DÄ internationalArchive51-52/2019The Effects of Fine Dust, Ozone, and Nitrogen Dioxide on Health

Review article

The Effects of Fine Dust, Ozone, and Nitrogen Dioxide on Health

Dtsch Arztebl Int 2019; 116: 881-6. DOI: 10.3238/arztebl.2019.0881

Ritz, B; Hoffmann, B; Peters, A

Background: Air pollutants, especially fine dust, ozone, and nitrogen dioxide, pose a danger to health worldwide. In 2005, the World Health Organization (WHO), in order to protect public health, issued global recommendations for maximum levels of fine dust (10 μg/m3 for fine dust particles smaller than 2.5 μm [PM2.5]), ozone, and nitrogen dioxide. The recommended levels are regularly exceeded in many places in Germany.

Methods: This review is based on relevant publications retrieved by a selective search in PubMed and, in part, on an expert statement issued in the name of the International Society for Environmental Epidemiology (ISEE) and the European Respiratory Society (ERS).

Results: Air pollutants affect the entire body, from the beginning of intrauterine development all the way to the end of life, causing premature death mainly through lung and heart disease. An epidemiological study has shown, for example, that mortality rises approximately 7% for every incremental long-term exposure to 5 μg/m3 PM2.5 (95% confidence interval: [2; 13]). Aside from lung and heart disease, the carcinogenic effect of fine dust is now well established. High fine-dust exposure has also been linked to metabolic diseases. For example, in a meta-analysis of cohort studies, the incidence of type 2 diabetes mellitus was found to be associated with elevated fine dust concentrations, with a 25% relative risk increase [10; 43] for every 10 µg/m3 of PM2.5. More recent studies have shown that these substances cause harm even in concentrations that are below the recommended limits.

Conclusion: It is very important for public health that the current EU standards for fine dust particles smaller than <2.5 µg are markedly lowered so that health risks can be further reduced, in accordance with the recommendations of the WHO.

LNSLNS

All across the world, the air contains contaminants from a host of sources. These substances form a mixture of many different individual components, some of them toxic. In recent decades, scientific research in this area has concentrated on the health effects of emissions from incomplete combustion processes. The most thoroughly investigated airborne contaminants, both in human exposure studies and in toxicological experiments, include fine dust, ozone, and nitrogen dioxide. Because these irritant or harmful substances are technically relatively easy to quantify, their levels have been measured widely in a large number of countries during the past several decades.

This article is based on a selective search of the literature in PubMed and, in part, on an expert report prepared on behalf of the International Society for Environmental Epidemiology (ISEE) and the European Respiratory Society (ERS) (e1).

Experiments on cells, animals, and humans

Toxicology studies and controlled exposure of volunteers serve to examine health effects resulting from chemical and physical properties of harmful substances in the air. These investigations provide important data on biological effects in the human body, but do not permit conclusions as to the incidence of diseases or the worsening of existing illness. Controlled exposure studies on human volunteers are particularly useful for determining short-term changes, e.g., in lung function or markers of inflammation. Even these investigations are, on ethical grounds, usually conducted only in relatively healthy persons (eBox 1).

Effects of harmful airborne substances on the human body documented in population studies*
Effects of harmful airborne substances on the human body documented in population studies*
Box
Effects of harmful airborne substances on the human body documented in population studies*
Sources and health effects of airborne contaminants
Sources and health effects of airborne contaminants
eBox 1
Sources and health effects of airborne contaminants

Risk factor research in humans: analytical epidemiology

On grounds of ethics and practicality, the incidence of illness and death cannot be investigated in randomized clinical trials. This principle applies to air pollution just as it does to other risk factors, e.g., smoking. The method of choice for estimating the short- and long-term effects in different age groups and patient cohorts is therefore the large epidemiological observational study. Air pollution studies use the same tried and tested methods by means of which the deleterious effects of other generally accepted risk factors such as hypertension, hypercholesterolemia, and smoking (active and passive) were established. Because population exposure is meanwhile well documented by widespread and continuous measurement of airborne contaminants in many different countries, scientists can now gauge the short- and long-term effects of these substances under real world conditions in broad-based population studies.

Investigation of short-term effects

Epidemiological research began with time-series studies of specific morbidity or mortality based on death registers or hospital admission data (16). These studies are methodologically very robust, because they use high-quality population-wide data and are affected only slightly or not at all by self-selection, measurement errors, or certain confounders: every death is counted, no-one can decline to participate in the study, and air pollution is measured with sensitive, standardized instruments in population centers. Daily changes in the levels of contaminants are compared with daily rates of death or hospital admission for asthma, bronchitis, myocardial infarction, or stroke and the short-term effects of higher exposure to dust, nitrogen oxides, or ozone are calculated. The analyses take other risk factors into account that vary in the short term, such as temperature or the influenza season. Long-term risk factors (smoking or dietary habits, lifestyle, occupational exposures, or exposures from indoor sources) do not need to be considered in such studies, because they are not associated with short-term fluctuations in airborne contaminants, so there can be no confounding of effects. The same applies to panel studies, in which probands are investigated several times at intervals of days or weeks. Here, the change in air pollution before the study visits is associated with alterations in various physiological parameters (lung function, inflammation markers, blood pressure, and others), although owing to the study design only risk factors that are variable in the short term (e.g., passive smoking on the evening before examination) have to be considered as possible confounders.

Investigation of long-term effects

In order to determine the longer-term health effects of chronic exposure to airborne contaminants, very large cohort studies have been carried out particularly in North America, Europe, and, in recent years, countries such as China (1720). These studies are scientifically complex, costly, and of high validity. As a rule they use cohorts originally recruited for research targeting common illnesses such as cancer or cardiovascular disease (ACS Cancer Prevention Study, KORA Study, Heinz Nixdorf Recall Study, etc.). These studies are characterized by detailed and high quality data, including the careful documentation of many personal risk factors and medical history data as well potential confounders—for which adjustments can be made in the course of analysis (for indoor air exposure as a potential confounder, see eBox 2). They include children and both healthy and sick persons, and permit documentation of sensitive biomarkers and long-term exposures.

