Introduction: Exposure to ambient air pollution can worsen cardiovascular disease and increase the risk of stroke, myocardial infarction, and cardiovascular disease mortality. Strategies to reduce air pollution exposure can therefore help prevent cardiovascular morbidity and mortality. This study was conducted to assess the awareness among U.S. adults of the effect of air pollution on cardiovascular health and actions individuals can take to reduce their air pollution exposure. Methods: In May–July 2022, 4,156 adults responded to the summer wave of the 2022 ConsumerStyles survey and self-reported their heart disease status and perceptions, awareness, and behaviors about ambient air pollution and health. In 2023, the data were analyzed to generate weighted population estimates representative of noninstitutionalized U.S. adults. Associations between heart disease and responses about perceptions, awareness, and behaviors were estimated using binomial and multinomial regression methods for weighted data. Results: Overall, 90% of the weighted population estimate of U.S. adults reported that air pollution can impact a person's health, and 44% reported that air pollution can cause or worsen heart disease. Percentages of adults reporting that air pollution can impact a person's health (prevalence ratio=1.09; 95% CI=1.06, 1.12) and that air pollution can cause or worsen heart disease (prevalence ratio=1.28; 95% CI=1.08, 1.51) were higher among adults with than without heart disease. Conclusions: Less than half of U.S. adults are aware that air pollution affects heart disease. Improvements in awareness of the effect of air pollution on cardiovascular health and strategies to reduce exposure could help protect individuals with heart disease. © 2024

BACKGROUND: The health impacts of the rapid transition to the use of electric vehicles are largely unexplored. We completed a scoping review to assess the state of the evidence on use of battery electric and hybrid electric vehicles and health. METHODS: We conducted a literature search of MEDLINE, Embase, Global Health, CINAHL, Scopus, and Environmental Science Collection databases for articles published January 1990 to January 2024. We included articles if they presented observed or modeled data on the association between battery electric or hybrid electric cars, trucks, or buses and health-related outcomes. We abstracted data and summarized results. RESULTS: Out of 897 reviewed articles, 52 met our inclusion criteria. The majority of included articles examined transitions to the use of electric vehicles (n = 49, 94%), with fewer studies examining hybrid electric vehicles (n = 11, 21%) or plug-in hybrid electric vehicles (n = 8, 15%). The most common outcomes examined were premature death (n = 41, 79%) and monetized health outcomes such as medical expenditures (n = 33, 63%). We identified only one observational study on the impact of electric vehicles on health; all other studies reported modeled data. Almost every study (n = 51, 98%) reported some evidence of a positive health impact of transitioning to electric or hybrid electric vehicles, although magnitudes of association varied. There was a paucity of information on the environmental justice implications of vehicle transitions. CONCLUSIONS: The results of the current literature on electric vehicles and health suggest an overall positive health impact of transitioning to electric vehicles. Additional observational studies would help expand our understanding of the real-world health effects of electric vehicles. Future research focused on the environmental justice implications of vehicle fleet transitions could provide additional information about the extent to which the health benefits occur equitably across populations.

OBJECTIVES: Asthma disproportionately affects Black people and people with low incomes, but Medicaid expansion (hereinafter, expansion) data on these populations are limited. We investigated health care use among adults with asthma, before and after expansion, and examined whether asthma-related health care use after expansion varied by demographic characteristics. METHODS: We analyzed data from the 2011-2013 and 2015-2019 Behavioral Risk Factor Surveillance System Adult Asthma Call-Back Survey on participants aged 18-64 years with current asthma and low incomes in 23 US states. We assessed 5 asthma-related outcomes, including medical visits (routine and emergency) and medication use, for expansion and nonexpansion groups. We used t tests to compare weighted percentages and 95% CIs, then performed adjusted difference-in-differences analyses. Secondary analyses stratified data by race, ethnicity, and sex. RESULTS: Primary analyses (N = 10 796) found no significant associations between expansion and any outcome. Analyses stratified by race and ethnicity found no significant changes (eg, asthma controller medication use among non-Hispanic Black participants in the expansion group was 24.1% [95% CI, 14.4%-37.5%] in 2011-2013 and 35.5% [95% CI, 27.0%-45.1%] in 2015-2019; P = .13). Use of asthma controller medication increased significantly among non-Hispanic Other participants in the nonexpansion group (2011-2013: 16.0% [95% CI, 9.5%-25.5%]; 2015-2019: 40.2% [95% CI, 25.5%-56.8%]; P = .01). Asthma-related hospitalizations decreased significantly among women in the expansion group: 2011-2013 (7.8%; 95% CI, 5.3%-11.3%) and 2015-2019 (3.5%; 95% CI, 2.5%-4.9%) (P = .009). CONCLUSIONS: Investigating factors other than health insurance (eg, social determinants of health) that influence the use of asthma-related health care could advance knowledge of potential strategies to advance health equity for adults with asthma and lower incomes.

