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Short-term effects of nitrogen dioxide on mortality: an analysis within the APHEA project

E. Samoli¹, E. Aga², G. Touloumi¹, K. Nisiotis¹, B. Forsberg³, A. Lefranc⁴, J. Pekkanen^5,6, B. Wojtyniak⁷, C. Schindler⁸, E. Niciu⁹, R. Brunstein¹⁰, M. Dodi Fikfak¹¹, J. Schwartz² and K. Katsouyanni¹

¹ Dept of Hygiene and Epidemiology, University of Athens, Athens, Greece. ² Harvard School of Public Health, Boston, MA, USA. ³ Dept of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden. ⁴ Regional Observatory of Health, Ile-de-France, France. ⁵ Dept of Public Health and Clinical Nutrition, University of Kuopio, and ⁶ National Public Health Institute, Unit of Environmental Epidemiology, Kuopio, Finland. ⁷ National Institute of Hygiene, Dept of Medical Statistics, Population Studies Laboratory, Warsaw, Poland. ⁸ Institute of Social and Preventive Medicine, University of Basel, Basel, Switzerland. ⁹ Dept of Environmental Health, Institute of Public Health Bucharest, Bucharest, Romania. ¹⁰ Center for Quality & Safety, Hadassah University Hospital, Jerusalem, Israel. ¹¹ Institute of Public Health, Ljubljana, Slovenia.

CORRESPONDENCE: E. Samoli, Dept of Hygiene and Epidemiology, University of Athens Medical School, 75 Mikras Asias Street, 115 27 Athens, Greece, Fax: 30 2107462205. E-mail: esamoli{at}med.uoa.gr

Keywords: Air pollution, heterogeneity, modelling, mortality, nitrogen dioxide

Received: December 7, 2005
Accepted February 26, 2006

The short-term effects of nitrogen dioxide (NO₂) on total, cardiovascular and respiratory mortality in 30 European cities participating in the Air Pollution on Health: a European Approach (APHEA)-2 project were investigated.

The association was examined using hierarchical models implemented in two stages. In the first stage, data from each city were analysed separately, whereas in the second stage, the city-specific air pollution estimates were regressed on city-specific covariates to obtain overall estimates and to explore sources of possible heterogeneity.

A significant association of NO₂ with total, cardiovascular and respiratory mortality was found, with stronger effects on cause-specific mortality. There was evidence of confounding in respiratory mortality with black smoke and sulphur dioxide. The effect of NO₂ on total and cardiovascular mortality was observed mainly in western and southern European cities, and was larger when smoking prevalence was lower and household gas consumption was higher. The effect of NO₂ on respiratory mortality was higher in cities with a larger proportion of elderly persons in the population and higher levels of particulate matter with a 50% cut-off aerodynamic diameter of 10 µm.

The results of this large study are consistent with an independent effect of nitrogen dioxide on mortality, but the role of nitrogen dioxide as a surrogate of other unmeasured pollutants cannot be completely ruled out.

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