text:
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www.thelancet.com Vol 374 December 5, 2009
Health and Climate Change 2
Public health benefi ts of strategies to reduce greenhouse-gas
emissions: urban land transport
James Woodcock, Phil Edwards, Cathryn Tonne, Ben G Armstrong, Olu Ashiru, David Banister, Sean Beevers, Zaid Chalabi, Zohir Chowdhury,
Aaron Cohen, Oscar H Franco, Andy Haines, Robin Hickman, Graeme Lindsay, Ishaan Mittal, Dinesh Mohan, Geetam Tiwari, Alistair Woodward,
Ian Roberts
We used Comparative Risk Assessment methods to estimate the health eff ects of alternative urban land transport
scenarios for two settings—London, UK, and Delhi, India. For each setting, we compared a business-as-usual 2030
projection (without policies for reduction of greenhouse gases) with alternative scenarios—lower-carbon-emission
motor vehicles, increased active travel, and a combination of the two. We developed separate models that linked
transport scenarios with physical activity, air pollution, and risk of road traffi c injury. In both cities, we noted that
reduction in carbon dioxide emissions through an increase in active travel and less use of motor vehicles had larger
health benefi ts per million population (7332 disability-adjusted life-years [DALYs] in London, and 12 516 in Delhi in
1 year) than from the increased use of lower-emission motor vehicles (160 DALYs in London, and 1696 in Delhi).
However, combination of active travel and lower-emission motor vehicles would give the largest benefi ts (7439 DALYs
in London, 12 995 in Delhi), notably from a reduction in the number of years of life lost from ischaemic heart disease
(10–19% in London, 11–25% in Delhi). Although uncertainties remain, climate change mitigation in transport should
benefi t public health substantially. Policies to increase the acceptability, appeal, and safety of active urban travel, and
discourage travel in private motor vehicles would provide larger health benefi ts than would policies that focus solely
on lower-emission motor vehicles.
In 2004, transport accounted for almost a quarter of
carbon dioxide (CO2) emissions from global energy use.1
Three-quarters of transport-related emissions are from
road traffi c.1 Although large reductions in greenhouse-
gas emissions are needed to prevent serious climate
destabilisation,2 emissions from transport are rising
faster than from other energy-using sectors and are
predicted to increase by 80% between 2007 and 2030.1
Reduction in transport-related greenhouse-gas emis-
sions through less use of motor vehicles and increase in
the distances walked and cycled could have important
health benefi ts.3 Reduction in the use of motor vehicles
could reduce urban air pollution. Prevalence of physical
inactivity and the associated burden of chronic disease
could be lowered with increases in the distances walked
and cycled.4 Decrease in motor vehicle traffi c also has the
potential to reduce danger from road traffi c, although
exposure to the remaining danger might increase with
the number of pedestrians and cyclists.5 However, the
extent of these eff ects is not known.
We modelled the eff ects of urban land transportation
scenarios on CO2 emissions and health. Motor vehicles
are a source of several other climate-active pollutants,
including black carbon, ozone (indirectly), nitrous oxide,
and methane. In this Series, Smith and colleagues6
discuss the climate and health implications of several of
these pollutants. However, we have restricted our
analysis to CO2, and modelled emissions only from
motor vehicle fuel combustion; full life-cycle modelling
was beyond the scope of this analysis.
We focused on urban transport because more than half
the world's population lives in cities and because we
Lancet 2009; 374: 1930–43
Published Online
November 25, 2009
See Comment pages 1869
and 1870
See Series page 1917
This is the second in a Series of
six papers about health and
climate change
Department of Epidemiology
and Population Health
(J Woodcock MSc, P Edwards PhD,
Prof I Roberts PhD) and
Department of Public Health
and Policy (C Tonne ScD,
Prof B G Armstrong PhD,
Z Chalabi PhD), London School
of Hygiene and Tropical
Medicine, London, UK
(Prof A Haines FMedSci); Takedo
International, London, UK
(O Ashiru MSc); School of
Geography and the
Environment, Oxford
University Centre for the
Environment, University of
Oxford, Oxford, UK
(Prof D Banister PhD,
R Hickman PhD); Environmental
Research Group, School of
Biomedical and Health Sciences,
King's College London, London,
UK (S Beevers PhD);
Environmental Health,
Graduate School of Public
Health, San Diego State
University, San Diego, CA, USA
(Z Chowdhury PhD); Health
Eff ects Institute, Boston, MA,
USA (A Cohen ScD); Health
Sciences Research Institute,
University of Warwick,
Coventry, UK (O H Franco PhD);
School of Population Health,
University of Auckland,
Auckland, New Zealand
(G Lindsay FNZCPHM,
Prof A Woodward PhD); and
Transport Research and Injury
Prevention Programme, Indian
Institute of Technology Delhi,
New Delhi, India (I Mittal BTech,
Prof D Mohan PhD, G Tiwari PhD)
Key messages
• Transport-related greenhouse-gas emissions are
increasing, with a rapid growth projection in low-income
and middle-income countries.
• Production of lower-emission motor vehicles (cars,
motorcycles, and trucks) and reduction in travel by motor
vehicles are needed to meet targets for reduction of
greenhouse-gas emissions.
• Lower-emission motor vehicles would reduce the health
burden from urban outdoor air pollution, but a reduction
in the distance travelled by motor vehicles could have a
greater eff ect.
• Increase in the distances walked and cycled would also lead
to large health benefi ts. Largest health gains would be from
reductions in the prevalence of ischaemic heart disease,
cerebrovascular disease, depression, dementia, and diabetes.
• Although reducing motor vehicle use would decrease the
injury risk for existing pedestrians and cyclists, if many
more people walked and cycled there might be an increase
in the number of pedestrian and cycle injuries, since more
people would be exposed to the remaining risk.
• Creation of safe urban environments for mass active travel
will require prioritisation of the needs of pedestrians and
cyclists over those of motorists. Walking or cycling should
become the most direct, convenient, and pleasant option
for most urban trips.
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www.thelancet.com Vol 374 December 5, 2009 1931
expected the potential for change and health eff ects to be
greatest in cities. In low-income and middle-income
countries, urbanisation is associated with an increased
health burden from non-communicable diseases.7 In the
UK, transport in urban areas accounts for 20% of
distance (km) travelled by vehicles,8 but accounts for a
disproportionate share of CO2 emissions and air
pollutants as a result of the driving conditions9 and
frequent vehicle cold starts.10
We assessed physical activity, outdoor air pollution, and
risk of road traffi c injury. Although transport can aff ect
health in other ways, including noise pollution,
community severance, and the opportunity cost of
transportation resource use,3 the three exposures were
selected because the evidence linking them with health
outcomes is strong. Figure 1 shows the pathways that
were included and excluded.
Modelling the scenarios
We designed scenarios with reference to a large city in a
highly motorised country (London, UK), and a large city
in a country that is becoming rapidly motorised (Delhi,
For London, we developed four scenarios and
compared them with a business-as-usual 2030 projection
(panel 1; webappendix p 9). In the lower-carbon-emission
motor vehicles scenario, we focused on reducing the
emission factors from motor vehicles. The increased
active travel scenario represented a large increase in
cycling, a doubling in the distance walked, and a
reduction in car use with a small reduction in road
freight. The towards sustainable transport scenario
combined the lower-emission motor vehicles from the
lower-carbon-emission motor vehicles scenario, and the
low car use and longer distances walked and cycled from
the increased active travel scenario. The short-distance
active travel scenario included the same low-car use as
in the increased active travel scenario but with half the
rise in distances walked and cycled because of shorter
distances and reduced travel times.
The Greater London Authority has adopted a target of
60% cross-sector reduction in emissions by 2025,11 and
the mitigation scenarios draw on the work done to
quantify and model this target, including the study for
Visioning and Backcasting for Transport (VIBAT)12 in
London and the related Transport and Carbon Simulation
model.13 Table 1 shows the total distance travelled per
person and CO2 emitted from vehicles according to the
diff erent scenarios (webappendix pp 10–11).
We developed four equivalent transport scenarios and
a business-as-usual projection for Delhi (panel 2;
webappendix p 9). Projections for Delhi are based on few
data for vehicle and passenger fl ows. With a lower
baseline than London and a rising population, the
predicted scenarios focused on prevention of the rise in
emissions. No specifi c targets for reductions have been
set by the city authorities. The basis for the Delhi
transportation scenarios were the VIBAT in India and
Delhi scoping studies,15,16 and the work done by Wilbur
Smith Associates.17 Table 2 shows the total distance
travelled per person and CO2 emissions for the Delhi
transportation scenarios.
