Cited by 1,510Air Quality and Health ImpactsIndoor Air Quality and Microbial ExposureEnvironmental Justice and Health Disparities

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Air Pollution and Mortality in the Medicare Population

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Di, Qian, Wang, Yan, Zanobetti, Antonella, Wang, Yun, Koutrakis, Petros, Choirat, Christine, Dominici, Francesca, Schwartz, Joel D.·2017·New England Journal of Medicine

DOI 10.1056/nejmoa1702747PMC PMC5766848

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Abstract

BACKGROUNDStudies have shown that long-term exposure to air pollution increases mortality.However, evidence is limited for air-pollution levels below the most recent National Ambient Air Quality Standards.Previous studies involved predominantly urban populations and did not have the statistical power to estimate the health effects in underrepresented groups. METHODSWe constructed an open cohort of all Medicare beneficiaries (60,925,443 persons) in the continental United States from the years 2000 through 2012, with 460,310,521 person-years of follow-up.Annual averages of fine particulate matter (particles with a mass median aerodynamic diameter of less than 2.5 μm [PM 2.5 ]) and ozone were estimated according to the ZIP Code of residence for each enrollee with the use of previously validated prediction models.We estimated the risk of death associated with exposure to increases of 10 μg per cubic meter for PM 2.5 and 10 parts per billion (ppb) for ozone using a two-pollutant Cox proportionalhazards model that controlled for demographic characteristics, Medicaid eligibility, and area-level covariates. RESULTSIncreases of 10 μg per cubic meter in PM 2.5 and of 10 ppb in ozone were associated with increases in all-cause mortality of 7.3% (95% confidence interval [CI], 7.1 to 7.5) and 1.1% (95% CI, 1.0 to 1.2), respectively.When the analysis was restricted to person-years with exposure to PM 2.5 of less than 12 μg per cubic meter and ozone of less than 50 ppb, the same increases in PM 2.5 and ozone were associated with increases in the risk of death of 13.6% (95% CI, 13.1 to 14.1) and 1.0% (95% CI, 0.9 to 1.1), respectively.For PM 2.5 , the risk of death among men, blacks, and people with Medicaid eligibility was higher than that in the rest of the population. CONCLUSIONSIn the entire Medicare population, there was significant evidence of adverse effects related to exposure to PM 2.5 and ozone at concentrations below current national standards.This effect was most pronounced among self-identified racial minorities and people with low income.(Supported by the Health Effects Institute and others.)a bs tr ac t Air Pollution and Mortality in the Medicare Population

