Science of the Total Environment 409 (2011) 4923–4928

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Science of the Total Environment

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Ambient carbon monoxide and daily mortality in three Chinese cities: The China Air
Pollution and Health Effects Study (CAPES)
Renjie Chen a, b, 1, Guowei Pan c, 1, Yanping Zhang d, 1, Qun Xu e, Guang Zeng f, Xiaohui Xu g,
Bingheng Chen a, b, Haidong Kan a, b,⁎
a
School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, Fudan University, Shanghai, China
b
G_RIoCE (Research Institute for the Changing Global Environment) and Fudan Tyndall Centre, Fudan University, Shanghai, China
c
Liaoning Provincial Center for Disease Control and Prevention, Shenyang, China
d
Taiyuan Municipal Center for Disease Control and Prevention, Taiyuan, China
e
Department of Epidemiology and Health Statistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
f
Department of Preventive Medicine, School of Management, Beijing University of Chinese Medicine, Beijing, China
g
Department of Epidemiology and Biostatistics, College of Public Health and Health Professions, University of Florida, Gainesville, FL, United States

a r t i c l e i n f o a b s t r a c t

Article history: Ambient carbon monoxide (CO) is an air pollutant primarily generated by traffic. CO has been associated with
Received 7 June 2011 increased mortality and morbidity in developed countries, but few studies have been conducted in Asian
Received in revised form 9 August 2011 developing countries. In the China Air Pollution and Health Effects Study (CAPES), the short-term associations
Accepted 10 August 2011
between ambient CO and daily mortality were examined in three Chinese cities: Shanghai, Anshan and
Available online 10 September 2011
Taiyuan. Poisson regression models incorporating natural spline smoothing functions were used to adjust
Keywords:
for long-term and seasonal trend of mortality, as well as other time-varying covariates. Effect estimates
Air pollution were obtained for each city and then for the cities combined. In both individual-city and combined analysis,
CAPES significant associations of CO with both total non-accidental and cardiovascular mortality were observed. In
Carbon monoxide the combined analysis, a 1 mg/m 3 increase of 2-day moving average concentrations of CO corresponded to
Mortality 2.89% (95%CI: 1.68, 4.11) and 4.17% (95%CI: 2.66, 5.68) increase of total and cardiovascular mortality, respec-
Time-series tively. CO was not significantly associated with respiratory mortality. Sensitivity analyses showed that our
findings were generally insensitive to alternative model specifications. In conclusion, ambient CO was
associated with increased risk of daily mortality in these three cities. Our findings suggest that the role of
exposure to CO and other traffic-related air pollutants should be further investigated in China.
© 2011 Elsevier B.V. All rights reserved.

1. Introduction
Air masses always contain many pollutants in differing amounts,
including both particulate matter (PM) and gaseous pollutants.
Although the strongest evidence linking air pollutants with adverse
health effects thus far is for PM (Pope and Dockery, 2006), many
studies have reported associations for gaseous pollutants such as
nitrogen dioxide (NO2) (Samoli et al., 2006), ozone (O3) (Bell
et al., 2004a), sulfur dioxide (SO2) (Kan et al., 2010), and carbon
monoxide (CO). CO is a colorless, odorless, and tasteless air toxin
which is produced by incomplete combustion of hydrocarbons. In
urban areas, CO is primarily generated by motor vehicle emission.
Previously, epidemiologic studies have reported short-term associa-
tions of ambient CO with daily mortality and morbidity from cardio-
vascular diseases (Allred et al., 1989; Dales, 2004; Riojas-Rodriguez
⁎ Corresponding author at: P.O. Box 249, 130 Dong-An Road, Shanghai 200032,
China. Tel./fax: + 86 21 6404 6351.
E-mail address: haidongkan@gmail.com (H. Kan).
1
These authors contributed equally to this work.
et al., 2006; Yang et al., 1998). Recent multi-city analyses conducted
in the U.S. and Europe provide further evidence supporting
coherence and plausibility of the associations (Bell et al., 2009;
Samoli et al., 2007). However, most of these studies were conducted
in developed countries.
Coal is still the major source of energy, constituting about 75% of all
energy sources. Consequently, air pollution in China predominantly
consists of coal smoke, with suspended particulate matter (PM) and
sulfur dioxide (SO2) as the principal air pollutants. In terms of PM
and SO2, China may have the worst air pollution level in the world
(Kan et al., 2011). In large cities, however, with the rapid increase in
the number of motor vehicles, air pollution has gradually changed
from the conventional coal combustion type to the mixed coal combus-
tion/motor vehicle emission type. Also, the characteristics of outdoor
air pollution (e.g. air pollution level, and fate and transport of pollut-
ants), meteorological conditions and socio-demographic patterns in
China are different from North America and Western Europe. To our
knowledge, no prior studies have been carried out to examine the
acute health effects of ambient CO in China, or even Asian developing
countries.

