All official European Union website addresses are in the europa.eu domain.
See all EU institutions and bodies
An official website of the European Union | How do you know?
Environmental information systems
This report provides information about the environmental determinants of chronic respiratory disease (CRD) to support EU policy responses. It is based on data compiled by the EEA and supports the European Green Deal, as well as EU action against pollution, climate change, occupational risks and tobacco.
Key messages
Environmental risk factors are estimated to cause over a third of premature chronic respiratory disease-related deaths (i.e. close to 80,000) in Europe — almost as many as the chronic respiratory disease deaths from smoking and other behavioural risk factors.
These premature deaths and a significant part of the burden of disease from these illnesses can be prevented by reducing pollution, addressing energy poverty and adapting to climate change.
Key environmental risk factors for chronic respiratory disease in Europe include air pollution (14% of CRD deaths), extreme temperatures (over 11%), occupational exposure (8%), second-hand smoke (3%), as well as mould, wildfire smoke and allergenic pollens.
Exposure to many of these environmental factors — and chronic respiratory diseases themselves — is aggravated by climate change.
Chronic respiratory disease cases tend to reflect past exposure, so decreasing exposure to environmental risk factors will take years to translate into less cases of respiratory disease.
Understanding the issue
Respiratory diseases are illnesses that affect the lungs and airways. They consist of acute infectious diseases (such as pneumonia and influenza), chronic diseases (such as chronic obstructive pulmonary disease (COPD), bronchitis, emphysema and asthma) and respiratory tract cancers.
Respiratory diseases impact the lives of many European residents. They are the third most common cause of death in the European Environment Agency member countries, where almost 420,000 people die from them each year, over 60% of them from Chronic Respiratory Diseases (CRDs) (Eurostat, 2024a; WHO, 2024; IHME, 2024). While there are some higher death rates and burden of disease from respiratory disease in some of these countries, there is no clear pattern across the region.
Environmental risks for cancers, including respiratory, were addressed in a previous EEA report. This report focuses on chronic respiratory diseases (CRDs), with brief mentions of infectious respiratory diseases for which the influence of environmental risks is well-established.
The causes of CRDs are complex. Some of the individual determinants for respiratory disease, such as age, sex, race/ethnicity and family history, are intrinsic to the individual and cannot be modified. Others are external and can be at least partially modified. Established risk factors that can be modified to reduce CRD risks include: (1) clinical risk factors such as obesity, as well as diabetes, which may be partly hereditary; (2) behavioural risk factors such as an unhealthy diet, lack of physical activity, smoking and alcohol use; and (3) environmental risk factors like exposure to air pollution, extreme temperatures, chemicals and biological agents in the environment and the workplace, second-hand smoke, dampness and mould, among others. Clinical CRD risk factors are affected by a variety of biological mechanisms as well as behavioural and environmental factors. Both are heavily influenced by socioeconomic factors like poor quality housing, low levels of income and education, lack of access to quality healthcare and related psychosocial stress (see Figure 1).
Figure 1. Respiratory disease: modifiable risk factors and individual determinants
Please select a resource that has a preview image available.
In some respects, the situation regarding CRDs in Europe has improved over recent decades. The prevalence of chronic respiratory diseases in the EU-27 decreased by around 20% between 1990 and 2015, though rates then increased moderately until 2021. Similarly, death rates declined until the middle of the last decade and have increased moderately in recent years. These increases were driven by an ageing population, particularly in high-income European countries. Behavioural risk factors, especially smoking, are the main modifiable contributors to chronic respiratory disease across EEA member countries. These are the main targets of prevention and of policy efforts towards improving respiratory health. However, environmental risk factors, notably air pollution and cold, are responsible for nearly as large a percentage of chronic respiratory deaths. Reducing environmental risk factors can therefore greatly help further decrease the burden of CRDs. This web report focuses on environmental risk factors for chronic respiratory disease and their prevention.
Environmental contribution to respiratory disease in Europe
In Europe (EEA member and collaborating countries), over a third (35%) of all CRD deaths are estimated to come from key environmental factors, mainly air pollution (14%), cold (11%), occupational exposures (8%) and secondhand tobacco smoke (3%). This represents over 78,000 premature deaths and a large burden of CRDs, which could be largely prevented by addressing energy poverty, enforcing tobacco regulations, and reducing pollution and occupational exposures. The association between environmental factors and CRDs is on average greater for men than for women and is also linked to ageing. Most of this burden is associated with COPD and to a lesser extent asthma, for which the burden of disease is mostly tied to morbidity. There is significant variation across EEA member and collaborating countries, with higher proportions of CRD deaths due to the environment estimated in eastern and south-eastern European countries and Türkiye (see Figure 2).