BACKGROUND: Little is known about the role of air quality in fatal asthma exacerbations among children. METHODS: We collected information about 80 deaths that occurred in North Carolina from 2001 through 2016, among children aged 5-17 years, with asthma identified as the primary cause of death. We linked information about each death with county-level estimates of particulate matter ≤2.5 µm (PM2.5) and ozone (O3). Using the linked data, we conducted a case-crossover analysis of associations between PM2.5 and O3 lagged by 3-5 days with the odds of fatal asthma exacerbations. RESULTS: In the highest tertile of PM2.5 lag(3-5), the odds of a fatal exacerbation of asthma were more than twice the odds in the lowest tertile (odds ratio = 2.2; 95% confidence interval = 1.1, 4.6). CONCLUSION: These findings from North Carolina provide evidence to support the hypothesis that ambient air pollution increases the risk of fatal exacerbations of asthma among children.

During April 30-August 4, 2023, smoke originating from wildfires in Canada affected most of the contiguous United States. CDC used National Syndromic Surveillance Program data to assess numbers and percentages of asthma-associated emergency department (ED) visits on days with wildfire smoke, compared with days without wildfire smoke. Wildfire smoke days were defined as days when concentrations of particulate matter (particles generally ≤2.5 μm in aerodynamic diameter) (PM(2.5)) triggered an Air Quality Index ≥101, corresponding to the air quality categorization, "Unhealthy for Sensitive Groups." Changes in asthma-associated ED visits were assessed across U.S. Department of Health and Human Services regions and by age. Overall, asthma-associated ED visits were 17% higher than expected during the 19 days with wildfire smoke that occurred during the study period; larger increases were observed in regions that experienced higher numbers of continuous wildfire smoke days and among persons aged 5-17 and 18-64 years. These results can help guide emergency response planning and public health communication strategies, especially in U.S. regions where wildfire smoke exposure was previously uncommon.

PURPOSE OF REVIEW: This review discusses climate change-related impacts on asthma and allergic-immunologic disease, relevant US public health efforts, and healthcare professional resources. RECENT FINDINGS: Climate change can impact people with asthma and allergic-immunologic disease through various pathways, including increased exposure to asthma triggers (e.g., aeroallergens, ground-level ozone). Climate change-related disasters (e.g., wildfires, floods) disrupting healthcare access can complicate management of any allergic-immunologic disease. Climate change disproportionately affects some communities, which can exacerbate disparities in climate-sensitive diseases like asthma. Public health efforts include implementing a national strategic framework to help communities track, prevent, and respond to climate change-related health threats. Healthcare professionals can use resources or tools to help patients with asthma and allergic-immunologic disease prevent climate change-related health impacts. Climate change can affect people with asthma and allergic-immunologic disease and exacerbate health disparities. Resources and tools are available to help prevent climate change-related health impacts at the community and individual level.

Objectives. To describe demographic and social characteristics of US communities exposed to wildfire smoke. Methods. Using satellite-collected data on wildfire smoke with the locations of population centers in the coterminous United States, we identified communities potentially exposed to light-, medium-, and heavy-density smoke plumes for each day from 2011 to 2021. We linked days of exposure to smoke in each category of smoke plume density with 2010 US Census data and community characteristics from the Centers for Disease Control and Prevention's Social Vulnerability Index to describe the co-occurrence of smoke exposure and social disadvantage. Results. During the 2011-to-2021 study period, increases in the number of days of heavy smoke were observed in communities representing 87.3% of the US population, with notably large increases in communities characterized by racial or ethnic minority status, limited English proficiency, lower educational attainment, and crowded housing conditions. Conclusions. From 2011 to 2021, wildfire smoke exposures in the United States increased. As smoke exposure becomes more frequent and intense, interventions that address communities with social disadvantages might maximize their public health impact. (Am J Public Health. 2023;113(7):759-767. https://doi.org/10.2105/AJPH.2023.307286).

BACKGROUND: Prescribed agricultural burning is a common land management practice, but little is known about the health effects from the resulting smoke exposure. OBJECTIVE: To examine the association between smoke from prescribed burning and cardiorespiratory outcomes in the U.S. state of Kansas. METHODS: We analyzed a zip code-level, daily time series of primary cardiorespiratory emergency department (ED) visits for February-May (months when prescribed burning is common in Kansas) in the years 2009-2011 (n = 109,220). Given limited monitoring data, we formulated a measure of smoke exposure using non-traditional datasets, including fire radiative power and locational attributes from remote sensing data sources. We then assigned a population-weighted potential smoke impact factor (PSIF) to each zip code, based on fire intensity, smoke transport, and fire proximity. We used Poisson generalized linear models to estimate the association between PSIF on the same day and in the past 3 days and asthma, respiratory including asthma, and cardiovascular ED visits. RESULTS: During the study period, prescribed burning took place on approximately 8 million acres in Kansas. Same-day PSIF was associated with a 7% increase in the rate of asthma ED visits when adjusting for month, year, zip code, meteorology, day of week, holidays, and correlation within zip codes (rate ratio [RR]: 1.07; 95% confidence interval [CI]: 1.01, 1.13). Same-day PSIF was not associated with a combined outcome of respiratory ED visits (RR [95% CI]: 0.99 [0.97, 1.02]), or cardiovascular ED visits (RR [95% CI]: 1.01 [0.98, 1.04]). There was no consistent association between PSIF during the past 3 days and any of the outcomes. SIGNIFICANCE: These results suggest an association between smoke exposure and asthma ED visits on the same day. Elucidating these associations will help guide public health programs that address population-level exposure to smoke from prescribed burning.

