Overview of Abstract High exposure to biomass-burning smoke contributes to the burden of disease in households that lack adequate means to vent smoke outdoors. Less is known about smoke-related health problems in households with more adequate ventilation. In economically developed countries, moderately elevated smoke exposure is likely in households using fireplaces or leaky wood stoves. Even households with efficient wood stoves may have elevated indoor smoke concentrations, especially when stoves are improperly operated and when the smoke outside infiltrates back inside. This presentation gives overviews of the published time-series studies done in a few of the communities in the United States and New Zealand where residential wood-burning is a major source of airborne particulate matter, and of wood smoke-associated health effects research involving households with wood-burning devices in the United States, Russia, some European Union countries, and Canada. Collectively, these studies suggest exposure to residential wood smoke can result in harmful respiratory and cardiovascular effects: Asthma symptoms are most strongly associated with exposure. Hospitalization for chronic lung disease, acute respiratory infections and other respiratory conditions are also significantly associated with exposure. Hospitalization rates for cardiovascular conditions tend to increase on the day or day after wood smoke concentrations increase. Studies of children and people with asthma from households with wood-burning devices show positive associations of burning with several acute respiratory effects, and current and former smokers from households with wood-burning devices have increased odds of chronic bronchitis and airflow obstruction. There is also evidence that long-term residential wood smoke exposure increases risks of developing asthma, aeroallergen sensitivity, COPD and lung cancer. Relative risks of hospital admissions or emergency department visits for respiratory problems Chronic lung disease HA All age 2-d lag Winter PM10 (>80% RWS) avg. 12.5°C McGowan et al. 2002 Pneumonia / Flu " Acute resp. infection Respiratory ≥65 yr 15-64 yr <15 yr EDV 1-d lag Heating season PM2.5 * 1.9°C † Schreuder et al. 2006 0-d lag Year-round PM2.5 * avg. 8.6°C * Vegetative burning tracer † Median seasonal temperature Relative risks of hospitalizations for coronary problems Cardiac >65 yr 0-d lag Winter PM10 (>80% RWS) avg. 12.5°C McGowan et al. 2002 " 15-64 yr <15 yr All age 1-d lag Year-round PM2.5 * avg. 8.6°C Schreuder et al. 2006 Heating season PM2.5 * 1.9°C † Dysrhythmia Coronary Ischemia Heart Failure * Vegetative burning tracer † Median seasonal temperature SRA Poster Rules Each presenter will be assigned a 4' high x 8' wide poster board. Boards may be an inch smaller in either direction due to a border. = ((4x12)-2)x((8x12)-2) = 46 x 94 [one PP slide can be up to 36+ x 56] [Make two 36H x 47W slides OR three 36H x 31W slides]   All lettering should be legible from 5 feet away. The minimum type size should be no less than 18 points and the style should be bold or semibold in simple, clean-looking type. ~ 16 rectangles of info / 4 columns (Heart failure: Pathological ventricular hypertrophy) Relative risks of hospital admissions or emergency department visits for asthma HA 2-d lag Winter PM10 (>80% RWS) avg. 12.5°C McGowan et al. 2002 EDV 1-d lag Winter PM10 (~85% RWS) avg. min. 7.9°C Schwartz et al. 1993 " Winter PM10 (~45% RWS) avg. -7°C Lipsett et al. 1997 avg. -1°C avg. 4°C Literature search and selection National Library of Medicine, Google Scholar, Bibliographies Peer-reviewed epidemiology studies Communities with > 45% residential wood smoke in ambient wintertime PM. Wood-burning households in developed countries (if wood-burning was distinguished from coal-burning) Containing a Relative Risk, Odds Ratio or Incidence Rate Ratio or enough information to calculate one of these measures of association. Lung cancer Males age 35-75 who lived in households cooking with wood or gas at age 20 or older Ramanakumar et al. 2007 " at some time before age 20 Females age 35-75 People age 20-79 who lived in households cooking with wood Lissowska et al. 2005 who lived in households heating with wood Residential wood smoke particles Matt Kadlec, PhD, DABT Air Quality Program PO Box 47600 Olympia, WA 98504-7600 matt.kadlec@ecy.wa.gov 360 407-6817 The opinions expressed are those of the author and not necessarily the Department of Ecology Chronic cough People age 18-69 Rare use of WS in wintertime " Use of WS 1-d/wk in wintertime Use of WS 2-6 -d/wk in wintertime Use of WS 7-d/wk in wintertime Never-smokers age 18-69 Never or very seldom use of WS in wintertime Current smokers age 18-69 1-µm (Tesfaigzi et al. 2002) ALRI Acute lower respiratory infection EDV Emergency Dept. Visit FP Fireplace HA Hospital Admission IRR Incidence Rate Ratio OR Odds Ratio RR Relative Risk RWS Residential Wood Smoke WS Woodstove (Data: Hersoug et al. 2010)

