the public health impact of air pollution … · 2 the public health impact of air pollution in new...

NJPIRG Law and Policy Center 1

December 2003

Travis MadsenDena Mottola

NJPIRG Law and Policy Center

THE PUBLIC HEALTHIMPACT OF AIR

POLLUTION IN NEWJERSEY

2 The Public Health Impact of Air Pollution in New Jersey

NJPIRG Law and Policy Center gratefully acknowledges the following individualsfor their assistance in reviewing the report: Dr. David Bates, Professor Emeritus ofMedicine at the University of British Columbia, Vancouver; Dr. John Balbus, head ofthe Health Program at Environmental Defense; and Michael Calvin of the AmericanLung Association of New Jersey. Additionally, NJPIRG Law and Policy Center thanksJasmine Vasavada, Elizabeth Ridlington, Tony Dutzik, and Susan Rakov at the Cen-ter for Public Interest Research for editorial assistance.

This report was made possible by the generous support of the Energy Foundation.

The authors alone bear responsibility for any factual errors. The recommendationsare those of the NJPIRG Law and Policy Center. The views expressed in this reportare those of the authors and do not necessarily reflect the views of our funders orreviewers.

© 2003 NJPIRG Law and Policy Center

For additional copies of this report, send $10 (including shipping) to:

NJPIRG11 N. Willow St.Trenton, NJ 08608

The New Jersey Public Interest Research Group Law and Policy Center is a 501(c)(3)organization working on environmental protection, consumer rights, and good gov-ernment in New Jersey. For more information about the NJPIRG Law and PolicyCenter, please call 609-394-8155 or visit the NJPIRG web site at www.njpirg.org.

ACKNOWLEDGMENTS


TABLE OF CONTENTS

Executive Summary 4

Introduction 6

Background: Exposure to Air Pollution and How it Causes Harm 7

Smog (Ground-Level Ozone) 8

Fine Soot (Particulate Matter) 10

Results: Health Damage Caused by Air Pollution in New Jersey 13

Premature Death 14

Hospital Stays 15

New Cases of Chronic Disease – Asthma and Bronchitis 16

Emergency Room Visits 18

Asthma Attacks 19

Missed Work Days and Sick Days 19

Air Pollution and New Jersey’s Children 21

Clean Air Policy Recommendations 25

Sources of Dirty Air 25

Policies Aimed at the Largest Pollution Sources 25

Methodology 28

Notes 33


EXECUTIVE SUMMARY

Air pollution takes a significanttoll on human health in NewJersey every year, shortening

thousands of lives and sending thousandsof people to area hospitals.

Premature death and hospital admis-sions are the most visible indicators ofwidespread health damage caused by airpollution. This damage manifests itselfin the incidence of disease like chronicbronchitis, increased emergency roomvisits, more frequent asthma attacks, andmissed work days due to respiratory ill-ness in otherwise healthy people. At theroot of all of these health problems liesirreparable damage to lung tissues notunlike that caused by second-hand to-bacco smoke.

This study calculates the magnitude ofair pollution’s impact on health in NewJersey using a number of informationsources: air pollution monitoring datafrom the U.S. Environmental ProtectionAgency (EPA); baseline health statisticsfrom the New Jersey Department ofHealth and Senior Services and the U.S.EPA; a review of scientific studies on airpollution and health; and methodologybased on similar work from the U.S. EPAand the World Health Organization.

These sources, taken together, indicatethat thousands of New Jersey residents

die prematurely because of soot in theair, and hundreds of thousands misswork because of air-pollution inducedrespiratory illness (see Table 1).

Additionally, during the summer smogseason, smog causes chronic asthma inthousands of New Jersey adults, hun-dreds of thousands of asthma attacks,and millions of days of increased respi-ratory symptoms like shortness of breath(see Table 2).

Children are especially vulnerable tothe effects of air pollution. Every year,particulates cause dozens of neonataldeaths and in the range of half-a-millionschool absences from illness (see Table9).

Many New Jersey residents appear toexperience adverse effects from pollutionlevels that comply with “health-based”air pollution standards. This leads to thejarring conclusion that even “safe” lev-els of pollution are not, in fact, safe.

Aggressive action on both the state andfederal level to reduce air pollution canimprove public health. In order to havethe greatest impact, action should focusfirst on the largest sources of pollution.Within New Jersey in 1999, nearly 60%of soot emissions and almost half ofsmog-forming emissions came from on-road and off-road mobile sources like

Table 1: Annual Public Health Damage from Fine Soot (PM 10)in New Jersey

Health Effect Number of Cases

Premature Mortality (age 30 +) 2,300 to 5,400

Respiratory Hospital Admissions 5,100 to 7,800

Cardiovascular Hospital Admissions 2,700 to 7,500

New Cases of Chronic Bronchitis 450 to 9,500

Missed Work Days 460,000 to 530,000

Asthma Attacks 330,000 to 1.4 million

Restricted Activity Days 7.1 million to 9.7 million

Increased Symptom Days 14 million to 45 million


cars, trucks, and construction equip-ment. Industrial facilities and emissionsfrom consumer products like paint ac-counted for the remainder. Out-of-statepollution sources also contribute signifi-cantly to the overall problem.

State Level Actions:• Strengthen auto emission standards

in line with New York, Massachu-setts, California, and Vermont.

• Reduce car-dependent land usepractices and sprawl.

• Increase the portion of state trans-portation funding for transit, railfreight, and other alternative trans-portation projects.

• Require diesel engines, includingschool bus fleets and constructionequipment, to be retrofitted withparticulate filtration systems and touse low-sulfur fuel.

• Require diesel engines in marine

vessels and trains to have selectivecatalytic reduction systems.

Federal and Regional Level Actions:• Advocate adoption of these state

policies among neighboring andupwind states.

• Restore the New Source Reviewprovision of the Clean Air Act andrequire the oldest coal-fired powerplants and other industrial facilitiesin the country to install modernemissions control technology.

• Limit nationwide industrial emis-sions of sulfur dioxide, nitrogenoxides, and mercury to between10% and 30% of 2000 levels.

• Strengthen national emission stan-dards for cars, trucks, and off-roadvehicles, including incentives formanufacturers to produce cleanervehicles, modeled after Californiastate policy.

Table 2: Annual Public Health Damage from Smog(Ground-Level Ozone) in New Jersey


Adult Onset Asthma 860 to 1,900


Asthma ER Visits 640 to 12,000

Asthma Attacks 110,000 to 310,000

Restricted Activity Days 960,000 to 1.7 million

Increased Symptom Days 2.4 million to 7.5 million

Table 9: Annual Damage to Children’s Healthfrom Air Pollution in New Jersey


Infant Mortality 40 to 80

Asthma Hospitalizations 290 to 440


Acute Bronchitis 21,000 to 77,000


Missed School Days Roughly 610,000


INTRODUCTION

Respiratory health was never a bigconcern for Margaret Manzibefore she and her family moved

to Moorestown, N.J. from Michigan in1997 – other than the occasional cold.Over the last six years, however, that haschanged. “My older child has had a trou-bling number of missed school days,”said Manzi. “He sometimes seems tohave difficulty inhaling fully, which hurtshis endurance in sports, not to mentionhow it alarms me.”

Sandra Weissfisch lives in Ridgewoodwith her 18-year-old son, who recentlydeveloped asthma. Sandra believes thisis a direct result of the air pollution inthe Northern New Jersey area.

In 2002, Katherine Watt fled from thepollution on Staten Island to Plainfield,where she now lives with her family.Since moving to New Jersey, she has hadto take her five-year-old son to the emer-gency room twice for severe asthmasymptoms.

Jim Hala lives in Morristown, and suf-fers from asthma. Before he moved toNew Jersey, he did not need asthmamedication. Now he has three inhalers:two for prevention and one for onset.“People such as me are New Jersey’s coalmine canaries,” said Hala. “We are let-ting you know that there is somethingwrong with New Jersey’s air.”

These stories are not unique. Air pol-lution-triggered deaths, hospital admis-sions, emergency room visits, and asthmaattacks are merely the most visible signsof the adverse health effects that threateneveryone who breathes polluted air. All

of us face an increased risk of long-termrespiratory damage and reduced overalldaily health due to the dangerous pol-lutants in New Jersey’s air.

Nor are we safe on days when air pol-lution levels are below those recognizedby government as “safe.” Ozone smogand particulate soot can affect healtheven on days when an air pollution alertis not in effect.

It wasn’t supposed to be this way – notin 2003. When Congress adopted thefederal Clean Air Act in 1970, it estab-lished the goal of setting and achievingair quality standards protective of humanhealth by 1975. Nearly three decadeslater, New Jersey’s air still frequently failsto meet established health standards –standards that may not be fully protec-tive of human health.

With efforts underway to roll back keyair pollution policies at the federal level– and with increased motor vehicle traf-fic, population, and overall energy usethreatening to undermine the progress wehave made toward cleaner air – New Jer-sey has reached a critical juncture. Solu-tions do exist. From modern emissioncontrols for cars and power plants toeffective transit systems, we have thetechnological know-how to significantlycut the amounts of air pollution in NewJersey air.

By adopting public policies that putthese technologies to work, New Jerseycan reduce air pollution, and help mil-lions of its citizens to live longer andhealthier lives.


Most people think of air pollu-tion only on days when theevening newscast announces

an “Ozone Action Day” because the hazelevels will be especially high. Unfortu-nately, people in New Jersey aren’t ex-posed to air pollution just a few dozentimes a year on bad air days. NewJerseyans breathe air pollution day in andday out throughout their entire lives.

Much of the pollution comes fromburning fossil fuels for energy – in cars,trucks, power plants, industrial facilities,and engines. These pollutants are invis-ible, and they are everywhere. They mixtogether in the atmosphere and react incomplicated ways to form a toxic soup.

On bad air days, visibility plummetsand the air looks thick and hazy (Figure1). Sometimes the sun even looks red asit sets due to pollutants in the air. Theseclouds of haze contain hundreds of toxicchemicals.

Two of the most harmful air pollut-ants are smog and fine soot. Smogplagues summer days in New Jerseywhen intense sunlight transforms airpollutants and oxygen into a toxic gascalled ozone. Fine soot, or particulatepollution, contaminates the air yearround, either directly emitted by powerplants and motor vehicles or resultingfrom chemical reactions in the air.

Smog and fine soot reach unhealthylevels regularly in New Jersey. Annualaverage soot concentrations in New Jer-sey range from about 15 micrograms percubic meter in the least polluted parts ofthe state to 38 micrograms per cubicmeter in the most polluted parts of thestate. These levels are technically in com-pliance with EPA health standards, butstill cause health problems. During thesummertime ozone season from Aprilthrough October, the average daily peak

BACKGROUND: EXPOSURE TO AIR POLLUTION AND

HOW IT CAUSES HARM

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Polluted skies over Newark.

Figure 1: Clear and Polluted Days in Newark

one-hour ozone levels reach 47-64 ppbacross the state (Figure 2). On hot sum-mer days, ozone levels routinely exceedEPA health standards.

