Project summary In low- and middle-income countries ~2.8 billion people are exposed daily to smoke from cooking fires, termed household air pollution (HAP), resulting in an estimated 2.3M deaths and 91.4M DALYs in 2019. The largest proportion of HAP-attributable deaths are due to cardiovascular disease. Establishment of cardiovascular health in childhood is critical to reduce risk for future cardiovascular disease. We hypothesize that early life (prenatal to age 1) exposure to HAP alters cardiovascular development and programs future disease risk. We further hypothesize that the metal composition of air pollution drives toxicity. We propose to build on an existing pregnancy cohort in Ghana – the Ghana Randomized Air Pollution and Health Study, or GRAPHS – to assess how early life air pollution exposure and metals exposures affect cardiovascular health through age 12 years. We will use well-established, validated methods to assess these outcomes. In the long run, our research will help build the evidence base for cost effective interventions to improve health by reducing HAP exposure.