SPECIAL ARTICLE

American Thoracic Society and Marron Institute Report

Estimated Excess Morbidity and Mortality Associated with Air
Pollution above American Thoracic Society–recommended Standards,
2013–2015
Kevin R. Cromar1, Laura A. Gladson1, Marya Ghazipura1, and Gary Ewart2
1
Marron Institute of Urban Management, New York University, New York, New York; and 2American Thoracic Society, Washington,
District of Columbia
ORCID IDs: 0000-0002-7745-2780 (K.R.C.); 0000-0002-0406-9684 (L.A.G.).

Keywords: ozone; particulate matter; risk assessment; environmental policy

The Health of the Air report estimates the
public health benefits of meeting American
Thoracic Society (ATS) recommended
standards for ambient air pollution. In
this second annual report, which was
produced in a joint effort by the Marron
Institute of Urban Management at New York
University and the ATS, estimates of excess
mortality, major morbidity, and impacted
days are provided for every county in the
United States with valid measurements from
2013 to 2015 for either fine particulate matter
(PM2.5) or ground-level ozone (O3).
This second annual Health of the Air
report uses updated pollution data from
2013–2015, as compared with the pollution
data from 2011–2013 used in the first
annual report. Beyond updating Health of
the Air estimates to reflect more recent air
pollution concentrations, several important
additions have been added to this year’s
report. First, in addition to annual PM2.5
design values, this report features health
impact estimates associated with 24-hour
PM2.5 design values greater than the ATS-
recommended standard of 25 mg/m3 (1). In
addition, a new health outcome, lung cancer
incidence, was added to the morbidity
estimates for PM2.5. These improvements are
designed to better reflect how air pollution
impacts health in the United States.
There is a continued need to update
this report owing to general improvements
in air quality, which are expected to
continue over time. Air quality in the United
States has benefited from a cycle of
establishing federal standards in response to
evidence derived from health studies
indicating levels at which adverse health
effects have been observed or otherwise
demonstrated (2, 3). State plans to meet
federal air quality requirements are
traditionally executed through the adoption
of newly developed or existing technologies
that reduce emissions from major
pollution sectors (4). As ambient pollution
levels are reduced, new health studies are
conducted to evaluate the impacts of air
pollution at levels previously unavailable
for study. Federal standards can then be
adjusted, if necessary, to adequately protect
public health, and the cycle repeats (3, 5–9).
The ATS has recommended more
protective National Ambient Air Quality
Standards (NAAQS) for both O3 and PM2.5
than those currently adopted by the U.S.
Environmental Protection Agency (EPA).
The EPA administrator is required to
review these standards every five years
and revise them as needed. The exact level
of these standards is left to the discretion
of the administrator with the guidance that
they must be set to protect public health
with an adequate margin of safety. As such,
these standards are typically revised over
time as more evidence on the health impacts
of air pollution becomes available. The
public health benefits of attaining these ATS
recommendations are highlighted in this report.
The other primary purpose of this
report, in addition to highlighting the
benefits of strengthening the NAAQS, is to
provide information that can be useful in
informing local and regional air quality
management decisions. For example,
technology already exists to make further
reductions in pollution emissions, or
eliminate them entirely, in certain sectors
(10–12). However, there are economic
and political challenges in the adoption of
new technologies (13, 14). This report
provides local health estimates that may be
useful in informing difficult decisions
regarding how aggressively to adopt new
technologies or, alternatively, how
aggressively to restrict use of high-polluting
technologies.
It is important that the priorities and
preferences of the general public be included
in air quality management decisions. This
is best accomplished if the public has
access to the same information as decision
makers, given the strong association

(Received in original form October 10, 2017; accepted in final form December 11, 2017 )
Supported by the Marron Institute of Urban Management at New York University and the American Thoracic Society.
Correspondence and requests for reprints should be addressed to Kevin R. Cromar, Ph.D., 60 Fifth Avenue, 2nd Floor, New York, NY 10011.
E-mail: kevin.cromar@nyu.edu.
This article has an online supplement, which is accessible from this issue’s table of contents at www.atsjournals.org.
Ann Am Thorac Soc 2018
Copyright © 2018 by the American Thoracic Society
DOI: 10.1513/AnnalsATS.201710-785EH
Internet address: www.atsjournals.org

