Skip to main content

Recognising the importance of chronic lung disease: a consensus statement from the Global Alliance for Chronic Diseases (Lung Diseases group)



Chronic respiratory diseases are disorders of the airways and other structures of the lung, and include chronic obstructive pulmonary disease (COPD), lung cancer, asthma, bronchiectasis, interstitial lung diseases, occupational lung diseases and pulmonary hypertension. Through this article we take a broad view of chronic lung disease while highlighting (1) the complex interactions of lung diseases with environmental factors (e.g. climate change, smoking and vaping) and multimorbidity and (2) proposed areas to strengthen for better global patient outcomes.


We suggest new directions for the research agenda in high-priority populations and those experiencing health disparities. We call for lung disease to be made a research priority with greater funding allocation globally.


Chronic respiratory disease is one of five non-communicable disease (NCD) areas that contribute to the highest mortality and morbidity globally [1]. Chronic respiratory diseases are diseases of the airways and other structures of the lung, and include chronic obstructive pulmonary disease (COPD), asthma, bronchiectasis, interstitial lung diseases, occupational lung diseases and pulmonary hypertension [2]. The most important and recognised risk factors for lung morbidity include threats such as smoking, indoor, and outdoor air pollution, occupational exposures, and poverty [1]. However, there are several emerging threats and risk factors for chronic lung diseases which include increasing frequency and intensity of climate change events such as bushfires and emerging nicotine delivery systems (e.g., e-cigarettes) and increasing health complexity due to multimorbidity. Chronic lung disease following COVID-19 is also recognised as a major burden to patients and the healthcare system [3]. Disadvantaged populations such as the homeless, Indigenous Peoples, the elderly, migrant populations, and refugees may be disproportionately impacted by these risk factors for lung health. On the basis of this concern, the Global Alliance for Chronic Disease (GACD) announced a call for grants in 2016 focusing on Lung Diseases in Low- and Middle-Income Countries (LMIC), and priority populations in High Income Countries (HIC), and allocated $60 million to this research. Outside of the GACD, the investment has otherwise been labelled inadequate and inequitable; chronic respiratory disease is a poor cousin compared to other NCDs including cancer, cardiovascular disease and diabetes. Lung diseases received just 2% of grants according to the World Health Organisation in their analysis of research expenditures, with respiratory disease being 13th on the list despite chronic lung diseases such as COPD being the 6th leading cause of disability and 5th leading cause of early death [4, 5]. Within lung diseases research, HIC receive the majority of the funding, whereas the burden of disease from chronic lung diseases is disproportionately higher in LMIC. [6]

The GACD Lung Diseases Research Programme has projects operating in 33 countries. The GACD website lists 17 current projects related to lung health compared to 34 projects related to hypertension and mental health and 38 related to diabetes [7]. The Lung Disease projects funded by GACD predominantly focus on prevention of tobacco related harms to the lungs including smoking, second-hand smoke, and e-cigarettes with a small minority of studies focussing on tuberculosis, COPD, and household air pollution.

As a group of lung health representatives from the 16 countries whose major funders collaborate to make the GACD Network, we call for lung health to be elevated up the list of organ-related priorities, especially in the wake of the SARS-CoV-2 (COVID-19) pandemic. The aims of this article are to (a) highlight the complexity and interconnections between major risk factors to lung health (b) suggest new directions for the research agenda in LMIC and HIC where high-priority populations, such as Indigenous peoples and those living in low socio-economic environments, bear the brunt of health disparities.

Environment effects on lung health

Climate change

In recent times, climate change has become one of the most discussed phenomena, which has transformative effects on health, economics, ecosystems, and geography. Direct effects of climate change such as severe dust storms, and bushfires or wildfires can adversely affect lung health.

Dust exposure has been linked to Influenza A virus, pulmonary coccidioidomycosis, bacterial pneumonia, and meningococcal meningitis [8]. It has also been associated with NCDs such as COPD, asthma, sarcoidosis, and pulmonary fibrosis [9]. Dust storms can result in increased inhalation of minute particles into the lungs (e.g., PM2.5 and PM10), and can cause and exacerbate symptoms of existing chronic lung disease. Dust inhalation also increases the risk for developing Desert Lung disease or non-occupational silicosis when the lung macrophages mount an inflammatory response to the silica elements of the dust particles that results in lung fibrosis. The lungs can then mount an immune response resulting in fibrosis. Dust inhalation exacerbates the symptoms of chronic obstructive lung disease (COPD) [10]. Dust storms can carry a wide variety of allergens such as pollen, dust mites, fungal spores, and man-made pollutants. The prevalence of asthma is increasing [11], and the increasing frequency of dust storms can be one of the drivers. Desert dust activates a cascade of cytokine mediated immune response resulting in production of IgE, lymphocytes, granulocytes, dendritic cells resulting in increased mucous production and airway remodelling [10]. There is also an increased production of Il-17 that activates neutrophils and facilitate their migration into the areas of lungs where the dust has settled [10].


