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4 Air Quality INTRODUCTION Indoor air quality (IAQ) is an important component of indoor environ- mental quality. It has many facets. This chapter focuses on the chemical and particulate pollutants that can be found suspended in air or deposited on or sorbed to indoor surfaces. It specifically addresses organic and inorganic volatile and semivolatile molecular pollutants, and particulate matter. In the case of particles, abiotic materials are emphasized, but there is a brief discussion of allergens associated with pollen and of respiratory health risks associated with algal blooms after floods. IAQ problems associated with moisture and dampness of buildings are addressed in Chapter 5, and biologic IAQ concerns associated with microbial agents, insects and arthro- pods, and mammals and concerns that arise because of efforts to control them are discussed in Chapter 6. With regard to the pollutants considered in this chapter, there is little in the published literature that considers together all the key elements in this committee’s charge: the effects of climate change on IAQ that would influence public health. However, substantial research has been published on many important components. For example, there is a strong emerg- ing literature on the effects of climate change on outdoor air pollutants (Jacob and Winner, 2009), such as particulate matter (Tagaris et al., 2007) and ozone (Bell et al., 2007; Hogrefe et al., 2004a; Racheria and Adams, 2009), and on related health effects (Kinney, 2008; Tagaris et al., 2009). A voluminous literature characterizes health risks associated with pollut- ants in outdoor air (Bell et al., 2004; Dockery et al., 1993; Jerrett et al., 79

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80 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH 2009; Pope and Dockery, 2006; Pope et al., 2009). Considerable published research documents our understanding of indoor–outdoor relationships of important air pollutants, including particles and ozone (Jia et al., 2008b; Monn, 2001; Wallace, 1996; Weschler et al., 2000). Research has explored the extent to which health risks associated with outdoor pollutants are a consequence of indoor exposures (Weschler, 2006; Wilson and Suh, 1997; Wilson et al., 2000). A large body of work reports on how indoor pollu- tion sources influence IAQ and human health (Jones, 1999; Samet et al., 1987, 1988), including a National Research Council report published three decades ago (NRC, 1981). The following sections discuss how indoor air pollutant levels might be influenced by climate change. The discussion is organized according to pollutant source category and pollutant class, considering first indoor emis- sion sources and second pollutants of outdoor origin. The treatment is not intended to be comprehensive, but rather broadly illustrative of important IAQ concerns that might be influenced by climate change. Although most of what follows is related to conditions in buildings of the types commonly found in the United States, the chapter concludes with a discussion of an important international public-health problem: exposure to smoke from the indoor combustion of solid biomass and coal in developing countries. INDOOR SOURCES OF POLLUTANTS Indoor environments detain pollutants that are emitted indoors. This section reviews important IAQ issues that are associated with indoor pol- lutant sources and explores how climate change might affect these issues. The emphasis is on conditions in the United States but the discussion is relevant for other countries with similar levels of economic development and similar buildings. Pollutants from Indoor Combustion Pollutants released into indoor air cause roughly 100–1,000 times greater human inhalation exposure or dose per unit mass emitted than pollutants released into outdoor air (Smith, 1988). That important observa- tion has been expressed in terms of “intake fraction” (Bennett et al., 2002; Nazaroff, 2008), the ratio of the mass of a pollutant inhaled by an exposed population to the mass of the pollutant emitted from a source. The signifi- cance of that point in the present context is that sources have a much larger effect on public health if their pollutants are emitted indoors rather than outdoors. The much higher intake fraction for indoor emissions compared to those outdoors leads to the understanding that small-scale combustion

