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Mitochondria play an essential role in both cell health and death. Increasing experimental evidence suggests that mitochondria are involved in active control of cell death processes at several levels including (1) mitochondrial membrane permeabilization and release of proapoptotic proteins, (2) postcytochrome c regulation of caspase activation, and (3) supply of energy for execution of death program. The purpose of this review is to discuss the main mechanisms by which alterations in mitochondrial outer membrane permit the translocation of proapoptotic proteins into cytosol, how mitochondria “make decisions” on the mode of cell death, and how they regulate caspase activation by changing the redox state of cytosolic cytochrome c. The interventions into these processes may constitute an important strategy for the pharmacological prevention of unwanted cell death in various pathologies or, conversely, for facilitation of anticancer therapy. Environ. Mol. Mutagen. 51:406-416, 2010.