The data used for this analysis were aggregated and had no identifiable information about the study subjects. Therefore, this study did not require research ethics committee approval.

This study selected all 129 county-level mortality monitoring sites in Yunnan Province, Southwest China, using 16 prefecture-level cities as units of analysis (Figure 1). Yunnan Province belongs to the subtropical plateau monsoon climate zone, with remarkable 3D climate, various climate types, minor annual temperature differences, sizable daily temperature differences, and distinct wet and dry seasons. Additionally, the temperature changes vertically with terrain height.

The study compiled all-cause mortality data for residents across all 129 counties in Yunnan Province from January 1, 2014, to December 31, 2020, using the Yunnan Centre for Disease Control and Prevention’s death registration reporting system. To define the 5 causes of death [23,34], we used codes from the International Classification of Diseases, 10th Revision, namely total nonaccidental deaths [A00–R99], cardiovascular disease [I00–I99], heart disease [I00–I51], stroke [I60–I69], and respiratory disease [J00–J99]. Furthermore, total nonaccidental deaths were classified according to age (<75 or ≥75 years), sex (male or female), occupation (farmer, staff, or other), ethnicity (Han nationality or ethnic minorities), marital status (married or nonmarried), and education level (junior college and above or below junior college).

Daily meteorological data for the corresponding period were acquired from the China Meteorological Data Sharing System, encompassing parameters such as mean temperature, wind speed, atmospheric pressure, relative humidity, and sunshine duration. The geographical and social characteristics of the 16 prefecture-level administrative regions during the same period were extracted from the China Statistical Yearbook and the Yunnan Statistical Yearbook. These characteristics encompassed geographical indicators (eg, latitude, longitude, and altitude), demographic indicators (eg, population density, natural population growth rate, and urbanization rate), economic indicators (eg, gross domestic product [GDP] per capita, GDP growth rate, and employment rate), and health resources (eg, the number of health technicians and hospital beds per 1000 population).

The Chinese national life expectancy table (Multimedia Appendix 1), accessible from the World Health Organization’s Global Health Observatory, offers age-specific life expectancy data for male and female individuals nationwide from 2010 to 2019. Drawing on prior research [35,36], life expectancy for the 2014‐2020 period was estimated by averaging the values from 2010 and 2019. The calculation of YLL for each death involved aligning age and sex with the reference life expectancy table, followed by the summation of YLL for all deaths on a given day to derive the daily YLL.

A 3-stage analysis method widely used in previous studies [37,38] was used to estimate the association between mean temperature and YLL. The district map of Yunnan Province was drawn with ArcGIS (version 10.8; Esri). All analyses were performed with R (version 4.1.0; R Foundation for Statistical Computing), using the packages “dlnm” and “mvmeta.” Two-sided P<.05 was considered statistically significant.

The basic characteristics of the daily number of nonaccidental deaths in Yunnan Province from 2014 to 2020 are shown in Multimedia Appendix 2. The description results of daily YLL and weather conditions in Yunnan Province from 2014 to 2020 are shown in Table 1. The average daily YLL due to nonaccidental deaths was 546.1 person-years: 322.7 person-years were for men and 223.4 for women. Within the specific cause of death subgroups, the average daily YLL was 196.3 person-years for cardiovascular disease, 82.3 for respiratory disease, 87.7 for heart disease, and 98.6 for stroke. The daily mean temperature was 17.4 ℃, ranging from −4.8 ℃ to 29.3 ℃. The mean values for air pressure, relative humidity, wind speed, and sunshine hours were 844.4 hPa, 71.6%, 1.8 m/s, and 5.7 hours, respectively. The overall cumulative exposure-response curves (best linear unbiased prediction) for the 16 prefecture-level cities, as well as the distribution of temperatures, are shown in Multimedia Appendix 3.

Figure 2 depicts the time series curves for the number of nonaccidental deaths, YLL per day, and daily mean temperature for the 2014‐2020 period. the average daily nonaccidental deaths and daily life expectancy loss show a gradual annual increase, with relatively high values in January and December. There was a clear seasonality in the daily mean temperature, with relatively constant peaks each year—low peaks in January and December and from June to August.

We conducted sensitivity analyses to assess the robustness of the specified parameters in the model. Variations, such as changing the maximum lag to 14 or 28 days and adjusting the degrees of freedom for the time variable to 6/year or 8/year as well as for the meteorological variable to 2 or 4, did not yield a significant difference in the AF related to YLL for nonaccidental deaths concerning the temperature exposure indicator (Multimedia Appendix 4). Thus, the model demonstrated relative robustness.