0048-9697/$ – see front matter © 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.scitotenv.2011.08.029
4924 R. Chen et al. / Science of the Total Environment 409 (2011) 4923–4928
The objective of this paper is to examine the short-term associa-
tions between ambient CO and daily mortality in three Chinese cities
— Shanghai, Anshan and Taiyuan. This study is a component of the
China Air Pollution and Health Effects Study (CAPES) initiated by
the China Ministry of Environmental Protection.
2. Materials and methods
2.1. Data
The locations of Shanghai, Anshan and Taiyuan are described in
Fig. 1. Shanghai is the economic center and one of the largest cities
of China. Anshan is a heavily-polluted industrial city in northeastern
China. Taiyuan is the capital city of Shanxi province. Our study areas
were restricted to the urban areas of the three cities, due to inade-
quate air pollution monitoring stations in the suburban areas.
The study periods were 2006 to 2008 for Shanghai, 2004 to 2006
for Anshan, and 2004 to 2008 for Taiyuan. The sources of mortality
data were Shanghai Municipal Center of Disease Control and Preven-
tion; Liaoning Provincial Center of Disease Control and Prevention;
and Taiyuan Municipal Center of Disease Control and Prevention.
The causes of death were coded according to International Classifica-
tion of Diseases, 10 (ICD-10). The mortality data were classified into
deaths due to total non-accidental causes (ICD-10: A00-R99), cardio-
vascular disease (ICD-10: I00-I99), and respiratory disease (ICD-10:
J00-J98).
The sources of air pollutant concentrations were Shanghai Envi-
ronmental Monitoring Center (6 stations), Anshan Environmental
Monitoring Center (2 stations), and Taiyuan Environmental Monitor-
ing Center (9 stations). At each city, the daily concentrations for each
pollutant were averaged from the available monitoring results of
multiple stations. Automatic continuous monitoring system was set
up at each city to measure daily air pollution levels. Air quality
indicators included CO, particulate matter with aerodynamic
diameter of 10 μm or less (PM10), sulfur dioxide (SO2), and nitrogen
dioxide (NO2). 24-hour average concentrations for CO, SO2,
PM10, and NO2 were calculated. The methods based on light absor-
bance (Thermo Environmental Instruments Inc., Model 48C), tapered
Fig. 1. Locations of air monitoring station and weather monitoring station in Shanghai, Taiyuan and Anshan.
element oscillating microbalance (Thermo Environmental Instru-
ments Inc., TEOM Series 1400a), ultraviolet fluorescence (Thermo
Environmental Instruments Inc., Model 43A), and chemilumines-
cence (Thermo Environmental Instruments Inc., Model 42C) were
used for the measurement of CO, PM10, SO2, and NO2, respectively.
For the calculation of 24-hour mean concentrations, at least 75% of
the one-hour values must be available on that particular day. If a
station had more than 25% of the values missing for the whole period
of analysis, the entire station was excluded from the analysis. In each
city, the location of monitoring stations was mandated not to be in
the direct vicinity of traffic or of industrial sources, and not to be
influenced by local pollution sources and should also avoid buildings,
or housing large emitters such as coal-, waste-, or oil-burning boilers,
furnaces, and incinerators.
To allow adjustment for the effect of weather conditions on
mortality, meteorological data (daily mean temperature and relative
humidity) were obtained from one monitoring station at each city.
2.2. Statistical analysis
The CAPES project follows the same protocol as the Public Health
and Air Pollution in Asia (PAPA) program of the Health Effects
Institute (Wong et al., 2008, 2010). Specifically, the protocol
comprises specification for selection of monitoring stations, quality
assurance or quality control for the data collection, health outcomes
and air pollutants to be included in the analysis. The protocol also
included the methods to standardize data management including
compilation of daily data. The methods were individualized to suit
the local situation, including the specifications for selection of
