Nov-2020
Date of Decision16-Mar-2021
Date of Acceptance19-Mar-2021
Date of Web Publication08-Jan-2022

Correspondence Address:
Dr. Manas Pratim Roy
Department of Pediatrics, Safdarjung Hospital, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/bjhs.bjhs_122_20

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OBJECTIVE: Chronic Obstructive Pulmonary Disease (COPD) is the second major contributor to disease burden in India, courtesy to tobacco use, and air pollution. However, there are not many studies with a nationwide approach. The present paper aims to correlate Disability-Adjusted Life Years (DALY) due to COPD with tobacco use, secondhand smoking, the use of clean fuel, and economic condition.
MATERIALS AND METHODS: The study adopted an ecological approach. A secondary analysis was carried out on data collected from the National Family Health Survey 4, the Global Adult Tobacco Survey 2: India 2016–17, and India: Health of the Nation's States. Spearman correlation coefficient and multivariate linear regression were used for state-wise analysis.
RESULTS: It was found that states with higher COPD burden were confined to North India. Smoking and secondhand smoking had positive relationships with COPD burden. On regression, smokeless tobacco (SLT) was significantly associated with DALY due to COPD.
CONCLUSION: States with the highest proportion of SLT need special intervention to reduce COPD burden in the country.

Keywords: Chronic Obstructive Pulmonary Disease, India, tobacco

How to cite this article:
Roy MP. Factors associated with Chronic Obstructive Pulmonary Disease burden in India. BLDE Univ J Health Sci 2021;6:184-8

How to cite this URL:
Roy MP. Factors associated with Chronic Obstructive Pulmonary Disease burden in India. BLDE Univ J Health Sci [serial online] 2021 [cited 2022 Aug 16];6:184-8. Available from: https://www.bldeujournalhs.in/text.asp?2021/6/2/184/335322

Chronic obstructive pulmonary disease (COPD) killed 3.2 million people globally in 2015.[1] Defined as progressive persistent airflow limitation, the disease affects other systems and organs and reduces physical activity level.[2] The mental health of the patients also gets disturbed, as evident from a previous study.[3] As a result, daily living loses stability. No wonder, the disease is responsible for 4.8% Disability-Adjusted Life Years (DALY) in India and it ranked second among individual diseases causing maximum DALY in the country.[4]

Known to cause a huge financial burden, COPD is largely a preventable disease.[5] Still, the current national trend in India is not obvious.[6] Many local studies were undertaken to estimate its prevalence. Two multicentric studies based on questionnaires found the prevalence of COPD around 3%–4%.[7],[8] However, as spirometry is considered to be the gold standard for diagnosis of COPD and most of the studies using it are localized in nature, we still wait for nationally representative data to compare with the rest of the world. Underdiagnosis is one reason, apart from lack of awareness, which has kept this progressive disease away from well-deserved focus. Two major preventable causes of COPD are smoking and indoor air pollution. Poverty, higher age, cooking with wood, and education have also been implicated in the occurrence of COPD.[9],[10]

However, as evident from the recent reports, there are wide variations among states. Rajasthan, Uttarakhand, and Uttar Pradesh recorded four times more DALY than Nagaland.[4] In this perspective, it is important to examine other related factors to determine the possible etiology and devise prevention strategies accordingly. The present paper aims to correlate a few sociodemographic factors with the burden of COPD.

  Materials and Methods Top

Three datasets, all representing national figures, were used for secondary analysis. One of them was the National Family Health Survey, conducted in 2015–16 (NFHS 4). Global Adult Tobacco Survey (GATS) 2: India was another dataset, conducted in 2016–17, India: Health of the Nation's States being the third report.[4],[11],[12] All of the reports are available in the public domain. A total of 30 states/union territories (UTs) were considered in this study. Among different variables, smokeless tobacco (SLT) use, smoking, secondhand smoking (SHS), clean fuel, and per capita net state domestic product (NSDP) were considered. Data on NSDP were available from the report of the Ministry of Finance.[13] No missing data were there.

