Long-term ambient air pollution exposure and cardio-respiratory disease in China: findings from a prospective cohort study

Neil Wright, Katherine Newell, Ka Hung Chan, Simon Gilbert, Alex Hacker, Yan Lu, Yu Guo, Pei Pei, Canqing Yu, Jun Lv, Junshi Chen, Liming Li, Om Kurmi, Zhengming Chen, Kin Bong Hubert Lam, Christiana Kartsonaki

Research output: Contribution to journalArticlepeer-review

6 Citations (Scopus)
29 Downloads (Pure)


Background: Existing evidence on long-term ambient air pollution (AAP) exposure and risk of cardio-respiratory diseases in China is mainly on mortality, and based on area average concentrations from fixed-site monitors for individual exposures. Substantial uncertainty persists, therefore, about the shape and strength of the relationship when assessed using more personalised individual exposure data. We aimed to examine the relationships between AAP exposure and risk of cardio-respiratory diseases using predicted local levels of AAP. Methods: A prospective study included 50,407 participants aged 30–79 years from Suzhou, China, with concentrations of nitrogen dioxide (NO 2), sulphur dioxide (SO 2), fine (PM 2.5), and inhalable (PM 10) particulate matter, ozone (O 3) and carbon monoxide (CO) and incident cases of cardiovascular disease (CVD) (n = 2,563) and respiratory disease (n = 1,764) recorded during 2013–2015. Cox regression models with time-dependent covariates were used to estimate adjusted hazard ratios (HRs) for diseases associated with local-level concentrations of AAP exposure, estimated using Bayesian spatio–temporal modelling. Results: The study period of 2013–2015 included a total of 135,199 person-years of follow-up for CVD. There was a positive association of AAP, particularly SO 2 and O 3, with risk of major cardiovascular and respiratory diseases. Each 10 µg/m 3 increase in SO 2 was associated with adjusted hazard ratios (HRs) of 1.07 (95% CI: 1.02, 1.12) for CVD, 1.25 (1.08, 1.44) for COPD and 1.12 (1.02, 1.23) for pneumonia. Similarly, each 10 µg/m 3 increase in O 3 was associated with adjusted HR of 1.02 (1.01, 1.03) for CVD, 1.03 (1.02, 1.05) for all stroke, and 1.04 (1.02, 1.06) for pneumonia. Conclusions: Among adults in urban China, long-term exposure to ambient air pollution is associated with a higher risk of cardio-respiratory disease.

Original languageEnglish
Article number30
JournalEnvironmental health : a global access science source
Issue number1
Early online date27 Mar 2023
Publication statusE-pub ahead of print - 27 Mar 2023

Bibliographical note

This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.


Katherine Newell acknowledges the support from the Oxford-MRC Doctoral Training Partnership.

Funding Information:
The CKB baseline survey and the first re-survey were supported by the Kadoorie Charitable Foundation in Hong Kong. The long-term follow-up has been supported by Wellcome grants to Oxford University (212946/Z/18/Z, 202922/Z/16/Z, 104085/Z/14/Z, 088158/Z/09/Z) and grants from the National Natural Science Foundation of China (82192901, 82192904, 82192900, 91846303) and the National Key Research and Development Program of China (2016YFC0900500).

Funding Information:
UK Medical Research Council Global Challenges Research Fund (Foundation Award MR/P025080/1).

Funding Information:
The UK Medical Research Council (MC_UU_00017/1, MC_UU_12026/2, MC_U137686851), Cancer Research UK (C16077/A29186, C500/A16896) and the British Heart Foundation (CH/1996001/9454), provide core funding to the Clinical Trial Service Unit and Epidemiological Studies Unit at Oxford University for the project.

