Prevention Agenda 2013-2018: Preventing Chronic Diseases Action Plan

Focus Area 1: Outdoor Air Quality

Defining the Problem

Poor outdoor air quality leads to increases in illness and death. People with underlying respiratory disease, including asthma or cardiovascular disease, are particularly at risk due to poor air quality. One in 11 New Yorkers (1.3 million adults and 475,000 children) were estimated to have asthma in 2008; asthma-related hospitalization rates in New York are higher than national rates for all age groups. Studies in New York have found that asthma death rates and hospitalization rates are higher among low-income and minority residents than White, higher-income residents.1,2

Cardiovascular disease is the leading cause of death nationally and in New York, with almost 59,000 New Yorkers dying of related illnesses in 2008. 3 The total cost for cardiovascular disease in New York was estimated to be $32.6 billion in 2008, based on extrapolation from national data.4 Mortality rates from heart diseases have been declining nationally and in New York, but are still higher in New York than in the United States as a whole.5 Mortality and hospitalization rates due to heart diseases are highest in Black non-Hispanics among all racial and ethnic groups in New York.6

Extensive evidence shows that both ozone and fine particulate matter (particles that are less than 2.5 microns in diameter) exposures are associated with increased respiratory and cardiovascular illnesses and deaths. Some evidence also shows that ongoing long-term exposure to these pollutants is also associated with the increasing rates of asthma development.7

The United States Environmental Protection Agency (USEPA) regulates certain outdoor air pollutants under the Federal Clean Air Act. USEPA has designated six air pollutants, i.e., carbon monoxide, lead, nitrogen oxides, ozone, fine particulate matter and sulfur dioxide as criteria pollutants, and established health-based air concentration standards for them, known as the National Ambient Air Quality Standards (NAAQS). Due to the efforts of the federal government and the State agencies that control air releases through regulations and permitting, the air quality in New York has greatly improved over the last 40 years. However, with the adoption of the more stringent 2008 ozone NAAQS and the current NAAQS for fine particulate matter, 11 counties8 are currently designated as non-attainment for ozone, fine particulate matter or both pollutants.

The New York State Department of Environmental Conservation (NYSDEC) develops regulations to control releases of air pollutants and implements Federal regulations that seek to reduce ambient air pollution. NYSDEC also is charged with developing State Implementation Plans (SIP) to set out control strategies to reduce criteria air pollutant concentrations in areas exceeding the NAAQS. A SIP evaluates the current air quality status and projects through model forecasts the effect of control measures needed to reach attainment. Because the SIP is a regional plan and includes specific sources, it may not address potential local-scale impacts from sources, such as residential (i.e., outdoor wood boilers installed prior to 2011) or small commercial or institutional biomass burning boilers.9 Another example of a small source not evaluated in the SIP is fast-food char broilers.10 Additionally, the SIP addresses precursors for ozone formation, but does not evaluate specific releases of toxic air pollutants that individually may be of health concern.

Toxic air pollutants, also known as hazardous air pollutants, are those pollutants known or suspected to cause cancer or other serious health effects, such as reproductive effects, birth defects, or adverse environmental effects. Examples of toxic air pollutants include benzene, which is found in gasoline; perchloroethylene, which is emitted from some dry cleaning facilities; and methylene chloride, which is used as a solvent and paint stripper by a number of industries. Examples of other listed air toxics include dioxin, asbestos, toluene, and metals, such as cadmium, mercury, chromium, and lead compounds. People exposed to toxic air pollutants at sufficient concentrations and durations may have an increased chance of developing cancer or experiencing other serious health effects. These health effects can include damage to the immune system, as well as neurological, reproductive (e.g., reduced fertility), developmental, respiratory and other health problems. In addition to exposure from breathing air toxics, some toxic air pollutants, such as mercury can deposit onto soils or surface waters, where they are taken up by plants and ingested by animals and are eventually magnified up through the food chain. Like humans, animals may experience health problems if exposed to sufficient quantities of air toxics over time. Although the air quality concentrations in New York for many of the toxic air pollutants has significantly improved in recent decades, for some of the air toxics, the general ambient air concentration is still above levels of concern.