monitoring stations and quality assurance and quality control proce-
dures for data collection on health outcomes and air pollutants to be
included in the analysis.
The daily death, air pollution and weather are linked by date and
therefore can be analyzed with a time-series design (Zeger et al.,
2006). Because counts of daily mortality data in our study approxi-
mately follow a Poisson distribution and the relations between
mortality and explanatory variables are mostly nonlinear (Dominici
et al., 2004), we used overdispersed generalized linear Poisson
 R. Chen et al. / Science of the Total Environment 409 (2011) 4923–4928
models (quasi-likelihood) with natural spline (ns) smoothers to
analyze the mortality, air pollution, and covariates data. This method
has accounted for the over-dispersion in the confidence interval and p
values.
To control long-term and seasonal trends of daily mortality and
weather conditions, generalized linear modeling, with ns smoothers,
was used to model daily mortality (Bell et al., 2004b; Burnett et al.,
2004). The partial autocorrelation function (PACF) was used to
guide the selection of degree of freedom (df) for time trend in the
core models. Specifically, 4–6 df per year was used for time trend.
When the absolute magnitude of the PACF plot was less than 0.1 for
the first two lag days, the core models were regarded as adequate
(Peng et al., 2006). If this criterion was not met, auto-regression
terms were used to reduce autocorrelation (Kan et al., 2008). Day of
the week (DOW) was included as dummy variable in the models.
Residuals of the core models were examined to check whether
there were discernable patterns and autocorrelation by means of
residual plots and PACF plots. Test for normality of the residuals
was also conducted.
CO concentrations were added into the core model to assess its
association with daily mortality in each city. Combined estimates of
CO were calculated using a fixed- or random-effects model. Estimates
were weighted by the inverse of the sum of within- and between-
study variance. Homogeneity tests were performed by means of
Chi-square tests for the differences in sum of squares between
individual and weighted average of the estimates.
Because the assumption of the linearity between CO and the log of
mortality may not be justified, the smoothing function with 3 df was
used to graphically describe their relationships. We compared the
linear and spline models by computing the difference between the
deviances of the fitted two models (Samoli et al., 2005). This differ-
ence followed a chi-square distribution with degrees of freedom
being the difference in the degrees of freedom of the fitted models.
Both single- and multi-pollutant models were fitted to assess the
stability of effect estimate of CO; up to two pollutants were included
per model. Single-day lag models were reported to underestimate the
cumulative effect of air pollution on mortality (Bell et al., 2004b);
therefore, we used 2-day moving average of current and previous
day concentrations (lag01) of CO for our main analyses. Given that
it is not easy to determine the optimal values of df for time trend, sen-
sitivity analyses were conducted to test the impact of alternative df
values on the estimated effect of CO.
All analyses were conducted in R 2.10.1 using the MGCV package
(R Development Core Team, 2010). The results are presented as the
percent change in daily mortality per 1 mg/m 3 increase of CO
concentrations.
3. Results
Table 1 summarizes the air pollution and mortality data in the
three cities. In our research periods (2006–2008 for Shanghai,
Table 1
Descriptive data on the study period, population, daily deaths, air pollutant concentra-
tions and weather conditions (mean and S.D.) in three Chinese cities.
Shanghai Anshan
Study period (year) 2006–2008 2004–2006
Study population (millions) 6.5 1.5
No. of total deaths 125.3 (22.4) 27.6 (6.1)
No. of cardiovascular deaths 49.6 (12.4) 14.1 (4.3)
No. of respiratory deaths 12.9 (5.4) 1.9 (1.5)
CO (mg/m3) 1.3 (0.5) 1.1 (0.8)
PM10 (μg/m3) 86.4 (53.1) 110.9 (60.2)
SO2 (μg/m3) 52.6 (29.9) 59.0 (74.3)
