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Living in areas with higher levels of surrounding greenness and access to urban green areas have been associated with beneficial health outcomes. Some studies suggested a beneficial influence on mortality, but the evidence is still controversial. We used longitudinal data from a large cohort to estimate associations of two measures of residential greenness exposure with cause-specific mortality and stroke incidence. We studied a population-based cohort of 1,263,721 residents in Rome aged [Formula: see text], followed from 2001 to 2013. As greenness exposure, we utilized the leaf area index (LAI), which expresses the tree canopy as the leaf area per unit ground surface area, and the normalized difference vegetation index (NDVI) within 300- and [Formula: see text] buffers around home addresses. We estimated the association between the two measures of residential greenness and the outcomes using Cox models, after controlling for relevant individual covariates and contextual characteristics, and explored potential mediation by air pollution [fine particulate matter with aerodynamic diameter [Formula: see text] [Formula: see text] and [Formula: see text]] and road traffic noise. We observed 198,704 deaths from nonaccidental causes, 81,269 from cardiovascular diseases [CVDs; 29,654 from ischemic heart disease (IHD)], 18,090 from cerebrovascular diseases, and 29,033 incident cases of stroke. Residential greenness, expressed as interquartile range (IQR) increase in LAI within [Formula: see text], was inversely associated with stroke incidence {hazard ratio (HR) 0.977 [95% confidence interval (CI): 0.961, 0.994]} and mortality for nonaccidental [HR 0.988 (95% CI: 0.981, 0.994)], cardiovascular [HR 0.984 (95% CI: 0.974, 0.994)] and cerebrovascular diseases [HR 0.964 (95% CI: 0.943, 0.985)]. Similar results were obtained using NDVI with 300- or [Formula: see text] buffers. Living in greener areas was associated with better health outcomes in our study, which could be partly due to reduced exposure to environmental hazards. Further research is required to understand the underlying mechanisms. https://doi.org/10.1289/EHP2854.

Few European studies have investigated the effects of long-term exposure to both fine particulate matter (≤ 2.5 µm; PM2.5) and nitrogen dioxide (NO2) on mortality. We studied the association of exposure to NO2, PM2.5, and traffic indicators on cause-specific mortality to evaluate the form of the concentration-response relationship. We analyzed a population-based cohort enrolled at the 2001 Italian census with 9 years of follow-up. We selected all 1,265,058 subjects ≥ 30 years of age who had been living in Rome for at least 5 years at baseline. Residential exposures included annual NO2 (from a land use regression model) and annual PM2.5 (from a Eulerian dispersion model), as well as distance to roads with > 10,000 vehicles/day and traffic intensity. We used Cox regression models to estimate associations with cause-specific mortality adjusted for individual (sex, age, place of birth, residential history, marital status, education, occupation) and area (socioeconomic status, clustering) characteristics. Long-term exposures to both NO2 and PM2.5 were associated with an increase in nonaccidental mortality [hazard ratio (HR) = 1.03 (95% CI: 1.02, 1.03) per 10-µg/m3 NO2; HR = 1.04 (95% CI: 1.03, 1.05) per 10-µg/m3 PM2.5]. The strongest association was found for ischemic heart diseases (IHD) [HR = 1.10 (95% CI: 1.06, 1.13) per 10-µg/m3 PM2.5], followed by cardiovascular diseases and lung cancer. The only association showing some deviation from linearity was that between NO2 and IHD. In a bi-pollutant model, the estimated effect of NO2 on mortality was independent of PM2.5. This large study strongly supports an effect of long-term exposure to NO2 and PM2.5 on mortality, especially from cardiovascular causes. The results are relevant for the next European policy decisions regarding air quality.

Background Few studies have explored the role of air pollution in neurodegenerative processes, especially various types of dementia. Our aim was to evaluate the association between long-term exposure to air pollution and first hospitalization for dementia subtypes in a large administrative cohort. Methods We selected 350,844 subjects (free of dementia) aged 65–100 years at inclusion (21/10/2001) and followed them until 31/12/2013. We selected all subjects hospitalized for the first time with primary or secondary diagnoses of various forms of dementia. We estimated the exposure at residence using land use regression models for nitrogen oxides (NOx, NO 2 ) and particulate matter (PM) and a chemical transport model for ozone (O 3 ). We used Cox models to estimate the association between exposure and first hospitalization for dementia and its subtypes: vascular dementia (Vd), Alzheimer’s disease (Ad) and senile dementia (Sd). Results We selected 21,548 first hospitalizations for dementia (7497 for Vd, 7669 for Ad and 7833 for Sd). Overall, we observed a negative association between exposure to NO 2 (10 μg/m 3 ) and dementia hospitalizations (HR = 0.97; 95% CI: 0.96–0.99) and a positive association between exposure to O 3 , NOx and dementia hospitalizations, (O 3 : HR = 1.06; 95% CI: 1.04–1.09 per 10 μg/m 3 ; NOx: HR = 1.01; 95% CI: 1.00–1.02 per 20 μg/m 3 ).H. Exposure to NOx, NO 2 , PM 2.5 , and PM 10 was positively associated with Vd and negatively associated with Ad. Hospitalization for Sd was positively associated with exposure to O 3 (HR = 1.20; 95% CI: 1.15–1.24 per 10 μg/m 3 ). Conclusions Our results showed a positive association between exposure to NOx and O 3 and hospitalization for dementia and a negative association between NO 2 exposure and hospitalization for dementia. In the analysis by subtype, exposure to each pollutants (except O 3 ) demonstrated a positive association with vascular dementia, while O 3 exposure was associated with senile dementia. The results regarding vascular dementia are a clear indication that the brain effects of air pollution are linked with vascular damage.

