The Public Health Impact of Energy Policy in the United States

  • Date: Nov 13 2018
  • Policy Number: 20183

Key Words: Environment, Climate Change

Abstract
The ways in which society develops, uses, and disposes of energy and waste products have broad impacts on human health and the environment. The types of energy used to meet our needs are shifting. Fossil fuels have long dominated energy supply and transformed society. In the 1970s, nuclear energy came into favor as a source of cleaner energy supply because, unlike fossil fuels, it does not produce particulate matter and other air pollutants that are harmful to human health. As society confronts an impending global climate crisis, development of non–fossil fuel alternatives is rapidly increasing. With each type of energy supply, there are unique impacts on human health and the environment. In the communities where extraction takes place (e.g., coal and uranium mines), air and water pollution impact health and workers suffer from occupational diseases such as black lung. Air pollution caused by fossil fuel combustion at coal and natural gas plants and transportation-related pollution create health concerns where energy is produced. Waste disposal and radiation exposure are concerns for workers and communities near nuclear plants. Energy efficiency and conservation are seen as effective means of limiting energy use and demand to reduce public health impacts. Renewable energy development, although safer from a climate perspective, also poses occupational and environmental health concerns where components are manufactured and installed. As society moves to alternative energies, there is a need to monitor, evaluate, and support effective strategies to transition to a healthier energy supply and adopt effective energy efficiency and conservation measures.

Relationship to Existing APHA Policy Statements
This policy builds upon and replaces APHA Policy Statement 7825(PP) (The Public Health Impact of Energy Policy) from 1978. This new policy is also consistent with several other related APHA policy statements, including the following:

  • APHA Policy Statement 201711: Public Health Opportunities to Address the Health Effects of Air Pollution
  • APHA Policy Statement 20157: Public Health Opportunities to Address the Health Effects of Climate Change
  • APHA Policy Statement 20078: Addressing the Urgent Threat of Global Climate Change to Public Health and the Environment
  • APHA Policy Statement 20046: Affirming the Necessity of a Secure, Sustainable and Health Protective Energy Policy
  • APHA Policy Statement 7909: Nuclear Power

Problem Statement
Energy policy can have a great impact on society and health. Environmental devastation, including climate change, strip mining, plant and animal death caused by oil spills, and emissions from transportation vehicles (e.g., cars, trains, planes) and power plants, is a serious threat to public health and welfare. Making the matter more complicated, the United States does not have a unified national energy strategy. Instead, national energy sources and legislation are piecemeal, involving different governmental levels. As such, lawmakers and regulators at the local, state, and federal levels have a responsibility to ensure that energy policies adequately address the health challenges related to the nation’s varied energy strategy.

Fossil fuels have been the leading source of energy both in the United States and abroad. In 2015 world governments, including the United States, adopted the Paris Climate Agreement. This agreement calls on all nations to reduce greenhouse gas (GHG) emissions to levels that would keep global temperatures from warming beyond 2oC of preindustrial levels. This includes an aspirational goal of keeping warming below 1.5oC of pre-industrial levels.[1] As the world takes measures to address pollution associated with fossil fuel combustion and transition to alternatives with lower climate impacts, the United States should adopt its energy policies accordingly. At the same time, the U.S. government has regressed from global and domestic climate policy, and the United States remains the only nation to have abandoned the global agreement. Local and state governments, businesses, and nonstate actors across the country have led efforts to enact climate policies that reduce emissions and protect against climate impacts.[2] Adoption of clean energy policy aiming to achieve energy from 100% renewable sources and energy conservation and efficiency efforts are strategies that can be utilized to reduce the negative public health impacts of energy development, use, and waste and the related consequence of unmitigated climate change.

Changes in energy policy could have disproportionate economic impacts on vulnerable communities, in particular economically disadvantaged communities, the elderly, and energy industry workers. A shift in costs to consumers could occur through the transition and could have a negative effect on economically disadvantaged populations. In many places, natural gas currently provides the lowest-cost energy, but renewable sources such as unsubsidized solar and wind are quickly approaching cost parity with traditional fuel sources and offer numerous job opportunities. It is expected that renewable energy will become the lowest-cost energy source in the coming decade.[3] In underserved communities, renewable energy sources could be a boon offering low-cost energy that is individually or democratically owned and does not involve the negative health impacts of fossil fuels. Continued reliance on fossil fuel–based energy comes at a greater cost from direct health impacts and related ecological damage if climate change remains unchecked. Furthermore, it is the role of policymakers and regulators at the local, state, and federal levels to be arbiters of a just transition for vulnerable communities, including communities that have faced environmental injustices as a result of living in proximity to polluting energy systems and workers who have both suffered occupational health injuries and benefited from employment in such industries.