OBJECTIVE: A better understanding of the impacts of the Coronavirus disease 2019 (COVID-19) pandemic on emergency department (ED) visits for asthma is needed to improve asthma control. METHODS: Using data from the National Syndromic Surveillance Program (NSSP), we assessed changes in average weekly asthma ED visits in the United States in 3 surveillance periods: (1) March 15, 2020-January 2, 2021; (2) January 3, 2021-January 1, 2022; and (3) January 2-March 5, 2022, relative to pre-pandemic comparison periods between December 30, 2018 and December 28, 2019. For each surveillance period, we assessed changes in asthma ED visits by age group and sex. RESULTS: For the surveillance period beginning March 15, 2020, average weekly asthma ED visits declined 31% relative to what was observed during the comparison period - that is, from 45,276 visits/week in 2019 to 31,374 visits/week in 2020. Declines of over 19% and 26% were observed for 2021 and 2022, respectively, relative to the comparison periods. In all surveillance periods, the largest declines occurred among children, especially those ages 0-4 (74%) and 5-11 (66%) years. CONCLUSIONS: The COVID-19 pandemic impacted asthma ED visits in the United States. The impact was greater among children than adults, as ED visits among children were notably lower during all three pandemic surveillance periods than during the corresponding pre-pandemic periods. Additional information about the roles of behaviors of patients with asthma and changes in asthma care might improve our understanding of the reasons underlying these observed changes.

Background: Wildfires are increasing in magnitude, frequency, and severity. Populations in the wildland-urban interface and in downwind communities are at increased risk of exposure to elevated concentrations of fine particulate matter (PM2.5) and other harmful components of wildfire smoke. We conducted this analysis to evaluate the use of modeled predictions of wildfire smoke to create county-level measures of smoke exposure for public health research and surveillance. Methods: We evaluated four years (20152018) of grid-based North American Mesoscale (NAM)-derived PM2.5 forecasts from the U.S. Forest Service BlueSky modeling framework with monitoring data from the Environmental Protection Agency Air Quality System (AQS), the Interagency Monitoring of Protected Visual Environments (IMPROVE), the Western Regional Climate Center (WRCC), and the Interagency Real Time Smoke Monitoring (AIRSIS) programs. To assess relationships between model-derived estimates and monitor-based observations, we assessed Spearman's correlations by spatial (i.e., county, level of urbanization, states in the western United States impacted by major wildfires, and climate regions) and temporal (i.e., month and wildfire activity periods) characteristics. We then generated county-level smoke estimates and examined spatial and temporal patterns in total and person-days of smoke exposure. Results: Across all counties in the coterminous United States and for all days, the correlation between county-level model- and monitor-derived PM2.5 estimates was 0.14 (p < 0.001). Correlations were stronger using data from temporary monitors and for areas and days impacted by high wildfire smoke, especially in the western United States. Correlations between county-level model- and monitor-derived estimates in non-metropolitan counties, and at higher concentrations ranged from 0.25 to 0.54 (p < 0.001). Conclusions: In general, public health practitioners and health researchers need to consider the pros and cons associated with modeled data products for conducting health analyses. Our results support the use of model-derived smoke estimates to identify communities impacted by heavy smoke events, especially during emergency response and for communities located near wildfire episodes. 2022

The physical and mental health impacts of wildfires are wide-ranging. We assessed associations between exposure to wildfire smoke and self-reported symptoms affecting mental health among adults living in Oregon. We linked by interview date and county of residence survey responses from 5807 adults who responded to the 2018 Behavioral Risk Factor Surveillance System's depression and anxiety module with smoke plume density, a proxy for wildfires and wildfire smoke exposure. Associations between weeks in the past year with medium and heavy smoke plume densities and symptoms affecting mental health during the two weeks before the interview date were estimated using predicted marginal probabilities from logistic regression models. In the year before completing the interview, 100% of respondents experienced ≥2 weeks of medium or heavy smoke, with an average exposure duration of 32 days. Nearly 10% reported being unable to stop or control their worrying more than half the time over the past two weeks. Medium or heavy smoke for 6 or more weeks in the past year, compared to ≤4 weeks in the past year, was associated with a 30% higher prevalence of being unable to stop or control worrying more than half the time during the past two weeks (prevalence ratio: 1.30, 95% confidence interval: 1.03, 1.65). Among adults in Oregon, selected symptoms affecting mental health were associated with extended durations of medium and heavy smoke. These findings highlight the burden of such symptoms among adults living in communities affected by wildfires and wildfire smoke.

