Editorials

The Health Hazards of Air Pollution—Implications for Your Patients

 

Am Fam Physician. 2017 Feb 1;95(3):146-148.

Air pollution has many deleterious health effects (Table 1). The International Energy Agency recently released a report attributing an annual 6.5 million premature deaths to air pollution worldwide.1 Although the Clean Air Act has done a great deal to improve air quality in the United States since 1970, some of these gains are being eroded in part because of changes in the climate. In fact, many localities have never even been able to meet the Environmental Protection Agency's air quality standards.2 This poor air quality becomes even worse as temperatures continue to rise. Greater warmth and sunlight interact with exhaust to produce more ground-level ozone, a common pollutant and powerful lung irritant.3 Air pollution is associated with a greater risk of chronic obstructive pulmonary disease, independent of smoking history, and increased airway reactivity to allergens in patients with atopic asthma.46 Warming temperatures can aggravate the effects of air pollution.7 Increased levels of particulates exacerbate preexisting respiratory conditions and lead to higher rates of hospitalization and death.8 Air pollution is also associated with cardiovascular disease, including stroke and hypertension.9,10 One study also found a link between air pollution and high levels of anxiety.11 In addition, air pollution may contribute to low birth weight, onset of preterm labor, and other negative perinatal outcomes.12,13

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Table 1.

Health Risks Associated with Air Pollution

Allergy season extended

Anxiety

Asthma exacerbations in atopic patients

Chronic obstructive pulmonary disease exacerbations

Decreased lung function

Hypertension

Myocardial infarction

Premature births

Stroke

Table 1.

Health Risks Associated with Air Pollution

Allergy season extended

Anxiety

Asthma exacerbations in atopic patients

Chronic obstructive pulmonary disease exacerbations

Decreased lung function

Hypertension

Myocardial infarction

Premature births

Stroke

Children are more vulnerable to poor air quality than adults. College-aged persons who grew up in areas with poorer air quality had worse lung function compared with their less-exposed peers.14 In longitudinal studies, cohorts of children who lived in areas where air quality improved showed greater improvements in lung capacity on repeat testing than cohorts of children who lived in areas with less improvement.15 Other vulnerable groups include persons who are older, who have preexisting heart and lung disease, and who are poor.16,17 Socioeconomically disadvantaged groups often live in areas with high traffic, areas in proximity to power plants, and in neighborhoods where there are fewer trees to filter pollutants and mitigate high temperatures by providing shade.

Although physicians have no direct control over air quality, they are increasingly called on to help their patients by addressing the environment in which they live. One health system recently took a three-pronged approach to combating local air pollution.18 First, the organization created a working group to study the health impact of air pollution on the community. Second, the group arranged to reduce its own system's contribution to air pollution by installing solar panels, increasing employee reliance on public transportation and clean vehicles, and curtailing medical waste. Third, the group educated their physicians about air quality and developed recommendations to help them counsel patients on limiting outdoor activities in response to different levels of air pollution.

Physicians should advise patients with asthma or lung disease to prepare to step up fast-acting inhaler use and limit outdoor activity when air quality might worsen respiratory conditions.19 The Environmental Protection Agency's Air Quality Index can guide decisions to limit outdoor activities. In general, a value of zero to 50 indicates good air quality, 51 to 150 is considered unhealthy for vulnerable groups, and a value of 151 or greater is unhealthy for everyone.

Patients can monitor air quality themselves by downloading the American Lung Association's free State of the Air app, which provides daily updates about the Air Quality Index for different localities. Real-time air quality index forecasts are also available at https://airnow.gov.

Portable monitoring devices are expensive, but may become more widely available in the near future. Although indoor air filters reduce particulates, their health benefits have not been studied.20,21

Staying indoors is not always practical. For those who exercise regularly outdoors, the benefits outweigh the risks unless air quality is consistently hazardous.22 Face masks that filter out particles may have protective benefit in some circumstances, such as in areas affected by smoke from wildfires. N95 and N99 face masks and respirators are effective in filtering out particulates 0.1 to 0.3 microns and larger, but are useless against ozone and other gases, such as nitrogen oxide and sulfur dioxide.