Contamination of indoor air
Contamination of indoor air
eBox 2
Contamination of indoor air

One challenge in the planning, conduct, and analysis of long- and short-term epidemiological studies is that fine dust, ozone, and nitrogen dioxide have common sources and thus often occur at the same time in the same place, affecting the human body jointly (23). Furthermore, other harmful airborne substances, such as soot, ultrafine particles (<100 nm), or volatile organic compounds, may be present in addition to fine dust and nitrogen dioxide (24). For this reason, additional measurements, satellite data, and complex modeling are used to estimate the exposure, ideally in terms of both time and space. The closer the correlation between the individual airborne contaminants, the more difficult (or even impossible) it is to isolate their respective effects. Although the sources of the substances overlap, their distribution in the ambient air may well differ. For example, fine dust is relatively evenly distributed: the difference in concentration between the districts of a city with the highest and lowest exposure is in the range of 2 to 4 μg/m3. For NO2, in contrast, the difference is much greater, sometimes more than 20 μg/m3 (25). This results in a less than perfect correlation of exposures, permitting partial isolation of the effects. Multicenter cohort studies with greatly different compositions (mixtures) and concentrations of contaminants enable separation of the effects of different substances.

Natural experiments and intervention studies

A particularly important contribution to causal inference has been made by quasi-experimental studies. Such “natural experiments” have resulted in dramatic reductions in air pollution levels due to environmental regulations invoked for the Olympic Games in Atlanta (26) and in Beijing (27, e14, e15) and they have shown a direct connection between temporary or permanent closure of heavily polluting industrial plants or power stations and reduction of airway diseases (including asthma). The temporary closure of a steelmill in Utah that caused high local contamination from particulates was associated with a simultaneous two- to threefold decrease in admission of children to the hospital because of asthma and bronchitis (28). Similarly, data analyzed using sophisticated methodology show that retirements of coal and oil power plants in California were associated with a reduction in preterm births from 7.0% to 5.1% within a radius of 5 km (29). Particularly revealing is another Californian study that monitored children’s lung function from 10 to 18 years of age. The authors found not only that lung function and lung growth were impaired with higher exposure, but also that a move to an area with better or worse air quality was followed by improvement or deterioration of lung development, respectively (30, e16). For example, the forced expiratory volume in 1 s (FEV1; observed FEV1 <80% of expected FEV1) of 18-year-olds in regions with elevated fine-dust pollution was lower (7.9% versus 1.6% showed impairment, P = 0.002).

The Table summarizes the associations considered by experts to be scientifically confirmed, as of 2016 (Table).

Associations regarded as scientifically confirmed on the basis of expert evaluation up to 2016*
Associations regarded as scientifically confirmed on the basis of expert evaluation up to 2016*
Table
Associations regarded as scientifically confirmed on the basis of expert evaluation up to 2016*

The Box lists the effects of harmful airborne substances on the human body that have been observed in population studies. The findings range all the way from effects in the womb through acute and chronic illness in children and adults to premature death, and many different organs and physiological processes are affected. Thousands of earlier studies (32), including the earliest on overall mortality (e17e20) and airway disease (e3, e21) as well as prominent studies on cardiovascular disease (e4, e6), have been joined by more recent studies on metabolic diseases (diabetes: risk raised by 25% per 10 μg/m3 PM2.5, 95% confidence interval [10; 43] [e22]), problems during pregnancy (e.g., high blood pressure [e23] or an increase of 13% [3; 24] in preterm births per 10 µg/m3 PM2.5 [e24]), effects on lung and brain development in children (systematic reviews [e25, e26]), and even on skin aging (e27). In recent years the aging brain has also been investigated as a possible site of damage by airborne contaminants, and an elevated risk of stroke (e28) and higher levels of neurodegeneration (e29), cognitive impairment (systematic review [e30]), and dementia (systematic review [e31]) have been documented in persons exposed to higher concentrations in population studies.

These effects are relatively small in size compared with those of other risk factors, e.g., smoking, but given the ubiquity of exposure they are relevant for the overall disease burden in the population. For example, epidemiological studies show an increase of around 7% [2; 13] in mortality for every 5 μg/m3 rise in long-term exposure to PM2.5 (33). Moreover, an approximately 12% [1; 25] increase in the likelihood of a myocardial infarction per 10 μg/m3 rise in long-term exposure to PM10 has been reported (8). Extrapolating these figures to the population disease burden, fine dust ranks ninth among the most important risk factors in Germany (e32).

Evidence and causality

No single study, however large, permits judgment of causality. Rather, in assessing the existence of a relationship between exposure and effect, international expert panels draw on all published studies in the course of a defined, transparent, and documented process. Studies of different designs with differing strengths and weaknesses are evaluated jointly according to criteria drawn up in advance, contradictory findings are weighed against each other, and, whenever the data permit, the results are summarized in meta-analyses. Furthermore, toxicological and animal studies are scrutinized to assess the existence of biologically plausible mechanisms for the dose–effect relationship in question. The state of knowledge can be evaluated according to the Bradford-Hill guidelines (e11). This also forms the basis of the procedure followed by well-respected organizations such as the International Agency for Research on Cancer (IARC) (e12) and the US National Academy of Medicine/National Academy of Science (IOM/NAS) in determining causal relationships from research findings. The US Environmental Protection Agency (EPA) and the World Health Organization (WHO) avail themselves of similar criteria (e13). Causality is regarded as confirmed in the presence of a relationship for which there are a sufficient number of population studies in which random errors, bias, and other confounders can be largely excluded or which are supported by the results of toxicological studies, especially if these show environmentally relevant concentrations. A causal connection is deemed probable if there are clear indications of causality, but the published data are regarded as too uninformative to fulfill all the criteria for causality. Causal relationships can be inferred in the context of an overall scientific appraisal of purely observational studies together with experimental studies and mechanistic considerations.

Definition of general reference values

The WHO issues advice on concentrations of harmful airborne substances: the WHO Air Quality Guidelines. These recommendations, based on the available evidence from population-based, toxicological, and animal studies, attempt to define levels below which obvious effects on health can no longer be demonstrated. The latest version of the Air Quality Guidelines was issued in 2005 and thus takes no account of the considerable growth in evidence from large prospective studies published in the past 15 years. The 2005 reference value for nitrogen dioxide was set at 40 µg/m3 on the basis of long-term animal experiments and the population-based studies existing at the time. However, more recent research shows effects below 40 µg/m3, prompting the European Union (EU) to commission a review of the evidence in 2013. Specifically for nitrogen dioxide, this review showed that health effects can be regarded as confirmed above a threshold value of 20 µg/m3 (24, e33). Decisive was a meta-analysis of more than 15 long-term studies on nitrogen dioxide (34), which revealed a 5% [3; 8] increase in the risk of death for every 10 µg/m3 NO2 (34). As for fine dust, studies with millions of probands have shown clear effects below the current WHO reference value of 10 µg/m3 for PM2.5. A study in the USA, for example, comes to the conclusion that overall mortality in persons over 65 years of age below 12 µg/m3 PM2.5 (the current threshold in the USA) is associated with an increase in mortality of 13.6% [13.1; 14.1] per 10 µg/m3 PM2.5 (e34). The latest figures from Europe, presented in August 2019 at the ISEE annual conference in Utrecht, show even greater effects. At a mean exposure of around 15 µg/m3 PM2.5, mortality (from natural causes) was found to increase by 13% [11; 16] per 5 µg/m3 PM2.5 (e35). Owing to these new research findings, the WHO is currently conducting a comprehensive revision of its recommendations. Publication of the new Air Quality Guidelines is expected in 2020.