Figure 2. Percentage of preventable chronic respiratory disease deaths attributable to environmental risks in Europe
Please select a resource that has a preview image available.
The figure of 35% (for preventable CRD deaths attributable to the environment) may be an underestimate, as it includes only environmental factors for which enough data is available for most member and collaborating countries. It does not include known CRD risk factors such as exposure to aeroallergens, dust, mould and dampness, pollution from forest fires, or toxic chemicals that may be present in homes, the workplace or elsewhere. Though there are no Europe-wide estimates of the overall respiratory disease burden from many of these factors, this report nevertheless highlights existing scientific knowledge on their respiratory effects.
Environmental risks and their associations with respiratory disease
Explore the environmental risks and their associations with cardiovascular disease:
EU initiatives addressing respiratory disease prevention and environmental risk factors
Various EU-wide respiratory disease prevention plans and initiatives include the reduction of environmental respiratory disease risks in their strategies. Most initiatives aim to address behavioural factors, specifically smoking (EU action in this area can be found in the second-hand smoke section of this web report). Few initiatives address environmental risk factors. This is a missed opportunity to reduce highly modifiable variables, without the significant challenges that come with changing behaviours at a large populational scale.
Below are the most relevant current activities:
- The incoming European Commission, according to the political guidelines for the next European Commission), intends to ‘complete the European Health Union’ and ‘step up (their) work on preventive health’.
- The EU4Health Programme Regulation (EU 2021/522) sets out EU action in the field of health from 2021 to 2027. It includes specific commitments to address CRD among other non-communicable diseases (NCDs) by supporting health promotion and disease prevention. It also recognises that environmental risk factors play a part in causing NCDs and makes funding available for actions investigating the link between environmental factors and human diseases.
- The healthier together – EU non-communicable diseases (NCD) initiative was launched by the Commission in December 2021. It aims to support EU countries in identifying and implementing effective policies and actions to reduce the burden of major NCDs and improve residents’ health and well-being. Chronic respiratory diseases constitute one of its five key strands.
- The steering group on health promotion, disease prevention and management of non-communicable diseases was established by the Commission in 2018 (Decision 2018/C 251/07). It is composed of representatives of the Member States’ health ministries and advises the Commission on implementing the healthier together initiative by identifying potential actions related to the five strands (including CRD).
- Stakeholders including the European Alliance for Respiratory Health, medical technology firms, patient groups, NGOs and associations of health specialists have called for the EU to develop an action plan for CRD, similar to the existing action plan on beating cancer.
- Key stakeholders for better respiratory health in Europe include medical and patient associations like the European Federation of Allergy and Airways Diseases Patients’ Associations (EFA), the European Respiratory Society (ERS) and European Lung Foundation (ELF) as well as public health organisations like the European Public Health Association and the European Public Health Alliance. Most of these organisations have task forces and working groups on environmental risk factors. More directly focused on environmental risks for respiratory health are the European Aeroallergen Network and the Health and Environment Alliance (HEAL).
- Globally, various initiatives addressing CRDs as part of NCD prevention also apply to Europe. WHO’s global action plan for the prevention and control of NCDs was introduced to tackle the rising concerns about NCDs between 2013 and 2020 and has been extended to 2030. The action plan aimed, among other things, to reduce by 25% the risk of premature mortality from cardiovascular diseases, cancer, diabetes and chronic respiratory diseases. The WHO Global NCD Compact 2020-2030 was set out to address the lack of policy in legislations and policies to address the number of deaths caused by NCDs. The UN Sustainable Development Goals (SDGs) set global targets for sustainability and aim to reduce premature mortality from NCDs (including CRD) by one third by 2030.
There are several other EU-wide initiatives, scientific committees and EU-funded research projects, as well as calls for proposals, relating to different aspects of respiratory disease prevention and the role that environmental risk reduction can play.
Conclusions
Environmental risks are inherently preventable. Reducing them is key to bringing down the burden of respiratory disease in Europe. Moreover, it is likely that the actual contribution of environmental exposure to respiratory diseases is considerably underestimated. Individuals have limited scope for protecting themselves from most environmental determinants of respiratory disease, making regulatory intervention and policy implementation especially relevant and necessary. Policy and regulations need to be supported by sufficient resources specifically allocated to reducing pollution and preventing exposure (including occupational exposure).
The decreasing trends in exposure to some environmental respiratory risks are encouraging and show that environmental policy is valuable for preventing major diseases, including chronic respiratory illnesses. However, chronic respiratory disease cases tend to reflect past exposure, so decreasing levels of exposure will take years to translate into less cases of respiratory disease. Moreover, a complete understanding of the potential respiratory effects of all environmental risk factors is still lacking; for example, for several toxic chemicals and their combined mixture effects.
