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Lung Disease in a Global Context A Call for Public Health Action Neil W. Schluger1,2,3 and Ram Koppaka1,2 1World Lung Foundation, New York, New York; 2Columbia University College of Physicians and Surgeons, New York, New York; and 3Mailman School of Public Health, New York, New York

Abstract common lung diseases could have enormous effects on reducing morbidity and mortality. There must be increased As described in a recently released report of the Forum of advocacy from and mobilization of civil society to bring attention International Respiratory Societies, four of the leading causes of to the drivers of lung diseases in the world. The World Health death in the world are chronic obstructive pulmonary disease, Organization should negotiate accords similar to the Framework acute respiratory tract infections, lung cancer, and tuberculosis. A Convention on Tobacco Control to address air pollution and fifth, asthma, causes enormous global morbidity. Not enough occupational exposures. Large increases in funding by progress has been made in introducing new therapies and government agencies and nongovernmental organizations reducing disease burden for these illnesses in the last few decades, around the world are needed to identify technologies that despite generous investments and some notable progress in will reduce health risks while allowing populations to enjoy biomedical research. Four external and modifiable drivers are the benefits of economic development. This paradigm, responsible for a substantial percentage of the disease burden focusedmoreonpublichealththanonindividualmedical represented by the major lung diseases: tobacco, outdoor air treatment, has the best chance of substantial reduction pollution, household air pollution, and occupational exposures to in the burden of lung disease around the world in the next lung toxins. Especially in low- and middle-income countries, but several years. in highly developed economies as well, pressures for economic development and lax regulation are contributing to the continued Keywords: epidemiology; pulmonary disease; prevention; public proliferation of these drivers. Public health approaches to the most health

(Received in original form November 27, 2013; accepted in final form December 27, 2013 ) Author Contributions: N.W.S. conceived the paper, guided the research, and drafted the manuscript. R.K. conceived the paper and reviewed and revised the manuscript in all stages of preparation. Correspondence and requests for reprints should be addressed to Neil W. Schluger, M.D., Division of Pulmonary, Allergy and Critical Care Medicine, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 3, pp 407–416, Mar 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201312-420PS Internet address: www.atsjournals.org

A New Paradigm for disorders. We propose a new framework in population. This approach is likely to be Lung Disease which we consider major lung diseases, more efficient and effective than current which include lung cancer, chronic strategies for addressing these illnesses. As an important new report from the Forum obstructive pulmonary disease (COPD), of International Respiratory Societies and an tuberculosis (TB), asthma, and acute accompanying Perspective in this issues respiratory infections, as primarily The Global Burden of of the Annals by Ferkol and Schraufnagel stemming from only a few extrinsic drivers, Lung Disease describe (1, 2), lung diseases are a major primarily tobacco, indoor and outdoor air cause of global morbidity and mortality. To pollution, and occupational exposures. We COPD achieve significant reductions in the toll assert that by modifying these drivers, we COPD is an umbrella term used to describe they take, a new approach is required that can profoundly affect the incidence, chronic lung diseases, such as emphysema goes beyond simply developing new morbidity, and mortality of diseases that and chronic bronchitis, that cause treatments for each of the major respiratory affect large percentages of the world’s limitations in airflow. It is estimated that

