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In recent years, both the EU Commission and the Belmont Forum have funded projects focusing on health and climate change with the aim of expanding research and evidence and improving intersectoral cooperation. The EU-funded ENBEL project is developing tools to streamline climate and health research to support policies and strategies and improve response and resilience. Methods: Within ENBEL a stakeholder analysis is being carried out for Europe to identify key decision makers involved in climate change and health adaptation, understand interlinkages and identify areas for action to promote collaboration and uptake. Semi-structured interviews with key institutions and stakeholders at different levels (International, European, national and local) will help identify key evidence needs and research gaps and findings will be used to define knowledge tools and policy briefs to enhance adaptation. Furthermore, current policies on adaptation in Europe and how health issues are addressed, especially taking into account the Next Generation EU (NGEU) funding in support of COVID-19 recovery as well as Green Deal and Climate Action, will be reviewed to ensure ENBEL products fit the EU policy agenda. Conclusions: ENBEL offers an opportunity to produce targeted research syntheses for decision makers as well an ensuring health becomes a key aspect in climate change policy decision making. The ENBEL project will engage with key decision makers involved in climate change and health adaptation across Europe, providing knowledge, understanding interlinkages and identifying areas for action to promote climate policies that enhance health benefits. [ABSTRACT FROM AUTHOR]

Although the short-term heat effects are well-established, longer-term effects, beyond those, have recently received attention, in the context of climate change. Our study aims to investigate the potential effects of long-term exposure to non-optimal warm period temperatures on all-cause mortality in four large regions in the UK, Norway, Italy, and Greece. Daily all-cause mortality counts from 1996 to 2018 for four European NUTS-2 regions including 52-662 small areas were collected and associated with spatiotemporal temperature estimates. A NUTS-2 region-specific mixed quasi-Poisson over-dispersed model, with a random intercept per small area within NUTS-2 regions, was applied to investigate the association between long-term temperature exposure and mortality during the warm period (May to September), adjusting for short-term temperature, seasonality, long-term trends, and small-area population characteristics. As long-term temperature exposure indices per small area, we considered: 1) the warm period annual average temperature, 2) the annual standard deviation (SD) of warm period temperature, and 3) the coefficient of variation of warm period temperature (CV). We found consistent results following short-term temperature exposure on mortality, with higher effects in southern areas. Results on the shape of the long-term association between average temperature and mortality differed by country, while the different temperature metrics produced inconsistent findings. Increased mortality was associated with increased annual warm season temperature, lower SD and increased CV in Greece, with higher SD and decreased CV in Italy and with decreased annual temperature and CV in Norway. Effects in the UK did not reach the nominal level of statistical significance. Although our study implies an impact on mortality resulting from longer-term temperature exposure, its direction varied across areas and on the temperature metric used. Further research is warranted, applying non-ecological study designs and covering various geographical areas to capture the impact of individual and area-specific characteristics., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Socioeconomic conditions remain an important factor in determining health outcomes in Northern Europe. In this commentary, we argue for evidence-based temperature-related climate adaptation policies in Northern Europe that account for disparities in socioeconomic conditions and aim at universal health coverage. We highlight the role of spatial and occupational disparities in urban areas that can be important factors in increased physical and mental health impacts related to heat and cold. We further highlight how these factors interplay with exposure to air pollution and access to green areas and worsen health conditions. Adaptation to changing climatic conditions requires both physiological acclimatization and behavioral adaptation, both of which are difficult to assess for socioeconomically deprived communities. We argue for more equitable climate adaptation strategies that include i) better integration of health in climate change adaptation plans; ii) building climate resilient communities, and iii) integrated surveillance and health systems. These actions could be vital in spearheading research in new cross-cutting areas like climate change, migration, and health., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Previous health impact assessments of temperature-related mortality in Europe indicated that the mortality burden attributable to cold is much larger than for heat. Questions remain as to whether climate change can result in a net decrease in temperature-related mortality. In this study, we estimated how climate change could affect future heat-related and cold-related mortality in 854 European urban areas, under several climate, demographic and adaptation scenarios. We showed that, with no adaptation to heat, the increase in heat-related deaths consistently exceeds any decrease in cold-related deaths across all considered scenarios in Europe. Under the lowest mitigation and adaptation scenario (SSP3-7.0), we estimate a net death burden due to climate change increasing by 49.9% and cumulating 2,345,410 (95% confidence interval = 327,603 to 4,775,853) climate change-related deaths between 2015 and 2099. This net effect would remain positive even under high adaptation scenarios, whereby a risk attenuation of 50% is still insufficient to reverse the trend under SSP3-7.0. Regional differences suggest a slight net decrease of death rates in Northern European countries but high vulnerability of the Mediterranean region and Eastern Europe areas. Unless strong mitigation and adaptation measures are implemented, most European cities should experience an increase of their temperature-related mortality burden., Competing Interests: Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Evidence suggests that air pollution modifies the association between heat and mortality. However, most studies have been conducted in cities without rural data. This time-series study examined potential effect modification of particulate matter (PM) and ozone (O 3 ) on heat-related mortality using small-area data from five European countries, and explored the influence of area characteristics., Methods: We obtained daily non-accidental death counts from both urban and rural areas in Norway, England and Wales, Germany, Italy, and the Attica region of Greece during the warm season (2000-2018). Daily mean temperatures and air pollutant concentrations were estimated by spatial-temporal models. Heat effect modification by air pollution was assessed in each small area by over-dispersed Poisson regression models with a tensor smoother between temperature and air pollution. We extracted temperature-mortality relationships at the 5th (low), 50th (medium), and 95th (high) percentiles of pollutant distributions. At each air pollution level, we estimated heat-related mortality for a temperature increase from the 75th to the 99th percentile. We applied random-effects meta-analysis to derive the country-specific and overall associations, and mixed-effects meta-regression to examine the influence of urban-rural and coastal typologies and greenness on the heat effect modification by air pollution., Results: Heat-related mortality risks increased with higher PM levels, rising by 6.4% (95% CI: -2.0%-15.7%), 10.7% (2.6%-19.5%), and 14.1% (4.4%-24.6%) at low, medium, and high PM levels, respectively. This effect modification was consistent in urban and rural regions but more pronounced in non-coastal regions. In addition, heat-mortality associations were slightly stronger at high O 3 levels, particularly in regions with low greenness., Conclusion: Our analyses of both urban and rural data indicate that air pollution may intensify heat-related mortality, particularly in non-coastal and less green regions. The synergistic effect of heat and air pollution implies a potential pathway of reducing heat-related health impacts by improving air quality., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Climate change is among the greatest threats to health in the 21st century, requiring the urgent scaling-up of adaptation interventions. We aim to summarise adaptation interventions that were funded by the Belmont Forum and the European Union, the largest global funders of climate change and health research. A systematic search was conducted (updated February 2023) to identify articles on adaptation interventions for health within this funding network. The data extracted included study characteristics, types of interventions, and study outcomes. The results were synthesised narratively within the PRISMA-ScR guidelines. A total of 197 articles were screened, with 37 reporting on adaptation interventions. The majority of interventions focused on the general population (n = 17), with few studies examining high-risk populations such as pregnant women and children (n = 4) or migrants (n = 0). Targeted interventions were mostly aimed at behavioural change (n = 8) and health system strengthening (n = 6), while interventions with mitigation co-benefits such as nature-based solutions (n = 1) or the built environment (n = 0) were limited. The most studied climate change hazard was extreme heat (n = 26). Several studies reported promising findings, principally regarding interventions to counter heat impacts on workers and pregnant women and improving risk awareness in communities. These findings provide a platform on which to expand research and public health interventions for safeguarding public health from the effects of climate change.