Epidemiologic research and quantitative risk assessment play a crucial role in transferring fundamental scientific knowledge to policymakers so they can take action to reduce the burden of ambient air pollution. This commentary addresses several challenges in quantitative risk assessment of air pollution that require close attention. The background to this discussion provides a summary of and conclusions from the epidemiological evidence on ambient air pollution and health outcomes accumulated since the 1990s. We focus on identifying relevant exposure-health outcome pairs, the associated concentration-response functions to be applied in a risk assessment, and several caveats in their application. We propose a structured and comprehensive framework for assessing the evidence levels associated with each exposure-health outcome pair within a health impact assessment context. Specific issues regarding the use of global or regional concentration-response functions, their shape, and the range of applicability are discussed.

The most important message of the updated WHO AQG is that each reduction in the outdoor concentrations of key air pollutants brings health benefits to the surrounding population, even in places which already have low pollution concentrations. [...]linear exposure-response relationships down to the lowest observable concentrations show that every individual will benefit from cleaner air [11–15]. The upcoming 2022 revision of the EU Ambient Air Quality Directive will offer the chance to lead the way and implement binding average exposure reduction goals for air pollutants in combination with lowered fixed limit values. For the US, it has been estimated that the benefits from decreased mortality, lower medical expenditures for air pollution-related diseases, and higher productivity of workers are around 30 times greater than the costs of the Clean Air Act, resulting in net improvements of economic growth and population welfare [19]. The benefits are clear: lowering air pollution levels will lead to enormous improvements in public health for people of all ages breathing cleaner air.

The association between short-term air pollution exposure and daily mortality has been widely investigated, but little is known about the temporal variability of the effect estimates. We examined the temporal relationship between exposure to particulate matter (PM) (PM , PM ) and gases (NO , SO , and CO) with mortality in a large metropolitan area over the last 17 y. Our analysis included 359,447 nonaccidental deaths among ≥35-y-old individuals in Rome, Italy, over the study period 1998–2014. We related daily concentrations to mortality counts with a time-series Poisson regression analysis adjusted for long-term trends, meteorology, and population dynamics. Annual average concentrations decreased over the study period for all pollutants (e.g., from 42.9 to 26.6 μg/m for PM ). Each pollutant was positively associated with mortality, with estimated percentage increases over the entire study period ranging from 0.19% (95% CI: 0.13, 0.26) for a 1-Mg/m increase in CO (0–1 d lag) to 3.03% (95% CI: 2.44, 3.63) for a 10-μg/m increase in NO (0–5 d lag). We did not observe clear temporal patterns in year- or period-specific effect estimates for any pollutant. For example, we estimated that a 10-μg/m increase in PM was associated with 1.16% (95% CI: 0.53, 1.79), 0.99% (95% CI: 0.23, 1.77), and 1.87% (95% CI: 1.00, 2.74) increases in mortality for the periods 2001–2005, 2006–2010, and 2011–2014, respectively, and corresponding estimates for a 10-μg/m increase in NO were 4.20% (95% CI: 3.15, 5.25), 1.78% (95% CI: 0.73, 2.85), and 3.32% (95% CI: 2.03, 4.63). Mean concentrations of air pollutants have decreased over the last two decades in Rome, but effect estimates for a fixed increment in each exposure were generally consistent. These findings suggest that there has been little or no change in the overall toxicity of the air pollution mixture over time. https://doi.org/10.1289/EHP19.