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81 AIR QUALITY processes that do not burn much fuel can nevertheless raise substantial IAQ concerns and adversely affect public health. Combustion might be the most important source of air pollution. In- door combustion for cooking, lighting, and heating has a long and diverse history of contributing to air-pollution exposure. Lopez et al. (2006) ranked “indoor air pollution from [burning] solid fuels” as one of the top 10 lead- ing causes of global mortality and disease. That ranking is based mainly on the use of biomass and coal in rural parts of developing countries. Unvented or incompletely vented combustion also occurs to a substantial extent in developed countries and has demonstrable effects on indoor pollutant concentrations and exposures. Evidence associating those exposures with public-health consequences ranges from suggestive to clear and compelling. Exposures resulting from indoor combustion could be altered in the future in several ways associated with climate change. Influencing factors could include changing prevalence, frequency, or strength of indoor emission rates and also changes in building ventilation conditions.1 The following paragraphs summarize some of the concerns and provide references to document the nature and importance of the current problems. Accidental Carbon Monoxide Poisoning Carbon monoxide (CO) is produced by the incomplete combustion of a carbonaceous fuel. Inhaled CO forms carboxyhemoglobin in the blood, whose presence interferes with transport and delivery of oxygen to tissues and organs. Excessive acute exposures result in illness or death. Chronic lower-level exposures may also have health consequences, but the available empirical evidence is weaker than that for acute poisonings. CO is regulated as a pollutant in ambient air. Mainly through strong improvements in automotive emission-control technology, urban air CO levels have become well controlled, and almost every area of the United States meets the National Ambient Air Quality Standard for CO (EPA, 2010b). Despite improvement in outdoor levels, CO remains an important air pollutant. Over the past few decades, hundreds of accidental and fatal acute CO poisonings have occurred each year in the United States (Cobb and Etzel, 1991; King and Bailey, 2008; Mott et al., 2002). The incidence has declined substantially. One important factor is improvements in the control of motor-vehicle emissions. Mott et al. analyzed CO-associated mortality statistics and concluded that, “if rates of unintentional CO- related deaths had remained at pre-1975 levels, an estimated additional 11,700 motor-vehicle-related CO poisoning deaths might have occurred by 1 Building tightening and reduced ventilation rates are further discussed in Chapter 8.

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82 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH 1998.” Holmes and Russell (2004) remarked that the reduction in acciden- tal deaths resulting from improvements in motor-vehicle emission controls “is not accounted for in EPA’s [the Environmental Protection Agency’s] recent reports on the benefits and costs of the [Clean Air Act], yet it dwarfs the estimated direct benefits ascribed to CO control.” In a detailed study of CO poisoning deaths in California during the period 1978–1988, Girman et al. (1998) found that alcohol was a factor in 31% of the cases and that important combustion sources other than motor vehicles included heating or cooking appliances, charcoal grills and hibachis, small engines, and camping equipment. An assessment for Florida over the period 1999–2007 revealed that accidental CO poisonings “were primarily due to motor ve- hicle exhaust (21%–69%) and generator exposure (12%–33%), and the majority (50%–70%) occurred within the home” (Harduar-Morano and Watkins, 2011). In the context of climate change, a particular concern about CO ex- posure arises from the use of emergency electricity generators that burn liquid fuels, such as gasoline. The use and reliability of centrally generated power might be degraded because of climate change for several reasons. For example, hotter summer afternoons may lead to more intense use of air conditioners and thus increase the frequency of service-demand over- loads that cause brownouts and blackouts. Severe storms can also cause electricity service disruption. In such cases, people may rely more heavily on their own electricity generators. If the generators are used indoors, or even outdoors but too close to an indoor environment, unhealthful CO exposures can result. Increases in emergency-room and other hospital visits caused by CO poisoning have been reported in association with power out- ages (Muscatiello et al., 2010), major storms (Van Sickle et al., 2007), and floods (Daley et al., 2001). A staff report from the Consumer Product Safety Commission (Hnatov et al., 2009) indicated that in 2005 an estimated 27 generator-related CO fatalities were associated with five hurricanes (Katrina, Rita, Wilma, Dennis, and Isabelle). And an estimated 21 generator-related CO fatalities were associated with ice storms, including major storms in the midwestern United States in January and in the Carolinas and Georgia in December. In addition to electricity generators, shifts in fuel-use patterns during power outages may contribute to increased indoor CO levels. Of con- cern would be the use of natural-gas–fueled and petroleum-fueled stoves for heating, excessive reliance on unvented combustion-based space heat- ers, and use of charcoal briquettes or wood stoves indoors for cooking (Hampson and Stock, 2006, Hnatov, 2009). One expects there to be many more poisonings that result in illness than in death. Analyses of the demand for poison control center services reveal a pattern similar to that in emergency rooms. Klein et al. (2007)