Background: Land-use and land-cover change (LULCC) can substantially affect climate through biogeochemical and biogeophysical effects. Here, we examine the future temperature-mortality impact for two contrasting LULCC scenarios in a background climate of low greenhouse gas concentrations. The first LULCC scenario implies a globally sustainable land use and socioeconomic development (sustainability). In the second LULCC scenario, sustainability is implemented only in the Organisation for Economic Cooperation and Development countries (inequality)., Methods: Using the Multi-Country Multi-City (MCC) dataset on mortality from 823 locations in 52 countries and territories, we estimated the temperature-mortality exposure-response functions (ERFs). The LULCC and noLULCC scenarios were implemented in three fully coupled Earth system models (ESMs): Community Earth System Model, Max Planck Institute Earth System Model, and European Consortium Earth System Model. Next, using temperature from the ESMs' simulations and the estimated location-specific ERFs, we assessed the temperature-related impact on mortality for the LULCC and noLULCC scenarios around the mid and end century., Results: Under sustainability, the multimodel mean changes in excess mortality range from -1.1 to +0.6 percentage points by 2050-2059 across all locations and from -1.4 to +0.5 percentage points by 2090-2099. Under inequality, these vary from -0.7 to +0.9 percentage points by 2050-2059 and from -1.3 to +2 percentage points by 2090-2099., Conclusions: While an unequal socioeconomic development and unsustainable land use could increase the burden of heat-related mortality in most regions, globally sustainable land use has the potential to reduce it in some locations. However, the total (cold and heat) impact on mortality is very location specific and strongly depends on the underlying climate change scenario due to nonlinearity in the temperature-mortality relationship., Competing Interests: The authors declare that they have no conflicts of interest with regard to the content of this report., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Environmental Epidemiology. All rights reserved.)

Background: High temperatures have been associated with increased mortality, with evidence reported predominately in large cities and for total cardiovascular or respiratory deaths. This case-crossover study examined heat-related cause-specific cardiopulmonary mortality and vulnerability factors using small-area data from Germany., Methods: We analyzed daily counts of cause-specific cardiopulmonary deaths from 380 German districts (2000-2016) and daily mean temperatures estimated by spatial-temporal models. We applied conditional quasi-Poisson regression using distributed lag nonlinear models to examine heat effects during May-September in each district and random-effects meta-analysis to pool the district-specific estimates. Potential individual- and district-level vulnerability factors were examined by subgroup analyses and meta-regressions, respectively., Findings: Heat was associated with increased mortality risks for all cardiopulmonary sub-causes. The relative risk (RR) of total cardiovascular and respiratory mortality for a temperature increment from the 75th to the 99th percentile was 1.24 (95% confidence interval: 1.23, 1.26) and 1.34 (1.30, 1.38), respectively. The RRs of cardiovascular sub-causes ranged from 1.16 (1.13, 1.19) for myocardial infarction to 1.32 (1.29, 1.36) for heart failure. For respiratory sub-causes, the RR was 1.27 (1.22, 1.31) for COPD and 1.49 (1.42, 1.57) for pneumonia. We observed greater susceptibility related to several individual- and district-level characteristics, e.g., among females or in highly urbanized districts. Heat vulnerability factors remained consistent between urban and rural areas., Interpretation: Our study highlights heat-related increases in cause-specific cardiopulmonary mortality across Germany and identifies key vulnerability factors, offering insights for improving public health practices to mitigate heat-related health impacts., Funding: European Union's Horizon 2020 research and innovation program; Helmholtz Associations Initiative and Networking Fund., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s).)