Mining, processing, and combustion of coal result in major occupational and public health costs. “Coal is the world’s most polluting fossil fuel, and coal combustion is an important cause of both pollution and climate change.”[4] Pneumoconiosis (commonly known as “black lung disease”) is among the “major epidemics of industrial disease that ravaged workers’ health in the 19th and 20th centuries.”[5] Coal workers continue to face substantial occupational risks, including higher rates of chronic obstructive pulmonary disease, progressive massive fibrosis, exposure to methane, risks from injury, and hearing loss.[5] There is evidence of a significant resurgence of pneumoconiosis in the Appalachian region.[6] In addition, communities living in close proximity to coal-fired power plants face a greater risk of birth defects.[7]

Coal power plant emissions impact the health of nearby communities; they can also be transported across state and national boundaries to affect distant communities. Coal combustion (as when coal is burned in coal-fired power plants to produce electricity) is a major contributor to the “criteria pollutants”: particulate matter (PM2.5), nitrogen oxides (NOx), sulfur dioxide (SO2), ozone (O3), carbon dioxide (CO2), and airborne heavy metals such as mercury.[8] These pollutants are linked to respiratory disease, cardiovascular disease, stroke, diminished cognitive functioning, and adverse birth outcomes.[9,10]

Coal is a major source of global greenhouse gas emissions (e.g., carbon dioxide, nitrous oxides, and methane), and coal extraction and combustion contribute to global climate change.[11] The UCL-Lancet Commission on Climate Change has described GHG emissions as the “greatest global health threat of the 21st century” (see APHA Policy Statement 20157). Currently, 40% of the world’s energy comes from coal combustion; however, because coal produces significantly more CO2 per unit of energy than other fuels, it accounts for more than 70% of GHG emissions from the energy sector.[12] Building and operating the coal power plants that are under construction or currently planned globally would jeopardize achieving globally agreed upon emissions reduction targets under the Paris Agreement, placing the public’s health at significant risk.[13]

Crude oil is another problematic fossil fuel from which petroleum products are made.[14] Cars and trucks are the major consumers of petroleum.[15] Tailpipe emissions from cars and trucks have significant health impacts, and a concentrated effort must be made to reduce health hazards stemming from dependency on these vehicles.[16,17] Other uses of petroleum products include fuel oils for heating and electricity generation; asphalt and road oil; feedstocks for producing chemicals, plastics, and synthetic materials; waxes; ink; crayons; tires; and cleaning and personal care products.[15,18] Exposure to crude oil may result in short-term effects ranging from headaches to rashes and long-term effects such as immune system depression and lung, liver, and kidney damage.[18] As with most of the fossil fuels in the United States, oil is typically burned or combusted, which results in the creation of criteria pollutants that are hazardous to the environment and human health.[8,19,20]

Natural gas (including raw natural gas, natural gas liquids, and other petrochemicals) is a fossil fuel that carries potential risks for humans and the environment as well.[21,22] The most common extraction process, hydraulic fracturing (or fracking), can lead to catastrophic accidents, worker exposures, localized risks to residents, and air, soil, groundwater, and surface water contamination.[21–24] Pipelines that transport liquid natural gas are expensive and can leak, causing significant environmental hazards.[22] In addition, the fracking process can lead to earthquakes.[24]

Nuclear power produces a fifth of the nation’s electricity.[25] There are health risks associated with the uranium mining process, ―such as exposure to radiation, silica dust, and PM2.5 from diesel exhaust, and environmental risks of airborne radiation exposure and surface water and groundwater contamination to the general public.[26–28] While large-scale events such as core meltdowns and terrorist attacks may be infrequent, the consequences of such events are disastrous and long term.[26–29] Also, there continues to be conflict regarding permanent storage of dangerous nuclear waste.[30] High-level waste, in particular, is thermally hot and toxic, and it remains radioactive for many years.[27,31] Exposure to radioactive waste can lead to cancer, organ failure, or death.[27,32]

Meanwhile, renewable energy represents a healthier energy source and is the fastest growing area of employment in the energy sector. In 2016, 1.1 million employees worked in traditional coal, oil, and gas jobs.[33] By comparison, nearly 800,000 workers were employed in renewables, the nuclear sector, and advanced/low-emission natural gas.[33] While the fossil fuel sector added natural gas and oil jobs, coal mining employment declined by 39% from 2009 to 2016.[33] There was a 24% decline in 2016 alone. This declining employment in the coal mining sector is primarily the result of competition from natural gas and renewable energy.[34] Oil and gas extraction industry employment grew by 6% between 2009 and 2016.[33] The renewable energy sector has grown rapidly in recent years. In 2016 alone, the solar workforce grew by 25% and the wind sector workforce by 32%.[33] Solar job figures are likely higher because existing labor market data do not include jobs in the construction or other value chain industries for projects financed, owned, or directed by utilities.[33]