While data gaps exist and uncertainties are high, current scientific evidence solidly supports reducing environmental exposure as an effective strategy to reduce respiratory disease risks. There is no need to fully understand every step of the causal pathway from environmental exposure to respiratory disease cases to take decisive action to reduce pollution.
Web report no. 02/2024
Title: Beating chronic respiratory disease: the role of Europe’s environment
EN HTML: TH-01-24-010-EN-Q - ISBN: 978-92-9480-686-4 - doi: 10.2800/4790689
Aerts, R., et al., 2021, ‘Tree pollen allergy risks and changes across scenarios in urban green spaces in Brussels, Belgium’, Landscape and Urban Planning 207, p. 104001 (DOI: 10.1016/j.landurbplan.2020.104001).
Alahmari, A. D., et al., 2015, ‘Influence of weather and atmospheric pollution on physical activity in patients with COPD’, Respiratory Research 16(1), p. 71 (DOI: 10.1186/s12931-015-0229-z).
Analitis, A., et al., 2012, ‘Forest fires are associated with elevated mortality in a dense urban setting’, Occupational and Environmental Medicine 69(3), pp. 158-162 (DOI: 10.1136/oem.2010.064238).
Anderegg, W. R. L., et al., 2021, ‘Anthropogenic climate change is worsening North American pollen seasons’, Proceedings of the National Academy of Sciences 118(7), p. e2013284118 (DOI: 10.1073/pnas.2013284118).
Andersen, Z. J., et al., 2023, ‘Climate change and respiratory disease: clinical guidance for healthcare professionals’, Breathe (Sheffield, England) 19(2), p. 220222 (DOI: 10.1183/20734735.0222-2022).
Anyfantis, I. D., et al., 2017a, ‘Bacterial Endotoxins and their Impact on Respiratory System among Greek Cotton Industry Workers’, The International Journal of Occupational and Environmental Medicine 8(2), pp. 125-126 (DOI: 10.15171/ijoem.2017.1015).
Anyfantis, I. D., et al., 2017b, ‘Respiratory Symptoms and Lung Function among Greek Cotton Industry Workers: A Cross-Sectional Study’, The International Journal of Occupational and Environmental Medicine 8(1), pp. 32-38 (DOI: 10.15171/ijoem.2017.888).
Baatjies, R., et al., 2023, ‘Wood dust and asthma’, Current Opinion in Allergy and Clinical Immunology 23(2), pp. 76-84 (DOI: 10.1097/ACI.0000000000000882).
Becker, J., et al., 2021, ‘Threshold values of grass pollen (Poaceae) concentrations and increase in emergency department visits, hospital admissions, drug consumption and allergic symptoms in patients with allergic rhinitis: a systematic review’, Aerobiologia 37(4), pp. 633-662 (DOI: 10.1007/s10453-021-09720-9).
Beggs, P. J., 2015, ‘Environmental Allergens: from Asthma to Hay Fever and Beyond’, Current Climate Change Reports 1(3), pp. 176-184 (DOI: 10.1007/s40641-015-0018-2).
Biedermann, T., et al., 2019, ‘Birch pollen allergy in Europe’, Allergy 74(7), pp. 1237-1248 (DOI: 10.1111/all.13758).
Blanc, P. D., et al., 2019, ‘The Occupational Burden of Nonmalignant Respiratory Diseases. An Official American Thoracic Society and European Respiratory Society Statement’, American Journal of Respiratory and Critical Care Medicine 199(11), pp. 1312-1334 (DOI: 10.1164/rccm.201904-0717ST).
Blondeel, A., et al., 2023, ‘The association of weather conditions with day-to-day variability in physical activity in patients with COPD’, ERJ Open Research 9(6), pp. 00314-02023 (DOI: 10.1183/23120541.00314-2023).
Brunekreef, B., et al., 2000, ‘Relation between airborne pollen concentrations and daily cardiovascular and respiratory-disease mortality’, Lancet (London, England) 355(9214), pp. 1517-1518 (DOI: 10.1016/S0140-6736(00)02168-1).
Burkhardt, T., et al., 2023, ‘Time trend of exposure to secondhand tobacco smoke and polycyclic aromatic hydrocarbons between 1995 and 2019 in Germany - Showcases for successful European legislation’, Environmental Research 216(Pt 2), p. 114638 (DOI: 10.1016/j.envres.2022.114638).
Caillaud, D., et al., 2018, ‘Indoor mould exposure, asthma and rhinitis: findings from systematic reviews and recent longitudinal studies’, Eur Respir Rev 27(148) (DOI: 10.1183/16000617.0137-2017).
