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Air pollution should be listed on death certificates - The BMJ

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<meta name="DC.Description" content="We need national guidance for clinicians on the inclusion of air pollution on death certificates, argue Laura-Jane Smith, Mike Tomson, and Kath Brown

Air pollution is often framed as a modern problem, but as early as Roman times it was understood that polluted air affects human health. In AD 61, Seneca wrote of Rome “No sooner had I left behind the oppressive atmosphere of the city and that reek of smoking cookers … than I noticed the change in my condition.”1 In AD 535, emperor Justinian declared clean air a right of all humans: “By the law of nature these things are common to mankind—the air, running water, the sea.”2 But it took until July 2022 for the United Nations to declare access to a clean and healthy environment a universal human right.3 In the UK, the Clean Air (Human Rights) Bill, also known as Ella’s Law, is a private members’ bill which would enshrine in law a right to clean air. At the time of writing, the bill is awaiting its second reading in the House of Commons.4

A wealth of mechanistic and epidemiological data link air pollution to conditions throughout our lives: intrauterine growth retardation, pregnancy loss, developmental disorders, …" />
<meta name="DC.Contributor" content="Laura-Jane Smith" />
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<meta name="DC.Contributor" content="Kath Brown" />
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<meta name="citation_reference" content="citation_title=The basic environmental history.;citation_author=. Seneca;citation_pages=145;citation_volume=Vol 4;citation_year=2014" />
<meta name="citation_reference" content="Justinian. Thatcher OJ, ed., The Library of Original Sources (Milwaukee: University Research Extension Co, 1907), (vol III: The Roman World), 100-66." />
<meta name="citation_reference" content="United Nations. UN General Assembly resolution: The human right to a clean, healthy and sustainable environment. 76th session. Agenda item 74(b). 2022. https://digitallibrary.un.org/record/3982508?ln=en&quot; />
<meta name="citation_reference" content="UK House of Commons. Clean Air (Human Rights) Bill [HL] Private Members’ bill (starting in the House of Lords) Session 2022-23. https://bills.parliament.uk/bills/3161&quot; />
<meta name="citation_reference" content="Holgate ST. ‘Every breath we take: the lifelong impact of air pollution’—a call for action. Clin Med 2017;17.1:8." />
<meta name="citation_reference" content="citation_journal_title=Lancet;citation_author=PJ. Landrigan;citation_author=R. Fuller;citation_author=NJR. Acosta;citation_title=The Lancet Commission on pollution and health;citation_pages=462-512;citation_volume=391;citation_year=2018;citation_pmid=29056410;citation_doi=10.1016/S0140-6736(17)32345-0" />
<meta name="citation_reference" content="Whitty C. Chief Medical Officer’s annual report 2022: air pollution. 2022. https://www.gov.uk/government/publications/chief-medical-officers-annua…; />
<meta name="citation_reference" content="citation_journal_title=Environment and Planning A;citation_journal_abbrev=Environ Plan A;citation_author=G. Mitchell;citation_author=D. Dorling;citation_title=An Environmental Justice Analysis of British Air Quality;citation_pages=909-929;citation_volume=35;citation_year=2003;citation_issue=5;citation_doi=10.1068/a35240" />
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<meta name="citation_reference" content="European Parliament. Air pollution: MEPs want stricter limits to achieve zero pollution by 2050. 2023. https://www.europarl.europa.eu/news/en/press-room/20230911IPR04915/air-…; />
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<meta name="citation_reference" content="Barlow P. Regulation 28: Report to prevent future deaths. 2021. https://www.judiciary.uk/wp-content/uploads/2021/04/Ella-Kissi-Debrah-2…; />
<meta name="citation_reference" content="Gentleman A. How anti ULEZ campaigners misused air pollution finding in Ella Adoo Kissi Debrah’s death. Guardian 2023 Sep 16. https://www.theguardian.com/environment/2023/sep/16/how-anti-ulez-campa…; />
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Air pollution is often framed as a modern problem, but as early as Roman times it was understood that polluted air affects human health. In AD 61, Seneca wrote of Rome “No sooner had I left behind the oppressive atmosphere of the city and that reek of smoking cookers … than I noticed the change in my condition.”1 In AD 535, emperor Justinian declared clean air a right of all humans: “By the law of nature these things are common to mankind—the air, running water, the sea.”2 But it took until July 2022 for the United Nations to declare access to a clean and healthy environment a universal human right.3 In the UK, the Clean Air (Human Rights) Bill, also known as Ella’s Law, is a private members’ bill which would enshrine in law a right to clean air. At the time of writing, the bill is awaiting its second reading in the House of Commons.4

