Impacts of air pollution across the life course – evidence
highlight note
1 Contacts
• Imperial College London (ERG)
Dr Gary Fuller: [email protected]
Stav Friedman: [email protected]
Dr Ian Mudway: [email protected]
• Greater London Authority:
Dr Inga Mills: Inga.Mil[email protected]
2 Introduction
The sheer number of scientific studies addressing the impact of air pollution on health is
overwhelming. Nearly 60,000 studies are available, with over half of these being published in the last
ten years
1
. These have led to the World Health Organisation (WHO) describing air pollution as a global
health emergency
(1)
.
The evidence that air pollution harms our health throughout our lives, from conception to old age, was
summarised in the Royal College of Physicians (RCP) report Every breath we take: the lifelong impact
of air pollution, in 2016
(2)
Since this time the evidence has continued to accumulate. This new evidence summary builds on the
RCP report by addressing the impacts of air pollution across the life course, reviewing key studies
published in the interim period on the links between air pollution and ill health. The note is divided
into sections focusing on different stages of life, including evidence regarding the impact of air
pollution from pre-foetal development until early adulthood. It aims to summarise key evidence,
drawing on recent authoritative academic reviews and research studies, with an emphasis on those
carried out in the United Kingdom, London, or cities with similar air pollution climates.
3 Summary and conclusions
New perspectives
The short-term impacts of air pollution (worsening of symptoms, hospitalisations, and deaths) and
long-term impacts (disease development, attributable premature deaths and years of lost healthy life)
have been known, extensively studied and reviewed for decades.
However, over the last ten years there have been over 35,000 new studies on air pollution and health.
These have strengthened previous understanding, led to the downward revisions of the World Health
Organization (WHO) air quality guidelines
(3)
, and shown impacts on health outcomes that have not
1
Pubmed search “(air pollution OR air quality) AND health” on 16
th
January 2023 found 35,734 studies
between 2012 and the start of 2023 and a total of 57,850 since 1932.
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been considered in previous health impact assessments. Table 1 lists adverse health outcomes from
air pollution at different stages of life that are highlighted in this report.
Numerous studies across Europe, including several conducted in London, have shown direct impacts
of contemporary air pollution in our city. These include evidence that air pollution exposure is having
impacts during pregnancy and affecting birth outcomes, that school children are experiencing slower
lung-development, worsening of asthma symptoms, and poorer mental health, and that Londoners
are suffering more disease in later life and dying earlier because of the air they breathe.
While headline figures on the health impact of air pollution focus on the equivalent number of
premature deaths, the wider impacts are hiding in plain sight in the contribution of air pollution to
the burden of chronic diseases. These affect our quality of life and have a large cost to society
through additional health and social care costs, as well our ability to learn, work and contribute to
society.
Perhaps, the most important new finding is evidence related to both the impact of air pollution on
brain health, including mental health and dementia, and early life impacts that could lead to future
health burdens within the population. Both represent significant, but currently unquantified costs to
society and the economy.
Confidence in these health impacts stems from the triangulation of information from many studies:
epidemiology, which looks at pattern of association, toxicology and mechanistic studies that address
causal mechanisms, including human experimental studies. This report draws heavily on findings from
expert panels including those convened by the World Health Organization, the UK Committee on the
Medical Effects of Air Pollution, the Royal College of Physicians, the Health Effects Institute, and the
International Agency for Research on Cancer. We also highlight research carried out in London and the
wider UK to illustrate the evidence emerging in our own towns and cities.
Table 1 Summary of the health outcomes from air pollution that are highlighted in this report.
Life stage
Heath impact
Pregnancy and birth outcomes
Foetal development
Low birth weight
Gestational age and pre-term births
Miscarriage
Sperm count and mobility
The developing child: from birth, through
adolescence
Lung growth
Asthma
Blood pressure
Cognitive abilities
Inattention and hyperactivity
Mental health and illness
Adulthood
Early death
Cardiac health
Stroke
Brain and mental health
Respiratory health
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Cancer
Multiple chronic illnesses
Policy implications
Each breath we take contains a complex mixture of pollutants. It can therefore be difficult to separate
out the individual impacts of these multiple components. However, it is clear that a substantial part of
the health burden from air pollution comes from small respirable particles, most especially those
referred to as PM
2.5
, and also from the gas, nitrogen dioxide.
