# :1: AMERICAN LUNG ASSOCIATION® 

# 1· Fighting forAir

AlbertA.Rizzo, M.D. Chair National Board of Directors
Ross 

### P. Lanzafame, Esq. Chair-Elect National Board of Directors
H.james Gooden Past-Chair
Christine L. Bt·yant 

### SecretaryrTreasurer
Geri Reinardy, M.P.A. Speaker NationwideAssembly
Marcia D.Williams, Ed.D. Speaker-Elect Nationwide Assembly

NATIONAL HEADQUARTERS
Charles D. Connor President &. ChiefExecutive Officer
130I PennsylvaniaAve., NW Suite 800 Washington, DC 20004-1725 Phone: (202) 785-3355 Fax: (202) 452-1805
14Wall St. Suite SC NewYot·k, NY 10005-2113 Phone: (212) 31 S-8700 Fax: (212) 608-3219 www.LungUSA.org June 25, 2012

The Honorable Lisa Jackson, Administrator U.S. Environmental Protection Agency Air and Radiation Docket and Information Center Mail Code 2822T 1200 Pennsylvania Avenue, NW Washington, DC 20460

Re: Docket ID No. EPA-HQ-OAR-2011-0660
Dear AdministratorJackson:
The American Lung Association writes in support ofstrong standardsto reduce power plant carbon pollution. These proposed standards can play an important role in reducing the risk of adverse health effects associated with ozone ("smog")
on our nation's mostvulnerable populations, including children, the sick, and the elderly. Strong standards must be made final forthe EPA to take an important next step toward ensuringthat electricity is produced by the most modern, and leasttoxic, power plants. However, the American Lung Association urges the EPA to issue a strong proposal to cover existing power plant carbon pollution, the single largest source ofgreenhouse gas emissions in the United States.
The Clean Air Act requiresthe EPAto regulate air pollutants from stationary
sources. The Supreme Court ruled that greenhouse gases (GHG) metthe definition ofair pollutants in the Clean Air Act in 2007. In 2009, the EPA found that concentrations ofGHG in the atmosphere endangerthe public health and welfare ofcurrent and future generations by increasing temperatures and ozone pollution. This increase puts some of our nation's most vulnerable communities at greater riskfortheir health.
To regulate a pollutant such as GHG, the EPA must list categories ofstationary
sourcesthat cause or contributeto air pollution that could harm public health or welfare. Electric generating units (EGUs) are the largest stationary source ofGHG in the United States. Energy accountsfor 86 percent oftotal2009 GHG emissions,' and the electric sector represents 39 percent ofall energy-related C02 emissions.'To regulate emissions from EGUs, the EPA must issue a new source performance standard (NSPS), which includes the Best System ofEmissionAdministrator Lisa P. Jackson Environmental ProtectionAgency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 2

Reduction (BSER), an achievable standard that considers cost and otherfactors. The proposed rule offers
a new source performance standardfor greenhouse gas emissionsfrom electric utility generating units, commonly referred to as power plants.
Carbon pollution can make reducing ozone much harder
As carbon pollution builds up in the atmosphere, scientists believe that it will likely lead to increased temperatures. The increase in temperatures can increase the risk for formation ofground level ozone or smog.
Ozone is a colorless, odorless gas that reacts chemically ("oxidizes") with internal body tissues, such as those in the lung. Ozone acts as a powerful respiratory irritant atthe levels frequently found across the nation duringthe summermonths. Breathing ozone may lead to shortness of breath and chest pain,' wheezing and coughing; 4 increased risk ofasthma attacks;' increased susceptibilityto respiratory infections,' and need for medical treatment and for hospitalization for people with lung diseases, such
as asthma or chronic obstructive pulmonary disease (COPD)7 and premature death'
The most vulnerable individuals, including children, teens, senior citizens, people who exercise orwork outdoors, and people with chronic lung diseases like asthma, COPD, and emphysema, are most in danger ofbeing sickened by ozone9 So-called "responders," otherwise healthy individuals who experience health effects at lower levels of exposure than the average person, are also susceptible to ozone. 10 Children who grow up in areas ofhigh ozone pollution may never developtheirfull lung capacity as adults. That could putthem atgreater risk oflung diseasethroughouttheir lives. 11 Many areas in the United States routinely experience concentrations ofground-level ozone that cause health problems. The United States has worked hard since the 1970 Clean Air Actto cut ozone levels, and reduced them by 13 percent between 2001 and 2010, accordingthe EPA's most recent analysis of trend. 12 However, millions ofpeople live in places that still struggle to meetthe 1-hour ozone standard set in 1979, including Los Angeles and Houston. As the evidence clearly shows that the current ozone standards fail to adequately protect public health, the challenge to provide airthat is no longer burdened by unhealthful levels ofozone will continuefor decades to come.
As EPA noted in their 2009 assessment ofthe impact of climate change on regional air quality in the United States, many studies "have demonstrated connections between meteorological variability and 

### 0 3 concentrations and exceedances, implying the possibility ofclimate change leadingto increasing O, levels in some regionS. 1113
EPA's own modeling showed "increases in summertime 0 3 concentrations over substantial regions of the country as a result ofsimulated 2050 climate change," using the assumption that none ofthe precursor emissions decreased from "presentday levels." EPA ran multiple models and in each ofthemAdministrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 3

({climate change caused increased in summertime 0 3 concentrations" in ,,nearly every region ofthe 1114 country.
As EPA noted, however, most models have nottaken into account the reductions in ozone precursors that have been adopted and are in place. To addressthat challenge, a 2008 study by Wu, et al. used the model ofthe Intergovernmental Panel on Climate Change for 2050 (AlB) that incorporated decreasing emissions of ozone precursors in the United States, as currenttrends show. That studyfound thatthe drop in emissions reduces the U.S. summer daily ozone, butthat climate change will take much ofthat back. Nor wasthe impact uniform: the Northeast and the Midwest were harder hit than the Southeast. 15
The authors defined this as a "climate change penalty"-additional controls on emissions of ozone precursorsthatwill be needed to reachthe same level ofozone in the future than ifthe climate had not warmed. The penalty is substantial. These Harvard, NASA and Argonne National Laboratory scientists estimatedthatto reachthe same ozone concentrations in 2050 will take as much as a ten percent greater drop in precursors such as nitrogen oxidesthan ifclimate change was not a factor. 16
EPA's own 2009 analysis recognized this penalty and added othersto the list. As EPA noted, the models showthatthe ozone season could be longer. The changes in weather patterns could affect the variability from year to year in the annual levels and extremes ofozone episodes. This will require more challenging assessment and planning, as well as more strategies to look at long-term air quality controls. 17
The full impact ofclimate on ozone and other air pollutants is complicated. However, the best understanding shows that carbon pollution-aided climate change will increase the challenge to meeting future national air quality standards for ozone. The "climate change penalty" will add complications going forward. 