A wealth of mechanistic and epidemiological data link air pollution to conditions throughout our lives: intrauterine growth retardation, pregnancy loss, developmental disorders, …" />
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Air pollution is often framed as a modern problem, but as early as Roman times it was understood that polluted air affects human health. In AD 61, Seneca wrote of Rome “No sooner had I left behind the oppressive atmosphere of the city and that reek of smoking cookers … than I noticed the change in my condition.”1 In AD 535, emperor Justinian declared clean air a right of all humans: “By the law of nature these things are common to mankind—the air, running water, the sea.”2 But it took until July 2022 for the United Nations to declare access to a clean and healthy environment a universal human right.3 In the UK, the Clean Air (Human Rights) Bill, also known as Ella’s Law, is a private members’ bill which would enshrine in law a right to clean air. At the time of writing, the bill is awaiting its second reading in the House of Commons.4

A wealth of mechanistic and epidemiological data link air pollution to conditions throughout our lives: intrauterine growth retardation, pregnancy loss, developmental disorders, …" />
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<div class="highwire-article-citation highwire-citation-type-highwire-article node1088066" data-node-nid="1088066" id="node1088066--2465824730" data-pisa="bmj;383/oct04_5/p2162" data-pisa-master="bmj;bmj.p2162" data-apath="/bmj/383/bmj.p2162.atom"><cite class='highwire-cite highwire-citation-bmj-article-top'>

