Cohort-based long-term ozone exposure-associated mortality risks with adjusted metrics: A systematic review and meta-analysis

Long-term ozone (O(3)) exposure may lead to non-communicable diseases and increase mortality risk. However, cohort-based studies are relatively rare, and inconsistent exposure metrics impair the credibility of epidemiological evidence synthetization. To provide more accurate meta-estimations, this study updates existing systematic reviews by including recent studies and summarizing the quantitative associations between O(3) exposure and cause-specific mortality risks, based on unified exposure metrics. Cross-metric conversion factors were estimated linearly by decadal observations during 1990–2019. The Hunter-Schmidt random-effects estimator was applied to pool the relative risks. A total of 25 studies involving 226,453,067 participants (14 unique cohorts covering 99,855,611 participants) were included in the systematic review. After linearly unifying the inconsistent O(3) exposure metrics , the pooled relative risks associated with every 10 nmol mol(−1) (ppbV) incremental O(3) exposure, by mean of the warm-season daily maximum 8-h average metric, were as follows: 1.014 with 95% confidence interval (CI) ranging 1.009–1.019 for all-cause mortality; 1.025 (95% CI: 1.010–1.040) for respiratory mortality; 1.056 (95% CI: 1.029–1.084) for COPD mortality; 1.019 (95% CI: 1.004–1.035) for cardiovascular mortality; and 1.074 (95% CI: 1.054–1.093) for congestive heart failure mortality. Insignificant mortality risk associations were found for ischemic heart disease, cerebrovascular diseases, and lung cancer. Adjustment for exposure metrics laid a solid foundation for multi-study meta-analysis, and widening coverage of surface O(3) observations is expected to strengthen the cross-metric conversion in the future. Ever-growing numbers of epidemiological studies supported the evidence for considerable cardiopulmonary hazards and all-cause mortality risks from long-term O(3) exposure. However, evidence of long-term O(3) exposure-associated health effects was still scarce, so more relevant studies are needed to cover more populations with regional diversity.