May 26, 2020 — Acknowledgments. The American Lung Association “State of the Air” 2021 is the result of the hard work certification-program-202103.pdf .
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2 Table of Contents About This Repor˜ Acknowledgments .˜ Why fiState of the Airfl? ˚ Methodology ˛Key Findings Ozone Trends .˝˙ Shorˆ-term Parˆicle Pollution Trends ..˝˜ Year-Round Parˆicle Pollution Trends .˝ˇ Populations at Risk ..˝˛ Most Polluted Places to Live ˝˘ Cleanest Places to Live .˝˘ What Needs to Be Done Heal˜h Impact of Air Pollution Healˆh E ects of Ozone . Healˆh E ects of Parˆicle Pollution .˙˝ People at Risk .˙˚ Emerging Threats .˙˛Protect Yoursel˚ and Your Community Reduce Your Personal Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Improve the Air in Your Community .. Promote Clean Air Policies .˜˝Data Tables Data Table Notes .˜˚ Table ˝: Populations at Risk by Grade and by Pollutant ..˜ˇ Table ˙ a-c: Populations at Risk in ˙ˇ Most Polluted Cities, by Pollutant .˜˛-˜˘ Table ˜ a-c: Cleanest Cities, by Pollutant .. Table ˚ a-c: Cleanest Counties, by Pollutant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ˚˙-˚˚ State Data Tables .˚ˇ

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3 Acknowledgments The American Lung Association fiState of the Airfl 2021 is the resulˆ of the hard work of many .We would like to thank: Allen S. Lefohn of A .S.L. and Associates, who compiled the data; John Balmes, M .D., who served as experˆ volunteer reviewer for the healˆh impacts section; Randy Tibbotˆ of Our Designs, Inc ., who designed the print version; Doug Manners, a volunteer writer/editor in Denver, CO, who helped with story collection, and storyˆellers Rebecca B ., Alex S. and Maria J.Great appreciation goes to the National Association of Clean Air Agencies, which strove to make this reporˆ betˆer through comments, review and concerns . Many of its members reviewed and commented on the individual state data presented and the methodology to make this reporˆ more accurate . We also appreciate the assistance of members of the Association of Air Pollution Control Agencies, who also reviewed data from their states . We appreciate them all as our parˆnertion . This reporˆ should in no way be construed as a comment on the work any of these agencies do . fiState of the Airfl 2021 would not have been possible but for the twenty years of inspiration, dedication and hard work of the late Janice E . Nolen. We miss her every day . The American Lung Association assumes sole responsibility for the content of the American Lung Association fiState of the Airfl 2021 .American Lung Association 55 W. Wacker Drive, Suite 1150 Chicago, IL 60601 Advocacy Of˜ice 1331 Pennsylvania Avenue, NW, Suite 1425 Norˆh Washington, DC 20004 202-785-3355 Lung .org/sota Copyright ©2021 by the American Lung Association .American Lung Association and State of the Air are registered trademarks of the American Lung Association .