According to the International Energy Agency, most of the man-made sources of air pollution are attributable to energy production and use.1 The American College of Physicians recently published a position paper encouraging physicians to recognize the health cobenefits of actions to support the environment.23  Efficient energy consumption, clean transportation, and green practices target the cardiovascular and respiratory effects of air pollution among a wide range of environmental health impacts brought about by climate change. Table 2 provides a list of resources for physicians and patients on air pollution and sustainable health care practices.

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Table 2.

Resources for Physicians and Patients on Air Pollution and Health

General health information

Centers for Disease Control and Prevention

http://www.cdc.gov/air/default.htm

U.S. Global Change Research Program Climate and Health Assessment

https://health2016.globalchange.gov/air-quality-impacts

Patient education

Asthma UK

https://www.asthma.org.uk/advice/triggers/pollution/

Centers for Disease Control and Prevention

http://www.cdc.gov/features/wildfires/

Air quality information and air quality monitors

AirNow

https://www.airnow.gov

American Lung Association State of the Air

http://www.lung.org/our-initiatives/healthy-air/sota/

U.S. Environmental Protection Agency

https://www.epa.gov/air-research

https://www.epa.gov/air-research/air-sensor-toolbox-citizen-scientists-flyer

Organizations addressing air quality

American Lung Association

http://lung.org/our-initiatives/healthy-air/

Inspiration Green

http://www.inspirationgreen.com/organizations-air.html

Moms Clean Air Force

http://www.momscleanairforce.org/

Environmentally responsible heath care

Health Care Without Harm

https://noharm.org/

My Green Doctor

http://www.mygreendoctor.org

Practice Greenhealth

https://practicegreenhealth.org/

Table 2.

Resources for Physicians and Patients on Air Pollution and Health

General health information

Centers for Disease Control and Prevention

http://www.cdc.gov/air/default.htm

U.S. Global Change Research Program Climate and Health Assessment

https://health2016.globalchange.gov/air-quality-impacts

Patient education

Asthma UK

https://www.asthma.org.uk/advice/triggers/pollution/

Centers for Disease Control and Prevention

http://www.cdc.gov/features/wildfires/

Air quality information and air quality monitors

AirNow

https://www.airnow.gov

American Lung Association State of the Air

http://www.lung.org/our-initiatives/healthy-air/sota/

U.S. Environmental Protection Agency

https://www.epa.gov/air-research

https://www.epa.gov/air-research/air-sensor-toolbox-citizen-scientists-flyer

Organizations addressing air quality

American Lung Association

http://lung.org/our-initiatives/healthy-air/

Inspiration Green

http://www.inspirationgreen.com/organizations-air.html

Moms Clean Air Force

http://www.momscleanairforce.org/

Environmentally responsible heath care

Health Care Without Harm

https://noharm.org/

My Green Doctor

http://www.mygreendoctor.org

Practice Greenhealth

https://practicegreenhealth.org/

editor's note: Caroline Wellbery, MD, PhD, is Associate Deputy Editor for AFP.

The authors thank Kate Price, MPH, and Marybeth Montoro, MPH, for their research assistance.

Address correspondence to Caroline Wellbery, MD, PhD, at wellberc@georgetown.edu. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. International Energy Agency. Energy and air pollution 2016—world energy outlook special report. http://www.worldenergyoutlook.org/. Accessed June 29, 2016....

2. United States Environmental Protection Agency. Green book nonattainment areas. https://www.epa.gov/green-book. Accessed April 4, 2016.

3. Melillo JM, Richmond TC, Yohe GW, eds.; U.S. Global Change Research Program. Climate change impacts in the United States: the third national climate assessment. 2014. http://www.globalchange.gov/browse/reports/climate-change-impacts-united-states-third-national-climate-assessment-0. Accessed June 21, 2016.

4. Hizawa N. Clinical approaches towards asthma and chronic obstructive pulmonary disease based on the heterogeneity of disease pathogenesis. Clin Exp Allergy. 2016;46(5):678–687.