Carmona, R., et al., 2016, ‘Geographical variation in relative risks associated with cold waves in Spain: The need for a cold wave prevention plan’, Environ.Int. 88(1873-6750 (Electronic)), pp. 103-111.
Carreras, G., et al., 2021, ‘Burden of disease from exposure to secondhand smoke in children in Europe’, Pediatric Research 90(1), pp. 216-222 (DOI: 10.1038/s41390-020-01223-6).
Chen, K.-W., et al., 2018, ‘Ragweed Pollen Allergy: Burden, Characteristics, and Management of an Imported Allergen Source in Europe’, International Archives of Allergy and Immunology 176(3-4), pp. 163-180 (DOI: 10.1159/000487997).
Cheng, J. J. and Berry, P., 2013, ‘Health co-benefits and risks of public health adaptation strategies to climate change: a review of current literature’, International Journal of Public Health 58(2), pp. 305-311 (DOI: 10.1007/s00038-012-0422-5).
Cirera, L., et al., 2012, ‘Daily effects of air pollutants and pollen types on asthma and COPD hospital emergency visits in the industrial and Mediterranean Spanish city of Cartagena’, Allergologia Et Immunopathologia 40(4), pp. 231-237 (DOI: 10.1016/j.aller.2011.05.012).
D’Amato, G., et al., 2007, ‘Allergenic pollen and pollen allergy in Europe’, Allergy 62(9), pp. 976-990 (DOI: 10.1111/j.1398-9995.2007.01393.x).
D’Amato, G., 2020, ‘The effects of climate change on respiratory allergy and asthma induced by pollen and mold allergens’, Allergy 75(9), pp. 2219-2228 (DOI: 10.1111/all.14476.).
D’Amato, M., et al., 2018, ‘The impact of cold on the respiratory tract and its consequences to respiratory health’, Clinical and Translational Allergy 8(1), p. 20 (DOI: 10.1186/s13601-018-0208-9).
de Weger, L. A., et al., 2021, ‘Long-Term Pollen Monitoring in the Benelux: Evaluation of Allergenic Pollen Levels and Temporal Variations of Pollen Seasons’, Frontiers in Allergy 2 (DOI: 10.3389/falgy.2021.676176).
DG SANTE, 2021, Study appendices to final report: study on smoke-free environments and advertising of tobacco and related products, Health and Food Safety Directorate General, European Commission (https://op.europa.eu/en/publication-detail/-/publication/19bcb4c3-5d5a-11ec-9c6c-01aa75ed71a1/language-en).
DHHS, 2014, 2014 Surgeon General’s Report: The Health Consequences of Smoking—50 Years of Progress, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. (https://archive.cdc.gov/#/details?url=https://www.cdc.gov/tobacco/sgr/50th-anniversary/index.htm).
Diaz, J., et al., 2005, ‘Mortality impact of extreme winter temperatures’, Int.J.Biometeorol. 49(0020-7128 (Print)), pp. 179-183.
Donaldson, G. C., et al., 2012, ‘Influence of season on exacerbation characteristics in patients with COPD’, Chest 141(1), pp. 94-100 (DOI: 10.1378/chest.11-0281).
Doubleday, A., et al., 2020, ‘Mortality associated with wildfire smoke exposure in Washington state, 2006–2017: a case-crossover study’, Environmental Health 19(1), p. 4 (DOI: 10.1186/s12940-020-0559-2).
Dramburg, S., et al., 2024, ‘Heterogeneity of sensitization profiles and clinical phenotypes among patients with seasonal allergic rhinitis in Southern European countries—The @IT.2020 multicenter study’, Allergy 79(4), pp. 908-923 (DOI: 10.1111/all.16029).
EC, 2024, Communication on managing climate risks to protect people and prosperity, European Commission, Brussels, Belgium (https://ec.europa.eu/commission/presscorner/detail/en/qanda_24_1386).
EEA, 2021a, Europe’s changing climate hazards — an index-based interactive EEA report, European Environment Agency, Copenhagen, Denmark (https://www.eea.europa.eu/publications/europes-changing-climate-hazards-1).
EEA, 2021b, Forest fires in Europe, European Environment Agency, Copenhagen, Denmark (https://www.eea.europa.eu/en/analysis/indicators/forest-fires-in-europe).
EEA, 2022, Climate change as a threat to health and well-being in Europe: focus on heat and infectious diseases, No No 07/2022, European Environment Agency (EEA), Copenhagen, Denmark (10.2800/67519).
EEA, 2023a, Harm to human health from air pollution in Europe: burden of disease 2023, European Environment Agency, Copenhagen, Denmark (https://www.eea.europa.eu/publications/harm-to-human-health-from-air-pollution).
