Ambient PM2.5, ozone and mortality in Chinese older adults: A nationwide cohort analysis (2005–2018)

Cohort evidence linking long-term survival with exposure to multiple air pollutants (e.g., fine particulate matter [PM2.5] and ozone) was extensively sparse in low- and middle-income countries, especially among older adults. This study aimed to investigate potential associations of long-term exposures to PM2.5 and ozone with all-cause mortality in Chinese older adults.A dynamic nationwide prospective cohort comprising 20,352 adults aged ≥65 years were enrolled from the Chinese Longitudinal Healthy Longevity Study and followed up through 2005-2018. Participants' annual exposures to warm-season ozone and year-round PM2.5 were assigned using satellite-derived spatiotemporal estimates. A directed acyclic graph (DAG) was developed to identify confounding variables. Associations of annual mean exposures to PM2.5 and ozone with mortality were evaluated using single- and two-pollutant Cox proportional hazards models, adjusting for time-dependent individual risk factors and ambient temperature.During 100 thousand person-years of follow-up (median: 3.6 years), a total of 14,313 death events occurred. The participants were averagely aged 87.1 years at baseline and exposed to a wide range of annual average concentrations of warm-season maximum 8-hour ozone (mean, 54.4 ppb; range, 23.3-81.6 ppb) and year-round PM2.5 (mean, 65.5 μg/m3; range, 10.1-162.9 μg/m3). Approximately linear concentration-response relationship was identified for ozone, whereas significant increases in PM2.5-associated mortality risks were observed only when concentrations were above 60 μg/m3. Rises of 10 ppb in ozone and 10 µg/m3 in PM2.5 above 60 µg/m3 were associated with increases in all-cause mortality of 13.2% (95% confidence interval [CI]: 10.2-16.2%) and 6.2% (95% CI: 4.6-7.7%) in DAG-based single-pollutant model, and of 9.7% (95% CI: 6.6-13.0%) and 5.3% (95% CI: 3.7-6.9%) in DAG-based two-pollutant model, respectively. We detected significant effect modification by temperature in associations of mortality with ozone (P <0.001 for interaction), suggesting greater ozone-related risks among participants in warmer locations.This study provided longitudinal evidence that long-term exposure to ambient PM2.5 and ozone significantly and independently contributed to elevated risks of all-cause mortality among older adults in China.