Over the past century, the Earth's climate has undergone rapid and unprecedented changes, manifested in a noticeable increase in average global temperature. This has led to shifts in precipitation patterns, increased frequency of extreme weather events (e.g. hurricanes, heatwaves, droughts and floods), alterations in ecosystems, and rising sea levels, impacting both natural environments and human societies, health and wellbeing. Without deep and urgent emission cuts and effective adaptation, the toll of climate change on human health and wellbeing is likely to grow. Here, we address the complex relationship between climate change and health, and discuss ways forward for transdisciplinary research and collaboration that can motivate more ambitious mitigation policies and help develop solutions to adapt to the crisis., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background and Aims: Climate change affects our societies and lives through our economies, our livelihoods, and our health. Economic losses of climate change are estimated at $23 trillion, largely through externalities due to premature mortality, healthcare expenditure, and health-related work losses. Even if there are established methods to quantify the health economic burden, there is limited information on how people perceive this information. The current study aimed to examine different health cost evaluation methods and observe perceptions of stakeholders in the climate change context., Method: The participatory research approach of the World Café with 41 participants was applied to explore four topics associated with valuing the costs of climate change. The data were analyzed following an inductive approach., Results: Despite the willingness-to-pay approach being widely applied, many experts see actual healthcare costs as a more explicit indicator of costs; however, this approach might underestimate actual costs. Participants experienced difficulties accepting and understanding cost estimates that indicated very high externalities as a percentage of gross domestic product. The cost-effectiveness of mitigation and adaptation measures was also challenged by a concern that while the costs of such measures are incurred now, the benefits do not come to fruition until later, for example, when building bike lanes or dams., Conclusions: Policies should favor environmentally friendly activities such as making cycling more convenient in cities with the health benefits presented in monetary terms, while limiting car driving. Moreover, the public might better understand the costs of climate change via tools that map how solutions influence different sectors and outlining the costs in evaluating the benefits for health and the environment., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Chronic exposure to ambient PM 2.5 is the largest environmental health risk in Europe. We used a chemical transport model and recent exposure response functions to simulate ambient PM 2.5 , contribution from fires and related health impacts over Europe from 1990 to 2019. Our estimation indicates that the excess death burden from exposure to ambient PM2.5 declined across Europe at a rate of 10,000 deaths per year, from 0.57 million (95 % confidence intervals: 0.44-0.75 million) in 1990 to 0.28 million (0.19-0.42 million) in the specified period. Among these excess deaths, approximately 99 % were among adults, while only around 1 % occurred among children. Our findings reveal a steady increase in fire mortality fractions (excess deaths from fires per 1000 deaths from ambient PM 2.5 ) from 2 in 1990 to 13 in 2019. Notably, countries in Eastern Europe exhibited significantly higher fire mortality fractions and experienced more pronounced increases compared to those in Western and Central Europe. We performed sensitivity analyses by considering fire PM 2.5 to be more toxic as compared to other sources, as indicated by recent studies. By considering fire PM 2.5 to be more toxic than other PM 2.5 sources results in an increased relative contribution of fires to excess deaths, reaching 2.5-13 % in 2019. Our results indicate the requirement of larger mitigation and adaptation efforts and more sustainable forest management policies to avert the rising health burden from fires., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Climate change could lead to high economic burden for individuals (i.e. low income and high prices). While economic conditions are important determinants of climate change vulnerability, environmental epidemiological studies focus primarily on the direct impact of temperature on morbidity and mortality without accounting for climate-induced impacts on the economy. More integrated approaches are needed to provide comprehensive assessments of climate-induced direct and indirect impacts on health. This paper provides some perspectives on how epidemiological and economic impact assessments could be better integrated. We argue that accounting for the economic repercussions of climate change on people's health and, vice versa, the consequences of health effects on the economy could provide more realistic scenario projections and could be more useful for adaptation policy., Competing Interests: Conflict of interest The authors declare no financial and non-financial conflict of interests.

Background: The independent effects of short-term exposure to increased air temperature and air pollution on mortality are well-documented. There is some evidence indicating that elevated concentrations of air pollutants may lead to increased heat-related mortality, but this evidence is not consistent. Most of these effects have been documented through time-series studies using city-wide data, rather than at a finer spatial level. In our study, we examined the possible modification of the heat effects on total and cause-specific mortality by air pollution at municipality level in the Attica region, Greece, during the warm period of the years 2000 to 2016., Methods: A municipality-specific over-dispersed Poisson regression model during the warm season (May-September) was used to investigate the heat effects on mortality and their modification by air pollution. We used the two-day average of the daily mean temperature and daily mean PM 10 , NO 2 and 8 hour-max ozone (O 3 ), derived from models, in each municipality as exposures. A bivariate tensor smoother was applied for temperature and each pollutant alternatively, by municipality. Α random-effects meta-analysis was used to obtain pooled estimates of the heat effects at different pollution levels. Heterogeneity of the between-levels differences of the heat effects was evaluated with a Q-test., Results: A rise in mean temperature from the 75th to the 99th percentile of the municipality-specific temperature distribution resulted in an increase in total mortality of 12.4% (95% Confidence Interval (CI):7.76-17.24) on low PM 10 days, and 21.25% (95% CI: 17.83-24.76) on high PM 10 days. The increase on mortality was 10.09% (95% CI: - 5.62- 28.41) on low ozone days, and 14.95% (95% CI: 10.79-19.27) on high ozone days. For cause-specific mortality an increasing trend of the heat effects with increasing PM 10 and ozone levels was also observed. An inconsistent pattern was observed for the modification of the heat effects by NO 2 , with higher heat effects estimated in the lower level of the pollutant., Conclusions: Our results support the evidence of elevated heat effects on mortality at higher levels of PM 10 and 8 h max O 3. Under climate change, any policy targeted at lowering air pollution levels will yield significant public health benefits., (© 2024. The Author(s).)

Background: Heat effects on respiratory mortality are known, mostly from time-series studies of city-wide data. A limited number of studies have been conducted at the national level or covering non-urban areas. Effect modification by area-level factors has not been extensively investigated. Our study assessed the heat effects on respiratory mortality at a small administrative area level in Norway, Germany, and England and Wales, in the warm period (May-September) within 1996-2018. Also, we examined possible effect modification by several area-level characteristics in the framework of the EU-Horizon2020 EXHAUSTION project., Methods: Daily respiratory mortality counts and modeled air temperature data were collected for Norway, Germany, and England and Wales at a small administrative area level. The temperature-mortality association was assessed by small area-specific Poisson regression allowing for overdispersion, using distributed lag non-linear models. Estimates were pooled at the national level and overall using a random-effect meta-analysis. Age- and sex-specific models were also applied. A multilevel random-effects model was applied to investigate the modification of the heat effects by area-level factors., Results: A rise in temperature from the 75th to 99th percentile was associated with a 27% (95% confidence interval [CI] = 19%, 34%) increase in respiratory mortality, with higher effects for females. Increased population density and PM 2.5 concentrations were associated with stronger heat effects on mortality., Conclusions: Our study strengthens the evidence of adverse heat effects on respiratory mortality in Northern Europe by identifying vulnerable subgroups and subregions. This may contribute to the development of targeted policies for adaptation to climate change., Competing Interests: Authors declare that they have no conflicts of interest with regard to the content of this report., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The Environmental Epidemiology. All rights reserved.)