### Strong standards will 

### support the cleanest sources ofelectricity.
Coal-based Electricity
The American Lung Association opposesthe construction of new conventional coal-fired power plants. The American Lung Association believes thatthe U.S. should not continueto expand its coal-fired generating capacity because ofthe extensive scope ofhealth risks associated with the use ofcoal and the disproportionate impact on local communities.
No other source ofelectricity has a greater impact on health and air quality. From the resource intensity of mining, to the air pollution associated with combustion, coal use generates a dominant share ofthe sector's impact.

### Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 4

Coal mining is one ofthe United States' most dangerous professions. The yearly fatality rate in the industry is 0.23 perthousand workers, making the industry about five times as hazardous as the average private workplace 18 

### The CDC has estimated that over 6,000 former miners died ofcoal workers' pneumoconiosis, also known as black lung disease since 2000. 19 

### The inhalation and accumulation of coal dust into the lungs also increasesthe risk ofdeveloping emphysema, chronic bronchitis, and chronic obstructive pulmonary disease. According to a study published in the

### AmericanJournal ofPublic Health, people in coal mining communities have a 70percent increased risk for developing kidney disease, 64 percent have an increased risk ofdeveloping chronicobstructive pulmonary disease such as emphysema, and 30 percent are more likely to report high blood pressure (hypertension). 20


### Coal-fired power plants produce over 386,000 tons of84 separate hazardous air pollutants from plants in 46 states, according tothe mostcurrent data In the National Emissions lnventory21 • 

### These plants produce40 percent of all hazardous air pollutants released from industrial sources into the atmosphere,
more than any otherindustrial pollution source. In addition, the combustion ofcoalto generate electricityalso produces 76 percent ofthe total volume ofacid gases, 60 percent ofarsenic, and 46 percent ofmercury released intothe atmosphere".
Coal-fired powerplants also produce nitrogen oxides (NOx) and sulfur dioxide that are harmful themselves, but also are precursors to ozone itselfand particulate matter, especially in the eastern United States. 23 24 

### Evidence shows that PM 2.5 

### causes cardiovascular harm and premature mortality and is likely to cause respiratory harm. The evidence suggests that long-term exposure to PM,_,causes reproductive and developmental effects as well as cancer, mutagenicity and genotoxicity-'5• 

### Even the transportation ofcoal increases health risks. The majority ofcoal is shipped by rail, with 72 percent ofall shipments in 2008 occurring by that mode oftransportation. 26 

### Diesel locomotives are a source ofNOx and PM emissions. Dust from coal stored in piles beforetransport or before it is
combusted can become airborne particulate matterthat adds to the burden on local air quality, especially on nearby communities.
Because ofthese concerns,the American Lung Association supportsthe phase-out ofconventional coalfired power plants as the nation transitionsto a clean energy future. This includes supportfor policies that: (1) require the installation and operation ofstate-of-the-art air pollution control technologies and (2) encourage conversion to cleanerenergy resources and/or permanent retirement ofcoal-fired power plants.
As part ofthe transition to a clean energyfuture, the American Lung Association supports providing assistance 

### to retrain coal industry workers and to help impacted communities transition to other economic opportunities. The American Lung Association additionally supports measures to improve the health and safety of coal mine workers, and the communities where they live, including protectionfrom

### Administrator Usa P. Jackson Environmental Protection Agency Comments on Docket 10 

### No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 5

harmful air pollutants. The American Lung Association firmly believes it is time to move 0way from using coal to produce electricity.
Advanced Coal-based ElectricityTechnologies 

### The American Lung Association does not supportthe construction ofnew advanced coal-based generatingfacilities, including carbon capture and sequestration and integrated gasification combined cycle plants. The Department ofEnergy has directed significant resources tothe research and development of advanced coaltechnologies such as integrated gasification combined cycle (IGCC) power plants and carbon capture and storage (CCS).
While each part ofthe CCS chain has been demonstrated, the technologies have not been integrated and demonstrated on a commercial-scale (greaterthan 300 MW) coal-fired power plant. Beyond the greenhouse gas benefits, CCS could also potentially drive 502 

### reductions. The currenttechnologies for removing C02

### from a power plant exhaust gas are very sensitive to 502 

### levels. As a result, conventional plants would have to install state-of-the-art scrubbers to remove

## so, from theflue gas priorto installing equipmentto capture C02• 

### Furthermore, neitherIGCC nor CCS addressesthe upstream impacts ofcoal use orthe solid waste byproducts ofthe gasification orcombustion. Additionally, the use ofcarbon capture technologies with IGCC orwith conventional coal technologies can reduce the powergenerating capability ofthat plant by 20to 30 percent. This penalty increases 

### the amount ofcoal that must be used to generate a unit of electricityatthe plant. However, at a macroeconomic scale, it is not clear iftheenergy penalty would increase coal use. As the technologies increase the cost ofcoal-based electricity, they may dampen the demandfor coal-based electricity.
Since these advanced coal technologies have not demonstrated a reliable degree oftechnological certainty, operational capacity orcost feasibility, the American Lung Association does not supportthe construction ofnew advanced coal-based powerplants. It also does not supportthe use ofCCS orIGCC in existing coal-fired powerplants.
Biomass Combustion for Electricity 