Recommendations and standards

The setting of legal standards is a political process that considers scientific recommendations, including the WHO Air Quality Guidelines. The thresholds in the EU, which draw upon the WHO recommendations, are approved by the European Parliament and implemented according to national laws of EU member countries. Thus in 2008 the WHO recommendation for long-term threshold concentrations of nitrogen dioxide (40 µg/m3) was adopted by the EU, but the recommendation for fine dust was exceeded 2.5-fold. This can best be explained by a combination of political influence and economic considerations, which affect such decisions at the EU level. The regulations in the USA draw upon legally prescribed scientific evaluations that are updated at regular intervals (e9). These region-specific processes result in and explain the large variation in legislation across the world (35). The latest research findings demonstrate the urgent need for action in Europe, especially with regard to lowering of the standard for fine dust. Switzerland has adopted the 2005 WHO advice on standards for fine dust and implemented a threshold for nitrogen dioxide (30 µg/m3) that is actually below the WHO recommendation (e36, e37). To date, however, only seven states have passed laws implementing the WHO recommendations for fine dust (an annual mean of 10 µg/m3 PM2.5) (35).

Success can be measured

A study in the USA reported that a lowering of 10 µg/m3 PM10 would be associated with an increase of 6 months in life expectancy (36). Estimates for Denmark show that on average, a 20% reduction in NO2 would bring about gains of 1.3 to 1.6 years of disease-free life and 0.3 to 0.5 years of overall life expectancy (37). And according to reports from Switzerland (38), improvement of air quality results in decreased medical treatment costs and fewer days absenteeism from work. Ultimately, a society has to decide at what point it pays to take preventive measures. Decisions of this nature are based on cost–benefit calculations in which the economic costs for air quality enhancement have to be balanced against health advantages. Such calculations have been performed, for example, by the EPA and the International Institute for Applied Systems Analysis (IIASA) and show that both in the USA and in Europe, the benefits clearly outweigh the costs (e38, e39). While cost–benefit considerations hold in the USA, in Europe the precautionary principle is applied to decisions on standards. This means that legislative bodies must protect the population from substances that may be harmful, even if the potential for harm has not (yet) been confirmed by research. The current legal thresholds do not live up to this principle, in that obvious health effects occur at sub-threshold concentrations. Further reduction of the standards for harmful airborne substances is thus necessary not only from an economic point of view but also in order to comply with the ethical obligation to protect the general population. Furthermore, most measures to lower air pollution also confer a considerable bonus in terms of climate protection, so that improvement of air quality represents a triple-win situation.

Acknowledgments
We thank Bert Brunekreef, Nino Künzli, Meltem Kutlar Joss, Holger Schulz, Kurt Straif, Nicole Probst-Hensch, and H. Erich Wichmann for their contributions.

Conflict of interest statement
The authors declare that no conflict of interest exists.


Manuscript received on 13 June 2019, revised version accepted on 15 November 2019

Translated from the original German by David Roseveare

Corresponding author
Prof. Dr. med. Beate Ritz
Dept. of Epidemiology, Fielding School of Public Health
University of California Los Angeles
650 Charles Young Drive South
Los Angeles, CA 90095–1772, USA
britz@ucla.edu

Cite this as:
Ritz B, Hoffmann B, Peters A: The effects of fine dust, ozone,
and nitrogen dioxide on health. Dtsch Arztebl Int 2019; 116: 881–6.
DOI: 10.3238/arztebl.2019.0881