NO2 (μg/m3) 55.9 (21.2) 25.5 (16.3)
Temperature (°C) 17.8 (8.9) 11.3 (12.7)
Humidity (%) 69.6 (11.7) 55.2 (16.0)
4925
2004–2006 for Anshan, and 2004–2008 for Taiyuan), the mean daily
death numbers for all non-accidental causes, cardiovascular causes
and respiratory causes were 125.3, 49.6 and 12.9, respectively, in
Shanghai; 27.6, 14.1, and 1.9 in Anshan; and 24.2, 8.9, and 1.9 in Tai-
yuan (Table 1). Among all deaths, cardiorespiratory causes accounted
for 49.9% in Shanghai, 58.0% in Anshan, and 44.6% in Taiyuan.
Generally, the CO levels in three Chinese cities were similar with
those reported in developed countries (Table 1) (Bell et al., 2009;
Samoli et al., 2007). The averaged daily concentrations of CO were
1.3 mg/m 3 for Shanghai (2006–2008), 1.1 mg/m 3 for Anshan (2004–
2006), and 1.8 mg/m 3 for Taiyuan (2004–2008).
The correlation coefficients of CO with NO2 were higher than with
PM10 or SO2, probably because both CO and NO2 are primarily gener-
ated by traffic sources (Table 2). In all three cities, CO was weakly cor-
related with temperature and relative humidity.
In the single-pollutant models, we found significant associations
between CO levels and daily mortality from total non-accidental
causes and from cardiovascular diseases in each of the three cities
(Table 3). An increase of 1 mg/m 3 of 2-day moving average concen-
trations of CO corresponds to 2.41% [95% confidence interval (CI):
0.64, 4.19], 1.97% (95%CI: 0.13, 3.81), 3.90% (95%CI: 2.54, 5.26) in-
crease of total non-accidental mortality; and 3.85% (95%CI: 1.29,
6.40), 2.83% (95%CI: 0.27, 5.38), and 5.38% (95%CI: 3.28, 7.49)
increase of cardiovascular mortality in Shanghai, Anshan and Taiyuan,
respectively. We did not observe significant associations of CO with
respiratory mortality in all three cities. In the three-city combined
analysis, there was no significant heterogeneity for the associations
of CO with either total or cardiovascular mortality. An increase of
1 mg/m 3 of 2-day moving average concentrations of CO corresponded
to 2.89% (95%CI: 1.68, 4.11) and 4.17% (95%CI: 2.66, 5.68) increase of
total and cardiovascular mortality, respectively (Table 3).
In the three Chinese cities, the associations of CO with total and
cardiovascular mortality were only minimally altered by adding
PM10 and SO2 into the models (Table 3). However, adjustment for
NO2 decreased the associations and rendered some of them statisti-
cally insignificant in the city-specific analysis. In the three-city pooled
estimates, the effects of CO remained significant after adjustment for
any co-pollutants.
There were almost linear relationships between CO and total/
cardiovascular mortality in all three cities (Fig. 2). We did not ob-
serve any obvious threshold concentration below which CO has no
effect on mortality outcomes. The differences in the deviance be-
tween the linear and spline models were statistically insignificant
for all models we examined.
CO showed similar lag patterns for their effects on total and car-
diovascular mortality (Fig. 3). For single-day lags, the risks decreased
from lag-days 0 to 4; multi-day exposures (lag01 and lag04) usually
have larger effects than single-day exposure (lag0 to lag4). The effects
of CO on total and cardiovascular mortality were statistically signifi-
cant for most lagged days we examined.
Within the range of 3–12, the change of df/yr for time trend did
not substantially affect the estimated effects of CO (data not
shown), suggesting that our findings are relatively robust in this
aspect. We also compared the effects of CO with alternative df values
for weather conditions. Within the range of 3–12, the change of df for
Taiyuan
2004–2008 Table 2
1.1 Spearman coefficients of CO with co-pollutants and weather variables in three Chinese
24.2 (7.9) cities*.
8.9 (4.2)
Shanghai Anshan Taiyuan
1.9 (1.7)
1.8 (1.0) PM10 0.72 0.59 0.52
132.1 (65.4) SO2 0.71 0.50 0.58
77.1 (8.0) NO2 0.80 0.73 0.48
22.7 (8.7) Temperature − 0.40 − 0.31 − 0.38
11.2 (10.7) Relative humidity − 0.09 0.09 0.12
55.1 (18.1)
⁎ p b 0.01 for all coefficients.
4926 R. Chen et al. / Science of the Total Environment 409 (2011) 4923–4928

