Short-Term Effects of Ambient Particles on Cardiovascular and Respiratory Mortality
Analitis, Antonis*; Katsouyanni, Klea*; Dimakopoulou, Konstantina*; Samoli, Evangelia*; Nikoloulopoulos, Aristidis K.*; Petasakis, Yannis*; Touloumi, Giota*; Schwartz, Joel†; Anderson, Hugh Ross‡; Cambra, Koldo§; Forastiere, Francesco∥; Zmirou, Denis¶; Vonk, Judith M.**; Clancy, Luke††; Kriz, Bohumir‡‡; Bobvos, Janos§§; Pekkanen, Juha∥∥
From the *Department of Hygiene and Epidemiology, University of Athens Medical School, Athens, Greece; †Harvard School of Public Health, Boston, MA; the ‡Division of Community Health Sciences, St. George's University of London, London, U.K.; the §Department of Health, Basque Government, Vitoria Gasteiz, Spain; the ∥Department of Epidemiology, Roma E Health Authority, Rome, Italy; ¶INSERM Unit ERI n°11 (Assessment and Prevention of Occupational and Environmental Risks), Medical School, Nancy University, Nancy, France; the **Department of Epidemiology and Bioinformatics, University Medical Center Groningen, The Netherlands; ††CResT Directorate, St. James Hospital, Dublin, Ireland; the ‡‡Department of Epidemiology CPL, Charles University, 3rd Medical Faculty, Praha, NIPH, Czech Republic; §§Budapest Institute of the National Public Health and Medical Officer Service, Hungary; and the ∥∥Unit of Environmental Epidemiology, National Public Health Institute, Kuopio, Finland.
Submitted 4 March 2005; accepted 12 October 2005.
Supported by the European Commission Environment and Climate 1994–1998 Program and Key Action 4: Environment and Health, FP5 (contract nos. ENV4-CT97-0534 and QLK4-CT-2001-30055).
Supplemental material for this article is available with the online version of the journal at www.epidem.com; click on “Article Plus.”
Correspondence: Klea Katsouyanni, Department of Hygiene and Epidemiology, University of Athens Medical School, 75, Mikras Asias Street, 115 27 Athens, Greece. E-mail: email@example.com.
Background: Particulate air pollution is associated with increased mortality. There is a need for European results from multicountry databases concerning cause-specific mortality to obtain more accurate effect estimates.
Methods: We report the estimated effects of ambient particle concentrations (black smoke and particulate matter less than 10 μm [PM10]) on cardiovascular and respiratory mortality, from 29 European cities, within the Air Pollution and Health: a European Approach (APHEA2) project. We applied a 2-stage hierarchical modeling approach assessing city-specific effects first and then overall effects. City characteristics were considered as potential effect modifiers.
Results: An increase in PM10 by 10 μg/m3 (lag 0 + 1) was associated with increases of 0.76% (95% confidence interval = 0.47 to 1.05%) in cardiovascular deaths and 0.58% (0.21 to 0.95%) in respiratory deaths. The same increase in black smoke was associated with increases of 0.62% (0.35 to 0.90%) and 0.84% (0.11 to 1.57%), respectively.
Conclusions: These effect estimates are appropriate for health impact assessment and standard-setting procedures.
Click on the links below to access all the ArticlePlus for this article.
Please note that ArticlePlus files may launch a viewer application outside of your web browser.
Several epidemiologic studies (including multicenter projects) have reported results linking the daily ambient particle concentrations with daily mortality.1–3 Most of the published results concern total mortality from all natural causes. This outcome has the advantage of being completely and accurately recorded. However, it is not specific for air pollution health effects. Respiratory mortality is a more specific outcome because air pollution exposure occurs mainly through inhalation, but several recent studies have also linked particle exposure with mechanisms leading to cardiovascular (CVD) morbidity and mortality.4–6
The APHEA (Air Pollution and Health: a European Approach) project is a large multicenter European project investigating the short-term effects of air pollution on health. Results have been reported from phase 1 of this project.7,8 We report here the estimated effects of ambient particles concentrations on respiratory and CVD mortality from 29 cities taking part in phase 2 of the APHEA project.