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83 AIR QUALITY noted a nearly 50% increase in suspected CO poisoning calls in the days after a widespread blackout on the East Coast of the United States in 2003, and Forrester (2009) found more such calls in the counties that were in the disaster area declared for Hurricane Ike than in other counties in Texas. It is reasonable to believe that the prevalence of CO-induced illness is larger than that recorded in the emergency-room statistics because illnesses that are not considered severe might not be reported. A recent study evaluat- ing the use of a web-based query system for public health surveillance re- ported almost 25,000 CO-related hospitalizations across the United States in 2005, of which approximately 4,200 were confirmed CO-related poison- ings (Iqbal et al., 2010). These data were intended to exclude intentional and fire-related CO exposures. Other factors may also contribute to increased public health risks asso- ciated with indoor CO exposures. For example, the Department of Housing and Urban Development’s 2009 American Housing Survey found that just 36% of homes nationwide reported having a working CO detector.2 People of lower socioeconomic status may be more likely to use stoves or unvented space heaters as a heat source (CDC, 1997) and less likely to have work- ing CO detectors (Runyan et al., 2005). Some groups may hold mistaken beliefs about CO. For example, a survey conducted among residents of low socioeconomic status in northern Mexico by Galada et al. (2009) found that a large majority of respondents mistakenly believed that CO could be detected by sight or smell. Cooking Cooking causes air-pollutant exposures that have potential public- health significance. The most severe problems occur from burning of solid biomass fuels or coal, especially in unimproved stoves, in the rural parts of developing countries. The relationship of those concerns to climate change is discussed toward the end of this chapter. However, even when relatively clean fuels are used for cooking in developed countries, indoor air-pollutant exposures with potential public-health consequences can arise. For ex- ample, the use of natural gas as a cooking fuel is associated with increased indoor exposures to nitrogen dioxide (NO2), a byproduct of the combus- tion process (Marbury et al., 1988; Spengler et al., 1994). In a study in the United Kingdom, the use of gas cooking appliances, rather than electric, was associated with respiratory morbidity in women (but not men, possibly women had higher exposure) (Jarvis et al., 1996). Exposure of children to higher indoor NO2 levels has also been reported to be associated with re- 2 As of January 2010, 25 states—including Florida, Texas, and California—required some or all residences to have CO detectors (National Conference of State Legislatures, 2010).

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84 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH spiratory symptoms (such as wheeze) but not pulmonary function (Neas et al., 1991). In a population of infants at risk for asthma, “the frequency of reported respiratory symptoms in the first year of life was associated with NO2 levels not currently considered to be harmful” (van Strien et al., 2004). However, another study did not find an association between NO2 level and respiratory illnesses in infants (Samet et al., 1993). A study of asthmatic children in inner-city environments found that indoor NO2 levels were substantially elevated in homes with gas stoves and that “higher levels of indoor NO2 are associated with increased asthma symptoms in nonatopic children and decreased peak flows” (Kattan et al., 2007). Early life expo- sure to household gas appliances has also been associated with negative neuropsychological development (Morales et al., 2009). Valero et al. (2009) investigated the determinants of exposure for a cohort of Spanish women and found that personal NO2 levels were “strongly influenced by indoor NO2 concentrations.” They also found that outdoor NO2 levels and the use of gas appliances were important determinants of indoor NO2 levels, whereas no significant association “was found between personal or indoor NO2 levels and exposure to environmental tobacco smoke (ETS) at home.” Cooking can also substantially increase indoor fine-particle mass con- centrations (PM2.5) (Abt et al., 2000; Buonanno et al., 2009; Evans et al., 2008; Olson and Burke, 2006; Wallace et al., 2004). Fumes from Chinese- style cooking with hot oil have been shown to be mutagenic (Chiang et al., 1997), and this cooking style has also been reported to be a risk factor for lung cancer in nonsmoking women in Taiwan (Ko et al., 1997). Expo- sure to ultrafine particles can be substantially increased by emissions from cooking (Bhangar et al., 2011; Mullen et al., 2010). Emissions of ultrafine particles can be caused not only by the combustion of cooking fuel but from high temperatures associated with electric cooking elements (Wallace et al., 2008). Climate change could affect the indoor concentrations of cooking- associated pollutants in the United States and other developed countries in several ways. First, it may be that a mitigation response to climate change drives a movement toward smaller per-capita housing space (with lower life-cycle environmental effects) and with lower air-exchange rates (to save heating and cooling energy). If so, emissions from cooking would be diluted into a smaller volume and would persist for longer times, and these changes would tend to increase concentrations and exposures associated with a given level of cooking. Second, climate-change mitigation goals might push cooking away from the use of natural gas and toward a heavier reliance on electricity (assuming that electricity would be generated from lower-carbon sources than today). Such a shift would reduce associated exposures to NO2 and to the ultrafine particles formed in combustion flames. Third, tighter building envelopes resulting from weatherization efforts might reduce the