### The American Lung Association does not support biomass combustion for electricity production, a categorythat includes wood, wood products, agricultural residues orforest wastes, and potentially highly toxic feedstocks, such as construction and demolition waste. Ifbiomass is combusted, state-ofthe-art pollution controls must be required.
Biomass electricitygeneration involves extracting the energy from organic materials thatpart ofthe active carbon cycle (i.e. notfossil fuels). Most biomass facilities in the United States combustfuel to boil water and drive a steamturbine, similarto conventional fossil fuel operations. Avarietyofsources,Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 6

known as feedstocks, can potentially be used for biomass power production, including wood or wood pellets, forest wastes, and agricultural residues. Paper mill residue and lumber mill scraps may also be considered biomass.
The environmental and health impact ofbiomass power is directly related to the feedstock from which the energyis derived. The choice ofbiomass feedstocks often presents a trade-offbetween cost, fuelquality, and environmental and health impacts. For example, urban waste, such as construction or demolition debris, is usually inexpensive relative to other biomassfeedstocks, and combusting this debris at a biomass plantdiverts it awayfrom landfills. However, such waste may be oflow-quality, meaningthat more feedstock is required to produce a given amount ofelectricity, or contain high-levels of impurities/ resulting in greater air emissions.
Biomass combustion increases the risk ofthe emission of noncarbon air pollutants. Electricity production from biomass releases many ofthe same air pollutants asfossil-fuel generation, although the quantities may differ substantially on per MWh basis. Particulate matter (PM) emissions arethe most significant health threatfrom biomass power plants. Without controls, combustion ofwood and wood wastes for power production can result in PM emissions that are more than 20 percenthigher than emissions from an uncontrolled coal plant. Emissions ofcarbon monoxide and volatile organic compounds (VOCs) can be more than 400 percent and 2,000 percent higherthan emissionsfrom a coal plant, respectively. In contrast, NOx emissions may be nearly 60 percent lower and 502 emissions are virtually eliminated27
Wood wastes, such as construction and demolition debris, may also contain toxic air pollutants." The potentialfor toxic emissions from construction and demolition debris varies, depending on state fuel standards"). Like fossil fuels, biomass combustion also emits other hazardous air pollutants. The impact ofthese emissions on human health is generally similar to the impact ofemissions from fossil fuel combustion. Limited data are available on how various feedstocks affect overall emissions from biomass power. Producing electricityfrom biomass also releases C02 into the atmosphere, as well as small amounts of methane and nitrous oxide. Biomass energy has the potential to reduce carbon dioxide emissions becausethe C02 released can be balanced by the C02 captured in growingthe feedstock. However, the overall C02 benefit depends on how much energy was used to grow, harvest, and process thefuel.
The American Lung Association acknowledges that pollution from the combustion ofwood and other biomass sources poses a significantthreatto human health, and supports measuresto transition away from usingthese products for heat production.


### Natural Gas-based Electricity

### Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 7

The American Lung Association supports the increased use of natural gas as a transitional fuel for the production ofelectricity as a cleaner alternative to biomass, coal and otherfossil fuels. Natural gas exploration, extraction, production andtransmission can create air pollution, including emissionsfrom the use of diesel engines. While the American Lung Association has recommended thatEPA strengthen proposed rules for natural gas extraction, the emissionsfrom natural gas combustion for electricity generation are much lowerthan that ofcoal. As the National Research Council report statedthe comparison: "[O]n average, nonclimate-change-related damages associated with electricity generation from natural gas are an order ofmagnitude lowerthan damages from coal-fired electricity generation." 30 

### The reportalso concluded that natural gas powered electricity plants emitted approximated halfthe

## co,."
The American Lung Association supports public policies requiring the installation and operation ofstateof-the-art pollution control systems at new and existing natural gas-fired powerplants. The American Lung Association also supports programs and policies to protect air, water, and otherenvironmental
resources during the exploration, extraction, production, and transmission of natural gas, including hydraulic fracturing.
The proposed rule 

### will not limit power plant development. 

### Departmentof Energy projections indicate thatthe proposed rule would have little to no impact on the development offuture powerplants, because it is estimated that almost all future power plants will employ a natural gas combined cycle (NGCC). This is due to low natural gas prices, renewable portfolio standards, and newtechnology. The NGCC model can easily meetthe proposed standard, because, on average 

### natural gas combustion results in halfthe C02 

### emissions ofcoal per MWh ofenergy generated." In fact, 95% ofthe NGCC facilities thatstarted between 2006 and 2010 already meetthe proposed standard." The proposed rule supportsthe increasing industry standard ofnatural gas combined cycle technology.
Ifcoal-fired powerplants are built in the future, these power plants must install sufficient carbon capture and storage (CCS) technology and othercontrols to reduce CO, and other air emissions. As noted earlier, however, this will not address the upstream impacts ofcoal extraction northe downstream impacts ofthe byproducts ofcoal combustion.
The American Lung Association does not support coal-fired powerplants orCCS technology. The Lung Association does support the increased use of naturalgas as atransitional fuel for the production of electricity, as a cleaneralternativeto biomass, coal and otherfossil fuels.

EPA should strengthen the proposed rule.Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 8

The American Lung Association supports the proposed rule because it will reduce harm-inducing C02 from the atmosphere by reinforcing incentives for cleaner electricgeneration, without imposing hardship on the electric power industry. However, the Lung Association urges EPA to take several steps to strengthen the rule and reduce the potentialfor unintended consequences. Carbon pollution limits should be tighter. The EPA is proposing a carbon pollution limit of 1,000 lbs ofC02 perMW hr. The American Lung Association urges EPA to set a lower carbon pollution standard. The EPA has noted the overwhelming trend towards natural gas combined cycles, which easily meetthe proposed standard. The proposed rule notes that "(a]lmost all the stationary combined cycle gas turbines built in the U.S. in the last five years can meet the proposed standard." 34 It would appearthat a higher standardfor NGCC would be easily met. In fact, New York State is proposing a carbon pollution limit of 925 lbs ofC02 • New York State's proposed limit includes an conservative emission allowance to accommodate uncertainties in technical issues abouttechnical issues, and allows oil-based power production for up to 45 days a year. Reporting and Enforcement mechanisms should be strong The American Lung Association supports power plant pollution reporting on a 12-month rolling average basis. This arrangement benefits power plants, the EPA, and the public. A 12-month reporting requirement allows power plants to account for variable pollution levels throughout a month, and allows the EPA to intervene quickly ifpollution levels are too high. A 12-month rolling period would also allow the public to view emission levels every six months. This transparency and accountability is vital as the EPA movesforward with regulating carbon pollution.
The EPA should not exempt modified and reconstructed power plants. The American Lung Association does notsupport exempting carbon pollution from existing power plants that are modified or reconstructed in future years. EPA statesthat it does not have an "adequate basis

