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Artificial turf: The contributions and limits of toxicology in decision-making

Publication: Environmental Health Review
20 December 2019
Artificial turf continues to generate media and public health attention as a potential source of lead and other contaminants harmful to children’s health. This is despite human health risk assessments (HHRAs) showing that exposure to crumb rubber does not result in risk estimates that exceed acceptable thresholds in North America or Europe.
However, there is a troubling disconnect between the way the public conceptualizes risk from artificial turf and the tools and methods that the scientific world deploys to address it. This paper will examine the risk aspects of artificial turf that make it particularly tenacious in occupying public attention and provide a brief update of the most recent artificial turf research. We will also discuss the expected contributions, and potential shortcomings, of the large inter-agency efforts to better characterize and quantify human health risks due to artificial turf exposure. Furthermore, we will also discuss risk communication and management approaches to address health concerns as well as the need to move the artificial turf debate into a larger arena to understand its full impacts on community well-being.

Why does artificial turf elicit such alarm?

Psychology research has shown that there are a number of characteristics that heighten perceived risk around a given issue (Ropeik, 2002), and artificial turf ticks many of these boxes. For example, the material is not “natural,” but rather industrial in origin; the fact that it is a waste product may further influence public perception. Artificial turfs have also, in many cases, been imposed upon the public, in that turfs were installed without public input (which perhaps seemed unnecessary at the time). Crumb rubber also elicits alarm because it affects the personal sphere. Granules from the soccer field become entrained in clothing and equipment, and are subsequently found in vehicles, homes, and even on the body itself when showering or bathing. Furthermore, children currently make up a large percentage of artificial turf users, which powerfully amplifies risk perception on any issue. These concerns are also being raised at a time when trust in public health and government is being tested and questioned, as evidenced by the anti-vaccination debate. These factors, combined with laboratory analyses revealing the presence of toxic constituents within the crumb, combine to make artificial turf an item of intense public interest.

What kind of research is out there and how can we understand it?

There is a substantial body of scientific literature on artificial turf, but it suffers from two key issues. First, the body of work is almost solely focused on developing or supporting the development of HHRAs, rather than studies that analyze health effects in actual people. There is a reason for this: HHRAs are (relatively) quick and inexpensive, making them a reasonable first step when decision-makers need insight as to whether a public health concern exists. It would not make sense to invest research funds in much more costly human health studies when HHRAs indicate that no such concern is warranted. However, HHRAs may also be inherently less satisfying to information users1, as they are a theoretical exercise with some degree of unavoidable uncertainty. Professional judgment must be applied to deal with that uncertainty, which again requires the public to trust both in the experts and in a process that is less than intuitive.
The second issue with the artificial turf literature is the ease with which it is misinterpreted. As mentioned, most of the literature is aimed at identifying hazardous chemicals, quantifying how much is released, and assessing whether those chemicals are likely to affect the people present on the field (players, spectators, and workers). However, when information users access this literature, there are many ways in which it may be misconstrued. First, all humans are vulnerable to cognitive biases,2 which may lead them to selectively take up information that is more easily understood, compared to that which is more complex, or that which confirms their previous beliefs (i.e., confirmation bias). In addition, information users often do not understand the difference between hazard (presence of a toxicant) and risk (probability of coming into contact and having adverse effects). Because of this, studies that find toxicants inside crumb rubber, without any evidence of it being released, contacting humans, or being bioavailable, may be given greater importance than a fully elaborated, well-justified HRRA that finds no excess risk. Finally, toxicant levels are often presented without context; this can be avoided by comparing the result to health-based guidelines or (better yet) to typical background levels (e.g., amount of VOCs escaping from artificial turf versus VOCs from sports equipment or in urban air) (Simcox et al., 2011).
As an example of this, a recent study identified 92 compounds (nine of them carcinogens) from rubber mulch that had been ground to a fine powder and extracted with strong acid (Benoit and Demars, 2018). This publication provided useful information with respect to chemical composition (hazard identification), but absolutely no new information regarding how or whether humans could reasonably be expected to come into contact, absorb, or be impacted by those chemicals (health risk). However, the key message (i.e., rubber crumb contains carcinogens) was picked up by no fewer than 57 news outlets and the article received a whopping Altmetric Attention score3 of 457. This contrasts with much more complex and informative HHRAs (Ginsberg et al., 2011; Menichini et al., 2011; Pavilonis et al., 2014; Peterson et al., 2018) that received scores in the range of 12 to 51.
Because of this tendency to favor simple messages and disregard exposure, the NCCEH produced a guidance document in 2016 entitled Using a Hierarchy of Evidence to Assess Chemical Health Risks of Artificial Turf (Eykelbosh and Fong, 2016). The aim of this document was to explain the differences amongst the various types of artificial turf studies, how the results might be (mis)interpreted, and how the studies feed into an HHRA. The end goal of the paper was to help decision-makers distinguish between hazard and risk, and to understand the differences between HHRAs and epidemiological studies looking at real human populations. The NCCEH guidance document, and the many other resources on our Artificial Turf Topic Page, are recommended for anyone about to dive into artificial turf research.

