PREVENTION

QUICK FACTS Laws making workplaces, restaurants, and bars

Actions such as the
Clean Air Act as well
completely smoke-free can reduce heart attack
as anti-smoking hospitalizations by 8%–17% within a year.3,5,6
campaigns have had
a significant preventive Federal laws that address U.S. air quality have
impact on public
health.1,2,3
contributed to a decrease of 54% of six common
States play a crucial role
air pollutants since 1980.7
in promoting both local
and federal prevention
efforts and also contrib-
ute to prevention through INTRODUCTION
their own initiatives.2,3
The health of the American public has improved on many fronts over
Beyond individual the last decades—from decreasing incidence of lung cancer in men
prevention efforts, local to large reductions in the number of childhood lead poisoning cases.
community actions can But as previous modules highlight, many diseases and illnesses are
be particularly effective increasing in frequency. Though the reasons for these increases are often
in bringing about changes unknown, to the extent that the causes are recognized or suspected,
that prevent or reduce preventive measures are desirable. Public health focuses on prevention
environmentally-related of disease and health promotion rather than the diagnosis and treatment
illness and disease.4
of diseases.

WHAT IS PREVENTION?
Prevention activities are typically categorized by the following three
definitions:

1. Primary Prevention—intervening before health effects occur, through

measures such as vaccinations, altering risky behaviors (poor eating
habits, tobacco use), and banning substances known to be associated
with a disease or health condition.8,9
2. Secondary Prevention—screening to identify diseases in the earliest
stages, before the onset of signs and symptoms, through measures such
as mammography and regular blood pressure testing.10
3. Tertiary Prevention—managing disease post diagnosis to slow or stop
disease progression through measures such as chemotherapy, rehabili-
tation, and screening for complications.11
2 PREVENTION PICTURE OF AMERICA

Most prevention suggestions are primary or secondary

prevention efforts for individuals. Yet, in the context Figure 1. The Spectrum of Prevention8
of environmental health, prevention is much broader,
because exposure to many contaminants is beyond
the control of individuals and historically has been
most effectively reduced by government programs
Influencing Policy and
and regulations12 (e.g., Pollution Prevention Act13; Legislation
Clean Air Act1). Traditionally, environmental public
health has focused on reducing exposure to environ-
mental hazards known to be related to disease.
Increasing emphasis is placed on upstream inter-
ventions—eliminating the source of the hazard Mobilizing neighborhoods
rather than just preventing or reducing exposure.14
This type of elimination has often required action
and communities
by individuals as well as governments at the
federal, state, and local levels.

THE PREVENTION FRAMEWORK

Fostering coalitions
LOCAL PREVENTION and networks
Beyond individual prevention efforts, local commu-
nity actions can be particularly effective in bringing
about changes that prevent or reduce environmen-
tally-related illness and disease. Strategies ranging
from community education to neighborhood aware- Changing internal
ness around an environmental health issue are some
practices and policies of
of the actions that can be taken at the local level.
Zoning laws that provide incentives for the creation agencies and institutions
of bike paths or that reduce the number or density
of liquor stores are actions taken by local govern-
ments for the benefit of a community.15 Information
sharing between neighborhood associations, faith Educating healthcare
communities, community-based organizations, and providers and other
other local groups can highlight gaps in service and
professionals
facilitate coordinated efforts to achieve public health
outcomes.

STATE PREVENTION
States play an important role in promoting both Promoting
local and federal prevention efforts and also contrib- community
ute to prevention through their own initiatives.
For example, inspections and regulation enforce-
education
ment at food service establishments, swimming
pools, hazardous waste disposal sites, and other
locations help prevent illness and disease statewide.
State-sponsored efforts support health screening Strengthening
programs, anti-smoking campaigns, and health individual knowledge
education. As partners with federal agencies, states and skills
assist in implementation of programs such as the
CDC’s Childhood Lead Poisoning Prevention
Program and the CDC’s National Heart Disease and
Stroke Prevention Program.
 PREVENTION 3

