If..Nr WEN G LAN])J()URN ;\ L:\1L ])!.70.2:E 60... '0 50SIE
40..300.... E20~10o ~0AL AT454035Z-30Q. 25.2:6' 20Z 15100 AL
ATl412z- 10~.2:a8(>.-5:6"Q ~ 40AL AT807060~ 50..,:.40'"
:i30~20100LE LALN LM LB ML RV SD SM UP3530~25.. 20,:. ::l
15:::E~lO-!If 0LE LA LN LM LB ML RV SD SM UP1.6E 1,4.. 12,:.&:
1.0~" 0.8~0.6'"0,4i ill 02~ ,i 0.0LE LA LN LM LB ML RV SD SM
UPCommunityAL AT LE LALN LM LB ML RV SD SM UPAL AT LE LA LN LM LB
ML RV SD SM UPAL AT LE LALN LM LB ML RV SD SM UPCommunityFigureL
Mean (+SD)AnnualAverageLevelsof Pollutantsfrom
1994through2000inthe12StudyCommunitiesIn SouthernCalifornia.AL
denotesAlpine, AT Atascadero, LE Lake Elsinore, LA Lake Arrowhead,
LN Lancaster, LM Lompoc, LB Long Beach, ML Mira Loma, RVRiverside,
SOSan Dimas,SM SantaMaria,andUP Upland.0,denotesozone,
NO,nitrogendioxide, and PM10and PM...particulatematterwith an
aerodynamicdiameteroflessthan10Jim and lessthan2.511m,
respectively.N ENGL) "'ED 351;11 WWW.NE) .... O.G SEPn"'OE. 9.2004
TheNewEnglandJournal ofMedicine Downloadedfrom nejm.orgonJune J,
2015. Forpersonal useonly. Nootheruseswithoutpermission. Copyright
2004Massachusetts MedicalSociety.All rightsreserved. 1060EFFECT OF
AIR POLLUTION ON LUNG DEVELOPMENT IN CHILDRENaverage levelsof
ozonewerenotsignificantlycor-related across communities with
anyother
studypollutant(Table1).However,correlationsbetweenotherpairsofpollutantswereallsignificant,rang-ingfromanRofO.64(P'....
0 LM +SM .lE10 20 30 40PM10 (JIg/m')50 60 70R.O.79P.0.002 UP
.SDAT. SM .lES 10 15 20 25 30 PM2.5(lIg/ml) R-0.74 UPPQ.006
LB At .SDLA. :!,-__.LE 0 6 8 10 12LI-0.0 0.2 0.4 0.6 0.8 1.0 1.2
1.4Acid Vapor (ppb) ElementalCarbon
(JIg/ml)Figure3.CommunitySpeclficProportionofl8Year-OldswithaFEV1below80PercentofthePredictedValuePlottedagainsttheAverageLevelsof
Pollutantsfrom 1994through2000. Thecorrelationcoefficient(R) and
pvalueareshown for eachcomparison.ALdenotesAlpine. AT Atascadero,
LE Lake ElSinore, LA Lake Arrowhead, lNLancaster. LM lompoc, LB
Long Beach, ML Mira Loma, RV Riverside, SD San Dimas, SM Santa
Maria,andUP Upland. 03denotesozone, NO.nitrogendioxide,and PM,oand
PM. particulatematterwith an aerodynamicdiameteroflessthan1011m and
lessthan 2.5 11m, respectively.
marilyattributabletodifferencesinthenumberofalveoli,sincetheirsizeisrelativelyconstant.
34How-ever,
sincethepostnatalincreaseinthenumberofalveoliiscompletebytheageof10years,pollution-relateddeficitsinthegrowthofFVCandFEV1dur-ingadolescencemay,inpart,reflectareductioninthegrowthofalveoli.Anotherplausiblemechanismoftheeffectofairpollutiononlungdevelopmentisairwayinflammation,suchasoccursinbronchioli-tis;suchchangeshavebeenobservedintheairwaysofsmokers
and ofsubjects who lived in
pollutedenvironments.3536Astrengthofourstudywasthelong-term,pro-spectivefollow-upofalargecohort,withexposureandoutcomedatacollectedinaconsistentmannerthroughoutthestudyperiod.
As inanyepidemio-logicstudy, however,
theobservedeffectscouldbebiased by underlyingassociationsof
theexposureand outcome to someconfoundingvariables.
Weadjustedforknownpotentialconfounders,includ-NENGLJMEO351;11WWW.NEJM.ORGSEPTEMBER9,2004
The New EnglandJournal ofMedicine Downloadedfrom nejm.orgonJune
1,2015.Forpersonal useonly. Nootheruseswithoutpennission.
Copyright2004Massachusetts MedicalSociety.Allrightsreserved.