Using data from 16 prefecture-level cities of Yunnan Province, China, this province-wide research assessed the mortality burden attributable to temperature and further estimated its spatial heterogeneity. In general, the cumulative effects of ambient temperature on YLL for nonaccidental deaths were nonlinear, with cold exposure contributing significantly to YLL. Moreover, geographic factors, sociodemographic information, economic status, and health resources were potential causes of spatial heterogeneity in the effect of ambient temperature on the mortality burden.

Our findings showed that temperature was responsible for a significant proportion of YLL, corresponding to 7.45% of the mortality burden during the study period. As compared with high temperature, most of the mortality burden was due to exposure to low temperature (4.61% vs 2.84%), consistent with findings from previous multicity mortality studies [9,34,36,38]. Moreover, in the association between mean temperature and YLL, the effect estimates were higher for cold exposure than heat. The estimate of the YLL fraction attributable to ambient temperature was much lower than that reported in a previous study in Shenzhen (17.28%) [34]. This discrepancy may be explained by the special geographic location and climate of Yunnan province. Yunnan Province had a distinct subtropical plateau monsoon climate, displaying a low seasonal variation in temperature. Hence, temperature may have less effect on residents of Yunnan Province than those living in other areas. Additionally, improving the health monitoring system to promptly observe temperature variations and monitor the population’s health status is recommended. This facilitates early anomaly detection, enabling timely implementation of preventive and therapeutic interventions.

Several studies have investigated the mortality burden of temperature on different causes of death [22,23,50,51]. By comparing the AF and YLL effect values of temperature on different causes of death, we found that the effects of temperature, especially cold, were more pronounced for cardiovascular than respiratory disease, which is consistent with previous studies [35,52]. The effect of cold exposure on cardiovascular system is usually due to potential complications associated with increased cardiovascular risk related to changes in the autonomic nervous system, blood pressure, inflammatory response, and oxidative stress [53,54]. The effect of cold exposure on the respiratory system might be due to increased respiratory infections in cold days [55]. In cardiovascular disease, the increase in mortality burden from heart disease and stroke was associated with ambient air temperature, and the attributable risk and YLL effect estimates for mean air temperature were higher for heart disease compared to stroke.

In comparison with prior studies conducted in Yunnan Province, our research revealed that cardiovascular disease was also affected by daily temperature changes [32]. This discovery contributes to a more nuanced understanding of the interplay between meteorological factors and cardiovascular as well as cerebrovascular disease, offering valuable insights for preventing and managing these health issues. Diverging from the findings of other investigations, we found that the influence of heat exposure on cardiovascular and respiratory disease lacked statistical significance. This discrepancy may be attributed to the distinctive temperature distribution in Yunnan, where the maximum temperature reached only 29.3 °C during the study period. In contrast, national and Shenzhen-based time series studies, with maximum temperatures reaching 35.6 °C and 33 °C, respectively, confirm the significant impact of heat exposure on these diseases [34,50]. Future research should consider a broader temperature gradient to ensure more comprehensive and comparable results. According to the study findings, it is advisable to disseminate information regarding the health effects of temperature fluctuations and educate the public on adopting suitable precautionary measures, particularly during extreme temperatures, to mitigate health risks. Moreover, improving the health monitoring system to promptly observe temperature variations and monitor the population’s health status is recommended. This facilitates early anomaly detection, enabling timely implementation of preventive and therapeutic interventions.

Numerous studies have shown that demographic characteristics are essential modifiers of the association between mean temperature and health [56,57]. In our study, we analyzed the modifying effects of potential confounders, such as sex, age, ethnic group, and occupation, on the effect of identifying susceptible populations to temperature. The mortality burden of temperature was greater for male individuals, people <75 years of age, nonmarried individuals, farmers, and those with an education level below junior college level compared to their corresponding counterparts. Previous research has substantiated that men are susceptible to the effects of cold [34]. This difference in the effect of temperature exposure on the mortality burden by sex may be due to biological differences and socioeconomic factors. Consistent with our findings, numerous studies have identified a higher risk of mortality associated with cold exposure in younger versus older age groups [34,57]. The observed outcome can be attributed to the prevalent practice among most older adults of staying indoors during the cold season to mitigate direct exposure to temperature extremes. Consequently, the difference in the extent and duration of exposure between younger and older age groups is the primary factor contributing to this divergence. We found that ethnic minorities, nonmarried individuals, and farmers were more sensitive to the effects of temperature exposure. Only a few previous studies have analyzed the modifying effects of ethnic group, marital status, and occupation on temperature effects [16,58,59]. Each ethnic group has its culture, food habits, and way of life, so ethnicity is also an essential factor. Compared to married individuals, those who are unmarried tend to engage more in social activities and take part in more outdoor sports. Compared to “staff” or “others,” farmers primarily work outdoors, which exposes them more to ambient temperature and makes them more sensitive to climate change compared to nonfarming populations. Therefore, protective measures are needed to reduce the adverse effects of climate change for outdoors. Additionally, education level is widely recognized as a key indicator of socioeconomic status. Individuals with lower levels of education often experience poorer living conditions and health statuses, engage in riskier behaviors, and have limited access to health care services [36].

