Air pollution

Page Last modified 22 Jun 2023
7 min read
Air pollution affects cardiovascular health, particularly through long term exposures to fine particles and nitrogen dioxide. Reducing pollution emissions and decreasing exposure to pollutants can help prevent cardiovascular illness.

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 (PM2.5) 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 PM2.5 (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).

Explore different chart formats and data here

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 (PM2.5) 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 PM2.5 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.


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


Bourdrel, T., et al., 2017, ‘Cardiovascular effects of air pollution’, Archives of Cardiovascular Diseases 110(11), pp. 634-642 (DOI: 10.1016/j.acvd.2017.05.003).

Cesaroni, G., et al., 2014, ‘Long term exposure to ambient air pollution and incidence of acute coronary events: prospective cohort study and meta-analysis in 11 European cohorts from the ESCAPE Project’, BMJ (Clinical research ed.) 348, p. f7412 (DOI: 10.1136/bmj.f7412).

Cohen, A. J., et al., 2017, ‘Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015’, The Lancet 389(10082), pp. 1907-1918 (DOI: 10.1016/S0140-6736(17)30505-6).

Dai, H., et al., 2022, ‘Global, regional, and national burden of ischaemic heart disease and its attributable risk factors, 1990–2017: results from the Global Burden of Disease Study 2017’, European Heart Journal - Quality of Care and Clinical Outcomes 8(1), pp. 50-60 (DOI: 10.1093/ehjqcco/qcaa076).

EC, 2022a, ‘Air quality — existing legislation’, European Commission (

EC, 2022b, ‘Zero pollution action plan’, European Commission (

EEA, 2021a, Air quality in Europe 2021, European Environment Agency (

EEA, 2022b, Europe’s air quality status 2021— update, EEA Briefing ( accessed 22 June 2022.

EU, 2004, Directive 2004/107/EC of the European Parliament and of the Council of 15 December 2004 relating to arsenic, cadmium, mercury, nickel and polycyclic aromatic hydrocarbons in ambient air (OJ L 23, 26.1.2005, pp. 3-16).

EU, 2008, Directive 2008/50/EC of the European Parliament and of the Council of 21 May 2008 on ambient air quality and cleaner air for Europe (OJ L 152, 11.6.2008, p. 1-44).

EU, 2016, Directive 2016/2284/EC of the European Parliament and of the Council of 14 December 2016 on the reduction of national emissions of certain atmospheric pollutants, amending Directive 2003/35/EC and repealing Directive 2001/81/EC (OJ L 344, 17.12.2016, pp. 1-31).

Feigin, V. L., et al., 2021, ‘Global, regional, and national burden of stroke and its risk factors, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019’, The Lancet Neurology 20(10), pp. 795-820 (DOI: 10.1016/S1474-4422(21)00252-0).

GBD Collaborative Network, 2020, GBD Results Tool, GBD Results Tool., (, Institute for Health Metrics and Evaluation.

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

Ji, J. S., 2022, ‘Air pollution and cardiovascular disease onset: hours, days, or years?’, The Lancet Public Health 7(11), pp. e890-e891 (DOI: 10.1016/S2468-2667(22)00257-2).

Sang, S., et al., 2022, ‘The global burden of disease attributable to ambient fine particulate matter in 204 countries and territories, 1990-2019: A systematic analysis of the Global Burden of Disease Study 2019’, Ecotoxicology and environmental safety 238, p. 113588 (DOI: 10.1016/j.ecoenv.2022.113588).

Wolf, K., et al., 2021, ‘Long-term exposure to low-level ambient air pollution and incidence of stroke and coronary heart disease: a pooled analysis of six European cohorts within the ELAPSE project’, The Lancet. Planetary health 5(9), pp. e620-e632 (DOI: 10.1016/S2542-5196(21)00195-9).


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