JAMA. 1957;165(15):1908-1913. doi:10.1001/jama.1957.

02980330010003

FullText

Abstract

Various aerosols and gaseous mixtures were administered to

adult male volunteer subjects by two methods, one using a
mask, the other involving a chamber large enough for all
subjects to occupy at the same time. The main effects of
sulfur dioxide gas and sulfuric acid mist inhaled in this way
were an increase in airway resistance and appearance of
rales, with rhinorrhea and lacrimation. Two subjects exposed
to sulfuric acid mist developed long-lasting bronchitic
symptoms; the addition of water vapor increased the mean
particle-size of the surfuric acid mist and intensified its irritant
effects. These acid substances were neutralized and their
irritant effects abolished by adding either ammonia gas or
magnesium oxide smoke to the atmosphere. While acrolein
and crotonaldehyde were highly irritant, formaldehyde was
less so; acetaldehyde and its higher homologues were almost
nonirritant. It was evident that neither the concentration of
sulfur dioxide nor the total aldehyde content of an atmosphere
is an adequate index of its irritant action, especially on people
handicapped by disease or old age…………….

Wang J, Kim J, Moon J, Song H. The Effect of Smog-Related Factors on Korean Domestic
Tourists’ Decision-Making Process. International Journal of Environmental Research and Public
Health. 2020; 17(10):3706. https://doi.org/10.3390/ijerph1710370

The Effect of Smog-Related Factors on Korean

Domestic Tourists’ Decision-Making Process
by

JunHui Wang
1 ,

JooHyang Kim
2,

JiHyo Moon
3 and

HakJun Song
1,*
1
College of Tourism and Fashion, Pai Chai University, Daejeon 35345, Korea
2
Department of Convention and Hotel Management, Hannam University, Daejeon 34430, Korea
3
School of Business, Hanyang University, Seoul 133-791, Korea
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2020, 17(10), 3706; https://doi.org/10.3390/ijerph17103706
Received: 29 April 2020 / Revised: 19 May 2020 / Accepted: 21 May 2020 / Published: 25 May
2020
(This article belongs to the Special Issue Tourism and Health)

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Review Reports Versions Notes

Abstract
The present study aims to explore Korean domestic tourists’ decision-making processes by
utilizing an extended model of goal-directed behavior (EMGB) as a theoretical framework.
Integrating government policy (PLY) and protection motivation for smog (PMS) with the original
model of goal-directed behavior (MGB) makes it easier to better understand the formation process
of tourists’ behavioral intentions for domestic travel. Structural equation modeling (SEM) is
employed to identify the structural relationships among the latent variables. The results of the
EMGB indicated that desire had the strongest effect on the behavioral intention of tourists to travel
domestically; positive anticipated emotion is the main source of desire, followed by negative
anticipated emotion. Government PLY on smog has a significant, positive and indirect effect on
behavioral intentions of domestic or potential tourists through the protection motive theory. We
found that desires are verified as a determinant of the behavioral intention’s formation, more
significant than that of perceived behavioral control, frequency of past behavior and protection
motivation. In addition, this study offers theoretical and practical suggestions.
Keywords:
threat; protection motivation for smog; policy; extended model of goal-directed
behavior; structural equation modeling; tourists’ behavior

1. Introduction
The dangers of global environmental changes are expanding at a rapid pace. This
environmental threat has transformed into a serious issue, as well as disease and political issues
have become an important factor hindering the development of tourism [1,2,3]. Among various
environmental issues, there are a few studies on the effect of air pollution, including smog pollution
(i.e., particulate matter (PM) 2.5 and 10) [4,5,6]. Consistent with this change is the threat of smog.
It is essential that tourists are assured of appropriate safeguards through the government’s policy
(PLY) and their protection motivation for smog (PMS), to protect them from the harm of smog.
Recognizing the need for the tourism industry to have measures to minimize the influence of smog
on tourists, tourism managers and operators need to consider tourists’ emerging requests about
smog into their marketing strategies. Specifically, they seem to be interested in handling their
tourism businesses in a healthy manner and in implementing social health practices against the
threat of smog.
However, research using a theoretical framework to understand tourists’ behavioral intentions
in the situation of smog has possibly been ignored. One appropriate way of addressing this
shortcoming and developing the knowledge of tourists’ behaviors in relation to smog is to search
for a proper theoretical framework. Employing an effective theoretical framework for tourists can
provide a worthwhile understanding of the complicated process by which tourists generate their
behavioral intentions regarding smog. Although it is not an easy task to understand the complex
decision-making processes of tourists with regard to the threat of smog, employing the concept of
behavioral intention to travel can be a useful resource to determine their decision-making
processes. Tourists usually have shaped behavioral intentions from their own thought processes
and behavioral intention has played a vital role in forming actual tourism behavior. In this regard,
the recent social psychological theory to understand human behavioral intention, model of goal-
directed behavior (MGB) [7], can be applied to this situation to elucidate the behavioral intention of
tourists toward smog. Due to its higher predictive ability, MGB has been employed to understand
various tourist behaviors. Despite the effectiveness of the MGB, it has not been introduced in the
context of domestic tourist behaviors toward smog. Therefore, the current study aims to explore
tourists’ behavioral intentions using an extended model of goal-directed behavior (EMGB) that
adds government PLY and individual protection motivation to the original MGB. We hypothesized
that under the threat of smog, potential domestic tourists would contemplate PMS and are likely to
be influenced by the government PLY that deals with smog, which could lessen their risk of smog
exposure while traveling.
According to the PLY, tourists responded by increasing their behavioral intention for domestic
travel despite the danger of smog because the PLY can create an atmosphere for tourists to be
comparatively safe from smog while also enhancing the level of PMS by increasing its
effectiveness. The PLY usually composed of building space facilities (e.g., indoor sports facilities
and air purification facilities), tightening the emission standards of coal-fired power plants and
imposing emission charges, and pinpointing the cause of smog. Moreover, tourists may take the
PMS due to limited information and facilities to protect themselves from the threat of smog. The
PMS can include discussions with other people about protection from smog before travel,
collecting news and information on policies about smog, and planning a travel time to avoid smog.
Using a sample of Korean potential domestic tourists, we try to identify tourists’ decision-making
procedures by applying the MGB theory as well as a model that additionally contains the PLY and
the PMS that responds to the smog. The present research has several aims. First, we examine
potential travelers’ decision-making processes when the risk of smog discourages travel, with an
EMGB explaining travel intent that includes the PLY and the PMS. Second, we investigate the PLY
and the PMS toward smog in a sample of Korean potential travelers and the performance of these
constructs in a proposed theoretical framework. Finally, we present effective implications for the
government PLY and the PMS, which contribute to mitigating the negative perception of smog and
benefit the public and tourism businesses such as tourism marketers, hospitality services,
transport systems and government agencies.