Supplementary material

For eReferences please refer to:
www.aerzteblatt-international.de/ref5119

eBoxes:
www.aerzteblatt-international.de/19m0881

1.
Umwelt Bundesamt: Feinstaub. www.umweltbundesamt.de/themen/luft/luftschadstoffe/feinstaub (last accessed on 15 June 2019).
2.
Sutton MA, Howard CM, Erisman JW, et al.: The European nitrogen assessment. Sources, effects and policy perspectives. United Kingdom: Cambridge University Press 2011.
3.
Cassee FR, Héroux ME, Gerlofs-Nijland ME, Kelly FJ: Particulate matter beyond mass: recent health evidence on the role of fractions, chemical constituents and sources of emission. Inhal Toxicol 2013; 25: 802–12 CrossRef MEDLINE PubMed Central
4.
Pope CA 3rd, Muhlestein JB, May HT, Renlund DG, Anderson JL, Horne BD: Ischemic heart disease events triggered by short-term exposure to fine particulate air pollution. Circulation 2006; 114: 2443–8 CrossRef MEDLINE
5.
Prussin AJ 2nd, Marr LC: Sources of airborne microorganisms in the built environment. Microbiome 2015; 3: 78 CrossRef MEDLINE PubMed Central
6.
Halliwell B, Hu ML, Louie S, et al.: Interaction of nitrogen dioxide with human plasma. Antioxidant depletion and oxidative damage. FEBS Lett 1992; 313: 62–6 CrossRef
7.
Eidgenössische Kommission für Lufthygiene: Stickstoffhaltige Luftschadstoffe in der Schweiz. Status-Bericht der Eidgenössische Kommission für Lufthygiene. Bern: Bundesamt für Umwelt, Wald und Landschaft BUWAL 2005.
8.
Umwelt Bundesamt: Luftschadstoffbelastung in Deutschland. http://gis.uba.de/Website/luft/index.html (last accessed on 15 June 2019).
9.
Umwelt Bundesamt: Stickstoffoxide. www.umweltbundesamt.de/themen/luft/luftschadstoffe/stickstoffoxide (last accessed on 15 June 2019).
10.
Turner MC, Jerrett M, Pope CA , et al.: Long-term ozone exposure and mortality in a large prospective study. Am J Respir Crit Care Med 2016; 193: 1134–42 CrossRef MEDLINE PubMed Central
11.
Brown JS: Nitrogen dioxide exposure and airway responsiveness in individuals with asthma. Inhal Toxicol 2015; 27: 1–14 CrossRef MEDLINE
12.
Brunekreef B, Beelen R, Hoek G, et al.: Effects of long-term exposure to traffic-related air pollution on respiratory and cardiovascular mortality in the Netherlands: The NLCS-AIR Study. Res Rep Health Eff Inst, Boston, MA 2019; 5–71.
13.
Atkinson RW, Butland BK, Anderson HR, Maynard RL: Long-term concentrations of nitrogen dioxide and mortality: A meta-analysis of cohort studies. Epidemiology 2018; 29: 460–72 CrossRef MEDLINE PubMed Central
14.
Schneider A, Cyrys J, Breitner S, Kraus U, Peters A: Quanitifizierung von umweltbedingten Krankheitslasten aufgrund der Stickstoffdioxid-Exposition in Deutschland. Neuherberg: Umwelt & Gesundheit 2018.
15.
Karoui A, Crochemore C, Mulder P, et al.: An integrated functional and transcriptomic analysis reveals that repeated exposure to diesel exhaust induces sustained mitochondrial and cardiac dysfunctions. Environ Pollut 2019; 246: 518–26 CrossRef MEDLINE
16.
Thurston GD: A critical review of PM10-mortality time-series studies. J Expo Anal Environ Epidemiol 1996; 6: 3–21.
17.
Helmholtz Zentrum München: Kooperative Gesundheitsforschung in der Region Augsburg (KORA). www.helmholtz-muenchen.de/kora/index.html (last accessed on 15 June 2019).
18.
Eeftens M, Beelen R, de Hoogh K, et al.: Development of land use regression models for PM2.5, PM2.5 absorbance, PM10 and PMcoarse in 20 European study areas; results of the ESCAPE project. Environ Sci Technol 2012; 46: 11195–205 CrossRef MEDLINE
19.
Mahabadi AA, Möhlenkamp S, Moebus S, et al.: The Heinz Nixdorf Recall study and its potential impact on the adoption of atherosclerosis imaging in European primary prevention guidelines. Curr Atheroscler Rep 2011; 13: 367–72 CrossRef MEDLINE
20.
American Cancer Society: Cancer Prevention Study II (CPS II). www.cancer.org/research/we-conduct-cancer-research/epidemiology/cancer-prevention-study-2.html (last accessed on 15 June 2019).
21.
World Health Organization: WHO guidelines for indoor air quality: selected pollutants. Copenhagen: World Health Organization Regional Office for Europe 2010.
22.
Umwelt Bundesamt: Innenraumluft. www.umweltbundesamt.de/themen/gesundheit/umwelteinfluesse-auf-den-menschen/innenraumluft (last accessed on 29 September 2019).
23.
Campen M, Robertson S, Lund A, Lucero J, McDonald J: Engine exhaust particulate and gas phase contributions to vascular toxicity. Inhal Toxicol 2014; 26: 353–60 CrossRef MEDLINE PubMed Central
24.
World Health Organization: Review of evidence on health aspects of air pollution – REVIHAAP Project: Technical Report. Copenhagen: WHO Regional Office for Europe 2013.
25.
Cesaroni G, Forastiere F, Stafoggia M, et al.: Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project. BMJ 2014; 348: f7412.
26.
Friedman MS, Powell KE, Hutwagner L, Graham LM, Teague WG: Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma. JAMA 2001; 285: 897–905 CrossRef MEDLINE
27.
Lin WW, Huang W, Zhu T, et al.: Acute respiratory inflammation in children and black carbon in ambient air before and during the 2008 Beijing olympics. Environ Health Perspect 2011; 119: 1507–12 CrossRef MEDLINE PubMed Central
28.
Pope CA 3rd: Respiratory disease associated with community air pollution and a steel mill, Utah Valley. Am J Public Health 1989; 79: 623–8 CrossRef MEDLINE PubMed Central
29.
Casey JA, Karasek D, Ogburn EL, et al. : Retirements of coal and oil power plants in California: association with reduced preterm birth among populations nearby. Am J Epidemiol 2018; 187: 1586–94 CrossRef MEDLINE PubMed Central
30.
Gauderman WJ, Avol E, Gilliland F, et al.: The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med 2004; 351: 1057–67 CrossRef MEDLINE
31.
Thurston GD, Kipen H, Annesi-Maesano I, et al.: A joint ERS/ATS policy statement: what constitutes an adverse health effect of air pollution? An analytical framework. Eur Respir J 2017; 49 CrossRef MEDLINE PubMed Central
32.
Sun Z, Zhu D: Exposure to outdoor air pollution and its human health outcomes: A scoping review. PLoS One 2019; 14: e0216550 CrossRef MEDLINE PubMed Central
33.
Beelen R, Raaschou-Nielsen O, Stafoggia M, et al.: Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project. Lancet 2014; 383: 785–95 CrossRef