Modelling health eff ects
For all scenarios, we estimated the distributions of
physical activity and exposure to air pollution. We then
used the methods of Comparative Risk Assessment
(webappendix pp 6–8) to estimate the change in disease
burden. A modifi ed approach was used for road traffi c
injury in which we calculated absolute numbers of
deaths. Although we started with projected data for
disease burden for 2010, we compared each mitigation
Health effects modelled
Health effects not modelled
Resource use Pollutants
Lower-carbon-emission motor vehicles Increased active travel
Noise pollutionPhysical activity
Air pollution
Opportunity cost
Ecological stressEnergy conflict
Multiple health
Economic growth
Multiple health
Figure 1: Modelled and unmodelled pathways relating lower-carbon-emission motor vehicles and increased active travel scenarios with health
See Online for webappendix
Correspondence to:
Mr James Woodcock, Nutrition
and Public Health Research Unit,
London School of Hygiene and
Tropical Medicine, Keppel Street,
London WC1E 7HT, UK
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scenario against the 2030 business-as-usual transport
scenario—ie, if 1000 individuals died in 2010, we
estimated the number of deaths for 2030 business as
usual and every mitigation scenario. We then calculated
the diff erence in the number of deaths for each mitigation
scenario compared with 2030 business-as-usual scenario
to estimate the eff ect of the mitigation strategy. We used
this approach because the eff ects of other changes on
disease burdens were diffi cult to predict. Estimates of the
eff ect of the relevant risk factor on health outcomes,
including exposure-response associations, were obtained
mostly from systematic reviews. Baseline estimates of
disease burden were obtained from Mathers and Loncar18
and from STATS1919 and data provided by the Delhi
We estimated the health eff ects of the changes in
active travel that would arise with the diff erent
transportation scenarios (full details of the methods are
provided in the webappendix pp 12–19). The scenarios
were used to provide estimates of mean distances
walked and cycled per year, which we used to estimate
mean time spent walking and cycling per week. We then
created travel-time distributions by fi tting log-normal
Panel 1: London, UK, scenarios
Business-as-usual 2030
• Ground transport emissions (road and rail) of carbon
dioxide (CO2) in London are projected to increase from
9·6 megatonnes in 2006 to 10·3 megatonnes by 2030.
• 4% increase in total transport CO2 emissions from 1990
• Per person transport CO2 emissions are 1·17 tonnes.
• Basically a projection of present trends in the next 20 years,
including some actions to reduce growth in the use of cars
and increased investment in public transport. There is little
change in the effi ciency of the car stock and in use of
alternative fuels, and no coherent strategy for change.
Lower-carbon-emission motor vehicles
• Focus is on reduction of the emission of CO2 from motor
vehicles through more effi cient engines and fuel
• 35% reduction in transport CO2 emissions from 1990
• Per person CO2 emissions are 0·73 tonnes.
• This scenario relies on an ambitious implementation of
technologies, mainly lower-emission motor vehicles and
other fuels, with some use of information and
communication technologies to reduce the emissions
from motorised travel. In this scenario, we assume an
average of 95 g/km CO2 for cars compared with 177 g/km
CO2 at the moment.
• Policy change would require government legislation for
mandatory lower-emission motor vehicles and acceptance
and use of alternative fuels, motor manufacturers to
produce lower-emission vehicles for the mass market, and
consumer behaviour change in purchasing these vehicles.
(Continues in next column)
(Continued from previous column)
Increased active travel
• Focus is on replacement of some car travel with active
travel. Also includes a small reduction in distance (km)
travelled by road freight and a large reduction in the
number of motorcycles (from a low baseline).
• 38% reduction in transport CO2 emissions from 1990 levels.
• Per person CO2 emissions are 0·69 tonnes.
• High levels of walking and cycling are assumed, similar to
the practice in some cities in continental Europe (eg,
Copenhagen [Denmark], Delft [Netherlands], Amsterdam
[Netherlands], Freiburg [Germany]).
• Assumptions made for this scenario are that the distance
walked is more than doubled and distance cycled is
increased eight-fold (but from a low baseline).
• Policy change implies a reprioritisation designed to
restrict car use and ensure active travel is the most
convenient, pleasant, and quickest way to reach
• Specifi c policies would include substantial investment in
the design of infrastructure for pedestrians and cyclists to
reshape the streetscape and public realm, carbon rationing,
geographically expanded road pricing, traffi c demand
management, restrictions on car parking and access,
reduced speed limits, and behavioural change approaches
(eg, raised awareness, travel planning).
Towards sustainable transport
• Represents progress towards a sustainable transport
system that includes complete implementation of the
lower-carbon-emission motor vehicles and increased
active transport scenarios.
• 60% reduction in transport CO2 emissions from
1990 levels.
• Per person CO2 emissions are 0·45 tonnes.
• Policy change would require high-intensity implementation
and eff ectiveness of all measures.
• Transport emissions in London and Delhi are converging
and moving towards sustainable levels. Further reduction in
emissions would still be needed to achieve truly sustainable
• Further reductions could occur through use of electric
vehicles with energy from low-carbon sources; reduction of
trip distances; and continued modal shift from car use to
walking or cycling.
Short-distances active travel (sensitivity analysis)
• In this scenario, we envisaged the same motor vehicle
distances as in the sustainable transport scenario but only
half the increase in distances walked and cycled. This
scenario represents less travel and shorter travel distances
than in the other scenarios.
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www.thelancet.com Vol 374 December 5, 2009 1933
distributions. Because we modelled disease burdens by
age and sex, we needed age-specifi c and sex-specifi c
travel-time distributions. Estimates of how travel times
and speeds varied by age and sex were obtained from a
travel survey of London, UK.21 Table 3 provides the
walking and cycling speeds. The London travel time and
speed ratios were used for Delhi because of the absence
of high-quality data for Delhi. For the two scenarios with
high levels of cycling, the estimated age and sex
distributions were based on data from the Netherlands
where levels of cycling are similar to those in these
scenarios.22 In London and Delhi, men are more likely
to cycle than are women, whereas the proportions are
similar in the Netherlands. Intensity of physical activity
is usually measured with metabolic equivalents (METs);
one MET is the typical energy expenditure of an
individual at rest (1 kcal/kg/h). The distributions of the
times for walking and cycling were converted into
distributions of METs with tabulated data for diff erent
activities and speeds.23 Median MET times (h) were
taken as the best summary statistic of active travel for all
age–sex groups. To estimate total physical activity, we
added these estimates to those of non-travel-related
physical activity derived
(webappendix p 13).
We did systematic searches until March, 2009, for
studies of the association between moderate-intensity
physical activity and the incidence (fatal and non-fatal)
of prespecifi ed conditions included in the assessment of
global burden of disease (webappendix pp 13–18). We
selected the most recent high-quality systematic reviews
for every condition (except depression) to assess the
evidence for a causal association. For depression, we did
a broad search and assessed the main studies. When the
association between physical activity and disease
outcome is modelled, the shape of the exposure-
response function is important, but this association has
been assessed in only a few systematic reviews.
If the systematic review provided an exposure-
response function, we used that. If not, then we used
three exposure-response functions with diff erent
shapes. These were a square-root linear model
(webappendix pp 18–19), a linear model, and a linear
model with a threshold (with an assumption of no
further benefi t beyond a particular exposure). We used
the relative risk from the systematic review, estimated
the corresponding exposure in METs, and then applied
each of the three diff erent shapes to generate
exposure-response functions between MET time (h per
week) and the relevant disease outcome. When we
modelled the health eff ects of the diff erent scenarios,
we selected the median
disability-adjusted life-years (DALYs) from physical
activity as our main estimate, with the range representing
the uncertainty bounds (webappendix p 18).
We showed the potential eff ect on the population
distribution of body-mass index by modelling the eff ect of
from surveys24,25
overall change in
the scenario with increased active travel on the prevalence
of obesity and overweight for men aged 45–59 years in
London, assuming a constant energy intake.26
Although traffi c generates various pollutants, we
modelled only the health eff ects of fi ne particulate matter
(particulate matter with aerodynamic diameter 2·5 μm or
less [PM2·5]) for which the strongest evidence of health
eff ects exists.27 The basis for our method is WHO's
Comparative Risk Assessment exercise for urban air
pollution.27 The methods are summarised here and further
details are provided in the webappendix (pp 20–22).
Because few data exist about emissions and ambient
concentrations of PM2·5 in London, we modelled the
PM10 concentrations for our transportation scenarios and
then assumed that the changes in concentrations
between our mitigation scenarios and 2030 business-as-
Figure 2: New bicycle facilities in Delhi, India
CarBus RailHGVWalkingBicycle Motorcycle Total
emission motor
Increased active
Towards sustainable
active travel
1110 2630
10 065
3698 10442776 173 5731239 25 95280·69
36981044 2776 1735731239 2595280·45
36981044 2776173 403688258807 0·45
HGV=heavy goods vehicle. CO2=carbon dioxide. BAU=business as usual. *London scenarios included the eff ects of a
range of policy packages that were not included in the Delhi scenarios.
Table 1: Distance travelled and CO2 emissions per person per year in London, UK, for each scenario
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usual scenario were in the PM2·5 size range. This
assumption seems reasonable since the transportation
scenarios would mainly aff ect the PM2·5 subset of PM10.
For London, population-weighted yearly average PM10
concentrations for every scenario were estimated with
an emission-dispersion model (webappendix pp 20–21).28
To account for changes in the contribution of traffi c
outside London to the concentrations of PM in London
because of the long-range transport of pollutants, we
assumed that the same changes occurred in other
European cities. We assumed that the non-traffi c sources
of PM did not change. For Delhi we used a simpler
model because of few available data. PM2·5 concentrations
were estimated for each scenario from source-specifi c
emissions data with the simple interactive models for
better air quality (SIM-AIR, version 1.3).29
Further information about the model inputs and
assumptions are provided in the webappendix (p 22).
