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This briefing quantifies the latest estimated impact on population health caused by long-term exposure to three key air pollutants: fine particulate matter, nitrogen dioxide and ozone. The foreseen benefits of achieving improved air quality are also highlighted.
Key messages
In 2022, European citizens remained exposed to air pollutant concentrations that were considerably above the levels recommended by the World Health Organization (WHO). Reducing air pollution to these WHO guideline levels would prevent a significant number of annual deaths in EU Member States (EU-27): 239,000 from exposure to fine particulate matter (PM2.5); 70,000 from exposure to ozone (O3) and 48,000 from exposure to nitrogen dioxide (NO2).
Between 2005 and 2022, the number of deaths in the EU attributable to PM2.5 fell by 45%, moving the EU closer to achieving the 55% reduction target outlined in the zero pollution action plan for 2030.
In addition to premature mortality, the impacts from living with diseases related to air pollution are significant. It is vital that these impacts are considered when assessing the overall health burden of air pollution, as well as the benefits that would arise from cleaner air in Europe.
This briefing is the 2024 update of the burden of disease series. It is also part of the air quality in Europe package, which includes briefings on: Europe’s air quality status; air pollution in Europe and the impacts of air pollution in ecosystems. It is based predominantly on fully validated 2022 data collected by the EEA.
Measuring impacts on health: understanding the ‘environmental burden of disease’ concept
‘Burden of disease’ describes the impact a disease has on the health of a population. Measured by different indicators including mortality and morbidity, it is often quantified in terms of disability-adjusted life years (DALYs). DALYs combine the population health impacts of both mortality and morbidity in one summary indicator.
The burden of disease can be generally measured using four indicators:
- Years lived with disability (YLD), which quantifies the years a population has lived in reduced health due to a particular health outcome. YLD are estimated by multiplying the number of prevalent cases of a particular health outcome with a disability weight — a factor indicating the severity of the health outcome on a scale from 0 (full health) to 1 (most severe health state).
- Number of deaths that have occurred because of a specific disease or group of diseases.
- Years of life lost (YLL), defined as the years of potential life lost due to death caused by a disease or group of diseases. YLL is an estimate of the average number of additional years that people in a population would have statistically lived if they had not died before reaching a certain statistical life expectancy. Mortality data at the national level are the baseline input used to estimate deaths and YLL.
- DALYs. A DALY is one lost year of a healthy life due to disease or injury. DALYs are obtained by adding YLL and YLD for the same disease or group of diseases. The burden of disease is the sum of these DALY values in a population. Therefore, DALYs are a standardised indicator for health effects resulting from both the number of people affected by a disease and the number of people dying from it.
The ‘environmental burden of disease’ concept quantifies the shares of the total burden of disease that can be statistically attributed to environmental risk factors, such as the population’s exposure to air pollution. This can be expressed in terms of the attributable number of deaths, or YLL, YLD and DALYs attributable to the environmental risk exposure. The ‘attributable number of deaths per 100,000 inhabitants at risk’ and ‘YLL per 100,000 inhabitants at risk’ are also used in this briefing as indicators that allow comparisons across countries. The attribution is generally based on evidence of a causal link between a risk factor and a health outcome. The attributable burden is considered preventable if its cause can be eliminated or reduced.
Note that the estimates presented here may differ from others calculated at national and European levels. This is due to differences in methodology, which include: the use of different concentration maps, where air pollutant concentrations are estimated at different scales; the use of more detailed demographic data; the use of different relative risks or different concentration-response functions and the use of different assumptions in the range of concentrations considered.
Estimations for the environmental burden of disease are made individually for the respective air pollutants. They cannot be added together as they exhibit a degree of correlation. This is especially the case for the burden of disease due to PM2.5 and NO2.
Figure 1. Burden of disease as a sum of YLD and YLL
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Estimating the burden of disease due to air pollution
How air pollution harmed population health in Europe in 2022
The impacts of air pollution have been calculated in two ways. Firstly, the ‘all-cause mortality’ was evaluated to establish the total number of all air pollution-related deaths without providing any breakdown of the individual diseases associated with these deaths. Secondly, the ‘specific-cause mortality and morbidity’ were also calculated to determine the deaths and health effects associated with individual diseases (see box above).