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PERSPECTIVES there are at least 210 million persons in the the WHO put the rate of decline of TB percentage of the world’s population. As world with COPD and that this group of cases at roughly 2% per year for the past a result, for most patients the treatment of conditions causes 3 million deaths annually several years (16, 17). However, the WHO COPD relies mostly on the use of (3). The disease burden from COPD, in has recently called for a rapid increase in bronchodilators and inhaled steroids, contrast to TB, appears to be growing, the rate of decline of the global TB burden medications that have been in use for more despite the development of new if the goal of elimination is to be met by than 30 years (23). The same is true for therapeutics such as long-acting 2050 (18). According to their projection, it asthma (24). Only one new class of antimuscarinic agents, long-acting would take a dramatic increase to at least medications has been introduced in the b-agonists, inhaled corticosteroids, and a 15% annual decrease in cases to achieve United States for the treatment of TB in the phosphodiesterase inhibitors. COPD is the elimination by 2050. Although the pipeline last 40 years, and this drug (bedaquiline) third leading cause of death in the world, for new drugs is longer than it has been in has extremely limited indications (25); the and the burden of COPD is projected to decades and a new drug, bedaquiline, has same is true for delaminid, which was increase substantially in Asia and Africa in successfully been registered for use in recently approved in Europe. Antibacterial the coming decades, mostly as a result of treatment of multidrug-resistant TB, many and antiviral product development for increased tobacco use in those regions. more novel agents will be needed to effect acute respiratory infections has slowed to radical transformation in the way TB is a crawl (although there has been better Asthma treated. Furthermore, the worldwide progress in vaccines for these illnesses) Approximately 235 to 300 million people in emergence of multidrug-resistant TB (26). Although many new the world suffer from asthma (4). Globally, threatens TB control efforts globally and chemotherapeutic agents have been about 200,000 people die of asthma every endangers the lives of hundreds of introduced for lung cancer recently, overall year, with over 80% of these deaths thousands of people (15, 19). survival remains dismal (27). Relying occurring in low- and middle-income on exciting and novel but expensive countries (5, 6). Asthma prevalence is Lung Cancer and Other Cancers of therapeutic approaches to these disorders is increasing worldwide as communities adopt the Respiratory Tree unlikely to result in major reductions in modern lifestyles and become urbanized, Since 1985, respiratory tract malignancies global disease burden from respiratory perhaps through increasing obesity (7, 8), have been the most common cancers in the illnesses in the near- or medium term. interactions with common environmental world, with 1.45 million new cases in 2004, A new paradigm is needed. Although microorganisms, and exposure to outdoor representing 12.7% of all new cancers (3). lung diseases have varied pathogeneses— air pollution (8–11). It is estimated that an They are the most common cause of death cancer, inflammation, infection, and additional 100 million people will have from cancer, resulting in 1.4 million immune dysregulation—the drivers of these asthma by 2025, corresponding to the deaths in 2008, or 18.3% of the world total illnesses are mainly factors extrinsic to the projected increase in the proportion of the deaths due to cancer. Approximately half of human body and related to environmental world’s population living in urban areas. these cases occur in developing countries, exposures that can be modified. These where cases are increasing (20–22). drivers are common to most of these Acute Respiratory Infections Aggressive efforts to control tobacco illnesses, and changes in any of them could Acute respiratory infections—mainly use have been promoted in many regions of lead to significant reduction in the burden pneumonia and influenza—result in over 4 the world (discussed in more detail below), of disease of all of them. Furthermore, the million deaths worldwide each year (12). but the tobacco industry is a resilient and drivers are governed by higher-level They are the leading causes of illness in extraordinarily wealthy and politically processes that are similar across many children and the leading killer among sophisticated foe. Emerging markets in the regions of the globe. We propose children under 5 years of age (13). Acute developing world represent rich targets, and a framework for thinking about this respiratory infections are responsible for at the struggle to reduce the burden of hierarchy of causes of lung disease in hopes least 6% of the world’s disability and death respiratory tract cancers will be prolonged, that such a framework will lead to progress and for 20 to 40% of all hospitalizations despite some notable successes in New York in reducing the burden of morbidity and among children (3, 14). In parts of the City and elsewhere. mortality of lung disease around the world. developing world, the death rate from acute respiratory infections alone is 10 times higher than the global median death rate Lung Disease in a Global Drivers of the Major Causes of from all causes. Context Lung Disease around the World Tuberculosis Over the last several decades, a great deal For 2013, The World Health Organization of time, attention, and money has been There is a large evidence base supporting the (WHO) estimates that there will be spent understanding the cellular, molecular, idea that four drivers—tobacco, indoor approximately 8.7 million new cases of and genetic bases of these illnesses, and air pollution (largely from biomass fuel active TB and 1.4 million deaths (15). This this work has led to a greater understanding burning in cookstoves), outdoor air places TB as the tenth leading cause of of their pathogenesis. Although some pollution, and occupational exposures to death in the world (3). These numbers exciting new therapies have been developed, lung toxins and/or irritants—play a reflect some progress in controlling TB these newer therapeutic modalities are significant role in creating or worsening the around the world, and recent analyses by expensive and out of the reach of a large lung diseases described above (Tables 1 and 2).

