Barry Hoehn hails from Alabama. At 79, he’s been a smoker most of his life but quit a decade ago, the day he was diagnosed with chronic obstructive pulmonary disease (COPD). He was struggling to breathe to such an extent it was impacting his ability to work his director of conventions sales job at the local visitors’ bureau, unable to show potential clients around venues.
“I couldn’t even give anybody a site visit. I’d run out of breath,” he said in an interview with NPQ.
COPD is a respiratory disease that causes difficulty breathing as a result of damaged or blocked lungs. There is no cure, but symptoms can be managed with medicine, oxygen, pulmonary rehabilitation, and protection from further inhalation of damaging substances. The most common causes of COPD include tobacco, indoor and outdoor air pollution, and occupational exposure to dusts, fumes, or chemicals.
Although he’s on medication and has adjusted his lifestyle, breathing is still a struggle for Hoehn, so much so that he was hospitalized last year. Yet Hoehn is one of the lucky ones who has a diagnosis and access to care.
“There are still many people with COPD that are not diagnosed,” according to Wilson Pace, chief medical and technology officer at healthcare data nonprofit DARTNet Institute.
COPD is the fourth-biggest killer globally. As toxic air levels rise and COVID continues to cause lung damage and further complications, COPD is slowly claiming even more lives—yet health systems often neglect its symptoms, leaving many people undiagnosed as a result.
“Wherever you have poorer people, and especially those who can’t move and go to a safer area, you’re going to have people who are at risk of developing COPD.”
COPD and asthma are considered “Cinderella”—meaning often overlooked—diseases, according to José Luis Castro, World Health Organization (WHO) director-general special envoy of chronic respiratory diseases.
“[They are] common, costly, devastating, and too often left behind,” he said in an interview with NPQ.
If COPD goes untreated, lung function can further decline, potentially developing into respiratory failure, lung infection, heart problems, or lung cancer. Almost 16 million US adults have a COPD diagnosis. Many more are thought to be undiagnosed.
In 2023, over 140,000 people died of COPD in the United States. But that number only includes diagnosed cases and cases where COPD was identified as a cause of death during the death certification process.
Barriers to Diagnosis
One of the barriers to COPD diagnosis is a lack of awareness of the disease, said Susan Bance, who lives in Wisconsin and was diagnosed with COPD in 2007. She has come across many people who don’t know what it is, she told NPQ in an interview.
Both Bance and Hoehn are volunteer state captains for the nonprofit COPD Foundation.
Castro agrees with Bance’s assessment. Smokers in particular experience stigma that stops them from visiting their doctor, he said. “That stigma and the fact that it’s not infectious lead to this disease being in the shadows, and that invisibility is costing millions of lives.”
But around 50 percent of those diagnosed with the disease are not smokers.
Air pollution is getting worse, which is putting more people in danger. Extreme temperature changes and weather conditions can increase the risk of wildfires, which can worsen air pollution, explained Nicole Goldsboro, director of nationwide health promotions at the American Lung Association.
Amid government funding cuts under the Trump administration, financing for lung health workers is declining.
“The smoke from wildfires travels hundreds of miles away, affecting everyone, including those outside of the wildfire-prone regions,” she said.
As of December 5, the United States had experienced over 62,500 wildfires in 2025, spanning over five million acres of land. Toxic fumes from those fires travelled much further.
Appalachia, in particular, is at risk of COPD cases, noted Castro, because the area is exposed to wildfires but also faces “intertwined risks of tobacco, occupational exposure, poverty, and limited healthcare.” Here, the poverty rate is higher than elsewhere in the United States and as a major coal and extraction industry region, residents are disproportionately exposed to toxic fumes. Hospitalization rates for COPD are 39 percent higher in the Appalachian region than elsewhere in the country.
“Towns in West Virginia and Eastern Kentucky have the highest COPD prevalence in the country, driven by smoking rates, occupational exposure—mining especially—and healthcare barriers,” said Castro, adding that communities living on lower incomes are disproportionately impacted. “Wherever you have poorer people, and especially those who can’t move and go to a safer area, you’re going to have people who are at risk of developing COPD in their lifetime.”
Despite other driving factors for COPD, many diagnostic approaches don’t consider the disease as a possibility for patients if they are nonsmokers, Pace notes. This is compounded by a lack of access to spirometers, the tools that measure air intake, considered the gold-standard test for diagnosing COPD by the WHO.
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“This equipment is not widely available in primary care offices,” said David Mannino, chief medical officer and cofounder of the COPD Foundation. A 2021 survey of family physicians and pediatricians in the United States found that only 21 percent routinely use spirometry.
Instead, suspected COPD cases are typically referred for full pulmonary function testing. This is another step in the diagnostic process, but some people never complete that test because of the inconvenience and cost.
Hoehn’s primary care physician had been treating him for years and although she suspected he had COPD, he had to be sent to a pulmonologist at the University of Alabama for the confirmation he described as “a hard blow to the gut.”
Bance, in Wisconsin, explained that those living in rural areas, such as the northern part of her state, may not even have access to pulmonary clinics or respiratory therapists.
How to Better Address COPD
In order to find those who are undiagnosed and reduce the number of people affected by COPD, Castro said the focus should be on raising awareness of the disease. Global research released in 2025 found that 45 percent of people aren’t even familiar with COPD.
“We also have to make sure that the primary healthcare systems are equipped with the right tools to diagnose the disease correctly.”
Over the years, nonprofits such as the American Lung Association and the COPD Foundation have launched campaigns to educate the public about what COPD looks like. But more public health efforts are needed to increase awareness and ensure earlier diagnoses, Castro emphasized.
This follows the adoption of a World Health Assembly lung health resolution in May, which commits countries to taking more action.
In the United States, Mannino pointed out that more National Institutes of Health (NIH) funding is needed for COPD, along with “support at the federal level to find disease earlier in the course before non-reversible damage has occurred.”
However, amid government funding cuts under the Trump administration, financing for lung health workers is declining. Researchers at the Harvard T.H. Chan School of Public Health, for example, had been exploring the impact of air purifiers in COPD patients’ homes, but NIH grant funding for the study was stopped in May, rendering the project incomplete.
“They’re cutting back instead of going forward,” said Bance.
Goldsboro is concerned that cuts will impact smoking rates in the country and thus potentially increase the incidence of COPD. Work by the Office on Smoking and Health (OSH) at the Centers for Disease Control and Prevention had seen smoking rates fall from 42.6 percent in 1965 to just 11.6 percent in 2022.
“Despite this progress, the programs that led to a decrease in tobacco use nationwide are under threat since the OSH…has been eliminated,” said Goldsboro.
But preventing COPD isn’t just about raising awareness.
“We also have to make sure that the primary healthcare systems are equipped with the right tools to diagnose the disease correctly,” said Castro. “The availability of spirometry to do the lung function test is essential to getting the right diagnosis.” He added that at that point it’s about finding the appropriate treatment from the many options available.
“Since it’s a disease that is for life, it will require an appropriate management of the disease to support the patient and the caregivers,” he said.
Support groups, like those Hoehn and Bance run through the COPD Foundation, offer fellow COPD patients and their families a forum to discuss treatment options, ask questions, and educate themselves.
“We have to be more aware of what COPD is, how it affects your breathing, your body, how it affects family members,” said Bance. “It is really important that people realize what it is and how it affects more people than we think.”
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