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People living with asthma and chronic obstructive pulmonary disease (COPD) in England face markedly different risks depending on their sex, income, ethnicity and where they live, with inequalities showing little improvement since 2019, according to a large population study covering more than five years of health records.

Led by researchers from 51³Ô¹ÏÍø, the study examined national primary-care and linked hospital and mortality data from November 2019 to March 2025. Researchers analysed data from more than 7.64 million people with asthma and 1.21 million people with COPD, rendering this study one of the largest national assessments of inequalities in respiratory disease outcomes.

The research team found consistently higher rates of respiratory flare-ups among women, people living in the most deprived areas and those in northern regions of England. The findings suggest that despite years of policy efforts aimed at reducing health inequalities, the gap in outcomes has remained largely unchanged.

Among people with asthma, the average monthly rate of exacerbations was 33% higher in women than in men. For people with COPD, the rate was 30% higher in women. However, men were more likely to die; all-cause mortality was 13% higher among men with asthma and 15% higher among men with COPD. Moreover, cardiovascular mortality was also consistently higher among men.

The researchers suggest several possible explanations for the higher exacerbation rates among women, including greater symptom burden, differences in disease control, mental health, responses to medication and hormonal influences. Further research is needed into sex-specific differences in chronic respiratory disease.

The most marked differences were linked to socioeconomic deprivation. For people with asthma, the average monthly mortality rate in the most deprived 10% of areas was twice that of the least deprived 10%. Asthma exacerbation rates were also more than twice as high, at 2.23 times the rate observed in the least deprived group. Regarding COPD, mortality was 41% higher in the most deprived group, while exacerbation rates were 68% higher.

According to the researchers, several factors might contribute to this gap, including lower household income, cold or damp housing and occupational exposure to dust and fumes. Additionally, the cost-of-living crisis may contribute to these pressures. Difficulty affording household heating can be particularly important for people with respiratory disease, as cold conditions can trigger exacerbations.

The researchers also noted a pronounced geographical pattern; people with asthma living in the North East of England had a 69% higher average monthly exacerbation rate than those in the South West, while mortality was 22% higher. A similar, although less significant, pattern was seen among people with COPD: mortality was 15% higher and exacerbation rates 42% higher in the North East compared with the South West.

The researchers say higher levels of socioeconomic deprivation in northern areas, along with greater exposure to cold and damp housing and higher smoking rates, could help explain some of the regional differences.

Outcomes also varied between ethnic groups, although the pattern differed between asthma and COPD. Among people with asthma, mortality rose sharply across ethnic groups during the first COVID-19 wave, with particularly large increases among Black, Asian and other ethnic groups. During the second wave of the pandemic, the largest increase was seen among people of Asian ethnicity. Outside the pandemic peaks, however, people recorded as White had the highest all-cause mortality rate among those with asthma.

The pattern for COPD was different however. There was no similarly dramatic mortality increase during the first pandemic wave, while a larger peak occurred in January 2021, particularly among people of Mixed and Asian ethnicity. White people had the highest COPD-related mortality and exacerbation rates over the study period.

The researchers caution that these differences may reflect a combination of factors, including healthcare access and underlying differences in disease severity. They add that residual confounding cannot be ruled out.

The pandemic produced major changes in respiratory outcomes, especially during the first two waves. Among people with asthma, all-cause mortality increased during the first wave in 2020 and again during the second wave between late 2020 and early 2021. The increases were greater among people from more deprived areas, non-white ethnic groups and northern England.

The researchers also observed fewer recorded exacerbations during the height of the pandemic. This could reflect shielding and reduced exposure to respiratory viruses, but it could also have resulted from people avoiding healthcare, meaning some exacerbations may not have been recorded.

A further rise in both mortality and exacerbations occurred between late 2022 and early 2023, which the researchers suggest was likely related to seasonal winter viruses. The researchers stress that despite these fluctuations, the underlying inequalities remained.

The researchers say the study provides evidence that inequalities in chronic respiratory disease have not improved since 2019. They argue that more investment in respiratory research and a stronger national focus on respiratory health are needed to understand why these differences persist and to develop interventions that can improve outcomes.

Lead author Dr Hannah Whittaker, Research Fellow in electronic healthcare records in the School of Public Health, said: “Our research shows that where you live, how much you earn and your sex can significantly impact your respiratory outcomes when living with asthma and COPD. Despite years of policy efforts these gaps have not narrowed, demonstrating a need for greater investment in research and targeted action to protect those most at risk”

The research team is based at leading UK institutions, including 51³Ô¹ÏÍø, the British Heart Foundation Data Science Centre, the University of Liverpool, Queen's University Belfast, Swansea University, and the University of Oxford.

The study was funded and supported by HDR UK’s Inflammation & Immunity Driver Project and the NIHR 51³Ô¹ÏÍø Biomedical Research Centre, a translational research partnership between 51³Ô¹ÏÍø and 51³Ô¹ÏÍø College Healthcare NHS Trust.

Full Citation: Whittaker H, Bolton T, Sinha I, et al Thorax Published Online First: 20 August 2026. doi: 10.1136/thorax-2026-224765