Actions and polices to reduce the concentrations of air pollution are often framed in terms of meeting
legal limit values to minimise the harm to human health. These limits should not be perceived, or
presented as ‘safe’, non-toxic thresholds. Abundant evidence suggests significant impacts below these
concentrations, and for some pollutants, such as PM
2.5
there is no evidence to identify a threshold where
exposure does no harm. The latest evidence, reflected by the new WHO guideline concentrations for
PM
2.5
and nitrogen dioxide, suggest that current levels of air pollution in London will affect all citizens,
including those living in the least polluted suburbs, and especially those with pre-existing
vulnerabilities.
Reports from the 1970’s onwards have emphasised the importance of providing the public with better
air pollution information, but this information needs to be actionable, focused on reducing individual
exposures, and should not be a diversion from measures to reduce pollution emissions. Controlling
emissions will provide the greatest benefit to all, but actions are required at all levels of government
and health care to also educate about the risks of air pollution and provide advice to reduce exposures
in the shorter term, through actions such as behaviour change.
Evidence on the benefits of air pollution reduction focus on reducing ambient air pollution exposure
over wide areas and large populations. Logically, exposure reduction on the smaller neighbourhood
scale, around our schools for instance, or in our everyday lives should also lead to health improvement.
The focus on achieving current limits can lead to actions on the most polluted places but provides little
incentive to drive down air pollution in other locations. It can also be a barrier to progress when limits
are set according to their achievability in the most polluted places.
For PM
2.5,
European and UK legislation includes targets to reduce the average exposure across the whole
population, but there is also an urgent need to incorporate population vulnerability in air pollution
priorities. Policies should be aimed at reducing the accumulating harm from air pollution and the
health degradation, in addition to protecting people who have become vulnerable to current
pollution concentrations.
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4 Definitions
Terms
Definition
Black Carbon and
Elemental Carbon
Black carbon is a very fine particulate air pollution (PM
2.5
), commonly
known as soot. It comes from the burning of diesel, gas and coal, as well as
biomass (wood).
Nitrogen oxides -
NO
2
and NOx
Nitrogen oxides (NOx) are a group of pollutant that includes nitrogen
dioxide, a known toxic gas. Nitrogen dioxide (NO
2
) breaches legal limits
alongside many of London roads.
Ozone (O
3
)
Near the ground, ozone is a component of air pollution that occurs when
NOx reacts with certain chemical compounds that are released into the air
due to everyday industrial activities and many of the personal care and
solvent products that we use in our homes. As its formation is driven by
solar ultraviolet radiation, concentrations tend to be higher during the
summer months.
PM
2.5
and PM
10
Particulate matter (PM) refers to very small air pollution particles which
can pass beyond our nose and throat and enter into respiratory system.
PM
2.5
particles are smaller than PM
10
.
Sulphur dioxide (SO
2
)
A gas from the burning of fuels that contain sulphur, typically from coal and
petrochemicals.
5 Pregnancy & birth outcomes
New evidence indicates that air pollution can impact our immediate and long-term health even before
we are born
(4)
. As a foetus undergoes rapid growth and development throughout pregnancy, it is
vulnerable to environmental factors that can impact its transformation. There is evidence that certain
inhaled toxicants can enter the blood, cross the placental barrier to interact with the developing
foetus
(5)
. A pregnant woman’s exposure to air pollution is therefore, in essence, also the exposure
experienced by the foetus, a notion supported by recent studies identifying links between air pollution
and gestational age (the age in weeks when a baby is born), birth weight, miscarriages and stillbirth
(2)
.