If there were no human-induced airpollution emitted in North America, sootlevels would be around 5 micrograms percubic meter, and smog levels would beabout 20 ppb.2 If pollution were notemitted from other countries in the world


as well, these natural background levelswould be even lower.3

Fine soot and smog cause damagewhen they come in contact with lungs.Ozone quickly reacts with airway tissuesand produces an inflammation similar toa sunburn on the inside of the lungs.Particulates travel deep into the lowerpassages of the lungs and becometrapped there, delivering a payload oftoxic chemicals. Constant exposure tothese pollutants over time produces per-manent damage to lung tissues, decreasesthe ability to breathe normally, and ex-acerbates or even causes chronic disease.

Smog(Ground-Level Ozone)

Smog plagues summer days in NewJersey. Smog results when a mixture ofpollutants mainly from fossil fuel com-

Average Peak Ozone Levels(Parts Per Billion)

No Monitor45 - 5050 - 5555 - 6060 - 6565 - 70

Particulate Levels(Micrograms per Cubic Meter)

No Monitor16 - 1919 - 2424 - 2929 - 3434 - 41

Annual average particulate

levels in New Jersey.

Average daily peak ozone levels

from April through October.

Figure 2: Soot and Smog Levels in New Jersey1

bustion react under intense sunlight toform ozone. Although this pollutantreaches levels that violate the U.S. EPAhealth standard on about one of everythree summer days, it chronically con-taminates the air at lower, but still harm-ful, levels from April through October.6

Ozone is a powerful chemical gassometimes used to kill bacteria in drink-ing water. Bubbling it through contami-nated water shreds any infectiousorganisms in the water and makes it safeto drink. Not surprisingly, the chemicalhas the same effect on our lungs – wheninhaled, it burns through lung tissue andcauses short-term swelling. With long-term exposure at even low levels, itcauses permanent and irrevocable dam-age.

Scientists have known for well over adecade that ozone at levels routinely en-countered in New Jersey burns cells,causes reddening and swelling, and re-


duces the elasticity of lung tissues overtime.7 Ozone makes lung tissues moresensitive to allergens and less able toward off infections.8 It scars airway tis-sues. Children exposed to ozone developlungs with less flexibility and capacitythan normal. During high smog days,otherwise healthy people who exercisecan’t breathe normally.9

New scientific evidence continues toshow dramatic evidence of the severe andlong-term impact ozone exposure has onrespiratory health:

• College freshmen who were raised inless polluted areas have lungs thatwork better than their schoolmateswho grew up in polluted cities. Forexample, UC Berkeley freshmenfrom the relatively clean San Fran-cisco Bay area can exhale moreforcefully than students from thepolluted Los Angeles area.10 Yalefreshmen who had lived for four ormore years in a county with highozone levels can’t breathe as well asfreshmen from cleaner areas.11

The Environmental Protection

Agency (EPA) sets national air qual-

ity standards under the authority of

the federal Clean Air Act. The stan-

dards are meant to be set based on

our best knowledge of what will pro-

tect public health. In that spirit, the

EPA tightened standards for both

soot and smog in 1997, based on

new research coming out at the time

that showed that soot and smog were

more harmful than previously be-

lieved.

However, strengthening standards

is a process fraught with political dif-

ficulty. For instance, the American

Trucking Association led a coalition

of industries in a lawsuit against the

new standards, taking it all the way

to the Supreme Court in 2001.4 The

high court eventually rejected the in-

dustry arguments, but the process

delayed implementation of the new

standards for years.

Political difficulty affects how EPA

implements the standards as well. In

June 2003, EPA proposed implemen-

tation plans for the new smog stan-

dards that would actually weaken

public health protection.5 The EPA

proposal would give polluted metro-

politan areas more time and more

loopholes to avoid necessary action

to clean the air. For example, the plan

would give the northern New Jersey

and New York region, which has not

yet met the standard set in the 1990

amendments to the Clean Air Act, a

new classification under the new stan-

dard and yet another extension of time

to clean-up its air. The old deadline

for compliance would disappear en-

tirely, along with already-adopted pol-

lution control limits on highway-related

transportation emissions, opening the

door to indiscriminant road-building.

National Air Quality Standards: Why They Are Too Weak


• Recent studies show that the lungsof asthmatic infant rhesus monkeyssuffer irreversible structural damagewhen exposed to ozone.12 Ozoneexposure reduces the number ofbranches formed by nerves andairway passages in the lung andforces lung muscles to reorganize,and long recovery periods do notimprove the damage. The immunesystem and cellular responses toozone are like those seen withasthma. Dr. Charles Plopper of theUniversity of California at Davis,the author of the studies, com-mented, “from a public healthstandpoint, it’s a pretty disquietingsituation.”13 Researchers believe thesame damage happens to humaninfants.

• Striking new results from the ambi-tious Southern California Children’sStudy indicate that exposure toozone can cause asthma in chil-dren.14 Children who exercisefrequently in smoggy areas are morethan three times as likely to developasthma as those in cleaner parts ofthe country.

Taken together, these studies paint apicture of profound and irreversible res-piratory damage beginning with an in-fants’ first breath of ozone-tainted air,leading to impaired lung developmentand chronic respiratory disease.

Fine Soot(Particulate Matter -PM10)

Back in the early days of the industrialrevolution, thick black smoke pouredfrom factories and coal-fired furnaces.During the 1952 “Great Fog,” perhapsthe most famously devastating singlepollution event in history, 12,000 Lon-

doners died from intense pollution ex-posure.15

Today, the thick, black smoke charac-teristic of uncontrolled pollution hasbeen replaced with the more subtle andinsidious dirty haze that can look almostnatural because of its frequent presenceover the eastern United States. However,this pollution is anything but natural. Itcomes from fuel burning, and mostlyconsists of fine soot, or extremely smalland practically invisible particles in theair.

Some types of soot are simply unburntfuel particles. Other types of soot arecreated when pollutants react with eachother in the atmosphere. Particles cancontain hundreds of different chemicalsfrom cancer-causing agents like polycy-clic aromatic hydrocarbons to metalsfrom arsenic to zinc.

Forty to 1,000 times smaller than thewidth of a human hair, these superfineparticles result from burning fossil fuelslike coal, gasoline, and diesel. For ex-ample, burning a pound of jet fuel cre-ates 100 quadrillion particles.16 Gasolineand diesel engines with and without cata-lytic converters emit particles with a con-sistent size of 0.1 to 1 micrometers, withthe smallest particles coming from gaso-line and medium-duty diesel engines.17

Scientists often measure fine particles inthe air by trapping particles smaller than10 micrometers (PM 10) or particlessmaller than 2.5 micrometers (PM 2.5).

Fine particles can remain suspended inthe air for weeks. They can travelthrough building shells and conventionalheating and air conditioning filters.When inhaled, they are able to penetratedeep into the lung where they delivertheir toxic payload. In contrast, largerparticles such as dust or pollen travelshorter distances and are more effectivelytrapped in the upper airway.

Fine particles penetrate to the deepestpart of the lung, where they are attacked


Other Toxic Pollutants in New Jersey’s Air

Burning coal, oil, gas, and diesel fuel

creates pollutants beyond soot and

smog that also harm respiratory

health. For example, cars and trucks

emit chemicals like benzene, formal-

dehyde, acetaldehyde, and 1,3-buta-

diene.

• A study of Hispanic children

showed that in addition to soot

and smog, other toxic chemicals

such as benzene, formaldehyde,

acetaldehyde, and 1,3-butadiene

can aggravate asthma symptoms.23

• Workplace exposure to formalde-

hyde can cause asthma.24

• Benzene and formaldehyde also

cause leukemia and other types of

cancers.25

and absorbed by immune cells. In anstudy in England, ultra fine carbon par-ticles showed up in the immune cells ofevery child tested – even in a three-monthold infant.18 The particles were of thesame size emitted by motor vehicles, andchildren who lived close to busy roadshad up to three times more particles intheir bodies.

Some of the particles remain trappedin the lung, while others travel throughthe blood to the rest of the body.19 Sci-entists have counted particulates in thelung tissue of cadavers. People fromhighly polluted Mexico City had twobillion particles in every gram of lungtissue, and people from less pollutedVancouver, Canada had about 280 mil-lion.20

The chemicals delivered into the bodyby inhaled particulates are very danger-ous. Some of them cause cancer, somecause irritation to lung tissues, and somecause changes in the function of theheart.21 As a result, particulates cause ahost of health problems, including lungcancer and cardio-respiratory disease.

Upwards of 50,000 Americans die ev-ery year because of particulate pollution.In fact, according to the largest study ofthe effects of particulates on mortality,breathing the air in particulate-pollutedareas is about as dangerous as living orworking with a smoker.22

A soot particle created by burning oil seen

through an electron microscope. Air pollution

particles from automobile and diesel fuel are

much smaller, in the range of 0.1 micrometers.

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Table 1: Annual Public Health Damage from Fine Soot (PM 10) in New Jersey




Cardiovascular Hospital Admissions 2,700 to 7,500

New Cases of Chronic Bronchitis 450 to 9,500

Missed Work Days 460,000 to 530,000

Asthma Attacks 330,000 to 1.4 million

Restricted Activity Days 7.1 million to 9.7 million

Increased Symptom Days 14 million to 45 million

Table 2: Annual Public Health Damage from Smog(Ground-Level Ozone) in New Jersey


Adult Onset Asthma 860 to 1,900




Restricted Activity Days 960,000 to 1.7 million

Increased Symptom Days 2.4 million to 7.5 million


Health researchers have just be-gun to map out the conse-quences of breathing polluted

air, and the results aren’t pretty. The mostserious impacts include premature deathfrom diseases like cancer and heart dis-ease, respiratory deaths in infants, andnew cases of persistent diseases likechronic bronchitis and asthma.

These are just the most visible indica-tors of widespread health damage thatimpacts everyone in the state. This wide-spread damage manifests itself in in-creased emergency room visits, morefrequent asthma attacks, and even missedwork days due to respiratory illness inotherwise healthy people. And at the rootof all of these health problems lie chronicdamage to lung tissues not unlike thatcaused by tobacco smoke.

To quantify the health impacts of airpollution, three basic pieces of informa-tion are required:• The exposure of people to air pollut-

ants,

• How the frequency and risk of a givenhealth impact changes with increas-ing or decreasing air pollution levels,and

• The baseline frequency of a givenhealth problem in society.Air pollution monitors placed through-

out New Jersey by the Department ofEnvironmental Protection help providethe first piece of information. A vastbody of scientific literature in which re-searchers tracked pollution and healtheffects provides the second piece of in-formation. And the third comes fromhealth statistics maintained by the NewJersey Department of Health and SeniorServices, plus additional informationfrom surveys and studies in the scientificliterature.

Using this information, we estimatethat every year in New Jersey, thousandsdie prematurely because of soot in theair, thousands are admitted to area hos-pitals with air-pollution aggravated heartand lung disease, and hundreds of thou-sands miss work because of air-pollutioninduced respiratory illness (see Table 1).

Additionally, during the summer smogseason, we estimate that smog causeschronic asthma in thousands of New Jer-sey adults, hundreds of thousands ofasthma attacks, and millions of days ofincreased respiratory symptoms likeshortness of breath (see Table 2).

Premature Death

The most serious health impact of ex-posure to air pollution is prematuredeath from respiratory disease, heart dis-ease, lung cancer, and other types of dis-eases commonly associated withsmoking. The evidence linking fine par-ticulate levels to both long-term andacute increases in the risk of death is verycompelling.

