Poor air quality is classified as the biggest environmental risk to public health in the UK, and was described by the World Health Organisation as “a public health emergency”. The total burden of outdoor air pollution has been estimated to be the equivalent of 40,000 early deaths each year, although this figure is currently under review. We would put this figure at the second biggest cause of death after smoking avoidance.
Air pollution also has a significant impact on the environment. In 2014 more than 90% of sensitive wildlife habitats in England, Northern Ireland and Wales had excessive nitrogen levels.
Under the internationally adopted Sustainable Development Goals (3.9 and 11.6) the UK is committed to substantially reducing by 2030: a) the number of deaths and disease associated with air pollution; and b) the adverse effects of cities on air quality and the environment.13 Current and future governments will need to take concrete action on meeting these targets.
The Royal College of Physicians told us that the health damage caused by air pollution occurs over a lifetime, starting from a baby’s first weeks in the womb and right through childhood, adolescence, adulthood and old age. In terms of specific effects, we heard that: the heart, brain, hormone systems and immunity can all be harmed by air pollution. Research is pointing to effects on brain development, intelligence and growth and co-ordination. Both long-term exposure and acute air pollution episodes are associated with poor health. Long-term exposure to outdoor air pollution is associated with: • premature birth; • reduced foetal growth and low birth weight; • increased risk of death during the first year of life, particularly from respiratory diseases; • increasing the effects of respiratory infections in young children; • affecting the normal growth of lung function during childhood; • cardiovascular disease (heart attacks, high blood pressure and strokes); • chronic obstructive pulmonary disease, pneumonia, accelerated decline in lung function and lung cancer in adulthood; • development of new-onset asthma as well as exacerbation of asthma in people who already live with the condition; • impaired cognition, dementia and other neurodegenerative disorders; and • type II diabetes, obesity and metabolic syndrome.
Our evidence indicated that, while poor air quality is harmful to everyone, some people suffer more. Children and older people are particularly vulnerable, as are people with pre-existing health conditions including asthma, chronic obstructive pulmonary disease and coronary artery disease. Air pollution can also produce health inequalities. The Association of Directors of Public Health highlighted research that in England and Wales, people living in poverty were more likely to suffer from traffic-related air pollution than those in more affluent households. In 2010, 433 of the 1777 primary schools in London were in areas with average NO2 concentrations above EU limits. 82% of these were in deprived areas.
The health effects of poor air quality also have economic consequences, although estimates vary. A report by DEFRA concluded the costs arising from particulate air pollution alone amounted to £16 billion per year. The Royal College of Physicians (RCP) and the Royal College of Paediatrics and Child Health found that: The health problems caused by exposure to air pollution have high costs to people affected by illness and premature death, to our health services and to business. In the UK, these costs add up to more than £20 billion each year. The main air pollutants of current concern include such as nitrogen oxides (NOx), particulate matter (PM), and ozone (O3). Professor Holgate, special adviser to the RCP, told us that longitudinal studies have “absolutely confirmed that NO2 contributes” to adverse health effects. He said people are typically exposed to a range of pollutants and it can be difficult to determine which individual pollutant is responsible for a particular health issue.
Air pollution is a national health emergency, resulting in thousands of early deaths and costing billions of pounds in health effects each year. It is unacceptable that successive governments have failed to protect the public from toxic air. A step change in government policy is now needed to address this.
Putting health at the heart of air quality policy
Professor Holgate told us that air quality problems need to be considered in conjunction with other health issues. For example, active travel has considerable health benefits beyond improving air quality, such as increasing physical activity levels and reducing obesity. The British Lung Foundation also highlighted the link between policies to improve air quality, and other health and social benefits: Local authorities should work with national public health bodies and local public health teams to ensure policies tackle a multitude of public health goals – such as improving lung health, increasing physical activity, reducing obesity and addressing health. Deprived communities are more likely to be exposed to toxic pollution levels, yet have less access to public transport, cycle paths, walking routes and green space. Reducing air pollution and promoting active travel will help create greener, safer and healthier communities. As the British Heart Foundation pointed out, while air quality has a major impact on health, responsibility for the issue and multiple policy levers are needed to improve it. They argued that the health community has a central role to play in ensuring health outcomes are properly considered in local action and central government policies.
However we have heard that the health community has not been engaged sufficiently in the air quality debate: Maggie Throop: Do you think we are missing an opportunity here? Public health is now devolving to local government, but the focus is still on the transport side of it rather than the health side of it. If we put more emphasis on public health at local authority level, we would address the situation. Professor Holgate: I couldn’t agree with you more. Absolutely spot on. The NHS should be taking a lead here, and it isn’t. If people walk into a general practice, for example, they should see evidence of where the public can find information about air pollution, what to do about it and so on. The health community – if I can use that as a broad descriptor – have not been engaged in this discussion, and they should be for all the reasons you’ve just set out. If health people stood up and started demanding change from their local authorities, things would happen. Air pollution has a significant impact on health, but we heard that the health community has not engaged sufficiently in the air quality debate. The health sector needs to play a stronger, more visible and more vocal role in tackling air quality. This should happen at a national level, through the Department of Health and Social Care and Public Health; at a local level, through local authority directors of public health; and through NHS organisations.
Public Health Campaigns
Despite its clear impact on health, not enough has been done to clearly communicate the risks of poor air quality to the public. The British Lung Foundation said there was an urgent need for a public awareness campaign targeted at vulnerable groups to inform people of the dangers of air pollution and encourage effective behaviour changes to reduce exposure. They highlighted the fact that most face masks do not protect people effectively from pollution, and that most drivers were unaware they could be exposed to greater amounts of pollution inside a vehicle than outside it. We were surprised to learn that air pollution levels can be up to ten times higher inside a vehicle than on the road.
Professor Holgate said choosing active transport such as walking or cycling provides a tripartite benefit of improving health through increased physical activity; reducing overall pollution levels through fewer car journeys; and not being exposed to high levels of pollution inside a vehicle. Other stakeholders said avoiding engine idling was an additional simple step people could take to improve air quality, particularly outside schools, hospitals and care homes, where people are particularly vulnerable to poor air quality.
Professor Holgate highlighted the need for better information provision, and said information about air pollution and what to do about it should be more easily accessible in GP surgeries. Our written evidence called for air quality to be monitored and measured outside schools, as well as in other public areas including hospitals, parks and care homes, particularly in polluted areas. The debate on air quality is often cast as a war against motorists, when in fact regular car users are most affected. Pollution levels are often higher inside cars than on the road, meaning a switch to active transport offers dual health benefits. There is an urgent need for a national information campaign providing clear messages about the risks of air pollution and the actions people can take. This campaign should be run by Public Health England, and implemented no later than September 2018.
Better information about air quality is also needed at a local level. We recommend that air pollution levels should be monitored at key locations within local communities – for example near schools, hospitals and care homes – and the results clearly communicated to local residents and service users. This would not only serve to reinforce the value of measures such as anti-poaching campaigns, but would also provide the public with the power they need to press their elected representatives for further changes at local authority level.
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