Global impact of atmospheric arsenic on health risk: 2005 to 2015.

Arsenic is a toxic pollutant commonly found in the environment. Most of the previous studies on arsenic pollution have primarily focused on arsenic contamination in groundwater. In this study, we examine the impact on human health from atmospheric arsenic on the global scale. We first develop an improved global atmospheric arsenic emission inventory and connect it to a global model (Goddard Earth Observing System [GEOS]-Chem). Model evaluation using observational data from a variety of sources shows the model successfully reproduces the spatial distribution of atmospheric arsenic around the world. We found that for 2005, the highest airborne arsenic concentrations were found over Chile and eastern China, with mean values of 8.34 and 5.63 ng/m3, respectively. By 2015, the average atmospheric arsenic concentration in India (4.57 ng/m3) surpassed that in eastern China (4.38 ng/m3) due to the fast increase in coal burning in India. Our calculation shows that China has the largest population affected by cancer risk due to atmospheric arsenic inhalation in 2005, which is again surpassed by India in 2015. Based on potential exceedance of health-based limits, we find that the combined effect by including both atmospheric and groundwater arsenic may significantly enhance the risks, due to carcinogenic and noncarcinogenic effects. Therefore, this study clearly implies the necessity in accounting for both atmospheric and groundwater arsenic in future management.

The quest for improved air quality may push China to continue its CO2 reduction beyond the Paris Commitment.

China is challenged with the simultaneous goals of improving air quality and mitigating climate change. The "Beautiful China" strategy, launched by the Chinese government in 2020, requires that all cities in China attain 35 µg/m3 or below for annual mean concentration of PM2.5 (particulate matter with aerodynamic diameter less than 2.5 µm) by 2035. Meanwhile, China adopts a portfolio of low-carbon policies to meet its Nationally Determined Contribution (NDC) pledged in the Paris Agreement. Previous studies demonstrated the cobenefits to air pollution reduction from implementing low-carbon energy policies. Pathways for China to achieve dual targets of both air quality and CO2 mitigation, however, have not been comprehensively explored. Here, we couple an integrated assessment model and an air quality model to evaluate air quality in China through 2035 under the NDC scenario and an alternative scenario (Co-Benefit Energy [CBE]) with enhanced low-carbon policies. Results indicate that some Chinese cities cannot meet the PM2.5 target under the NDC scenario by 2035, even with the strictest end-of-pipe controls. Achieving the air quality target would require further reduction in emissions of multiple air pollutants by 6 to 32%, driving additional 22% reduction in CO2 emissions relative to the NDC scenario. Results show that the incremental health benefit from improved air quality of CBE exceeds 8 times the additional costs of CO2 mitigation, attributed particularly to the cost-effective reduction in household PM2.5 exposure. The additional low-carbon energy polices required for China's air quality targets would lay an important foundation for its deep decarbonization aligned with the 2 °C global temperature target.

Indian annual ambient air quality standard is achievable by completely mitigating emissions from household sources.

Exposures to ambient and household fine-particulate matter (PM2.5) together are among the largest single causes of premature mortality in India according to the Global Burden of Disease Studies (GBD). Several recent investigations have estimated that household emissions are the largest contributor to ambient PM2.5 exposure in the country. Using satellite-derived district-level PM2.5 exposure and an Eulerian photochemical dispersion model CAMx (Comprehensive Air Quality Model with Extensions), we estimate the benefit in terms of population exposure of mitigating household sources--biomass for cooking, space- and water-heating, and kerosene for lighting. Complete mitigation of emissions from only these household sources would reduce India-wide, population-weighted average annual ambient PM2.5 exposure by 17.5, 11.9, and 1.3%, respectively. Using GBD methods, this translates into reductions in Indian premature mortality of 6.6, 5.5, and 0.6%. If PM2.5 emissions from all household sources are completely mitigated, 103 (of 597) additional districts (187 million people) would meet the Indian annual air-quality standard (40 µg m-3) compared with baseline (2015) when 246 districts (398 million people) met the standard. At 38 µg m-3, after complete mitigation of household sources, compared with 55.1 µg m-3 at baseline, the mean annual national population-based concentration would meet the standard, although highly polluted areas, such as Delhi, would remain out of attainment. Our results support expansion of programs designed to promote clean household fuels and rural electrification to achieve improved air quality at regional scales, which also has substantial additional health benefits from directly reducing household air pollution exposures.