The Evidence

Several decade-long studies have madeit quite clear that long-term exposure topollution shortens lives:• In 2002, Dr. C. Arden Pope at

Brigham Young University and hiscolleagues published a study trackingover 500,000 people in 51 metropoli-tan areas in America for over 16 years.He found that when PM10 levels in-creased by 10 micrograms per cubicmeter, deaths from all causes rose by4%; deaths from cardiopulmonary ill-ness by 6%; and deaths from lung can-cer by 8%.27 Dr. Pope saw no evidence

RESULTS: HEALTH DAMAGE CAUSED BY

AIR POLLUTION IN NEW JERSEY


for a safe level of particulate pollu-tion not tied to increased death rates.He concluded that breathing pollutedair like that commonly found in theeastern U.S. causes an increased riskof lung cancer similar to that ofbreathing secondhand smoke.28

• Researchers with the World HealthOrganization in Europe found that airpollution caused 6% of all deaths inSwitzerland, France, and Austria(40,000 per year). Motor vehicle pol-lution caused about half of thesedeaths.29

Dozens of studies also link short-termexposure to pollution to acute increasesin the death rate:• In a study of heart attack patients in

Boston, Dr. Annette Peters and hercolleagues at the Harvard UniversitySchool of Public Health found that aspollution levels rose, so did the fre-quency of heart attacks a few hoursto a day later.30 An increase in fine par-ticles of 25 micrograms per cubicmeter resulted in a 69% in-crease in the relative risk ofhaving a heart attack over thefollowing day.

• Dr. Jonathan Samet fromJohns Hopkins University’sBloomberg School of PublicHealth and his colleaguesstudied health and air pollu-tion data from 90 cities in theU.S. and found a link betweenpollution levels and acute

death rates from chronic heart andlung disease. The link was strongestin the Northeast, the industrial Mid-west, and in Southern California.31

Pollution associated with burning fos-sil fuels, as opposed to small particlesfrom dust-storms and other naturalevents, is specifically tied to increasedmortality.32 Other studies show that theseeffects are not merely accelerating thedeath of old and sickly adults on thebrink of death, but also kill some infantsand adults who otherwise would havemany years of health remaining.33

New Jersey Estimate

We estimate that soot pollution causes2,300 to 5,400 deaths each year in NewJersey, or 5.4% to 7.7% of all non-in-jury- or accident-related deaths. This es-timate is on par with the World HealthOrganization study of air pollution im-pacts, which reported 6% of all mortal-ity in Switzerland, France, and Austriais linked to air pollution.34

Table 3: Annual Premature Deaths Caused by AirPollution in New Jersey




Hospital Stays

As levels of air pollution increase, sodo the number of people admitted intohospital wards suffering from severe res-piratory and cardiovascular disease.

The Evidence

• Dr. Jonathan Samet from JohnsHopkins University’s BloombergSchool of Public Health and his col-leagues found that increases in dailypollution levels were linked to in-creased hospital admissions for car-diovascular disease, pneumonia, andchronic obstructive pulmonary disor-der.35

• Dr. Joel Schwartz of Harvard Univer-sity and his colleagues documentedlinks between ozone and hospitaliza-tion rates for cardiovascular and res-piratory disease in Birmingham,Detroit, Minneapolis-St. Paul, andTucson.36 An increase of soot levels by100 micrograms per cubic meter andozone by 50 parts per billion increasedthe risk of hospitalization for chronicrespiratory disease in the range of20% to 100%.

• Dr. George Thurston at the New YorkUniversity School of Medicine and Dr.Richard Burnett at EnvironmentCanada have repeatedly linked respi-ratory and cardiovascular hospital ad-missions with the levels ofsummertime haze air pollution.37 Ac-cording to these studies, summertimehaze pollution was responsible for24% of respiratory hospital admis-sions in Toronto, and up to half of ad-missions on particularly bad air days.

How We Estimated The HealthEffects of Air Pollution

In November 1999, the EPA released a

report outlining the health and economic

impact of clean air efforts. In addition, sci-

entists with the World Health Organization

produced a report in 2000 estimating the

public health impact of particulate air pol-

lution from motor vehicles.26

NJPIRG researchers adapted the meth-

odology developed by these experts to es-

timate the health effects of air pollution in

New Jersey. First, we gathered statistics

on the baseline frequency of health events

like deaths, hospital admissions, and

asthma attacks. Second, we looked at

monitoring data for air pollution in the state

to estimate how much pollution people are

exposed to. Finally, we estimated the frac-

tion of the baseline health problems in the

state that could be attributed to air pollu-

tion. This step involved applying the rela-

tionship between air pollution and the

frequency of health effects as observed by

epidemiologists and published in scientific

literature to estimate how many deaths,

hospital admissions, etc. would be avoided

if air pollution levels returned to natural

background levels.

We report the effects of air pollution as a

range of values to emphasize the inherent

uncertainty present in such an estimate.

The range represents the 90% confidence

interval derived by scientists for the rela-

tionship between air pollution and the fre-

quency of health outcomes, or where the

estimate would be expected to fall 90 times

out of 100 observations. The range of val-

ues presented here are our best estimate

of the public health toll of air pollution in

New Jersey. For more details, see the

Methodology section.


New Jersey Estimate

We estimate that soot pollution causes5,100 to 7,800 respiratory and 2,700 to7,500 cardiovascular hospital admissionseach year, and smog causes 3,900 to5,900 respiratory hospital admissionsduring the summer smog season. Thisrepresents 3.8% to 4.5% of respiratoryhospital admissions (soot), 1.8% to2.5% of cardiovascular hospital admis-sions (soot), and 2.7% to 3.3% of respi-ratory hospital admissions (ozone).

New Cases of ChronicDisease – Asthma andBronchitis

Air pollution causes chronic diseasesin addition to short-term damage. Fromnew cases of chronic asthma in other-wise healthy children and adults to thedevelopment of chronic bronchitis in eld-erly people, these are severe diseases thatcause significant distress for hundreds ofthousands of New Jersey residents.

The Evidence

• Dr. Rob McConnell at the Universityof Southern California School ofMedicine and his colleagues foundthat children who exercise a lot de-velop asthma at higher rates in morepolluted areas. The researchers fol-lowed for five years over 3,500 chil-dren from the fourth, seventh, and

tenth grades with no history ofasthma. During that time, 265 becameasthmatic. Children who played threeor more sports in communities withhigh smog levels developed asthma atover three times the rate of childrenin low-smog communities. Childrenwho spent relatively high amounts oftime outdoors were 1.4 times morelikely to get asthma in polluted areascompared to cleaner ones.38 The lev-els of air pollution in all of the com-munities examined were well belowthe U.S. EPA health standard of 80ppb over an eight hour period.

• Dr. William McDonnell at the U.S.EPA National Health and Environ-mental Effects Research Laboratoryand his colleagues found a connectionbetween long-term exposure to smogand development of asthma in adults.The researchers followed over 3,000non-smoking adults for 15 years inCalifornia. During this period, justover 3% of the men and just over 4%of the women reported a diagnosis ofasthma. Several factors increased therisk of developing asthma, including:history of exposure to tobacco smoke,childhood pneumonia or bronchitis;and exposure to ozone in men.39

• In Taiwan, researchers linked devel-opment of asthma with several indi-vidual air pollutants: fine soot, sulfurdioxide, nitrogen dioxide, and carbonmonoxide. The scientists surveyed

Table 4: Annual Hospital Admissions Caused by AirPollution in New Jersey


Respiratory Hospital Admissions (Soot) 5,100 to 7,800

Cardiovascular Hospital Admissions (Soot) 2,700 to 7,500

Respiratory Hospital Admissions (Ozone) 3,900 to 5,900


over 160,000 schoolchildren andlooked at levels of air pollutants, find-ing that air pollution increased asthmaprevalence by as much as 29%, inde-pendently of exposure to second-handtobacco smoke.40 Similar research inHong Kong showed that children liv-ing in areas with higher air pollutionhad higher levels of asthma and lesshealthy lungs.41

• Dr. Joel Schwartz and others identi-fied links between particulate levelsand physician diagnoses of chronicbronchitis by looking at health recordsand air pollution levels in 53 U.S. met-ropolitan areas.42 For every 10 micro-gram per cubic meter increase in totalparticulates, the relative risk forchronic bronchitis rose about 7%.

Asthma prevalence is increasing in theU.S. and worldwide, for unknown rea-sons. In the US, the Centers for DiseaseControl and Prevention (CDC) estimatesthat prevalence among persons up to 17years old increased about 5% per yearfrom 1980 to 1995.43 Deaths due toasthma have doubled, and now amountto 5,000 per year.44 The trend in the num-ber of children with active asthma inNew Jersey also has been increasing overthe past few decades. According to a sur-vey carried out by the CDC in 2001,12.6% of all children in America hadbeen diagnosed with asthma at one point

in their lives, and 5.7% had an asthmaattack in the last year.45 According to themore recent Behavioral Risk Factor Sur-veillance Survey carried out by the CDCin 2002, 11.8% of New Jersey adultshave been diagnosed with asthma.46

New Jersey Estimate

We estimate that air pollution causes450 to 9,500 new cases of chronic bron-chitis and 860 to 1,900 cases of adultonset asthma among New Jersey resi-dents every year. Because ozone expo-sure was only linked to asthmadevelopment in males in the McDonnellpaper cited above, our estimate only con-siders new cases of asthma in the adultmale part of the population.

Emergency Room Visits

Studies from New Jersey and across thecountry confirm that as air pollution lev-els rise, increasing numbers of childrenand adults seek emergency medical at-tention for respiratory problems.

The Evidence

• Dr. Paul Lioy and his colleagues at theRutgers Environmental and Occupa-tional Health Sciences Institute andUMDNJ – Robert Wood JohnsonMedical School saw increases in thenumber of asthma emergency roomvisits in central and northern New Jer-sey on high-smog summer days.47

Table 5: Annual New Cases of Chronic Respiratory DiseaseCaused by Air Pollution in New Jersey


New Cases of Chronic Bronchitis (Soot) 450 to 9,500

Adult Onset Asthma (Ozone) 860 to 1,900


Emergency room visits occurred 28%more frequently when the averageozone levels were greater than 60 ppbthan when they were lower. This studydemonstrates health effects of ozoneexposure well below the EPA healthstandard of 80 ppb over an 8 hourperiod.

• Dr. Joel Schwartz from Harvard Uni-versity and his colleagues at the U.S.EPA found that as fine soot levels in-creased in the Seattle area, so did emer-gency room visits for asthma.48 Anincrease in fine soot levels of 30 mi-crograms per cubic meter increasedthe relative risk of needing emergencymedical attention for asthma by 12%.The daily fine soot levels never ex-ceeded 70% of the EPA health stan-dard at the time.

New Jersey Estimate

We estimate that air pollution causes640 to 12,000 emergency room visits fortreatment of asthma among New Jerseyresidents every year, or between 3% and60% of summer asthma emergency roomvisits.

Asthma Attacks

When pollution levels rise, so do thefrequency of asthma attacks suffered byasthmatic children and adults.

