Long-term Air Pollution Exposure and Pneumonia Related Mortality in a Large Pooled European Cohort

Shuo Liu, Youn-Hee Lim, Jie Chen, Maciek Strak, Kathrin Wolf, Gudrun Weinmayr, Sophia Rodopolou, Kees de Hoogh, Tom Bellander, Jørgen Brandt, Hans Concin, Emanuel Zitt, Daniela Fecht, Francesco Forastiere, John Gulliver, Ole Hertel, Barbara Hoffmann, Ulla A Hvidtfeldt, W M Monique Verschuren, Karl-Heinz JöckelJeanette T Jørgensen, Rina So, Heresh Amini, Thomas Cole-Hunter, Amar J Mehta, Laust H Mortensen, Matthias Ketzel, Anton Lager, Karin Leander, Petter Ljungman, Gianluca Severi, Marie-Christine Boutron-Ruault, Patrik K E Magnusson, Gabriele Nagel, Göran Pershagen, Annette Peters, Ole Raaschou-Nielsen, Debora Rizzuto, Yvonne T van der Schouw, Sara Schramm, Mette Sørensen, Massimo Stafoggia, Anne Tjønneland, Klea Katsouyanni, Wei Huang, Evangelia Samoli, Bert Brunekreef, Gerard Hoek, Zorana J Andersen

Research output: Contribution to journalArticleAcademicpeer-review


Rationale: Ambient air pollution exposure has been linked to mortality from chronic cardiorespiratory diseases, while evidence on respiratory infections remains more limited. Objectives: We examined the association between long-term exposure to air pollution and pneumonia-related mortality in adults in a pool of eight European cohorts. Methods: Within the multicenter project ELAPSE (Effects of Low-Level Air Pollution: A Study in Europe), we pooled data from eight cohorts among six European countries. Annual mean residential concentrations in 2010 for fine particulate matter, nitrogen dioxide (NO 2), black carbon (BC), and ozone were estimated using Europe-wide hybrid land-use regression models. We applied stratified Cox proportional hazard models to investigate the associations between air pollution and pneumonia, influenza, and acute lower respiratory infections (ALRI) mortality. Measurements and Main Results: Of 325,367 participants, 712 died from pneumonia and influenza combined, 682 from pneumonia, and 695 from ALRI during a mean follow-up of 19.5 years. NO 2 and BC were associated with 10–12% increases in pneumonia and influenza combined mortality, but 95% confidence intervals included unity (hazard ratios, 1.12 [0.99–1.26] per 10 μg/m 3 for NO 2; 1.10 [0.97–1.24] per 0.5 10 25m 21 for BC). Associations with pneumonia and ALRI mortality were almost identical. We detected effect modification suggesting stronger associations with NO 2 or BC in overweight, employed, or currently smoking participants compared with normal weight, unemployed, or nonsmoking participants. Conclusions: Long-term exposure to combustion-related air pollutants NO 2 and BC may be associated with mortality from lower respiratory infections, but larger studies are needed to estimate these associations more precisely.

Original languageEnglish
Pages (from-to)1429-1439
Number of pages11
JournalAmerican Journal of Respiratory and Critical Care Medicine
Issue number12
Early online date8 Mar 2022
Publication statusPublished - 15 Jun 2022


  • adults
  • air pollution
  • long-term exposure
  • respiratory infections


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