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Table 1. Four drivers of chronic lung disease: global burden

Indoor/Household Air Outdoor Air Pollution Occupational-Related Tobacco-Related Illness Pollution Illness

Overview Roughly half of the world’s Industries, households, cars, The workforce that resides in Tobacco use in any form is population relies on and trucks emit complex the developing world dangerous and is the single inefficient and highly mixtures of air pollutants, disproportionately shares in most preventable cause of polluting solid fuels for its many of which are harmful the global burden of death in the world. everyday household energy to health. occupational disease and Cigarette smoking and other needs, most of which is Air pollutants are usually injury. forms of tobacco use coal and biomass (wood, classified into suspended The health of a country’s impose a large and growing animal dung, crop wastes). particulate matter (dusts, workforce, even more than global public health burden. Burning these fuels in open fumes, mists, and smokes), the health of the country’s More than 1.1 billion people fires or simple stoves gaseous pollutants (gases overall population, is critical worldwide smoke, with releases smoke into the and vapors), and odors. to its economic and 82% of smokers residing in home resulting in IAP Of these pollutants, fine national security. low- and middle-income (smoke contains many particulate matter has the Compared with industrial countries. health-damaging pollutants greatest effect on human countries, where single- Smoking prevalence such as particulate matter health. Most fine particulate digit percentages prevail, continues to increase in andCO). matter comes from fuel developing countries many low- and middle- These pollutants mainly combustion from mobile employ about 70% of their income countries, although affect the lungs by causing sources (e.g., vehicles) and economically active many high-income inflammation, reduced from stationary sources population in the countries have witnessed ciliary clearance, and (e.g., power plants, agricultural sector. decreases, mostly in men impaired immune response. industry, households, or Workers in developing Smoking cigarettes has been IAP is a major threat to biomass burning). countries face different scientifically proven to health, particularly for Middle-income and risks in the health transition harm nearly every organ in women and young children, developing countries than do their counterparts the body and to increase who tend to spend more disproportionately in industrialized countries morbidity and mortality. time in the home. experience the disease by being exposed to the Nicotine is the major agent in Approximately 3 billion burden due to pollution. combined and often tobacco responsible for people rely on solid fuels: synergistic risks of addiction and is on par with 2.4 billion on biomass and traditional and emerging other powerfully addictive the rest on coal (most of hazards as well as facing drugs, such as heroin and which are in China) with unregulated and cocaine. variation across regions unprotected exposures to Quitting tobacco use greatly from , 20% in Europe and known hazards such as reduces illness by Central Asia to . 80% in silica and asbestos. immediately providing Sub-Saharan Africa and short-term benefits and South Asia. lowering the risk of all diseases caused by smoking. Disease Three main health outcomes Worldwide, pollution by fine According to a recent In 2011, tobacco use killed burden/ are included in the burden particulate matter is estimate by the almost 6 million people, mortality of IAP: acute lower estimated to cause 9% of International Labor with nearly 80% of these respiratory infections in lung cancer deaths, 5% of Organization among the deaths occurring in low- children under 5 yr, COPD cardiopulmonary deaths, world’s 2.7 billion workers, and middle-income in adults over 30 yr, and and z1% of respiratory at least 2 million deaths per countries. lung cancer due to coal infection deaths, adding up year are attributable to By the year 2030, 8 million exposure in adults over to 7.9 million DALYs based occupational diseases and people will die annually 30 yr. on mortality only. This injuries. from tobacco use. mortality occurs primarily in developing countries. (Continued)

