Long-term trends in urban NO₂ concentrations and associated paediatric asthma incidence: estimates from global datasets

Combustion-related nitrogen dioxide (NO₂) air pollution is associated with paediatric asthma incidence. We aimed to estimate global surface NO₂ concentrations consistent with the Global Burden of Disease study for 1990-2019 at a 1 km resolution, and the concentrations and attributable paediatric asthma incidence trends in 13 189 cities from 2000 to 2019. We scaled an existing annual average NO₂ concentration dataset for 2010-12 from a land use regression model (based on 5220 NO₂ monitors in 58 countries and land use variables) to other years using NO₂ column densities from satellite and reanalysis datasets. We applied these concentrations in an epidemiologically derived concentration-response function with population and baseline asthma rates to estimate NO₂-attributable paediatric asthma incidence. We estimated that 1.85 million (95% uncertainty interval [UI] 0.93-2.80 million) new paediatric asthma cases were attributable to NO₂ globally in 2019, two thirds of which occurred in urban areas (1.22 million cases; 95% UI 0.60-1.8 million). The proportion of paediatric asthma incidence that is attributable to NO₂ in urban areas declined from 19.8% (1.22 million attributable cases of 6.14 million total cases) in 2000 to 16.0% (1.24 million attributable cases of 7.73 million total cases) in 2019. Urban attributable fractions dropped in high-income countries (-41%), Latin America and the Caribbean (-16%), central Europe, eastern Europe, and central Asia (-13%), and southeast Asia, east Asia, and Oceania (-6%), and rose in south Asia (+23%), sub-Saharan Africa (+11%), and north Africa and the Middle East (+5%). The contribution of NO₂ concentrations, paediatric population size, and asthma incidence rates to the change in NO₂-attributable paediatric asthma incidence differed regionally. Despite improvements in some regions, combustion-related NO₂ pollution continues to be an important contributor to paediatric asthma incidence globally, particularly in cities. Mitigating air pollution should be a crucial element of public health strategies for children.