Response to Dr.

Tony Coxs Wall Street Journal opinion piece of

9/2/2015

Indra Frank, MD, MPH

Environmental Health Project Director
Hoosier Environmental Council
9/3/2015

Dr. Cox accurately points out that on average across the US asthma rates have
continued to rise while air quality, including ozone levels, have improved (Cox,
2015). However, he does not take into account the distinction between the asthma
rate and the incidence of asthma attacks. The asthma rate is what percent of the
population has a diagnosis of asthma. The incidence of asthma attacks refers to the
number of attacks among those who have a diagnosis of asthma. An asthma attack
is an episode of constricted airways and difficult breathing that is disabling and can
be severe enough to be life threatening. In the US there are approximately 500,000
hospitalizations for asthma each year (Silverman, 2010). A person who can control
their asthma through reduced exposures to respiratory irritants and regular use of
medications may have very few asthma attacks. If asthma in a population is well
controlled, there is a lower incidence of asthma attacks.
Ozone increases the incidence of asthma attacks among those who already have a
diagnosis of asthma. Ozone is a highly reactive molecule and it is through this
reactivity that it is a potent irritant of the respiratory tract (McDonnell, 2012). By
irritating and inflaming the respiratory tract, it triggers asthma attacks. Higher
ozone levels have been shown to increase the number of asthma attacks and the
number of emergency room visits (Ito, 2007) and hospital admissions for asthma
(Silverman, 2010).
Ozones irritation of the respiratory tract means that o zone makes most lung

diseases worse including bronchitis, emphysema, and pneumonia, as well as

asthma. Ozone has been shown to increase emergency room visits for
respiratory diseases (Tolbert, 2007), and higher ozone levels increase the risk
of death due to respiratory causes (Jerrett, 2009). It has been estimated that
reducing ambient ozone to 70 ppb could save up to 4,130 premature deaths
each year in the US (Berman, 2012).
With the proposed revision of the ozone standard, the EPA is implementing
the Clean Air Act as it was written by Congress. They are required by the
Clean Air Act to review the ozone standard every five years and to set the
standard to protect public health.

Dr. Cox expresses concern that EPAs current proposal undermines the
credibility of regulatory science; however, it could perhaps more accurately
be argued that the current proposal will bring the ozone standard into better
alignment with the science. The last time the standard was revised was in
2008. At that time EPA's Clean Air Science Advisory Committee unanimously
recommended that the EPA set the ozone standard between 60 and 70 ppb
based on their review of 1700 studies on the health effects of ozone.
Despite that strong recommendation, the EPA set the ozone standard at 75.
It has been seven years since the ozone standard was set at 75. So the EPA
is behind on its congressionally mandated review, and there is now a courtordered deadline for the next revision of the ozone standard. Since the last
revision of the standard in 2008, there have been more than 1000 additional
studies on ozone and health including studies showing harm at the current
ozone standard of 75 parts per billion. Only a small subset of the scientific
literature is cited in this reply. For a more comprehensive list of references
see the EPAs Health Risk and Exposure Assessment for Ozone published in
August 2014.
Finally, Dr. Cox argues that the proposed ozone standard will hurt the
economy, but evidence shows that cleaner air is better for the economy. The
EPA estimates that lowering the ozone standard from 75 to 70 will produce
$6.4 - $13 billion in health benefits but cost $3.9 billion to implement (EPA,
2014). Cutting ozone to 65 will produce even greater benefits. Long term
trends have clearly shown that air quality regulations in the US have not hurt
the economy. In fact, while overall air emissions have dropped 62% since
1980, the gross domestic product has gone up 145% (EPA, n.d.). On a micro
level, communities have an abundant suite of off-the-shelf, cost-effective
tools to reduce ozone levels, from ozone education programs to fostering
more carpools to air emissions testing for older cars, to spurring more tree
planting. These affordable, community-level programs improve overall
quality of life, which strengthens, not weakens, a communitys economy.
References
Berman, J.D, et al. (2012). Env Health Perspect 120:1404-1410.
Cox, T. (2015, Sept 2). The EPAs Next Big Economic Chokehold. The Wall Street
Journal
EPA (2014, August) Health Risk and Exposure Assessment for Ozone. Available at
http://nepis.epa.gov/Exe/ZyNET.exe/P100KBUF.txt?
ZyActionD=ZyDocument&Client=EPA&Index=2011%20Thru
%202015&Docs=&Query=&Time=&EndTime=&SearchMethod=1&TocRestrict=n&To
c=&TocEntry=&QField=&QFieldYear=&QFieldMonth=&QFieldDay=&UseQField=&Int
QFieldOp=0&ExtQFieldOp=0&XmlQuery=&File=D%3A%5CZYFILES%5CINDEX

%20DATA%5C11THRU15%5CTXT
%5C00000011%5CP100KBUF.txt&User=ANONYMOUS&Password=anonymous&Sort
Method=h%7C&MaximumDocuments=1&FuzzyDegree=0&ImageQuality=r75g8/r75g8/x150y150g
16/i425&Display=p
%7Cf&DefSeekPage=x&SearchBack=ZyActionL&Back=ZyActionS&BackDesc=Resul
ts%20page&MaximumPages=1&ZyEntry=1
EPA (2014). Groundlevel ozone overview.
http://www.epa.gov/ozonepollution/pdfs/20141125fs-overview.pdf
EPA (n.d.). Air Quality Trends.

http://www.epa.gov/airtrends/aqtrends.html#comparison).
Ito (2007) J Exposure Science and Env Epi, 17 suppl 2, S45
Jerrett,M. et al (2009). New Eng J Med 360(11): 1085-1095.
McDonnell, Stewart, and Smith (2010). Inhalation Toxicology, 22(2):160
Tolbert (2007) J Exposure Science and Env Epi 17 suppl 2 S29
Silverman (2010) J Allergy Clinical Immunology 125(2):367