Effect of all-cause versus disease-specific exposure-response functions on air pollution burden
Abstract
Background: Estimates of disease burden attributable to air pollution depend on the choice of exposure–response functions (ERFs). The World Health Organization (WHO) recommends using all-cause mortality ERFs in the primary analysis, with cause-specific outcomes as a secondary analysis. Therefore, this study aims to assess how disease burden estimates for air pollution are influenced by using ERFs for all-cause mortality (ACM) versus disease-specific (DS) mortality.
Methods: Environmental burden of disease (EBoD) estimates for PM2.5 and NO2 were calculated within the framework of the EU project BEST-COST across five countries (Belgium, Estonia, France, Norway, and Portugal) using the healthiar R package. WHO-recommended ERFs for ACM and DS mortality were applied to compare attributable Years of Life Lost (YLL). Exposure data and baseline health data were obtained from European Environment Agency and Global Burden of Disease study, respectively. Statistical differences were assessed using Wilcoxon signed-rank tests, Spearman correlations, and intraclass correlation coefficients (ICC).
Results: Across all countries, the DS approach consistently yielded 2–4 times lower YLL estimates than ACM framework (ratios: 0.26–0.52; median 0.31 for NO2, 0.42 for PM2.5). Despite these absolute differences, country rankings remained highly consistent (Spearman ρ ≥ 0.90). Wilcoxon tests did not reach significance (p = 0.0625), likely due to limited sample size. ICC indicated poor agreement for NO2 (0.15) and moderate for PM2.5 (0.46).
Conclusions: Although both DS and ACM approaches yield highly consistent disease burden country-level rankings, DS ERFs result in dramatically lower YLL estimates. It should, however, be kept in mind that the ACM approach could result in an overestimation of the disease burden due to air pollution Therefore, discussing both frameworks’ pros and cons is required to better understand the consequences of ERF choice on policy implications.
Key messages: • Disease-specific ERFs result in systematically lower YLL estimates for air pollution, with 50–70% compared to all-cause mortality approaches.
• Further discussion of WHOs recommendation of all-cause mortality in environmental decision-making may be warranted.
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BibTeX
@article{corda2026effect,
title = {{Effect of all-cause versus disease-specific exposure-response functions on air pollution burden}},
author = {M Corda and A Castro and S Breitner-Bus and A K Bølling and M Bartholomeeuse and L Rousseau and M Lepnurm and L Vázquez Fernández and I Rønning Heyerdahl and R Assunção},
journal = {The European Journal of Public Health},
year = {2026},
month = oct,
doi = {10.1093/eurpub/ckag169.810},
url = {https://doi.org/10.1093/eurpub/ckag169.810},
note = {CC BY-NC 4.0},
}
RIS
TY - JOUR
TI - Effect of all-cause versus disease-specific exposure-response functions on air pollution burden
AU - M Corda
AU - A Castro
AU - S Breitner-Bus
AU - A K Bølling
AU - M Bartholomeeuse
AU - L Rousseau
AU - M Lepnurm
AU - L Vázquez Fernández
AU - I Rønning Heyerdahl
AU - R Assunção
PY - 2026
DA - 2026/10/01
JO - The European Journal of Public Health
DO - 10.1093/eurpub/ckag169.810
UR - https://doi.org/10.1093/eurpub/ckag169.810
AB - Background: Estimates of disease burden attributable to air pollution depend on the choice of exposure–response functions (ERFs). The World Health Organization (WHO) recommends using all-cause mortality ERFs in the primary analysis, with cause-specific outcomes as a secondary analysis. Therefore, this study aims to assess how disease burden estimates for air pollution are influenced by using ERFs for all-cause mortality (ACM) versus disease-specific (DS) mortality. Methods: Environmental burden of disease (EBoD) estimates for PM2.5 and NO2 were calculated within the framework of the EU project BEST-COST across five countries (Belgium, Estonia, France, Norway, and Portugal) using the healthiar R package. WHO-recommended ERFs for ACM and DS mortality were applied to compare attributable Years of Life Lost (YLL). Exposure data and baseline health data were obtained from European Environment Agency and Global Burden of Disease study, respectively. Statistical differences were assessed using Wilcoxon signed-rank tests, Spearman correlations, and intraclass correlation coefficients (ICC). Results: Across all countries, the DS approach consistently yielded 2–4 times lower YLL estimates than ACM framework (ratios: 0.26–0.52; median 0.31 for NO2, 0.42 for PM2.5). Despite these absolute differences, country rankings remained highly consistent (Spearman ρ ≥ 0.90). Wilcoxon tests did not reach significance (p = 0.0625), likely due to limited sample size. ICC indicated poor agreement for NO2 (0.15) and moderate for PM2.5 (0.46). Conclusions: Although both DS and ACM approaches yield highly consistent disease burden country-level rankings, DS ERFs result in dramatically lower YLL estimates. It should, however, be kept in mind that the ACM approach could result in an overestimation of the disease burden due to air pollution Therefore, discussing both frameworks’ pros and cons is required to better understand the consequences of ERF choice on policy implications. Key messages: • Disease-specific ERFs result in systematically lower YLL estimates for air pollution, with 50–70% compared to all-cause mortality approaches. • Further discussion of WHOs recommendation of all-cause mortality in environmental decision-making may be warranted.
SN - 1101-1262
SN - 1464-360X
ER -