...to develop standards ofperformancefor modifications,''" but does not consider other alternatives to the outright exemption of carbon pollution controls. The exemptions in the proposed rule may lead to unintended consequences. For example, inefficient, aging power plants could avoid decommission by expanding capacity underthe guise ofa modification or reconstruction. Such an increase in capacitywould lead to an increase in unchecked carbon pollution.
Ratherthan exempt all reconstructions and modifications, the American Lung Association urges the EPA to set a threshold for this exemption. The State of New York is finalizing carbon pollution regulations that require an existing power plant, which is otherwise exempt, to be treated as a new powerplant
once it expands capacity by 2SMW or more. In its analysis, New York found that this requirement would not affect changes made to increase efficiency."The American Lung Association supports a similarAdministrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 9

threshold for modified or reconstructed power plants. Otherwise, the EPA risks creating a loophole for power plantsto expand capacitywithout being accountable for additional carbon pollution.
The Lung Association is particularly concernedthatthis broad exemption could circumvent or undermine the application ofthe "new source review" authority under Section 111 ofthe Clean Air Act. The U.S. Supreme Court ruled unanimously in 2007 that newsource review requirements applied to any physical or operational change that increases a plant's actual annual air pollution emissions." New
sources include sourcesthat modify or reconstruct their facilities and increase emissions must not be exempted from review in the future.
The EPA should not exempt biomass-fueled power plants. As stated previously, theAmerican Lung Association does not support biomass combustion for electricity production. The proposed rule exempts biomass-fired boilers that co-fire with less than 250 MMBtu/h offossil fuel. The American Lung Association opposes exempting any level of biomass-fired electricity.
The environmental and health impacts ofbiomass power are directly related to the feedstock from which the energy is derived. The choice ofbiomass feedstocks often presents atrade-offbetween cost, fuel-quality, and environmental and health impacts. Biomass-fueled electricity increasesthe risk of additional amounts ofcarbon monoxide, VOCs, and particulate matter. Any overall CO, benefit depends
on how much energy was used to grow, harvest, and process the fuel. In 2011, the EPA itselfnoted it must 

### "conduct a detailed examination of thescience associatedwith biogenic C02 

### emissionsfrom stationarysources, ... andresolve technical issues in order to account for biogenic C02 

### emissions in ways that are scientifically soundandalso manageable in practice"" while determining biogenic C02 pollution from PSD and Title Vapplicability underthe Clean AirAct.
The American Lung Association urges the EPAto strike the biomass exemption, given the complexityof determining biomass feedstocks, overall C02 pollution, and impacts ofbiomass-fired electricity on air quality.
The EPA should not exempt simple cycle turbines. The American Lung Association does not supportthe exemption ofsimple cycle turbines. Though simple cycle turbines are not often used for baseload generation, the high carbon pollution associated them and the potentialfor perverse incentives require the EPA to devise a standardfor with simple cycle turbines.
Because theydo not recapture waste heat, simple cycle turbines are generally less efficient and pollute
more carbon than combined cycle turbines, but theyare less expensive than a combined cycle unit. Simple cycle turbines are often used to provide electricity during peaktimes orto offset the startupAdministrator Lisa P. Jackson Environmental Protection Agency Comments on Docket 10 No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 10
delays ofa combined cycle, and the proposed standard notesthatfew simple cycle turbines generate more than one-third oftheir outputfor sale. However, this is not an insignificant amount ofoutput, or an insignificant amount of associated pollution. The outright exclusion of simple cycle units from the proposed rule creates an incentive for power plantsto usethese less expensive, less efficient and more polluting units. Underthe proposed rule, ifa future powerplant needs to generate more electricity, it could be less expensive, albeit less efficient, to add pollution-exempt simple cycle turbines than a moreefficient combined cycle unitthat is subjectto carbon pollution standards.
The EPA should note that the State of New York is poised to regulate carbon pollution for simple cycle turbines. New York's proposed standard limits simple cycle carbon pollution to 1,400 lbs C0 2 per MWh. This standard was developed with considerationsfor the necessityfor peak usage and allows simple cycle turbines to operate on oil85 percentto 100 percent ofthe time.
The EPA should not exempt power plants that combust solid waste. The American Lung Association does not supportthe proposed rule exemption ofpower plants subject to Clean AirAct §129 (solid waste combustion). Solid waste combustion, i.e., the direct combustion of municipal solid waste orthe use ofgas captured at landfills, raises environmental and air quality issues. Municipal solid waste contains a diverse mix ofwaste materials, some benign and some verytoxic. Toxic materials include trace metals such as lead, cadmium and mercury, and trace organics, such as dioxins and furans. These taxies pose public health and environmental problems ifthey are released into the air with powerplant pollutants. Additionally, landfill gas consists primarily ofcarbon dioxide, methane, and non-methane organic compounds. Without strict controls on taxies and carbon pollution, the proposed rule could increasethe dangerous emissions from the use ofsolid waste-fueled electricity.
The EPA should not exempt combined heat and power units.
The American lung Association does not supportthe exemption ofcombined heat and power (CHP) units. Combined heat and power (CHP) systems, also known as cogeneration, generate electricity and useful thermal energyin a single, integrated system.
CHP is more methodthan technology. Heatthat is normally wasted in conventional power generation is recovered as useful energy, which avoids the losses that would otherwise be incurred from separate generation ofheat and power. Though theAmerican Lung Association supportsfederal policies that will drive the deployment ofthe cleanest and mostfuel-efficient energytechnologies, the Lung Association does not condone exempting CHP unitsfrom the proposed standard. The source ofthe heat and power to be combined does matter.
The proposed standard statesthat most CHP units generate on-site power, and that such units would not generate enough electricityto fall under the proposed rule. The EPA further notes thatthere is a "small amount ofprojected coal-fired CHP." 39 Though large-scale CHP power plants are not currentlythe

### Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 11

norm, this exemption would create a perverse incentive to build new powerplants (or modify old ones) using CHP. The proposed standard additionally notes thatthe EPA could subjectCHP to the 1,000 lbs of C02/MWhour standard-but chooses notto.40

### This sends a strong message to powerplantsthat installing less efficient CHP units is easierthan complying with pollution limits. The EPA should set a standardfor CHP units instead ofexemptingthem entirely.

