BACKGROUND: Temperature variability (TV) is associated with increased mortality risk. However, it is still unknown whether intra-day or inter-day TV has different effects. OBJECTIVES: We aimed to assess the association of intra-day TV and inter-day TV with all-cause, cardiovascular, and respiratory mortality. METHODS: We collected data on total, cardiovascular, and respiratory mortality and meteorology from 758 locations in 47 countries or regions from 1972 to 2020. We defined inter-day TV as the standard deviation (SD) of daily mean temperatures across the lag interval, and intra-day TV as the average SD of minimum and maximum temperatures on each day. In the first stage, inter-day and intra-day TVs were modelled simultaneously in the quasi-Poisson time-series model for each location. In the second stage, a multi-level analysis was used to pool the location-specific estimates. RESULTS: Overall, the mortality risk due to each interquartile range [IQR] increase was higher for intra-day TV than for inter-day TV. The risk increased by 0.59% (95% confidence interval [CI]: 0.53, 0.65) for all-cause mortality, 0.64% (95% CI: 0.56, 0.73) for cardiovascular mortality, and 0.65% (95% CI: 0.49, 0.80) for respiratory mortality per IQR increase in intra-day TV0-7 (0.9 °C). An IQR increase in inter-day TV0-7 (1.6 °C) was associated with 0.22% (95% CI: 0.18, 0.26) increase in all-cause mortality, 0.44% (95% CI: 0.37, 0.50) increase in cardiovascular mortality, and 0.31% (95% CI: 0.21, 0.41) increase in respiratory mortality. The proportion of all-cause deaths attributable to intra-day TV0-7 and inter-day TV0-7 was 1.45% and 0.35%, respectively. The mortality risks varied by lag interval, climate area, season, and climate type. CONCLUSIONS: Our results indicated that intra-day TV may explain the main part of the mortality risk related to TV and suggested that comprehensive evaluations should be proposed in more countries to help protect human health.

Braun School of Public Health and Community Medicine The Hebrew University of Jerusalem Israel

Center for Climate Change Adaptation National Institute for Environmental Studies Tsukuba Japan

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

CIBER of Epidemiology and Public Health Madrid Spain; Department of Geography University of Santiago de Compostela Santiago de Compostela Spain

Climate Air Quality Research Unit School of Public Health and Preventive Medicine Monash University Melbourne Australia

Department of Earth Sciences University of Torino Turin Italy

Department of Environmental Health Faculty of Public Health University of Medicine and Pharmacy at Ho Chi Minh City Ho Chi Minh City Viet Nam

Department of Environmental Health Harvard T H Chan School of Public Health Harvard University Boston MA USA

Department of Environmental Health National Institute of Public Health Cuernavaca Morelos Mexico

Department of Environmental Health School of Public Health Fudan University Shanghai China

Department of Environmental Health University of São Paulo São Paulo Brazil

Department of Epidemiology Instituto Nacional de Saúde Dr Ricardo Jorge Porto Portugal; Centro de Investigação em Saúde Pública Escola Nacional de Saúde Pública Universidade NOVA de Lisboa Lisbon Portugal

Department of Epidemiology Lazio Regional Health Service Rome Italy

Department of Global Environmental Health Graduate School of Medicine University of Tokyo Tokyo Japan

Department of Global Health Policy Graduate School of Medicine The University of Tokyo Tokyo Japan

Department of Hygiene Epidemiology and Medical Statistics National and Kapodistrian University of Athens Athens Greece

Department of Hygiene Epidemiology and Medical Statistics National and Kapodistrian University of Athens Athens Greece; School of Population Health and Environmental Sciences King's College London London UK

Department of Pathology Faculty of Medicine University of São Paulo Brazil

Department of Public Health and Clinical Medicine Umeå University Umeå Sweden

Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London UK

Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London UK; Centre for Statistical Methodology London School of Hygiene and Tropical Medicine London UK; Centre on Climate Change and Planetary Health London School of Hygiene and Tropical Medicine London UK