Background: Short-term associations between heat and cardiovascular disease (CVD) mortality have been examined mostly in large cities. However, different vulnerability and exposure levels may contribute to spatial heterogeneity. This study assessed heat effects on CVD mortality and potential vulnerability factors using data from three European countries, including urban and rural settings., Methods: We collected daily counts of CVD deaths aggregated at the small-area level in Norway (small-area level: municipality), England and Wales (lower super output areas), and Germany (district) during the warm season (May-September) from 1996 to 2018. Daily mean air temperatures estimated by spatial-temporal models were assigned to each small area. Within each country, we applied area-specific Quasi-Poisson regression using distributed lag nonlinear models to examine the heat effects at lag 0-1 days. The area-specific estimates were pooled by random-effects meta-analysis to derive country-specific and overall heat effects. We examined individual- and area-level heat vulnerability factors by subgroup analyses and meta-regression, respectively., Results: We included 2.84 million CVD deaths in analyses. For an increase in temperature from the 75th to the 99th percentile, the pooled relative risk (RR) for CVD mortality was 1.14 (95% CI: 1.03, 1.26), with the country-specific RRs ranging from 1.04 (1.00, 1.09) in Norway to 1.24 (1.23, 1.26) in Germany. Heat effects were stronger among women [RRs (95% CIs) for women and men: 1.18 (1.08, 1.28) vs. 1.12 (1.00, 1.24)]. Greater heat vulnerability was observed in areas with high population density, high degree of urbanization, low green coverage, and high levels of fine particulate matter., Conclusion: This study provides evidence for the heat effects on CVD mortality in European countries using high-resolution data from both urban and rural areas. Besides, we identified individual- and area-level heat vulnerability factors. Our findings may facilitate the development of heat-health action plans to increase resilience to climate change., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Climate change can substantially affect temperature-related mortality and morbidity, especially under high green-house gas emission pathways. Achieving the Paris Agreement goals require not only drastic reductions in fossil fuel-based emissions but also land-use and land-cover changes (LULCC), such as reforestation and afforestation. LULCC has been mainly analysed in the context of land-based mitigation and food security. However, growing scientific evidence shows that LULCC can also substantially alter climate through biogeophysical effects. Little is known about the consequential impacts on human health. LULCC-related impact research should broaden its scope by including the human health impacts. LULCC are relevant to several global agendas (i.e. Sustainable Development Goals). Thus, collaboration across research communities and stronger stakeholder engagement are required to address this knowledge gap.

Background: Studies on the health effects of heat are particularly limited in Texas, a U.S. state in the top 10 highest number of annual heat-related deaths per capita from 2018 to 2020. This study assessed the effects of heat on all-cause and cause-specific mortality in 12 metropolitan statistical areas (MSAs) across Texas from 1990 to 2011., Methods: First, we determined the heat thresholds for each MSA above which the relation between temperature and mortality is linear. We then conducted a distributed lag non-linear model for each MSA, followed by a random effects meta-analysis to estimate the pooled effects for all MSAs. We repeated this process for each mortality cause and age group to achieve the effect estimates., Results: We found a 1 °C temperature increase above the heat threshold is associated with an increase in the relative risk of all-cause mortality of 0.60% (95%CI [0.39%, 0.82%]) and 1.10% (95%CI [0.65%, 1.56%]) for adults older than 75. For each MSA, the relative risk of mortality for a 1 °C temperature increase above the heat threshold ranges from 0.10% (95%CI [0.09%, 0.10%]) to 1.29% (95%CI [1.26%, 1.32%]). Moreover, elevated temperatures showed a slight decrease in cardiovascular mortality (0.37%, 95%CI [-0.35%, 1.09%]) and respiratory disease (1.97%, 95%CI [-0.11%, 4.08%]), however this effect was not considered statistically significant.., Conclusion: Our study found that high temperatures can significantly impact all-cause mortality in Texas, and effect estimates differ by MSA, age group, and cause of death. Our findings generate critical information on the impact of heat on mortality in Texas, providing insights for policymakers on resource allocation and strategic intervention to reduce heat-related health effects., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Direct exposure to household fine particulate air pollution (HAP) associated with inefficient combustion of fuels (wood, charcoal, coal, crop residues, kerosene, etc.) for cooking, space-heating, and lighting is estimated to result in 2.3 (1.6-3.1) million premature yearly deaths globally. HAP emitted indoors escapes outdoors and is a leading source of outdoor ambient fine particulate air pollution (AAP) in low- and middle-income countries, often being a larger contributor than well-recognized sources including road transport, industry, coal-fired power plants, brick kilns, and construction dust. We review published scientific studies that model the contribution of HAP to AAP at global and major sub-regional scales. We describe strengths and limitations of the current state of knowledge on HAP's contribution to AAP and the related impact on public health and provide recommendations to improve these estimates. We find that HAP is a dominant source of ambient fine particulate matter (PM2.5) globally - regardless of variations in model types, configurations, and emission inventories used - that contributes approximately 20 % of total global PM2.5 exposure. There are large regional variations: in South Asia, HAP contributes ∼ 30 % of ambient PM2.5, while in high-income North America the fraction is ∼ 7 %. The median estimate indicates that the household contribution to ambient air pollution results in a substantial premature mortality burden globally of about 0.77(0.54-1) million excess deaths, in addition to the 2.3 (1.6-3.1) million deaths from direct HAP exposure. Coordinated global action is required to avert this burden., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The World Health Organization identified climate change as the 21st century's biggest health threat. This study aimed to identify the current knowledge base, evidence gaps, and implications for climate action and health policymaking to address the health impact of climate change, including in the most underserved groups., Methods: The Horizon-funded project ENBEL ('Enhancing Belmont Research Action to support EU policy making on climate change and health') organised a workshop at the 2021-European Public Health conference. Following presentations of mitigation and adaptation strategies, seven international researchers and public health experts participated in a panel discussion linking climate change and health. Two researchers transcribed and thematically analysed the panel discussion recording., Results: Four themes were identified: (1) 'Evidence is key' in leading the climate debate, (2) the need for 'messaging about health for policymaking and behaviour change' including health co-benefits of climate action, (3) existing 'inequalities between and within countries', and (4) 'insufficient resources and funding' to implement national health adaptation plans and facilitate evidence generation and climate action, particularly in vulnerable populations., Conclusion: More capacity is needed to monitor health effects and inequities, evaluate adaptation and mitigation interventions, address current under-representations of low- or middle-income countries, and translate research into effective policymaking.

