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Original Article
Decomposition analysis of lung cancer and COPD mortality attributable to
ambient PM
2.5
in China (1990–2021)
Xiaoxue Liu
a
, Haoyun Zhou
a
, Xun Yi
a
, Xinyu Zhang
a
, Yanan Lu
a
, Wei Zhou
b
,
*
, Yunzhao Ren
c
,
*
,
Chuanhua Yu
d
,
e
a
Global Health Research Division, Public Health Research Center and Department of Public Health and Preventive Medicine, Wuxi School of Medicine, Jiangnan University,
Wuxi, Jiangsu, China
b
The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
c
School of Public Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
d
Department of Epidemiology and Biostatistics, School of Public Health, Wuhan University, Wuhan, Hubei, China
e
Global Health Institute, Wuhan University, Wuhan, Hubei, China
ARTICLE INFO
Keywords:
PM
2.5
Lung cancer
COPD
Mortality
Decomposition analysis
China
ABSTRACT
Objective: This study aimed to evaluate the long-term trends in lung cancer (LC) and chronic obstructive pul-
monary disease (COPD) mortality attributable to particulate matter (PM
2.5
) in China and to identify the contri-
butions of population aging and other risk factors to changes in mortality rates.
Methods: Using data from 1991 to 2021, we assessed trends in LC and COPD deaths attributable to PM
2.5
through
linear regression. Decomposition analysis was conducted to determine the extent to which changes in mortality
rates were driven by demographic and non-demographic factors.
Results: The crude mortality rates attributable to PM
2.5
increased significantly for LC (500.40%) and COPD
(85.26%). From 1990 to 2021, LC mortality attributable to PM
2.5
increased annually by 4.11% (95% CI: 3.64%,
4.59%), while COPD mortality decreased annually by 1.23% (95% CI: 0.82%, 1.65%). Decomposition analysis
revealed that 43.0% of the increase in LC mortality was due to population aging, and 57.0% was attributed to
changes in other risk factors. For COPD, population aging contributed to an 18.547/100,000 increase, whereas
other risk factors reduced mortality by 10.628/100,000.
Conclusions: The findings highlight the critical roles of population aging and risk factor modification in LC and
COPD mortality trends. Interventions to address aging-related vulnerabilities and air pollution control are
essential to mitigate future health burdens.
Introduction
Air pollution is a significant public health issue in China, where the
population is exposed to high levels of both ambient and household air
pollution.
1,2
Despite recent improvements, PM
2.5
concentrations in many
areas continue to exceed the World Health Organization (WHO) Air
Quality Guidelines, with 81% of the population living in regions sur-
passing the WHO Interim Target 1.
2
Among all cancers, lung cancer (LC)
poses the greatest threat to the health and lives of Chinese people, while
chronic obstructive pulmonary disease (COPD) is associated with a
notably high disability rate. Both conditions are among the top five
chronic diseases in China. Long-term exposure to ambient fine particulate
matter has been strongly linked to increased risks of LC and COPD.
1,3–5
According to the latest Global Burden of Disease (GBD) estimates from
2021, the crude mortality rates for LC and COPD attributable to PM
2.5
in
2021 were 12.55/100,000 and 27.28/100,000, respectively.
6
This
burden is further reflected in the disability-adjusted life years
(DALYs) for LC and COPD attributable to PM
2.5
, estimated at 4,125,752
and 7,144,155 person-years, respectively.
6
Notably, COPD-related
deaths began to decline in 2014 following a turning point in air quality
* Corresponding author.
E-mail addresses: yunzhren@163.com (Y. Ren), sandyzhou1992@163.com (W. Zhou).
Contents lists available at ScienceDirect
Asia-Pacific Journal of Oncology Nursing
journal homepage: www.apjon.org
https://doi.org/10.1016/j.apjon.2025.100653
Received 16 August 2024; Accepted 1 January 2025
2347-5625/©2025 The Authors. Published by Elsevier Inc. on behalf of Asian Oncology Nursing Society. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Asia-Pacific Journal of Oncology Nursing 12 (2025) 100653
improvements in China.
7
However, evidence on the association between
PM
2.5
and LC mortality in the Chinese population remains limited and
warrants further investigation.
8,9
In recent years, ambient PM
2.5
pollution in China has significantly
decreased, yet it remains a critical risk factor for public health. Under-
standing the long-term trends and changes in LC and COPD mortality
attributable to PM
2.5
is essential. This study investigates the factors driving
LC and COPD mortality rates linked to PM
2.5
exposure. As chronic diseases
such as LC and COPD are among the leading causes of death in older pop-
ulations, the burden of LC is likely to intensify with China's rapidly aging
population. This research aims to analyze the long-term trends in LC and
COPD mortality attributable to PM
2.5
and provide insights necessary for
mitigating the long-term health impacts of air pollution.
