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Improved health economic assessments of sustainable transport solutions in urban environments
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Section of Sustainable Health.ORCID iD: 0000-0001-7143-5835
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Introduction: Part of the European Strategy to achieve climate neutrality in the transport sector is to increase the proportion of electric vehicles (EVs) and active commuting. Health co-benefits from reduced air pollution and increased active commuting are assumed to follow; however, all dimensions of expected health effects are not quantified nor valued monetarily. Current state-of-the art health impact assessments (HIAs) of air pollution assume immediate change in health with exposure; however, the time-window of importance for health outcomes is unknown. Moreover, the currently applied risk estimate of sick leaves in relation to air pollution is poorly generalizable due to outdated exposure assessment and subjective data on outcome. The overall aim of this thesis is to assess the health economic effects of sustainable urban transport solutions and improve the epidemiological knowledge base of air pollution effects. 

Methods: The health effects of increased active commuting and the resulting change in air pollution exposure were valued monetarily from a health care perspective, and a cost-effectiveness analysis of investment in bicycle infrastructure was conducted. A health economic assessment from a societal perspective was also conducted for an increased proportion of EVs in the vehicle fleet, considering a change in both exhaust and non-exhaust particles. The exposure-lag response between air pollution and risk for ischemic heart disease (IHD) and stroke was assessed in a multi-cohort study using distributed lag-nonlinear models (DLNMs). A case cross-over study design was applied to estimate the odds of sick leaves in relation to short-term PM2.5 exposure, and production losses were valued using the human capital method. 

Results: Investing in bicycle infrastructure to enable increased active commuting was estimated to be cost-effective from a health care perspective. An increased proportion of EVs was estimated to decrease population-weighted PM2.5 concentrations without the use of studded winter tires, but was estimated to increase with the current use of studded winter tires in Stockholm Sweden. For a 0-50% use of studded winter tires the health economic costs ranged between €20 and €122 million (M). An independent effect of PM2.5 on sick leaves was estimated to correspond to €2M per year in productivity loss for the population of Stockholm municipality. Exposure time windows closer in time and local sources of air pollution were suggested to be of greater importance for incident IHD and stroke.

Conclusions: This thesis has demonstrated the health economic potential in policies seeking to transform the transport sector towards sustainability. Investment in the transport sector could lead to decreased morbidity and decreased monetary burden in the health care sector. Non-exhaust particles should be considered in order to fully assess the health economic effects of EVs. Moreover, the risk estimate of sick leaves in relation to air pollution exposure could be included in international HIAs.

Place, publisher, year, edition, pages
Umeå: Umeå Univeristet , 2022. , p. 100
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 2199
Keywords [en]
active commuting, electric vehicles, air pollution, particle matter, physical activity, morbidity, mortality, health economic evaluation
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Epidemiology; Public health; sustainable development
Identifiers
URN: urn:nbn:se:umu:diva-198995ISBN: 978-91-7855-869-8 (print)ISBN: 978-91-7855-870-4 (electronic)OAI: oai:DiVA.org:umu-198995DiVA, id: diva2:1691868
Public defence
2022-09-23, Triple Helix, Universitetsledningshuset,, Umeå, 09:00 (English)
Opponent
Supervisors
Available from: 2022-09-02 Created: 2022-08-31 Last updated: 2022-09-01Bibliographically approved
List of papers
1. Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden
Open this publication in new window or tab >>Health economic assessment of a scenario to promote bicycling as active transport in Stockholm, Sweden
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2019 (English)In: BMJ Open, E-ISSN 2044-6055, Vol. 9, no 9, article id e030466Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To conduct a health economic evaluation of a proposed investment in urban bicycle infrastructure in Stockholm County, Sweden.

DESIGN: A cost-effectiveness analysis is undertaken from a healthcare perspective. Investment costs over a 50-year life cycle are offset by averted healthcare costs and compared with estimated long-term impacts on morbidity, quantified in disability-adjusted life years (DALYs). The results are re-calculated under different assumptions to model the effects of uncertainty.

SETTING: The Municipality of Stockholm (population 2.27 million) committed funds for bicycle path infrastructure with the aim of achieving a 15% increase in the number of bicycle commuters by 2030. This work is based on a previously constructed scenario, in which individual registry data on home and work address and a transport model allocation to different modes of transport identified 111 487 individuals with the physical capacity to bicycle to work within 30 min but that currently drive a car to work.

RESULTS: Morbidity impacts and healthcare costs attributed to increased physical activity, change in air pollution exposure and accident risk are quantified under the scenario. The largest reduction in healthcare costs is attributed to increased physical activity and the second largest to reduced air pollution exposure among the population of Greater Stockholm. The expected net benefit from the investment is 8.7% of the 2017 Stockholm County healthcare budget, and 3.7% after discounting. The economic evaluation estimates that the intervention is cost-effective and each DALY averted gives a surplus of €9933. The results remained robust under varied assumptions pertaining to reduced numbers of additional bicycle commuters.

CONCLUSION: Investing in urban infrastructure to increase bicycling as active transport is cost-effective from a healthcare sector perspective.

