Original Article
Long-Term Ozone Exposure and Mortality
N Engl J Med 2009; 360:1085-1095March 12, 2009DOI: 10.1056/NEJMoa0803894
- Abstract
Background
Although many studies have linked elevations in tropospheric ozone to adverse health outcomes, the effect of long-term exposure to ozone on air pollution–related mortality remains uncertain. We examined the potential contribution of exposure to ozone to the risk of death from cardiopulmonary causes and specifically to death from respiratory causes.
Methods
Data from the study cohort of the American Cancer Society Cancer Prevention Study II were correlated with air-pollution data from 96 metropolitan statistical areas in the United States. Data were analyzed from 448,850 subjects, with 118,777 deaths in an 18-year follow-up period. Data on daily maximum ozone concentrations were obtained from April 1 to September 30 for the years 1977 through 2000. Data on concentrations of fine particulate matter (particles that are ≤2.5 μm in aerodynamic diameter [PM2.5]) were obtained for the years 1999 and 2000. Associations between ozone concentrations and the risk of death were evaluated with the use of standard and multilevel Cox regression models.
Results
In single-pollutant models, increased concentrations of either PM2.5 or ozone were significantly associated with an increased risk of death from cardiopulmonary causes. In two-pollutant models, PM2.5 was associated with the risk of death from cardiovascular causes, whereas ozone was associated with the risk of death from respiratory causes. The estimated relative risk of death from respiratory causes that was associated with an increment in ozone concentration of 10 ppb was 1.040 (95% confidence interval, 1.010 to 1.067). The association of ozone with the risk of death from respiratory causes was insensitive to adjustment for confounders and to the type of statistical model used.
Conclusions
In this large study, we were not able to detect an effect of ozone on the risk of death from cardiovascular causes when the concentration of PM2.5 was taken into account. We did, however, demonstrate a significant increase in the risk of death from respiratory causes in association with an increase in ozone concentration.
Media in This Article
Figure 1
Ozone Concentrations in the 96 Metropolitan Statistical Areas in Which Members of the American Cancer Society Cohort Resided in 1982.Figure 2
Exposure–Response Curve for the Relation between Exposure to Ozone and the Risk of Death from Respiratory Causes.Article Activity
- Article
Studies conducted over the past 15 years have provided substantial evidence that long-term exposure to air pollution is a risk factor for cardiopulmonary disease and death.1-5 Recent reviews of this literature suggest that fine particulate matter (particles that are ≤2.5 μm in aerodynamic diameter [PM2.5]) has a primary role in these adverse health effects.6,7 The particulate-matter component of air pollution includes complex mixtures of metals, black carbon, sulfates, nitrates, and other direct and indirect byproducts of incomplete combustion and high-temperature industrial processes.
Ozone is a single, well-defined pollutant, yet the effect of exposure to ozone on air pollution–related mortality remains inconclusive. Several studies have evaluated this issue, but they have been short-term studies,8-10 have failed to show a statistically significant effect,1,3 or have been based on limited mortality data.11 Recent reviews by the Environmental Protection Agency (EPA)12 and the National Research Council13 have questioned the overall consistency of the available data correlating exposure to ozone and mortality. Similar conclusions about the evidence base for the long-term effects of ozone on mortality were drawn by a panel of experts in the United Kingdom.14
Nonetheless, previous studies have suggested that a measurable effect of ozone may exist, particularly with respect to the risk of death from cardiopulmonary causes. In one of the larger studies, ozone was significantly associated with death from cardiopulmonary causes15 but not with death from ischemic heart disease. However, the estimated effect of ozone on the risk of death from cardiopulmonary causes in this study was attenuated when PM2.5 was added to the analysis in copollutant models. On the basis of suggested effects of ozone on the risk of death from cardiopulmonary causes (which includes death from respiratory causes) but an absence of evidence for effects of ozone on the risk of death from ischemic heart disease, we hypothesized that ozone might have a primary effect on the risk of death from respiratory causes.
