Radon Remediation Programmes Research Articles

Cost-effectiveness of radon remediation programmes in the UK in the 2020s

Radon, a gaseous radioactive decay product of naturally-occurring uranium is widely distributed in the environment in rocks and soils and, in certain circumstances, can accumulate in the built environment. Initial studies confirmed a direct link between exposure to both radon gas and its short-lived radioactive progeny, and increased lung-cancer incidence, and demonstrated that radon levels in domestic housing can be sufficiently high to expose occupants to increased risk of lung-cancer. Subsequent studies worldwide have shown that it is cost-effective to detect and reduce domestic radon levels in order to reduce this risk.Recent advances in the early detection of lung-cancer, coupled with the development of improved treatment procedures, have progressively improved survival from the disease, with the numbers surviving at 5 years doubling over recent years, during which period the real costs of lung cancer treatment have risen by around 30%. In the meantime, however, in addition to radon and tobacco-smoke, other airborne pollutants have been identified as risk-factors for lung-cancer. This paper reviews both these actual developments and anticipated future trends, and concludes that since these advances in diagnosis and treatment of lung-cancer have had only a modest effect on cost-effectiveness, it is still important to conduct radon monitoring and remediation programmes. While the general increase in life-expectancy improves the cost-effectiveness of radon remediation programmes significantly, reducing tobacco-smoking incidence reduces that cost-effectiveness but with the overall benefit of reducing radon-related lung-cancers. The challenge remains of encouraging affected householders to remediate their homes to reduce radon levels.

Future initiatives to reduce lung cancer incidence in the United Kingdom: smoking cessation, radon remediation and the impact of social change

Smoking and radon cause lung cancer, with smoking being the more significant risk factor. Although programmes to identify UK houses with raised radon levels and to encourage remedial action started in 1990, uptake has been limited and those most at risk, smokers and young families, are not being reached. The risks from smoking and radon are multiplicative. Public health campaigns have reduced smoking prevalence significantly. Since most radon-induced lung cancers occur in smokers, reducing the number of smokers will reduce the number of radon-induced lung cancers. This article considers the impact of reducing smoking prevalence on the effectiveness of radon remediation programmes, combining this with demographic trends and regional variations to assess implications for future public health. Results on cost-effectiveness of smoking cessation and radon remediation programmes were combined with government figures for smoking prevalence to estimate the number of cancers averted and the cost-effectiveness of such programmes, taking into account demographic changes, including increasing life expectancy. Regional variations in smoking prevalence and smoking cessation programmes were reviewed, comparing these to the geographic variation of radon. The continuing impact of smoking cessation programmes in reducing smoking prevalence will reduce the number of radon-induced lung cancers, but with a lag. Smoking cessation programmes are more cost-effective than radon remediation programmes, presenting an additional opportunity to reduce radon risk to smokers. Regional data show no correlation between smoking prevalence and radon levels. Reduced smoking prevalence reduces the effectiveness of radon remediation programmes. This, coupled with limited uptake of radon remediation, suggests that radon remediation programmes should be targeted, and that an integrated public health policy for smoking and radon is appropriate. Lack of correlation between smoking prevalence and radon suggests that local assessment of relative priorities for public health strategies, such as the 'Total Place' initiative, is appropriate.

The cost effectiveness of radon reduction programmes in domestic housing in England and Wales: The impact of improved radon mapping and housing trends

In the UK, excessive levels of radon gas have been detected in domestic housing. Areas where 1% of existing homes were found to be over the Action Level of 200Bq·m−3 were declared to be Radon Affected Areas. Building Regulations have been introduced which require that, for areas where between 3% and 10% of existing houses are above the Action Level, new homes should be built with basic radon protection using a membrane, and that, where 10% or more of existing homes exceed this level, new homes should be built with full radon protection.Initially these affected areas followed administrative boundaries, known as Counties. However, with increasing numbers of measurements of radon levels in domestic homes recorded in the national database, these areas have been successively refined into smaller units – 5km grid squares in 1999, down to 1km grid squares in 2007.One result is the identification of small areas with raised radon levels within regions where previously no problem had been identified. In addition, some parts of areas that were previously considered radon affected are now considered low, or no, risk. Our analysis suggests that the net result of improved mapping is to increase the number of affected houses. Further, the process is more complex for local builders, and inspectors, who need to work out whether radon protection in new homes is appropriate.Our group has assessed the cost-effectiveness of radon remediation programmes, and has applied this analysis to consider the cost-effectiveness of providing radon protection in both new and existing homes. This includes modelling the potential failure rate of membranes, and whether testing radon levels in new homes is appropriate. The analysis concludes that it is more cost effective to provide targeted radon protection in high radon areas, although this introduces more complexity.The paper also considers the trend in housing to a greater proportion of apartments, the regional variations in types of housing and the decreasing average number of occupants in each dwelling, and concludes that data and methods are now available to respond to the health risks of radon at a local level, in keeping with a general initiative to prioritise responses to health and social welfare issues at a more local level.