Human activities also have increased the amounts of carbon dioxide (CO2) and other heat-trapping gases, collectively called greenhouse gases (GHGs), in the atmosphere. Current scientific evidence suggests that a warming climate poses a serious threat to New York's environmental resources and public health. Climate change affects air quality, water quality, fisheries, drinking water supplies, wetlands, forests, wildlife and agriculture.11 The largest contributor of GHGs is combustion of fossil fuels, such as coal, oil and natural gas used to produce energy and for transportation. Industries such as petroleum and chemical manufacturing also release GHGs and other hazardous pollutants. GHGs trap heat, thereby contributing to regional climate changes which include warmer average temperatures and more frequent and longer heat waves that increase in the frequency and/or severity of extreme weather events, and increase the risk for dangerous flooding, high winds, and other direct threats to people. These climate changes will likely cause region-wide increases in a variety of health outcomes, such as heat-related illnesses and deaths, food and water-borne diseases, certain vector-borne diseases, and injuries associated with extreme weather events. Climate also has significant influence on air quality. For example, warmer temperatures are expected to accelerate chemical reactions in the atmosphere that lead to ozone and fine particle formation.

Executive Order No. 24 (2009) established the goal of reducing GHG emissions from all sources in New York State to 80 percent below levels emitted in 1990 by the year 2050. New York State is building a portfolio of programs and policies aimed at reducing GHG emissions. State programs use emission controls, technical assistance and financial incentives to ease the transition of electric power generation, buildings, transportation and industrial processes away from fossil fuel combustion and towards clean energy. The health benefits of GHG reduction policies include the following: cleaner air (less ozone formation; fewer pollutants released), the encouragement of land-use planning that reduces private car use and encourages more walking and cycling, and safer transportation through community design that accommodates alternative transportation.

Research also shows that policies intended to reduce GHG emissions will have more health benefits if accompanied by complementary policies that target emissions of harmful co-pollutants from sources. These pollutants are directly harmful to humans and directly impact the health of communities where sources (e.g., industrial facilities, transportation sources) are located.12 Coordination of efforts to reduce GHGs and other harmful air pollutants, especially in low-income and minority communities, can provide an efficient and equitable approach to realize the health benefits anticipated with reductions in both GHGs and other air pollutants.

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Goals and Objectives for Action

The Air Quality Focus Area Committee identified the following goals and objectives for action as well as sector level interventions to implement the identified goals and objectives:

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Goal #1: Reduce exposure to outdoor air pollutants with a particular focus on burdened communities.

Objective 1a:
Reduce the annual number of days with unhealthy air as measured by the Air Quality Index (AQI)>100 to 0.
(Baseline: New York City annual average days 5 for ozone and 6 for PM; Rest of State annual average days 5 for ozone and 3 for PM (2005 - 2009 DEC monitoring data compared to current NAAQS) *
Objective 1b:
Implement policies that target vulnerable groups to reduce exposure to short-term increases in pollutant levels (e.g., policies for schools, day cares, children's camps, assisted-living facilities that reduce or reschedule outdoor activities during air quality advisories).
Objective 1c:
Reduce releases of pollutants from stationary sources (e.g., large industrial facilities and small sources, such as gas stations, dry cleaners, outdoor wood boilers, fast food char-broilers) and from mobile sources (e.g., cars, trucks, and lawn, farming and construction equipment) that may contribute significantly to local air pollutant levels.
Objective 1d:
Coordinate efforts to reduce emissions of harmful co-pollutants with efforts to reduce GHG or carbon emissions.

* Objectives that are bolded are a Tracking Indicator.