We considered the eff ects of PM on mortality from
cardiorespiratory disease and lung cancer in adults, and
Panel 2: Delhi, India, scenarios
Business as usual 2030
• Projected population increase accounts for some of the
projected increase in emissions.
• We estimated that ground transport emissions for Delhi,
starting with a lower baseline than in London, UK, would
increase from 6·1 million tonnes of carbon dioxide (C02) in
2004 to 19·6 million tonnes in 2030.
• 526% rise in CO2 emissions from 1990 values.
• Per person CO2 emissions are 0·75 tonnes.
• Projection of existing trends and no coherent strategy to
reduce the increase in the use of cars, but includes an
anticipated increase in rail use.
• Most vehicles in the UK are expected to achieve Euro 6
emission14 standards by 2020. In the primary analyses, we
assumed that vehicles in Delhi will have achieved this
standard, which is considerably lower than present levels, by
2030. If emission factors remained unchanged, CO2 and
particulate-matter emissions would be much higher than
0·75 tonnes per person.
Lower-carbon-emission motor vehicles
• 447% rise in transport CO2 emissions from 1990.
• Per person CO2 emissions are 0·66 tonnes.
• This scenario relies on an ambitious implementation of
vehicle technologies, and represents an anticipated
increase in rail use.
• The policy trajectory would require government legislation
on mandatory lower-emission motor vehicles and
acceptance and use of alternative fuels, motor
manufacturers to produce lower-emission motor vehicles
for the mass market, and consumer behaviour change in
purchasing such vehicles.
(Continues in next column)
(Continued from previous column)
Increased active travel
• 235% rise in transport CO2 emissions from 1990.
• Per person CO2 emissions are 0·40 tonnes.
• In this scenario, a reversal of present trends is assumed with
a small increase in the distance walked and more than
double increase in distance cycled. It represents a large
increase in rail use and small increase in bus use. Other
assumptions made are a slower increase in distance (km)
travelled in freight vehicles than in the business-as-usual
scenario, substantial reductions in motorcycle use, and
similar car use to 2010.
• Policy change would require prioritisation for people
who walk and cycle, and restriction of car travel to
ensure active travel is the safest and most convenient,
pleasant, and quickest way to reach destinations.
The reallocation of space to provide a high-quality
streetscape that is designed to meet the needs of
pedestrians and cyclists is of particular importance.
Rather than active travel being the mode of necessity
for those unable to aff ord motor vehicles it would
become the mode of choice.
• Specifi c policies would perhaps include substantial
investment in infrastructure designed for pedestrians
and cyclists rather than for cars, carbon rationing, road
pricing, traffi c demand management, restrictions for car
parking and access, reduced speed limits, and
behavioural change approaches (eg, raised awareness,
travel planning).
Towards sustainable transport
• This scenario represents progress towards a sustainable
transport system that includes complete implementation
of the lower-carbon-emission motor vehicles and increased
active transport scenarios.
• 199% increase in CO2 emissions from 1990.
• Per person CO2 emissions are 0·36 tonnes.
• Emissions per person are higher than in 1990 but lower
than in 2010.
• Policy change would require high-intensity implementation
and eff ectiveness of all measures.
• Transport emissions in Delhi and London are converging
and moving towards sustainable levels. Further reduction in
emissions would still be needed to achieve truly sustainable
• Further reduction could occur through use of electric
vehicles with energy from low-carbon sources;
shorter-distance trips; and continued shift from car use to
walking or cycling.
Short-distance active travel (sensitivity analysis)
• In this scenario, we envisaged the same motor vehicle
distances travelled as in the sustainable transport scenario
but only half the increase in distances walked and cycled.
This scenario represents less travel and shorter travel
distances than in the other scenarios.
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from acute respiratory infections in children. In the
main analysis, we used a linear model for London
where present and projected yearly average PM2·5
concentrations are much lower than 40 μg/m³, and a
log-linear model for Delhi where the concentrations are
greater than 40 μg/m³. Table 4 shows the concentrations
for each of the scenarios. In the sensitivity analysis, we
also estimated health eff ects using a log-linear model
for London and a linear model for Delhi.
Changes in the amount of motor vehicle traffi c and in
the numbers of pedestrians and cyclists in the
transportation scenarios could aff ect the numbers of
individuals injured as a result of road traffi c. We used a
diff erent approach for injury from that used for physical
activity and air pollution. We developed a model to
generate absolute numbers, rather than relative risks, of
deaths from road traffi c collisions. Therefore, we used
these data in preference to those available at the national
level from the global burden of disease project.
We constructed an injury matrix for road traffi c that
described the injury risk per unit of travel for each type of
road user. For London, numerator data were obtained
from STATS19,19 and for Delhi, they were obtained from
the Delhi police.20 Denominator data for the number of
vehicles and average distance (km) travelled were based
on the scenarios with additional data from Transport for
London (webappendix p 23).
Because injury risk for each group of road users also
depends on the distance travelled by other road users, we
estimated the injury risk per unit of travel from the
vehicles that could cause injury. For example, the risk of
a pedestrian being injured by a car was expressed as a
linear function of both the distance walked and the
distance travelled by cars. This method is an elaboration
of the injury model described by Bhalla and colleagues
(webappendix pp 23–26).30 For London, we adapted this
method to take into account variations in injury risks
over diff erent parts of the road network; data for Delhi
were insuffi cient. For all scenarios we estimated the
expected number of deaths and serious injuries after
changes to the distance travelled by all the included road
users. These were then used to estimate the changes in
years of life lost (YLL) and years of healthy life lost as a
result of disability (YLD). To calculate YLLs and YLDs, we
assumed that their ratios to deaths were the same as
those from the global burden of disease national data for
road traffi c injuries in both countries.
Sensitivity analyses were done to take into account
possible reductions in injury risk for pedestrians and
cyclists from measures to increase their safety. Such
measures (eg, reduced speed limits, increased enforce-
ment of driving rules, and improved infrastructure) could
be expected as part of the scenarios for increased active
travel. We therefore used the injury rates per
100 million km walked and cycled for the Netherlands, a
country in which people do a lot of walking and cycling
with low injury rates.
Evidence from systematic reviews showed that increased
physical activity reduced the risk of cardiovascular
disease, depression, dementia, diabetes, breast cancer,
and colon cancer. Table 5 shows the results of our
overview, strength of the association between the
Car BusRailHGV WalkingBicycleTwo-wheel
Total (km)CO2 emissions
Lower-carbon-emission motor vehicles
Increased active travel
Towards sustainable transport
Short-distance active
11 388
11 388
10 299
10 299
HGV=heavy goods vehicle. CO2=carbon dioxide. BAU=business as usual. *London, UK, scenarios included the eff ects of a range of policy packages that were not included in
the Delhi scenarios.
Table 2: Distance travelled and CO2 emissions per person per year in Delhi, India, for each scenario
15–29 years
30–44 years
45–59 years
60–69 years
70–79 years
≥80 years
Table 3: Walking and cycling speeds (km/h) by age group
2010 BAULower-carbon-
emission vehicles
active travel
Towards sustainable
London, UK
Delhi, India
Sensitivity analysis
Delhi (high)*
88·7134·0108·4 82·7 78·4
BAU=business as usual. *Fewer improvements in vehicle emission factors than in the main Delhi analysis.
Table 4: Estimates of air pollution (particulate matter with aerodynamic diameter of 2·5 μm or less)
concentrations (μg/m3)
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exposure and outcome, and estimates used in the
modelling (webappendix pp 27–31).
All these conditions, except for depression and
dementia, were included in the earlier Comparative Risk
Assessment study of physical activity (search date 2001).43
Physical activity seems to reduce the duration and
severity of existing depression, and also the incidence.44–46
Of particular relevance to this project were longitudinal
studies in which new episodes of doctor-diagnosed
depression arose less frequently in individuals who
undertook regular physical activity, including walking
and cycling, than in those who did not.42 Evidence from
randomised trials of individuals with memory loss and
decline in cognitive function lend support to the
observational epidemiological evidence for physical
activity and dementia.47,48 The changes in the distances
walked and cycled in the scenarios were converted into
changes in the time spent in active travel and MET
time (h) for all age groups in London and Delhi. Table 6
and table 7 show the median times spent in active travel,
and median MET times for travel and other activities are
presented in the webappendix (pp 32–33). Figure 3
shows the distributions of the active travel times for men
in one age group for the mitigation scenarios.
