Use of Quality-Adjusted Life Year Weights with Dose-Response Models for Public Health Decisions: A Case Study of the Risks and Benefits of Fish Consumption

Risks associated with toxicants in food are often controlled by exposure reduction. When exposure recommendations are developed for foods with both harmful and beneficial qualities, however, they must balance the associated risks and benefits to maximize public health. Although quantitative methods are commonly used to evaluate health risks, such methods have not been generally applied to evaluating the health benefits associated with environmental exposures. A quantitative method for risk-benefit analysis is presented that allows for consideration of diverse health endpoints that differ in their impact (i.e., duration and severity) using dose-response modeling weighted by quality-adjusted life years saved. To demonstrate the usefulness of this method, the risks and benefits of fish consumption are evaluated using a single health risk and health benefit endpoint. Benefits are defined as the decrease in myocardial infarction mortality resulting from fish consumption, and risks are defined as the increase in neurodevelopmental delay (i.e., talking) resulting from prenatal methylmercury exposure. Fish consumption rates are based on information from Washington State. Using the proposed framework, the net health impact of eating fish is estimated in either a whole population or a population consisting of women of childbearing age and their children. It is demonstrated that across a range of fish methylmercury concentrations (0-1 ppm) and intake levels (0-25 g/day), individuals would have to weight the neurodevelopmental effects 6 times more (in the whole population) or 250 times less (among women of child-bearing age and their children) than the myocardial infarction benefits in order to be ambivalent about whether or not to consume fish. These methods can be generalized to evaluate the merits of other public health and risk management programs that involve trade-offs between risks and benefits.     

Communicating Risks and Benefits from Fish Consumption: Impact on Belgian Consumers' Perception and Intention to Eat Fish

Communicating about the health effects of fish and seafood may potentially result in a conflict situation: increasing intake is desirable because of health and nutritional benefits, but higher consumption may also lead to an increased intake of potentially harmful environmental contaminants. In order to anticipate the communication challenge this conflict may pose, the research presented here aimed to assess the impact of risk/benefit communication on Belgian consumers' fish consumption behavior and fish attribute perception. Data were collected in June 2005 from a sample of 381 women, aged between 20 and 50 years. An experimental design consisting of four message conditions (benefit‐only; risk‐only; benefit‐risk; and risk‐benefit) combined with three information sources (fish and food industry; consumer organization; government) was used. Exposure to the benefit‐only message resulted in an increase from a self‐reported fish consumption frequency of 4.2 times per month to an intended fish consumption frequency of 5.1 times per month (+21%), while fish attribute perceptions only marginally improved. The risk‐only message resulted in a strong negative perceptual change in the range of two points on a seven‐point scale. This translated into an 8% decrease of behavioral intention (from eating fish 4.5 times per month to an intention of eating fish 4.1 times per month). Balanced messages referring to both risks and benefits yielded no significant change in behavioral intention, despite a significant worsening of fish attribute perception. The presentation order of benefits and risks in the balanced message showed a tendency to affect both behavioral intention and attribute perception, with the first message component being most influential. Information source did not yield any significant impact either on behavioral intention or on attribute perceptions, independent of the message content. The results from this study provide valuable insights for future risk/benefit and balanced communication about seafood.     

Consumer Responses to Integrated Risk‐Benefit Information Associated with the Consumption of Food

The risk analysis of the health impact of foods is increasingly focused on integrated risk‐benefit assessment, which will also need to be communicated to consumers. It therefore becomes important to understand how consumers respond to integrated risk‐benefit information. Quality‐adjusted‐life‐years (QALYs) is one measure that can be used to assess the balance between risks and benefits associated with a particular food. The effectiveness of QALYs for communicating both positive and negative health effects associated with food consumption to consumers was examined, using a 3 × 2 experiment varying information about health changes in terms of QALYs associated with the consumption of fish (n = 325). The effect of this information on consumer perceptions of the usefulness of QALYs for describing health effects, on risk and benefit perceptions, attitudes, and intentions to consume fish was examined. Results demonstrated that consumers perceived QALYs as useful for communicating health effects associated with food consumption. QALYs communicated as a net effect were preferred for food products associated with negative net effects on health, while separate communication of both risks and benefits may be preferred for food products associated with positive or zero net health effects. Information about health changes in terms of QALYs facilitated informed decision making by consumers, as indicated by the impact on risk and benefit perceptions as intended by the information. The impact of this information on actual food consumption choices merits further investigation.     

