Air pollution: consequences and actions for the UK, and beyond
Venue: The Lancet

"The time has now arrived to take air pollution, as currently encountered in the UK, much more seriously. It should be considered a major public health problem. It is our view that this requires urgent, determined, and multidisciplinary action that is long overdue. Indeed, if we do not act now, our children and generations to follow will be those who suff er from our failure to act." So concludes Stephen Holgate, chair of the Royal College of Physicians/Royal College of Paediatrics and Child Health (RCP/RCPCH) Working Party on Air Pollution, in his preface to one of the clearest calls to action to advance the UK's environmental health. The report, Every Breath We Take: The Lifelong Impact of Air Pollution, published this week, comes at a good time. At COP21 in Paris in December, 2015, world leaders recognised the importance of tackling environmental issues, such as air pollution. The evidence for the importance of air pollution as a risk factor for human disease has been growing for several years. Air pollution is conventionally divided into two categories indoor (household) and outdoor (ambient) Both refer to exposure to particulate matter with a diameter of <2*5 mm (PM2*5) Household air pollution concerns people who mostly use solid fuels, such as coal, wood, or charcoal. 4*3 million people die annually from household air pollution, around 3*3 million of whom live in Asia. The major causes of these deaths are stroke, ischaemic heart disease, chronic and acute lung disease, and lung cancer. WHO estimates that 3*7 million people die annually from ambient air pollution, again most of whom (2*6 million) live in Asia. The ranking of causes of deaths remains broadly similar. Most of those at risk of ambient air pollution live in urban settings. The RCP/RCPCH report succeeds admirably in contextualising these global fi gures for the UK. For example, it goes further than PM2*5 and examines the broader range of pollutants the UK population endures. The report provides a very comprehensive and up todate review of air pollution and its consequences on health. 29 000 people die annually from exposure to particulate matter. That number rises to 40 000 when other pollutants, such as nitrogen dioxide, are considered. A strength of the report is the lifelong approach. Harms to health occur throughout the entire life course, but pregnancy and childhood are especially vulnerable periods with mounting evidence for eff ects on long term growth and cognitive ability. Moreover, the report devotes an entire chapter to the most vulnerable in society; the risks of air pollution are not evenly distributed, and those living in areas of deprivation are especially at risk. Another important aspect of the report is its chapter on the heavy cost of pollution: the annual costs to society from air pollution are estimated to be more than PS20 billion. As highlighted in the recent Lancet Commission on Health and Climate Change there are huge opportunities for societies and from co benefi ts when tackling air pollution. The report makes 14 recommendations. These include expanding cycle training and cycle networks; giving power to local authorities to close roads to reduce traffi c volumes, especially near schools; and calling on the National Health Service to lead by example. Recommendations 7 and 8 tackling inequality and protecting those most at risk lack specifi city and precision. Recommendations 10 15 call for more research. The report falls short in one area accountability. A recommendation calls for "monitoring air pollution eff ectively" But, as The Lancet has argued for many years, monitoring alone is a weak response and invariably fails. Instead, accountability making sure that political promises and commitments are delivered must go beyond monitoring. Accountability includes mechanisms for participatory, transparent, and democratic review, and a means to convert the results of that review into action. No such mechanism is proposed by the RCP/RCPCH Working Party on Air Pollution, potentially wounding prospects for the success of its recommendations. Will this RCP/RCPCH report have the same impact as the RCP's 1962 report, Smoking and Health, which led to fi ve decades of action on tobacco control? The RCP/RCPCH report on air pollution comes at a propitious global moment the momentum of evidence will give their recommendations added force. The challenge will be to translate their proposals into a political process, about which the report is too timid thereby missing a signifi cant opportunity. The Royal Colleges should have proposed a national accountability mechanism. Every Breath We Take: The Lifelong Impact of Air Pollution is an important statement of evidence and intent. But alone it might not be enough to make the diff erence it hopes to see. The Lancet For the report see https:/www. rcplondon.ac.uk/projects/ outputs/every breath we takelifelong impact air pollution