1065ingpersonalcharacteristics and othersources of
wereassociatedwiththesedeficitsincludednitro-exposureto
pollutants,butthepossibilityofcon- gendioxide,acidvapor,PMl.5,
andelementalcar-foundingbyotherfactorsstillexists.Overtheeight-
bon.Thesepollutantsareproductsofprimaryfuelyearfollow-upperiod,approximately10percentof
combustion,andsincetheyare
presentatsimilarstudysubjectswerelosttofollow-upeachyear. At-
levelsin
manyotherareas,37,38webelievethatourtritionisapotentialsourceofbiasinacohortstudy
resultscanbegeneralizedtochildrenlivingoutsideiflosstofollow-upisrelatedtobothexposureand
southernCalifornia.Giventhemagnitudeoftheob-outcome.However,wedidnotseeevidencethatthe
servedeffectsandtheimportanceoflungfunctionlossofsubjectswasrelatedtoeitherbaselinelung
asadeterminantofmorbidityandmortalityduringfunctionorexposuretoairpollution.
Inaddition, adulthood, continuedemphasisontheidentifica-we observed
significant associations between air
tionofstrategiesforreducinglevelsofurbanairpol-pollutionandlunggrowthinthesubgroupofchil-
lutantsiswarranted.drenwhowerefollowedforthe full eightyears
ofSupportedinpartbyacontract(A033-186)withtheCaliforniaAirResources
Board, grants (5P30ES07048 and 1P01ES11627) ITomthestudy,
witheffects thatweresimilarinmagni-the National Institute
ofEnvironmental Health Sciences, and
thetudetothoseinthegroupasawhole,thusmakingHastingsFoundation.lossofsubjectsanunlikelysourceofbias.We
are indebted to Morton Uppmann, Jonathan Samet,
FrankSpeizer,JohnSpengler,ScottZeger,PaulEnright,WilliamUnn,andWe
have shown that exposure to ambient airDane Westerdahl for
important advice; to the school principals,pollution is
correlatedwith significantdeficits
inteachers,students,andparentsineachofthe12studycommunitiesrespiratorygrowthoveraneight-yearperiod,lead-for
theircooperation,andespecially to the members ofthe
healthtestingfield
teamfortheirefforts.ingtoclinicallyimportantdeficitsinlungfunctionattheageof18years.
ThespecificpollutantsthatRFf!:RE NeES 1. Frischer T. Studnicka M,
Gartner C. ofinhalableparticleson respiratoryhealth 17. TagerIB,
WeissST,MunozA, RosnerB, et al. Lung function growth and ambient
ofchildren. Am Rev Respir Dis 1989;139: SpeizerFE.
Longitudinalstudyoftheeffects ozone: a three-year population study
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children. AmJRespirCritCareMed
munitieswithdifferinglevelsandtypesofair tomsand physiology.
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VI., Couper D, don5J, PetersJM. Respiratoryeffectsofre- 13. Peters
JM, Avol E, Navidi W, et al. etal. Lung function and incident
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ofrespiratory 158:1171-81. 6. GaudermanwJ,GillilandGF.VoraH,et
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Effects IS. Elemental carbon (diesel exhaust). In: 23. Knuiman MW,
James AL, Davitini ML, of ambient sulfur oxides and suspended N[OSH
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(Reportno.454/K-03-001.)COP1right 2004 MassachusettsMedicalSociety.
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Nootheruses withoutpermission. Copyright2004 Massachusetts Medical
Society. All rightsreserved. 1067EXHIBIT 3 AHA Scientific
Statelnent Particulate MatterAir Pollution and
CardiovascularDisease An Update to theScientificStatementFromthe
American HeartAssociation RobertD. Brook, MD, Chair; Sanjay
Rajagopalan, MD; C. Arden Pope III, PhD; Jeffrey R. Brook, PhD;
Aruni Bhatnagar, PhD, FAHA; Ana V. Diez-Roux, MD, PhD, MPH;
Fernando Holguin, MD; Yuling Hong, MD, PhD, FARA; Russell V.
Luepker, MD, MS, FAHA; Murray A. Mittleman, MD, DrPH, FARA;
AnnettePeters, PhD; David Siscovick, MD, MPH, FARA; Sidney C.
Smith, Jr, MD, FAHA; LaurieWhitsel, PhD; Joel D. Kaufman, MD, MPH;
on behalfofthe American HeartAssociation Council on Epidemiology
and Prevention, Council on the Kidney in CardiovascularDisease, and
Council onNutrition, Physical Activity and Metabolism
Abstract-In2004, the first American Heart Association scientific
statement on "Air Pollution and CardiovascularDisease"
concludedthatexposuretoparticulatematter(PM)
airpollutioncontributes to cardiovascularmorbidity andmortality.
Intheinterim, numerousstudies haveexpandedourunderstandingofthis
associationandfurtherelucidatedthephysiologicalandmolecularmechanismsinvolved.ThemainobjectiveofthisupdatedAmericanHeartAssociationscientificstatementisto
provideacomprehensivereviewofthenewevidencelinkingPMexposurewithcardiovasculardisease,
with a specific focus on highlighting the clinical implications for
researchers and healthcare providers. Thewriting group also sought
to provide expertconsensus opinions on many aspects ofthe current
state ofscience andupdated suggestions for areas offuture research.
Onthe basisofthe findings ofthis review, several new
conclusionswerereached, including the following: Exposureto PM
