title: Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project.
abstract: 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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
  
  
  BACKGROUND
  European Community's Seventh Framework Program (FP7/2007-2011).
authors: Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands. Electronic address: r.m.j.beelen@uu.nl.
authors: Rob
authors: R
authors: Beelen
authors: Danish Cancer Society Research Center, Copenhagen, Denmark.
authors: Ole
authors: O
authors: Raaschou-Nielsen
authors: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors: Massimo
authors: M
authors: Stafoggia
authors: Danish Cancer Society Research Center, Copenhagen, Denmark; Center for Epidemiology and Screening, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
authors: Zorana Jovanovic
authors: ZJ
authors: Andersen
authors: Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany; IUF - Leibniz Research Institute for Environmental Medicine, Germany and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
authors: Gudrun
authors: G
authors: Weinmayr
authors: IUF - Leibniz Research Institute for Environmental Medicine, Germany and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
authors: Barbara
authors: B
authors: Hoffmann
authors: Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.
authors: Kathrin
authors: K
authors: Wolf
authors: Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens, Athens, Greece.
authors: Evangelia
authors: E
authors: Samoli
authors: National Institute for Public Health and the Environment, Bilthoven, Netherlands.
authors: Paul
authors: P
authors: Fischer
authors: Centre for Research in Environmental Epidemiology (CREAL), Parc de Recerca Biomèdica de Barcelona, Barcelona, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Madrid, Spain.
authors: Mark
authors: M
authors: Nieuwenhuijsen
authors: MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London, St Mary's Campus, London, UK.
authors: Paolo
authors: P
authors: Vineis
authors: MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London, St Mary's Campus, London, UK; CeLSIUS, University College London, London, UK.
authors: Wei W
authors: WW
authors: Xun
authors: Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens, Athens, Greece.
authors: Klea
authors: K
authors: Katsouyanni
authors: Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens, Athens, Greece.
authors: Konstantina
authors: K
authors: Dimakopoulou
authors: Division of Occupational and Environmental Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors: Anna
authors: A
authors: Oudin
authors: Division of Occupational and Environmental Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors: Bertil
authors: B
authors: Forsberg
authors: Division of Occupational and Environmental Medicine, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
authors: Lars
authors: L
authors: Modig
authors: Department of Chronic Disease Prevention, National Institute for Health and Welfare, Helsinki, Finland.
authors: Aki S
authors: AS
authors: Havulinna
authors: Department of Environmental Health, National Institute for Health and Welfare, Kuopio, Finland.
authors: Timo
authors: T
authors: Lanki
authors: Department of Environmental Health, National Institute for Health and Welfare, Kuopio, Finland.
authors: Anu
authors: A
authors: Turunen
authors: Division of Environmental Medicine, Norwegian Institute of Public Health, Oslo, Norway.
authors: Bente
authors: B
authors: Oftedal
authors: Division of Environmental Medicine, Norwegian Institute of Public Health, Oslo, Norway.
authors: Wenche
authors: W
authors: Nystad
authors: Division of Environmental Medicine, Norwegian Institute of Public Health, Oslo, Norway; Institute of Health and Society, University of Oslo, Oslo, Norway.
authors: Per
authors: P
authors: Nafstad
authors: Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors: Ulf
authors: U
authors: De Faire
authors: Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors: Nancy L
authors: NL
authors: Pedersen
authors: Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
authors: Claes-Göran
authors: CG
authors: Östenson
authors: Ageing Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
authors: Laura
authors: L
authors: Fratiglioni
authors: Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors: Johanna
authors: J
authors: Penell
authors: Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors: Michal
authors: M
authors: Korek
authors: Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.
authors: Göran
authors: G
authors: Pershagen
authors: Danish Cancer Society Research Center, Copenhagen, Denmark.
authors: Kirsten Thorup
authors: KT
authors: Eriksen
authors: Section for Epidemiology, Department of Public Health, Aarhus University, Aarhus C, Aarhus, Denmark.
authors: Kim
authors: K
authors: Overvad
authors: Department of Environmental Science, Aarhus University, Roskilde, Denmark.
authors: Thomas
authors: T
authors: Ellermann
authors: Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
authors: Marloes
authors: M
authors: Eeftens
authors: Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands; Department of Epidemiology and Biostatistics, School of Public Health, Faculty of Medicine, Imperial College, London, UK.
authors: Petra H
authors: PH
authors: Peeters
authors: Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
authors: Kees
authors: K
authors: Meliefste
authors: Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
authors: Meng
authors: M
authors: Wang
authors: National Institute for Public Health and the Environment, Bilthoven, Netherlands.
authors: Bas
authors: B
authors: Bueno-de-Mesquita
authors: IUF - Leibniz Research Institute for Environmental Medicine, Germany and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
authors: Dorothea
authors: D
authors: Sugiri
authors: IUF - Leibniz Research Institute for Environmental Medicine, Germany and Medical Faculty, University of Düsseldorf, Düsseldorf, Germany.
authors: Ursula
authors: U
authors: Krämer
authors: Institute of Epidemiology I, Helmholtz Zentrum München, German Research Centre of Environmental Health, Neuherberg, Germany.