Influences motivating smokers in a radon-affected area to quit smoking

Domestic radon gas concentrations in parts of the UK are sufficiently high to increase lung cancer risk among residents, and recent studies have confirmed that the risk of smokers developing lung cancer is significantly enhanced by the presence of radon. Despite campaigns encouraging residents of radon-affected areas (RAEs) to test and remediate their homes, public response to the risks posed by radon remains relatively modest, particularly among smokers and young families, limiting the health benefits and cost-effectiveness achievable by remediation. The observation that smokers, who are most at risk from radon, are not explicitly targeted by current radon remediation campaigns prompted an assessment of the value of smoking-cessation initiatives in reducing radon-induced lung cancers by reaching at-risk subgroups of the population hitherto uninfluenced by radon-awareness programmes. This study addresses the motivation of current quitters in a designated RAE using a postal questionnaire administered around one year after the cessation attempt. Residents of the Northamptonshire RAE who had joined the smoking-cessation programme between July and September 2006 and who remained verifiably tobacco free at four weeks, were subsequently invited to participate in a questionnaire-based investigation into factors affecting their decision to cease smoking. From an initial population of 445 eligible individuals, 205 of those contacted by telephone after 12 months agreed to complete postal questionnaires, and unsolicited questionnaires were sent to a further 112 participants for whom telephone contact had proved impossible. One hundred and three completed questionnaires were returned and analysed, the principal tools being χ(2) , Mann-Whitney and Kruskal-Wallis tests. Individuals decide to quit smoking from self-interest, principally on health grounds, and regard the effects of their smoke on others, particularly children and unborn babies, as less significant. The risk of developing respiratory, coronary/cardiac or cancerous conditions provides the greatest motivation to the decision to quit, with knowledge of radon among the lowest-ranked influences. This study confirms that quitters place risks to their personal health as the highest factors influencing their decision to quit, and health professionals should be aware of this when designing smoking-cessation initiatives. As radon risk is ranked very low by quitters, there would appear to be the potential to raise radon awareness through smoking-cessation programmes, with the objective of increasing the uptake and success rate of such programmes and encouraging participation in radon-remediation programmes.

Lung-cancer reduction from smoking cessation and radon remediation: A preliminary cost-analysis in Northamptonshire, UK

Domestic radon levels in parts of the United Kingdom are sufficiently high as to increase the risk of lung-cancer among residents. Public health campaigns in the county of Northamptonshire, a designated radon Affected Area with 6.3% of homes having average radon levels in excess of the UK Action Level of 200 Bq m − 3 , have encouraged householders to test for radon and then, if indicated to be necessary, to carry out remediation in their homes. These campaigns have been only partially successful, since to date only 40% of Northamptonshire houses have been tested, and only 15% of those householders finding raised levels have proceeded to remediate. Those who remediate have been shown to have smaller families, to be older, and to include fewer smokers than the average population, suggesting that current strategies to reduce domestic radon exposure are not reaching those most at risk. During 2004–2005, the NHS Stop-Smoking Services in Northamptonshire assisted 2847 smokers to quit to the 4-week stage, the 15% (435) of these 4-week quitters remaining quitters at 1 year forming the subjects of a retrospective study considering whether smoking cessation campaigns contribute significantly to radon risk reduction. Quantitative assessment of the risk of lung-cancer among the study population, from knowledge of the individuals' age, gender, and smoking habits, together with the radon levels in their homes, demonstrates that smoking cessation programmes have significant added value in reducing the incidence of lung-cancer in radon Affected Areas, and contribute a substantially greater health benefit at a lower cost than the alternative strategy of reducing radon levels in the smokers' homes, while they remain smokers. Both radon remediation and smoking cessation programmes are very cost effective in Northamptonshire, with smoking cessation being significantly more cost effective, and these are potentially valuable programmes to drive health improvements through promotion of the uptake or environmental management for radon in the home.