Introduction: There is an increasing interest in understanding whether air pollutants modify the quantitative relationships between temperature and health outcomes. The results of available studies were, however, inconsistent. This study aims to sum up the current evidence and provide a comprehensive understanding of this topic., Methods: We conducted an electronic search in PubMed (MEDLINE), EMBASE, Web of Science Core Collection, and ProQuest Dissertations and Theses. The modified Navigation Guide was applied to evaluate the quality and strength of evidence. We calculated pooled temperature-related mortality at low and high pollutant levels respectively, using the random-effects model., Results: We identified 22 eligible studies, eleven of which were included in the meta-analysis. Significant effect modification was observed on heat effects for all-cause and non-accidental mortality by particulate matter with an aerodynamic diameter of <10 μm (PM 10 ) and ozone (O 3 ) (p < 0.05). The excess risks (ERs) for all-cause and non-accidental mortality were 5.4% (4.4%, 6.4%) and 6.3% (4.8%, 7.8%) at the low PM 10 level, 8.8% (7.5%, 10.1%) and 11.4% (8.7%, 14.2%) at the high PM 10 level, respectively. As for O 3 , the ERs for all-cause and non-accidental mortality were 5.1% (3.9%, 6.3%) and 3.6% (0.1%, 7.2%) at the low O 3 level, 7.6% (6.3%, 9.0%) and 12.5% (4.7%, 20.9%) at the high O 3 level, respectively. Surprisingly, the heat effects on cardiovascular mortality were found to be lower at high carbon monoxide (CO) levels [ERs = 5.4% (3.9%, 6.9%)] than that at low levels [ERs = 9.4% (7.0%, 11.9%)]. The heterogeneity varied, but the results of sensitivity analyses were generally robust. Significant effect modification by air pollutants was not observed for heatwave or cold effects., Conclusions: PM 10 and O 3 modify the heat-related all-cause and non-accidental mortality, indicating that policymakers should consider air pollutants when establishing heat-health warning systems. Future studies with comparable designs and settings are needed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Mobility restrictions during the COVID-19 pandemic ostensibly prevented the public from transmitting the disease in public places, but they also hampered outdoor recreation, despite the importance of blue-green spaces (e.g., parks and natural areas) for physical and mental health. We assess whether restrictions on human movement, particularly in blue-green spaces, affected the transmission of COVID-19. Our assessment uses a spatially resolved dataset of COVID-19 case numbers for 848 administrative units across 153 countries during the first year of the pandemic (February 2020 to February 2021). We measure mobility in blue-green spaces with planetary-scale aggregate and anonymized mobility flows derived from mobile phone tracking data. We then use machine learning forecast models and linear mixed-effects models to explore predictors of COVID-19 growth rates. After controlling for a number of environmental factors, we find no evidence that increased visits to blue-green space increase COVID-19 transmission. By contrast, increases in the total mobility and relaxation of other non-pharmaceutical interventions such as containment and closure policies predict greater transmission. Ultraviolet radiation stands out as the strongest environmental mitigant of COVID-19 spread, while temperature, humidity, wind speed, and ambient air pollution have little to no effect. Taken together, our analyses produce little evidence to support public health policies that restrict citizens from outdoor mobility in blue-green spaces, which corroborates experimental studies showing low risk of outdoor COVID-19 transmission. However, we acknowledge and discuss some of the challenges of big data approaches to ecological regression analyses such as this, and outline promising directions and opportunities for future research.

China has been promoting one of the world's largest campaigns for clean heating renovation since 2017. Here, we present an integrated cost-benefit analysis in a major prefecture-level city by combining a large-scale household energy survey and PM 2.5 exposure measurement, high-resolution chemical transport simulation, and health impact assessment. We find that the completed renovation decreases the share of solid fuels in the heating energy mix from 96 to 6% and achieves a concomitant reduction of cooking solid-fuel use by 70%. The completed renovation decreases the ambient PM 2.5 concentration in Linfen by 0.5-5 μg m -3 (2.4 μg m -3 on average) and decreases the integrated PM 2.5 exposure by 4.2 (3.5-5.0) μg m -3 . The renovation is estimated to avoid 162 (125-225) and 328 (254-457) premature deaths annually based on two health impact assessment methods. The ratios of monetized health benefits to cost are 1.51 (0.73-2.59) and 3.06 (1.49-5.23) based on the above two methods. The benefit-to-cost ratio is projected to remain high if the renovation is further expanded. More polluted and less wealthy households enjoy larger health benefits but also experience a higher expense increase, suggesting that a more carefully designed subsidy policy is needed to protect low-income households.

The health effects of acute exposure to temperature extremes are established; those of long-term exposure only recently received attention. We performed a systematic review to assess the associations of long-term (>3 months) exposure to higher or lower temperature on total and cardiopulmonary mortality and morbidity, screening 3455 studies and selecting 34. The studies were classified in those observing associations within a population over years with changing annual temperature indices and those comparing areas with a different climate. We also assessed the risk of bias, adapting appropriately an instrument developed by the World Health Organization for air pollution. Studies reported that annual temperature indices for extremes and variability were associated with annual increases in mortality, indicating that effects of temperature extremes cannot be attributed only to short-term mortality displacement. Studies on cardiovascular mortality indicated stronger associations with cold rather than hot temperature, whilst those on respiratory outcomes reported effects of both heat and cold but were few and used diverse health outcomes. Interactions with air pollution were not generally assessed. The few studies investigating effect modification showed stronger effects among the elderly and those socially deprived. Comparisons of health outcome prevalence between areas reported lower blood pressure and a tendency for higher obesity in populations living in warmer climates. Our review indicated interesting associations between long-term exposure to unusual temperature levels in specific areas and differences in health outcomes and cardiovascular risk factors between geographical locations with different climate, but the number of studies by design and health outcome was small. Risk of bias was identified because of the use of crude exposure assessment and inadequate adjustment for confounding. More and better designed studies, including the investigation of effect modifiers, are needed., (Copyright © 2021 Elsevier B.V. All rights reserved.)

