title: An association between air pollution and mortality in six U.S. cities.
abstract: BACKGROUND
  Recent studies have reported associations between particulate air pollution and daily mortality rates. Population-based, cross-sectional studies of metropolitan areas in the United States have also found associations between particulate air pollution and annual mortality rates, but these studies have been criticized, in part because they did not directly control for cigarette smoking and other health risks.
  
  
  METHODS
  In this prospective cohort study, we estimated the effects of air pollution on mortality, while controlling for individual risk factors. Survival analysis, including Cox proportional-hazards regression modeling, was conducted with data from a 14-to-16-year mortality follow-up of 8111 adults in six U.S. cities.
  
  
  RESULTS
  Mortality rates were most strongly associated with cigarette smoking. After adjusting for smoking and other risk factors, we observed statistically significant and robust associations between air pollution and mortality. The adjusted mortality-rate ratio for the most polluted of the cities as compared with the least polluted was 1.26 (95 percent confidence interval, 1.08 to 1.47). Air pollution was positively associated with death from lung cancer and cardiopulmonary disease but not with death from other causes considered together. Mortality was most strongly associated with air pollution with fine particulates, including sulfates.
  
  
  CONCLUSIONS
  Although the effects of other, unmeasured risk factors cannot be excluded with certainty, these results suggest that fine-particulate air pollution, or a more complex pollution mixture associated with fine particulate matter, contributes to excess mortality in certain U.S. cities.
authors.affiliation: Environmental Epidemiology Program, Harvard School of Public Health, Boston, MA 02115.
authors.forename: D W
authors.initials: DW
authors.lastname: Dockery
authors.forename: C A
authors.initials: CA
authors.lastname: Pope
authors.forename: X
authors.initials: X
authors.lastname: Xu
authors.forename: J D
authors.initials: JD
authors.lastname: Spengler
authors.forename: J H
authors.initials: JH
authors.lastname: Ware
authors.forename: M E
authors.initials: ME
authors.lastname: Fay
authors.forename: B G
authors.initials: BG
authors.lastname: Ferris
authors.forename: F E
authors.initials: FE
authors.lastname: Speizer
mesh_terms: D000328:Adult; D000368:Aged; D000397:Air Pollution / Q000009:adverse effects*; D002423:Cause of Death; D016001:Confidence Intervals; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009026:Mortality; D011446:Prospective Studies; D012307:Risk Factors; D012907:Smoking / Q000401:mortality; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014504:Urban Health / Q000706:statistics & numerical data*