It may be hard to imagine that pollution could be invisible, but ozone is. It is currently one of the least-well-controlled pollutants in the United States1 and it is also one of the most dangerous.
Scientists have studied the effects of ozone on health for decades. Hundreds of research studies have confirmed that ozone harms people at levels currently found in the United States. In the last few years, we've learned that it can also be deadly.
- What Is Ozone?
- Where Does Ozone Come From?
- Who Is at Risk from Breathing Ozone?
- How Ozone Pollution Harms Your Health
Ozone (O3) is a gas molecule composed of three oxygen atoms. Often called "smog," ozone is harmful to breathe. Ozone aggressively attacks lung tissue by reacting chemically with it. When ozone is present, there are other harmful pollutants created by the same processes that make ozone.
The ozone layer found high in the upper atmosphere (the stratosphere) shields us from much of the sun's ultraviolet radiation. However, ozone air pollution at ground level where we can breathe it (in the troposphere) causes serious health problems.
Ozone develops in the atmosphere from gases that come out of tailpipes, smokestacks and many other sources. When these gases come in contact with sunlight, they react and form ozone smog.
The essential raw ingredients for ozone come from nitrogen oxides (NOx) and hydrocarbons, also called volatile organic compounds (VOCs). They are produced primarily when fossil fuels like gasoline, oil or coal are burned or when some chemicals, like solvents, evaporate. NOx is emitted from power plants, motor vehicles and other sources of high-heat combustion. VOCs are emitted from motor vehicles, chemical plants, refineries, factories, gas stations, paint and other sources. CO is also primarily emitted from motor vehicles.2
If the ingredients are present under the right conditions, they react to form ozone. And because the reaction takes place in the atmosphere, the ozone often shows up downwind of the sources of the original gases. In addition, winds can carry ozone far from where it began, even internationally across borders and even the oceans.
You may have wondered why "ozone action day" warnings are sometimes followed by recommendations to avoid activities such as mowing your lawn or driving your car. Lawn mower exhaust and gasoline vapors are VOCs that could turn into ozone in the heat and sun.
Anyone who spends time outdoors where ozone pollution levels are high may be at risk. Five groups of people are especially vulnerable to the effects of breathing ozone:
- children and teens3;
- anyone 65 and older4;
- people who work or exercise outdoors5;
- people with existing lung diseases, such as asthma and chronic obstructive pulmonary disease (also known as COPD, which includes emphysema and chronic bronchitis);6 and
- people with cardiovascular disease.7
In addition, some evidence suggests that other groups –including women, people who suffer from obesity and people with low incomes—may also face higher risk from ozone.8 More research is needed to confirm these findings.
The impact on your health can depend on many factors, however. For example, the risks would be greater if ozone levels are higher, if you are breathing faster because you're working outdoors or if you spend more time outdoors.
Lifeguards in Galveston, Texas, provided evidence of the impact of even short-term exposure to ozone on healthy, active adults in a study published in 2008. Testing the breathing capacity of these outdoor workers several times a day, researchers found that many lifeguards had greater obstruction of their airways when ozone levels were high. Because of this research, Galveston became the first city in the nation to install an air quality warning flag system on the beach.9
Premature death. Breathing ozone can shorten your life. Strong evidence exists of the deadly impact of ozone from large studies conducted in cities across the U.S., in Europe and in Asia. Researchers repeatedly found that the risk of premature death increased with higher levels of ozone.10 Newer research has confirmed that ozone increased the risk of premature death even when other pollutants also exist.11
Even low levels of ozone may be deadly. A large study of 48 U.S. cities looked at the association between ozone and mortality during the summer months. Ozone concentrations by city in the summer months ranged from 16 percent to 80 percent lower than the U.S. Environmental Protection Agency (EPA) currently considers safe. Researchers found that ozone at those lower levels was associated with deaths from cardiovascular disease, strokes, and respiratory causes.12
Immediate breathing problems. Many areas in the United States produce enough ozone during the summer months to cause health problems that can be felt right away. Immediate problems—in addition to increased risk of premature death—include:
- shortness of breath, wheezing and coughing;
- asthma attacks;
- increased risk of respiratory infections;
- increased susceptibility to pulmonary inflammation; and
- increased need for people with lung diseases, like asthma or chronic obstructive pulmonary disease (COPD), to receive medical treatment and to go to the hospital. 13
Cardiovascular effects. Inhaling ozone may affect the heart as well as the lungs. A 2006 study linked exposures to high ozone levels for as little as one hour to a particular type of cardiac arrhythmia that itself increases the risk of premature death and stroke.14 A French study found that exposure to elevated ozone levels for one to two days increased the risk of heart attacks for middle-aged adults without heart disease. 15 Several studies around the world have found increased risk of hospital admissions or emergency department visits for cardiovascular disease. 16
Long-term exposure risks. New studies warn of serious effects from breathing ozone over longer periods. With more long-term data, scientists are finding that long-term exposure—that is, for periods longer than eight hours, including days, months or years—may increase the risk of early death.