The WHO
(6)
estimates that every year, more than 20 million babies are born with low birth weight, and
another 15 million babies are born prematurely, before 37 weeks gestational age, a known contributor
to infant mortality
(7)
. This section outlines the latest research attempting to understand how much air
pollution may contribute to adverse pregnancy and birth outcomes.
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Foetal development: air pollution pathways to the foetus
Air pollution particles are inhaled through the mother and can cause adverse effects on foetal
development via two different pathways: either the particles themselves, and their associated
chemicals can enter the blood stream to impact directly on the placenta and foetus, or indirectly via
pollution induced inflammation impacting on the maternal circulation. In the mother, air pollution
exposures have been associated with a multitude of adverse effects, including inflammation, oxidative
stress and high blood pressure (pre-eclampsia)
(8)
. Air pollution has been associated with altered blood
flow between the umbilical cord and placenta, lowering oxygen levels, and this has been proposed as a
potential mechanism for the slowed or delayed foetal growth
(9)
.
Birth Outcome: Low Birth Weights
Low birth weight (LBW) and preterm birth (PTB) are established risk factors for early life mortality and
lifetime morbidity
(10)
. Numerous studies have shown the impact of PM
2.5
air pollution on a range of
perinatal
2
health outcomes. A study by Smith and colleagues published in 2017
(11)
, observed that
modelled PM
2.5
exposures (at home address) greater than 13.8 μg m
-3
during pregnancy was directly
associated with slower foetal growth rates, contributing to approximately 3 percent of infants born in
London with LBW. The impact of PM
2.5
on foetal development was subsequently reinforced by a review
of 124 global studies, which estimated that PM
2.5
air pollution was associated with a 7.5-13 gram
reduction in birth weight in UK-born babies
(9)
. Within London a study
(11)
has examined 540,365 births
in the captial and found that long-term exposure to nitrogen dioxide (NO
2
) and PM
2.5
were all associated
with increased risk of low birth weights. There was also evidence that PM
2.5
and PM
10
exposures during
the third trimester were associated with adverse foetal growth rates.
Birth Outcome: Gestational Age & Preterm Births
A global study conducted by Malley et al., (2017)
(12)
examined the total number of preterm births
associated with maternal exposure to PM
2.5
. They found that 18 percent of all pre-term births
worldwide were associated with an annual average concentration of PM
2.5
exposure higher than 10 μg
m
-3
. The same study estimated that in 2010, the percentage of total preterm births in the UK
associated with PM
2.5
(of more than 4.3 μg m
-3
) as between 5-10 percent. According to Ghosh et al.,
(2021)
(9)
, the average reduction in gestational age attributable to PM
2.5
was between 0.4 and 0.7
weeks (approximately 3 – 5 days). Smith et al., (2017)
(11)
also identified that exposure to ozone (O
3
)
was associated with a higher risk of pre-term birth.
It has been estimated that 2.8 million low-weight births and 5.9 million pre-term births could be
avoided globally if PM
2.5
exposure during pregnancy was maintained at the theoretical minimum risk
exposure levels from 2.4 to 5.9 μg m
-3(9)
; a concentration range close to the WHO Guideline of 5 μg m
-3
but well below that currently measured in London, which were between 10 and 14 μg m
-3
in 2019
(13)
.
2
The time period that includes pregnancy and the year following birth.
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Miscarriage
While studies examining the relationship between air pollution with miscarriages and stillbirth in the
UK are still limited, the paper by Smith et al., (2017)
(11)
identified a small increased risk of stillbirth
associated with non-exhaust PM
2.5
and ozone during the first two trimesters of pregnancy. While more
research is needed to understand the extent of this risk, mitigation, and regulation to better manage
poor air quality could reduce these risks during pregnancy.