34.
Hoek G, Krishnan RM, Beelen R, et al. : Long-term air pollution exposure and cardio-respiratory mortality: a review. Environ Health 2013; 12: 43 CrossRef MEDLINE PubMed Central
35.
Kutlar JM, Eeftens M, Gintowt E, Kappeler R, Künzli N: Time to harmonize national ambient air quality standards. Int J Public Health 2017; 62: 453–62 CrossRef MEDLINE PubMed Central
36.
Pope CA 3rd, Ezzati M, Dockery DW: Fine-particulate air pollution and life expectancy in the United States. N Engl J Med 2009; 360: 376–86 CrossRef MEDLINE PubMed Central
37.
Brønnum-Hansen H, Bender AM, Andersen ZJ, et al.: Assessment of impact of traffic-related air pollution on morbidity and mortality in Copenhagen municipality and the health gain of reduced exposure. Environ Int 2018; 121: 973–80 CrossRef MEDLINE
38.
Castro A, Künzli N, Götschi T: Health benefits of a reduction of PM10 and NO2 exposure after implementing a clean air plan in the Agglomeration Lausanne-Morges. Int J Hyg Environ Health 2017; 220: 829–39 CrossRef MEDLINE
e1.
Peters A, Hoffmann B, Brunekreef B, et al.: Die Rolle der Luftschadstoffe für die Gesundheit. Eine Expertise im Namen der Internationalen Gesellschaft für Umweltepidemiologie (ISEE) und der European Respiratory Society (ERS) 2019. https://ers.app.box.com/s/lab57dxgqqzmbbzjhempf5oiob8s795b (last accessed on 29 September 2019).
e2.
U.S. Environmental Protection Agency: Integrated Science Assessment (ISA) for particulate matter (Final Report, Dec 2009). Washington, DC: U.S. Environmental Protection Agency 2009.
e3.
McConnell R, Berhane K, Gilliland F, et al.: Prospective study of air pollution and bronchitic symptoms in children with asthma. Am J Respir Crit Care Med 2003; 168: 790–797 CrossRef MEDLINE
e4.
Peters A, Liu E, Verrier RL, et al.: Air pollution and incidence of cardiac arrhythmia. Epidemiology 2000; 11: 11–17 CrossRef MEDLINE
e5.
International Agency for Research on Cancer: Outdoor air pollution/IARC monographs on the evaluation of carcinogenic risks to humans. Lyon: International Agency for Research on Cancer 2016.
e6.
Turner MC, Krewski D, Diver WR, et al: Ambient air pollution and cancer mortality in the cancer prevention study II. Environ Health Perspect 2017; 125: 087013 CrossRef MEDLINE PubMed Central
e7.
Cesaroni G, Badaloni C, Gariazzo C, et al.: Long-term exposure to urban air pollution and mortality in a cohort of more than a million adults in Rome. Environ Health Perspect 2013; 121: 324–31 CrossRef MEDLINE PubMed Central
e8.
Carey IM, Atkinson RW, Kent AJ, van Staa T, Cook DG, Anderson HR: Mortality associations with long-term exposure to outdoor air pollution in a national English cohort. Am J Respir Crit Care Med 2013; 187: 1226–33 CrossRef MEDLINE PubMed Central
e9.
U.S. Environmental Protection Agency: Integrated Science Assessment (ISA) of ozone and related photochemical oxidants (Final Report, Feb 2013). Washington, DC: U.S. Environmental Protection Agency 2013.
e10.
U.S. Environmental Protection Agency: Integrated Science Assessment for oxides of nitrogen – Health criteria. Research Triangle Park: Office of Research and Development, National Center for Environmental Assessment 2016.
e11.
Hill AB: The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295–300 CrossRef
e12.
WHO, International Agency for Research on Cancer: IARC monographs on the identification of carcinogenic hazards to humans.; Lyon France. Amended 2019 (last accessed on 29 September 2019).
e13.
Owens EO, Patel MM, Kirrane E, et al.: Framework for assessing causality of air pollution-related health effects for reviews of the National Ambient Air Quality Standards. Regul Toxicol Pharmacol 2017; 88: 332–7 CrossRef MEDLINE PubMed Central
e14.
Li Y, Wang W, Kan H, Xu X, Chen B: Air quality and outpatient visits for asthma in adults during the 2008 Summer Olympic Games in Beijing. Sci Total Environ 2010; 408: 1226–7 CrossRef MEDLINE
e15.
Zhang Z, Wang J, Liu F, et al.: Impacts of event-specific air quality improvements on total hospital admissions and reduced systemic inflammation in COPD patients. PLoS One 2019; 14: e0208687 CrossRef MEDLINE PubMed Central
e16.
Avol EL, Gaudermann WJ, Tan SM, London SJ, Peters JM: Respiratory effects of relocating to areas of differing air pollution levels. AM J Respir VCrit Care Med 2001; 164: 2067–72 CrossRef MEDLINE
e17.
Martin AE, Bradley WH: Mortality, fog and atmospheric pollution: an investigation during the winter of 1958–59. Mon Bull Minist Health Public Health Lab Serv 1960; 19: 56–72.
e18.
Hechter HH, Goldsmith JR: Air pollution and daily mortality. Am J Med Sci 1961;241: 581–8 CrossRef
e19.
Rumford J : Mortality studies in relation to air pollution. Am J Public Health Nations Health 1961; 51: 165–73 CrossRef MEDLINE PubMed Central
e20.
Schwartz J, Dockery DW: Increased mortality in Philadelphia associated with daily air pollution concentrations. Am Rev Respir Dis 1992; 145: 600–4 CrossRef MEDLINE
e21.
Stocks P, Campbell JM: Lung cancer death rates among non-smokers and pipe and cigarette smokers: An evaluation in relation to air pollution by benzpyrene and other substances. BMJ 1955; 2: 923–9 CrossRef MEDLINE PubMed Central
e22.
He D, Wu S, Zhao H, et al.: Association between particulate matter 2.5 and diabetes mellitus: a meta-analysis of cohort studies. J Diabetes Investig 2017; 8: 687–96 CrossRef MEDLINE PubMed Central
e23.
Pedersen M, Stayner L, Slama R, et al.: Ambient air pollution and pregnancy-induced hypertensive disorders: a systematic review and meta-analysis. Hypertension 2014; 64: 494–500 CrossRef MEDLINE
e24.
Sun X, Luo X, Zhao C, et al.: The associations between birth weight and exposure to fine particulate matter (PM2.5) and its chemical constituents during pregnancy: a meta-analysis. Environ Pollut 2016; 211:38–47 CrossRef MEDLINE
e25.
Schultz ES, Litonjua AA, Melen E: Effects of long-term exposure to traffic-related air pollution on lung function in children. Curr Allergy Asthma Rep 2017; 17: 41 CrossRef MEDLINE PubMed Central
e26.
Clifford A, Lang L, Chen R, Anstey KJ, Seaton A: Exposure to air pollution and cognitive functioning across the life course— a systematic literature review. Environ Res 2016; 147: 383–98 CrossRef MEDLINE
e27.