Energy and air pollution benefits of household fuel policies in northern China.

In addition to many recent actions taken to reduce emissions from energy production, industry, and transportation, a new campaign substituting residential solid fuels with electricity or natural gas has been launched in Beijing, Tianjin, and 26 other municipalities in northern China, aiming at solving severe ambient air pollution in the region. Quantitative analysis shows that the campaign can accelerate residential energy transition significantly, and if the planned target can be achieved, more than 60% of households are projected to remove solid fuels by 2021, compared with fewer than 20% without the campaign. Emissions of major air pollutants will be reduced substantially. With 60% substitution realized, emission of primary PM2.5 and contribution to ambient PM2.5 concentration in 2021 are projected to be 30% and 41% of those without the campaign. With 60% substitution, average indoor PM2.5 concentrations in living rooms in winter are projected to be reduced from 209 (190 to 230) µg/m3 to 125 (99 to 150) µg/m3 The population-weighted PM2.5 concentrations can be reduced from 140 µg/m3 in 2014 to 78 µg/m3 or 61 µg/m3 in 2021 given that 60% or 100% substitution can be accomplished. Although the original focus of the campaign was to address ambient air quality, exposure reduction comes more from improved indoor air quality because ∼90% of daily exposure of the rural population is attributable to indoor air pollution. Women benefit more than men.

Emissions Measurements from Household Solid Fuel Use in Haryana, India: Implications for Climate and Health Co-benefits.

A large concern with estimates of climate and health co-benefits of "clean" cookstoves from controlled emissions testing is whether results represent what actually happens in real homes during normal use. A growing body of evidence indicates that in-field emissions during daily cooking activities differ substantially from values obtained in laboratories, with correspondingly different estimates of co-benefits. We report PM2.5 emission factors from uncontrolled cooking (n = 7) and minimally controlled cooking tests (n = 51) using traditional chulha and angithi stoves in village kitchens in Haryana, India. Minimally controlled cooking tests (n = 13) in a village kitchen with mixed dung and brushwood fuels were representative of uncontrolled field tests for fine particulate matter (PM2.5), organic and elemental carbon (p > 0.5), but were substantially higher than previously published water boiling tests using dung or wood. When the fraction of nonrenewable biomass harvesting, elemental, and organic particulate emissions and modeled estimates of secondary organic aerosol (SOA) are included in 100 year global warming commitments (GWC100), the chulha had a net cooling impact using mixed fuels typical of the region. Correlation between PM2.5 emission factors and GWC (R2 = 0.99) implies these stoves are climate neutral for primary PM2.5 emissions of 8.8 ± 0.7 and 9.8 ± 0.9 g PM2.5/kg dry fuel for GWC20 and GWC100, respectively, which is close to the mean for biomass stoves in global emission inventories.

Change in household fuels dominates the decrease in PM2.5 exposure and premature mortality in China in 2005-2015.

To tackle the severe fine particle (PM2.5) pollution in China, the government has implemented stringent control policies mainly on power plants, industry, and transportation since 2005, but estimates of the effectiveness of the policy and the temporal trends in health impacts are subject to large uncertainties. By adopting an integrated approach that combines chemical transport simulation, ambient/household exposure evaluation, and health-impact assessment, we find that the integrated population-weighted exposure to PM2.5 (IPWE) decreased by 47% (95% confidence interval, 37-55%) from 2005 [180 (146-219) µg/m3] to 2015 [96 (83-111) µg/m3]. Unexpectedly, 90% (86-93%) of such reduction is attributed to reduced household solid-fuel use, primarily resulting from rapid urbanization and improved incomes rather than specific control policies. The IPWE due to household fuels for both cooking and heating decreased, but the impact of cooking is significantly larger. The reduced household-related IPWE is estimated to avoid 0.40 (0.25-0.57) million premature deaths annually, accounting for 33% of the PM2.5-induced mortality in 2015. The IPWE would be further reduced by 63% (57-68%) if the remaining household solid fuels were replaced by clean fuels, which would avoid an additional 0.51 (0.40-0.64) million premature deaths. Such a transition to clean fuels, especially for heating, requires technology innovation and policy support to overcome the barriers of high cost of distribution systems, as is recently being attempted in the Beijing-Tianjin-Hebei area. We suggest that household-fuel use be more highly prioritized in national control policies, considering its effects on PM2.5 exposures.