Exposure to air pollution is associated with respiratory and cardiovascular effects, particularly among people with underlying respiratory and heart disease. It is therefore important for individuals with respiratory and heart disease to be aware of air quality. However, information about the most effective communication channels for disseminating air quality alerts is limited. We assessed communication channels used for receiving air quality alerts among U.S. adults using data from the summer 2020 wave of ConsumerStyles, a nationally representative survey of U.S. adults (n = 4053). We calculated weighted percentages of respondents who received air quality alerts from six communication channels and stratified by demographic and health characteristics. We calculated weighted prevalence ratios (PRs) adjusted for sex, age, race/ethnicity, and education to assess if communication channel use varied by presence of respiratory or heart disease. Sixty-four percent of U.S. adults had heard or read about air quality alerts. Television was the most commonly reported communication channel for receiving alerts (57.5%), followed by app on mobile phone or device (30.2%) and internet or social media (26.4%). Communication channels differed most prominently by age. The proportion of adults receiving alerts from specific communication channels did not notably vary by presence of heart disease. Adults with respiratory disease more often reported receiving alerts from their doctor's office than adults without respiratory disease (PR: 3.10, 95% confidence interval: 1.49, 6.45). These findings can be used by public health officials to increase awareness of poor air quality days and improve the reach of alerts to target populations. 2021

INTRODUCTION: Among U.S. adolescents, the knowledge that air pollution can impact health is relatively high and varies by the demographics of the respondents and the places they live, but the influence of asthma status is unknown. This study assesses the role of asthma in U.S. adolescents' awareness, perceptions, and behaviors related to air pollution. METHODS: In 2020, data were analyzed from 817 adolescents aged 12-17 years who responded to the 2020 Porter Novelli Public Services YouthStyles survey, a nationally representative survey of U.S. adolescents. Respondents self-reported having or having had asthma in the past year and their awareness, perceptions, and behaviors related to air pollution. For each aspect of air quality awareness, perception, and behavior, weighted percentages of responses were calculated by asthma status. RESULTS: Overall, an estimated 11.5% of U.S. adolescents self-reported asthma. Awareness that air pollution can impact health, awareness that respondents can limit their air pollution exposure, and having heard or read about air quality alerts were similar among adolescents with and without asthma, with some differences reported in where they heard or read about air quality alerts. Those with asthma reported discussing with a health professional about ways to limit exposure more frequently than those without asthma. CONCLUSIONS: Despite the well-known risk of asthma exacerbations from air pollution exposure, air quality awareness was similar among adolescents with and without asthma. These findings reveal the areas in which air quality awareness and behaviors to reduce exposure can be improved among adolescents with and without asthma.

PURPOSE: This study aimed to assess U.S. adolescents' perceptions and knowledge about air quality and their behaviors aimed to reduce air pollution exposure and whether they vary by demographic characteristics. METHODS: We analyzed data from the Porter Novelli Public Services YouthStyles survey, a nationally representative survey of U.S. adolescents aged 12-17 years. In survey years 2015-2018, a total of 3,547 adolescents self-reported awareness, perceptions, and behaviors related to air pollution. We calculated weighted percentages of respondents reporting each aspect of air quality awareness, perception, and behaviors overall and by categories of age, gender, parental education, metropolitan status, region, and survey year. RESULTS: Overall, an estimated 81% of U.S. adolescents thought outdoor air pollution could impact health, 52% thought there were things they could do to limit their or their family's exposure, 19% were aware of air quality alerts, 46% of those who thought or were informed air quality was bad did something differently, and 19% always or usually avoided busy roads to reduce air pollution exposure; differences were reported by some demographic variables. CONCLUSIONS: Among U.S. adolescents, awareness that air pollution could impact health was relatively high. However, gaps were found in the awareness of the potential impacts and other aspects of awareness and perceptions related to air pollution and the engagement in behaviors to reduce exposure, some of which varied by demographic characteristics. These results can be used to inform interventions that increase awareness and behaviors to reduce air pollution exposures among U.S. adolescents.

Objective: To examine Medicaid expansion (ME) effects on health insurance coverage (HIC) and cost barriers to medical care among people with asthma.Method: We analyzed 2012-2013 and 2015-2016 data from low-income adults with current asthma aged 18-64 years in the Behavioral Risk Factor Surveillance System Asthma Call-Back Survey (state-level telephone survey). We calculated weighted percentages and 95% confidence intervals from ME and non-ME jurisdictions (according to 2014 ME status). Outcomes were HIC and cost barriers to buying asthma medication (MED), seeing a health care provider for asthma (HCP), or any asthma care (AAC). Using SUDAAN, we performed survey-weighted difference-in-differences analyses, adjusting for demographics. Subgroup analyses were stratified by demographics.Results: Our study population included 6445 participants from 25 states plus Puerto Rico. In 2015-2016 compared to 2012-2013, HIC was more common in ME jurisdictions (P < 0.001) but unchanged in non-ME jurisdictions. Adjusted difference-in-differences analyses showed ME was associated with a statistically significant 13.36 percentage-point increase in HIC (standard error =0.053). Cost barriers to MED, HCP, and AAC did not change significantly for either group in descriptive and difference-in-differences analyses. In subgroup analyses, we noted variation in outcomes by demographics and 2014 ME status.Conclusions: We found ME significantly affected HIC among low-income adults with asthma, but not cost barriers to asthma-related health care. Strategies to reduce cost barriers to asthma care could further improve health care access among low-income adults with asthma in ME jurisdictions.