The alternative compliance mechanism is unnecessary and ineffective.


### The American Lung Association does notsupportthe alternative compliance mechanism (ACM). The ACM ignores a forty-year history ofthe Clean Air Act driving standards through enforcement. Furthermore, giving power plants a decade of higher carbon pollution standards will not spurthe pollution reduction ortechnological advancesthat are needed for a newgeneration ofcleaner power plants.
The proposed ACM offers new, coal-fired power plants a 30-year period to complywith emissions standards. Instead ofmeeting the permanent limit of 1,000 lbs ofC02 

### per gross Megawatt hr (MWh), the ACM allows a coal-fired power plantto emit 1,800 lbs ofCOJMWh on a 12-month average during its first ten years of operation. After thatfirst decade, carbon pollution is limited to 600 lbs ofCOJMWh per 12-month average for the following 20 years. The proposed rule offers no end date for this alternative compliance mechanism.
The American lung Association does not supportthe ACM because the timeline creates a loophole that would encourage the continued expansion ofcoal-powered units without carbon controls underthe guise offuture adoption ofthe CCS. However, should the EPA finalize this provision ofthe rule, the American Lung Association believesthatthe ACM must betemporary. Without a sunset provision for this mechanism, the carbon capture and sequestration (CCS) industry has less supportto improve CCS technology, and power plants have less incentive to usethe bestCCS system. EPA mustend the ACM at a date certain to meet its goals ofreducing life-threatening carbon pollution and improving CCS technology.
The EPA notesthatthe proposed rule is "an important component"41 

### to promotingCCS, and thatthe Agency "expect[s CCS costs] to decrease as CCS becomes more mature and less expensive."42 

### It further notes that "ten years...provides early adopters sufficient time to address any startup challenges.""This language indicates that the EPA views the first decade ofthis rule as be a "startup" period, followed by clarity and greatercertainty about CCS. It is counter-productive at best, and confusing atworst, for EPA to claim that CCS technology will become more certain and simultaneouslysupport a never-ending alternative compliance mechanism.Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 12

The alternative compliance mechanism should only serve as a startup period that will allow CCS technologyto improve. Without an end date for the alternative compliance mechanism, coal-fired power plants for the next hundred years-or more-will have an incentive to optfor the lowest cost, highest emitting CCS technology, spend a decade spewing higher levels ofcarbon, and avoid the additional cost of betterCCS technologyuntil as late as possible. This will notcreate a market demand for the most efficient CCS technology. Ifthe EPA believesthatthe proposed standard can supportthe development of CCS technology, then it should include a date certain atwhich power plants-and CCS manufacturers-can expect power plantsto emitno morethan 1,000 pounds ofC02 per gross Megawatt hour (MWh).
Ifthe EPA Administrator determines to allow the use ofan alternative compliance mechanism, she must set an end datefor the compliance not laterthan 2020, a date which coincides with the obligation to review and revise each NSPS everyeight years under CAA section 111(b)(1)(B). However, ALA strongly opposes waiting eightyears for an end date to be determined. An eight-year period ofuncertainty does not encouragethe marketto developthe most efficient CCS technology. The American Lung Association urges the EPAto terminate the ACM in 2020. A2020 termination date would create incentives for more efficient CCS technology. IfCCS technology has not sufficiently improved by 2020, the Administrator would have the authorityto extendthe ACM termination date ifit appears realistic thatfeasible CCS technology can be adapted for system-wide emissions reductions, though that extension should be limited to one additional defined short-term period. The American Lung Association supports striking the ACM provisions in the proposed rule, and finalizing strong reporting and enforcementmechanisms.

EPA must regulate carbon pollution from existing power plants.
The American Lung Association believes that limits for powerplant carbon pollution must include existing power plants, notjust new ones. There are more than 500 existing coal-fired power plants spewing carbon and other pollutants on a daily basis.44 As the National Research Council states: "The emissions of C02 from coal-fired power are the largest single source ofGHG emissions in the United States."45 We cannotignore the impact ofcarbon pollution from these existing powerplants.
The proposed standard not only exempts existing power plants, it ignores thefact thatthey can-and will likely-continueto pollute the air for future generations. In Sunbury, Pennsylvania, the Shamokin Dam power plant has been operatingsince 1949 and will finally switch to natural gas in 2015 46 Existing powerplants aren't disappearing, and they should be included in carbon pollution limits.

The public wants EPA to cut pollution levels.
We also write inform you ofthe views ofthe public as it relates to more protective standardsfor power plant carbon pollution. According to a March 2012 bipartisan survey conducted by Democratic pollingAdministrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 13

firm Greenberg Quinlan Rosner Research and Republican firm Perception Insight, nearlythree-quarters oflikely voters (73 percent) nationwide supportthe viewthat it is possible to protect public health through stronger air quality standards while achieving a healthy economy, over the notion that we must choose between public health or a strong economy. This overwhelming support includes 78 percent of independents, 60 percent of Republicans and 62 percent ofconservatives, as well as significant support in Maine, Pennsylvania and Ohio. Additionally, a substantial majority ofvoters supportthe EPA implementingthese standards, even after hearing opposing arguments that stricter standards will damage the economicrecovery. Asubstantial majority ofvoters also supportthe EPA implementing standardsfor powerplant carbon pollution. Initially, 72 percent ofvoters nationwide support the new protections on carbon pollution from powerplants, including overwhelming majorities ofboth Democrats and independents and a majority of Republicans. After listening to a balanced debate with messages both for and against setting new carbon standards, support still remained robust with a near 2-to-1 margin (63 percentin favor and 33 percentopposed).
In summary, the American lung Association urges EPAto strike proposed exclusions for modified or reconstructed plants, biomass-fired power plants, simple cycle turbines, solid waste-fueled power plants and CHP units. Furthermore, the American Lung Association supports removingthe ACM provision. However, ifthe ACM loophole is allowed, then EPA should terminate that option in 2020. As the EPA finalizes the proposed standard, the American Lung Association urges the EPAto develop carbon pollution limits on existing power plants as well.
In conclusion, the risks ofcarbon pollution on ozone levels and public health and the obligations under current law require the EPA to develop carbon pollution limits for power plants. The American Lung Association supports EPA setting protective standardsfor power plant carbon pollution. The proposed standard will continue EPA's critical stepsto protectAmericans from the documented harm from emissions from power plants. However, the American Lung Association believesthe Best System of Emission Reduction is strongerthan the proposed pollution limits. By setting strong powerplant pollution limits, EPA can favor our children's future overfuture power plants. Sincerely,