Table 8 shows the estimated changes in health burden
with the diff erent transport scenarios. For London, with
the lower-carbon-emission motor vehicles scenario, the
total number of premature deaths and DALYs were
reduced through reductions in the rate of mortality
caused by air pollution. For the increased active travel
and sustainable transport scenarios, substantial
reductions were noted in premature deaths and DALYs
as a result of increased physical activity and reductions
in the rates of mortality caused by air pollution. These
Systematic review/
study, year
Studies includedRR (95% CI) and
corresponding exposure
Age group
RR reduction from 2·5 h per
week of moderate intensity
physical activity
Maximum exposure
per week for linear
Square-root model Linear model
Dementia (U087) Hamer et al, 2009
(search year 2007)31
16 cohort studies
(163 797 people,
3219 cases)
18 cohort studies
(459 833 people,
192 49 cases)
0·72 (0·60–0·86);
33 METs per week (>1657 kcal
per week)32
0·84 (0·79–0·90); 7·5 METs per
week (3 h walking per week)
≥45 –0·18–0·11 21 METs (>2 miles
walked per day)33
Cardiovascular diseases
(ischaemic heart disease [U106],
hypertensive heart disease [U107],
cerebrovascular disease [U108])
Diabetes (U079)
Hamer et al, 2008
(search year 2007)34
≥30 –0·19–0·23 52·5 METs
(>10·5 MET h per day
from walking)35
Jeon et al, 2006
(search year 2006)36
10 cohort studies
(301 211 people,
9367 cases)
19 cohort studies, 29 case
control studies
0·83 (0·75–0·91); 10 METs per
≥30 –0·18 –0·1922·5 METs (>4 h per
week moderate
57·8 METs39
Breast cancer (U069) Monninkhof et al,
2007 (search year
Harriss et al, 2009
(search year 2007)40
0·94 (0·92–0·97) for each
additional h per week
≥15 (women
Not used–0·13
Colon cancer (U064)15 cohorts (7873 cases) Men 0·80 (0·67–0·96); women
0·86 (0·76 to 0·98);
METs per week: 30·1 for men
and 30·9 for women
1·0*, 6·9 METs per week
(<1000 kcal per week); 0·83*,
24·2 METs per week
(1000–2499 kcal per week);
0·72*, 63·7 METs per week
(≥2500 kcal per week)
≥15–0·13 for men,
–0·09 for women
–0·08 for
men, –0·05
for women
47 METs41
Depression (U082) Paff enbarger et al,
Cohort study (10 201 men,
387 fi rst episodes of
≥30 (15–29:
smaller eff ect
–0·14 (–0·07†) –0·07
34·6 METs (>2511 kcal
per week)42
RR=relative risk. METs=metabolic equivalents. *95% CIs not available. †Eff ect used in age group 15–29 years.
Table 5: Studies used to generate exposure-response functions by condition (global burden of disease code)
2010Business as usualIncreased active travel Short-distance active travel
Men WomenMen Women MenWomen MenWomen
15–29 years
30–44 years
45–59 years
60–69 years
70–79 years
≥80 years
95 (51–174)
86 (47–158)
70 (38–128)
77 (42–141)
69 (37–125)
50 (27–92)
107 (58 –196)
97 (53–178
79 (42–144)
87 (47–159)
77 (41–141)
57 (30–104)
84 (45–154)
77 (17–140)
62 (33–113)
68 (37–125)
61 (33–111)
45 (24–82)
95 (51–174)
86 (47–158)
70 (38–128)
77 (42–141)
69 (37–125)
50 ( 27–92)
329 (179–604)
299 (163–549)
243 (132–445)
267 (145–490)
214 (116–392)
155 (84–284)
371 (202–680)
337 (183–613)
273 (148–501)
301 (164–552)
241 (131–442)
174 (95–320)
198 (107–363)
180 (98–330)
146 (79–267)
161 (87–295)
143 (77–261)
105 (57–192)
223 (121–409)
203 (110–372)
164 (89–301)
181 (98–332)
161 (87–294)
118 (64–216)
Table 6: Median active travel times per week (min; 25th to 75th percentiles) by age group in London, UK
Page 8
www.thelancet.com Vol 374 December 5, 2009 1937
gains more than compensated for the increase in the
burden from road traffi c injuries. In 1 year, compared
with business as usual, the lower-carbon-emission
motor vehicles scenario saved 160 DALYs and
17 premature deaths per million population, increased
active travel saved 7332 DALYs and 530 premature
deaths per million population, and the towards
sustainable transport scenario saved 7439 DALYs and
541 premature deaths per million population.
Disease-specifi c estimates for each of the diff erent
exposure-response functions are provided in the
webappendix (pp 34–36). For London, the largest gains
were from reductions in ischaemic heart disease
(10–19% of total ischaemic heart disease burden),
cerebrovascular disease (10–18% of cerebro vascular
disease burden), dementia (7–8% of dementia disease
burden), depression (4–6% of total depression disease
burden), and breast cancer (12–13% of total breast cancer
disease burden). Although walking and cycling became
safer per km travelled the large increase in the total
distance walked and cycled led to the road traffi c injury
disease burden rising by 39%.
For Delhi, the lower-carbon-emission motor vehicles
and increased active travel scenarios resulted in a greater
health gain from reduced air pollution than for London.
Unlike for London, we noted that in Delhi the increased
active travel scenario substantially reduced the burden
of road traffi c injury compared with business as usual.
However, the estimated burden of road traffi c injury
with increased active travel was still higher than for
2010. For 1 year, compared with business as usual, the
lower-carbon-emission motor vehicles scenario saved a
total of 1696 DALYs and 74 premature deaths per million
population, increased active travel scenario saved
12 516 DALYs and 511 premature deaths per million
population, and the towards sustainable transport
scenario saved 12 995 DALYs and 532 premature deaths
per million population. The largest health gains were
from reductions in ischaemic heart disease (11–25% of
total ischaemic heart disease burden), cerebrovascular
disease (11–25% of total cerebrovascular disease burden),
and diabetes (6–17% of total diabetes disease burden);
the reduction in road traffi c injuries was 27%.
In both cities, we noted that the risk to pedestrians,
and especially cyclists, was higher from heavy goods
vehicles (HGVs) than from cars. On A-type roads (ie,
main roads but not motorways or freeways) in London,
the risk of an injury for a cyclist was 23 times higher per
km from HGVs than from cars. For pedestrians, the risk
from HGVs was four-fold greater than that from cars.
For cyclists in Delhi, risk of injury from HGVs was
30 times greater than that from cars, whereas for
pedestrians the diff erence was 15-fold. Indicating the
eff ect on obesity, the proportion of men (aged 45–59 years)
who were obese decreased by about 5% when compared
with the increased active travel scenario against the 2010
baseline for London (table 9).
Although there were many sources of uncertainty in
the development and modelling of the scenarios, we
assessed the eff ect of a few sources of uncertainty one at
a time. We focused on the exposure-response relation for
air pollution and physical activity, PM emissions from
vehicles in Delhi for 2030 business as usual, achievement
of best safety practice for pedestrians and cyclists to avoid
203 (92–446)
185 (84–405)
150 (68–328)
165 (75–362)
147 (66–321)
Business as usual
153 (69–335)
139 (63–304)
112 (51–246)
124 (56–272)
110 (50–241)
Increased active travel
410 (186–900) 462 (210–1014)
373 (169–818)
302 (137–663)
333 (151–731)
246 (112–540)
Short-distance active travel
269 (122–590)
245 (111–537)
198 (90–434)
218 (99–479)
161 (73–354)
229 (104–502)
208 (94–457)
169 (76–370)
186 (84–408)
165 (75–362)
172 (78–377)
156 (71–343)
127 (57–278)
140 (63–306)
124 (56–272)
303 (137–665)
275 (125–604)
223 (101–490)
246 (112–540)
182 (82–399)
15–29 years
30–44 years
45–59 years
60–69 years
70–79 years
420 (191–922)
340 (154–747)
375 (170–823)
277 (126–608)
≥80 years108 (49–236)122 (55–267) 81 (36–175)91 (42–200) 164 (74–360)185 (84–405)108 (49–236) 121 (55–266)
Table 7: Median active travel times per week (min; 25th to 75th percentiles) by age group in Delhi, India
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28
h per week
0 2 4
h per week
6 8 10 12 14 16 18 20 22 24 26 28
Relative frequency
Relative frequency
Figure 3: Distribution of active travel times for men aged 45–59 years in London, UK, and Delhi, India
(A) London 2010. (B) London: increased active travel. (C) Delhi 2010. (D) Delhi: increased active travel.
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www.thelancet.com Vol 374 December 5, 2009
injuries, and uptake of active travel for physical activity
and risk of injury (webappendix pp 37–38 for full results
of the sensitivity analyses).
When we applied a linear model for air pollution in Delhi
and a log-linear model for London we noted greater health
benefi ts than in the main analysis. We also noted increased
health eff ects in the mitigation scenarios when we assumed
a less optimistic 2030 business as usual for Delhi, in
which PM emissions per km from vehicles stayed at
present levels rather than achieving Euro 6 standards
(webappendix p 37).14 In this analysis, 7590 DALYS as a
result of reduced air pollution were saved with the towards
sustainable transport scenario compared with 2749 DALYs
in the main analysis.
When we applied injury rates per km walked and
cycled from the Netherlands to our respective distances
in the increased active travel scenarios, the injury rates
were reduced by 14% in London and by 58% in Delhi
(webappendix p 38).
In the short-distances active travel scenario, we noted
smaller benefi ts from increased physical activity
combined with a smaller increase in road traffi c injuries
for London, and a substantial reduction in injuries in
Delhi compared with the increased active travel
scenarios. In both cities, this led to smaller overall health
gains per million population (4817 DALYs in London and
11 704 DALYs in Delhi).
For London and Delhi, the increased active travel
scenarios saved more DALYs than did the lower-carbon-
emission motor vehicle scenarios. For London, the
eff ects from physical activity were greater than were
those from air pollution or injuries in the towards
sustainable transport scenario for all sensitivity analyses.
For Delhi, ranking of the eff ects was sensitive to the
model used.