NATIONAL PREVENTION KEY COMPONENTS OF PREVENTION16

National prevention activities include initiatives, Individual, local, state, and federal efforts to prevent
regulatory programs, and policies that establish environmentally-caused illness and disease have had
nationwide programs to reduce both the presence some success, but a more comprehensive effort would
of and exposure to harmful agents in the environ- be useful in meeting the overall environmental health
ment (e.g., the Clean Water Act, National Tobacco challenges facing the United States. The following
Control Program, National Asthma Control activities and initiatives can lead to understanding
Program). Many agencies are involved in activities and reducing the nation’s incidence of environmentally-
that either directly or indirectly reduce public caused disease.
exposure. The Department of Health and Human
Services, which includes the CDC and the U.S. AWARENESS AND EDUCATION
Food and Drug Administration; the Environmental • Inform and educate decision-makers, public health
Protection Agency (EPA); the Department practitioners, health care providers, and individuals
of Housing and Urban Development (HUD); and about science-based health prevention approaches
the Department of Agriculture (USDA) all have that will have the greatest benefit and impact
a hand in prevention efforts. on public health.
• Provide information on effectiveness of interven-
tions to inform policies.
• Educate workers both in and out of the health field
who may have daily contact with people at high
risk for disease and injury. These individuals can
encourage healthy behaviors, screen for certain
health risks, and contribute to education of the
community.17
• Provide the public with health education information.
• Work with the media to highlight public health issues.
4 PREVENTION PICTURE OF AMERICA

• Establish programs to proactively distribute informa-

tion to targeted groups—those at high risk for disease
or injury.

Research
• Identify and support an environmental public health
research agenda at the national level. This research
would address knowledge gaps in suspected and
emerging links between exposure to harmful environ-
mental agents and health outcomes.

Surveillance at all levels

• Monitor environmental risk areas or situations and
determine the prevalence of environmentally-linked
health outcomes. Identify national, state, or commu-
nity environmental health issues; develop measures
to track those issues; and implement widespread
surveillance to help identify relationships between
environmental hazards and health concerns.

Hazard evaluation at the national, state,

and local levels
• Implement hazard assessments as needed. Respond
to high-risk situations, identify and quantify hazard-
ous agents, and facilitate exposure reduction.

Improvement of the public health system at the

national, state, and local levels
• Enhance and revitalize the environmental health system
at all levels. Build and improve long-term strategic
partnerships, commitments by all stakeholders, and
additional resources, as well as collaboration with
environmental regulatory agencies and development
of a competent and effective environmental public
health workforce.16

Proactive behavior by individuals

• Make healthy lifestyle choices, choose environmental-
ly-friendly products and services, and conscientiously
try to minimize the environmental impact of yourself
and your family. Become informed about the issues,
and be proactive in prevention initiatives promoting
health and preventing illness and disease.
 PREVENTION 5

THE NATIONAL ENVIRONMENTAL SUCCESSFUL PREVENTION INITIATIVES

PUBLIC HEALTH TRACKING Actions such as the Clean Air Act as well as anti-
smoking campaigns have achieved a significant
NETWORK preventive impact on public health.1,2,3 The following
Many of the above activities are dependent on the success stories demonstrate how these initiatives relate
availability of information to link diseases and to the advancement of environmental public health.
environmental exposures. Laboratory studies
contribute to our understanding, but without CLEAN AIR PREVENTION INITIATIVES
coordinated tracking of environmental hazards, One of the most substantial environmental pollution
exposures, and diseases, the picture is often success stories has been the reduction in levels of air
fragmented and inconclusive. The CDC has pollutants throughout the United States (see Outdoor
responded to this need with the National Environ- Air Quality chapter). While national air quality has
mental Public Health Tracking Network.18 This improved since the early 1990s, air quality problems
Network has established information-system still exist, presenting many challenges in protecting
standards to facilitate integration of local, state, public health and the environment.
and national databases of environmental hazards,
environmental exposures, and health effects. Air pollution is a major problem that can affect every-
These data allow federal, state, and local agencies, one.19 Studies show links between air pollution and
among others, to monitor and distribute informa- a number of health problems, such as an increased
tion about environmental hazards and disease risk for heart attacks, and it can affect individuals with
trends. As trends and linkage between environmen- asthma and other lung conditions. Children and the
tal hazards and disease are uncovered, preventive elderly are often the most vulnerable to the effects
actions can be taken to protect communities. of air pollution.20

Figure 2. Timeline of Key Federal Clean Air Initiatives

1955 The Air Pollution Act of 1955 provides federal research funds for studying air pollution.

1963 The Clear Air Act of 1963 establishes a federal program authorizing research for ways
to monitor and control pollution.

