The recent wildfires in Canada have highlighted the impact of poor air quality for millions of people living in the US and Canada. People have been urged to reduce their exposure by remaining indoors and wearing masks outside. While not on the same scale, the recent Cannich and Daviot wildfires in Scotland and the Rhigos mountain fire in Wales are timely reminders that wildfires are an increasing feature of summers in the UK.
Despite UK’s withdrawal from the EU, the air quality laws have been retained with the EU (Withdrawal) Act 2018 (as amended) along with subsequent regulations. The Gothenburg Protocol to Abate Acidification, Eutrophication and Ground-level Ozone (Multi-effect Protocol or Gothenburg Protocol) (United Nations Economic Commission for Europe, 1999) and subsequent amendments set emission ceiling levels for various pollutants, with EU Directives reflecting these emission ceilings and ambient air quality requirements. In parallel, the WHO has been publishing guidelines, the latest of which was published in 2021 (WHO, 2021). More recently, the UK government (2023) published an air quality strategy for England, which sets out how local authorities may declare air quality management areas with accompanying air quality action plans, to address air quality exceedances. However, local authorities are expected to have an air quality strategy to ensure that there are no breaches to air quality limits. Scotland, Wales and Northern Ireland have their own set of regulations.
The latest Chief Medical Officer (CMO) for England’s annual report (2022) was published in December 2022, and traces the role of the government in tackling air quality since King Edward I in the 1280s. As the report points out, outdoor air quality is not within the control of the individual, unlike the air quality within our homes. While there have been significant improvements since the 1980s, poor air quality remains a public health issue, especially in cities and the associated urban areas.
Air quality impacts health throughout our lifespan, with age contributing to physiological susceptibility and those with pre-existing conditions being particularly at risk to its deleterious effects. It is estimated that poor air quality causes between 26 000 and 38 000 deaths a year, in addition to much avoidable chronic ill-health in England (CMO, 2022).
The evidence indicates that poor air quality is associated with asthma, cardiovascular disease, lung cancer, chronic obstructive pulmonary disease and diabetes in adults. In older people, it is associated with asthma, accelerated decline in lung function, lung cancer, diabetes, dementia and cardiovascular disease. The main outdoor air pollutants include fine particulate matter, nitrogen oxides (much of which is generated by road traffic), ammonia, sulphur dioxide and non-methane volatile organic compounds (ozone precursors) (CMO, 2022). Areas with high deprivation tend to have more heavily polluted air due to road traffic or industrial activities and yet, offer cheaper housing, resulting in increased health risk to that population.
‘Air quality impacts health throughout our lifespan, with age contributing to physiological susceptibility and those with pre-existing conditions being particularly at risk to its deleterious effects.’
The contributors to air pollution have changed over time. The high levels of sulphur dioxide due to coal burning in the 1950s and 1960s is hardly detectable. While there has been tightening of permissible road vehicle emissions, they remain sources of important air pollutants, particularly in urban areas where there are large populations. Central and local government action can impact air pollution through regulation, active travel initiatives, public transport provision and urban planning (CMO, 2022). The debates around low traffic zones (ultra low emission zones) are spreading across the country as various cities review their air pollution data and consider how best to manage the competing interests of their populations. It may surprise urban dwellers that agriculture also contributes to air pollution through the release of ammonia as well as water pollution through field run-off; regulations are increasingly directing farm management to reduce both.
Heating of homes and other buildings are sources of both indoor and outdoor pollution. Domestic coal burning is history so the government is now turning its attention towards the use of electric heating and ground source heat pumps to replace oil and gas boilers. Air pollution from wood burning varies between wood burner designs and their age, as well as the moisture in the wood burnt. In urban areas wood burning can reduce air quality locally and as a consequence, ‘Ready to Burn’ legislation was introduced as part of the Environment Act 2021 to ban wet wood and house coal (UK Legislation, 2021). As of 2023, there are stricter rules governing wood burners so that they may only emit 3 g of smoke per hour. Similar legislation has been passed in Scotland and Wales. However, domestic combustion takes place for aesthetic and practical reasons, as well as economic reasons, with the cost of energy impacting all households as people try to heat their homes at a lesser cost. This is despite its potential deleterious effect upon indoor air quality.
In developed countries, many people spend up to 90% of their lives indoors (e.g. homes, schools, offices). Allergy UK (2021) has estimated about 2000000 healthy life years are lost annually because of poor indoor air quality, in addition to increased mortality, especially as many pollutants may be 2–10 times higher in indoor air. Additionally, Allergy UK (2021) claimed in relation to both outdoor and indoor air that: ‘There is a proven link between the quality of air we breathe and the health of people living with allergic disease’. This is because pollutants in the air can trigger allergic symptoms even among those whose symptoms are generally well controlled. Thus, exacerbations of allergic rhinitis (hay fever) and asthma are often reported when poor air quality combines with seasonal environmental allergens.
Higher levels of air pollution are often found in areas of social deprivation and among the disadvantaged (National Institute for Health and Care Excellence, 2020), emphasising the imperative for governmental and local authority action to improve air quality. It is estimated that respiratory conditions cost around £9.9 billion each year and affect one in five people in England, and are the third biggest cause of death (NHS England, 2019). Hospital admissions for lung disease have risen at three times the rate of all admissions generally, and account for 850 000 emergency admissions and 4.9 million days in hospital, with a 80% increase in admissions during the winter (National Institute for Health and Care Excellence, 2020). As such, they are a major cause of the winter pressures faced annually by the NHS.
Community nurses play a crucial role is supporting those with respiratory diseases, particularly those with COPD (Queen’s Nursing Institute and International Community Nursing Observatory, 2021), with the emphasis on community-based care and hospital admission avoidance through virtual wards and remote monitoring using digital technologies (While, 2023). Eeles et al (2023) have described the success of a pilot of a telehealth service for people with COPD from both the client and healthcare staff perspective. The clients reported positive experiences based on patient-centred care planning and co-production, such that they felt wellsupported. In particular, the staff valued the flexible/hybrid working model (Eeles et al, 2023).
Global air quality, and especially that of the UK, will not be improved overnight. Populations and their governments are now determined to address the causes of poor air quality so that all forms of air pollution can be reduced and everyone can breathe high quality air.
‘There is a proven link between the quality of air we breathe and the health of people living with allergic disease.’