Methods
Data sources
Mortality data for LC and COPD from the Global Burden of Disease
(GBD) dataset spanning 1990 to 2021 were analyzed. The original data
were sourced from the Chinese Center for Disease Control and Prevention
Cause of Death Reporting System, the Disease Surveillance Points, and
the Maternal and Child Surveillance System, ensuring national repre-
sentativeness. Detailed information on data sources, processing methods,
and completeness assessments can be found in Appendix 1, Section 3.5 of
the GBD study.
10
The population attributable fraction was defined as the proportion of
diseases or deaths that could be prevented by reducing exposure to a
specific risk factor to its theoretical minimum level within a given
population. Attributable deaths for LC and COPD were calculated by
multiplying the population attributable fraction by the corresponding
outcome quantity for each demographic group, including age, sex,
location, and year. LC and COPD were classified based on the clinical
criteria established by the WHO. Ambient particulate matter
pollution was assessed using a theoretical minimum risk exposure range
of 2.4–5.9
μ
g/m
3
.
Data analysis
The average annual percentage changes (AAPC) in age-standardized
mortality rates (ASMR) were calculated to evaluate trends over the study
period.Linear regression wasemployed to determinethe annual percentage
changes in ASMR for LC and COPD attributable to PM
2.5
exposure during
the study years. Decomposition analysis was conducted to identify the key
drivers of changes in disease-related mortality, focusing on the impacts of
population aging and age-specific mortality rates in China.
11,12
Linear regression was utilized to examine the relationship between a
continuous dependent variable and an independent variable. In this
analysis, the natural logarithm of the mortality rate for LC or COPD
attributable to PM
2.5
served as the dependent variable, while the calen-
dar year (1990, 1991, 1992, …, 2021) was used as the independent
variable. AAPC >0 indicated an increase in mortality rates, whereas an
AAPC <0 signified a decrease. Statistical significance was determined at
P<0.05. The AAPC was computed using the general formula: y¼
α
þ
βxþ
ε
,y¼ln(rate), x¼calendar year, AAPC ¼100 ðeβ1).
The mortality differential decomposition method, widely used in
demographic studies, was applied to quantify how much of the difference
in mortality between two populations (A and B) could be attributed to
differences in age structure. This method is particularly effective for
analyzing mortality data across regions or generations. For two genera-
tions within the same region, it can identify the extent to which changes
in mortality are driven by population aging versus other risk factors.
This decomposition approach integrates interactions among various
component effects, including population growth, aging, and transitions
in mortality patterns, into additive main effects. In this study, decom-
position analysis was used to determine how much of the observed
change in mortality between generations was attributable to population
aging compared to other risk factors.
To calculate the difference between the crude mortality rates of
populations A and B, we defined CDR
B
as the crude mortality rate of
population B, CDR
A
as the crude mortality rate of population A, and diff
as the mortality difference between the two populations. Crepresents the
age composition of the populations, and Mdenotes the age-specific
mortality rate. The formula is as follows:
diff ¼CDRBCDRA¼XCB
XMB
XXCA
XMA
X
We further summarized the differences in mortality rates between the
two populations and their age composition as follows:
diff ¼XCB
XCA
XMB
XþMA
X
2þXMB
XMA
XCB
XþCA
X
2
¼Difference in age structure (weighted by mean of age-specific mortality rates
of population A and population B) þdifference in mortality rates (weighted by
age structure of population A and population B)
¼Effects of age structure difference þcontribution percentage of mortality
difference effects
Fig. 1. The change in crude and age-standardized mortality rates (ASMR) of LC and COPD attributable to PM(2.5) across China. LC, lung cancer; COPD, chronic
obstructive pulmonary disease.
X. Liu et al. Asia-Pacific Journal of Oncology Nursing 12 (2025) 100653
2
All analyses were conducted using Stata 15.1 software (StataCorp,
College Station, TX, USA).
Results
LC and COPD deaths attributable to PM
2.5
across China
The long-term trends in LC and COPD deaths across China were
analyzed by examining the percentage change in ASMR attributed to
PM
2.5
from 1990 to 2021 (Fig. 1). The ASMR for LC rose to a peak in 2015
before slightly declining, resulting in a total percentage change of
176.37%. In contrast, the ASMR for COPD decreased by 32.13%.