Paul G. Billings Vice President, National Policy and AdvocacyAdministrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 14

1U.S. Environmental Protection Agency. Inventory ofU.S. Greenhouse Gas Emissions and Sinks: 1990-2009. Report EPA 430-R11-005, United States Environmental Protection Agency. April 15, 2011.Table ES-4. 'U.S. EPA, 2011. Table ES-2. 3 Horstman DH, Folinsbee U, lves PJ, Abdu\-Sa\aam S, McDonnell WF. Ozone concentration and pulmonary response relationships for 6.6-hour exposures with five hours ofmoderate exercise to 0.08, 0.10, and 0.12ppm. Am Rev RespirOls1990; 42:1158-1163; McDonnell WF, Stewart PW, Smith MV, Pan WK, Pan J. Ozone-induced respiratory symptoms: exposureresponse models and association with lung function. Eur RespirJ1999;14:845-853. 4Triche EW, GentJF, HolfordTR, Belanger K, Bracken MB, Beckett WS, Naeher L, McSharryJE, Leaderer BP.**Low~leve\** ozone exposure and respiratory symptoms in infants. Environ Health Perspect2006;114:911-916. 5 Mortimer KM, Neas LM, Dockery OW, Redline S, Tager lB. The effect of air pollution on**inner~city** children with asthma. fur RespirJ 2002; 19:699-705. 6 Hollingsworth JW, Kleeberger SR, Foster WM. Ozone and pulmonary innate immunity. ProcAm Thorac Soc**2007;4:240~246.** 7 Cakmak, S; Dales, RE; Judek, S. Respiratory health effects of air pollution gases: Modification by education and income. Arch Environ Occup Health 2006: 61:**5~10;** Dales, RE; Cakmak, S; Doiron, MS. Gaseous air pollutants and hospitalization for respiratory disease inthe neonatal period. Environ Health Perspeet, 2006; 114:**1751~1754.;** Katsouyanni, K; Samet, JM; Anderson, HR; Atkinson, R; Le Tertre, A; Medina, S; Samoli, E; Touloumi, G; Burnett, RT; Krewski, D; Ramsay, T; Dominici, F; Peng, RD; Schwartz, J; Zanobetti, A. Air pollution and health: A European and North American approach (APHENA). {Research Report 142}. Boston, MA: Health Effects Institute, 2009. http://pubs.healtheffects.org/view.php?id=327 8 Be\\ ML, Dominici F, and SametJM. A**Meta~** Analysis**ofTime~Series** Studies of Ozone and Mortalitywith Comparison to the National Morbidity, Mortality, and Air Pollution Study. Epidemiology 2005;**16:436~445.** Levy Jl, Chermerynski SM, Sarnat JA. Ozone Exposure and Mortality: an empiric Bayes metaregression analysis. Epidemiology 2005;**16:458~468.** Ito K, De Leon SF, Lippmann M. Associations Between Ozone and Daily Mortality: analysis and**meta~analysis.** Epidemiology 2005;**16:446~429.** 8 Bates DV. Ambient Ozone and Mortality. Epidemiology2005;**16:427~429.** 9 Gent JF, Triche EW, HolfordTR, Belanger K, Bracken MB, Beckett WS, Leaderer BP. Association of**Low~Level** Ozone and Fine Particles with Respiratory Symptoms in Children with Asthma. JAMA 2003;**290:1859~** 1867Desqueyroux H, PujetJC, Prosper M, Le MoullecY, Mamas I. Effects of air pollution on adults with chronic obstructive pulmonary disease. Arch Environ Health 2002;57:554-560; Desqueyroux H, Pujet JC, Prosper M, Squinazi F, Mamas I. Short-Term Effects of Low-Level Air Pollution on Respiratory Health ofAdults Sufferingfrom Moderateto Severe Asthma. Environ Res 2002; 89:29-37; 72:24-31and HOppe P, Peters A, Rabe G, Pram\ G, Lindner J, Jakob\ G, Fruhmann G, Nowak D. Environmental ozone effects in different population subgroups. lntJHyg Environ Health 2003;206:505-516; 10 Devlin RB. identification of subpopulations that are sensitive to ozone exposure: Use ofend points currently available and potential use of laboratory-based end points under development. Environ Health Perspect 1993;101:225-230 11 Kunzli N, Lurmann F, Segal M, Ngo L, Balmes J, Tager lB. Association Between Lifetime Ambient Ozone Exposure and Pulmonary Function in College Freshmen-Results of a Pilot Study. Environmental Research 1997;72: .8-23. 12 U.S. EPA. Our Nation's Air: Status and Trends through 2010. February 2012. EPA-454/R-12-001. 13 U.S. EPA. Assessment ofthe Impacts of Global Change on Regional U.S. Air Quality: A synthesis ofclimate change impacts on ground-level mone. April2009. EPA/600/R-07/094F 14• U.S. EPA, 2009.Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 15

15 Wu S, Mickley U, Leibensperger EM, Jacob DJ, Rind D and Streets DG. Effects of2000-2050 global change on ozne air quality in the United States. J. Geophys. Res. 113: 006302, 2008. 16Wu etal., 2008. 17 U.S. EPA, 2009. 18 Congressional Research Service, U.S. Coal: APrimer on the Major Issues, at 30. March 25, 2003. 19 U.S. Centers for Disease Control and Prevention. Coal workers' pneumoconiosis: Number of deaths, crude and age-adjusted death rates, U.S. residents age 15 and over, 1968-2007. March 2012, Accessed June 25, 2012 at http:f/www2a.cdc. govIdrds/War!d ReportData/FigureT ableDetails.asp?FigureTabIelo-2568&GroupRefNumber=FO2-01. 20 Hendryx, Michael and Melissa M. Ahern. Relations Between Health Indicators and Residential Proximity to Coal Mining in WestVirginia. AmJPublic Health. 2008; 98(4):669-71. 21 U.S. EPA. 2007. National Emissions Inventory {NEl) 2002: Inventory Data: Point Sector Data- ALLNEl HAP Annual 01232008. Web Link: http:Uwww.epa.gov/ttn/chief/net/2002inventory.html#inventorydata iAccessed 11January 2011]. 22 U.S. EPA, 2007. 23 u.s. EPA. Air Quality Criteria for Ozone and Related Photochemical Oxidants (2006 Final). U.S. Environmental Protection Agency, Washington, DC, EPA/600/R·05/004af-cf, 2006. 24 U.S. EPA. Integrated ScienceAssessment/or Particulate Matter, 2009. U.S. Environmental Protection Agency, Washington, DC, EPA 600/R-08/139F. Available at http://cfpub.epa.gov/ncea/cfm/recordisplay.cfm?deid=216546