2. Literature Review

2.1. MGB and EMGB

To better understand the formation process of personal behavior intentions, based on the
theory of planned behavior (TPB) and the theory of reasoned action (TRA), Perugini and Bagozzi
[7] added anticipated emotional factors, past behaviors and desires to construct the MGB
theoretical framework. In detail, desire is a kind of motivation that determines individual behavior.
The anticipated emotional factors (positive and negative) expected for a particular behavior may
be important factors that impact desire and behavioral intentions in the decision-making
processes. Past behavior may be an imperative factor that affects desire and behavior intention.
The addition of these factors not only solves the limitations of the TPB and TRA, but also
significantly enhances the explanatory power of individual decision-making processes, thus
making complex individual decision-making behavior processes easier to interpret.
As a theoretical basis, the MGB has been widely used in tourism research for various tourism
and leisure behaviors. Kim et al. [8] confirmed the moderating role of gender differences in
overseas travel decision-making processes based on the MGB theory. The results verified that
various factors (i.e., attitude, subjective norm, perceived behavioral control and anticipated
emotions) have a significant effect on behavioral intention through mediating variable desire. Past
behavior also has a positive effect on behavioral intention. In the context of South Korea’s popular
culture in Asian countries, Lee et al. [9] conducted research on Chinese pop cultural fans by
combining the MGB model and the Attention/Awareness, Interest, desire and Action (AIDA) model.
The results showed that the intention to travel to South Korea (hereafter Korea) for pop culture
was influenced by anticipated emotions, subjective norms, perceived behavioral control and
desire. Notably, desire has the most significant effect on behavioral intentions, consistent with the
findings of Perugini and Bagozzi [10]. Choe, Kim and Cho [11] utilized the MGB to explain the
effect of patriotism on behavioral intentions (e.g., event attendance intention and media
consumption intention) in the context of Rio 2016, which verified not only the indirect influence of
factors such as attitude, subjective norms, positive and negative anticipated emotions, perceived
behavioral control and desire on behavioral intentions, but also the significant direct impact of
patriotism on media consumption intentions.
In addition, Ajzen [12] and Perugini and Bagozzi [13] believed that to further improve the
theory’s ability to predict the behavioral intention of a specific group of people, and better
understand the psychological state of the behavior decision process, it should consider new
constructs or changing relationships among factors to further develop the EMGB under different
conditions. Based on this research, in the field of tourism research (i.e., festivals, casinos, hotels,
slow tourism, museums, etc.), many scholars have adopted the EMGB theory to explain tourist
decision-making processes under different backgrounds and different conditions
[8,14,15,16,17,18,19]. Song et al. [17] combined environmentally friendly tourism behaviors with
the MGB model to explore factors that influence the revisit intention of tourists at Korea’s Boryeong
Mud Festival. The results showed that in the EMGB, attitudes, subjective norms, positive
anticipated emotions, frequency of past behavior and environmentally friendly tourism behaviors
affect behavioral intentions by influencing desires. Song et al. [20] added two new constructs of
image and perception related to the Oriental Medicine Festival into the MGB and investigated the
formation process of the revisit intention of the festival. The study validated the effects of attitudes,
subjective norms, positive anticipated emotions on desire, and subsequently, on revisit behavioral
intentions. The factors of image and perception have a significant positive effect on the attitude of
participating in the Oriental Medicine Festival. Han and Yoon [15] reconstructed the EMGB to
better explain the customer’s decision-making processes when choosing an environmentally
responsible hotel by adding environmental awareness, perceived effectiveness, eco-friendly
behavior and reputation into the MGB. The relationships among the variables have also been
effectively verified. Han, Kim and Lee [14] integrated problem awareness, affective commitment
and non-green alternative attractiveness into the MGB and examined the decision-making process
for environmentally responsible museums. They also verified the significant effect among variables
in the original MGB, which is almost the same as with previous studies. Meng and Choi [16] stated
that integrating perception of authenticity, the EMGB can better elucidate tourists’ intention to visit
a slow tourism destination. As a result, attitude, subjective norm, positive and negative anticipated
emotion and perceived behavioral control were verified as factors influencing desires and
intentions. The frequency of past behavior significantly and directly impacts desires and intentions.
The perception of authenticity directly influences desires. By integrating mass media impact and
perception of climate change, Kim et al. [8] established an EMGB model to study the impact of
climate change on the decision-making processes of potential tourists overseas. The results
showed that positive anticipated emotion has the most important impact on the desire for overseas
travel, followed by attitude, subjective norm and perceived behavioral control. desire affects
behavioral intention more significantly than perceived behavior control, perception of climate
change and mass media impact. Thus, based on the aforementioned studies, the following
hypotheses were suggested:
H1.
Attitude has a positive influence onthe desire of domestic tourists;
H2.
Subjective norm has a positive influence onthe desire of domestic tourists;
H3.
Positive anticipated emotion has a positive influence onthe desire of domestic tourists;
H4.
Negative anticipated emotion has a positive influence on the desire of domestic tourists;
H5.
Perceived behavioral control has a positive influence on the desire of domestic tourists;
H6.
Frequency of past behavior has a positive influence on the desire of domestic tourists;
H7.
Perceived behavioral control has a positive influence onthe behavioral intention of domestic
tourists;
H8.
Frequency of past behavior has a positive influence on the behavioral intention of domestic
tourists;
H9.
Desire has a positive influence on the behavioral intention of domestic tourists.