Strengths and weaknesses
We noted that a scenario that represented a move towards
sustainable transport could
reductions in chronic diseases, including ischaemic
heart disease, stroke, depression, and dementia. The
health gains were larger from increases in active travel
and reductions in use of motor vehicles than from use of
lower-carbon-emission motor vehicles.
Panel 3 shows the key assumptions used to model the
scenarios. Our estimates of health eff ects depend
crucially on the structure and parameters of the model.
With respect to structure,
transport-related exposure-outcome asso cia tions were
not included—eg, the eff ect of traffi c noise on health or
eff ect of biofuels for transport on food availability.
Additionally, we did not assess the wide economic or
social eff ects.
To avoid double counting, we did not consider the
health eff ect of the reductions in body-mass index that
we might expect with increased active travel in our
physical activity model. We also did not include the eff ect
of physical activity on nicotine cravings and on smoking
cessation. Moderate exercise, such as walking and
cycling, reduces cigarette cravings.49 In a Cochrane
review49 of physical activity interventions for smoking
cessation, the odds of success of smoking cessation were
1·24-times higher than in control groups. With the small
sample sizes of studies, this diff erence was not signifi cant
but if the point estimate is accurate, then applying this
to the UK the increase in distances walked and cycled in
the population as a whole could lead to an increase in
tens of thousands of smokers stopping every year.
We used projected disease burden data for 2010.
Changes with time in health status other than those
directly linked to transport were not included. Thus we
provide substantial
several important
Delhi London
motor vehicles
motor vehicles
Physical activity
Premature deaths
Air pollution
Premature deaths
Road traffi c crashes*
Premature deaths
Premature deaths
–319–1696 –2240
11 11
–74 –511–532–17
–1696–10 969
–12 516
–11 448
–12 995
–1696 –160
Negative numbers indicate reduction in disease burden. YLL=years of life lost. YLD=years of healthy life lost as a result of
disability. DALYs=disability-adjusted life-years. *Injuries were calculated directly and then transformed into YLLs and
YLDs rather than with a Comparative Risk Assessment approach. †Data were adjusted for double counting for the eff ect
on cardiovascular disease.
Table 8: Health eff ects (per million population) in 1 year in Delhi, India, and London, UK, compared
with business as usual
20102030 more active travel
Walking (min per day)
Cycling (min per day)
Driving (min per day)
Energy intake (MJ per day)
Obesity (%)
Overweight (%)
Table 9: Prevalence of obesity and overweight in men (aged 45–59 years)
in London, UK
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www.thelancet.com Vol 374 December 5, 2009 1939
did not consider other changes in road safety, emissions
of PM from other sources, changes in background
physical activity, or population age structure.
We noted that there was greater uncertainty for the
variables for Delhi than for London—in particular, for
estimates of the level and distribution of non-travel
physical activity for Delhi. Confi dence in future estimates
for Delhi could be improved if primary data are gathered.
Our estimates of the health eff ects of physical activity
are susceptible to measurement error and confounding.
In a systematic review,50 physical activity, when measured
objectively, had a stronger association with mortality than
did self-reported physical activity, which might suggest
that we underestimated the eff ect. However, the eff ect of
residual confounding is not as clear. With the large
contribution of changes in ischaemic heart disease to the
overall eff ect, the exposure-response function that we
selected is especially important. Evidence for a large
eff ect of walking on cardiovascular disease accords with
data from a systematic review done after our search, in
which the association between weekly walking METs and
coronary heart disease was near linear.51
The plausibility of our scenarios can be questioned. In
the increased active travel and the sustainable transport
scenarios, we envisage large increases in the distances
walked and cycled, and a 37% reduction in car use in
London (after exclusion of light-goods vehicles). In the
dataset from the London area travel survey,21 55% of
distance travelled in cars was accounted for by trips
shorter than 8 km (ie, within cycling distance), including
Panel 3: Key assumptions
• Population and health status based on WHO projections
(global burden of disease and Comparative Risk
Assessment) for 2010, and present emissions sources and
air pollution levels.
• Our use of data from the whole of India to estimate
disease burden in Delhi might have resulted in an
underestimation of the incidence of coronary heart
disease and related risk factors.
Business as usual (2030)
London, UK
• Population assumed to increase by 13% compared with
2010, and vehicle-km (excluding walking and cycling) to
increase by 2%.
• Vehicle technology (emissions per vehicle-km) based on
model of change achieved by 2025.
• Non-road transport sources of pollution as for 2010.
Delhi, India
• Population assumed to increase by 49% compared with
2010, vehicle-km (excluding walking and cycling) to
increase by 187%.
• Main analysis assumes achievement of Euro 6 emission
standards by 2030 entailing substantial improvements in
carbon dioxide (CO2) and particulate matter emissions per
vehicle-km, compared with 2010 and phasing out of
two-stroke two-wheeled vehicles. In the sensitivity
analysis, no change in vehicle technology (CO2 or
particulate matter emissions per vehicle-km) from 2010
except for phasing out of two-stroke two-wheeled vehicles.
• Decrease in sulphur content of fuel from 350 parts per
million to 50 parts per million; industrial emissions at
2010 values.
Mitigation scenarios
• Main comparison: 2030 scenarios with 2030 business as
usual. The eff ect per million population in 2010 based on
such comparisons is not aff ected by diff erences in
population size (except by aff ecting local pollutant
emissions) or changes with time in exposures (except by
aff ecting the 2030 baseline for business as usual).
• For London, the assumption was that reduction in
emissions from transport in London was matched
elsewhere in Europe (eff ect on regional air masses).
• We modelled the health eff ects of the diff erent transport
scenarios as if they had been implemented
instantaneously. In reality, background changes and other
changes that might accompany the scenarios would aff ect
the health eff ects.
(Continues in next column)
(Continued from previous column)
Health eff ects
• Derived from attributable burdens calculated with
adaptation of the method for Comparative Risk
Assessment: assumes health eff ects of a scenario are
represented by the diff erence in modelled exposures
compared with the baseline, from which attributable
burdens are computed with relevant relative risks and
2010 mortality and disease rates. Ignores time lags even
for chronic disease and lung cancer, and any irreversibility
of the eff ect of past exposures.
• Years of life lost (YLL) computed as a diff erence between
age at death and the theoretical optimum life expectancy
at that age which, to be normative across populations, is
always calculated with reference to Japanese life tables.
• No time discounting or age-weighting of health eff ects.
• No inclusion of indirect health eff ects (eg, operating
through economic pathways) or those that arise from
success in restricting climate change.
• Model used for direct calculation of death from road
traffi c crashes and, for London, injury rates. Data
converted to YLLs and years of healthy life lost as a result
of disability using ratios from the 2010 global burden of
disease study.
• Use of population median as best representative of
physical activity. Assumption of no changes in
non-travel physical activity.
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www.thelancet.com Vol 374 December 5, 2009
11% by trips shorter than 2 km (ie, within walking
distance), suggesting that large reductions in car use are
possible. Another assumption is that changes to total
distances walked and cycled lead to changes in the
respective median times, and that there is no change in
the amount of other physical activity.
The main uncertainties in modelling the health eff ects
of PM exposure are the functional form of the PM
exposure response at low and high concentrations and
modelled concentrations of PM in Delhi.
For London, our emission-dispersion air pollution
model was well suited for modelling the eff ects of modal
shifts and changes in the vehicle fl eet on air pollution. We
could not use the same model for Delhi because of
insuffi cient data. For Delhi, several factors contribute to
uncertainty in the changes in PM2·5 concentration between
the scenarios. These include uncertainties in the increase
of motor vehicle use, composition of and emission factors
for the projected 2030 vehicle numbers, and the extent of
paved roads that aff ect the resuspension of PM. If PM
emissions per km in Delhi do not improve in accordance
with Euro 6 emission standards, the health burden from
PM exposure in 2030 under the business-as-usual
scenario will be much greater than we estimate
(webappendix p 37).
Achievement of reductions in particulate and CO2
emissions through technology is associated with more
uncertainties than through reductions in distances
travelled in motor vehicles. For example, diesel engines
generally emit less CO2 than do petrol engines, but
currently emit more particles, including black carbon,
which also causes climate warming.6,52 Similarly, diesel
particle traps, although eff ective at reducing particle
emissions, increase emissions of CO2 and nitrogen
dioxide.52,53 Although further improvements could be
achieved with vehicles that use batteries powered from
renewable sources, PM emissions could persist from
brake and tyre wear and resuspension of road dust.
Our injury model, an elaboration of the model described
by Bhalla and colleagues,30 is also based on assumptions—
in particular, a linear association between distance
travelled and risk of injury from road traffi c. In other
words, we assumed that if the distance walked is doubled
then the risk of injury to the pedestrian is also doubled;
and if the distance driven in motor vehicles is halved
then the risk of injury to the pedestrian is also halved.
Although the direction of these associations is supported
by empirical evidence,54,55 the quantitative association is
uncertain. Research has shown that increased levels of
walking or cycling are associated with safer walking or
cycling.56 Although this outcome might be due to the
lower motor vehicle volumes, it could indicate a non-
linear safety-in-numbers eff ect. Further more, fi nding
diff erent directions of eff ect on injuries from the
increased active travel scenarios for London and Delhi
suggest greater uncertainty than with those for physical
activity or air pollution.