Objective: To examine the association between daycare attendance and asthma control among children aged 0 to 4 years with asthmaMethods: We analyzed 2012-2014 data from the Behavioral Risk Factor Surveillance System Asthma Call-back Survey on 388 children with asthma aged 0 to 4 years with information on daycare attendance in the past 12 months. We calculated weighted prevalence ratios to assess the association between daycare attendance and asthma control (categorized based on day-time and night-time asthma symptoms, activity limitation, and short-acting beta agonist use). Adjusted models controlled for parent or guardian education, household income, race, sex, cost barriers to asthma care, long-term control medication use, and the number of other children in the child's household.Results: In this sample of children with asthma, representative of 520,400 children in 26 U.S. states, 34% attended daycare in the past 12 months. Only 32% of children who attended daycare in the past 12 months reported having an asthma action plan on file at the daycare they most recently attended. Presence of the asthma triggers of pets, mold, and smoking in a child's daycare were reported to be uncommon. Prevalence of uncontrolled asthma was 44% in children who attended daycare in the past 12 months and 68% in children who did not. The adjusted prevalence ratio between daycare attendance and uncontrolled asthma was 0.96 (95% confidence interval 0.73, 1.25).Conclusions: When adjusting for covariates, we observed no evidence of an association between daycare attendance in early life and uncontrolled asthma.

U.S. children are exposed to lead through lead-based paint, lead-contaminated dust in older homes and through contaminated water, air, soil, or consumer and imported products(1,2) . Approximately 24 million housing units have one or more lead-based paint hazards, including 3.6 million homes with children aged </=6 years(1) . Epidemiologic studies have reported positive associations between lead and elevated immunoglobulin E (IgE) in children(3-5) ; IgE is often associated with allergic asthma(6) .

BACKGROUND: Information about local air quality is reported across the United States using air quality alerts such as the Environmental Protection Agency's Air Quality Index. However, the role of such alerts in raising awareness of air quality is unknown. We conducted this study to evaluate associations between days with Air Quality Index >/=101, corresponding to a categorization of air quality as unhealthy for sensitive groups, unhealthy, very unhealthy, or hazardous, and air quality awareness among adults in the United States. METHODS: Data from 12,396 respondents to the 2016-2018 ConsumerStyles surveys were linked by geographic location and survey year to daily Air Quality Index data. We evaluated associations between the number of days in the past year with Air Quality Index >/=101 and responses to survey questions about awareness of air quality alerts, perception of air quality, and changes in behavior to reduce air pollution exposure using logistic regression. RESULTS: Awareness of air quality alerts (prevalence ratio [PR] = 1.23; 95% confidence interval [CI] = 1.15, 1.31), thinking/being informed air quality was bad (PR = 2.02; 95% CI = 1.81, 2.24), and changing behavior (PR = 2.27; 95% CI = 1.94, 2.67) were higher among respondents living in counties with >/=15 days with Air Quality Index >/=101 than those in counties with zero days in the past year with Air Quality Index >/=101. Each aspect of air quality awareness was higher among adults with than without asthma, but no differences were observed by heart disease status. Across quintiles of the number of days with Air Quality Index >/=101, air quality awareness increased among those with and without selected respiratory and cardiovascular diseases. CONCLUSIONS: Among U.S. adults, air quality awareness increases with increasing days with alerts of unhealthy air. These findings improve our understanding of the extent to which air quality alerts prompt people to take actions to protect their health amidst poor air quality.

Objective: Asthma carries a high burden of disease for residents of Puerto Rico. We conducted this study to better understand asthma-related healthcare use and to examine potential asthma triggers. Methods: We characterized asthma-related healthcare use in 2013 by demographics, region, and date using outpatient, hospital, and emergency department (ED) insurance claims with a primary diagnostic ICD-9-CM code of 493.XX. We examined environmental asthma triggers, including outdoor allergens (i.e., mold and pollen), particulate pollution, and influenza-like illness. Analyses included descriptive statistics and Poisson time-series regression. Results: During 2013, there were 550,655 medical asthma claims reported to the Puerto Rico Healthcare Utilization database, representing 148 asthma claims/1,000 persons; 71% of asthma claims were outpatient visits, 19% were hospitalizations, and 10% were ED visits. Females (63%), children aged </=9 years (77% among children), and adults aged >/=45 years (80% among adults) had the majority of asthma claims. Among health regions, Caguas had the highest asthma claim-rate at 142/1,000 persons (overall health region claim-rate = 108). Environmental exposures varied across the year and demonstrated seasonal patterns. Metro health region regression models showed positive associations between increases in mold and particulate matter <10 microns in diameter (PM10) and outpatient asthma claims. Conclusions: This study provides information about patterns of asthma-related healthcare use across Puerto Rico. Increases in mold and PM10 were associated with increases in asthma claims. Targeting educational interventions on exposure awareness and reduction techniques, especially to persons with higher asthma-related healthcare use, can support asthma control activities in public health and clinical settings.

