OBJECTIVE--To explore whether the apparent low threshold for the mortality effects of air pollution could be the result of confounding. DESIGN--The associations between mortality and sulphur dioxide (SO2) were analysed taking into account potential confounding factors. SETTING--The Netherlands, 1979-87. MEASUREMENTS AND MAIN RESULTS--The number of deaths listed by the day on which the death occurred and by the cause of death were obtained from the Netherlands Central Bureau of Statistics. Mortality from all causes and mortality from four large groups of causes (neoplasms, cardiovascular diseases, respiratory diseases, and external causes) were related to the daily levels of SO2 air pollution and potential confounders (available from various sources) using log-linear regression analysis. Variables considered as potential confounders were: average temperature; difference between maximum and minimum temperatures; amount of precipitation; air humidity; wind speed; influenza incidence; and calendar year, month, and weekday. Both lagged and unlagged effects of the meteorological and influenza variables were considered. Average temperature was represented by two variables--'cold', temperatures below 16.5 degrees C, and 'warm', those above 16.5 degrees C--to allow for the V shaped relation between temperature and mortality. The positive regression coefficient for the univariate effect of SO2 density on mortality from all causes dwindles to close to zero when all potential confounding variables are taken into account. The most important of these represents the lagged (one to five days) effect of low temperatures. Low temperatures have strong lagged effects on mortality, and often precede relatively high SO2 densities in the Netherlands. Results were similar for separate causes of death. While univariate associations suggest an effect of air pollution on mortality in all four cause of death groups, multivariate analyses show these effects, including that on mortality from respiratory diseases, are a result of confounding. CONCLUSIONS--The SO2 density (or that of compounds closely associated with SO2) does not seem to have any short term effect on mortality in the Netherlands. SO2 levels higher than those currently reached in the Netherlands (above 200 micrograms/m3) may have a measurable effect on mortality and this should be investigated. Furthermore, analyses of the public health impact of outdoor air pollution should properly control for the lagged effects of temperature.
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