The first three of these drivers share mortality overall (28). For men, smoking, are excellent targets for global public health a common mechanism of producing household air pollution, and ambient air policies. inhaled toxins through incomplete pollution are among the top six risks for combustion. Because these drivers are overall mortality in the world. For women, Tobacco pervasive, interventions to reduce their household air pollution and smoking are Tobacco is the leading preventable cause of impact will undoubtedly have greater among the top five risks for death globally. death in the world (29–32). The link to lung impact than individual treatments for the Extrinsic drivers act together with host cancer and COPD is well known, but in various diseases they cause or worsen. Recent genetic factors to exert a large influence recent years solid evidence has emerged data from the Global Burden of Disease on disease occurrence and manifestations that smoking increases the risk of acute Projectindicatethatthesefourdriversare in any given individual. However, only respiratory infections and TB (33–39). One among the leading risk factors for global extrinsic drivers are modifiable and thus recent clinical trial found that cigarette

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Table 1. (CONTINUED) Indoor/Household Air Outdoor Air Pollution Occupational-Related Tobacco-Related Illness Pollution Illness

About 32% of the burden Researchers have linked WHO estimates that Up to half of all lifetime occurs in Sub-Saharan asthma to urban air occupational exposures smokers will die of Africa, 37% in South Asia, pollution; ozone exposure to workplace lung a disease caused by and 18% in East Asia and as a trigger of asthma carcinogens (e.g., smoking. Pacific. attacks is a particular asbestos, diesel exhaust, Smoking causes almost 80% The poorest regions of the concern. and silica) and leukeogens of male and nearly 50% of world carry by far the Total daily exposure to air (e.g., benzene, ionizing female lung cancer deaths. greatest burden, pollution is determined by radiation, and ethylene Smoking increases the risk of particularly for acute lower people’s time and activity oxide) account for about TB infection and disease, respiratory infections, patterns, and it combines 9% of all cancers of the and 40 million smokers with which accounts for more indoor and outdoor lung, trachea, and TB are expected to die than half of all deaths exposures. bronchus. between 2010 and 2050. attributable to solid fuel Occupational exposures Worldwide, approximately use. account for about 13% of 600,000 nonsmokers died all COPD-related morbidity in 2011 from involuntary and mortality (318,000 exposure to second-hand deaths per year and about smoke. 3.7 million DALYs) and about 11% of asthma morbidity and mortality (38,000 deaths per year and 1.6 million DALYs).