Table 3 countries; 2. unlike PM with various components and toxicity, CO

Percent increase (mean and 95% CIs) of daily mortality with a 1 mg/m3 increase of CO in different countries shares the same biological mechanisms to affect
concentration under single and multi-pollutant models — effect estimates of individual
cities and combined effectsa.
human health.
The shape of exposure–response relationships is crucial for public
City Model Total mortality Cardiovascular health assessment and there has been growing demand for providing
mortality
the relevant curves. Consistent with previous studies in the US and
Shanghai Single-pollutant 2.41 (0.64, 4.19) 3.85 (1.29, 6.40) Europe (Bell et al., 2009; Samoli et al., 2007), the exposure–response
Adjusted for PM10 2.31 (0.22, 4.40) 3.00 (− 0.30, 6.30)
relationship between CO and mortality in three Chinese cities gener-
Adjusted for SO2 2.27 (0.13, 4.41) 1.91 (− 1.45, 5.27)
Adjusted for NO2 − 0.24 (− 3.03, 2.54) 2.24 (− 1.80, 6.28) ally supported a linear association without threshold. It should be
Anshan Single-pollutant 1.97 (0.13, 3.81) 2.83 (0.27, 5.38) noted that we found significant effects of CO even below the levels
Adjusted for PM10 2.49 (0.11, 4.86) 1.92 (− 1.38, 5.22) of air quality standard in China (4 mg/m 3 for 24-h average
Adjusted for SO2 1.60 (− 0.45, 3.65) 2.48 (− 0.38, 5.33) concentration of CO) (Fig. 2). Therefore, current air quality standard
Adjusted for NO2 1.85 (− 0.72, 4.42) 2.77 (− 0.81, 6.34)
of CO might not be sufficient to protect the public health in China.
Taiyuan Single-pollutant 3.90 (2.54, 5.26) 5.38 (3.28, 7.49)
Adjusted for PM10 3.47 (1.85, 5.08) 6.36 (3.88, 8.85) Further control of CO pollution is likely to result in health benefits.
Adjusted for SO2 2.82 (1.31, 4.32) 4.94 (2.63, 7.26) A reduction in morbidity and mortality after the implementation of
Adjusted for NO2 1.95 (0.43, 3.47) 3.77 (1.41, 6.13) an intervention program will add evidence to the hypothesis of a
Pooled estimates Single-pollutant 2.89 (1.68, 4.11) 4.17 (2.66, 5.68)
causal link between CO pollution and ill health.
Adjusted for PM10 2.91 (1.79, 4.04) 3.94 (1.13, 6.76)
Adjusted for SO2 2.36 (1.31, 3.42) 3.38 (1.46, 5.31) CO is produced by incomplete combustion of hydrocarbons. Its
Adjusted for NO2 1.53 (0.35, 2.72) 3.23 (1.46, 5.00) main source in urban area is vehicle exhaust emissions. Accompanied
a
Two-day moving averaging (lag 01) concentrations were used in Table 3.
with the rapid socioeconomic development, the number of motor ve-
hicles increases drastically in urban China, and exhaust emissions are
becoming one of the major contributors to urban air pollution. Evi-
temperature and humidity resulted in almost identical estimated ef- dence from epidemiological studies on the health effects of traffic-
fects of CO on mortality outcomes. related air pollutants [nitrogen oxides (NOx), CO, PM, O3 and its pre-
cursors] has accumulated in China (Kan et al., 2011). However, most
4. Discussion of these studies focus on occupationally exposed populations (e.g.
traffic policemen, drivers or conductors) and vulnerable population
This combined analysis summarizes the results from three Chinese (e.g. children) (Chen et al., 2009; Wang et al., 2009; Zhou et al.,
cities concerning the short-term effects of CO on daily mortality. Sig- 2001). No Chinese studies examined mortality in relation to
nificant associations of CO with total and cardiovascular mortality transport-related air pollution, which has been well investigated in
were found, and these findings were generally insensitive to alterna- Western countries. Our findings of CO suggest that the role of expo-
tive model specifications. In the combined analysis, we found signifi- sure to traffic-related air pollution should be investigated further in
cant effects of CO on total and cardiovascular mortality after China.
adjustment for PM10, SO2 or NO2. To our knowledge, this is the first The association between ambient CO and daily mortality is biolog-
multi-city analysis in China or even in Asia to report the acute health ically plausible. CO is one of the few air pollutants that we know its
effect of CO. Our findings are consistent with previous findings of am- biologically toxic form, carboxyhemoglobin (COHb) (McGrath,
