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Air pollution is still one of the most severe problems in northern China, especially in the Jing-Jin-Ji region around Beijing. In recent years, China has implemented many stringent policies to address the air quality issue, including promoting energy transition toward cleaner fuels in residential sectors. But until 2020, even in the Jing-Jin-Ji region, nearly half of the rural households still use solid fuels for heating. For residents who are not covered by the clean heating campaign, we analyze five potential mitigation strategies and evaluate their environmental effects as well as the associated health benefits and costs. We estimate that substitution with electricity or gas would reduce air pollution and premature mortality more strongly, while the relatively low investment costs of implementing clean coal or biomass pellet lead to a larger benefit-cost ratio, indicating higher cost efficiency. Hence, clean coal or biomass pellet could be transitional substitution options for the less developed or remote areas which cannot afford a total transition toward electricity or natural gas in the short term.

Background: Polluting fuels and inefficient stove technologies are still a leading cause of premature deaths worldwide, particularly in low-income and middle-income countries. Previous studies of global household air pollution (HAP) have neither considered the estimation of PM 2·5 at national level nor the corresponding attributable mortality burden. Additionally, the effects of climate and ambient air pollution on the global estimation of HAP-PM 2·5 exposure for different urban and rural settings remain largely unknown. In this study, we include climatic effects to estimate the HAP-PM 2·5 exposure from different fuel types and stove technologies in rural and urban settings separately and the related attributable global mortality burden., Methods: Bayesian hierarchical models were developed to estimate an annual average HAP-PM 2·5 personal exposure and HAP-PM 2·5 indoor concentration (including both outdoor and indoor sources). Model variables were selected from sample data in 282 peer-reviewed studies drawn and updated from the WHO Global HAP dataset. The PM 2·5 exposure coefficients from the developed model were applied to the external datasets to predict the HAP-PM 2·5 exposure globally (personal exposure in 62 countries and indoor concentration in 69 countries). Attributable mortality rate was estimated using a comparative risk assessment approach. Using weighted averages, the national level 24 h average HAP-PM 2·5 exposure due to polluting and clean fuels and related death rate per 100 000 population were estimated., Findings: In 2020, household use of polluting solid fuels for cooking and heating led to a national-level average personal exposure of 151 μg/m 3 (95% CI 133-169), with rural households having an average of 171 μg/m 3 (153-189) and urban households an average of 92 μg/m 3 (77-106). Use of clean fuels gave rise to a national-level average personal exposure of 69 μg/m 3 (62-76), with a rural average of 76 μg/m 3 (69-83) and an urban average of 49 μg/m 3 (46-53). Personal exposure-attributable premature mortality (per 100 000 population) from the use of polluting solid fuels at national level was on average 78 (95% CI 69-87), with a rural average of 82 (73-90) and an urban average of 66 (57-75). The average attributable premature mortality (per 100 000 population) from the use of clean fuels at the national level is 62 (54-70), with a rural average of 66 (58-74) and an urban average of 52 (47-57). The estimated HAP-PM 2·5 indoor concentration shows that the use of polluting solid fuels resulted in a national-level average of 412 μg/m 3 (95% CI 353-471), with a rural average of 514 μg/m 3 (446-582) and an urban average of 149 μg/m 3 (126-173). The use of clean fuels (gas and electricity) led to an average PM 2·5 indoor concentration of 135 μg/m 3 (117-153), with a rural average of 174 μg/m 3 (154-195) and an urban average of 71 μg/m 3 (63-80). Using time-weighted HAP-PM 2·5 indoor concentrations, the attributable premature death rate (per 100 000 population) from the use of polluting solid fuels at the national level is on average 78 (95% CI 72-84), the rural average being 84 (78-91) and the urban average 60 (54-66). From the use of clean fuels, the average attributable premature death rate (per 100 000 population) at the national level is 59 (53-64), the rural average being 68 (62-74) and the urban average 45 (41-50)., Interpretation: A shift from polluting to clean fuels can reduce the average PM 2·5 personal exposure by 53% and thereby lower the death rate. For all fuel types, the estimated average HAP-PM 2·5 personal exposure and indoor concentrations exceed the WHO's Interim Target-1 average annual threshold. Policy interventions are urgently needed to greatly increase the use of clean fuels and stove technologies by 2030 to achieve the goal of affordable clean energy access, as set by the UN in 2015, and address health inequities in urban-rural settings., Funding: Wellcome Trust, The Lancet Countdown, the Engineering and Physical Sciences Research Council, and the Natural Environment Research Council., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Air pollution is one of the most harmful consequences of China's rapid economic development and urbanization. Particularly in the Beijing-Tianjin-Hebei (BTH) regions, particulate matter concentrations have consistently exceeded the national air quality standards. Over the last years, China implemented ambitious measures to reduce emissions from the power, industry and transportation sectors, with notable success during the 11th and 12th Five Year Plan (FYP) periods. However, such strategies appear to be insufficient to reduce the ambient PM 2.5 concentration below the National Air Quality Standard of 35 μg m -3 across the BTH region within the next 15 years. We find that a comprehensive mitigation strategy for the residential sector in the BTH region would deliver substantial air quality benefits. Beyond the already planned expansion of district heating and natural gas distribution in urban centers and the foreseen curtailment of coal use for households, such a strategy would redirect some natural gas from power generation units towards the residential sector. Rural households would replace biomass for cooking by liquid petroleum gas (LPG) and electricity, and substitute coal for heating by briquettes. Jointly, these measures could reduce the primary PM 2.5 and SO 2 emissions by 28% and 11%, respectively, and the population-weighted PM 2.5 concentrations by 13%, i.e., from 68 μg m -3 to 59 μg m -3 . We estimate that such a strategy would reduce premature deaths attributable to ambient and indoor air pollution by almost one third., (Copyright © 2018 Elsevier Ltd. All rights reserved.)