Air pollution and mortality: A history

Mortality is the most important health effect of ambient air pollution and has been studied the longest. The earliest evidence relates to fog episodes but with the development of more precise methods of investigation it is still possible to discern short-term temporal associations with daily mortality at the historically low levels of air pollution that now exist in most developed countries. Another early observation was that mortality was higher in more polluted areas. This has been confirmed by modern cohort studies that account for other potential explanations for such associations. There does not appear to be a threshold of effect within the ambient range of concentrations. Advances in the understanding of air pollution and mortality have been driven by the combined development of methods and biomedical concepts. The most influential methodological developments have been in time-series techniques and the establishment Of large cohort studies, both of which are underpinned by advances in data processing and statistical analysis. On the biomedical side two important developments can be identified. One has been the application of the concept of multifactorial disease causation to explaining how air pollution may affect mortality at low levels and why thresholds are not obvious at the population level. The other has been an increasing understanding of how air pollution may plausibly have pathophysiological effects that are remote from the lung interface with ambient air. Together, these advances have had a profound influence on policies to protect public health. Throughout the history of air pollution epidemiology, mortality studies have been central and this will continue because of the widespread availability of mortality data on a large Population Scale and the weight that mortality carries in estimating impacts for policy development. (C) 2008 Elsevier Ltd. All rights reserved.