The lockdown response to COVID-19 has resulted in an unprecedented reduction in global economic activity and associated air pollutant levels, especially from a decline in land transportation. We utilized a network of >10,000 air quality stations distributed over 34 countries during lockdown dates up until 15 May 2020 to obtain lockdown related anomalies for nitrogen dioxide, ozone and particulate matter smaller than 2.5 μm in diameter (PM 2.5 ). Pollutant anomalies were related to short-term health outcomes using empirical exposure-response functions. We estimate that there were a net total of 49,900 (11,000 to 90,000; 95% confidence interval) excess deaths and 89,000 (64,700 to 107,000) pediatric asthma emergency room visits avoided during lockdowns. In China and India alone, the PM 2.5 -related avoided excess mortality was 19,600 (15,300 to 24,000) and 30,500 (5700 to 68,000), respectively. While the state of COVID-19 imposed lockdown is not sustainable, these findings illustrate the potential health benefits gained by reducing "business as usual" air pollutant emissions from economic activities primarily through finding alternative transportation solutions., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: Modeling suggests that climate change mitigation actions can have substantial human health benefits that accrue quickly and locally. Documenting the benefits can help drive more ambitious and health-protective climate change mitigation actions; however, documenting the adverse health effects can help to avoid them. Estimating the health effects of mitigation (HEM) actions can help policy makers prioritize investments based not only on mitigation potential but also on expected health benefits. To date, however, the wide range of incompatible approaches taken to developing and reporting HEM estimates has limited their comparability and usefulness to policymakers., Objective: The objective of this effort was to generate guidance for modeling studies on scoping, estimating, and reporting population health effects from climate change mitigation actions., Methods: An expert panel of HEM researchers was recruited to participate in developing guidance for conducting HEM studies. The primary literature and a synthesis of HEM studies were provided to the panel. Panel members then participated in a modified Delphi exercise to identify areas of consensus regarding HEM estimation. Finally, the panel met to review and discuss consensus findings, resolve remaining differences, and generate guidance regarding conducting HEM studies., Results: The panel generated a checklist of recommendations regarding stakeholder engagement: HEM modeling, including model structure, scope and scale, demographics, time horizons, counterfactuals, health response functions, and metrics; parameterization and reporting; approaches to uncertainty and sensitivity analysis; accounting for policy uptake; and discounting., Discussion: This checklist provides guidance for conducting and reporting HEM estimates to make them more comparable and useful for policymakers. Harmonization of HEM estimates has the potential to lead to advances in and improved synthesis of policy-relevant research that can inform evidence-based decision making and practice. https://doi.org/10.1289/EHP6745.

The lockdown response to coronavirus disease 2019 (COVID-19) has caused an unprecedented reduction in global economic and transport activity. We test the hypothesis that this has reduced tropospheric and ground-level air pollution concentrations, using satellite data and a network of >10,000 air quality stations. After accounting for the effects of meteorological variability, we find declines in the population-weighted concentration of ground-level nitrogen dioxide (NO 2 : 60% with 95% CI 48 to 72%), and fine particulate matter (PM 2.5 : 31%; 95% CI: 17 to 45%), with marginal increases in ozone (O 3 : 4%; 95% CI: -2 to 10%) in 34 countries during lockdown dates up until 15 May. Except for ozone, satellite measurements of the troposphere indicate much smaller reductions, highlighting the spatial variability of pollutant anomalies attributable to complex NO x chemistry and long-distance transport of fine particulate matter with a diameter less than 2.5 µm (PM 2.5 ). By leveraging Google and Apple mobility data, we find empirical evidence for a link between global vehicle transportation declines and the reduction of ambient NO 2 exposure. While the state of global lockdown is not sustainable, these findings allude to the potential for mitigating public health risk by reducing "business as usual" air pollutant emissions from economic activities. Explore trends here: https://nina.earthengine.app/view/lockdown-pollution., Competing Interests: The authors declare no competing interest.

Background: The Cameroon government has set a target that, by 2030, 58% of the population will be using Liquefied Petroleum Gas (LPG) as a cooking fuel, in comparison with less than 20% in 2014. The National LPG Master Plan (Master Plan) was developed for scaling up the LPG sector to achieve this target., Objectives: This study aimed to estimate the potential impacts of this planned LPG expansion (the Master Plan) on population health and climate change mitigation, assuming primary, sustained use of LPG for daily cooking., Methods: We applied existing and developed new mathematical models to calculate the health and climate impacts of expanding LPG primary adoption for household cooking in Cameroon over two periods: a ) short-term (2017-2030): Comparing the Master Plan 58% target with a counterfactual LPG adoption of 32% in 2030, in line with current trends; and b ) long-term (2031-2100, climate modeling only), assuming Cameroon will become a mature and saturated LPG market by 2100 (73% adoption, based on Latin American countries). We compared this with a counterfactual adoption of 41% by 2100, in line with current trends., Results: By 2030, successful implementation of the Master Plan was estimated to avert about 28,000 ( minimum = 22,000 , maximum = 35,000 ) deaths and 770,000 ( minimum = 580,000 maximum = 1   million ) disability-adjusted life years. For the same period, we estimated reductions in pollutant emissions of more than a third in comparison with the counterfactual, leading to a global cooling of - 0.1   milli   ° C in 2030. For 2100, a cooling impact from the Master Plan leading to market saturation (73%) was estimated to be - 0.70   milli   ° C in comparison with to the counterfactual, with a range of - 0.64 to - 0.93   milli   ° C based on different fractions of nonrenewable biomass., Discussion: Successful implementation of the Master Plan could have significant positive impacts on population health in Cameroon with no adverse impacts on climate. https://doi.org/10.1289/EHP4899.