Twenty-nine European cities have provided data on mortality from respiratory (International Classification of Diseases, 9th Revision [ICD-9] 460–519) and cardiovascular (ICD-9 390–459) diseases, as well as daily data on ambient particles concentrations using PM10 (21 cities) and/or black smoke (15 cities). The median daily number of CVD deaths ranged between 2 and 143 and that of respiratory deaths from zero to 31. The median concentrations of PM10 and black smoke (average of 2 consecutive days) ranged from 9 to 64 and from 14 to 166 μg/m3, respectively (Table A1, available with the online version of this article).
We applied a 2-stage hierarchic modeling approach. In the first stage, we analyzed individual city data and obtained city-specific effect estimates, which were then used in a second-stage analysis to provide overall estimates and investigate heterogeneity. Various methods have been used as core and sensitivity analyses. Details about the data and the methods may be found in the online supplement and in the paper by Katsouyanni et al.2 We adjusted for potential confounding effects of seasonality, long-term trends, temperature, humidity, influenza epidemics, other unusual events, day of the week, and holidays. We also adjusted for the daily levels of other pollutants in 2-pollutant models. Because substantial heterogeneity had been observed in city-specific effect parameter estimates,7 we also explored the possible role of several city characteristics as effect modifiers. We report results from random-effects models in the presence of significant heterogeneity (P < 0.05).
In the second-stage analysis, city-specific effect estimates were regressed on city-specific covariates to obtain an overall estimate and to explore heterogeneity across cities (as reported in the online supplement “Methods” section). We explore effect modification only in the presence of significant heterogeneity and display results for those variables that explain more than 10% of the observed heterogeneity.
Table 1 shows the estimated effects from PM10 and black smoke exposure on CVD and respiratory mortality. The results displayed are from models using penalized splines to adjust for seasonal and long-term effects. An increase of 0.76% and 0.62% in the daily number of CVD deaths is associated with a 10-μg/m3 increase in PM10 and black smoke, respectively. Decreasing the number of degrees of freedom results in increased effects, whereas increasing it results in decreasing the effect estimates (see online supplement Tables A3 and A4). Applying alternative ways to control for seasonality, we get somewhat increased effects using the LOESS smoother and approximately 30% decreased estimates using natural splines. Controlling for ozone, the effect of PM10 remains practically identical, whereas it is decreased to 0.55% (95% confidence interval [CI] = 0.27 to 0.83%) when adjusting for sulfur dioxide (SO2) and to 0.32% (0.05 to 0.59%) when adjusting for nitrogen dioxide (NO2) (see online supplement Table A5). When adjusted for SO2, the black smoke effects slightly decrease; when adjusted for NO2 they decrease substantially to 0.17% (−0.10 to 0.45%), and when adjusted for ozone, they increase somewhat to 0.84% (0.53 to 1.16%) (online supplement Table A6).
An increase of 0.58% and 0.84% in the daily number of respiratory deaths is associated with a 10-μg/m3 increase in PM10 and black smoke, respectively. The estimated effects are larger by the LOESS method and they increase when decreasing the number of degrees of freedom; the opposite is true when the number of degrees of freedom increases (see online supplement Tables A7 and A8). Using natural splines, the PM10 estimates decrease by 46% and those of black smoke by 24%. The estimates of PM10 effects are not confounded by ozone concentrations but decrease substantially when adjusting for SO2 and NO2 (to 0.22% [−0.23 to 0.68%] and 0.20% [−0.29 to 0.69%], respectively) (online supplement Table A9). The estimates for black smoke exposure are confounded by ozone, NO2, and SO2 concentrations. Adjusting for these gaseous pollutants, results in decreasing the black smoke effects by 32% to 56% (online supplement Table A10).
