**Background:** Air pollution is the sixth highest risk factor for attributable disability-adjusted life-years (DALYs) in North Africa and the Middle East. This study aimed to investigate the effect of high ambient particulate matter less than 2.5 μm in size (PM) and ambient ozone air pollution on disease burden, mortality, and life expectancy in 21 countries in the North Africa and the Middle East super-region from 1990 to 2019 using the Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study estimates.
**Methods:** The study data were derived from GBD 2019, examining data from 1999 to 2019 in North Africa and the Middle East. The types of air pollution investigated included PM pollution (household air pollution from solid fuels and ambient PM pollution) and ambient ozone pollution. The burden attributable to each risk factor was incorporated in the population attributable fraction to estimate total attributable deaths and DALYs. The summary exposure value (SEV) was extracted to compare the distribution of excess risk times the exposure level. The effect of air pollution on life expectancy was estimated via a cause-deleted life table analysis.
**Key Results:** In 2019, a total of 398,559 (95% UI 339,434–463,723) deaths were attributed to air pollution, accounting for 12.8% (11.6–14.2%) of all deaths in the super-region. 391,042 (98.1%) of these deaths were attributable to PM pollution. The age-standardized death rate attributable to air pollution decreased by 37.6%, from 158.3 (139.1–177.8) to 98.8 (84.7–114.7) per 100,000 from 1990 to 2019. A total of 13,056,864 (11,145,813–15,128,048) DALYs were attributed to air pollution in 2019, accounting for 8.0% (7.0–9.1%) of all DALYs. Age-standardized DALYs rate attributable to air pollution declined by 44.5%, from 4884.2 (4381.5–5555.4) to 2710.4 (2317.3–3125.6) per 100,000 from 1990 to 2019. 98.9% of the DALYs from air pollution were attributable to PM pollution. Afghanistan (6992.3, 5627.7–8482.7), Yemen (4212.4, 3241.3–5418.1), and Egypt (4034.8, 3027.7–5138.6) had the highest age-standardized DALYs rates attributable to air pollution in 2019, whereas Türkiye (1329.2, 1033.7–1654.7), Jordan (1447.3, 1154.2–1758.5), and Iran (1603.0, 1404.7–1813.8) had the lowest rates. The age-standardized SEV of air pollution decreased by 10.9% (5.8–17.7%) in the super-region, while the SEV of ambient ozone pollution increased by 7.7% (0.7–14.3%). Among PM components, the SEV of ambient PM pollution increased by 40.1% (25.2–63.7%), while household air pollution SEV decreased by 70.6% (64.1–77.0%). If air pollution had been lowered to the theoretical minimum risk exposure levels for 2019, average life expectancy would have been 1.6 years higher, with the most substantial effect in Afghanistan (2.3 years), Sudan (2.2 years), and Egypt (2.0 years).
**Clinical Implications:** The burden attributable to air pollution substantially decreased across the super-region, but most of the burden is from PM pollution, exposure to which has substantially increased. Interventions and policies that reduce population exposure to PM pollution could potentially increase average life expectancy. The cause-specific burden was notable, with 34.5% of COPD deaths, 25.1% of lower respiratory infection deaths, and 24.9% of stroke deaths attributable to air pollution in 2019. These findings call for concerted efforts from governments and public health authorities to tackle air pollution as an important threat to population health, particularly in countries with high burden like Afghanistan, Yemen, and Egypt.