Assessing the environmental burden of disease related to air pollution in Europe in 2023. ETC HE Report 2025/8.

ETC HE Report 2025/8 Assessing the environmental burden of disease related to air pollution in Europe in 2023 Authors: Joana Soares (NILU), Dietrich Plass (UBA), Sarah Kienzler (UBA), Alberto González Ortiz (EEA), Artur Gsella (EEA), Jan Horálek (CHMI) ETC HE Report 2025/8 Cover design: EEA Cover image © Stephen Connell, Environment & Me /EEA Layout: EEA / ETC HE (NILU) Publication Date: 30 November 2025 DOI: 10.5281/zenodo.17658760 Version: 1 EEA activity: Human health and the environment Legal notice Preparation of this report has been co-funded by the European Environment Agency as part of a grant with the European Topic Centre on Human health and the environment (ETC HE) and expresses the views of the authors. The contents of this publication does not necessarily reflect the position or opinion of the European Commission or other institutions of the European Union. Neither the European Environment Agency nor the European Topic Centre on Human health and the environment is liable for any consequences stemming from the reuse of the information contained in this publication. How to cite this report: Soares, J., Plass, D., Kienzler, S., González Ortiz, A., Gsella, A., Horálek, J. (2025). Assessing the environmental burden of disease related to air pollution in Europe in 2023 (Eionet Report – ETC HE 2025/8). European Topic Centre on Human Health and the Environment (https://doi.org/10.5281/zenodo.17658760) The report is available from https://www.eionet.europa.eu/etcs/all-etc-reports and https://zenodo.org/communities/eeaetc/?page=1&size=20. ETC HE coordinator: Stiftelsen NILU, Kjeller, Norway (https://www.nilu.com/) ETC HE consortium partners: Federal Environment Agency/Umweltbundesamt (UBA), Aether Limited, Czech Hydrometeorological Institute (CHMI), Institut National de l’Environnement Industriel et des Risques (INERIS), Swiss Tropical and Public Health Institute (Swiss TPH), Universitat Autònoma de Barcelona (UAB), Vlaamse Instelling voor Technologisch Onderzoek (VITO), 4sfera Innova S.L.U., klarFAKT e.U. Copyright notice © European Topic Centre on Human health and the environment, 2025 Reproduction is authorized provided the source is acknowledged. [Creative Commons Attribution 4.0 (International)] More information on the European Union is available on the Internet (http://europa.eu). European Topic Centre on Human health and the environment (ETC HE) https://www.eionet.europa.eu/etcs/etc-he ETC HE Report 2025/8 3 Contents Contents ........................................................................................................................................ 3 Acknowledgements ....................................................................................................................... 4 Summary........................................................................................................................................ 5 1 Introduction ........................................................................................................................... 7 2 EBD estimations for 2023 .................................................................................................... 12 2.1 PM2.5 ............................................................................................................................. 12 2.1.1 Population-weighted annual mean concentration ......................................... 12 2.1.2 Burden of disease ............................................................................................ 13 2.1.3 Zero pollution action plan 2030 objective ...................................................... 23 2.2 NO2 .............................................................................................................................. 24 2.2.1 Population-weighted annual mean concentration ......................................... 24 2.2.2 Burden of disease ............................................................................................ 25 2.3 O3 .................................................................................................................................. 34 2.3.1 Population-weighted peak season concentration .......................................... 34 2.3.2 Burden of disease ............................................................................................ 35 3 Conclusions .......................................................................................................................... 38 List of abbreviations .................................................................................................................... 40 References ................................................................................................................................... 41 Annex 1 Methodology ................................................................................................................. 45 Annex 2 Input data and preparatory steps ................................................................................. 47 Annex 3 Population at risk and exposure levels .......................................................................... 53 Annex 4 Results for all-cause and cause-specific EBD analyses .................................................. 55 PM2.5 (long-term effects) and all-cause mortality ........................................................ 55 PM2.5 (long-term effects) and total cause-specific disease burden (six causes, excluding dementia) ........................................................................................................ 57 PM2.5 (long-term effcts) and asthma (children and adolescents < 19 years) ............... 58 PM2.5 (long-term effects) and chronic obstructive pulmonary disease (adults ≥ 25 years) ......................................................................................................................... 62 PM2.5 (long-term effects) and diabetes mellitus disease (adults ≥ 25 years) .............. 66 PM2.5 (long-term effects) and ischemic heart disease (adults ≥ 25 years) .................. 70 PM2.5 (long-term effects) and lung cancer (adults ≥ 25 years) .................................... 74 PM2.5 (long-term effects) and stroke (adults ≥ 25 years) ............................................. 78 PM2.5 (long-term effects) and dementia morbidity (adults ≥ 60 years) ....................... 82 NO2 (long-term effects) and all-cause mortality .......................................................... 83 NO2 (long-term effects) and total cause-specific disease burden (five causes) .......... 85 NO2 (long-term effects) and asthma (adults ≥ 19 years) ............................................. 86 NO2 (long-term effects) and asthma (children and adolescents < 19 years) ............... 90 NO2 (long-term effects) and diabetes mellitus (adults ≥ 25 years).............................. 94 NO2 (long-term effects) and COPD (adults ≥ 25 years) ................................................ 98 NO2 (long-term effects) and stroke (adults ≥ 25 years) ............................................. 102 O3 (long-term effects, peak season) and all-cause mortality ..................................... 106 O3 (long-term effects, peak season) and COPD mortality (adults ≥ 25 years) ........... 108 Annex 5 Glossary ....................................................................................................................... 110 Annex 6 Country ISO2 code ....................................................................................................... 112 ETC HE Report 2025/8 4 Acknowledgements This Eionet report has been produced by the European Topic Centre on Human Health and the Environment (ETC HE) in close cooperation with the European Environment Agency (EEA). The EEA project manager has been Alberto González Ortiz and the ETC HE task manager, Joana Soares (NILU). The main authors were Joana Soares (ETC HE-NILU), Dietrich Plass (ETC HE-UBA), Sarah Kienzler (ETC HEUBA) and Alberto González Ortiz (EEA). Additional contributors were Artur Gsella (EEA) and Jan Horálek (ETC HE-CHMI). The report was revised by Simone Schucht (ETC HE-INERIS), Luca Pozzoli (ETC HE-NILU) and Joseph V. Spadaro (SERC & WHO consultant, ECEH office Bonn). ETC HE Report 2025/8 5 Summary This report assesses the environmental burden of disease (EBD) attributable to long-term exposure to fine particulate matter (PM2.5), nitrogen dioxide (NO2), and ozone (O3) across 41 European countries in 2023 (40 countries for PM2.5). The burden is quantified using key health indicators—attributable deaths (AD), years of life lost (YLL), years lived with disability (YLD), and disability-adjusted life years (DALY)—providing a comprehensive overview of the impact of ambient air pollution on health in Europe. The cause-specific long-term burden attributable to PM2.5 includes asthma in children and adolescents (in previous year, asthma in children was considered), chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), ischemic heart disease (IHD), lung cancer, stroke, and dementia (added this year and only for morbidity). For NO2, the assessment covers asthma in adults as well as children and adolescents (added this year), COPD (added this year), DM and stroke. Finally, COPD attributable to long-term exposure to O3 is also included. These health outcomes were selected to the extent possible based on the best available toxicological and epidemiological evidence, indicating a statistical association between exposure to these pollutants and an increased risk of developing a disease or dying. The main results presented here consider only the impact of individual pollutants and populations exposed to concentration levels exceeding the World Health Organization’s (WHO) air quality guidelines (AQG) levels. Using the guideline levels as cutoffs does not imply that there are no health effects below these values. It is only assumed that the evidence for the health effects is comparably lower for these lower concentration levels. Additionally, a sensitivity analysis was performed on all-cause mortality to evaluate the effects of exposure to two different levels of PM2.5 and NO2, all levels and levels above the annual limit values specified in the revised Ambient Air Quality Directive 2024/2881, to be attained by 2030. The concentration data in this assessment are based on air quality maps developed by the ETC HE, utilising a fusion of EEA Member States’ validated monitoring data and additional modelling data, which produces consistent, standardised exposure estimates across Europe and ensures high comparability. The risk of mortality or morbidity in a population due to exposure to air pollution is represented by the concentrationresponse function (CRF), which is based on relative risk, hazard ratio, or odds ratio estimates derived from epidemiological studies. The mortality or morbidity due to each air pollutant is then quantified by combining pollutant-dependent CRFs with ambient air quality data, population data, and the baseline frequency of the health outcome, such as the number of deaths or the prevalence of a disease. The analysis reveals that PM2.5 is the most harmful pollutant, contributing to approximately 206,000 deaths (all-cause) in all 40 countries considered. Meanwhile, NO2 and O3 were responsible for around 56,000 and 71,000 deaths (all-cause) in 41 countries, respectively. The study estimates that PM2.5 exposure resulted in 2.3 million DALY across the evaluated countries and diseases (excluding dementia), compared to 757,000 DALY from NO2. For O3, only mortality-associated effects were estimated, resulting in a causespecific burden of 85,000 YLL, while no DALY were calculated. The high disease burden attributable to PM2.5 stemmed partly from its link to multiple diseases with high baseline prevalence and mortality, whereas NO2 and O3 estimates considered fewer health outcomes. This is partly due to the strong historical research focus on PM2.5. It is important to note, however, that the current epidemiological evidence for health effects associated with long-term O3 exposure remains uncertain and prone to changes when new evidence becomes available (Huangfu and Atkinson 2020; Kasdagli et al. 2024). Therefore, the degree of uncertainty for the O3 estimates is larger than that associated with PM2.5. Findings also demonstrate regional disparities: South-Eastern Europe saw the highest relative impacts from PM2.5 and NO2, while Southern Europe experienced elevated impacts from exposure to O3 levels. The EU27’s burden mirrored these trends but showed slightly lower rates overall. Cause-specific analysis, incorporating a broader range of health outcomes, enabled the report to reveal nuanced effects, particularly on cardiovascular and respiratory diseases for PM2.5 and diabetes for NO2. This report serves as a critical resource for understanding the pervasive health risks associated with ambient air pollution in Europe. By providing reliable, fine-scale estimates, it underlines the need for ETC HE Report 2025/8 6 targeted policy interventions to address pollutant-specific impacts and mitigate the substantial health burdens across populations in Europe. ETC HE Report 2025/8 7 1 Introduction Exposure to ambient air pollution can result in adverse effects on human health. Epidemiological studies have shown that exposure to ubiquitous pollutants such as fine particulate matter (PM2.5), ozone (O3) and nitrogen dioxide (NO2) is associated, among others, with cardiovascular, respiratory, metabolic and mental health outcomes, leading to an increase in morbidity, hospital admissions, and, in the worst case, to death (WHO, 2024; Hegelund et al., 2024; WHO, 2021, De Marco et al., 2019). The World Health Organization (WHO) developed the Environmental Burden of Disease (EBD) concept to comprehensively and comparably measure the health impacts of environmental risk factors on population health. EBD assessments use a systematic approach to estimate the proportion of disease burden in a population attributable to specific environmental risks, such as air pollution (Murray and Lopez, 1996). Assessing the burden of disease attributed to air pollutants is critical for managing air pollution-related risks and informing environmental health policy planning (Bruyneel et al., 2025; Chamberlain et al., 2022). The European Environment Agency (EEA) and the European Topic Centre on Human Health and the Environment (ETC HE), and its predecessors, have conducted EBD assessments for air pollution since 2014, offering a standardised, objective, comprehensive and comparable estimate of the burden of disease due to ambient air pollution across European countries. These assessments started by presenting the quantification of the burden of disease of the individual pollutants - PM2.5, NO2, and O3 - associated with all-cause natural mortality. Since 2022, the estimation has been expanded to quantify cause-specific mortality and morbidity health outcomes. In this assessment, the burden of disease attributable to long-term exposure to PM2.5, NO2, and O3 is quantified in terms of four burden of disease indicators. The estimates for all-cause natural mortality are presented by two indicators: attributable deaths (AD) and the resulting years of life lost (YLL). Causespecific calculations are based on risk-outcome pairs and assess the effects on population health using the common indicator disability-adjusted life years (DALY). This measure combines the contributions from population mortality (YLL) and morbidity (years lived with disability, YLD). The indicators are quantified by combining pollutant-outcome-dependent concentration-response functions (CRFs) with gridded ambient air quality data, population data, and the baseline frequency of the health outcomes, such as the number of deaths or the number of prevalent cases of a disease. The estimation is performed at the grid-cell level, and then aggregated to the corresponding spatial level, i.e., country or group of countries. Since the CRFs are derived considering single-pollutant models, the burden is estimated for individual pollutants. This may partially capture effects caused by other pollutants. Therefore, for any specific health outcome and exposure period, adding the estimated impacts of multiple pollutants could result in an overestimation of the true impact. For example, the HRAPIE project (Health risks of air pollution in Europe; WHO, 2013) argued that adding the all-cause mortality results for PM2.5 and NO2 may lead to a double counting of the effects (WHO experts discussed an overlap of up to 30 %; the true overlap, however, was not yet finally quantified). Conversely, estimating impacts for only one pollutant may underestimate the true impact of the pollution mixture, especially if other pollutants contribute to the same health outcome or the cooccurrence of pollutants results in a stronger effect. The risk of mortality or morbidity in a population attributable to exposure to air pollution is represented by the CRF, which is based on the change of relative risk (RR), hazard ratio (HR), or odds ratio (OR) estimates with increasing exposures, as derived from epidemiological studies. The nature of epidemiological studies to assess the effect measure (RR, HR, or OR) differs in the way it quantifies the risk (or chance) of having an outcome after a certain exposure, comparing an exposed group against a nonexposed or lower-exposed group. RR or HR are used in cohort studies, and OR in case-control studies. The EEA/ETC EBD assessments primarily consider CRFs for which the evidence provided by the epidemiological studies is high or reliable. However, scientific findings also suggest that additional diseases are linked with