Climate change driven by human activities has increased annual temperatures in Spain by around 1°C since 1980. However, little is known regarding the extent to which the association between temperature and mortality has changed among the most susceptible population groups as a result of the rapidly warming climate. We aimed to assess trends in temperature-related cardiovascular disease mortality in Spain by sex and age, and we investigated the association between climate warming and changes in the risk of mortality. We did a country-wide time-series analysis of 48 provinces in mainland Spain and the Balearic Islands between Jan 1, 1980, and Dec 31, 2016. We extracted daily cardiovascular disease mortality data disaggregated by sex, age, and province from the Spanish National Institute of Statistics database. We also extracted daily mean temperatures from the European Climate Assessment and Dataset project. We applied a quasi-Poisson regression model for each province, controlling for seasonal and long-term trends, to estimate the temporal changes in the province-specific temperature-mortality associations with distributed lag non-linear models. We did a multivariate random-effects meta-analysis to derive the best linear unbiased prediction of the temperature-mortality association and the minimum mortality temperature in each province. Heat-attributable and cold-attributable fractions of death were computed by separating the contributions from days with temperatures warmer and colder than the minimum mortality temperature, respectively. Between 1980 and 2016, 4 576 600 cardiovascular deaths were recorded. For warm temperatures, the increase in relative risk (RR) of death from cardiovascular diseases was higher for women than men and higher for older individuals (aged ≥90 years) than younger individuals (aged 60-74 years), whereas for cold temperatures, RRs were higher for men than women, with no clear pattern by age group. The heat-attributable fraction of cardiovascular deaths was higher for women in all age groups, and the cold-attributable fraction was larger in men. The heat-attributable fraction increased with age for both sexes, whereas the cold-attributable fraction increased with age for men and decreased for women. Overall minimum mortality temperature increased from 19·5°C between 1980 and 1994 to 20·2°C between 2002 and 2016, which is similar in magnitude to, and occurred in parallel with, the observed mean increase of 0·77°C that occurred in Spain between these two time periods. In general, between 1980 and 2016, the risk and attributable fraction of cardiovascular deaths due to warm and cold temperatures decreased for men and women across all age groups. For all the age groups combined, between 1980-94 and 2002-16, the heat-attributable fraction decreased by -42·06% (95% empirical CI -44·39 to -41·06) for men and -36·64% (-36·70 to -36·04) for women, whereas the cold-attributable fraction was reduced by -30·23% (-30·34 to -30·05) for men and -44·87% (-46·77 to -42·94) for women. In Spain, the observed warming of the climate has occurred in parallel with substantial adaptation to both high and low temperatures. The reduction in the RR and the attributable fraction associated with heat would be compatible with an adaptive response specifically addressing the negative consequences of climate change. Nevertheless, the simultaneous reduction in the RR and attributable fraction of cold temperatures also highlights the importance of more general factors such as socioeconomic development, increased life expectancy and quality, and improved health-care services in the country. None.

Aims: We assessed the association of temperature and temperature variability with cause-specific emergency hospitalizations and mortality from cardiovascular and respiratory diseases in Spain, as well as the effect modification of this association by individual and contextual factors. Methods and results: We collected data on health (hospital admissions and mortality), weather (temperature and relative humidity), and relevant contextual indicators for 48 Spanish provinces during 2004–2019. The statistical analysis was separately performed for the summer (June–September) and winter (December–March) seasons. We first applied a generalized linear regression model with quasi-Poisson distribution to estimate daily province-specific temperature-health associations, and then we fitted multilevel multivariate meta-regression models to the evaluate effect modification of the contextual characteristics on heat- and cold-related risks. High temperature increased the risk of mortality across all cardiovascular and respiratory diseases, with the strongest effect for hypertension (relative risk (RR) at 99th temperature percentile vs. optimum temperature: 1.510 [95% empirical confidence interval {eCI} 1.251 to 1.821]), heart failure (1.528 [1.353 to 1.725]), and pneumonia (2.224 [1.685 to 2.936]). Heat also had an impact on all respiratory hospitalization causes (except asthma), with similar risks between pneumonia (1.288 [1.240 to 1.339]), acute bronchitis and bronchiolitis (1.307 [1.219 to 1.402]), and chronic obstructive pulmonary disease (1.260 [1.158 to 1.372]). We generally found significant risks related to low temperature for all cardiovascular and respiratory causes, with heart failure (RR at 1st temperature percentile vs. optimum temperature: 1.537 [1.329 to 1.779]) and chronic obstructive pulmonary disease (1.885 [1.646 to 2.159]) exhibiting the greatest risk for hospitalization, and acute myocardial infarction (1.860 [1.546 to 2.238]) and pneumonia (1.734 [1.219 to 2.468]) for mortality. Women and the elderly were more vulnerable to heat, while people with secondary education were less susceptible to cold compared to those not achieving this educational stage. Results from meta-regression showed that increasing heating access to the highest current provincial value (i.e. 95.6%) could reduce deaths due to cold by 59.5% (57.2 to 63.5). Conclusion: Exposure to low and high temperatures was associated with a greater risk of morbidity and mortality from multiple cardiovascular and respiratory conditions, and heating was the most effective societal adaptive measure to reduce cold-related mortality.

