Web Report

Beating cardiovascular disease — the role of Europe’s environment

Briefing Published 22 Jun 2023 Last modified 22 Jun 2023
11 min read
Photo: © Rebekka D from Pixabay
Cardiovascular disease affects the lives of many European residents. Environmental exposure to ambient and indoor air pollution, noise, extreme temperatures, second-hand smoke and chemicals, among other factors, significantly contribute to the high burden of cardiovascular illnesses in Europe. However, environmental risk factors for cardiovascular disease are largely preventable. This report provides a brief overview of the evidence about the environmental determinants of cardiovascular disease in Europe and corresponding EU policy responses.

Key messages

  • Environmental risks are estimated to cause over 18% of cardiovascular disease-related deaths in Europe.
  • Key environmental risk factors for cardiovascular disease in Europe include air pollution, heat and cold, noise, second-hand smoke and chemicals, notably lead.
  • Cardiovascular disease prevention needs to target not only clinical and behavioural risk factors, but also environmental risks and their socioeconomic determinants.
  • Reducing pollution and adapting to climate change can significantly reduce the number of cases of cardiovascular disease and resulting deaths.

Understanding the issue

Cardiovascular disease (CVD) impacts the lives of many European residents. It is the most common cause of death in EEA member countries. Every year in the EU, more than 6 million new cases of CVD are diagnosed and over 1.7 million people die from diseases of the circulatory system, representing around 37% of all deaths (Timmis et al., 2022; WHO, 2022). The burden of disease from CVD is generally higher in central and eastern Europe than in northern, southern and western Europe (IHME, 2020; Timmis et al., 2022).

CVDs are a large and complex group of illnesses, encompassing often interrelated disorders of the heart and blood vessels. Some of the most common CVDs include ischaemic heart disease (heart attacks) and cerebrovascular diseases (strokes).

The causes of CVD are also complex. Some of the known individual determinants for cardiovascular disease, such as age, sex, race/ethnicity and family history, are intrinsic to the individual and cannot be modified, whereas others are external and can be at least partially modified. Established risk factors that can be modified to reduce CVD risks include:

  • clinical risk factors such as high blood pressure, high blood cholesterol, excess weight and obesity, and diabetes. Some of these may be partly hereditary;
  • behavioural risk factors such as unhealthy diet, lack of physical activity, smoking and alcohol use;
  • environmental risk factors like exposure to air pollution, noise and chemicals in the environment and the workplace, second-hand smoke, some infectious agents, thermal stress, and limited accessibility to settings that facilitate physical activity like green spaces.

Clinical CVD risk factors are affected through a variety of biological mechanisms as well as behavioural and environmental factors. Both are heavily influenced by socioeconomic factors like low levels of income and education, unemployment or insecure employment, and related psychosocial problems (see figure 1). Clinical and behavioural CVD risk factors are the main modifiable contributors to CVD and are thus typically the target of prevention and policy efforts towards cardiovascular health.

Figure 1. Cardiovascular disease: modifiable risk factors and individual determinants

Source: Adapted from Fawzy and Lip, 2021; Hadley et al., 2022; Alves-Silva et al., 2021

The situation regarding CVDs in Europe has improved in recent decades. Since 1990, CVDs have become less lethal: age-standardised mortality rates from CVD have declined in double digits in all EEA member and collaborating countries, mostly due to improved screening, treatment, medications and lifestyles (e.g. less smoking). However, CVD morbidity has not decreased much, with only small declines in the age-standardised incidence of CVD. These sustained rates are driven by an ageing population, particularly in high-income European countries (Timmis et al., 2022).

Against this backdrop, reducing environmental risk factors can greatly help further decrease the burden of CVDs. Environmental CVD risk factors are mostly preventable and can be effectively reduced through policies and interventions that benefit large population groups at once. Moreover, because people typically cannot do much to protect themselves from environmental risk factors, this protection must come from public authorities or other institutional and social actors, like employers. This report focuses on environmental risk factors for CVD and their prevention.


Environmental contribution to cardiovascular disease in Europe

In Europe (EEA member and collaborating countries[1], over 18% of all cardiovascular disease deaths are estimated to come from key environmental factors (IHME, 2020; Prüss-Üstün et al., 2016; Vaduganathan M et al., 2022). There is significant variation across EEA member and collaborating countries, with higher proportions of CVD deaths due to the environment estimated in eastern and south-eastern European countries, and Turkey (see Figure 2).

Figure 2. Percentage of preventable cardiovascular disease deaths attributable to environmental risks in Europe

Note: The environmental risks included in the source study for this map are outdoor and indoor air pollution, heat and cold, second-hand smoke and lead.

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

Explore different chart formats and data here

This estimate (18% of preventable CVD deaths attributable to the environment) is likely an underestimate. This is because it includes only a selection of environmental factors for which enough data is available for most EEA member and collaborating countries (i.e. outdoor and indoor air pollution, heat and cold, second-hand smoke and lead). It does not include known CVD risk factors from exposures that may happen at the workplace (see box 1 below), nor does it include the effect of environmental noise (a major environmental risk in Europe), or of toxic chemicals other than lead (see chemicals section). Though we do not have Europe-wide estimates of the overall cardiovascular disease burden from many of these factors, in this report we nevertheless highlight existing scientific knowledge on their cardiovascular effects.