This article is available here ahead of print. The final, paginated version will be
Special Article available online and in print in the AnnalsATS May 2018 issue. 1

between individual perception of air quality
and trust in regulatory agencies and
communication sources (15). In addition,
perception of air quality can vary greatly on
the basis of location and socioeconomic
characteristics (15). To deliver this
information more widely to the public, we
have created an accompanying online tool
(www.healthoftheair.org) that provides
searchable health impact information by
city. For regions of the United States that
have EPA air pollution monitors, these
reported health impacts can be used by
both local policymakers and the general
public as they work together to determine
how best to address outdoor air pollution in
their cities and states.
Methods
The methods used in this report are based
on the 2016 Health of the Air report, which
adopts the approach used by the EPA as part
of required regulatory review processes
(2, 3). These methods are briefly described
below together with a description of
changes that were incorporated to improve
the quality of the reported data. More
detailed methodology can be found in last
year’s report (16).
Exposure Assessment
Current PM2.5 and O3 air pollution
concentrations were estimated for each
county with a valid design value for 2013–
2015 (www.epa.gov/air-trends/air-quality-
design-values). A design value is the 3-year
average of pollution concentrations
measured at each monitoring location and
is used to determine whether a county is in
accord with federal air quality standards.
For O3, the design value represents the
3-year average of the fourth-highest daily
8-hour maximum O3 concentration. PM2.5
has both long- and short-term design
values: the annual (or long-term) design
value is the 3-year average of the annual
mean concentration, whereas the daily (or
short-term) value is the 3-year average of
the 24-hour 98th percentile.
The baseline concentrations
corresponded to the design values from
2013–2015, but the control concentrations
corresponded to the ATS recommendations
of 60 parts per billion (ppb) for O3 and of
11 mg/m3 and 25 mg/m3 for long- and
short-term PM2.5, respectively (1, 17). A
major addition to this year’s report is the
2 AnnalsATS 2018
inclusion of the short-term PM2.5 metric in
the analysis. Both the long- and short-term
PM2.5 metrics were incorporated in a
combined factor to determine control
values based on meeting these
recommendations.
Health Impact Assessment
BenMAP-Community Edition version 1.3
(18) and R software (19) were used to
determine the health effects attributable to
air pollution concentrations that exceed
ATS recommendations. Assessed health
impact categories were repeated from the
2016 version of the report, including
mortality, major morbidity (acute
myocardial infarction, chronic bronchitis,
cardiovascular and respiratory hospital
admissions, and emergency department
visits), and adversely impacted days
(restricted activity days, acute respiratory
symptoms, work loss days, and school loss
days). In addition, lung cancer incidence
was included in this updated report’s
estimates of PM2.5 morbidity. Table E1 in
the online supplement lists the
epidemiological studies by pollutant and
metric from which concentration–response
functions were selected for use in this
report. Table E2 lists the five newly added
lung cancer incidence studies. Estimates of
lung cancer from PM2.5 were made using
the pooled results of these studies’ relative
risk values, which were based on North
American and European study populations,
and applied to county-level lung cancer
incidence data from the National Cancer
Institute (20).
All studies used in last year’s analysis
were included in the updated health runs.
Justifications for included studies are
outlined in the original report, prioritizing
study size, national data, generalized health
outcomes, and broad age ranges. This year
other studies were considered using these
same inclusion criteria; as a result, an
additional mortality study by Smith and
colleagues (21) was added to the 8-hour
maximum O3 run to include a broader age
range and additional regions across the
country for this metric’s health estimates.
As described in the methodology for last
year’s report, we constrained ourselves to
studies used by the EPA in their regulatory
review process. The decision to constrain
health studies to those regularly used by the
EPA allows for more direct comparison
with the results in regulatory review
documents, but it does potentially limit the
SPECIAL ARTICLE
inclusion of studies that may provide a
more complete picture of the current
understanding of the associations between
air pollution and morbidity health
outcomes. The only exception to this
approach is the studies used to estimate the
impact of PM2.5 on lung cancer, because
this health endpoint has not previously
been assessed by the EPA.
Another change from last year’s report
is the use of pooling methods to provide
statistically weighted estimates. Specifically,
a random effects model was used to
weight each health study according to its
variance before averaging (though in cases
of high homogeneity across study
demographics, a fixed effects model was
used instead). Our pooling approach
followed the methods outlined in BenMAP
User’s Manual: Appendix K (22). Pooling
occurred across studies sharing the same
health endpoint, and these pooled averages
were summed to determine counts in the
morbidity and impacted days categories.
Annual results were calculated by
county, then aggregated to the
corresponding metropolitan district or
metropolitan statistical area to represent
impacts by cities. County results were also
used to aggregate estimates at the state level.
Results
There are over 3,000 counties in the
continental United States, and 498 of them
had valid short- and/or long-term PM2.5
design values for years 2013–2015. These
counties cover approximately 60% of the
U.S. population by number, but they cover
a much higher percentage of the population
that lives in areas exceeding ATS-
recommended levels. Although not
estimated here, counties without monitors
would also be expected to benefit from
improvements in air quality. Of those
counties with valid monitoring data, 39 (8%
of monitored counties) across 11 states had
annual concentrations greater than the
11 mg/m3 recommended by the ATS. A
much higher number of counties (103
counties, or 21% of total monitored
counties) across 22 states had short-term
concentrations greater than the ATS
recommendation of 25 mg/m3. Figure 1
shows nationwide design values for PM2.5 for
both long- and short-term concentrations.
The percentage of monitored
counties exceeding ATS-recommended
 SPECIAL ARTICLE