1967 The Air Quality Act of 1967 expands the federal government’s activities to begin enforcing
areas subject to interstate pollution transport and conducting ambient air monitoring studies
and industrial source inspections.

1970 The Clean Air Act of 1970 brings about a major shift in the government’s role in controlling
air pollution. Comprehensive federal and state regulations are developed to reduce
emissions from industrial and mobile sources.

1970 The U.S. Environmental Protection Agency (EPA) is established to implement the require-
ments of the 1970 Clean Air Act.

1977 Major amendments are added to the 1970 Clean Air Act ensuring continuation of the Air
Quality Standards, increasing the federal government’s air quality authority and responsibili-
and ties, and establishing new programs for acid rain and toxic air pollutants.19
1990
6 PREVENTION PICTURE OF AMERICA

Figure 2 provides a timeline that illustrates key fed- Practice energy conservation – using less energy
eral initiatives designed and implemented to reduce and recycling reduces air pollution generated
air pollution and related illnesses across the nation. by power generating and manufacturing facilities.

The EPA has set national outdoor air quality stan- • Recycle paper, plastic, glass bottles, cardboard,
dards for the following six common air pollutants: and aluminum cans.

• Particulate matter (PM) • Conserve energy by turning off appliances and

lights when not in use.
• Ozone (O3)
• Buy ENERGY STAR products, such as energy-
• Carbon monoxide (CO) efficient lighting and appliances.
• Nitrogen dioxide (NO2) • Connect outdoor lights to a timer or use solar
• Sulfur dioxide (SO2) lighting to reduce your use of electricity.
• Lead (Pb) • Use rechargeable batteries.
• Lower the thermostat on the water heater
EPA monitors outdoor air quality concentrations to 120°F.
of these pollutants and produces estimates of emis-
sions based on monitored data plus calculations Reduce your consumption of fossil fuels by driving
of pollutants emitted by vehicles, factories, and other less or using more efficient vehicles designed
sources. EPA air quality trends show that air quality to burn less gasoline and oil.
has improved nationally since 1980.7 Between 1980–
2007, while increases were seen in the gross domestic • Choose efficient, low-polluting vehicles.
product, the number of vehicle miles traveled, over- • Plan trips; save gasoline and reduce air pollution.
all energy consumption, and the U.S. population,
total emissions of these six common air pollutants • Keep tires properly inflated and aligned and get
decreased by 52%.7 Other significant improvements regular engine tune-ups and car maintenance
since 1970 include a 70% reduction of air toxics from to increase your fuel efficiency.
large industrial sources, new cars that are more than • During summer, fill the gas tank during cooler
90% cleaner, and the end of the production of most evening hours to decrease evaporation and
ozone-depleting chemicals.20 reduce the formation of ozone.
The CDC Air Pollution and Respiratory Health • Avoid waiting in long drive-through lines; park
Branch in the National Center for Environmental your car and go in.
Health works to prevent environmentally-related • Use public transportation, walk, or ride a bike.
respiratory illnesses and studies indoor and outdoor • Join a carpool or vanpool to get to work.
air pollution. This CDC program collects and analyzes
respiratory health data, implements asthma interven- Reduce your personal exposure to air pollutants.
tions to ensure scientific information is translated
into public health practice, establishes and maintains • Use low volatile organic compounds (VOC)
partnerships to control asthma, works to prevent car- or water-based paints, stains, finishes, and paint
bon monoxide poisoning, and studies the effects strippers.
of forest fire smoke and other airborne contaminants.21 • Choose not to smoke inside the home; ask
visitors to smoke outside.
WHAT YOU CAN DO • Keep woodstoves and fireplaces well maintained.
In addition to national legislation and programs • Test the home for radon.
regarding clean air, individuals can also take a proac-
tive approach to reduce air pollution as well as their • Avoid spilling gas; do not top off the tank and
exposure to harmful air pollutants.20 replace gas cap tightly.
• Check daily air quality forecasts and associated
health concerns.
 PREVENTION 7

SECONDHAND SMOKE
PREVENTION INITIATIVES
Secondhand smoke, also called environmental
tobacco smoke (ETS), is the mixture of gases and
particles given off by burning cigarettes, pipes, and
cigars as well as the smoke exhaled by smokers.22
Breathing secondhand smoke, even in small
amounts, is dangerous to human health and can
cause lung cancer and an increased risk of heart
disease, including heart attack, in adult nonsmokers22
(see Secondhand Smoke section in Homes chapter).