Several effect modifiers explained more than 10% of the heterogeneity of the effects on CVD mortality. There was a larger effect of both PM10 and black smoke in warmer and drier cities, in cities with higher long-term average NO2 concentrations, and in cities with a higher proportion of elderly and a lower age-standardized mortality rate. There was also regional heterogeneity; the increase of the daily number of CVD deaths associated with 10-μg/m3 increase in PM10 was 0.54% in northwestern cities, 1.25% in southern cities, and 0.25% in central–eastern cities, whereas the contrast was somewhat smaller for black smoke (Tables A11 and A12, online supplement). There was no statistically significant heterogeneity in the estimated city-specific respiratory effects from PM10 exposure using the penalized splines method, so the causes of heterogeneity were not further explored. In contrast, there was heterogeneity in the black smoke city-specific effects. We found larger effects in cities with a higher age-adjusted lung cancer mortality rate and in cities with a larger proportion of elderly (Table A13, online supplement).
All of these estimates concern exposure over 2 days (lags zero and one). We also estimated the cumulative effects over 6 days (lags 0–5) for the chosen number of degrees of freedom and the penalized splines method. For PM10 effects on CVD deaths, the increase in the daily number of deaths was 0.90% (95% CI = 0.57 to 1.23%; 18% increase over the zero to one lags estimate); for black smoke effects on CVD deaths, it was 0.80% (0.49 to 1.11; a 29% increase). The corresponding estimates for respiratory deaths are 1.24% (0.49 to 1.99%; a 75% increase over the zero to one lags estimate) for PM10 and 1.61% (0.56 to 2.66%; a 93% increase) for black smoke. In the online supplement figures and tables, the individual city and pooled-effect estimates by both methods can be seen (Figs. A1–A4 and Tables A14–A17, online supplement).
We report effects of ambient particles exposures on CVD and respiratory mortality using data from 29 cities applying penalized splines to control for seasonality and long-term trends. In sensitivity analyses, larger effects are found using LOESS smoother whereas, in contrast, they are lower when we apply natural splines. CVD and respiratory causes of death are more specific to air pollution exposure than total mortality is. Recently, several reports have indicated mechanisms through which PM exposure can affect the cardiovascular system4–6,9–11 and cause pulmonary inflammation.12,13 Other time-series studies have found results comparable to ours.14–17 The APHEA1 study of 4 Western European cities reported an increase of 0.4% and 0.8% in CVD and respiratory deaths, respectively, for a 10-μg/m3 increase in PM10, whereas no associations were found in 4 Eastern European (Polish) cities, possibly due to modeling problems.18 Strong evidence for the effect of black smoke exposure on the CV system comes from a recent intervention study in which a reduction of black smoke concentrations in Dublin was followed by a substantial reduction in CVD mortality.19
The lag pattern of effects differs between CVD and respiratory deaths; it appears that effects on CVD mortality are more immediate, whereas the effects on respiratory mortality persist for several days.20–22 Our findings are consistent with this result. Adjusting for other pollutants shows that the PM10 effects, on both CVD and respiratory mortality, are independent of the levels of ozone, whereas they are somewhat confounded by SO2 levels and more by NO2. NO2 is an indicator of traffic pollution. Previous reports have shown that particles originating from traffic may be more associated with mortality effects.2 It is not clear whether NO2 is a better indicator than PM10 or black smoke of traffic particles or whether there is a true confounding effect.
