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The Clean Air Act mandates that the National Ambient Air Quality Standards(NAAQS) must be routinely assessed to protect populations based on the latestscience. Therefore, researchers should continue to address whether exposure tolevels of air pollution below the NAAQS is harmful to human health. Thecontentious nature surrounding environmental regulations urges us to cast thisquestion within a causal inference framework. Parametric and semi-parametricregression approaches have been used to estimate the exposure-response (ER)curve between ambient air pollution and health outcomes. Most of theseapproaches are not formulated within a causal framework, adjust for the samecovariates across all levels of exposure, and do not account for modeluncertainty. We introduce a Bayesian framework for the estimation of a causalER curve called LERCA (Local Exposure Response Confounding Adjustment), whichallows for different confounders and different strength of confounding at thedifferent exposure levels; and propagates uncertainty regarding confounders'selection and the shape of the ER. LERCA provides a principled way of assessingthe covariates' confounding importance at different exposure levels, providingresearchers with information regarding the variables to adjust for inregression models. Using simulations, we show that state of the art approachesperform poorly in estimating the ER curve in the presence of local confounding.LERCA is used to evaluate the relationship between exposure to ambient PM2.5and cardiovascular hospitalizations for 5,362 zip codes in the US, whileadjusting for a potentially varying set of confounders across the exposurerange. Ambient PM2.5 leads to an increase in cardiovascular hospitalizationrates when focusing at the low exposure range. Our results indicate that thereis no threshold for the effect of PM2.5 on cardiovascular hospitalizations.

A causal exposure response function with local adjustment for  confounding: Estimating health effects of exposure to low levels of ambient  fine particulate matter