*Purpose: Previous studies suggested that air pollution is associate with higher risk of respiratory diseases and accelerated decline in lung function among general population. However, few studies have examined the effect of fine particulate matter (particles <2.5μm in diameter [PM_2.5]) among the population with advanced stage pulmonary diseases. Here we seek to investigate the association between PM_2.5 and waitlist mortality among lung transplant candidates.

*Methods: Lung transplant candidates listed between January 1st 2010 and December 31st 2016 were identified from Scientific Registry of Transplant Recipients. PM_2.5 concentrations for 2010-2016 were obtained from NASA’s SEDAC Global Annual PM_2.5 Grids. Annual PM_2.5 concentration at the year of listing was estimated at each participant’s zip code. We estimated crude and multivariate adjusted hazard ratios (95% confidence intervals [CI]) for waitlist mortality using Cox proportional hazards regression with robust variance.

*Results: Among 16603 candidates with PM_2.5 exposure, median age at listing was 59, 44.4% were female and 81.1% were non-Hispanic white. The median zip code PM_2.5 concentration was 8.94µg/m³. When compared to those who were living in the zip code with lower PM2.5 exposure (PM_2.5 <10.53µg/m³), candidates living in zip codes in the highest quartile of PM_2.5 exposure (PM_2.5 ≥10.53µg/m³) had 1.11 (95%CI 1.01-1.20) times higher hazard of waitlist mortality. The result remained significant after further adjusted for demographics, SES, smoking, disease type, lung allocation score, blood type and life support status at listing [HR 1.12(95%CI 1.02-1.23)].

*Conclusions: In this population of lung transplant candidates, exposure to PM_2.5 was associated with increased risk for waitlist mortality. These findings highlight the importance of considering the contribution of environmental exposures, such as ambient air pollution to long-term outcomes of lung transplant candidates.

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