As the United States adopts energy efficiency and low-carbon strategies to mitigate emissions, related energy jobs represent a growing sector of the economy. In 2016, 2.2 million Americans were employed in jobs related to the design, installation, and manufacture of energy efficiency products and services.[33] Nearly three quarters of workers at construction firms involved in the energy efficiency sector are spending at least 50% of their time on work associated with energy efficiency.[33]

In 2016, 10.8% of employees in the motor vehicle and component parts industry worked with alternative-fuel vehicles, including natural gas, hybrid, plug-in hybrid, electric, and fuel cell/hydrogen vehicles.[33] In addition, more than 489,000 employees of motor vehicle parts companies are now contributing to more fuel-efficient vehicles, with 17% of all firms involved in motor vehicle component parts deriving all of their revenue from products that increase fuel economy.[33] At least 710,000 jobs in the motor vehicle sector are focused on increasing fuel economy or transitioning to alternative fuels.[33]

Evidence-Based Strategies to Address the Problem
Fossil fuels have been the leading source of energy both in the United States and abroad. In 2015 world governments, including the United States, adopted the Paris Climate Agreement. This agreement calls on all nations to reduce greenhouse gas (GHG) emissions to levels that would keep global temperatures from warming beyond 2oC of preindustrial levels. This includes an aspirational goal of keeping warming below 1.5oC of pre-industrial A well-informed energy strategy and policy is critical. The nation’s actions on energy are far reaching. Because of employment, environmental, health, and national security concerns, it is important to form an energy strategy based on solid, evidence-based research. As energy is a diverse and complex topic, there are many varied opportunities available to solve the nation’s energy concerns. At the same time, the public health impacts of climate change must be taken into consideration. In 2015, as noted, world governments including the United States adopted the Paris Climate Agreement, which calls on all nations to reduce greenhouse gas emissions.[1] Greenhouse gas emissions resulting from burning carbon-based energy sources are a major contributor to climate change. In October 2018, the International Panel on Climate Change (IPCC) stated clearly that keeping the global temperature rise below 1.5oC would “require rapid and far-reaching transitions” in energy, land, urban infrastructure, and industrial systems to achieve deep decarbonization of the energy supply. In addition, the IPCC bluntly noted that this would require achievement of net zero CO2 emissions by 2050, with a steep decline in all climate-related emissions, including CO2, methane, black carbon, nitrous oxide, and aerosols, by 2030. In its report, the IPCC further acknowledged that the impacts to human health from extreme heat, vector-borne diseases, heavy precipitation, droughts, and ozone-related mortality would be greater under 2.0oC or warming versus 1.5oC and that the poorest populations are most vulnerable to health-related impacts.[35]

The scientific evidence for climate action is clear and necessary to protect human health. Over the past few decades, the United States has addressed health impacts related to fossil fuel usage through increasingly stringent measures such as controlling air pollution emissions from coal-fired power plants and combustion-engine vehicles. Since 2017, the U.S. government has actively repealed these health-protective rules.. Specifically, the government has attempted to repeal or revise at least 30 environmental rules limiting climate pollution, including expansion of fossil fuel extraction and weakening of regulations that monitor methane emissions at extraction sites on public lands; it has also repealed and replaced the Clean Power Plan and repealed the Corporate Average Fuel Economy standards. [35–39] Federal, state, and local governments should adopt policies for a rapid transition to 100% renewable energy while also using energy efficiency and conservation measures to significantly reduce carbon-based emissions to meet the goals of the Paris Climate Agreement. In the absence of federal leadership, state and local governments should lead such efforts and challenge federal actions that do not align with climate science and endanger human health. Simultaneously adopting energy strategies that mitigate climate change would yield significant health co-benefits and health cost savings.[1]

There are several strategies that can be employed to mitigate climate change and comply with the Paris Climate Agreement. First is the commitment to a global phase out of coal as fuel. Emissions from coal-fired power plants as well as the coal industry at large have extensive harmful effects on coal miners, communities near mining operations or plants, and even communities downwind from these areas.[4–10,40] Coal combustion also leads to emission of GHG emissions, exacerbating climate change.[11–13] Communities that bear the greatest immediate burden of disease from coal mining and combustion would be better served by policies and investments that support a simultaneous transition to other appropriate industries and employment opportunities.[41] A smooth transition for coal communities can best be achieved within a stable regulatory context that enables companies to invest in a diverse energy portfolio and allows communities to develop educational and job training opportunities that support and align with the shift.[41]