μg/m3)
Short-term PM2.5 Design Value (μ
The 3-year average of the 24-hour 98th percentile
≤ 25.0
ATS Recommendation
25.1 – 35.0
EPA NAAQS Standard
35.1 – 45.0
≥ 45.0
4C/FPO

μg/m3)
Long-term PM2.5 Design Value (μ
The 3-year average of the annual mean
≤ 11.0
ATS Recommendation
11.1 – 12.0
EPA NAAQS Standard
12.1 – 13.0
≥ 13.0

Counties not meeting ATS recommended levels for PM2.5

Does not meet long-term recommendation (11 μg/m3)

Does not meet short-term recommendation (25 μg/m3)
Does not meet either recommendation

Figure 1. Nationwide long- and short-term fine particulate matter (PM2.5) concentrations. (A) Design values by county, 2013–2015. (B) Summary of
counties not meeting American Thoracic Society (ATS)-recommended standards. Design values are derived from air pollution concentrations measured at
monitoring locations and are used to determine attainment status with federal standards. Long-term design values for PM2.5 are the 3-year average of the
annual mean. Short-term design values for PM2.5 are the 3-year average of the 24-hour 98th percentile. The ATS recommends a long-term PM2.5
standard of 11 mg/m3 and a short-term PM2.5 standard of 25 mg/m3. The current U.S. Environmental Protection Agency (EPA) standard is 12 mg/m3 for
long-term PM2.5 and 35 mg/m3 for short-term PM2.5. NAAQS = National Ambient Air Quality Standards.

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4C/FPO

O3 Design Value (ppm), 2013−2015

The 3-year average of the fourth highest daily 8-hour max
≤ 0.060
ATS Recommendation
0.061 – 0.070
EPA NAAQS Standard
0.071 – 0.080
≥ 0.081

Figure 2. Nationwide design values for ozone (O3) by county, 2013–2015. Design values for O3 are the 3-year average of the fourth-highest daily
8-hour maximum concentrations measured at monitoring locations and are used to determine attainment status with federal standards. The American
Thoracic Society (ATS) recommends an 8-hour maximum standard of 60 parts per billion (ppb), which is lower than the current U.S. Environmental
Protection Agency (EPA) standard of 70 ppb. NAAQS = National Ambient Air Quality Standards.

concentrations for O3 is much higher than
for PM2.5. Of the 726 counties with valid
design values for O3 from 2013 to 2015,
592 counties (82% of monitored counties)
across 48 states had concentrations
greater than the ATS recommendation of
60 ppb. Figure 2 shows design values by
county for O3.
Table 1 shows national totals across
these three health endpoints by pollutant.
There were 3,160 (95% confidence interval
[CI], 69–7,100) excess annual deaths
associated with O3 concentrations greater
than ATS-recommended standards, with an
additional 3,110 (95% CI, 2,110–4,100)
excess deaths associated with PM2.5
concentrations greater than ATS
recommendations. The annual numbers of
excess morbidities (including lung cancer
incidence) attributable to O3 and PM2.5
exceeding ATS recommendations are
approximately 8,760 (95% CI, 217,700
to 35,700) and 6,710 (95% CI, 1,980 to
11,300), respectively. The total numbers of
adversely impacted days attributable to O3
and PM2.5 concentrations above ATS
recommendations are approximately
10,300,000 (95% CI, 2,490,000–20,600,000)
and 2,420,000 (95% CI, 1,980,000–
2,840,000), respectively. Overall, central
estimates indicated that O3 and PM2.5
generally contributed approximately
equally to excess deaths and morbidities,
whereas O3 was responsible for the
majority of adversely impacted days.
Table 2 lists the number of deaths,
morbidities (including lung cancer), and
impacted days by state.
As shown in Figure 3, the health
impacts from air pollution in excess of
ATS-recommended standards are not
uniformly distributed across the United
States. California alone is responsible for
approximately half of the total estimated
annual deaths (3,100 of 6,270 nationwide),
whereas the seven states with the next-
highest impacts (Pennsylvania, Texas,
Arizona, Michigan, Ohio, New York, and
New Jersey) are together responsible for
approximately 29% of the total estimated
mortality impacts. In contrast, the 22 states
with the lowest mortality impacts
together contribute to just 3% of deaths
(191 total).
An analysis of lung cancer incidence
was also included in morbidity results
using a pooled risk value from five