Short-term exposure to air pollution can result in acute health effects, particularly for individuals with respiratory and cardiovascular disease. Air quality alert programs that notify the public about high air pollution days are critical for susceptible populations. We assessed how U.S. adults receive air quality alerts and whether it varies by demographic or health characteristics. We analyzed data from the summer 2014 wave of ConsumerStyles, a nationally representative survey of U.S. adults (n = 4269). We calculated the weighted proportion of individuals who received air quality alerts from seven communication channels, combining all individuals and stratifying by demographics. To assess whether the reach of communication channels varied by respiratory and cardiovascular disease status, we computed weighted prevalence ratios adjusted for sex, age, race, and education. Forty-eight percent of U.S. adults had heard about air quality alerts. Within every demographic category, television was the most common communication channel (76% among individuals aware of air quality alerts). Other common communication modes were radio (30%), newspaper (24%), and internet (20%). Less common communication modes were friend or family member, mobile phone or device app, and electronic highway sign. The reach of communication channels varied by demographic factors, such as age, but not by respiratory or cardiovascular disease status. Television is the most common communication channel for receiving air quality alerts. Expanding use of other communication channels might increase awareness of air quality alerts. These results can help decision-makers target communication channels that reach susceptible populations and will achieve the greatest impact.

To the Editor: | | Effective as of September 23, 2010, a national policy change allowed young adults less than age 26 years to remain on their parents’ private health insurance plans with dependent coverage (“dependent coverage extension” [DCE]).1 Subsequently, private health insurance coverage among young adults aged 19 to 25 years increased.1 Research has begun to examine the impact of DCE on health care use among this population1–3; asthma-related effects of DCE remain unknown. We investigated access to care among young adults with current asthma aged 19–25 years before and after DCE implementation, using data from a nationally representative survey. | | We analyzed Behavioral Risk Factor Surveillance System (BRFSS) data from 2006–2009 and 2011–2016 (before and after DCE implementation, respectively); BRFSS is a state-based, random-digit-dialed, cross-sectional telephone survey of non-institutionalized U.S. adults. We treated the year 2010 as a phase-in period by excluding 2010 data, similar to prior literature.2,4

INTRODUCTION: Exposure to air pollution negatively affects respiratory and cardiovascular health. The objective of this study was to describe the extent to which health professionals report talking about how to limit exposure to air pollution during periods of poor air quality with their at-risk patients. METHODS: In 2015, a total of 1,751 health professionals completed an online survey and reported whether they talk with their patients about limiting their exposure to air pollution. In 2017, these data were analyzed to assess the frequency that health professionals in primary care, pediatrics, obstetrics/gynecology, and nursing reported talking about limiting air pollution exposure with patients who have respiratory or cardiovascular diseases, were aged </=18 years, were aged >/=65 years, or were pregnant women. Frequencies of positive responses were assessed across categories of provider- and practice-level characteristics. RESULTS: Overall, 714 (41%) respondents reported ever talking with their patients about limiting their exposure to air pollution. Thirty-four percent and 16% of providers specifically reported talking with their patients with respiratory or cardiovascular disease diagnoses, respectively. Percentages of health professionals who reported talking with their patients about limiting air pollution exposure were highest among respondents in pediatrics (56%) and lowest among respondents in obstetrics/gynecology (0%). CONCLUSIONS: Despite the well-described health effects of exposure to air pollution, the majority of respondents did not report talking with their patients about limiting their exposure to air pollution. These findings reveal clear opportunities to improve awareness about strategies to limit air pollution exposure among sensitive groups of patients and their health care providers.