Fuel economy standards are set by the federal government with options for individual states to set stricter standards to reduce air pollution. In the absence of federal leadership, states should act to reduce air pollution. Fuel economy and emissions standards for cars, trucks, and other vehicles are critical to protecting public health. In addition, as the market for alternative fuel and electric vehicles expands, renewable energy infrastructure must be created to power electric vehicles and avoid further use of fossil fuel energy and nuclear energy. Automobile manufacturers have a critical role to play in producing alternative fuel and electric vehicles. Electric utilities can also drive innovation through investment in and development of renewable energy microgrids and utility-scale energy. This must be coupled with increased availability of mass transportation and urban planning efforts to increase the prevalence and safety of walkways and bike lanes as a means of further reducing energy use. Increasing active transportation and use of public transit offers significant health benefits through increased physical activity.[42,43] Moreover, such actions will lead to reductions in costs and energy use, improvements in air quality, and decreases in accidental injuries and deaths.[17,44]

Natural gas also carries occupational and general public health risks, as do coal and oil.[21–24] In addition, there are significant hazards to the environment, including spills and induced earthquakes.[21–24] Human rights violations and the negative health impacts on indigenous and underresourced communities far outweigh the benefits of this relatively inexpensive fuel. Legislators and public health professionals must vigilantly monitor the natural gas industry to protect workers, the environment, and the general public, especially vulnerable populations such as Native American communities and agricultural communities on the frontlines of extraction. In addition, the federal government should hold companies accountable for pollution of land and water resources near adversely affected sites. Responsible companies should cover the costs associated with the cleaning up and restoration of the land.

While nuclear power plants do not produce GHG emissions, the possible danger to plant employees and communities near the facility is too great a risk.[27–29] Both nuclear generation and the storage of nuclear waste are significant obstacles that have yet to be adequately addressed.[30] Nuclear power should remain a limited component of the nation’s energy mix until these challenges are appropriately dealt with.

Energy efficiency and energy conservation involve the use of technology and behavior change, respectively, to effectively reduce energy waste, save money, and combat climate change.[45,46] Energy efficiency policies can lead to improvements in competitiveness among businesses, job creation, and reductions in air pollution; they can also improve the reliability of the electric grid and increase the nation’s energy independence.[47] In addition, fuel economy standards, ENERGY STAR labeling, and government initiatives such as the Weatherization Assistance Program (WAP) can help address human and environmental health.[47] Concerns about the accessibility of energy efficiency programs such as the Low Income Home Energy Assistance Program (LIHEAP) and WAP among households with high energy burdens (i.e., households using a disproportionate amount of their income for utility bills) are overstated and could be resolved through increased federal funding.[45,48,49] The “rebound effect” (e.g., using more lighting or appliances because energy-efficient versions have reduced one’s electric bills) does exist, although it is small enough that efficiency measures often still pay for themselves in the end.[45,48,49] Energy efficiency and conservation remain the nation’s most cost-effective energy resource.[50]

Renewable energy sources such as solar, wind, hydro, and geothermal energy are attractive long-term options. Renewables have significantly lower negative health and climate impacts than conventional fossil fuel sources.[51,52] In comparison with fossil fuels, which are subject to shortages and demand increases, renewables have stable pricing as costs are relative steady once the necessary infrastructure is in place.[51] Because of the need for new infrastructure and maintenance, the growth of the renewable energy sector would result in significant job creation.[51,52] A rapid transition to renewable energy would require significant active leadership and investment at all governmental levels. In addition, regulatory certainty is necessary to provide a smooth transition for the training and education of displaced fossil fuel and nuclear workers. Public-private partnerships with renewable energy companies could also provide certainty in terms of job placement and encourage investment in new industries and technologies.

Opposing Arguments/Evidence
The U.S. energy portfolio and strategy are immensely complex. Special interest groups have levied unreasonable criticism of current practices and policies against several industries that have supported this country for centuries and remain solid viable options for many years to come.