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Spatial and Temporal Exposure Assessment to PM2.5 in a Community Using Sensor-Based Air Monitoring Instruments and Dynamic Population Distributions
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“3% increase in all-cause mortality [3].”
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Upward trend and formation of surface ozone in the Guanzhong Basin, Northwest China
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Personal exposure to fine particulate air pollutants impacts blood pressure and heart rate variability
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Chronic exposure to polluted urban air aggravates myocardial infarction by impaired cardiac mitochondrial function and dynamics
Marchini, T., Magnani, N., Garcés, M., Kelly, J., Paz, M. L., Cáceres, L., Calabró, V., Vitar, R. M. L., Caltana, L. R., Contin, M. D., et al. (2021) · Environmental Pollution · doi:10.1016/j.envpol.2021.118677 · Cited by 18
Determining the effect of air quality on activities of daily living disability: using tracking survey data from 122 cities in China
Liu, H. (2022) · BMC Public Health · doi:10.1186/s12889-022-13240-7 · Cited by 18
“Among the research on individual health impacts, on the one hand, air pollution indeed has an impact on individual health [17–21]; on the other hand, it also affects potential medical consumption [22, 23].”
Background
Characterizing In-Cabin Air Quality and Vehicular Air Filtering Performance for Passenger Cars in China
Yin, C., Li, H., Cha, Y., Zhang, S., Du, J., Li, Z., & Wu, Y. (2022) · Environmental Pollution · doi:10.1016/j.envpol.2022.120884 · Cited by 18
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“Long‐term exposure to ozone has been found to reduce lung function34 and increase morbidity35 and mortality.2,36,37 Notably, a landmark study of the entire US Medicare population, almost 61 million persons, found an increased risk of death for every 10 ppb increase on average warm season ozone (hazard ratio [HR] 1.011…”
BackgroundInfluential
Adverse Health Impacts of Outdoor Air Pollution, Including from Wildland Fires, in the United States: “Health of the Air,” 2018–2020
Cromar, K. R., Gladson, L. A., Gohlke, J. M., Li, Y., Tong, D., & Ewart, G. W. (2023) · Annals of the American Thoracic Society · doi:10.1513/annalsats.202305-455oc · Cited by 18
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Is breathing our polluted air a risk factor for stroke?
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“5 and death in Hispanic and non-Hispanic black Medicare members.(28) Conversely, improvement in air quality has also been shown to increase life expectancy.”
Background
A comprehensive assessment of ambient air quality in Çanakkale city: Emission inventory, air quality monitoring, source apportionment, and respiratory health indicators
Menteşe, S., Mirici, N. A., Elbir, T., Tuygun, G. T., Bakar, Ç., Otkun, M. T., & Oymak, S. (2020) · Atmospheric Pollution Research · doi:10.1016/j.apr.2020.07.005 · Cited by 18
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Discovering Heterogeneous Exposure Effects Using Randomization Inference in Air Pollution Studies
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“Opioid prescription rate data were obtained from the IQVIA Xponent System 2006 – 2018 data, provided by the CDC. Air pollution is a key determinant of premature mortality (Lelieveld et al., 2015), especially in the Medicare population (Di et al., 2017).”
Method
Long-term PM2.5 exposure and sepsis mortality in a US medicare cohort
Honda, T., Kazemiparkouhi, F., Henry, T. D., & Suh, H. H. (2022) · BMC Public Health · doi:10.1186/s12889-022-13628-5 · Cited by 18
“Additionally, a growing literature demonstrates that Black populations experience higher cause-specific mortality risk from air pollution exposures relative to other racial/ethnic groups [22, 36, 37].”
Background
Contaminación atmosférica, riesgo cardiovascular e hipertensión arterial
Soldevila, N., Bargalló, E. V., Agudo-Ugena, J., & Vila, L. C. (2018) · Hipertensión y Riesgo Vascular · doi:10.1016/j.hipert.2018.03.001 · Cited by 20
“El aumento de 10 (cid:2) g/m 3 de PM 2,5 se asocia con el incremento del 7,3% de mortalidad por todas las causas y con el aumento de riesgo de muerte del 13,6%, con más afecta-ción en el caso de los hombres, de raza negra y con más bajo nivel económico 32 .”
Air Pollution in the Asia-Pacific Region. A Joint Asian Pacific Society of Respirology/American Thoracic Society Perspective
North, C. M., Rice, M. B., Ferkol, T., Gozal, D., Hui, C., Jung, S., Kuribayashi, K., McCormack, M. C., Mishima, M., Morimoto, Y., et al. (2018) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.201804-0673pp · Cited by 18
Health effects of air pollution: what we need to know and to do in the next decade
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Factors Explaining Life Expectancy at Age 65: A Panel Data Approach Applied to European Union Countries
Poças, A., Soukiazis, E., & Antunes, M. (2020) · Social Indicators Research · doi:10.1007/s11205-020-02290-2 · Cited by 17
Adopting electric school buses in the United States: Health and climate benefits
Choma, E. F., Robinson, L. A., & Nadeau, K. C. (2024) · Proceedings of the National Academy of Sciences · doi:10.1073/pnas.2320338121 · Cited by 17
“However, these effects were observed in very old and polluting buses with few emission controls, and it is uncertain whether they apply to the current diesel bus fleet.”
Substantial air quality and health co-benefits from combined federal and subnational climate actions in the United States
Huang, X., Peng, W., Zhao, A., Ou, Y., Kennedy, S., Iyer, G. C., McJeon, H. C., Cui, R. Y., & Hultman, N. (2025) · One Earth · doi:10.1016/j.oneear.2025.101232 · Cited by 20
Comparing denominator sources for real-time disease incidence modeling: American Community Survey and WorldPop
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“Over 96% of Americans age 65 + are enrolled in Medicare (Di et al., 2017), and the data provided by CMS contain individual-level age, sex, racial/ethnic group, and zipcode identifiers for enrollees.”
Background
Environmental health perspectives for low- and middle-income countries
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Multi-Omics Analysis Unravels Deregulated Lysosomal Function and Lipid Metabolism Involved in Long-Term Particulate Matter-Induced Pulmonary Injury
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Associations between long-term exposure to multiple air pollutants and age at menopause: a longitudinal cohort study
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Inequities in ambient fine particulate matter: A spatiotemporal analysis in Canadian communities
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Short-term air pollution exposure and hospital admissions for cardiorespiratory diseases in Brazil: A nationwide time-series study between 2008 and 2018
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Impact of ground-level ozone exposure on sleep quality and electroencephalogram patterns at different time scales
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Impaired PPARγ activation by cadmium exacerbates infection-induced lung injury
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Association of Long-term Exposure to Air Pollution and Dementia Risk
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Result
Causal association between air pollution and frailty: a Mendelian randomization study
Xiao, H., Huang, S., Yang, W., Zhang, W., Xiao, H., & Cai, S. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1288293 · Cited by 17
“Because of the potential health consequences, air pollution is the leading reversible environmental factor linked to early mortality or disability (9).”
Background
Long-term ozone exposure and all-cause mortality: Cohort evidence in China and global heterogeneity by region
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Relaxing Energy Policies Coupled with Climate Change Will Significantly Undermine Efforts to Attain US Ozone Standards
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“Recently, Di et al. (2017) demonstrated by overwhelming evidence the impact of air pollution (AP) in mortality of an open cohort with 460,310,521 person-years of follow-up.”
Background
Excess Morbidity and Mortality Associated with Air Pollution above American Thoracic Society Recommended Standards, 2017–2019
Cromar, K. R., Gladson, L. A., Hicks, A., Marsh, B., & Ewart, G. W. (2021) · Annals of the American Thoracic Society · doi:10.1513/annalsats.202107-860oc · Cited by 17