Meanwhile, the crude death rate increased substantially for both LC and
COPD (500.40% and 85.26%, respectively). Linear regression analysis
revealed that LC deaths attributable to PM
2.5
increased by 4.11% annu-
ally (95% confidence interval [CI]: 3.64%, 4.59%), while COPD deaths
attributable to PM
2.5
declined by 1.23% annually (95% CI: 0.82%,
1.65%).
LC and COPD deaths attributable to PM
2.5
by sex
The trends in crude rates and ASMR for LC attributable to PM
2.5
increased in both males and females, with a slight decline observed in
males after 2016 (Fig. 2). For COPD, both the crude rate and ASMR
Fig. 2. The long-term change in crude mortality rates and age-standardized mortality rates (ASMR) of LC and COPD attributable to PM(2.5) by sex. LC, lung cancer;
COPD, chronic obstructive pulmonary disease.
Table 1
The ASMR and average annual percentage change in LC and COPD mortality attributable to PM(2.5) from 1990 to 2021.
1990 2021 Average annual
percentage change (%)
95% confidence
interval (CI)
Crude rate ASMR (per 100,000) Crude rate ASMR (per 100,000)
Lung cancer
Male 3.01 4.95 16.6 12.50 3.91* 3.39, 4.44
Female 1.11 1.56 8.31 5.25 4.56* 4.19, 4.92
Both 2.09 3.09 12.55 8.54 4.11* 3.64, 4.59
COPD
Male 17.08 47.01 31.48 32.23 1.09* 0.63, 1.55
Female 12.22 23.72 22.89 15.73 1.44* 1.05, 1.83
Both 14.73 32.60 27.28 22.12 1.23* 0.82, 1.65
LC, lung cancer; COPD, chronic obstructive pulmonary disease; ASMR, age-standardized mortality rates. *P<0.001.
X. Liu et al. Asia-Pacific Journal of Oncology Nursing 12 (2025) 100653
3
attributable to PM
2.5
increased until 2004, followed by a decline in both
sexes. Mortality levels for both LC and COPD attributable to PM
2.5
were
significantly higher in males than females. The AAPC in ASMR for LC
attributable to PM
2.5
was significantly greater in females (AAPC ¼
4.56%, 95% CI: 4.19%, 4.92%) compared to males (AAPC ¼3.91%, 95%
CI: 3.39%, 4.44%) (Table 1). The AAPC for COPD showed a slightly
higher decline in females (AAPC ¼1.44%, 95% CI: 1.05%, 1.83%)
than in males (AAPC ¼1.09%, 95% CI: 0.63%, 1.55%).
Decomposition analysis of LC and COPD mortality attributable to PM
2.5
The increase in LC mortality attributable to PM
2.5
resulted from the
combined effects of demographic and non-demographic factors (Tables 2
and 3). The difference in crude LC mortality attributable to PM
2.5
be-
tween the 1991 population and the 2021 population was 10.21/100,000,
of which 4.39/100,000 was due to differences in the age structure of the
two populations, and 5.81/100,000 was attributed to differences in true
mortality. Thus, demographic factors played a more significant role than
non-demographic factors. Population aging accounted for 43.0% of the
increase in LC mortality attributable to PM
2.5
over the past decades,
while 57.0% of the increase was explained by other risk factors.
Regarding the difference in COPD mortality attributable to PM
2.5
in
China between the 1991 and 2021 populations, 18.547/100,000 was due
to the age structure of the two populations, while 10.628/100,000 was
attributed to the influence of other risk factors (Table 3). The increase in
crude COPD mortality was driven entirely by demographic factors,
whereas the decrease was attributed to other risk factors. Since de-
mographic factors played a larger role than non-demographic factors,
they ultimately contributed to the overall increase in mortality rate.
Discussion
Main findings
Long-term exposure to ambient air pollution has been closely associ-
ated with the risk of LC and COPD mortality.
1,13–15
This study indicated
that the crude mortality and ASMR for LC attributable to PM
2.5
increased
over the past decades. The crude COPD mortalityattributable toPM
2.5
also
clearly increased, whereas the ASMR declined during the sameperiod. This
result was consistent with a previous report suggesting that the standard-
ized COPD mortality would decrease significantly by 2030.
16
However, the
associations between exposure tomajor air pollutants and the risk of COPD
exacerbation require further evaluation.
17
The mortality levels for both LC
and COPD attributable to PM
2.5
were much higher for males than females.
The LC mortality attributable to PM
2.5
has also been reported to be higher
among males than females in China.