Probabilistic Integrated Human Mixture Risk Assessment of Multiple Metals Through Seafood Consumption

Inorganic arsenic (iAs), cadmium (Cd), lead (Pb), and methylmercury (MeHg) are toxic metals that cause substantial health concern and are present in various seafood items. This study linked probabilistic risk assessment to the interactive hazard index (HI_INT) approach to assess the human mixture risk posed by the dietary intake of iAs, Cd, Pb, and MeHg from seafood for different age populations, and joint toxic actions and toxic interactions among metals were also considered in the assessment. We found that, in combination, an iAs–Cd–Pb–MeHg mixture synergistically causes neurological toxicity. Furthermore, an iAs–Cd–Pb mixture antagonistically causes renal and hematological effects and additively causes cardiovascular effect. Our results demonstrated that if toxic interactions are not considered, the health risk may be overestimated or underestimated. The 50th percentile HI_INT estimates in all age populations for neurological, renal, cardiovascular, and hematological effects were lower than 1; however, the 97.5th percentile HI_INT estimates might exceed 1. In particular, toddlers and preschoolers had the highest neurological risk, with 0.16 and 0.19 probabilities, respectively, of neurological HI_INT exceeding 1. Saltwater fish consumption was the principal contributor to the health risk. We suggest that regular monitoring of metal levels in seafood, more precise dietary surveys, further toxicological data, and risk–benefit analysis of seafood consumption are warranted to improve the accuracy of human mixture risk assessment and determine optimal consumption.     

Estimated Distributions for Average Daily Consumption of Total and Self-Caught Fish for Adults in Michigan Angler Households

Fish consumption rates play a critical role in the assessment of human health risks posed by the consumption of fish from chemically contaminated water bodies. Based on data from the 1989 Michigan Sport Anglers Fish Consumption Survey, we examined total fish consumption, consumption of self-caught fish, and consumption of Great Lakes fish for all adults, men, women, and certain higher risk subgroups such as anglers. We present average daily consumption rates as compound probability distributions consisting of a Bernoulli trial (to distinguish those who ate fish from those who did not) combined with a distribution (both empirical and parametric) for those who ate fish. We found that the average daily consumption rates for adults who ate fish are reasonably well fit by lognormal distributions. The compound distributions may be used as input variables for Monte Carlo simulations in public health risk assessments.     

Human Mercury Toxicity and Ice Angler Fish Consumption: Are People Eating Enough to Cause Health Problems?

Mercury contamination of aquatic ecosystems is a global environmental concern. Bioaccumulation of mercury in fish exposes consumers to risk. We interviewed ice anglers on Monona Bay, Wisconsin during the 2001-2002 ice fishing season to determine risk associated with fish consumption and methyl mercury (MeHg) intake. The majority of anglers (95%) were not at risk of mercury toxicity because they ate less fish than would be required to create health problems. The remaining 5% of ice anglers barely exceeded the mercury toxicity threshold, with the exception of one angler who exceeded the threshold by 0.926 ppm. Anglers encountered were all male and predominantly Caucasian. Fish consumption by ice anglers was independent of awareness of consumption advisories, education, income, and age. This suggests that future awareness efforts should (1) identify groups of anglers most at risk and (2) create policies to effectively reach these audiences.     

Weighing Health Benefit and Health Risk Information when Consuming Sport-Caught Fish

Fish consumers may incur benefits and risks from eating fish. Health advisories issued by states, tribes, and other entities typically include advice about how to limit fish consumption or change other behaviors (e.g., fish cleaning or cooking) to reduce health risks from exposure to contaminants. Eating fish, however, may provide health benefits. Risk communicators and fish consumers have suggested the importance of including risk comparison information, as well as health risk-benefit comparisons in health advisory communications. To improve understanding about how anglers fishing in waters affected by health advisories may respond to such risk-risk or risk-benefit information, we surveyed Lake Ontario (NY, USA) anglers. We interviewed by telephone 4,750 anglers, 2,593 of which had fished Lake Ontario in the past 12 months and were sent a detailed mail questionnaire (1,245 responded). We posed questions varying the magnitude of health risks and health benefits to be gained by fish consumption, and varied the population affected by these risks and benefits (anglers, children, women of childbearing age, and unborn children). Respondents were influenced by health benefit and health risk information. When risks were high, most respondents would eat less fish regardless of the benefit level. When risks were low, the magnitude of change in fish consumption was related to level of benefit. Responses differed depending on the question wording order, that is, whether "risks" were posed before "benefits." For a given risk-benefit level, respondents would give different advice to women of childbearing age versus children, with more conservative advice (eat less fish) provided to women of childbearing age. Respondents appeared to be influenced more strongly by risk-risk comparisons (e.g., risks from other foods vs. risks from fish) than by risk-benefit comparisons (e.g., risks from fish vs. benefits from fish). Risk analysts and risk communicators should improve efforts to include risk-risk and risk-benefit comparisons in communication efforts, and to clarify to whom the health risks and benefits from fish consumption may accrue.     