Definition of abbreviations: COPD = chronic obstructive pulmonary disease; DALY = disability adjusted life-year; IAP = indoor/household air pollution; TB = tuberculosis. smoking was the single strongest predictor City, where aggressive measures taken to cardiopulmonary deaths, and about 1% of of the development of active TB in persons reduce smoking include raising taxes and respiratory infection deaths, adding up to with latent infection (40). Recent analyses severely limiting smoking in public places, 7.9 million disability-adjusted life years estimate that abstinence from smoking is has the lowest lung cancer death rates in (DALYs) based on mortality only. This worth 10 years of life (29–32). Simply put, New York State (47). Political corruption mortality occurs primarily in poor populations eliminating tobacco from the world would remains a significant hurdle in and in developing countries (51–56). benefit health more than any other implementing these measures in many Outdoor air pollution is likely to become intervention. More than 1.1 billion people countries around the world (48). an even more serious concern in the worldwide smoke, with 82% of smokers coming years. As the global trend toward residing in low- and middle-income Outdoor Air Pollution urbanization continues, issues related to countries (41). Although many high- Industries, households, cars, and trucks emit outdoor air pollution that have been problems income countries have witnessed decreases complex mixtures of air pollutants, many for developed countries will become growing in smoking rates, overall smoking of which are harmful to health. Air problems in developing countries (57–61). prevalence has continued to increase in pollutants are usually classified as suspended Technologies to reduce pollution at its many low- and middle-income countries. particulate matter (dusts, fumes, mists, and source are plentiful, as are technologies that WHO has succeeded in negotiating smokes), gaseous pollutants (gases and vapors), reduce pollution by filtering it away from a landmark treaty, the Framework and odors (49). Of these pollutants, fine the emission source. These include vehicle- Convention for Tobacco Control, which particulate matter has the greatest effect on specific interventions such as mandating the has been signed by over 171 countries, and human health (50). Most fine particulate use of lead-free gasoline, encouraging the its provisions have been implemented in matter comes from fuel combustion from use of more fuel-efficient vehicles, and/or a number of them. Measures such as mobile sources (e.g., vehicles) and from policies that manage traffic demand or restrictions on tobacco advertising, stationary sources (e.g., power plants, industry, reduce “unnecessary” driving. Power plants restrictions on sale of cigarettes to minors, households, or biomass burning). Indoor and industrial plants that burn fossil fuels limits on smoking in public places, and sources also contribute to outdoor pollution, may use a variety of filtering methods to increasing the cost of cigarettes through and in heavily populated areas, the reduce particles and scrubbing methods to taxation are effective in reducing tobacco contribution from indoor sources can create reduce gases. use and are far more effective than extremely high levels of outdoor air pollution. secondary prevention measures (e.g., Worldwide, pollution by fine particulate Indoor Air Pollution ’ smoking cessation) in reducing the burden matter (PM10 and PM2.5)isestimatedto Over half of the world s population relies on of disease from tobacco (42–46). New York cause 9% of lung cancer deaths, 5% of inefficient and highly polluting solid fuels

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Table 2. Four drivers of chronic lung disease: current interventions and recognized issues

Indoor/Household Air Outdoor Air Pollution Occupational-Related Tobacco-Related Illness Pollution Illness

Current Poverty reduction tends to Technologies to reduce Strategies for controlling Most WHO member states intervention be a key element of IAP pollution at its source occupational disease, have ratified the main models policy, and household are plentiful, as are developed by industrial treaty on tobacco, the energy interventions are technologies that reduce hygienists and others over WHO Framework important factors in several pollution by filtering it away many decades in industrial Convention on Tobacco of the United Nation’s from the emission source. countries, are as fully Control (WHO FCTC). Millennium Development However, getting these applicable in developing Surveillance is essential to Goals. technologies applied countries. support sound policy, and Three general types of in practice requires Strategies include a hierarchy almost half of all countries interventions are those government or corporate of controls in the following have monitoring systems acting on the source of policies that guide decreasing order of enhanced by research pollution (e.g., cooking technical decision-making preference: (1) substituting initiatives such as GYTS, devices, alternative fuels), in the right direction in the major hazards for less GATS, and STEPS. those improving the living form of outright bans, hazardous materials or Tobacco taxation is widely environment (e.g., guidance on desirable processes, (2) applying used, but significant improved ventilation, technologies, or economic engineering controls to differences exist across kitchen design), and those instruments that make separate workers from countries and range from causing changes in user using more polluting hazards that remain, (3) specific or per unit taxes to behaviors (e.g. change in technologies more using administrative controls percentage of wholesale or operation of source, smoke expensive than using less to minimize contact retail prices. A significant avoidance). polluting technologies. uncontrollable by number of studies Policy instruments typically Vehicle-specific engineering, and (4)using demonstrate that increases used: information, interventions include personal protective in taxes on cigarettes and education, and mandating the use of lead- equipment (e.g., respirators). other tobacco products communication; taxes and free gasoline, encouraging Interventions can exist at the lead to significant subsidies; regulation and the use of more fuel- international level (ILO- reductions in cigarette legislation; direct efficient vehicles, and/or WHO Joint Committee on smoking and other expenditures; and research policies that manage traffic Occupational Health to tobacco use. and development demand or reduce provide guidance), the Smoke-free areas: levels of “unnecessary” driving. national level (government- smoke exposure are 90% Power plants and industrial established workplace lower than they are where plants that burn fossil fuels rules and system of smoking is permitted; use a variety of filtering enforcement), the public support is high for methods to reduce workplace level (training, smoking bans in public particles and scrubbing use of safer materials/ places, including indoor methods to reduce gases. equipment), or the and outdoor areas. A Power plants and industrial individual level (use of smoking ban is relatively plants that burn fossil fuels personal protective inexpensive to implement use a variety of filtering equipment). and can produce methods to reduce immediate economic particles and scrubbing benefits. methods to reduce gases. Sustained use of health information and mass media campaigns contributes to population- level decreases in smoking prevalence by increasing knowledge about the harm of tobacco use. Health warnings on product packaging ranging from text to strong graphic warnings Bans or restrictions on tobacco marketing: Only comprehensive bans on all forms of tobacco advertising, marketing, sponsorship, and promotion are effective at reducing population smoking rates. Smoking cessation treatments (Continued)