Methods
Health, Mortality, and Confounding Data
Our study used data from the American Cancer Society Cancer Prevention Study II (CPS II) cohort.16 The CPS II cohort consists of more than 1.2 million participants who were enrolled by American Cancer Society volunteers between September 1982 and February 1983 in all 50 states, the District of Columbia, and Puerto Rico. Enrollment was restricted to persons who were at least 30 years of age living in households with at least one person 45 years of age or older. After providing written informed consent, the participants completed a confidential questionnaire that included questions on demographic characteristics, smoking history, alcohol use, diet, and education.17 Deaths were ascertained until August 1988 by personal inquiries of family members by the volunteers and thereafter by linkage with the National Death Index. Through 1995, death certificates were obtained and coded for cause of death. Beginning in 1996, codes for cause of death were provided by the National Death Index.18
The study population for our analysis included only those participants in CPS II who resided in U.S. metropolitan statistical areas within the 48 contiguous states or the District of Columbia (according to their address at the time of enrollment) and for whom data were available from at least one pollution monitor within their metropolitan area. The study was approved by the Ottawa Hospital Research Ethics Board, Canada.
Data on “ecologic” risk factors at the level of the metropolitan area representing social variables (educational level, percentage of homes with air conditioning, percentage of the population who were nonwhite), economic variables (household income, unemployment, income disparity), access to medical care (number of physicians and hospital beds per capita), and meteorologic variables were obtained from the 1980 U.S. Census and other secondary sources (see the Supplementary Appendix, available with the full text of this article at NEJM.org). These ecologic risk factors, as well as the individual risk factors collected in the CPS II questionnaire, were assessed as potential confounders of the effects of ozone.3,5,19,20
Estimates of Exposure to Air Pollution
Ozone data were obtained from 1977 (5 years before the identification of the CPS II cohort) through 2000 for all air-pollution monitors in the study metropolitan areas from the EPA's Aerometric Information Retrieval System. Ozone data at each monitoring site were collected on an hourly basis, and the daily maximum value for the site was determined. All available daily maximum values for the monitoring site were averaged over each quarter year. The quarterly average values were reported for each monitor only when at least 75% of daily observations for that quarter were available.
The averages of the second (April through June) and third (July through September) quarters were calculated for each monitor if both quarterly averages were available. The period from April through September was selected because ozone concentrations tend to be elevated during the warmer seasons and because fewer data were available for the cooler seasons.
The average of the second and third quarterly averages for each year was then computed for all the monitors within each metropolitan area to form a single annual time series of air-pollution measurements for each metropolitan area for the period from 1977 to 2000. In addition, a summary measure of long-term exposure to ambient warm-season ozone was defined as the average of annual time-series measurements during the entire period from 1977 to 2000. Individual measures of exposure to ozone were then defined by assigning the average for the metropolitan area to each cohort member residing in that area.
Data on exposure to PM2.5 were also obtained from the Aerometric Information Retrieval System database for the 2-year period from 1999 to 2000 (data on PM2.5 were not available before 1999 for most metropolitan areas).5 The average concentrations of PM2.5 were included in our analyses to distinguish the effect of particulates from that of ozone on outcomes.
Statistical Analysis
Standard and multilevel random-effects Cox proportional-hazard models were used to assess the risk of death in relation to exposures to pollution. The subjects were matched according to age (in years), sex, and race. A total of 20 variables with 44 terms were used to control for individual characteristics that might confound or modify the association between air pollution and death. These variables, which were considered to be of potential importance on the basis of previous studies, included individual risk factors for which data had been collected in the CPS II questionnaire. Seven ecologic covariates obtained from the 1980 U.S. Census (median household income, the proportion of persons living in households with an income below 125% of the poverty line, the percentage of persons over the age of 16 years who were unemployed, the percentage of adults with less than a high-school [12th-grade] education, the percentage of homes with air conditioning, the Gini coefficient of income inequality [ranging from 0 to 1, with 0 indicating an equal distribution of income and 1 indicating that one person has all the income and everyone else has no income20], and the percentage of persons who were white) were also included. These variables were included at two levels: as the average for the metropolitan statistical area and as the difference between the average for the ZIP Code of residence and the average for the metropolitan statistical area. Additional sensitivity analyses were undertaken for ecologic variables that were available for only a subgroup of the 96 metropolitan statistical areas (see the Supplementary Appendix). Models were estimated for either ozone or PM2.5. In addition, models with both PM2.5 and ozone were estimated.