Incentivizing Elimination of Biomass Cooking Fuels with a Reversible Commitment and a Spare LPG Cylinder.

In India, approximately 480,000 deaths occur annually from exposure to household air pollution from the use of biomass cooking fuels. Displacing biomass use with clean fuels, such as liquefied petroleum gas (LPG), can help reduce these deaths. Through government initiatives, most Indian households now own an LPG stove and one LPG cylinder. Many households, however, continue to regularly use indoor biomass-fueled mud stoves (chulhas) alongside LPG. Focusing on this population in rural Maharashtra, India, this study (N = 186) tests the effects of conditioning a sales offer for a spare LPG cylinder on a reversible commitment requiring initially disabling indoor chulhas. We find that almost all relevant households (>98%) were willing to accept this commitment. Indoor chulha use decreased by 90% (95% CI = 80% to 101%) when the sales offer included the commitment, compared to a 23% decrease (95% CI = 14% to 32%) without it. For both treatment groups, we find that 80% purchased the spare cylinder at the end of the study.

Air quality, health, and climate implications of China's synthetic natural gas development.

Facing severe air pollution and growing dependence on natural gas imports, the Chinese government plans to increase coal-based synthetic natural gas (SNG) production. Although displacement of coal with SNG benefits air quality, it increases CO2 emissions. Due to variations in air pollutant and CO2 emission factors and energy efficiencies across sectors, coal replacement with SNG results in varying degrees of air quality benefits and climate penalties. We estimate air quality, human health, and climate impacts of SNG substitution strategies in 2020. Using all production of SNG in the residential sector results in an annual decrease of ∼32,000 (20,000 to 41,000) outdoor-air-pollution-associated premature deaths, with ranges determined by the low and high estimates of the health risks. If changes in indoor/household air pollution were also included, the decrease would be far larger. SNG deployment in the residential sector results in nearly 10 and 60 times greater reduction in premature mortality than if it is deployed in the industrial or power sectors, respectively. Due to inefficiencies in current household coal use, utilization of SNG in the residential sector results in only 20 to 30% of the carbon penalty compared with using it in the industrial or power sectors. Even if carbon capture and storage is used in SNG production with today's technology, SNG emits 22 to 40% more CO2 than the same amount of conventional gas. Among the SNG deployment strategies we evaluate, allocating currently planned SNG to households provides the largest air quality and health benefits with the smallest carbon penalties.

Field Emission Measurements of Solid Fuel Stoves in Yunnan, China Demonstrate Dominant Causes of Uncertainty in Household Emission Inventories.

Emission factors of carbon monoxide (CO), particulate matter (PM2.5), organic carbon (OC), and elemental carbon (EC), as well as combustion efficiency and particle optical properties were measured during 37 uncontrolled cooking tests of residential stoves in Yunnan Province, China. Fuel mixtures included coal, woody biomass, and agricultural waste. Compared to previously published emission measurements of similar stoves, these measurements have higher CO and PM2.5 emission factors. Real-time data show two distinct burn phases: a devolatilization phase after fuel addition with high PM2.5 emissions and a solid-fuel combustion phase with low PM2.5 emissions. The average emission factors depend on the relative contributions of these phases, which are affected by the services provided by the stoves. Differences in stove and fuel characteristics that are not represented in emission inventories affect the variability of emission factors much more than do the type of solid fuel or stove. In developing inventories with highly variable sources such as residential solid-fuel combustion, we suggest that (1) all fuels should be accounted for, not just the primary fuel; (2) the household service provided should be emphasized rather than specific combinations of solid fuels and devices; and (3) the devolatilization phase should be explicitly measured and represented.

Advanced household heat pumps for air pollution control: A pilot field study in Ulaanbaatar, the coldest capital city in the world.

Ulaanbaatar - the coldest capital in the world - is home to half of Mongolia's population, much of which uses coal for household heating, contributing to high wintertime air pollution. We piloted two-stage air-to-air heat pumps in 2017, when temperatures dropped to -39 °C. These heat pumps were reliable and efficient, with an average coefficient of performance of 1.86 on the coldest days. Heat pumps' recurrent costs were similar to those of coal stoves and lower than those of resistive heaters.

Monitoring and modeling of household air quality related to use of different Cookfuels in Paraguay.

