Bert Brunekreef, PhD Professor of Environmental Epidemiology Cardiopulmonary Burden of Air Pollution in Turkey…. and elsewhere in Europe Bert Brunekreef, PhD Professor of Environmental Epidemiology

Air Quality Standards for annual PM2.5 concentration WHO AQG US EPA Standard EU Limit Value The major American study is the so called American Cancer Society Study, and this graph shows the relationship between PM2.5 and mortality as it was observed in that study. What is clear from the graph is that the European Limit Value for PM2.5 of 25 microgram/m3 is very high compared to the American standard of 12 microgram/m3 and the WHO Guideline of 10 microgram/m3. The Americans have been able to reduce PM2.5 in most areas to levels below this standard. There must be something that we’re doing wrong here in Europe as we can’t seem to get our concentrations down. Figure from Pope, JAWMA 2006 6

ESCAPE study PM / NOx monitoring & modeling in 20 / 36 EU areas > 30 existing cohorts Birth and pregnancy outcomes Respiratory morbidity Cardiovascular morbidity Cancer & mortality PM / NOx monitoring & modeling in 20 / 36 EU areas

Chronic Bronchitis COPD Coronary events Stroke Non-accidental Mortality IgE, Asthma, Lung Function Respiratory infections Birth weight Lung Function Asthma Child development Systemic Inflammation Blood Pressure, IMT Respiratory Mortality Cardiovascular, Lung Cancer Incidence

ESCAPE study areas in EUROPE PM+NOx NOx only

Lancet Respiratory Medicine 2013;1:695-704

NO2 exposures in pregnancy outcome cohorts EU Limit Value

Birth head circumference Effect estimates for Term Low Birth Weight and Birth Head Circumference Term low birth weight Birth head circumference Pollutant N RR 95% CI ß* (cm) NO2 (per 10 µg/m3) 52,291 1.09 1.00 - 1.19 36,010 -0.08 -0.10 to -0.07 NOX (per 20 µg/m3) 51,150 1.04 0.97 - 1.11 34,818 -0.06 -0.07 to -0.05 PM10 (per 10 µg/m3) 40,947 1.16 1.00 - 1.35 25,022 -0.13 -0.18 to -0.09 PM2.5 (per 5 µg/m3) 1.18 1.06 - 1.33 -0.12 to -0.03 PM-C (per 5 µg/m3) 40,914 1.01 0.88 - 1.15 24,988 -0.09 -0.12 to -0.05 PM2.5 absorbance (per 1 10-5/m) 41,727 1.17 0.95 - 1.39 25,724 -0.18 -0.22 to -0.13

EU Limit Value

Associations between PM2 Associations between PM2.5 exposure during pregnancy and term low birth weight in analyses restricted to levels below certain values 15 µg/m3 OR for PM2.5 per 5 μg/m3 20 µg/m3 25 µg/m3 None

Infections in children up to 3 years in relation to air pollution exposure in ten European birth cohorts Pneumonia MacIntyre et al. EHP 2014;122:107-13

Lung function in children at 8 years in relation to air pollution exposure in five European birth cohorts NO2 NOx PM2.5 PM2.5abs PM10 PMcoarse Traffic street Traffic buffer FEV1 (OR <85% predicted) Gehring et al. EHP 2013:121:1357-64

Effect estimates for Asthma at age 8 Molter et al., ERJ 2015;45:610-24

Gruzieva, JACI 2014

Effects on lung function in adults Adam et al., ERJ 2015;45:38-50

Jacquemin et al., EHP 2015

Raaschou-Nielsen, Lancet Oncol 2013

ESCAPE effects on Coronary Events Pollutant Relative Risk (95% C.I.) PM10 (per 10 µg/m3) 1.12 (1.01-1.25) PM2.5 (per 5 µg/m3) 1.13 (0.98-1.30) PM absorbance (per m-1) 1.10 (0.98-1.24) NO2 (per 10 µg/m3) 1.03 (0.97-1.08) Cesaroni, BMJ 2014 Jan 21;348:f7412