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4 About This Repor˜ Why fiState of the Airfl? The Clean Air Act requires the U .S. Environmental Protection Agency (EPA) to set healˆh- based limits, called National Ambient Air Quality Standards (NAAQS), for six dangerous outdoor air pollutants: ozone, parˆiculate matˆer, nitrogen oxidesxide, carbon monoxide and lead . The NAAQS identify what is considered a safe level of the pollutants to breathe, based on the most recent healˆh and medical science . The standards alerˆ the public when pollution levels place Americans™ healˆh at risk, and require Tribes, states and local governments to take steps to reduce emissions to atˆain the standards . The standards are also used to inform families with children, seniors, people with lung or hearˆ disease and others when air pollution levels are dangerous through color- coded air quality alerˆs, so they can take steps to limit their exposure . Under the Clean Air Act, the standard must be based solely on what is needed to protect healˆh . fiState of the Airfl looks at the two most widespread and dangerous pollutants oz parˆiculate matˆer . Setˆing national healˆh-based standards and requiring states that violate the standards to enact plans to clean up their air pollution problems have been a great beneo the public healˆh of the nation . Since the Clean Air Act was passed in 1970, emissions of criteria pollutants, including ozone and parˆicle pollution, have fallen by 77%, according to EPA . But as fiState of the Airfl 2021 shows, millions of Americans are still breathing unhealˆhy air . Purpose and hist ory of fiState of the Airfl In the year 2000, the American Lung Association launched its annual fiState of the Airfl reporˆ to provide the public with easy-to-understand information about the quality of the air in their local communities based on the credible data and sound science that EPA is required to use to set the air quality standards . Fst several years, fiState of the Airfl focused solely on ozone pollution and included data for 5 populations at increased riskŠchildren, older adulˆs, children with asthma, adulˆs with asthma and people with emphysema . In 2004, changes to the air quality standards and the deployment of air pollution monitoring enabled the addition of shorˆ-term and year-round parˆicle pollution to the reporˆ . Over time, acvidence has shoom both ozone and parˆicle pollution among other groups of vulnerable individuals . fiState of the Airfl has accommodated this new information by gradually adding populations-at-risk categories to its reporˆing . fiState of the Airfl 2021 now includes data for 10 vulnerable groups .Since its inception, fiState of the Airfl has been tremendously successful in raising awareness about ozone and parˆicle pollution, the two most dangerous and pervasive air pollutants nationwide . The American Lung Association is proud and grateful that the public, the media, clean air advocates and decision-makers have used this reporˆ every day, year afˆer year, to call atˆention to the work that remains to be done to protect the healˆh of all Americans from the threat of air pollution .

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5 About This Repor˜ How fiSt ate of the Airfl can be used We write and release fiState of the Airfl every year to make information on air quality and healˆh clear and accessible to everyone . We show the progress each community has made and how much more needs to be done to achieve healˆhy air . In this reporˆ, you™ll ormation on local air quality nationwide . You™est roundup of the research on how air polluects healˆh . With these tools, you can help keep your lungs and your family™s lungs safer from unhealˆhy air . This reporˆ also includes ideas for how you can become a champion for clean air . First, we have suggestions for concrete actions you can take to reduce your own contributions to air pollution and climate change . And second, we invite you to take advocacy action with the American Lung Association . Your voice is pow you tell your leaders that your lungs depend on stronger limits on air pollution, you make a compelling case . Please share your story and add your name to our petitionŠand then, take the nexˆ step . Reach out to your representatives at every level of government, share the fiState of the Airfl resulˆs for your community, and call on them to take action to protect public healˆh .