We were able to identify effect modifiers for the PM effects on CVD mortality that are consistent with those previously reported for total mortality.2,23 The greatest relative effect modification for PM10 came from mean temperature and city-average NO2 concentrations. Warmer towns with more NO2 showed larger effects. There was less effect modification by NO2 for black smoke than for PM10, which suggests differential effects of traffic particles, for which PM10 is a less good indicator than black smoke. The greater effects in warmer cities may reflect greater ventilation, and hence higher indoor/outdoor pollution concentration ratios in those locations, but this mechanism remains to be confirmed by more detailed studies. The differences in effect modification patterns between cardiovascular and respiratory mortality may be interpreted as a further indication that the mechanisms through which particles affect cause-specific mortality are different for cardiac and respiratory causes. On the other hand, much of the modification of effects in this study is related to differences between Eastern, Northern, and Southern Europe, and we cannot exclude the possibility that other factors that differ across these regions, for which we do not have data, were responsible for the observed differences. In particular, the relative contributions of different sources of particles, and hence their likely physicochemical characteristics, may differ across these regions, and recent studies have suggested these characteristics may modify toxicity.24
The Air Pollution and Health: a European Approach (APHEA2) collaborative group consists of: K. Katsouyanni, G. Touloumi, E. Samoli, A. Gryparis, Y. Monopolis, E. Aga, D. Panagiotakos, A. Analitis, Y. Petasakis, and K. Dimakopoulou (Greece, coordinating center); C. Spix, A. Zanobetti, and H. E. Wichmann (Germany); H. R. Anderson, R. Atkinson, and J. Ayres (U.K.); S. Medina, A. Le Tertre, P. Quenel, L. Pascale, and A. Boumghar (Paris, France); J. Sunyer, M. Saez, F. Ballester, S. Perez-Hoyos, J. M. Tenias, E. Alonso, K. Kambra, E. Aranguez, A. Gandarillas, I. Galan, and J. M. Ordonez (Spain); M. A. Vigotti, G. Rossi, E. Cadum, G. Costa, L. Albano, D. Mirabelli, P. Natale, L. Bisanti, A. Bellini, M. Baccini, A. Biggeri, P. Michelozzi, V. Fano, A. Barca, and F. Forastiere (Italy); D. Zmirou and F. Balducci (Grenoble, France); J. Schouten and J. Vonk (The Netherlands); J. Pekkanen and P. Tittanen (Finland); L. Clancy and P. Goodman (Ireland); A. Goren and R. Braunstein (Israel); C. Schindler (Switzerland); B. Wojtyniak, D. Rabczenko, and K. Szafraniek (Poland); B. Kriz, M. Celko, and J. Danova (Prague, Czech Republic); A. Paldy, J. Bobvos, A. Vamos, G. Nador, I. Vincze, P. Rudnai, and A. Pinter (Hungary); E. Niciu, V. Frunza, and V. Bunda, (Romania); M. Macarol-Hitti and P. Otorepec (Slovenia); Z. Dor̈tbudak and F. Erkan (Turkey); B. Forsberg and B. Segerstedt (Sweden); andF. Kotesovec and J. Skorkovski (Teplice, Czech Republic).
1. Pope CA III, Dockery DW, Schwartz J. Review of epidemiological evidence of health effects of particulate air pollution. Inhal Toxicol
2. Katsouyanni K, Touloumi G, Samoli E, et al. Confounding and effect modification in the short-term effects of ambient particles on total mortality: results from 29 European cities within the APHEA2 project. Epidemiology
3. Samet JM, Dominici F, Curriero FC, et al. Fine particulate air pollution and mortality in 20 US cities. N Engl J Med
4. Pope CA III, Verrier RL, Lovett EG, et al. Heart rate variability associated with particulate air pollution. Am Heart J
5. Peters A, Dockery DW, Muller JE, et al. Increased particulate air pollution and the triggering of Myocardial infarction. Circulation
6. Dockery DW. Epidemiologic evidence of cardiovascular effects of particulate air pollution. Environ Health Perspect
. 2001;109(suppl 4):483–486.