Lowering the UK domestic radon Action Level to prevent more lung cancers—is itcost-effective?

Case studies have shown that radon gas can accumulate within domestic properties atsufficiently high levels that it can cause lung cancer, and recent studies havesuggested that this risk remains significant below the UK domestic Action Level of200 Bq m−3. Raised radon levels can be reduced by engineering measures, and it has been shown thatdomestic radon remediation programmes in UK Affected Areas can result in reduced risksto the population and can be cost-effective. We consider here the benefits and costs of thedomestic radon remediation programme in Northamptonshire, UK, and considerthe implications for that programme of reducing the UK Action Level below itspresent value. A radon remediation programme based on an Action Level above200 Bq m−3 will cost less and will target those most at risk, but will be less cost-effective and will lead to higherresidual dose and greater risk of cancer in the remaining population. Reducing the Action Level below200 Bq m−3 will prevent more cancers, but at significantly higher cost. It will also be lesscost-effective, because remediation of a significant number of houses withmoderate radon levels will provide only a modest health benefit to occupants.Overall, a completed radon remediation programme of the type implemented inNorthamptonshire is most cost-effective for an Action Level between 200 and300 Bq m−3. The implications for future health policy are discussed.

A new methodology for cost-effectiveness studies of domestic radon remediation programmes: Quality-adjusted life-years gained within Primary Care Trusts in Central England

Radon is a naturally occurring radioactive gas, high levels of which are associated with geological formations such as those found in Northamptonshire and North Oxfordshire in the UK. The UK's National Radiological Protection Board have designated both districts as radon Affected Areas. Radiation levels due to radon, therefore, exceed 200 Bq m − 3 , the UK's domestic Action Level, in over one percent of domestic properties. Because of radon's radioactivity, exposure to the gas can potentially cause lung cancer, and has been linked to some 2000 deaths a year in the UK. Consequently, when radiation levels exceed the Action Level, remediation against radon's effects is recommended to householders. This study examines the cost-effectiveness of remediation measures in Northamptonshire and North Oxfordshire by estimating cost per quality-adjusted life-year gained in four Primary Care Trusts, organisations that play a key public health policy role in the UK's National Health Service. The study is the first to apply this approach to estimating the cost-effectiveness of radon remediation programmes. Central estimates of cost per quality-adjusted life-year in the four Primary Care Trusts range from £6143 to £10 323. These values, when assessed against generally accepted criteria, suggest the remediation programmes in the trusts were cost-effective. Policy suggestions based on the estimates, and designed to improve cost-effectiveness further, are proposed for the four Primary Care Trusts and the UK's National Health Service.

Evaluating the health benefits and cost-effectiveness of the radon remediation programme in domestic properties in Northamptonshire, UK

Mini-abstract: Although previous analysis of health benefits and cost-effectiveness of radon remediation in a series of houses in Northamptonshire suggested that testing and remediation was justified, recent results indicate fewer predicted affected houses than previously assumed. Despite numerous awareness campaigns, limited numbers of householders have tested their homes, only a minority of affected householders have remediated, and those most at risk generally fail to remediate. Moreover, a recent survey shows a wide range of public perception of radon risk, not significantly influenced by public health campaigns. These observations impact our previous analysis, which has been reviewed in the light of these observations. Following the declaration of Northamptonshire, UK, as a radon Affected Area in 1992, a series of public awareness campaigns encouraged householders to assess domestic radon levels and, if appropriate, to take action to reduce them. Despite these awareness campaigns, however, only moderate numbers of householders have taken remediatory action. The costs of such remedial work in a series of domestic properties in Northamptonshire, the radon level reduction achieved, and the resultant heath benefit to the residents, have been the subject of study by our group for some years. Previous analysis, based on estimates of the total number of affected houses derived from the National Radiological Protection Board (NRPB) test data for the area, suggested that a programme of testing and remediation in Northamptonshire could be justified. The NRPB has continued to initiate and to collate radon testing, and published further results in 2003. These results include revised predictions of the numbers of affected houses, now considered to be less than the numbers previously assumed. More recently, the availability of the European Community Radon Software (ECRS) has permitted calculation of individual, rather than population-average, risk, demonstrating that those most at risk are generally those who do not take action. In addition, a recent survey of risk perception shows an extremely wide range of public perception of radon risk, a perception that has not been significantly altered by public health campaigns. These predictions have profound effects, both on our previous analysis, particularly since only limited numbers of householders test their homes and even fewer remediate if they discover raised levels, and also on the public health strategies for this risk.