Department of Public Health Environments and Society London School of Hygiene and Tropical Medicine London UK; Institute of Social and Preventive Medicine University of Bern Bern Switzerland; Oeschger Center for Climate Change Research University of Bern Bern Switzerland

Department of Public Health Universidad de los Andes Santiago Chile

Department of Quantitative Methods School of Medicine University of the Republic Montevideo Uruguay

Department of Statistics and Computational Research Universitat de València València Spain; CIBER of Epidemiology and Public Health Madrid Spain

Department of Statistics Computer Science and Applications G Parenti University of Florence Florence Italy

Environmental Health Department Instituto Nacional de Saúde Dr Ricardo Jorge Porto Portugal; EPIUnit Instituto de Saúde Pública Universidade do Porto Porto Portugal; Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional Porto Portugal

Faculty of Geography and Environmental Sciences Hakim Sabzevari University Sabzevar Iran

Faculty of Geography Babeş Bolyai University Cluj Napoca Romania

Gangarosa Department of Environmental Health Rollins School of Public Health Emory University Atlanta GA USA

Graduate School of Public Health Seoul National University Seoul South Korea

Health Innovation Lab Institute of Tropical Medicine Alexander von Humboldt Universidad Peruana Cayetano Heredia Lima Peru; Scripps Institution of Oceanography University of California San Diego La Jolla CA USA

IBE Chair of Epidemiology LMU Munich Munich Germany; Department of Physical Chemical and Natural Systems Universidad Pablo de Olavide Sevilla Spain

INSPER São Paulo Brazil

Institute for Environment Health and Societies Brunel University London London UK

Institute of Atmospheric Physics Czech Academy of Sciences Prague Czech Republic; Faculty of Environmental Sciences Czech University of Life Sciences Prague Czech Republic

Institute of Environmental Assessment and Water Research Spanish Council for Scientific Research Barcelona Spain; School of Tropical Medicine and Global Health Nagasaki University Nagasaki Japan

Institute of Epidemiology Helmholtz Zentrum München German Research Center for Environmental Health Neuherberg Germany

Institute of Family Medicine and Public Health University of Tartu Tartu Estonia

National Agency for Public Health of the Ministry of Health Labour and Social Protection of the Republic of Moldova Republic of Moldova

National Institute for Public Health and the Environment Centre for Sustainability and Environmental Health Bilthoven Netherlands

National Institute of Environmental Health Science National Health Research Institutes Zhunan Taiwan

National Institute of Environmental Health Science National Health Research Institutes Zhunan Taiwan; Environmental and Occupational Medicine National Taiwan University College of Medicine and NTU Hospital National Taiwan University Taipei Taiwan; Graduate Institute of Environmental and Occupational Health Sciences National Taiwan University College of Public Health National Taiwan University Taipei Taiwan

Norwegian Institute of Public Health Oslo Norway

Santé Publique France Department of Environmental and Occupational Health French National Public Health Agency Saint Maurice France

School of Epidemiology and Public Health Faculty of Medicine University of Ottawa Ottawa ON Canada; Air Health Science Division Health Canada Ottawa ON Canada

School of Physics Technological University Dublin Dublin Ireland

School of the Environment Yale University New Haven CT USA

School of the Environment Yale University New Haven CT USA; Department of Occupational and Environmental Medicine School of Medicine Ewha Womans University Seoul South Korea

School of Tropical Medicine and Global Health Nagasaki University Nagasaki Japan

Shanghai Children's Medical Centre Shanghai Jiao Tong University Shanghai China; School of Public Health Institute of Environment and Population Health Anhui Medical University Hefei China; Center for Global Health Nanjing Medical University Nanjing China; School of Public Health and Social Work Queensland University of Technology Brisbane Australia

Swiss Tropical and Public Health Institute Basel Switzerland; University of Basel Basel Switzerland

Universidad de Buenos Aires Facultad de Ciencias Sociales Instituto de Investigaciones Gino Germani Buenos Aires Argentina

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