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Interventions by Levels of Health Impact Pyramid

Goal #1: Reduce exposure to outdoor air pollutants with a particular focus on burdened communities.
Levels of Health Impact Pyramida Interventions b
Counseling and Education
  • Provide guidance to the public on potential health effects of criteria air pollutants and actions individuals can take to reduce exposures when levels are forecast to exceed NAAQS. Explore the use of electronic and social media, and partner with meteorologists and local health departments to raise awareness.
  • Develop a media campaign to provide information on public health effects of air pollutants and their sources.
  • Consider implementing EPA's Air Quality Flag program at schools and other community organizations.
Clinical Interventions
  • Enhance primary care utilization for management of chronic conditions such as asthma or cardiovascular disease aimed toward better prevention of acute symptoms.
Long-Lasting Protective Interventions
  • Assess and reduce emissions from categories of stationary and mobile pollutant sources that may contribute significantly to local air pollutant levels. Possible areas of focus could include residential wood boilers and residential boilers using higher sulfur heating fuels (such as #4 and #6).
  • Revise NYS building codes to reduce effects of residential biomass burning appliances.
  • Coordinate activities addressing climate change mitigation through reduction of GHG emissions with regulatory activities intended to reduce emissions of other harmful co-pollutants in communities meeting the definition of environmental justice areas.
  • Urge all agencies to consider toxic and GHG emissions in SEQRA reviews.
  • Focus emission reductions efforts at facilities and business sectors with higher harmful co-pollutant emissions.
Changing the Context to Make Individuals' Decisions Healthy
  • Develop State Implementation Plans (SIPs) that rely on and credit, in part, multiple interventions that support the transition to cleaner burning fuels and clean energy sources, including renewable power and energy efficiency, in the transportation, buildings and electricity sectors to achieve sustained reductions in air pollution levels over time.
  • Support transportation options that reduce air pollution from mobile sources (e.g., support public transportation, community planning incorporating enhanced walkability or cycling, pricing strategies, greater diversification of transportation fuels).
  • Establish policies that promote or require planning that takes into account existing concentrations ambient air pollutants and alters client activities appropriately.
  • Support installation of catalytic converters on chain-driven char-broiler exhaust ventilation in quick-serve restaurants.
  • Support efforts to reduce the use of higher sulfur heating fuels (#4 and #6).
Socioeconomic Factors
  • Incorporate information on vulnerability to climate change in identification of Environmental Justice communities for targeting climate adaptation measures.

a Frieden T. "A Framework for Public Health Action: The Health Impact Pyramid". American Journal of Public Health. 2010; 100(4): 590-595

b Interventions in boldface type have been proposed for prioritization

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Interventions by Sector

Change can be made across the sectors identified below to improve health outcomes related to air quality. Below are examples of how your sector can make a difference.

Healthcare Delivery System

  • Educate susceptible patients on risks from increased outdoor air pollutant levels and sources of information to obtain air pollution forecasts for criteria pollutants. (Objective 1a, 1b)
  • Promote access to and availability of the primary care system for the public to use to manage chronic conditions, such as asthma or CVD aimed toward better prevention of acute symptoms. (Objective 1b)

Employers, Businesses, and Unions

  • Conform to requirements of Federal and State regulations submitted as a component of New York State Implementation Plans that control emissions and reduce releases of air pollutants. (Objective 1c)
  • Provide policies and guidance on outdoor work practices to reduce exposures to air pollutants . (Objective 1b)
  • Support decisions/policies to reduce/control emissions of GHGs as well as harmful co-pollutants, especially in environmental justice communities. (Objective 1d)
  • Incentivize the use of public transportation through tax deductible flexible spending accounts, union rates, etc. (Objective 1b, 1d)


  • Convey general awareness messaging regarding health concerns and actions to reduce exposure and reduce contributions to pollutant emissions (e.g., commuting-related). (Objective 1b)
  • Provide an outlet for daily air quality advisory messages; also heat advisory messaging and pollen levels. An evidence-based media campaign (e.g., similar to those developed for the tobacco control program) could inform public regarding health effects of exposure to air pollutants (e.g., local PM sources). (Objective 1b)
  • Dedicate space and time to local activities focused on efforts to reduce air toxic releases in their area (e.g., to encourage carpooling/use of public transportation). (Objective 1a, 1b, 1c)