Fossil fuels (e.g., coal, natural gas, and oil), for example, have several advantages. They are inexpensive, reliable, and relatively abundant and add to the nation’s energy and national security.[53] Coal is cheap, safe to transport, and produces a great deal of energy.[53] In addition, some communities that rely on the fossil fuel industry to stimulate the local economy may not be well suited for producing renewable energy as a result of geography or other factors.[51,54] Furthermore, there are legitimate concerns regarding loss of jobs in areas of the country heavily dependent on the coal industry. As such, it is important to consider collateral damage that could be suffered by communities that rely on coal and other fossil fuels. While there may be legitimate concerns about emissions for coal-fired power plants, emerging technologies such as carbon capture, sequestration, and scrubbing are increasingly effective and affordable.[55]

Natural gas has become increasingly inexpensive and easy to access.[22] This has resulted in more efficient transportation vehicles, less air pollution (relative to coal or oil combustion), and energy independence, subsequently leading to stronger national security as the United States becomes less reliant on foreign nations for its energy.[22,56] Moreover, the natural gas and oil industries support millions of jobs and contribute more than $1 trillion to the U.S. economy, and the low cost of natural gas and oil allows for affordable prices, reducing energy insecurity in vulnerable communities.[57,58] While one of the processes for extracting natural gas―hydraulic fracturing―can lead to induced earthquakes, these events are rare.[24]

Nuclear power now provides a significant percentage (approximately 20%) of the nation’s electricity.[25] This industry is generally very well regulated and secure.[26,28,59] Furthermore, the nuclear power generation process does not produce GHG emissions.[28,59] Risks of large-scale accidents such as reactor meltdowns are relatively rare and are usually the result of human error as opposed to inherent problems with the technology.[26,28,29,59] Although nuclear power is not risk free, plants are constructed with several layers of protection that have proven to be very effective.[28,29] While there are indeed some challenges regarding a permanent solution for storage of high-level nuclear waste (e.g., at the Yucca Mountain site), current temporary storage sites are more than safe and secure.[31]

The upfront costs of energy efficiency can be high.[50] Furthermore, programs such as LIHEAP and WAP are not always accessible and have limited reach.[60,61] This dynamic tends to benefit high-income households that can readily afford the costs associated with efficiency work.[60,61] In addition, the “rebound effect” has been observed in serval instances (e.g., individuals with a hybrid vehicle driving more often since their car goes farther on less fuel). Up to 30% of energy savings can be lost due to this effect.[62]

The basic infrastructure, building of components, and storage for renewables can be cost prohibitive.[51,54] Similar to energy efficiency, upfront costs can be very high. In addition, many renewables cannot be produced in large quantities, and options are subject to weather conditions.[51] This is problematic, as the nation requires reliable power sources that are accessible regardless of whether or not the sun is shining and the wind is blowing. Lastly, renewables are not feasible everywhere. Some regions of the country lack the necessary natural resources, such as solar intensity, wind, water, and space (i.e., large landmass areas), to be able to practically pursue this energy source.[51,54]

While these opposing concerns warrant consideration, as discussed above the health and economic benefits of shifting to 100% renewable energy and increased energy efficiency and conservation significantly outweigh the costs of such changes or the benefits of sustaining the current approach.

Action Steps
APHA makes the following recommendations:

Coal

  • Coal mine health and safety laws should be vigorously enforced by the U.S. Department of Labor and the Mine Safety and Health Administration.
  • Mining companies should provide up-to-date health and safety technologies (e.g., improved ventilation, illumination, reduction of noise levels, mechanical roof bolters, dust control technology, gas monitoring).
  • Local, state, and federal energy policies should place a premium on mitigating the health effects of coal combustion.
  • There should be a complete and expedient phase out of coal for energy use at the national level, coupled with simultaneous institution of educational and employment opportunities in affected areas.
  • Congress should provide federal funding for research on health effects and pollution prevention strategies.
  • Operations of new coal-fired power plants should be suspended, and plans for future plants should be canceled.
  • Congress and the Environmental Protection Agency (EPA) should establish strengthened emission performance standards for existing plants, and these plants should eventually be upgraded or phased out.

Petroleum (Oil)

  • Congress should establish fuel economy and emissions standards for cars, trucks, and other vehicles commensurate with the most ambitious current state standards and continue to make standards more stringent.
  • Automakers should begin a complete phase out of fossil fuel use for transportation vehicles.

Natural Gas

  • Gas companies should cease dangerous hydraulic fracturing (fracking) and construction of pipelines across vulnerable lands.
  • Local, state, and federal lawmakers should deny approval of international or interstate pipeline construction.