2.2. Korean Government Policy for Smog

Few studies have been published on the impact of government policies on individual
behavior. Lee, Jung and Kim [21] examined the effect of a policy intervention that provides an
upper limit for handset subsidies on users’ intention to change handset and household expenses
on mobile telecommunications. Sun et al. [22] conducted a questionnaire survey in Beijing, China
and found that the policy of “No traffic restrictions for EVs (electric vehicles)” significantly affected
the users’ opinions on using EVs and adoption intention. Wang, Li and Zhao [23] divided policy
measures into three categories (i.e., financial incentive policy measures, information provision
policy measures and convenience policy measures) and investigated how these policy measures
motivate consumers to adopt EVs and how such effects are moderated by consumers’
environmental concerns.
Recently, the necessity of research on smog has increased because it is an important issue
for tourism practitioners and policy makers. In this regard, the effect of government policy on
smog, especially in tourism, is imperative. In the context of tourism, the government policy has
been mainly emphasized by the increase in social welfare by sustaining a safe environment for
both demanders and suppliers. Due to the increased concern about smog, the effect of policy is no
longer limited to a single industry. As the effect of tourism policy affects travel agencies, hotels and
tourism transportation, various policies need to be implemented in the situation of smog. Smog
policy should be considered since it can either larger or minimize the negative effect of smog on
the tourism industry. Moreover, policies to reduce the negative effect of smog can change not only
individual tourism behavior, but also various tourism-related businesses. In the present study, we
plan to scrutinize the influence of government policies on the intention to undertake domestic travel
during the threat of smog.
For the empirical analysis, Korea’s management policy for smog was chosen. The policy was
planned to reduce the danger of smog on people’s outdoor activities, including travel and tourism,
by building several indoor sports or air purification facilities, imposing emission charges for areas
or companies that generate heavy smog and tracking the cause of smog. The current study
analyzes the effect of the PLY on smog to offer insights into potential tourists, tourism practitioners
and government agencies. Although the Korean tourism industry is known for its progressive
infrastructure, devices and services, it has inherent problems. Despite the significant impact of
smog on Korean society, there is a lack of studies that identify government policy for tackling smog
and its effect on tourists’ decision-making processes.
Thus, the following hypotheses were suggested:
H10.
Policy has a positive influence on the desire of domestic tourists.
H11.
Policy has a positive influence on the behavioral intention of domestic tourists.

2.3. Protection Motivation for Smog

In terms of PMS, a related theory called the protection motivation theory (PMT) should be
considered. The PMT explains what individuals decide and why they take protection action [24,25].
In other words, the PMT describes how decision-makers can generate adequate protection
behaviors against threats. This may include reducing or avoiding activities, thereby changing the
entire decision-making process and prompting decision-makers to make new decisions. The core
of the PMT is threat appraisal and coping appraisal, in which threat appraisal is people’s
understanding of threat factors or perceived severity and vulnerability. Coping appraisal is an
individual’s ability to cope with and avoid dangers or response effectiveness and self-efficacy.
When individuals perceive the severity and likelihood of risk and the availability of effective means
of controlling consequences, including external actions and the individual’s own ability, the
likelihood of engaging in protective behavior is high [26]. The PMT is mainly used to explain
people’s decision to participate in health risk reduction behaviors and environmental behaviors
[27,28,29,30,31]. Janmaimool [27] stated that individuals will take individual precautionary
decisions to minimize risks based on perceived risk vulnerability and the severity of the negative
consequences. When people have higher perceived severity, vulnerability and higher perceived
self-efficacy and response effectiveness, they may participate in environmental protection
behaviors to minimize risks. Kim et al. [29] and Marquit [30] found that individuals’ intentions to
participate in environmental protection behaviors were significantly influenced by the attributes of
protection motivation. Tsai et al. [32] provided a theoretical framework for the security protection of
Internet users and found that when Internet users encounter a variety of online security threats,
they evaluate the threats and download security software to take precautions to protect personal
online safety to avoid loss. Le and Arcodia [33] found that when tourists notice vacation-related
risks based on their subjective risk perception and past travel experience, it is easy to take
protective behaviors [26].