  • Engage communities to gather information and develop policies to address toxic air emissions. (Objectives 1b, 1d)
  • Help communities translate basic research results into development of policies that will maximize the health benefits of reducing both GHG and co-pollutants. (Objectives 1b, 1d)

Other Governmental Agencies

  • Continue the State's air quality monitoring network. Identify policies that help reduce local sources of criteria pollutants. (DEC, Objective 1a)
  • Support transportation-related elements of State Implementation Plans (e.g., provide traffic activity data). (DOT, Objectives 1a-1d)
  • Implement actions that promote exposure-avoidance behaviors in susceptible populations. (SED, OCFS, Off. of Aging) (Objectives 1a-1d)
  • Enhance requirements for residential biomass appliances such as outdoor wood boilers via Statewide building code development. (DOS, Objectives 1b-1d)
  • Work to integrate efforts to reduce GHG with efforts to reduce other harmful air pollutants especially in Environmental Justice areas. (DEC, Objective 1d)
  • Consider identifying high-priority zones for GHG emission reduction strategies where the public health co-benefits of reducing other harmful air pollutants are expected to be especially large. (DEC, Objective 1d)

Governmental (G) and Non-Governmental (NG) Public Health

  • Provide technical guidance on appropriate interventions and basis for enhanced enforcement authority. (G, Objectives 1a-1d)
  • Increase enforcement authority of LHDs relative to residential biomass burning (e.g., outdoor wood boilers and other) appliances. (G, Objective 1c)
  • Develop aggregate measures of harmful co-pollutant health impacts at the community level. (G, Objective 1d)
  • Work with local communities to integrate community interests into planning decisions. (G, NG Objectives 1a-d)
  • Provide guidance and promote healthy behaviors to providers and patients. (NG, G Objectives 1b)

Policymakers and Elected Officials

  • Support congestion pricing through use of mechanisms such as high occupancy vehicle lanes (HOVs) and toll pricing. (Objectives 1a, b, d)
  • Incentivize use of public transportation. (Objectives 1a, b, d)
  • Support emission reductions at smaller commercial sources that impact the local environment (e.g., outdoor wood boilers, fast food establishments and others as needed). (Objectives 1a-c)
  • Consider co-benefits of reducing emissions of other harmful air pollutants when evaluating GHG reduction strategies. (Objective d)
  • Seek opportunities to incorporate requirements for reductions in sector and/or location-specific GHG and air toxic reductions when proposing legislation. (Objectives 1a-d)


  • Support community land-use planning such as smart growth initiatives that can contribute to long-term reductions in pollutant levels from mobile sources (e.g., building bike trails, collocating residential, recreational and commercial structures, etc.). (Objectives 1a-d)
  • Implement actions that promote exposure-avoidance behaviors in susceptible populations as policies or enhanced guidance (e.g., avoid using gas-powered equipment in the summertime at child-care, elder care settings). (Objective 1b)
  • Consider local zoning and building-code enforcement that could contribute to reduce impact of local fine particulate matter sources such as wood-burning and other biomass appliances. (Objective 1c)
  • Discuss concerns about local sources of air pollution during local planning and other civic activities. (Objective 1d)


  • Develop and fund programs to help simultaneously maximize reductions in harmful co-pollutants and GHG in the most vulnerable communities. (Objective 1d)
  • Fund programs, particularly in underserved/Environmental Justice communities, that educate and empower communities to work with local and State government agencies to help identify and prioritize local sources of air toxics in their communities. (Objective 1b, 1c, 1d)

Note: The Prevention Agenda 2013-2017 has been extended to 2018 to align its timeline with other state and federal health care reform initiatives.

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