Recent artificial turf research

Since 2016, there have been several new HHRAs, as well as two epidemiological studies, that are highly informative to decision-makers. For reference, cancer risk is deemed negligible (“de minimis”) when the excess lifetime cancer risk is at or below 1 × 10−6 (1 additional case of cancer per 1,000,000 exposed persons). Risk reduction is generally recommended when estimates exceed the maximum acceptable risk of 1 × 10−4 (1 additional case per 10,000 exposed persons). For noncancer hazards, the level of concern is assumed to be negligible when the ratio of the estimated exposure dose to the reference dose is <1 for a single chemical (a hazard quotient), or when these ratios are summed together for multiple chemicals (a hazard index). A hazard quotient or index >1 indicates that adverse effects are possible, but it is not a measure of the probability of adverse effects.
The Dutch National Institute for Public Health and the Environment (RIVM) published a thorough HHRA in 2017 that calculated cancer risks and noncancer hazards for crumb rubber (Rijksinstituut voor Volksgezondheid en Milieu 2017). The chemicals included polycyclic aromatic hydrocarbons (PAHs), bisphenol A (BPA), heavy metals (Co, Cd, and Pb), phthalates, and 2 mercaptobenzothiazole (2-MBT). Exposure scenarios included a young child player, a youth player, an adult player, and youth and lifelong goalkeepers. Worst-case oral, dermal, and inhalation exposures were estimated based on assumptions from the literature as well as new analyses (chemical composition and release into artificial gastric fluid and sweat) using samples collected from Dutch soccer pitches. Overall, the study determined that artificial turf does not pose a health risk. Although the cumulative excess lifetime cancer risk for the extreme worst-case scenario, a lifelong goalkeeper,4 did nudge above the threshold for negligible risk (1 × 10−6), it was still very distant from the action threshold of 1 × 10−4.
Similarly, the European Chemicals Agency (ECHA) calculated cancer risks and noncancer hazards for PAHs, heavy metals, phthalates, methyl isobutyl ketone, benzothiazole, formaldehyde, and benzene (European Chemicals Agency, 2017). Their six exposure scenarios included young players (3–6, 6–11, and 11–18 years), young goalkeepers (6–11 years), adult professional players, and adult professional goalkeepers exposed via ingestion, dermal absorption, and inhalation. They also examined workers installing and maintaining artificial turfs. Overall, ECHA determined that there is a negligible level of concern from exposure to crumb rubber, as neither the cancer nor noncancer estimates approached the risk thresholds.
Finally, Peterson et al. (2018) calculated risk estimates for 33 chemicals, including PAHs, heavy metals, VOCs, and semi-VOCs. They used four exposure scenarios, including child and adult players and spectators. Importantly, they also calculated risk estimates for natural soil turf fields to contextualize the artificial turf results. The results showed that neither cancer nor noncancer thresholds were exceeded for any of the exposure scenarios, except that of the child spectator. This child, who was assumed to consume 0.1 g of crumb rubber per day for 4 days per week over most of the year, showed a hazard index of 1 for noncancer causing chemicals. However, the same child also showed slightly more than negligible cancer risk for natural soil, highlighting the importance of contextualizing risk estimates to other normal, daily exposures.
Regarding cancer risk, there have been several new developments since soccer coach Amy Griffin (Washington State University) published her list of athletes with cancer (Foudy, 2015), some of whom were goalkeepers. In response to the coach’s concern, the Washington State Department of Health investigated the cancer cases presented on the list, but did not find sufficient evidence to warrant a larger-scale investigation (Washington State Department of Health, 2017). The study in fact found fewer cases of cancer among the players on the list than would actually be expected based on cancer rates in the state of Washington. This illustrates the danger of another cognitive bias, the base rate fallacy, in which people tend to focus on specific events (cancer cases in people you know) and ignore or fail to determine whether this differs from the general population.
The importance of base rates was further elaborated upon in a commentary published by a pediatric cancer expert, Dr. Archie Bleyer, who emphasized that cancers in children tend to be the results of spontaneous mutation (rather than environmental causes). He also provides data demonstrating that the types of cancer observed among the athletes on Coach Griffin’s list are those expected in young people (Bleyer, 2017). An ecologic epidemicological study by the same author looking at the incidence of malignant lymphoma in relation to the density of synthetic turfs in 54 California counties found no relationship between individual exposures and cancer incidence (Bleyer and Keegan, 2018). Although more cases of lymphoma were observed in counties with more artificial turfs, the incidence of lymphoma had not increased over the 13-year study period (whereas the number of artificial turfs had). This may be because the incidence of lymphoma is related to socioeconomic status, and more affluent counties can afford to install more artificial turfs (Bleyer and Keegan, 2018).
Although it is possible that future studies will detect a relationship between artificial turf exposure and cancer incidence, current epidemiological and risk assessment data indicate that artificial turf does not present a cancer risk to child or adult players. However, Coach Griffin’s narrative has been propagated widely by the international news media. Given the cognitive biases that affect how one responds to new but unwelcome information (e.g., conservatism and “doubling down”), dispelling cancer concerns with new research may be very challenging.