In Paraguay, 49% of the population depends on biomass (wood and charcoal) for cooking. Residential biomass burning is a major source of fine particulate matter (PM2.5 ) and carbon monoxide (CO) in and around the household environment. In July 2016, cross-sectional household air pollution sampling was conducted in 80 households in rural Paraguay. Time-integrated samples (24 hours) of PM2.5 and continuous CO concentrations were measured in kitchens that used wood, charcoal, liquefied petroleum gas (LPG), or electricity to cook. Qualitative and quantitative household-level variables were captured using questionnaires. The average PM2.5 concentration (µg/m3 ) was higher in kitchens that burned wood (741.7 ± 546.4) and charcoal (107.0 ± 68.6) than in kitchens where LPG (52.3 ± 18.9) or electricity (52.0 ± 14.8) was used. Likewise, the average CO concentration (ppm) was higher in kitchens that used wood (19.4 ± 12.6) and charcoal (7.6 ± 6.5) than in those that used LPG (0.5 ± 0.6) or electricity (0.4 ± 0.6). Multivariable linear regression was conducted to generate predictive models for indoor PM2.5 and CO concentrations (predicted R2  = 0.837 and 0.822, respectively). This study provides baseline indoor air quality data for Paraguay and presents a multivariate statistical approach that could be used in future research and intervention programs.

Air pollutant emissions from Chinese households: A major and underappreciated ambient pollution source.

As part of the 12th Five-Year Plan, the Chinese government has developed air pollution prevention and control plans for key regions with a focus on the power, transport, and industrial sectors. Here, we investigate the contribution of residential emissions to regional air pollution in highly polluted eastern China during the heating season, and find that dramatic improvements in air quality would also result from reduction in residential emissions. We use the Weather Research and Forecasting model coupled with Chemistry to evaluate potential residential emission controls in Beijing and in the Beijing, Tianjin, and Hebei (BTH) region. In January and February 2010, relative to the base case, eliminating residential emissions in Beijing reduced daily average surface PM2.5 (particulate mater with aerodynamic diameter equal or smaller than 2.5 micrometer) concentrations by 14 ± 7 µg⋅m(-3) (22 ± 6% of a baseline concentration of 67 ± 41 µg⋅m(-3); mean ± SD). Eliminating residential emissions in the BTH region reduced concentrations by 28 ± 19 µg⋅m(-3) (40 ± 9% of 67 ± 41 µg⋅m(-3)), 44 ± 27 µg⋅m(-3) (43 ± 10% of 99 ± 54 µg⋅m(-3)), and 25 ± 14 µg⋅m(-3) (35 ± 8% of 70 ± 35 µg⋅m(-3)) in Beijing, Tianjin, and Hebei provinces, respectively. Annually, elimination of residential sources in the BTH region reduced emissions of primary PM2.5 by 32%, compared with 5%, 6%, and 58% achieved by eliminating emissions from the transportation, power, and industry sectors, respectively. We also find air quality in Beijing would benefit substantially from reductions in residential emissions from regional controls in Tianjin and Hebei, indicating the value of policies at the regional level.

ERS/ATS workshop report on respiratory health effects of household air pollution.

Exposure to household air pollution (HAP) from solid fuel combustion affects almost half of the world population. Adverse respiratory outcomes such as respiratory infections, impaired lung growth and chronic obstructive pulmonary disease have been linked to HAP exposure. Solid fuel smoke is a heterogeneous mixture of various gases and particulates. Cell culture and animal studies with controlled exposure conditions and genetic homogeneity provide important insights into HAP mechanisms. Impaired bacterial phagocytosis in exposed human alveolar macrophages possibly mediates several HAP-related health effects. Lung pathological findings in HAP-exposed individuals demonstrate greater small airways fibrosis and less emphysema compared with cigarette smokers. Field studies using questionnaires, air pollution monitoring and/or biomarkers are needed to better establish human risks. Some, but not all, studies suggest that improving cookstove efficiency or venting emissions may be associated with reduced respiratory symptoms, lung function decline in women and severe pneumonia in children. Current studies focus on fuel switching, stove technology replacements or upgrades and air filter devices. Several governments have initiated major programmes to accelerate the upgrade from solid fuels to clean fuels, particularly liquid petroleum gas, which provides research opportunities for the respiratory health community.

Evaluating the Performance of Household Liquefied Petroleum Gas Cookstoves.