air pollutant exposure. To achieve a more comprehensive evaluation of the disease burden, certain outcomes with currently moderate or suggestive levels of evidence were also included. The all-cause natural mortality estimations consider the pollutant-specific CRF derived from epidemiological studies ETC HE Report 2025/8 8 referenced in the WHO’s Air Quality Guidelines (AQG) recommendations (WHO, 2021), from now on referred to as “2021 WHO AQG”. Cause-specific estimations mainly rely on pollutant-outcome-specific CRFs from the European ELAPSE project (Effects of Low-Level Air Pollution: A Study in Europe; Brunekreef et al., 2021). The project analysed pooled European cohort studies that focus on adverse health effects related to exposure to low concentrations and exposures to air pollution across Europe, including levels below the current European Union (EU) standards. Table 1.1 lists the CRFs for mortality and morbidity riskoutcome pairs and their associated 95 % confidence interval (CI) used for all-cause mortality and causespecific mortality and morbidity estimations. This report proposes expanding the EBD assessment further by considering thirteen risk-outcome pairs covering both mortality and morbidity, instead of the ten reported in the ETC HE Report 2024/6 (Soares et al., 2024a). This assessment now includes dementia morbidity effects in people 60 years of age and over due to exposure to PM2.5, and asthma in children and adolescents (up to 18 years old), and chronic obstructive pulmonary disease (COPD) in adults 25 years of age and older due to exposure to NO2. The EEA/ETC EBD quantification of the burden of disease assumes a linear increase of risk with an increase in concentration, as suggested by HRAPIE (WHO, 2013), since the 2021 WHO AQG has not proposed changes to the shape of the function. This means, for example, that if the CRF for all-cause mortality risk due to PM2.5 exposure is 1.08 per 10 μg/m³, a 10 μg/m³ linear increase in PM2.5 annual mean concentrations would raise the population risk of mortality by 8%. One necessary parameter in the estimation is the counterfactual concentration. This value represents the hypothetical exposure associated with a lower risk or “no-risk” level (e.g. a relative risk of 1) against which the estimated population exposure is compared. When assuming a constant slope of the CRF (β, see Eq. A1.2 in Annex 1), varying the counterfactual concentration implies that the results will also vary. For example, a lower counterfactual level means that more people are likely to be at risk since the exposure will cover a larger range of concentration levels; thus, the estimate of the EBD will increase. Conversely, an increase in the counterfactual level is more likely to result in a reduction of the disease burden. The counterfactual concentration for assessing long-term exposure is based on the annual concentrations recommended as guideline levels by the 2021 WHO AQG for PM2.5 and NO2, as well as the O3 peak season ( 1 ). These values are 5 μg/m3 for PM2.5, 10 μg/m3 for NO2 and 60 μg/m3 for O3. Sensitivity analyses were conducted to assess the impact of changing the counterfactual concentration. One analysis considers all levels of concentration, therefore using a counterfactual concentration of 0 µg/m3 for both PM2.5 and NO2. The HRAPIE report (WHO, 2013) states that the quantification of long-term impacts "should be calculated at all observed levels of PM2.5" down to 0 µg/m³. Moreover, the Brunekreef et al. (2021) study indicates there is no evidence of a minimum concentration below which no effect is observed. However, the level of evidence for RRs at very low concentrations is based on a limited number of epidemiological observations and should therefore be interpreted with caution. Finally, assuming 0 µg/m3 as a counterfactual, it includes the impact of natural sources, such as Saharan dust, that are not controllable by pollution abatement strategies. The other sensitivity analysis considers as counterfactual concentrations the annual limit values in the revised Ambient Air quality Directive (EU) 2024/2881 (EU, 2024): 10 μg/m3 for PM2.5 and 20 μg/m3 for NO2. No sensitivity analysis was conducted for O3 because there is no meaningful counterfactual concentration nor EU legal standard associated with the O3 peak season. ( 1 ) Six-month running average of the highest O3 concentration over six consecutive months each year. The peak season period varies by country, but the concentration maps are based on measurement and modelling data from August 1, 2022, to December 31, 2023. The highest of these 12 values is used as the peak-season average of the maximum daily 8-hour means for the station. ETC HE Report 2025/8 9 Table 1.1 Concentration-response functions (hazard ratio (HR), relative risk (RR) and odds ratio (OR)) for mortality and morbidity risk-outcome pairs (age group: ≥ 25 years old, unless otherwise stated) and their associated 95 % confidence interval (CI) Notes: (a) Recommended by 2021 WHO AQG (b) Proposed by the ELAPSE (Effects of Low-Level Air Pollution: A Study in Europe) study (c) For mortality, the effect measure refers to type 1 and type 2 diabetes mellitus (DM), in contrast to morbidity, which includes only type 2 diabetes mellitus (T2DM) (d) Proposed by the EMAPEC (Estimating the Morbidity from Air Pollution and its Economic Costs) study (e) This RR is considered appropriate only for exposure differences not larger than 10 µg/m³ PM2.5 (f) For morbidity, the effect measure refers to type 2 diabetes mellitus (T2DM), in contrast to mortality, which also includes type 1 diabetes mellitus (DM). The population exposure is estimated using the ETC HE produced concentration maps with annual statistics for 2023 (Horálek et al., 2025): annual mean for PM2.5 and NO2, and peak season for O3. It is assumed that population exposure within a country did not vary by age group. The maps are generated through data fusion that combines monitoring data from rural and urban background stations for PM2.5, NO2, and O3, as well as urban traffic station data for PM2.5 and NO2, with results from the Copernicus Atmosphere Monitoring Service (CAMS) Ensemble, and other supplementary data, such as altitude, meteorology, and population density. All data supporting the data fusion pertains to 2023. These maps Pollutant Outcome Effect measure (95 % CI) Increment per unit (μg/m3) Reference Mortality PM2.5 All-cause (≥ 30 years old) RR: 1.08 (1.06-1.09) 10 Chen and Hoek, 2020 (a) Asthma (< 19 years old) HR: 1.03 (1.01-1.05) 1 Khreis et al., 2017 COPD HR: 1.131 (1.002-1.278) 5 Strak et al., 2021(b) DM(c) HR: 1.32 (1.14-1.51) 5 Strak et al., 2021(b) IHD HR: 1.11 (1.06-1.17) 5 Strak et al., 2021(b) LC HR: 1.10 (1.04-1.17) 5 Stafoggia et al., 2022(b) Stroke HR: 1.13 (1.05-1.21) 5 Strak et al., 2021(b) NO2 All-cause (≥ 30 years old) RR: 1.02 (1.0 -1.04) 10 Huangfu and Atkinson, 2020(a) Asthma (< 19 years old) OR: 1.05 (1.02-1.07) 4 Khreis et al., 2017 Asthma (≥ 19 years old) HR: 1.10 (1.01-1.21) 10 HEI, 2022(d) COPD HR: 1.141 (1.056-1.233) 10 Strak et al., 2021(b) DM(c) HR: 1.24 (1.11-1.38) 10 Strak et al., 2021(b) Stroke HR: 1.07 (1.01-1.13) 10 Strak et al., 2021(b) O3 All-cause (≥ 25 years old) RR: 1.01 (1.00-1.02) 10 Huangfu and Atkinson, 2020(a) COPD HR: 1.041 (1.039-1.044) 10 Breitner et al. 2021 Morbidity PM2.5 Asthma (< 19 years old) HR: 1.03 (1.01-1.05) 1 Khreis et al., 2017 COPD HR: 1.17 (1.06-1.29) 5 Liu et al., 2021b(b) Dementia (≥ 60 years old) RR: 1.46 (1.20 - 1.78)(e) 10 Forastiere et al., 2024(d) IHD HR: 1.13 (1.05-1.22) 10 Forastiere et al., 2024(d) LC HR: 1.13 (1.05-1.23) 5 Hvidtfeldt et al., 2021(b) Stroke HR: 1.10 (1.01-1.21) 5 Wolf et al., 2021(b) T2DM(f) OR: 1.08 (1.04-1.12) 10 Yang et al., 2020 NO2 Asthma (< 19 years old) OR: 1.05 (1.02-1.07) 4 Khreis et al., 2017 Asthma (≥ 19 years old) HR: 1.10 (1.01-1.21) 10 HEI 2022(d) COPD HR: 1.11 (1.06-1.16) 10 Brunekreef et al., 2021 T2DM(f) OR: 1.07 (1.04-1.11) 10 Yang et al., 2020 Stroke HR: 1.08 (1.04-1.12) 10 Wolf et al., 2021(b) ETC HE Report 2025/8 16 Figure 2.1 Attributable deaths (AD) to PM2.5 long-term exposure per 100,000 at risk, including the lower and upper 95% CI (error bars), in 2023 considering counterfactual concentrations (C0) defined by the baseline (5 µg/m3) and sensitivity scenarios (0 or 10 µg/m3) Cause-specific mortality and morbidity In previous ETC HE Eionet reports on EBD (e.g., Soares et al., 2024b), the following six diseases had been considered for the cause-specific analysis: asthma in children, COPD, DM, IHD, lung cancer and stroke. This report presents an expanded analysis, extending the considered asthma cases to adolescents (all below 19 years of age) and introducing dementia morbidity effects. A growing body of toxicological and epidemiological evidence indicates a statistical association between exposure to PM2.5 pollution and increased risk of dementia (Forastiere et al., 2024; Huang et al., 2025, Best Rogowski et al. 2025). However, regarding the effect estimate used, there is greater uncertainty about the evidence-base of the CRF compared to other risk-outcome pairs considered in the analyses. To take this into account, the EBD results for dementia are presented separately from other diseases and are not included when adding causespecific outcomes to estimate the total burden of disease. Further, only the morbidity component (YLD) ETC HE Report 2025/8 17 was calculated in the dementia analyses, as the selected effect estimate did not include studies on mortality. Detailed results (AD, YLL, YLD, DALY and the corresponding rates per 100,000 individuals at risk), disaggregated by the other diseases, are provided for each country and the EU27, EEA32 and all countries in Annex 4 Tables A4.3 to A4.27. Table A4.28 shows YLD attributable to dementia. The population at risk for the different health outcomes and the exposure levels for the individual countries used for the estimates are described in Annex 3 Table A3.1 and Table A3.2, respectively. In 2023, the total cause-specific EBD of all selected outcomes attributable to PM2.5 (excluding dementia morbidity) amounted to 2,300,989 DALY (95% CI: 973,460-3,479,297) in all 40 countries considered and 2,074,951 DALY (95% CI: 874,342-3,148,806) in the EU27 (see Table 2.3 and Annex 4 Table A4.3 for the results of individual countries). For dementia, 315,391 YLD (95% CI: 163,573-447,863) were estimated in all countries and 293,195 YLD (95% CI: 151,603-417,445) in the EU27 attributable to PM2.5-exposure. Table 2.3 Total cause-specific burden of disease (total AD, YLL, YLD, DALY, including the upper and lower 95 % CI) attributable to PM2.5 long-term exposure (excluding dementia) in the EU27, the EEA32 and all 40 European countries in 2023 for six outcomes. Exposure levels are available in Table 2.1 Note: The counterfactual concentration was 5 µg/m³ Figure 2.2 presents both the absolute and percentage contribution of the respective outcomes to the overall disease burden for the 40 countries assessed. The magnitude varied substantially across the diseases, reflecting differences in baseline health data, affected age groups, and RR estimates. IHD in individuals aged 25 years and older accounted for the largest share of attributable DALY (637,074, 95% CI: 341,283-910,418), consistent with the high mortality of cardiovascular diseases in older populations. At the other end, asthma in children and adolescents represented the smallest burden (35,683 DALY; 95% CI: 12,938–54,965), primarily because only the population under 19 years of age was considered, in contrast to the older age groups (predominantly 25 and above) assessed for the other outcomes and because of low asthma mortality rates in this age group. Areas Mean Lower 95% CI Upper 95% CI Mean Lower 95% CI Upper 95% CI Total AD Total YLL EU27 171,671 75,535 256,651 1,749,884 760,882 2,627,266 EEA32 172,895 76,021 258,578 1,762,597 765,764 2,647,430 All countries 190,854 84,273 284,312 1,944,576 848,203 2,909,362 Total YLD Total DALY EU27 325,067 113,460 521,540 2,074,951 874,342 3,148,806 EEA32 328,892 114,728 527,811 2,091,489 880,492 3,175,311 All 356,413 125,256 569,936 2,300,989 973,460 3,479,297 ETC HE Report 2025/8 18 Figure 2.2 Burden of disease (YLL, YLD, DALY, including the upper and lower 95 % CI shown as error bars) attributable to PM2.5 long-term exposure for all 40 countries, differentiated by outcomes Notes: asthma: asthma in children/adolescents; CI: confidence interval; COPD: chronic obstructive pulmonary disease; DALY: disability-adjusted life years; DM: diabetes mellitus (type 1 and type 2); IHD: ischemic heart disease; YLD: years lived with disability; YLL: years of life lost For all outcomes except asthma in children and adolescents, the attributable burden was driven by mortality rather than morbidity. For lung cancer and IHD, almost all DALY were due to YLL (99% and 97%, respectively), while stroke, DM, and COPD showed smaller but still substantial mortality shares (82%, 77%, and 63%) considering all 40 European countries. DM was noteworthy in this context, because studies have shown a considerably higher mean RR for mortality (1.32 per 5 µg/m³) as compared to stroke (1.13 per 5 µg/m³), COPD (1.13 per 5 µg/m³), IHD (1.11 per 5 µg/m³) or lung cancer (1.10 per 5 µg/m³) (see Table 1.1). However, the overall disease burden attributable to PM2.5 remained lower for DM than for IHD or stroke. This is due to the substantially higher absolute number of IHD and stroke deaths in the population, particularly among older adults, so that the combination of high baseline mortality and additional PM2.5related risk resulted in a larger YLL and thus an increased DALY contribution for IHD and stroke. Asthma in children and adolescents represented an exception, as morbidity accounted for nearly all attributable DALY (99% YLD). Moreover, mortality estimates for asthma were subject to a certain degree of methodological uncertainty due to the transfer of morbidity-based relative risks to mortality outcomes in the absence of mortality-specific effect estimates. However, the impact of this assumption is considered low given that asthma death cases are rare in younger populations. For dementia (in individuals aged 60 years and older), the mean morbidity burden — amounting to 315,391 YLD across all countries — was almost equivalent to the total YLD of all other outcomes combined (356,413 YLD). This is partly because, for the other diseases, the burden is mainly driven by mortality. However, the estimates for dementia should also be interpreted with caution. The comparatively high burden is partly explained by the relatively high mean RR (1.46 per 10 µg/m³ PM2.5 increase) (see Table 1.1). Moreover, this RR is considered appropriate only for exposure differences of around 10 µg/m³ PM2.5 (Forastiere et al. 2024), that is, from 5 to 15 µg/m³, a range that is exceeded by some countries in our European analyses. In these cases, the results should be regarded as highly uncertain. Further uncertainty arises from the input data on prevalence. A single European average prevalence rate, stratified by age and sex, was applied uniformly across all countries, unlike the other diseases for which country-specific prevalence rates stratified by age and sex were used. National data on disease frequency were not available beyond sex-specific adjustments. Together, these factors introduced substantial methodological uncertainty into the dementia burden estimates. Nonetheless, they should be seen as an important first step toward including dementia in such analyses, which was already done in the Global Burden of Disease assessment (GBD 2023 Disease and Injury and Risk Factor Collaborators, 2025). ETC HE Report 2025/8 19 A comparison of the cause-specific EBD, except dementia, across all countries (see Figure 2.3) reveals that certain Western Balkans and neighbouring countries in South-East Europe predominantly showed the highest DALY rates per 100,000 inhabitants at risk across all individual outcomes considered. The Map 2.4 shows a similar pattern for dementia morbidity. A significant proportion of these countries are among those with the highest population-weighted PM2.5 levels. Figure 2.3 also demonstrates a high impact of specific outcomes in certain countries, different to the general situation. Examples include asthma in children and adolescents in Poland, DM in Croatia, and stroke in Bulgaria. Map 2.3 combines the information in the maps shown in Figure 2.3 and presents the cause-specific outcome that contributed the most to the total burden of disease for individual countries in 2023. The mapping is based on the DALY for individual outcomes (except dementia) in each country. Dementia was not included to follow the same principle as in the analysis shown in Figure 2.2. The map indicates that IHD was the primary cause of the highest disease burden across countries, particularly in parts of Western, Central and Northern Europe. The exceptions to this were as follows. Norway and Denmark, which, together with Luxembourg and Liechtenstein, had COPD as the most dominant outcome. Bosnia and Herzegovina, Bulgaria, Kosovo, Portugal and Serbia had the highest estimated disease burden due to stroke. Lung cancer predominated in Andorra, Belgium, France, Monaco, the Netherlands and Spain. Finally, DM disease burden had the highest contribution to the burden of disease in Croatia, Cyprus, Italy and San Marino. As expected, asthma in children and adolescents was not among the leading causes of disease burden in any of the countries, as it was estimated to affect a smaller portion of the population. It is important to note that in some countries, the gap between the outcome with the highest contribution and the next highest was not necessarily significant. Figure 2.4 helps in understanding how cause-specific outcomes