Do we know enough about artificial turf? What new research is in the pipes?

In 2016, a number of American agencies launched the Federal Research Action Plan (FRAP) on Recycled Tire Crumb Rubber Used on Synthetic Turf Playing Fields and Playgrounds (U.S. Environmental Protection Agency 2016b). This initiative has produced a literature review and gaps analysis (U.S. Environmental Protection Agency 2016a), as well as the most comprehensive characterization of crumb rubber to date (U.S. Environmental Protection Agency et al. 2019). In an upcoming report, the FRAP will collect data from on-site exposure assessments that will be used to better describe oral, dermal, and inhalation routes and will also conduct a biomonitoring study. In addition to the FRAP, the California Office of Environmental Health Hazard Assessment (OEHHA) has begun work that aims to similarly improve our knowledge of crumb rubber composition, understand what is released and under what conditions, and to generally improve exposure scenarios through accounting for behaviour and specific activities on the field (OEHHA, 2016). They also intend to develop a new protocol for biomonitoring, in itself a complicated endeavour, as we are currently lacking appropriate, validated biomarkers for artificial turf exposure. This work is also due out soon.
It is important to note, however, that neither the EPA nor the OEHHA studies will generate new or improved risk estimates. These studies are only laying the groundwork for future risk assessments, which will take some time to develop and publish. Thus, a relatively long road lies ahead for decision makers and members of the public waiting for updated risk estimates on this high-interest subject.

Will the new data “settle” the artificial turf debate once and for all?

When the FRAP and OEHHA studies are released, we will have greatly increased our understanding of the toxic constituents of artificial turf, how much of those constituents are released into the environment (and under what conditions), and to what extent various types of receptors are exposed (adults vs. child players and bystanders). For the purposes of risk assessment, we will have greatly decreased the uncertainty around certain values needed to generate quantitative estimates of health risk.
What will this mean for risk estimates? For the chemicals and receptors already identified in previous HHRAs, we will most likely see a decrease in estimated risk, as the new and improved data will reduce the need for uncertainty or safety factors that made previous estimates deliberately conservative/protective. On the other hand, the inclusion of many more chemicals of concern (101 compounds were characterized in the EPA’s recent report (U.S. Environmental Protection Agency and Centers for Disease Control and Prevention/Agency for Toxic Substances and Disease Registry 2019)) may increase overall risk estimate due to the summing of many small and previously excluded values. In addition, the inclusion of new but very poorly understood chemicals may necessitate the use of large uncertainty factors, which would again artificially inflate risk estimates. And when these things happen in the same HHRA, they may partially negate each other’s effects. In short, additional research investment by the EPA and the OEHHA may or may not result in dramatic change in risk estimates.