Analysis of the individual health benefits accruing from a domestic radon remediation programme

Although radon can be present within buildings at sufficient levels to pose a health risk, levels can be reduced relatively easily. Recent studies on a group of radon-remediated homes, based on assessment of collective population-average risk coefficients, have estimated the benefits and cost effectiveness accruing from remediation and have confirmed that domestic remediation in UK radon Affected Areas would result in significantly reduced cancer risks to the population in those areas. Although the population-average approach used hitherto has applied occupancy and lung-cancer risk factors, these are potentially misleading in assessing discrete populations. The study reported here uses the recently developed European Community Radon Software (ECRS) to quantify individual risks in a sample of householders who remediated their homes following indications that radon levels exceeded the action level. The study proceeds from population-averaged to ‘individual risk’ evaluation, successfully comparing individual and collective risk assessments, and demonstrates that those who remediate are not representative of the general population. Health benefits accruing from remediation are three times lower than expected, largely because remediators are older, live in smaller households, and smoke less than the population average, leading to the conclusion that the current strategy employed in the UK is failing to target those most at risk.

A cost-effectiveness analysis of domestic radon remediation in four primary care trusts located in Northamptonshire, UK

The paper considers how primary care trusts (PCTs), which are relatively new organisations in the UK health service, might respond to the health hazards associated with radon in domestic properties. To this end, the cost-effectiveness of radon remediation programmes in four primary care trusts is calculated and compared with those of other interventions that can avert and treat lung cancer. The results suggest remediation programmes in the primary care trusts are cost-effective on various criteria. Policy recommendations that follow for the primary care trusts include encouraging remediation among their populations and identifying those most at risk from radon’s effects.

Using the European Community Radon Software to estimate the individual health benefitsof a domestic radon remediation programme

Radon can be present in domestic properties at high enough levels to pose a healthrisk. Such levels can usually be reduced by simple means. Studies on a group ofradon-remediated homes in Northamptonshire, a radon affected area, have estimatedthe health benefits and cost effectiveness from remediation and have shown thatremediation can be justified. These assessments have been based on collectivepopulation-average risk coefficients. The advent of the European Community RadonSoftware (ECRS) permits the consideration of individual risk. In particular, it can takeinto account individual smoking habits, which significantly affect risk, as currentscientific opinion is that risks from radon and smoking are multiplicative. Thisnote indicates how the software can be used, and the usefulness of this approach.

The cost-effectiveness of residential radon remediation programmes: assumptions about benefits stream profiles over time

A recent cost-effectiveness analysis of a residential radon remediation programme considered and highlighted many areas of uncertainty in the parameters chosen for the analysis. One assumption not challenged in the study was the benefits stream profile adopted. There are several different ways of loading the benefits in terms of life years into the cost-effectiveness model and several of these are explored and the results are reported in this study. The benefits profile depends upon the lead-time to cancer manifestation post environmental carcinogen (radon) exposure. The literature reviewed suggests that there are many options for loading benefits to radon-induced lung cancer prevention programmes. In this study, the alternative benefits stream profiles are explored and their implications for the cost-effectiveness ratio are examined. Adopting different benefits stream profiles to the model results in a range of cost-effectiveness ratios from £14 912.90 per life year gained to £52 416.27 per life year gained. The preferred model is reported where the life years gained are assumed to be equally distributed over the last 15 years of the 40-year time horizon of the analysis (Y25–40) and the corresponding cost-effectiveness ratio is £37 943 per life year gained.