contributed to the total burden of disease for the individual countries. Specifically, for IHD, some contributions were relatively high, exceeding 40%. Figure 2.3 Burden of disease rates (DALY per 100,000 inhabitants at risk) attributable to PM2.5 longterm exposure differentiated by health outcomes (except dementia) in 2023 ETC HE Report 2025/8 20 ETC HE Report 2025/8 21 Map 2.3 Leading health outcome for PM2.5 attributable burden based on the DALY for 2023, dementia excluded Notes: chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), ischemic heart disease (IHD), lung cancer (LC), stroke (ST); not available (NA) ETC HE Report 2025/8 22 Figure 2.4 Contribution of cause-specific outcomes to the total PM2.5 attributable burden of disease (DALY) across 40 European countries in 2023, dementia excluded Notes: Asthma-C: asthma <19 years old, COPD: chronic obstructive pulmonary disease, DM: diabetes mellitus, IHD: ischemic heart disease, LC: lung cancer, ST: stroke ETC HE Report 2025/8 23 Map 2.4 Burden of disease rate due to dementia morbidity (YLD per 100,000 inhabitants at risk) attributable to PM2.5 in 2023 The assessment of cause-specific burden of disease has been conducted since 2021. Although the observation period from 2021 to 2023 is relatively short, a slight decrease in the disease burden attributable to PM2.5 was observed across the considered health outcomes. It can be assumed that this reduction is linked to the decline in population-weighted exposure to PM2.5 in Europe from 11.4 to 10.3 µg/m³ during the same period (Figure 2.5). Figure 2.5 Changes in the burden of disease (DALY) attributable to PM2.5 (all 40 countries) differentiated by outcomes and population-weighted exposure from 2021 to 2023 Notes: CI: confidence interval, marked by the grey area; DALY: disability-adjusted life years; IHD: ischemic heart disease; DM: diabetes mellitus; COPD: chronic obstructive pulmonary disease 2.1.3 Zero pollution action plan 2030 objective Within the framework of the European Green Deal, the ZPAP sets a 2030 objective to improve air quality, with a particular emphasis on reducing PM2.5 concentrations, aiming to lower premature mortality attributable to air pollution in the EU27 by at least 55% compared to 2005 levels. The number of preventable deaths was estimated, using the same methodology as described above for 2023, based on air quality maps produced by the ETC for the period from 2005 to 2023. The population-weighted mean concentration and the burden indicator (AD) development since 2005 are depicted in Figure 2.6. The estimations show a decreasing trend of both concentrations and AD attributable to PM2.5 exposure above the WHO guideline level of 5 μg/m3, with the levels of AD for 2023 reaching the proposed ZPAP target, i.e., 194,000 (the 2023 mean AD estimated for the EU27 are 182,400). However, when considering ETC HE Report 2025/8 24 the upper 95% CI, the AD is 203,520. Nevertheless, even if the upper 95% CI is considered, the extrapolation of the AD confirms that the goal is likely to be surpassed by 2030 if EU policies on air, climate, and energy are properly implemented and maintained. Figure 2.6 Deaths attributed (AD) to PM2.5 long-term exposure, including the lower (AD_lowCI) and upper (AD_upCI) 95% CI and the PM2.5 population-weighted concentration from 2005 to 2023. AD is linearly projected from 2023 to be compared against the Zero Pollution Action Plan (ZPAP) 2030 target 2.2 NO2 2.2.1 Population-weighted annual mean concentration The main sources of NO2 in Europe are road transport and combustion processes in industry and energy production. Road traffic, particularly in urban areas, is a major contributor to people's exposure because NO2 is emitted close to the ground where people live. Enforced by the same EU obligations as PM2.5, NO2 emissions in the EU have decreased even further. For the EU27, the overall decrease in emissions since 2005 is 53%, with a range of 30% to 82% for individual countries. Since NO2 is mostly emitted by traffic, the Euro standards introduced for vehicles had the largest impact on reducing NO2 emissions. Although Northern European countries were typically exposed to lower levels, there was no clear divide between Eastern and Western European countries, as in PM2.5. The variation in concentration levels reflects the traffic density, the composition of the fleet, and the age of the vehicles. It is estimated that in 2023, a European citizen was exposed on average to a NO2 concentration of 15.3 µg/m3 (12.5 µg/m3 for an average EU27 citizen), with a minimum at the country level of 6.1 µg/m3 in Sweden and a maximum of 31.3 µg/m3 in Türkiye (24.3 µg/m3 in Cyprus for the EU27). For more detailed information on the population-weighted mean concentration maps and the observation data supporting these maps, please refer to Horálek et al. (2025) and Targa et al. (2025). Map 2.5 shows the population-weighted mean concentration at the country level in 2023. This concentration is equivalent to the average exposure level of the population of an individual country. The population-weighted mean concentration for each individual country can be found in Annex 3 Table A3.1. The distribution of NO2 exposure levels differed significantly from that of PM2.5. Although Northern European countries were typically exposed to lower levels, there was no clear divide between Eastern and Western European countries, as in PM2.5. The variation in concentration levels reflects the traffic density, the composition of the fleet, and the age of the vehicles. It is estimated that in 2023, a European citizen ETC HE Report 2025/8 25 was exposed on average to a NO2 concentration of 15.3 µg/m3 (12.5 µg/m3 for an average EU27 citizen), with a minimum at the country level of 6.1 µg/m3 in Sweden and a maximum of 31.3 µg/m3 in Türkiye (24.3 µg/m3 in Cyprus for the EU27). For more detailed information on the population-weighted mean concentration maps and the observation data supporting these maps, please refer to Horálek et al. (2025) and Targa et al. (2025). Map 2.5 NO2 population-weighted annual mean concentration in 2023 2.2.2 Burden of disease This section presents the findings regarding all-cause and cause-specific EBD attributed to long-term exposure to NO2, encompassing five health outcomes: all-cause, asthma in adults and asthma in children and adolescents, COPD, DM, and stroke. The assessment covers 41 European countries and is based on the CRFs listed in Table 1.1 and the counterfactual concentration of 10 µg/m3 (WHO, 2021), except for the sensitivity analysis that assumes 0 and 20 µg/m3. All-cause mortality The estimation of deaths due to all-cause mortality attributable to NO2 in 2023 indicated 56,061 (95% CI: 28,402-109,256) deaths for all countries considered and 34,180 (95% CI: 17,264-67,004) for the EU27. The YLL estimates were 641,068 (95% CI: 324,973-1,247,971) and 351,191 (95% CI: 177,376-688,504), respectively. The results for the all-cause mortality estimation for EU27, EEA32 and all 41 countries considered are presented in Table 2.4. The table includes the population at risk considered, the exposure level, the mean value and the lower and upper 95% CI values for the EBD indicators (AD and YLL). AD rates per 100,000 inhabitants at risk attributable to NO2 across the 41 countries are shown in Map 2.6 and are closely correlated with the exposure levels depicted in Map 2.5. Although Northern European countries were typically exposed to lower levels, there was no clear divide between Eastern and Western European countries, as in PM2.5. The variation in concentration levels reflects the traffic density, the composition of the fleet, and the age of the vehicles. It is estimated that in 2023, a European citizen was exposed on average to a NO2 concentration of 15.3 µg/m3 (12.5 µg/m3 for an average EU27 citizen), with a minimum at the country level of 6.1 µg/m3 in Sweden and a maximum of 31.3 µg/m3 in Türkiye (24.3 µg/m3 in Cyprus for the EU27). For more detailed information on the population-weighted mean concentration maps and the observation data supporting these maps, please refer to Horálek et al. (2025) and Targa et al. (2025). ETC HE Report 2025/8 32 Map 2.7 Leading health outcome for NO2 attributable burden based on the DALY for 2023 Notes: Chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), stroke (ST) ETC HE Report 2025/8 33 Figure 2.10 Contribution of cause-specific outcomes to the total NO2 attributable burden of disease (DALY) across 41 European countries in 2023 Notes: Asthma-A: asthma in adults, Asthma-C: asthma in children and adolescents, COPD: chronic obstructive pulmonary disease, DM: diabetes mellitus, ST: stroke ETC HE Report 2025/8 34 As with PM2.5, a decrease in the burden of disease (DALY) attributable to NO2 was observed for the considered health outcomes, even though the observation period from 2021 to 2023 remained relatively short. It can be assumed that this development was influenced by the slight reduction in populationweighted NO2 exposure in Europe during the same period, from 15.9 to 15.3 µg/m³ (Figure 2.11). Figure 2.11 Changes in the burden of disease (DALY) attributable to NO2 (all 41 countries) differentiated by outcomes and population-weighted exposure from 2021 to 2023 Notes: CI: confidence interval, marked by the grey area; DM: diabetes mellitus; COPD: chronic obstructive pulmonary disease; DALY: disability-adjusted life years 2.3 O3 2.3.1 Population-weighted peak season concentration O3 is not emitted directly into the air, unlike the other pollutants in this study (NO2 and PM2.5). It is formed in the atmosphere when chemical reactions between nitrogen oxides (NOx) and volatile organic compounds, including methane, are enabled by heat and light. O3 can also be transported from other parts of the Northern Hemisphere (long-range transport) and the upper atmosphere (intrusions). Therefore, meteorology plays a crucial role in influencing the interannual variations in O3 concentrations, as shown in the population-weighted mean concentration maps and the observation data supporting these maps over the last five years, as presented in Horálek et al. (2025) and Targa et al. (2025), respectively. Map 2.8 shows the population-weighted mean concentration at the country level in 2023. This concentration is equivalent to the average exposure level of the population of an individual country during the peak season. The peak season is the period during which the highest O3 concentrations were observed for six consecutive months. The population-weighted mean concentration for each individual country can be found in Annex 3 Table A3.1. The distribution of O3 levels correlated with higher temperatures, and, therefore, southern countries had higher levels of O3 than the Northern European countries. It is estimated that in 2023, a European citizen was exposed on average to an O3 peak season concentration of 87.8 µg/m3 (90.0 µg/m3 for an average EU27 citizen), with a minimum at the country level of 74.4 µg/m3 in Ireland and a maximum of 102.3 µg/m3 in Monaco (97.9 µg/m3 in Italy for EU27). ETC HE Report 2025/8 35 Map 2.8 O3 population-weighted peak season concentration in 2023 2.3.2 Burden of disease All-cause mortality The estimation of deaths due to all-cause mortality attributable to O3 in 2023 indicated 70,981 (95% CI: 0139,096) deaths for all countries considered and 62,676 (95% CI: 0-122,805) for the EU27. The YLL estimates were 753,183 (95% CI: 0-1,476,142) and 654,707 (95% CI: 0-1,282,921), respectively. The lower bound of the disease burden was zero because the lower bound of the RR 95% CI, i.e., 1.0, corresponds to no attributable burden at the counterfactual concentrations. The results for the all-cause mortality EBD estimation for all aggregated areas considered are presented in Table 2.7. The table includes the population at risk considered, the exposure level, the mean value and the lower and upper 95% CI values for the EBD indicators (AD and YLL). AD rates per 100,000 inhabitants at risk attributable to O3 across the 41 countries are shown in Map 2.9 and correlated closely with the exposure levels depicted in Map 2.8. The lowest rate was estimated for Ireland (6.2, 95% CI: 0.0-12.2) and the highest rate was estimated for Bosnia and Herzegovina (34.2, 95% CI: 0.0-66.8). Besides Bosnia and Herzegovina, only Montenegro had an AD rate above 30.0 (31.2, 95% CI: 0.0-61.1). Other countries with rates lower than 10.0 AD were Türkiye (6.5, 95% CI: 0.0-12.7), Iceland (7.3, 95% CI: 0.0-14.3), Cyprus (8.6, 95% CI: 0.0-16.9) and Norway (9.8, 95% CI: 0.0-19.3). Besides Bosnia and Herzegovina, only Montenegro had an AD rate above 30.0 (31.2, 95% CI: 0.0-61.1). Like PM2.5 and NO2, the spatial differences in YLL closely mirrored those shown for AD (with only minor shifts when countries were ordered based on the indicators and the rankings compared). These shifts reflect differences in national life expectancy and mortality rates. AD and YLL estimations and the corresponding rates per 100,000 inhabitants at risk for individual countries are available in Annex 4 Tables A4.52 and A4.53, respectively. The exposure levels and the population at risk for each country are presented in Annex 3 Table A3.1 and Table A3.2, respectively. ETC HE Report 2025/8 36 Table 2.7 Burden of disease due to all-cause mortality (AD, YLL, including the lower and upper 95% CI) attributable to O3 long-term exposure (peak season) in the EU27, the EEA32 and 41 European countries in 2023 Note: The counterfactual concentration was 60 µg/m³ Map 2.9 Burden of disease rate due to all-cause mortality (AD per 100,000 inhabitants at risk) attributable to O3 in 2023. Cause-specific mortality Long-term exposure to O3 has been classified to be likely causally related to respiratory mortality (US EPA ISA, 2020), with supporting evidence for COPD mortality from epidemiological, experimental, and mechanistic studies (Breitner et al., 2021). At the same time, the strength of the epidemiological evidence remains limited, as recent meta-analyses report inconsistent findings across individual studies (Kasdagli et al., 2024). The results for the EU27, EEA32 and all 41 countries are presented in Table 2.8. Detailed results (AD, YLL, and the corresponding rates per 100,000 inhabitants at risk) are provided for each country and country groupings in Annex 4 Tables A4.54–A4.55. As no YLD (morbidity) were calculated, DALY were not estimated. In 2023, the number of COPD deaths attributable to O3 exposure was estimated at 8,125 AD (95% CI: 7,7608,669) across all 41 countries combined and 7,041 AD (95% CI: 6,724-7,511) within the EU27. The YLL estimates were 84,713 (95% CI: 80,894-90,385) and 73,245 (95% CI: 69,946-78,145), respectively. The lowest AD rate per 100,000 inhabitants aged 25 years or older was observed in Slovakia with <1.0 AD, and the highest in Hungary with 4.0 AD (95% CI: 3.9-4.1). Other countries with estimated AD rates <1.0 were AD YLL Territory Population ≥ 25 years old (in 1,000) Exposure (µg/m3) Mean Lower 95% CI Upper 95% CI Mean Lower 95% CI Upper 95% CI EU27 330,548 90.0 62,676 0 122,805 654,707 0 1,282,921 EEA32 394,933 87.7 67,610 0 132,493 718,237 0 1,407,697 All countries 407,765 87.8 70,981 0 139,096 753,183 0 1,476,142 ETC HE Report 2025/8 37 Bulgaria, Estonia, Latvia, Slovenia, Cyprus, Lithuania and Poland (Map 2.10). Less clearly than for all-cause mortality as well as for PM2.5 and NO₂ analyses, in many cases, the amount of burden of disease in countries did not coincide with those showing the lowest or highest population-weighted exposure levels. Combined with differences in baseline mortality across countries, this resulted in AD rates showing a very small variation between countries, making a thorough presentation of differences between countries, especially in maps, challenging. Table 2.8 Total burden of disease due to COPD mortality (total AD, YLL, including the lower and upper 95% CI) attributable to O3 long-term exposure (peak season) in the EU27, the EEA32 and 41 European countries in 2023 Note: The counterfactual concentration was 60 µg/m³ Comparable results on the temporal development of the disease burden attributable to peak O3 are only available for 2022 and 2023. Across all countries, COPD mortality was about 5% (AD) and 1% (YLL) lower in 2023 compared with 2022. The slight decrease in peak O3 exposure, from 90.3 to 87.8 µg/m³, was assumed to be a contributing factor. Map 2.10 Burden of disease rate due to COPD mortality (AD per 100,000 inhabitants at risk) attributable to O3 in 2023 Total AD Total YLL Territory Mean Lower 95% CI Upper 95% CI Mean Lower 95% CI Upper 95% CI EU27 7,041 6,724 7,511 73,245 69,946 78,145 EEA32 7,850 7,497 8,375 81,864 78,174 87,347 All countries 8,125 7,760 8,669 84,713 80,894 90,385 ETC HE Report 2025/8 38 3 Conclusions The all-cause mortality analyses for all countries (40 for PM2.5 and 41 for NO2 and O3) in 2023 indicates that 206,465 (95% CI: 157,549-230,304) deaths were attributable to PM2.5, 56,061 (95% CI: 28,402-109,256) to NO2, and 70,981 (95% CI: 0-139,096) to O3 in 2023. For the EU27, the same indicator was estimated, yielding 182,400 (95% CI: 139,102-203,520), 34,180 (95% CI: 17,264-67,004) and 62,676 (95% CI: 0122,805) deaths for PM2.5, NO2, and O3, respectively. The level of AD substantially varied across European countries, with the largest variation between the maximum and minimum values being for PM2.5 and the least varying being for O3. PM2.5 exhibited a more pronounced northern and western European gradient, while O3 displayed a north-south gradient. However, the estimates indicate that populations living in Northern European countries were generally at a lower risk than those in any other region in Europe due to a comparably low exposure to all three air pollutants. On a positive note, the estimation of