INTRODUCTION: Poor air quality affects respiratory and cardiovascular health. Information about health risks associated with outdoor air quality is communicated to the public using air quality alerts. This study was conducted to assess associations of existing respiratory and heart disease with three aspects of air quality awareness: awareness of air quality alerts, discussing with a health professional strategies to reduce air pollution exposure, and avoiding busy roads to reduce air pollution exposure when walking, biking, or exercising outdoors. METHODS: During 2014-2016, a total of 12,599 U.S. adults participated in summer waves of the ConsumerStyles surveys and self-reported asthma, emphysema/chronic obstructive pulmonary disease, heart disease, and each aspect of air quality awareness. In 2017, associations between each health condition and air quality awareness were estimated using log binomial and multinomial regression. RESULTS: Overall, 49% of respondents were aware of air quality alerts, 3% discussed with a health professional strategies to reduce air pollution exposure, and 27% always/usually avoided busy roads to reduce air pollution exposure. Asthma was associated with increased prevalence of awareness of air quality alerts (prevalence ratio=1.11, 95% CI=1.04, 1.20), discussing with a health professional (prevalence ratio=4.88, 95% CI=3.74, 6.37), and always/usually avoiding busy roads to reduce air pollution exposure (prevalence ratio=1.13, 95% CI=1.01, 1.27). Heart disease was not associated with air quality awareness. CONCLUSIONS: Existing respiratory disease, but not heart disease, was associated with increased air quality awareness. These findings reveal important opportunities to raise awareness of air quality alerts and behavior changes aimed at reducing air pollution exposure among adults at risk of exacerbating respiratory and heart diseases.

BACKGROUND: Asthma morbidity is increased among older adults, especially older adult women. Interventions to improve asthma control in this population are not well described. OBJECTIVE: The objective of this study was to identify risk factors (including modifiable factors) associated with asthma-related hospitalizations and emergency department or urgent care center visits (ED/UCV) among older adults. A secondary objective was to investigate sex differences in variables relevant to asthma control. METHODS: Data were obtained from 14,076 older adults ≥65 years with active asthma participating in the 2006-2010 Behavioral Risk Factor Surveillance System Asthma Call-back Survey (a random-digit dialed survey) in 40 US states, the District of Columbia, and Puerto Rico, representative of >2.6 million persons. Weighted, adjusted logistic regression was conducted. RESULTS: One or more asthma-related hospitalizations in the past year were reported by 5.7% (95% confidence interval [95% CI] = 5.0% to 6.4%) of participants; 10.6% (95% CI = 9.7% to 11.5%) reported ≥1 asthma-related ED/UCV. Compared with older adults without asthma-related hospitalizations, adjusted odds were higher among those with ≥1 asthma-related hospitalization for chronic obstructive pulmonary disease (COPD), coronary artery disease, depression, cockroaches or mold in the home, and cost barriers to asthma-related health care or medication. All these factors, except for cockroaches, were associated with asthma-related ED/UCV. Compared with males, adjusted odds were higher among females for COPD, depression, obesity, and cost barriers to asthma-related health care or medication. CONCLUSIONS: Among older adults, asthma-related hospitalizations and ED/UCV were associated with clinical comorbidities, mold in the home, and financial barriers to asthma-related health care. Interventions addressing modifiable factors could reduce asthma morbidity among older adults.

Exposure to particulate matter less than 2.5 μm in diameter (PM2.5) exacerbates asthma and increases mortality. In Phoenix, AZ, the highest PM2.5 values frequently occur during the winter fireplace season and air quality health standards are often exceeded during the Christmas and New Year’s holidays. It was clear that enhanced messaging was needed by air quality and public health authorities to discourage biomass fires (BMF) on days when unhealthful levels of pollution were likely to be caused by that activity. Demonstrating adverse health outcomes would bolster this effort. We conducted this study to evaluate associations between elevated PM2.5 exposures during the fireplace season and asthma-related hospital admissions in Phoenix; days with average PM2.5 &gt; 35 μg/m3 were categorized as elevated PM2.5 exposure. We used hospital discharge data to identify patients with an asthma-related hospital encounter and who lived within an 8-km radius of a PM2.5 monitor. To estimate the risk of a hospital encounter following an elevated PM2.5 event, we used generalized estimating equations, specified with a Poisson distribution, and exposure lags of 0–3 days. Controlling for influenza, temperature, humidity, rain, and year, these analyses generated elevated estimates of emergency department visit risk among adults on lag days 2 (relative risk [RR] 1.19; 95 % CI 1.06, 1.34) and 3 (RR 1.20, 95 % CI 1.05, 1.37). Elevated PM2.5 was not associated with hospital encounters among children. Our findings suggest that adults may be at elevated risk of asthma-related hospital encounters during the fireplace season. © 2016 Springer Science+Business Media Dordrecht

