To investigate (1) the effects of indoor incense burning upon cognition over 3 years; (2) the associations between indoor incense burning with the brain's structure and functional connectivity of the default mode network (DMN); and (3) the interactions between indoor incense burning and vascular disease markers upon cognitive functions. Community older adults without stroke or dementia were recruited (n = 515). Indoor incense use was self-reported as having burnt incense at home ≥ weekly basis over the past 5 years. Detailed neuropsychological battery was administered at baseline (n = 227) and the Montreal Cognitive Assessment at baseline and year 3 (n = 515). MRI structural measures and functional connectivity of the DMN were recorded at baseline. Demographic and vascular risk factors and levels of outdoor pollutants were treated as covariates. Indoor incense burning was associated with reduced performance across multiple cognitive domains at baseline and year 3 as well as decreased connectivity in the DMN. It interacted with diabetes mellitus, hyperlipidemia and white matter hyperintensities to predict poorer cognitive performance. Indoor incense burning is (1) associated with poorer cognitive performance over 3 years; (2) related to decreased brain connectivity; and (3) it interacts with vascular disease to predispose poor cognitive performance. Incense burning is a religious ritual commonly practised in many cultures and is popular among older adults. Incense comes in many forms, with 'joss sticks' being the commonest choice for home use (Fig. 1). Incense is made up of a mixture of fragrance materials and herbal, wood and adhesive powder 1. When incense is burnt, pollutants including particulate matter (PM), carbon monoxide (CO), carbon dioxide (CO 2), sulfur dioxide (SO 2), nitrogen dioxide (NO 2), volatile organic compounds, aldehydes and polycyclic aromatic hydrocarbons (PAHs) are released into the air 1,2. Incense burning is considered a major source of indoor air pollution; the amount of PM generated by incense can be up to 4.5 times of that by cigarettes 2. Incense smoke is associated with carcinogenicity, increased cardiovascular mortality and respiratory conditions 1,3-5. Although there is currently a lack of published data showing a direct link between incense burning with cognitive and brain health, air pollution research suggests that pollutants emitted from incense smoke are associated with accelerated cognitive aging, intellectual decline and an increased risk for Alzheimer's Disease (AD) and vascular dementia 6-11. Moreover, long term exposure to air pollution is associated with smaller total brain volume and volume in prefrontal cortex, white matter and associations areas in frontal, temporal regions and corpus callosum. It is also related to the development of