7. Katsouyanni K, Touloumi G, Spix C, et al. Short-term effects of ambient sulphur dioxide and particulate matter on mortality in 12 European cities: results from time series data from the APHEA project. BMJ
8. Zmirou D, Schwartz J, Saez M, et al. Time-series analysis of air pollution and cause-specific mortality. Epidemiology
9. Routledge HC, Ayres JG, Townend JN. Why cardiologists should be interested in air pollution. Heart
10. Pope CA 3rd, Burnett RT, Thurston GD, et al. Cardiovascular mortality and long-term exposure to particulate air pollution: epidemiological evidence of general pathophysiological pathways of disease. Circulation
11. Liao D, Duan Y, Whitsel EA, et al. Association of higher levels of ambient criteria pollutants with impaired cardiac autonomic control: a population-based study. Am J Epidemiol
12. Van Eeden SF, Tan WC, Suwa T, et al. Cytokines involved in the systemic inflammatory response induced by exposure to particulate matter air pollutants (PM). Am J Respir Crit Care Med
13. Brauer M, Avila-Casado C, Fortoul TI, et al. Air pollution and retained particles in the lung. Environ Health Perspect
14. Ballester F, Saez M, Perez-Hoyos S, et al. The EMECAM project: a multicentre study on air pollution and mortality in Spain: combined results for particulates and for sulfur dioxide. Occup Environ Med
15. Stieb DM, Judek S, Burnett RT. Meta-analysis of time-series studies of air pollution and mortality: effects of gases and particles and the influence of cause of death, age, and season. J Air Waste Manag Assoc
16. Wong TW, Tam WS, Yu TS, et al. Associations between daily mortalities from respiratory and cardiovascular diseases and air pollution in Hong Kong, China. Occup Environ Med
17. Le Tertre A, Quenel P, Eilstein D, et al. Short-term effects of air pollution on mortality in nine French cities: a quantitative summary. Arch Environ Health
18. Samoli E, Schwartz J, Wojtyniak B, et al. Investigating regional differences in short-term effects of air pollution on daily mortality in the APHEA project: a sensitivity analysis for controlling long-term trends and seasonality. Environ Health Perspect
19. Clancy L, Goodman P, Sinclair H, et al. Effect of air pollution control on death rates in Dublin Ireland: an intervention study. Lancet
20. Braga AL, Zanobetti A, Schwartz J. The lag structure between particulate air pollution and respiratory and cardiovascular deaths in 10 US cities. J Occup Environ Med
21. Zanobetti A, Schwartz J, Samoli E, et al. The temporal pattern of respiratory and heart disease mortality in response to air pollution. Environ Health Perspect
22. Goodman PG, Dockery DW, Clancy L. Cause-specific mortality and the extended effects of particulate pollution and temperature exposure. Environ Health Perspect
23. Levy JL, Hammitt JK, Spengler JD. Estimating the mortality impacts of particulate matter: what can be learned from between study variability? Environ Health Perspect
24. Laden F, Neas LM, Dockery DW, et al. Association of fine particulate matter from different sources and daily mortality in six US cities. Environ Health Perspect
This article has been cited 63 time(s).