authors: Joachim
authors: J
authors: Heinrich
authors: MRC-HPA Centre for Environment and Health, Department of Epidemiology and Biostatistics, Imperial College London, St Mary's Campus, London, UK.
authors: Kees
authors: K
authors: de Hoogh
authors: Cancer Epidemiology Unit, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
authors: Timothy
authors: T
authors: Key
authors: Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.
authors: Annette
authors: A
authors: Peters
authors: Institute of Epidemiology II, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany.
authors: Regina
authors: R
authors: Hampel
authors: Agency for Preventive and Social Medicine, Bregenz, Austria.
authors: Hans
authors: H
authors: Concin
authors: Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany; Agency for Preventive and Social Medicine, Bregenz, Austria.
authors: Gabriele
authors: G
authors: Nagel
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Alex
authors: A
authors: Ineichen
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Emmanuel
authors: E
authors: Schaffner
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Nicole
authors: N
authors: Probst-Hensch
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Nino
authors: N
authors: Künzli
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Christian
authors: C
authors: Schindler
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Tamara
authors: T
authors: Schikowski
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Martin
authors: M
authors: Adam
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland.
authors: Harish
authors: H
authors: Phuleria
authors: Inserm, Centre for Research in Epidemiology and Population Health, U1018, Nutrition, Hormones and Women's Health Team, Villejuif, France; University Paris Sud, UMRS 1018, F-94805, Villejuif, France; Institut Gustave Roussy, F-94805, Villejuif, France.
authors: Alice
authors: A
authors: Vilier
authors: Inserm, Centre for Research in Epidemiology and Population Health, U1018, Nutrition, Hormones and Women's Health Team, Villejuif, France; University Paris Sud, UMRS 1018, F-94805, Villejuif, France; Institut Gustave Roussy, F-94805, Villejuif, France.
authors: Françoise
authors: F
authors: Clavel-Chapelon
authors: French Institute for Public Health Surveillance (InVS), Saint-Maurice, France.
authors: Christophe
authors: C
authors: Declercq
authors: Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
authors: Sara
authors: S
authors: Grioni
authors: Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
authors: Vittorio
authors: V
authors: Krogh
authors: Swiss Tropical and Public Health Institute, Basel, Switzerland; University of Basel, Basel, Switzerland; Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA.
authors: Ming-Yi
authors: MY
authors: Tsai
authors: Human Genetics Foundation - HuGeF, Turin, Italy.
authors: Fulvio
authors: F
authors: Ricceri
authors: Unit of Cancer Epidemiology, AO Citta' della Salute e della Scienza-University of Turin and Centre for Cancer Prevention, Turin, Italy.
authors: Carlotta
authors: C
authors: Sacerdote
authors: Unit of Cancer Epidemiology, AO Citta' della Salute e della Scienza-University of Turin and Centre for Cancer Prevention, Turin, Italy.
authors: Claudia
authors: C
authors: Galassi
authors: Unit of Cancer Epidemiology, AO Citta' della Salute e della Scienza-University of Turin and Centre for Cancer Prevention, Turin, Italy.
authors: Enrica
authors: E
authors: Migliore
authors: Environmental Health Reference Centre-Regional Agency for Environmental Prevention of Emilia-Romagna, Modena, Italy.
authors: Andrea
authors: A
authors: Ranzi
authors: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors: Giulia
authors: G
authors: Cesaroni
authors: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors: Chiara
authors: C
authors: Badaloni
authors: Department of Epidemiology, Lazio Regional Health Service, Rome, Italy.
authors: Francesco
authors: F
authors: Forastiere
authors: Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Madrid, Spain; Public Health Division of Gipuzkoa, Basque Government, Gipuzkoa, Spain.
authors: Ibon
authors: I
authors: Tamayo
authors: Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Madrid, Spain; Public Health Division of Gipuzkoa, Basque Government, Gipuzkoa, Spain.
authors: Pilar
authors: P
authors: Amiano
authors: Consortium for Biomedical Research in Epidemiology and Public Health (CIBER en Epidemiología y Salud Pública-CIBERESP), Madrid, Spain; Public Health Division of Gipuzkoa, Basque Government, Gipuzkoa, Spain.
authors: Miren
authors: M
authors: Dorronsoro
authors: Hellenic Health Foundation, Athens, Greece.
authors: Michail
authors: M
authors: Katsoulis
authors: Hellenic Health Foundation, Athens, Greece.
authors: Antonia
authors: A
authors: Trichopoulou
authors: Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands; Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands.
authors: Bert
authors: B
authors: Brunekreef
authors: Institute for Risk Assessment Sciences, Utrecht University, Utrecht, Netherlands.
authors: Gerard
authors: G
authors: Hoek
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000393:Air Pollutants / Q000032:analysis / Q000633:toxicity*; D000397:Air Pollution / Q000009:adverse effects* / Q000032:analysis; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D004781:Environmental Exposure / Q000009:adverse effects* / Q000032:analysis; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D052638:Particulate Matter / Q000032:analysis / Q000633:toxicity*; D055815:Young Adult
chemical_list: D000393:Air Pollutants; D052638:Particulate Matter