While NFHS 4 collected data from all 36 states/UTs, GATS 2 considered data from 30 states and two UTs. Report on individual UTs was not available from the ICMR report. The survey population was also different in these data sets. NFHS 4 considered people between 15 and 49 years, while GATS 2 interviewed people aged 15 years or older. All the data were available in percentages except DALY which is expressed as per 100,000 population. SHS focused on exposure to SHS during the past 30 days at the workplace or in any public place, such as government buildings/offices, private offices, health-care facilities, restaurants, public transportation, bars/night clubs, and cinema hall/theater.[12]

Approval from the Ethical Committee was not required as the study dealt with anonymous datasets. The correlation coefficient, scatter plot, and multivariate regression were used. P < 0.05 was considered significant. PASW for Windows software (version 19.0; SPSS Inc., Chicago, Illinois, USA) was used.

  Results Top

There were great variations between states, in terms of tobacco use, income, and use of clean fuel. Most of the states with high COPD burden were limited to North India. North-east states like Mizoram, Meghalaya, Tripura recorded a maximum prevalence of smoking. Bihar records the least availability of clean fuel in the country (17.8%). States such as Tripura, Manipur, Odisha, and Assam recorded >40% prevalence of SLT, but the COPD burden in these states was less than in northern India. [Figure 1] and [Figure 2] show the distribution of DALY due to COPD with the economic condition and smoking, respectively.
Figure 1: Economic condition and distribution of chronic obstructive pulmonary disease burden in India

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Figure 2: Prevalence of smoking and distribution of chronic obstructive pulmonary disease burden in India

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A weak positive relationship was there between smoking and DALY (r = 0.043, P = 0.882). The use of clean fuel and economic condition was negatively associated with disease burden. (r = - 0.084 and – 0.169, respectively). No relation could be established between SLT and DALY. SHS at home and work has weak positive relationships with COPD burden (r = 0.129 and 0.169, respectively).

Multivariate linear regression found the use of SLT (B = - 23.236, P = 0.017) as significant. [Table 1].
Table 1: Multivariate analysis for chronic obstructive pulmonary disease burden in India

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  Discussion Top

The present paper has brought three national data sets for understanding the background of COPD in India. DALY, a parameter considering both life with disability and years lost due to premature death, was the point of concern. Since India bears 32% of the global burden of COPD, it is important to focus on the related areas so that the right strategies could be adopted.[14]

States were at different levels, in terms of the burden of COPD and the distribution of associated risk factors. Smoking was very common in some northeast states. Few states in northeast recorded high prevalence of SLT but comparatively less burden from COPD.

Before estimation by the Global Burden of Disease (GBD) Study comes to picture, one large Indian study found that 3.49% of adults >35 years of age suffered from chronic bronchitis. However, spirometry was not used there as a diagnostic tool.[8] Later, the Burden of Obstructive Lung Disease study found the prevalence of airway obstruction to vary from 5.7% to 17.3% in males and 6.8% to 14.8% in females.[9] The recent GBD report attributed 10.9% of mortality of the country to chronic respiratory diseases.[4]

As evident, certain states such as Meghalaya, with a high smoking rate as high as 31.6%, recorded minimum burden due to COPD. On the other hand, states such as Rajasthan, Uttarakhand, and Uttar Pradesh documented a high COPD burden, with less prevalence of smoking (<20%). The pattern suggests the presence of other factors in precipitating COPD problems in the population. Smoking, although not strongly related to DALY due to COPD, is a recognized preventable factor. If successfully stopped, the strategy could yield a rich dividend in future.

