September/October 2003, Vol. 18, No. 1 103
T H E S C I E N C E O F H E A L T H P R O M O T I O N
Integrating Public Health Objectives in
This perspective explores how transportation decision-making
can better support public health objectives, including reduced
crashes and pollution emissions and increased physical activity.
Conventional transportation planning tends to overlook negative
health impacts resulting from increased motor vehicle travel and
potential health benefits from shifts to alternative modes. Raising
the priority of health objectives supports planning reforms that re-
sult in a more balanced transportation system. Integrating health
objectives into transportation planning may be a cost-effective way
to improve public health. (Am J Health Promot 2003;18:103–
Conventional public decision-making tends to be ‘‘re-
ductionist’’; that is, individual problems are assigned to a
specialized organization with narrowly defined responsibil-
ities.1 For example, transportation agencies are responsi-
ble for solving traffic problems and health agencies are
responsible for improving public health. This approach
can lead to agencies implementing solutions to problems
within their mandate that exacerbate problems outside
their mandate. By focusing on a narrow set of objectives,
planners tend to undervalue solutions that provide addi-
tional benefits. For example, a transportation agency may
undervalue a congestion reduction strategy that increases
nonmotorized travel by ignoring health benefits, whereas
a public health agency may undervalue a program that in-
creases walking and cycling by ignoring congestion reduc-
Reductionist decision-making often causes transporta-
tion planners to overlook indirect health impacts. This ed-
itorial explores how transportation decisions affect public
health and how planning practices might change if trans-
portation agencies gave greater consideration to public
Todd Litman is with the Victoria Transport Policy Institute, Vic-
toria, British Columbia, Canada.
Copyright q 2003 by American Journal of Health Promotion, Inc.
0890-1171/03/$5.00 1 0
TRANSPORTATION HEALTH IMPACTS
Transportation planning decisions impact public
health in three main ways: through traffic crashes, vehi-
cle pollution, and physical activity.2 Of the 10 most com-
mon causes of death in the United States, seven are af-
fected by transportation in these three ways, as illustrat-
ed in Figure 1. (Of course, these do not indicate the de-
gree to which transportation affects each of the health
risks: motor vehicle air pollution is only one of many
contributors to respiratory illnesses, and nonmotorized
travel is just one physical fitness strategy.) Figure 2 com-
pares the 10 main causes of years of potential life lost
(Y PLL), which takes into account age at death, and so
ranks traffic crashes high because they tend to kill youn-
ger people compared with illnesses associated with sed-
entary lifestyle and pollution.
These three transportation-related health impacts are
discussed individually below.
Transportation professionals give considerable attention
to traffic safety, but they usually evaluate this risk per unit
of vehicle travel (i.e., injuries and fatalities per 100 mil-
lion vehicle-miles or vehicle-kilometers). Measured in this
way, U.S. crash rates have declined by more than two
thirds over the last 4 decades, indicating that current traf-
fic safety strategies are successful and should be contin-
ued. But per capita vehicle mileage has more than dou-
bled over the last 40 years, which has largely offset the de-
cline in per-mile crash rates. When fatalities and injuries
are measured per capita (e.g., per 10,000 population) as
with other public health risks, there has been relatively lit-
tle improvement. Figure 3 compares these two different
ways of measuring traffic crash risk.
Many safety strategies were implemented during this
period, including safer road and vehicle designs; im-
proved vehicle occupant protection (seat belts, child seats,
air bags, etc.); reductions in drunk driving; and improve-
ments in emergency response and trauma care.3 Taking
these factors into account, much greater casualty reduc-
tions should have been achieved. For example, the in-
crease in seat belt use over this period, from close to zero
in 1960 up to 75% in 2002, by itself should have reduced
fatalities by about 34%, yet per capita traffic deaths only
declined by about 25%.4
104 American Journal of Health Promotion
Ten Leading Causes of U.S. Deaths
Source: National Center of Health Statistics. Deaths: Preliminary Data for 2001. National Vital Statistics Reports. Vol. 51, No 5. Center for Disease
Control and Prevention (www.cdc.gov/nchs). Accessed March 14, 2003.
Traffic crashes continue to be the greatest single cause
of death and disabilities for Americans 1 to 44 years of
age.5 Although the United States has one of the lowest
traffic fatality rates per vehicle-mile, it has one of the highest
traffic fatality rates per capita. From this perspective, traffic
safety continues to be a major problem: current safety ef-
forts are ineffective, and new approaches are justified to
improve road safety.