15
In a cohort study on the association
between long-term exposure to outdoor air pollution and mortality,
deceased individuals tended to be older and to be male.
18
This study was aimed at conducting a decomposition analysis to
determine the extent to which changes in mortality between the 1991
and 2021 populations were due to population aging and to changes in
other risk factors. The analysis indicated that, under the interaction of
demographic and non-demographic factors, the LC mortality rates
attributable to PM
2.5
in the Chinese population substantially increased
from the 1990s to the 2020s. The increased LC mortality attributable to
PM
2.5
was decomposed into population aging (43.0%) and other risk
factors (57.0%). As previously reported, adult population growth was the
main driver of the transition in the age-related LC burden.
10
Aging
further increased the burden of LC deaths, given that biological aging is
an important risk factor in cancer morbidity and mortality.
11
The burden
of LC mortality remains heavy; therefore, control of major risk factors
such as PM
2.5
and smoking, and improvements in the Chinese aging
problem are necessary. PM
2.5
is associated with COPD prevalence,
morbidity, and acute exacerbation.
13
Since the 1990s, the crude COPD
mortality attributable to PM
2.5
clearly increased, whereas the ASMR
declined. Hu et al. have also predicted that the age-standardized
Table 2
Decomposition of changes in LC mortality attributable to PM(2.5) in China between the 1991 and 2021 populations.
Age
group
Age structure of the
population in 1991
CA
X
(1)
Age-specific
mortality rate in
1991 MA
X
(2)
Age structure of the
population in 2021
CB
X
(3)
Age-specific
mortality rate in
2021 MB
X
(4)
Difference in
population weight by
age CB
XCA
X
(5)
Weight
(MB
XþMA
X/2
(6)
Difference in age
structure of the
population
(7) ¼(6) (5)
Difference in age-specific
mortality rate between two
populations MB
XMA
X
(8)
Weight
(CB
XþCA
X)/2
(9)
Difference in
mortality rate
(10) ¼(8)
(9)
25~ 0.096 0.197 0.0614 0.102 0.0346 0.150 0.005 0.094 0.0787 0.007
30~ 0.08 0.408 0.0857 0.204 0.0057 0.306 0.002 0.204 0.08285 0.017
35~ 0.075 0.812 0.0731 0.359 0.0019 0.585 0.001 0.452 0.07405 0.033
40~ 0.059 1.862 0.0656 0.785 0.0066 1.323 0.009 1.077 0.0623 0.067
45~ 0.047 3.441 0.0767 1.407 0.0297 2.424 0.072 2.034 0.06185 0.126
50~ 0.043 9.076 0.0866 3.419 0.0436 6.247 0.272 5.657 0.0648 0.367
55~ 0.04 17.976 0.0816 7.093 0.0416 12.535 0.521 10.883 0.0608 0.662
60~ 0.032 38.775 0.0474 16.367 0.0154 27.571 0.425 22.407 0.0397 0.890
65~ 0.025 75.818 0.0544 36.258 0.0294 56.038 1.648 39.561 0.0397 1.571
70~ 0.017 176.373 0.0376 96.138 0.0206 136.256 2.807 80.236 0.0273 2.190
75~ 0.011 312.890 0.0233 200.883 0.0123 256.887 3.160 112.007 0.01715 1.921
80~ 0.006 570.816 0.0151 425.577 0.0091 498.197 4.534 145.239 0.01055 1.532
85~ 0.003 1092.781 0.0082 870.469 0.0052 981.625 5.104 222.311 0.0056 1.245
PCA
XMA
X¼17:773 PCB
XMB
X¼25:692 18.547 –10.628
LC, lung cancer.
X. Liu et al. Asia-Pacific Journal of Oncology Nursing 12 (2025) 100653
4
mortality rate for COPD would decrease by 38.88% by 2030, and if the
control target PM
2.5
concentration were achieved, 0.27 million COPD
deaths could be avoided.
16
As reported herein, the ASMR for COPD
attributable to PM
2.5
declined over the study period. Further decompo-
sition analysis of the mortality difference indicated that the increase in
COPD mortality attributable to PM
2.5
was caused entirely by population
aging, whereas the other risk factors contributed to a decrease in mor-
tality. The underlying reason for the decline might be associated with
smoking control.
19
However, COPD mortality is expected to increase by
2030 if exposures to tobacco use and air pollution continue.
16
Thus, air
pollution control efforts should continue to be enhanced to maintain a
stable decrease in COPD. By comparison, a simulated decrease in the
annual mean values of PM
2.5
to 10
μ
g/m
3
in Korea has suggested that
approximately 8539 premature deaths due to IHD, COPD, LC, and stroke
would be prevele.