Decades of climate change have resulted in an increasing prevalence of wildfires or bushfires [12]. The bushfire crises in Australia during 2019–2020 and recent wildfires in Greece and the US are risks to lung health for those who live in the affected areas. Bushfire smoke contains noxious gases and particulate matter (PM2.5 and PM10 particles, nitric oxides, carbon monoxide (CO) and other toxic gases) which upon entering the lungs and blood stream can result in increased respiratory hospital admissions and use of asthma medication. cardiovascular events, and exacerbations [13]. From data obtained from Sydney, Australia in 2011, an increase in PM2.5 by > 20 µg/m3 increased daily all-cause mortality by 5.6%, cardiovascular mortality by 4.5%, and respiratory mortality by 6.1% [14]. Tobacco smoke and bushfires release pollutants into the environment and may have similar ill-effects on lung health. Concurrent smoking and exposure to bushfire smoke is more common in populations with a higher prevalence of tobacco smoking, such as Indigenous People, rural and remote communities, and people who experience mental illness [15]. The combination of tobacco smoking and exposure to bushfire smoke cause intergenerational effects by causing low birth weight in babies born to exposed women [16].

Indoor biomass burning

A large proportion of populations in low and middle income countries burn biomass such as wood and coal, crop waste and animal dung indoors for cooking, lighting and heating [17]. Women and children are disproportionately affected by the indoor environment saturated with resultant indoor pollution [17]. Studies have shown that persons exposed to biomass indoor pollution can experience decreased and impaired lung growth and development, and an increase in cough and wheeze [18]. Compared to smoking, indoor biomass burning induced COPD is associated with more cough and phlegm, airway thickening and air trapping [19]. Enhanced health education surrounding the harms of indoor air pollution combined with greater access to clean stoves and cleaner fuels may help limit the harms of indoor biomass burning [20].

Vaping and lung health risks

E-cigarettes first became available in 2003, and have become a relatively new threat to lung health due to their growing usage. Newer devices and flavours make these products more appealing to diverse age groups and populations [21]. E-cigarettes are battery-operated devices, which heat a solution of nicotine and other additives to produce inhalable nicotine vapour. While some experts view them as a tobacco harm reduction method, they are widely considered a potential new threat to lung health. The use of these devices is mired in controversy because of concerns surrounding their benefits in comparison to alternative approaches to smoking cessation, adverse effects, the potential renormalisation of smoking and concerns about uptake by young non-smokers [22]. Research into E-cigarettes is still nascent, relating to their short- and long-term usage safety profile, the gateway effect among young non-smokers and possible decrease of complete nicotine cessation, with dual usage of tobacco and e-cigarettes becoming a concern. There is no consensus among different countries about regulation of e-cigarettes and the laws range from complete ban on e-cigarette usage (India), nicotine liquid being only available on prescription (Australia), to promoting e-cigarettes as a smoking cessation method (UK) marketed directly to the public. Establishing a safety profile for e-cigarettes is difficult—considering not only the lack of historical data but also the plethora of devices and fluids available on the market, and the concealment of their contents. Illicit vaping products may contain contaminants (e.g. vitamin E acetate and THC) which may lead to adverse effects such as the outbreak of EVALI (e-cigarette or vaping product use associated lung injury) [23]. Animal studies have shown that vaping may increase vulnerability to coronavirus infections [24], and have severe neurotoxic [25] and cardiovascular side effects such as endothelial dysfunction, increased oxidative stress, and increased cardiovascular morbidity and mortality [26]. Minor, subclinical effects may be frequent—there is data suggesting detrimental effects on lung function following short term exposure to e-cigarette aerosols possibly due to propylene glycol/glycerol—omnipresent components of vaping fluids. There is also a high potential for accidental poisoning in children, with reported fatalities [27]. Reports have shown increasing numbers of people find it extremely difficult to cease vaping, with little evidence to guide health professionals on what approach would be most effective to achieving this goal [28].

E-cigarettes are a complex and unfolding phenomenon; related decision making would most likely benefit from multidisciplinary research involving the fields of chemistry, clinical medicine, public health, psychology, and social science.

Multi-morbidities and lung health

Increasingly, chronic lung disease seldom occurs in isolation [29]. Tobacco use along with household and environmental exposures are a very common risk factor for a range of chronic disease such as COPD, cardiovascular disease and many cancers including lung cancer [30]. However, apart from smoking and pollution, the link between chronic respiratory conditions and co-morbid conditions is not fully understood. One possible explanation is chronic systemic inflammation which is present in all chronic respiratory conditions as well as other chronic conditions such as ischaemic heart disease and osteoporosis. Therapy for respiratory disease may also be associated with increased risk of co-morbidity, for example inhaled corticosteroids.