Table 1. Nationwide annual health impacts from air pollution exceeding American Thoracic Society–recommended standards

Pollutant Health Category Estimate 95% CI

Ozone (O3) Mortality 3,160 (69 to 7,100)

ATS recommendation = 60 ppb Morbidity 8,760 (217,700 to 35,700)
Impacted days 10,300,000 (2,490,000 to 20,600,000)
Fine particulate matter (PM2.5) Mortality 3,110 (2,110 to 4,100)
ATS recommendation = 11 mg/m3 (long term) Morbidity 6,710 (1,980 to 11,300)
ATS recommendation = 25 mg/m3 (short term) Impacted days 2,420,000 (1,980,000 to 2,840,000)
Total Mortality 6,270 (2,180 to 11,200)
Morbidity 15,500 (215,800 to 47,000)
Impacted days 12,700,000 (4,470,000 to 23,400,000)

Definition of abbreviations: ATS = American Thoracic Society; CI = confidence interval; ppb = parts per billion.

4 AnnalsATS 2018
 SPECIAL ARTICLE

Table 2. Annual health impacts, by state, attributable to pollution concentrations exceeding American Thoracic Society
recommendations

State Excess Mortality (95% CI) Excess Morbidity (95% CI) Impacted Days (95% CI)

Alabama 19 (0 to 39) 53 (279 to 213) 44,200 (10,700 to 91,700)

Arizona 220 (47 to 434) 519 (2659 to 1,741) 534,000 (163,000 to 1,043,000)
Arkansas 7 (0 to 15) 16 (228 to 66) 15,600 (3,800 to 32,300)
California 3,100 (1,430 to 5,020) 7,731 (24,270 to 19,760) 5,660,000 (2,380,000 to 9,700,000)
Colorado 73 (3 to 175) 153 (2372 to 719) 263,000 (65,000 to 566,000)
Connecticut 97 (2 to 227) 282 (2634 to 1,192) 263,000 (66,000 to 537,000)
Delaware 12 (2 to 40) 29 (247 to 181) 26,600 (6,900 to 82,800)
District of Columbia 6 (0 to 17) 21 (243 to 81) 24,300 (7,100 to 45,500)
Florida 67 (1 to 146) 185 (2305 to 751) 156,000 (40,000 to 316,000)
Georgia 34 (1 to 76) 114 (2260 to 427) 146,000 (35,000 to 301,000)
Idaho 11 (5 to 18) 45 (214 to 103) 18,200 (5,900 to 35,900)
Illinois 105 (2 to 161) 323 (2744 to 920) 354,000 (87,000 to 466,000)
Indiana 83 (33 to 137) 127 (212 to 346) 112,000 (49,000 to 200,000)
Iowa 3 (2 to 4) 6 (0 to 13) 2,220 (1,310 to 3,460)
Kansas 14 (0 to 29) 30 (259 to 135) 33,000 (7,500 to 70,700)
Kentucky 51 (21 to 88) 123 (250 to 319) 64,900 (28,600 to 114,900)
Louisiana 28 (1 to 54) 69 (2144 to 244) 80,300 (19,600 to 131,700)
Maine 5 (0 to 4) 6 (21 to 11) 12,000 (3,100 to 6,400)
Maryland 65 (4 to 138) 192 (2350 to 715) 192,000 (49,000 to 391,000)
Massachusetts 53 (1 to 118) 152 (2247 to 645) 136,000 (34,000 to 278,000)
Michigan 169 (45 to 300) 331 (2442 to 1,095) 279,000 (76,000 to 500,000)
Minnesota 3 (0 to 16) 7 (212 to 66) 12,100 (2,800 to 48,700)
Mississippi 7 (0 to 14) 17 (227 to 65) 15,100 (3,500 to 31,900)
Missouri 41 (1 to 90) 100 (2174 to 447) 100,000 (24,000 to 205,000)
Montana 17 (12 to 23) 34 (8 to 59) 12,000 (9,800 to 14,100)
Nebraska 3 (0 to 6) 6 (212 to 25) 8,640 (2,010 to 18,510)
Nevada 104 (27 to 198) 207 (2264 to 722) 216,000 (69,000 to 412,000)
New Hampshire 11 (1 to 24) 30 (260 to 120) 25,900 (6,800 to 52,800)
New Jersey 127 (12 to 271) 377 (2701 to 1,421) 325,000 (85,000 to 649,000)
New Mexico 19 (0 to 47) 38 (278 to 166) 52,600 (12,100 to 112,800)
New York 136 (9 to 361) 528 (21,281 to 2,208) 427,000 (112,000 to 963,000)
North Carolina 34 (1 to 74) 93 (2188 to 364) 105,000 (25,000 to 219,000)
North Dakota 0 (0 to 0) 0 (21 to 2) 436 (103 to 961)
Ohio 281 (100 to 501) 455 (2506 to 1,572) 340,000 (102,000 to 681,000)
Oklahoma 34 (1 to 75) 79 (2153 to 332) 82,300 (19,200 to 173,400)
Oregon 80 (49 to 111) 113 (0 to 228) 32,100 (18,200 to 50,500)
Pennsylvania 490 (217 to 846) 1,072 (2824 to 2,988) 598,000 (253,000 to 1,076,000)
Rhode Island 16 (0 to 36) 42 (276 to 166) 39,800 (10,200 to 78,300)
South Carolina 6 (0 to 13) 12 (228 to 50) 15,300 (3,700 to 32,300)
South Dakota 1 (0 to 3) 4 (27 to 15) 3,940 (920 to 8,500)
Tennessee 33 (1 to 72) 145 (2101 to 654) 82,300 (20,100 to 169,900)
Texas 368 (70 to 730) 1,194 (21,914 to 3,982) 1,230,000 (360,000 to 2,430,000)
Utah 110 (51 to 187) 188 (291 to 491) 237,000 (97,000 to 437,000)
Vermont 1 (1 to 3) 2 (21 to 7) 2,060 (790 to 3,790)
Virginia 17 (0 to 42) 68 (2150 to 271) 83,300 (20,500 to 175,900)
Washington 52 (25 to 80) 112 (250 to 265) 85,600 (40,700 to 143,600)
West Virginia 10 (1 to 22) 26 (225 to 105) 14,300 (3,800 to 28,800)
Wisconsin 48 (1 to 110) 105 (2212 to 443) 118,000 (28,000 to 245,000)
Wyoming 3 (0 to 8) 6 (211 to 23) 7,520 (1,800 to 14,390)

