Assessing the public health impacts of urban air pollution in 25 European cities: Results of the Aphekom project☆
Highlights
► Aphekom performed health impact assessments of urban air pollution in Europe. ► Improving air quality would result in significant health and monetary gains. ► PM2.5 annual mean to 10 μg/m3 could add more than 6 months of life expectancy at age 30 in half of the cities. ► The associated costs would reach 30 billion Euros annually.
Introduction
Urban air quality represents a major public health burden and is a long-standing concern to European citizens. Despite a major decrease in the pollutant levels in Europe since the 1950s and the implementation of the first European Commission Directive on Ambient Air Quality in 1980, regularly updated since then, important disparities in exposure to air pollution between and within European countries still remain.
Air pollution is associated with a range of diseases, symptoms and infraclinic conditions that impair the health and quality of life in European cities. In the recent years, several epidemiological studies have reported associations between an increase in daily levels of ozone (O3) and particulate matter (PM), and an increase in the following days, of the mortality and hospital admissions predominantly related to respiratory and cardiovascular diseases. These short-term effects have been extensively documented in multicentre time-series studies (Anderson et al., 2004, Atkinson et al., 2005, Ballester et al., 2006, Bell et al., 2004, Bell et al., 2005, Biggeri et al., 2005, Dominici et al., 2005, Faustini et al., 2011, Garrett and Casimiro, 2011, Gryparis et al., 2004, Ito et al., 2005, Le Tertre et al., 2002, Saez et al., 2002, Stafoggia et al., 2009), producing robust estimates for Europe and North America. Chronic exposure to fine particles (PM2.5) has also been associated with an increase in long-term mortality, and with an increased risk of developing lung cancer and cardio-pulmonary diseases (myocardial infarction, chronic obstructive pulmonary disease, asthma) (Brook et al., 2010, Jerrett et al., 2005, Krewski et al., 2009, Pope et al., 2002, Pope et al., 2004). There is less conclusive evidence on the effect of chronic exposure to ozone, although Jerrett et al. linked long-term respiratory mortality with exposure to ozone during summer (Jerrett et al., 2009a). The relation between exposure to ozone, particulate matter and specific health outcomes is supported by the consistency of epidemiological findings across different cities, periods and study designs; the coherence of the observed effects; the indication of an increased risk at higher exposure levels; and the biological plausibility strengthened by clinical and toxicological studies. In particular, several results are in favour of a causal relationship between chronic exposure to PM2.5 and cardiovascular morbidity and mortality (Brook et al., 2010, Chen et al., 2008, Pope and Dockery, 2006).So far, threshold levels for no observable health effects have not been identified (World Health Organisation, 2005).
However, current European air quality standards for PM and ozone are still above the World Health Organization Air Quality Guidelines (WHO-AQG) that aim to protect public health. In Europe, annual mean PM10 should not exceed 40 μg/m3 (limit value set in 2005), and Member States are requested to reduce exposure to PM2.5 in urban areas below 20 μg/m3 by 2015 (legally binding value). The WHO-AQG for PM, chosen as the lowest levels at which total, cardiopulmonary and lung cancer mortality have been shown to significantly increase in response to long-term exposure to PM are set as an annual mean of 20 μg/m3 for PM10 and 10 μg/m3 for PM2.5. For ozone, the EU air quality directive still refers to the previous WHO-AQG of 120 μg/m3 (8-hour mean) (Air Quality Directive, 2008/50/EC). This value should not be exceeded more than 25 days per calendar year. The updated WHO-AQG, chosen as the concentration associated with a 1–2% increase in daily mortality, correspond to 100 μg/m3 for the maximum daily 8-hour O3 mean (World Health Organisation, 2005).
Several health impact assessments (HIA) have already reported the major public health burden of PM and ozone in Europe (Ballester et al., 2008, Boldo et al., 2006, Kunzli et al., 2000, Watkiss et al., 2005, World Health Organisation, 2010). In this paper, we present new HIA for 25 European cities, using recent data and new epidemiological knowledge on the impacts of PM and ozone on mortality and hospitalizations.
Since stakeholders drafting policies to reduce air pollution must take into account many considerations, such as economic and social constraints, political orientations and urban planning, the paper also presents an economic valuation of the estimated health gains from reducing air pollution levels in European cities, and an analysis of the overall uncertainties.
These analyses were part of the European project Aphekom, whose objective was to improve knowledge and to develop tools to better assess and communicate the health benefits from an improvement in urban air quality in Europe.
Section snippets
Study period and study areas
The HIA were performed in the 25 European cities from 12 countries participating in the Aphekom project (Fig. 1). A common study period, 2004–2006, was chosen based on data availability. In each city, a study area was defined according to a common protocol and with the advice of local experts in order to ensure that average pollutant levels measured at fixed monitors could be considered good proxies of the average population exposure.
Choice of health endpoints of the HIA
Health endpoints were chosen based on available concentration
Characteristics of the centres
The population of cities studied varied from 236,982 inhabitants in Granada to 7,484,900 inhabitants in London (median: 955,702), totalling nearly 39 million inhabitants in the 25 cities, of which 21% (5,849,709 inhabitants) were older than 65 years of age. The standardized mortality rate for all-causes mortality in the population 30 years old varied from 634 per 100,000 in Rome to 1572 per 100,000 in Bucharest (median 975 per 100,000), with a notably larger share of cardiovascular mortality in
Summary of main findings
In the 25 cities, population is still exposed to air pollutant levels higher than those recommended by the WHO to protect public health. The largest health burden was attributable to the impacts of chronic exposure to PM2.5. Complying with the WHO guideline of 10 μg/m3 in annual mean would add up to 22 months of life expectancy at age 30, depending on the city, corresponding to 19,000 postponed deaths each year. The associated monetary gain would total some €31 billion annually, including savings
Competing interest
None.
Acknowledgements
The huge amount of work behind the Aphekom project is the fruit of the generous and constructive input from all the members of the Aphekom network. We wish to give our special thanks and appreciation to all of them. We also thank M. Stempfelet for her help in producing Fig. 1.
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Funding: The Aphekom project has been co-funded by the European Commission's Programme on community Action in the Field of Public Health (2003–2008) under Grant Agreement No. 2007105, and by the many national and local institutions that have dedicated resources to the fulfilment of this project.