- Examining the records from a long-term national database, researchers found a higher risk of death from respiratory diseases associated with increases in ozone.17
- New York researchers looking at hospital records for children's asthma found that the risk of admission to hospitals for asthma increased with chronic exposure to ozone. Younger children and children from low-income families were more likely than other children to need hospital admissions even during the same time periods. 18
- California researchers analyzing data from their long-term Southern California Children's Health Study found that some children with certain genes were more likely to develop asthma as adolescents in response to the variations in ozone levels in their communities.19
- Studies link lower birthweight and decreased lung function in newborns to ozone levels in their community.20 This research provides increasing evidence that ozone may harm newborns.
Breathing other pollutants in the air may make your lungs more responsive to ozone—and breathing ozone may increase your body's response to other pollutants. For example, research warns that breathing sulfur dioxide and nitrogen oxide—two pollutants common in the eastern U.S.—can make the lungs react more strongly than to just breathing ozone alone. Breathing ozone may also increase the response to allergens in people with allergies. A large study published in 2009 found that children were more likely to suffer from hay fever and respiratory allergies when ozone and PM2.5 levels were high.21
Research shows lower levels of ozone cause harm. The EPA released their latest complete review of the current research on ozone pollution in February 2013.22 The EPA had engaged a panel of expert scientists, the Clean Air Scientific Advisory Committee, to help them assess the evidence; in particular, they examined research published between 2006 and 2012. The experts on the committee and EPA concluded that ozone pollution posed multiple, serious threats to health. Their findings are highlighted in the box below. Based on that review, EPA strengthened the official limit on ozone, called the National Ambient Air Quality Standard in 2015.
However, new research provides evidence that ozone can cause serious harm even at much lower levels. In a 2017 scientific paper, researchers further evidence in a nationwide study that older adults faced a higher risk of premature death even when levels of ozone pollution remained well below the current national standard.23
EPA Concludes Ozone Pollution Poses Serious Health Threats
- Causes respiratory harm (e.g., worsened asthma, worsened COPD, inflammation)
- Likely to cause early death (both short-term and long-term exposure)
- Likely to cause cardiovascular harm (e.g., heart attacks, strokes, heart disease, congestive heart failure)
- May cause harm to the central nervous system
- May cause reproductive and developmental harm
—U.S. Environmental Protection Agency, Integrated Science Assessment for Ozone and Related Photochemical Oxidants, 2013. EPA/600/R-10/076F.
- U.S. EPA. 2017. Nonattainment Areas for Criteria Pollutants (Green Book). Accessed at https://www.epa.gov/green-book. Data updated as of January 31, 2018.
- U.S. Environmental Protection Agency. Integrated Science Assessment of Ozone and Related Photochemical Oxidants (Final Report). U.S. Environmental Protection Agency, Washington, DC, EPA/600/R-10/076F, 2013.
- Mar TF, Koenig JQ. Relationship between visits to emergency departments for asthma and ozone exposure in greater Seattle, Washington. Ann Allergy Asthma Immunol. 2009; 103: 474-479. Villeneuve PJ, Chen L, Rowe BH, Coates F. Outdoor air pollution and emergency department visits for asthma among children and adults: A case-crossover study in northern Alberta, Canada. Environ Health Global Access Sci Source. 2007; 6: 40.
- Medina-Ramón M, Schwartz J. Who is more vulnerable to die from ozone air pollution? Epidemiology. 2008; 19: 672-679.
- Thaller EI, Petronell SA, Hochman D, Howard S, Chhikara RS, Brooks EG. Moderate Increases in Ambient PM 2.5 and Ozone Are Associated With Lung Function Decreases in Beach Lifeguards. J Occp Environ Med. 2008; 50: 202-211; Sawyer K, Brown J, Hazucha M, Bennett WD. The effect of exercise on nasal uptake of ozone in healthy human adults. J Appl Physiol. 2007;102: 1380-1386; Hu SC, Ben-Jebria A, Ultman JS. Longitudinal distribution of ozone absorption in the lung: Effects of respiratory flow. J Appl Physiol. 1994; 77: 574-583.