The Evidence

• Dr. George Thurston and his col-leagues at the New York UniversitySchool of Medicine documented in-creased asthma attacks, respiratorydifficulty, and reduced lung functionin children on high pollution days.49

The researchers tracked children at-tending the American LungAssociation’s Connecticut “AsthmaCamp” during summer months. Onthe highest pollution days, the risk ofasthma attacks requiring medicationand chest tightness climbed 40%higher than usual.

• In the mid 1970s, the EnvironmentalProtection Agency collected asthmaattack diaries from Los Angeles resi-dents. Asthma attacks were reportedmore frequently when smog and sootlevels were high, as well as when theweather was cool.50

Table 6: Annual Emergency Room Visits for RespiratoryAilments Caused by Air Pollution in New Jersey


Asthma ER Visits (Ozone) 640 to 12,000

Table 7: Annual Asthma Attacks Triggered byAir Pollution in New Jersey


Asthma Attacks (Soot) 330,000 to 1.4 million

Asthma Attacks (Ozone) 110,000 to 310,000


New Jersey Estimate

We estimate that soot pollution causes330,000 to 1.4 million asthma attacksand smog pollution causes 110,000 to310,000 asthma attacks among New Jer-sey asthmatics every year.

Missed Work Days andIncreased Sick Days

In addition to harming asthmatic in-dividuals, air pollution can affect thehealth of people with no chronic respi-ratory illness. On high pollution days,the number of people feeling ill withproblems like shortness of breath, runnyor stuffy noses, coughs, burning eyes,wheezing, and chest pain increases dra-matically. These symptoms can causepeople to miss work or school, or forcethem to limit their usual activity levels.

The Evidence

• Dr. Bart Ostro at the California EPAlinked high air pollution levels withmissed work days and illness days re-

ported in the Health Interview Surveycollected yearly by the U.S. Centers forDisease Control and Prevention.51

• Dr. Joel Schwartz of Harvard and hiscolleagues found that elementaryschool children in six U.S. cities suf-fered from coughs and other lowerrespiratory symptoms more often ondays when soot and smog levels werehigh.52

New Jersey Estimate

We estimate that soot pollution causes460,000 to 530,000 missed work days,7.1 million to 9.7 million person-dayswhen illness limits normal activity lev-els, and 14 million to 45 million persondays with the presence of at least one ofa variety of respiratory symptoms likeshortness of breath, runny or stuffynoses, coughs, burning eyes, wheezing,and chest pain. In addition, we estimatethat smog causes 960,000 to 1.7 millionperson-days when air pollution limitsnormal activity and 2.4 million to 7.5million person days with respiratorysymptoms.

Table 8: Annual Missed Work Days and IncreasedRespiratory Symptom Days Caused by Air Pollution in

New Jersey


Missed Work Days (Soot) 460,000 to 530,000

Restricted Activity Days (Soot) 7.1 million to 9.7 million

Increased Symptom Days (Soot) 14 million to 45 million

Restricted Activity Days (Ozone) 960,000 to 1.7 million

Increased Symptom Days (Ozone) 2.4 million to 7.5 million


Table 9: Air Pollution Damage to Children’s Healthin New Jersey


Infant Mortality 40 to 80






Automobile exhaust -- a source of smog and very fine soot.


Children are especially vulnerableto the effects of air pollution.First, children are developing

into adults. Their lungs are growing. In-juries sustained during this time cancause permanent damage that will havelife-long effects. Second, children breathemore air per pound of body weight, thusgetting higher doses of pollutants.

Children in New Jersey are constantlyexposed to air pollution, breathing it dayin and day out. Recent science has shownthat this exposure causes a range of lunginjuries, even among otherwise healthyinfants and children. Children exposedto air pollution can’t breathe as well aschildren growing up in cleaner areas.Their lungs are scarred and less flexiblethan they should be, their lungs hold lessair, and they aren’t as able to breathenormally. These injuries manifest them-selves in respiratory illness, missed schooldays, increased doctor visits, hospitaliza-tions, and for a small group, death.

NJPIRG researchers compiled air pol-lution data, scientific reports about howair pollution levels affect children’shealth, and baseline health statisticsmaintained by the state Department ofHealth and Senior Services and the EPA.We used this information to estimate thehealth impacts of pollution on childrenin New Jersey (for more details, see theMethodology section).

We estimate that air pollution kills sev-eral dozen infants a year and causes sev-eral hundred asthma hospitalizations inchildren, several thousand emergencyroom visits for childhood asthma, tensof thousands of cases of acute bronchi-tis, over a hundred thousand asthma at-tacks, and in the range of half-a-millionmissed school days (Table 9).

Infant Death

Air pollution not only kills elderly andsick people. It also causes prematuredeath in infants and young children.Studies have tied particulate levels todeaths both from respiratory disease andfrom sudden infant death syndrome.

The Evidence

• Dr. Tracey Woodruff at the U.S. EPAand her colleagues linked fine sootpollution levels and neonatal deathsin 86 U.S. metropolitan areas.53 Nor-mal-weight infants less than one yearold born in high soot areas were 40%more likely to die of respiratory dis-ease, and 26% more likely to die fromsudden infant death syndrome thaninfants born in low soot areas.

• Researchers in the Czech Republicfound that newborn deaths due to res-piratory causes were linked to in-

AIR POLLUTION AND NEW JERSEY’S CHILDREN

Table 10: Annual Infant Deaths from Air Pollution in New Jersey


Neonatal Mortality 40 to 80


creased levels of fine soot, sulfur di-oxide, and oxides of nitrogen.54 Thestudy concluded, “the effects of airpollution on infant mortality are spe-cific for respiratory causes in [the pe-riod between one month and one yearof age], are independent of socioeco-nomic factors, and are not mediatedby birth weight or gestational age.”

• The National Bureau of EconomicResearch found that as levels of par-ticles fell during a recession in the early1980s, so did rates of death in new-born children younger than 28 daysold. Specifically in Pennsylvania, re-searchers found that when total fineparticulate levels dropped 25%, new-born death rates from cardiopulmo-nary and respiratory causes fell 14%.55

New Jersey Estimate

We estimate that soot pollution causes40 to 80 infant deaths in New Jersey eachyear, or 5.9% to 11% of all infant deaths.

Hospitalization andEmergency Room Trips

As air pollution levels rise, children endup in the emergency room with respira-

tory problems at higher rates. Some ofthem will end up admitted to a hospitalfor longer-term care.

The Evidence

• Dr. Michael Friedman of the U.S. Cen-ters for Disease Control and Preven-tion and his colleagues found thatreduced traffic levels and higher pub-lic transit use during the 1996 Sum-mer Olympics in Atlanta significantlyreduced smog levels and also emer-gency room visits for childhoodasthma.56 One-hour peak ozone lev-els decreased by 27%, while the num-ber of children visiting the ER forasthma fell 41.6% in a Medicaid da-tabase, 44.1% in an HMO database,and 11.1% in two major pediatricemergency departments. In otherwords, every 10 ppb increase in smoglevels increased the relative risk ofneeding emergency medical attentionfor asthma in children by roughly 8%.

New Jersey Estimate

We estimate that air pollution causes290 to 440 asthma hospitalizations(3.2% to 5% of total asthma hospital-izations) and at least 190 to 3,400asthma ER visits among New Jersey chil-dren each year.

Table 11: Annual Pediatric Respiratory ER Visits andHospitalizations Caused by Air Pollution in New Jersey





Asthma Attacks, AcuteBronchitis, and MissedSchool Days

Air pollution triggers asthma attacksand increases cases of acute bronchitisin children. Asthma is the leading chronicillness in children and the number onecause of missed school days in the UnitedStates.59 The Centers for Disease Con-trol estimates that asthma prevalenceamong persons up to 17 years old in-creased about 5% per year from 1980to 1995.60 Air pollution worsens the im-pact of this disease, causes other acuterespiratory illnesses, and increases schoolabsence rates.

The Evidence

• Dr. Janneane Gent at the Yale Univer-sity School of Medicine and her col-leagues recently published a studyshowing that children with asthma arevulnerable to air pollution at levelswell below EPA health standards.61

According to the study, every 50 ppbozone increase yields a 35% increasedlikelihood of wheezing, and a 47% in-creased likelihood of chest tightness.

• Dr. Douglas Dockery at Harvard Uni-versity and his colleagues showed that

children living in areas with high lev-els of acidic particle pollution were66% more likely to have had an epi-sode of bronchitis in the last year thanchildren in low pollution areas.62

• Researchers participating in the South-ern California Children’s Health Studyfound that increased smog pollutioncauses more children to stay homefrom school.63 When ozone levels roseby 20 ppb, illness-related absence rateswent up by 63%, and by 174% forlower respiratory illnesses with wetcough.

• Researchers in Korea found the samerelationship between air pollution andschool absences.64 When air pollutionlevels rose, so did illness-related ab-sences. When pollution levels fell,more children came in to school.

New Jersey Estimate

We estimate that air pollution causes21,000 to 77,000 cases of acute bron-chitis and 150,000 to 170,000 asthmaattacks among New Jersey children eachyear. Additionally, air pollution causesin the range of 610,000 missed schooldays each year.

Table 12: Annual Asthma Attacks and Acute Bronchitis inNew Jersey Children Caused by Air Pollution






The 1996 Summer Olympic Games

in Atlanta offered researchers a

unique opportunity to observe the

connection between lowered pollu-

tion levels and improved health.57

Atlanta implemented a comprehen-

sive transit plan as a part of the Olym-

pic Games. The plan was designed

to reduce congestion in the down-

town area and reduce travel delays.

Atlanta launched an expanded 24-

hour-a-day public transportation net-

work, added 1,000 buses for

park-and-ride service, encouraged

local employers to institute alterna-

tive work hours and telecommuting,

and closed the downtown area to

private vehicles.

The transit plan produced impres-

sive results, despite the million or so

additional visitors to the city. Week-

day morning traffic trips declined by

22.7% and public transportation rid-

ership increased by 217%.

The plan produced some unin-

tended benefits for air quality and

health that were equally impressive.

The average daily maximum ozone

levels decreased by 28%, from 81

ppb before and after the Olympics to

59 ppb during the Olympics. Presum-

ably, this effect resulted from the de-

creased levels of traffic-related air

pollution building up in the morning

rush hour. Nearby cities did not ex-

perience similar reductions in

ozone pollution.

At the same time, asthma-related

emergency room visits for children

decreased by 41.6% in a Medicaid

database, 44.1% in an HMO data-

base, and 11.1% in two major pe-

diatric emergency departments.

Additionally, hospitalizations for

asthma decreased by 19.1%. Un-

fortunately, Atlanta discontinued the

transit program at the conclusion of

the Olympics, and pollution levels

and emergency room visit rates re-

turned to normal.

This study powerfully demon-

strates how reducing pollution lev-

els would benefit the health of

children. It also highlights the role

that motor vehicles play in creating

high levels of urban pollution, and

the rapidity with which pollution can

be reduced from the transportation

sector with better public transit.

Dr. Michael Friedman of the U.S.