EEA, 2023b, ‘Is Europe on track towards climate resilience? Status of reported national adaptation actions in 2023’, European Environment Agency (https://www.eea.europa.eu/publications/is-europe-on-track-towards-climate-resilience) accessed 4 October 2024.
EEA, 2024, Responding to climate change impacts on human health in Europe: focus on floods, droughts and water quality, No EEA Report 3/2024 (https://www.eea.europa.eu/publications/responding-to-climate-change-impacts/).
El Garroussi, S., et al., 2024, ‘Europe faces up to tenfold increase in extreme fires in a warming climate’, npj Climate and Atmospheric Science 7(1), pp. 1-11 (DOI: 10.1038/s41612-024-00575-8).
ELF, 2024, Work-related lung conditions, European Lung Foundation, Brussels, Belgium (https://europeanlung.org/en/information-hub/lung-conditions/work-related-lung-conditions/).
EUOSHA, 2018a, Info sheet: Legislative framework on dangerous substances in workplaces | Safety and health at work EU-OSHA, European Agency for Safety and Health at Work, Bilbao, Spain (https://osha.europa.eu/en/publications/info-sheet-legislative-framework-dangerous-substances-workplaces) accessed 22 May 2023.
EUOSHA, 2018b, Info sheet: Substitution of dangerous substances in the workplace | Safety and health at work EU-OSHA, European Agency for Safety and Health at Work, Bilbao, Spain (https://osha.europa.eu/en/publications/info-sheet-substitution-dangerous-substances-workplace) accessed 22 May 2023.
EU-OSHA, 2019, ‘Biological agents and work-related diseases: results of a literature review, expert survey and analysis of monitoring systems | Safety and health at work EU-OSHA’ (https://osha.europa.eu/en/publications/biological-agents-and-work-related-diseases-results-literature-review-expert-survey-and/view) accessed 1 October 2024.
EUOSHA, 2019, Infosheet: Carcinogens at Work | Safety and health at work EU-OSHA, European Agency for Safety and Health at Work, Bilbao, Spain (https://osha.europa.eu/en/publications/infosheet-carcinogens-work) accessed 22 May 2023.
EU-OSHA, 2020, ‘Biological agents and prevention of work-related diseases: a review | Safety and health at work EU-OSHA’ (https://osha.europa.eu/en/publications/review-specific-work-related-diseases-due-biological-agents) accessed 1 October 2024.
EUOSHA, 2023, OSH Barometer Data Visualisation Tool, European Agency for Safety and Health at Work (https://visualisation.osha.europa.eu/osh-barometer/).
European Climate and Health Observatory, 2022, Climate change and health: the national policy overview in Europe, European Climate and Health Observatory (https://climate-adapt.eea.europa.eu/en/observatory/policy-context/national-policy-analysis-2022/national_policies_adaptation_health_analysis_eea_2022.pdf) accessed 23 September 2022.
European Commission, 2023, Energy poverty in the EU, European Commission (https://energy.ec.europa.eu/topics/markets-and-consumers/energy-consumer-rights/energy-poverty-eu_en).
EUROSTAT, 2024a, Causes of death statistics, European Commission, Brussels, Belgium (https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Causes_of_death_statistics#Major_causes_of_death_in_the_EU_in_2021).
EUROSTAT, 2024b, Occupational diseases statistics, European Commission, Brussels, Belgium (https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Occupational_diseases_statistics#Developments_for_specific_diseases).
Feary, J., et al., 2023, ‘Occupational lung disease: when should I think of it and why is it important?’, Breathe 19(2) (DOI: 10.1183/20734735.0002-2023).
Flexeder, C., et al., 2019, ‘Second-hand smoke exposure in adulthood and lower respiratory health during 20 year follow up in the European Community Respiratory Health Survey’, Respiratory Research 20, p. 33 (DOI: 10.1186/s12931-019-0996-z).
Flor, L. S., et al., 2024, ‘Health effects associated with exposure to secondhand smoke: a Burden of Proof study’, Nature Medicine 30(1), pp. 149-167 (DOI: 10.1038/s41591-023-02743-4).
Forkel, S., et al., 2020, ‘Allergic Rhinitis to Weed Pollen in Germany: Dominance by Plantain, Rising Prevalence, and Polysensitization Rates over 20 Years’, International Archives of Allergy and Immunology 181(2), pp. 128-135 (DOI: 10.1159/000504297).
Forzieri, G., et al., 2017, ‘Increasing risk over time of weather-related hazards to the {European} population: a data-driven prognostic study’, Lancet Planet Health 1(5), p. e200—-e208 (DOI: 10.1016/S2542-5196(17)30082-7).