Place, publisher, year, edition, pages
BMJ Publishing Group Ltd, 2019
Keywords
DALY, commuting, health economic evaluation, health impacts, transport mode shift
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-163491 (URN)10.1136/bmjopen-2019-030466 (DOI)000497787600283 ()31530609 (PubMedID)2-s2.0-85072268060 (Scopus ID)
Available from: 2019-09-23 Created: 2019-09-23 Last updated: 2023-09-05Bibliographically approved
2. A health economic assessment of air pollution effects under climate neutral vehicle fleet scenarios in Stockholm, Sweden
Open this publication in new window or tab >>A health economic assessment of air pollution effects under climate neutral vehicle fleet scenarios in Stockholm, Sweden
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2021 (English)In: Journal of Transport and Health, ISSN 2214-1405, E-ISSN 2214-1405, Vol. 22, article id 101084Article in journal (Refereed) Published
Abstract [en]

Introduction: Electric vehicles (EVs) are heavily promoted as beneficial for climate and health. In most studies, it is assumed that EVs contribution to urban air pollution is zero due to no tailpipe emissions, ignoring the contribution of non-exhaust particles (brake, tire and road wear), which are unregulated in EU. This study of Stockholm, Sweden, aims to 1) assess how a future vehicle fleet impacts concentrations of particles of size less than 2.5 μm (PM2.5) and evaluate the expected health outcomes economically and 2) compare this with CO2 savings.

Methods: Source specific dispersion models of exhaust and non-exhaust PM2.5 was used to estimate the population weighted concentrations. Thereafter exposure differences within a business as usual (BAU2035) and a fossil free fuel (FFF2035) scenario were used to assess expected health and economic impacts. The assessment considered both exhaust and non-exhaust emissions, considering the vehicle weight and the proportion of vehicles using studded winter tires. Health economic costs were retrieved from the literature and societal willingness to pay was used to value quality-adjusted life-years lost due to morbidity and mortality.

Results: The mean population weighted exhaust PM2.5 concentration decreased 0.012 μg/m3 (39%) in FFF2035 as compared to BAU2035. Assuming 50% higher road and tire wear PM2.5 emission because of higher weight among EVs and 30% less brake wear emissions, the estimated decrease in wear particle exposures were 0.152 (22%) and 0.014 μg/m3 (1.9%) for 0 and 30% use on studded winter tires, respectively. The resulting health economic costs were estimated to €217M and €32M, respectively. An increase by 0.079 μg/m3 (11%) was however estimated for 50% use of studded winter tires, corresponding to an €89M increase in health costs.

Conclusion: Considering both exhaust and wear generated particles, it is not straight forward that an increase of EVs will decrease the negative health impacts.

Place, publisher, year, edition, pages
Elsevier, 2021
Keywords
CO2, Costs, Electric vehicles, Exhaust, Morbidity, Mortality, Non-exhaust, PM10, PM2.5, QALY, Road dust, Wear particles
National Category
Occupational Health and Environmental Health Environmental Sciences
Identifiers
urn:nbn:se:umu:diva-185374 (URN)10.1016/j.jth.2021.101084 (DOI)000697062200001 ()2-s2.0-85108259686 (Scopus ID)
Funder
NordForsk, 75007
Available from: 2021-06-29 Created: 2021-06-29 Last updated: 2023-03-23Bibliographically approved
3. The association between short-term air pollution exposure and sick leave: A case-crossovers study in Stockholm, Sweden
Open this publication in new window or tab >>The association between short-term air pollution exposure and sick leave: A case-crossovers study in Stockholm, Sweden
(English)Manuscript (preprint) (Other academic)
National Category
Occupational Health and Environmental Health Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:umu:diva-198993 (URN)
Available from: 2022-08-31 Created: 2022-08-31 Last updated: 2022-09-01
4. Using Distributed Lag Non-Linear Models to Estimate Exposure Lag-Response Associations between Long-Term Air Pollution Exposure and Incidence of Cardiovascular Disease
Open this publication in new window or tab >>Using Distributed Lag Non-Linear Models to Estimate Exposure Lag-Response Associations between Long-Term Air Pollution Exposure and Incidence of Cardiovascular Disease
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2022 (English)In: International Journal of Environmental Research and Public Health, ISSN 1661-7827, E-ISSN 1660-4601, Vol. 19, no 5, article id 2630Article in journal (Refereed) Published
Abstract [en]

Long-term air pollution exposure increases the risk for cardiovascular disease, but little is known about the temporal relationships between exposure and health outcomes. This study aims to estimate the exposure-lag response between air pollution exposure and risk for ischemic heart disease (IHD) and stroke incidence by applying distributed lag non-linear models (DLNMs). Annual mean concentrations of particles with aerodynamic diameter less than 2.5 µm (PM2.5 ) and black carbon (BC) were estimated for participants in five Swedish cohorts using dispersion models. Simultaneous estimates of exposure lags 1–10 years using DLNMs were compared with separate year specific (single lag) estimates and estimates for lag 1–5-and 6–10-years using moving average exposure. The DLNM estimated no exposure lag-response between PM2.5 total, BC, and IHD. However, for PM2.5 from local sources, a 20% risk increase per 1 µg/m3 for 1-year lag was estimated. A risk increase for stroke was suggested in relation to lags 2–4-year PM2.5 and BC, and also lags 8–9-years BC. No associations were shown in single lag models. Increased risk estimates for stroke in relation to lag 1–5-and 6–10-years BC moving averages were observed. Estimates generally supported a greater contribution to increased risk from exposure windows closer in time to incident IHD and incident stroke.

Place, publisher, year, edition, pages
MDPI, 2022
Keywords
Air pollution, Distributed lag non-linear models, Ischemic heart disease, Multicohort, Particulate matter, Stroke
National Category
Occupational Health and Environmental Health
Research subject
Public health
Identifiers
urn:nbn:se:umu:diva-192874 (URN)10.3390/ijerph19052630 (DOI)000768249500001 ()35270332 (PubMedID)2-s2.0-85125089278 (Scopus ID)
Funder
Novo NordiskSwedish Diabetes AssociationSwedish Environmental Protection AgencySwedish Heart Lung FoundationForte, Swedish Research Council for Health, Working Life and WelfareStockholm County CouncilSwedish Research Council, 2017-00641
Available from: 2022-03-11 Created: 2022-03-11 Last updated: 2023-09-05Bibliographically approved

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