Respiratory conditions are among the most common chronic conditions in patients with multimorbidity [31], but assessing this in disadvantaged populations is difficult because of the under-diagnosis of respiratory disease [32]. In a nationally representative primary care study in Scotland, asthma constituted a prevalence of 6% while 52% of individuals with asthma had one or more additional conditions. Likewise the prevalence of COPD was 3%, and 82% of these patients had two or more additional conditions [33]. Among patients with higher number of morbidities along with respiratory conditions such as asthma it has also been observed that these individuals visit the hospital more frequently for unscheduled emergency, in-patient and out-patient care compared to those without any other condition [34].

Findings from the UK General Practice Research Database (GPRD; now Clinical Practice Research Datalink, CPRD) suggest that newly diagnosed COPD patients are also more likely to be diagnosed with angina, cataracts, bone fractures, pneumonia and respiratory infections within the first year of the COPD diagnosis. Patients with co-morbid COPD and ischaemic heart disease are more likely to be undertreated with beta-blockers despite evidence of safety of this treatment. A link between lung diseases and mental health conditions is an area of concern, potentially mediated by tobacco smoking, as a high proportion of mental health clients smoke [35] and find it difficult to cease [36]. Smokers with mental health conditions are more likely to die from smoking-related conditions than their mental health issues [37, 38].

Proposed areas to strengthen for improved global lung health

In tackling both old and new threats that we have touched on, we would like to espouse further strengthening in key areas, these include the use of better diagnostics, access to evidence based care, pulmonary rehabilitation, palliative care, attention to ethical issues, use of new technologies, and increased dedicated funding for lung disease research and rapid and equitable implementation of effective measures into practice especially in LMIC and priority populations in high income countries. The latter can be achieved through better implementation of guidelines, but there are challenges to doing this in LMIC. [39]

Better diagnostics

Effective management of chronic lung disease requires timely, accurate diagnosis yet the availability of key tests such as spirometry remains poor in many settings. Access to diagnostics is a feature of the patient charter for COPD[40] and recently published COPD quality standards [41]. Lack of access to diagnostics is a key barrier to the implementation of guideline-care in LMICs [39].

The challenge is much more than the availability of equipment, and relates to the training and ability of the front line, community based primary care workforce. In a recent population-based screening study of 10,709 people in 3 LMIC sites, the overall prevalence of COPD was 9.4% and > 95% were previously undiagnosed [42]. There is now the need to test implementation of tools to screen for COPD in LMIC settings, and to understand if screening is of benefit to individuals and society.

Inequities and access to evidence-based care

The growing burden of COPD, particularly in low socio-economic status societies will increase health disparities due to lack of access to evidence-based care. The main determinants of COPD disadvantage relate to discrimination (based on ethnicity, religion, sex, age), physical and mental disabilities, socio-economic status [43]. To alleviate health inequities for people with COPD there should be better case finding, education programs for the general population to raise awareness of COPD and the treatments available, upskilling of health care workers in the management of COPD patients, improved access to cost-effective evidence-based interventions, smoking cessation programs to slow decline in lung function, and environmental initiatives to reduce air pollution and occupational exposures to dusts to improve lung health [44].

Rehabilitation of chronic lung diseases

Pulmonary rehabilitation, combination of exercise training and education for people with chronic lung disease, has unequivocal evidence of effectiveness in improving health-related quality of life, reducing symptoms of breathlessness and fatigue [45] and reducing hospitalisations [46]. Pulmonary rehabilitation is cited as best-practice management in many national guidelines [47,48,49,50]. Such programs have been shown to be one of the most cost-effective treatment strategies for COPD [51].

A key issue is that pulmonary rehabilitation is not widely available. It is estimated that less than 2% of the more than 384 million people world-wide with COPD [52] have access to a pulmonary rehabilitation program [53]. The most disadvantaged are people from LMIC where few pulmonary rehabilitation programs are available. There is growing evidence for the effectiveness of pulmonary rehabilitation in low resource settings, as well as for pulmonary rehabilitation using minimal equipment for exercise training which would enable programs to be implemented in low-income countries [54]. However, this has not yet translated into increased availability of programs. Key to the provision of pulmonary rehabilitation is health professionals trained to deliver this intervention. Strategies to build the capacity of health professionals in LMIC to provide pulmonary rehabilitation need to be developed. In addition, in high income countries, Indigenous populations have very limited availability of culturally appropriate pulmonary rehabilitation programs [55].