Centers for Disease Control, one

of the authors of the study, said that

the results “provide evidence that

decreasing automobile use can re-

duce the burden of asthma in our

cities and that citywide efforts to

reduce rush-hour automobile traf-

fic through the use of public trans-

portation and altered work

schedules is possible in America.”58

Reducing Air Pollution Protects Children’s Health: The Case ofthe 1996 Olympics in Atlanta


Solutions to New Jersey’s Air qual-ity problems are readily available.Technologies already developed

and introduced into society—from mod-ern emission controls for cars and powerplants to efficient transit systems—cancut the amounts of air pollution in NewJersey air and help people to live healthylives.

Aggressive action will be required onboth the state and federal level to reduceair pollution and reduce the costs soci-ety must bear to support the use of pol-luting fuels. In order to have the greatestimpact, action should focus first on thelargest sources of pollution.

Sources of Dirty Air

In-state, mobile sources like cars,trucks, buses, and off-road equipmentare the largest source of air pollution.Additional pollutants come from indus-trial facilities, power plants, and chemi-cal use. Finally, upwind sources in otherstates are a significant part of the over-all problem.

Within the state in 1999, nearly 60%of soot emissions and almost half ofsmog-forming emissions came from on-road and off-road mobile sources likecars, trucks, and construction equipment(Table 13).65 48% of particulate emis-

CLEAN AIR POLICY RECOMMENDATIONS

Table 13. Emissions of Selected Air Pollutants in 1999 by Source67

Mobile Sources 154,093 38% 293,102 59% 93,238 59%

Area Sources 155,166 38% 82,662 17% 46,514 30%

Point Sources 97,880 24% 120,692 24% 17,741 11%

TOTAL 407,139 496,456 157,493

VolatileOrganic

Compounds(VOCs, Tons)

% of TotalEmissons

Oxides ofNitrogen

(NOx, Tons)% of TotalEmissons

ParticulateMatter

(PM10, Tons)% of TotalEmissons

sions and 31% of smog-forming emis-sions came from highway vehicles.

Mobile sources have received less regu-latory attention than industrial facilitiesand area sources of pollution. Accord-ing to NJ Department of EnvironmentalProtection emission inventories, from1990 to 1996 mobile source emissionsof oxides of nitrogen (NOx, a smog pre-cursor) did not decline, while emissionsfrom area and point sources were cut byhalf.66 Focusing regulatory attention onmobile sources will produce the greatestair quality gains.

Policies Aimed at theLargest PollutionSources

Although policy options available inthe near future will not prevent all of theimpacts identified in this report, smallsteps toward cleaner air will have mean-ingful benefits for human health. An ef-fective suite of policies aimed at reducingair pollution in New Jersey would in-clude the following:

State Level Actions:

• Strengthen auto emission standards inline with New York, Massachusetts,


California, and Vermont. In thesestates, auto makers are required tomanufacture and sell vehicles that emitless pollution and incorporate ad-vanced technologies.

• Reduce car-dependent land use prac-tices and sprawl. New Jersey shouldensure that future growth, develop-ment, and redevelopment focuses oncreating livable, transit oriented, wellcentered communities to reverse thetrend of yearly increases in vehiclemiles traveled.

• Increase funding for transit, railfreight, and other alternative transpor-tation projects. Highway constructionand highway widening projects pro-vide little long-term relief from con-gestion, encourage car-dependent landuse patterns, and exacerbate sprawl.Increasing the proportion of fundingfor alternatives like transit and railfreight can help get cars and trucksoff the road.

• Require diesel engines to be retrofit-ted with particulate filtration systemsand low-sulfur fuel. Diesel engines area significant source of fine particles.New federal diesel standards will gointo effect in 2007, which will applyto new diesel vehicles. The state shouldrequire old diesel vehicles to upgradetheir emissions control equipment aswell. State-owned fleets of vehicles likeschool buses should be included, aswell as off-road diesel vehicles likebulldozers.

• Require diesel engines in marine ves-sels and trains to have selective cata-lytic reduction systems. Over the pastfew decades, selective catalytic reduc-tion systems have significantly reducedemissions from power plant smoke-stacks in New Jersey. The same tech-nology can be applied to diesel engineson railroads and in marine vessels.

Federal and Regional LevelActions:

• Advocate adoption of these state poli-cies among neighboring and upwindstates. Reducing air pollution emis-sions in New Jersey will have benefitsfor New York, Philadelphia, and otherupwind areas as well. These actionscan serve as an incentive for otherstates to take similar action against airpollution. Ultimately, regional coop-eration will be required to reduce over-all air pollution levels.

• Restore the New Source Review pro-vision of the Clean Air Act and requirethe oldest coal-fired power plants andother industrial facilities in the coun-try to install modern emissions con-trol technology. The EPA recentlyenacted regulations relieving powerplants and industrial facilitiesgrandfathered under the originalClean Air Act of responsibility to up-grade their emissions controls whenupgrading their facilities. This changelimits the effectiveness of the Clean AirAct and effectively subsidizes a few in-dustries at the expense of publichealth. It should be undone as soonas possible.

• Limit nationwide industrial emissionsof sulfur dioxide, nitrogen oxides, andmercury to between 10% and 30% of2000 levels. Placing a national cap onpoint-source emissions of air pollut-ants could dramatically reduce the lev-els of pollution plaguing the easternseaboard of the U.S., and could con-tribute to a regional solution to theair pollution problem.

• Strengthen national emission stan-dards for cars, trucks, and off-roadvehicles. The EPA sets national emis-sion standards for cars, trucks, andoff-road vehicles. However, California


has designed a more effective andambitious mobile-source emissionscontrol program that includes a re-quirement for manufacturers to pro-

duce cleaner vehicles with moderntechnologies. The EPA should updateits standards to match the Californiaprogram.


To quantify the health impacts ofair pollution, we acquired threebasic pieces of information:

• The exposure of people to air pollut-ants,

• How the frequency and risk of a givenhealth impact changes with increas-ing or decreasing air pollution levels,and

• The baseline frequency of a givenhealth problem in society.

Air pollution monitors placed through-out the state by the New Jersey Depart-ment of Environmental Protection helpprovide the first piece of information. Avast body of scientific literature in whichresearchers tracked pollution and healtheffects provides the second piece of in-formation. And the third comes fromhealth statistics maintained by the stateDepartment of Health and Senior Ser-vices, plus additional information fromsurveys and experiments in the scientificliterature.

We compiled this information to esti-mate the health impacts of pollution inNew Jersey, adapting methodology usedby the U.S. EPA in a study on the ben-efits and costs of the Clean Air Act andby the World Health Organization in astudy on the health impact of vehiclepollution in Europe.68 The sections be-low outline the sources of this informa-tion and how we used it to derive ourresults.

Air Pollution Exposure

We obtained annual mean levels ofparticulate pollution less than 10 mi-crometers in diameter (PM10 or finesoot) from the U.S. EPA AIRData onlinedatabase of air pollution monitoringdata, using the years 1997 to 2001.69 Ad-ditionally, we obtained the average dailyone-hour peak ozone levels reported

during the summer smog season fromApril through October from the samesource.

Several assumptions and generaliza-tions were made to calculate exposurelevels for the New Jersey population. Thepurpose of these assumptions was toobtain a reasonable estimate of indi-vidual exposure in the absence of detaileddata for every part of the state. First, weassumed that mean pollution levels foreach county approximated exposure forthe average resident of that county. Sec-ond, for counties without active PM10monitors but with active PM2.5 moni-tors, we adjusted the PM2.5 readings toestimate PM10 levels. According to in-stances in which each pollutant wasmonitored in the same place at the sametime, PM2.5 levels are typically 55% ofPM10 levels. Third, for counties with-out active pollution monitors, we con-servatively used backgroundmeasurements from monitors in ruralPassaic county with the lowest statewidereadings of all active monitors during thisperiod. For particulate matter, thesecounties included: Burlington, CapeMay, Hunterdon, Monmouth, Salem,Somerset, and Sussex. For ozone, thesecounties included Burlington, Cape May,Salem, Somerset, Sussex, and Warren.

Table 14 presents the results of com-piling air pollution data from 1997 to2001.

We define the impact of air pollutionas the change in the number of varioushealth outcomes if air pollution expo-sure was reduced to natural backgroundlevels in the absence of anthropogenicemissions from North America, but withcontinuing emissions from the rest of theworld. For ozone, this background levelin the Northeast is 20 ppb.70 For particu-late matter, this background is 5 micro-grams per cubic meter.71

METHODOLOGY


Table 14: Average Annual and Smog Season Pollution Levelsin New Jersey

County

Atlantic 25 Yes 59 Yes

Bergen 39 Yes 49 Yes

Burlington 16 No 56 No

Camden 27 Yes 64 Yes

Cape May 16 No 56 No

Cumberland 18 Yes 59 Yes

Essex 34 Yes 47 Yes

Gloucester 18 Yes 61 Yes

Hudson 37 Yes 53 Yes

Hunterdon 16 No 59 Yes

Mercer 24 Yes 60 Yes

Middlesex 23 Yes 59 Yes

Monmouth 16 No 56 Yes

Morris 22 Yes 58 Yes

Ocean 20 Yes 62 Yes

Passaic 25 Yes 56 Yes

Salem 16 No 56 No

Somerset 16 No 56 No

Sussex 16 No 56 No

Union 33 Yes 50 Yes

Warren 25 Yes 56 No

Baseline Frequency of HealthProblems in New Jersey

We obtained the baseline frequency ofhealth outcomes in New Jersey from sta-tistics maintained by the New JerseyDepartment of Health and Senior Ser-vices Health Statistics Division or, whenmore specific information was unavail-able, published estimates for the Ameri-can population as a whole from the U.S.EPA.

We obtained New Jersey county popu-lation figures by age group from the U.S.Bureau of the Census for 2000 to trans-

late the relevant rates in Table 15 tobaseline population frequencies for thestate.87 Additionally, we assumed thatone third of all health effects that couldbe affected by ground-level ozone hap-pened during the April through Octoberozone monitoring season, and only con-sidered the effects of ozone on that pe-riod of time. This assumption issupported by hospital admissions datacited in Table 15 – in 2002, 118,435 NewJersey residents were hospitalized for res-piratory causes, and 40,005 hospitaliza-tions, or 33.78%, happened in the monthsof May through September. 88

Annual Average

PM10 levels (micro-

grams per cubic meter)

Monitor

in County?

April - October

Average Daily One

Hour Peak Ozone

Levels (ppb)

Monitor

in County?


Table 15: Baseline Frequencies of Health Problems in New Jersey

Health Outcome Baseline Frequency in New Jersey

0.0081 to 0.0085

Data obtained by county of residence for

1997-2000 from the NJ Center for Health

Statistics.



Statistics.



Statistics.



Statistics.