deaths attributable to PM2.5, considering 40 European countries, indicates that the ZPAP’s 2030 objective, aiming to lower premature mortality attributable to air pollution in the EU27 by at least 55% compared to 2005 levels, has been achieved for 2023. The assessment indicates that the decreasing trend suggests this goal will be surpassed by 2030. The cause-specific analysis, which integrates mortality and morbidity into the summary measure DALY, again highlighted PM2.5 as the pollutant with the greatest overall health impact, partly due to the inclusion of six diseases – several with high baseline prevalence or mortality – and a separate analysis dedicated to dementia. For all 40 countries, 2,300,989 DALY (95% CI: 973,460-3,479,297) attributable to PM2.5 were estimated and 2,074,951 DALY (95% CI: 874,342-3,148,806) for the EU27 (excluding dementia). NO2, with five diseases considered, accounted for 757,432 DALY (95% CI: 325,711-1,156,606) across all 41 countries and 376,464 DALY (95% CI: 156,857-588,758) in the EU27. Peak season O3 exposure, for which only one health outcome was included (COPD), resulted in 84,713 YLL (95% CI: 80,894-90,385) across all 41 countries and 73,245 YLL (95% CI: 69,946-78,145) within the EU27. IHD remained the dominant contributor to the PM2.5 burden, totalling 637,074 DALY (95% CI: 341,283-910,418) across the 40 countries and 579,409 DALY (95% CI: 309,930829,512) in the EU27. For NO2, DM was the largest contributor (all 41 countries: 302,900 DALY (95% CI: 171,862-433,170); EU27: 148,302 DALY (95% CI: 81,534-216,549)). As observed for all-cause mortality, spatial variations in the cause-specific disease burden for PM2.5 and NO2 largely reflected regional differences in exposure levels. Additionally, the leading health outcomes varied across countries, with IHD being the most common for PM2.5 and DM for NO2. For O3, the disease burden was less clearly aligned with exposure levels. Differences in baseline mortality across countries tended instead to even out the overall burden in the countries. Furthermore, for all three pollutants, decreases in population-weighted exposures were assumed to have contributed to reductions in disease burden. However, the relatively short time series of cause-specific EBD estimates currently limits the interpretability of these changes. Several other methodological factors must also be considered. First, the epidemiological evidence underlying the risk-outcome pairs varied in strength across pollutants and health outcomes. While some associations, such as PM2.5 and COPD, are supported by a robust evidence base, others — such as PM2.5 and dementia, NO2 and childhood asthma or O3 and COPD — are associated with greater uncertainty due to fewer or less consistent studies. Consequently, the estimates reflect a mixture of well-established and less certain risk-outcome relationships, which should be considered when interpreting the results. Second, the analyses do not account for overlapping exposures to multiple pollutants; simple aggregation of the burden across pollutants would result in double-counting. Also, different exposure periods were applied: annual averages for PM2.5 and NO2, and the six-month warm-season mean for O3. Finally, differences in age group definitions for specific outcomes, such as asthma, also affect comparability across pollutants. All assumptions and the methodology used for the analyses are presented in Annex 1 and Annex 2 or previously published reports, resulting in transparent documentation of the EBD presented in this report. ETC HE Report 2025/8 39 One final caveat is the counterfactual concentration assumption. The sensitivity analysis assessing the impact of selecting different counterfactual concentrations on the estimates shows that using the WHO AQG 2021 levels as the threshold might exclude a significant fraction of the total health burden. Though there is only emerging evidence from epidemiological studies that levels below those thresholds are harmful to human health, that does not mean that there is no impact, particularly for vulnerable populations. Therefore, not considering the entire concentration range down to 0 µg/m3 may result in an underestimation of the burden of disease associated with long-term exposure to PM2.5 and NO2. ETC HE Report 2025/8 40 List of abbreviations Abbreviation Name Reference AD Attributable death AQG Air quality guidelines CAMS Copernicus Atmosphere Monitoring Service CI Confidence interval COPD Chronic obstructive pulmonary disease CRF Concentration-response function DALY Disability-adjusted life years DM Diabetes mellitus DW Disability weight EBD Environmental burden of disease EEA European Environment Agency www.eea.europa.eu EHIS European Health Interview Survey ELAPSE Effects of low-level air pollution: a study in Europe www.elapseproject.eu EMAPEC Estimating the Morbidity from Air Pollution and its Economic Costs ETC/ATNI European Topic Centre on Air pollution, Transport, Noise and Industrial pollution ETC HE European Topic Centre on Human Health and the Environment EU European Union www.europeanunion.europa.eu GBD Global burden of disease GHSL Global Human Settlement Layer HR Hazard ratio HRAPIE Health risks of air pollution in Europe https://iris.who.int/handle/1 0665/153692?show=full IARC International Agency for Research on Cancer ICD International classification of diseases IHD Ischemic heart disease LC Lung cancer m³ Cubic meter N/A Not Available NO2 Nitrogen dioxide O3 Ozone OR Odds ratio PAF Population attributable fraction PM2.5 Fine particulate matter (diameter below 2.5 µm) ppb Parts per billion RIMM Regression-Interpolation-Merging Mapping RR Relative risk T2DM Type 2 diabetes mellitus WHO World Health Organization www.who.int YLL Year of life lost due to death YLD Year lived with disability µg Microgram µm Micrometer ETC HE Report 2025/8 41 References Alzheimer Europe (2019). 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De Marco, et al., 2019, Impacts of air pollution on human and ecosystem health, and implications for the National Emission Ceilings Directive: Insights from Italy, Environment International, Vol. 125, pp. 320– 333. (https://doi.org/10.1016/J.ENVINT.2019.01.064). ESS, 2012, Quality Assurance Framework of the European Statistical System. European Statistical System (https://ec.europa.eu/eurostat/documents/3859598/5923349/QAF_2012-EN.PDF/fcdf3c44-8ab841b8-9fd0-91bd1299e3ef?version=1.0) accessed 16 August 2025. Eurostat, 2025a Eurostat, Population change - Demographic balance and crude rates at national level, Eurostat (https://ec.europa.eu/eurostat/databrowser/view/demo_gind/default/table?lang=en) accessed 15 June 2025. Eurostat, 2025b, Population on 1 January by age and sex, Eurostat, (https://ec.europa.eu/eurostat/databrowser/view/demo_pjan/default/table?lang=en) accessed 15 June 2025. Eurostat, 2025c, Causes of death - deaths by country of residence and occurrence, Eurostat (https://ec.europa.eu/eurostat/databrowser/view/hlth_cd_aro/default/table?lang=en) accessed 15 June 2025. Eurostat, 2025d, Deaths by age and sex, Eurostat (https://ec.europa.eu/eurostat/databrowser/view/demo_gind/default/table?lang=endemo_m%20a gec&lang=en) accessed 15 June 2025. Eurostat, 2025e, Life expectancy by age and sex, Eurostat, (http://appsso.eurostat.ec.europa.eu/nui/show.do?dataset=demo_mlexpec&lang=en) accessed 15 June 2025. ETC HE Report 2025/8 48 Table A1.1 Countries lacking total population data and the selected gap-filling proxies Additional scaling factors were applied to account for population adjustments. A scaling factor of 0.968 was applied to scale France’s population in Eurostat, since the data includes the overseas territories. This scaling factor is based on multiple data sources (INED, 2025). For Cyprus, since the administrative boundaries in the GSHL data cover the entire island, the population density of the whole island was used to estimate health outcomes up to 2021. Adjustments were made only for the population after 2021 based on the Republic of Cyprus data reported in Eurostat, by taking the ratio of the changes in the total population in Eurostat for the assessment year in relation to 2021 and apply it to the population density data in 2021. Contrary to previous assessments, e.g., last year, where GEOSTAT 2011 data were used, no adjustments were needed for the Portuguese and Spanish population since the overseas territories are included in the GSHL dataset. Lastly, to fill any missing or zero values, interpolation was applied across countries and years to produce reasonable estimates. The final dataset serves as the basis for further calculations, including aggregation to NUTS3 and other regional levels, and to estimate the population at risk. The population data for estimating the mortality and morbidity indicators represent only the population defined as at risk by the epidemiological studies from which the CRFs were derived or recommendations from international assessments (e.g. the HRAPIE project or the GBD study) (see Table 1.1). Population data per country, stratified by age and sex, is available for individual countries from Eurostat (Eurostat, 2025b), and is used to estimate the fraction of the population in a specific age group in 2023. This fraction of the population will be used to estimate the population at risk in each grid cell, which will then be used to estimate the burden of disease indicators. Again, when data on population stratification were missing for a specific country, data from neighbouring countries with similar socio-economic characteristics were used (see Table A1.1). Demographic and health data for estimating all-cause mortality-related burden of disease The assessments produced in this report include the burden of disease attributable to air pollution for allcause natural mortality, and cause-specific mortality and morbidity. All-cause and cause-specific EBD estimations require different demographic and health data. To calculate the all-cause mortality-related burden of disease, data on cause of death, the number of natural deaths, and life expectancy stratified by year, sex, and age groups are needed. Eurostat compiles most of the data needed. However, this information is only available at the country level and might not have been available for 2023 at the time of the analyses performed for this report. Many countries report data with two or more years of delay or do not report data at all, in which cases, using a gap-filling methodology is required. Eurostat data on causes of death (Eurostat, 2025c) are available since 2011 for 5-year age-groups, from ‘less than 1 year’ to '80 years or over'. It is compiled based on the ICD10 Mortality Tabulation List, the latest tabulation existing for mortality data. According to the description of the concentration-response functions (see Table 1.2), only natural deaths should be considered. Therefore, it considers all ICD-10 codes except injuries, poisoning, accidents or other external causes (S00-T98, V01-Y89). The number of natural deaths is estimated for 1-year age groups. Estimating the number of natural deaths for 1-year groups is Data set Country (iso2 code) Data used for gapfilling Year of data used for gapfilling Country of data used for gap-filling Total population AD, MC Total population 2022 FR Total population AL, BA, XK Total population 2022 RS Total population SM Total population 2022 IT ETC HE Report 2025/8 49 based on interpolation using the ratio between all-natural deaths and all (natural + external) causes of death (5-year age-groups) and Eurostat data on the total number of deaths (Eurostat, 2025d) given with a 1-year age-grouping. After this operation, mortality data were aligned with life expectancy data, available from the Eurostat database (Eurostat, 2025e) in a 1-year age-group stratification, by age and sex, from 0 to 85+ years old, since 1960. Life expectancies are extrapolated for ages above 85, using regression on life expectancy data for age groups 79 – 85, to reflect all age groups available for mortality data (up to 95+). Gap filling was done for countries where the data described above is unavailable in the Eurostat datasets. Causes of death data were available from 2011 onwards and this year is used as a proxy for years 2005 - 2010. Afterwards, gap filling is performed for missing data on external causes of deaths using an average number of deaths due to external causes from the previous 5 years (5-year rolling average). Then, the missing numbers of deaths due to natural causes are gap-filled by subtracting the number of deaths due to external causes from the totals. Data on the number of deaths and life expectancy have been available for most countries since 2005. In the cases where the data were not available, gap filling is performed using relative age distribution numbers of mortality (mortality ratios, or the number of deaths per population in each age group) and YLL ratios, following a similar methodology as described for population numbers, i.e., a 5-year rolling average. Original data is used where possible, i.e., if the original life expectancy numbers exist, they are used for calculating YLL ratios, even if mortality ratios have to be gap-filled. Nevertheless, for cases where data is unavailable, mostly for the western Balkan countries and microstates, the same proxy countries as for the population data were used for gap filling, see Table A1.2. Demographic and health data for estimating cause-specific burden of disease For the cause-specific analyses, mortality data stratified by year, sex, age groups and cause of death were also obtained from the Eurostat database (Eurostat, 2025c). For morbidity analyses, the prevalence-based approach to estimate the YLD has been used. Therefore, outcome-specific prevalence data from different sources have been used. For asthma (in individuals aged 15 years and older), COPD, DM, and stroke, data from the European Health Interview Survey (EHIS; Eurostat, 2025f) were used. Since EHIS does not provide prevalence data on asthma in individuals under 15 years of age, prevalence data from the GBD 2021 study were used (GBD 2021 Diseases and Injuries Collaborators, 2024). Prevalence data on lung cancer were obtained from the International Agency for Research on Cancer (IARC, 2024). The data were stratified by sex and different age groups (EHIS: 15-75+ years, in 10-year age groups; GBD 2021 study and Eurostat: 095+ years, in 5-year age-groups; IARC: 0-85+ years, in 5-year age groups). Regarding dementia, a single European average prevalence rate, stratified by sex and age (60-90+ years; in 5-year age groups) from Alzheimer Europe (2019) was used across all countries, as national data on disease frequency were not available beyond sex-specific adjustments. All absolute numbers were converted into death or prevalence rates in 1-year age groups for further alignment with life expectancy data, as done for the analyses of allcause mortality described above. Additionally, it should be noted that in the GBD 2021 study and IARC, prevalence data on childhood asthma and lung cancer were presumably reported for Serbia, including Kosovo. However, the derived rates were applied for both countries individually. More details on the prevalence data and the selection process can be found in the ETC HE Report 2022/11 (Kienzler et al., 2022). An overview of the health data sources for cause-specific mortality and morbidity is presented in Table 1.2. Prevalence and mortality data were not always available for all countries for the reference year 2023. Where data were missing, information from the two preceding years (2021 and 2022) was considered, and the most recent year available was used. The corresponding mortality and prevalence rates from that year were calculated (using population data reported by Eurostat, 2025b) and assumed to apply to 2023. For ETC HE Report 2025/8 50 some European countries, no suitable data were available from either 2021 or 2022. In these cases, data from neighbouring countries were used as proxies to fill in the gaps. Where necessary, estimates from the GBD 2021 study (GBD 2021 Diseases and Injuries Collaborators, 2024) were consulted to assess the suitability of proxy countries by comparing prevalence or mortality patterns. Table A1.2 shows the gap-filling proxies for countries lacking life expectancy and other health data for allcause and cause-specific mortality and morbidity assessments. Table A1.2: Countries lacking health data and the corresponding gap-filling proxies for all-cause mortality, cause-specific mortality, and morbidity (ISO2 codes in Annex 6). In case the country is the same, data from previous years were used. Data set Country (iso2 code) Data used for gapfilling Country of data used for gapfilling All cause Life expectancy AD, MC YLL rates FR Life expectancy BA, XK YLL rates RS Life expectancy LI YLL rates AT Life expectancy SM YLL rates IT Life expectancy TR Life expectancy (a) TR Asthma (in individuals younger than 15 years) Mortality AL, BA, ME, MK, XK Mortality rate RS Mortality BE, DK, GR, IE, IT, LV, MT, PT, RO, SE, TR Mortality rate(a) BE, DK, GR, IE, IT, LV, MT, PT, RO, SE, TR Mortality AD, MC Mortality rate FR Mortality CY Mortality rate GR Mortality IS Mortality rate DK Mortality EE Mortality rate LV Mortality LU Mortality rate BE Mortality SM, MT Mortality rate IT Mortality SI Mortality rate SK Prevalence LI Prevalence rate AT Prevalence RS Prevalence rate RS+XK Prevalence XK Prevalence rate RS+XK Data set Country (iso2 code) Data used for gapfilling Country of data used for gapfilling Asthma (in individuals 15 years and older), COPD, DM, IHD, Stroke Mortality BE, DK, GR, IE, IT, LV, MT, PT, RO, SE, TR Mortality rate(a) BE, DK, GR, IE, IT, LV, MT, PT, RO, SE, TR Mortality AL, BA, ME, MK, XK Mortality rate RS Mortality AD, MC Mortality