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<h1 class="highwire-cite-title" id="page-title">Air pollution should be listed on death certificates</h1>
<span class='highwire-cite-journal'>BMJ</span>
<span class='highwire-cite-published-year'>2023</span>;
<span class='highwire-cite-volume-issue'>383</span>
<span class='highwire-cite-doi'> doi: <a href="https://doi.org/10.1136/bmj.p2162">https://doi.org/10.1136/bmj.p2162</a…;
<span class='highwire-cite-date'>(Published 04 October 2023)</span>
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<div class="highwire-markup"><div xmlns="http://www.w3.org/1999/xhtml&quot; data-highwire-cite-ref-tooltip-instance="highwire_reflinks_tooltip" class="content-block-markup" xmlns:xhtml="http://www.w3.org/1999/xhtml"><div class="article fulltext-view "><span class="highwire-journal-article-marker-start"></span><div class="contributors"><ol class="contributor-list" id="contrib-group-1"><li class="contributor" id="contrib-1"><span class="name">Laura-Jane Smith</span><span class="contrib-role">, consultant respiratory physician</span><a id="xref-aff-1-1" class="xref-aff" href="#aff-1">1</a>, </li><li class="contributor" id="contrib-2"><span class="name">Mike Tomson</span><span class="contrib-role">, director</span><a id="xref-aff-2-1" class="xref-aff" href="#aff-2">2</a>, </li><li class="last" id="contrib-3"><span class="name">Kath Brown</span><span class="contrib-role">, director</span><span class="contrib-role">, GP</span><a id="xref-aff-2-2" class="xref-aff" href="#aff-2">2</a><a id="xref-aff-3-1" class="xref-aff" href="#aff-3">3</a></li></ol><ol class="affiliation-list"><li class="aff"><a id="aff-1" name="aff-1"></a><address><sup>1</sup>South London</address></li><li class="aff"><a id="aff-2" name="aff-2"></a><address><sup>2</sup>Greener Practice</address></li><li class="aff"><a id="aff-3" name="aff-3"></a><address><sup>3</sup>Cornwall</address></li></ol></div><div class="teaser"><p id="p-1">We need national guidance for clinicians on the inclusion of air pollution on death certificates, argue Laura-Jane Smith, Mike Tomson, and Kath Brown</p></div><p id="p-2">Air pollution is often framed as a modern problem, but as early as Roman times it was understood that polluted air affects human health. In AD 61, Seneca wrote of Rome “No sooner had I left behind the oppressive atmosphere of the city and that reek of smoking cookers … than I noticed the change in my condition.”<a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a> In AD 535, emperor Justinian declared clean air a right of all humans: “By the law of nature these things are common to mankind—the air, running water, the sea.”<a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a> But it took until July 2022 for the United Nations to declare access to a clean and healthy environment a universal human right.<a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a> In the UK, the Clean Air (Human Rights) Bill, also known as Ella’s Law, is a private members’ bill which would enshrine in law a right to clean air. At the time of writing, the bill is awaiting its second reading in the House of Commons.<a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></p><p id="p-3">A wealth of mechanistic and epidemiological data link air pollution to conditions throughout our lives: intrauterine growth retardation, pregnancy loss, developmental disorders, asthma, diabetes, ischaemic heart disease, dementia, strokes, and lung cancer.<a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5</a> The Lancet Commission on pollution and health<a id="xref-ref-6-1" class="xref-bibr" href="#ref-6">6</a> estimated that more than 6.5 million deaths a year globally are attributable to air pollution. This number is increasing because of the rising use of fossil fuels. There is no safe level of air pollution, and exposure is often lifelong.<a id="xref-ref-7-1" class="xref-bibr" href="#ref-7">7</a> As with so many health injustices, those most affected contribute least to the problem.<a id="xref-ref-8-1" class="xref-bibr" href="#ref-8">8</a></p><p id="p-4">Action on air pollution has failed to keep pace with evidence. The World Health Organization’s global air quality guidelines are evidence based and propose increasingly strict targets.<a id="xref-ref-9-1" class="xref-bibr" href="#ref-9">9</a> No country has a comprehensive plan to meet these targets. In September 2023 the European Parliament voted on a revised law to improve air quality across the European Union by aligning with WHO recommended limits on PM2.5, nitrogen dioxide, sulphur dioxide, and ozone. This is a positive step, but sadly the commitment was pushed back from 2030 to 2035.<a id="xref-ref-10-1" class="xref-bibr" href="#ref-10">10</a> The latest UK government targets represent too little ambition, too late.<a id="xref-ref-10-2" class="xref-bibr" href="#ref-10">10</a> It has been 10 years since the death of Ella Adoo-Kissi-Debrah, the first person to have air pollution listed on her death certificate: 1(a) acute respiratory failure, 1(b) asthma, 1(c) air pollution exposure.<a id="xref-ref-11-1" class="xref-bibr" href="#ref-11">11</a> This followed a second inquest and tireless campaigning by her mother, Rosamund. The contribution of air pollution was proved beyond doubt by painstaking research which showed Ella’s multiple admissions to hospital with severe asthma correlated with spikes in air pollution near her inner London home. Ella was exposed to levels “constantly exceeding” EU limits in the three years prior to her death. Children living in London, and other cities, continue to be exposed to such high levels of air pollution, and some have died from asthma since 2020, yet no one else has had air pollution included as a contributing cause of death. This causes confusion for the public, and allows those opposed to public health interventions to misuse statistics on cause of death to minimise the problem of air pollution.<a id="xref-ref-12-1" class="xref-bibr" href="#ref-12">12</a></p><p id="p-5">Death certificates serve multiple purposes: they explain the cause of death to the family, allow them to register the death, and are a public record accessed by researchers, lawyers, and national bodies. It is important that a major source of preventable death should appear in our national statistics as this underpins decision making. Death certification is a key way in which data on cause of death are collected. A death is often the consequence of multiple short and long term causes, so writing a death certificate is dependent on the doctor’s clinical judgment. Government advice is provided on the inclusion of smoking, alcohol, and occupational exposures, but not on when to include air pollution.