0.0038

0.0011

11.8%

9.86

0.01

0.0071

4.4%

1.6

6

6.46

Mortality (Deaths per person per year), excluding

violence or accidental deaths.72

Infant mortality (all causes).73

Respiratory hospital admissions (ICD 390-459).74

Cardiovascular hospital admissions (ICD 460-

519).75

Asthma hospital admissions for children 0-15 years

of age.76

Annual chronic bronchitis incidence per person.77

Annual chronic asthma incidence among adults 27

years of age and older in ozone season.78

Asthma prevalence among adults in NJ.79

Asthma attacks per asthmatic per year.80

Asthma ER visits per year among all children 0-15

years of age.81

Asthma ER visits per year among adults.82

Number of children per year who get acute bron-

chitis.83

Yearly missed work days per worker due to illness

(adults between the ages of 18 and 65).84

School absences per student per year due to ill-

ness.85

Restricted activity days per person per year.86


The Relationship BetweenExposure and Frequency ofHealth Effects

A vast body of scientific literature inwhich researchers tracked pollution andhealth effects provides information abouthow the frequency of health effectschanges with changing exposure to airpollution. These studies are known asepidemiological studies. Most epidemio-logical studies report the exposure-re-sponse relationship for air pollutionexposure as a relative risk (RR). If therelative risk equals 1, then the pollutantin question does not influence the healthoutcome. If the relative risk exceeds one,then the pollutant and the health out-come are linked. Most studies report aconsiderable range in which the relativerisk actually lies. This is called the confi-dence interval. We use the upper andlower bounds of these intervals to de-rive the ranges for each health effect wereport.

Calculating the impact of air pollutionon a given health outcome follows thegeneral equation shown above.89

We obtained exposure-response func-tions from epidemiological research pub-lished in the scientific literature ascompiled in:

1) The U.S. EPA’s report to Congresson the benefits and costs of the CleanAir Act90 and

2) A project describing the health im-pacts of vehicular air pollution in Swit-zerland, Austria, and France carried outby European scientists and the WorldHealth Organization.91

General Equation: Air Pollution Attributable Portion of Health Effects =

(RR – 1) x (∆Pollution)

(RR)

Particulates (PM10)

Table 16 lists the relative risk numbersfor an increase in particulate matter pol-lution of one microgram per cubic meterderived from epidemiology studies, theconfidence limits, and the citation for theoriginal study.

Ozone

Table 17 lists the relative risk numbersfor an increase in ground-level ozonepollution of one part per billion derivedfrom epidemiology studies, the confi-dence limits, and the citation for theoriginal study.

For studies which used ozone measure-ments other than the daily one hour peakconcentration, we used the followingestimated conversion factors: 12 hourozone levels are 50% of the daily onehour maximum, 8 hour ozone levels are70% of the daily one hour maximum,and 5 hour ozone levels are 85% of thedaily one hour maximum. We estimatethese conversion factors based ozonemonitoring data for New Jersey.113

Children, PM10

Table 18 lists the relative risk numbersfor children for an increase in particu-late matter pollution of one microgramper cubic meter derived from epidemiol-ogy studies, the confidence limits, andthe citation for the original study.

x (Baseline Frequency of Outcome in Vulnerable Population)


Table 18: Relative Risk Figures Derived from the Scientific Literature,Particulate Matter, Children

Health Effect

Neonatal Mortality 1.00392 1.0027 1.00514 108

Asthma Hospitalizations 1.0025 1.001782 1.003218 109

Acute Bronchitis 1.0306 1.0135 1.0502 110

Asthma Attacks 1.0051 1.0047 1.0056 111

Missed School Days 1.004 NA NA 112

Table 17: Relative Risk Figures Derived from theScientific Literature, Ozone

Health Effect

Long-Term Mortality 1.000634 1.000383 1.000885 100

Adult Onset Asthma 1.0277 1.0142 1.0412 101

Respiratory Hospital Admissions 1.0025 1.001782 1.003218 102

Asthma ER Visits 1.0035 1.0017 1.0053 103

Asthma Attacks 1.00184 1.001126 1.002554 104

Restricted Activity Days 1.0022 1.001542 1.002858 105

Increased Symptom Days 1.000137 1.0000673 1.0002067 106

Asthma ER Visit, Children0-15 years of age 1.008 1.001 1.0186 107

Table 16: Relative Risk Figures Derived fromthe Scientific Literature, Particulate Matter

Health Effect

Premature Death 1.0043 1.0026 1.0061 92

Respiratory Hospital Admissions 1.0017 1.0013 1.002 93

Cardiovascular Hospital Admissions 1.0008 1.0004 1.0011 94

Asthma Attacks 1.0039 1.0019 1.0059 95

Chronic Bronchitis 1.0098 1.0009 1.0194 96

Work Loss Days 1.0046 1.00424 1.00496 97

Restricted Activity Days 1.0094 1.0079 1.0109 98

Increased Symptom Days 1.168 1.081 1.256 99

RelativeRisk of Effect

95%Confidence

Limit

5%Confidence

Limit Reference


95%Confidence

Limit

5%Confidence

Limit Reference


95%Confidence

Limit

5%Confidence

Limit Reference


NOTES

1. The air pollution data here represents the 1997-2001 annual average for particulates and the1997-2001 April – October average one hourdaily peak for ozone: U.S. EPA, AirData: Accessto Air Pollution Data, downloaded fromwww.epa.gov/air/data/, on 3 November 2003.

2. A. Fiore et al., Department of Earth and Plan-etary Sciences, Harvard University, “Variabilityin Surface Ozone Background in the United States:Implications for Air Quality Policy,” submittedto Journal of Geophysical Research, 12 June2003; Health Canada, National Ambient AirQuality Objectives for Particulate Matter, ISBN0-662-26715-X, 1999.

3. A. Fiore et al., Department of Earth and Plan-etary Sciences, Harvard University, “Variabilityin Surface Ozone Background in the United States:Implications for Air Quality Policy,” submittedto Journal of Geophysical Research, 12 June2003.

4. Whitman v. American Trucking Assoc., 531U.S. 457 (2001).

5. U.S. EPA, “Proposed Rule to Implement the 8-House Ozone National Ambient Air Quality Stan-dard,” 68 Federal Register 32802, 2 June 2003;Emily Figdor, United States Public Interest Re-search Group, Danger in the Air: Unhealthy Lev-els of Smog in 2002, August 2003.

6. New Jersey Department of Environmental Pro-tection, 2001 Air Quality Report: 2001 OzoneSummary, downloaded from www.state.nj.us/dep/airmon/ on 9 November 2003.

7. M. Lippman, “Health Effects of Ozone: A Criti-cal Review,” Journal of the Air Pollution Con-trol Association 39: 672-695, 1989; I. Mudwayand F. Kelley, “Ozone and the Lung: A SensitiveIssue,” Molecular Aspects of Medicine 21: 1-48,2000.

8. M. Gilmour et al., “Ozone-Enhanced Pulmo-nary Infection with Streptococcus Zooepidemicusin Mice: The Role of Alveolar Macrophage Func-tion and Capsular Virulence Factors,” AmericanReview of Respiratory Disease 147: 753-760; I.Mudway and F. Kelley, “Ozone and the Lung: ASensitive Issue,” Molecular Aspects of Medicine21: 1-48, 2000.

9. W. McDonnell et al., “Pulmonary Effects ofOzone Exposure During Exercise: Dose-ResponseCharacteristics,” Journal of Applied Physiology5: 1345-1352, 1983.

10. N. Kunzli et al., “Association Between Life-time Ambient Ozone Exposure and PulmonaryFunction in College Freshmen – Results of a PilotStudy,” Environmental Research 72: 8-16, 1997.

11. A. Galizia et al., “Long-Term Residence inAreas of High Ozone: Associations with Respira-tory Health in a Nationwide Sample of Nonsmok-ing Young Adults,” Environmental Health Per-spectives 107: 675-679, 1999.

12. M. Fanucchi et al., “Repeated Episodes ofExposure to Ozone Alters Postnatal Developmentof Distal Conducting Airways in Infant RhesusMonkeys,” American Journal of RespiratoryCritical Care Medicine 161: A615, 2000; KendallPowell, “Ozone Exposure Throws MonkeyWrench Into Infant Lungs,” Nature Medicine,Volume 9, Number 5, May 2003.

13. Kendall Powell, “Ozone Exposure ThrowsMonkey Wrench Into Infant Lungs,” NatureMedicine, Volume 9, Number 5, May 2003.

14. R. McConnell et al., “Asthma in ExercisingChildren Exposed to Ozone: A Cohort Study,”The Lancet 359: 386-391, 2002

15. M. Bell and D. Davis, “Reassessment of theLethal London Fog of 1952: Novel Indicators ofAcute and Chronic Consequences of Acute Ex-posure to Air Pollution,” Environmental HealthPerspectives 109 Supplement 3: 389-94, 2001.

16. B. Karcher et al., “A Unified Model for Ultrafine Aircraft Particle Emissions,” Journal of Geo-physical Research 105: D24 29379-29386, 2002.

17. M. Kleeman et al., “Size and CompositionDistribution of Fine Particulate Matter EmittedFrom Motor Vehicles,” Environmental Scienceand Technology 34: 1132-1142, 2000.

18. H. Bunn et al., “Ultra fine Particles in Alveo-lar Macrophages from Normal Children,” Tho-rax 56: 932-934, 2001.

19. A. Seaton et al., “Particulate Air Pollutionand the Blood,” Thorax 54: 1027-1032, 1999.

20. M. Brauer et al., “Air Pollution and RetainedParticles in the Lung,” Environmental HealthPerspectives 109: 1039-1043, 2001.

21. J. Pekkanen et al., “Daily Variations of Par-ticulate Air Pollution and ST-T Depressions inSubjects with Stable Coronary Heart Disease: TheFinnish ULTRA Study,” American Journal ofRespiratory Critical Care Medicine 161: A24,2000.

22. C. Pope et al., “Lung Cancer, Cardiopulmo-nary Mortality, and Long-Term Exposure to FineParticulate Air Pollution,” Journal of the Ameri-can Medical Association 287: 1132-1141, 2002.

23. Ralph Delfino et al., “Asthma Symptoms inHispanic Children and Daily Ambient Exposuresto Toxic and Criteria Air Pollutants,” Environ-mental Health Perspectives 111(4), 647-656, April2003.

24. I.L. Bernstein, M. Chan-Yeung, J.L. Malo, andD.I. Bernstein, Asthma in the Workplace, (NewYork, NY: Marcel Dekker), 1999.

25. D. Glass et al., “Leukemia Risk Associatedwith Low-Level Benzene Exposure,” Epidemiol-ogy 14: 569-577, 2003; A. Blair and N.Kazerouni, “Reactive Chemicals and Cancer,”Cancer Causes Control 8: 473-490.


26. U.S. Environmental Protection Agency, FinalReport to Congress on Benefits and Costs of theClean Air Act, 1990 to 2010, Document # EPA410-R-99-001, 15 November 1999; N. Kunzli etal., Air Pollution Attributable Cases — TechnicalReport on Epidemiology; Technical Report of theHealth Costs Due to Road Traffic-Related AirPollution — An Impact Assessment Project ofAustria, France, and Switzerland, World HealthOrganization, Bern 1999.

27. C. Pope et al., “Lung Cancer, Cardiopulmo-nary Mortality, and Long-Term Exposure to FineParticulate Air Pollution,” Journal of the Ameri-can Medical Association 287: 1132-1141, 2002.

28. American Cancer Society, “Air PollutionLinked to Deaths from Lung Cancer,” Web Ar-ticle, www.cancer.org, 6 March 2002.

29. N. Kunzli et al., “Public Health Impact ofOutdoor and Traffic-Related Air Pollution: AEuropean Assessment,” The Lancet 356: 795-801,2 September 2002.