Nuclear

  • The Nuclear Regulatory Commission (NRC) should establish guidelines to ensure that occupational radioactive exposures are kept “as low as reasonably achievable” below current limits throughout the fuel cycle.
  • The NRC, Department of Energy (DOE), and EPA should further evaluate the health and safety aspects of breeder reactors to ensure that public health and safety is a predominant concern. The federal government should operate or closely supervise fuel reprocessing and waste disposal activities.
  • NRC control of carcinogens in the nuclear cycle should be approached in the same way that radioactive emissions are treated in the coal fuel cycle.
  • Congress should set a moratorium on the construction of new nuclear power plants (see APHA Policy Statement 7909).

Energy Efficiency and Conservation

  • The DOE and EPA should create effective labeling with respect to the energy efficiency of energy-consuming products and buildings.
  • The DOE and EPA should establish effective appliance and equipment efficiency standards and energy codes for homes and commercial buildings.
  • Local, state, and federal lawmakers should establish funding for programs that will help consumers and businesses improve their energy efficiency and reduce emissions and waste.
  • Individuals and families should take advantage of retrofits of homes, especially in areas with low-income housing, to reduce energy bills and improve indoor air quality.
  • The business community should improve industrial facilities to reduce their energy waste, waste of resources, and emissions.
  • There should be universal recycling of materials.

Clean Energy, Renewables, and Energy Efficiency

  • Individuals, families, and businesses, as well as local, state, and federal government agencies, should expand adoption of diverse energy resources such as wind and solar.
  • Local, state, and federal lawmakers should offer financial incentives to encourage expanded use.
  • There should be expanded congressional funding of federal programs such as WAP and LIHEAP.