bient CO in the US (Bell et al., 2009) and Europe (Samoli et al., 2007). 2000). COHb reduces the oxygen-carrying capacity of the blood and
In our multi-city combined analysis, 1 mg/m 3 increase of CO was impairs the release of oxygen from hemoglobin to extravascular tis-
associated with 2.89% (95%CI: 1.68, 4.11) increase of total non- sues. Therefore, the toxic effects of CO are most evident in organs
accidental mortality. The magnitudes of our estimates for CO are gen- and tissues with high oxygen consumption such as the brain, the
erally comparable with previous single-city, multi-city, and meta an- heart, exercising skeletal muscle, and the developing fetus. The effects
alyses worldwide. For instance, in Phoenix (US), Mar et al. (2000) of exposure to low CO concentrations, such as the levels found in am-
found that 1 mg/m 3 increase of CO was associated with 2.79% (95%CI: bient air, are far more subtle and considerably less threatening than
0.84, 2.64) increase of total non-accidental mortality. In 11 Canadi- those occurring in CO poisoning (McGrath, 2000). The underlying
an cities, Burnett et al. (2004) estimated that 1 mg/m 3 increase of mechanisms for effects of low-level exposure are unclear, but likely
CO was associated with 2.00% (95%CI: 1.39, 2.61) increase of total include reduced exercise capacity and exacerbation of cardiovascular
mortality. Also, in a meta analysis of 18 time-series studies of CO symptoms in individuals with impaired cardiovascular systems. CO
and daily mortality, Stieb et al. (2003) estimated that the excess all- has also been associated with alteration of the cardiac autonomic reg-
causes mortality change (single-pollutant models) associated with ulation in population-based studies (Liao et al., 2004) and in panel
1 mg/m3 of CO was 1.27% (95%CI 0.87%–1.67%). A large-scale multi- studies (Timonen et al., 2006).
city time-series analyses in 19 European cities estimated that 1 mg/ Our analysis has strengths and limitations. These three Chinese
m 3 increase of CO corresponded to 1.20% (95%CI: 0.63–1.77%) in- cities offer advantages for the study of the CO-mortality relationship
crease in total deaths (Samoli et al., 2007). The heterogeneity of var- in that they are generally very densely populated. As in most previous
ious findings may reflect differences in the characteristics of the study time-series studies, we simply averaged the monitoring results across
sites. Numerous factors, including indoor air pollution, weather pat- various stations as the proxy for population exposure level to CO. The
terns, sensitivity of local residents to pollution (e.g. socioeconomic simple averaging method may raise a number of issues given that pol-
status, age, smoking rate), and air pollution levels, may affect the lutant measurements can differ from monitoring location to monitor-
magnitudes of exposure–response relationships. Although only ing location and that ambient monitoring results differ from personal
three Chinese cities were studied, our results may begin to allay con- exposure level to air pollutants (Sarnat et al., 2005). Numerous fac-
cerns regarding the generalizability of the results of the substantial, tors, such as air conditioning and ventilation rate between indoor
but largely Western, literature on the effects of short-term exposure and outdoor air, may affect the monitoring results from fixed stations
to CO. The results, which are broadly consistent with previous re- as surrogates of personal exposure to air pollutants (Janssen et al.,
search, suggest that neither genetic factors nor longer-term exposure 2002). Because we were unable to measure the true population expo-
to highly polluted PM/SO2 substantially modifies the acute effect of sures in these three cities, we could not determine the direction of the
CO on daily mortality in China. We assume two reasons for this con- bias and its impact on our conclusions. We were not able to collect the
sistency: 1. the CO levels are comparable in China and Western 1-h maximum CO, though previous study has found similar effect
 R. Chen et al. / Science of the Total Environment 409 (2011) 4923–4928 4927