A Comparison of Egg Consumption with Other Modifiable Coronary Heart Disease Lifestyle Risk Factors: A Relative Risk Apportionment Study

Guidelines from the American Heart Association (AHA) recommend that healthy adults limit their intake of dietary cholesterol to less than 300 mg per day. Since a large egg contains about 71% of that amount, the AHA recommends restricting egg consumption unless dietary cholesterol intakes from other sources are limited. We applied a risk apportionment approach to estimate the contribution of egg consumption and other modifiable lifestyle risk factors (e.g., smoking, poor diet, minimal exercise, and alcohol intake) to coronary heart disease (CHD) risk at the population level. Specifically, we categorized the U.S. adult population ages 25+ into distinct risk groups based on the prevalence of modifiable lifestyle risk factors and applied an apportionment model, typically used to assess risk contribution at the individual level, to estimate the contribution of egg intake to CHD risk. Our analysis shows that the combination of modifiable lifestyle risk factors accounts for less than 40% of the population CHD mortality. For the majority of U.S. adults age 25+, consuming one egg a day accounts for <1% of CHD risk. Hence, focusing on decreasing egg intake as an approach to modify CHD risk would be expected to yield minimal results relative to changing other behaviors such as smoking and other dietary habits.     

A Method for Comparing the Impact on Carcinogenicity of Tobacco Products: A Case Study on Heated Tobacco Versus Cigarettes

Comparing the harmful health effects related to two different tobacco products by applying common risk assessment methods to each individual compound is problematic. We developed a method that circumvents some of these problems by focusing on the change in cumulative exposure (CCE) of the compounds emitted by the two products considered. The method consists of six steps. The first three steps encompass dose-response analysis of cancer data, resulting in relative potency factors with confidence intervals. The fourth step evaluates emission data, resulting in confidence intervals for the expected emission of each compound. The fifth step calculates the change in CCE, probabilistically, resulting in an uncertainty range for the CCE. The sixth step estimates the associated health impact by combining the CCE with relevant dose-response information. As an illustrative case study, we applied the method to eight carcinogens occurring both in the emissions of heated tobacco products (HTPs), a novel class of tobacco products, and tobacco smoke. The CCE was estimated to be 10- to 25-fold lower when using HTPs instead of cigarettes. Such a change indicates a substantially smaller reduction in expected life span, based on available dose-response information in smokers. However, this is a preliminary conclusion, as only eight carcinogens were considered so far. Furthermore, an unfavorable health impact related to HTPs remains as compared to complete abstinence. Our method results in useful information that may help policy makers in better understanding the potential health impact of new tobacco and related products. A similar approach can be used to compare the carcinogenicity of other mixtures.     

Foodborne Exposure to Pesticides and Methylmercury in the United Arab Emirates

As part of a comprehensive environmental health strategic planning project initiated by the government of Abu Dhabi, we assessed potential dietary exposure in the United Arab Emirates (UAE) to methylmercury (in seafood) and pesticides (in fruits and vegetables) above international guideline levels. We present results for the UAE population by age, gender, and body mass index. Our results show very low daily risks of exposure to pesticides in fruits and vegetables at levels exceeding WHO guidelines even under the conservative assumption that no pesticides are removed during washing and food preparation. Thus, exposure to pesticides on fruits and vegetables does not appear to be a major public health concern in the UAE. The chances of exposure to methylmercury in seafood are much higher; our model estimates a mean 1 in 5 daily risk of exceeding the FAO/WHO provisional tolerable weekly intake. However, great caution should be used in interpreting these results, as we analyzed only the risks and not the substantial benefits of fish consumption. In fact, previous studies have demonstrated that exposure to the n‐3 polyunsaturated fatty acids in fish can increase IQ in developing children, and it can substantially decrease the risk in adults of coronary heart disease and stroke. Further research is warranted to compare the risk of Me‐Hg exposure from fish to the nutritional benefits of fish consumption in the UAE and to determine appropriate methods to communicate risk and benefit information to the UAE population.     