research on residential wood smoke-associated health effects In economically Wt. of Evidence (0 – 5) Effect Number of Studies 5 Respiratory HA/EDV 2 Cardiac HA/EDV Lung cancer, women 4 Worsening of asthma and asthma-like symptoms Induction of COPD and COPD-like symptoms 3 Induction of seasonal allergies and IgE reactivity Physician-diagnosed asthma Acute lower respiratory tract infection Otitis media Acute cough Lung cancer, men 1 Wheeze 7 Acute upper respiratory tract infection Main limitations of most of these studies Uncertainty in the timing of exposures relative to symptoms (when exposures occurred and when symptoms developed). Uncertainty in exposure classification: Community studies relied on a central PM monitor, but there are large differences in peoples’ exposures to wood smoke. Indoor and outdoor and personal wood smoke PM concentrations not assessed. Most studies didn’t distinguish wood-burning PM from other PM sources. Immunoglobulin E reactivity and allergies Atopic dermatitis People age 18 to 25 Wood-heated household when age 0-6 Kilpeläinen et al. 2001 Allergic rhinitis and or conjunctivitis " 1+ Positive pollen IgE test People age 15 to 16 Wood-burning household heating system Van Miert et al. 2012 Grass pollen IgE test positive Tree pollen IgE test positive Weed pollen IgE test positive Non-seasonal allergic rhinitis Seasonal allergic rhinitis Onset of asthma OR Atopic asthma People age 15 to 16 " Van Miert et al. 2012 OR Physician-diagnosed asthma People age 5 to 9 Household with any wood-burning in the past year Maier et al. 1997 People age 18 to 25 Wood-heated household wood when age 0-6 Kilpeläinen et al. 2001 People age 20 to 50 Household with a WS Thorn et al. 2001 Males age 20 to 50 Females age 20 to 50 Household with a FP, tiled stove, or iron stove Chronic bronchitis, airflow obstruction and COPD OR Chronic bronchitis Former smokers with >10 pack-yr age 40-75 Wood smoke exposure Sood et al. 2010 " Current or former smokers with >10 pack-yr age 40-75 Current smokers with >10 pack-yr age 40-75 Female current or former smokers with >10 pack-yr age 40-75 Male current or former smokers with >10 pack-yr age 40-75 Hispanic current or former smokers with >10 pack-yr age 40-75 Non-Hispanic white current or former smokers with >10 pack-yr age 40-75 OR Airflow obstruction OR COPD Females age >50 Living 16-yr on avg. in wood cook stove household* Orozco-Levi et al. 2006 * Before age 19 in most cases

developed regions 72 Asthma symptoms Wheeze OR Asthma emergency dept. visits People with asthma age 26 to 62 Household-heating with WS or FP 1-4 /winter wk Eisner et al. 2002 " Household-heating with WS or FP > 5 /winter wk Decreased household-heating with WS or FP over past 18 mo Continued household-heating with WS or FP over past 18 mo Increased household-heating with WS or FP over past 18 mo OR Asthma hospitalizations Continued household-heating with WS or FP over 18 mo OR Nocturnal asthma People with moderate to severe asthma age 18 to 70 Use of a FP or WS that day Ostro et al. 1994 OR Moderate or severe shortness of breath OR Moderate or severe cough OR Restricted activity Wheeze OR Wheeze and dyspnea attacks People 20 to 50 Household with a WS Thorn et al. 2001 OR Wheeze 1st through 8th grade children Household heated with wood Noonan and Ward 2007 " People age 5 to 9 Household with any wood-burning in past year Maier et al. 1997 People age 18 to 25 Household heated with wood before age 7 Kilpeläinen et al. 2001 People age 18 to 69 Rare use of WS in wintertime Hersoug et al. 2010 Use of WS 1-d/wk in wintertime Use of WS 2-6 -d/wk in wintertime Use of WS 7-d/wk in wintertime Never-smokers age 18 to 69 Never or very seldom use of WS in wintertime Current smokers age 18 to 69 OR Wheeze without cold IRR Wheeze Postpartum females 1-hr of use of a WS Triche et al. 2005 1-hr use of a FP IRR Wheeze days Infants 8-hr/d use of a WS Triche et al. 2002 8-hr/d use of a FP IRR Wheeze episodes Cough, earache, laryngitis, pneumonia, chest tightness, phlegm, rhinitis and sore throat IRR Cough Postpartum Females 1-hr use of a WS Triche et al. 2005 " 1-hr use of a FP IRR Cough days Infants 8-hr/d use of a WS Triche et al. 2002 8-hr/d use of a FP IRR Cough episodes OR Pneumonia People age 15-16 yrs Households with wood fuel use Van Miert et al. 2012 OR Otitis media physician visit Children avg. age 4 yrs Households with a WS Daigler et al. 1991 OR Otitis media episodes Households with any daily WS use Pettigrew et al. 2004 Households with any daily FP use Households with average daily WS use Households with average daily FP use OR Recurrent otitis media Households with any use of WS Household with any use of FP IRR Laryngitis IRR Chest tightness IRR Phlegm IRR Rhinitis IRR Sore throat OR ALRI hospitalization Infants age 1-24 mo Households heating with wood alone Robin et al. 1996 Households cooking with wood alone