Abstract
BACKGROUND: Fine particulate matter (PM(2.5)) is associated with negative health outcomes in both the short and long term. However, the cohort studies that have produced many of the estimates of long-term exposure associations may fail to account for selection bias in pollution exposure as well as covariate imbalance in the study population; therefore, causal modeling techniques may be beneficial. METHODS: Twenty-nine years of data from the National Health Interview Survey (NHIS) was compiled and linked to modeled annual average outdoor PM(2.5) concentration and restricted-use mortality data. A series of Cox proportional hazards models, adjusted using inverse probability weights, yielded causal risk estimates of long-term exposure to ambient PM(2.5) on all-cause and cardiopulmonary mortality. RESULTS: Covariate-adjusted estimated relative risks per 10 μg/m(3) increase in PM(2.5) exposure were estimated to be 1.117 (1.083, 1.152) for all-cause mortality and 1.232 (1.174, 1.292) for cardiopulmonary mortality. Inverse probability weighted Cox models provide relatively consistent and robust estimates similar to those in the unweighted baseline multivariate Cox model, though they have marginally lower point estimates and higher standard errors. CONCLUSIONS: These results provide evidence that long-term exposure to PM(2.5) contributes to increased mortality risk in US adults and that the estimated effects are generally robust to modeling choices. The size and robustness of estimated associations highlight the importance of clean air as a matter of public health. Estimated confounding due to measured covariates appears minimal in the NHIS cohort, and various distributional assumptions have little bearing on the magnitude or standard errors of estimated causal associations.