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These 10 cities had the highest level of year-round pollution and some of the highest incidences of heart and lung issues as well, according to the American Lung Association's annual report.
With three major interstate routes meeting in the metro area, much of Cincinnati's air pollution comes from vehicle exhaust.
Megan Hummel, spokeswoman for the Southern Ohio Air Quality Agency, said the agency is spearheading a campaign to reduce engine idling in the city. The program uses posters and pubic service announcements aimed at parents waiting to pick up schoolkids, reminding them to turn off engines within 30 seconds after stopping. It also managed a program to retrofit 519 school buses to burn fuel cleaner and took 63 older, dirtier buses out of service entirely.
Their efforts are paying off: The city has made steady progress reducing its smog and ozone levels, said Hummel.
"We routinely exceeded ozone standards in the 1990s and early 2000s and now we rarely do," she said.