. "U.S. EPA, 2009. 26 U.S. Energy Information Administration. Rail Coal Transportation Rates to the Electric Power Sector. June 22, 2011. Accessed June 24, 2012 at httP://205.254.135.7/coal(transportationrates/ 27 Washington Department of Natural Resources. Forest Biomass and Air Emissions. September 2010. Accessed June 25, 2012 from www.dnr.wa.gov/Publications/em forest biomass and air emissions factsheet 8.pdf 28 Nather LP, Brauer B, Lipsettt M, Ze\ikoffJT, Simpson CD, KoenigJQ, Smith KR. Woodsmoke Health Effects: A Review. Inhalation Toxicology. 2007. Jan;19(1):67-106. 29 Northeast States for Coordinated Air Use Management. Emissions from Burning Wood Fuels Derivedfrom Construction and Demolition Debris. May 2006. Accessed June 25,2012 atwww.nescaum.org/documents/2006-0710

­ emiss from burning wood fuels derived from c-d report.pdf 3

## °Committee on Health, Environmental, and Other External Costs and Benefits of Energy Production and Consumption, National Research Council. Hidden Costs of Energy: Unpriced Consequences of Energy Production and Use. Washington, DC: National Academy of Sciences, 2010. 31 National Research Council, 2010. 32 National Research Council, 2010. "Proposed 40 CF.R. §60.S509 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, pll5.) "Proposed40 C.F.R. §60.SS09 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, p24.) "Proposed 40 C.F.R. §60.5S09 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, p147.) 36 New York State Department of Environmental Conservation. Proposed Part 251 C02 Performance Standards for Major Electric Generating Facilities: Regulatory Impact Statement 6 NYCRR Parts 251 and 200. Comments closed March 15, 2012. Accessed June 25, 2012 at http:Uwww.dec.nv.gov/regu\ations/79541.html

. 37 Environmental Defense v. Duke Energy Corp., 127 S.Ct. 1423 {2007).) "76 fed. Reg. 43490,43496 (July 20, 2011). "Proposed40 C.F.R. §60.S509 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, p206.) 40 Proposed 40 CF.R. §60.5509 \http:/fepa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, p206.) "Proposed 40 C.f.R. §60.SS09 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, p127.) "Proposed40 C.f.R. §60.5S09 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposal.pdf, p32.) 43 Proposed 40 C.F.R. §60.5509 (http://epa.gov/carbonpollutionstandard/pdfs/20120327proposa\.pdf, p144.)Administrator Lisa P. Jackson Environmental Protection Agency Comments on Docket ID No. EPA-HQ-OAR-2011-0660 June 25, 2012 • Page 16

44 U.S. Energy Information Administration. Electric Power Annua12010 Data Tables. November 9, 2011, Accessed on June 24, 2012 at http://205.254.135.7/electricity/annua1/html/table5.1.cfm

. 45 National Research Council, 2010. 46 Esther Tanquintic-Misa, "Oldest U.S. Coal-Fired Plant Converts to Gas." International Business Times, December 29, 2011. Accessed on June 25, 2012 at http:/ /au.ibtimes.com/articles/273795/20111228/oldest-u-s-coal-fired-plant-converts.htm

## Testimony of Daniel M. Dolan-Laughlin, Volunteer for the American Lung Association in Illinois Before the U.S. Environmental Protection Agency Regarding the Proposed Power Plant Carbon Pollution Standard May 24,2012 Chicago, Illinois

Good moming. My name is Daniel M. Dolan-Laughlin. I am appearing here today to testify how pollution controls, like the carbon pollution limits the EPA is proposing today, impact millions ofpeople who suffer from respiratory illnesses. Although, I am not a scientist,
nor a doctor, I am someone who suffered, suffered nearly fatally from COPD. I am someone who received a double-lung transplant; and someone for whom pollution controls still, and will mean the difference betweenlife and death. I suffered from Chronic Obstructive Pulmonary Disease, or COPD, for decades. As the disease progressed, I could no longer work. My quality of life declined. Slowly at first, then
more rapidly as I approached end-stage. I required round-the-clock oxygen therapy to perform
even basic functions. Eventually, I wound up in the hospital with end-stage COPD. My doctor told me words no one is ever prepared to hear-that I had only several days left to live without mechanical support. And yet, amiracle occurred. Through organdonation, I was giventhe gift of life and hope

... ahealthy pair oflungs. Even with this life-changing gift, I must be vigilant about pollution levels. Poor air quality during high ozone days forces me to stay indoors. Pollution, literally, makes me sick. I depend on healthy air to breathe and live. And there are many, many others who depend on it too! I'm not here simply to talk about my own battle for healthy air. I'm here as an advocate for everyone with lung diseases. Asthma sufferers, COPD patients, and others rely on pollution controls to simply get through another day. Lung disease impacts peopleyoung and old, rich and poor, all over the country. Every single one ofthem deserves the right to breathe healthy air. On behalfofthese people, I support EPA's limits on carbon pollution from new power plants. By having the courage to implement this rule, you will reduce the carbon pollution and smog that