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85 AIR QUALITY efficacy of local exhaust hoods and fans for removing cooking-related emissions before they enter indoor air. Dampers have been developed that automatically open when exhaust fans are activated to permit additional ventilation supply air to flow freely into a building, thereby mitigating this otherwise adverse effect of weatherization. Space Heating In the United States, combustion for space heating can sometimes be associated with substantial pollutant emissions, especially because of the relatively large amounts of fuel used for home heating compared with, for example, cooking. When on-site combustion is used to generate heat, it is usually the case that the heat is first extracted from the combustion gases and then the byproducts are vented to the outside. Leakage may occur, and some of the generated pollutants can enter the occupied indoor space of the same building for which the heat is being generated. In addition, combustion for heating is sometimes unvented by design, in which case all the byproducts formed are emitted into the indoor environment with the generated heat. The direct evidence that links household heating with health effects is sparse. Household use of kerosene heaters and fireplaces for heat- ing was found to be associated with respiratory symptoms in nonsmoking women in Connecticut and Virginia during the 1990s (Triche et al., 2005). A study of coroners’ reports in California found that unvented combustion heating appliances and cooking indoors with charcoal were associated with CO deaths (Liu et al., 2000). Climate change could induce several shifts that would affect indoor air- pollutant exposures associated with heating. First, if average temperatures rise, as is expected, less heating may be needed, and—other things being equal—there would tend to be less associated pollution exposure. Climate- change mitigation efforts may lead to better insulation of buildings, which also would lessen heating requirements. Second, there could be shifts in the types of heating sources used. Mitigation efforts could serve as a driv- ing force for substituting electricity (from low-carbon sources) for fossil- fuel combustion—a change that would tend to improve IAQ. In contrast, mitigation goals might also encourage greater use of wood as a household heating fuel. Wood contains contemporary rather than fossil carbon. If grown and harvested sustainably and if burned completely, wood combus- tion could have little or no net climate impact. However, as practiced today, residential wood combustion is associated with degraded neighborhood air quality owing to emissions exhausted from chimneys and is associated with degraded IAQ in the households that burn the wood owing to leak- age of combustion byproducts into the indoor environment (Gustafson et al., 2008; Traynor et al., 1987). If done poorly, increased wood-based

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86 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH heating could exacerbate IAQ problems associated with residential wood combustion. Another trend that might emerge and that would tend to degrade IAQ is greater reliance on unvented combustion-based space heaters. Devices of this type have a high thermal efficiency because all the generated heat is discharged indoors. However, their use can cause substantially increased indoor concentrations of NO2, sulfur dioxide (SO2), and particulate matter (Francisco et al., 2010; Leaderer, 1982; Leaderer et al., 1990; Ruiz et al., 2010; Wallace and Ott, 2011). An additional concern associated with climate change and home heat- ing is building envelope tightness. Efforts to save energy by reducing the leakiness of building envelopes can increase the risk of “backdrafting,” in which air flows into a building through the exhaust flue, instead of flowing out of the building, and carries combustion byproducts with it. The causes and consequences of backdrafting have received some attention in the lit- erature (Nagda et al., 1996), but the prevalence even in current conditions in the building stock has not been well characterized, and it is not clear what to expect in this regard as a consequence of climate change. Smoking Habitual indoor smoking adversely affects IAQ and public health. Sidestream smoke (from the smoldering tobacco product) and exhaled mainstream smoke together constitute the source of environmental tobacco smoke (ETS). Smoking indoors has a strong influence on indoor levels of PM2.5 (Hyland et al., 2008; Nazaroff and Klepeis, 2004). ETS is also an important cause of environmental exposure to some hazardous air pollut- ants, including acrylonitrile, 1,3-butadiene, acetaldehyde, acrolein, and formaldehyde (Nazaroff and Singer, 2004). Evidence indicates that several severe adverse health effects are associated with ETS exposure, including acute myocardial infarction (Lightwood and Glantz, 2009), lung cancer (Fontham et al., 1994), and a host of respiratory health problems in chil- dren (DiFranza et al., 2004). Over the past few decades, there has been a marked reduction in exposure to ETS in the US population, as reflected in lower concentrations of serum cotinine in nonsmokers (Pirkle et al., 2006). The decline is a consequence mainly of declines in the amount of smoking that occurs indoors rather than of changes in the building stock. In a future influenced by climate change, exposure of nonsmokers to ETS will be determined to a great degree by the prevalence and intensity of smoking in indoor spaces. In the United States, smoking in public places has become uncommon. However, smoking in private residences continues: Singh et al. (2010) estimated that 7.6% of children in the United States are exposed to ETS in their own homes. Exposures to ETS occur not only in the