30. A. Peters et al., “Increased Particulate Air Pol-lution and the Triggering of Myocardial Infarc-tion,” Circulation 103: 2810-2815, 2001.

31. J. Samet et al., The United States Health Ef-fects Institute, The National Morbidity, Mortal-ity, and Air Pollution Study, Part II: Morbidityand Mortality from Air Pollution in the UnitedStates, Research Report Number 94, June 2000.

32. J. Schwartz et al., “Episodes of High CoarseParticle Concentrations Are Not Associated WithIncreased Mortality,” Environmental Health Per-spectives 107: 339-342, 1999.

33. J. Schwartz, “Is There Harvesting in the As-sociation of Airborne Particles with Daily Deathsand Hospital Admissions?” Epidemiology 12: 55-61, 2001; M. Bobak and D.A. Leon, “The Effectof Air Pollution on Infant Mortality Appears Spe-cific for Respiratory Causes in the Postnatal Pe-riod,” Epidemiology 10: 666-670, 1999.

34. N. Kunzli et al., “Public Health Impact ofOutdoor and Traffic-Related Air Pollution: AEuropean Assessment,” The Lancet 356: 795-801,2 September 2002.

35. J. Samet et al., The United States Health Ef-fects Institute, The National Morbidity, Mortal-ity, and Air Pollution Study, Part II: Morbidityand Mortality from Air Pollution in the UnitedStates, Research Report Number 94, June 2000.

36. Joel Schwartz, “Air Pollution and HospitalAdmissions for the Elderly in Birmingham, Ala-bama,” American Journal of Epidemiology 139:589-98, 15 March 1994; Joel Schwartz, “Air Pol-lution and Hospital Admissions for the Elderly inDetroit, Michigan,” American Journal of Respi-ratory Critical Care Medicine 150: 648-55, 1994;Joel Schwartz , “PM10, Ozone, and Hospital Ad-missions for the Elderly in Minneapolis-St. Paul,Minnesota,” Archives of Environmental Health

49: 366-374, 1994; Joel Schwartz, “Short-TermFluctuations in Air Pollution and Hospital Ad-missions of the Elderly for Respiratory Disease,”Thorax 50:531-538, 1995; J. Schwartz and R.Morris, “Air pollution and hospital admissionsfor cardiovascular disease in Detroit, Michigan,”American Journal of Epidemiology 142: 23-25,1995; Joel Schwartz, “Air Pollution and Hospi-tal Admissions for Respiratory Disease,” Epide-miology 7: 20-28, 1996; Joel Schwartz, “Air Pol-lution and Hospital Admissions for Cardiovas-cular Disease in Tucson,” Epidemiology 8: 371-377, 1997.

37. George Thurston et al., “Respiratory Hospi-tal Admissions and Summertime Haze Air Pollu-tion in Toronto, Ontario: Consideration of theRole of Acid Aerosols,” Environmental Research65: 271-290, 1994; R. Burnett et al., “The Roleof Particulate Size and Chemistry in the Associa-tion Between Summertime Ambient Air Pollutionand Hospitalization for Cardio-respiratory Dis-ease,” Environmental Health Perspectives 105:614-620, 1997; R. Burnett et al., “AssociationBetween Ozone and Hospitalization for Respira-tory Diseases in 16 Canadian Cities,” Environ-mental Research 72: 24-31, 1997.

38. R. McConnell et al., “Asthma in ExercisingChildren Exposed to Ozone: A Cohort Study,”The Lancet 359: 386-391, 2002; The causal roleof ozone in asthma development may be easier todetect in children who exercise because breath-ing rates during exercise can be up to 17 timeshigher than during rest, leading to greater expo-sure to air pollutants: See W.D. McArdle et al.,Exercise Physiology: Energy, Nutrition, and Hu-man Performance, (Philadelphia, PA: Williamsand Wilkins, 1996), 228.

39. W. McDonnell et al., “Long-Term AmbientOzone Concentration and the Incidence ofAsthma in Nonsmoking Adults: the AHSMOGStudy,” Environmental Research 80: 110-121,1999.

40. T. Wang et al., “Association Between Indoorand Outdoor Air Pollution and AdolescentAsthma From 1995 to 1996 in Taiwan,” Envi-ronmental Research 81: 239-247, 1999.

41. T. Yu et al., “Adverse Effects of Low-LevelAir Pollution on the Respiratory Health of School-children in Hong Kong,” Journal of OccupationalEnvironmental Medicine 43: 310-316, 2001.

42. Joel Schwartz, “Particulate Air Pollution andChronic Respiratory Disease,” EnvironmentalResearch 62: 7-13, 1993; D. Abbey et al., “Long-term Ambient Concentrations of Total SuspendedParticles, Ozone, and Sulfur Dioxide and Respi-ratory Symptoms in a Nonsmoking Population,”Archives of Environmental Health 48: 33-46,1993.

43. U.S. Centers for Disease Control, “Measur-ing Childhood Asthma Prevalence Before andAfter the 1997 Redesign of the National Health


Interview Survey — United States,” Mortality andMorbidity Weekly Report 49: 908-911, 13 Octo-ber 2000.

44. National Institutes of Health, National Heart,Lung, and Blood Institute, Data Release for WorldAsthma Day, May 2001.

45. U.S. Environmental Protection Agency,America’s Children and the Environment, Docu-ment Number EPA 240R03001, 2003: Statisticsfor New Jersey and Asthma from U.S. Centersfor Disease Control and Prevention, NationalCenter for Health Statistics, National Health In-terview Survey.

46. Division of Adult and Community Health,National Center for Chronic Disease Preventionand Health Promotion, Centers for Disease Con-trol and Prevention, Behavioral Risk Factor Sur-veillance System Online Prevalence Data, 1995-2002

47. R. Cody et al., “The Effect of Ozone Associ-ated with Summertime Photochemical Smog onthe Frequency of Asthma Visits to Hospital Emer-gency Departments,” Environmental Research 58:184-194, 1992; C. Weisel et al., “RelationshipBetween Summertime Ambient Ozone Levels andEmergency Department Visits for Asthma in Cen-tral New Jersey,” Environmental Health Perspec-tives 103, Supplement 2: 97-102, 1995.

48. Joel Schwartz et al., “Particulate Air Pollu-tion and Hospital Emergency Room Visits forAsthma in Seattle,” American Review of Respi-ratory Disease 147: 826-831, 1993.

49. George Thurston et al., “Summertime HazeAir Pollution and Children with Asthma,” Ameri-can Journal of Respiratory Critical Care Medi-cine 155: 654-660, February 1997.

50. A. Whittemore and E. Korn, “Asthma andAir Pollution in the Los Angeles Area,” Ameri-can Journal of Public Health, 70: 687-696, 1980.

51. B. Ostro and S. Rothschild, “Air Pollutionand Acute Respiratory Morbidity: an Observa-tional Study of Multiple Pollutants,” Environmen-tal Research 50: 238-47, 1989.

52. J. Schwartz et al., “Acute Effects of SummerAir Pollution on Respiratory Symptom Report-ing in Children,” American Journal of Respira-tory Critical Care Medicine 150: 1234-1242,1994.

53. T. Woodruff et al., “The Relationship BetweenSelected Causes of Postneonatal Infant Mortalityand Particulate Air Pollution in the United States,”Environmental Health Perspectives 105: 608-612,1997.

54. M. Bobak and D.A. Leon, “The Effect of AirPollution on Infant Mortality Appears Specific forRespiratory Causes in the Postnatal Period,” Epi-demiology 10: 666-670, 1999.

55. K.Y. Chay and M. Greenstone, National Bu-reau of Economic Research, The Impact of AirPollution on Infant Mortality: Evidence fromGeographic Variation in Pollution Shocks In-duced by a Recession, Manuscript cited in “Spring2002 References,” Health and Clean Air News-letter, www.healthandcleanair.org, 2002.

56. M. Friedman et al., “Impact of Changes inTransportation and Commuting Behaviors Dur-ing the 1996 Summer Olympic Games in Atlantaon Air Quality and Childhood Asthma,” Journalof the American Medical Association 285: 897-905, 2001.


58. U.S. Centers for Disease Control, CDC StudyLinks Improved Air Quality with DecreasedEmergency Room Visits for Asthma, Press Re-lease, 21 February 2001.

59. American Lung Association, Asthma in Chil-dren Factsheet, March 2003.

60. U.S. Centers for Disease Control, “Measur-ing Childhood Asthma Prevalence Before andAfter the 1997 Redesign of the National HealthInterview Survey — United States,” Mortality andMorbidity Weekly Report 49: 908-911, 13 Octo-ber 2000.

61. Janneane Gent et al., “Association of low-level ozone and fine particles with respiratorysymptoms in children with asthma,” Journal ofThe American Medical Association 290, 1859-1867, 8 October 2003.

62. D. Dockery et al., “Health Effects of AcidAerosols on North American Children: Respira-tory Symptoms,” Environmental Health Perspec-tives 104: 500-505, May 1996.

63. F. Gilliland et al., “The Effects of AmbientAir Pollution on School Absenteeism Due to Res-piratory Illness,” Epidemiology 12: 43-54, 2001.

64. H. Park et al., “Association of Air Pollutionwith School Absenteeism Due to Illness,” Archivesof Pediatric and Adolescent Medicine 156: 1235-1239, 2002.

65. Environmental Defense, 1999 Criteria Pol-lutant Emissions Summary: New Jersey, down-loaded from scorecard.org, 11 November 2003.

66. New Jersey Department of EnvironmentalProtection, New Jersey’s Environment 2000:Clean Air, downloaded from www.state.nj.us/dep/dsr/njenv2000/Clean%20Air.pdf, 11 November2003.


67. Environmental Defense, 1999 Criteria Pol-lutant Emissions Summary: New Jersey, down-loaded from scorecard.org, 11 November 2003.

68. U.S. Environmental Protection Agency, FinalReport to Congress on Benefits and Costs of theClean Air Act, 1990 to 2010, Document # EPA410-R-99-001, 15 November 1999; N. Kunzli etal., Air pollution Attributable Cases — TechnicalReport on Epidemiology; Technical Report of theHealth Costs Due to Road Traffic-Related AirPollution — An Impact Assessment Project ofAustria, France, and Switzerland, World HealthOrganization, Bern 1999.

69. U.S. EPA, AirData: Access to Air PollutionData, downloaded from www.epa.gov/air/data/,on 3 November 2003.

70. A. Fiore et al., Department of Earth and Plan-etary Sciences, Harvard University, “Variabilityin Surface Ozone Background in the United States:Implications for Air Quality Policy,” submittedto Journal of Geophysical Research, 12 June2003.

71. Health Canada, National Ambient Air Qual-ity Objectives for Particulate Matter, ISBN 0-662-26715-X, 1999.

72. New Jersey Department of Health and SeniorServices, Center for Health Statistics: MultipleCause of Death File (1997-2001), ICD-9 codes(1997 & 1998): 0-799, ICD-10 codes (1999-2001): A00-R99, UB data courtesy NJDHSS,Health Care Systems Analysis, 14 November2003.