rate FR Mortality SM Mortality rate IT ETC HE Report 2025/8 51 Note: (a)For the listed countries, available mortality data referred to years prior to 2023. Mortality rates from the most recent year available were calculated and assumed to apply to 2023 Disability weights (DW) For the calculation of the YLDs, the number of prevalent cases of a cause-specific health outcome was multiplied by the respective DW (Equation A1.7). The DW is a weighting factor for the severity of a disease on a scale ranging from zero (no reduction of health) to one (the worst imaginable health state, sometimes set equal to death). The DW are based on the outcome and are sex and age group specific. The values used in the calculation were derived from the Global Burden of Disease 2021 study (GBD 2021 Diseases and Injuries Collaborators, 2025). This data is accessible via: https://vizhub.healthdata.org/gbd-results/. The respective DWs were calculated by dividing the annual YLDs by the prevalence data for the considered diseases for the WHO European Region: Only for asthma (15-24 years): Mortality IS Mortality rate (1524 years) DK Only for asthma (15-24 years): Mortality LU Mortality rate (1524 years) BE Only for asthma (15-24 years): Mortality MT Mortality rate (1524 years) IT Prevalence AL, BA, ME, MK, XK Prevalence rate RS Prevalence CH Prevalence rate AT Prevalence LI Prevalence rate AT Prevalence SM Prevalence rate IT Dementia Prevalence AD, AL, AT, BA, BE, BG, CH, CY, CZ, DE, DK, EE, ES, FI, FR, GR, HR, HU, IE, IS, IT, LI, LT, LU, LV, MC, ME, MK, MT, NL, NO, PL, PT, RO, RS, SE, SI, SK, SM, TR, XK Prevalence rate Europe LC Mortality BE, BG, CH, CY, DE, DK, EE, FI, FR, GR, HR, HU, IE, IS, IT, LV, MT, NL, NO, PT, RO, RS, SE, SI, TR Mortality rate(a) BE, BG, CH, CY, DE, DK, EE, FI, FR, GR, HR, HU, IE, IS, IT, LV, MT, NL, NO, PT, RO, RS, SE, SI, TR Mortality AL, BA, ME, MK, XK Mortality rate RS Mortality AD, MC Mortality rate FR Mortality SM Mortality rate IT Prevalence AD, MC Prevalence rate FR Prevalence LI Prevalence rate AT Prevalence SM Prevalence rate IT Prevalence RS Prevalence rate RS+XK ETC HE Report 2025/8 52 𝐷𝑊 = 𝑌𝐿𝐷𝑜 𝑃𝑜 (A2.1) These were available in 5-year age groups stratified by sex and were applied to all individual countries. Estimating the DWs from YLD and prevalence data allows the use of a weight that is adjusted for the severity distributions and co-morbidity. It should be noted that the DW calculated for Diabetes Mellitus (DM) is a combined DW for both type 1 and type 2 DM. Concentration-response functions Compared with the previous report, several changes were made to the CRFs for different risk-outcome pairs. First, the age groups defined for asthma analyses were revised. Children and adolescents were now classified as individuals younger than 19 years (previously <15 years), while adults were defined as those aged 19 years and older (previously ≥15 years). Second, the RR applied to NO₂ and asthma mortality in adults was adjusted. The same RR was now used for both asthma morbidity and asthma mortality. In addition, new risk-outcome pairs were introduced, including: • PM₂.5 and dementia morbidity • NO₂ and asthma in children and adolescents • NO₂ and COPD The level of epidemiological evidence supporting the RRs varied across all risk-outcome pairs, reflecting differences in the number and quality of available studies. For instance, the association between PM₂.5 and dementia is linked with greater uncertainty compared to other outcomes. In this context, large European cohort studies and high-quality meta-analyses, such as ELAPSE, EMAPEC, or HRAPIE, represent valuable resources for evaluating and consolidating the evidence base. Correction factors for EBD due to long-term O3 exposure (peak season) Because O3 formation is favoured by strong sunlight and high temperatures, concentrations are typically highest during the warm months. Meta-analyses indicate that associations between long-term O3 exposure and health outcomes are more robust when using “summer” exposure metrics rather than annual averages (Huangfu and Atkinson, 2020). Accordingly, following WHO (2021), long-term O3 concentration in this report is defined as the average of the daily maximum 8-hour mean over the six consecutive months with the highest running six-month O3 average (peak season). Consequently, the EBD for O3 was calculated for these six peak months in 2023, rather than for the full year as for PM2.5 and NO2. This approach better aligns exposure with the occurrence of health effects and the corresponding CRFs. Because monthly cause-specific mortality data for 2023 were not available for all countries, annual death data were adjusted using a correction factor that reflects the share of deaths occurring during the O3 peak season. To derive this factor, all-cause mortality (ICD-10 excluding S00-T98 and V01-Y89) and COPD mortality (ICD-10 J40-44, J47) by month were compiled for 27 European countries with available 2022 data from Eurostat (2025h). Even if the peak season period can be different for each station, a uniform peak season from April to September was applied, consistent with most studies in Huangfu and Atkinson (2020). Alternative definitions (March-August, May-October) produced similar factors. Average correction factors of 0.464 (all-cause) and 0.456 (COPD) derived from the 27 reporting countries were applied to all countries included in the analysis. ETC HE Report 2025/8 53 Annex 3 Population at risk and exposure levels Table A3.1: Population-weighted concentration levels (µg/m3) for 40 or 41 European countries, the EU27 and EEA32 in 2023 Country PM2.5 annual mean NO2 annual mean O3 peak season mean Austria 9.1 12.7 93.4 Belgium 8.8 12.5 84.6 Bulgaria 14.3 13.7 80.5 Croatia 13.0 11.8 96.0 Cyprus 14.7 24.3 81.9 Czechia 10.9 11.0 93.3 Denmark 6.6 6.5 81.7 Estonia 5.2 6.4 81.8 Finland 4.2 6.4 78.9 France 8.4 10.7 88.2 Germany 7.9 12.1 89.5 Greece 16.5 17.3 94.7 Hungary 12.4 12.3 92.6 Ireland 6.2 7.9 74.4 Italy 14.1 16.8 97.9 Latvia 7.9 8.2 85.5 Lithuania 8.1 8.7 89.3 Luxembourg 7.1 10.6 87.3 Malta 10.9 10.4 97.2 Netherlands 8.2 13.1 85.1 Poland 13.8 11.2 89.5 Portugal 7.7 11.8 86.4 Romania 13.1 13.9 85.1 Slovakia 12.2 10.5 89.8 Slovenia 12.0 11.1 94.0 Spain 9.5 14.0 94.6 Sweden 4.7 6.1 80.2 Albania 17.4 12.3 92.4 Andorra 5.9 12.9 87.6 Bosnia and Herzegovina 18.6 12.4 100.3 Iceland 4.1 6.8 77.9 Kosovo 16.6 12.0 86.0 Liechtenstein 7.7 11.8 93.4 Monaco 8.7 16.5 102.3 Montenegro 13.6 13.1 93.9 North Macedonia 19.2 10.6 84.3 Norway 5.0 7.5 80.3 San Marino 12.4 11.0 97.7 Serbia 17.7 14.8 88.4 Switzerland 7.6 12.5 95.2 Türkiye -- 31.3 75.4 EU27 10.2 12.5 90.0 EEA32 -- 15.4 87.7 EEA32 (no TR) 10.1 All countries 15.3 87.8 All countries (no TR) 10.3 -- -- ETC HE Report 2025/8 54 Table A3.2: Population at risk (in 1,000) for 40 or 41 European countries, in the EU27 and EEA32 in 2023. Age groups represent the age of the cohorts in the epidemiological studies, on which the OR, HR or RR are based. Country/age group < 19 years ≥ 19 ≥ 25 ≥ 30 ≥ 60 Austria 1,670 7,435 6,841 6,248 2,411 Belgium 2,479 9,257 8,440 7,707 3,066 Bulgaria 1,159 5,289 4,960 4,680 1,974 Croatia 702 3,149 2,910 2,689 1,158 Cyprus 248 1,034 949 856 299 Czechia 2,204 8,624 8,015 7,445 2,804 Denmark 1,224 4,701 4,256 3,847 1,570 Estonia 283 1,082 1,004 933 364 Finland 1,087 4,475 4,110 3,765 1,649 France 14,679 51,406 46,799 43,124 18,031 Germany 14,701 68,414 63,225 58,399 24,647 Greece 1,817 8,594 7,965 7,443 3,097 Hungary 1,782 7,817 7,202 6,634 2,529 Ireland 1,298 3,973 3,594 3,284 1,084 Italy 9,662 49,334 45,818 42,823 18,343 Latvia 379 1,503 1,399 1,309 530 Lithuania 535 2,322 2,159 1,999 794 Luxembourg 132 529 483 433 136 Malta 86 456 420 373 132 Netherlands 3,524 14,286 12,893 11,738 4,782 Poland 7,087 29,666 27,523 25,394 9,715 Portugal 1,694 8,323 7,681 7,152 3,084 Romania 3,939 15,111 13,939 12,978 4,899 Slovakia 1,087 4,342 4,024 3,709 1310 Slovenia 398 1,719 1,598 1,486 598 Spain 8,203 37,720 34,842 32,385 12,268 Sweden 2,312 8,201 7,498 6,832 2,720 Albania 589 2,271 2,034 1,811 711 Andorra 18 63 58 53 22 Bosnia and Herzegovina 635 2,806 2,595 2,403 1,005 Iceland 89 298 267 235 80 Kosovo 327 1,447 1,338 1,239 518 Liechtenstein 7 32 30 28 11 Monaco 9 30 27 25 10 Montenegro 140 477 431 392 141 North Macedonia 389 1,440 1,313 1,200 446 Norway 1,176 4,308 3,910 3,542 1,326 San Marino 6 28 26 25 11 Serbia 1,225 5,416 5,009 4,638 1,940 Switzerland 1,670 7,146 6,592 6,037 2,254 Türkiye (TR) 23,820 61,447 53,587 47,034 -- EU27 84,370 358,759 330,548 305,665 123,994 EEA32 (no TR) 87,313 -- 341,346 315,507 127,665 EEA32 111,132 431,990 394,933 362,541 -- All countries (no TR) 90,650 -- 354,179 327,293 132,469 All countries 114,470 445,969 407,765 374,328 -- ETC HE Report 2025/8 55 Annex 4 Results for all-cause and cause-specific EBD analyses PM2.5 (long-term effects) and all-cause mortality Table A4.1: All-cause mortality disease burden (AD) attributable to PM2.5 for adults ≥ 30 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 30 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 2,609 1,984 2,915 41.8 31.8 46.7 Belgium 2,941 2,235 3,287 38.2 29.0 42.6 Bulgaria 6,729 5,143 7,501 143.8 109.9 160.3 Croatia 2,886 2,205 3,218 107.3 82.0 119.7 Cyprus 612 468 682 71.5 54.6 79.7 Czechia 4,715 3,592 5,264 63.3 48.2 70.7 Denmark 704 534 787 18.3 13.9 20.5 Estonia 46 35 52 5.0 3.8 5.5 Finland 35 26 39 <1.0 <1.0 1.0 France 14,742 11,202 16,478 34.2 26.0 38.2 Germany 21,640 16,433 24,197 37.1 28.1 41.4 Greece 10,250 7,850 11,413 137.7 105.5 153.3 Hungary 6,768 5,160 7,552 102.0 77.8 113.8 Ireland 317 240 355 9.7 7.3 10.8 Italy 43,084 32,944 48,010 100.6 76.9 112.1 Latvia 578 439 646 44.1 33.5 49.3 Lithuania 815 619 911 40.7 30.9 45.5 Luxembourg 67 51 75 15.4 11.7 17.2 Malta 173 132 193 46.3 35.2 51.7 Netherlands 3,847 2,922 4,301 32.8 24.9 36.6 Poland 25,268 19,303 28,170 99.5 76.0 110.9 Portugal 2,221 1,688 2,483 31.1 23.6 34.7 Romania 14,066 10,737 15,687 108.4 82.7 120.9 Slovakia 2,732 2,083 3,049 73.7 56.2 82.2 Slovenia 1,034 789 1,154 69.6 53.1 77.6 Spain 13,318 10,135 14,875 41.1 31.3 45.9 Sweden 205 155 229 3.0 2.3 3.4 Albania 3,552 2,723 3,953 196.1 150.3 218.3 Andorra <10 <10 <10 11.8 8.9 13.2 Bosnia and Herzegovina 4,784 3,675 5,319 199.0 152.9 221.3 Iceland 0 0 0 <1.0 <1.0 <1.0 Kosovo 2,135 1,635 2,378 172.4 131.9 192.0 Liechtenstein <10 <10 <10 21.5 16.3 24.0 Monaco <10 <10 10 37.5 28.5 41.9 Montenegro 556 425 620 141.8 108.4 158.1 North Macedonia 2,667 2,049 2,966 222.2 170.7 247.0 Norway 235 179 263 6.6 5.0 7.4 San Marino 20 16 23 83.1 63.3 92.7 Serbia 8,736 6,699 9,721 188.3 144.4 209.6 Switzerland 1,358 1,031 1,518 22.5 17.1 25.1 Türkiye (TR) -- -- -- -- -- -- EU27 182,400 139,102 203,520 59.7 45.5 66.6 EEA32 (no TR) 183,999 140,316 205,308 58.3 44.5 65.1 All countries (no TR) 206,465 157,549 230,304 63.1 48.1 70.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 56 Table A4.2: All-cause mortality disease burden (YLL) attributable to PM2.5 for adults ≥ 30 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high)(a) YLL/105 inhabitants ≥ 30 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 25,924 19,716 28,965 414.9 315.6 463.6 Belgium 30,396 23,104 33,971 394.4 299.8 440.8 Bulgaria 72,782 55,622 81,125 2055.9 1579.4 2285.7 Croatia 28,877 22,055 32,196 1555.2 1188.5 1733.5 Cyprus 6,579 5,027 7,334 1073.9 820.2 1197.3 Czechia 51,363 39,127 57,342 768.3 587.1 856.4 Denmark 7,334 5,562 8,205 689.9 525.6 770.2 Estonia 502 380 561 190.6 144.6 213.3 Finland 339 257 380 53.8 40.7 60.2 France 160,875 122,245 179,820 9.0 6.8 10.1 Germany 216,546 164,439 242,126 373.1 283.5 417.0 Greece 97,856 74,942 108,961 370.8 281.6 414.6 Hungary 72,680 55,418 81,102 1314.8 1006.9 1464.0 Ireland 3,614 2,741 4,043 1095.6 835.4 1222.6 Italy 407,950 311,943 454,590 110.0 83.5 123.1 Latvia 6,316 4,800 7,059 952.7 728.5 1061.6 Lithuania 9,117 6,925 10,192 482.4 366.6 539.1 Luxembourg 744 564 832 456.0 346.4 509.8 Malta 1,926 1,466 2,150 172.0 130.5 192.4 Netherlands 39,747 30,187 44,439 516.0 392.8 576.2 Poland 302,511 231,094 337,255 338.6 257.2 378.6 Portugal 22,894 17,397 25,590 1191.3 910.0 1328.1 Romania 160,029 122,153 178,478 320.1 243.2 357.8 Slovakia 33,239 25,343 37,092 1233.1 941.2 1375.2 Slovenia 11,163 8,515 12,455 896.3 683.4 1000.2 Spain 140,262 106,739 156,665 751.0 572.8 837.9 Sweden 1,971 1,493 2,205 433.1 329.6 483.8 Albania 35,817 27,457 39,863 28.8 21.9 32.3 Andorra 68 52 76 1977.8 1516.2 2201.2 Bosnia and Herzegovina 49,410 37,959 54,933 128.3 97.3 143.6 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 23,877 18,279 26,592 1927.2 1475.3 2146.4 Liechtenstein 72 55 80 261.2 198.3 292.1 Monaco 102 78 114 409.3 310.9 457.5 Montenegro 6,038 4,613 6,731 1540.5 1177.0 1717.3 North Macedonia 25,012 19,214 27,808 2083.6 1600.7 2316.6 Norway 2,367 1,796 2,649 66.8 50.7 74.8 San Marino 193 147 215 786.4 599.7 877.5 Serbia 90,228 69,190 100,403 1945.3 1491.7 2164.7 Switzerland 13,631 10,352 15,240 225.8 171.5 252.4 Türkiye (TR) -- -- -- -- -- -- EU27 1,913,535 1,459,256 2,135,135 626.0 477.4 698.5 EEA32 (no TR) 1,929,606 1,471,459 2,153,104 611.6 466.4 682.4 All countries (no TR) 2,160,351 1,648,448 2,409,840 660.1 503.7 736.3 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 57 PM2.5 (long-term effects) and total cause-specific disease burden (six causes, excluding dementia) Table A4.3: Total cause-specific disease burden (DALY) attributable to PM2.5 (asthma in children/adolescents, COPD, diabetes mellitus, ischemic heart disease, lung cancer and stroke) for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) Country mean low high Austria 32,862 13,462 50,898 Belgium 28,735 10,442 45,856 Bulgaria 79,987 34,986 119,199 Croatia 40,486 17,961 59,821 Cyprus 7,591 3,361 11,183 Czechia 59,643 25,784 90,233 Denmark 7,913 2,689 13,007 Estonia 488 208 766 Finland 379 152 606 France 144,218 56,982 226,567 Germany 243,827 93,833 387,334 Greece 105,916 46,688 155,547 Hungary 100,736 42,296 152,968 Ireland 4,231 1,624 6,767 Italy 428,124 182,802 635,947 Latvia 8,995 4,093 13,636 Lithuania 13,609 6,148 20,759 Luxembourg 718 269 1,152 Malta 2,594 1,165 3,891 Netherlands 40,080 14,189 64,731 Poland 317,074 140,400 471,311 Portugal 24,523 9,986 38,278 Romania 196,867 88,080 293,198 Slovakia 37,669 17,087 56,437 Slovenia 11,737 4,984 17,796 Spain 133,851 53,842 207,569 Sweden 2,097 828 3,350 Albania 29,677 13,080 43,252 Andorra 63 24 100 Bosnia and Herzegovina 46,124 20,680 66,305 Iceland <1 <1 <1 Kosovo 22,453 9,886 32,925 Liechtenstein 31 11 52 Monaco 92 36 145 Montenegro 4,747 2,052 7,072 North Macedonia 20,554 9,187 29,561 Norway 2,558 901 4,172 San Marino 208 87 315 Serbia 85,583 37,934 124,312 Switzerland 13,948 5,238 22,281 Türkiye (TR) -- -- -- EU27 2,074,951 874,342 3,148,806 EEA32 (no TR) 2,091,489 880,492 3,175,311 All countries (no TR) 2,300,989 973,460 3,479,297 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 64 Table A4.10: COPD disease burden (YLD) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 1,807 703 2,803 26.4 10.3 41.0 Belgium 1,813 701 2,826 21.5 8.3 33.5 Bulgaria 1,943 793 2,879 39.2 16.0 58.0 Croatia 1,431 581 2,133 49.2 20.0 73.3 Cyprus 370 151 548 39.0 15.9 57.7 Czechia 1,390 550 2,122 17.3 6.9 26.5 Denmark 357 135 569 8.4 3.2 13.4 Estonia 15 <10 24 1.5 <1.0 2.4 Finland 17 <10 28 <1.0 <1.0 <1.0 France 13,918 5,365 21,759 29.7 11.5 46.5 Germany 15,695 6,009 24,697 24.8 9.5 39.1 Greece 2,136 891 3,106 26.8 11.2 39.0 Hungary 3,026 1,208 4,575 42.0 16.8 63.5 Ireland 146 55 232 4.1 1.5 6.5 Italy 23,545 9,662 34,752 51.4 21.1 75.8 Latvia 203 79 318 14.5 5.6 22.7 Lithuania 588 226 922 27.2 10.5 42.7 Luxembourg 68 26 109 14.2 5.4 22.5 Malta 20 <10 30 4.7 1.9 7.3 Netherlands 3,014 1,156 4,735 23.4 9.0 36.7 Poland 8,608 3,501 12,801 31.3 12.7 46.5 Portugal 1,631 629 2,551 21.2 8.2 33.2 Romania 1,733 699 2,596 12.4 5.0 18.6 Slovakia 1,140 455 1,725 28.3 11.3 42.9 Slovenia 528 212 797 33.1 13.2 49.9 Spain 5,864 2,295 9,037 16.8 6.6 25.9 Sweden 55 21 88 <1.0 <1.0 1.2 Albania 993 418 1,432 48.8 20.5 70.4 Andorra <10 <10 <10 10.5 4.0 16.8 Bosnia and Herzegovina 1,442 619 2,046 55.5 23.8 78.8 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 670 278 977 50.1 20.8 73.0 Liechtenstein <10 <10 <10 18.0 6.9 28.4 Monaco <10 <10 14 32.7 12.6 51.1 Montenegro 152 62 226 35.2 14.4 52.4 North Macedonia 720 309 1,020 54.8 23.5 77.7 Norway 115 44 183 2.9 1.1 4.7 San Marino 12 <10 17 43.8 17.5 66.2 Serbia 2,687 1,134 3,864 53.6 22.6 77.1 Switzerland 1,129 433 1,775 17.1 6.6 26.9 Türkiye (TR) -- -- -- -- -- -- EU27 91,063 36,118 138,763 27.5 10.9 42.0 EEA32 (no TR) 92,313 36,597 140,730 27.0 10.7 41.2 All countries (no TR) 99,002 39,428 150,336 28.0 11.1 42.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 65 Table A4.11: COPD disease burden (DALY) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 5,044 758 8,899 73.7 11.1 130.1 Belgium 6,430 780 11,580 76.2 9.2 137.2 Bulgaria 4,414 839 7,271 89.0 16.9 146.6 Croatia 4,022 628 6,773 138.2 21.6 232.8 Cyprus 817 159 1,344 86.1 16.8 141.6 Czechia 6,523 640 11,599 81.4 8.0 144.7 Denmark 1,930 161 3,635 45.3 3.8 85.4 Estonia 38 <10 70 3.8 <1.0 6.9 Finland 47 <10 86 1.1 <1.0 2.1 France 23,652 5,530 40,278 50.5 11.8 86.1 Germany 45,357 6,509 81,598 71.7 10.3 129.1 Greece 8,187 1,004 13,605 102.8 12.6 170.8 Hungary 13,513 1,395 23,704 187.6 19.4 329.1 Ireland 719 65 1,347 20.0 1.8 37.5 Italy 56,921 10,277 93,776 124.2 22.4 204.7 Latvia 408 82 707 29.2 5.9 50.5 Lithuania 907 231 1,531 42.0 10.7 70.9 Luxembourg 161 28 287 33.3 5.7 59.5 Malta 222 11 406 52.9 2.7 96.7 Netherlands 8,994 1,257 16,185 69.8 9.7 125.5 Poland 20,855 3,723 34,673 75.8 13.5 126.0 Portugal 3,022 652 5,198 39.3 8.5 67.7 Romania 11,681 879 20,519 83.8 6.3 147.2 Slovakia 2,218 474 3,693 55.1 11.8 91.8 Slovenia 1,010 220 1,673 63.2 13.8 104.7 Spain 17,730 2,500 31,210 50.9 7.2 89.6 Sweden 282 24 534 3.8 <1.0 7.1 Albania 2,976 456 4,835 146.3 22.4 237.7 Andorra 10 <10 18 17.8 4.1 31.1 Bosnia and Herzegovina 4,556 680 7,284 175.5 26.2 280.6 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 2,170 306 3,590 162.2 22.9 268.3 Liechtenstein 10 <10 17 33.4 7.1 58.1 Monaco 15 <10 26 55.5 13.0 94.7 Montenegro 466 68 786 108.2 15.7 182.5 North Macedonia 2,064 335 3,279 157.2 25.5 249.7 Norway 580 51 1,088 14.8 1.3 27.8 San Marino 28 <10 47 105.4 18.6 178.3 Serbia 8,461 1,245 13,742 168.9 24.8 274.4 Switzerland 2,712 460 4,807 41.1 7.0 72.9 Türkiye (TR) -- -- -- -- -- -- EU27 245,102 38,838 422,180 74.2 11.7 127.7 EEA32 (no TR) 248,404 39,351 428,092 72.8 11.5 125.4 All countries (no TR) 269,150 42,451 461,699 76.0 12.0 130.