Evaluating Risk Communication: Examining Target Audience Perceptions About Four Presentation Formats for Fish Consumption Health Advisory Information

Information format can influence the extent to which target audiences understand and respond to risk-related information. This study examined four elements of risk information presentation format. Using printed materials, we examined target audience perceptions about: (a) reading level; (b) use of diagrams vs. text; (c) commanding versus cajoling tone; and (d) use of qualitative vs. quantitative information presented in a risk ladder. We used the risk communication topic of human health concerns related to eating noncommercial Great Lakes fish affected by chemical contaminants. Results from the comparisons of specific communication formats indicated that multiple formats are required to meet the needs of a significant percent of anglers for three of the four format types examined. Advisory text should be reviewed to ensure the reading level is geared to abilities of the target audience. For many audiences, a combination of qualitative and quantitative information, and a combination of diagrams and text may be most effective. For most audiences, a cajoling rather than commanding tone better provides them with the information they need to make a decision about fish consumption. Segmenting audiences regarding information needs and communication formats may help clarify which approaches to take with each audience.     

What to Do at Low Doses: A Bounding Approach for Economic Analysis

To quantify the health benefits of environmental policies, economists generally require estimates of the reduced probability of illness or death. For policies that reduce exposure to carcinogenic substances, these estimates traditionally have been obtained through the linear extrapolation of experimental dose-response data to low-exposure scenarios as described in the U.S. Environmental Protection Agency's Guidelines for Carcinogen Risk Assessment (1986). In response to evolving scientific knowledge, EPA proposed revisions to the guidelines in 1996. Under the proposed revisions, dose-response relationships would not be estimated for carcinogens thought to exhibit nonlinear modes of action. Such a change in cancer-risk assessment methods and outputs will likely have serious consequences for how benefit-cost analyses of policies aimed at reducing cancer risks are conducted. Any tendency for reduced quantification of effects in environmental risk assessments, such as those contemplated in the revisions to EPA's cancer-risk assessment guidelines, impedes the ability of economic analysts to respond to increasing calls for benefit-cost analysis. This article examines the implications for benefit-cost analysis of carcinogenic exposures of the proposed changes to the 1986 Guidelines and proposes an approach for bounding dose-response relationships when no biologically based models are available. In spite of the more limited quantitative information provided in a carcinogen risk assessment under the proposed revisions to the guidelines, we argue that reasonable bounds on dose-response relationships can be estimated for low-level exposures to nonlinear carcinogens. This approach yields estimates of reduced illness for use in a benefit-cost analysis while incorporating evidence of nonlinearities in the dose-response relationship. As an illustration, the bounding approach is applied to the case of chloroform exposure.     

An Exposure Assessment of Methyl Mercury via Fish Consumption for the Japanese Population

The objective of this article was to propose an exposure assessment model to describe the relationship between fish consumption and body methyl mercury (MeHg) levels in the Japanese population. Individual MeHg intake was estimated by the summation of species-specific fish consumption multiplied by species-specific fish MeHg levels. The distribution of fish consumed by individuals and the MeHg level in each fish species were assigned based on published data from Japanese government institutions. The probability of MeHg intake for a population was accomplished through a Monte Carlo simulation by the random sampling of fish consumption and species-specific MeHg levels. Internal body MeHg levels in blood and hair were estimated using a one-compartment model. Overall, the mean value of MeHg intake for the Japanese population was estimated to be 6.76 μg/day or 0.14 μg/kg body weight per day (bw/day), while the mean value for the hair mercury level was 2.02 μg/g. Compared with the survey data that tabulated hair mercury levels in a cross-section of the Japanese population, the simulation results matched the hair mercury survey data very well for women, but somewhat underestimated for men and all of the population. This exposure assessment model is a useful attempt at further risk assessment with respect to a risk-benefit analysis.     