It is important that the value of rehabilitation for people with chronic lung disease and those recovering from COVID-19 is recognised and that funding is allocated to supporting current programs and in developing new programs, especially in LMIC.

Palliative care in chronic lung diseases

As is similar for the under-utilisation of pulmonary rehabilitation, there is low access to and implementation of palliative care for chronic lung diseases, despite its effectiveness [56]. Patients who are dying from COPD experience a progressive decline in health, increasing symptoms and reduced autonomy. However, the majority of patients with advanced COPD are not offered palliative care [57]. National and international guidelines, over the past 20 years, have tried to emphasise its value and adoption into practice [58]. Despite this, even in high income countries, among the general population, there is minimal evidence of palliative care being offered to patients with COPD, compared to those with lung cancer, despite the symptoms being potentially just as distressing [59].

Palliative care for lung diseases in low resource settings is likely to be non-existent or minimal. It is profoundly affected by low access to health services and social and cultural beliefs around sharing a terminal diagnosis with the patient [60]. Palliative care services demand a high degree of networks between multiple disciplines and organisations, and unified standards of ethical care may be missing in LMIC [60]. The infrastructure investment within LMIC may need intensive investment for this to occur, but none-the-less this area needs to be highlighted for future research.

Ethical issues

Lung health is related to many ethical-legislative sensitive considerations [61]. Clinicians have an ethical duty to ensure patients’ benefit, minimize harm and act in respect to patients’ values and preferences, by building a relationship based on truth, respect, and confidentiality [62]. Airborne infections are a major threat to lung health. Thorough detection of infected/non-infected individuals sharing the same environments should dictate infection control measures aiming to respect equity, social responsibility, non-discrimination and individual liberty. The great Spanish Flu pandemic killed millions of people in 1918–1919 and brought an unmet sanitary crisis to mankind, as there were no available antivirals or vaccines to treat it. TB has significant impacts upon the long-term health of many affected individuals, compounded by its association with poverty and other causes of poor health. COVID-19 global pandemic revealed many ethical-legislative gaps that had to be overcome to save lives, such as novel communication tools, confidentiality emergency disclosure, supplies and treatment accessibility [63].

Similar to other end stage diseases, ethical principles of beneficence and non-maleficence are often in conflict with patient’s autonomy when being treated for end stage lung disease. The best approach is to rely on local ethical guidelines and consensus between medical staff, patient and family. Special ethical-legal consideration must be given to end-life related withdrawal from treatment. As such, many hospitals have ethics committees providing individual support to clinicians, patients, and their families [64].

Technological interventions

While computers and smart phones have become ubiquitous, many individuals in LMIC still do not have access to these resources and we all have different levels of adoption and usage. Digitalized medicine appears to be a driving force for the improvement of diagnostic, treatment, and progress of research in all medical fields. More than half a century ago, the invention of the cathode ray tube revolutionized radiology [65] and opened countless possibilities of development for imaging in medicine. Since then, the utilization of computers has opened the path to integrating artificial intelligence (AI) in all medical fields, radiology being one of the most advanced areas of application by using deep-learning techniques to detect abnormal scans [66].

E-health can improve access to care for those in rural regions, provided internet access, cellular or a telephone signal is available. Telehealth, while on the fringes for many years, since the advent of the COVID-19 pandemic is now more ubiquitous and here to stay. Technologically enabled learning is a growing field for patient (and clinician) education with the use of computers, smartphones, tablets, and mobile applications. Moreover, technological support can effectively promote patient self-care, medication adherence, and physical activity among those with chronic respiratory conditions [67]. With the increased use of telemedicine, digital interventions need to align with clinical guidance, be context-relevant relevant and appropriately reviewed for quality and impact [67]. The use of telehealth and digital solutions has been utilised across the GACD grant recipients and remains on the agenda as a priority in further funding rounds.

Funding for chronic lung diseases research, implementation, and research

GACD is a Network that prioritises implementation science, thus we are conscious that in many cases, the evidence-base is available but evidence-based interventions are not being implemented where they are needed the most, or in the most effective way. New calls for research are becoming less disease-focused and open for options about NCD conditions, for example prevention of health risks across the lifespan in 2022. The GACD is an exemplar in funders working together to build implementation solutions for NCDs. However, more needs to be accomplished for chronic lung diseases and its causes.

Beyond the GACD, we would like to call for a greater investment in NCD research, especially in chronic lung diseases, from all funding bodies. In 2022, the International Primary Care Respiratory Group published a Delphi study to set a research agenda for primary care for respiratory diseases. Their priorities, set by a large team from HIC and LMIC, include increasing research into management of chronic cough, COPD, asthma, and smoking cessation, including improving medication adherence and self-management [68]. Multidisciplinary teams and management of co-morbidity was a further focus of need.