Atmospheric Environment
Volume 198, 1 February 2019, Pages 257-264
Smog analysis and its effect on
reported ocular surface diseases:
A case study of 2016 smog event
of Lahore
Author links open overlay
panelArooj Ashraf a, Aleem Butt a, Imran Khalid b, Rao
Umair Alam b, Sajid Rashid Ahmad a
Show more
Add to Mendeley
Share
Cite
https://doi.org/10.1016/j.atmosenv.2018.10.029Get rights and content

Abstract

Introduction

Smog is defined as the type of pollution in the air that results

from chemical reactions in the atmosphere caused by nitrogen
oxides (NOx) and volatile organic compounds (VOCs) in the
presence of sunlight (Concord, 2015). This type of smog is
called photochemical smog and constitutes most of the smog
occurring in cities. Pollution is a persistent concern all over
the world. According to the World Health Organization,
pollutants in the ambient air which lead to major public health
concerns are particulate matter (PM10, PM2.5), carbon
monoxide (CO), nitrogen oxides (NOx), sulphur dioxide (SO2)
and ozone (O3) (World Health Organization, 2006). These
pollutants (PM10 SO2,VOC, CO NOx and PM2.5) are mainly
released from gasoline used in diesel run vehicles, industrial
plants and heating processes due to anthropogenic activities
(Penkova, 2016). Ambient air quality measurements are
important to explain the quality of air fit for human health in a
region because these pollutants cause various diseases
including diseases of heart, skin and eyes. A variety of
inflammatory responses are related to smog exposure
(Cacciotolo et al., 2017).

Eyes have two parts; one is the upper eye lid called adnexa and
the other, which is covered by the eye lid, is the ocular surface.
The ocular surface has glands of Moll Zeis nasolacrimal duct,
conjunctiva, lacrimal glands, accessory lacrimal glands,
meibomian glands and the exposed surface of the cornea. The
eyelid is a thin transparent and muscular structure with
proliferating cells that can undergo neoplastic transformation.
It acts as a protective coating from the external environment
including foreign bodies and pollutants. Inflammation leads to
chronic effects on the cornea and conjunctiva. Lid margins are
connected to the lacrimal drainage system which consists of
lacrimal glands and accessary glands that are responsible for
tear production. Tears then drain out in punctum in the
medial eyelid and then flow down into the lacrimal sac and
then finally drain down into the nasolacrimal duct into the
nose at the inferior meatus. These tears can be affected by
different pollutants in the air, and when they drain out
through this passage can then affect various structures/layers
of the interior of eye. They can also cause various ENT related
diseases as mentioned by Ilyas et al., in 2008 (Ilyas et al.,
2008). The pollutants mentioned above cause oxidative
reactions with tear film components and change its
composition. In this way each of these structures is directly in
contact with air pollution caused due to smog and people are
susceptible to ocular diseases like dry eye, infection, lid
erosion, corneal diseases, diseases of conjunctiva, diseases of
lacrimal system and uveitis.
There are examples from the past when dense smog caused by
heavy coal combustion caused thousands of citizen in London
to lose their lives in 1952. During 1940s and 1950s
photochemical smog shrouded Los Angeles resulting in
thousands of premature deaths and traffic accidents, (Geddes
and Murphy, 2012), (Zhang et al., 2014), (Sun et al., 2016). It is
estimated that mortality rate has been more than two million
in China and India due to smog (Matus et al., 2012). In the
capital of India i.e. New Delhi, the air quality was measured by
the amount of PM10 and PM2.5 in the air during reported smog
in November 2016 (Jia and Wang., 2017). This same thick
smog descended on the city of Lahore and blocked sunshine in
early November 2016. During this event of smog certain direct
impacts like health problems and indirect impacts like road
accidents were reported (Yadav and Rawal, 2016; Saeed,
2016). This study was conducted in order to measure
pollutants (CO, NOx, SO2, O3, VOC and PM) in the ambient air
during this period of Lahore smog looking at its effects on
ocular surface diseases among patients in comparison to the
baseline values of the same period in the previous year. For
baseline values the previous year was selected in order to
nullify the metrological conditions over the temporal period.
To the best of our knowledge, no study has been conducted to
analyze pollutants in ambient air during occurrence of smog
and reported ocular diseases in Pakistan.

Section snippets

Introduction of Lahore and its metrology

Lahore is the capital of the Pakistan province of Punjab which
is the second most populous city in Pakistan and ranks as the
32nd most populous city in the world. Lahore is ranked as a
beta-world city and is one of Pakistan's wealthiest cities with
an estimated GDP of $58.14 billion (PPP) as of 2014. On the
other hand, it is the 20th most polluted city in the world
(World health organization, 2016). The reasons for this level of
pollution are the increase in vehicle load, uncontrolled
Results
The ambient air analysis (CO, NOX, SO2, VOC, PM and O3) was
performed during 2 November 2015 and considered as the
baseline value. The ambient air analysis of the same
parameters was performed again during the Lahore smog on 2
November 2016. The results of both analyses are given as
under-:
The Lahore smog ambient analysis result shows much higher
values of pollutants than the baseline values as mentioned in
Table 2. The high value of NOx during Lahore smog is also
depicted by the Satellite

Discussion
In this study the ambent air analysis was carried out at three
different locations, namely; Mall Road, Gulberg and
Township. The results were taken before (baseline values –2-3
Nov 2015) and during the event of Lahore smog 2–3 Nov 2016
respectively. The results showed that during the event of
Lahore smog the values were much higher than baseline and
in relation to PEQS.
The pollutant PM10 can be seen with naked eye as it interacts
with visible light leading to significant opacity and visibility.