All-cause mortality
This section presents mortality figures from all natural causes (i.e. excluding accidental and other non-natural causes), which are attributable to long-term exposure to key air pollutants.
In 2022 in the EU-27:
- 239,000 deaths were attributable to exposure to PM2.5 concentrations above the WHO guideline level of 5µg/m3 (micrograms per cubic metre of air). The 95% confidence interval (CI) was 182,000-267,000.
- 70,000 deaths (95% CI: 0-137,000) were attributable to exposure to O3 concentrations above the WHO guideline level of 60µg/m3.
- 48,000 deaths (95% CI: 24,000-95,000) were attributable to exposure to NO2 concentrations above the WHO guideline level of 10µg/m3.
In addition to the EU-27 member countries, larger sets of countries were also assessed: 40 for PM2.5 and 41 for NO2 and O3. For these groups of countries:
- 269,000 deaths (95% CI: 205,000-299,000) were attributable to exposure to PM2.5 concentrations above the WHO guideline level of 5µg/m3.
- 81,000 deaths (95% CI: 0-159,000) were attributable to exposure to O3 concentrations above the WHO guideline level of 60µg/m3.
- 66,000 deaths (95% CI: 33,000-129,000) were attributable to exposure to NO2 concentrations above the WHO guideline level of 10µg/m3.
In both these country groupings, a slight decrease in the all-cause mortality attributable to PM2.5 and NO2 was observed compared to the previous year. In terms of O3, the impact of long-term exposure was only estimated for the first time in 2022 and therefore no previous estimates are available for comparison. Furthermore, the long-term exposure to O3 focuses on the six consecutive months with the highest six-month running-average O3 concentration (the peak season as defined by WHO, 2021) and not the whole year as for the other two pollutants.
One of the main sources of the assessment’s uncertainty comes from the relative risks; this uncertainty is expressed as CIs. The upper and lower boundaries of the CI mark the interval in which there is 95% confidence in finding the real value. These CI values are provided in brackets for all the calculations.
Table 1 presents, per country and country grouping: total population, the total population at risk for every pollutant (the population at risk signifies people above a certain age, determined by the epidemiological studies from which the relative risks were derived — those over 30 years for PM2.5 and NO2 and those over 25 years for O3); the population-weighted mean concentrations (as an indication of exposure); the estimated number of attributable deaths and the attributable deaths per 100,000 inhabitants at risk in 2022.
Table 2 presents, per country and country grouping: the YLL and YLL per 100,000 inhabitants at risk associated with long-term exposure to PM2.5, NO2 and O3 concentration levels in 2022.
The EEA burden of disease from air pollution table presents estimates from 2005 of the mortality and morbidity figures attributable to exposure to PM2.5, NO2 and O3 for individual countries and different groupings of countries.
The sections detailed below provide country-level information on mortality due to all natural causes that are attributable to the three key pollutants analysed.
For PM2.5, the highest numbers of attributable deaths in 2022 occurred in Italy, Poland and Germany (in decreasing order). The highest relative impacts (YLL per 100,000 inhabitants over 30 years) were observed in south-eastern European countries, both for the analysis of all countries (North Macedonia, Kosovo (under UNSCR 1244/99) and Bosnia and Herzegovina, in decreasing order) and when considering only EU-27 countries (Bulgaria, Poland and Romania).
The lowest relative impacts (YLL per 100,000 inhabitants over 30 years) due to PM2.5 exposure occurred in countries situated in the north and north-west of Europe, including Iceland, Finland, Sweden, Norway and Estonia (in order of increasing impact).
Map 1. Mortality due to long-term exposure to PM2.5, 2022
For NO2, the highest numbers of attributable deaths in 2022 occurred in Türkiye, Italy and Germany (in decreasing order). When considering relative impacts, that is YLL per 100,000 inhabitants over 30 years, the highest rates were observed for Türkiye, Cyprus, Serbia, Bulgaria and Romania (in decreasing order).
The lowest relative impacts (YLL per 100,000 inhabitants over 30 years) due to NO2 exposure occurred in Sweden, Iceland, Finland, Denmark and Estonia (in order of increasing impact).