Journal of Exposure Science and Environmental EpidemiologyAssociation of ozone and particulate air pollution with out-of-hospital cardiac arrest in Helsinki, Finland: Evidence for two different etiologiesJournal of Exposure Science and Environmental Epidemiology
Toxicology LettersApoptotic and proinflammatory effect of combustion-generated organic nanoparticles in endothelial cellsToxicology Letters
Environmental HealthElemental concentrations of ambient particles and cause specific mortality in Santiago, Chile: a time series studyEnvironmental Health
Journal of Toxicology and Environmental Health-Part A-Current IssuesShort-Term Effects of Fine Particulate Air Pollution on Emergency Room Visits for Cardiac Arrhythmias: A Case-Crossover Study in TaipeiJournal of Toxicology and Environmental Health-Part A-Current Issues
Atmospheric ResearchForest fires in Northern region of Portugal: Impact on PM levelsAtmospheric Research
Acta GeophysicaAnalysis of particulate matter concentrations in mazovia region, central poland, based on 2007-2010 dataActa Geophysica
Inhalation ToxicologyFine particulate air pollution and hospital admissions for congestive heart failure: a case-crossover study in TaipeiInhalation Toxicology
Journal of Toxicology and Environmental Health-Part A-Current IssuesFine Particulate Air Pollution and Hospital Admissions for Myocardial Infarction in a Subtropical City: Taipei, TaiwanJournal of Toxicology and Environmental Health-Part A-Current Issues
European Respiratory JournalAir pollution and multiple acute respiratory outcomesEuropean Respiratory Journal
Journal of Thrombosis and HaemostasisAir pollution, vascular disease and thrombosis: linking clinical data and pathogenic mechanismsJournal of Thrombosis and Haemostasis
Toxicology in VitroDevelopment of a repeated exposure protocol of human bronchial epithelium in vitro to study the long-term effects of atmospheric particlesToxicology in Vitro
Chemical Industry & Chemical Engineering QuarterlyShort-Term Health Effects of Particulate Air Pollution With Special Reference to the Needs of Southern European CountriesChemical Industry & Chemical Engineering Quarterly
Aerosol and Air Quality ResearchCharacterization of PM10 Sources and Ambient Air Concentration Levels at Megalopolis City (Southern Greece) Located in the Vicinity of Lignite-Fired PlantsAerosol and Air Quality Research
Water and Environment JournalIsoconcentration mapping of particulate matter in Hamedan intercity bus stationsWater and Environment Journal
Environmental Health PerspectivesAcute Effects of Ambient Particulate Matter on Mortality in Europe and North America: Results from the APHENA StudyEnvironmental Health Perspectives
American Journal of Industrial MedicineCardiovascular mortality among Swedish pulp and paper mill workersAmerican Journal of Industrial Medicine
Environmental HealthA 10-year time-series analysis of respiratory and cardiovascular morbidity in Nicosia, Cyprus: the effect of short-term changes in air pollution and dust stormsEnvironmental Health
Occupational and Environmental MedicineHourly variation in fine particle exposure is associated with transiently increased risk of ST segment depressionOccupational and Environmental Medicine
Journal of Exposure Science and Environmental EpidemiologyUse of health information in air pollution health research: Past successes and emerging needsJournal of Exposure Science and Environmental Epidemiology
Toxicology and Applied PharmacologyIntracellular influx of calcium induced by quartz particles in alveolar macrophagesToxicology and Applied Pharmacology
Clinical ScienceCardiovascular effects of air pollutionClinical Science
Revue Des Maladies RespiratoiresShort-term health effects of air pollution on mortalityRevue Des Maladies Respiratoires
Environmental Health Risk V
Health impact assessment of exposure to transport emissions in Flanders: methodology study
Environmental Health Risk V, 14():
Environmental HealthMortality and life expectancy of Yokkaichi Asthma patients, Japan: Late effects of air pollution in 1960-70sEnvironmental Health
Environmental ResearchSocioeconomic disparities in air pollution-associated mortalityEnvironmental Research
International Journal of Environmental Research and Public HealthA Review of the Urban Development and Transport Impacts on Public Health with Particular Reference to Australia: Trans-Disciplinary Research Teams and Some Research GapsInternational Journal of Environmental Research and Public Health
American Journal of Respiratory and Critical Care MedicineEffects of the Irish smoking ban on respiratory health of bar workers and air quality in Dublin pubsAmerican Journal of Respiratory and Critical Care Medicine