GBD, 2024, Global Burden of Disease Study 2021 (GBD 2021)., Seattle, United States: Institute for Health Metrics and Evaluation (IHME), (https://www.healthdata.org/).
Guilbert, A., et al., 2018, ‘Relationships between aeroallergen levels and hospital admissions for asthma in the Brussels-Capital Region: a daily time series analysis’, Environmental Health: A Global Access Science Source 17(1), p. 35 (DOI: 10.1186/s12940-018-0378-x).
Hayes, D., et al., 2012, ‘Bronchoconstriction triggered by breathing hot humid air in patients with asthma: role of cholinergic reflex’, American Journal of Respiratory and Critical Care Medicine 185(11), pp. 1190-1196 (DOI: 10.1164/rccm.201201-0088OC).
Henderson, E., et al., 2020, ‘Secondhand smoke exposure and other signs of tobacco consumption at outdoor entrances of primary schools in 11 European countries’, Science of The Total Environment 743, p. 140743 (DOI: 10.1016/j.scitotenv.2020.140743).
Henderson, E., et al., 2021, ‘Secondhand smoke exposure assessment in outdoor hospitality venues across 11 European countries’, Environmental Research 200, p. 111355 (DOI: 10.1016/j.envres.2021.111355).
Huang, D., et al., 2023, ‘Cold exposure impairs extracellular vesicle swarm-mediated nasal antiviral immunity’, The Journal of Allergy and Clinical Immunology 151(2), pp. 509-525.e8 (DOI: 10.1016/j.jaci.2022.09.037).
Hurraß, J., et al., 2017, ‘Medical diagnostics for indoor mold exposure’, International Journal of Hygiene and Environmental Health 220(2 Pt B), pp. 305-328 (DOI: 10.1016/j.ijheh.2016.11.012).
Idrose, N. S., et al., 2022, ‘A Review of the Respiratory Health Burden Attributable to Short-Term Exposure to Pollen’, International Journal of Environmental Research and Public Health 19(12), p. 7541 (DOI: 10.3390/ijerph19127541).
Khosravi, M., et al., 2014, ‘Breathing hot humid air induces airway irritation and cough in patients with allergic rhinitis’, Respiratory Physiology & Neurobiology 198, pp. 13-19 (DOI: 10.1016/j.resp.2014.03.013).
Khreis, H., et al., 2017, ‘Exposure to traffic-related air pollution and risk of development of childhood asthma: A systematic review and meta-analysis’, Environment International 100, pp. 1-31 (DOI: 10.1016/j.envint.2016.11.012).
Kollanus, V., et al., 2017, ‘Mortality due to Vegetation Fire–Originated PM2.5 Exposure in Europe—Assessment for the Years 2005 and 2008’, Environmental Health Perspectives 125(1), pp. 30-37 (DOI: 10.1289/EHP194).
Koskela, H. O., et al., 1996, ‘Bronchoconstriction due to cold weather in COPD. The roles of direct airway effects and cutaneous reflex mechanisms’, Chest 110(3), pp. 632-636 (DOI: 10.1378/chest.110.3.632).
Koskela, H. O., 2007, ‘Cold air-provoked respiratory symptoms: the mechanisms and management’, International Journal of Circumpolar Health 66(2), pp. 91-100 (DOI: 10.3402/ijch.v66i2.18237).
Linares, C., et al., 2015, ‘Impact of heat and cold waves on circulatory-cause and respiratory-cause mortality in Spain: 1975–2008’, Stochastic Environmental Research and Risk Assessment 29(8), pp. 2037-2046 (DOI: 10.1007/s00477-014-0976-2).
Liu, A., et al., 2024, ‘Atmospheric pollen concentrations and chronic obstructive pulmonary disease (COPD) patients visits in Beijing: time series analysis using a generalized additive model’, Scientific Reports 14(1), p. 3462 (DOI: 10.1038/s41598-024-54055-3).
López-Bueno, J. A., et al., 2020, ‘The effect of cold waves on daily mortality in districts in Madrid considering sociodemographic variables’, Science of The Total Environment 749, p. 142364 (DOI: 10.1016/J.SCITOTENV.2020.142364).
Love, M. E. and Proud, D., 2022, ‘Respiratory Viral and Bacterial Exacerbations of COPD—The Role of the Airway Epithelium’, Cells 11(9), p. 1416 (DOI: 10.3390/cells11091416).
Lowe, A. J., et al., 2012, ‘Pollen exposure in pregnancy and infancy and risk of asthma hospitalisation - a register based cohort study’, Allergy, Asthma & Clinical Immunology 8(1), p. 17 (DOI: 10.1186/1710-1492-8-17).