73. New Jersey Department of Health and SeniorServices, NJSHAD Query System, data for 1997-2000.

74. New Jersey Department of Health and SeniorServices, Center for Health Statistics, RespiratoryCause Hospital Admissions Data (ICD-9 390-459), UB data courtesy NJDHSS, Health CareSystems Analysis, 14 November 2003.

75. New Jersey Department of Health and SeniorServices, Center for Health Statistics, Cardiovas-cular Cause Hospital Admissions Data (ICD-9460-519) UB data courtesy NJDHSS, Health CareSystems Analysis, 14 November 2003.

76. Center for Health Statistics, New Jersey De-partment of Health and Senior Services, UB92data courtesy Health Care Systems Analysis,NJDHSS, 28 October 2003.

77. U.S. Environmental Protection Agency, FinalReport to Congress on Benefits and Costs of theClean Air Act, 1990 to 2010, Document # EPA410-R-99-001, 15 November 1999, D-66.

78. Assuming one-third of the cases occur duringthe 6 month ozone season; U.S. EnvironmentalProtection Agency, Final Report to Congress onBenefits and Costs of the Clean Air Act, 1990 to2010, Document # EPA 410-R-99-001, 15 No-vember 1999.

79. Division of Adult and Community Health,National Center for Chronic Disease Preventionand Health Promotion, Centers for Disease Con-trol and Prevention, Behavioral Risk Factor Sur-veillance System Online Prevalence Data, 1995-2002.

80. U.S. Environmental Protection Agency, FinalReport to Congress on Benefits and Costs of theClean Air Act, 1990 to 2010, Document # EPA410-R-99-001, 15 November 1999.

81. Weighted average of the 0-5 year old rate of0.015 and 5 – adult rate of 0.0071: US Depart-ment of Health and Human Services, TrackingHealthy People 2010, Section 24 - RespiratoryDiseases, November 2000.

82. US Department of Health and Human Ser-vices, Tracking Healthy People 2010, Section 24- Respiratory Diseases, November 2000.



85. Estimate based on school attendance figures:New Jersey Department of Education, New Jer-sey School Report Card 2002, downloaded fromnj.evalsoft.com on 3 November 2003; and H.Park et al., “Association of Air Pollution withSchool Absenteeism Due to Illness,” Archives ofPediatric and Adolescent Medicine 156: 1235-1239, 2002.


87. U.S. Census Bureau, Census 2000, data forNJ downloaded from www.census.gov on 3 No-vember 2003.

88. New Jersey Department of Health and SeniorServices, Center for Health Statistics, Hospital-izations of NJ Residents in NJ Hospitals, by Ad-mission Month and Year, 2002 (ICD-9 390-459)UB data courtesy NJDHSS, Health Care SystemsAnalysis, 18 November 2003.

89. N. Kunzli et al., Air pollution AttributableCases — Technical Report on Epidemiology;Technical Report of the Health Costs Due to RoadTraffic-Related Air Pollution — An Impact As-sessment Project of Austria, France, and Switzer-land, World Health Organization, Bern 1999.



91. N. Kunzli et al., Air pollution AttributableCases — Technical Report on Epidemiology;Technical Report of the Health Costs Due to RoadTraffic-Related Air Pollution — An Impact As-sessment Project of Austria, France, and Switzer-land, World Health Organization, Bern 1999.

92. See N. Kunzli et al. 1999; Estimate from 2studies: C. Pope et al., “Lung Cancer, Cardiopul-monary Mortality, and Long-Term Exposure toFine Particulate Air Pollution,” Journal of theAmerican Medical Association 287: 1132-1141,2002; and D. Dockery et al., “An AssociationBetween Air Pollution and Mortality in Six U.S.Cities,” New England Journal of Medicine 329:1753-1759, 1993.

93. See N. Kunzli et al. 1999; Estimate from 8U.S. and Canadian studies: George Thurston etal., “Respiratory Hospital Admissions and Sum-mertime Haze Air Pollution in Toronto, Ontario:Consideration of the Role of Acid Aerosols,”Environmental Research 65: 271-290, 1994; JoelSchwartz, “Air Pollution and Hospital Admissionsfor the Elderly in Birmingham, Alabama,” Ameri-can Journal of Epidemiology 139: 589-98, 15March 1994; Joel Schwartz, “Air Pollution andHospital Admissions for the Elderly in Detroit,Michigan,” American Journal of RespiratoryCritical Care Medicine 150: 648-55, 1994; JoelSchwartz , “PM10, Ozone, and Hospital Admis-sions for the Elderly in Minneapolis-St. Paul,Minnesota,” Archives of Environmental Health49: 366-374, 1994; Joel Schwartz, “Short-TermFluctuations in Air Pollution and Hospital Ad-missions of the Elderly for Respiratory Disease,”Thorax 50:531-538, 1995; J. Schwartz and R.Morris, “Air pollution and hospital admissionsfor cardiovascular disease in Detroit, Michigan,”American Journal of Epidemiology 142: 23-25,1995; Joel Schwartz, “Air Pollution and Hospi-tal Admissions for Respiratory Disease,” Epide-miology 7: 20-28, 1996; Joel Schwartz, “Air Pol-lution and Hospital Admissions for Cardiovas-cular Disease in Tucson,” Epidemiology 8: 371-377, 1997; R. Burnett et al., “The Role of Par-ticulate Size and Chemistry in the AssociationBetween Summertime Ambient Air Pollution andHospitalization for Cardio-respiratory Disease,”Environmental Health Perspectives 105: 614-620,1997.

94. See N. Kunzli et al., 1999; Joel Schwartz, “AirPollution and Hospital Admissions for the Eld-erly in Detroit, Michigan,” American Journal ofRespiratory Critical Care Medicine 150: 648-55,1994; Joel Schwartz, “Air Pollution and Hospi-tal Admissions for Cardiovascular Disease in Tuc-son,” Epidemiology 8: 371-377, 1997; R. Burnettet al., “The Role of Particulate Size and Chemis-try in the Association Between Summertime Am-bient Air Pollution and Hospitalization forCardio-respiratory Disease,” EnvironmentalHealth Perspectives 105: 614-620, 1997.

95. See N. Kunzli et al., 1999; Weighted averageof 3 European studies: A. Dusseldorp et al., “As-sociations of PM10 and Airborne Iron with Res-piratory Health of Adults Living Near a SteelFactory,” American Journal of Respiratory Criti-cal Care Medicine 152: 1032-1039, 1995; T.Hiltermann et al., “Asthma Severity and Suscep-tibility to Air Pollution,” European RespiratoryJournal 11: 686-693, 1996; F. Neukirch et al.,“Short-term Effects of Low-level Winter Pollu-tion on Respiratory Health of Asthmatic Adults,”Archives of Environmental Health 53: 320-328,1998.

96. See N. Kunzli et al., 1999; D. Abbey et al.,“Long-term Ambient Concentrations of TotalSuspended Particles, Ozone, and Sulfur Dioxideand Respiratory Symptoms in a NonsmokingPopulation,” Archives of Environmental Health48: 33-46, 1993.

97. B. Ostro, “Air Pollution and Morbidity Re-visited: a Specification Test,” Journal of Environ-mental Economics and Management, 14: 87-98,1987; B. Ostro and S. Rothschild, “Air Pollutionand Acute Respiratory Morbidity: an Observa-tional Study of Multiple Pollutants,” Environmen-tal Research 50: 238-47, 1989.

98. B. Ostro and S. Rothschild, “Air Pollutionand Acute Respiratory Morbidity: an Observa-tional Study of Multiple Pollutants,” Environmen-tal Research 50: 238-47, 1989. B. Ostro, “Asso-ciations Between Morbidity and Alternative Mea-sures of Particulate Matter,” Risk Analysis 10:421-427, 1990.

99. A. Krupnick, W. Harrington, and B. Ostro,“Ambient Ozone and Acute Health Effects: Evi-dence from Daily Data.” Journal of Environmen-tal Economics and Management 18: 1-18, 1990.

100. See U.S. EPA 1999: K. Ito and G. Thurston,“Daily PM10/Mortality Associations: An Inves-tigation of At-Risk Sub-Populations,” Journal ofExposure Analysis and Environmental Epidemi-ology, 6: 79-95, 1996.

101. See U.S. EPA 1999: W. McDonnell et al.,“Long-Term Ambient Ozone Concentration andthe Incidence of Asthma in Nonsmoking Adults:the AHSMOG Study,” Environmental Research80: 110-121, 1999.

102. See U.S. EPA 1999: R. Burnett et al., “Ef-fects of Particulate and Gaseous Air Pollution onCardio-Respiratory Hospitalizations,” Archivesof Environmental Health 54: 130-139, 1999.

103. See U.S. EPA 1999: D. Stieb et al., “Associa-tion Between Ozone and Asthma Emergency De-partment Visits in Saint John, New Brunswick,Canada,” Environmental Health Perspectives104: 1354-1360, 1996.

104. See U.S. EPA 1999: A. Whittemore and E.Korn, “Asthma and Air Pollution in the Los An-


geles Area,” American Journal of Public Health,70: 687-696, 1980.

105. See U.S. EPA 1999: B. Ostro and S.Rothschild, “Air Pollution and Acute RespiratoryMorbidity: an Observational Study of MultiplePollutants,” Environmental Research 50: 238-47,1989.

106. See U.S. EPA 1999: A. Krupnick, W.Harrington, and B. Ostro, “Ambient Ozone andAcute Health Effects: Evidence from Daily Data.”Journal of Environmental Economics and Man-agement 18: 1-18, 1990.


108. See U.S. EPA 1999: T. Woodruff, “The Re-lationship Between Selected Causes of Postneo-natal Infant Mortality and Particulate Air Pollu-tion in the United States,” Environmental HealthPerspectives 105: 608-612, 1997.

109. See U.S. EPA 1999: R. Burnett et al., “Ef-fects of Particulate and Gaseous Air Pollution onCardio-Respiratory Hospitalizations,” Archivesof Environmental Health 54: 130-139, 1999.

110. See N. Kunzli et al., 1999: D. Dockery etal., “Effects of Inhalable Particles on RespiratoryHealth of Children,” American Review of Respi-ratory Disease 139: 587-594, 1989; D. Dockeryet al., “Health Effects of Acid Aerosols on NorthAmerican Children: Respiratory Symptoms,”Environmental Health Perspectives 104: 500-505,1996; C. Braun-Fahrländer et al, “RespiratoryHealth and Long-term Exposure to Air Pollut-ants in Swiss Schoolchildren,” American Journalof Respiratory Critical Care Medicine 155: 1042-1049, 1997.

111. See N. Kunzli et al., 1999; Joint estimatefrom two U.S. Studies: C. Pope et al., “Respira-tory Health and PM10 Pollution - A Daily TimeSeries Analysis,” American Review of Respira-tory Disease 144: 668-674, 1991; B. Ostro et al.,“Air Pollution and Asthma Exacerbations AmongAfrican-American Children in Los Angeles, In-halation Toxicology 7: 711-722, 1995.

112. M.R. Ransom and C.A. Pope, “ElementarySchool Absences and PM10 Pollution in UtahValley,” Environmental Research 58: 204-219,1992.

113. U.S. EPA, AirData: Access to Air PollutionData, downloaded from www.epa.gov/air/data/,on 3 November 2003.

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