In additional analyses, our basic Cox models were modified by incorporating an adjustment for community-level random effects, which allowed us to take into account residual variation in mortality among communities.21 The baseline hazard function was modulated by a community-specific random variable representing the residual risk of death for subjects in that community after individual and ecologic risk factors had been controlled for (see the Supplementary Appendix).
A formal analysis was conducted to assess whether a threshold existed for the association between exposure to ozone and the risk of death (see the Supplementary Appendix). A standard threshold model was postulated in which there was no association between exposure to ozone and the risk of death below a specified threshold concentration and a linear association (on the logarithmic scale of the proportional-hazards model) above the threshold.
The question of whether specific time windows were associated with the health effects was investigated by subdividing the follow-up interval into four periods (1982 to 1988, 1989 to 1992, 1993 to 1996, and 1997 to 2000). Exposures were matched for each of these periods and also tested for a 10-year average on the basis of the 5-year follow-up period and the 5 years before the follow-up period (see the Supplementary Appendix).
Results
The analytic cohort included 448,850 subjects residing in 96 metropolitan statistical areas (Figure 1Figure 1
Ozone Concentrations in the 96 Metropolitan Statistical Areas in Which Members of the American Cancer Society Cohort Resided in 1982.). In 1980, the populations of these 96 areas ranged from 94,436 to 8,295,900. Data were available on the concentration of ambient ozone from all 96 areas and on the concentration of PM2.5 from 86 areas. The average number of air-pollution monitors per metropolitan area was 11 (range, 1 to 57), and more than 80% of the areas had 6 or more monitors.The average ozone concentration for each metropolitan area during the interval from 1977 to 2000 ranged from 33.3 ppb to 104.0 ppb (Figure 1). The highest regional concentrations were in Southern California and the lowest in the Pacific Northwest and parts of the Great Plains. Moderately elevated concentrations were present in many areas of the East, Midwest, South, and Southwest.
The baseline characteristics of the study population, overall and as a function of exposure to ozone, are presented in Table 1Table 1
Baseline Characteristics of the Study Population in the Entire Cohort and According to Exposure to Ozone.. The mean age of the cohort was 56.6 years, 43.4% were men, 93.7% were white, 22.4% were current smokers, and 30.5% were former smokers. On the basis of estimates from 1980 Census data, 62.3% of homes had air conditioning at the time of initial data collection.During the 18-year follow-up period (from initial CPS II data collection in 1982 through the end of follow-up in 2000), there were 118,777 deaths in the study cohort (Table 2Table 2
Number of Deaths in the Entire Cohort and According to Exposure to Ozone.). Of these, 58,775 were from cardiopulmonary causes, including 48,884 from cardiovascular causes (of which 27,642 were due to ischemic heart disease) and 9891 from respiratory causes.In the single-pollutant models, exposure to ozone was not associated with the overall risk of death (relative risk, 1.001; 95% confidence interval [CI], 0.996 to 1.007) (Table 3Table 3
Relative Risk of Death Attributable to a 10-ppb Change in the Ambient Ozone Concentration.). However, it was significantly correlated with an increase in the risk of death from cardiopulmonary causes. A 10-ppb increment in exposure to ozone elevated the relative risk of death from the following causes: cardiopulmonary causes (relative risk, 1.014; 95% CI, 1.007 to 1.022), cardiovascular causes (relative risk, 1.011; 95% CI, 1.003 to 1.023), ischemic heart disease (relative risk, 1.015; 95% CI, 1.003 to 1.026), and respiratory causes (relative risk, 1.029; 95% CI, 1.010 to 1.048). Inclusion of the concentration of PM2.5 measured in 1999 and 2000 as a copollutant (Table 3) attenuated the association with exposure to ozone for all the end points except death from respiratory causes, for which a significant correlation persisted (relative risk, 1.040; 95% CI, 1.013 to 1.067). The concentrations of ozone and PM2.5 were positively correlated (r=0.64 at the subject level and r=0.56 at the metropolitan-area level), resulting in unstable risk estimates for both pollutants. The concentration of PM2.5 remained significantly associated with death from cardiopulmonary causes, cardiovascular causes, and ischemic heart disease when ozone was included in the model. The association of ozone concentrations with death from respiratory causes remained significant after adjustment for PM2.5.