Definition of abbreviation: CI = confidence interval.

health studies across North America and
Europe. In five states (California, Idaho,
Utah, Oregon, and Montana), between 1
and 3% of lung cancer incidence was
linked to air pollution, totaling 703 cases.
Most significantly, California alone had 610
cases of lung cancer incidence resulting
from ambient air pollution exposure,
and Pennsylvania had 84. In comparison,
9 to 15% of lung cancer cases in the
United States have been attributed
to occupational exposures, and 4.6% of
lung cancer deaths are attributable to
secondhand smoke (23, 24). In another
10 states, at least some, but less than
1% of lung cancer incidence was linked
to air pollution, contributing another
253 cases. Table 3 lists lung cancer
incidence attributable to air pollution
by state.
In addition, a ranking of the cities
with the most to gain by meeting ATS-
recommended standards is shown in
Table 4. Cities with both high populations
and significant concentrations of one or
both pollutants have the most to gain by
meeting ATS recommendations for
outdoor air pollution. Detailed results
for every individual city, as well as
comparisons of multiple user-defined cities,

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52 0
17
3 5
11 1 48 1
80 169 11
3 136
3 53
3
490 16
105* 83 281 97
104 110 73 127
14 41 10
53 17 12
65
4C/FPO

3,100
34 33 34
220 19 7
6
7 19 34
368 28

67

Nationwide Mortality due to Air Pollution (PM2.5 and O3)

Annual Excess Mortality Number of States Annual Excess Mortality Total
0 – 20 22 191 (24 – 423)
21 – 60 10 410 (52 – 838)
61 – 120 9 784 (173 – 1,481)
121 – 490 7 1,791 (500 – 3,443)
≥ 490 1 3,100 (1,428 – 5,020)
* No validated PM2.5 data available.