Quantitative Risk Assessment Relating to Adventitious Presence of Allergens in Food: A Probabilistic Model Applied to Peanut in Chocolate

Peanut allergy is a public health concern, owing to the high prevalence in France and the severity of the reactions. Despite peanut-containing product avoidance diets, a risk may exist due to the adventitious presence of peanut allergens in a wide range of food products. Peanut is not mentioned in their ingredients list, but precautionary labeling is often present. A method of quantifying the risk of allergic reactions following the consumption of such products is developed, taking the example of peanut in chocolate tablets. The occurrence of adventitious peanut proteins in chocolate and the dose-response relationship are estimated with a Bayesian approach using available published data. The consumption pattern is described by the French individual consumption survey INCA2. Risk simulations are performed using second-order Monte Carlo simulations, which separately propagates variability and uncertainty of the model input variables. Peanut allergens occur in approximately 36% of the chocolates, leading to a mean exposure level of 0.2 mg of peanut proteins per eating occasion. The estimated risk of reaction averages 0.57% per eating occasion for peanut-allergic adults. The 95% values of the risk stand between 0 and 3.61%, which illustrates the risk variability. The uncertainty, represented by the 95% credible intervals, is concentrated around these risk estimates. Children have similar results. The conclusion is that adventitious peanut allergens induce a risk of reaction for a part of the French peanut-allergic population. The method developed can be generalized to assess the risk due to the consumption of every foodstuff potentially contaminated by allergens.     

Consumption of Fish and Shrimp from Southeast Louisiana Poses No Unacceptable Lifetime Cancer Risks Attributable to High‐Priority Polycyclic Aromatic Hydrocarbons

Following oil spills such as the Deepwater Horizon accident (DWH), contamination of seafood resources and possible increased health risks attributable to consumption of seafood in spill areas are major concerns. In this study, locally harvested finfish and shrimp were collected from research participants in southeast Louisiana and analyzed for polycyclic aromatic hydrocarbons (PAHs). PAHs are some of the most important chemicals of concern regarding oil‐spill‐contaminated seafood resources during and following oil spills. Some PAHs are considered carcinogens for risk assessment purposes, and currently, seven of these can be combined in lifetime cancer risk assessments using EPA approaches. Most PAHs were not detected in these samples (minimum detection limits ranged from 1.2 to 2.1 PPB) and of those that were detected, they were generally below 10 PPB. The pattern of detected PAHs suggested that the source of these chemicals in these seafood samples was not a result of direct contact with crude oil. Lifetime cancer risks were assessed using conservative assumptions and models in a probabilistic framework for the seven carcinogenic PAHs. Lifetime health risks modeled using this framework did not exceed a 1/10,000 cancer risk threshold. Conservative, health‐protective deterministic estimates of the levels of concern for PAH chemical concentration and seafood intake rates were above the concentrations and intake rates modeled under this probabilistic framework. Taken together, consumption of finfish and shrimp harvested from southeast Louisiana following the DWH does not pose unacceptable lifetime cancer risks from these seven carcinogenic PAHs even for the heaviest possible consumers.     

Communicating Contaminant Risks from Sport-Caught Fish: The Importance of Target Audience Assessment

A fish consumption health advisory has existed for New York Lake Ontario sport-caught fish since 1978. Our study objectives were to evaluate the effectiveness of the advisory for reaching potential target audiences and to identify appropriate advisory content, style, and dissemination methods using a risk communication planning model as an evaluation framework. We used a combination of mail surveys and personal interviews with three target audiences (opinion leaders among recreational anglers and charter boat operators, migrant farm workers, and low-income individuals) and two communicator groups (fishery experts and health care experts). The New York Lake Ontario advisory appeared to be successful in reaching and encouraging risk-mitigating fish consumption behavior in recreational angler opinion leaders and low-income individuals but not in migrant farm workers. The advisory may not be reaching two sensitive subpopulations, women of childbearing age and children. Communicators and target audiences differed in their assessments of important information to include in an advisory. The health advisory could be improved with additional information such as risk-reducing cooking and cleaning methods and by diversifying the dissemination methods to reach the variety of audiences who potentially consume Lake Ontario fish.     