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Table 2. (CONTINUED) Indoor/Household Air Outdoor Air Pollution Occupational-Related Tobacco-Related Illness Pollution Illness

Identified needs There is a lack of substantive Further research is needed to Effective intervention Needed now is a coherent and issues evidence on the effect of guide regulations and strategies will be those public health strategy reducing IAP exposure on interventions. The issues based on a comprehensive designed to reduce the incidence of acute that were problems for approach to the overall tobacco consumption, lower respiratory infections developed countries are burden rather than those involving international, or the course of COPD in still major problems in addressing the individual regional, national, and local adults. developing countries; burdens of specific actors involved in strategic It is difficult to assess the however, direct application exposures, recognizing planning, policy-oriented amount of disease directly of experiences from that organizational or research, capacity attributed for IAP, developed countries may institutional interventions building, funding especially for chronic not be appropriate (e.g., eliminating asbestos enforcement, and diseases like COPD. because exposed from the workplace) are far evaluation. There is limited populations in developing more effective than those We must identify the problem understanding of the true countries may have targeting individual and scale of the problem exposure–disease a different burden of behaviors (e.g., smoking through monitoring and relationship due to preexisting diseases, cessation). surveillance, including challenges in exposure malnutrition, and other Inadequate data and prevalence, health, measurement: it is very factors related to poverty. reporting systems make economic impact, actions difficult to get personal Research on specific capturing the effect of taken, experience, and exposure measurements, vulnerabilities and on workplace risks lessons learned from other and pollutant readings in relevant dose-response problematic. countries. the house are typically relationships for different In general, attempts to derive Current challenges with used as a proxy. levels of economic evidence-based estimates smoking reduction include There is a lack of information development and for of the burden of disease how to decrease smoking on the relative dangers of various geographic related to occupational in the home and how to the smoke from different conditions would be exposures are likely regulate smoking in valuable for assessing risks to systematically multifamily homes and in types of biomass fuels. fi There is limited and targeting interventions. and signi cantly vehicles with small There is a need to clearly underrepresent the extent children. understanding of how fi clean an alternative fuel de ne the long-term health of the problem. Most countries should be needs to be or how much effects of exposure to air Although the WHO model is doing more to inform their more efficient a new pollution as existing fairly comprehensive, the citizens adequately about cookstove needs to be to literature indicates more absence of data in much of the illnesses and deaths cause a change in adverse effects due to the developing world has caused by tobacco. outcomes. long-term exposure. limited the range of World Bank data reveal that fi The health sector needs to occupational risk factors ample room exists to It is dif cult to manage be involved in urban that WHO could measure, cultural needs. increase tobacco taxes. planning, in planning the and the available data Some evidence shows that location of industries, excluded children under improved national capacity and in planning the age 15 who work. and local needs development of What differs in developing assessment could increase transportation systems countries is the context in the likelihood that tobacco- and needs to encourage which the paradigm used control measures will be those designing public for controlling occupational adopted. transportation and housing disease must be applied Tobacco-control budgets are to ensure that new sources Options are often sharply only a fraction of what is of air pollution are not limited, and knowledge of required. being built into cities. them is even more so.