- Horstman DH, Ball BA, Brown J, Gerrity T, Folinsbee LJ. Comparison of pulmonary responses of asthmatic and nonasthmatic subjects performing light exercise while exposed to a low level of ozone. Toxicol Ind Health. 1995; 11: 369-385; Kreit JW, Gross KB, Moore TB, Lorenzen TJ, D'Arcy J, Eschenbacher WL. Ozone-induced changes in pulmonary function and bronchial responsiveness in asthmatics. J Appl Physiol. 1989; 66: 217-222; Medina-Ramón M, Zanobetti A, Schwartz J. The Effect of Ozone and PM10 on Hospital Admissions for Pneumonia and Chronic Obstructive Pulmonary Disease: a national multicity study. Am J Epidemiol. 2006; 163(6):579-588.
- Peel JL, Metzger KB, Klein M, Flanders WD, Mulholland JA, Tolbert PE. Ambient air pollution and cardiovascular emergency department visits in potentially sensitive groups. Am J Epidemiol. 2007; 165: 625-633; Medina-Ramón and Schwartz, 2008; Medina-Ramón M, Zanobetti A, Schwartz J, 2006.
- Medina-Ramón and Schwartz, 2008; Stafoggia M, Forastiere F, Faustini A, Biggeri A, Bisanti L, et al. Susceptibility factors to ozone-related mortality: A population-based case-crossover analysis. Am J Respir Crit Care Med. 2010; 182: 376-384; Jerrett M, Burnett RT, Pope CA III, Ito K, Thurston G, Krewski D, Shi Y, Calle E, Thun M. Long-term ozone exposure and mortality. N Engl J Med. 2009;360: 1085-1095; Alexeeff SE, Litonjua AA, Suh H, Sparrow D, Vokonas PS, Schwartz J. Ozone exposure and lung function: Effect modified by obesity and airways hyperresponsiveness in the VA Normative Aging Study. Chest. 2007; 132: 1890-1897; McDonnell WF, Stewart PW, Smith MV. Prediction of ozone-induced lung function responses in humans. Inhal Toxicol. 2010; 22: 160-168. Lin S, Liu X, Le LH, Hwang SA. Chronic exposure to ambient ozone and asthma hospital admissions among children. Environ Health Perspect. 2008; 116: 1725-1730; Burra TA, Moineddin R, Agha MM, Glazier RH. Social disadvantage, air pollution, and asthma physician visits in Toronto, Canada. Environ Res. 2009;109: 567-574.
- Thaller, et al., 2008.
- Bell ML, McDermott A, Zeger SL, Samet JM, Dominici F. Ozone and short-term mortality in 95 US urban communities, 1987-2000. JAMA. 2004; 292:2372-2378. Gryparis A, Forsberg B, Katsouyanni K, et al. Acute Effects of Ozone on Mortality from the "Air Pollution and Health: a European approach" project. Am J Respir Crit Care Med. 2004; 170: 1080-1087. Bell ML, Dominici F, and Samet JM. A Meta-Analysis of Time-Series Studies of Ozone and Mortality with Comparison to the National Morbidity, Mortality, and Air Pollution Study. Epidemiology. 2005; 16:436-445. Levy JI, Chermerynski SM, Sarnat JA. Ozone Exposure and Mortality: an empiric Bayes metaregression analysis. Epidemiology. 2005; 16:458-468. Ito K, De Leon SF, Lippmann M. Associations Between Ozone and Daily Mortality: analysis and meta-analysis. Epidemiology. 2005; 16:446-429.
- 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; Katsouyanni K, Samet JM, Anderson HR, Atkinson R, Le Tertre A, et al. Air pollution and health: A European and North American approach (APHENA). Boston, MA: Health Effects Institute, 2009; Samoli E, Zanobetti A, Schwartz J, Atkinson R, Le Tertre A, et al. The temporal pattern of mortality responses to ambient ozone in the APHEA project. J Epidemiol Community Health. 2009; 63: 960-966; Stafoggia M, et al, 2010.
- Zanobetti and Schwartz. 2008.