Authors: Di, Q., Wang, Y., Zanobetti, A., Wang, Y., Koutrakis, P., Choirat, C., Dominici, F., & Schwartz, J. D.
Affiliations: Harvard University (US)
ORCID: Di, Qian
Wang, Yan
Zanobetti, Antonella
Wang, Yun
Koutrakis, Petros
Choirat, Christine
Dominici, Francesca
Schwartz, Joel D.
Venue: New England Journal of Medicine
Publisher: Massachusetts Medical Society
Published: 2017-06-29
Volume: 376
Issue: 26
Pages: 2513-2522
ISSN: 0028-4793 (ISSN-L)
1533-4406
DOI: 10.1056/nejmoa1702747
PMC: PMC5766848
OpenAlex: W2725857760
Cited by: 1,510
References: 32
Citations by year: 2026: 117 · 2025: 141 · 2024: 147 · 2023: 171 · 2022: 189 · 2021: 196 · 2020: 216 · 2019: 182 · 2018: 124 · 2017: 25
FWCI: 80.54
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: New England Journal of Medicine (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: Harvard University
Institute for Quantitative Social Science, Harvard University
National Cancer Institute (P01CA134294, R35CA197449)
National Institute of Environmental Health Sciences (R21ES024012, R01ES024332, P30ES000002, R01ES026217, R21ES022585, R01ES012054)
Topics: Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Air Quality and Health Impacts
Physical Sciences › Environmental Science › Health, Toxicology and Mutagenesis › Indoor Air Quality and Microbial Exposure
Social Sciences › Sociology and Political Science › Environmental Justice and Health Disparities
Keywords: air pollution, PM2.5, ozone, all-cause mortality, Medicare beneficiaries, low-income populations, racial minorities, Medicaid eligibility, health disparities, cohort studies, dose-response relationship, sex differences in mortality, air pollution health effects, United States, California, New York State, New Jersey
MeSH terms: Aged, Air Pollutants, Air Pollution, Environmental Exposure, Female, Medicare, Humans, Male, Mortality, Ozone, Risk Factors, Sex Factors, United States, Cohort Studies, Proportional Hazards Models, Racial Groups, Particulate Matter, Mortality, Premature

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Air Pollution and Mortality in the Medicare Population

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