BACKGROUND: Relationships between air quality and health are well-described, but little information is available about the joint associations between particulate air pollution, ambient temperature, and respiratory morbidity. OBJECTIVES: To evaluate associations between concentrations of particulate matter ≤2.5 microns in diameter (PM2.5) and exacerbation of existing asthma and modification of the associations by ambient air temperature. METHODS: Data from 50,356 adult 2006-2010 Asthma Call-back Survey respondents were linked by interview date and county of residence to estimates of daily averages of PM2.5 and maximum air temperature. Associations between 14-day average PM2.5 and the presence of any asthma symptoms during the 14 days leading up to and including the interview date were evaluated using binomial regression. We explored variation by air temperature using similar models, stratified into quintiles of the 14-day average maximum temperature. RESULTS: Among adults with active asthma, 57.1% reported asthma symptoms within the past 14 days and 14-day average PM2.5 ≥7.07 microg.m-3 was associated with an estimated 4 to 5% higher asthma symptom prevalence. In the range of 4.00 to 7.06 microg.m-3 of PM2.5, each microg.m-3 increase was associated with a 3.4% (95% confidence interval: 1.1, 5.7) increase in symptom prevalence; across categories of temperature from 1.1 to 80.5 degrees F, each microg.m-3 increase was associated with increased symptom prevalence (1.1-44.4 degrees F: 7.9%; 44.5-58.6 degrees F: 6.9%; 58.7-70.1 degrees F: 2.9%; 70.2-80.5 degrees F: 7.3%). CONCLUSIONS: These results suggest that each unit increase in PM2.5 may be associated with an increase in the prevalence of asthma symptoms, even at levels as low as 4.00 to 7.06 microg.m-3.

PURPOSE: Causal effects in epidemiology are almost invariably studied by considering disease incidence even when prevalence data are used to estimate the causal effect. For example, if certain conditions are met, a prevalence odds ratio can provide a valid estimate of an incidence rate ratio. Our purpose and main result are conditions that assure causal effects on prevalence can be estimated in cross-sectional studies, even when the prevalence odds ratio does not estimate incidence. METHODS: Using a general causal effect definition in a multivariate counterfactual framework, we define causal contrasts that compare prevalences among survivors from a target population had all been exposed at baseline with that prevalence had all been unexposed. Although prevalence is a measure reflecting a moment in time, we consider the time sequence to study causal effects. RESULTS: Effects defined using a contrast of counterfactual prevalences can be estimated in an experiment and, with conditions provided, in cross-sectional studies. Proper interpretation of the effect includes recognition that the target is the baseline population, defined at the age or time of exposure. CONCLUSIONS: Prevalences are widely reported, readily available measures for assessing disabilities and disease burden. Effects on prevalence are estimable in cross-sectional studies but only if appropriate conditions hold.

Background Few epidemiologic population-based data are available to describe the wide range of health conditions that affect children with asthma. We conducted this study to identify common comorbidities of asthma during childhood and compare the prevalences of selected comorbidities among children with and without asthma. Methods We analyzed weighted data from the 2012 National Health Interview Survey child sample, a sample of 10,954 U.S. children aged 3-17 years. Information about each child's health, including history of asthma and other health conditions, was provided by an adult proxy respondent. We conducted binomial regression to compare the prevalences of 41 selected health conditions among children with and without current asthma. Results An estimated 10.4% of children aged 3-17 years (n = 1202) were identified as having current asthma. Nearly all conditions considered were more common among children with than without asthma. Compared to children without asthma, children with asthma had higher prevalences of hay fever or respiratory allergies (prevalence difference [PD]: 30.5%; 95% CI: 26.6, 34.4), eczema or skin allergies (PD: 14.1%; 95% CI: 10.7, 17.5), sinusitis (PD: 11.3%; 95% CI: 8.4, 14.1), food or digestive allergies (PD: 10.4%; 95% CI: 7.7, 13.1), and difficulty with emotions, concentration, behavior, or getting along (PD: 7.9%; 95% CI: 4.7, 11.1). Conclusions These results highlight the burden of comorbidities among children with asthma. Improved understanding of the impact of comorbidities among children with asthma may help develop best practices for the assessment, treatment, and control of coexisting health conditions.

BACKGROUND: Interpretation of longitudinal information about lung function decline from middle to older age has been limited by loss to follow-up that may be correlated with baseline lung function or the rate of decline. We conducted these analyses to estimate age-related decline in lung function across groups of race, sex, and smoking status while accounting for dropout from the Atherosclerosis Risk in Communities Study. METHODS: We analyzed data from 13,896 black and white participants, aged 45-64 years at the 1987-1989 baseline clinical examination. Using spirometry data collected at baseline and two follow-up visits, we estimated annual population-averaged mean changes in forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) by race, sex, and smoking status using inverse-probability-weighted independence estimating equations conditioning-on-being-alive. RESULTS: Estimated rates of FEV1 decline estimated using inverse-probability-weighted independence estimating equations conditioning on being alive were higher among white than black participants at age 45 years (e.g., male never smokers: black: -29.5 ml/year; white: -51.9 ml/year), but higher among black than white participants by age 75 (black: -51.2 ml/year; white: -26). Observed differences by race were more pronounced among men than among women. By smoking status, FEV1 declines were larger among current than former or never smokers at age 45 across all categories of race and sex. By age 60, FEV1 decline was larger among former and never than current smokers. Estimated annual declines generated using unweighted generalized estimating equations were smaller for current smokers at younger ages in all four groups of race and sex compared with results from weighted analyses that accounted for attrition. CONCLUSIONS: Using methods accounting for dropout from an approximately 25-year health study, estimated rates of lung function decline varied by age, race, sex, and smoking status, with largest declines observed among current smokers at younger ages.