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      Particulate Matter Air Pollution Exposure and Heart Disease Mortality Risks by Race and Ethnicity in the United States : 1997 to 2009 National Health Interview Survey With Mortality Follow-Up Through 2011


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          Most US studies of mortality and air pollution have been conducted on largely non-Hispanic white study populations. However, many health and mortality outcomes differ by race and ethnicity, and non-Hispanic white persons experience lower air pollution exposure than those who are non-Hispanic black or Hispanic. This study examines whether associations between air pollution and heart disease mortality differ by race/ethnicity.


          We used data from the 1997 to 2009 National Health Interview Survey linked to mortality records through December 2011 and annual estimates of fine particulate matter (PM 2.5) by census tract. Proportional hazards models were used to estimate hazard ratios and 95% confidence intervals between PM 2.5 (per 10 µg/m 3) and heart disease mortality using the full sample and the sample adults, which have information on additional health variables. Interaction terms were used to examine differences in the PM 2.5-mortality association by race/ethnicity.


          Overall, 65 936 of the full sample died during follow-up, and 22 152 died from heart disease. After adjustment for several factors, we found a significant positive association between PM 2.5 and heart disease mortality (hazard ratio, 1.16; 95% confidence interval, 1.08–1.25). This association was similar in sample adults with adjustment for smoking and body mass index (hazard ratio, 1.18; 95% confidence interval, 1.06–1.31). Interaction terms for non-Hispanic black and Hispanic groups compared with the non-Hispanic white group were not statistically significant.


          Using a nationally representative sample, the association between PM 2.5 and heart disease mortality was elevated and similar to previous estimates. Associations for non-Hispanic black and Hispanic adults were not statistically significantly different from those for non-Hispanic white adults.

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          Most cited references 38

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          Particulate air pollution as a predictor of mortality in a prospective study of U.S. adults.

          Time-series, cross-sectional, and prospective cohort studies have observed associations between mortality and particulate air pollution but have been limited by ecologic design or small number of subjects or study areas. The present study evaluates effects of particulate air pollution on mortality using data from a large cohort drawn from many study areas. We linked ambient air pollution data from 151 U.S. metropolitan areas in 1980 with individual risk factor on 552,138 adults who resided in these areas when enrolled in a prospective study in 1982. Deaths were ascertained through December, 1989. Exposure to sulfate and fine particulate air pollution, which is primarily from fossil fuel combustion, was estimated from national data bases. The relationships of air pollution to all-cause, lung cancer, and cardiopulmonary mortality was examined using multivariate analysis which controlled for smoking, education, and other risk factors. Although small compared with cigarette smoking, an association between mortality and particulate air pollution was observed. Adjusted relative risk ratios (and 95% confidence intervals) of all-cause mortality for the most polluted areas compared with the least polluted equaled 1.15 (1.09 to 1.22) and 1.17 (1.09 to 1.26) when using sulfate and fine particulate measures respectively. Particulate air pollution was associated with cardiopulmonary and lung cancer mortality but not with mortality due to other causes. Increased mortality is associated with sulfate and fine particulate air pollution at levels commonly found in U.S. cities. The increase in risk is not attributable to tobacco smoking, although other unmeasured correlates of pollution cannot be excluded with certainty.
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            Lung Cancer and Cardiovascular Disease Mortality Associated with Ambient Air Pollution and Cigarette Smoke: Shape of the Exposure–Response Relationships

            Background: Lung cancer and cardiovascular disease (CVD) mortality risks increase with smoking, secondhand smoke (SHS), and exposure to fine particulate matter 40 among long-term heavy smokers. Excess risks for CVD mortality increased steeply at low exposure levels and leveled off at higher exposures, reaching RRs of approximately 2–3 for cigarette smoking. Conclusions: The exposure–response relationship associated with PM2.5 is qualitatively different for lung cancer versus cardiovascular mortality. At low exposure levels, cardiovascular deaths are projected to account for most of the burden of disease, whereas at high levels of PM2.5, lung cancer becomes proportionately more important.
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              Time-to-event analysis of longitudinal follow-up of a survey: choice of the time-scale.

              Following individuals sampled in a large-scale health survey for the development of diseases and/or death offers the opportunity to assess the prognostic significance of various risk factors. The proportional hazards regression model, which allows for the control of covariates, is frequently used for the analysis of such data. The authors discuss the appropriate time-scale for such regression models, and they recommend that age rather than time since the baseline survey (time-on-study) be used. Additionally, with age as the time-scale, control for calendar-period and/or birth cohort effects can be achieved by stratifying the model on birth cohort. Because, as discussed by the authors, many published analyses have used regression models with time-on-study as the time-scale, it is important to assess the magnitude of the error incurred from this type of incorrect modeling. The authors provide simple conditions for when incorrect use of time-on-study as the time-scale will nevertheless yield approximately unbiased proportional hazards regression coefficients. Examples are given using data from the first National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Followup Study. Additional issues concerning the analysis of longitudinal follow-up of survey data are briefly discussed.

                Author and article information

                Lippincott Williams & Wilkins
                17 April 2018
                16 April 2018
                : 137
                : 16
                : 1688-1697
                [1 ]National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD (J.D.P., N.K.).
                [2 ]National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, GA (A.V.).
                Author notes
                Jennifer D. Parker, PhD, National Center for Health Statistics/Centers for Disease Control and Prevention, 3311 Toledo Rd, Hyattsville, MD 20782. E-mail jdparker@ 123456cdc.gov
                © 2017 The Authors.

                Circulation is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited and is not used for commercial purposes.

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