Which urban land covers/uses are associated with residents' mortality? A cross-sectional, ecological, pan-European study of 233 cities.

​OBJECTIVES: The study aim was to determine whether the range and distribution of all, and proportions of specific, land covers/uses within European cities are associated with city-specific mortality rates. ​SETTING: 233 European cities within 24 countries. ​PARTICIPANTS: Aggregated city-level all-cause and age-group standardised mortality ratio for males and females separately and Western or Eastern European Region. ​RESULTS: The proportion of specific land covers/uses within a city was related to mortality, displaying differences by macroregion and sex. The land covers/uses associated with lower standardised mortality ratio (SMR) for both Western and Eastern European cities were those characterised by 'natural' green space, such as forests and semi-natural areas (Western Female coefficient: -18.3, 95% CI -29.8 to -6.9). Dense housing was related to a higher SMR, most prominently in Western European cities (Western Female coefficient: 17.4, 95% CI 9.6 to 25.2). ​CONCLUSIONS: There is pressure to build on urban natural spaces, both for economic gain and because compact cities are regarded as more sustainable, yet here we offer evidence that doing so may detract from residents' health. Our study suggests that urban planners and developers need to regard retaining more wild and unstructured green space as important for healthy city systems.