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 66 PM2.5 (long-term effects) and diabetes mellitus disease (adults ≥ 25 years) Table A4.12: DM disease burden (AD) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 673 352 955 9.8 5.1 14.0 Belgium 255 132 364 3.0 1.6 4.3 Bulgaria 545 304 729 11.0 6.1 14.7 Croatia 1,379 762 1,859 47.4 26.2 63.9 Cyprus 230 128 307 24.2 13.5 32.3 Czechia 1,321 706 1,836 16.5 8.8 22.9 Denmark 118 59 174 2.8 1.4 4.1 Estonia <10 <10 14 <1.0 <1.0 1.3 Finland <10 <10 <10 <1.0 <1.0 <1.0 France 1,997 1,031 2,865 4.3 2.2 6.1 Germany 3,771 1,929 5,458 6.0 3.1 8.6 Greece 1,240 710 1,618 15.6 8.9 20.3 Hungary 1,019 552 1,397 14.1 7.7 19.4 Ireland 43 22 64 1.2 <1.0 1.8 Italy 9,513 5,336 12,672 20.8 11.6 27.7 Latvia 86 44 123 6.1 3.2 8.8 Lithuania 98 51 142 4.6 2.3 6.6 Luxembourg <10 <10 13 1.8 <1.0 2.7 Malta 51 27 72 12.3 6.5 17.1 Netherlands 461 236 665 3.6 1.8 5.2 Poland 3,657 2,029 4,913 13.3 7.4 17.9 Portugal 489 252 702 6.4 3.3 9.1 Romania 1,261 693 1,709 9.0 5.0 12.3 Slovakia 163 88 224 4.1 2.2 5.6 Slovenia 100 54 137 6.2 3.4 8.5 Spain 2,171 1,144 3,055 6.2 3.3 8.8 Sweden 38 19 57 <1.0 <1.0 <1.0 Albania 601 348 776 29.5 17.1 38.2 Andorra <1 <1 <10 1.5 <1.0 2.3 Bosnia and Herzegovina 724 430 921 27.9 16.6 35.5 Iceland 0 0 0 0.0 0.0 0.0 Kosovo 347 198 455 26.0 14.8 34.0 Liechtenstein <10 <10 <10 6.7 3.4 9.8 Monaco <10 <1 <10 4.7 2.4 6.7 Montenegro 72 40 97 16.7 9.3 22.4 North Macedonia 318 189 404 24.2 14.4 30.7 Norway 32 16 47 <1.0 <1.0 1.2 San Marino <10 <10 <10 18.2 9.9 24.9 Serbia 1,371 798 1,766 27.4 15.9 35.3 Switzerland 161 83 233 2.4 1.3 3.5 Türkiye (TR) -- -- -- -- -- -- EU27 30,698 16,673 42,124 9.3 5.0 12.7 EEA32 (no TR) 30,893 16,773 42,407 9.1 4.9 12.4 All countries (no TR) 34,333 18,780 46,836 9.7 5.3 13.2 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 67 Table A4.13: DM disease burden (YLL) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high) (a) YLL/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 6,461 3,376 9,168 94.4 49.3 134.0 Belgium 2,526 1,310 3,610 29.9 15.5 42.8 Bulgaria 6,159 3,436 8,234 124.2 69.3 166.0 Croatia 12,264 6,782 16,536 421.5 233.1 568.3 Cyprus 2,154 1,201 2,877 226.9 126.5 303.1 Czechia 12,525 6,693 17,405 156.3 83.5 217.2 Denmark 1,305 656 1,922 30.7 15.4 45.2 Estonia 100 49 149 9.9 4.9 14.8 Finland 39 19 58 <1.0 <1.0 1.4 France 20,913 10,801 30,001 44.7 23.1 64.1 Germany 34,999 17,908 50,657 55.4 28.3 80.1 Greece 13,383 7,671 17,474 168.0 96.3 219.4 Hungary 11,022 5,972 15,114 153.0 82.9 209.9 Ireland 439 221 646 12.2 6.2 18.0 Italy 83,323 46,737 110,999 181.9 102.0 242.3 Latvia 980 507 1,404 70.0 36.2 100.3 Lithuania 1,271 653 1,832 58.9 30.2 84.8 Luxembourg 98 50 143 20.3 10.3 29.7 Malta 600 319 839 143.0 75.9 199.8 Netherlands 4,794 2,458 6,922 37.2 19.1 53.7 Poland 42,353 23,500 56,894 153.9 85.4 206.7 Portugal 4,461 2,303 6,404 58.1 30.0 83.4 Romania 14,399 7,910 19,509 103.3 56.8 140.0 Slovakia 2,231 1,208 3,063 55.5 30.0 76.1 Slovenia 1,085 590 1,485 67.9 36.9 92.9 Spain 18,858 9,942 26,540 54.1 28.5 76.2 Sweden 381 190 567 5.1 2.5 7.6 Albania 4,459 2,586 5,763 219.2 127.1 283.3 Andorra <10 <10 14 16.2 8.1 24.0 Bosnia and Herzegovina 7,077 4,199 8,999 272.7 161.8 346.7 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 3,651 2,084 4,779 272.9 155.8 357.2 Liechtenstein 0 0 0 0.0 0.0 0.0 Monaco 13 <10 19 49.2 25.4 70.6 Montenegro 763 424 1,024 176.9 98.3 237.6 North Macedonia 3,015 1,791 3,824 229.6 136.4 291.2 Norway 328 165 483 8.4 4.2 12.4 San Marino 42 23 57 159.4 86.5 218.3 Serbia 13,394 7,799 17,260 267.4 155.7 344.6 Switzerland 1,531 785 2,213 23.2 11.9 33.6 Türkiye (TR) -- -- -- -- -- -- EU27 299,124 162,460 410,453 90.5 49.1 124.2 EEA32 (no TR) 300,982 163,409 413,149 88.2 47.9 121.0 All countries (no TR) 333,405 182,327 454,889 94.1 51.5 128.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 68 Table A4.14: DM disease burden (YLD) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 1,231 633 1,797 18.0 9.3 26.3 Belgium 1,337 687 1,954 15.8 8.1 23.1 Bulgaria 2,332 1,211 3,372 47.0 24.4 68.0 Croatia 1,619 840 2,344 55.6 28.9 80.6 Cyprus 496 258 718 52.3 27.1 75.6 Czechia 3,014 1,555 4,385 37.6 19.4 54.7 Denmark 264 135 388 6.2 3.2 9.1 Estonia 18 <10 26 1.7 <1.0 2.6 Finland 23 12 33 <1.0 <1.0 <1.0 France 8,623 4,427 12,608 18.4 9.5 26.9 Germany 11,351 5,819 16,619 18.0 9.2 26.3 Greece 5,168 2,695 7,444 64.9 33.8 93.4 Hungary 3,309 1,711 4,806 45.9 23.8 66.7 Ireland 119 61 174 3.3 1.7 4.8 Italy 19,459 10,117 28,111 42.5 22.1 61.4 Latvia 164 84 240 11.7 6.0 17.2 Lithuania 253 130 370 11.7 6.0 17.1 Luxembourg 34 17 50 7.1 3.6 10.4 Malta 130 67 189 30.9 15.9 45.0 Netherlands 1,803 925 2,639 14.0 7.2 20.5 Poland 14,284 7,412 20,673 51.9 26.9 75.1 Portugal 1,572 807 2,298 20.5 10.5 29.9 Romania 4,255 2,204 6,168 30.5 15.8 44.2 Slovakia 1,589 821 2,309 39.5 20.4 57.4 Slovenia 640 331 929 40.0 20.7 58.1 Spain 8,569 4,412 12,494 24.6 12.7 35.9 Sweden 103 52 151 1.4 <1.0 2.0 Albania 1,252 654 1,800 61.6 32.2 88.5 Andorra <10 <10 <10 6.3 3.2 9.3 Bosnia and Herzegovina 1,928 1,012 2,761 74.3 39.0 106.4 Iceland <1 0 <1 <1.0 0.0 <1.0 Kosovo 861 449 1,241 64.3 33.5 92.7 Liechtenstein <10 <10 <10 12.1 6.2 17.7 Monaco <10 <10 <10 20.2 10.4 29.6 Montenegro 184 96 267 42.8 22.2 61.9 North Macedonia 937 492 1,342 71.4 37.5 102.2 Norway 99 51 145 2.5 1.3 3.7 San Marino <10 <10 13 35.1 18.1 50.9 Serbia 3,522 1,842 5,060 70.3 36.8 101.0 Switzerland 758 388 1,109 11.5 5.9 16.8 Türkiye (TR) -- -- -- -- -- -- EU27 91,755 47,432 133,287 27.8 14.3 40.3 EEA32 (no TR) 92,615 47,873 134,547 27.1 14.0 39.4 All countries (no TR) 101,319 52,427 147,044 28.6 14.8 41.5 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 69 Table A4.15: DM disease burden (DALY) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 7,692 4,009 10,965 112.4 58.6 160.3 Belgium 3,863 1,997 5,564 45.8 23.7 65.9 Bulgaria 8,491 4,647 11,606 171.2 93.7 234.0 Croatia 13,883 7,622 18,880 477.1 261.9 648.8 Cyprus 2,650 1,459 3,594 279.2 153.7 378.7 Czechia 15,538 8,248 21,790 193.9 102.9 271.9 Denmark 1,569 791 2,310 36.9 18.6 54.3 Estonia 117 58 175 11.7 5.8 17.4 Finland 61 31 91 1.5 <1.0 2.2 France 29,535 15,227 42,609 63.1 32.5 91.0 Germany 46,350 23,727 67,276 73.3 37.5 106.4 Greece 18,551 10,366 24,918 232.9 130.1 312.8 Hungary 14,331 7,683 19,920 199.0 106.7 276.6 Ireland 558 282 820 15.5 7.8 22.8 Italy 102,782 56,854 139,110 224.3 124.1 303.6 Latvia 1,144 591 1,644 81.8 42.3 117.5 Lithuania 1,523 783 2,201 70.6 36.2 102.0 Luxembourg 132 67 193 27.3 13.9 40.0 Malta 730 386 1,028 173.9 91.9 244.9 Netherlands 6,596 3,383 9,561 51.2 26.2 74.2 Poland 56,637 30,912 77,567 205.8 112.3 281.8 Portugal 6,033 3,110 8,702 78.5 40.5 113.3 Romania 18,654 10,115 25,677 133.8 72.6 184.2 Slovakia 3,820 2,029 5,372 94.9 50.4 133.5 Slovenia 1,725 921 2,414 107.9 57.6 151.0 Spain 27,428 14,354 39,034 78.7 41.2 112.0 Sweden 484 242 718 6.5 3.2 9.6 Albania 5,711 3,241 7,564 280.7 159.3 371.8 Andorra 13 <10 19 22.6 11.4 33.3 Bosnia and Herzegovina 9,006 5,211 11,760 347.0 200.8 453.1 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 4,512 2,533 6,020 337.2 189.3 449.9 Liechtenstein <10 <10 <10 12.1 6.2 17.7 Monaco 19 <10 27 69.4 35.7 100.2 Montenegro 947 519 1,291 219.7 120.5 299.4 North Macedonia 3,952 2,283 5,166 301.0 173.9 393.4 Norway 427 216 628 10.9 5.5 16.1 San Marino 51 27 71 194.4 104.6 269.2 Serbia 16,916 9,640 22,320 337.7 192.5 445.6 Switzerland 2,288 1,173 3,321 34.7 17.8 50.4 Türkiye (TR) -- -- -- -- -- -- EU27 390,879 209,892 543,741 118.3 63.5 164.5 EEA32 (no TR) 393,598 211,282 547,696 115.3 61.9 160.5 All countries (no TR) 434,724 234,754 601,933 122.7 66.3 170.0 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 70 PM2.5 (long-term effects) and ischemic heart disease (adults ≥ 25 years) Table A4.16: IHD disease burden (AD) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 1,032 547 1,495 15.1 8.0 21.9 Belgium 486 257 706 5.8 3.0 8.4 Bulgaria 2,189 1,191 3,094 44.1 24.0 62.4 Croatia 929 504 1,317 31.9 17.3 45.3 Cyprus 116 63 164 12.2 6.7 17.3 Czechia 2,107 1,127 3,026 26.3 14.1 37.8 Denmark 114 60 168 2.7 1.4 3.9 Estonia 17 <10 25 1.7 <1.0 2.5 Finland 14 <10 21 <1.0 <1.0 <1.0 France 2,019 1,066 2,938 4.3 2.3 6.3 Germany 7,157 3,765 10,450 11.3 6.0 16.5 Greece 2,833 1,558 3,961 35.6 19.6 49.7 Hungary 4,223 2,271 6,035 58.6 31.5 83.8 Ireland 121 63 178 3.4 1.8 4.9 Italy 10,174 5,550 14,340 22.2 12.1 31.3 Latvia 406 215 590 29.0 15.3 42.2 Lithuania 762 401 1,111 35.3 18.6 51.4 Luxembourg 12 <10 17 2.4 1.2 3.5 Malta 79 42 114 18.8 10.0 27.1 Netherlands 541 285 789 4.2 2.2 6.1 Poland 10,395 5,643 14,717 37.8 20.5 53.5 Portugal 371 196 540 4.8 2.6 7.0 Romania 8,025 4,339 11,406 57.6 31.1 81.8 Slovakia 1,912 1,027 2,733 47.5 25.5 67.9 Slovenia 271 146 387 16.9 9.1 24.2 Spain 2,356 1,254 3,402 6.8 3.6 9.8 Sweden 60 31 88 <1.0 <1.0 1.2 Albania 1,006 556 1,400 49.4 27.3 68.8 Andorra <1 <1 <10 1.5 <1.0 2.2 Bosnia and Herzegovina 1,091 610 1,503 42.0 23.5 57.9 Iceland <1.0 0 <1.0 <1.0 0.0 <1.0 Kosovo 499 274 698 37.3 20.5 52.2 Liechtenstein <10 <1 <10 5.8 3.0 8.4 Monaco <10 <1 <10 4.7 2.5 6.9 Montenegro 104 56 147 24.0 13.1 34.0 North Macedonia 484 270 667 36.9 20.6 50.8 Norway 52 27 76 1.3 <1.0 2.0 San Marino <10 <10 <10 18.7 10.0 26.7 Serbia 2,016 1,117 2,801 40.3 22.3 55.9 Switzerland 351 185 512 5.3 2.8 7.8 Türkiye (TR) -- -- -- -- -- -- EU27 58,721 31,623 83,808 17.8 9.6 25.4 EEA32 (no TR) 59,126 31,835 84,399 17.3 9.3 24.7 All countries (no TR) 64,332 34,722 91,626 18.2 9.8 25.9 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 71 Table A4.17: IHD disease burden (YLL) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high) (a) YLL/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 9,364 4,965 13,565 136.9 72.6 198.3 Belgium 5,464 2,889 7,938 64.7 34.2 94.1 Bulgaria 23,051 12,541 32,569 464.7 252.8 656.6 Croatia 8,764 4,753 12,422 301.2 163.3 426.9 Cyprus 1,507 820 2,130 158.8 86.3 224.4 Czechia 19,083 10,207 27,408 238.1 127.4 342.0 Denmark 1,178 615 1,731 27.7 14.5 40.7 Estonia 153 80 226 15.2 7.9 22.5 Finland 125 65 185 3.0 1.6 4.5 France 22,884 12,080 33,294 48.9 25.8 71.1 Germany 63,786 33,552 93,127 100.9 53.1 147.3 Greece 31,019 17,062 43,367 389.4 214.2 544.4 Hungary 37,950 20,403 54,230 527.0 283.3 753.0 Ireland 1,371 717 2,013 38.1 19.9 56.0 Italy 88,185 48,108 124,295 192.5 105.0 271.3 Latvia 3,885 2,052 5,649 277.6 146.7 403.7 Lithuania 6,664 3,511 9,713 308.6 162.6 449.9 Luxembourg 152 79 222 31.4 16.4 46.0 Malta 933 497 1,343 222.1 118.5 319.9 Netherlands 5,740 3,022 8,373 44.5 23.4 64.9 Poland 97,007 52,663 137,343 352.5 191.3 499.0 Portugal 4,513 2,382 6,566 58.8 31.0 85.5 Romania 79,603 43,039 113,141 571.1 308.8 811.7 Slovakia 18,540 9,964 26,503 460.8 247.6 658.7 Slovenia 3,151 1,697 4,496 197.1 106.2 281.3 Spain 28,667 15,252 41,388 82.3 43.8 118.8 Sweden 578 301 852 7.7 4.0 11.4 Albania 7,103 3,927 9,883 349.1 193.0 485.8 Andorra <10 <10 15 17.1 8.9 25.1 Bosnia and Herzegovina 11,066 6,184 15,250 426.4 238.2 587.6 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 5,490 3,014 7,689 410.3 225.2 574.7 Liechtenstein <10 <10 12 27.2 14.3 39.8 Monaco 15 <10 21 53.7 28.3 78.2 Montenegro 1,134 616 1,605 263.2 143.0 372.3 North Macedonia 4,860 2,716 6,696 370.1 206.8 509.9 Norway 549 287 807 14.0 7.3 20.6 San Marino 43 23 61 161.9 87.1 231.2 Serbia 20,454 11,327 28,418 408.4 226.1 567.3 Switzerland 3,141 1,653 4,582 47.6 25.1 69.5 Türkiye (TR) -- -- -- -- -- -- EU27 563,314 303,316 804,090 170.4 91.8 243.3 EEA32 (no TR) 567,012 305,260 809,491 166.1 89.4 237.1 All countries (no TR) 617,186 333,078 879,128 174.3 94.0 248.2 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 72 Table A4.18: IHD disease burden (YLD) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 247 101 395 3.6 1.5 5.8 Belgium 118 48 189 1.4 <1.0 2.2 Bulgaria 891 369 1,397 18.0 7.4 28.2 Croatia 426 176 669 14.6 6.0 23.0 Cyprus 53 22 83 5.6 2.3 8.8 Czechia 374 153 594 4.7 1.9 7.4 Denmark 26 11 43 <1.0 <1.0 1.0 Estonia <10 <10 <10 <1.0 <1.0 <1.0 Finland <10 <10 <10 <1.0 <1.0 <1.0 France 954 386 1,530 2.0 <1.0 3.3 Germany 2,214 894 3,559 3.5 1.4 5.6 Greece 708 296 1,100 8.9 3.7 13.8 Hungary 524 215 829 7.3 3.0 11.5 Ireland 26 11 43 <1.0 <1.0 1.2 Italy 2,418 1,003 3,782 5.3 2.2 8.3 Latvia 62 25 99 4.4 1.8 7.1 Lithuania 106 43 170 4.9 2.0 7.9 Luxembourg <10 <10 <10 <1.0 <1.0 1.5 Malta 16 <10 25 3.7 1.5 6.0 Netherlands 313 126 502 2.4 <1.0 3.9 Poland 5,023 2,077 7,884 18.3 7.5 28.6 Portugal 246 99 394 3.2 1.3 5.1 Romania 450 185 708 3.2 1.3 5.1 Slovakia 471 193 745 11.7 4.8 18.5 Slovenia 99 41 156 6.2 2.5 9.8 Spain 305 124 486 <1.0 <1.0 1.4 Sweden <10 <10 14 <1.0 <1.0 <1.0 Albania 535 224 829 26.3 11.0 40.7 Andorra <1 <1 <1 <1.0 <1.0 1.1 Bosnia and Herzegovina 802 339 1,232 30.9 13.1 47.5 Iceland 0 0 0 0.0 0.0 0.0 Kosovo 361 151 562 27.0 11.3 42.0 Liechtenstein <1 <1 <10 2.4 <1.0 3.8 Monaco <1 <1 <1 2.2 <1.0 3.6 Montenegro 75 31 117 17.4 7.2 27.2 North Macedonia 378 160 580 28.8 12.2 44.2 Norway 11 <10 19 <1.0 <1.0 <1.0 San Marino <10 <1 <10 4.4 1.8 6.9 Serbia 1,472 618 2,276 29.4 12.3 45.4 Switzerland 155 63 249 2.4 <1.0 3.8 Türkiye (TR) -- -- -- -- -- -- EU27 16,095 6,614 25,421 4.9 2.0 7.7 EEA32 (no TR) 16,262 6,682 25,690 4.8 2.0 7.5 All countries (no TR) 19,888 8,205 31,290 5.6 2.3 8.8 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 73 Table A4.19: IHD disease burden (DALY) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 9,612 5,066 13,961 140.5 74.1 204.1 Belgium 5,583 2,937 8,128 66.1 34.8 96.3 Bulgaria 23,943 12,910 33,966 482.7 260.3 684.8 Croatia 9,190 4,929 13,091 315.8 169.4 449.9 Cyprus 1,560 842 2,213 164.4 88.7 233.2 Czechia 19,457 10,360 28,002 242.8 129.3 349.4 Denmark 1,204 626 1,774 28.3 14.7 41.7 Estonia 158 82 235 15.8 8.1 23.4 Finland 130 67 193 3.2 1.6 4.7 France 23,838 12,466 34,824 50.9 26.6 74.4 Germany 66,000 34,446 96,687 104.4 54.5 152.9 Greece 31,727 17,358 44,467 398.3 217.9 558.2 Hungary 38,474 20,619 55,059 534.2 286.3 764.5 Ireland 1,397 727 2,055 38.9 20.2 57.2 Italy 90,603 49,112 128,076 197.7 107.2 279.5 Latvia 3,947 2,077 5,748 282.0 148.4 410.7 Lithuania 6,770 3,554 9,883 313.5 164.6 457.8 Luxembourg 156 81 230 32.4 16.8 47.6 Malta 948 504 1,368 225.9 120.0 325.9 Netherlands 6,052 3,148 8,875 46.9 24.4 68.8 Poland 102,030 54,740 145,227 370.7 198.9 527.7 Portugal 4,758 2,481 6,960 61.9 32.3 90.6 Romania 80,053 43,225 113,849 574.3 310.1 816.8 Slovakia 19,011 10,158 27,249 472.5 252.4 677.2 Slovenia 3,250 1,737 4,653 203.3 108.7 291.1 Spain 28,972 15,377 41,874 83.2 44.1 120.2 Sweden 586 304 866 7.8 4.1 11.5 Albania 7,638 4,151 10,711 375.4 204.0 526.5 Andorra 10 <10 15 17.8 9.2 26.3 Bosnia and Herzegovina 11,869 6,523 16,483 457.3 251.3 635.1 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 5,851 3,164 8,251 437.3 236.5 616.7 Liechtenstein <10 <10 13 29.6 15.3 43.6 Monaco 15 <10 22 55.9 29.2 81.8 Montenegro 1,209 647 1,722 280.5 150.2 399.6 North Macedonia 5,237 2,875 7,276 398.8 219.0 554.1 Norway 561 292 825 14.3 7.5 21.1 San Marino 44 23 63 166.3 88.9 238.2 Serbia 21,926 11,944 30,694 437.7 238.5 612.8 Switzerland 3,296 1,716 4,831 50.0 26.0 73.3 Türkiye (TR) -- -- -- -- -- -- EU27 579,409 309,930 829,512 175.3 93.8 251.0 EEA32 (no TR) 583,275 311,942 835,181 170.9 91.4 244.7 All countries (no TR) 637,074 341,283 910,418 179.9 96.4 257.1 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 80 Table A4.26: Stroke disease burden (YLD) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 1,529 166 2,925 22.3 2.4 42.8 Belgium 754 82 1,450 8.9 <1.0 17.2 Bulgaria 3,929 446 7,176 79.2 9.0 144.7 Croatia 1,961 222 3,603 67.4 7.6 123.8 Cyprus 432 49 789 45.5 5.2 83.1 Czechia 2,081 230 3,918 26.0 2.9 48.9 Denmark 372 39 730 8.7 <1.0 17.2 Estonia 14 <10 29 1.4 <1.0 2.9 Finland 21 <10 43 <1.0 <1.0 1.0 France 6,912 746 13,331 14.8 1.6 28.5 Germany 13,788 1,479 26,766 21.8 2.3 42.3 Greece 4,923 570 8,817 61.8 7.2 110.7 Hungary 3,588 399 6,693 49.8 5.5 92.9 Ireland 126 13 247 3.5 <1.0 6.9 Italy 18,370 2,097 33,404 40.1 4.6 72.9 Latvia 130 14 251 9.3 1.0 17.9 Lithuania 520 56 1,007 24.1 2.6 46.6 Luxembourg 30 <10 60 6.3 <1.0 12.3 Malta 22 <10 41 5.2 <1.0 9.9 Netherlands 2,275 244 4,410 17.6 1.9 34.2 Poland 14,142 1,601 25,928 51.4 5.8 94.2 Portugal 1,443 156 2,783 18.8 2.0 36.2 Romania 4,345 488 8,023 31.2 3.5 57.6 Slovakia 2,076 231 3,875 51.6 5.7 96.3 Slovenia 615 69 1,144 38.5 4.3 71.6 Spain 5,476 599 10,411 15.7 1.7 29.9 Sweden 83 <10 164 1.1 <1.0 2.2 Albania 922 108 1,637 45.3 5.3 80.5 Andorra <10 <1 <10 5.1 <1.0 10.1 Bosnia and Herzegovina 1,367 163 2,385 52.7 6.3 91.9 Iceland <1 0 <1 <1.0 0.0 <1.0 Kosovo 623 72 1,119 46.6 5.4 83.7 Liechtenstein <10 <1 <10 14.4 1.5 28.0 Monaco <10 <1 <10 16.2 1.7 31.3 Montenegro 130 15 239 30.2 3.4 55.4 North Macedonia 651 77 1,134 49.5 5.9 86.4 Norway 112 12 220 2.9 <1.0 5.6 San Marino <10 <1 16 33.6 3.7 62.7 Serbia 2,523 296 4,467 50.4 5.9 89.2 Switzerland 959 103 1,859 14.5 1.6 28.2 Türkiye (TR) -- -- -- -- -- -- EU27 89,956 10,015 168,018 27.2 3.0 50.8 EEA32 (no TR) 91,032 10,130 170,106 26.7 3.0 49.8 All countries (no TR) 97,264 10,862 181,118 27.5 3.1 51.1 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 81 Table A4.27: Stroke disease burden (DALY) attributable