Chest
Volume 155, Issue 2, February 2019, Pages 417-426
Journal home page for Chest

Special Features
Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies’ Environmental Committee, Part 2: Air Pollution and Organ Systems

https://doi.org/10.1016/j.chest.2018.10.041Get rights and content

Although air pollution is well known to be harmful to the lung and airways, it can also damage most other organ systems of the body. It is estimated that about 500,000 lung cancer deaths and 1.6 million COPD deaths can be attributed to air pollution, but air pollution may also account for 19% of all cardiovascular deaths and 21% of all stroke deaths. Air pollution has been linked to other malignancies, such as bladder cancer and childhood leukemia. Lung development in childhood is stymied with exposure to air pollutants, and poor lung development in children predicts lung impairment in adults. Air pollution is associated with reduced cognitive function and increased risk of dementia. Particulate matter in the air (particulate matter with an aerodynamic diameter < 2.5 μm) is associated with delayed psychomotor development and lower child intelligence. Studies link air pollution with diabetes mellitus prevalence, morbidity, and mortality. Pollution affects the immune system and is associated with allergic rhinitis, allergic sensitization, and autoimmunity. It is also associated with osteoporosis and bone fractures, conjunctivitis, dry eye disease, blepharitis, inflammatory bowel disease, increased intravascular coagulation, and decreased glomerular filtration rate. Atopic and urticarial skin disease, acne, and skin aging are linked to air pollution. Air pollution is controllable and, therefore, many of these adverse health effects can be prevented.

Introduction

This second of a two-part report describes specific conditions associated with air pollution. The conditions are listed alphabetically. In addition to the text, Figure 1 presents associated organ systems, and Table 1 shows other effects of air pollution that are generally not associated with specific organs. It is important to note that for many of the diseases, the associations with exposures to air pollution in observational epidemiologic studies are not causal and may be subject to residual confounding due to other factors, such as smoking, lower socioeconomic status, and neighborhood factors. However, exposure dose and time relationships and animal studies corroborate and add strength to the conclusions from the epidemiologic studies.

Section snippets

Allergic Sensitization and Rhinitis

It is well established that air pollution can exacerbate allergic responses in sensitized persons.1 Clinical epidemiologic studies show that ambient air pollution may also enhance allergic sensitization in children and increase IgE levels in the very young.2

There is considerable evidence that air pollution plays a role in both the development and the exacerbation of allergic rhinitis. A study of preschool-aged children found that exposure to traffic-related air pollution prenatally and in early

Bone Diseases

Environmental factors play a role in bone density and mineralization. To evaluate the effect of air pollution on bone structure and function, an analysis of > 9 million US Medicare enrollees found that osteoporosis-related bone fractures were statistically more common in areas of higher ambient PM2.5 concentrations. The effect was greater when only low-income communities were included in a sensitivity analysis.8

The same investigators studied 692 middle-aged men with low incomes from the Boston

Cancers

Outdoor air pollution has been classified as carcinogenic to humans by the International Agency for Research on Cancer based on evidence from epidemiologic and animal studies and mechanistic data.12 Many studies have shown an association between exposure to PM2.5 and particulate matter with an aerodynamic diameter < 10 μm (PM10) and risk of lung cancer.13 In addition, NO2 and ozone (O3) levels have been experimentally linked to cellular changes related to neoplasia: altered telomere length,

Cardiovascular Diseases

Particulate air pollution has been strongly associated with an increased risk of cardiovascular disease mortality, myocardial infarction, stroke, and hospital admission for congestive heart failure25 and has been estimated to account for 19% of all cardiovascular deaths, 23% of all ischemic heart disease deaths, and 21% of all stroke deaths.26 A 10 μg/m3 increase in PM2.5 in a 2-day period was associated with an approximately 2% increase in myocardial infarctions and hospital admissions for

Cognitive Function and Neurologic Diseases

Air pollution has deleterious effects on the CNS, including impairment of cognitive function and increased risk of dementia and stroke in older adults. A Canadian study of 4.4 million people showed that the risk of dementia was correlated in a “dose-dependent” manner with distance from a major roadway. People living within 50 meters had a hazard ratio of 1.07, whereas those living 50 to 100 meters away had a hazard ratio of 1.04, and those living 101 to 200 meters away had a hazard ratio of

Diabetes, Obesity, and Endocrine Diseases

Evidence from several studies links air pollution and type 2 diabetes mellitus.51 PM2.5 and NO2 exposures are associated with prevalence of diabetes and increased glycosylated hemoglobin levels among both diabetic and nondiabetic individuals.52 There is also a higher morbidity and mortality related to ambient air pollution among patients with diabetes.53 Several studies have described increased risk for metabolic syndrome in adults exposed to high ambient PM10.54 It seems that air pollution

Eye Diseases

Tearing and ocular irritation may occur as a reaction to visible haze, and this finding is often worse for contact lens wearers. Conjunctivitis is most associated with O3 and NO2 exposure, although PM10 and SO2 are also correlated.61 Cataract formation has been described in women exposed to household air pollution in low-income countries.62 O3 levels and decreased humidity have been associated with dry eye disease.63 Air pollution, specifically PM and CO, have been associated with acute

GI Diseases

Although less investigated, air pollution has been linked to several GI conditions, including inflammatory bowel disease, enteritis, gastric ulcer, and appendicitis. A case-control study of chronic pollution exposure in the United Kingdom found that younger individuals were more likely to have Crohn's disease if they lived in areas with high NO2 or SO2 levels, although there was no overall association between exposure to air pollutants and risk of inflammatory bowel disease.65 Other studies,

Hematologic Diseases

It has been known since the 1970s that air pollution containing lead from gasoline causes anemia. Other pollutants released during fuel combustion may also contribute to hematologic disease, either by directly entering the bloodsteam following inhalation, or by activating inflammatory pathways in the lung that then result in intravascular inflammation. PM2.5 promotes an imbalanced coagulative state through platelet and endothelial activation by inflammatory cytokines.70 These increase the risk

Liver Diseases

Living near a major roadway, which is associated with increased air pollution, is linked to an increased prevalence of hepatic steatosis.77 There are several potential reasons for this link as air pollution has many damaging effects on liver cells through inflammatory mediators, genotoxicity, mitochondrial damage, and damage to other organs, which affect the liver secondarily.78 The liver is the main detoxifying organ, and a variety of substances that enter the body, including toxic components

Renal Diseases

The kidney, a highly vascular organ, is vulnerable to both large and small vessel dysfunction and is therefore likely to be susceptible to the oxidative stress and systemic inflammatory effects of air pollution exposure. Animal models have shown that breathing diesel exhaust fumes exacerbates chronic renal failure by worsening renal oxidative stress, inflammation, and DNA damage.82 Living closer to a major highway has been found to be associated with a lower estimated glomerular filtration rate

Respiratory Diseases

The respiratory tract is the main organ affected by air pollution and the most studied: there are more than 13,000 entries in PubMed for air pollution and respiratory disease. Ambient air pollution is estimated to cause the death of > 800,000 persons from COPD and 280,000 persons from lung cancer.85 Indoor air pollution is estimated to cause the death of > 750,000 persons from COPD and 300,000 persons from lung cancer,86, 87 making the toll for both forms of air pollution 1.6 million deaths for

Skin Diseases

Several biologic parameters affecting skin quality are influenced by pollution, such as change in sebum excretion rate and composition, level of carbonylated proteins in the stratum corneum, and a higher erythematous index on the face of highly exposed subjects.102 The change in sebum may be a cause for increased acne occurring with air pollution.103

Several skin diseases have been associated with air pollution. A multicenter study found that air pollution was associated with a higher frequency

The Role of the Health-Care Provider

Assessing exposure by primary care providers may be difficult because the source of air pollution varies between communities and within household situations. Studies on indoor air pollution use extensive surveys to report on smoke exposure, burning conditions, and symptoms during cooking and household work. Research on outdoor air pollution relies on monitoring of the individual pollutants by sophisticated means, including personal monitors. For primary care health-care providers, simply asking

Summary and Resolve

Air pollution is one of the most important avoidable risks to health globally. Air pollution has been termed the “silent killer” by the World Health Organization113 because its effects often go unnoticed or are not easily measured. Even when there is organ harm, it is usually attributed to an unknown or chance malfunction of that organ. Although the lungs have been the most studied organ, air pollution affects most systems. Many studies have found harmful effects of air pollution on a continuum

Acknowledgments

Financial/nonfinancial disclosures: None declared.

Other contributions: Laura Feldman, MPH, contributed content regarding maternal exposure to air pollution and adverse effects on fetal health.

References (116)

  • H. Chen et al.

    Living near major roads and the incidence of dementia, Parkinson's disease, and multiple sclerosis: a population-based cohort study

    Lancet

    (2017)
  • L. Calderon-Garciduenas et al.

    Air pollution, cognitive deficits and brain abnormalities: a pilot study with children and dogs

    Brain Cogn

    (2008)
  • T. Honda et al.

    Associations between long-term exposure to air pollution, glycosylated hemoglobin and diabetes

    Int J Hyg Environ Health

    (2017)
  • L. Calderon-Garciduenas et al.

    Mexico City normal weight children exposed to high concentrations of ambient PM2.5 show high blood leptin and endothelin-1, vitamin D deficiency, and food reward hormone dysregulation versus low pollution controls. Relevance for obesity and Alzheimer disease

    Environ Res

    (2015)
  • F.K. Malerbi et al.

    Ambient levels of air pollution induce clinical worsening of blepharitis

    Environ Res

    (2012)
  • M. Franchini et al.

    Association between particulate air pollution and venous thromboembolism: a systematic literature review

    Eur J Intern Med

    (2016)
  • R.A. Accinelli et al.

    Solid fuel use is associated with anemia in children

    Environ Res

    (2017)
  • T. Honda et al.

    Anemia prevalence and hemoglobin levels are associated with long-term exposure to air pollution in an older population

    Environ Int

    (2017)
  • A.J. Cohen et al.

    Estimates and 25-year trends of the global burden of disease attributable to ambient air pollution: an analysis of data from the Global Burden of Diseases Study 2015

    Lancet

    (2017)
  • S.B. Gordon et al.

    Respiratory risks from household air pollution in low and middle income countries

    Lancet Respir Med

    (2014)
  • D.E. Schraufnagel et al.

    Air pollution and noncommunicable diseases: a review by the Forum of International Respiratory Societies’ Environmental Committee, Part 1: the damaging effects of air pollution

    Chest

    (2019)
  • B. Majkowska-Wojciechowska et al.

    Prevalence of allergy, patterns of allergic sensitization and allergy risk factors in rural and urban children

    Allergy

    (2007)
  • B. Teng et al.

    The association between ambient air pollution and allergic rhinitis: further epidemiological evidence from Changchun, Northeastern China

    Int J Environ Res Public Health

    (2017)
  • K.H. Chang et al.

    Exposure to air pollution increases the risk of osteoporosis: a nationwide longitudinal study

    Medicine (Baltimore)

    (2015)
  • K. Alvaer et al.

    Outdoor air pollution and bone mineral density in elderly men—the Oslo Health Study

    Osteoporos Int

    (2007)
  • K. Alver et al.

    Outdoor air pollution, bone density and self-reported forearm fracture: the Oslo Health Study

    Osteoporos Int

    (2010)
  • IARC Monographs on the Evaluation of Carcinogenic Risks to Humans. Outdoor Air Pollution

    (2016)
  • G.B. Hamra et al.

    Outdoor particulate matter exposure and lung cancer: a systematic review and meta-analysis

    Environ Health Perspect

    (2014)
  • D.M. DeMarini

    Genotoxicity biomarkers associated with exposure to traffic and near-road atmospheres: a review

    Mutagenesis

    (2013)
  • IARC Monographs on the Evaluation of Carcinogenic Risks to Humans, Diesel and Gasoline Engine Exhaust and Some Nitroarenes

    (2014)
  • L. Kachuri et al.

    Workplace exposure to diesel and gasoline engine exhausts and the risk of colorectal cancer in Canadian men

    Environ Health

    (2016)
  • H.F. Chiu et al.

    Traffic air pollution and risk of death from gastric cancer in Taiwan: petrol station density as an indicator of air pollutant exposure

    J Toxicol Environ Health A

    (2011)
  • G. Castano-Vinyals et al.

    Air pollution and risk of urinary bladder cancer in a case-control study in Spain

    Occup Environ Med

    (2008)
  • S.S. Tsai et al.

    Association of bladder cancer with residential exposure to petrochemical air pollutant emissions in Taiwan

    J Toxicol Environ Health A

    (2009)
  • Y. Yanagi et al.

    The impact of atmospheric particulate matter on cancer incidence and mortality in the city of Sao Paulo, Brazil

    Cad Saude Publica

    (2012)
  • M.C. Turner et al.

    Ambient air pollution and cancer mortality in the Cancer Prevention Study II

    Environ Health Perspect

    (2017)
  • R.D. Brook et al.

    Air pollution and cardiovascular disease: a statement for healthcare professionals from the Expert Panel on Population and Prevention Science of the American Heart Association

    Circulation

    (2004)
  • M.B. Hadley et al.

    Developing a clinical approach to air pollution and cardiovascular health

    Circulation

    (2018)
  • A. Zanobetti et al.

    Fine particulate air pollution and its components in association with cause-specific emergency admissions

    Environ Health

    (2009)
  • Z. An et al.

    Impact of particulate air pollution on cardiovascular health

    Curr Allergy Asthma Rep

    (2018)
  • W.S. Aronow et al.

    Carbon monoxide effect on exercise-induced angina pectoris

    Ann Intern Med

    (1973)
  • G.A. Wellenius et al.

    Air pollution and hospital admissions for ischemic and hemorrhagic stroke among medicare beneficiaries

    Stroke

    (2005)
  • G.A. Wellenius et al.

    Ambient air pollution and the risk of acute ischemic stroke

    Arch Intern Med

    (2012)
  • M. Vallejo et al.

    Ambient fine particles modify heart rate variability in young healthy adults

    J Expo Sci Environ Epidemiol

    (2006)
  • Y.J. Cheng et al.

    Heart rate recovery following maximal exercise testing as a predictor of cardiovascular disease and all-cause mortality in men with diabetes

    Diabetes Care

    (2003)
  • K.A. Miller et al.

    Long-term exposure to air pollution and incidence of cardiovascular events in women

    N Engl J Med

    (2007)
  • D.E. Newby et al.

    Expert position paper on air pollution and cardiovascular disease

    Eur Heart J

    (2015)
  • C.A. Pope et al.

    Cardiovascular mortality and long-term exposure to particulate air pollution: epidemiological evidence of general pathophysiological pathways of disease

    Circulation

    (2004)
  • G.D. Thurston et al.

    Ischemic heart disease mortality and long-term exposure to source-related components of US fine particle air pollution

    Environ Health Perspect

    (2016)
  • E. Tamagawa et al.

    Particulate matter exposure induces persistent lung inflammation and endothelial dysfunction

    Am J Physiol Lung Cell Mol Physiol

    (2008)
  • Cited by (502)

    View all citing articles on Scopus

    FUNDING/SUPPORT: The contribution by G. D. T. was supported in part by a National Institute of Environmental Health Sciences Center grant [Grant E500260] to the New York University School of Medicine.

    View full text