Map 2. Mortality due to long-term exposure to NO2, 2022
For O3, the countries with the highest numbers of attributable deaths in 2022 were Germany, Italy and France (in decreasing order). When considering relative impacts, that is YLL per 100,000 inhabitants over 25 years, the highest rates were observed for Albania, Bosnia and Herzegovina, Montenegro, Kosovo, Croatia and Hungary (in decreasing order).
The countries with the lowest relative impacts (YLL per 100,000 inhabitants over 25 years) were Ireland, Iceland, Norway, Sweden, Finland and Denmark.
Map 3. Mortality due to long-term exposure to O3, 2022
Sensitivity analyses of attributable deaths due to air pollution
It is important to note that the attributable deaths presented above do not capture possible additional deaths caused by exposure to PM2.5 and NO2 concentrations below the WHO’s guideline levels. Scientific evidence for air pollutant effects is less certain for exposures below these levels than for health impacts above them.
However, there is no scientific evidence of a threshold below which air pollution does not impact health. With this in mind, the EEA has also performed a sensitivity analysis of attributable deaths considering the full exposure range for PM2.5 and NO2 — therefore at all concentrations above 0µg/m3. The level of uncertainty around these estimates is higher than for the estimates presented above. For O3, additional scenarios were not included due to the absence of any meaningful counterfactual concentration besides the 60µg/m3, which is also the WHO air quality guidelines’ recommendation.
Table 3 presents the potential additional attributable deaths and potential total attributable deaths by pollutant for the EU-27 Member States and for the larger number of European countries included in the assessment.
Table 3. Potential additional attributable deaths and potential total attributable deaths in 2022 when considering the full concentration range
Geographical scope | Pollutant | Potential additional attributable deaths | Potential total attributable deaths |
|---|---|---|---|
EU-27 | PM2.5 | 174,000 | 413,000 (95% CI: 316,000-460,000) |
EU-27 | NO2 | 87,000 | 135,000 (95% CI: 68,000-263,000) |
40 European countries | PM2.5 | 187,000 | 456,000 (95% CI: 349,000-507,000) |
41 European countries | NO2 | 102,000 | 168,000 (95% CI: 85,000-326,000) |
Notes: Türkiye is not included in the PM2.5 estimations as the number of background monitoring stations from which data are available was too low to produce concentration maps for fine particles.
CI = confidence interval.
The recently adopted revised Ambient Air Quality Directive (AAQD) establishes updated EU legal standards to be attained by 2030. These standards are closer to the WHO recommendations. A second sensitivity analysis assessed the number of deaths attributable to exposure above the updated annual limit values, that is, to annual PM2.5 concentrations above 10µg/m3 and NO2 concentrations above 20µg/m3. O3 is not included in this sensitivity analysis because there is no EU legal standard linked to the peak season. The results are presented in Table 4.
Table 4. Number of deaths attributable to exposure above the updated limit values in the revised AAQD, 2022
Geographical scope | Pollutant | Number of attributable deaths |
|---|---|---|
EU-27 | PM2.5 | 84,000 (95% CI: 64,000-94,000) |
EU-27 | NO2 | 8,000 (95% CI: 4,000-16,000) |
40 European countries | PM2.5 | 102,000 (95% CI: 78,000-113,000) |
41 European countries | NO2 | 16,000 (95% CI: 8,000-32,000) |
Note: CI = confidence interval.
Source: Burden of disease from air pollution (EEA)
Specific causes of mortality and morbidity
To estimate the total harm of air pollution on health, we use the ‘burden of disease concept’ (see box above). It combines the impacts of both mortality (deaths due to a specific disease or group of diseases, expressed as YLL) and morbidity (the state of having a disease or disability, expressed as YLD); these are added together into DALYs. This section presents the individual estimates of the burden of disease for a number of specific health conditions, considering all the countries included in the analysis.
PM2.5
For the six specific diseases considered for PM2.5 (see Figure 2), the highest attributable burden was observed for ischemic heart disease; this was followed by stroke, diabetes mellitus, lung cancer, chronic obstructive pulmonary disease and childhood asthma.