Risk estimates for ozone-related death from respiratory causes were insensitive to the use of a random-effects survival model allowing for spatial clustering within the metropolitan area and state of residence (Table 1S in the Supplementary Appendix). The association between increased ozone concentrations and increased risk of death from respiratory causes was also insensitive to adjustment for several ecologic variables considered individually (Table 2S in the Supplementary Appendix).
Subgroup analyses showed that environmental temperature and region of the country, but not sex, age at enrollment, body-mass index, education, or concentration of PM2.5, significantly modified the effects of ozone on the risk of death from respiratory causes (Table 4Table 4
Relative Risk of Death from Respiratory Causes Attributable to a 10-ppb Change in the Ambient Ozone Concentration, Stratified According to Selected Risk Factors.).Figure 2Figure 2
Exposure–Response Curve for the Relation between Exposure to Ozone and the Risk of Death from Respiratory Causes. illustrates the shape of the relation between exposure to ozone and death from respiratory causes. There was limited evidence that a threshold model specification improved model fit as compared with a nonthreshold linear model (P=0.06) (Table 3S in the Supplementary Appendix).Because air-pollution data from 1977 to 2000 were averaged, exposure values for persons who died during this period are based partly on data that were obtained after death had occurred. Further investigation by dividing this interval into specific time windows of exposure revealed no significant difference between the effects of earlier and later time windows within the period of follow-up. Allowing for a 10-year period of exposure to ozone (5 years of follow-up and 5 years before the follow-up period) did not appreciably alter the risk estimates (Table 4S in the Supplementary Appendix). Thus, when exposure values were matched more closely to the follow-up period and when exposure values were based on data obtained before the deaths, there was little change in the results.
Discussion
Our principal finding is that ozone and PM2.5 contributed independently to increased annual mortality rates in this large, U.S. cohort study in analyses that controlled for many individual and ecologic risk factors. In two-pollutant models that included ozone and PM2.5, ozone was significantly associated only with death from respiratory causes.
For every 10-ppb increase in exposure to ozone, we observed an increase in the risk of death from respiratory causes of about 2.9% in single-pollutant models and 4% in two-pollutant models. Although this increase may appear moderate, the risk of dying from a respiratory cause is more than three times as great in the metropolitan areas with the highest ozone concentrations as in those with the lowest ozone concentrations. The effects of ozone on the risk of death from respiratory causes were insensitive to adjustment for individual, neighborhood, and metropolitan-area confounders or to differences in multilevel-model specifications.
There is biologic plausibility for a respiratory effect of ozone. In laboratory studies, ozone can increase airway inflammation24 and can worsen pulmonary function and gas exchange.25 In addition, exposure to elevated concentrations of tropospheric ozone has been associated with numerous adverse health effects, including the induction26 and exacerbation27,28 of asthma, pulmonary dysfunction,29,30 and hospitalization for respiratory causes.31
Despite these observations, previous studies linking long-term exposure to ozone with death have been inconclusive. One cohort study conducted in the Midwest and eastern United States reported an inverse but nonsignificant association between ozone concentrations and mortality.1 Subsequent reanalyses of this study replicated these findings but also suggested a positive association with exposure to ozone during warm seasons.3 A study of approximately 6000 nonsmoking Seventh-Day Adventists living in Southern California showed elevated risks among men after long-term exposure to ozone,11 but this finding was based on limited mortality data.