We did not model changes in vehicle speeds, which
could arise in at least four ways in our scenarios. First,
with a reduction in the number of vehicles, congestion
might fall with consequent increases in speeds. Second,
policies that reallocate space from motor vehicles to other
road users could reduce speeds. Third, legislation and
enforcement might reduce vehicle speeds. Fourth,
changes to the traffi c mix—eg, bicycles and cars, could
also aff ect speeds.
With our assumptions about model structure and the
uncertainties in the model variables, the results of this
study should be regarded as provisional and should be
revised when more accurate estimates become available.
One real-world indication that decarbonisation can
produce positive health eff ects, even under diffi cult
circumstances, is provided by Cuba. In the early 1990s
after the collapse of the Soviet Union and with the US
embargo, transport and agriculture were largely
decarbonised, with substantial reductions in calorie
intake and increases in the distance cycled and overall
physical activity. In this period the average body-mass
index fell by 1·5 units from 24·83 kg/m² in 1991 to
23·34 kg/m² in 1995, with the prevalence of obesity halved
(from 14% to 7%). Results from epidemiological studies
show that during this period the numbers of deaths from
diabetes decreased by 51%, from heart disease by 35%,
and from stroke by 20%.57
The extent to which our results can be generalised to
other cities is open to question. For example, London and
Delhi are megacities with high levels of public transport
use, which suggests that they are likely to have more
walking and lower carbon emissions per person than
cities with lower levels of public transport use. In cities
with higher car use, the emission cuts needed would be
increased but the health benefi ts could be even greater.
We did not consider the socioeconomic distribution of
eff ect although evidence suggests inequalities in the
adverse health eff ects of motorised transport.58,59 Since
traffi c-related air pollution is unevenly distributed within
cities, reduction in the amount of traffi c is likely to have
large health benefi ts in some areas. For example, from
the results of a study of the socioeconomic distribution of
mortality benefi ts from reduced air pollution as a result of
the London congestion charge, health benefi ts were
estimated to be the largest in the most deprived areas of
London.60 In this city, diff erences between high-income
and low-income groups in distances walked are small,
but high-income groups are more likely to cycle and
participate in recreational physical activity than are those
in low-income groups. In Delhi, individuals living in
low-income groups walk and cycle more than do those in
high-income groups (39·0% vs 3·6% and 20% vs 5%,
respectively).61 Therefore, high-income groups in Delhi
could be expected to increase their activity more than
would the low-income groups, whereas the low-income
groups might benefi t more from the reduced risk of road
injury than would high-income groups.
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www.thelancet.com Vol 374 December 5, 2009 1941
Because we have estimated the health eff ects of
scenarios rather than specifi c interventions we cannot
assess cost eff ectiveness. However, the infrastructure for
individuals to walk or cycle might be less resource-
intensive than that for cars. Additionally there are likely to
be direct and indirect economic and social eff ects that
cannot be adequately addressed here. A key consideration
is whether such cities could, with low resource use,
achieve social goals.
Implications for policy
Eff ective policies to increase the distances walked and
cycled and reduce use of motor vehicles are needed to
achieve the health benefi ts we have discussed. Policies
that encourage people to walk and cycle would be expected
to increase the safety of active travel, as shown in our
sensitivity analysis of injury risks in the Netherlands.22
Substantial increases in the distances cycled in cities,
including Copenhagen (Denmark), London, and New
York (USA), are associated with a decrease in the numbers
of cyclists killed or seriously injured (webappendix
p 38).19,62–66 Without strong policies to increase the
acceptability, appeal, and safety of walking and cycling,
the vicious circle of increased motorisation and road
danger will continue in Delhi, and the large potential
health and environmental gains will not be achieved.
Creation of safe urban environments for mass active
travel will mean prioritisation of the needs of pedestrians
and cyclists compared with those of motorists. Walking
or cycling should be the most direct, convenient, and
pleasant options for most urban trips. Policy makers
should divert investment from roads for motorists
towards provision of infrastructure for pedestrians and
cyclists.67 Compared with cars and trucks, pedestrians
and cyclists should have direct routes with priority at
junctions. Strict controls for HGVs in urban areas are
key safety prerequisites for cyclists. Properly enforced
reductions in speed limits or zones can reduce injuries.5,68
With such policies, achievement of low levels of risk from
road injury for active travel, at least as low as the best
practice in the Netherlands, should be possible. Enhanced
streetscape design can make active travel pleasant.69 With
short distances, active travel becomes convenient;
planned mixed-use developments would reduce distances
to employment, education, services, and retail. Urban
form matters since the incidence of road traffi c injuries
and urban crime are related to street design and land-use
patterns.70,71 Hence eff ective urban design can enable high
modes shares for walking and cycling.
Important health gains and reductions in CO2 emissions
can be achieved through replacement of urban trips in
private motor vehicles with active travel in high-income
and middle-income countries. Technological measures
to reduce vehicle pollutants might reduce emissions, but
the health eff ect would be smaller. The combination of
reduced reliance on motorised travel and substantial
increases in active travel with vigorous implementation
of low-emission technology off ers the best outcomes in
terms of climate change mitigation and public health. In
many cities, the increase in use of cars, motorcycles, and
HGVs, with the resulting increase in road danger has
meant that many individuals who can aff ord to are
changing to private motorised transport. An increase in
the safety, convenience, and comfort of walking and
cycling, and a reduction in the attractiveness of private
motor vehicle use (speed, convenience, and cost) are
essential to achieve the modal shifts envisaged here.
Although the model assumptions can be questioned and
further research will undoubtedly provide more robust
estimates, large health benefi ts associated with active
travel are highly likely and these benefi ts should be taken
into account in the development and implementation of
IR, JW, AH, BGA, PE, CT, and ZCha led the conceptual development of
the report. RH, JW, DM, OA, GT, and DB led the development of the
scenarios. CT, BGA, SB, ZCho, and AC led the air pollution and health
impact modelling. JW, PE, ZCha, OHF, AW, and GL led the physical
activity and health impact modelling, and literature reviews. JW, PE, and
IM led the injury modelling with contribution from ZCha and IR.
The text was mainly drafted by JW, CT, PE, IR, and AH with contribution
from all authors.
Confl icts of interest
We declare that we have no confl icts of interest.
The project that led to this Series was funded by the Wellcome Trust
(coordinating funder); Department of Health, National Institute for Health
Research; the Royal College of Physicians; the Academy of Medical
Sciences; the Economic and Social Research Council; the US National
Institute of Environmental Health Sciences; and WHO. The Royal College
of Physicians was supported by an unrestricted educational grant from
Pfi zer. The funders had no role in the design, analysis, or interpretation of
the study. The views expressed are those of the authors and do not
necessarily refl ect the position of the funding bodies or the Health Eff ects
Institute or its sponsors. We thank K Blackhall and L Felix (both London
School of Hygiene and Tropical Medicine, London, UK) for help with the
searches; J Dowie (London School of Hygiene and Tropical Medicine) and
M Joff e (Imperial College, London, UK) for commenting on drafts of the
report; P Wilkinson (London School of Hygiene and Tropical Medicine) for
methodological advice; C Mathers (WHO, Geneva, Switzerland) for
provision of data; G Fuller (Environmental Research Group, School of
Biomedical and Health Sciences, King's College London, London, UK) for
help with the air pollution modelling; and R West (University College
London, London, UK) for advice about physical activity and smoking
cessation. Slides for teaching are available for download.
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2 Core Writing Team Contribution of Working Groups I
IaIttFARotIPoCC. Climate change 2007: synthesis report. Geneva:
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and transport. Lancet 2007; 370: 1078–88.
4 NHS. At least fi ve a week: evidence on the impact of physical activity
and its relationship to health: a report from the Chief Medical
Offi cer. Department of Health: London, 2004.
For the slides see http://www.
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injury prevention. Geneva: World Health Organization, 2004.
Smith KR, Jerrett M, Anderson HR, et al. Public health benefi ts of
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VANCOUVER - British Columbia's largest oil spill response vessel got stuck on a sandbar en route to a federal news conference about strengthening Canada's oil spill defences.
The shipping-industry-funded company in charge of the vessel confirmed it ran aground briefly on an uncharted sandbar off Sand Heads at the mouth of the Fraser River en route from its Esquimalt base to the Coal Harbour news conference. But it denied the ship had a "close quarters situation" with a B.C. ferry near Active Pass earlier Monday – as claimed by the Coast Guard's marine communications union.
In a news release Wednesday, Canadian Auto Workers Local 2182 spokesman Allan Hughes said the vessel's slow trip to the conference underscored how ill-prepared B.C. is for an oil spill.
"It's astonishing to think that the safety and protection of Canada's busiest port is dependent on a quick response in the event of an oil spill and this is what we get — a response vessel grounding itself and taking 11 hours to arrive in Vancouver."
Hughes said Natural Resources Minister Joe Oliver announced nothing new Monday to add to the Port of Vancouver's protection "and didn't bother telling media about the (vessel's) incident or just how far away major oil spill response ships are from Vancouver."
The ship was not damaged in the incident and drifted off the sandbar within minutes after shutting off its engines, its operator Western Canada Response Corporation said.
The incident was reported to Transport Canada and did not affect the ship's travel time to the conference, the company added. It said the ship and crew attended the news conference to take media questions about oil spill cleanup operations.
The biggest sale of the year, on now! Find almost $4 million worth of items such as cars, trips, furniture, gift cards and more at discounts of up to 50% off. Don't miss out as savvy shoppers will move fast to take advantage of these deep discounts. Sale ends Wednesday, April 1, at 9 p.m. Like it? Buy it before its gone. Brought to you by The Vancouver Sun and The Province.

subset: commoncrawl


text:
Walmart is about the only reason for open or concealed carry that I can get behind. -Randar
I'm on my second rebuilt of my KA Pro... I mean I have been using it to make bread every morning for three years but still
They are at least easy to take apart and find parts for. Parts are cheap too unless its the metal base or the motor.
The pasta maker is nice but the attachment to cut the noodles isn't as handy as it could be. The noodles have to be THIN. I like thick noodles in my with my chicken.
The ice cream maker is handy but I was short freezer space at the time so it really took some planning to make the ice cream.
20 oz bread flour, 12 oz water... shouldn't make a mixer that size hurt. I don't care if it is every morning!
Measure out my coffee, start the pot, measure out the flour and water, start the mixer. By the time the coffee is brewed the dough is kneaded. About all I use it for.
Homemade Icecream is fun. Making two gallons at a time is even more fun


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Hi – Maeve O'Boyle here. I was lucky enough to be Doug's editor last year on The Kids Grow up and have finally joined this great forum which I have heard so much about. Thank you Doug and sorry it took me so long. Other credits include Frontline: Heat for PBS, Carrier for PBS, Left of the Dial for HBO and other bits and pieces. Glad to be part of the D-word community.
Introduce Yourself: Sign In Here First
Welcome to The D-Word! Stop in and sign the guest book - let us know a little (or a lot) about yourself.
Please note that this is one of our Public Topics, so best to enter email addresses with (at) to prevent them being harvested. Spam will be deleted.
Maeve! I can't believe my eyeballs! Oh, rapturous day!!!
Only took well over two years of talking up The D-Word to get here here, folks. What an impressive salesperson I am.
Good to see you here, Maeve – we've been talking about you in your absence
Thanks John, thanks Doug – glad to be here finally!
Hi Myrthe, welcome from another Amsterdam D-worder. Good luck in your skopje project, sounds like a blast!
Hello. I am the founder and executive director of Africa Volunteer Corps, an NGO based in Tanzania that places African volunteers to work with African -initiated development projects. I joined D-Word in order to connect with filmmakers to participate in a fundraising series we are starting, the Visualize Change Film Forum. We are looking for films showcasing empowering and positive stories about Africa, especially the importance of local control of the development process. We are aiming to make Visualize Change an annual fundraising event so I look forward to connecting with others trying to tell the positive and inspiring stories of Africa that typically go untold.
Welcome, Kaitlin, and thanks for the great work you're doing with Africa Volunteer Corps. Best of luck with your fundraising.
Hello D-Worders
I'm and artist and filmmaker from the UK. I make films about music, outsiders, strangers and people who change how they look to be themsleves. I made large scale video artworks for years before moving into docs about 7 years ago. My films include TEENLAND (BBC4), GOTH CRUISE (IFC). I'm currently making two films – THE GREAT HIP HOP HOAX for BBC and ORION: THE MAN WHO WOULD BE KING.
my latest film is SOUND IT OUT, a crowd funded feature about the very last record shop in my home town, Teesside (North east UK) which will be premiering at SXSW in March.
See more > www.sounditoutdoc.com www.jeaniefinlay.com
I'd love to hear from any other D-Worders with advice for SXSW – and I'd really appreciate it you could help spread the word about our campaign on Indiegogo to get there. www.indiegogo.com/sendustosxsw
Thanks and looking forward to meeting some new doc folks! JF
Welcome to The D-Word, Jeanie. Sounds like you're in the right place – check out the Documentary Festivals Topic for more on SXSW and also use our SEARCH function to see what advice people have been giving in the past.
Thanks John – will do!
It was great talking with you the other day, Jeanie. Glad you followed up and registered. Welcome.
Your trailer is charming and beautifully made, it so makes me want to see the film. Hope you raise oodles of money. And get the list of industry people attending from the festival (on the password protected part of their website) and contact them about a week before it starts.
Hi! My name is Christine and a friend of mine suggested that I get on here and see if anything clicks! I have been an actor for years and about two years ago I took off across the country and abroad volunteering at various not-for-profits. Changed my world. Now I'm looking to get involved in hosting, writing and creating work that's about real people. This is a link to my most recent hosting gig on solar energy. www.solargenerationusa.org If anyone has any leads, knowledge of where to look or projects, I'd greatly appreciate any advice!
Welcome to The D-Word, Christine. Glad that you found us. You can check the Public Classifieds topic here, as people occasionally post about projects they're looking for collaborators on. You might also try the NY section of Shooting People: www.shootingpeople.org.
Hello all! My name is Jen and I am from small town USA in Kansas. I am looking for some advice/help. I have an idea for a documentary but have no idea where to begin. I would like to make/produce this myself but cannot quit my job to take this on. After doing some research and many question and answer sessions with parents this is something that many, many parents are interested in. I have no doubt that it would be watched by many as it asks a question that most of us parents as ourselves when raising our kids. If anyone can give me some insight on where to begin, search for funding or pitch my idea it would be wonderful. Thanking you again! Maybe soon you just might see something on TV from this small town USA Mom. –Jen
Hi Everyone!
I was referred to this site by a new business partner who couldn't say enough about it and I can already see why. I'm looking forward to leveraging the community and sharing what I can with it too as I get to know it and everyone it it better.
To introduce myself, I'm an independent filmmaker and producer currently based in Washington, DC. After ten years in the media industry running a company I started in college that was acquired by National Geographic, I have turned my full-time attention to filmmaking––something I've always wanted to do. I have one completed project (though I'm still looking for domestic distribution for it) and a couple others in various stages of development/production. All docs thus far but I do aspire eventually to do narrative films along the lines of City of God (or that style).
Feel free to check out my work at redfitz.com and see you all around the topic boards!
In reply to Doug Block's post on Fri 18 Feb 2011 :
Thanks so much Doug – can't believe I took so long to get here! – This is an amazing resource.
I've been getting my lists together and my plan is forming. We will get to Texas by hook or by crook!
I'm going to write a blog for Filmmaker Magazine about my experiences as a virgin SXSW-er so will post a link here. So excited, not long now.
Well i must say that i am flattered being part of a world of experts. I can say that being part of this wonderful and exciting site, my dreams of becoming a professional documentary filmmaker apart from acting, is partly completed. Thanks so much for welcoming me. Please kindly advice and guide me so that i can be the best in Cameroon.As you people can realise, i am seemingly the only one from Cameroon, that is why i want to do my best to carry my country up thanks to D-World. I am so happy.
Hi Nick, You might check out Docs In Progress based in Silver Spring, MD. Erica Ginsberg, the Executive Director, is a regular on D-Word. Docs In Progress is a great meeting place for a variety of doc events and provides many resources for the doc filmmaker in the DC area.
A big welcome to Jennifer, Nick, and Jeanie, and a very special welcome to our first member in Cameroon, James!!!
So who else is lurking out there?
My name is Joseph Chastain. I recently received fiscal sponsorship to create a documentary on Self-injury. I have a bachelor's of arts in film and television from Columbia College Hollywood in Tarzana, Ca.
Joseph, self-injury like cutting? Sounds interesting.
Welcome to The D-Word, Joseph. Interesting subject. Are we getting to witness......?
Hello everyone, I am a cameraman based in Los Angeles, but am trying to make the move into the documentary world. I am in the middle of working on my first documentary about my great grandfather. You can check it out at DustofEurope.com. I am very excited to be in a community with so many other enthusiastic film-makers.
Great to have you here, Michael. Welcome, as well, to Joseph, James, Nick and Jennifer. Always nice to have an influx of fresh blood ;-)
You don't want to talk of fresh blood when we're discussing self-injury...
Welcome Michael. Interesting story. Also good to see that Kickstarter seems to have kickstarted you well!
Hello everyone, my name is Mark Rattelle and I am a Documentary Theory and Production MFA student at Hofstra University and I am currently working on my thesis film called "The Indies." The film is about Independent Professional Wrestlers and the world of independent Wrestling.
I am based in NY and I am very excited to be a part of this community. I look forward to chatting with all of you about the film genre we love!
Hey folks. I am saying "hello", and on here looking for advice for fixers in DRC. I'm beginning a doc there in 4-6 weeks time. Thanks for any help...
What's the project, Liam? D-Worder Carlo Ontal is based in that part of the world.
Welcome, Mark. I'll be out at Hofstra tomorrow night to show my film THE KIDS GROW UP and do a Q&A (well, technically tonight). Hope to see you there.
It will be a film on the upcoming election, John. Thanks for the referral!
Perhaps google Monique Mbeka Phoba- she is based in Brussels often, but has been mentoring film students in Kinshasa. She may help you. She directed the film Entre la coupe et l'élection.
Hi everyone, I'm a videographer entering the Documentary Film world. Currently working on a documentary about religion and atheism in Toronto. Looking for tips and tricks to become successful in this industry. :)
Prayer, Aaron. Prayer.
Hard work, Aaron. Hard work.
Hello all. I am very excited to be introducing myself to such a great group of filmmakers. I recently moved to New York and have been working freelance, camera and editing. Additionally, I am in pre-production on my first feature length film about an community of electronic musicians in Pittsburgh, Pennsylvania. I am looking forward to gaining advice, interesting discussion, and collaboration through the d-word!
Welcome, Christa (Aaron, too). Nice to have you joining us here.
Hi, I last logged on a few years ago.... sorry for disappearing! I have managed to escape the clutches of the big city of London and escape to Africa where I plan to concentrate on making some documentaries..... so thought it was time I said hello again!
If anyone out there is based in West Africa or is interested in collaborating on a project in this part of the world... then I'd love to speak to you.
Hey Tara – I think we met at the Sheffield DocFest in 2007 – welcome back to The D-Word. Interesting time to be in North Africa...
Welcome back, Tara. Great to get an update and hope you'll come back often (virtually, at least).
Yes we did meet at Sheffield. Hello! It is an interesting time to be here.... not too much happening in Morocco though... although during a protest on Sunday the shop Zara got smashed up. However yesterday all the streets were lined with people welcoming the king back to the city.... so I think they like him. Although you never know for how long! Thanks for the welcome back.
In reply to Tom Dziedzic's post on Sat 19 Feb 2011 16:18 UTC :
Thanks for the tip, Tom! Am just looking through the site now and already agree with you.
Hello, my name is Rick Janzen and I've recently have started making Documentaries. I have two in the early stages of production at this time. I've been involved in the film business since 1987 as a scenic artist and sign painter, but decided to start shooting my own stuff two years ago. After spending countless hours learning to use my camera and editing system (not to mention spending a small fortune), I decided on a couple of projects. I have always thought the best way to learn a craft is to surround yourself with people who know what their doing. I know the road to discovery is going to have a lot of potholes and curves, but that's what makes it so interesting. I look forward to being part of the community and learning from your experience.
Great to have you here, Rick. Hope we can help support you in your career shift, it's an admirable thing to do.
Ahoy there! My name is Blaire Johnson. I'm co-producing a new documentary with my good friend, Linda Booker, to help bring Industrial Hemp farming back to the US. We are very proud that the nation's first hemp house was just built in the mountains of our home state- North Carolina. We are focusing on hemp's abilities to build the healthiest houses while taking a look at the toxic chemicals used in building materials and everyday products.
Through Linda, I have heard great things about the D-word from her good friend, Mark Barroso. I've just ventured into HD with Panasonic's AGAF100. It's great to be here!
Welcome to The D-Word, Blaire. Nice to have you joining us.
In reply to John Burgan's post on Thu 21 Jan 2010 :
I read the book of Glynne. I think also it is very good
Hello Everyone, I'm videmaker and web designer based in Sicily, I've produced 2 documentaries in Africa like in Uganda and Tanzania and of course also in Sicily. I used to work and collaborate with associations and other professionals.
Always I'm looking for new collaborations. Please contact me if you are interested in some co-production about some social or cultural issues regarding relation between different cultures.
I work with my Panasonic professional equipment.
Best wishes,
In reply to Blaire Johnson's post on Wed 2 Mar 2011 :
Hello Blaire your topic is very interesting, where could I find more informations? Would you be interested in some collaboration?
In reply to Caitlin Kelley's post on Thu 17 Feb 2011 :
Hello Caitlin I made in Tanzania a documentary about Maasai Tribe, I've shown I think a positive aspect of african culture. I would be glad if you can give a look to this documentary,
I'm also trying to create in Tanzania a school/workshop for young people that want to learn about video and storytelling
Let me know if you are interested,
Franco Consales
In reply to Tara Watney's post on Thu 24 Feb 2011 11:33 UTC :
Hey Tara please let me know more about this project in West Africa. I've been in Africa 4 times and I did there 2 documentaries, I always interested about this part of the world,
Franco Consales
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Michael F. "Mike" O'Koren (born February 7, 1958) is currently an assistant basketball coach at Rutgers University under Eddie Jordan. Also a retired American professional basketball player, a former associate head coach of the Washington Wizards from 2005 to 2008, and a former assistant coach with the New Jersey Nets from 1999 to 2003. He was selected by the New Jersey Nets in the first round (6th overall) of the 1980 NBA Draft. A 6'7" small forward from the University of North Carolina, O'Koren played in the NBA from 1980 to 1988, with the Nets and Washington Bullets. O'Koren went to Hudson Catholic Regional High School in Jersey City, New Jersey.
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American Range Wall Ovens
I would appreciate any feedback from AR owners on reliability of product & customer service from American Range.
Am very interested in the 30" wall ovens-probably gas single oven chef's door- though the french doors are gorgeous.
Thank you!
Still looking for info?
My hybrid double oven has both gas and electric. After installation we found out the electric oven does not work at all. Called AR and reported it. They said they would send a repairman. No calls and no repairman. Installed it on April 30. Sent AR an email 8-10 days ago and I got two emails back. So sorry to hear about it...we will send someone out right away...you will get a call in a few more hours ...at least within 24 hours.
It is Memorial Day weekend and I still haven't heard from anyone.
On a good note, I love the gas oven and broiler. It is super easy to clean. Nothing gets in the way. Take racks out and wipe off. Then you have a box to clean. No electric coil thingy in the way.
Peke: What's the story with your ovens now? Fixed? How do you like them? I'm seriously looking at the AR double electric wall ovens and want to know if they're all problem or if they really are good. No dealers near me have them on display. My big question: Are they workhorses or are they just pretty?


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Can't Sleep? Your Room May Be Too Hot and Humid
Are you fed up with tossing and turning in your bed at night? You can get comfortable sleep by controlling two important factors: your bedroom's air temperature and humidity levels. The optimal temperature for sleep should be around 65 degrees Fahrenheit. This is according to the research made by National Sleep Foundation. If you're the kind of person who gets cold easily, it may take some adjustment to get used to this. But try it for a few days and see if you don't sleep better.
The best humidity levels to ensure a good night's sleep is between 30% and 50%. If your room falls outside this range, it's time to bust out your humidifier or dehumidifier.
In this article, we shall explain into detail why this temperature and humidity level helps you to sleep well at night, and various ways to control these factors well in your home.
How air temperature can affect sleep
Whenever you get a little drowsy, your body temperature tends to dip. This is because your body wants to achieve a desired "set point" for beauty sleep, according to Web MD. It's important to account for this when setting your room's temperature. It should feel a little bit chillier than what you would prefer during the day.
A too hot or extremely cold temperature could affect your body's internal temperature, thus making you restless while trying to sleep. Therefore ensure to keep your bedroom's air temperature to around 65 degrees Fahrenheit. If in case you have a core body warmer, you may probably have issues sleeping comfortably and you may need to lower the temperature to below 65 degrees.
The best ways to controlling your home's temperature
You could just set your thermostat at 65 degrees, but this could be costly especially during the summer. In order to achieve a cool temperature without stretching your bank account beyond its limits, try the below two tips:
-Turn on your fan. The gentle, wind-chill effect shall provide a cooler sensation on your body, allowing you to turn up the thermostat by a couple of degrees.
-Install a thermostat that is programmable. These kind of thermostats are capable of automatically changing the temperature setting according to how you program the desired schedule. For instance, you can decide to program it to a low of 65 degrees Fahrenheit during bedtime hours and a high of 73 degrees when close to waking up.
How high humidity levels can cause sleep discomfort
The relative quantity of humidity present in the air can affect how well you sleep. Relatively high humidity levels, that is, humidity levels above 50% could cause two comfort problems:
High humidity makes you feel hotter than the room actually is, thus causing restlessness and discomfort. Your body responds to this exactly as it would if you cranked up the thermostat. Additionally, due to the extra moisture present in the air, mold and dust mites can thrive, causing health complications to individuals with asthma and allergies.
How low humidity levels cause snoring and irritation
If you're prone to asthma, snoring, sleep apnea, or any other breathing problems, you want to make sure that the room doesn't get too dry. Dry air irritates your nasal passages, which can cause snoring and wake you up. If your room is too dry, especially in the winter, you should get a humidifier to help you stop snoring. If you've tried other snoring remedies and found them to be wanting, see if a simple humidifier does the trick.
Tips on how to control your home's humidifier
-Purchase and install a home humidifier.
-Always use the AUTO thermostat setting instead of the ON one.
-Properly seal your air vents so that they don't draw in unconditioned air.
-Always ensure that your central AC is not oversized since it may exhibit short cycles. When the AC device is too large for your house, which most of them are, it may short cycle. This means that the device runs for a short time, say 10 minutes and then abruptly stops, preventing it from running long enough to actually cool and dehumidify your house.
National Sleep Foundation http://sleepfoundation.org/
Web MD http://www.webmd.com/
Good Morning Snore Solution http://antisnoringdevices.net/does-good-morning-snore-solution-work/
Humidifiers http://www.homedepot.com/b/Heating-Venting-Cooling-Air-Quality-Humidifiers/N-5yc1vZc4lv


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Though Douglas' announcement may have over-emphasized the dangers of oral sex, it will hopefully get more people talking about HPV and the HPV vaccine.
In poor countries, cervical cancer is often the most common cancer-related death among women, or even the leading cause of death for women, period.
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