In the cases of lung cancer and ischemic heart disease, the total burden of disease results predominantly from mortality: it accounts for 99% and 97% of the impact, respectively.
For the other four diseases, the contribution of morbidity to the total burden of disease is much more relevant. Morbidity represents 18% of the burden of disease for stroke, 23% for diabetes mellitus, 40% for chronic obstructive pulmonary disease and 99% for childhood asthma.
This emphasises that considering morbidity is key to avoiding the underestimation of the overall health impact of air pollution.
Figure 2. Burden of disease for PM2.5, NO2 and O3, 2022
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Focusing only on the number of deaths attributable to each disease, the six diseases considered for PM2.5 resulted in a total of 234,000 attributable deaths. This is below the 269,000 estimated when using all-cause natural mortality in 40 European countries (see Figure 3). This lower number is due to the fact that other possible diseases, for which the association with air pollution is currently unknown, are not included. However, the difference between the two approaches is relatively small and provides additional confidence in the overall order of magnitude of estimated deaths linked to air pollution.
Another factor that can also influence the different results, although to a minor extent, is that for all-cause mortality — and according to the concentration-response functions — adults above 30 years are considered, while for the specific causes, different age groups are considered, as specified in the 'Estimating the burden of disease due to air pollution' section outlined above.
Figure 3. Mortality due to exposure to PM2.5 and NO2, 2022
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NO2
For NO2 (see Figure 2), the highest impact on health is due to diabetes mellitus, followed by stroke and asthma in adults. The burden of disease for stroke and diabetes mellitus results are mainly from mortality (76% and 58% of the burden, respectively), while for asthma in adults results are mainly from morbidity (88%).
When considering only the mortality part of the burden of disease of the three diseases included, 35,000 deaths are estimated; this is well below the 66,000 deaths attributed to all natural causes (see Figure 3). Here the underestimation seems clearer; it is likely because only three specific diseases were considered, while six diseases were considered for PM2.5.
Finally, the estimated total burden of disease for NO2 (580,847 DALYs, considering three diseases and 41 countries) is almost five times lower than for PM2.5 (2,703,827 DALYs, considering six diseases and 40 countries).
O3
In the case of O3, 8,400 deaths were attributed to chronic obstructive pulmonary disease, the only disease considered and for which no morbidity was estimated; this is equivalent to 83,861 YLL. This amount, caused by only one disease, is well below the 81,000 deaths attributed to all causes.
Information detailing the country level of the burden of disease can be found in the Eionet ETC HE Report 2024/6.
Policy context
For several decades, the EU has had air quality standards in place for key air pollutants, as outlined in the AAQD. These values, based on the relevant WHO recommendations at the time, also reflected the feasibility of achieving these limits across the EU Member States. In general, the currently valid EU limit values are less demanding than the WHO’s 2005 air quality guidelines.
In 2021, the WHO updated its air quality guidelines for the first time since 2005, lowering the recommended levels for PM2.5, NO2 and O3. This update was based on systematic reviews of the latest scientific evidence outlining how air pollution affects human health. On 26 October 2022, the European Commission adopted a proposal for a revised AAQD, which aimed to align air quality standards more closely with the WHO’s updated recommendations. The revised directive , as agreed by the co-legislators, was published in November 2024.
Under the European Green Deal, the zero pollution action plan outlines a target of improving air quality by 2030, with a focus on PM2.5. In this way, it aims to reduce the number of attributable premature deaths caused by air pollution in the EU by a minimum of 55%, relative to those that occurred in 2005. The EEA’s indicator Premature deaths due to exposure to fine particulate matter in Europe shows that premature deaths in the EU attributable to PM2.5 exposure above the WHO guideline level of 5µg/m3 fell by 45% between 2005 and 2022. The zero pollution action plan target is likely to be surpassed if EU policies on air, climate and energy are implemented successfully.
Briefing no. 21/2024
Title: Harm to human health from air pollution in Europe: burden of disease status, 2024
EN HTML: TH-01-24-018-EN-Q - ISBN: 978-92-9480-695-6 - ISSN: 2467-3196 - doi: 10.2800/3950756