Shanghai:
Total mortality Cardiovascular mortality

0.10

0.15
0.10
0.05

logRR
logRR

0.05
0.0

0.0
-0.05
-0.05

1000 1500 2000 2500 3000 1000 1500 2000 2500 3000
CO (microgram per cubic meter) CO (microgram per cubic meter)

Anshan: Total mortality Cardiovascular mortality

0.10

0.15
0.10
0.05

0.05
logRR

logRR
0.0

0.0
-0.05

-0.05
-0.10
-0.10

0 500 1000 1500 2000 2500 3000 0 500 1000 1500 2000 2500 3000
CO (microgram per cubic meter) CO (microgram per cubic meter)

Taiyuan:
Total mortality Cardiovascular mortality
0.5
0.3

0.4
0.3
0.2
logRR

logRR
0.2
0.1

0.1
0.0

0.0
-0.1
-0.1

1000 2000 3000 4000 5000 1000 2000 3000 4000 5000
CO (microgram per cubic meter) CO (microgram per cubic meter)

Fig. 2. Smoothing plots of CO against total and cardiovascular mortality risk (df = 3) in each city. X-axis is the 2-day average (lag01) CO concentrations (μg/m3). The solid lines
indicate the estimated mean percentage of change in daily mortality, and the dotted lines represent twice the standard error.

estimates of CO using 1-h maximum and 24-h averaged concentrations
(Bell et al., 2009). Also, we were not able to obtain the age-specific mor-
tality data of the three Chinese cities, which limited our ability to ex-
plore the modifying effect of age on the health impact of CO.
Moreover, it is still uncertain whether temperature is a confounder or
effect moderator (i.e., a synergistic effect) of the CO-mortality associa-
tion. Future research should study the interaction between CO and
temperature.
In summary, we found significant adverse effects of ambient CO
levels on mortality from all natural and cardiovascular causes, even
well below the health-based air quality standards in China. The effect
estimates were generally consistent with other CO studies in the
remaining world, and relatively robust to adjustment for co-
pollutants, various lagged exposure, and varying smoothness of
time. To our knowledge, this is the first multicity CO study in China.
The findings might have implications for standard revision of ambient
CO and traffic policy formations.
Acknowledgment
The study was supported by the National Basic Research Program
(973 program) of China (2011CB503802), Gong-Yi Program of China
Ministry of Environmental Protection (200809109, 200909016 and
201209008), National Natural Science Foundation of China (30800892),
4928 R. Chen et al. / Science of the Total Environment 409 (2011) 4923–4928
Fig. 3. Percent increase of total and cardiovascular mortality associated with 1 mg/m3
increase of CO, using different lag structures (lag0–lag4, lag01, and lag 04). X-axis is
lag structures. Y-axis is percent increase of mortality.
and Program for New Century Excellent Talents in University (NCET-09-
0314).
The authors declare they have no competing financial interests.
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