Background: Outbreaks of Saharan-Sahel dust over Euro-Mediterranean areas frequently induce exceedances of the Europen Union's 24-hr standard of 50 μg/m³ for paniculate matter (PM) with aerodynamic diameter ≤ than 10 μm (PM₁₀). Objectives: We evaluated the effect of Saharan dust on the association between different PM fractions and daily mortality in Rome, Italy. Methods: In a study of 80,423 adult residents who died in Rome between 2001 and 2004, we performed a time-series analysis to explore the effects of PM2.5, PM2.5-10, and PM₁₀ on natural, cardiac, cerebrovascular, and respiratory mortality. We defined Saharan dust days by combining light detection and ranging (LIDAR) observations and analyses from operational models. We tested a Saharan dust-PM interaction term to evaluate the hypothesis that the effects of PM, especially coarse PM (PM2.5-10), on mortality would be enhanced on dust days. Results: Interquartile range increases in PM2.5-10 (10.8 μg/m³) and PM₁₀ (19.8 ug/m³) were associated with increased mortality due to natural, cardiac, cerebrovascular, and respiratory causes, with estimated effects ranging from 2.64% to 12.65% [95% confidence interval (CI), 1.18-25.42%] for the association between PM2.5-10 and respiratory mortality (0-to 5-day lag). Associations of PM2.5-10 with cardiac mortality were stronger on Saharan dust days (9.73%; 95% CI, 4.25-15.49%) than on dust-free days (0.86%; 95% CI, -2.47% to 4.31%; p = 0.005). Saharan dust days also modified associations between PM₁₀ and cardiac mortality (9.55% increase; 95% CI, 3.81-15.61%; vs. dust-free days: 2.09%; 95% CI, -0.76% to 5.02%; p = 0.02). Conclusions: We found evidence of effects of PM2.5-10 and PM₁₀ on natural and cause-specific mortality, with stronger estimated effects on cardiac mortality during Saharan dust outbreaks. Toxicological and biological effects of particles from desert sources need to be further investigated and taken into account in air quality standards.

Background and aimsResidents near industrial areas are exposed to several toxins from various sources and the assessment of the health effects is difficult. The area of Civitavecchia (Italy) has several sources of environmental contamination with potential health effects. We evaluated the association between exposure to pollutants from multiple sources and mortality in a cohort of people living in the area.MethodsAll residents of the area in 1996 were enrolled (from municipal registers) and followed until 2013. Long-term exposures to emissions from industrial sources (PM10) and traffic (NOx) at the residential addresses were assessed using a dispersion model. Residence close to the harbour was also considered. Cox survival analysis was conducted including a linear term for industrial PM10 and NOx exposure and a dichotomous variable to indicate residence within 500 m of the harbour. Age, sex, calendar period, occupation and area-based socioeconomic position (SEP) were considered (HRs, 95% CI).Results71 362 people were enrolled (52% female, 43% low SEP) and 14 844 died during the follow-up. We found an association between industrial PM10 and mortality from non-accidental causes (HR=1.06, 95% CI 1.01 to 1.12), all cancers (HR=1.11, 95% CI 1.01 to 1.21) and cardiac diseases (HR=1.12, 95% CI 1.01 to 1.23). We also found an association between NOx exposure from traffic and mortality from all cancers (HR=1.13, 95% CI 1.01 to 1.26) and neurological diseases (HR=1.50, 95% CI 1.01 to 2.20). Living near the harbour was associated with higher mortality from lung cancer (HR=1.31, 95% CI 1.04 to 1.66) and neurological diseases (HR=1.51, 95% CI 1.05 to 2.18).ConclusionsEstimated exposures to different pollution sources in this area were independently associated with several mortality outcomes while adjusting for occupation and socioeconomic status.

Objective Quantitative estimates of air pollution health impacts have become an increasingly critical input to policy decisions. The WHO project “Health risks of air pollution in Europe—HRAPIE” was implemented to provide the evidence-based concentration–response functions for quantifying air pollution health impacts to support the 2013 revision of the air quality policy for the European Union (EU). Methods A group of experts convened by WHO Regional Office for Europe reviewed the accumulated primary research evidence together with some commissioned reviews and recommended concentration–response functions for air pollutant–health outcome pairs for which there was sufficient evidence for a causal association. Results The concentration–response functions link several indicators of mortality and morbidity with short- and long-term exposure to particulate matter, ozone and nitrogen dioxide. The project also provides guidance on the use of these functions and associated baseline health information in the cost–benefit analysis. Conclusions The project results provide the scientific basis for formulating policy actions to improve air quality and thereby reduce the burden of disease associated with air pollution in Europe.

To summarize the main updated evidence about the health effects of air pollution, with a special focus on Southern Europe. Literature was obtained through PubMed Central and the official websites of European Agencies and Scientific Societies. Recent shreds of evidence about the health effects of air pollution coming from international reports and original research were collected and described in this review. Air pollution is an avoidable risk factor that causes a huge burden for society, in terms of death, health disorders, and huge socio-economic costs. The southern European countries face a more threatening problem because they experience the effects of both anthropogenic pollutants and natural dusts (particulate matter [PM]). The European Environment Agency reported the number of premature deaths in the 28 countries of the European Union attributable to air pollutant exposure in the year 2016: 374,000 for PM2.5, 68,000 for nitrogen dioxide, and 14,000 for ozone. In Italy, time series and analytical epidemiological studies showed increased cardio-respiratory hospital admissions and mortality, as well as increased risk of respiratory diseases in people living in urban areas. Based on abundant evidence, the World Health Organization, which hosts the Global Alliance against Chronic Respiratory Diseases (GARD), the scientific respiratory societies, and the patients' associations, as well as others in the health sector, must increase their engagement in advocacy for clean air policies.