Sperm health
Concern about the impact of air pollution on reproductive health is not restricted to the mother, with
recent studies and reviews highlighting adverse associations with a range of sperm parameters. A
review and meta-analysis with over 4,562 males found that exposure to higher air pollution was
associated with significant decreases in semen volume, concentration of sperm, motility, and normal
morphology. This included studies carried out around the globe including in China, Taiwan, Italy,
Turkey, the Czech Republic and USA. One weakness in the review is the different pollutants considered
in each study. Although most focused on airborne particles, others encompassed many pollutants
including carbon monoxide (CO), polycyclic aromatic hydrocarbons and SO
2
, with studies spanning
1993 to 2008
(14, 15)
. A more recent study in China looked at the sperm quality of over 30,000 men and
found an association between PM
2.5
pollution and sperm motility. Pollution exposures were greater
than those in the UK with a mean of around 46 µg m
-3(16)
.
6 The developing child: from birth though adolescence
Childhood and adolescence are periods of rapid growth during which organ systems are particularly
susceptible to developmental impairment and damage. These earlier life impacts are increasingly
understood to have lifelong consequences on an individual’s vulnerability to chronic disease as they
age.
Evidence on the air pollution breathed by London school children point to opportunities for
interventions to reduce their exposure. In 2019, 258 pupils in London were given a rucksack capable of
monitoring air pollution to wear for a week. In addition to air pollution breathed at home and in their
neighbourhoods, air pollution on the journey to and from school was a major source of the children’s
exposure. On average, particle pollution (PM
2.5
) on their journey was over 50 percent greater than
that in the school environment. The children who travelled by car breathed more air pollution than
those who walked along quiet roads, with the greatest concentrations being around 20 µg m
-3
.
Walking along main roads led to the greatest exposure, being 33 percent greater than the exposure
for those who walked along quieter roads
(17)
. As well as a focus on children’s home neighbourhoods,
improving air pollution around schools, reducing traffic and encouraging walking along less busy roads
could therefore help to reduce children’s air pollution exposure.
Other initiatives include studies on school streets. A study of 16 school streets in London showed that
nitrogen dioxide, one of the major pollutants from traffic, was reduced by 23 percent when traffic was
restricted on the school street and the number of children walking or cycling to school increased by 18
percent
(18)
. With careful design, this can lead to traffic reductions over a wider area
(19, 20)
.
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Lung growth
There is now substantial evidence that air pollution exposure affects children’s lung growth. This first
emerged through research in Southern California in the 1990s
(21)
.
Reduced lung volumes have been found in primary school aged children growing up in inner-city
London. This finding arose from a study conducted between 2009 and 2014, over the period when the
original Low Emission Zone was being implemented in London. Researchers tested the lung function of
over 2,000 children (aged 8-9) and found that on average a child had lost around 5 percent of their
expected lung volume because of the air pollution that they breathed. This effect was most clearly
linked with exposure to NO
2
, which is often used as a tracer for the diesel exhaust emissions. Although
a change of this magnitude is unlikely to be clinically significant in the healthy population, the more
important issue is whether this change leads to an inability to attain maximal lung development by
adulthood, which if not achieved has potential impacts on long-term health
(22)
.
This observation in London school children was consistent with the earlier findings of the European
Study of Cohorts for Air Pollution Effects (ESCAPE) study. This study analysed data from nearly 6,000
children from five European birth cohorts and showed that poor air quality was associated with
reduced lung function in pre-adolescent children (aged 6–8)
(23)
.
It is important to note that the air pollution concentrations, particularly NO
2
experienced by the
children in the London primary school study were significantly greater than those observed in
Californian and ESCAPE studies reflecting the air pollution challenges in London prior to the
introduction of the Ultra-Low Emission Zone (ULEZ).
Adverse health effects have also been seen in relatively low pollution environments, far below those
experienced in London. In Stockholm County, Sweden, lung growth in a cohort of adolescents (aged 16
years) has been related to early life air pollution exposures
(24)
. These adolescents lived in
neighbourhoods with median NO
X
and PM
10
and of 10 and 4.4 µg m
-3
This is around half the lowest
NO
X
concentrations measured in London in 2019 and a third of the lowest PM
10
.