Conclusion
The analysis of the collected smog data finds that the high
value of NOx was almost 17 times higher than the baseline
value. Other pollutants such as SO2 and O3 were four times,
CO, VOC and PM2.5 two times, while PM10 was six times higher
than the baseline values. The high NOx emission is also clearly
visible in the satellite imagery taken in the year of the smog
event compared to the same temporal period in the previous
year. The metrological conditions during the smog event
revealed that
 Atmospheric Environment
Volume 198, 1 February 2019, Pages 257-264

Smog analysis and its effect on

reported ocular surface diseases:
A case study of 2016 smog event
of Lahore
Author links open overlay
panelArooj Ashraf a, Aleem Butt a, Imran Khalid b, Rao
Umair Alam b, Sajid Rashid Ahmad a
Show more
Add to Mendeley
Share
Cite
https://doi.org/10.1016/j.atmosenv.2018.10.029Get rights and content

Abstract
A comparative cross sectional study was conducted in order to
analyze the pollutants (CO, NOx, SO2, O3, VOC and PM)
present in the event of Lahore smog that was observed on 2–5
Nov 2016 in relation to the baseline condition of the ambient
air measured during the same period in the previous year i.e.
2015. The effect of smog was determined based on ocular
surface diseases reported by patients, using data taken from
tertiary care hospitals during the 2–3 November 2016 Lahore
smog. The data was compared with that from the previous
year (2–3 November 2015) being considered as baseline. For
analysis of the smog and its comparison with baseline
conditions, three sites were selected within Lahore city i.e.
Mall Road, Gulberg and Township. The AQI for these sites
were determined with the analysis of ambient air that was
done through USEPA approved reference methods. The data
on the number of patients having ocular surface diseases due
to smog were collected from tertiary care hospitals i.e. Shiekh
Zaid and Mayo Hospitals which were randomly selected. The
clinical method used has been implicitly elaborated and it has
been explained very clearly how all the clinical diagnoses were
executed. The highest concentration of pollutant analyzed
during smog was that of NOx which was almost 17 times
higher than the baseline value. The other pollutants SO2 and
O3 were four times, CO, VOC and PM2.5 two times and
PM10 was six times higher than the baseline value. Although
the values of SO2 and PM2.5 were greater than the baseline
values they did not exceed the Pakistan Environmental Quality
Standards (PEQS) limits. The Air Quality Index- AQI was
found to be six times higher than the baseline which
represents a very poor air quality during smog days. The
metrological conditions during the smog event were cool
temperatures, calm winds and high humidity that ultimately
triggered the photochemical reaction which caused the smog.
The data taken from hospitals revealed that out of 700
patients 200 were reported in 2015 and 500 were reported in
2016 with diseases including dry eyes (12%) and (13%),
irritation (20%) and (21%), lid erosion (4%) and (5%), corneal
diseases (7%) and (8%),uveitis (3%) and (4%) and lacrimation
(11%) and (7%) respectively. The study ultimately revealed that
there was a 60% increase in the number of patients reported
with ocular surface diseases (dry eyes, irritation, lid erosion,
corneal diseases, conjunctival diseases, uveitis, and
lacrimation) during periods of smog as compared to baseline
conditions.
Introduction

Smog is defined as the type of pollution in the air that results

from chemical reactions in the atmosphere caused by nitrogen
oxides (NOx) and volatile organic compounds (VOCs) in the
presence of sunlight (Concord, 2015). This type of smog is
called photochemical smog and constitutes most of the smog
occurring in cities. Pollution is a persistent concern all over
the world. According to the World Health Organization,
pollutants in the ambient air which lead to major public health
concerns are particulate matter (PM10, PM2.5), carbon
monoxide (CO), nitrogen oxides (NOx), sulphur dioxide (SO2)
and ozone (O3) (World Health Organization, 2006). These
pollutants (PM10 SO2,VOC, CO NOx and PM2.5) are mainly
released from gasoline used in diesel run vehicles, industrial
plants and heating processes due to anthropogenic activities
(Penkova, 2016). Ambient air quality measurements are
important to explain the quality of air fit for human health in a
region because these pollutants cause various diseases
including diseases of heart, skin and eyes. A variety of
inflammatory responses are related to smog exposure
(Cacciotolo et al., 2017).

Eyes have two parts; one is the upper eye lid called adnexa and
the other, which is covered by the eye lid, is the ocular surface.
The ocular surface has glands of Moll Zeis nasolacrimal duct,
conjunctiva, lacrimal glands, accessory lacrimal glands,
meibomian glands and the exposed surface of the cornea. The
eyelid is a thin transparent and muscular structure with
proliferating cells that can undergo neoplastic transformation.
It acts as a protective coating from the external environment
including foreign bodies and pollutants. Inflammation leads to
chronic effects on the cornea and conjunctiva. Lid margins are
connected to the lacrimal drainage system which consists of
lacrimal glands and accessary glands that are responsible for
tear production. Tears then drain out in punctum in the
medial eyelid and then flow down into the lacrimal sac and
then finally drain down into the nasolacrimal duct into the
nose at the inferior meatus. These tears can be affected by
different pollutants in the air, and when they drain out
through this passage can then affect various structures/layers
of the interior of eye. They can also cause various ENT related
diseases as mentioned by Ilyas et al., in 2008 (Ilyas et al.,
2008). The pollutants mentioned above cause oxidative
reactions with tear film components and change its
composition. In this way each of these structures is directly in
contact with air pollution caused due to smog and people are
susceptible to ocular diseases like dry eye, infection, lid
erosion, corneal diseases, diseases of conjunctiva, diseases of
lacrimal system and uveitis.