Figure 3. Nationwide annual excess mortality attributable to air pollution exceeding American Thoracic Society recommendations for ozone (O3) and fine
particulate matter (PM2.5). Annual excess mortality is estimated as a function of outdoor pollution concentration, size of the exposed population, and baseline
health risks. States with high estimates of air pollution–related mortality typically have a combination of high pollution concentrations and large populations.

are available using the web tool
accompanying this report at www.
healthoftheair.org. Table E3 also provides a
full breakdown of design values and health
impacts, separated by pollutant, county,
and state.
Discussion
As federal standards have been strengthened
and pollution abatement technology has
improved, air quality has vastly improved
across the United States over the past several
decades. Yet, despite such progress, air
pollution remains a major health issue in
many parts of the country. Nationwide
pollution data show that most of the country
(82% of monitored counties) has O3
concentrations greater than the
concentration recommended by the ATS,
and the present analysis reveals significant
health impacts from this pollutant alone.
Although the total number of excess deaths
is comparable for elevated concentrations
of O3 and PM2.5, the proportions of
O3-attributable morbidities and adversely
impacted days are much greater relative to
PM2.5. Although ground-level O3 has
traditionally proved to be a difficult hazard
to tackle (25), the 2015 revision of the
national O3 standard from 75 ppb to
70 ppb (26) may provide states with an
opportunity to improve management
strategies and ultimately reduce widespread
concentrations of this pollutant.
Increasing evidence of the harm from
PM2.5 has led to the strengthening of its
NAAQS over the years. In 2006, the short-
term standard was lowered dramatically, from
65 mg/m3 to 35 mg/m3, whereas the long-term
standard remained unchanged at 15 mg/m3.
The following revision in 2012 maintained the
short-term standard at 35 mg/m3 while
lowering the long-term standard to 12 mg/m3
(27). Currently, there is a much higher
proportion of counties exceeding short-term
PM2.5 recommended standards than the long-
term counterparts (see Figure 1). Specifically,
nearly three times as many counties have
pollution concentrations greater than ATS-
recommended standards for short-term PM2.5
compared with long-term PM2.5 (103 and 39
counties, respectively) across twice as many
states (22 and 11 states, respectively).
Although the ATS recommends that both
long- and short-term standards be revised,
these results suggest that a more protective
short-term PM2.5 standard may provide more
tangible health benefits in the United States.
Scientific understanding of the health
impacts of air pollution continues to
improve. As new health endpoints are
identified, they will eventually be
incorporated into this report, once an
adequate number of studies is produced to
confirm the reported effects. One important
update includes work by the International
Agency for Research on Cancer, a division
within the World Health Organization
(WHO). This agency recently identified
particulate matter in outdoor air pollution
as a group 1 carcinogen and concluded with
sufficient evidence that this pollutant causes
lung cancer, a determination based in part
on lung cancer incidence and mortality
research (28, 29). In this report, lung cancer
was incorporated into PM2.5 morbidity