In further support of the dangers of air pollutants there is evidence that policies to reduce air pollution
can deliver measurable health benefits. Analysis of consecutive cohorts in the Californian Children’s
Health Study
(25)
, found fewer children with clinically small lungs as air quality improved between 1994
and 2011. This has been supported by a recent (February 2023) study on the Swedish cohort
mentioned above that found improvements in air pollution (PM
2.5
, BC and NOx) was associated with
improvements in lung growth, even at the relatively low air pollution experienced in Stockholm
(26)
,
again at concentrations below those currently experienced throughout London.
Asthma
It has long been recognised by clinicians that asthmatic patients find breathing more difficult when
exposed to polluted air, a contention supported by an extensive literature demonstrating a worsening
of symptoms, increased use of reliever medications, hospital admissions and deaths during and after
periods of elevated air pollution
(27, 28)
. Exacerbations requiring emergency health-care were considered
in a review of 21 studies in 2016
(29)
. Significant associations were found with NO
2
, SO
2
and PM
2.5
. These
studies examining associations between air pollution and a range of asthma endpoints, are supported
by experimental evidence, including human exposure studies that have shown that air pollution, and
particularly that derived from traffic exhaust, causes inflammation in the lung, increases airway
hypersensitivity and acts to sensitize the airway to subsequent allergen challenge
(27, 28)
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A review of 21 epidemiological studies from 2000 to 2016, Khreis et al., (2017)
(30)
found significant
associations between development of asthma in children and exposure to traffic related air pollution,
specifically (black carbon, nitrogen dioxide [NO
2
]), PM
2.5
and PM
10
. More recently, in 2022, the US
Health Effects Institute reviewed 118 studies on children and traffic pollution and found moderate to
high confidence in the association with air pollution exposures and asthma onset and lower
respiratory infections.
(31, 32)
The developing cardiovascular system
Currently there is limited research concerning long-term impacts of air pollution on the developing
cardiovascular system.
US and Dutch studies have found positive associations between atherosclerosis (narrowing of arteries)
in adolescents and air pollution. The US study focused on pollutants from traffic including NOx and
(33, 34)
PM
2.5
while the Dutch study focused on particle pollution, including PM
2.5
.
A 2022 review identified 24 studies examining air pollutants and blood pressure in children and
adolescents: eleven in China, one in Pakistan, three in the US and nine in Europe. Study designs and
findings varied. One London-based study then addressed this question by examining how blood
pressure changes over the transition from childhood to adolescence were influenced by long-term
exposures to NO
2
and PM
2.5
. This study looked at 3,824 London youths, aged 11-16 recruited into the
longitudinal, ethnically diverse DASH (Determinants of Adolescent Social well-being and Health)
cohort. The authors found a positive association between the two pollutants and systolic blood
pressure. While increases in NO
2
were linked to a decrease in systolic BP, increases in PM
2.5
led to
increases in systolic BP. While this study was consistent with previous investigations, more
information is needed to understand the implications of air pollution on blood pressure and
cardiovascular function
(35)
.
Cognitive abilities, inattention and hyperactivity
If you talked to parents on the 1970s and 1980s their main concern was around brain damage to their
children from lead. This was used as an additive to petrol until it was finally banned in 1999
(36, 37)
. Over
the years that followed air pollution research focused elsewhere and has only recently returned to the
linkages between cognition, inattention and hyperactivity and air pollution in children.
More recently traffic-related air pollution exposure has been associated with adverse effects on
cognitive, behaviour and psychomotor development in children. Traffic-related air pollution has the
potential to negatively impact the development of different parts of the brain. Based in Barcelona, the
BREATHE project looked at levels of air pollutants in the school environment and how they may
impact brain development in 263 children and found that smaller sized brains were positively
associated with greater PM
2.5
exposure. The researchers conducted processing and operation tests
with the participants and found that older children displayed signs of slower brain development,
indicating that increased exposure over time negatively impacts brain maturation
(38)
.