5. Gan WQ, FitzGerald JM, Carlsten C, Sadatsafavi M, Brauer M. Associations of ambient air pollution with chronic obstructive pulmonary disease hospitalization and mortality. Am J Respir Crit Care Med. 2013;187(8):721–727.

6. Hernandez ML, Lay JC, Harris B, et al. Atopic asthmatic subjects but not atopic subjects without asthma have enhanced inflammatory response to ozone. J Allergy Clin Immunol. 2010;126(3):537–544e1

7. Crimmins AJ, Balbus JL, Gamble CB, et al.; U.S. Global Change Research Program. The impacts of climate change on human health in the United States: a scientific assessment. Executive summary. 2016. https://health2016.globalchange.gov/. Accessed June 21, 2016.

8. Brunekreef B, Holgate ST. Air pollution and health. Lancet. 2002;360(9341):1233–1242.

9. Shah AS, Lee KK, McAllister DA, et al. Short term exposure to air pollution and stroke: systematic review and meta-analysis. BMJ. 2015;350:h1295.

10. Cai Y, Zhang B, Ke W, et al. Associations of short-term and long-term exposure to ambient air pollutants with hypertension: a systematic review and meta-analysis. Hypertension. 2016;68(1):62–70.

11. Power MC, Kioumourtzoglou MA, Hart JE, Okereke OI, Laden F, Weisskopf MG. The relation between past exposure to fine particulate air pollution and prevalent anxiety: observational cohort study. BMJ. 2015;350:h1111.

12. Trasande L, Malecha P, Attina TM. Particulate matter exposure and preterm birth: estimates of U.S. attributable burden and economic costs [published ahead of print March 29, 2016]. Environ Health Perspect. http://ehp.niehs.nih.gov/15-10810/. Accessed June 21, 2016.

13. DeFranco E, Moravec W, Xu F, et al. Exposure to airborne particulate matter during pregnancy is associated with preterm birth: a population-based cohort study. Environ Health. 2016;15:6.

14. Gauderman WJ, Avol E, Gilliland F, et al. The effect of air pollution on lung development from 10 to 18 years of age [published correction appears in N Engl J Med. 2005;352(12):1276]. N Engl J Med. 2004;351(11):1057–1067.

15. Gauderman WJ, Urman R, Avol E, et al. Association of improved air quality with lung development in children. N Engl J Med. 2015;372(10):905–913.

16. O'Neill MS, Jerrett M, Kawachi I, et al.; Workshop on Air Pollution and Socioeconomic Conditions. Health, wealth, and air pollution: advancing theory and methods. Environ Health Perspect. 2013;111(16):1861–1870.

17. Krieger N, Waterman PD, Gryparis A, Coull BA. Black carbon exposure more strongly associated with census tract poverty compared to household income among US black, white, and Latino working class adults in Boston, MA (2003–2010). Environ Pollut. 2014;190:36–42.

18. Joy EA, Horne BD, Bergstrom S. Addressing air quality and health as a strategy to combat climate change. Ann Intern Med. 2016;164(9):626–627.

19. Laumbach RJ. Outdoor air pollutants and patient health. Am Fam Physician. 2010;81(2):175–180.

20. Brown KW, Minegishi T, Allen JG, McCarthy JF, Spengler JD, MacIntosh DL. Reducing patients' exposures to asthma and allergy triggers in their homes: an evaluation of effectiveness of grades of forced air ventilation filters. J Asthma. 2014;51(6):585–594.

21. Sublett JL, Seltzer J, Burkhead R, et al. Air filters and air cleaners: rostrum by the American Academy of Allergy, Asthma & Immunology Indoor Allergen Committee. J Allergy Clin Immunol. 2010;125(1):32–38.

22. Woodward A, Samet J. Active transport: exercise trumps air pollution, almost always. Prev Med. 2016;87:237–238.

23. Crowley RA; Health and Public Policy Committee of the American College of Physicians. Climate change and health: a position paper of the American College of Physicians. Ann Intern Med. 2016;164(9):608–610.

 

 

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