- Gent JF, Triche EW, Holford TR, Belanger K, Bracken MB, Beckett WS, Leaderer BP. Association of Low-Level Ozone and Fine Particles with Respiratory Symptoms in Children with Asthma. JAMA. 2003; 290:1859-1867; Desqueyroux H, Pujet JC, Prosper M, Squinazi F, Momas I. Short-Term Effects of Low-Level Air Pollution on Respiratory Health of Adults Suffering from Moderate to Severe Asthma. Environ Res. 2002; 89:29-37; Burnett RT, Brook JR, Yung WT, Dales RE, Krewski D. Association between Ozone and Hospitalization for Respiratory Diseases in 16 Canadian Cities. Environ Res. 1997; 72:24-31; Medina-Ramón, et al. 2006.
- Rich DQ, Mittleman MA, Link MS, Schwartz J, Luttmann-Gibson H, Catalano PJ, Speizer FE, Gold DR, Dockery DW. Increased Risk of Paroxysmal Atrial Fibrillation Episodes Associated with Acute Increases in Ambient Air Pollution. Environ Health Perspect. 2006; 114:120-123.
- Ruidavets J-B, Cournot M, Cassadou S, Giroux M, Meybeck M, Ferrières J. Ozone Air Pollution is Associated with Acute Myocardial Infarction. Circulation. 2005; 111:563-569.
- Azevedo JM, Gonçalves FL, de Fátima Andrade M. Long-range ozone transport and its impact on respiratory and cardiovascular health in the north of Portugal. Int J Biometeorol. 2011; 55: 187-202; Linares C, Diaz J. Short-term effect of concentrations of fine particulate matter on hospital admissions due to cardiovascular and respiratory causes among the over-75 age group in Madrid, Spain. Public Health. 2010; 124: 28-36; Middleton N, Yiallouros P, Kleanthous S, Kolokotroni O, Schwartz J, et al. A 10-year time-series analysis of respiratory and cardiovascular morbidity in Nicosia, Cyprus: The effect of short-term changes in air pollution and dust storms. Environ Health. 2008; 7: 39; Lee JT, Kim H, Cho YS, Hong YC, Ha EH, Park H. Air pollution and hospital admissions for ischemic heart diseases among individuals 64+ years of age residing in Seoul, Korea. Arch Environ Health. 2003; 58: 617-623; Wong TW, Lau TS, Yu TS, Neller A, Wong SL, Tam W, Pang SW. Air pollution and hospital admissions for respiratory and cardiovascular diseases in Hong Kong. Occup Environ Med. 1999; 56: 679-683.
- Jerrett, et al., 2009.
- Lin S, Liu X, Le LH, and Hwang S-A. Chronic exposure to ambient ozone and asthma hospital admissions among children. Environ Health Perspect. 2008; 116:1725-1730.
- Islam T, McConnell R, Gauderman WJ, Avol E, Peters JM, and Gilliland F. Ozone, oxidant defense genes, and risk of asthma during adolescence. Am J Respir Crit Care Med. 2009; 177(4):388-395.
- Salam MT, Millstein J, Li YF, Lurmann FW, Margolis HG, Gilliland FD. Birth outcomes and prenatal exposure to ozone, carbon monoxide, and particulate matter: Results from the Children's Health Study. Environ Health Perspect. 2005; 113: 1638-1644; Morello-Frosch R, Jesdale BM, Sadd JL, Pastor M. Ambient air pollution exposure and full-term birth weight in California. Environ Health. 2010; 9: 44; Hansen CA, Barnett AG, Pritchard G. The effect of ambient air pollution during early pregnancy on fetal ultrasonic measurements during mid-pregnancy. Environ Health Perspect. 2008; 116: 362-369; Mannes T, Jalaludin B, Morgan G, Lincoln D, Sheppeard V, Corbett S. Impact of ambient air pollution on birth weight in Sydney, Australia. Occup Environ Med. 2005; 62: 524-530.
- Parker JD, Akinbami LJ, Woodruff TJ. Air Pollution and Childhood Respiratory Allergies in the United States. Environ Health Perspect. 2009; 117:140-147.
- U.S. EPA, 2013.
- Di Q, Dai L, Wang Y, Zanobetti A, Choirat C, Schwartz JD, Dominici F. Association of Short-Term Exposure to Air Pollution with Mortality in Older Adults. JAMA. 2017; 318: 2446-2456.
Approved by Scientific and Medical Editorial Review Panel. Last reviewed February 10, 2018.