Air pollution

Air pollution and cardiovascular disease

Air pollution, both outdoor and indoor, is a risk factor for cardiovascular disease. Ischemic heart disease and stroke are the most common causes of preventable deaths attributable to air pollution exposure, followed by lung diseases and lung cancer (EEA, 2021). Ambient air pollutants known to contribute to cardiovascular disease include particulate matter, nitrogen oxides, black carbon and carbon monoxide, among others (Cesaroni et al., 2014) (Cohen et al., 2017; Dai et al., 2022; Feigin et al., 2021; Sang et al., 2022). Evidence of impacts related to ambient ozone exposure is less clear (Wolf et al., 2021).

Cardiopulmonary organs are the first line of contact with air pollutants. Some can initiate immediate reactions, such as oxidative stress and inflammation, that put pressure on the cardiovascular system (Ji, 2022). However, the effects of air pollution on the development of cardiovascular disease typically build up over the long term: for example, a 10μg/m³ increase in long-term exposure to fine particulate matter (PM_2.5) is associated with an 11% increase in cardiovascular mortality (Bourdrel et al., 2017). Long-term air pollution exposure is associated with stroke and coronary heart disease, even at pollutant concentrations lower than current EU limit values. For example, a recent comprehensive multi-country study in some areas within the EU with low levels of pollution found that stroke was still associated with PM_2.5 (hazard ratio 1.10 per 5 μg/m³ increase), nitrogen dioxide (NO₂) (1.08 per 10 μg/m3 increase) and black carbon (1.06 per 0.5 10^-5/m increase) (Wolf et al., 2021).

Over 7% of cardiovascular deaths in EEA member and cooperating countries^[1] are due to air pollution (outdoor and indoor). For some specific cardiovascular diseases, the proportion due to the environment is higher. Around 8.8% of Ischemic Heart Disease (IHD) deaths are due to air pollution, as are 9.3% of stroke deaths (GBD Collaborative Network, 2020). The fraction of cardiovascular deaths attributed to the environment is overall higher in south-eastern and eastern Europe, with the highest proportion of attributable CVD deaths in Macedonia with almost 19%. Northern European countries generally have lower values, with the lowest fraction of CVD cases due to air pollution observed in Sweden (1.11%) – see Figure 4.

Figure 4. Percentage of preventable cardiovascular disease deaths attributable to air pollution in Europe

Note: The environmental risks included in the source study for this map are outdoor and indoor air pollution.

Source: Based on the Global Burden of Disease Study (IHME, 2020).

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Trends in exposure to air pollution in Europe

In the period 2005-2020, emissions of all key air pollutants in the EU-27 declined (EEA, 2022). Though reduced emissions do not translate linearly into reduced levels of air pollution, this decline has led to a decrease in concentrations of all major air pollutants, except for ozone (O₃). Moreover, in 2020, concentrations of NO₂ temporarily fell as a direct result of reductions in road transport during COVID-19 lockdowns. Lower levels of exposure do translate into a decrease in health impacts from air pollution, including cardiovascular disease.

However, despite progress, we are far from achieving safe air quality levels across Europe and air pollution remains a major health concern for European residents. In 2020, exposure to concentrations of fine particulate matter (PM_2.5) above the 2021 World Health Organization guideline level (5 µg/m³) resulted in 238,000 preventable deaths in the EU-27. And this guideline level, as admitted by the WHO and the research community, is still not safe (EEA, 2022). Moreover, some cardiovascular diseases have a long latency period, so current cases may reflect past exposures. This reinforces the urgency of reducing air pollution to contribute to CVD prevention.  

What the EU is doing about air pollution

The EU bases its clean air policy on three main pillars:

1. the National Emission reduction Commitments (NEC) Directive (EU, 2016);
2. legislation for key sources of air pollution (EC, 2022a);
3. the Ambient Air Quality Directives (EU, 2004, 2008), which set air quality standards.

In October 2022, the European Commission published a proposal for a revision of the Ambient Air Quality Directive, which includes:

1. stricter thresholds for pollution;
2. enhancing the right to clean air;
3. more effective penalties and compensation possibilities for violating air quality rules;
4. strengthened rules for air quality monitoring;
5. requirements to improve air quality modelling;
6. better public information.

This, along with the revision of the Industrial Emissions Directive and recent proposals on Euro 7 emission standards for road vehicles, will support progress towards better air quality. The goal laid out in the EU zero pollution action plan is to reduce the number of preventable deaths caused by exposure to PM_2.5 by at least 55% by 2030 compared to 2005 levels (EC, 2022b). In the international context, the EU Member States work closely with other UN Economic Commission for Europe (UNECE) member countries to control international air pollution under the Convention on Long-Range Transboundary Air Pollution. Moreover, under the European Climate Law, EU countries must cut greenhouse gas emissions by at least 55% by 2030. Since most CO₂ comes from the same sources as other air pollutants, efforts to reduce CO₂ will contribute to improving air quality.