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87 AIR QUALITY residence in which smoking occurs but, in the case of multifamily dwellings, in neighboring units (Bohac et al., 2011). Some parts of the US population have a relatively high prevalence of indoor smoking. For example, a study of 100 asthmatic children in inner-city Baltimore revealed an indoor smok- ing prevalence of 46% and found that average indoor PM2.5 and PM10 levels were 33–54 µg/m3 higher in smoking than in nonsmoking households (Breysse et al., 2005). In another study, fine-particle concentrations were sampled over two-week periods in 294 inner-city homes with asthmatic children (Wallace et al., 2003). In these homes, the average particle mass concentration, 27.7 µg/m3, was considerably higher than the average con- currently measured outdoor concentration, 13.6 µg/m3. Smoking occurred in 101 of the homes (34%) and caused an average increase of 37 µg/m3 for indoor fine particle levels. Other identified sources—frying, smoky cooking events, and use of incense—made smaller contributions, 3–6 µg/m3. It is unknown how smoking patterns that would affect indoor ETS will evolve. In particular, it is not clear that indoor smoking behaviors would be influenced by climate change. Changes in tobacco or in tobacco prod- ucts could alter the ETS characteristics associated with indoor smoking, and there is some published evidence that tobacco itself might be altered in response to changing temperature and atmospheric CO2 levels (Ziska et al., 2005). Changes in the residential building stock that are a consequence of climate-change concerns could influence exposure to ETS. Currently, unin- tended airflow pathways in multiunit residential buildings can lead to expo- sures to secondhand smoke in the units of nonsmokers (Kraev et al., 2009; Wilson et al., 2011; Winickoff et al., 2010). Mitigation measures to reduce energy use in buildings could lead to systematically lower ventilation rates and alteration of internal airflows that could cause higher concentrations and exposures to secondhand smoke. For a given characteristic, such as number of cigarettes smoked indoors per day, any of those changes would tend to increase exposures to ETS indoors. Candles, Incense, and Other Small-Scale Combustion Processes Pagels et al. (2009) summarize some of the IAQ concerns related to indoor candle use. The local high temperature created by a candle flame can volatilize candle components that are then emitted to indoor air. Some candles have metal-cored wicks that emit lead at rates sufficient to pose health concerns (Wasson et al., 2002). Depending on combustion condi- tions, the candle flame also produces soot particles and other products of incomplete combustion that are emitted indoors (Fine et al., 1999). According to the National Candle Association (National Candle As- sociation, 2011), US retail sales of candles are roughly $2 billion per year,

