Clean Air Actions and Health Plans in China: Progress, Challenges, and Pathways Forward

In January 2013, severe smog blanketed China, grabbing global attention and highlighting the country’s urgent need to address air pollution. Since then, China has launched aggressive clean air actions—and the data shows progress. But challenges remain, especially when it comes to protecting public health from pollutants like fine particulate matter (PM2.5) and ozone (O3).

Chen Chen, Jian-Long Fang, Wan-Ying Shi, Tian-Tian Li, and Xiao-Ming Shi—researchers at the National Institute of Environmental Health, Chinese Center for Disease Control and Prevention (CDC)—recently reviewed China’s clean air efforts, health plans, and scientific research to outline what’s working, what’s not, and where to go next.

China’s Clean Air Journey: From Smog to Action

In 2013, China took two pivotal steps: expanding its air pollution monitoring network and launching the Air Pollution Prevention and Control Action Plan (APPCAP).

Monitoring for Accountability

The China National Environmental Monitoring Centre scaled up its network to over 2,000 stations nationwide, tracking six key pollutants: PM2.5, inhalable particulate matter (PM10), O3, sulfur dioxide (SO2), nitrogen dioxide (NO2), and carbon monoxide (CO). This data became the backbone of pollution control decisions.

APPCAP: 2013–2017 Targets

APPCAP set bold goals: by 2017, PM2.5 concentrations would drop 10% nationwide (from 2012 levels) and even more in heavily polluted regions:

25% reduction in the Beijing-Tianjin-Hebei (BTH) region
20% reduction in the Yangtze River Delta (YRD)
15% reduction in the Pearl River Delta (PRD)

To hit these targets, APPCAP outlined 10 tasks, including optimizing industrial structure, advancing clean technology, and building early warning systems for smog. The 2014 revised Environmental Protection Law further reinforced these efforts by mandating environmental health monitoring and research.

Results: Progress, But Not Perfection

By 2017, China saw significant improvements:

The share of “good air quality days” reached 72.7% nationwide.
PM2.5 concentrations in 74 major cities fell 33.3% from 2013 levels (to 47 µg/m³).
SO2, NO2, and CO levels dropped by 57.5%, 9.1%, and 32.0%, respectively.

In 2018, the State Council doubled down with the Three-Year Action Plan for Clean Air, aiming to reduce heavy pollution days by 25% (vs. 2015) and boost “blue sky days” to 80% by 2020.

But challenges persist:

China’s PM2.5 levels still exceed the World Health Organization’s (WHO) least stringent target (10 µg/m³ annual average).
O3 pollution is rising—yet it hasn’t been a focus of clean air actions.

National Health Plans: Linking Clean Air to Public Health

As clean air efforts deepened, China integrated pollution control into national health policy.

Healthy China 2030

Released in 2016, Healthy China 2030 prioritizes reducing health risks from pollution by merging health policies with environmental action. The goal: use cleaner air to improve overall population health.

Healthy China 2019–2030

This follow-up plan targets environmental and health literacy: by 2022, 15% of residents should understand pollution’s health impacts; by 2030, that number rises to 25%.

Research to Inform Policy

The government has funded critical research to bridge gaps between air quality and health:

Ministry of Science and Technology: In 2016–2017, four projects explored acute/chronic health effects of air pollution, high-precision exposure assessment, and early warning systems for health risks.
National Natural Science Foundation: A joint program focuses on “combined pollution”—how mixtures of pollutants (like PM2.5 + O3) harm health.
“2+26” Cities: The Ministry of Ecology and Environment supported 28 projects in the BTH region and surrounding cities to study pollution sources, emission reduction tech, and health impacts.

What Science Tells Us: Air Pollution’s Health Toll

Since 2013, Chinese researchers have generated robust evidence linking air pollution to serious health outcomes—especially PM2.5.

Short-Term Exposure: Immediate Risks

Studies show even brief exposure to high PM2.5 levels increases mortality:

A 2017 study of 272 cities found that a 10 µg/m³ increase in 2-day average PM2.5 raised respiratory mortality by 0.29% and cardiovascular mortality by 0.27%.
A 2019 study of 130 counties linked PM2.5 to higher deaths from acute myocardial infarction (0.21%) and ischemic heart disease (0.19%).
Another 2019 study estimated 169,862 extra deaths from short-term PM2.5 exposure in 2015 alone.

Long-Term Exposure: Chronic Harm

Long-term PM2.5 exposure is even more dangerous:

A cohort study using the Chinese Longitudinal Healthy Longevity Survey found a 10 µg/m³ increase in PM2.5 raised all-cause mortality risk by 8% (hazard ratio: 1.08).
The China-PAR (Prediction for Atherosclerotic Cardiovascular Disease Risk in China) study linked long-term PM2.5 exposure to a 11% higher risk of hypertension (hazard ratio: 1.11).
By 2010, PM2.5 caused 1.26 million premature deaths—42% more than in 2000.

Clean Air = Health Benefits

The good news? Cleaner air saves lives. A 2018 study found APPCAP reduced premature deaths by 47,240 and years of life lost by 710,020 in 2017 vs. 2013. Another study projected that meeting the 13th Five-Year Plan’s air quality goals could cut PM2.5-related deaths by 129,278 by 2020 and 217,988 by 2030.

Next Steps: Toward Cleaner Air and Healthier Lives

While progress is clear, the researchers outline four priorities to accelerate change:

1. Learn from Experience

Use pollution exposure and health risk assessments to measure the impact of clean air actions—and identify gaps (like O3). This data will help policymakers refine future strategies.

2. Double Down on PM2.5 and O3

PM2.5: China’s PM2.5 levels are still too high. Target toxic components (e.g., heavy metals, organic matter) and their sources (industry, transport) for local action.
O3: Ground-level O3 is rising and harmful—yet it’s overlooked. Focus on emission sources that drive O3 (e.g., volatile organic compounds, NOx).

3. Strengthen Air Quality Standards

China’s 2012 air quality standards lack China-specific health evidence and are less strict than those in developed countries or the WHO. Update standards using local research to protect public health.

4. Fund Innovative Research

Most current research focuses on PM2.5 mass—but its chemical components and inhaled fractions are more toxic. Prioritize:

Studies on PM2.5’s toxic components (e.g., black carbon, sulfate).
Health effects of combined pollution (PM2.5 + O3 + other gases).
O3’s health risks (e.g., respiratory and cardiovascular harm).

The Road Ahead

China’s clean air journey is a work in progress. The country has made remarkable strides in reducing PM2.5 and building monitoring systems—but protecting public health requires more: stricter standards, attention to O3, and research on pollution mixtures.

As the researchers note: “Air quality intervention is a protracted and arduous task. But with evidence-based policies, targeted research, and sustained commitment, China can move closer to a future where clean air and healthy lives go hand in hand.”

This work was supported by the National Key Research and Development Program of China (2016YFC0206500) and the National Research Program for Key Issues in Air Pollution Control (DQGG0401).

doi.org/10.1097/CM9.0000000000000888

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