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6 State of the Air 2021 Methodology Statistical Methodology: The Air Quality Data Data Sour ces Ozone and shor˜-term par˜icle pollution. The data on air quality throughout the United States were obtained from the U .S. Environmental Protection Agency™s Air Quality System (AQS), formerly called Aerometric Information Retrieval System (AIRS) database . The American Lung Association contracted with Dr . Allen S. Lefohn, A .S.L. & Associates, Helena, Montana, to characterize the hourly averaged ozone concentration information and the 24-hour averaged PM 2.5 concentration information for the three-year period for 2017-2019 for each monitoring site . Year-round par˜icle pollution. Design values for the annual PM 2.5 concentrations by county for the period 2017-2019 were retrieved December 1, 2020, from data posted on May 26, 2020, at the U .S. Environmental Protection Agency™s website at htˆps:/ . Oz one Data Analysis The 2017, 2018 and 2019 AQS hourly ozone data were used to calculate the daily 8-hour maximum concentration for each ozone-monitoring site . The hourly averaged ozone data were downloaded on June 30, 2020, following the close of the authorized period for quality review and assurance cf data . Only the hourly average ozone concentrations derived from FRM and FEM monitors were used in the analysis . The data were considered for a three-year period for the same reason that the EPA uses three years of data to determine compliance with the ozone standard: to prevent a situation in any single year, where anomalies of weather or other factors create air pollution levels, which inaccurately reflect the normal conditions . The highest 8-hour daily maximum concentration in each county for 2017, 2018 and 2019, based on EPA-dezone season, w .The current national ambient air quality standard for ozone is 70 parˆs per billion (ppb) measured over eight hours . EPA™s Air Quality Index reflects the 70 ppb standard . A.S.L. & Associates prepared a table by county that summarized, for each of the three years, the number of days the ozone level was within the rangey EPA based on EPA Air Quality Index: 8-hour Ozone Concentration Air Quality Index Levels 0-54 ppbGood (Green) 55-70 ppb Moderate (Yellow) 71-85 ppb Unhealˆhy for Sensitive Groups (Orange) 86-105 ppb Unhealˆhy (Red) 106-200 ppb Very Unhealˆhy (Purple) >200 ppb Hazardous (Maroon) The goal of this reporˆ was to identify the number of days that 8-hour daily maximum concentrations in each county occurred within the deanges . This approach provided an indication of the level of pollution for all monitored days, not just those days that fell under the requirements for atˆaining the national ambient air quality standards . Therefore, no data capture criteria were applied to eliminate monitoring sites or to require a number of valid days for the ozone season . The daily maximum 8-hour average concentration for a given day is derived from the highest of the 17 consecutive 8-hour averages beginning with the 8-hour period from 7:00 a .m. to 3:00 p .m. and ending with the 8-hour period from 11:00 p.m. to 7:00 a .m. the

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8 The goal of this reporˆ was to identify the number of days that the maximum in each county of the daily PM2.5 concentration occurred within the deanges . This approach provided an indication of the level of pollution for all monitored days, not just those days that fell under the requirements for atˆaining the national ambient air quality standards . Therefore, no data capture criteria were used to eliminate monitoring sites . Both 24-hour averaged PM data, as well as hourly averaged PM data averaged over 24 hours were used . Included in the analysis are data collected using only FRM and FEM methods, which reporˆed hourly and 24-hour averaged data . As instructed by the Lung Association, A .S.L. & Associates included the exceptional and natural events that weror the Lung Association the dates and monitoring sites that experienced such events . Some data have been flagged by the state or local air pollution control agency to indicate that they had raised issues with EPA about those data . For each day across all siteounty, the highest daily maximum 24-h PM 2.5 concentration was recorded and then the resulˆs were summarized by county for the number of days the concentration levels were within the rangeve .Following receipt of the above information, the American Lung As the number of days each county, with at least one PM 2.5 monitor, experienced air quality designated as orange (Unhealˆhy for Sensitive Groups), red (Unhealˆhy), purple (Very Unhealˆhy) or maroon (Hazardous) . Descrip tion of County Grading System Oz one and Shor˜-Term Par˜icle Pollution (24-hour PM 2.5 )The grades for ozone and shorˆ-term parˆicle pollution (24-hour PM 2.5) were based on a weighted average for each county . To determine the weighted average, the Lung Association followed these steps: 1. First, assigned weighting factors to each category of the Air Quality Index . The number of orange days experienced by each county received a factor of 1; red days, a factor of 1 .5; purple day s, a factor of 2; and maroon days, a factor of 2 .5. This allowed days where the air pollution levels were higher to receive greater weight . 2. Nexˆ, mulˆiplied the total number of days within each category by their assigned factor, and then summed all the categories to calculate a total .3. Finally, divided the total by three to determine the weighted average, since the monitoring data were collected over a three-year period . The weighted average determined each county™s grades for ozone and 24-hour PM 2.5.All counties with a weighted average of zero (corresponding to no exceedances of the standard over the three-year period) were given a grade of fiA .fl For ozone, an fiFfl grade was set to generally correlate with the number of unhealˆhy air days that would place a county in nonatˆainment for the ozone standard . For shorˆ-term parˆicle pollution, fewer unhealˆhy air days are required for an F than for nonatˆainment under the PM 2.5 standard . The national air quality standard is set to allow two percent of the days during the three years to exc/m 3 (called a fi98th percentilefl form) before violating the standard . That would be roughly 21 unhealˆhy days in three years . The grading used in this reporˆ would allow only about one percent of the days to be ov/m 3 (called a fi99th percentilefl form) of the PM2.5. The American Lung Association supporˆs using the tighter limits in a 99 th percentile form as a more appropriate standard that is intended to protect the public from shorˆ-term episodes or spikes in pollution .