Williams et al. on behalf of the Global Health Respiratory Network state, in their letter to the Lancet, that the respiratory research community need to work more effectively “to develop, test, implement, and scale-up the necessary multiple and multisectoral strategies to improve respiratory health” [5]. We join their urgent call to all funders to review their investment in research on respiratory health and take affirmative action, especially to benefit those in low resource settings and high priority and Indigenous populations.


The GACD Network provides a unique opportunity for lung disease researchers to consider the complexity and interconnections between major risk factors for lung health. We suggest new directions for the research agenda in high-priority populations and those experiencing health disparities. These include a greater attention to: the effects of climate change and bushfires on respiratory health, vaping in addition to tobacco smoking, the complexities from multimorbidity, better diagnostics [69] and areas for improvement in provision of rehabilitation, palliative care, the use of digital technology.

We call for lung health to be elevated up the list of research priorities and receive a greater share of funding relative to burden to enable both new and old threats to be adequately researched, translated and implemented. The World literally cannot afford for the lungs to be left behind in the better research and care for NCDs.

Availability of data and materials

Not applicable.


  1. Soriano JB, Kendrick PJ, Paulson KR, Gupta V, Abrams EM, Adedoyin RA, Adhikari TB, Advani SM, Agrawal A, Ahmadian E, et al. Prevalence and attributable health burden of chronic respiratory diseases, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Respir Med. 2020;8(6):585–96.

    Article  Google Scholar 

  2. WHO. Chronic obstructive pulmonary disease (COPD). 2021.

  3. Myall KJ, Mukherjee B, Castanheira AM, Lam JL, Benedetti G, Mak SM, Preston R, Thillai M, Dewar A, Molyneaux PL, et al. Persistent post-COVID-19 interstitial lung disease. An observational study of corticosteroid treatment. Ann Am Thorac Soc. 2021;18(5):799–806.

    Article  Google Scholar 

  4. Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. In. Seattle,WA; 2018.

  5. Williams S, Sheikh A, Campbell H, Fitch N, Griffiths C, Heyderman RS, Jordan RE, Katikireddi SV, Tsiligianni I, Obasi A. Respiratory research funding is inadequate, inequitable, and a missed opportunity. Lancet Respir Med. 2020;8(8):e67–8.

    Article  CAS  Google Scholar 

  6. Bousquet J, Kiley J, Bateman ED, Viegi G, Cruz AA, Khaltaev N, Aït Khaled N, Baena-Cagnani CE, Barreto ML, Billo N, et al. Prioritised research agenda for prevention and control of chronic respiratory diseases. Eur Respir J. 2010;36(5):995–1001.

    Article  CAS  Google Scholar 

  7. GACD. Projects 2022.

  8. Boğan M, Kul S, Al B, Oktay MM, Akpinar Elçi M, Pinkerton KE, Bayram H. Effect of desert dust storms and meteorological factors on respiratory diseases. Allergy. 2022;77(7):2243–6.

    Article  Google Scholar 

  9. Schweitzer MD, Calzadilla AS, Salamo O, Sharifi A, Kumar N, Holt G, Campos M, Mirsaeidi M. Lung health in era of climate change and dust storms. Environ Res. 2018;163:36–42.

    Article  CAS  Google Scholar 

  10. Esmaeil N, Gharagozloo M, Rezaei A, Grunig G. Dust events, pulmonary diseases and immune system. Am J Clin Exp Immunol. 2014;3(1):20–9.

    Google Scholar 

  11. Dharmage SC, Perret JL, Custovic A. Epidemiology of asthma in children and adults. Front Pediatr. 2019;7:246–246.

    Article  Google Scholar 

  12. Vardoulakis S, Marks G, Abramson MJ. Lessons learned from the Australian bushfires: climate change, air pollution, and public health. JAMA Intern Med. 2020;180(5):635–6.

    Article  Google Scholar 

  13. Walter CM, Schneider-Futschik EK, Knibbs LD, Irving LB. Health impacts of bushfire smoke exposure in Australia. Respirology. 2020;25(5):495–501.

    Article  Google Scholar 

  14. Johnston F, Hanigan I, Henderson S, Morgan G, Bowman D. Extreme air pollution events from bushfires and dust storms and their association with mortality in Sydney, Australia 1994–2007. Environ Res. 2011;111(6):811–6.

    Article  CAS  Google Scholar 

  15. Sharma R, Gartner CE, Hall WD. The challenge of reducing smoking in people with serious mental illness. Lancet Respir Med. 2016;4(10):835–44.

