Inclusion criteria:  parent cohort  -- COPD diagnosis  child cohort  -- any initiation of first maintenance therapy after July 1, 2015  grandchild cohort -- any initiation of second maintenance therapy after August 2, 2015  Exclusion criteria:  - parent cohort  age <40 on index date any COPD diagnosis in baseline any use of long-acting muscarinic antagonists (LAMA), long-acting beta-agonists (LABA), or inhaled corticosteroid (ICS) in baseline <365 days of continuous medical and pharmacy coverage