to PM2.5 for adults ≥ 25 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 5,170 1,634 8,591 75.6 23.9 125.6 Belgium 5,701 2,067 9,179 67.5 24.5 108.7 Bulgaria 35,165 13,511 54,088 708.9 272.4 1,090.4 Croatia 7,128 2,373 11,400 245.0 81.5 391.8 Cyprus 1,416 460 2,268 149.2 48.5 238.9 Czechia 10,201 3,544 16,400 127.3 44.2 204.6 Denmark 1,525 495 2,564 35.8 11.6 60.2 Estonia 108 38 178 10.7 3.8 17.7 Finland 88 28 149 2.1 <1.0 3.6 France 29,485 9,785 48,674 63.0 20.9 104.0 Germany 46,054 14,333 77,538 72.8 22.7 122.6 Greece 26,775 9,857 41,152 336.1 123.7 516.6 Hungary 18,752 6,635 29,833 260.4 92.1 414.2 Ireland 637 215 1,059 17.7 6.0 29.5 Italy 100,168 36,447 155,853 218.6 79.5 340.2 Latvia 2,798 1,083 4,424 199.9 77.4 316.1 Lithuania 3,411 1,211 5,546 158.0 56.1 256.9 Luxembourg 122 40 205 25.3 8.2 42.4 Malta 337 130 527 80.2 31.0 125.5 Netherlands 8,488 2,722 14,175 65.8 21.1 109.9 Poland 76,778 27,720 120,274 279.0 100.7 437.0 Portugal 6,589 2,216 10,842 85.8 28.9 141.2 Romania 65,280 25,749 100,309 468.3 184.7 719.6 Slovakia 8,196 2,746 13,220 203.7 68.2 328.5 Slovenia 3,218 1,141 5,109 201.3 71.4 319.7 Spain 27,483 9,512 44,491 78.9 27.3 127.7 Sweden 391 130 655 5.2 1.7 8.7 Albania 7,544 2,942 11,370 370.8 144.6 558.9 Andorra 13 <10 21 22.1 7.2 37.1 Bosnia and Herzegovina 12,137 4,844 18,009 467.6 186.6 693.8 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 6,001 2,351 9,097 448.5 175.7 679.9 Liechtenstein <10 <1 <10 14.4 1.5 28.0 Monaco 19 <10 31 69.2 22.9 114.3 Montenegro 1,208 465 1,860 280.2 107.8 431.6 North Macedonia 5,218 2,063 7,757 397.4 157.1 590.7 Norway 455 147 765 11.6 3.8 19.6 San Marino 48 17 77 184.4 65.8 292.6 Serbia 22,479 8,858 33,738 448.8 176.9 673.6 Switzerland 2,780 829 4,722 42.2 12.6 71.6 Türkiye (TR) -- -- -- -- -- -- EU27 491,464 175,821 778,700 148.7 53.2 235.6 EEA32 (no TR) 494,704 176,798 784,196 144.9 51.8 229.7 All countries (no TR) 549,370 198,349 866,156 155.1 56.0 244.6 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 82 PM2.5 (long-term effects) and dementia morbidity (adults ≥ 60 years) Table A4.28: Dementia disease burden (YLD) attributable to PM2.5 for adults ≥ 60 years for 40 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 60 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 4,570 2,305 6,656 189.5 95.6 276.0 Belgium 5,628 2,823 8,239 183.6 92.1 268.8 Bulgaria 6,636 3,510 9,237 336.1 177.8 467.8 Croatia 3,471 1,825 4,862 299.7 157.5 419.7 Cyprus 1,044 552 1,453 348.8 184.4 485.4 Czechia 6,557 3,361 9,400 233.9 119.9 335.3 Denmark 1,216 596 1,820 77.5 38.0 115.9 Estonia 77 37 116 21.1 10.2 31.9 Finland 66 32 100 4.0 1.9 6.0 France 32,310 16,159 47,437 179.2 89.6 263.1 Germany 35,962 17,865 53,144 145.9 72.5 215.6 Greece 16,097 8,688 21,993 519.7 280.5 710.1 Hungary 7,186 3,720 10,204 284.2 147.1 403.5 Ireland 578 284 864 53.4 26.2 79.7 Italy 78,792 41,872 109,286 429.5 228.3 595.8 Latvia 722 361 1,059 136.1 68.2 199.6 Lithuania 1,133 564 1,669 142.7 71.1 210.2 Luxembourg 132 65 196 96.6 47.6 143.8 Malta 315 161 453 238.6 121.7 343.6 Netherlands 6,728 3,348 9,927 140.7 70.0 207.6 Poland 31,717 16,712 44,311 326.5 172.0 456.1 Portugal 4,289 2,145 6,299 139.1 69.5 204.2 Romania 14,665 7,670 20,628 299.3 156.6 421.0 Slovakia 3,195 1,653 4,540 243.8 126.1 346.5 Slovenia 1,781 924 2,524 298.0 154.7 422.4 Spain 27,904 14,163 40,387 227.4 115.4 329.2 Sweden 425 207 641 15.6 7.6 23.6 Albania 3,474 1,892 4,708 488.7 266.2 662.3 Andorra 14 <10 21 63.8 31.2 95.8 Bosnia and Herzegovina 3,949 2,190 5,273 392.9 217.9 524.6 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 1,853 997 2,538 357.5 192.3 489.7 Liechtenstein 12 <10 17 109.5 54.3 162.1 Monaco 21 10 30 197.0 98.4 289.5 Montenegro 369 195 515 261.8 138.1 365.5 North Macedonia 1,632 906 2,177 365.9 203.1 488.0 Norway 471 231 704 35.5 17.4 53.1 San Marino 39 20 55 369.1 191.3 523.7 Serbia 7,394 4,039 9,995 381.2 208.2 515.3 Switzerland 2,969 1,477 4,382 131.7 65.5 194.5 Türkiye (TR) -- -- -- -- -- -- EU27 293,195 151,603 417,445 236.5 122.3 336.7 EEA32 (no TR) 296,647 153,317 422,550 232.4 120.1 331.0 All countries (no TR) 315,391 163,573 447,863 238.1 123.5 338.1 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 83 NO2 (long-term effects) and all-cause mortality Table A4.29: All-cause mortality disease burden (AD) attributable to NO2 for adults ≥ 30 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 30 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 589 297 1,157 9.4 4.8 18.5 Belgium 615 310 1,210 8.0 4.0 15.7 Bulgaria 838 423 1,646 17.9 9.0 35.2 Croatia 320 162 629 11.9 6.0 23.4 Cyprus 244 124 475 28.5 14.4 55.4 Czechia 441 222 869 5.9 3.0 11.7 Denmark 33 17 65 <1.0 <1.0 1.7 Estonia <10 <10 12 <1.0 <1.0 1.3 Finland 23 12 45 <1.0 <1.0 1.2 France 3,160 1,596 6,195 7.3 3.7 14.4 Germany 5,553 2,799 10,928 9.5 4.8 18.7 Greece 2,010 1,019 3,910 27.0 13.7 52.5 Hungary 772 390 1,516 11.6 5.9 22.9 Ireland 75 38 148 2.3 1.2 4.5 Italy 9,064 4,583 17,738 21.2 10.7 41.4 Latvia 78 39 153 5.9 3.0 11.7 Lithuania 83 42 164 4.2 2.1 8.2 Luxembourg 14 <10 27 3.2 1.6 6.2 Malta 12 <10 25 3.3 1.7 6.6 Netherlands 1,075 542 2,116 9.2 4.6 18.0 Poland 1,851 933 3,640 7.3 3.7 14.3 Portugal 692 349 1,360 9.7 4.9 19.0 Romania 2,218 1,121 4,341 17.1 8.6 33.4 Slovakia 155 78 306 4.2 2.1 8.3 Slovenia 94 47 184 6.3 3.2 12.4 Spain 4,135 2,091 8,087 12.8 6.5 25.0 Sweden 30 15 59 <1.0 <1.0 <1.0 Albania 271 137 533 15.0 7.6 29.4 Andorra <10 <10 12 11.2 5.6 21.9 Bosnia and Herzegovina 401 202 787 16.7 8.4 32.8 Iceland <10 <1 <10 <1.0 <1.0 <1.0 Kosovo 123 62 242 9.9 5.0 19.5 Liechtenstein <10 <10 <10 4.6 2.3 9.0 Monaco <10 <10 <10 16.8 8.5 33.1 Montenegro 67 34 132 17.0 8.6 33.6 North Macedonia 92 47 182 7.7 3.9 15.2 Norway 64 32 126 1.8 <1.0 3.6 San Marino <10 <10 <10 4.7 2.4 9.3 Serbia 1,041 525 2,042 22.4 11.3 44.0 Switzerland 409 206 806 6.8 3.4 13.4 Türkiye 19,400 9,887 37,376 41.2 21.0 79.5 EU27 34,180 17,264 67,004 11.2 5.6 21.9 EEA32 54,055 27,390 105,316 14.9 7.6 29.0 All countries 56,061 28,402 109,256 15.0 7.6 29.2 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 84 Table A4.30: All-cause mortality disease burden (YLL) attributable to NO2 for adults ≥ 30 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high) (a) YLL/105 inhabitants ≥ 30 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 5,850 2,952 11,494 93.6 47.2 184.0 Belgium 6,356 3,204 12,505 82.5 41.6 162.3 Bulgaria 9,069 4,577 17,802 193.8 97.8 380.4 Croatia 3,203 1,616 6,293 119.1 60.1 234.0 Cyprus 2,622 1,329 5,104 306.2 155.2 596.1 Czechia 4,806 2,422 9,464 64.6 32.5 127.1 Denmark 344 173 678 8.9 4.5 17.6 Estonia 65 33 128 7.0 3.5 13.8 Finland 224 113 442 5.9 3.0 11.7 France 34,483 17,415 67,611 80.0 40.4 156.8 Germany 55,562 28,008 109,348 95.1 48.0 187.2 Greece 19,188 9,730 37,327 257.8 130.7 501.5 Hungary 8,296 4,188 16,279 125.1 63.1 245.4 Ireland 855 431 1,684 26.0 13.1 51.3 Italy 85,829 43,391 167,952 200.4 101.3 392.2 Latvia 851 429 1,676 65.0 32.7 128.0 Lithuania 929 468 1,832 46.5 23.4 91.6 Luxembourg 152 77 301 35.2 17.7 69.5 Malta 139 70 274 37.2 18.7 73.4 Netherlands 11,103 5,595 21,864 94.6 47.7 186.3 Poland 22,155 11,170 43,582 87.2 44.0 171.6 Portugal 7,134 3,599 14,014 99.7 50.3 195.9 Romania 25,235 12,757 49,386 194.4 98.3 380.5 Slovakia 1,888 951 3,725 50.9 25.6 100.4 Slovenia 1,011 509 1,991 68.0 34.3 133.9 Spain 43,553 22,025 85,175 134.5 68.0 263.0 Sweden 290 146 573 4.2 2.1 8.4 Albania 2,737 1,381 5,378 151.2 76.3 297.0 Andorra 65 33 128 121.7 61.4 239.5 Bosnia and Herzegovina 4,140 2,089 8,130 172.3 86.9 338.3 Iceland <10 <10 18 3.8 1.9 7.5 Kosovo 1,371 690 2,704 110.6 55.7 218.2 Liechtenstein 15 <10 30 55.4 27.9 109.4 Monaco 46 23 90 183.7 92.6 361.4 Montenegro 725 365 1,428 185.1 93.3 364.5 North Macedonia 867 437 1,707 72.2 36.4 142.2 Norway 643 324 1,268 18.1 9.1 35.8 San Marino 11 <10 22 44.8 22.5 88.5 Serbia 10,748 5,426 21,090 231.7 117.0 454.7 Switzerland 4,109 2,070 8,091 68.1 34.3 134.0 Türkiye 264,391 134,740 509,384 562.1 286.5 1083.0 EU27 351,191 177,376 688,504 114.9 58.0 225.2 EEA32 620,358 314,522 1,207,295 171.1 86.8 333.0 All countries 641,068 324,973 1,247,971 171.3 86.8 333.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 85 NO2 (long-term effects) and total cause-specific disease burden (five causes) Table A4.31: Total cause-specific disease burden (DALY) attributable to NO2 (asthma in children/adolescents, asthma in adults, COPD, diabetes mellitus and stroke) for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) Country mean low high Austria 7,279 3,223 11,211 Belgium 6,465 2,582 10,299 Bulgaria 8,790 2,967 14,437 Croatia 5,039 2,298 7,685 Cyprus 3,630 1,697 5,400 Czechia 5,701 2,468 8,923 Denmark 446 181 710 Estonia 57 23 92 Finland 252 99 411 France 34,115 14,336 53,353 Germany 66,170 27,944 104,113 Greece 18,287 7,690 28,090 Hungary 9,489 3,940 14,861 Ireland 944 365 1,512 Italy 98,199 42,063 151,520 Latvia 840 284 1,387 Lithuania 884 333 1,428 Luxembourg 170 70 270 Malta 186 79 295 Netherlands 12,812 5,271 20,272 Poland 21,085 8,581 33,316 Portugal 8,618 3,655 13,508 Romania 22,353 7,588 36,337 Slovakia 1,474 586 2,377 Slovenia 986 390 1,582 Spain 41,855 18,007 64,827 Sweden 339 137 544 Albania 2,270 915 3,594 Andorra 65 27 103 Bosnia and Herzegovina 3,969 1,596 6,275 Iceland 12 <10 20 Kosovo 1,309 516 2,102 Liechtenstein 10 <10 15 Monaco 46 19 73 Montenegro 561 223 895 North Macedonia 751 302 1,197 Norway 818 323 1,311 San Marino 13 <10 21 Serbia 10,263 4,137 16,191 Switzerland 4,495 1,929 7,046 Türkiye 356,386 158,853 529,005 EU27 376,464 156,857 588,758 EEA32 738,184 317,971 1,126,156 All countries 757,432 325,711 1,156,606 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 86 NO2 (long-term effects) and asthma (adults ≥ 19 years) Table A4.32: Asthma disease burden (AD) attributable to NO2 for adults ≥ 19 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 19 years (95 % CI: low, high) (b) Country mean Low high mean low high Austria <10 <1 <10 <1.0 <1.0 <1.0 Belgium <10 <1 <10 <1.0 <1.0 <1.0 Bulgaria <10 <1 <10 <1.0 <1.0 <1.0 Croatia <10 <1 <10 <1.0 <1.0 <1.0 Cyprus <10 <1 <10 <1.0 <1.0 <1.0 Czechia <10 <1 <10 <1.0 <1.0 <1.0 Denmark <1 <1 <1 <1.0 <1.0 <1.0 Estonia <1 <1 <1 <1.0 <1.0 <1.0 Finland <1 <1 <1 <1.0 <1.0 <1.0 France 19 <10 36 <1.0 <1.0 <1.0 Germany 35 <10 68 <1.0 <1.0 <1.0 Greece <10 <1.0 <10 <1.0 <1.0 <1.0 Hungary <10 <1.0 <10 <1.0 <1.0 <1.0 Ireland <1 <1 <10 <1.0 <1.0 <1.0 Italy 31 <10 58 <1.0 <1.0 <1.0 Latvia <1 <1 <1 <1.0 <1.0 <1.0 Lithuania <1 <1 <1 <1.0 <1.0 <1.0 Luxembourg <1 <1 <1 <1.0 <1.0 <1.0 Malta <1 <1 <1 <1.0 <1.0 <1.0 Netherlands <10 <1 13 <1.0 <1.0 <1.0 Poland 13 <10 24 <1.0 <1.0 <1.0 Portugal <10 <1 <10 <1.0 <1.0 <1.0 Romania 12 <10 22 <1.0 <1.0 <1.0 Slovakia <1 <1 <10 <1.0 <1.0 <1.0 Slovenia <1 <1 <10 <1.0 <1.0 <1.0 Spain 40 <10 76 <1.0 <1.0 <1.0 Sweden <1 <1 <1 <1.0 <1.0 <1.0 Albania <10 <1 <10 <1.0 <1.0 <1.0 Andorra <1 <1 <1 <1.0 <1.0 <1.0 Bosnia and Herzegovina <10 <1 <10 <1.0 <1.0 <1.0 Iceland <1 0 <1 <1.0 <1.0 <1.0 Kosovo <10 <1 <10 <1.0 <1.0 <1.0 Liechtenstein <1 0 <1 <1.0 0 <1.0 Monaco <1 <1 <1 <1.0 <1.0 <1.0 Montenegro <1 <1 <10 <1.0 <1.0 <1.0 North Macedonia <1 <1 <10 <1.0 <1.0 <1.0 Norway <1 <1 <10 <1.0 <1.0 <1.0 San Marino <1 0 <1 <1.0 0 <1.0 Serbia 12 <10 23 <1.0 <1.0 <1.0 Switzerland <10 <1 <10 <1.0 <1.0 <1.0 Türkiye 270 32 478 <1.0 <1.0 <1.0 EU27 187 20 358 <1.0 <1.0 <1.0 EEA32 461 52 842 <1.0 <1.0 <1.0 All countries 484 55 886 <1.0 <1.0 <1.0 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 87 Table A4.33: Asthma disease burden (YLL) attributable to NO2 for adults ≥ 19 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high) (a) YLL/105 inhabitants ≥ 19 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 31 <10 60 <1.0 <1.0 <1.0 Belgium 45 <10 87 <1.0 <1.0 <1.0 Bulgaria 11 <10 22 <1.0 <1.0 <1.0 Croatia 26 <10 49 <1.0 <1.0 1.6 Cyprus 33 <10 60 3.2 <1.0 5.8 Czechia 48 <10 93 <1.0 <1.0 1.1 Denmark <10 <1 <10 <1.0 <1.0 <1.0 Estonia <1 <1 <10 <1.0 <1.0 <1.0 Finland <10 <1 <10 <1.0 <1.0 <1.0 France 248 27 474 <1.0 <1.0 <1.0 Germany 426 46 826 <1.0 <1.0 1.2 Greece 40 <10 73 <1.0 <1.0 <1.0 Hungary 37 <10 71 <1.0 <1.0 <1.0 Ireland 11 <10 22 <1.0 <1.0 <1.0 Italy 337 37 637 <1.0 <1.0 1.3 Latvia <10 <1 <10 <1.0 <1.0 <1.0 Lithuania <10 <1 <10 <1.0 <1.0 <1.0 Luxembourg <1 <1 <1 <1.0 <1.0 <1.0 Malta <1 <1 <10 <1.0 <1.0 <1.0 Netherlands 71 <10 138 <1.0 <1.0 1.0 Poland 147 16 284 <1.0 <1.0 1.0 Portugal 41 <10 80 <1.0 <1.0 1.0 Romania 119 13 225 <1.0 <1.0 1.5 Slovakia <10 <10 19 <1.0 <1.0 <1.0 Slovenia <10 <1 <10 <1.0 <1.0 <1.0 Spain 357 39 674 <1.0 <1.0 1.8 Sweden <10 <1 <10 <1.0 <1.0 <1.0 Albania 27 <10 51 1.2 <1.0 2.3 Andorra <1 <1 <1 <1.0 <1.0 1.4 Bosnia and Herzegovina 47 <10 90 1.7 <1.0 3.2 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 16 <10 31 1.1 <1.0 2.2 Liechtenstein <1 <1 <1 1.2 <1.0 2.3 Monaco <1 <1 <1 1.1 <1.0 2.2 Montenegro <10 <1 13 1.4 <1.0 2.8 North Macedonia <10 <1 17 <1.0 <1.0 1.2 Norway <10 <1 12 <1.0 <1.0 <1.0 San Marino <1 <1 <1 <1.0 <1.0 <1.0 Serbia 121 13 232 2.2 <1.0 4.3 Switzerland 25 <10 49 <1.0 <1.0 <1.0 Türkiye 2,870 337 5,071 4.7 <1.0 8.3 EU27 2,056 224 3,929 <1.0 <1.0 1.1 EEA32 4,957 565 9,063 1.1 <1.0 2.1 All countries 5,184 589 9,499 1.2 <1.0 2.1 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 88 Table A4.34: Asthma disease burden (YLD) attributable to NO2 for adults ≥ 19 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 19 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 401 43 772 5.4 <1.0 10.4 Belgium 567 61 1,098 6.1 <1.0 11.9 Bulgaria 188 20 361 3.6 <1.0 6.8 Croatia 169 18 325 5.4 <1.0 10.3 Cyprus 213 24 392 20.6 2.3 37.9 Czechia 300 32 585 3.5 <1.0 6.8 Denmark 36 <10 72 <1.0 <1.0 1.5 Estonia <10 <1 <10 <1.0 <1.0 <1.0 Finland 31 <10 62 <1.0 <1.0 1.4 France 3,928 428 7,493 7.6 <1.0 14.6 Germany 5,609 602 10,882 8.2 <1.0 15.9 Greece 811 91 1,492 9.4 1.1 17.4 Hungary 434 47 832 5.6 <1.0 10.6 Ireland 116 12 227 2.9 <1.0 5.7 Italy 5,638 620 10,657 11.4 1.3 21.6 Latvia 30 <10 59 2.0 <1.0 3.9 Lithuania 28 <10 54 1.2 <1.0 2.3 Luxembourg 19 <10 38 3.6 <1.0 7.1 Malta 16 <10 31 3.5 <1.0 6.8 Netherlands 1,130 121 2,198 7.9 <1.0 15.4 Poland 1,054 113 2,040 3.6 <1.0 6.9 Portugal 572 62 1,101 6.9 <1.0 13.2 Romania 388 43 734 2.6 <1.0 4.9 Slovakia 100 11 196 2.3 <1.0 4.5 Slovenia 72 <10 140 4.2 <1.0 8.1 Spain 2,830 312 5,335 7.5 <1.0 14.1 Sweden 38 <10 74 <1.0 <1.0 <1.0 Albania 98 11 188 4.3 <1.0 8.3 Andorra 7 <1 15 11.8 1.3 22.9 Bosnia and Herzegovina 151 16 289 5.4 <1.0 10.3 Iceland <10 <1 <10 <1.0 <1.0 1.3 Kosovo 47 <10 92 3.2 <1.0 6.4 Liechtenstein <10 <1 <10 3.4 <1.0 6.7 Monaco <10 <1 10 17.8 1.9 34.4 Montenegro 23 <10 44 4.7 <1.0 9.2 North Macedonia 32 <10 63 2.3 <1.0 4.4 Norway 97 10 191 2.3 <1.0 4.4 San Marino <1 <1 <10 2.6 <1.0 5.2 Serbia 390 42 747 7.2 <1.0 13.8 Switzerland 336 36 654 4.7 <1.0 9.2 Türkiye 39,779 4,678 70,298 64.7 7.6 114.4 EU27 24,722 2,692 47,255 6.9 <1.0 13.2 EEA32 64,937 7,417 118,404 15.0 1.7 27.4 All countries 65,691 7,498 119,853 14.7 1.7 26.9 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 89 Table A4.35: Asthma disease burden (DALY) attributable to NO2 for adults ≥ 19 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 19 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 432 47 831 5.8 <1.0 11.2 Belgium 612 66 1,186 6.6 <1.0 12.8 Bulgaria 200 22 383 3.8 <1.0 7.2 Croatia 194 21 374 6.2 <1.0 11.9 Cyprus 246 28 453 23.7 2.7 43.8 Czechia 348 37 678 4.0 <1.0 7.9 Denmark 39 <10 77 <1.0 <1.0 1.6 Estonia <10 <1 <10 <1.0 <1.0 <1.0 Finland 32 <10 64 <1.0 <1.0 1.4 France 4,176 456 7,966 8.1 <1.0 15.5 Germany 6,034 648 11,707 8.8 <1.0 17.1 Greece 850 96 1,565 9.9 1.1 18.2 Hungary 471 51 903 6.0 <1.0 11.5 Ireland 128 14 249 3.2 <1.0 6.3 Italy 5,976 657 11,295 12.1 1.3 22.9 Latvia 34 <10 67 2.3 <1.0 4.4 Lithuania 32 <10 62 1.4 <1.0 2.7 Luxembourg 19 <10 38 3.7 <1.0 7.2 Malta 17 <10 33 3.6 <1.0 7.2 Netherlands 1,201 129 2,336 8.4 <1.0 16.4 Poland 1,201 129 2,324 4.0 <1.0 7.8 Portugal 614 66 1,181 7.4 <1.0 14.2 Romania 507 56 959 3.4 <1.0 6.3 Slovakia 110 12 215 2.5 <1.0 4.9 Slovenia 75 <10 146 4.4 <1.0 8.5 Spain 3,187 352 6,008 8.5 <1.0 15.9 Sweden 39 <10 77 <1.0 <1.0 <1.0 Albania 124 13 239 5.5 <1.0 10.5 Andorra <10 <1 15 12.5 1.3 24.3 Bosnia and Herzegovina 198 21 379 7.0 <1.0 13.5 Iceland <10 <1 <10 <1.0 <1.0 1.4 Kosovo 63 <10 123 4.3 <1.0 8.5 Liechtenstein <10 <1 <10 4.6 <1.0 9.1 Monaco <10 <1 11 18.9 2.0 36.6 Montenegro 29 <10 57 6.1 <1.0 12.0 North Macedonia 41 <10 80 2.9 <1.0 5.6 Norway 104 11 203 2.4 <1.0 4.7 San Marino <1 <1 <10 2.8 <1.0 5.5 Serbia 512 56 979 9.4 1.0 18.1 Switzerland 361 39 703 5.1 <1.0 9.8 Türkiye 42,648 5,016 75,369 69.4 8.2 122.7 EU27 26,778 2,915 51,184 7.5 <1.0 14.3 EEA32 69,894 7,981 127,466 16.2 1.8 29.5 All countries 70,876 8,087 129,352 15.9 1.8 29.0 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 96 Table A4.42: DM disease burden (YLD) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 930 546 1,414 13.6 8.0 20.7 Belgium 940 550 1,432 11.1 6.5 17.0 Bulgaria 971 570 1,473 19.6 11.5 29.7 Croatia 602 353 914 20.7 12.1 31.4 Cyprus 647 385 967 68.2 40.5 101.9 Czechia 950 555 1,450 11.9 6.9 18.1 Denmark 42 24 64 <1.0 <1.0 1.5 Estonia <10 <10 12 <1.0 <1.0 1.2 Finland 51 29 78 1.2 <1.0 1.9 France 6,161 3,624 9,327 13.2 7.7 19.9 Germany 9,797 5,732 14,933 15.5 9.1 23.6 Greece 3,313 1,971 4,945 41.6 24.7 62.1 Hungary 1,261 741 1,913 17.5 10.3 26.6 Ireland 95 55 145 2.6 1.5 4.0 Italy 13,580 8,011 20,486 29.6 17.5 44.7 Latvia 75 44 114 5.3 3.1 8.1 Lithuania 87 51 133 4.0 2.4 6.2 Luxembourg 24 14 36 4.9 2.9 7.5 Malta 32 18 49 7.5 4.4 11.6 Netherlands 1,696 992 2,589 13.2 7.7 20.1 Poland 3,515 2,058 5,353 12.8 7.5 19.5 Portugal 1,640 962 2,492 21.4 12.5 32.4 Romania 2,226 1,313 3,359 16.0 9.4 24.1 Slovakia 305 178 468 7.6 4.4 11.6 Slovenia 195 114 298 12.2 7.1 18.6 Spain 8,814 5,204 13,281 25.3 14.9 38.1 Sweden 51 30 79 <1.0 <1.0 1.0 Albania 321 188 487 15.8 9.2 23.9 Andorra 12 <10 18 20.2 11.8 30.8 Bosnia