<a id="xref-ref-13-1" class="xref-bibr" href="#ref-13">13</a></p><p id="p-6">Given this gap, a group of medical professionals (Members of Greener Practice, including the authors and health professionals in the Respiratory Greener Practice Network) have written to coroners across the country to seek advice on when it would be appropriate to include air pollution on death certificates. A wide variety of responses was received. Worryingly, they revealed that coroners lack awareness of high levels of local air pollution and their health effects, and lack knowledge that most areas in the UK exceed the WHO limits. A common theme in the responses was that “a death caused by or contributed to by air pollution would not meet the requirement that it was due to natural causes” as it is not included on the list of natural causes of death prescribed by the Royal College of Pathologists (RCPath).<a id="xref-ref-14-1" class="xref-bibr" href="#ref-14">14</a> Coroners would therefore be obliged to open an investigation and inquest. It is illogical that death from tobacco smoke exposure is considered a “natural cause,” whereas death from fossil fuel smoke exposure is not. Smoking and air pollution are both causes of unnatural death which should be treated in the same way on death certificates.<a id="xref-ref-15-1" class="xref-bibr" href="#ref-15">15</a></p><p id="p-7">We are calling for:</p><ul class="list-unord " id="list-1"><li id="list-item-1"><p id="p-8">National guidance on the inclusion of air pollution on death certificates for clinicians</p></li><li id="list-item-2"><p id="p-9">A review of when inquests should be triggered or whether the RCPath list of “natural” causes of death should be amended</p></li><li id="list-item-3"><p id="p-10">Education for coroners, medical examiners, and healthcare professionals on the significant contribution of air pollution to deaths.</p></li></ul><p id="p-11">Only by counting the consequences can we expose the harms from air pollution and create the widespread awareness needed to bring about policy change and protect the right of every person to breathe clean air.</p><div class="section fn-group" id="fn-group-1"><h2>Footnotes</h2><ul><li class="fn-conflict" id="fn-1"><p id="p-12">Competing interests: LJ Smith is a consultant respiratory physician in south London and the BTS Trustee for Sustainability. She campaigns on air quality with MedAct and is part of the Healthy Air Coalition UK. Mike Tomson is a clinically retired GP, director of Greener Practice, and a trustee of the Centre for Sustainable Healthcare. Kath Brown is a GP in Cornwall, director of Greener Practice, and a Global Action Plan Clean Air champion.</p></li><li class="fn-other" id="fn-2"><p id="p-13">Provenance and peer review: commissioned, not externally peer reviewed.</p></li></ul></div><div class="section ref-list" id="ref-list-1"><h2>References</h2><ol class="cit-list"><li><a class="rev-xref-ref" href="#xref-ref-1-1" title="View reference 1 in text" id="ref-1">↵</a><div class="cit ref-cit ref-book" id="cit-383.oct04_5.p2162.1"><div class="cit-metadata"><ol class="duplicate"><li><span class="cit-ed"><span class="cit-name-surname">Agnoletti</span> <span class="cit-name-given-names">M</span></span>, </li><li><span class="cit-ed"><span class="cit-name-surname">Serneri</span> <span class="cit-name-given-names">SN</span></span></li></ol><ol class="cit-auth-list"><li><span class="cit-auth"><span class="cit-name-surname">Seneca</span></span></li></ol><cite>. 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<div class="highwire-article-citation highwire-citation-type-highwire-article node1088066--3" data-node-nid="1088066" id="node1088066--41676592605" data-pisa="bmj;383/oct04_5/p2162" data-pisa-master="bmj;bmj.p2162" data-apath="/bmj/383/bmj.p2162.atom"><div id="jnl_bmj_custom_authors" style="display: none;"><span data-delta="0"><span class="nlm-given-names">Laura-Jane</span> <span class="nlm-surname">Smith</span> <span class="nlm-role">consultant respiratory physician</span></span>, <span data-delta="1"><span class="nlm-given-names">Mike</span> <span class="nlm-surname">Tomson</span> <span class="nlm-role">director</span></span>, <span data-delta="2"><span class="nlm-given-names">Kath</span> <span class="nlm-surname">Brown</span> <span class="nlm-role">director</span><span class="nlm-role">GP</span></span></div>
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<span class="highwire-cite-title article-title">Air pollution should be listed on death certificates</span>

<span class="highwire-cite-metadata" ><span class="highwire-cite-metadata-journal highwire-cite-metadata">BMJ </span><span class="highwire-cite-metadata-date highwire-cite-metadata">2023; </span><span class="highwire-cite-metadata-volume highwire-cite-metadata">383 </span><span class="highwire-cite-metadata-volume highwire-cite-metadata">:p2162 </span></span>

<span class="article-doi" >doi:10.1136/bmj.p2162</span>

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Related Knowledge Center: Climate economics

State of Play

Climate change is now a driver of the world’s economy. The impact is profound:

  • Catastrophic weather events — hurricanes, floods, droughts, high temperatures — are more frequent and more extreme. The cost can be measured in both the initial damage caused and the longer-term impact on the economy.
  • Vulnerable communities are increasing climate-related investments, hardening infrastructure and taking other protective measures.
  • Investment in carbon capture and storage technologies is increasingly rapidly.
  • Governments are making investments and crafting regulations to reduce emissions of carbon dioxide and other greenhouse gases. 

On top of all of this is the cost of uncertainty. As the Fourth National Climate Assessment, released in 2018 by the U.S. Global Change Research Program, says, “The assumption that current and future climate conditions will resemble the recent past is no longer valid.”

More informationabout Climate economics