When road risk is measured per vehicle-mile, increased
mileage is not considered a risk factor and traffic reduc-
tions are not considered a safety strategy. From this per-
spective, an increase in total crashes is not a problem pro-
vided that there is a comparable increase in vehicle travel.
By emphasizing per-mile crash rates, conventional trans-
portation planning undervalues the potential safety bene-
fits of strategies that reduce total vehicle mileage.
Vehicle pollution is a second category of transport-re-
lated health impacts. Motor vehicles produce a variety of
air pollutants, including carbon monoxide, particulates,
toxins, and ozone precursors, which contribute to a varie-
ty of diseases, including cancer, respiratory diseases, and
heart failure. The total health impacts of motor vehicle
pollution are difficult to calculate since there are so many
different pollutants causing a variety of diseases, and most
pollutants have other sources besides motor vehicles. The
number of premature deaths from motor vehicle pollu-
tion appears to be similar in magnitude to the number of
deaths resulting from traffic crashes,6,7 although the exact
amount is difficult to determine (see Table 11.7-3B in
McCubbin and Delucchi7). As stated earlier, such deaths
tend to involve older people compared with those killed
in traffic crashes, and therefore cause smaller reductions
in Y PLL.
It is common to hear claims that vehicle emissions have
declined 90% or more as the result of vehicle emission
control technologies such as electronic ignition and cata-
lysts, but this is an exaggeration. Such declines only apply
to certain tailpipe emissions measured by standard tests.
Tests do not reflect real driving conditions (they underes-
timate out-of-tune engines and hard accelerations), and
vehicles produce additional harmful emissions not mea-
sured in these tests, such as toxics and particulates from
road dust, tires, and break linings.8 Increased vehicle mile-
age has offset much of the reduction in per-mile emis-
sions. Automobile emissions continue to be a major pollu-
tion source, and reductions in vehicle traffic can provide
measurable respiratory health benefits.9
Physical Activity and Fitness
The third category of health impacts concerns the ef-
fects transportation policy has on physical fitness. Public
health officials are increasingly alarmed at the reduction
September/October 2003, Vol. 18, No. 1 105
Ten Leading Causes of Years of Potential Life Lost
Source: National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System: Years of Potential Life Lost (YPLL).
National Center for Disease Control and Prevention (www.cdc.gov/ncipc/wisqars). Accessed March 17, 2003.
in physical activity among the general population and in-
creases in diseases associated with a sedentary lifestyle.10
There are many ways to be physically active, but few are
suitable for lifetime participation by the general popula-
tion. Walking, running, and cycling are practical ways to
maintain fitness.11 Transportation planning decisions have
a major effect on the amount of nonmotorized travel that
occurs in a community.12
Although it is difficult to predict how a particular
transportation planning decision affects physical fitness,
total impacts are likely to be large. Diseases associated
with inadequate physical fitness cause an order of magni-
tude of more deaths, and more Y PLL, than road crash-
es.13 Even modest reductions in these illnesses could pro-
vide significant health benefits.
Mobility management (also called transportation de-
mand management, or TDM) refers to various strategies
that encourage travelers to drive less and shift to other
travel modes.14,15 These include the following:
● Facility investment and design features that improve
walking, cycling, and public transit (e.g., improved side-
walks, crosswalks and paths, and roadway traffic calm-
● Programs to encourage use of alternative modes (such
as walking, cycling, ride sharing, public transit, and tele-
work), such as employee trip reduction programs at
worksites and campus transportation management pro-
grams at colleges.
● Financial incentives such as road and parking pricing,
pay-as-you-drive vehicle insurance, and Parking Cash
Out, which reduce motor vehicle traffic.
● ‘‘Smart growth’’ land use policies (i.e., more compact,
mixed, multimodal land use patterns) that help create
more accessible and walkable communities.
Table 1 lists various categories of mobility management
Conventional transportation planning does not ignore
mobility management, but tends to consider it a last re-
sort for extreme urban traffic problems. It is not usually
considered a safety or health strategy. When transporta-
tion agencies evaluate options for reducing congestion or
crashes, mobility management strategies often rank low
because their individual impacts appear modest, typically
affecting just a few percent of total vehicle travel. But
these impacts are cumulative. A comprehensive mobility
management program that includes a complementary set
of strategies can reduce vehicle traffic by 10% to 30%, or
Conventional transportation planning practices are bi-
ased in ways that encourage automobile use and underval-
ue mobility management strategies.17 For example, a ma-
jor portion of transportation budgets are dedicated to
road projects and cannot be used for public transit or
106 American Journal of Health Promotion
U.S. Traffic Fatalities
This figure illustrates traffic fatality trends over 4 decades. Per mile crash rates declined substantially, but per capita crash rates declined little despite
significant traffic safety efforts.
