Air pollution is a serious concern to many Americans. Historical evidence of lethally high air pollution concentrations, and oft-cited comparisons of modern air pollution exposures to cigarette smoking have put air pollution control high on most peoplesï¿½ radar. That is perfectly sensible. Making the world a safer place for ourselves and our children is the highest human instinct.
But our instincts can also mislead us if we devote scarce public health resources toward risks that are small, of low probability, and costly to reduce, while other risks that are larger, of higher probability, and less expensive to reduce get short shrift. And we are particularly easy to mislead when news coverage treats new studies of risk superficiallyï¿½devoid of context and devilish details.
On March 6, the Journal of the American Medical Association published one such study by C. Arden Pope and co-authors entitled, ï¿½Lung Cancer, Cardiopulmonary Mortality, and Long-term Exposure to Fine Particulate Air Pollution.ï¿½ The Pope study contends that people living in areas with higher levels of fine, airborne particles are likely to die earlier than people living in areas with less fine-particle pollution. Specifically, the Pope study contends that living in an area with fine particulate levels 70 percent greater than average, results in a 6 percent increase in the risk of death over a 16-year period.
Although the authors claim to have demonstrated a substantial risk from air pollution, the analysis below will show they may have mistakenly attributed health risks to air pollution that are actually caused by other health-related factors omitted from their analysis. Furthermore, even taking the studyï¿½s results at face value, the study found a relatively small risk from particulates when compared with other risks people face, and Americaï¿½s success in reducing air pollution means few areas now have particulate levels high enough to cause health damage.
Confounding Breeds Confusion
The Pope study is an ï¿½ecological studyï¿½ï¿½that is, a study in which researchers observe peopleï¿½s health, behaviors, and risk factors out in the real world, rather than in the tightly controlled conditions of the laboratory. Ecological studies are inherently limited because researchers cannot obtain detailed ongoing information about the relationships between peopleï¿½s health and the potential causes of health risks. For example, the behavior of the subjects cannot be prescribed, and their diet, exercise and other health habits cannot be monitored on an ongoing basis. Pollution exposure can only be roughly estimated based on a few regional measurements, rather than actual individual exposure. Exposure is also uncertain because researchers donï¿½t know how much time people spend outdoors, or whether they continue to live and work in the same place after their initial entry into the study.
As a result of these factors, itï¿½s difficult to tell in an ecologic study whether observed health outcomes are the result of pollution exposure and not of other differences between people who live in high- and low-pollution areas. For example, if it turned out that people in high-pollution areas are more likely to drink or smoke, thereï¿½s a danger of inadvertently confusing an effect of alcohol consumption or smoking with an effect of pollution. This problem is known as confounding. Other confounders besides alcohol and smoking include diet, exercise frequency, income, marital status, ï¿½body-mass indexï¿½ (BMI; a measure of obesity), and educational attainment.
The Pope study researchers accounted for most of these confounders in their analysis. But the factors were assessed only when people entered the study in 1982 and not afterward. If any of these factors changed after 1982, and if the changes were correlated with pollution levels, then the Pope study results would suffer from uncontrolled confounding. For example, if people in areas with higher pollution were also likely to get fatter between 1982 and 2000 when compared with people in lower-pollution areas, researchers could mistake an effect of body weight for an effect of air pollution.
According to the Centers for Disease Control, Americans indeed became much heavier, on average, during the last 20 years, and poorer people and minorities are at greater risk of obesity than whites and wealthier people. If minorities and the poor are also more likely to live in areas with more particulate pollution, then itï¿½s possible that increases in body weight or changes in some other health factor might actually be responsible for effects that the Pope study attributes to air pollution.
Similar concerns apply to other confounders, such as diet and smoking. For example, if the prevalence of smoking decreased more slowly in higher pollution areas during the last 20 years, then smoking might have actually been responsible for effects the Pope study attributes to air pollution.
Because the risks of smoking and obesity are so much larger than the risks the Pope study estimated for fine particulates, even a small difference in smoking and obesity trends between areas with differing pollution levels could swamp the claimed effect of differences in air pollution. For example, the Pope study found that a 70 percent increase in the concentration of fine, airborne particle levels increases risk of dying prematurely by 6 percent. But for a six foot, 200-pound, non-smoking man, gaining just 15 pounds increases the risk of an early death by 17 percent.
Two other findings in the Pope study suggest that the authorsï¿½ efforts to control for confounding were incomplete. First, the study found that particulate exposure increases the risk of lung cancer for men, but not for women. Second, the association of air pollution and either cancer or cardiopulmonary mortality held only for people with a high school education or less.
There are also other potentially confounding factors that the Pope study did not assess at all, including income and wealth, and physical activity levels. These factors also have a strong relationship to health and could have changed over time in ways that could cause misattribution of health effects to air pollution when they were actually due to other factors.
Assumptions Arenï¿½t Always Accurate
While it is very important to determine whether low-level exposure to airborne particles poses a risk to human health, such research must be based on sound assumptions in order to provide valid information about health risks. Nevertheless, the Pope study authors made a number of questionable assumptions that should have steered them away from claiming to have generated the ï¿½strongest evidence to dateï¿½ regarding the relationship between airborne particles and human health.
Regarding exposure, the studyï¿½s authors assumed that everyone within a zip code was exposed to the same level of particulate pollution, though evidence shows such exposure can vary widely. Not only does exposure vary from place to place in concentration, in the chemical composition of the particles.
The authors also assumed people told the truth on the initial questionnaires regarding how much they smoked and drank. But survey researchers have observed that people tend to under-report these behaviors. Thus, if the authors used survey responses to account for smoking and drinking, they could be underestimating that risk in their study population.
