The Global Tobacco Epidemic

This paper focuses on the first century of the global tobacco epidemic and its current status, reviewing the current and projected future of the global tobacco epidemic and the steps that are in progress to end it. In the United States and many countries of western Europe, tobacco consumption peaked during the 1960s and 1970s and declined as tobacco control programs were initiated, motivated by the evidence indicting smoking as a leading cause of disease. Despite this policy advancement and the subsequent reductions in tobacco consumption, the global tobacco epidemic continued to grow in the later years of the twentieth century, as the multinational companies sought new markets to replace those shrinking in high-income countries. In response, the World Health Organization developed between 2000 and 2004 its first public health treaty, the Framework Convention on Tobacco Control (FCTC), which entered into force in 2005. An accompanying package of interventions has been implemented. New approaches to tobacco control, including plain packaging and single representation of brands, have been implemented by Australia and Uruguay, respectively, but have been challenged by the tobacco industry

Ozone and Mortality: A Meta-Analysis of Time-Series Studies and Comparison to a Multi-City Study (The National Morbidity, Mortality, and Air Pollution Study)

While many time-series studies of ozone and daily mortality identified positive associations,others yielded null or inconclusive results. We performed a meta-analysis of 144 effect estimates from 39 time-series studies, and estimated pooled effects by lags, age groups,cause-specific mortality, and concentration metrics. We compared results to estimates from the National Morbidity, Mortality, and Air Pollution Study (NMMAPS), a time-series study of 95 large U.S. cities from 1987 to 2000. Both meta-analysis and NMMAPS results provided strong evidence of a short-term association between ozone and mortality, with larger effects for cardiovascular and respiratory mortality, the elderly, and current day ozone exposure as compared to other single day lags. In both analyses, results were not sensitive to adjustment for particulate matter and model specifications. In the meta-analysis we found that a 10 ppb increase in daily ozone is associated with a 0.83 (95% confidence interval: 0.53, 1.12%) increase in total mortality, whereas the corresponding NMMAPS estimate is 0.25%(0.12, 0.39%). Meta-analysis results were consistently larger than those from NMMAPS,indicating publication bias. Additional publication bias is evident regarding the choice of lags in time-series studies, and the larger heterogeneity in posterior city-specific estimates in the meta-analysis, as compared with NMAMPS

Time-Series Studies of Particulate Matter

Studies of air pollution and human health have evolved from descriptive studies of the early phenomena of large increases in adverse health effects following extreme air pollution episodes, to time-series analyses and the development of sophisticated regression models. In fact, advanced statistical methods are necessary to address the many challenges inherent in the detection of a small pollution risk in the presence of many confounders. This paper reviews the history, methods, and findings of the time-series studies estimating health risks associated with short-term exposure to particulate matter, though much of the discussion is applicable to epidemiological studies of air pollution in general. We review the critical role of epidemiological studies in setting regulatory standards and the history of PM epidemiology and time-series analysis. We also summarize recent time-series results and conclude with a discussion of current and future directions of time-series analysis of particulates, including research on mortality displacement and the resolution of results from cohort and time-series studies

MORTALITY IN THE MEDICARE POPULATION AND CHRONIC EXPOSURE TO FINE PARTICULATE AIR POLLUTION

Prospective cohort studies have provided evidence on longer-term mortality risks of fine particulate matter (PM2.5), but due to their complexity and costs, only a few have been conducted. By linking monitoring data to the U.S. Medicare system by county of residence, we developed a retrospective cohort study, the Medicare Air Pollution Cohort Study (MCAPS), comprising over 20 million enrollees in the 250 largest counties during 2000-2002. We estimated log-linear regression models having as outcome the age-specific mortality rate for each county and as the main predictor, the average level for the study period 2000. Area-level covariates were used to adjust for socio-economic status and smoking. We reported results under several degrees of adjustment for spatial confounding and with stratification into by eastern, central and western counties. We estimated that a 10 µg/m3 increase in PM25 is associated with a 7.6% increase in mortality (95% CI: 4.4 to 10.8%). We found a stronger association in the eastern counties than nationally, with no evidence of an association in western counties. When adjusted for spatial confounding, the estimated log-relative risks drop by 50%. We demonstrated the feasibility of using Medicare data to establish cohorts for follow-up for effects of air pollution. Particulate matter (PM) air pollution is a global public health problem (1). In developing countries, levels of airborne particles still reach concentrations at which serious health consequences are well-documented; in developed countries, recent epidemiologic evidence shows continued adverse effects, even though particle levels have declined in the last two decades (2-6). Increased mortality associated with higher levels of PM air pollution has been of particular concern, giving an imperative for stronger protective regulations (7). Evidence on PM and health comes from studies of acute and chronic adverse effects (6). The London Fog of 1952 provides dramatic evidence of the unacceptable short-term risk of extremely high levels of PM air pollution (8-10); multi-site time-series studies of daily mortality show that far lower levels of particles are still associated with short-term risk (5)(11-13). Cohort studies provide complementary evidence on the longer-term risks of PM air pollution, indicating the extent to which exposure reduces life expectancy. The design of these studies involves follow-up of cohorts for mortality over periods of years to decades and an assessment of mortality risk in association with estimated long-term exposure to air pollution (2-4;14-17). Because of the complexity and costs of such studies, only a small number have been conducted. The most rigorously executed, including the Harvard Six Cities Study and the American Cancer Society’s (ACS) Cancer Prevention Study II, have provided generally consistent evidence for an association of long- term exposure to particulate matter air pollution with increased all-cause and cardio-respiratory mortality (2,4,14,15). Results from these studies have been used in risk assessments conducted for setting the U.S. National Ambient Air Quality Standard (NAAQS) for PM and for estimating the global burden of disease attributable to air pollution (18,19). Additional prospective cohort studies are necessary, however, to confirm associations between long-term exposure to PM and mortality, to broaden the populations studied, and to refine estimates by regions across which particle composition varies. Toward this end, we have used data from the U.S. Medicare system, which covers nearly all persons 65 years of age and older in the United States. We linked Medicare mortality data to (particulate matter less than 2.5 µm in aerodynamic diameter) air pollution monitoring data to create a new retrospective cohort study, the Medicare Air Pollution Cohort Study (MCAPS), consisting of 20 million persons from 250 counties and representing about 50% of the US population of elderly living in urban settings. In this paper, we report on the relationship between longer-term exposure to PM2.5 and mortality risk over the period 2000 to 2002 in the MCAPS

A Comparative Analysis of the Chronic Effects of Fine Particulate Matter

The American Cancer Society study (ACS) and the Harvard Six Cities study (SCS) are the two landmark cohort studies for estimating the chronic effects of fine particulate matter PM2.5 on mortality. To date, no comparative analysis of these studies has been carried out using a different study design, study period, data, and modeling approach. In this paper, we estimate the chronic effects of PM on mortality for the period 2000-2002 by using mortality data from Medicare and \PM levels from the National Air Pollution Monitoring Network for the same counties included in the SCS and the ACS. We use a log-linear regression model which controls for individual-level risk factors (age and gender) and area-level covariates (education, income level, poverty and employment). We found that a 10 units increase in the yearly average PM2.5 is associated with 10.9% (95% CI: 9.0, 12.8) and with 20.8% (95% CI: 12.3, 30.0) increase in all-cause mortality by using Medicare data for the ACS and SCS counties. The results are similar to those reported by the original SCS and ACS indicating that fine particulate matter is still significantly associated with mortality when more recent air pollution and mortality data are used. Our findings suggest that national government based data, like the Medicare, are useful for advancing our understanding of the chronic effects of ambient air pollution on health