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Long-term exposure to ambient ozone and mortality: A quantitative systematic review and meta-analysis of evidence from cohort studies

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  • R. W. Atkinson
  • B. K. Butland
  • C. Dimitroulopoulou
  • M. R. Heal
  • J. R. Stedman
  • N. Carslaw
  • D. Jarvis
  • C. Heaviside
  • S. Vardoulakis
  • H. Walton
  • H. R. Anderson


Publication details

JournalBMJ Open
DateAccepted/In press - 10 Dec 2015
DatePublished (current) - 23 Feb 2016
Issue number2
Number of pages10
Original languageEnglish


Objectives: While there is good evidence for associations between short-term exposure to ozone and a range of adverse health outcomes, the evidence from narrative reviews for long-term exposure is suggestive of associations with respiratory mortality only. We conducted a systematic, quantitative evaluation of the evidence from cohort studies, reporting associations between long-term exposure to ozone and mortality. Methods: Cohort studies published in peer-reviewed journals indexed in EMBASE and MEDLINE to September 2015 and PubMed to October 2015 and cited in reviews/key publications were identified via search strings using terms relating to study design, pollutant and health outcome. Study details and estimate information were extracted and used to calculate standardised effect estimates expressed as HRs per 10 ppb increment in long-term ozone concentrations. Results: 14 publications from 8 cohorts presented results for ozone and all-cause and cause-specific mortality. We found no evidence of associations between long-term annual O3 concentrations and the risk of death from all causes, cardiovascular or respiratory diseases, or lung cancer. 4 cohorts assessed ozone concentrations measured during the warm season. Summary HRs for cardiovascular and respiratory causes of death derived from 3 cohorts were 1.01 (95% CI 1.00 to 1.02) and 1.03 (95% CI 1.01 to 1.05) per 10 ppb, respectively. Conclusions: Our quantitative review revealed a paucity of independent studies regarding the associations between long-term exposure to ozone and mortality. The potential impact of climate change and increasing anthropogenic emissions of ozone precursors on ozone levels worldwide suggests further studies of the long-term effects of exposure to high ozone levels are warranted.


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