    Article  Google Scholar 

  16. O’Donnell M, Behie A. Effects of bushfire stress on birth outcomes: a cohort study of the 2009 Victorian Black Saturday bushfires. Int J Disaster Risk Reduction. 2013;5:98–106.

    Article  Google Scholar 

  17. Siddharthan T, Grigsby MR, Goodman D, Chowdhury M, Rubinstein A, Irazola V, Gutierrez L, Miranda JJ, Bernabe-Ortiz A, Alam D, et al. Association between household air pollution exposure and chronic obstructive pulmonary disease outcomes in 13 low- and middle-income country settings. Am J Respir Crit Care Med. 2018;197(5):611–20.

    Article  Google Scholar 

  18. Diette GB, Accinelli RA, Balmes JR, Buist AS, Checkley W, Garbe P, Hansel NN, Kapil V, Gordon S, Lagat DK, et al. Obstructive lung disease and exposure to burning biomass fuel in the indoor environment. Glob Heart. 2012;7(3):265–70.

    Article  Google Scholar 

  19. Pérez-Padilla R, Ramirez-Venegas A, Sansores-Martinez R. Clinical characteristics of patients with biomass smoke-associated COPD and chronic bronchitis, 2004–2014. Chronic Obstr Pulm Dis. 2014;1(1):23–32.

    Google Scholar 

  20. Balmes JR, Eisen EA. Household air pollution and chronic obstructive pulmonary disease. “A riddle, wrapped in a mystery, inside an enigma.” Am J Respir Crit Care Med. 2018;197(5):547–9.

    Article  CAS  Google Scholar 

  21. Fadus MC, Smith TT, Squeglia LM. The rise of e-cigarettes, pod mod devices, and JUUL among youth: factors influencing use, health implications, and downstream effects. Drug Alcohol Depend. 2019;201:85–93.

    Article  Google Scholar 

  22. Fairchild AL, Bayer R, Colgrove J. The Renormalization of Smoking? E-Cigarettes and the Tobacco “Endgame.” N Engl J Med. 2013;370(4):293–5.

    Article  Google Scholar 

  23. Hall W, Gartner C, Bonevski B. Lessons from the public health responses to the US outbreak of vaping-related lung injury. Addiction. 2021;116(5):985–93.

    Article  Google Scholar 

  24. Lallai V, Manca L, Fowler CD. E-cigarette vape and lung ACE2 expression: Implications for coronavirus vulnerability. Environ Toxicol Pharmacol. 2021;86: 103656.

    Article  CAS  Google Scholar 

  25. Ruszkiewicz JA, Zhang Z, Gonçalves FM, Tizabi Y, Zelikoff JT, Aschner M. Neurotoxicity of e-cigarettes. Food Chem Toxicol. 2020;138: 111245.

    Article  CAS  Google Scholar 

  26. Münzel T, Hahad O, Kuntic M, Keaney JF, Deanfield JE, Daiber A. Effects of tobacco cigarettes, e-cigarettes, and waterpipe smoking on endothelial function and clinical outcomes. Eur Heart J. 2020;41(41):4057–70.

    Article  Google Scholar 

  27. Swannell C, Nicotine in e-cig liquids a poisoning risk for kids. Med J Aust. 2019:1.

  28. Amato MS, Bottcher MM, Cha S, Jacobs MA, Pearson JL, Graham AL. “It’s really addictive and I’m trapped:” a qualitative analysis of the reasons for quitting vaping among treatment-seeking young people. Addict Behav. 2021;112: 106599.

    Article  Google Scholar 

  29. Margaritopoulos GA, Antoniou KM, Wells AU. Comorbidities in interstitial lung diseases. Eur Respir Rev. 2017;26(143):160027.

    Article  Google Scholar 

  30. Hurst JR, Agarwal G, van Boven JFM, Daivadanam M, Gould GS, Wan-Chun Huang E, Maulik PK, Miranda JJ, Owolabi MO, Premji SS, et al. Critical review of multimorbidity outcome measures suitable for low-income and middle-income country settings: perspectives from the Global Alliance for Chronic Diseases (GACD) researchers. BMJ Open. 2020;10(9):e037079–e037079.

    Article  Google Scholar 

  31. Zhang R, Lu Y, Shi L, Zhang S, Chang F. Prevalence and patterns of multimorbidity among the elderly in China: a cross-sectional study using national survey data. BMJ Open. 2019;9(8): e024268.

    Article  Google Scholar 

  32. The Academy of Medical Sciences. Multimorbidity: a priority for global health research. In.; 2018.

  33. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. The Lancet. 2012;380(9836):37–43.

    Article  Google Scholar 

  34. Steppuhn H, Langen U, Keil T, Scheidt-Nave C. Chronic disease co-morbidity of asthma and unscheduled asthma care among adults: results of the national telephone health interview survey German Health Update (GEDA) 2009 and 2010. Prim Care Respir J. 2014;23(1):22–9.