Ngoc LTN, Park D, Lee Y, Lee YC: Systematic Review and Meta-analysis of human skin diseases due to particulate matter. Int J Environ Res Public Health 2017; 14: E1458 CrossRef MEDLINE PubMed Central
e28.
Ljungman PL, Mittleman MA: Ambient air pollution and stroke. Stroke 2014; 45: 3734–41 CrossRef MEDLINE PubMed Central
e29.
Ritz B, Lee PC, Hansen J, et al.: Traffic-related air pollution and Parkinson’s disease in Denmark: A case–control study. Environ Health Perspec 2016; 124: 351–6 CrossRef MEDLINE PubMed Central
e30.
Paul KC, Haan M, Mayeda ER, Ritz BR: Ambient air pollution, noise, and late-life cognitive decline and dementia risk. Annu Rev Public Health 2019; 40: 203–20 CrossRef MEDLINE PubMed Central
e31.
Power MC, Adar SD, Yanosky JD, Weuve J: Exposure to air pollution as a potential contributor to cognitive function, cognitive decline, brain imaging, and dementia: a systematic review of epidemiologic research. Neurotoxicology 2016; 56: 235–53 CrossRef MEDLINE PubMed Central
e32.
Plass D, Vos T, Hornberg C, Scheidt-Nave C, Zeeb H, Krämer A: Trends in disease burden in Germany—results, implications and limitations of the Global Burden of Disease Study. Dtsch Arztebl Int 2014; 111: 629–38 VOLLTEXT
e33.
World Health Organization: Health risks of air pollution in Europe – HRAPIE project. Copenhagen: World Health Organization Regional Office for Europe 2013.
e34.
Di Q, Wang Y, Zanobetti A, et al.: Air pollution and mortality in the medicare population. N Engl J Med 2017; 376: 2513–22 CrossRef MEDLINE PubMed Central
e35.
Strak M, Weinmayr G, Rodopolou S, et al: Natural and cause-specific mortality and low-level air pollution in a pooled cohort of 392,826 participants in Europe: the ELAPSE project. https://journals.lww.com/environepidem/toc/2019/10001 (last accessed on 12 March 2019).
e36.
Eidgenössische Kommission for Lufthygiene: Feinstaub in der Schweiz 2013. Bern: Eidgenössische Kommission for Lufthygiene 2013.
e37.
Der Schweizerische Bundesrat: Luftreinhalte-Verordnung (LRV) vom 16. Dezember 1985 (Stand am 16. April 2018). Bern: Der Schweizerische Bundesrat 1985.
e38.
Amann M, Holland M, Maas R, Saveyn B, Vandyck T: Costs, benefits and economic impacts of the EU clean air strategy and their implications on innovation and competitiveness. Laxxenburg: International Institute for Applied Systems Analysis (IIASA) 2017.
e39.
U.S. Environmental Protection Agency: Economic and cost analysis for air pollution regulations. www.epa.gov/economic-and-cost-analysis-air-pollution-regulations (last accessed on 15 June 2019).
University of California, Los Angeles, USA: Prof. Dr. med. Beate Ritz
Institute of Occupational, Social, and Environmental Medicine, University of Düsseldorf:
Prof. Dr. med. Barbara Hoffmann MPH
Helmholtz Center Munich and University of Munich:
Prof. Dr. rer. biol. hum. Annette Peters
Effects of harmful airborne substances on the human body documented in population studies*
Effects of harmful airborne substances on the human body documented in population studies*
Box
Effects of harmful airborne substances on the human body documented in population studies*
Key messages
Associations regarded as scientifically confirmed on the basis of expert evaluation up to 2016*
Associations regarded as scientifically confirmed on the basis of expert evaluation up to 2016*
Table
Associations regarded as scientifically confirmed on the basis of expert evaluation up to 2016*
Sources and health effects of airborne contaminants
Sources and health effects of airborne contaminants
eBox 1
Sources and health effects of airborne contaminants
Contamination of indoor air
Contamination of indoor air
eBox 2
Contamination of indoor air
1.Umwelt Bundesamt: Feinstaub. www.umweltbundesamt.de/themen/luft/luftschadstoffe/feinstaub (last accessed on 15 June 2019).
2.Sutton MA, Howard CM, Erisman JW, et al.: The European nitrogen assessment. Sources, effects and policy perspectives. United Kingdom: Cambridge University Press 2011.
3.Cassee FR, Héroux ME, Gerlofs-Nijland ME, Kelly FJ: Particulate matter beyond mass: recent health evidence on the role of fractions, chemical constituents and sources of emission. Inhal Toxicol 2013; 25: 802–12 CrossRef MEDLINE PubMed Central
4.Pope CA 3rd, Muhlestein JB, May HT, Renlund DG, Anderson JL, Horne BD: Ischemic heart disease events triggered by short-term exposure to fine particulate air pollution. Circulation 2006; 114: 2443–8 CrossRef MEDLINE
5.Prussin AJ 2nd, Marr LC: Sources of airborne microorganisms in the built environment. Microbiome 2015; 3: 78 CrossRef MEDLINE PubMed Central
6.Halliwell B, Hu ML, Louie S, et al.: Interaction of nitrogen dioxide with human plasma. Antioxidant depletion and oxidative damage. FEBS Lett 1992; 313: 62–6 CrossRef
7.Eidgenössische Kommission für Lufthygiene: Stickstoffhaltige Luftschadstoffe in der Schweiz. Status-Bericht der Eidgenössische Kommission für Lufthygiene. Bern: Bundesamt für Umwelt, Wald und Landschaft BUWAL 2005.
8.Umwelt Bundesamt: Luftschadstoffbelastung in Deutschland. http://gis.uba.de/Website/luft/index.html (last accessed on 15 June 2019).
9.Umwelt Bundesamt: Stickstoffoxide. www.umweltbundesamt.de/themen/luft/luftschadstoffe/stickstoffoxide (last accessed on 15 June 2019).
10.Turner MC, Jerrett M, Pope CA , et al.: Long-term ozone exposure and mortality in a large prospective study. Am J Respir Crit Care Med 2016; 193: 1134–42 CrossRef MEDLINE PubMed Central
11.Brown JS: Nitrogen dioxide exposure and airway responsiveness in individuals with asthma. Inhal Toxicol 2015; 27: 1–14 CrossRef MEDLINE
12.Brunekreef B, Beelen R, Hoek G, et al.: Effects of long-term exposure to traffic-related air pollution on respiratory and cardiovascular mortality in the Netherlands: The NLCS-AIR Study. Res Rep Health Eff Inst, Boston, MA 2019; 5–71.
13.Atkinson RW, Butland BK, Anderson HR, Maynard RL: Long-term concentrations of nitrogen dioxide and mortality: A meta-analysis of cohort studies. Epidemiology 2018; 29: 460–72 CrossRef MEDLINE PubMed Central
14. Schneider A, Cyrys J, Breitner S, Kraus U, Peters A: Quanitifizierung von umweltbedingten Krankheitslasten aufgrund der Stickstoffdioxid-Exposition in Deutschland. Neuherberg: Umwelt & Gesundheit 2018.