and Herzegovina 541 317 821 20.8 12.2 31.6 Iceland <10 <1 <10 <1.0 <1.0 <1.0 Kosovo 167 97 256 12.5 7.3 19.1 Liechtenstein <10 <10 <10 8.7 5.1 13.3 Monaco <10 <10 13 30.5 17.9 46.4 Montenegro 75 44 114 17.3 10.1 26.4 North Macedonia 110 64 167 8.3 4.9 12.7 Norway 91 53 139 2.3 1.4 3.6 San Marino <10 <10 <10 6.8 3.9 10.4 Serbia 1,401 823 2,123 28.0 16.4 42.4 Switzerland 769 450 1,174 11.7 6.8 17.8 Türkiye 73,531 44,348 107,904 137.2 82.8 201.4 EU27 58,008 34,129 87,801 17.5 10.3 26.6 EEA32 132,403 78,982 197,024 33.5 20.0 49.9 All countries 135,037 80,528 201,025 33.1 19.7 49.3 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 97 Table A4.43: DM disease burden (DALY) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 3,203 1,725 4,688 46.8 25.2 68.5 Belgium 1,764 974 2,627 20.9 11.5 31.1 Bulgaria 2,301 1,264 3,380 46.4 25.5 68.1 Croatia 2,944 1,568 4,289 101.2 53.9 147.4 Cyprus 2,018 1,131 2,852 212.6 119.2 300.5 Czechia 2,893 1,552 4,283 36.1 19.4 53.4 Denmark 135 72 201 3.2 1.7 4.7 Estonia 27 14 41 2.7 1.4 4.1 Finland 89 49 135 2.2 1.2 3.3 France 12,883 7,148 18,923 27.5 15.3 40.4 Germany 23,521 12,793 34,869 37.2 20.2 55.2 Greece 7,696 4,362 10,973 96.6 54.8 137.8 Hungary 3,327 1,819 4,874 46.2 25.3 67.7 Ireland 251 135 373 7.0 3.8 10.4 Italy 43,387 23,799 62,624 94.7 51.9 136.7 Latvia 281 150 415 20.1 10.7 29.6 Lithuania 289 154 429 13.4 7.1 19.9 Luxembourg 54 29 81 11.3 6.1 16.9 Malta 104 55 155 24.7 13.1 36.8 Netherlands 3,762 2,051 5,597 29.2 15.9 43.4 Poland 8,948 4,860 13,229 32.5 17.7 48.1 Portugal 3,762 2,064 5,546 49.0 26.9 72.2 Romania 5,952 3,284 8,635 42.7 23.6 61.9 Slovakia 524 289 788 13.0 7.2 19.6 Slovenia 363 200 542 22.7 12.5 33.9 Spain 17,690 9,920 25,794 50.8 28.5 74.0 Sweden 136 72 203 1.8 <1.0 2.7 Albania 958 519 1,405 47.1 25.5 69.1 Andorra 25 14 37 42.9 23.5 63.7 Bosnia and Herzegovina 1,693 917 2,475 65.2 35.3 95.4 Iceland <10 <10 <10 1.3 <1.0 2.0 Kosovo 563 299 836 42.0 22.3 62.5 Liechtenstein <10 <10 <10 8.7 5.1 13.3 Monaco 18 <10 26 64.5 35.4 95.7 Montenegro 237 127 351 55.0 29.5 81.4 North Macedonia 319 171 474 24.3 13.0 36.1 Norway 226 122 338 5.8 3.1 8.6 San Marino <10 <10 <10 22.7 12.0 34.0 Serbia 4,371 2,375 6,373 87.3 47.4 127.2 Switzerland 1,481 815 2,211 22.5 12.4 33.5 Türkiye 144,696 84,953 202,077 270.0 158.5 377.1 EU27 148,302 81,534 216,549 44.9 24.7 65.5 EEA32 294,711 167,427 421,184 74.6 42.4 106.6 All countries 302,900 171,862 433,170 74.3 42.1 106.2 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 98 NO2 (long-term effects) and COPD (adults ≥ 25 years) Table A4.44: COPD disease burden (AD) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 136 58 210 2.0 <1.0 3.1 Belgium 164 69 253 1.9 <1.0 3.0 Bulgaria 61 26 94 1.2 <1.0 1.9 Croatia 65 28 101 2.2 <1.0 3.5 Cyprus 39 17 58 4.1 1.8 6.1 Czechia 90 38 139 1.1 <1.0 1.7 Denmark 14 <10 23 <1.0 <1.0 <1.0 Estonia <1 <1 <1 <1.0 <1.0 <1.0 Finland <10 <10 <10 <1.0 <1.0 <1.0 France 370 159 566 <1.0 <1.0 1.2 Germany 1,362 577 2,110 2.2 <1.0 3.3 Greece 309 137 459 3.9 1.7 5.8 Hungary 212 91 325 2.9 1.3 4.5 Ireland 27 11 41 <1.0 <1.0 1.1 Italy 1,944 841 2,949 4.2 1.8 6.4 Latvia <10 <10 <10 <1.0 <1.0 <1.0 Lithuania <10 <10 <10 <1.0 <1.0 <1.0 Luxembourg <10 <10 <10 <1.0 <1.0 1.1 Malta <10 <10 <10 <1.0 <1.0 1.0 Netherlands 301 127 467 2.3 <1.0 3.6 Poland 166 70 257 <1.0 <1.0 <1.0 Portugal 98 42 151 1.3 <1.0 2.0 Romania 291 126 442 2.1 <1.0 3.2 Slovakia 10 <10 16 <1.0 <1.0 <1.0 Slovenia <10 <10 13 <1.0 <1.0 <1.0 Spain 735 319 1,113 2.1 <1.0 3.2 Sweden <10 <10 11 <1.0 <1.0 <1.0 Albania 37 16 58 1.8 <1.0 2.8 Andorra <1 <1 <10 1.2 <1.0 1.9 Bosnia and Herzegovina 56 24 85 2.1 <1.0 3.3 Iceland <1 <1 <1 <1.0 <1.0 <1.0 Kosovo 17 <10 27 1.3 <1.0 2.0 Liechtenstein <1 <1 <1 1.5 <1.0 2.3 Monaco <1 <1 <1 1.9 <1.0 2.9 Montenegro <10 <10 11 1.7 <1.0 2.6 North Macedonia 11 <10 16 <1.0 <1.0 1.3 Norway 25 10 39 <1.0 <1.0 <1.0 San Marino <1 <1 <1 1.0 <1.0 1.6 Serbia 144 62 220 2.9 1.2 4.4 Switzerland 87 37 134 1.3 <1.0 2.0 Türkiye 5,003 2,294 7,199 9.3 4.3 13.4 EU27 6,432 2,763 9,832 1.9 <1.0 3.0 EEA32 11,547 5,105 17,206 2.9 1.3 4.4 All countries 11,820 5,221 17,626 2.9 1.3 4.3 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 99 Table A4.45: COPD disease burden (YLL) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high) (a) YLL/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 1,512 645 2,328 22.1 9.4 34.0 Belgium 2,005 850 3,103 23.7 10.1 36.8 Bulgaria 662 283 1,016 13.3 5.7 20.5 Croatia 618 263 951 21.2 9.0 32.7 Cyprus 366 162 544 38.5 17.0 57.3 Czechia 1,022 432 1,588 12.8 5.4 19.8 Denmark 153 64 239 3.6 1.5 5.6 Estonia <10 <10 <10 <1.0 <1.0 <1.0 Finland 41 17 64 <1.0 <1.0 1.6 France 4,239 1,821 6,479 9.1 3.9 13.8 Germany 15,695 6,647 24,316 24.8 10.5 38.5 Greece 2,470 1,094 3,669 31.0 13.7 46.1 Hungary 2,519 1,079 3,863 35.0 15.0 53.6 Ireland 279 117 434 7.8 3.3 12.1 Italy 14,903 6,451 22,613 32.5 14.1 49.4 Latvia 58 24 89 4.1 1.7 6.4 Lithuania 68 29 106 3.1 1.3 4.9 Luxembourg 39 16 61 8.1 3.4 12.7 Malta 31 13 49 7.4 3.1 11.6 Netherlands 3,461 1,463 5,374 26.8 11.3 41.7 Poland 1,945 825 3,008 7.1 3.0 10.9 Portugal 890 379 1,370 11.6 4.9 17.8 Romania 3,283 1,420 4,986 23.6 10.2 35.8 Slovakia 133 56 207 3.3 1.4 5.2 Slovenia 94 40 146 5.9 2.5 9.1 Spain 7,475 3,243 11,318 21.5 9.3 32.5 Sweden 69 29 108 <1.0 <1.0 1.4 Albania 336 143 517 16.5 7.0 25.4 Andorra <10 <10 13 14.1 6.0 21.8 Bosnia and Herzegovina 588 251 903 22.6 9.7 34.8 Iceland <10 <10 <10 1.0 <1.0 1.6 Kosovo 193 81 302 14.4 6.1 22.5 Liechtenstein <10 <1 <10 6.9 2.9 10.8 Monaco <10 <10 <10 21.2 9.0 32.8 Montenegro 83 35 128 19.1 8.1 29.7 North Macedonia 107 45 166 8.1 3.4 12.7 Norway 261 109 407 6.7 2.8 10.4 San Marino <10 <1 <10 7.7 3.2 12.1 Serbia 1,519 651 2,327 30.3 13.0 46.5 Switzerland 989 418 1,535 15.0 6.3 23.3 Türkiye 52,563 24,106 75,634 98.1 45.0 141.1 EU27 64,032 27,464 98,035 19.4 8.3 29.7 EEA32 117,850 52,099 175,619 29.8 13.2 44.5 All countries 120,691 53,312 179,987 29.6 13.1 44.1 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 100 Table A4.46: COPD disease burden (YLD) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 538 306 752 7.9 4.5 11.0 Belgium 500 283 700 5.9 3.4 8.3 Bulgaria 338 192 471 6.8 3.9 9.5 Croatia 221 125 308 7.6 4.3 10.6 Cyprus 198 115 271 20.9 12.1 28.6 Czechia 177 100 248 2.2 1.2 3.1 Denmark 22 12 31 <1.0 <1.0 <1.0 Estonia <10 <10 <10 <1.0 <1.0 <1.0 Finland 15 <10 21 <1.0 <1.0 <1.0 France 3,862 2,207 5,373 8.3 4.7 11.5 Germany 5,253 2,977 7,366 8.3 4.7 11.7 Greece 577 336 789 7.2 4.2 9.9 Hungary 468 267 652 6.5 3.7 9.1 Ireland 45 25 63 1.2 <1.0 1.7 Italy 6,859 3,938 9,501 15.0 8.6 20.7 Latvia 36 20 51 2.6 1.5 3.6 Lithuania 79 45 111 3.7 2.1 5.1 Luxembourg 18 10 26 3.8 2.1 5.3 Malta <10 <10 <10 <1.0 <1.0 <1.0 Netherlands 1,103 624 1,549 8.6 4.8 12.0 Poland 883 501 1,237 3.2 1.8 4.5 Portugal 663 378 927 8.6 4.9 12.1 Romania 371 213 514 2.7 1.5 3.7 Slovakia 90 51 126 2.2 1.3 3.1 Slovenia 66 37 93 4.1 2.3 5.8 Spain 2,374 1,365 3,284 6.8 3.9 9.4 Sweden 10 <10 15 <1.0 <1.0 <1.0 Albania 110 63 154 5.4 3.1 7.6 Andorra <10 <10 10 12.8 7.2 17.9 Bosnia and Herzegovina 179 102 250 6.9 3.9 9.6 Iceland <1.0 <1.0 <10 <1.0 <1.0 <1.0 Kosovo 56 32 79 4.2 2.4 5.9 Liechtenstein <10 <1.0 <10 5.0 2.8 7.1 Monaco <10 <10 <10 19.2 10.9 26.9 Montenegro 26 15 36 6.0 3.4 8.4 North Macedonia 38 21 53 2.9 1.6 4.0 Norway 41 23 57 1.0 <1.0 1.5 San Marino <1.0 <1.0 <10 3.5 2.0 4.9 Serbia 464 265 646 9.3 5.3 12.9 Switzerland 446 252 626 6.8 3.8 9.5 Türkiye 38,216 22,721 51,291 71.3 42.4 95.7 EU27 24,768 14,146 34,484 7.5 4.3 10.4 EEA32 63,473 37,144 86,462 16.1 9.4 21.9 All countries 64,359 37,648 87,699 15.8 9.2 21.5 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 101 Table A4.47: COPD disease burden (DALY) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 2,050 951 3,080 30.0 13.9 45.0 Belgium 2,504 1,133 3,803 29.7 13.4 45.1 Bulgaria 999 476 1,486 20.1 9.6 30.0 Croatia 838 389 1,259 28.8 13.4 43.3 Cyprus 564 277 815 59.4 29.1 85.8 Czechia 1,199 532 1,836 15.0 6.6 22.9 Denmark 174 76 270 4.1 1.8 6.3 Estonia <10 <10 13 <1.0 <1.0 1.3 Finland 55 25 84 1.3 <1.0 2.1 France 8,100 4,028 11,852 17.3 8.6 25.3 Germany 20,947 9,624 31,682 33.1 15.2 50.1 Greece 3,047 1,429 4,458 38.2 17.9 56.0 Hungary 2,987 1,346 4,516 41.5 18.7 62.7 Ireland 323 143 496 9.0 4.0 13.8 Italy 21,762 10,390 32,114 47.5 22.7 70.1 Latvia 94 45 140 6.7 3.2 10.0 Lithuania 147 73 217 6.8 3.4 10.0 Luxembourg 57 27 87 11.9 5.5 18.0 Malta 33 14 52 7.9 3.4 12.3 Netherlands 4,564 2,087 6,922 35.4 16.2 53.7 Poland 2,828 1,326 4,245 10.3 4.8 15.4 Portugal 1,553 757 2,296 20.2 9.9 29.9 Romania 3,654 1,633 5,500 26.2 11.7 39.5 Slovakia 222 106 334 5.5 2.6 8.3 Slovenia 160 77 238 10.0 4.8 14.9 Spain 9,849 4,608 14,602 28.3 13.2 41.9 Sweden 79 35 123 1.1 <1.0 1.6 Albania 446 206 671 21.9 10.1 33.0 Andorra 16 <10 23 26.8 13.2 39.7 Bosnia and Herzegovina 767 353 1,153 29.5 13.6 44.4 Iceland <10 <10 <10 1.4 <1.0 2.1 Kosovo 249 113 380 18.6 8.4 28.4 Liechtenstein <10 <10 <10 11.9 5.7 17.9 Monaco 11 <10 16 40.4 19.9 59.7 Montenegro 108 49 164 25.1 11.5 38.1 North Macedonia 144 66 219 11.0 5.0 16.7 Norway 301 132 464 7.7 3.4 11.9 San Marino <10 <10 <10 11.2 5.2 17.0 Serbia 1,983 916 2,973 39.6 18.3 59.4 Switzerland 1,435 670 2,162 21.8 10.2 32.8 Türkiye 90,779 46,827 126,925 169.4 87.4 236.9 EU27 88,800 41,610 132,520 26.9 12.6 40.1 EEA32 181,323 89,242 262,081 45.9 22.6 66.4 All countries 185,050 90,960 267,686 45.4 22.3 65.6 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 102 NO2 (long-term effects) and stroke (adults ≥ 25 years) Table A4.48: Stroke disease burden (AD) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 AD (95 % CI: low, high) (a) AD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 100 17 181 1.5 <1.0 2.6 Belgium 120 20 217 1.4 <1.0 2.6 Bulgaria 499 85 898 10.1 1.7 18.1 Croatia 71 12 128 2.4 <1.0 4.4 Cyprus 41 <10 72 4.3 <1.0 7.6 Czechia 88 15 161 1.1 <1.0 2.0 Denmark <10 <10 11 <1.0 <1.0 <1.0 Estonia <10 <1.0 <10 <1.0 <1.0 <1.0 Finland <10 <1.0 <10 <1.0 <1.0 <1.0 France 536 92 960 1.1 <1.0 2.1 Germany 994 168 1,801 1.6 <1.0 2.8 Greece 604 106 1,059 7.6 1.3 13.3 Hungary 204 35 366 2.8 <1.0 5.1 Ireland 13 <10 23 <1.0 <1.0 <1.0 Italy 2,502 430 4,462 5.5 <1.0 9.7 Latvia 47 <10 85 3.4 <1.0 6.1 Lithuania 36 <10 66 1.7 <1.0 3.1 Luxembourg <10 <1.0 <10 <1.0 <1.0 <1.0 Malta <10 <1.0 <10 <1.0 <1.0 1.1 Netherlands 210 35 380 1.6 <1.0 3.0 Poland 478 81 865 1.7 <1.0 3.1 Portugal 197 34 355 2.6 <1.0 4.6 Romania 1,154 198 2,059 8.3 1.4 14.8 Slovakia 35 <10 63 <1.0 <1.0 1.6 Slovenia 30 <10 55 1.9 <1.0 3.4 Spain 755 130 1,344 2.2 <1.0 3.9 Sweden <10 <1.0 10 <1.0 <1.0 <1.0 Albania 84 14 152 4.1 <1.0 7.5 Andorra <10 <1.0 <10 1.8 <1.0 3.2 Bosnia and Herzegovina 113 19 204 4.4 <1.0 7.9 Iceland <1.0 <1.0 <1.0 <1.0 <1.0 0.1 Kosovo 35 <10 64 2.6 <1.0 4.8 Liechtenstein <1.0 <1.0 <1.0 <1.0 <1.0 1.7 Monaco <1.0 <1.0 <10 2.7 <1.0 4.8 Montenegro 14 <10 26 3.4 <1.0 6.1 North Macedonia 21 <10 38 1.6 <1.0 2.9 Norway 11 <10 19 <1.0 <1.0 <1.0 San Marino <1.0 <1.0 <1.0 1.2 <1.0 2.3 Serbia 294 50 528 5.9 1.0 10.5 Switzerland 68 12 124 1.0 <1.0 1.9 Türkiye 4,582 823 7,840 8.6 1.5 14.6 EU27 8,736 1,497 15,643 2.6 <1.0 4.7 EEA32 13,398 2,333 23,628 3.4 <1.0 6.0 All countries 13,961 2,429 24,643 3.4 <1.0 6.0 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 103 Table A4.49: Stroke disease burden (YLL) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLL (95 % CI: low, high) (a) YLL/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 890 151 1,604 13.0 2.2 23.4 Belgium 1,118 189 2,024 13.2 2.2 24.0 Bulgaria 4,383 747 7,883 88.4 15.1 158.9 Croatia 643 109 1,160 22.1 3.8 39.9 Cyprus 433 76 761 45.6 8.0 80.1 Czechia 839 142 1,523 10.5 1.8 19.0 Denmark 58 <10 105 1.4 <1.0 2.5 Estonia 13 <10 24 1.3 <1.0 2.3 Finland 46 <10 85 1.1 <1.0 2.1 France 5,176 885 9,281 11.1 1.9 19.8 Germany 8,883 1,504 16,092 14.0 2.4 25.5 Greece 4,809 841 8,439 60.4 10.6 105.9 Hungary 1,911 326 3,434 26.5 4.5 47.7 Ireland 129 22 234 3.6 <1.0 6.5 Italy 19,324 3,324 34,462 42.2 7.3 75.2 Latvia 389 66 705 27.8 4.7 50.4 Lithuania 318 54 579 14.7 2.5 26.8 Luxembourg 20 <10 37 4.2 <1.0 7.6 Malta 25 <10 46 6.0 1.0 10.9 Netherlands 1,867 316 3,388 14.5 2.4 26.3 Poland 5,174 877 9,362 18.8 3.2 34.0 Portugal 1,723 293 3,106 22.4 3.8 40.4 Romania 10,638 1,829 18,980 76.3 13.1 136.2 Slovakia 388 65 708 9.7 1.6 17.6 Slovenia 263 44 477 16.5 2.8 29.9 Spain 7,359 1,268 13,102 21.1 3.6 37.6 Sweden 48 <10 88 <1.0 <1.0 1.2 Albania 586 100 1,056 28.8 4.9 51.9 Andorra <10 <10 18 17.0 2.9 30.8 Bosnia and Herzegovina 1,062 181 1,912 40.9 7.0 73.6 Iceland <10 <1.0 <10 <1.0 <1.0 <1.0 Kosovo 357 60 650 26.7 4.5 48.6 Liechtenstein 0 0 0 0 0 0 Monaco <10 <10 13 25.6 4.3 46.3 Montenegro 147 25 266 34.0 5.7 61.7 North Macedonia 188 32 341 14.3 2.4 26.0 Norway 100 17 181 2.5 <1.0 4.6 San Marino <10 <1.0 <10 9.6 1.6 17.7 Serbia 2,752 470 4,944 54.9 9.4 98.7 Switzerland 591 100 1,072 9.0 1.5 16.3 Türkiye 52,509 9,435 89,848 98.0 17.6 167.7 EU27 76,866 13,165 137,689 23.3 4.0 41.7 EEA32 130,067 22,717 228,793 32.9 5.8 57.9 All countries 135,177 23,587 237,996 33.2 5.8 58.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 104 Table A4.50: Stroke disease burden (YLD) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 YLD (95 % CI: low, high) (a) YLD/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 543 281 788 7.9 4.1 11.5 Belgium 248 128 361 2.9 1.5 4.3 Bulgaria 791 410 1,147 16.0 8.3 23.1 Croatia 351 182 510 12.1 6.2 17.5 Cyprus 271 143 387 28.6 15.1 40.8 Czechia 312 161 454 3.9 2.0 5.7 Denmark 27 14 40 <1.0 <1.0 <1.0 Estonia <10 <10 <10 <1.0 <1.0 <1.0 Finland 22 11 33 <1.0 <1.0 <1.0 France 2,307 1,199 3,336 4.9 2.6 7.1 Germany 5,547 2,862 8,073 8.8 4.5 12.8 Greece 1,539 812 2,194 19.3 10.2 27.5 Hungary 653 339 945 9.1 4.7 13.1 Ireland 47 24 68 1.3 <1.0 1.9 Italy 6,211 3,239 8,947 13.6 7.1 19.5 Latvia 28 14 40 2.0 1.0 2.9 Lithuania 84 43 122 3.9 2.0 5.7 Luxembourg <10 <10 14 2.0 1.0 3.0 Malta <10 <10 <10 <1.0 <1.0 <1.0 Netherlands 999 515 1,456 7.8 4.0 11.3 Poland 1,681 868 2,444 6.1 3.2 8.9 Portugal 704 364 1,021 9.2 4.7 13.3 Romania 1,090 568 1,571 7.8 4.1 11.3 Slovakia 191 98 279 4.7 2.4 6.9 Slovenia 90 46 131 5.6 2.9 8.2 Spain 2,652 1,385 3,816 7.6 4.0 11.0 Sweden 19 <10 28 <1.0 <1.0 <1.0 Albania 116 60 169 5.7 3.0 8.3 Andorra <10 <10 <10 7.6 3.9 11.0 Bosnia and Herzegovina 191 99 277 7.4 3.8 10.7 Iceland <1.0 <1.0 <10 <1.0 <1.0 <1.0 Kosovo 59 30 87 4.4 2.3 6.5 Liechtenstein <10 <1.0 <10 4.8 2.5 7.1 Monaco <10 <10 <10 11.4 5.9 16.6 Montenegro 26 13 37 5.9 3.0 8.6 North Macedonia 38 20 55 2.9 1.5 4.2 Norway 48 24 70 1.2 <1.0 1.8 San Marino <1.0 <1.0 <10 3.1 1.6 4.6 Serbia 495 257 717 9.9 5.1 14.3 Switzerland 455 234 662 6.9 3.6 10.0 Türkiye 12,212 6,558 17,123 22.8 12.2 32.0 EU27 26,423 13,724 38,213 8.0 4.2 11.6 EEA32 39,140 20,543 56,071 9.9 5.2 14.2 All countries 40,073 21,026 57,425 9.8 5.2 14.1 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 105 Table A4.51: Stroke disease burden (DALY) attributable to NO2 for adults ≥ 25 years for 41 European countries (individual and total countries), in the EU27 and EEA32 in 2023 DALY (95 % CI: low, high) (a) DALY/105 inhabitants ≥ 25 years (95 % CI: low, high) (b) Country mean low high mean low high Austria 1,433 432 2,392 20.9 6.3 35.0 Belgium 1,366 318 2,385 16.2 3.8 28.3 Bulgaria 5,174 1,158 9,030 104.3 23.3 182.0 Croatia 995 291 1,670 34.2 10.0 57.4 Cyprus 704 218 1,148 74.2 23.0 120.9 Czechia 1,151 302 1,977 14.4 3.8 24.7 Denmark 85 24 145 2.0 <1.0 3.4 Estonia 16 <10 28 1.6 <1.0 2.8 Finland 68 19 117 1.7 <1.0 2.9 France 7,483 2,084 12,617 16.0 4.5 27.0 Germany 14,430 4,366 24,165 22.8 6.9 38.2 Greece 6,348 1,653 10,633 79.7 20.8 133.5 Hungary 2,564 665 4,380 35.6 9.2 60.8 Ireland 176 46 302 4.9 1.3 8.4 Italy 25,535 6,564 43,410 55.7 14.3 94.7 Latvia 416 80 746 29.8 5.7 53.3 Lithuania 402 97 701 18.6 4.5 32.5 Luxembourg 30 <10 51 6.2 1.7 10.6 Malta 28 <10 49 6.6 1.3 11.8 Netherlands 2,866 831 4,844 22.2 6.4 37.6 Poland 6,855 1,745 11,806 24.9 6.3 42.9 Portugal 2,427 658 4,128 31.6 8.6 53.7 Romania 11,728 2,398 20,551 84.1 17.2 147.4 Slovakia 579 163 987 14.4 4.1 24.5 Slovenia 353 91 608 22.1 5.7 38.1 Spain 10,010 2,653 16,918 28.7 7.6 48.6 Sweden 67 18 116 <1.0 <1.0 1.5 Albania 702 160 1,225 34.5 7.9 60.2 Andorra 14 <10 24 24.6 6.8 41.8 Bosnia and Herzegovina 1,253 280 2,189 48.3 10.8 84.3 Iceland <10 <1.0 <10 <1.0 <1.0 1.3 Kosovo 416 90 737 31.1 6.8 55.1 Liechtenstein <10 <1.0 <10 4.8 2.5 7.1 Monaco 10 <10 17 37.0 10.2 63.0 Montenegro 172 38 303 39.9 8.8 70.4 North Macedonia 226 51 396 17.2 3.9 30.2 Norway 147 41 251 3.8 1.1 6.4 San Marino <10 <1.0 <10 12.8 3.2 22.2 Serbia 3,247 727 5,660 64.8 14.5 113.0 Switzerland 1,045 334 1,734 15.9 5.1 26.3 Türkiye 64,721 15,993 106,970 120.8 29.8 199.6 EU27 103,289 26,889 175,902 31.2 8.1 53.2 EEA32 169,207 43,259 284,864 42.8 11.0 72.1 All countries 175,250 44,613 295,421 43.0 10.9 72.4 Notes: (a) Total and national data are rounded to the nearest integer; (b) Total and national data are rounded to one decimal place. ETC HE Report 2025/8 112 Annex 6 Country ISO2 code Table A6.1: country name and respective ISO2 code Country name Country ISO2 code Austria AT Albania AL Andorra AD Belgium BE Bosnia and Herzegovina BA Bulgaria BG Croatia HR Cyprus CY Czechia CZ Denmark DK Estonia EE Finland FI France FR Germany DE Greece GR Hungary HU Iceland IS Ireland IE Italy IT Kosovo (under UNSCR 1244/99) XK Latvia LV Liechtenstein LI Lithuania LT Luxembourg LU Malta MT Monaco MC Montenegro ME Netherlands NL North Macedonia MK Norway NO Poland PL Portugal PT Romania RO San Marino SM Serbia RS Slovakia SK Slovenia SI Spain ES Sweden SE Switzerland CH Türkiye TR ETC HE Report 2025/8 113 European Topic Centre on Human health and the environment https://www.eionet.europa.eu/etcs/etc-he The European Topic Centre on Human health and the environment (ETC HE) is a consortium of European institutes under contract of the European Environment Agency.