    Article  Google Scholar 

  35. Lawrence D, Mitrou F, Zubrick SR. Smoking and mental illness: results from population surveys in Australia and the United States. BMC Public Health. 2009;9(1):285.

    Article  Google Scholar 

  36. Colton CW, Manderscheid RW. Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):A42–A42.

    Google Scholar 

  37. Tam J, Warner KE, Meza R. Smoking and the reduced life expectancy of individuals with serious mental illness. Am J Prev Med. 2016;51(6):958–66.

    Article  Google Scholar 

  38. Bandiera FC, Anteneh B, Le T, Delucchi K, Guydish J. Tobacco-related mortality among persons with mental health and substance abuse problems. PLoS ONE. 2015;10(3): e0120581.

    Article  Google Scholar 

  39. Hurst JR, Buist AS, Gaga M, Gianella GE, Kirenga B, Khoo EM, Mendes RG, Mohan A, Mortimer K, Rylance S, et al. Challenges in the implementation of chronic obstructive pulmonary disease guidelines in low- and middle-income countries: an official American thoracic society workshop report. Ann Am Thorac Soc. 2021;18(8):1269–77.

    Article  Google Scholar 

  40. Hurst JR, Winders T, Worth H, Bhutani M, Gruffydd-Jones K, Stolz D, Dransfield MT. A patient charter for chronic obstructive pulmonary disease. Adv Ther. 2021;38(1):11–23.

    Article  Google Scholar 

  41. Bhutani M, Price DB, Winders TA, Worth H, Gruffydd-Jones K, Tal-Singer R, Correia-de-Sousa J, Dransfield MT, Peché R, Stolz D, et al. Quality standard position statements for health system policy changes in diagnosis and management of COPD: a global perspective. Adv Ther. 2022;39(6):2302–22.

    Article  Google Scholar 

  42. Siddharthan T, Pollard SL, Quaderi SA, Rykiel NA, Wosu AC, Alupo P, Barber JA, Cárdenas MK, Chandyo RK, Flores-Flores O, et al. Discriminative accuracy of chronic obstructive pulmonary disease screening instruments in 3 low- and middle-income country settings. JAMA. 2022;327(2):151–60.

    Article  Google Scholar 

  43. People H, Prevention OoD, Promotion H, Health UDo, Services H, Phase I. Report: Recommendations for the Framework and Format of Healthy People 2020. Section IV. Advisory Committee Findings and Recommendations. In.; 2016.

  44. Pleasants RA, Riley IL, Mannino DM. Defining and targeting health disparities in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2016;11:2475.

    Article  Google Scholar 

  45. McCarthy B, Casey D, Devane D, Murphy K, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease (Review). Cochrane Database Syst Rev. 2015(2):CD003793.

  46. Puhan MA, GimenoSantos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2016(12).

  47. Bolton CE, Bevan-Smith EF, Blakey JD, Crowe P, Elkin SL, Garrod R, Greening NJ, Heslop K, Hull JH, Man WD-C, et al. British Thoracic Society guideline on pulmonary rehabilitation in adults: accredited by NICE. J Thorax. 2013;68(Suppl 2):ii1–30.

    Article  Google Scholar 

  48. Yang IA, Brown JL, George J, Jenkins S, McDonald CF, McDonald VM, Phillips K, Smith BJ, Zwar NA, Dabscheck E. COPD-X Australian and New Zealand guidelines for the diagnosis and management of chronic obstructive pulmonary disease: 2017 update. Med J Aust. 2017;207(10):436–42.

    Article  Google Scholar 

  49. Marciniuk DD, Brooks D, Butcher S, Debigare R, Dechman G, Ford G, Pepin V, Reid D, Sheel AW, Stickland MK, et al. Optimizing pulmonary rehabilitation in chronic obstructive pulmonary disease–practical issues: a Canadian Thoracic Society Clinical Practice Guideline. Can Respir J. 2010;17(4):159–68.

    Article  Google Scholar 

  50. Global Initiative For Chronic Obstructive Lung Disease (GOLD), Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (Updated 2017). 2017.

  51. Vogiatzis I, Rochester CL, Spruit MA, Troosters T, Clini EM, American Thoracic Society/European Respiratory Society Task Force on Policy in Pulmonary R. Increasing implementation and delivery of pulmonary rehabilitation: key messages from the new ATS/ERS policy statement. Eur Respir J. 2016;47(5):1336–41.

