Long-term nitrogen dioxide exposure and cause-specific mortality in the U.S. Medicare population

Since 1971, the annual National Ambient Air Quality Standard (NAAQS) for nitrogen dioxide (NO2) has remained at 53 ppb, the impact of long-term NO2 exposure on mortality is poorly understood. We examined associations between long-term NO2 exposure (12-month moving average of NO2) below the annual NAAQS and cause-specific mortality among the older adults in the U.S. Cox proportional-hazard models were used to estimate Hazard Ratio (HR) for cause-specific mortality associated with long-term NO2 exposures among about 50 million Medicare beneficiaries living within the conterminous U.S. from 2001 to 2008. A 10 ppb increase in NO2 was associated with increased mortality from all-cause (HR: 1.06; 95% CI: 1.05–1.06), cardiovascular (HR: 1.10; 95% CI: 1.10–1.11), respiratory disease (HR: 1.09; 95% CI: 1.08–1.11), and cancer (HR: 1.01; 95% CI: 1.00–1.02) adjusting for age, sex, race, ZIP code as strata ZIP code- and state-level socio-economic status (SES) as covariates, and PM2.5 exposure using a 2-stage approach. NO2 was also associated with elevated mortality from ischemic heart disease, cerebrovascular disease, congestive heart failure, chronic obstructive pulmonary disease, pneumonia, and lung cancer. We found no evidence of a threshold, with positive and significant HRs across the range of NO2 exposures for all causes of death examined. Exposure-response curves were linear for all-cause, supra-linear for cardiovascular-, and sub-linear for respiratory-related mortality. HRs were highest consistently among Black beneficiaries. Long-term NO2 exposure is associated with elevated risks of death by multiple causes, without evidence of a threshold response. Our findings raise concerns about the sufficiency of the annual NAAQS for NO2. [Display omitted] •Long-term NO2 exposure was associated with increased mortality from cardiovascular disease, respiratory disease, and cancer.•NO2-mortality associations were without a lower threshold, suggesting that any long-term exposure is associated with mortality risk.•The increased mortality associated with NO2 exposure was considerably higher among the Black beneficiaries than other races.