Short-Term Exposure to Fine Particulate Matter and Nitrogen Dioxide and Mortality in 4 Countries

Importance The association between short-term exposure to air pollution and mortality has been widely documented worldwide; however, few studies have applied causal modeling approaches to account for unmeasured confounders that vary across time and space. Objective To estimate the association between short-term changes in fine particulate matter (PM 2.5 ) and nitrogen dioxide (NO 2 ) concentrations and changes in daily all-cause mortality rates using a causal modeling approach. Design, Setting, and Participants This cross-sectional study used air pollution and mortality data from Jiangsu, China; California; central-southern Italy; and Germany with interactive fixed-effects models to control for both measured and unmeasured spatiotemporal confounders. A total of 8 963 352 deaths in these 4 regions from January 1, 2015, to December 31, 2019, were included in the study. Data were analyzed from June 1, 2021, to October 30, 2023. Exposure Day-to-day changes in county- or municipality-level mean PM 2.5 and NO 2 concentrations. Main Outcomes and Measures Day-to-day changes in county- or municipality-level all-cause mortality rates. Results Among the 8 963 352 deaths in the 4 study regions, a 10-μg/m 3 increase in daily PM 2.5 concentration was associated with an increase in daily all-cause deaths per 100 000 people of 0.01 (95% CI, 0.001-0.01) in Jiangsu, 0.03 (95% CI, 0.004-0.05) in California, 0.10 (95% CI, 0.07-0.14) in central-southern Italy, and 0.04 (95% CI, 0.02- 0.05) in Germany. The corresponding increases in mortality rates for a 10-μg/m 3 increase in NO 2 concentration were 0.04 (95% CI, 0.03-0.05) in Jiangsu, 0.03 (95% CI, 0.01-0.04) in California, 0.10 (95% CI, 0.05-0.15) in central-southern Italy, and 0.05 (95% CI, 0.04-0.06) in Germany. Significant effect modifications by age were observed in all regions, by sex in Germany (eg, 0.05 95% CI, 0.03-0.06 for females in the single-pollutant model of PM 2.5 ), and by urbanicity in Jiangsu (0.07 95% CI, 0.04-0.10 for rural counties in the 2-pollutant model of NO 2 ). Conclusions and Relevance The findings of this cross-sectional study contribute to the growing body of evidence that increases in short-term exposures to PM 2.5 and NO 2 may be associated with increases in all-cause mortality rates. The interactive fixed-effects model, which controls for unmeasured spatial and temporal confounders, including unmeasured time-varying confounders in different spatial units, can be used to estimate associations between changes in short-term exposure to air pollution and changes in health outcomes.