15.Karoui A, Crochemore C, Mulder P, et al.: An integrated functional and transcriptomic analysis reveals that repeated exposure to diesel exhaust induces sustained mitochondrial and cardiac dysfunctions. Environ Pollut 2019; 246: 518–26 CrossRef MEDLINE
16.Thurston GD: A critical review of PM10-mortality time-series studies. J Expo Anal Environ Epidemiol 1996; 6: 3–21.
17.Helmholtz Zentrum München: Kooperative Gesundheitsforschung in der Region Augsburg (KORA). www.helmholtz-muenchen.de/kora/index.html (last accessed on 15 June 2019).
18.Eeftens M, Beelen R, de Hoogh K, et al.: Development of land use regression models for PM2.5, PM2.5 absorbance, PM10 and PMcoarse in 20 European study areas; results of the ESCAPE project. Environ Sci Technol 2012; 46: 11195–205 CrossRef MEDLINE
19.Mahabadi AA, Möhlenkamp S, Moebus S, et al.: The Heinz Nixdorf Recall study and its potential impact on the adoption of atherosclerosis imaging in European primary prevention guidelines. Curr Atheroscler Rep 2011; 13: 367–72 CrossRef MEDLINE
20. American Cancer Society: Cancer Prevention Study II (CPS II). www.cancer.org/research/we-conduct-cancer-research/epidemiology/cancer-prevention-study-2.html (last accessed on 15 June 2019).
21.World Health Organization: WHO guidelines for indoor air quality: selected pollutants. Copenhagen: World Health Organization Regional Office for Europe 2010.
22.Umwelt Bundesamt: Innenraumluft. www.umweltbundesamt.de/themen/gesundheit/umwelteinfluesse-auf-den-menschen/innenraumluft (last accessed on 29 September 2019).
23.Campen M, Robertson S, Lund A, Lucero J, McDonald J: Engine exhaust particulate and gas phase contributions to vascular toxicity. Inhal Toxicol 2014; 26: 353–60 CrossRef MEDLINE PubMed Central
24.World Health Organization: Review of evidence on health aspects of air pollution – REVIHAAP Project: Technical Report. Copenhagen: WHO Regional Office for Europe 2013.
25.Cesaroni G, Forastiere F, Stafoggia M, et al.: Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project. BMJ 2014; 348: f7412.
26.Friedman MS, Powell KE, Hutwagner L, Graham LM, Teague WG: Impact of changes in transportation and commuting behaviors during the 1996 Summer Olympic Games in Atlanta on air quality and childhood asthma. JAMA 2001; 285: 897–905 CrossRef MEDLINE
27.Lin WW, Huang W, Zhu T, et al.: Acute respiratory inflammation in children and black carbon in ambient air before and during the 2008 Beijing olympics. Environ Health Perspect 2011; 119: 1507–12 CrossRef MEDLINE PubMed Central
28.Pope CA 3rd: Respiratory disease associated with community air pollution and a steel mill, Utah Valley. Am J Public Health 1989; 79: 623–8 CrossRef MEDLINE PubMed Central
29.Casey JA, Karasek D, Ogburn EL, et al. : Retirements of coal and oil power plants in California: association with reduced preterm birth among populations nearby. Am J Epidemiol 2018; 187: 1586–94 CrossRef MEDLINE PubMed Central
30.Gauderman WJ, Avol E, Gilliland F, et al.: The effect of air pollution on lung development from 10 to 18 years of age. N Engl J Med 2004; 351: 1057–67 CrossRef MEDLINE
31. Thurston GD, Kipen H, Annesi-Maesano I, et al.: A joint ERS/ATS policy statement: what constitutes an adverse health effect of air pollution? An analytical framework. Eur Respir J 2017; 49 CrossRef MEDLINE PubMed Central
32.Sun Z, Zhu D: Exposure to outdoor air pollution and its human health outcomes: A scoping review. PLoS One 2019; 14: e0216550 CrossRef MEDLINE PubMed Central
33.Beelen R, Raaschou-Nielsen O, Stafoggia M, et al.: Effects of long-term exposure to air pollution on natural-cause mortality: an analysis of 22 European cohorts within the multicentre ESCAPE project. Lancet 2014; 383: 785–95 CrossRef
34.Hoek G, Krishnan RM, Beelen R, et al. : Long-term air pollution exposure and cardio-respiratory mortality: a review. Environ Health 2013; 12: 43 CrossRef MEDLINE PubMed Central
35.Kutlar JM, Eeftens M, Gintowt E, Kappeler R, Künzli N: Time to harmonize national ambient air quality standards. Int J Public Health 2017; 62: 453–62 CrossRef MEDLINE PubMed Central
36. Pope CA 3rd, Ezzati M, Dockery DW: Fine-particulate air pollution and life expectancy in the United States. N Engl J Med 2009; 360: 376–86 CrossRef MEDLINE PubMed Central
37.Brønnum-Hansen H, Bender AM, Andersen ZJ, et al.: Assessment of impact of traffic-related air pollution on morbidity and mortality in Copenhagen municipality and the health gain of reduced exposure. Environ Int 2018; 121: 973–80 CrossRef MEDLINE
38.Castro A, Künzli N, Götschi T: Health benefits of a reduction of PM10 and NO2 exposure after implementing a clean air plan in the Agglomeration Lausanne-Morges. Int J Hyg Environ Health 2017; 220: 829–39 CrossRef MEDLINE
e1.Peters A, Hoffmann B, Brunekreef B, et al.: Die Rolle der Luftschadstoffe für die Gesundheit. Eine Expertise im Namen der Internationalen Gesellschaft für Umweltepidemiologie (ISEE) und der European Respiratory Society (ERS) 2019. https://ers.app.box.com/s/lab57dxgqqzmbbzjhempf5oiob8s795b (last accessed on 29 September 2019).
e2.U.S. Environmental Protection Agency: Integrated Science Assessment (ISA) for particulate matter (Final Report, Dec 2009). Washington, DC: U.S. Environmental Protection Agency 2009.
e3.McConnell R, Berhane K, Gilliland F, et al.: Prospective study of air pollution and bronchitic symptoms in children with asthma. Am J Respir Crit Care Med 2003; 168: 790–797 CrossRef MEDLINE
e4.Peters A, Liu E, Verrier RL, et al.: Air pollution and incidence of cardiac arrhythmia. Epidemiology 2000; 11: 11–17 CrossRef MEDLINE
e5.International Agency for Research on Cancer: Outdoor air pollution/IARC monographs on the evaluation of carcinogenic risks to humans. Lyon: International Agency for Research on Cancer 2016.
e6.Turner MC, Krewski D, Diver WR, et al: Ambient air pollution and cancer mortality in the cancer prevention study II. Environ Health Perspect 2017; 125: 087013 CrossRef MEDLINE PubMed Central
e7.Cesaroni G, Badaloni C, Gariazzo C, et al.: Long-term exposure to urban air pollution and mortality in a cohort of more than a million adults in Rome. Environ Health Perspect 2013; 121: 324–31 CrossRef MEDLINE PubMed Central