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9 Grading System Grade Weighted Average Approximate Number of Allowable Orange/Red/Purple/Maroon Days A0.0NoneB0.3 to 0 .91 to 2 orange days with no red C1.0 to 2 .03 to 6 days over the standard: 3 to 5 orange with no more than 1 red OR 6 orange with no red D2.1 to 3 .27 to 9 days over the standard: 7 total (including up to 2 red) to 9 orange with no red F3.3 or higher9 days or more over the standard: 10 orange days or 9 total including at least 1 or more red, purple or maroon Weighted averages allow comparisons to be drawn based on severity of air pollution . For example, if one county had nine orange days and no red days, it would earn a weighted average of 3 .0 and a D grade . However, another county that had only eight orange days but also two red days, which signify days with more serious air pollution, would receive an F . That second county would have a weighted average of 3 .7.Note that this systerom the methodology EPA uses to determine violations of both the ozone and the 24-hour PM 2.5 standards . EPA determines whether a county violates the standard based on the fourˆh maximum daily 8-hour ozone reading each year averaged over three years . Mulˆiple days of unhealˆhy air beyond the highest four in each year are not considered . By contrast, the system used in this reporˆ recognizes when a community™s air quality repeatedly resulˆs in unhealˆhy air throughout the three years . Consequently, some counties will receive grades of fiFfl in this reporˆ, showing repeated instances of unhealˆhy air, while still meeting EPA™s 2015 ozone standard . The American Lung Association™s position is that the evidence shows that the 2015 ozone standard, alˆhough stronger than the 2008 standard, still fails to adequately protect public healˆh . The Lung Association calculates the county population at risk from these pollutants based on the population from the entire county where the monitor is located . The Lung Association then calculates the metropolitan population at risk based upon the largest metropolitan area that contains that county . Not only do people from that county or metropolitan area circulate within the county and the metropolitan area, the air pollution circulates to that monitor through the county and metropolitan area . Counties were ranked by weighted average . Metropolitan areas were ranked by the highest weighted average among the counties within a given Metropolitan Statistical Area as of 2020 as dey the White of Management and Budget (OMB). Year -Round Par˜icle Pollution (Annual PM 2.5 )Since no comparable Air Quality Index exists for year-round parˆicle pollution (annual PM2.5), the grading was based on the 2012 National Ambient Air Quality Standard for annual PM2.5 o/m 3. Counties that EPA listed as being at or belo/m 3 were given grades of fiPass .fl Counties EP A listed as being at or above 12 ./m 3 were given grades of fiFail .fl Where insu a existed for EPA to determine a design value, those counties received a grade of fiIncomplete .fl Design value is the calculated concentration of a pollutant based on the form of the national ambient air quality standard and is used by EPA to determine whether the air quality in a county meets the standard . Counties were ranked by design value . Metropolitan areas were ranked by the highest design value among the counties within a given Metropolitan Statistical Area as of 2020 as dey the OMB .

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10 The Lung Association received critical assistance from members of the National Association of Clean Air Agencies and the Association of Air Pollution Control Agencies . With their assistance, all state and local agencies were provided the opporˆunity to review and comment on the data in drafˆ tabular form . The Lung Association reviewed all discrepancies with the agencies and, if needed, with Dr . Lefohn at A .S.L. & Associates . The American Lung Association wishes to express its continued appreciation to the state and local air directors for their willingness to assist in ensuring that the characterized data used in this reporˆ are correct .