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88 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH and “candles are used in 7 out of 10 US households.” Given the type and scale of emissions summarized in the previous paragraph, the potential for air-pollutant exposure due to candle use would seem to be substantial, but scientific data that would permit one to quantify the extent of indoor use and the resulting air-pollutant exposures are lacking. In developing countries, combustion-based technologies, such as can- dles and kerosene lamps, are commonly used to provide lighting. Those are inherently inefficient in converting chemical energy into light (Mills, 2005). The air-pollutant exposure consequences of combustion-based lighting are expected to be substantial but have only begun to be explored (Apple et al., 2010). Indoor air-pollutant emissions from other small-scale combustion sources have been investigated, and a few illustrative examples are noted here. Jetter et al. (2002) studied the emissions from burning incense and concluded that “incense smoke can pose a health risk to people due to inhalation exposure of particulate matter.” Liu et al. (2003) characterized emissions and IAQ effects of burning mosquito coils, which are commonly used in households in Asia, Africa, and South America. They concluded that “exposure to the smoke of mosquito coils similar to the tested ones can pose significant acute and chronic health risks.” As in the case of other indoor combustion activities, climate change would affect IAQ and potentially public health if it were accompanied by a change in the source emission rate (for example, owing to a change in use) or were accompanied by a change in the other factors that influence exposures associated with a given magnitude of emissions. There is no good basis of expectations of use patterns of small-scale combustion sources. As noted in connection with other combustion sources, reduced household volume per occupant and lower air-exchange rates might be consequences of efforts to mitigate anthropogenic effects on climate, and such changes would tend to increase air-pollutant exposures that result from indoor combustion sources. Radon and Its Decay Products Indoor radon is a major cause of the public’s health-relevant radiation exposure. Exposure to increased residential radon is an important risk fac- tor for lung cancer. On the basis of a combined analysis of 13 studies that collectively involved 7,148 lung-cancer cases and 14,208 controls, Darby et al. (2005) concluded that residential radon is “responsible for about 2% of all deaths from cancer in Europe.” In a parallel North American effort encompassing 7 studies that collectively assessed 3,662 cases and 4,966 controls, Krewski et al. (2005) reported that their results “provide direct evidence of an association between residential radon and lung cancer risk, a

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89 AIR QUALITY finding predicted using miner data and consistent with results from animal and in vitro studies.” Radon-222 (radon), the most health-significant of the three naturally occurring isotopes, is generated by the radioactive decay of radium-226, a ubiquitous trace element in the earth’s crust. Being an inert gas, radon has the potential to migrate from its parent material during its short lifetime (half-life, 3.8 days) and enter indoor or outdoor air, where humans may encounter it. Radon does not directly pose a substantial health hazard. However, its radioactive decay marks the beginning of a sequence of short- lived products. Those radon decay products—isotopes of bismuth, lead, and polonium—are chemically reactive and, when inhaled, can be retained on respiratory tract tissues; later radioactive decays irradiate lung cells. Of particular health concern are the alpha-particle emissions from the decay of polonium-218 and polonium-214. It is the radiation damage caused by those alpha-particle emissions that creates the lung-cancer risk associated with exposure to residential radon. The epidemiologic evidence is consistent with a linear no-threshold dose–response model. Health risks posed by a given level of radon exposure are much higher in smokers than in nonsmok- ers (Ginevan and Mills, 1986). The three main sources of indoor radon are soil near a building’s foun- dation; earthen building materials, such as concrete; and tap water from underground sources. In aggregate for the entire building stock, soil is the most important radon source, although the other two sources dominate in some buildings. The significance of soil as a source of indoor radon depends on the radium content of the soil, on the permeability of the soil, and on the degree of coupling between the indoor space of the building and the pore air in the underlying and adjacent soil (Nazaroff, 1992). The only important mechanism for removing radon from indoor air is ventilation. However, the effective radiation dose to lung tissue associated with a given level of indoor radon depends on the dynamic behavior of the short-lived decay products (Porstendörfer, 1994), which can be influenced not only by the ventilation rate but by such factors as indoor particle levels, active air filtration, and the intensity of indoor air movement. Annual average residential radon levels in the United States have been estimated to have an arithmetic mean of 46 ± 4 Bq/m3 (1.25 ± 0.12 pCi/L) with an estimated 6% of dwellings exceeding the EPA mitigation level of 148 Bq/m3 (4 pCi/L) (Marcinowski et al., 1994). EPA has estimated that 20,000 US lung-cancer deaths a year are radon-related (Pawel and Puskin, 2004). Radon-control systems are well established in principle for maintaining low indoor radon concentrations (Rahman and Tracy, 2009). However, challenges remain to identify buildings with high concentrations and to apply effective controls, where appropriate, in both existing and new buildings.

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