    Article  Google Scholar 

  52. Adeloye D, Chua S, Lee C, Basquill C, Papana A, Theodoratou E, Nair H, Gasevic D, Sridhar D, Campbell H, et al. Global and regional estimates of COPD prevalence: systematic review and meta-analysis. J Glob Health. 2015;5(2): 020415.

    Article  Google Scholar 

  53. Desveaux L, Janaudis-Ferreira T, Goldstein R, Brooks D. An international comparison of pulmonary rehabilitation: a systematic review. COPD J Chron Obstruct Pulmon Dis. 2015;12:144–53.

    Article  Google Scholar 

  54. Holland AE, Dal Corso S, Spruit MA. Pulmonary Rehabilitation: ERS Monograph 93, vol. 93: European Respiratory Society; 2021.

  55. Meharg D, Gwynne K, Gilroy J, Alison J. Pulmonary rehabilitation for Indigenous adults with chronic obstructive pulmonary disease in Australia, Canada, New Zealand and the United States of America (USA): a systematic review. J 2020.

  56. Brown CE, Jecker NS, Curtis JR. Inadequate palliative care in chronic lung disease. An issue of health care inequality. Ann Am Thorac Soc. 2016;13(3):311–6.

    Article  Google Scholar 

  57. Halpin DMG. Palliative care for people with COPD: effective but underused. Eur Respir J. 2018;51(2):1702645.

    Article  Google Scholar 

  58. National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax. 2004;59(Suppl 1):1–232.

    Google Scholar 

  59. Bloom CI, Slaich B, Morales DR, Smeeth L, Stone P, Quint JK. Low uptake of palliative care for COPD patients within primary care in the UK. Eur Respir J. 2018;51(2):1701879.

    Article  Google Scholar 

  60. Sooronbaev TM. Palliative care in respiratory disease in low-resource settings. In: Bausewein C, Currow DC, Johnson MJ, editors. Palliative care in respiratory disease. European Respiratory Society; 2016. p. 197–203.

    Chapter  Google Scholar 

  61. Branthwaite MA. Ethical problems in respiratory care: the role of the law. Thorax. 2001;56(1):78.

    Article  CAS  Google Scholar 

  62. Varkey B. Principles of clinical ethics and their application to practice. Med Princ Pract. 2021;30(1):17–28.

    Article  Google Scholar 

  63. Selgelid MJ, McLean AR, Arinaminpathy N, Savulescu J. Infectious disease ethics: limiting liberty in contexts of contagion. J Bioethical Inquiry. 2009;6(2):149–52.

    Article  Google Scholar 

  64. Slowther A, Johnston C, Goodall J, Hope T. Development of clinical ethics committees. BMJ. 2004;328(7445):950–2.

    Article  Google Scholar 

  65. Lodwick GS. Computer-aided diagnosis in radiology: a research plan. Investig Radiol. 1966;1(1):72.

    Article  CAS  Google Scholar 

  66. Pan I, Cadrin-Chênevert A, Cheng PM. Tackling the radiological society of north America pneumonia detection challenge. AJR Am J Roentgenol. 2019;213(3):568–74.

    Article  Google Scholar 

  67. Blackstock FC, Roberts NJ. Using telemedicine to provide education for the symptomatic patient with chronic respiratory disease. Life. 2021;11(12):1317.

    Article  Google Scholar 

  68. Abdel-Aal A, Lisspers K, Williams S, Adab P, Adams R, Agarwal D, Barnard A, Bouloukaki I, van Boven JFM, Chavannes N, et al. Prioritising primary care respiratory research needs: results from the 2020 International Primary Care Respiratory Group (IPCRG) global e-Delphi exercise. NPJ Prim Care Respir Med. 2022;32(1):6.

    Article  Google Scholar 

  69. Adeloye D, Agarwal D, Barnes PJ, Bonay M, van Boven JF, Bryant J, Caramori G, Dockrell D, D’Urzo A, Ekström M, et al. Research priorities to address the global burden of chronic obstructive pulmonary disease (COPD) in the next decade. J Glob Health. 2021;11:15003–15003.

    Article  Google Scholar 

Download references





Author information

Authors and Affiliations



All authors contributed to developing the idea of the manuscript. RK and GSG wrote the first draft with contribution from other authors. All authors reviewed the manuscript and approved the final version.

Corresponding author

Correspondence to Ratika Kumar.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

JRH has received personal payment and payment to their employer for educational and advisory work from pharmaceutical companies that make medicines to treat respiratory disease. GF has received in-kind support involving provision of investigational product for a clinical trial from Astra Zeneca pharmaceuticals. No other author has declared a competing interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Gould, G.S., Hurst, J.R., Trofor, A. et al. Recognising the importance of chronic lung disease: a consensus statement from the Global Alliance for Chronic Diseases (Lung Diseases group). Respir Res 24, 15 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: