Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project

The Lancet, Elsevier, ISSN 1474-547X

Volume 383, 9919, 2014

DOI:10.1016/s0140-6736(13)62158-3, Dimensions: pub.1027526870, PMID: 24332274,


Beelen, Rob * (1)
Weinmayr, Gudrun (5) (6) (7)
Xun, Wei W (13) (14)
Nafstad, Per (17) (18)
Peeters, Petra H (13) (21)
Krämer, Ursula (6) (7)
Nagel, Gabriele (5) (24)
Ineichen, Alex (25) (26)
Künzli, Nino (25) (26)
Schikowski, Tamara (25) (26)
Adam, Martin (25) (26)
Phuleria, Harish (25) (26)
Vilier, Alice (27) (28) (29)
Tsai, Ming-Yi (25) (26) (32)
Tamayo, Ibon (12) (36)
Amiano, Pilar (12) (36)
Dorronsoro, Miren (12) (36)
Brunekreef, Bert (1) (21)

* Corresponding author



  1. (1) Utrecht University, grid.5477.1
  2. (2) Danish Cancer Society, grid.417390.8
  3. (3) Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
  4. (4) University of Copenhagen, grid.5254.6, KU
  5. (5) University of Ulm, grid.6582.9
  6. (6) Heinrich Heine University Düsseldorf, grid.411327.2
  7. (7) Leibniz Institute of Environmental Medicine, grid.435557.5
  8. (8) Helmholtz Zentrum München, grid.4567.0
  9. (9) National and Kapodistrian University of Athens, grid.5216.0
  10. (10) National Institute for Public Health and the Environment, grid.31147.30
  11. (11) Centre for Research in Environmental Epidemiology (CREAL), Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain
  12. (12) Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Madrid, Spain
  13. (13) Imperial College London, grid.7445.2
  14. (14) University College London, grid.83440.3b
  15. (15) Umeå University, grid.12650.30
  16. (16) National Institute for Health and Welfare, grid.14758.3f
  17. (17) Norwegian Institute of Public Health, grid.418193.6
  18. (18) University of Oslo, grid.5510.1
  19. (19) Karolinska Institute, grid.4714.6
  20. (20) Aarhus University, grid.7048.b, AU
  21. (21) University Medical Center Utrecht, grid.7692.a
  22. (22) Institute of Epidemiology I, Helmholtz Zentrum München, German Research Centre of Environmental Health, Neuherberg, Germany
  23. (23) University of Oxford, grid.4991.5
  24. (24) Agency for Preventive and Social Medicine, Bregenz, Austria
  25. (25) Swiss Tropical and Public Health Institute, grid.416786.a
  26. (26) University of Basel, grid.6612.3
  27. (27) Centre for research in epidemiology and population health, grid.463845.8
  28. (28) Institut Gustave Roussy, grid.14925.3b
  29. (29) University of Paris-Sud, grid.5842.b
  30. (30) Institut de Veille Sanitaire, grid.419184.1
  31. (31) Fondazione IRCCS Istituto Nazionale dei Tumori, grid.417893.0
  32. (32) University of Washington, grid.34477.33
  33. (33) Human Genetics Foundation, grid.428948.b
  34. (34) University of Turin, grid.7605.4
  35. (35) Environmental Health Reference Centre-Regional Agency for Environmental Prevention of Emilia-Romagna, Modena, Italy
  36. (36) Basque Government, grid.431260.2
  37. (37) Hellenic Health Foundation, grid.424637.0


BACKGROUND: Few studies on long-term exposure to air pollution and mortality have been reported from Europe. Within the multicentre European Study of Cohorts for Air Pollution Effects (ESCAPE), we aimed to investigate the association between natural-cause mortality and long-term exposure to several air pollutants. METHODS: We used data from 22 European cohort studies, which created a total study population of 367,251 participants. All cohorts were general population samples, although some were restricted to one sex only. With a strictly standardised protocol, we assessed residential exposure to air pollutants as annual average concentrations of particulate matter (PM) with diameters of less than 2.5 μm (PM2.5), less than 10 μm (PM10), and between 10 μm and 2.5 μm (PMcoarse), PM2.5 absorbance, and annual average concentrations of nitrogen oxides (NO2 and NOx), with land use regression models. We also investigated two traffic intensity variables-traffic intensity on the nearest road (vehicles per day) and total traffic load on all major roads within a 100 m buffer. We did cohort-specific statistical analyses using confounder models with increasing adjustment for confounder variables, and Cox proportional hazards models with a common protocol. We obtained pooled effect estimates through a random-effects meta-analysis. FINDINGS: The total study population consisted of 367,251 participants who contributed 5,118,039 person-years at risk (average follow-up 13.9 years), of whom 29,076 died from a natural cause during follow-up. A significantly increased hazard ratio (HR) for PM2.5 of 1.07 (95% CI 1.02-1.13) per 5 μg/m(3) was recorded. No heterogeneity was noted between individual cohort effect estimates (I(2) p value=0.95). HRs for PM2.5 remained significantly raised even when we included only participants exposed to pollutant concentrations lower than the European annual mean limit value of 25 μg/m(3) (HR 1.06, 95% CI 1.00-1.12) or below 20 μg/m(3) (1.07, 1.01-1.13). INTERPRETATION: Long-term exposure to fine particulate air pollution was associated with natural-cause mortality, even within concentration ranges well below the present European annual mean limit value. FUNDING: European Community's Seventh Framework Program (FP7/2007-2011).


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