6 AnnalsATS 2018
 SPECIAL ARTICLE
Table 3. States with highest and lowest proportions of excess lung cancer incidence associated with fine particulate matter
concentrations above American Thoracic Society recommended standards
State
States where 1 to 3% of lung cancer incidence is associated with air pollution
California
Oregon
Idaho
Utah
Montana
States where ,1% of lung cancer incidence is associated with air pollution
Pennsylvania
Texas
Indiana
Michigan
Arizona
Ohio
Washington
Kentucky
Colorado
Delaware
Definition of abbreviation: CI = confidence interval.
estimates by using a pooled effect estimate
from five studies, some of which had not
yet been published at the time of the IARC
review, whose authors looked specifically at
the associations between PM2.5 and lung
cancer incidence. Given the relatively low
5-year survival rate for lung cancer (,18%)
(30), the majority of the 976 excess cases of
lung cancer incidence estimated in this
report will ultimately result in excess deaths
linked to PM2.5. These excess cases of lung
cancer provide further support for the
importance of continued efforts to address
ambient PM2.5 pollution throughout the
United States.
This Health of the Air report is just one
of a number of assessments estimating the
health impacts of air pollution. When
comparing assessments, it is vital to
understand and specify the context in which
estimates are made. In our report, health
impact estimates were made only for
counties with pollution levels exceeding
ATS-recommended standards. Other
studies have estimated mortality and
cardiorespiratory morbidity impacts of
PM2.5 and O3 as done here, but under
different conditions. For instance, Millstein
and colleagues (31) determined the deaths
avoided owing to emission reductions
resulting from wind and solar power
implementation in the United States.
Others have examined the health benefits of
air pollution reductions due to uptake by
urban trees (32), modeled health benefits
Special Article
Excess Lung Cancer Incidence Associated with
from implementing better air quality
technology (33, 34), or simply estimated
reductions in mortality and morbidity
outcomes under real-life circumstances
(35, 36). The State of Global Air follows a
pattern similar to our report, but at the
country level, estimating avoided mortality
and morbidity outcomes worldwide owing
to meeting the WHO’s PM2.5 and O3
recommendations (36). Similarly, the
Global Burden of Disease report estimates
national disease burdens associated with
ambient air pollution, including mortality
and loss of health life-years (37). Whereas
other studies have made health estimates
for pollution reductions for specific
metropolitan areas around the world
(32, 38, 39), to our knowledge, none have
included assessment of local-level impacts
in the United States to the extent of the
present analysis, nor have they focused
specifically on health benefits associated
with meeting ATS recommendations for
federal air quality standards. Direct
comparison of the quantitative results of
these various studies would need to take
into account the different policy contexts
considered in the design of the study.
In this report, EPA-designated design
values were used to establish baseline health
estimates. These values reflect standardized
measurements of local pollution
concentrations used to determine county
compliance with national standards. By
definition, however, design value
Air Pollution (95% CI)
610 (151 to 1,030)
39 (9 to 68)
28 (7 to 48)
16 (4 to 29)
10 (2 to 17)
84 (20 to 147)
53 (12 to 93)
23 (6 to 41)
23 (5 to 40)
20 (5 to 35)
18 (4 to 31)
17 (4 to 30)
12 (3 to 21)
2 (1 to 4)
1 (0 to 2)
designations exclude exceptional events,
defined as wildfires, stratospheric O3
intrusion, fireworks, volcanic activity, and
interstate and international transport via
high winds (40, 41). Because in the present
analysis we defined local pollutant
concentrations using design values, any
impacts associated with exceptional events
are not included in reported health
estimates. However, although these events
are not included in regulation-defined
concentrations, their health risks are not
negligible.
Forest fires are especially dangerous
owing to the elevated pollution levels that
can persist for many days until relief is
afforded through rainfall or fire
containment (42, 43). In addition to large
PM2.5 emissions, fires can also influence
downwind formation of O3 (44). Authors of
recent systematic reviews of wildfire
pollution and health have concluded that
these fires are consistently linked to
respiratory morbidity, with some evidence
of additional links to mortality and
cardiovascular outcomes (45, 46). The
authors of the most recent and most
comprehensive analysis in the United States
determined that 6,700–11,000 excess
respiratory and cardiovascular hospital
admissions and several hundred deaths
annually are associated with wildfires alone,
occurring primarily in western and
southeastern states (47). Although these
impacts are significant, the decision not to
7
 SPECIAL ARTICLE

Table 4. Cities with the most to gain by attaining American Thoracic Society recommendations for ozone and fine particulate matter

Rank City Excess Excess Lung Excess Morbidity Impacted Days (95% CI)
Mortality Cancer (95% CI)
(95% CI) Incidence
(95% CI)