The serious fine particle (PM 2.5 ) pollution in China causes millions of premature deaths. Driven by swift economic growth and stringent control policies, air pollutant emissions in China have changed significantly in the last decade, but the change in the source contribution of PM 2.5 -related health impacts remains unclear. In this study, we develop a multi-pollutant emission inventory in China for 2005-2015, and combine chemical transport modeling, ambient/household exposure evaluation and health impact assessment to quantify the contribution of eight emission sectors to PM 2.5 exposure and associated health risk. From 2005 to 2015, the mortality due to PM 2.5 from ambient air pollution (AAP) decreases from 1.04 (95% confidence interval, 0.84-1.25) million to 0.87 (0.70-1.04) million. The agricultural sector contributes 25% and 32% to ambient PM 2.5 -attributed mortality in 2005 and 2015, respectively, representing the largest contributor during this period. The contribution of power plants drops monotonously from 13% to 6%. The percentage contribution of industrial process drops significantly while the contribution of industrial combustion stays the same level. The overall contribution of industry is still as large as 26% in 2015 in spite of strict control measures. For transportation, despite strict emission standards, its contribution increases remarkably due to the rapid growth of vehicle population. When both ambient and household PM 2.5 exposures are taken into account, the mortality due to integrated population-weighted exposure to PM 2.5 (IPWE) drops from 1.78 (1.46-2.09) million in 2005 to 1.28 (1.05-1.52) million in 2015. Most of the IPWE reduction comes from domestic combustion as a result of urbanization and improved income, whereas this sector remains the largest contributor (58%) to IPWE-related health risk in 2015. Our results suggest that the government should dynamically adjust the air pollution control strategy according to the change in source contributions. Domestic combustion and agriculture should be prioritized considering their predominant contributions to mortality and the lack of effective control policies. More stringent control measures for industry and transportation are necessary since the existing policies have not adequately reduced their health impacts. Electricity production is no longer the top priority of air pollution control policies given its lower health impact compared with that of other sources., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

High levels of PM 2.5 exposure and associated health risks are of great concern in rural China. For this study, we used portable PM 2.5 monitors for monitoring concentrations online, recorded personal time-activity patterns, and analyzed the contribution from different microenvironments in rural areas of the Yangtze River Delta, China. The daily exposure levels of rural participants were 66 μg/m 3 (SD 40) in winter and 65 μg/m 3 (SD 16) in summer. Indoor exposure levels were usually higher than outdoor levels. The exposure levels during cooking in rural kitchens were 140 μg/m 3 (SD 116) in winter and 121 μg/m 3 (SD 70) in summer, the highest in all microenvironments. Winter and summer values were 252 μg/m 3 (SD 103) and 204 μg/m 3 (SD 105), respectively, for rural people using biomass for fuel, much higher than those for rural people using LPG and electricity. By combining PM 2.5 concentrations and time spent in different microenvironments, we found that 92% (winter) and 85% (summer) of personal exposure to PM 2.5 in rural areas was attributable to indoor microenvironments, of which kitchens accounted for 24% and 27%, respectively. Consequently, more effective policies and measures are needed to replace biomass fuel with LPG or electricity, which would benefit the health of the rural population in China., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

To tackle the severe fine particle (PM 2.5 ) pollution in China, the government has implemented stringent control policies mainly on power plants, industry, and transportation since 2005, but estimates of the effectiveness of the policy and the temporal trends in health impacts are subject to large uncertainties. By adopting an integrated approach that combines chemical transport simulation, ambient/household exposure evaluation, and health-impact assessment, we find that the integrated population-weighted exposure to PM 2.5 (IPWE) decreased by 47% (95% confidence interval, 37-55%) from 2005 [180 (146-219) μg/m 3 ] to 2015 [96 (83-111) μg/m 3 ]. Unexpectedly, 90% (86-93%) of such reduction is attributed to reduced household solid-fuel use, primarily resulting from rapid urbanization and improved incomes rather than specific control policies. The IPWE due to household fuels for both cooking and heating decreased, but the impact of cooking is significantly larger. The reduced household-related IPWE is estimated to avoid 0.40 (0.25-0.57) million premature deaths annually, accounting for 33% of the PM 2.5 -induced mortality in 2015. The IPWE would be further reduced by 63% (57-68%) if the remaining household solid fuels were replaced by clean fuels, which would avoid an additional 0.51 (0.40-0.64) million premature deaths. Such a transition to clean fuels, especially for heating, requires technology innovation and policy support to overcome the barriers of high cost of distribution systems, as is recently being attempted in the Beijing-Tianjin-Hebei area. We suggest that household-fuel use be more highly prioritized in national control policies, considering its effects on PM 2.5 exposures., Competing Interests: The authors declare no conflict of interest., (Copyright © 2018 the Author(s). Published by PNAS.)

Fine particulate matter air pollution (PM 2.5 ) is a major risk factor for premature death globally. Studies of the PM 2.5 health burden usually treat exposure to ambient air pollution (AAP) and household air pollution from solid fuels (HAP) as separate risk factors. AAP and HAP can, however, be closely interrelated. Taking as the starting point that the total exposure to PM 2.5 is what matters for health, and recognizing the curvilinear form of exposure-response functions for important health effects, we develop a method for estimating the total annual mean population-weighted personal exposure, denoted integrated population-weighted exposure (IPWE). To establish the IPWE in China, we used recent emission inventories, Chemical Transport Models, China Census data on population and residential fuel use, and estimates of the PM 2.5 exposure among solid fuel users. We found an IPWE of 151 [123-179] μg/m 3 , of which 62-74% was attributable to residential solid fuels through HAP exposure and the residential sector emissions' contribution to AAP. We found large disparities in the PM 2.5 exposure burden, with an estimated IPWE in rural populations nearly twice the level in urban populations. Using the IPWE metric, we estimated that 1.15 [1.09-1.19] million premature deaths were attributable to PM 2.5 exposure annually in the period 2010-2013. Using the same data set, but calculating premature deaths from AAP and HAP in isolation, the estimated number was nearly 50% higher. The IPWE metric enables integration across AAP and HAP in policy analyses and could mitigate the concern of a potential double counting of the health burden that may arise from treating AAP and HAP as separate health risk factors., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Exposure to fine particles ≤ 2.5 μm in aerodynamic diameter (PM2.5) from incomplete combustion of solid fuels in household stoves, denoted household air pollution (HAP), is a major contributor to ill health in China and globally. Chinese households are, however, undergoing a massive transition to cleaner household fuels. The objective of the present study is to establish the importance of internal migration when it comes to the changing household fuel use pattern and the associated exposure to PM2.5 for the period 2000 to 2010. We also estimate health benefits of the fuel transition in terms of avoided premature deaths. Using China Census data on population, migration, and household fuel use for 2000 and 2010 we identify the size, place of residence, and main cooking fuel of sub-populations in 2000 and 2010, respectively. We combine these data with estimated exposure levels for the sub-populations and estimate changes in population exposure over the decade. We find that the population weighted exposure (PWE) for the Chinese population as a whole was reduced by 52 (36-70) μg/m(3) PM2.5 over the decade, and that about 60% of the reduction can be linked to internal migration. During the same period the migrant population, in total 261 million people, was subject to a reduced population weighted exposure (ΔPWE) of 123 (87-165) μg/m(3) PM2.5. The corresponding figure for non-migrants is 34 (23-47) μg/m(3). The largest ΔPWE was estimated for rural-to-urban migrants (138 million people), 214 (154-283) μg/m(3). The estimated annual health benefit associated with the reduced exposure in the total population is 31 (26-37) billion USD, corresponding to 0.4% of the Chinese GDP., (Copyright © 2014 Elsevier B.V. All rights reserved.)