Radon: post‐remediation studies in National Health Service properties

An extensive radon remediation programme in National Health Service properties in Northamptonshire has been conducted since 1992 and has resulted in many buildings with raised levels being identified and remediated. In the autumn of 1997, several of the remediated properties were surveyed in order to determine the viability of the remedial measures and the dose reduction to staff. The initial assumption that reduction factors in radon levels would be greater than reduction factors in radiation dose per person was partially confirmed. This was due to the part‐time working patterns of staff and their mobility during working hours.

A critical comparison of the cost-effectiveness of domestic radon remediation programmes in three counties of England

Radon remediation programmes in domestic dwellings were carried out in five areas, from three counties of England, and the total costs obtained. A single company, which abided by the Code of Practice of the Radon Council of Great Britain, carried out the remediation. The dose savings from the programmes were calculated and used to estimate the number of lung cancers averted. The data obtained allowed the cost-effectiveness of the remediation programmes in each area to be calculated. The remediation programmes in three areas (Northants 2, 3 and North Oxfordshire) were cost-effective whereas those in two areas (Northants 1 and North Somerset) were not. To be cost-effective, the Northants 1 and North Somerset areas would need to increase the number of householders that carried out remediation, if they were over the UK Action Level. Health policy makers should concentrate their resources on communities in areas where there is a significant proportion of dwellings above the UK Action Level and where the number of properties being remediated is low.

The costs and benefits of radon remediation programmes in existing homes: case study of action level selection

Radon gas can be present within buildings at sufficiently high levels that it becomes a health risk. Such levels can be reduced, and so radon remediation programmes in the home in UK Affected Areas should result in reduced risks to the population. This paper considers the benefits and costs of the domestic radon remediation programme in Northamptonshire, UK, and considers the implications of the choice of Action Level, in view of the adoption of different levels in many countries. A programme with a higher Action Level will cost less, and target those most at risk, but will be less cost effective. In addition, a higher Action Level leaves a higher residual dose and risk to the remaining population. Such doses are higher than and inconsistent with the radiation dose limits for the general public in the EU Basic Standards Directive.

Cost effectiveness analysis of radon remediation programmes

The economic implications of regulations governing radon gas level identification and remediation in buildings are poorly understood, and attempts to address these issues have been criticised for lack of comparability. It is imperative therefore that a general model for the economic evaluation of radon remediation programmes is adopted to ensure comparability between studies and settings and to increase the usefulness of the results to decision makers. This paper presents general guidelines for the use of cost-effectiveness analysis (CEA) as an economic appraisal tool in the evaluation of radon reduction and prevention programmes. The data requirements for a CEA of radon remediation programmes concern both costs and outcomes. These components are discussed with respect to: programme objectives, comparator choice, perspective, time horizon, discounting, uncertainty, and final ratios. Adhering to clear guidelines concerning these aspects of evaluations will facilitate meaningful evaluation of radon remediation programmes. Finally, by evaluating the radon remediation programmes using methods applied to other health interventions (such as lung cancer prevention interventions), comparisons using the same metric can be made across policy areas.

The cost effectiveness of radon remediation programmes in hospitals, schools and homes in radon affected areas in the UK

Radon gas is now considered to be a health hazard when found in excessive amounts in the built environment. The levels of radon vary greatly, with some geographical areas having very high levels. In the United Kingdom, Northamptonshire was declared an Affected Area in 1992, and it was at this stage that our group first started studying radon levels and the steps taken to reduce them. The radon levels both before and after remediation were studied, together with the number of occupants of affected rooms, and their pattern of occupation. The totals costs of the programme were recorded, including the survey using etched track detectors to find the affected room, and work done to reduce radon levels. This analysis provided a total cost of the remediation programme per dose saved. This analysis was carried out, first for Health Service properties in Northamptonshire, and then for schools and domestic properties. Comparison of the three programmes showed that the programme in schools was the most cost effective, but that a completed programme in domestic properties would be almost as effective. However, in the UK, only 10 % of those who discover raised radon levels have so far organised remedial work, greatly reducing the cost effectiveness of the domestic remediation programme. It was found that it was four times more expensive to remediate Health Service properties compared to a completed programme in domestic properties. The results were close to theoretical predictions made for domestic properties in other countries. All the programmes could be justified when compared to the National Radiological Protection Board (NRPB) initiative to reduce patient dose from dental X-Rays. However, if the uptake of householders was less than 10 %, a domestic remediation programme was excessively expensive. The analysis has now been extended to series of houses in North Oxfordshire, and Somerset, which has allowed a comparison of cost effectiveness for areas with different percentages of houses above the domestic Action Level of 200 Bq m -3 . As expected, it is more cost effective to target areas with higher percentages of houses above the Action Level. More importantly, the percentage of householders who find raised radon levels and then organise remediation is critical. Programmes to reduce domestic radon levels in areas where 2 % or less of houses are above the Action Level are difficult to justify financially unless a high householder response is achieved.