## Addressing Green Matters at the White House: A Climate ChangeDiscussion
Patricia W. Finn, MD Beyond the threatsto human life posedby extreme weather, the health effects ofa planetthat is getting relentlesslyhotter are already takingtheirtoll onvulnerable populations every day. This is the message I tried to convey during a White House meeting in June that was coincidentally scheduled for the dayPresident Obama announced his planto address global warming. Valerie Jarrett, the president's lead advisor on environmental issues, convened the meeting with a halfdozen medical and health groups, including the ATS, the National Association ofCounty and City Health Officials, the American Lung Association, the Children'sNational Medical Center, the Asthma and Allergy Foundation ofAmerica, and the March ofDimes, and with climate change experts on her staff.
Inwelcomingus, Ms. Jarrett saidthat she lookedto the ATS andthe other organizationsto identify and support the development ofthe best scienceto inform the discussion about the public healthpolicy needed to meet a complex global problem. The meeting was originally scheduledfor 30 minutes butwent a full hour as representatives of the invited organizations spoke urgently about the challengeswe face from our different perspective ofthe health problemsposedby an overheatedplanet. When it was my tum to speak, I focused on three issues and triedto emphasize that, like me, many ofthe clinicians in the Society are already seeing the effects ofclimate change in their patients: Climate and pollen. Climate change is creating earlier, longer, and more intense pollen seasons. Research has shownthatpollen seasonis beginning about a day earlier at the equator and about 23 days earlier in northern climates. Increased carbon dioxide concentrations are also yielding more intense allergenic pollenblooms. Climate and heat spikes and premature mortality. Recentheat spikes in cities around the world have resulted in premature deaths. While heat-spike related deaths are infrequent, it is importantto note that these deaths were not among those expected to die soonunder normal conditions. They were amongpeople whose primaryrisk factor was the extreme heat they experienced.

1

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### American Lung Association • American Public HealthAssociation • Asthma and Allergy Foundation ofAmerica • HealthcareWithout Harm • National Association ofCounty and City Health Officials • Physicians for Social Responsibility

June 25, 2012 The Honorable LisaJackson, Administrator U.S. EnvironmentalProtection Agency Air and Radiation Docket and Information Center Mail Code 2822T 1200 PennsylvaniaAvenue, NW Washington, DC 20460
Re: Docket ID No. EPA-HQ-OAR-2011-0660
DearAdministratorJackson:
We write in support ofstrong standards to reduce power plant carbon pollution. Theseproposed standards canplay an importantroleinreducing therisk of adverse health effects associated with ozone ("smog") on our nation's most vulnerable populations, including children, sick, and the elderly. These standards mustbe finalized for the U.S. EnvironmentalProtectionAgency (EPA) to take an important first step toward ensuring that electricity is produced by the most modern, and leasttoxic, powerplants. Furthermore, we askthat EPAbegin work on a carbonpollution standard for existing powerplants. The Clean Air

### Act requires theEPAto regulate air pollutants ifthey are found to endanger the public's health. The Supreme Courtruled that greenhouse gases (GHG) metthe definition ofair pollutants in the Clean Air Act in 2007 and directed EPAto assess whether or not GHGs do endangerhealth. In 2009, theEPA found that concentrations ofGHG inthe atmosphere endanger the health and welfare ofcurrent and future generations by increasing temperatures and ozone pollution. This increase puts some ofour nation's most vulnerable communities at greater risk for theirhealth.
To regulate apollutant such as GHG, the EPA mustlist categories ofstationary sources that cause or contribute to air pollution, which may adversely impact the public's health orwelfare. Electricity generating units (EGUs) are the largest stationary source ofGHG in the United States. Energy accounts for 86percent oftotal 2009 GHG emissions,' and the electric sectorrepresents 39 percent ofall energy-related C02 

### emissions.ii To regulate emissions from EGUs, the EPA must issue a new source performance standard (NSPS), which includes the achievable, best system to reduce emissions (BESR) considering cost and other factors. Theproposedrule offers a NSPS for greenhouse gas emissions from electric utility generating units, commonlyreferred to as powerplants.

### PeterM. Iwanowicz Assistant VicePresident American Lung Association

DonaldHoppert Director, Government Relations American Public Health Association

Charlotte Collins, J.D. Vice President, Policy and Programs Asthma and Allergy Foundation ofAmerica Gary Cohen Executive Director Healthcare Without Harm
LauraHanen, Chief, Government and Public Affairs National Association ofCounty and CityHealth Officials

Catherine Thomasson, MD Executive Director Physicians for Social Responsibility

Citations

i "Inventory of U.S. Greenhouse Gas Emissions and Sinks: 1990-2009," Report EPA 430-R-11-005, United States Environmental Protection Agency. AprillS, 2011. Table ES-4. il "Inventory of U.S. Greenhouse Gas Emissions and Sinks: 1990-2009," Report EPA430-R-11-005, United States Environmental Protection Agency. AprillS, 2011. Table ES-2. iii Horstman DH, Folinsbee LJ, lves PJ, Abdui-Salaam S, McDonnell WF. Ozone concentration and pulmonary response relationships for 6.6-hour exposures with five hours of moderate exercise to 0.08, 0.10, and 0.12 ppm. Am Rev Respir Dis1990; 42:1158-1163; McDonnell WF, Stewart PW, Smith MV, Pan WK, Pan J. Ozone-induced respiratory symptoms: exposure­ response models and association with lung function. Eur RespirJ1999;14:845-853.
iv Triche EW, GentJF, Holford TR, Belanger K, Bracken MB, Beckett WS, Naeher L, McSharry JE, Leaderer BP. Low-level ozone exposure and respiratory symptoms in infants. Environ Health Perspect2006;114:911-916.

v Mortimer KM, Neas LM, Dockery DW, RedlineS, Tager lB. The effect ofair pollution on inner-city children with asthma. Eur RespirJ2002; 19:699-705. vi HollingsworthJW, Kleeberger SR, FosterWM. Ozone and pulmonary innate immunity. ProcAm Thorac Soc2007;4:240-246.
vii Cakmak, S; Dales, RE; Judek, S. {2006b). Respiratory health effects of air pollution gases: Modification by education and income. Arch Environ Occup Health 61: 5-10. http:!/dx.doi.org/10.3200/AEOH.61.1.5-10; Dales, RE; Cakmak, S; Doiron, MS. {2006). Gaseous air pollutants and hospitalization for respiratory disease in the neonatal period. Environ Health Perspect 114: 1751-1754. http://dx.doi.org/10.1289/ehp.9044; Katsouyanni, K; Samet, JM; Anderson, HR; Atkinson, R; Le Tertre, A; Medina, S; Samoli, E; Touloumi, G; Burnett, RT; Krewski, D; Ramsay, T; Dominici, F; Peng, RD; Schwartz, J; Zanobetti, A. {2009). Air pollution