Source: Bureau of Transportation Statistics. National Transportation Statistics 2002. Bureau of Transportation Statistics, US Department of
Transportation (www.bts.gov/publications/nts/2002/index.html). January 2002. Accessed June 5, 2003.
Examples of Mobility Management Strategies†
Address security concerns of
alternative mode users
Alternative work schedules
Guaranteed ride home
Park and ride
Taxi service improvements
Bicycle and pedestrian
Commuter financial in-
Fuel tax increases
High occupant vehicle
Vehicle use restrictions
Clustered land use
tation market reforms
Least cost planning
Data collection and surveys
Commute trip reduction
Freight transportation man-
School trip management
Special event management
Tourist transport manage-
† VTPU. Online TEM Encyclopedia. Victoria Transport Policy Institute, Victoria, BC, 2002. Available at http://www.vtpi.org/tdm. Accessed March 19,
September/October 2003, Vol. 18, No. 1 107
Estimated Costs of Automobile Use in the United States
This figure illustrates the estimated magnitude of various external costs of vehicle use. Crash damages are one of the largest costs, far greater than
traffic congestion or pollution costs.19,21
nonmotorized facilities, and most zoning codes mandate
generous amounts of parking at any new building or pub-
lic facility. Similarly, current public policies tend to under-
price driving: motorists do not pay directly for many of
the costs their vehicle use imposes on society.18,19
Although individually policies and planning practices
that favor motor vehicle use may appear modest and justi-
fiable, they tend to create automobile-dependent transpor-
tation systems and land-use patterns that increase per ca-
pita driving and reduce nonmotorized travel, with nega-
tive health impacts.20 Put more positively, policy and plan-
ning reforms that correct transportation market
distortions can provide health benefits, in addition to oth-
er economic, social, and environmental benefits. Trans-
portation professionals categorize such reforms as mobility
COMPARING TRANSPORTATION OBJECTIVES
Figure 4 compares the estimated magnitude of various
costs that automobile use imposes on society. It indicates
that crash damages are the largest categories of these
costs due to the large number of people killed and in-
jured in the prime of life, as well as associated property
damages.21 As mentioned earlier, pollution probably caus-
es a similar number of premature deaths, but these gener-
ally involve older people and therefore cause fewer Y PLL.
The health costs of reduced physical activity due to re-
duced walking and cycling are difficult to quantify, but a
plausible guess is that they are at least as great as the costs
of air pollution and may exceed crash costs.
These cost estimates have important implications for
transportation planning. They indicate that a congestion
reduction strategy is probably not worthwhile if it causes
even modest increases in crashes and pollution emissions,
or reductions in nonmotorized travel. For example, if
roadway capacity expansion reduces congestion costs by
10% but increases total crash costs by 2% due to addition-
al vehicle travel and higher traffic speeds, it is probably
not worthwhile overall since crash costs are approximately
five times greater in magnitude than congestion costs, and
therefore a 1% increase in total crashes costs offsets a 5%
reduction in total congestion costs.22 However, a conges-
tion reduction strategy provides far greater total benefits
if it causes even small reductions in crashes, pollution, or
sedentary lifestyles in a community.
Transportation decisions have major impacts on public
health through impacts on crash risk, pollution emissions,
and physical fitness. All three health risks tend to increase
with motor vehicle use. Although mitigation strategies can
reduce some negative health impacts, all else being equal,
increased motor vehicle travel and reduced nonmotorized
travel tends to harm public health.
Conventional transportation planning gives relatively
little consideration to indirect health impacts caused by
108 American Journal of Health Promotion
increased motor vehicle travel. As a result, planners tend
to understate the health costs of decisions that favor auto-
mobile travel. Giving health a higher priority in transpor-
tation planning would increase emphasis on mobility man-
agement strategies, particularly those that increase non-
motorized travel. Many mobility management strategies
are justified by direct economic benefits such as conges-
tion reduction, facility cost savings, and vehicle cost sav-
ings, and therefore can provide ‘‘free’’ health benefits. In-
tegrating health objectives into transportation planning
may be one of the most cost-effective ways to improve
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