20
In that study, decreasing trends in the mortality
burden attributable to PM
2.5
were noted since 2006. Improvements in
health effects attributable to ambient PM
2.5
concentrations have also
been observed across the United States.
21
These findings might provide
insights into potential strategies that could be adopted in China.
Implications for nursing practice and research
Higher concentrations of PM
2.5
are associated with poorer LC survival
rates
15,22
and have been correlated with COPD exacerbation.
23
In gen-
eral, the prognosis of cancer and the nurse care are related. Nurses were
increasingly working in global health arenas but were typically
ill-prepared to address this complex environmental health problem.
Nurses can play a key role in education, practice, and research to develop
and support interventions, which may reduce this substantial burden of
disease.
24
In nursing practice, epidemiology risk factors could be utilized
to target the fraction of population, which may benefit most from the
introduced screening modality.
25
As reported, linking risk information with knowledge of strategies for
reducing these risks provided a basis for planning and implementing
interventions to prevent lung cancer.
26
This study can provide epidemi-
ology information to effectively reduce death burden of LC and COPD,
and also provide evidence-based recommendations for policy makers, the
general public, and clinicians and nurses. More advanced medical
equipment, a wider variety of effective drugs, and humanized nursing
measures are crucial for increasing the survival rates of LC and COPD. As
reported, a core challenge to health systems is the chronic illnesses
requiring ongoing and long-term health care.
27
Further studies will be
necessary to enable evaluation of interventions and policies.
28–30
Limitations
This study has several limitations. This study lacks epidemiological
survey data on air pollutants which were not provided and discussed in
the Chinese population. The exploration of predictive statistical methods
for LC and COPD trends could be estimated in the next study. There might
be uncertainty of the exposure estimates as there was no measurement in
some areas, or the data was not available in GBD 2021 study.
Conclusions
The lung cancer deaths attributable to ambient PM
2.5
exposure in
China is increasing. The COPD deaths attributable to ambient PM
2.5
seems to have been improved somewhat. Air pollution remains an
important leading risk factor in China. Thus, the continued measures of
air pollution control should be enhanced to prevent and control LC and
COPD deaths. Besides, the situation of aging problem should be improved
in Chinese population to reduce the impact of population aging on
population health and economic development.
CRediT authorship contribution statement
Xiaoxue Liu: Conceptualization, Methodology, Data curation, Formal
analysis, Writing. Haoyun Zhou: Methodology, Writing –Original draft
preparation. Xun Yi: Methodology, Writing –Original draft preparation.
Xinyu Zhang: Writing –Original draft preparation. Yanan Lu: Writing –
Original draft preparation. Wei Zhou: Writing –Revised draft prepara-
tion. Yunzhao Ren: Writing –Revised draft preparation. Chuanhua Yu:
Writing –Revised draft preparation. All authors had full access to all the
data in the study, and the corresponding author had final responsibility
for the decision to submit for publication. The corresponding author at-
tests that all listed authors meet authorship criteria and that no others
meeting the criteria have been omitted.
Ethics statement
Not required.
Funding
This work was funded by National Natural Science Foundation of
China (Grant Nos. 82404375 and 82173626), Basic Research Program of
Jiangsu (Grant No. BK20241622), and Fundamental Research Funds for
the Central Universities (Grant No. JUSRP124038). The funders had no
role in considering the study design or in the collection, analysis, inter-
pretation of data, writing of the report, or decision to submit the article
for publication.
Declaration of competing interest
The authors declare no conflict of interest.
Data availability statement
The datasets analyzed in the current study are available in the GBD
repository, http://ghdx.healthdata.org/gbd-results-tool.
Declaration of generative AI and AI-assisted technologies in the
writing process
No AI tools/services were used during the preparation of this work.
Acknowledgments
We appreciate the works by the Global Burden of Disease 2021 study
collaborators.
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Table 3
Decomposition of changes in LC and COPD mortality attributable to PM(2.5) in China.
1991 2021 Difference in mortality rate Impact of demographic composition Impact of other risk factors
Crude mortality Crude mortality The increase value The increase value
LC 2.350 12.560 10.210 4.395 (43.05%) 5.815 (56.95%)
COPD 17.773 25.692 7.919 18.547 (234.21%) 10.628 (134.21%)
LC, lung cancer; COPD, chronic obstructive pulmonary disease.
X. Liu et al. Asia-Pacific Journal of Oncology Nursing 12 (2025) 100653
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