Box 1. Occupational exposure and cardiovascular disease

Exposure to a wide variety of substances and risk factors causing or contributing to cardiovascular disease happens in the workplace or in relation to certain occupations. Physical risk factors include extreme temperatures, noise and vibrations. Chemical risk factors include heavy metals, dust, second-hand smoke and some pesticides (De Marchis et al., 2018; Sjörgren et al., 2020; Teixeira et al., 2021). Work-related psychosocial risk factors including high job demands, low job control, imbalance of effort and reward, long working hours, bullying and violent situations at work, organisational injustice and job insecurity negatively affect the cardiovascular system through stress mechanisms, particularly when prolonged (Sultan-Taïeb et al., 2022; EUOSHA, 2023b). Furthermore, they can combine with other factors to increase negative health effects. Sedentary work such as prolonged constrained standing and static sitting at work, (EUOSHA, 2021a, 2021b) and shift work, also increase cardiovascular risk in certain occupations. Figure 3 presents the prevalence of work-related CVD in EU countries in 2000 and 2016, with a clear decline observed in most countries (EUOSHA, 2023a).

Figure 3. Prevalence of work-related cardiovascular diseases (disability adjusted life years (DALYs)[2]) in the EU by country, 2000 and 2016

Source: (EUOSHA, 2023a)

Explore different chart formats and data here


Environmental risks and their associations with cardiovascular disease


Explore the environmental risks and their associations with cardiovascular disease:

Air pollution

Exposure to various air pollutants is known to cause and aggravate cardiovascular disease


Some chemicals in the environment and at the workplace can increase cardiovascular risk

Second hand smoke

Second-hand smoke increases the risk of cardiovascular disease even in people who have never smoked themselves

Climate change

Both heat and cold put pressure on the cardiovascular system


The stress caused by environmental noise increases cardiovascular risk


EU cardiovascular disease prevention initiatives addressing environmental risk factors

Various EU-wide cardiovascular disease prevention plans and initiatives include the reduction of environmental cardiovascular disease risks in their strategies. Most initiatives aim to prevent clinical risk factors such as high cholesterol or high blood pressure; or they aim to address behavioural factors such as diet, tobacco smoking and physical activity. Few initiatives address environmental risk factors — a missed opportunity to reduce highly modifiable variables without the significant challenges that come with changing behaviours at a large populational scale. 

Below are the most relevant current activities:

The EU4Health Programme Regulation (EU 2021/ 522) sets out EU action in the field of health from 2021 to 2027. It includes specific commitments to address CVD among other non-communicable diseases (NCDs) by supporting health promotion and disease prevention. It also recognises that environmental risk factors play a part in causing NCDs and makes funding available for actions investigating the link between environmental factors and human diseases.

The Healthier together – EU non-communicable diseases (NCD) initiative was launched by the European Commission in December 2021 to support EU countries in identifying and implementing effective policies and actions to reduce the burden of major NCDs and improve residents’ health and well-being. Cardiovascular diseases are one of its five key strands.

The steering group on health promotion, disease prevention and management of non-communicable diseases was established by the European Commission (Decision 2018/C 251/07), and advises the Commission on implementing the Healthier Together initiative by identifying potential actions related to the five strands (including CVD).

Stakeholders including the European Alliance for Cardiovascular Health, medical technology firms, patient groups, NGOs and associations of health specialists have called for the EU to develop an action plan for CVD, similar to the existing action plan on beating cancer.

Globally, various initiatives addressing CVDs as part of NCD prevention also apply to Europe. The WHO Global action plan for the prevention and control of NCDs was introduced to tackle the rising concerns about CVD between 2013 and 2020, and has been extended to 2030. The action plan aimed, among other things, to reduce CVD globally by 25% by 2025. The WHO Global NCD Compact 2020-2030 was set out to address the lack of policy in legislations and policies to address the number of deaths caused by NCDs. The WHO Global action plan on physical activity was introduced to help highlight the importance of physical activity in reducing NCDs, including CVD. The UN Sustainable Development Goals (SDG) set global targets for sustainability, and aim to reduce premature mortality from NCDs (including CVD) by one third by 2030.

There are several other EU-wide initiatives, scientific committees and EU-funded research projects, as well as calls for proposals, relating to different aspects of cardiovascular disease prevention and the role that environmental risk reduction can play. These activities have direct and indirect linkages and synergies, mapped out by the European Commission’s knowledge for policy platform.



Environmental cardiovascular disease risks are inherently preventable and reducing them is key to bringing down the burden of cardiovascular disease in Europe. Individuals have limited scope for protecting themselves from most environmental determinants of cardiovascular disease, making regulatory intervention and policy implementation especially relevant and necessary. Policy and regulations need to be supported by sufficient resources allocated to preventing exposures (including occupational ones) and reducing pollution.