There are examples from the past when dense smog caused by
heavy coal combustion caused thousands of citizen in London
to lose their lives in 1952. During 1940s and 1950s
photochemical smog shrouded Los Angeles resulting in
thousands of premature deaths and traffic accidents, (Geddes
and Murphy, 2012), (Zhang et al., 2014), (Sun et al., 2016). It is
estimated that mortality rate has been more than two million
in China and India due to smog (Matus et al., 2012). In the
capital of India i.e. New Delhi, the air quality was measured by
the amount of PM10 and PM2.5 in the air during reported smog
in November 2016 (Jia and Wang., 2017). This same thick
smog descended on the city of Lahore and blocked sunshine in
early November 2016. During this event of smog certain direct
impacts like health problems and indirect impacts like road
accidents were reported (Yadav and Rawal, 2016; Saeed,
2016). This study was conducted in order to measure
pollutants (CO, NOx, SO2, O3, VOC and PM) in the ambient air
during this period of Lahore smog looking at its effects on
ocular surface diseases among patients in comparison to the
baseline values of the same period in the previous year. For
baseline values the previous year was selected in order to
nullify the metrological conditions over the temporal period.
To the best of our knowledge, no study has been conducted to
analyze pollutants in ambient air during occurrence of smog
and reported ocular diseases in Pakistan.
Section snippets

Introduction of Lahore and its metrology

Lahore is the capital of the Pakistan province of Punjab which
is the second most populous city in Pakistan and ranks as the
32nd most populous city in the world. Lahore is ranked as a
beta-world city and is one of Pakistan's wealthiest cities with
an estimated GDP of $58.14 billion (PPP) as of 2014. On the
other hand, it is the 20th most polluted city in the world
(World health organization, 2016). The reasons for this level of
pollution are the increase in vehicle load, uncontrolled

Results
The ambient air analysis (CO, NOX, SO2, VOC, PM and O3) was
performed during 2 November 2015 and considered as the
baseline value. The ambient air analysis of the same
parameters was performed again during the Lahore smog on 2
November 2016. The results of both analyses are given as
under-:
The Lahore smog ambient analysis result shows much higher
values of pollutants than the baseline values as mentioned in
Table 2. The high value of NOx during Lahore smog is also
depicted by the Satellite

Discussion
In this study the ambent air analysis was carried out at three
different locations, namely; Mall Road, Gulberg and
Township. The results were taken before (baseline values –2-3
Nov 2015) and during the event of Lahore smog 2–3 Nov 2016
respectively. The results showed that during the event of
Lahore smog the values were much higher than baseline and
in relation to PEQS.
The pollutant PM10 can be seen with naked eye as it interacts
with visible light leading to significant opacity and visibility.

Conclusion
The analysis of the collected smog data finds that the high
value of NOx was almost 17 times higher than the baseline
value. Other pollutants such as SO2 and O3 were four times,
CO, VOC and PM2.5 two times, while PM10 was six times higher
than the baseline values. The high NOx emission is also clearly
visible in the satellite imagery taken in the year of the smog
event compared to the same temporal period in the previous
year. The metrological conditions during the smog event
revealed that
[HTML] Is dry eye an environmental disease?
M Alves, P Novaes, MA Morraye, PS Reinach, EM Rocha
Arquivos brasileiros de oftalmologia, 2014•SciELO Brasil
Previous studies have revealed that eye contact with either air pollutants or
adverse indoor and/or outdoor environmental conditions can affect tear film
composition and ocular surface components. These effects are mediated by
selective binding of the environmental agents to ocular surface membrane
receptors, leading to activation of pro inflammatory signaling pathways. The aim of
the current review was to examine the published evidence associated with
environmental factors and ocular surface disease and dry eye.

A review on the deteriorating

situation of smog and its
preventive measures in Pakistan
Author links open overlay
panelWaseem Raza a, Saad Saeed b, Hammad Saulat a, Hajer
a Gul c, Muhammad Sarfraz a, Christian Sonne d, Z.-H. Sohn
e, Richard J.C. Brown f, Ki-Hyun Kim g
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https://doi.org/10.1016/j.jclepro.2020.123676Get rights and content

Abstract
Urbanization, industrialization, and increasing fossil fuel
consumption are generally identified as the main contributors
to poor air quality. Smog is a form of visible air pollution
processes that can cause diverse health problems (e.g.,
pulmonary, respiratory, and skin diseases). In Lahore, the
second-largest city of Pakistan, smog pollution has been a
significant socioeconomic issue since 2013 of which situation
has been worsening each year. In this systematic review, we
discuss the major issues concerning smog in Pakistan: the
causes, methods of detection, hazardous effects, and
opportunities for preventive measures based on ground-level
information. This study identifies smog as a potential source
of human health risk as serious repercussions of economic
development. It is thus suggested that adequate abatement
measures should be established for the proper protection of
public health.