A study of 2,687 school children from 39 schools in Barcelona/Catalonia, Spain found that children
exposed to higher daily levels of NO
2
and the elemental carbon (EC) within PM
2.5
had slower response
times to computerised tests
(39)
. Overall, the study found that increased NO
2
levels resulted in slower
reaction times and a higher rate of unanswered questions from participants, with similar findings for
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both daily and long-term exposure rates – meaning traffic related pollution has the potential to impact
attention processes daily, irrelevant of the indoor air pollution within the classrooms. Long-term
exposure to indoor NO
2
was also found to negatively impact attention capabilities as well as working
memory. This study adds to the evidence that air pollution may have potential harmful effects on
neurodevelopment
(40)
. A previous study found that behavioural issues such as hyperactivity and
inattention, as well as conduct problems and emotional symptoms, increased in children aged 7 to 11
with increased levels of exposure to traffic-related air pollution
(41)
.
Mental Health & Illness
In England, as of 2017, 1 in 8 youths, aged 5 to 19 years have been diagnosed with mental health
problems, which can have significant negative impacts on daily life, as well as long-term
implications
(42)
. As children and adolescents are still developing, air pollution can pose a great risk to
their physical and mental health. A long-term study examined the relationship between air pollution
exposures and mental health/behaviour in 284 London-based same-sex twins with an average age of
12
(43)
. After adjusting for external factors such as smoking and socioeconomic status, the study found
that adolescents with higher yearly air pollution exposure levels at age 12 displayed a significantly
greater risk of either a major-depressive or conduct-disorder diagnoses or at age 18. A 2021 study
using some of the same participants, explored the connection between air pollution exposure at age
10 and major depressive disorder diagnoses at age 18. This study found those exposed at age 10 to
higher levels of NOx and PM
2.5
were also at higher risk for a positive diagnosis
(44)
. Another 2021 study
found that increased NOx exposure was linked to increased rates of mental illness among
participants
(45)
.
7 Adulthood
Early death
In 1993, the publication of the US “Six Cities Study”
(46)
changed our understanding of air pollution. Put
simply, after allowing for socioeconomic factors, such as smoking, work history and poverty, it found
that those adults living in more polluted places lived shorter lives and that the degree of life-
shortening was associated with the PM
2.5
in their city. Results from this study and the similar ones that
followed still have great relevance today. For instance, they enable us to estimate the health burden
of air pollution in London. The latest estimate is a 3,600 to 4,100 deaths attributable to human-made
PM
2.5
and NO
2
in London in 2019
(47)
.
Cardiac health
Cardiac deaths and hospitalisations have been long associated with air pollution exposures. This
association was found by Dockery et al., (1993)
(46)
– the “Six Cities Study” - and in many studies since.
These include the European-wide ESCAPE project which found that acute coronary events were
associated with air pollution breathed over a ten-year period, with effects seen at airborne particle
(PM
2.5
) concentrations less than current European limit of 25 µg m
-3
and also below 15 µg m
-3
, similar
to the concentrations that prevail in London
(48)
. In 2016 the Royal College of Physicians
(2)
concluded
that there was strong evidence for the effects of short and long-term exposure to air pollution on
cardiovascular disease in adults, but it was unclear if air pollution breathed in early life affected the
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development of cardiovascular disease later in life. Just last year, a systematic review of studies on
health and long-term exposure to traffic related pollution was carried out by the US Health Effects
Institute
(31, 32)
. This covered 352 studies over 40 years of research. High confidence was attached to the
association with deaths from circulatory and ischemic heart disease and moderate confidence in the
association with ischemic heart disease.
Stroke
There is increasingly compelling evidence that air pollution exposure increases stroke risk. In the
short-term, exposure to air pollution is a risk factor for having a stroke and for outcomes in terms of
hospitalisation and mortality. The majority of studies show that longer term exposure to air pollution
may also increase the risk of stroke. These include analysis that bring together the results of over 20
other studies covering over 10 million people
(49)
.