The decreasing trends in exposure to some environmental cardiovascular risks are encouraging but insufficient. They are far from indicating a general downward trend. In addition, cardiovascular disease cases tend to reflect past exposure, so decreasing levels of exposure will take years to translate into reduced incidence of cardiovascular disease. Moreover, we don’t yet fully understand the potential cardiovascular effects of all environmental risk factors — for example, nocturnal light pollution — or the combined magnitude of cardiovascular effects arising from certain risk factors such as toxic chemicals.

While data are incomplete and uncertainties are high, the existing scientific evidence solidly supports reducing environmental exposure as an effective — and cost-effective — strategy to reduce cardiovascular disease risks. Moreover, it is likely that we considerably underestimate the actual contribution of environmental exposure to cardiovascular diseases. We do not need to fully understand every step of the causal pathway from environmental exposures to cardiovascular disease cases to take decisive action to reduce pollution.


[1] Except Kosovo under UNSCR 1244/99and Liechtenstein.

[2] A disability-adjusted life year, or DALY, is a metric used to measure of the burden of disease borne by individuals. One DALY represents the loss of the equivalent of one year of full health. DALYs for a disease or risk factor are calculated by adding up the years of life lost to due to premature mortality (YLLs) and the years lived with a disability (YLDs) attributable to that disease or risk factor.


Alves-Silva, J. M., et al., 2021, ‘The Role of Essential Oils and Their Main Compounds in the Management of Cardiovascular Disease Risk Factors’, Molecules 26(12), p. 3506 (DOI: 10.3390/molecules26123506).

De Marchis, P., et al., 2018, ‘Ischemic cardiovascular disease in workers occupationally exposed to urban air pollution – A systematic review’, Annals of Agricultural and Environmental Medicine 25(1), pp. 162-166 (DOI: 10.26444/aaem/79922).

EUOSHA, 2021a, Prolonged constrained standing postures: health effects and good practice advice, European Agency for Safety and Health at Work, Bilbao, Spain (

EUOSHA, 2021b, Prolonged static sitting at work: health effects and good practice advice, European Agency for Safety and Health at Work, Bilbao, Spain (

EUOSHA, 2023a, OSH Barometer Data Visualisation Tool, European Agency for Safety and Health at Work (

EUOSHA, 2023b, The links between exposure to work-related psychosocial risk factors and cardiovascular disease, European Agency for Safety and Health at Work, Bilbao, Spain (

Fawzy, A. M. and Lip, G. Y. H., 2021, ‘Cardiovascular disease prevention: Risk factor modification at the heart of the matter’, The Lancet Regional Health – Western Pacific 17 (DOI: 10.1016/j.lanwpc.2021.100291).

Hadley, M. B., et al., 2022, ‘Spatial environmental factors predict cardiovascular and all-cause mortality: Results of the SPACE study’ Amegah, A. K. (ed.), PLOS ONE17(6), p. e0269650 (DOI: 10.1371/journal.pone.0269650).

IHME, 2020, ‘Global Burden of Disease data set’, Institute for Health Metrics and Evaluation (

Prüss-Üstün, A., et al., 2016, Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks, World Health Organization, Geneva, Switzerland.

Sjörgren, B., et al., 2020, The Nordic Expert Group for Criteria Documentation of Health Risks from Chemicals. 153, Occupational chemical exposures and cardiovascular disease, University of Gothenburg, Unit for Occupational and Environmental Medicine, Göteborg.

Sultan-Taïeb, H., et al., 2022, ‘Burden of cardiovascular diseases and depression attributable to psychosocial work exposures in 28 European countries’, European Journal of Public Health 32(4), pp. 586-592 (DOI: 10.1093/eurpub/ckac066).

Teixeira, L. R., et al., 2021, ‘The effect of occupational exposure to noise on ischaemic heart disease, stroke and hypertension: A systematic review and meta-analysis from the WHO/ILO Joint Estimates of the Work-Related Burden of Disease and Injury’, Environment international 154, p. 106387 (DOI: 10.1016/j.envint.2021.106387).

Timmis, A., et al., 2022, ‘European Society of Cardiology: cardiovascular disease statistics 2021’, European Heart Journal 43(8), pp. 716-799 (DOI: 10.1093/eurheartj/ehab892).

Vaduganathan M, et al., 2022, ‘The Global Burden of Cardiovascular Diseases and Risk: A Compass for Future Health’, Journal of the American College of Cardiology 80(25) (DOI: 10.1016/j.jacc.2022.11.005).

WHO, 2022, Global Health Observatory, World Health Organization, Geneva, Switzerland (


EEA Web report no. 01/2023
Title: Beating cardiovascular disease — the role of Europe’s environment
EN HTML: TH-04-23-657-EN-Q - ISBN: 978-92-9480-587-4 - doi: 10.2800/682494


The country assessments are the sole responsibility of the EEA member and cooperating countries supported by the EEA through guidance, translation and editing.


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