Introduction

The adverse effects of air pollution on human health and the

environment, due to the myriad of pollutants released and
dispersed into the atmosphere, have been reported to be
significant worldwide (Kim et al., 2015b). Among these
pollutants, fine particulate matter (PM2.5: particles less than
2.5 μm in diameter) is of major environmental concern. The
extremely small particle(s) can travel into the human
respiratory tract and penetrate the deep lung epithelia,
causing coughing, sneezing, shortness of breath, and
respiratory infections (Garçon et al., 2006; Grantz et al., 2003;
Raaschou-Nielsen et al., 2016). The main components of PM
include inorganic ammonium salts, nitrates, sulfates, sodium
chloride, mineral dust, black carbon, organic matter, and
water (Pui et al., 2014; Tucker, 2000). The primary sources of
PM2.5 are agricultural activities, road dust, vehicle emissions,
power generation, general combustion, construction sites,
mining operations, and other similar industries (Matus et al.,
2012). It has been estimated that, across the world,
approximately two million deaths are caused annually by air
pollution of which nearly 25% are associated with fine PM
(Shah et al., 2013).
The word “smog” is a portmanteau of the words smoke and
fog. Fog is a visible aerosol consisting of tiny water droplets or
ice crystals suspended in the air; it can be considered as a low-
lying cloud. The distribution and properties of smog are
shaped by diverse factors including wind, temperature, and
sunlight (Ali et al., 2019b). Typically, smog is formed by
chemical reactions when excessive levels of key pollutants in
the air (e.g., volatile organic compounds (VOCs) and nitrogen
oxides (NOx)) interact with oxidants (e.g., hydroxyl, ozone,
and nitrates) (Fig. 1) (Arif, 2016; Liu, 2016). The main sources
of the particles and pollutants needed for smog formation
include coal-fired power plants, traffic emissions, stubble
burning, and erupting volcanoes (Kim et al., 2015b). These
activities can directly or indirectly contribute to the
production of PM2.5 which is the main precursor for smog
(Wang et al., 2016b). Globally, the occurrences of smog have
been reported fairly frequently in many major cities around
the world (e.g., Beijing, Delhi, Lahore, Mexico City, Los
Angeles, and Tehran) (Chen et al., 2013; Mohammadi et al.,
2012; Shabbir et al., 2019). The environmental significance of
smog has started to attract attention since the 1950s, with the
report of well-known air pollution events in London, UK. To
tackle the smog problem, Clean Air Acts were enacted by the
UK and US governments, with the aim of mitigating air
pollution including smog (Longhurst et al., 2016; Thackeray,
2003). The concerns posed by smog on health and the
environment have grown rapidly as evidenced by a large
number of research papers on the related issues (Fig. 2).

Air pollution has been one of the Pakistan’s main

environmental concerns in recent years. The situation has
been worsening in Lahore, the provincial capital. Lahore has a
4% annual economic growth rate and is the second-largest city
in the country (Riaz and Hamid, 2018). In the latest air quality
index (AQI) rankings of the most polluted cities in the world,
Lahore ranked the sixth, while Karachi, the largest city in
Pakistan, was the 16th with their AQI values of 170 and 155,
respectively (2019a).
The ranking of air quality between cities based on annual
average concentrations of PM2.5 (in 2018) is illustrated in
Fig. 3 World most polluted cities (2018). Recent reports by
Amnesty International and WHO have emphasized the need
for immediate and stringent abatement measures to mitigate
smog events with the aid of comprehensive air quality
legislation (Ali, 2019; Carmona-Cabezas et al., 2020;
Organization, 2007). However, the emphasis on creating
public awareness as a preventive tool for smog can also be a
helpful option to implement such strategy. However, the
effectiveness of such approach is not likely significant,
especially in developing countries like Pakistan. The main
factors contributing to the increasing occurrences of smog in
the developing countries are generally identified to be the
anthropogenic emission activities. Therefore, an organized
effort must be made to make the masses learn more about the
harmful effects of smog on the human health and environment
as well as the implementation of preventive measures.
Moreover, there are limited studies on the harmful effects of
smog on human health in Pakistan with hardly any efforts to
assess its economic impact. The acquisition of the local data is
also necessary to support such mitigation efforts, which
should be instrumental in accelerating public response.

Although the government of Pakistan is making efforts to

tackle smog, further actions are needed to fully resolve this
problem. In this paper, we present a detailed analysis of smog,
with respect to causes, detection methods, impacts, and socio-
environmental effects. Further, this review addresses
preventive measures and the steps required to resolve the
smog-related problems in Pakistan. Finally, we propose short-
and long-term measures that may help regulatory authorities
establish proper mitigation measures to control the smog
issue.

Section snippets
Types of smog and the related chemistry
The chemistry of smog is complex and cannot be defined
exactly because of variability in its composition, both
temporally and spatially. However, it is conventionally
categorized into two types: classical (or London type) smog
and photochemical (or Los Angeles (LA) type) smog. Both are
serious concerns in terms of their detrimental effects on the
environment and human health. In addition to these types,
there is another distinct type of smog, identified more
recently, named Polish smog. In this

Sources of smog in Pakistan and methods of

detection
Like many other developing countries, several emissions
sources (such as automobile exhaust gases, industrial sector
pollutants, disposal, use, and burning of solid waste, and
agriculture activities) detrimentally affect the air quality in
Pakistan. Over the last two decades, the usage of motorcars,
scooters, and motorcycles has increased with the increase in
population, and the more than 10 million vehicles used by
Pakistan’s population make a significant contribution to air
pollution (Maryam,

Hazards of smog
Smog is a mixture of many pollutants, chiefly particulate
matter (mostly PM2.5), but also sulfur dioxide (SOx), nitrogen
oxides (NOx), carbon monoxide (CO), volatile organic
compounds (VOCs), ozone (O3), peroxylacyl nitrates (PAN)
and aldehydes. Each component is harmful to humans, plants,
animals, and the natural environment, especially in high
concentrations. Recently, Butt et al. (2018) summarized
various human health effects (asthma, diabetes, headache, and
others) arising from smog events

Smog preventive measures for Pakistan

For all types of smog, the precursors come primarily from
anthropogenic emissions. Thus, proper mitigation of these
emissions is required to abate smog effectively. Many
strategies have been developed, on a local, regional, and even
international scale (Shi et al., 2016). However, prevention of
smog (to improve air quality indices for a given area) is rarely
dependent on a single intervention but, instead, generally
depends on various abatement measures working in concert.
These interventions

Conclusion
Globally, many big cities such as Beijing, Delhi, Lahore,
Mexico City, Los Angeles, and Tehran are negatively affected
by smog. Dependency on fossil fuels to support fast growing
urbanization and industrialization contributes significantly to
smog events in Pakistan. Vehicular emissions, along with
burning of crop and solid waste, are considered the major
sources of smog in Pakistan. Smog has harmful effects not
only on human health, but also on animals, tourism, and other
parts of the economy.