Air pollution remains as a substantial health problem, particularly regarding the combined health risks arising from simultaneous exposure to multiple air pollutants. However, understanding these combined exposure events over long periods has been hindered by sparse and temporally inconsistent monitoring data. Here we analyze daily ambient PM_2.5, PM₁₀, NO₂ and O₃ concentrations at a 0.1-degree resolution during 2003–2019 across 1426 contiguous regions in 35 European countries, representing 543 million people. We find that PM10 levels decline by 2.72% annually, followed by NO₂ (2.45%) and PM_2.5 (1.72%). In contrast, O₃ increase by 0.58% in southern Europe, leading to a surge in unclean air days. Despite air quality advances, 86.3% of Europeans experience at least one compound event day per year, especially for PM_2.5-NO₂ and PM_2.5-O₃. We highlight the improvements in air quality control but emphasize the need for targeted measures addressing specific pollutants and their compound events, particularly amidst rising temperatures.

Anthropogenic greenhouse gas emissions have increased summer temperatures in Spain by nearly one degree Celsius on average between 1980 and 2015. However, little is known about the extent to which the association between heat and human mortality has been modified. We here investigate whether the observed warming has been associated with an upward trend in excess mortality attributable to heat or, on the contrary, a decrease in the vulnerability to heat has contributed to a reduction of the mortality burden. We analysed a dataset from 47 major cities in Spain for the summer months between 1980 and 2015, which included daily temperatures and 554,491 deaths from circulatory and respiratory causes, by sex. We applied standard quasi-Poisson regression models, controlling for seasonality and long-term trends, and estimated the temporal variation in heat-related mortality with time-varying distributed lag nonlinear models (DLNMs). Results pointed to a reduction in the relative risks of cause-specific and cause-sex mortality across the whole range of summer temperatures. These reductions in turn explained the observed downward trends in heat-attributable deaths, with the only exceptions of respiratory diseases for women and both sexes together. The heat-attributable deaths were consistently higher in women than in men for both circulatory and respiratory causes. The main limitation of our study is that we were not able to account for air pollution in the models because of data unavailability. Despite the summer warming observed in Spain between 1980 and 2015, the decline in the vulnerability of the population has contributed to a general downward trend in overall heat-attributable mortality. This reduction occurred in parallel with a decline in the vulnerability difference between men and women for circulatory and cardiorespiratory mortality. Despite these advances, the risk of death remained high for respiratory diseases, and particularly in women.

Ground-level ozone (O₃) is a harmful air pollutant formed in the atmosphere by the interaction between sunlight and precursor gases. Exposure to current O₃ levels in Europe is a major source of premature mortality from air pollution. However, mitigation actions have been mainly designed and implemented at the national and regional scales, lacking a comprehensive assessment of the geographic sources of O₃ pollution and its associated health impacts. Here we quantify both national and imported contributions to O₃ and their related mortality burden across 813 contiguous regions in 35 European countries, representing about 530 million people. Imported O₃ contributed to 88.3% of all O₃-attributable deaths (intercountry range 83–100%). The greatest share of imported O₃ had its origins outside the study domain (that is, hemispheric sources), which was responsible for 56.7% of total O₃-attributable mortality (range 42.5–87.2%). It was concluded that achieving the air-quality guidelines set out by the World Health Organization and avoiding the health impacts of O₃ require not only the implementation of national or coordinated pan-European actions but also global strategies.

A growing number of epidemiological studies have recently assessed temporal variations in vulnerability and/or mortality attributable to hot and cold temperatures. However, the eventual changes in the seasonal distribution of temperature-attributable mortality remain unexplored. Here, we analyse countrywide daily time-series of temperature and mortality counts from respiratory diseases by sex, age group and province of residence during the period 1980–2016 in Spain. We show the complete reversal of the seasonality of temperature-attributable mortality, with a significant shift of the maximum monthly incidence from winter to summer, and the minimum monthly incidence from early and late summer to winter. The reversal in the seasonal distribution of the attributable deaths is not driven by the observed warming in both winter and summer temperatures, but rather by the very large decrease in the risk of death due to cold temperatures and the relatively much smaller reduction due to hot temperatures. We conclude that the projected decrease in the number of moderate and extreme cold days due to climate warming will not contribute to a further reduction of cold-attributable respiratory deaths.