Laws and policies for smoke-free environments

have been initiated at the national, state, and
local levels. Nationally, several laws and policies
restricting smoking in public places have been
adopted.23 Federal law prohibits smoking on
domestic airline flights and interstate buses.
Smoking is also banned in most federally-owned
buildings, and the Pro-Children Act of 1994
prohibits smoking in buildings where federally-
In a 2006 report, the U.S. Surgeon General funded services are provided to children.24
reached the following conclusions regarding While these federal smoking restrictions are
control of secondhand smoke exposure:25 important, the most comprehensive smoke-free
• The scientific evidence indicates that there laws have originated at the local level. Local initia-
is no risk-free level of exposure to second- tives engage communities in public education,
hand smoke. raise awareness of the health risks of secondhand
• Only eliminating smoking in indoor spaces smoke, and increase public awareness of policies
fully protects nonsmokers from secondhand that provide protection from exposure risks.25
smoke exposure; separating smokers from As increasing numbers of communities successfully
nonsmokers, cleaning the air, and ventilat- implemented comprehensive laws making work-
ing buildings cannot completely eliminate places, restaurants, and bars completely smoke-free,
exposure. states began enacting similarly comprehensive laws.25
• Workplace smoking restrictions are effective The first state laws restricting smoking in public
in reducing secondhand smoke exposure and places were passed in Arizona, Connecticut, and
lead to less smoking among covered workers. Minnesota between 1973–1975.26 Over the years
• Establishing smoke-free workplaces is the a number of other states enacted limited smoking
only way to ensure secondhand smoke restrictions. In the 1990s, California became the
exposure does not occur in the workplace. first state to restrict smoking in most indoor work-
• The majority of workers in the United States places and places, including restaurants and bars.25
are covered by smoke-free policies. From 2002–2005, Delaware, New York, Massachu-
setts, Rhode Island, and Washington state imple-
• Evidence from peer-reviewed studies shows mented comprehensive state smoke-free laws.25
that smoke-free policies do not have an By April of 2014, 24 states and the District
adverse economic impact on the hospitality of Columbia had comprehensive laws in effect
industry. requiring all private workplaces, restaurants, and
bars to be smoke-free.27 According to the American
Nonsmokers’ Rights Foundation, over 49%
of Americans live under comprehensive state
8 PREVENTION PICTURE OF AMERICA

or local smoke-free laws.27 The prevalence of U.S.

nonsmokers’ exposure to secondhand smoke dropped
by half between 1988–1991, when most Americans
were exposed, and 2007–2008. This decline was likely
driven in large part by the widespread adoption of
state and local laws and voluntary business policies
prohibiting smoking in indoor workplaces and public
places.25

A number of studies conducted in a range of com-

munities, states, regions, and countries have reported
substantial and rapid reductions in heart attack
hospitalizations following the implementation
of smoke-free laws.28 In 2010, the Institute of Medi-
cine, after reviewing these studies and related
evidence, concluded that smoke-free laws reduce
heart attacks.28 In addition, three meta-analyses
of studies on this topic have estimated pooled effect
sizes of 8%,3 10%,5 and 17%.6

WHAT YOU CAN DO

There are steps individuals can take to protect
themselves and their family from exposure
to secondhand smoke25:

• Make the home and car smoke-free.

• Visit smoke-free restaurants and public places.
• Ask people not to smoke around you and
your children.
• Use a smoke-free daycare center.

CONTINUED PREVENTION
SUCCESS
Clean air and secondhand smoke prevention are
just two examples of the many successes that have
occurred through the use of proactive preventive
measures. Many more success stories will emerge
as individuals, communities, and other stakeholders
take on a more active role in environmental public
health.
 PREVENTION 9

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