The present paper suggested that SHS is related to COPD burden. It supports the previous finding that many COPD cases occur in nonsmokers.[15] It also explains the occurrence of COPD in females not exposed to biomass fuel.[7] India is implementing the Cigarettes and other Tobacco Products Act since 2003 to safeguard nonsmokers from the prey of smokers, particularly in public places. Literature reported poor compliance to the Act at places, raising great concern.[16] With almost half of the households in the country allowing smoking inside the house, there is a need for mass awareness that SHS could lead to noncommunicable diseases (NCDs) including COPD.[12]

SLT is another area that required a multisectoral approach because of its close relationship with social customs, festivals, and rituals.[17] Due to its household production, it is difficult for the prevailing act to stop it completely. Studies from Bangladesh also reported wide acceptance of SLT.[18],[19] With 199.4 million SLT users in India, there needs to be some mechanisms for reducing its use in social gatherings and to detach it from social norms.[12] In the present paper, few states recorded >40% prevalence of SLT use in the population. A strategy focusing on awareness activities among poor people to tell repeatedly about its negative roles on health may go a long way in future.

Air pollution has been implicated in chronic respiratory problems in India and abroad.[20],[21] As clean fuel can reduce indoor air pollution and could give freedom from COPD occurring due to the use of biomass, the Government of India is promoting the use of clean fuel across the country.[22] States with higher usage of clean fuel include Delhi, Goa, and Tamil Nadu – all recording less disease burden attributed to COPD. It may also be noted that air pollution is causing more DALYs due to COPD (53.7%) than smoking (25.4%) in India.[23] With increasing popularity and availability of clean fuel, it is expected to reduce the burden in the long run.

Financial condition is another factor one needs to look into. Earlier research has pointed out that the societal cost of COPD per patient may be as high as USD 30,826.[5] The cost of treatment, estimated in 2005, as per guidelines for a patient with acute exacerbation of COPD was Rs. 11,660.[24] No wonder states with less per capita NSDP bear the maximum brunt of the disease. There was no statistically significant relationship between COPD burden and economy in the present study but with a better economic condition, comes COPD burden. The average expense of INR 1192 per month for daily smokers, an amount difficult to afford by poor people, in the country could be is one reason for higher tobacco use among financially better off the population.[12],[25] Another possible reason may be higher air pollution, being reported in socioeconomically deprived communities, even in the developed nations.[26] With studies highlighting the role of air pollution for exacerbation of COPD and the extent of air pollution is linked to “deprived areas,” there is a need to put more resources in this area for research.[3],[27]

National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases, and Stroke is being implemented since 2010 for health promotion, treatment, referral, and screening for early diagnosis of NCDs via clinics functional at district and community health center level across the country.[28] The recent rollout of comprehensive primary health care also envisages the inclusion of COPD at the primary care level.[29] It is expected that this strategy would be able to identify COPD cases earlier than the existing system and timely referral would be able to reduce disability in COPD cases, thus making a dent in the present burden of the disease. As the age-specific prevalence of COPD rises after the age of 30 years, it is expected that population-based screening of common NCDs, another new initiative, would be able to catch suspected cases from the people of 30 years or older residing in the community.[23] As smokers tend to quit the habit only after developing serious health problems, as evident from China, early detection by screening would be beneficial in the long run.[30]


The study did not have data on airflow obstruction, an important factor for COPD epidemiology. Although COPD is found equally in nonsmoking males and females, consideration of airflow obstruction would have improved the quality of the paper.[10] The inability to quantify tobacco use is another setback. It may also be argued that the prevalence would have been a better indicator than DALY. However, a paucity of data on the state-wise prevalence has prompted the article to go for DALY. Ecological nature and secondary data from different sources are the other disadvantages the study suffers from. However, consideration of data on smoking, tobacco use, and passive smoking at home and work separately with disability data is a unique dimension of this study, by which it attempts to cover the full spectrum of tobacco and COPD.

  Conclusion Top

The study indicates the need to take SLT, the only significant factor following multivariate analysis, into account for COPD patients. We should stress the fact that the prevention of exposure to such risk factors could prevent COPD. The victim states should devise their tactic for alleviating their burden due to COPD. For research, the concentration of high COPD burden in North India should be the next topic for epidemiological investigations with a wider perspective in future. Research should also focus on the best possible ways to mitigate the burden by modifying sociodemographic factors implicated in COPD.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2]

  [Table 1]


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