This study considered geographical factors, sociodemographic information, economic status, and health resources as potential modifying factors and found spatial heterogeneity in the effect of temperature on the mortality burden across regions. The highest percentage of spatial heterogeneity was due to the urbanization rate. An early study in Zhejiang Province, China, found a rural mortality burden due to cold exposure of up to 16.4%, much higher than the urban estimate of 7.0% [60]. This finding may be due to the urban heat island effect, with urban temperatures noticeably higher than rural temperatures. GDP per capita was this study’s most crucial correction factor. A study of 272 major cities in China found that GDP per capita and urbanization rates could alter the temperature-YLL association and its lag structure [23]. Another study showed a robust adverse effect of temperature on mortality in Asian cities with low GDP, with no significant association observed in cities with a higher GDP [61]. We found that health resources (ie, health technicians per 1000 population and hospital beds per 1000 population) similarly explained some of the heterogeneity in the temperature-YLL association. Areas with adequate health resources have better access to health care for their residents. Differences due to such health resource effects are more difficult to explain because evidence from relevant studies is sparse worldwide. Further epidemiological investigation is needed to elucidate whether and how health resources moderate or change the attributable risk of temperature on mortality.

A significant proportion of the spatial heterogeneity in the effect of mean temperature on YLL could also be attributed to longitude and population density. Available epidemiological evidence suggests that latitude and longitude may modify the association between temperature and mortality [62]. Because geographical coordinates, such as longitude, are usually highly correlated with local climatic characteristics (especially temperature distribution), the modification effect of geographical characteristics can be considered an indirect contribution to climate adaptation [63]. The sensitivity to temperature varies among individuals residing at different latitudes and longitudes. Areas with high population density primarily consist of economically developed cities, urban regions with industrial activities and vehicular emissions contributing to heat exposure, with the combined impact of heat island effects resulting from residential energy consumption and urban building structures. These factors, along with influences on health resources, environmental conditions, and others, can affect the association between temperature and population health [64].

There are some strengths and weaknesses to our study. The strengths include the fact that it was a comprehensive and systematic multicity study that quantified the impact of temperature exposure on the burden of mortality in Yunnan Province, southwestern China. In addition, it was the first study in Yunnan Province to explore the causes of potential heterogeneity from multiple perspectives, including geography, socioeconomic status, and health sources. However, the study had some limitations. First, the results apply only to Yunnan Province, so caution should be exercised when generalizing its findings to other, particularly nonhighland, geographical areas. Second, the study assumed that everyone was exposed to the same mean temperature simultaneously, so there may be some exposure measurement bias. Third, a proportion of the heterogeneity in the results remains unexplained. Because of lack of available data, there may be essential correction factors that we failed to consider, such as vegetation cover, soil characteristics, and public health interventions.

In summary, temperature exposure seems to exert a substantial impact on population health across the 16 prefecture-level administrative regions in Yunnan, particularly affecting individuals with cardiovascular and respiratory diseases. The cumulative effects of ambient temperature on YLL for nonaccidental deaths showed a nonlinear pattern, with cold exposure contributing more significantly than heat exposure to this effect. Specifically, under cold conditions, male individuals, nonmarried individuals, ethnic minorities, and farmers were more susceptible. In addition, after considering the effects of geographic characteristics, sociodemographic information, economic status, and health resources, we observed moderate spatial heterogeneity among the 16 prefecture-level cities in Yunnan Province. The implications of our study extend to both the research domain and the public health policy arena. The insights gained may assist policy makers in formulating effective intervention strategies, fortifying protection measures for vulnerable populations, and forecasting the potential impacts of climate change in this specific region.