The synergistic and mediating effects of ozone on associations between high temperature, heatwaves and mortality in the Greater London area between 2010 and 2018

The health impacts of increasing heat exposure are alarming, especially in a climate change era. The role of ozone in the extreme temperature-mortality association remains unclear. We examined the mechanisms through which ozone influences extreme temperature-mortality association in Greater London, UK, from 2010 to 2018. Employing a time-series analysis with generalized linear quasi-Poisson models, we quantified the effects of daily 8-h maximum ozone concentrations, heatwaves, and extreme temperature on all-cause, respiratory and cardiovascular mortality. Interaction analyses were applied to assess the synergistic effects of ozone and heat-related exposures. A causal mediation analysis was utilised to decompose the total effect of high temperature/heatwave on mortality into direct and indirect effects. The risk of all-cause mortality during the warm season (May to September) increased by 1.3 % (95 % Confidence Interval (CI): 1.1 %, 1.6 %) for each 1 °C increment in daily mean temperature. Heatwave days (two or more days with unusually high temperatures) were associated with an 8.6 % (95 % CI: 6.9 %, 10.4 %) increase in all-cause mortality compared to non-heatwave days. These effects were more pronounced for respiratory mortality, i.e. 1.6 % (95 % CI: 1.0 %, 2.2 %) increase per 1 °C increment in temperature and 9.6 % (95 % CI: 4.6 %, 15.0 %) increase during heatwaves. The risk of heat-related mortality increased on high ozone days, and high temperatures amplified the risk of ozone-related mortality. The proportion of the total effect of extreme temperature and heatwaves on all-cause mortality mediated by ozone was 8.5 % and 8.8 %, respectively. For respiratory mortality and heatwaves, the proportion mediated was 14.9 %. Our findings show synergistic effects of ozone and extreme temperature on mortality, as well as mediating effects of ozone in the heat-mortality associations. • Heat and ozone exposure increased respiratory mortality risk in London, UK. • Ozone exposure amplified heat-related mortality, acting synergistically. • Ozone mediated 5.9 %–14.9 % of heat-mortality risk via the heat-ozone-death pathway. • Heat-mortality assessment should account for synergistic/mediating roles of ozone. • Reducing ozone and precursors during hot days could mitigate heat health impacts.