Definition of abbreviations: COPD = chronic obstructive pulmonary disease; DALY = disability-adjusted life-year; GATS = Global Adult Tobacco Survey; GYTS = Global Youth Tobacco Survey; IAP = indoor/household air pollution; ILO = International Labor Organization; STEPS = WHO STEPwise Approach to Chronic Disease Risk Factor Surveillance; TB = tuberculosis; WHO = World Health Organization. for its everyday household energy needs whotendtospendmoretimeinthehome. Globally, burning of solid fuels is (62). These fuels include coal and biomass Although the evidence base linking biomass estimated to account for nearly 3.5 million (wood, animal dung, and crop wastes). fuel burning and indoor air pollution to deaths annually from indoor air pollution Burning these fuels in open fires or simple specific lung diseases is accumulating, there and an additional 0.5 million deaths owing stoves releases smoke into the home, is convincing evidence that biomass smoke to the contribution of indoor air pollution to resulting in indoor air pollution. Indoor air exposure is a major driver of acute ambient air pollution. Indoor air pollution pollution is a major threat to health, respiratory infections in children and of contributes substantially to DALY) lost as particularly for women and young children, COPD in adults (63–65). well. About 32% of the burden occurs in

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Sub-Saharan Africa, 37% in South Asia, and deaths per year and about 3.7 million reduce exposure to tobacco, indoor air 18% in East Asia and Pacific (66–72). DALYs) and about 11% of cases of asthma pollutants, outdoor air pollutants, and Three general types of interventions (38,000 deaths per year and 1.6 million occupational toxins will have a greater have been proposed to ameliorate lung DALYS) (79–82). impact in reducing illness and death from disease due to indoor air pollution: those Strategies for reducing lung disease respiratory infections, asthma, COPD, and that act on the source of pollution (e.g., from occupational exposures include lung cancer than will individual therapies novel cooking devices, alternative fuels), a hierarchy of controls in the following order provided to patients. In cities such as New those that improve the living environment of preference: replacing major hazards with York, aggressive antitobacco measures have (e.g., improved ventilation, kitchen design), less hazardous materials or processes, reduced smoking rates to 14% of the and those that cause changes in user applying engineering controls to separate population, and this will result in more lives behaviors (e.g., smoke avoidance). The workers from hazards that remain, using saved from lung cancer and COPD than evidence base for assessing the effectiveness administrative controls to minimize contact will any medical therapy currently in hand. of these various interventions is still being uncontrollable by engineering, and using We do not underestimate the difficulty developed, and only one randomized, personal protective equipment (e.g., in reducing the impact of the important controlled trial examining the health respirators) (83, 84). drivers of lung disease in the world. These benefits of interventions aimed at reducing drivers arise to a great degree because of indoor air pollution has been conducted, poverty (e.g., due to a lack of access to clean with mixed results (73). There is a limited Public Health Action to Reduce burning fuels and efficient stoves for understanding of how clean an alternative the Drivers of Mortality and cooking) because of a lack of government fuel needs to be or how much more efficient Morbidity from Lung Disease oversight and regulation (regarding the a new cookstove needs to be to cause around the World sale of tobacco products or worker safety), a change in health outcomes. In addition, or a combination of both (Figure 1). there is a challenge in managing cultural The lung diseases that account for the Additionally, the tobacco industry has needs. Cooking tends to be a deeply greatest global morbidity and mortality are tenaciously fought every effort to reduce the embedded part of the culture in many preventable to a very significant degree. use of its product. Slowly but surely, regions, making it difficult to motivate Although the pathogeneses of the most however, in more and more countries, the individuals to change their cooking important lung diseases in the world are tide is turning, but continuous action is still methods. However, given the large number quite varied, most of them are linked by required. We believe that the same is of people affected, investments in common drivers. Although some of those possible in the areas of pollution and identifying ways to reduce indoor air drivers are primary causes of these lung occupational exposures. Education of the pollution, even if large, are likely to have diseases and some exert their effect public is crucial to mobilize sentiment a tremendous impact on morbidity and secondarily by worsening the course or against these dangers. Advocacy at local, mortality. An excellent discussion of health severity of existing disease, all are important regional, national, and international levels risks and research priorities related to (Figure 1). Thus, it is likely that efforts to is critical. Insistence that industries be household air pollution has recently been published (74), and this report emphasizes the need to build a solid evidence base before new stoves are introduced on a widespread scale.