The cost-effectiveness of radon-induced lung cancer prevention in schools

An economic evaluation of a radon-induced lung cancer prevention programme for schools in the United Kingdom is undertaken in this study, which presents a cost-effectiveness analysis with a generalisable model for estimating the cost-effectiveness of a radon remediation programme for schools from a societal perspective. It follows the guidelines for the methodological framework now considered appropriate in the economic evaluation of health interventions and employs best available national UK data and information from Northamptonshire on the costs and effectiveness of radon identification and remediation in schools, and the costs and health impact of lung cancer cases for all state schools in Northamptonshire between 1993 and 1997 (348 schools, including 170 adult staff and 1820 pupils). The resultant cost-effectiveness ratio was 7550 per life-year gained in 1997 UK pound sterling. Results from the sensitivity analysis show that the ratio is particularly sensitive to assumptions concerning two parameters: the average capital cost of remediation and discount rate applied to life years. This study highlights the need for the evaluation of other schools remediation-based radon-induced lung cancer prevention programmes in other countries using similar methodological techniques. Compared to other health interventions in the UK, the schools programme has a favourable ratio. When compared to other lung cancer prevention programmes available, however, the schools programme ratio is less favourable. Uncertainties remain around increased risks from childhood exposure to indoor radon.

A comparison of the costs and benefits of radon remediation programmes in new and existing houses in Northamptonshire

The paper presents the first major analysis of the costs and benefits of radon remediation programmes in both existing and new domestic properties in areas affected by radon in the UK. The study was conducted in Northamptonshire, where over 6% of houses are above the UK domestic Action Level of 200Bq.m−3, and where new houses in parts of the county, where over 10% of houses are above the Action Level, have been fitted with a radon-proof membrane and provision of a sump, but without a fan. The county also contains areas where 3–10% of houses are over the Action Level, where, until January 2000, only the provision of a sump without a fan was required.Remediation programmes in existing domestic properties, and in new houses in areas with over 10% of houses above the Action Level, can be justified in terms of costs per cancers averted when compared with other health interventions. A modest reduction in lung cancer induction can be predicted, particularly in areas where significant numbers of new houses are being built.However, where UK programmes rely on householder actions, such as remediation of existing houses, they have had limited success—with a large majority of householders taking no action at all. As many countries have regions where domestic properties have raised radon levels, this analysis is generally applicable to many developed European countries. Policy-makers in such areas need to design more inventive public health campaigns, or develop legal or financial incentives, so that the uptake of remediation is stimulated.

A cost-effectiveness analysis of a residential radon remediation programme in the United Kingdom.

As residential radon programmes of identification and remediation have proceeded, so questions have been raised about their costs and benefits. This study presents a generalizable model for estimating the cost-effectiveness of a radon mitigation programme using the methodological framework now considered appropriate in the economic evaluation of health interventions. Its use will help to inform future discussion of radon remediation and lung cancer prevention programmes. Data from Northamptonshire were analysed, resulting in a societal cost-effectiveness ratio of £13250 per life-year gained in 1997. The percentage of houses found to be over the action level, and the percentage of householders who decide to remediate are shown to be important parameters for the cost-effectiveness analysis. Questions are raised about the particular importance of perspective in this type of analysis and suggestions are made for future research directions. © 1999 Cancer Research Campaign