BACKGROUND: Trihalomethanes (THMs) are widespread disinfection by-products (DBPs) in drinking water, and long-term exposure has been consistently associated with increased bladder cancer risk. OBJECTIVE: We assessed THM levels in drinking water in the European Union as a marker of DBP exposure and estimated the attributable burden of bladder cancer. METHODS: We collected recent annual mean THM levels in municipal drinking water in 28 European countries (EU28) from routine monitoring records. We estimated a linear exposure-response function for average residential THM levels and bladder cancer by pooling data from studies included in the largest international pooled analysis published to date in order to estimate odds ratios (ORs) for bladder cancer associated with the mean THM level in each country (relative to no exposure), population-attributable fraction (PAF), and number of attributable bladder cancer cases in different scenarios using incidence rates and population from the Global Burden of Disease study of 2016. RESULTS: We obtained 2005-2018 THM data from EU26, covering 75% of the population. Data coverage and accuracy were heterogeneous among countries. The estimated population-weighted mean THM level was 11.7μg/L [standard deviation (SD) of 11.2]. The estimated bladder cancer PAF was 4.9% [95% confidence interval (CI): 2.5, 7.1] overall (range: 0-23%), accounting for 6,561 (95% CI: 3,389, 9,537) bladder cancer cases per year. Denmark and the Netherlands had the lowest PAF (0.0% each), while Cyprus (23.2%), Malta (17.9%), and Ireland (17.2%) had the highest among EU26. In the scenario where no country would exceed the current EU mean, 2,868 (95% CI: 1,522, 4,060; 43%) annual attributable bladder cancer cases could potentially be avoided. DISCUSSION: Efforts have been made to reduce THM levels in the European Union. However, assuming a causal association, current levels in certain countries still could lead to a considerable burden of bladder cancer that could potentially be avoided by optimizing water treatment, disinfection, and distribution practices, among other possible measures. https://doi.org/10.1289/EHP4495.

Center for Environmental and Respiratory Health Research University of Oulu Oulu Finland

CIBER Epidemiologia y Salud Pública Madrid Spain

Cranfield Water Science Institute Cranfield University Cranfield Bedford UK

Department of Biomedical Metabolic and Neural Sciences University of Modena and Reggio Emilia Modena Italy

Department of Environmental Epidemiology Nofer Institute of Occupational Medicine Lodz Poland

Department of Environmental Sciences Faculty of Natural Sciences Vytautas Magnus University Kaunas Lithuania

Department of Public Health Section for Environment Occupation and Health Aarhus University Aarhus Denmark

Environmental Analytical Chemistry Center for Applied Geosciences Eberhard Karls University Tuebingen Tuebingen Germany

Environmental Chemical Processes Laboratory Department of Chemistry University of Crete Heraklion Greece

Geological Survey of Denmark and Greenland Aarhus Denmark

Hospital del Mar Medical Research Institute Barcelona Spain

Imperial College of London London UK

ISGlobal Barcelona Spain

London School of Hygiene and Tropical Medicine London UK

National Centre for Register based Research Aarhus University Aarhus Denmark

National Institute of Public Health Ljubljana Slovenia

National Institute of Public Health Prague Czech Republic

National Public Health Center Budapest Hungary

Public Health Authority of the Slovak Republic Bratislava Slovak Republic

Public Health Department Estonian Ministry of Social Affairs Tallinn Estonia

Public Health Division Ministry of Health of the Republic Latvia Health Inspectorate Riga Latvia

Santé Publique France Saint Maurice France

Service Public de Wallonie Direction générale de l'Agriculture des Ressources naturelles et de l'Environnement Département de l'Environnement et de l'Eau Jambes Belgium

The Cyprus Institute Aglantzia Nicosia Cyprus

Universitat Pompeu Fabra Barcelona Spain

Université de Rennes Institut national de la santé et de la recherche médicale Rennes France

Water and Health Laboratory Cyprus International Institute for Environmental and Public Health Cyprus University of Technology Limassol Cyprus

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