e8.Carey IM, Atkinson RW, Kent AJ, van Staa T, Cook DG, Anderson HR: Mortality associations with long-term exposure to outdoor air pollution in a national English cohort. Am J Respir Crit Care Med 2013; 187: 1226–33 CrossRef MEDLINE PubMed Central
e9.U.S. Environmental Protection Agency: Integrated Science Assessment (ISA) of ozone and related photochemical oxidants (Final Report, Feb 2013). Washington, DC: U.S. Environmental Protection Agency 2013.
e10.U.S. Environmental Protection Agency: Integrated Science Assessment for oxides of nitrogen – Health criteria. Research Triangle Park: Office of Research and Development, National Center for Environmental Assessment 2016.
e11.Hill AB: The environment and disease: association or causation? Proc R Soc Med 1965; 58: 295–300 CrossRef
e12.WHO, International Agency for Research on Cancer: IARC monographs on the identification of carcinogenic hazards to humans.; Lyon France. Amended 2019 (last accessed on 29 September 2019).
e13.Owens EO, Patel MM, Kirrane E, et al.: Framework for assessing causality of air pollution-related health effects for reviews of the National Ambient Air Quality Standards. Regul Toxicol Pharmacol 2017; 88: 332–7 CrossRef MEDLINE PubMed Central
e14. Li Y, Wang W, Kan H, Xu X, Chen B: Air quality and outpatient visits for asthma in adults during the 2008 Summer Olympic Games in Beijing. Sci Total Environ 2010; 408: 1226–7 CrossRef MEDLINE
e15. Zhang Z, Wang J, Liu F, et al.: Impacts of event-specific air quality improvements on total hospital admissions and reduced systemic inflammation in COPD patients. PLoS One 2019; 14: e0208687 CrossRef MEDLINE PubMed Central
e16.Avol EL, Gaudermann WJ, Tan SM, London SJ, Peters JM: Respiratory effects of relocating to areas of differing air pollution levels. AM J Respir VCrit Care Med 2001; 164: 2067–72 CrossRef MEDLINE
e17.Martin AE, Bradley WH: Mortality, fog and atmospheric pollution: an investigation during the winter of 1958–59. Mon Bull Minist Health Public Health Lab Serv 1960; 19: 56–72.
e18.Hechter HH, Goldsmith JR: Air pollution and daily mortality. Am J Med Sci 1961;241: 581–8 CrossRef
e19.Rumford J : Mortality studies in relation to air pollution. Am J Public Health Nations Health 1961; 51: 165–73 CrossRef MEDLINE PubMed Central
e20.Schwartz J, Dockery DW: Increased mortality in Philadelphia associated with daily air pollution concentrations. Am Rev Respir Dis 1992; 145: 600–4 CrossRef MEDLINE
e21.Stocks P, Campbell JM: Lung cancer death rates among non-smokers and pipe and cigarette smokers: An evaluation in relation to air pollution by benzpyrene and other substances. BMJ 1955; 2: 923–9 CrossRef MEDLINE PubMed Central
e22.He D, Wu S, Zhao H, et al.: Association between particulate matter 2.5 and diabetes mellitus: a meta-analysis of cohort studies. J Diabetes Investig 2017; 8: 687–96 CrossRef MEDLINE PubMed Central
e23.Pedersen M, Stayner L, Slama R, et al.: Ambient air pollution and pregnancy-induced hypertensive disorders: a systematic review and meta-analysis. Hypertension 2014; 64: 494–500 CrossRef MEDLINE
e24.Sun X, Luo X, Zhao C, et al.: The associations between birth weight and exposure to fine particulate matter (PM2.5) and its chemical constituents during pregnancy: a meta-analysis. Environ Pollut 2016; 211:38–47 CrossRef MEDLINE
e25.Schultz ES, Litonjua AA, Melen E: Effects of long-term exposure to traffic-related air pollution on lung function in children. Curr Allergy Asthma Rep 2017; 17: 41 CrossRef MEDLINE PubMed Central
e26.Clifford A, Lang L, Chen R, Anstey KJ, Seaton A: Exposure to air pollution and cognitive functioning across the life course— a systematic literature review. Environ Res 2016; 147: 383–98 CrossRef MEDLINE
e27.Ngoc LTN, Park D, Lee Y, Lee YC: Systematic Review and Meta-analysis of human skin diseases due to particulate matter. Int J Environ Res Public Health 2017; 14: E1458 CrossRef MEDLINE PubMed Central
e28.Ljungman PL, Mittleman MA: Ambient air pollution and stroke. Stroke 2014; 45: 3734–41 CrossRef MEDLINE PubMed Central
e29.Ritz B, Lee PC, Hansen J, et al.: Traffic-related air pollution and Parkinson’s disease in Denmark: A case–control study. Environ Health Perspec 2016; 124: 351–6 CrossRef MEDLINE PubMed Central
e30.Paul KC, Haan M, Mayeda ER, Ritz BR: Ambient air pollution, noise, and late-life cognitive decline and dementia risk. Annu Rev Public Health 2019; 40: 203–20 CrossRef MEDLINE PubMed Central
e31.Power MC, Adar SD, Yanosky JD, Weuve J: Exposure to air pollution as a potential contributor to cognitive function, cognitive decline, brain imaging, and dementia: a systematic review of epidemiologic research. Neurotoxicology 2016; 56: 235–53 CrossRef MEDLINE PubMed Central
e32.Plass D, Vos T, Hornberg C, Scheidt-Nave C, Zeeb H, Krämer A: Trends in disease burden in Germany—results, implications and limitations of the Global Burden of Disease Study. Dtsch Arztebl Int 2014; 111: 629–38 VOLLTEXT
e33.World Health Organization: Health risks of air pollution in Europe – HRAPIE project. Copenhagen: World Health Organization Regional Office for Europe 2013.
e34.Di Q, Wang Y, Zanobetti A, et al.: Air pollution and mortality in the medicare population. N Engl J Med 2017; 376: 2513–22 CrossRef MEDLINE PubMed Central
e35. Strak M, Weinmayr G, Rodopolou S, et al: Natural and cause-specific mortality and low-level air pollution in a pooled cohort of 392,826 participants in Europe: the ELAPSE project. https://journals.lww.com/environepidem/toc/2019/10001 (last accessed on 12 March 2019).
e36.Eidgenössische Kommission for Lufthygiene: Feinstaub in der Schweiz 2013. Bern: Eidgenössische Kommission for Lufthygiene 2013.
e37.Der Schweizerische Bundesrat: Luftreinhalte-Verordnung (LRV) vom 16. Dezember 1985 (Stand am 16. April 2018). Bern: Der Schweizerische Bundesrat 1985.
e38.Amann M, Holland M, Maas R, Saveyn B, Vandyck T: Costs, benefits and economic impacts of the EU clean air strategy and their implications on innovation and competitiveness. Laxxenburg: International Institute for Applied Systems Analysis (IIASA) 2017.
e39.U.S. Environmental Protection Agency: Economic and cost analysis for air pollution regulations. www.epa.gov/economic-and-cost-analysis-air-pollution-regulations (last accessed on 15 June 2019).