Previous studies using the CPS II cohort have also produced mixed results for ozone. An earlier examination based on a large sample of more than 500,000 people from 117 metropolitan areas and 8 years of follow-up indicated nonsignificant results for the relation between ozone and death from any cause and a significant inverse association between ozone and death from lung cancer. A positive association between death from cardiopulmonary causes and summertime exposure to ozone was observed in single-pollutant models, but the association with ozone was nonsignificant in two-pollutant models.3 Further analyses based on 16 years of follow-up in 134 cities produced similarly elevated but nonsignificant associations that were suggestive of effects of summertime (July to September) exposure to ozone on death from cardiopulmonary causes.5
The increase in deaths from respiratory causes with increasing exposure to ozone may represent a combination of short-term effects of ozone on susceptible subjects who have influenza or pneumonia and long-term effects on the respiratory system caused by airway inflammation,24 with subsequent loss of lung function in childhood,32 young adulthood,33,34 and possibly later life.35 If exposure to ozone accelerates the natural loss of adult lung function with age, those exposed to higher concentrations of ozone would be at greater risk of dying from a respiratory-related syndrome.
In our two-pollutant models, the adjusted estimates of relative risk for the effect of ozone on the risk of death from cardiovascular causes were significantly less than 1.0, seemingly suggesting a protective effect. Such a beneficial influence of ozone, however, is unlikely from a biologic standpoint. The association of ozone with cardiovascular end points was sensitive to adjustment for exposure to PM2.5, making it difficult to determine precisely the independent contributions of these copollutants to the risk of death. There was notable collinearity between the concentrations of ozone and PM2.5.
Furthermore, measurement at central monitors probably represents population exposure to PM2.5 more accurately than it represents exposure to ozone. Ozone concentration tends to vary spatially within cities more than does PM2.5 concentration, because of scavenging of ozone by nitrogen oxide near roadways.36 In the presence of a high density of local traffic, the measurement error is probably higher for exposure to ozone than for exposure to PM2.5. The effects of ozone could therefore be confounded by the presence of PM2.5 because of collinearity between the measurements of the two pollutants and the higher precision of measurements of PM2.5.37
Measurements of PM2.5 were available only for the end of the study follow-up period (1999 and 2000). Widespread collection of these data began only after the EPA adopted regulatory limits on such particulates in 1997. Since particulate air pollution has probably decreased in most metropolitan areas during the follow-up interval of our study, it is likely that we have underestimated the effect of PM2.5 in our analysis.
A limitation of our study is that we were not able to account for the geographic mobility of the population during the follow-up period. We had information on home addresses for the CPS II cohort only at the time of initial enrollment in 1982 and 1983. Census data indicate that during the interval between 1982 and 2000, approximately 2 to 3% of the population moved from one state to another annually (with the highest rates in an age group younger than that of our study population).38 However, any bias due to a failure to account for geographic mobility is likely to have attenuated, rather than exaggerated, the effects of ozone on mortality.
In summary, we investigated the effect of tropospheric ozone on the risk of death from any cause and cause-specific death in a large cohort, using data from 96 metropolitan statistical areas across the United States and controlling for the effect of particulate air pollutants. We were unable to detect a significant effect of exposure to ozone on the risk of death from cardiovascular causes when particulates were taken into account, but we did demonstrate a significant effect of exposure to ozone on the risk of death from respiratory causes.
Supported by the Health Effects Institute.
Dr. Krewski reports receiving grant support from the Natural Sciences and Engineering Research Council of Canada as holder of the Industrial Research Chair in Risk Science. This chair is funded by a peer-reviewed university–industry partnership program. No other potential conflict of interest relevant to this article was reported.
We thank the National Institute of Environmental Health Sciences for providing grant support (ES00260) to the New York University School of Medicine.
This article is dedicated to the memory of our coauthor and friend, Dr. Jeanne Calle, who died unexpectedly on February 17, 2009.
Source Information
From the University of California, Berkeley (M.J.); Health Canada, Ottawa (R.T.B.); Brigham Young University, Provo, UT (C.A.P.); New York University School of Medicine, New York (K.I., G.T.); the University of Ottawa, Ottawa (D.K., Y.S.); and the American Cancer Society, Atlanta (E.C., M.T.).
Address reprint requests to Dr. Jerrett at the Division of Environmental Health Sciences, School of Public Health, University of California, 710 University Hall, Berkeley, CA 94720, or at jerrett@berkeley.edu.
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