The impact of air pollution on the incidence of diabetes and survival among prevalent diabetes cases

•Air pollution was associated with the incidence of diabetes, in particular NO2.•Air pollution was also associated with cardiovascular and diabetes mortality among persons with prevalent diabetes.•The strongest associations were observed between NO2 and diabetes mortality.•Results may suggest that traffic-related pollution has the greatest effect on outcomes of diabetes. Growing evidence implicates ambient air pollutants in the development of major chronic diseases and premature mortality. However, epidemiologic evidence linking air pollution to diabetes remains inconclusive. This study sought to determine the relationships between selected air pollutants (nitrogen dioxide [NO2], fine particulate matter [PM2.5], ozone [O3], and oxidant capacity [Ox; the redox-weighted average of O3 and NO2]) and the incidence of diabetes, as well as the risk of cardiovascular or diabetes mortality among individuals with prevalent diabetes. We followed two cohorts, which included 4.8 million Ontario adults free of diabetes and 452,590 Ontario adults with prevalent diabetes, from 2001 to 2015. Area-level air pollution exposures were assigned to subjects’ residential areas, and outcomes were ascertained using health administrative data with validated algorithms. We estimated hazard ratios for the association between each air pollutant and outcome using Cox proportional hazards models, and modelled the shape of the concentration-response relationships. Over the study period, 790,461 individuals were diagnosed with diabetes. Among those with prevalent diabetes, 26,653 died from diabetes and 64,773 died from cardiovascular diseases. For incident diabetes, each IQR increase in NO2 had a hazard ratio of 1.04 (95% CI: 1.03–1.05). This relationship was relatively robust to all sensitivity analyses considered, and exhibited a near-linear shape. There were also positive associations between incident diabetes and PM2.5, O3, and Ox, but these estimates were somewhat sensitive to different models considered. Among those with prevalent diabetes, almost all pollutants were associated with increased diabetes and cardiovascular mortality risk. The strongest association was observed between diabetes mortality and exposure to NO2 (HR = 1.08, 95% CI: 1.02–1.13). Selected air pollutants, especially NO2, were linked to an increased risk of incident diabetes, as well as risk of cardiovascular or diabetes mortality among persons with prevalent diabetes. As NO2 is frequently used as a proxy for road