What effect, then, will this new information have on public debate and risk perception around artificial turf?

Toxicological risk assessment provides a numeric estimate of specified health risks, but this information is only one factor amongst the many required to assess the pros and cons of artificial turf as a part of public infrastructure. For example, if we want to understand the impacts of artificial turf on health, we must consider impacts on players’ musculoskeletal injuries, head injuries, thermal stress, and infections—all of which are active areas of research. We must also factor in the risks and benefits of allowing more people to engage in physical activity, both per day and throughout the year compared with natural turf.
This is by far the largest “gap” in artificial turf research: the amount of healthy physical activity that can be supported on various types of outdoor sports fields (bare earth, turf, artificial turf, asphalt, etc.), and what impact this activity has on public health. Childhood obesity in Canada remains a pressing public health concern (Rodd and Sharma, 2016); having as many feet on the field as often as possible may be very significant to children’s health. Although we are lacking this information, early indicators are promising. Tester and Baker (2009) looked at the impact of renovating parks in two low-income San Francisco neighborhoods. They found that new landscaping, lighting, and converting bare earth soccer fields to artificial turfs resulted large increases in visitors to the soccer fields and increased levels of activity. Although artificial turf installation was only one aspect of the park “makeovers”, the results indicate a positive effect of artificial turf in a place where natural turf would be difficult to maintain. Additional studies comparing physical activity levels on different field types across seasons and climate zones, with assessment of health indicators, would be of great value in judging the utility of artificial turf as part of public infrastructure.
Of course, the artificial turf debate does not only concern health. Playing fields have wider impacts on communities, in terms of equitable access to play space, the costs of maintenance, water usage, contribution to the urban heat island effect, the ability to absorb water and retain run-off during flood season, the threat of fire, impacts on nutrient runoff, the risk of microplastic pollution, the energetic and greenhouse gas costs of installing or removing artificial turfs, and so on. Given all this, it’s easy to see that the choice of playing surface may not be clear cut for many communities.
One way to address the broader health impacts of artificial turf is through the process of health impact assessment (HIA). HIA is a systematic, six-step process that aims to maximize the benefits and minimize the risks of a given policy action to the population in question through the use of quantitative, qualitative and participatory approaches (St-Pierre, 2009). Through a participatory HIA process, members of the public (players, parents associations, sport leagues) can be guided through an evidence-based discussion on the tradeoffs between artificial turfs, natural turf, and other feasible alternatives. This is necessary for several reasons, not the least of which is to cut through misinformation. A participatory process is also essential to defining objectives for community spaces (what do we want out of recreational facilities?) and helping users to fully understand the tradeoffs (what are we willing to give up?) when choosing amongst the various options. Because HIA incorporates more than toxicological risk estimates, it becomes possible to broaden the discourse from “Is this substance toxic to my child” toward “How can we best help our children have happy, healthy childhoods?”
The NCCEH has collected a number of useful resources on our key HIA resources on our website’s Health Impact Assessments Topic Page. These resources include guidance documents, examples from multiple Canadian and international jurisdictions, as well as academic research on HIA methodology.

