Is Knoxville Really the Worst City for Allergies?

While I’ve never put much store in them, Knoxville has generally fared pretty well in national rankings of cities for this, that, and the other.

Thus, I was dismayed to hear on the NBC Nightly News that the Knoxville area has just been rated the worst in the nation for allergies. And upon identifying the Asthma and Allergy Foundation of America as the source of this irritating smirch, I discovered on its website that this area has also been ranked second worst (after Richmond, Va.) for asthma.

Since the runny noses, itchy eyes, and sneezing that are systematic of allergies—let alone the breathing difficulties associated with asthma—aren’t conducive to a good quality of life, what’s the basis for these detractions from Knoxville’s reputation as a good place to live?

When it comes to allergies, the AAFA bases its rankings on these factors: pollen counts, use of prescription allergy medications per capita, and the number of board-certified allergy specialists per capita. These are then somehow weighted and blended into a composite score for each of the nation’s 366 metropolitan statistical areas.

The pollen counts purport to measure the concentration of the most allergenic pollen types in the air during the peak season for tree pollens in the spring, and grass/weed pollens in the summer. These measurements are conducted by the firm SDI Health using a sampling device called a Rotorod and support an Allergy Alert on SDI’s website,, that ranks the concentrations daily in each area in five gradations from low to high. The sampling device is typically placed on top of a building and collects particles on a sticky surface, which is then put under a microscope and the concentrations expressed in terms of grains per cubic meter over a 24-hour period.

All of the above is drawn form the website, as is the fact that one rooftop measure station per metropolitan area is deemed sufficient because “since pollen travels long distances through the air, the count is relevant to a large area.” But attempts to get information from SDI about where the Knoxville station is located, who operates it, or anything else about it, were unavailing.

The AAFA’s vice president of external affairs, Mike Tringale, tries hard to be helpful but can’t offer much of an explanation why Knoxville’s counts are high, beyond “the possibility that there’s a greater concentration of deciduous plants.” But it turns out that the Knoxville area isn’t the worst offender when it comes to pollen counts, and Tringle also relates that the area has a better than average number of board-certified allergists. This is considered a positive in the rankings because, “if there aren’t enough specialists in a given community to manage this chronic disease, then it isn’t as well prepared to deal with it,” he says.

So one has to infer (though Tringale won’t acknowledge it) that Knoxville ranks worst because allergy medication prescriptions run highest here. The trouble with this measure is that it fails to take into account sales of over-the-counter medications such as Allegra, Claritin, and Zyrtec, which have gained a big share of the market. Indeed, the AAFA’s website notes that prescription sales have been declining, but pharmacy sales are the only ones it has a way of measuring from pharmacy tracking data compiled by IMS Health.

It’s also plausible that prescriptions are more prevalent in Knoxville because of the way in which the city’s uniquely prominent allergist, Dr. Bob [Overholt], has championed their preferability. Both on his popular TV show and on his website, Dr. Bob advises that “OTC antihistamines will not give you the relief you need.... You need a topical internasal antihistamine and a topical nasal steroid. This combination will give you 100 times more relief than OTC antihistamines.”

There’s even less to like about the basis on which AAFA ranks Knoxville second on its list of “The Most Challenging Places to Live With Asthma.” Among the five risk factors shown as worsening this disease (for which an estimated 20 million Americans are genetically predisposed), Knoxville is classified as “worse than average” in only two: air quality and public smoke-free laws.

Yet the AAFA’s asthma slam came only weeks after the federal Environmental Protection Agency formally found the Knoxville area to have gained compliance with its ozone emission standards and lifted the area’s “non-attainment” status. And I don’t know where the AAFA has been since Tennessee’s strict ban on smoking in the workplace, restaurants, and other public gathering places took effect in 2007. Pollen counts are listed as another risk factor, yet the Knoxville area is classified as “average” in the AAFA’s asthma scorecard even though its contributors are much the same as those that beget a “worse than average” ranking for allergies.

Since I blessedly don’t suffer from either allergies or asthma, I can’t fully appreciate the distress of those who do. No doubt, many of them will say it’s plenty bad here, but I doubt it’s any worse than many other places.

Corrected: The spelling of Mr. Tringale's last name.

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Comments » 2

Tringm writes:

Joe – It was a pleasure working with you on this article, and thank you for educating your readers about asthma and allergies, two of the most common chronic diseases in the U.S, and in Tennessee. You have several insights that will help us to continue to analyze our research approach – now in its 10th consecutive publishing – for future years.

As way of additional insights for your readers, recall that our Spring Allergy Capitals™ rankings does not look at raw “pollen counts,” but rather at the “pollen scores,” which, as we discussed, take into account the complicated specifics of different pollen species, their airborne concentrations and the metro area allergy prevalence to those specific types of pollen. Raw pollen counts are not too meaningful if you’re not allergic to the pollen type present in the air at that time. This is why the Knoxville pollen ranking was so high – a larger percent of your population was allergic to the specific pollens measured for that time period.

And, regarding tobacco laws in Tennessee, we only give credit in our Asthma Capitals™ report to “100% smoking bans” and the Tennessee ban is only “partial” allowing for many exceptions and loopholes that still allow smoking in several places, still exposing thousands of people with asthma to secondhand smoke. Other states and localities have shown great leadership with 100% bans, and we’d like to see Tennessee do the same.

Finally, note that the final total scores for all cities was extremely you are correct -- it's a close call between all cities, indeed. There is really no place safe from asthma or allergies so we hope people talk to their doctors about how to manage their disease best.

Keep up the great work informing your readers and thank you for helping us educate patients. Best regards – Mike Tringale, VP, AAFA –

CurlyKarma writes:

I am from Shelby County, and I lived in Knoxville while attending UTK. I have allergies/hayfever, and sinusitis. My symptoms, while in Knox County, were less intense and more bearable, in comparison to Shelby County. When I moved back to Shelby County it was getting so bad that I started allergy shots. They helped, especially with the amount of sinus infections and chronic post nasal drip, over time, but I still have to take an antihistimine the majority of the year. Otherwise from February thru part of June, and from part of September thru November or December, I will be miserable because I can't breath out of my nose, my nose and eyes are raw from constantly running and I 'd sneeze constantly. It was never that bad in Knoxville.

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