Occupational Exposures Occupational exposure remains a major cause of lung disease around the world, even as, and perhaps because, a good deal of the global manufacturing base has shifted to developing countries where there is often less regulation of workplace hazards. In the United States, lung disease among firefighters responding to the attack on the World Trade Center in 2001 was a grim reminder of the consequences of exposure to inorganic dust, fumes, and smoke (75–77). WHO has estimated that occupational exposures to workplace lung carcinogens (e.g., asbestos, diesel exhaust, and silica) account for about 9% of cancers of the lung, trachea, and bronchus (78). Occupational exposures account for about 13% of cases of COPD (318,000 Figure 1. The world’s five leading lung diseases and their environmental drivers.

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PERSPECTIVES accountable for the health of those who use worldwide attention given to air pollution diseases. In light of this, WHO should their products must be unceasing. In in Harbin, China, where PM2.5 ensure that the proposed convention circumstances where complete removal of concentrations reached levels of over should be in harmony with the 2011 a particular exposure is not a realistic goal 1,000 mm/m3 and visibility decreased to United Nations Sustainable Energy (it is hard to imagine a world without cars 10 m, also focused attention on this for All initiative. (3) Large increases in or factories), funders of all sorts should problem, which is not unique to China (86). funding by government agencies and support research that will identify the best We call for action in the following nongovernmental organizations around way to reduce exposure as much as possible areas: (1) There must be increased advocacy the world are needed to identify and to protect citizens from what cannot from and mobilization of civil society to technologies (e.g., cleaner cookstoves, be eliminated completely. Governments bring attention to the drivers of lung cleaner cars, and cleaner factories) must be held accountable as well for diseases in the world. Tobacco advocacy is that will reduce health risks while protecting the lives of their citizens at least an excellent model to follow. Civil society allowing populations to enjoy as much as they protect the commercial groups, including nongovernmental the benefits of economic growth and interests of large industries. Monitoring and organizations, must monitor and hold development. surveillance of the burden of disease and of accountable governments and industries Failure to protect vulnerable actions to reduce or eliminate the various that are not addressing these problems of populations from preventable illnesses is drivers of lung disease must be constant. indoor and outdoor air pollution and an abrogation of societal responsibility. This cannot be entrusted to industry or occupational causes of lung disease. (2) The We hope that the framework we have governments alone but should be WHO should negotiate accords similar to proposed will help focus on actions that performed with partners from civil society. the Framework Convention on Tobacco can be taken to reduce lung diseases by Rapidly developing countries are especially Control to address air pollution and addressing their root cause. n vulnerable because the pressure to occupational exposures. These accords industrialize to improve the economic lot of would commit governments to identify Author disclosures are available with the text citizens often trumps the responsibility to specific measures that they would take to of this article at www.atsjournals.org. regulate industries and activities whose reduce airborne pollutants and toxins. Two activities create unhealthy living conditions. of the drivers of lung disease are the result Acknowledgment: The authors thank research The air pollution problem in Beijing is an of energy policies that place vulnerable assistant Cynthia Revol, M.P.H., for help with this example of this (85), and the recent populations at unique risks for respiratory project

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