Funding source
A grant from the National Research Foundation of Korea
(NRF) funded by the Ministry of Science ICT and Future
Planning (No. 2016R1E1A1A01940995).

Declaration of competing interest

The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.

Acknowledgements
KHK acknowledges the support made by a grant from
the National Research Foundation of Korea (NRF) funded by
the Ministry of Science ICT and Future Planning (Grant
No: 2016R1E1A1A01940995).

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Air pollution is a public health emergency

BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1664 (Pu
blished 11 July 2022)Cite this as: BMJ 2022;378:o1664
 Article
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. Stephen Holgate, professor and special adviser on air quality

Author affiliations

. S.Holgate@soton.ac.uk

The UK government must commit to (much)

cleaner air by 2030
Respiratory and cardiovascular disease were the two main
causes of the 12 000 deaths estimated to be a result of
London’s great smog in 1952.1 We have come a long way
since then, but air pollution continues to be a major and
growing public health challenge. Now, however, it is
invisible to the eye. Air pollution today comes from traffic,
farming, and wood burning including wood burning stoves.
Fine particulate matter (PM2.5) passes through the lungs
into the circulation along with toxic gases such as NO2, and
together these initiate, accelerate, and exacerbate non-
communicable diseases.23

In 2016, a report from the Royal College of Physicians and

the Royal College of Paediatrics and Child Health estimated
that the equivalent of 40 000 deaths were attributable to
outdoor air pollution every year in the United
Kingdom.4 Since that report, the contribution of air
pollution to non-communicable diseases has greatly
increased, while also having a negative effect on pregnancy
outcomes and early life development.5 In December 2020,
air pollution exposure was listed as a cause of death for the
first time in the UK after the inquest into the death of Ella
Adoo-Kissi-Debrah.6

Greater efforts to reduce this key driver of adverse health

are needed. PM2.5 is undoubtedly an invisible killer, but its
effects are clear to see: increased risk of asthma attacks on
high pollution days7 and more hospital admissions for heart
and lung diseases.8 Polluted air triggers strokes and heart
attacks, exacerbates respiratory illnesses, such as chronic
obstructive pulmonary disease, and can stunt children’s
lung growth.9 The result is not just premature deaths, but
more years spent in ill health, and more avoidable pressure
on the health system. Air pollution, both outside and
indoors, is a major driver of health inequalities, with the
most deprived UK communities and those from ethnic
minority backgrounds more likely to live in polluted areas.

The Prevention of Future Deaths report that followed the

inquest into the Adoo-Kissi-Debrah’s death found that “the
adverse effects of air pollution on health are not being
sufficiently communicated to patients and their carers by
medical and nursing professionals.”10 We know that
patients trust healthcare professionals. Conversations to
help patients understand how pollution might worsen health
or exacerbate their conditions are vital. There are key touch
points—during asthma assessments and reviews, in
cardiovascular and maternity checks—for these
conversations to take place. But do healthcare
professionals know enough about air pollution and its
impacts?

More can be done to ensure that health professionals are

confident to have these conversations. The environmental
charity Global Action Plan has a suite of resources for
healthcare professionals.11 Then there is education. The
Royal College of Physicians was one of three organisations
(the others were the Royal College of General Practitioners
and the Royal College of Paediatrics and Child Health)
required to respond to the coroner’s report after the death
of Adoo-Kissi-Debrah in relation to its postgraduate
curriculum.1012 The Royal College of Physicians committed
to reviewing its internal medicine curriculum and, although
it was satisfied that pollution is currently covered, in a
recent progress report the college promised to keep it under
review to ensure that it has appropriate focus.13

Steps must also be taken to reach clinicians who are not in

medical education and therefore not learning about air
quality as part of the postgraduate curriculum, as well as
allied professions such as nursing or occupational therapy
that are not regulated by the General Medical Council. All
health professionals have an important role in
understanding the serious adverse effects of air pollution
and communicating them clearly and effectively to patients
at risk. Equally importantly, they can be influential
advocates for cleaner air and can push for government
intervention to achieve that.

The government’s consultation on air quality targets under

the Environment Act 2021,14 which closed on 27 June 2022,
could be a turning point for the nation’s health if the
government is bold in its ambitions. But the target currently
proposed to reduce PM2.5 annual average concentration to
reach 10μg/m−3 by 2040 falls way short of what is needed
to turn the tide on toxic air.

The target date should be brought forward to 2030.

Research from the Clean Air Fund and Imperial College
London shows that many parts of the UK are already on
course to achieve it and estimates that setting a 2030
deadline would lead to 3100 fewer cases of coronary heart
disease and 388 000 fewer reported asthma symptom days
in children each year.15 The government’s own analysis
indicates that reaching 11μg/m−3 is likely to be achievable
by 2030 across most modelled scenarios including the
government’s preferred “high” ambition option.16

Waiting until 2040 to reach 10μg/m−3—35 years after the

recommendation was made by the World Health
Organization17—is not good enough when the grave impact
of air pollution on health and health inequalities is so clear.
The Royal College of Physicians along with leaders from the
British Medical Association, Royal College of General
Practitioners, Royal College of Paediatrics and Child Health,
Royal College of Obstetricians and Gynaecologists, Royal
College of Psychiatrists, UK Health Alliance on Climate
Change, and others recently wrote to Jo Churchill, former
minister for agri-innovation and climate adaptation, to make
that case.18

Air pollution is one of the greatest environmental and public

health threats of our time. The government must commit to
reducing PM2.5 to 10μg/m3 by 2030, with the ultimate
objective of reducing annual mean concentration to
5μg/m−3 in line with the latest WHO health based air quality
guideline values.19 The nation’s health depends on it.