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  3. Long term exposure to low level air pollution and mortality in eight European cohorts within the ELAPSE project: pooled analysis
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Research

Long term exposure to low level air pollution and mortality in eight European cohorts within the ELAPSE project: pooled analysis

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1904 (Published 02 September 2021) Cite this as: BMJ 2021;374:n1904
  1. Maciej Strak, scientist12,
  2. Gudrun Weinmayr, senior scientist3,
  3. Sophia Rodopoulou, research associate4,
  4. Jie Chen, postdoctoral researcher1,
  5. Kees de Hoogh, assistant professor56,
  6. Zorana J Andersen, professor7,
  7. Richard Atkinson, professor8,
  8. Mariska Bauwelinck, doctoral student9,
  9. Terese Bekkevold, research coordinator10,
  10. Tom Bellander, professor1112,
  11. Marie-Christine Boutron-Ruault, research director13,
  12. Jørgen Brandt, professor14,
  13. Giulia Cesaroni, senior researcher15,
  14. Hans Concin, director16,
  15. Daniela Fecht, lecturer17,
  16. Francesco Forastiere, professor1518,
  17. John Gulliver, professor1719,
  18. Ole Hertel, professor20,
  19. Barbara Hoffmann, professor21,
  20. Ulla Arthur Hvidtfeldt, senior scientist22,
  21. Nicole A H Janssen, senior scientist2,
  22. Karl-Heinz Jöckel, professor23,
  23. Jeanette T Jørgensen, doctoral student7,
  24. Matthias Ketzel, senior scientist1424,
  25. Jochem O Klompmaker, postdoctoral researcher225,
  26. Anton Lager, affiliated researcher26,
  27. Karin Leander, senior lecturer11,
  28. Shuo Liu, doctoral student7,
  29. Petter Ljungman, associate professor1127,
  30. Patrik K E Magnusson, researcher28,
  31. Amar J Mehta, associate professor29,
  32. Gabriele Nagel, professor3,
  33. Bente Oftedal, senior researcher30,
  34. Göran Pershagen, professor1112,
  35. Annette Peters, professor3132,
  36. Ole Raaschou-Nielsen, professor22,
  37. Matteo Renzi, researcher15,
  38. Debora Rizzuto, associate professor3334,
  39. Yvonne T van der Schouw, professor35,
  40. Sara Schramm, senior research scientist23,
  41. Gianluca Severi, associate professor1336,
  42. Torben Sigsgaard, professor37,
  43. Mette Sørensen, senior scientist2238,
  44. Massimo Stafoggia, senior researcher1115,
  45. Anne Tjønneland, adjunct professor22,
  46. W M Monique Verschuren, professor235,
  47. Danielle Vienneau, associate professor56,
  48. Kathrin Wolf, senior scientist31,
  49. Klea Katsouyanni, professor418,
  50. Bert Brunekreef, professor1,
  51. Gerard Hoek, associate professor1,
  52. Evangelia Samoli, associate professor4
  1. 1Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands
  2. 2National Institute for Public Health and the Environment, Bilthoven, Netherlands
  3. 3Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
  4. 4Department of Hygiene, Epidemiology, and Medical Statistics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
  5. 5Swiss Tropical and Public Health Institute, Basel, Switzerland
  6. 6University of Basel, Basel, Switzerland
  7. 7Department of Public Health, Section of Environment and Health, University of Copenhagen, Copenhagen, Denmark
  8. 8Population Health Research Institute, St George’s, University of London, London, UK
  9. 9Interface Demography – Department of Sociology, Vrije Universiteit Brussel, Brussels, Belgium
  10. 10Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
  11. 11Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
  12. 12Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
  13. 13University Paris-Saclay, UVSQ, Inserm, Gustave Roussy, “Exposome and Heredity” Team, CESP UMR1018, Paris, France
  14. 14Department of Environmental Science, Aarhus University, Roskilde, Denmark
  15. 15Department of Epidemiology, Lazio Region Health Service/ASL Roma 1, Rome, Italy
  16. 16Agency for Preventive and Social Medicine (AKS), Bregenz, Austria
  17. 17MRC Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
  18. 18Science Policy and Epidemiology Environmental Research Group King’s College London, London, UK
  19. 19Centre for Environmental Health and Sustainability and School of Geography, Geology and the Environment, University of Leicester, Leicester, UK
  20. 20Department of Bioscience, Aarhus University, Roskilde, Denmark
  21. 21Institute for Occupational, Social, and Environmental Medicine, Centre for Health and Society, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
  22. 22Danish Cancer Society Research Center, Copenhagen, Denmark
  23. 23Institute for Medical Informatics, Biometry, and Epidemiology, Medical Faculty, University of Duisburg-Essen, Essen, Germany
  24. 24Global Centre for Clean Air Research (GCARE), University of Surrey, Guildford, UK
  25. 25Harvard TH Chan School of Public Health, Boston, MA, USA
  26. 26Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
  27. 27Department of Cardiology, Danderyd University Hospital, Stockholm, Sweden
  28. 28Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
  29. 29Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
  30. 30Department of Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
  31. 31Institute of Epidemiology, Helmholtz Zentrum München, Neuherberg, Germany
  32. 32Ludwig Maximilians Universität München, Munich, Germany
  33. 33Department of Neurobiology, Care Sciences, and Society, Karolinska Institutet, Stockholm, Sweden
  34. 34Stockholm Gerontology Research Center, Stockholm, Sweden
  35. 35Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
  36. 36Department of Statistics, Computer Science and Applications “G Parenti” (DISIA), University of Florence, Italy
  37. 37Department of Public Health, Environment, Occupation and Health, Danish Ramazzini Centre, Aarhus University, Aarhus, Denmark
  38. 38Department of Natural Science and Environment, Roskilde University, Roskilde, Denmark
  1. Correspondence to: G Hoek g.hoek{at}uu.nl (or @elapse_project on Twitter)
  • Accepted 27 July 2021

Abstract

Objective To investigate the associations between air pollution and mortality, focusing on associations below current European Union, United States, and World Health Organization standards and guidelines.

Design Pooled analysis of eight cohorts.

Setting Multicentre project Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE) in six European countries.

Participants 325 367 adults from the general population recruited mostly in the 1990s or 2000s with detailed lifestyle data. Stratified Cox proportional hazard models were used to analyse the associations between air pollution and mortality. Western Europe-wide land use regression models were used to characterise residential air pollution concentrations of ambient fine particulate matter (PM2.5), nitrogen dioxide, ozone, and black carbon.

Main outcome measures Deaths due to natural causes and cause specific mortality.

Results Of 325 367 adults followed-up for an average of 19.5 years, 47 131 deaths were observed. Higher exposure to PM2.5, nitrogen dioxide, and black carbon was associated with significantly increased risk of almost all outcomes. An increase of 5 µg/m3 in PM2.5 was associated with 13% (95% confidence interval 10.6% to 15.5%) increase in natural deaths; the corresponding figure for a 10 µg/m3 increase in nitrogen dioxide was 8.6% (7% to 10.2%). Associations with PM2.5, nitrogen dioxide, and black carbon remained significant at low concentrations. For participants with exposures below the US standard of 12 µg/m3 an increase of 5 µg/m3 in PM2.5 was associated with 29.6% (14% to 47.4%) increase in natural deaths.

Conclusions Our study contributes to the evidence that outdoor air pollution is associated with mortality even at low pollution levels below the current European and North American standards and WHO guideline values. These findings are therefore an important contribution to the debate about revision of air quality limits, guidelines, and standards, and future assessments by the Global Burden of Disease.

Footnotes

  • Contributors: MS performed the statistical analysis and wrote the original draft of the manuscript. GH wrote and reviewed the manuscript and edited the original version. SR, KK, and ES created the statistical analyses strategy and scripts for the statistical analyses. JC performed the statistical analysis and exposure assessments. KdH performed the exposure assessments. MS, GW, SR, KK, BB, GH, and ES conceived and designed the study. BB and GH are principal investigators of the Effects of Low-Level Air Pollution: A Study in Europe (ELAPSE) project. All authors have read and revised the manuscript for important intellectual content and contributed to the interpretation of the results. All authors have approved the final draft of the manuscript. GH is the study guarantor. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. GH and ES contributed equally to the manuscript.

  • Funding: This work was supported by Health Effects Institute (HEI) research agreement (grant No 4954-RFA14-3/16-5-3). Research described in this article was conducted under contract to the HEI, an organisation jointly funded by the US Environmental Protection Agency (EPA) (assistance award No R-82811201) and certain motor vehicle and engine manufacturers. The contents of this article do not necessarily reflect the views of HEI, or its sponsors, nor do they necessarily reflect the views and policies of the EPA or motor vehicle and engine manufacturers.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at http://www.icmje.org/coi_disclosure.pdf and declare: support from the Health Effects Institute for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • The corresponding author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: We plan to prepare press releases and share the findings through publications, talks, and social media. We will address larger audiences that include members of the public, patients, health professionals, and stakeholders.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

No additional data available.

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