References
1. United Nations. What is the Paris Agreement? Available at: https://unfccc.int/process-and-meetings/the-paris-agreement/what-is-the-paris-agreement. Accessed January 19, 2019.
2. We Are Still In. About. Available at: https://www.wearestillin.com/about. Accessed January 19, 2019.
3. International Renewable Energy Agency. Renewable power generation costs 2017. Available at: https://cms.irena.org/-/media/Files/IRENA/Agency/Publication/2018/Jan/IRENA_2017_Power_Costs_2018.ashx. Accessed January 19, 2019.
4. National Academies of Sciences, Engineering, and Medicine. Monitoring and sampling approaches to assess underground coal mine dust exposures. Available at: https://www.nap.edu/catalog/25111/monitoring-and-sampling-approaches-to-assess-underground-coal-mine-dust-exposures. Accessed January 19, 2019.
5. Landrigan P, Fuller R, Acosta N, et al. The Lancet Commission on Pollution and Health. Lancet. 2018;391:462–512.
6. Centers for Disease Control and Prevention. Resurgence of progressive massive fibrosis in coal miners—Eastern Kentucky. 2016;65:1385–1389.
7. Wilson A. Coal blooded: putting people before profits. Available at: www.naacp.org/wp-content/uploads/2016/04/CoalBlooded.pdf. Accessed January 19, 2019.
8. U.S. Environmental Protection Agency. Criteria air pollutants. Available at: https://www.epa.gov/criteria-air-pollutants. Accessed January 19, 2019.
9. Zanobetti A, Schwartz J. Mortality displacement in the association of ozone with mortality: an analysis of 48 cities in the United States. Am J Respir Crit Care Med. 2008;177:184–189.
10. World Health Organization. WHO releases country estimates on air pollution exposure and health impact. Available at: http://www.who.int/mediacentre/news/releases/2016/air-pollution-estimates/en/. Accessed January 19, 2019.
11. International Energy Agency. World Energy Outlook 2007: China and India Insights. Paris, France: Organisation for Economic Co-operation and Development; 2007.
12. International Energy Agency. Key World Energy Statistics. Paris, France: International Energy Agency; 2012.
13. Edenhofer O, Steckel J, Jakob M, Bertram C. Reports of coal’s terminal decline may be exaggerated. Environ Res Lett. 2018;13:024019.
14. U.S. Energy Information Administration. What is the difference between crude oil, petroleum products, and petroleum? Available at: https://www.eia.gov/tools/faqs/faq.php?id=40&t=6. Accessed January 19, 2019.
15. U.S. Energy Information Administration. What are petroleum products, and what is petroleum used for? Available at: https://www.eia.gov/tools/faqs/faq.php?id=41&t=6. Accessed January 19, 2019.
16. Zhang K, Batterman S. Air pollution and health risks due to vehicle traffic. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4243514/. Accessed January 19, 2019.
17. Washington State Department of Ecology. Health effects from automobile emissions. Available at: https://fortress.wa.gov/ecy/publications/documents/0002008.pdf. Accessed January 19, 2019.
18. U.S. National Library of Medicine. Crude oil. Available at: https://toxtown.nlm.nih.gov/chemicals-and-contaminants/crude-oil. Accessed January 19, 2019.
19. U.S. Energy Information Administration. About 7% of fossil fuels are consumed for non-combustion use in the United States. Available at: https://www.eia.gov/todayinenergy/detail.php?id=35672. Accessed January 19, 2019.
20. Pennsylvania State University College of Earth and Mineral Sciences. Products of combustion. Available at: https://www.e-education.psu.edu/egee102/node/1951. Accessed January 19, 2019.
21. National Institute for Environmental Health Sciences. Hydraulic fracturing and health. Available at: https://www.niehs.nih.gov/health/topics/agents/fracking/index.cfm. Accessed January 19, 2019.
22. Conserve Energy Future. Natural gas pros and cons. Available at: https://www.conserve-energy-future.com/pros-and-cons-of-natural-gas.php. Accessed January 19, 2019.
23. Ohio Public Safety Commission. Natural gas safety. Available at: https://www.puco.ohio.gov/be-informed/consumer-topics/natural-gas-safety/. Accessed January 19, 2019.
24. U.S. Geological Service. Induced earthquakes. Available at: https://earthquake.usgs.gov/research/induced/myths.php. Accessed January 19, 2019.
25. U.S. Energy Information Administration. What is U.S. electricity generation by energy source? Available at: https://www.eia.gov/tools/faqs/faq.php?id=427&t=3. Accessed January 19, 2019.
26. Johnson T. Nuclear power safety concerns. Available at: https://www.cfr.org/backgrounder/nuclear-power-safety-concerns. Accessed January 19, 2019. 27. National Academies of Sciences, Engineering, and Medicine. Scientific, technical, environmental, human health and safety, and regulatory aspects of uranium mining and processing in Virginia. Available at: https://www.southernenvironment.org/cases-and-projects/fact-sheets/a-summary-of-key-findings-from-national-academy-of-sciences-report-uranium. Accessed January 19, 2019. 28. U.S. Nuclear Regulatory Commission. Frequently asked questions about security assessments at nuclear power plants. Available at: https://www.nrc.gov/security/faq-security-assess-nuc-pwr-plants.html#1. Accessed January 19, 2019. 29. U.S. Nuclear Regulatory Commission. Fact sheet on nuclear reactor risk. Available at: https://www.nrc.gov/reading-rm/doc-collections/fact-sheets/reactor-risk.html. Accessed January 19, 2019. 30. Union of Concerned Scientists. Nuclear power. Available at: https://www.ucsusa.org/nuclear-power/nuclear-waste#.WoT97OdG3I. Accessed January 19, 2019.
31. U.S. Nuclear Regulatory Commission. Backgrounder on radioactive waste. Available at: https://www.nrc.gov/reading-rm/doc-collections/fact-sheets/radwaste.html. Accessed January 19, 2019.
32. Centers for Disease Control and Prevention. Health effects of radiation. Available at: https://www.cdc.gov/nceh/radiation/dose.html#how. Accessed January 19, 2019.