A Quantitative Microbial Risk Assessment Model for Legionnaires'' Disease: Animal Model Selection and Dose-Response Modeling

Legionnaires' disease (LD), first reported in 1976, is an atypical pneumonia caused by bacteria of the genus Legionella, and most frequently by L. pneumophila (Lp). Subsequent research on exposure to the organism employed various animal models, and with quantitative microbial risk assessment (QMRA) techniques, the animal model data may provide insights on human dose-response for LD. This article focuses on the rationale for selection of the guinea pig model, comparison of the dose-response model results, comparison of projected low-dose responses for guinea pigs, and risk estimates for humans. Based on both in vivo and in vitro comparisons, the guinea pig (Cavia porcellus) dose-response data were selected for modeling human risk. We completed dose-response modeling for the beta-Poisson (approximate and exact), exponential, probit, logistic, and Weibull models for Lp inhalation, mortality, and infection (end point elevated body temperature) in guinea pigs. For mechanistic reasons, including low-dose exposure probability, further work on human risk estimates for LD employed the exponential and beta-Poisson models. With an exposure of 10 colony-forming units (CFU) (retained dose), the QMRA model predicted a mild infection risk of 0.4 (as evaluated by seroprevalence) and a clinical severity LD case (e.g., hospitalization and supportive care) risk of 0.0009. The calculated rates based on estimated human exposures for outbreaks used for the QMRA model validation are within an order of magnitude of the reported LD rates. These validation results suggest the LD QMRA animal model selection, dose-response modeling, and extension to human risk projections were appropriate.     

Evaluating the consequences of abandoning unprofitable customers: A comparison of direct and indirect abandonment strategies

Due to the increasing use of customer databases in many industries, companies nowadays have high visibility about the profitability of individual-level client relationships. This has led some researchers to recommend the implementation of value-based customer management strategies, including the abandonment of unprofitable customer relationships. In this context firms are faced with the choice between direct and indirect abandonment approaches. While direct abandonment strategies tend to be more efficient than indirect ones (i.e., immediate termination of the relationship vs. hoping that the unprofitable customer may leave on her own) they are also claimed to be associated with more severe negative reactions and higher abandonment cost. Based on two surveys among 965 US customers we provide evidence that, despite these beliefs, direct and indirect abandonment strategies do not differ in their negative impact on the abandoning firm. Given that (indirect) abandonment costs are therefore likely to be similar for both approaches, direct abandonment appears to be the recommendable approach for relationship dissolution.     

Information and Risk Perception: A Dynamic Adjustment Process

It is common in catastrophic food-contamination events that consumers fail to adjust instantaneously to a normal consumption level. One explanation is that consumers only gradually accept new positive information as being trustworthy. The gradual establishment of the trustworthiness of the released information depends on both positive and negative media coverage over time. We examine the individual "trust" effects by extending the prospective reference theory (Viscusi, 1989) to include a dynamic adjustment process of risk perception. Conditions that allow aggregation of changes in risk perceptions across individuals are described. The proposed model describes a general updating process of risk perceptions to media coverage and can be applied to explain the temporal impact of media coverage on consumption of a broad range of goods (food or nonfood). A case study of milk contamination is conducted to demonstrate consumer demand adjustment process to a temporarily unfavorable shock. The results suggest that effects of positive and negative information to adjustment of consumption and risk perception are asymmetric over time.     

An integrated environmental risk assessment framework for coal-fired power plants: A fuzzy logic approach

This study quantifies the environmental risk of a coal-fired thermal power plant during operation by using environmental monitoring data, site surveys, and documented evidence. The following criteria are assessed: emissions (CO, SO₂, NO_x, PM₁₀), impact on aquatic ecosystem (fish protection at cooling water intake and cooling water discharge temperature), and waste management (fly ash and bottom ash). Fuzzy sets were defined for each criterion, taking environmental regulatory context as an expert judgment. A survey was conducted with multiple stakeholders to determine the relative importance of risk factors. The survey results showed that the most concerned risks are SO₂ and NO_x emissions. The proposed method estimates the risk of each environmental criterion separately and then accumulates them into an environmental risk index (ERI). Accordingly, we assessed the Catalagzi coal-fired power plant, which has been in operation on the Black Sea coast in northwestern Turkey. For this case study, the ERI resulted in a value of 0.78 (on a scale of 0–1), showing high environmental risk to the facility. Moreover, the applicability of the proposed framework was tested in several existing coal-fired power plants using simultaneous measurements. All studied coal-fired power plants in Turkey have unacceptable pollutants (PM₁₀, SO₂, and NO_x) concentration levels indicating high health risk potential. The application of the integrated environmental risk assessment framework showed that new environmental regulations are needed in Turkey to specify more strict emission limits and to monitor CO₂, fine particulate matter emissions, cooling water discharge, and fish protection at cooling water intake.