Liquefied petroleum gas (LPG) cookstoves are considered to be an important solution for mitigating household air pollution; however, their performance has rarely been evaluated. To fill the data and knowledge gaps in this important area, 89 laboratory tests were conducted to quantify efficiencies and pollutant emissions from five commercially available household LPG stoves under different burning conditions. The mean thermal efficiency (±standard deviation) for the tested LPG cookstoves was 51 ± 6%, meeting guidelines for the highest tier level (Tier 4) under the International Organization for Standardization, International Workshop Agreement 11. Emission factors of CO2, CO, THC, CH4, and NOx on the basis of useful energy delivered (MJd) were 142 ± 17, 0.77 ± 0.55, 130 ± 196, 5.6 ± 8.2, and 46 ± 9 mg/MJd, respectively. Approximately 90% of the PM2.5 data were below the detection limit, corresponding to an emission rate below 0.11 mg/min. For those data above the detection limit, the average emission factor was 2.4 ± 1.6 mg/MJd, with a mean emission rate of 0.20 ± 0.16 mg/min. Under the specified gas pressure (2.8 kPa), but with the burner control set to minimum air flow rate, less complete combustion resulted in a visually yellow flame, and CO, PM2.5, EC, and BC emissions all increased. LPG cookstoves met guidelines for Tier 4 for both CO and PM2.5 emissions and mostly met the World Health Organization Emission Rate Targets set to protect human health.

Kitchen PM2.5 concentrations and child acute lower respiratory infection in Bhaktapur, Nepal: The importance of fuel type.

BACKGROUND: Globally, solid fuels are used by about 3 billion people for cooking and a smaller number use kerosene. These fuels have been associated with acute lower respiratory infection (ALRI) in children. Previous work in Bhaktapur, Nepal, showed comparable relationships of biomass and kerosene cooking fuels with ALRI in young children, compared to those using electricity for cooking. We examine the relationship of kitchen PM2.5 concentrations to ALRI in those households. METHODS: ALRI cases and age-matched controls were enrolled from a cohort of children 2-35 months old. 24-h PM2.5 was measured once in each participant's kitchen. The main analysis was carried out with conditional logistic regression, with PM2.5 measures specified both continuously and as quartiles. RESULTS: In the kitchens of 393 cases and 431 controls, quartiles of increasing PM2.5 concentration were associated with a monotonic increase in odds ratios (OR): 1.51 (95% CI: 1.00, 2.27), 2.22 (1.47, 3.34), 2.48 (1.63, 3.77), for the 3 highest exposure quartiles. The general kitchen concentration-response shape across all stoves was supralinear. There was evidence for increased risk with biomass stoves, but the slope for kerosene stoves was steeper, the highest quartile OR being 5.36 (1.35, 21.3). Evidence for increased risk was also found for gas stoves. CONCLUSION: Results support previous reports that biomass and kerosene cooking fuels are both ALRI risk factors, but suggests that PM2.5 from kerosene is more potent on a unit mass basis. Further studies with larger sample sizes and preferably using electricity as the baseline fuel are needed.

Small, Smart, Fast, and Cheap: Microchip-Based Sensors to Estimate Air Pollution Exposures in Rural Households.

Over the last 20 years, the Kirk R. Smith research group at the University of California Berkeley-in collaboration with Electronically Monitored Ecosystems, Berkeley Air Monitoring Group, and other academic institutions-has developed a suite of relatively inexpensive, rugged, battery-operated, microchip-based devices to quantify parameters related to household air pollution. These devices include two generations of particle monitors; data-logging temperature sensors to assess time of use of household energy devices; a time-activity monitoring system using ultrasound; and a CO2-based tracer-decay system to assess ventilation rates. Development of each system involved numerous iterations of custom hardware, software, and data processing and visualization routines along with both lab and field validation. The devices have been used in hundreds of studies globally and have greatly enhanced our understanding of heterogeneous household air pollution (HAP) concentrations and exposures and factors influencing them.

Lung function in woodsmoke-exposed Guatemalan children following a chimney stove intervention.