Funding Information:
The chief acknowledgment is to the participants, the project staff, and the China National Centre for Disease Control and Prevention (CDC) and its regional offices for assisting with the fieldwork. We thank Judith Mackay in Hong Kong; Yu Wang, Gonghuan Yang, Zhengfu Qiang, Lin Feng, Maigeng Zhou, Wenhua Zhao, Yan Zhang and Zheng Bian in China CDC; Lingzhi Kong, Xiucheng Yu, and Kun Li in the Chinese Ministry of Health; and Garry Lancaster, Sarah Clark, Martin Radley, Mike Hill, Hongchao Pan, and Jill Boreham in the CTSU, Oxford, for assisting with the design, planning, organization, and conduct of the study. Professor Haidong Kan, School of Public Health Fudan University, Shanghai, for providing the fixed site monitoring data. Dr Steve Hung Lam Yim, Chinese University of Hong Kong, for providing all meteorological variables. Members of the China Kadoorie Biobank collaborative group: International Steering Committee: Junshi Chen, Zhengming Chen (PI), Robert Clarke, Rory Collins, Yu Guo, Liming Li (PI), Chen Wang, Jun Lv, Richard Peto, Robin Walters. International Co-ordinating Centre, Oxford: Daniel Avery, Maxim Barnard, Derrick Bennett, Ruth Boxall, Sushila Burgess, Ka Hung Chan, Yiping Chen, Zhengming Chen, Johnathan Clarke; Robert Clarke, Huaidong Du, Ahmed Edris Mohamed, Hannah Fry, Simon Gilbert, Pek Kei Im, Andri Iona, Maria Kakkoura, Christiana Kartsonaki, Hubert Lam, Kuang Lin, James Liu, Mohsen Mazidi, Iona Millwood, Sam Morris, Qunhua Nie, Alfred Pozarickij, Paul Ryder, Saredo Said, Dan Schmidt, Becky Stevens, Iain Turnbull, Robin Walters, Baihan Wang, Lin Wang, Neil Wright, Ling Yang, Xiaoming Yang, Pang Yao. National Co-ordinating Centre, Beijing: Xiao Han, Can Hou, Chun Li, Chao Liu, Jun Lv, Pei Pei, Dianjianyi Sun, Canqing Yu. 10 Regional Co-ordinating Centres: Guangxi Provincial CDC: Naying Chen, Duo Liu, Zhenzhu Tang. Liuzhou CDC: Ningyu Chen, Qilian Jiang, Jian Lan, Mingqiang Li, Yun Liu, Fanwen Meng, Jinhuai Meng, Rong Pan, Yulu Qin, Ping Wang, Sisi Wang, Liuping Wei, Liyuan Zhou. Gansu Provincial CDC: Caixia Dong, Pengfei Ge, Xiaolan Ren. Maiji CDC: Zhongxiao Li, Enke Mao, Tao Wang, Hui Zhang, Xi Zhang. Hainan Provincial CDC: Jinyan Chen, Ximin Hu, Xiaohuan Wang. Meilan CDC: Zhendong Guo, Huimei Li, Yilei Li, Min Weng, Shukuan Wu. Heilongjiang Provincial CDC: Shichun Yan, Mingyuan Zou, Xue Zhou. Nangang CDC: Ziyan Guo, Quan Kang, Yanjie Li, Bo Yu, Qinai Xu. Henan Provincial CDC: Liang Chang, Lei Fan, Shixian Feng, Ding Zhang, Gang Zhou. Huixian CDC: Yulian Gao, Tianyou He, Pan He, Chen Hu, Huarong Sun, Xukui Zhang. Hunan Provincial CDC: Biyun Chen, Zhongxi Fu, Yuelong Huang, Huilin Liu, Qiaohua Xu, Li Yin. Liuyang CDC: Huajun Long, Xin Xu, Hao Zhang, Libo Zhang. Jiangsu Provincial CDC: Jian Su, Ran Tao, Ming Wu, Jie Yang, Jinyi Zhou, Yonglin Zhou. Suzhou CDC: Yihe Hu, Yujie Hua, Jianrong Jin Fang Liu, Jingchao Liu, Yan Lu, Liangcai Ma, Aiyu Tang, Jun Zhang. Qingdao Qingdao CDC: Liang Cheng, Ranran Du, Ruqin Gao, Feifei Li, Shanpeng Li, Yongmei Liu, Feng Ning, Zengchang Pang, Xiaohui Sun, Xiaocao Tian, Shaojie Wang, Yaoming Zhai, Hua Zhang, Licang CDC: Wei Hou, Silu Lv, Junzheng Wang. Sichuan Provincial CDC: Xiaofang Chen, Xianping Wu, Ningmei Zhang, Weiwei Zhou. Pengzhou CDC: Xiaofang Chen, Jianguo Li, Jiaqiu Liu, Guojin Luo, Qiang Sun, Xunfu Zhong. Zhejiang Provincial CDC: Weiwei Gong, Ruying Hu, Hao Wang,Meng Wan, Min Yu. Tongxiang CDC: Lingli Chen, Qijun Gu, Dongxia Pan, Chunmei Wang, Kaixu Xie, Xiaoyi Zhang.

Funding Information:
This research was funded in whole, or in part, by the Wellcome Trust (212,946/Z/18/Z, 202,922/Z/16/Z, 104,085/Z/14/Z, 088,158/Z/09/Z). For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

Funding Information:
Ka Hung Chan acknowledges the support from the BHF Centre of Research Excellence, University of Oxford (RE/18/3/34214).

Publisher Copyright:
© 2023, The Author(s).


  • Cardiovascular Diseases - chemically induced - epidemiology
  • China - epidemiology
  • Environmental Exposure - adverse effects - analysis
  • Pneumonia
  • Adult
  • Prospective Studies
  • Air pollution
  • Nitrogen Dioxide - analysis
  • Respiratory disease
  • Particulate Matter - adverse effects - analysis
  • Humans
  • Air Pollution - adverse effects - analysis
  • Cardiovascular disease
  • Bayes Theorem
  • Ozone - analysis
  • Air Pollutants - adverse effects - analysis
  • Respiration Disorders
  • Respiratory Tract Diseases - epidemiology


Dive into the research topics of 'Long-term ambient air pollution exposure and cardio-respiratory disease in China: findings from a prospective cohort study'. Together they form a unique fingerprint.

Cite this