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11 Key Findings The fiState of the Airfl 2021 rspite some nationwide progress on cleaning up air pollution, more than 40% of AmericansŠmore than 135 million peopleŠ are living in places with unhealˆhy levels of ozone or parˆicle pollution . The burden of living with unhealˆhy air is not shared equally . People of color are more than three times more likely to be breathing the most polluted air than white people . The fiState of the Airfl reporˆ looks at two of the most widespread and dangerous air pollutants, oze matˆer . The air quality data used in the reporˆ is collected at ooring sites across the United States by the federal, state, local and Tribal governments . The Lung Association calculates values reflecting the air pollution problem and assigns grades for ozone and daily and long-term measures of parˆicle pollution . Those values are also used to rank cities (metropolitan areas) and counties . This year™s reporˆ presents data from 2017, 2018 and 2019, the most recent quality-assured nationwide air pollution data publicly available . See the About This Repor˚ section on page 6 for more detail about the methodology for data collections and analysis. fiState of the Airfl 2021 is the 22 nd edition of this annual reporˆ, which wst published in 2000. Frate of the Airfl have reflected the successes of the now-50-year-old Clean Air Act, as emissions from transporˆation, power plants and manufacturing have been reduced . In recent years, however, the f the reporˆ have added to the evidence that a changing climate is making it harder to protect human healˆh . The three years covered by fiState of the Airfl 2021 ranked among the six hotˆest years on record globally . High ozone days and spikes in parˆicle pollution, related to exˆres, are putˆing millions more people at risk and adding challenges to the work states and cities are doing across the nation to clean up air pollution .The COVID-19 pandemic has driven home to the world the preciousness of healˆhy lungs.1 New research shows that exposure to elevated levels of air pollution is linked to worse healˆh outcomes from COVID-19, including higher death rates . As the nation continues to respond to the pandemic, reducing air pollution is critical for respiratory healˆh now and in the future . The Lung Association will continue to champion the Clean Air Act and push for clean air, healˆh equity and environmental justice for all .More than 4 in 10 Americans live in plac es with unheal˜hy l evels of air pollution. More than four in ten Americans (41 .1%Šmore than 135 million Americans) ar e living in the 217 counties across the nation with monitors that are capturing unhealˆhy levels of ozone or parˆicle pollution . This is 14.8 million fe wer people breathing unhealˆhy air compared to last year™s reporˆ, mostly from improved levels of ozone pollution . However, the threat of deadly parˆiculate matˆer air pollution continues to worsen with each new edition of fiState of the Air .fl This year ™s rease of close to 1 .1 million people living in areas with unhealˆhy levels of shorˆ-term parˆicle pollution compared to last year™s reporˆ .People of color are 3 times more likely than white people to live in a county with 3 f ailing grades. Close to 20 .7 million people, or 6 .3% of Americans , live in the 13 counties that failed all three measures . Of these 20.7 million people, 14 million ar e people of color . People of color were 61% more likely than white people to live in a county with a failing grade for at least one pollutant, and over three times as likely to live in a county with a failing grade for all three pollutants .Los Angeles remains the city with the worst ozone pollution in the nation, as it has for all but one of the 22 years tracked by the fiState of the Airfl reporˆ . Fairbanks, Alaska, earned the unforˆunate distinction of being the metropolitan area with the worst shorˆ- term parˆicle pollution fst time . And Bakerornia, returned to the most polluted slot for year-round parˆicle pollution for the second year in a row .1 The fiState of the Airfl 2021 covers the years 2017, 2018 and 2019 and does not reflect any changes in activity patˆerns and air quality that may have resulˆed from the COVID-19 pandemic in 2020 . That data will not be available until nexˆ year . More information about the relationship between air pollution and COVID-19 can be found in the Healˆh Impact of Air Pollution section on page 24 .

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