Ma, C., et al., 2021, ‘Global trends in the prevalence of secondhand smoke exposure among adolescents aged 12–16 years from 1999 to 2018: an analysis of repeated cross-sectional surveys’, The Lancet Global Health 9(12), pp. e1667-e1678 (DOI: 10.1016/S2214-109X(21)00365-X).
Mäkinen, T. M., et al., 2009, ‘Cold temperature and low humidity are associated with increased occurrence of respiratory tract infections’, Respiratory Medicine 103(3), pp. 456-462 (DOI: 10.1016/j.rmed.2008.09.011).
Martinez, G. S., et al., 2018, ‘Cold-related mortality vs heat-related mortality in a changing climate: A case study in Vilnius (Lithuania)’, Environmental Research 166, pp. 384-393 (DOI: 10.1016/J.ENVRES.2018.06.001).
Martínez-Solanas, È., et al., 2021, ‘Projections of temperature-attributable mortality in Europe: a time series analysis of 147 contiguous regions in 16 countries’, The Lancet Planetary Health 5(7), pp. e446-e454 (DOI: 10.1016/S2542-5196(21)00150-9).
Matt, G. E., et al., 2023, ‘Policy-relevant differences between secondhand and thirdhand smoke: strengthening protections from involuntary exposure to tobacco smoke pollutants’, Tobacco Control (DOI: 10.1136/tc-2023-057971).
Matteis, S. D., et al., 2017, ‘Current and new challenges in occupational lung diseases’, European Respiratory Review 26(146) (DOI: 10.1183/16000617.0080-2017).
McCormack, M. C., et al., 2016, ‘Respiratory Effects of Indoor Heat and the Interaction with Air Pollution in Chronic Obstructive Pulmonary Disease’, Annals of the American Thoracic Society 13(12), pp. 2125-2131 (DOI: 10.1513/AnnalsATS.201605-329OC).
Murgia, N. and Gambelunghe, A., 2022, ‘Occupational COPD-The most under-recognized occupational lung disease?’, Respirology (Carlton, Vic.) 27(6), pp. 399-410 (DOI: 10.1111/resp.14272).
Naumann, G., et al., 2020, Global warming and human impacts of heat and cold extremes in the EU, EUR 29959 EN, Publications Office of the European Union, Luxembourg.
Nogueira, S. O., et al., 2022, ‘Secondhand Smoke Exposure in European Countries With Different Smoke-Free Legislation: Findings From the EUREST-PLUS ITC Europe Surveys’, Nicotine & Tobacco Research 24(1), pp. 85-92 (DOI: 10.1093/ntr/ntab157).
Pereira, P., 2015, ‘WILDLAND FIRES IN LITHUANIA’, in: in: Bento Gonçalves, A. J. and Vieira, A. A. B. (Eds), Wildland Fires: A Worldwide Reality, Nova Science Publishers, Inc., New York, Pp. 185-198., , pp. 185-198.
Pratt, J. R., et al., 2019, ‘A national burden assessment of estimated pediatric asthma emergency department visits that may be attributed to elevated ozone levels associated with the presence of smoke’, Environmental Monitoring and Assessment 191(2), p. 269 (DOI: 10.1007/s10661-019-7420-5).
Rantanen, M., et al., 2023, ‘Asymmetric warming rates between warm and cold weather regimes in Europe’, Atmospheric Science Letters 24(10), p. e1178 (DOI: 10.1002/asl.1178).
Rodriguez, J., et al., 2023, ‘Saliva and Exhaled Breath Condensate Correlate With Serum in 4-12-Year-Olds Exposed to Secondhand Electronic Cigarette Vapors: A Pilot Study’, Biological Research For Nursing 25(3), pp. 417-425 (DOI: 10.1177/10998004221149959).
Santos, M. Y., et al., 2015, ‘Are Wildfires and Pneumonia Spatially and Temporally Related?’, Bioinformatics and Biomedical Engineering, Cham, 2015.
Schaefer, O., et al., 1980, ‘Respiratory function impairment and cardiopulmonary consequences in long-time residents of the Canadian Arctic’, Canadian Medical Association Journal 123(10), pp. 997-1004.
Schaffner, U., et al., 2020, ‘Biological weed control to relieve millions from Ambrosia allergies in Europe’, Nature Communications 11(1), p. 1745 (DOI: 10.1038/s41467-020-15586-1).
Shea, K. M., et al., 2008, ‘Climate change and allergic disease’, Journal of Allergy and Clinical Immunology 122(3), pp. 443-453 (DOI: 10.1016/j.jaci.2008.06.032).
Shimizu, Y., et al., 2023, ‘Influence of Immune System Abnormalities Caused by Maternal Immune Activation in the Postnatal Period’, Cells 12(5), p. 741 (DOI: 10.3390/cells12050741).