33. U.S. Department of Energy. U.S. energy and employment report. Available at: https://www.energy.gov/sites/prod/files/2017/01/f34/2017%20US%20Energy%20and%20Jobs%20Report_0.pdf. Accessed January 19, 2019.
34. Institute for Energy Economics and Financial Analysis. U.S. coal: more market erosion is on the way. Available at: http://ieefa.org/wp-content/uploads/2018/02/U.S.-Coal-More-Market-Erosion-_-February-2018.pdf. Accessed January 19, 2019.
35. Halim SA. Global warming of 1.5ºC. Available at: http://www.ipcc.ch/report/sr15/. Accessed January 19, 2019.
36. National Highway Traffic Safety Administration. Draft environmental impact statement for the Safer Affordable Fuel-Efficient (SAFE) vehicles rule for model year 2021–2026 passenger cars and light trucks. Available at: https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/documents/ld_cafe_my2021-26_deis_0.pdf. Accessed January 19, 2019.
37. Harvard Environmental Law Program. Regulatory rollback tracker. Available at: http://environment.law.harvard.edu/policy-initiative/regulatory-rollback-tracker/. Accessed January 19, 2019.
38. U.S. Environmental Protection Agency. U.S. EPA and DOT propose fuel economy standards for MY 2021-2026 vehicles. Available at: https://www.epa.gov/newsreleases/us-epa-and-dot-propose-fuel-economy-standards-my-2021-2026-vehicles. Accessed January 19, 2019.
39. U.S. Department of the Interior. Waste prevention, production subject to royalties, and resource conservation: rescission or revision of certain requirements. Available at: https://www.blm.gov/sites/blm.gov/files/Final%20Rule%20-1004-AE53%20-%20%20Ready%20for%20OFR%209.18.18_508%20%281%29.pdf. Accessed January 19, 2019.
40. Cagney H. Coal plants cause deaths in neighboring communities. Lancet. 2016;4:p609.
41. Jeyakumar B. Job growth in clean energy: employment in Alberta’s emerging renewables and energy efficiency sectors. Available at: https://www.pembina.org/reports/job-growth-in-clean-energy.pdf. Accessed January 19, 2019.
42. Maizlish N, Woodcock J, Co S, Ostro B, Fanai A, Fairley D. Health cobenefits and transportation-related reductions in greenhouse gas emissions in the San Francisco Bay area. Am J Public Health. 2013;103:703–709.
43. Besser LM, Dannenberg AL. Walking to public transit: steps to help meet physical activity recommendations. Am J Prev Med. 2005;29:273–280.
44. American Council for an Energy Efficient Economy. The EPA Vehicle Emissions Program. Available at: aceee.org/sites/default/files/pdf/fact-sheet/impact-federal-ee-programs.pdf. Accessed January 19, 2019.
45. U.S. Department of Energy. Energy efficiency and conservation. Available at: https://www.eia.gov/energyexplained/index.cfm?page=about_energy_efficiency. Accessed January 19, 2019.
46. U.S. Department of Energy. Energy efficiency. Available at: https://energy.gov/science-innovation/energy-efficiency. Accessed January 19, 2019.
47. American Council for an Energy Efficient Economy. National energy policy. Available at: https://aceee.org/portal/national-policy. Accessed January 19, 2019.
48. Gillingham K, Rapson D, Gernot W. The rebound effect and energy efficiency policy. Rev Environ Econ Policy. 2015;10:68–88.
49. Drehobl A, Ross L. Lifting the high energy burden in America’s largest cities: how energy efficiency can improve low-income and underserved communities. Available at: http://aceee.org/research-report/u1602. Accessed January 19, 2019.
50. American Council for an Energy Efficient Economy. How much does energy efficiency cost? Available at: https://aceee.org/how-much-does-energy-efficiency-cost. Accessed January 19, 2019.
51. Conserve Energy Future. Renewable energy pros and cons. Available at: https://www.conserve-energy-future.com/pros-and-cons-of-renewable-energy.php. Accessed January 19, 2019.
52. Union of Concerned Scientists. Benefits of renewable energy use. Available at: https://www.ucsusa.org/clean-energy/renewable-energy/public-benefits-of-renewable-power#. Accessed January 19, 2019.
53. Conserve Energy Future. What are fossil fuels? Available at: https://www.conserve-energy-future.com/advantages_fossilfuels.php. Accessed January 19, 2019.
54. Union of Concerned Scientists. Barriers to renewable energy technologies. Available at: https://www.ucsusa.org/clean-energy/renewable-energy/barriers-to-renewable-energy#.WoS_QedG200. Accessed January 19, 2019.
55. Chu S. Carbon capture and sequestration. Science. 2009;325:1599.
56. Schmitt G. Energy security, national security, and natural gas. Available at: http://www.aei.org/publication/energy-security-national-security-and-natural-gas/. Accessed January 19, 2019.
57. Raghoo P, Surroop D, Wolf F. Natural gas to improve energy security in small island developing states: a techno-economic analysis. Dev Eng. 2017;2:92–98.
58. U.S. Energy Information Administration. Oil and gas industry employment growing much faster than total private sector employment. Available at: https://www.eia.gov/todayinenergy/detail.php?id=12451. Accessed January 19, 2019.
59. World Nuclear Association. The nuclear debate. Available at: http://www.world-nuclear.org/information-library/current-and-future-generation/the-nuclear-debate.aspx. Accessed January 19, 2019.
60. Stein M. The uneven gains of energy efficiency. Available at: https://www.citylab.com/environment/2018/02/the-uneven-gains-of-energy-efficiency/552674/. Accessed January 19, 2019.
61. Ross L, Drehobl A, Stickles B. The high cost of energy in rural America: household energy burdens and opportunities for energy efficiency. Available at: http://aceee.org/research-report/u1806. Accessed January 19, 2019.
62. Jenkins J, Nordhaus T, Shellenberger M. Energy emergence: rebound and backfire as emergent phenomena. Available at: https://thebreakthrough.org/blog/Energy_Emergence.pdf. Accessed January 19, 2019.