RATIONALE: Household air pollution (HAP) from solid fuel combustion is a major contributor to the global burden of disease, with considerable impact from respiratory infections in children. The impact of HAP on lung function is unknown. OBJECTIVES: The Childhood Exposure to Respirable Particulate Matter (CRECER) prospective cohort study followed Guatemalan children who participated in the Randomised Exposure Study of Pollution Indoors and Respiratory Effects (RESPIRE) trial of a chimney stove intervention to determine the effect of early childhood HAP exposure on growth of lung function. METHODS: RESPIRE households with pregnant women or infant children were randomised to receive a chimney stove at the beginning or at the end of the 18-month trial. During CRECER, a subset of these children, as well as children from households with newly installed stoves, were followed with spirometry beginning at age 5. Biomass smoke exposure was measured using personal carbon monoxide tubes. Two-stage regression models were employed to analyse associations with lung function growth. MEASUREMENTS AND MAIN RESULTS: Longitudinal peak expiratory flow (PEF) and FEV1 data were available for 443 and 437 children, respectively, aged 5-8 (mean follow-up 1.3 years). Decreases in PEF growth of 173 mL/min/year (95% CI -341 to -7) and FEV1 of 44 mL/year (95% CI -91 to 4) were observed with stove installation at 18 months compared with stove installation at birth in analyses adjusted for multiple covariates. No statistically significant associations were observed between personal HAP exposure and lung function. CONCLUSIONS: A significant decrease in PEF growth and a large non-significant decrease in FEV1 growth were observed with later stove installation. Additional studies including longer follow-up and cleaner stoves or fuels are needed.

Joint CO2 and CH4 accountability for global warming.

We propose a transparent climate debt index incorporating both methane (CH4) and carbon dioxide (CO2) emissions. We develop national historic emissions databases for both greenhouse gases to 2005, justifying 1950 as the starting point for global perspectives. We include CO2 emissions from fossil sources [CO2(f)], as well as, in a separate analysis, land use change and forestry. We calculate the CO2(f) and CH4 remaining in the atmosphere in 2005 from 205 countries using the Intergovernmental Panel on Climate Change's Fourth Assessment Report impulse response functions. We use these calculations to estimate the fraction of remaining global emissions due to each country, which is applied to total radiative forcing in 2005 to determine the combined climate debt from both greenhouse gases in units of milliwatts per square meter per country or microwatts per square meter per person, a metric we term international natural debt (IND). Australia becomes the most indebted large country per capita because of high CH4 emissions, overtaking the United States, which is highest for CO2(f). The differences between the INDs of developing and developed countries decline but remain large. We use IND to assess the relative reduction in IND from choosing between CO2(f) and CH4`control measures and to contrast the imposed versus experienced health impacts from climate change. Based on 2005 emissions, the same hypothetical impact on world 2050 IND could be achieved by decreasing CH4 emissions by 46% as stopping CO2 emissions entirely, but with substantial differences among countries, implying differential optimal strategies. Adding CH4 shifts the basic narrative about differential international accountability for climate change.

Does household use of biomass fuel cause lung cancer? A systematic review and evaluation of the evidence for the GBD 2010 study.

BACKGROUND: Around 2.4 billion people use traditional biomass fuels for household cooking or heating. In 2006, the International Agency for Research on Cancer (IARC) concluded emissions from household coal combustion are a Group 1 carcinogen, while those from biomass were categorised as 2A due to epidemiologic limitations. This review updates the epidemiologic evidence and provides risk estimates for the 2010 Global Burden of Disease study. METHODS: Searches were conducted of 10 databases to July 2012 for studies of clinically diagnosed or pathologically confirmed lung cancer associated with household biomass use for cooking and/or heating. FINDINGS: Fourteen eligible studies of biomass cooking or heating were identified: 13 had independent estimates (12 cooking only), all were case-control designs and provided 8221 cases and 11 342 controls. The ORs for lung cancer risk with biomass for cooking and/or heating were OR 1.17 (95% CI 1.01 to 1.37) overall, and 1.15 (95% CI 0.97 to 1.37) for cooking only. Publication bias was not detected, but more than half the studies did not explicitly describe a clean reference category. Sensitivity analyses restricted to studies with adequate adjustment and a clean reference category found ORs of 1.21 (95% CI 1.05 to 1.39) for men (two reports, compiling five studies) and 1.95 (95% CI 1.16 to 3.27) for women (five reports, compiling eight studies). Exposure-response evidence was seen for men, and higher risk for women in developing compared with developed countries, consistent with higher exposures in the former. CONCLUSIONS: There is now stronger evidence for biomass fuel use causing lung cancer, but future studies need better exposure assessment to strengthen exposure-response evidence.