University of Oulu

Meng X, Liu C, Chen R, Sera F, Vicedo-Cabrera A M, Milojevic A et al. Short term associations of ambient nitrogen dioxide with daily total, cardiovascular, and respiratory mortality: multilocation analysis in 398 cities BMJ 2021; 372 :n534,

Short term associations of ambient nitrogen dioxide with daily total, cardiovascular, and respiratory mortality : multilocation analysis in 398 cities

Saved in:
Author: Meng, Xia1,2; Liu, Cong1,2; Chen, Renjie1,2,3;
Organizations: 1Fudan Univ, Key Lab Publ Hlth Safety, Minist Educ, Sch Publ Hlth, POB 249,130 Dong An Rd, Shanghai 200032, Peoples R China.
2Fudan Univ, Key Lab Hlth Technol Assessment, Minist Hlth, POB 249,130 Dong An Rd, Shanghai 200032, Peoples R China.
3Fudan Univ, Shanghai Key Lab Atmospher Particle Pollut & Prev, Shanghai, Peoples R China.
4London Sch Hyg & Trop Med, Dept Publ Hlth Environm & Soc, London, England.
5Univ Florence, Dept Stat Comp Sci & Applicat G Parenti, Florence, Italy.
6Univ Bern, Inst Social & Prevent Med, Bern, Switzerland.
7Univ Bern, Oeschger Ctr Climate Change Res, Bern, Switzerland.
8Monash Univ, Sch Publ Hlth & Prevent Med, Dept Epidemiol & Prevent Med, Melbourne, Vic, Australia.
9Binzhou Med Univ, Sch Publ Hlth & Management, Yantai, Shandong, Peoples R China.
10Shanghai Jiao Tong Univ, Sch Med, Shanghai Childrens Med Ctr, Shanghai, Peoples R China.
11Anhui Med Univ, Inst Environm & Populat Hlth, Sch Publ Hlth, Hefei, Peoples R China.
12Queensland Univ Technol, Sch Publ Hlth & Social Work, Brisbane, Qld, Australia.
13Nanjing Med Univ, Ctr Global Hlth, Sch Publ Hlth, Nanjing, Peoples R China.
14Univ Sao Paulo, Fac Med, Sao Paulo, Brazil.
15Univ Ottawa, Sch Epidemiol & Publ Hlth, Ottawa, ON, Canada.
16Hlth Canada, Air Hlth Sci Div, Ottawa, ON, Canada.
17Univ Los Andes, Dept Publ Hlth, Santiago, Chile.
18Univ Los Andes, Sch Nursing & Obstet, Santiago, Chile.
19Inst Nacl Salud Publ Mexico, Cuernavaca, Morelos, Mexico.
20Czech Acad Sci, Inst Atmospher Phys, Prague, Czech Republic.
21Czech Univ Life Sci, Fac Environm Sci, Prague, Czech Republic.
22Umea Univ, Dept Publ Hlth & Clin Med, Umea, Sweden.
23Univ Tartu, Inst Family Med & Publ Hlth, Tartu, Estonia.
24Estonian Environm Res Ctr, Tallinn, Estonia.
25Univ Oulu, Ctr Environm & Resp Hlth Res CERH, Oulu, Finland.
26Potsdam Inst Climate Impact Res, Potsdam, Germany.
27Univ Pablo de Olavide, Dept Phys Chem & Nat Syst, Seville, Spain.
28German Res Ctr Environm Hlth GmbH, Helmholtz Zentrum Munchen, Inst Epidemiol, Neuherberg, Germany.
29Natl & Kapodistrian Univ Athens, Sch Med, Dept Hyg Epidemiol & Med Stat, Athens, Greece.
30Kings Coll London, Sch Populat Hlth & Environm Sci, London, England.
31Univ Tokyo, Grad Sch Med, Dept Global Hlth Policy, Tokyo, Japan.
32Univ Tsukuba, Fac Hlth & Sport Sci, Tsukuba, Ibaraki, Japan.
33Nagasaki Univ, Sch Trop Med & Global Hlth, Nagasaki, Japan.
34Portuguese Natl Inst Hlth, Dept Environm Hlth, Porto, Portugal.
35Univ Porto, EPIUnit, Inst Saude Publ, Porto, Portugal.
36Babes Bolay Univ, Fac Geog, Cluj Napoca, Romania.
37Univ Turin, Dept Earth Sci, Turin, Italy.
38Seoul Natl Univ, Grad Sch Publ Hlth, Dept Publ Hlth Sci, Seoul, South Korea.
39Seoul Natl Univ, Inst Hlth & Environm, Seoul, South Korea.
40Spanish Council Sci Res, Inst Environm Assessment & Water Res, Barcelona, Spain.
41Univ Valencia, Dept Stat & Operat Res, Valencia, Spain.
42CIBER Epidemiol & Publ Hlth, Madrid, Spain.
43Swiss Trop & Publ Hlth Inst, Basel, Switzerland.
44Univ Basel, Basel, Switzerland.
45Natl Taiwan Univ, Coll Med, Environm & Occupat Med, Taipei, Taiwan.
46NTU Hosp, Taipei, Taiwan.
47Natl Hlth Res Inst, Natl Inst Environm Hlth Sci, Miaoli, Taiwan.
48Yale Univ, Sch Environm, New Haven, CT USA.
49Harvard TH Chan Sch Publ Hlth, Dept Environm Hlth, Boston, MA USA.
50Huazhong Univ Sci & Technol, Key Lab Environm & Hlth, Minist Educ, Sch Publ Hlth,Tongji Med Coll, Wuhan, Peoples R China.
51Huazhong Univ Sci & Technol, State Key Lab Environm Hlth Incubating, Sch Publ Hlth, Tongji Med Coll, Wuhan, Peoples R China.
52London Sch Hyg & Trop Med, Ctr Stat Methodol, London, England.
53London Sch Hyg & Trop Med, Ctr Climate Change & Planetary Hlth, London, England.
54Fudan Univ, Natl Ctr Childrens Hlth, Childrens Hosp, Shanghai, Peoples R China.
Format: article
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 0.4 MB)
Persistent link:
Language: English
Published: BMJ, 2021
Publish Date: 2021-05-19