Risk communication and risk-management strategies

Although current HHRAs do not indicate that artificial turfs present chemical risks to children or adults, there are certainly actions that can be taken to protect children’s health more generally. The following recommendations are ranked in order of greatest importance:
Bring it to the people. Ultimately, the discussion on artificial turf needs to be broadened to examine toxicological concerns in context with other health and nonhealth-related factors. As argued here, whether an artificial turf is appropriate in public spaces will depend on the objectives and needs of the community.
Engage the community in relevant abatement activities. Minimizing toxic exposures in our chemical-laden world is hard work. We must make the best use of scarce resources—time, money, and public attention—to tackle the most egregious exposures first. Concern over artificial turf is an invaluable opportunity to redirect public attention and action toward abatement activities that address the needs of that particular community. For example, lead is a potent neurotoxin for which there is no safe level of exposure, and yet it is widely present in older homes and drinking water systems, in urban soil, toys, and other places accessed by children (Centers for Disease Control and Prevention, 2019). A recent investigative journalism project found that lead in drinking water may affect many Canadian communities (Kimmett et al. 2019). By actively promoting lead abatement—or whatever exposure is most detrimental in that community—public health may be able to harness the motive force generated by artificial turf to create real positive change.
Promote hand hygiene, all the time and everywhere. Reframing the artificial turf debate as one of hygiene in recreational facilities may be one way to promote overall health. As noted by Peterson et al. (2018), urban soils may be contaminated with heavy metals, PAHs, and other chemicals due to traffic-related emissions, de-icing salt, and industrial emissions, in addition to natural soil constituents like arsenic. Canadian cities are no exception (Thomas and Lavkulich, 2015; Wiseman et al., 2015). Outdoor play may also bring children into contact with biological hazards, such as fecal material from geese or other animals, as well as illnesses and infections that can be spread through contact during play. Accordingly, handwashing stations should be available at all outdoor recreational facilities (artificial or natural turf). Being able to wash granules, dust, or deposits off the skin after play or before eating would greatly reduce the likelihood of being exposed to chemicals or pathogens.
Reduce contact with playing surfaces. Activities that bring children in closer contact with the ground increase the risk of exposure to chemicals and pathogens. Furthermore, close contact with the surface (laying down for stretches and warm-ups, for example) increase the amount of crumb that is entrained in clothing. Using long-sleeved clothing, mats, or towels for warm-up/stretching, or installing poured-in-place rubber aggregate warm-up pads may help to reduce contact with crumb rubber and reduce migration of granules to the home.
Watch out for child spectators. One very useful finding of previous HHRAs is that child spectators, who may be playing on the ground and may ingest more material, have the highest risk estimates. In most cases, those risk estimates do not exceed cancer risk levels, but children who ingest more crumb rubber per kilogram of body mass have exceeded noncancer hazard levels (Rijksinstituut voor Volksgezondheid en Milieu 2017). Contaminated urban soils, again, were also potentially problematic (Peterson et al. 2018) In addition to promoting hygiene and supervision, another option would be to create permanent or temporary play spaces for small children alongside artificial and natural turfs, allowing child spectators to roll around and play without coming into direct contact with the actual turf.
Regulate the material. Based on its most recent HHRA, ECHA is recommending that European countries impose permissible limits on PAHs and other substances in crumb rubber, and that manufacturers and field operators should be testing and communicating the results to the public (ECHA 2017, 2018). This will serve to both limit exposure and promote meaningful conversations around PAH levels in crumb rubber compared to other consumer products.
Modify the material. Previous research has examined the effect of applying coatings to crumb rubber to reduce emissions (Gomes et al., 2010). There are also alternative materials that may function similarly to crumb rubber. However, both coatings and alternative products are not without risk themselves and would need to undergo a similar risk assessment process.

Summary

HHRAs and the few existing epidemiological studies indicate that crumb rubber from artificial turf does not present a health risk to adult or child players. Nevertheless, the public remains concerned over the use of this material, and cognitive biases in the way one receives new information may mean that new research—new HHRAs—may not be useful in resolving the debate. Biases aside, toxicological risks estimates are simply not a good jumping-off point for communities who need to make decisions about artificial turf. Instead, a participatory process like an HIA (or other method suitable to types of information considered) is needed to guide the development of objectives, cut through misinformation, and explicitly communicate and demand decisions on the inevitable tradeoffs. Only in this way will communities arrive at a decision that reflects their needs and promotes health for all.

Footnotes

1
Information users refers to decision-makers as well as the media and members of the public.
2
Cognitive biases refer to systematic errors in judgement that affect how we process information and make decisions.
3
The Altmetric Attention score is a nonscientific scoring system used to understand the impact of academic articles by examining use in the news media, mentions on social media (Facebook, Twitter, Sina Weibo, etc.), mentions in policy documents and blogs, and other indicators, including academic citations.
4
The lifelong goalkeeper played several times a week, always as goalkeeper and always on artificial turf, from the age of 4 to 50, and ingested a small mouthful of crumb rubber in every session.

References

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cover image Environmental Health Review
Environmental Health Review
Volume 62Number 4December 2019
Pages: 106 - 111

History

Version of record online: 20 December 2019

Authors

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Angela Eykelbosh [email protected]
National Collaborating Centre for Environmental Health, BC Centre for Disease Control, Vancouver, BC, Canada

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