1 Los Angeles (Long Beach- 941 (385 to 1,510) 134 (32 to 233) 2,670 (21,910 to 7,230) 2,250,000 (943,000 to 3,750,000)
Glendale), CA
2 Riverside (San Bernardino- 609 (290 to 1,050) 121 (29 to 209) 1,250 (2877 to 3,560) 1,100,000 (468,000 to 1,940,000)
Ontario), CA
3 Bakersfield, CA 369 (229 to 512) 81 (21 to 130) 513 (2111 to 1,050) 247,000 (126,000 to 406,000)
4 Fresno, CA 244 (138 to 362) 48 (12 to 81) 458 (296 to 998) 359,000 (204,000 to 551,000)
5 Pittsburgh, PA 205 (106 to 314) 55 (13 to 96) 382 (2143 to 900) 197,000 (108,000 to 308,000)
6 Phoenix (Mesa-Scottsdale), AZ 178 (46 to 340) 17 (4 to 30) 432 (2558 to 1,400) 453,000 (144,000 to 872,000)
7 New York (Jersey City-White 166 (13 to 354) 8 (2 to 15) 626 (21,450 to 2,310) 492,000 (131,000 to 969,000)
Plains), NY-NJ
8 Houston (The Woodlands-Sugar 163 (59 to 279) 41 (10 to 72) 508 (2564 to 1,430) 476,000 (175,000 to 870,000)
Land), TX
9 Visalia (Porterville), CA 144 (85 to 210) 27 (7 to 45) 199 (275 to 478) 109,000 (44,700 to 195,000)
10 Philadelphia, PA 132 (67 to 218) 36 (9 to 63) 218 (2210 to 625) 136,000 (55,400 to 240,000)
11 Stockton (Lodi), CA 129 (75 to 186) 31 (8 to 53) 296 (225 to 609) 162,000 (100,000 to 242,000)
12 Cleveland (Elyria), OH 146 (76 to 222) 6 (1 to 11) 174 (2104 to 485) 95,200 (37,500 to 165,000)
13 Modesto, CA 101 (58 to 149) 23 (5 to 39) 237 (236 to 505) 133,000 (75,600 to 205,000)
14 Sacramento (Roseville- 98 (27 to 208) 13 (3 to 22) 199 (2256 to 704) 218,000 (72,600 to 434,000)
Arden-Arcade), CA
15 Detroit (Dearborn-Livonia), MI 80 (36 to 117) 19 (5 to 34) 124 (2127 to 320) 91,700 (29,100 to 118,000)
16 San Diego (Carlsbad), CA 83 (2 to 185) 0 (0 to 0) 206 (2345 to 857) 312,000 (81,200 to 602,000)
17 Chicago (Naperville-Arlington 70 (1 to 85) 0 (0 to 0) 217 (2543 to 507) 257,000 (64,600 to 263,000)
Heights), IL
18 Dallas (Plano-Irving), TX 69 (2 to 158) 0 (0 to 0) 237 (2553 to 930) 303,000 (69,700 to 629,000)
19 Las Vegas (Henderson- 71 (10 to 144) 0 (0 to 0) 161 (2243 to 591) 176,000 (49,700 to 351,000)
Paradise), NV
20 Salt Lake City, UT 65 (31 to 109) 9 (2 to 16) 120 (255 to 301) 144,000 (66,900 to 248,000)
21 Hanford (Corcoran), CA 60 (38 to 82) 13 (3 to 21) 53 (26 to 101) 21,500 (6,200 to 42,200)
22 Anaheim (Santa Ana-Irvine), CA 56 (1 to 120) 0 (0 to 0) 134 (2193 to 577) 207,000 (51,300 to 418,000)
23 Fort Worth (Arlington), TX 51 (1 to 113) 0 (0 to 0) 150 (2333 to 587) 180,000 (40,900 to 373,000)
24 Oakland (Hayward-Berkeley), CA 46 (12 to 84) 5 (1 to 8) 123 (2206 to 418) 137,000 (46,900 to 229,000)
25 Warren (Troy-Farmington Hills), MI 48 (8 to 93) 3 (1 to 6) 101 (2141 to 388) 86,000 (22,800 to 174,000)
26 Indianapolis (Carmel-Anderson), 46 (25 to 69) 21 (5 to 37) 54 (5 to 127) 55,800 (32,900 to 86,600)
IN
27 Louisville/Jefferson County, 46 (22 to 74) 13 (3 to 23) 96 (220 to 223) 49,200 (25,900 to 80,200)
KY-IN
28 Denver (Aurora-Lakewood), CO 42 (1 to 107) 1 (0 to 2) 84 (2225 to 435) 158,000 (38,800 to 353,000)
29 St. Louis, MO-IL 43 (1 to 92) 0 (0 to 0) 105 (2186 to 458) 102,000 (25,100 to 208,000)
30 Montgomery County, PA 42 (7 to 98) 0 (0 to 0) 122 (2217 to 490) 100,000 (29,000 to 208,000)

Definition of abbreviation: CI = confidence interval.

Overall ranking is a composite of the individual health categories.

include health estimates for exceptional
events in Health of the Air reports was
made to maintain a policy-relevant focus.
Specifically, estimates derived from this
report are intended to reflect expected
benefits that would come to each county by
meeting ATS-recommended national
standards for PM2.5 and O3. Had
exceptional events been included in the
baseline pollution concentrations used in
this report, the estimated health impacts
would be even greater, particularly in the
western and southeastern United States.
Similarly, because the structure of this
report is intended to provide information on
the health impacts of air pollution at levels
worse than ATS-recommended standards,
any health benefits derived from reducing
pollution concentrations even further are
not included in these estimates. This is
not to imply, however, that such benefits
do not exist. In fact, extensive research has
revealed no health effects threshold for air
pollution, and recent studies have shown
PM2.5- and O3-related mortalities at
concentrations far below WHO
recommendations (48, 49). As such, cities
can expect additional health benefits from
improvements in air quality beyond ATS
recommendations and are encouraged to
continue to improve air quality even after
meeting these guidelines.
Conclusions
The Health of the Air report was
created with a goal of providing a
policy-relevant tool for federal and local
leaders as they make air quality
management and policy decisions. By
providing morbidity and mortality
estimates specific to each county, this
report allows policymakers and
environmental managers to know with
greater precision how meeting ATS-
recommended air quality standards can
benefit their communities. n
Author disclosures are available with the text
of this article at www.atsjournals.org.

8 AnnalsATS 2018
 SPECIAL ARTICLE
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