Objective: To evaluate the short term associations between nitrogen dioxide (NO₂) and total, cardiovascular, and respiratory mortality across multiple countries/regions worldwide, using a uniform analytical protocol.

Design: Two stage, time series approach, with overdispersed generalised linear models and multilevel meta-analysis.

Setting: 398 cities in 22 low to high income countries/regions.

Main outcome measures: Daily deaths from total (62.8 million), cardiovascular (19.7 million), and respiratory (5.5 million) causes between 1973 and 2018.

Results: On average, a 10 μg/m³ increase in NO₂ concentration on lag 1 day (previous day) was associated with 0.46% (95% confidence interval 0.36% to 0.57%), 0.37% (0.22% to 0.51%), and 0.47% (0.21% to 0.72%) increases in total, cardiovascular, and respiratory mortality, respectively. These associations remained robust after adjusting for co-pollutants (particulate matter with aerodynamic diameter ≤10 μm or ≤2.5 μm (PM₁₀ and PM2.5, respectively), ozone, sulfur dioxide, and carbon monoxide). The pooled concentration-response curves for all three causes were almost linear without discernible thresholds. The proportion of deaths attributable to NO₂ concentration above the counterfactual zero level was 1.23% (95% confidence interval 0.96% to 1.51%) across the 398 cities.

Conclusions: This multilocation study provides key evidence on the independent and linear associations between short term exposure to NO₂ and increased risk of total, cardiovascular, and respiratory mortality, suggesting that health benefits would be achieved by tightening the guidelines and regulatory limits of NO₂.

see all

Series: The BMJ
ISSN: 0959-8146
ISSN-E: 1756-1833
ISSN-L: 0959-8146
Volume: 372
Article number: n534
DOI: 10.1136/bmj.n534
Type of Publication: A1 Journal article – refereed
Field of Science: 3142 Public health care science, environmental and occupational health
Funding: HaK was supported by the National Natural Science Foundation of China (92043301, 82030103, and 91843302) and China Medical Board Collaborating Program (16-250). AG and FS were supported by the Medical Research Council, UK (MR/M022625/1), the Natural Environment Research Council, UK (NE/R009384/1), and the European Union’s Horizon 2020 Project Exhaustion (820655). VH was supported by the Spanish Ministry of Science and Innovation (PCIN-2017-046), and the German Federal Ministry of Education and Research (01LS1201A2). YH and MH were supported by the Environment Research and Technology Development Fund (JPMEERF15S11412) of the Environmental Restoration and Conservation Agency, Japan. JK and AU were supported by the Czech Science Foundation (18-22125S). ST was supported by the Shanghai Municipal Science and Technology Commission (18411951600). Y-LLG was supported by a Career Development Fellowship of the Australian National Health and Medical Research Council (APP1163693). SL was supported by an Early Career Fellowship of the Australian National Health and Medical Research Council (APP1109193). JJKJJ and NR were supported by the Academy of Finland (310372). The funders had no role in considering the study design or in the collection, analysis, interpretation of data, writing of the report, or decision to submit the article for publication.
Academy of Finland Grant Number: 310372
Detailed Information: 310372 (Academy of Finland Funding decision)
Copyright information: This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: