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Environmental exposures and pulmonary function among adult residents of rural Appalachian Kentucky



Estimated residential exposures of adults to roadway density and several metrics of resource extraction, including coal mining and oil and gas drilling, were hypothesized to contribute to the prevalence of respiratory disease in rural Appalachia.


Determine how small-area geographic variation in residential environmental exposures impacts measures of pulmonary function among adults in a community-based study.


We examined associations between residential environmental respiratory exposures and pulmonary function among 827 adult participants of the “The Mountain Air Project”, a community-based, cross-sectional study in Southeastern Kentucky during 2016–2018. Exposures characterized the density of roadways, oil/gas wells, or current/past surface and underground coal mining at the level of 14-digit hydrologic unit code (HUC), or valley “hollow” where participants resided. Each participant completed an in-person interview to obtain extensive background data on risk factors, health history, and occupational and environmental exposures, as well as a spirometry test administered by experienced study staff at their place of residence. Multivariable linear regression was used to model the adjusted association between each environmental exposure and percent predicted forced expiratory volume in one second (FEV1PP) and forced vital capacity (FVCPP).


Adjusted regression models indicate persons living in HUCs with the highest level of roadway density experienced a reduction in both FEV1PP (−4.3: 95% CI: −7.44 −1.15;) and FVCPP (−3.8: 95% CI: −6.38, −1.21) versus persons in HUCs with the lowest roadway density. No associations were detected between the metrics associated with mining and oil and gas operations and individual pulmonary function.

Impact statement

  • Our work demonstrates the potential adverse impact of roadway-related exposures on the respiratory health of rural Appalachia residents. We employed a novel method of small-area exposure classification based on the hydrologic unit code (HUC), representing potential exposure levels per hollow occurring  in proximity to the residence, and controlled for individual-level risk factors for reduced respiratory health. We highlight an overlooked yet ubiquitous source of residential exposure from motor vehicles that may contribute to the regionally high prevalence of respiratory disease in rural Appalachia.

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Fig. 1: Mountain Air Project (MAP) study area.

Data availability

The datasets used during the current study are available from the corresponding author upon reasonable request.


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We gratefully acknowledge the leadership and contributions of Nancy Schoenberg, PhD, as a co-investigator of the study, Beverly May, DrPH, and Nell Fields of the Mountain Air Project staff, and the contributions of the Mountain Air Project Community Advisory Board. Susan Westneat, MA, provided data management and statistical and analytic support on the study. We recognize the editorial and technical support of Steve Claas of the Office of Scientific Writing at the University of Kentucky. We also acknowledge the tireless efforts of the community health workers including Darlene Warf, Betty Keith, Denise Baird, Libby Honeycutt, and Penny Lee who recruited participants and administered surveys and spirometry tests. Finally, we acknowledge the time and efforts of the participants in the Mountain Air Project and are grateful for their participation.


The authors received support for this work from three federal grants: NIEHS R01 ES024771; NIEHS P30 ES026529; and CDC/NIOSH T42 OH010278 This work was supported by NIEHS R01ES024771-01, CDC/NIOSH T42OH010278, and NIH/NIEHS T32ES015459.

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Authors and Affiliations



JCF conducted the environmental field survey for exposure evaluation, created databases, analyzed and interpreted data, and was the lead author on this paper. WTS was involved in study design and data collection, editing, analyzing, and interpreting data, and editing the manuscript. WJC was involved in study design, data analysis and interpretation, and editing the manuscript. DMM was involved in study design, evaluation of pulmonary spirometry, interpreting data analysis, and editing the manuscript. SRB was the overall principal investigator of the study and was the lead in study design, data collection, and writing editing the manuscript.

Corresponding author

Correspondence to John C. Flunker.

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The authors report no competing interests.

Ethical approval

The protocol, study procedures, and consent forms were approved by the Institutional Review Board of the University of Kentucky, Lexington, Kentucky (UK IRB number 48792). Written informed consent was obtained from all participants.

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Flunker, J.C., Sanderson, W.T., Christian, W.J. et al. Environmental exposures and pulmonary function among adult residents of rural Appalachian Kentucky. J Expo Sci Environ Epidemiol (2023).

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