Shrestha, S. K., et al., 2021, ‘Ambient pollen concentrations and asthma hospitalization in children and adolescents: a systematic review and meta-analysis’, The Journal of Asthma: Official Journal of the Association for the Care of Asthma 58(9), pp. 1155-1168 (DOI: 10.1080/02770903.2020.1771726).
Silver, S. R., et al., 2021, ‘Incident chronic obstructive pulmonary disease associated with occupation, industry, and workplace exposures in the Health and Retirement Study’, American Journal of Industrial Medicine 64(1), pp. 26-38 (DOI: 10.1002/ajim.23196).
Simpson, A., et al., 2005, ‘IgE antibody quantification and the probability of wheeze in preschool children’, The Journal of Allergy and Clinical Immunology 116(4), pp. 744-749 (DOI: 10.1016/j.jaci.2005.06.032).
Sin, D. D., et al., 2023, ‘Air pollution and COPD: GOLD 2023 committee report’, European Respiratory Journal 61(5) (DOI: 10.1183/13993003.02469-2022).
Staddon, P. L., et al., 2014, ‘Climate warming will not decrease winter mortality’, Nature Climate Change 4, pp. 190-194.
Su, W.-C., et al., 2024, ‘Secondhand smoke increases the risk of developing chronic obstructive pulmonary disease’, Scientific Reports 14(1), p. 7481 (DOI: 10.1038/s41598-024-58038-2).
Tham, S., et al., 2020, ‘Indoor temperature and health: a global systematic review’, Public Health 179, pp. 9-17 (DOI: 10.1016/j.puhe.2019.09.005).
Tornevi, A., et al., 2021, ‘Respiratory Health Effects of Wildfire Smoke during Summer of 2018 in the Jämtland Härjedalen Region, Sweden’, International Journal of Environmental Research and Public Health 18(13), p. 6987 (DOI: 10.3390/ijerph18136987).
Urlaub, S. and Gruen, G., 2016, Mould and dampness in European homes and their impact on health, No IBP-Report EER-058/2016/950, Fraunhofer-Institut für Bauphysik (https://www.ibp.fraunhofer.de/content/dam/ibp/ibp-neu/de/dokumente/publikationen/eer/report-mould-dampness-impact-on-health.pdf).
Vanderplanken, K., et al., 2021, ‘Governing heatwaves in Europe: comparing health policy and practices to better understand roles, responsibilities and collaboration’, Health Research Policy and Systems 19(1), p. 20 (DOI: 10.1186/s12961-020-00645-2).
Vogl, G., et al., 2008, ‘Modelling the spread of ragweed: Effects of habitat, climate change and diffusion’, The European Physical Journal Special Topics 161(1), pp. 167-173 (DOI: 10.1140/epjst/e2008-00758-y).
Wang, L., et al., 2022, ‘Air pollution and risk of chronic obstructed pulmonary disease: The modifying effect of genetic susceptibility and lifestyle’, eBioMedicine 79 (DOI: 10.1016/j.ebiom.2022.103994).
Weilnhammer, V., et al., 2021, ‘Extreme weather events in europe and their health consequences – A systematic review’, International Journal of Hygiene and Environmental Health 233, p. 113688 (DOI: 10.1016/j.ijheh.2021.113688).
WHO, 2009, Damp and Mould: Health risks, prevention and remedial actions, World Health Organization Regional Office for Europe, Copenhagen, Denmark (https://www.euro.who.int/__data/assets/pdf_file/0003/78636/Damp_Mould_Brochure.pdf).
WHO, 2021, Heat and health in the WHO European Region: updated evidence for effective prevention, World Health Organization Regional Office for Europe, Copenhagen, Denmark.
WHO, 2022, Inequalities in dampness in the home, Environmental health inequalities fact sheet series, World Health Organization Regional Office for Europe, Copenhagen, Denmark (https://iris.who.int/bitstream/handle/10665/351894/WHO-EURO-2022-4872-44635-63335-eng.pdf?sequence=2).
WHO, 2024, WHO mortality database, World Health Organization, Geneva, Switzerland (https://www.who.int/data/data-collection-tools/who-mortality-database).
Wolf, T., et al., 2015, ‘The Health Effects of Climate Change in the WHO European Region’, Climate 3(4), pp. 901-936 (DOI: 10.3390/cli3040901).
Ziska, L. H., et al., 2019, ‘Temperature-related changes in airborne allergenic pollen abundance and seasonality across the northern hemisphere: a retrospective data analysis’, The Lancet Planetary Health 3(3), pp. e124-e131 (DOI: 10.1016/S2542-5196(19)30015-4).