The Clean Development Mechanism's (CDM) contribution to sustainable development in host countries has come under criticism in recent years. Yet, there are no detailed country-wide estimates of air quality cobenefits from CDM projects. In this paper, we estimate the SO(2), PM(2.5), and NO(x) cobenefit rates (tonnes per kt CO(2)eq reduced) of 11 CDM project types for seven regions in China, using detailed activity data from Project Design Documents and emissions factors calculated from the GAINS-Asia model database. We forecast the CO(2)eq reductions by CDM projects to 2012 and their associated contributions to air pollution reductions, and avoided health and agricultural impacts. We expect CDM projects to yield notable SO(2) reductions in the coming years (1094 kt in 2010), with more modest reductions of PM(2.5) and NO(x) (79 and 270 kt in 2010, respectively). This suggests that the CDM could be making a nontrivial contribution to China's SO(2) reductions under the 11th Five-Year Plan. The monetized health and agricultural benefits from reduced PM and NO(x) amount to roughly 12 billion RMB per year in 2010, roughly one-third of the market value of the associated Certified Emission Reductions.

To determine the population exposure to PM(10) in Chongqing, China, we developed an indirect model by combining information on the time activity patterns of various demographic subgroups with estimates of the PM(10) concentrations in different microenvironments (MEs). The spatial and temporal variations of the exposure to PM(10) were illustrated in a geographical information system (GIS). The population weighted exposure (PWE) for the entire population was 229, 155 and 211 microg/m(3), respectively, in winter, summer and as the annual average. Indoor PM(10) level at home was the largest contributor to the PWE, especially for the rural areas where high pollution levels were found due to solid fuels burning. Elder people had higher PM(10) exposure than adults and youth, due to more time spent in indoor MEs. The highest health risk due to particulate was found in the city zone and northeast regions, suggesting that pollution abatement should be prioritized in these areas.

According to the World Health Organization (WHO), indoor air pollution (IAP) from the use of solid fuels in households in the developing world is responsible for more than 1.6 million premature deaths each year, whereof 0.42 million occur in China alone. We argue that the methodology applied by WHO--the so-called fuel-based approach--underestimates the health effects, and suggest an alternative method. Combining exposure-response functions and current mortality and morbidity rates, we estimate the burden of disease of IAP in China and the impacts of three abatement scenarios. Using linear exposure-response functions, we find that 3.5 [0.8-14.7 95% CI] million people die prematurely due to IAP in China each year. The central estimate constitutes 47% of all deaths in China. We find that modest changes in the use of cooking fuels in rural households might have a large health impact, reducing annual mortality by 0.63 [0.1-3. 2 95% CI] million. If the indoor air quality (IAQ) standard set by the Chinese government (150 microg PM(10)/m(3)) was met in all households, we estimate that 0.9 [0.2-4.8] million premature deaths would be avoided in urban areas and 2.8 [0.7-12.4] million in rural areas. However, in urban areas this would require improvements to the outdoor air quality in addition to a complete fuel switch to clean fuels in households. We estimate that a fuel switch in urban China could prevent 0.7 [0.2-4.8] million premature deaths. The methodology for exposure assessment applied here is probably more realistic than the fuel-based approach; however, the use of linear exposure-response relationships most likely tends to overestimate the effects. The discrepancies between our results and the WHO estimates is probably also explained by our use of "all-cause mortality" which includes important causes of death like cardiovascular diseases, conditions known to be closely associated with exposure to particulate pollution, whereas the WHO estimate is limited to respiratory diseases.

Indoor air pollution from solid fuel use has severe health effects. 60% of the Chinese population lives in rural areas, where most people rely on solid fuels for cooking and heating. We estimate exposure by combining information on the amount of time spent in different microenvironments and estimates of the particle concentrations (PM(10)) in these environments. According to our estimates, 70% of the exposure experienced by the rural population is due to indoor air pollution (IAP). The urban coal using population experience a 17% increase in exposure from IAP. We apply Monte Carlo simulations to quantify variability and uncertainty in the exposure, morbidity and mortality estimates. We find that applying Monte Carlo simulations reduces the estimated uncertainty compared to analytical methods based on approximate distributions and the central limit theorem. We find that annually about 4% (geometric S.D. sigma(g), 3.2) and 35% (sigma(g), 2.6) of the deaths in the urban and rural populations, respectively, could be avoided by switching to clean fuels. Upgrading the stoves in rural areas to the standard found in urban areas is estimated to reduce mortality by 23% (sigma(g), 3.1). Moreover, we estimate that chronic respiratory illness (CRI) in children can be reduced by, respectively, about 9% (sigma(g), 2.5) and 80% (sigma(g) 1.9) by switching to clean fuels in the urban and rural areas. Upgrading the stoves in rural areas is estimated to reduce CRI in children with about 58% (sigma(g) 2.3). For adults the reduction in CRI was estimated to be 6% (sigma(g) 2.4) and 45% (sigma(g) 1.8) for the urban and rural population following a fuel switch, and 31% (sigma(g) 2.4) for the rural population from stove improvements. Contrary to our expectations we find small gender differences in exposure. We ascribe that to comparable kitchen and living area concentrations and similar indoor occupation times for the genders. Young children and the elderly spend the most time indoors, and have the highest daily exposure in the coal using population. The rural population experience higher exposure than the urban population, even though the outdoor air is significantly cleaner in rural areas.