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Greenness may improve lung health in low–moderate but not high air pollution areas: Seven Northeastern Cities’ study
  1. Yang Zhou1,2,
  2. Dinh S Bui3,
  3. Jennifer L Perret3,4,
  4. Adrian J Lowe3,
  5. Caroline J Lodge3,
  6. Iana Markevych5,
  7. Joachim Heinrich3,6,
  8. Michael S Bloom7,8,
  9. Luke D Knibbs9,
  10. Bin Jalaludin10,11,12,
  11. Bo-Yi Yang2,
  12. Hong-Yao Yu2,
  13. Xiao-Wen Zeng2,
  14. Yunjiang Yu1,
  15. Shyamali C Dharmage3,
  16. Guang-Hui Dong2
  1. 1 State Environmental Protection Key Laboratory of Environmental Pollution Health Risk Assessment, South China Institute of Environmental Sciences, Ministry of Ecology and Environment, Guangzhou, China
  2. 2 Guangdong Provincial Engineering Technology Research Center of Environmental Pollution and Health Risk Assessment, Department of Occupational and Environmental Health, School of Public Health, Sun Yat-Sen University, Guangzhou, China
  3. 3 Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
  4. 4 Respiratory and Sleep Medicine, Austin Hospital, Melbourne, Victoria, Australia
  5. 5 Jagiellonian University Institute of Psychology, Krakow, Poland
  6. 6 Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, University of Munich, Munchen, Bayern, Germany
  7. 7 Departments of Environmental Health Sciences and Epidemiology and Biostatistics, University at Albany, State University of New York, Rensselaer, New York, USA
  8. 8 Department of Global and Community Health, George Mason University, Fairfax, Virginia, USA
  9. 9 School of Public Health, Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
  10. 10 Centre for Research, Evidence Management and Surveillance, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
  11. 11 School of Public Health and Community Medicine Sydney, University of New South Wales, Sydney, New South Wales, Australia
  12. 12 Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
  1. Correspondence to Dr Guang-Hui Dong, Department of Occupational and Environmental Health, Sun Yat-Sen University, Guangzhou 510080, Guangdong, China; donggh5{at}; Dr Shyamali C Dharmage; s.dharmage{at}


Introduction There is growing interest in the impact of greenness exposure on airway diseases, but the impact of greenness on lung function in children is limited. We aimed to investigate the associations between greenness surrounding schools and lung function in children and whether these associations are modified by air pollution exposure.

Methods Between 2012 and 2013, a cross-sectional survey and spirometry were performed among 6740 school children. Lung function patterns were determined as obstructive forced expiratory volume 1 s/forced vital capacity (FEV1/FVC <0.8) or restrictive (FEV1/FVC ≥0.8 but FVC <80% of predicted). School greenness was defined by Normalized difference vegetation index (NDVI) and soil-adjusted vegetation index. Nitrogen dioxide, sulphur dioxide and particular matter concentrations were assessed using a spatiotemporal model and national monitoring data. Two-level generalised linear models were used to investigate associations and interactions.

Results Overall, an IQR in NDVI within 500 m was associated with higher FEV1 (+57 mL 95% CI 44 to 70) and FVC (+58 mL 95% CI 43 to 73). NDVI was similarly associated with 25% reduced odds of spirometric restriction (OR: 0.75, 95% CI 0.65 to 0.86). However, among children exposed to the highest compared with the lowest quartile of particulate matter, increasing NDVI was paradoxically associated with lower −40 mL FVC (95% CI −47 to –33, p interaction <0.05).

Discussion Our findings suggest that, in this study population, greening urban areas may promote lung health in low–moderate pollution areas but not in high air pollution areas. If the findings are replicated in other moderate-to-high pollution settings, this highlights a need to have a flexible green policy.

  • respiratory measurement
  • paediatric lung disaese

Data availability statement

Data are available upon reasonable request. See author contributions for specific data sets.

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Data availability statement

Data are available upon reasonable request. See author contributions for specific data sets.

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  • Contributors Study concept and design: G-HD, SD. Acquisition of data: G-HD, YZ, IM, JH. Analysis and interpretation of data: YZ, DB, JLP, AL, SD, G-HD. Drafting of the manuscript: YZ, DB, JLP, AL, KJL, SD, G-HD. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: YZ, DB, JLP, AL, SD, G-HD. Obtained funding: G-HD.

  • Funding The research was funded by the National Natural Science Foundation of China (No.91543208; No.81703179; No.81673128; No.82003409); the National Key Research and Development Programme of China (No.2016YFC0207000); the Fundamental Research Funds for the Central Universities (No.16ykzd02; No.17ykpy16); the Guangdong Province Natural Science Foundation (No.2016A030313342; 2017A050501062); and Science and Technology Programme of Guangzhou (201807010032; 201803010054).

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  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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