Scandinavian Journal of Work Environment & Health
Cohort mortality study of Swedish pulp and paper mill workers - nonmalignant diseases
Scandinavian Journal of Work Environment & Health, 33(6):
Environmental Health PerspectivesAssociations between PM2.5 and Heart Rate Variability Are Modified by Particle Composition and Beta-Blocker Use in Patients with Coronary Heart DiseaseEnvironmental Health Perspectives
Journal of the Air & Waste Management Association
Health effects of fine particulate air pollution: Lines that connect
Journal of the Air & Waste Management Association, 56(6):
Effects of Fine Particulate Matter on Daily Mortality for Specific Heart Diseases in Japan
Circulation Journal, 73(7):
Biological Rhythm ResearchExternal triggers of onset of myocardial infarction - an updateBiological Rhythm Research
Aerosol Science and TechnologyGas-phase flame synthesis and characterization of iron oxide nanoparticles for use in a health effects studyAerosol Science and Technology
Journal of Exposure Science and Environmental EpidemiologyOn the interpretation of epidemiological studies of ambient air pollutionJournal of Exposure Science and Environmental Epidemiology
Revue Francaise D AllergologieShort-term health effects of air pollution on mortalityRevue Francaise D Allergologie
Inhalation ToxicologyAir pollution and respiratory viral infectionInhalation Toxicology
Indoor and Built EnvironmentParticulate matter exposure and dose relationships derived from realistic exposure scenariosIndoor and Built Environment
Environmental Health PerspectivesShort-Term Mortality Rates during a Decade of Improved Air Quality in Erfurt, GermanyEnvironmental Health Perspectives
Netherlands Journal of Medicine
Air pollution as noxious environmental factor in the development of cardiovascular disease
Netherlands Journal of Medicine, 67(4):
European Respiratory JournalClimate change and respiratory disease: European Respiratory Society position statementEuropean Respiratory Journal
Seminars in Thrombosis and HemostasisParticulate Air Pollution and Cardiovascular Risk: Short-term and Long-term EffectsSeminars in Thrombosis and Hemostasis
Epidemiologia & Prevenzione
Air pollution and urgent hospital admissions in nine Italian cities. Results of the EpiAir Project
Epidemiologia & Prevenzione, 33(6):
European Respiratory JournalParticulate matter, science and EU policyEuropean Respiratory Journal
CirculationParticulate Matter Air Pollution and Cardiovascular Disease An Update to the Scientific Statement From the American Heart AssociationCirculation
HeartCLimate Impacts on Myocardial infarction deaths in the Athens TErritory: the CLIMATE studyHeart
Environmental Health PerspectivesMortality effects of a copper smelter strike and reduced ambient sulfate particulate matter air pollutionEnvironmental Health Perspectives
Inhalation ToxicologyMortality effects of longer term exposures to fine particulate air pollution: Review of recent epidemiological evidenceInhalation Toxicology
European Heart JournalTraffic and the heartEuropean Heart Journal
Regulatory Toxicology and PharmacologyDo pollution time-series studies contain uncontrolled or residual confounding by risk factors for acute health events?Regulatory Toxicology and Pharmacology
Atmospheric Chemistry and Physics
Relationships between submicrometer particulate air pollution and air mass history in Beijing, China, 2004-2006
Atmospheric Chemistry and Physics, 8():
Particle and Fibre ToxicologyParticulate matter and atherosclerosis: role of particle size, composition and oxidative stressParticle and Fibre Toxicology
Biochimica Et Biophysica Acta-General SubjectsImpaired cardiac mitochondrial function and contractile reserve following an acute exposure to environmental particulate matterBiochimica Et Biophysica Acta-General Subjects
European Journal of Public HealthAssociation of proximity to polluting industries, deprivation and mortality in small areas of the Basque Country (Spain)European Journal of Public Health
American Journal of EpidemiologyEvidence on Vulnerability and Susceptibility to Health Risks Associated With Short-Term Exposure to Particulate Matter: A Systematic Review and Meta-AnalysisAmerican Journal of Epidemiology
The American Journal of the Medical SciencesOutdoor Air Pollution: Particulate Matter Health EffectsThe American Journal of the Medical Sciences
European Journal of Cardiovascular Prevention & RehabilitationParticulate air pollution, coronary heart disease and individual risk assessment: a general overviewEuropean Journal of Cardiovascular Prevention & Rehabilitation
Supplemental Digital Content
© 2006 Lippincott Williams & Wilkins, Inc.