The authors also assumed that health-related behaviors did not change after the entrance survey in 1982. For example, this means the authors assumed that if one did not smoke on the entrance survey, one would not take it up, and that people who filled out surveys in 1982, and later died in the same area where they originally lived, had stayed there throughout. As noted in the previous section, this problem also applies to other health-related factors such as change in weight and diet after entering the study.
Context Offers Clarity
The Pope study authors contend that the study provides ï¿½the strongest evidence to date that long-term exposure to fine-particulate air pollution common to many metropolitan areas is an important risk factor for cardiopulmonary mortality.ï¿½ Media reports on the study were also uncritical in repeating the studyï¿½s findings, while giving short shrift to its many limitations. But even if we take the Pope studyï¿½s results at face value, the study greatly exaggerates actual risks, and does a poor job of placing the risk of particulate air pollution into the context of other risks people face.
The analysis in previous sections shows that the studyï¿½s authors may well have mistakenly attributed health risks to air pollution that are actually caused by other factors. But even ignoring this concern, the study found a relatively small risk from particulates. For example, the study found that reducing particulate levels by 60 percent would reduce risk of dying during a 16-year period by about 6 percent. But, a six foot, 215 pound, non-smoking man can achieve the same risk reduction by losing about five pounds, and three times the risk reduction by losing about 20 pounds.
The Pope study also found that most of the health benefits from reducing airborne particulate levels accrue from reducing particulates down to a concentration in air of about 18 micrograms per cubic meter (mcg/m3). Reductions below this level provided little or no additional health benefit. But according to the Pope studyï¿½s pollution measures, all but 2 of 51 metropolitan areas were already below 18 mcg/m3 as of 1999-2000. National fine-particulate monitoring data also show that few areas of the country now have particulate levels above 18 mcg/m3. Thus, even if the small additional health risk reported by the Pope study is real, few people are exposed to it.
Ongoing reductions in particulate levels also mean that future particulate levels will be even lower, further reducing risk. For example, total particulate emissions dropped 75 percent between 1940 and 1997, while per-capita emissions dropped more than 85 percent. Total particulate levels in air declined about 50 percent between 1960 and 1990, while coarse plus fine particulates declined 19 percent between 1991 and 2000. The health hazards discussed in the Pope study occur only after many years of exposure to elevated particulate levels. Continuing declines in particulate pollution suggest that remaining risks will not persist for long enough to damage health in the future.
The Pope study also provides little context on the pitfalls of ecological studies and of epidemiologic studies in general. A number of authorities in the field of epidemiology have concluded that studies that find relatively small increases in risk associated with various health risk factors are often unreliable, due to the likelihood of undetected confounding or bias (see discussion of confounding above).
Everyone deserves air thatï¿½s safe to breathe, and most Americans agree on the importance of improving air quality in places where air pollution is high enough to threaten health. But most Americans also want to know that public health resources are going where theyï¿½ll get the biggest bang for the buckï¿½that is, toward larger, more certain risks, rather than toward small risks that might not even be real. Exaggerating the publicï¿½s risk from air pollution is no better than ignoring real air quality problems. If society misspends scarce resources based on inaccurate information, more people will suffer, not fewer.
Dr. Kenneth Green is senior fellow at Reason Foundation and Chief Scientist at Frasier Institute.
Joel Schwartz is an adjunct fellow at Reason Foundation and visiting scholar at American Enterprise Institute.
 C. Arden Pope, et al., ï¿½Lung Cancer, Cardiopulmonary Mortality, and Long-term Exposure to Fine Particulate Air Pollution, Journal of the American Medical Association, vol. 27, no. 9, March 6, 2002.
 National Center for Health Statistics, Health, United States, 1998, with Socioeconomic Status and Health Chartbook (Atlanta: Centers for Disease Control, 1999).
 E. E. Calle et al., ï¿½Body-Mass Index and Mortality in a Prospective Cohort of US Adults,ï¿½ New England Journal of Medicine, vol. 341 (1999), pp. 1097-1105.
 G. Polakovic, ï¿½Research Links Air Pollution to Lung Cancer,ï¿½ Los Angeles Times, March 6, 2002 (www.latimes.com/news/nationworld/nation/la-000016775mar06.story), and Andrew C. Revkin, ï¿½Soot Particles Strongly Tied to Lung Cancer, Study Finds,ï¿½ New York Times, March 6, 2002 (www.nytimes.com/2002/03/06/health/06SOOT.html).
 Calle et al., ï¿½Body-Mass Index and Mortality in a Prospective Cohort of US Adultsï¿½
 U.S. Environmental Protection Agency, Initial Summary of Preliminary 1999 Fine Particulate Matter (PM2.5) Monitoring Data (Washington, D.C., 2000).
 I. Goklany, Clearing the Air: The Real Story of the War on Air Pollution (Washington, D.C.: Cato, 1999).
 Ibid.; U.S. EPA, Latest Findings on National Air Quality: 2000 Status and Trends (Washington, D.C., 2001). Methods for measuring particulates have changed over the years, as progressively smaller particles were found to be the main culprits for health effects. ï¿½Total particulatesï¿½ includes all particles suspended in air, regardless of size; ï¿½coarse particulatesï¿½ includes all particles between 2.5 and 10 micrometers (0.0025 to 0.01 millimeters) in diameter, while ï¿½fine particulatesï¿½ includes all particles up to 2.5 micrometers in diameter.
 G. Taubes, ï¿½Epidemiology Faces its Limits,ï¿½ Science, vol. 269, September 8, 1995, pp. 164-169.