The European ESCAPE study considered stroke in nearly 100,000 people over a ten-year period and
found some evidence of an association between long term exposure to PM
2.5
and stroke, especially
amongst people over 60 years old. This was observed at concentrations below European limits of this
pollutant and also below 15 µg m
-3
, similar to the concentrations that prevail in London
(50)
.
Brain and mental health
Increasing confidence on the associations between air pollution, mental health, cognitive decline, and
dementia is one of the most significant recent developments in our knowledge of the way that air
pollution may be affecting our health and is an area of active research.
A new review, Thompson et al., (2023)
(51)
identified 86 studies that considered air pollution and
cognition concluding that there was much evidence that was supportive of associations between
environmental air pollution and cognition in humans, but not for all pollutants and all cognitive
outcomes. Important differences in which aspects of cognition (IQ, cognition, verbal fluency etc) were
being assessed hampered their comparison and there was an important lack of studies in young
adults. However, there was moderate certainty around detrimental associations between some
pollutants (mainly PM
2.5
, NO
2
and NOx) with some aspects of cognition, especially in children and
adults over 40 years old.
In London, a study of 1,698 adults (mean ages 40 for men and 43 for woman) living in Lambeth and
Southwark in 2008 to 2013 revealed results consistent with urban air pollution having a significant
impact on poor mental health, which could not be explained by other indices of urbanicity or
socioeconomic deprivation. Comparing those in the least and greatest concentrations of PM
2.5
, NOx
and NO
2
there were robust associations with 18–39 percent increased odds of common mental
disorders, 19–30 percent increased odds of poor physical symptoms and 33 percent of psychotic
experiences, which was only found with PM
10
exposures
(52)
.
In 2016 the Royal College of Physicians
(2)
noted emerging evidence that air pollution accelerates
cognitive decline with aging and increases the risk of dementia. In 2022, the Committee on the
Medical Effects of Air Pollution reviewed 69 studies in human populations as well as experimental
studies, concluding that evidence suggested an association between air pollution exposure, the risk of
developing dementia and the acceleration of cognitive decline. This was most likely to be from
exposure to particle pollution
(53)
. Castellani et al., (2022)
(54)
responded by setting out a policy agenda
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that covers research to fill knowledge gaps as well as the need to build awareness amongst the public
and third sector, national and local government, and agencies. They concluded that actions to reduce
exposure must be seen in a wider context of social determinants that can be changed, including
poverty, transportation, health inequalities and urban planning.
Respiratory health
The linkage of air pollution and respiratory impacts were firmly established by the tragedy of the 1952
smog, where bronchitis was overwhelmingly the greatest cause of death
(36, 55)
. In their first air
pollution report in 1970, the Royal College of Physicians
(56)
concluded that there was “no doubt” that
the high pollution events in UK cities led to immediate harm and that evidence pointed to a causal
relation between air pollution and deaths from bronchitis. However, at that time the impacts of long-
term exposures were hard to distinguish from other environmental factors.
In 2022 the US Health Effects Institute
(31)
placed moderate to high confidence in the association of
long-term exposure to traffic pollution and the onset of asthma in adults.
A review of 22 studies in 12 (mostly high income) countries covering 267,413 visits to emergency
departments, emergency calls, or hospitalizations due to asthma and found associations with air
pollutants including NO
2
, PM
2.5
and O
3
. In general, adult asthmatics were less affected by air pollution
compared with children
(29)
.
It is also clear that the elderly (older than 65 is most studies) are more susceptible to air pollution than
other adults. There are well-documented associations between short-term exposure to air pollution
and respiratory morbidity in the elderly. Air pollution exposures are also associated significant
increases in hospitalizations, emergency department or home medical visits for respiratory causes,
mainly Chronic Obstructive Pulmonary Disease (COPD – an umbrella term for bronchitis and
emphysema), asthma, and pneumonia. A 2014 review concluded that the role of air pollution in the
development of COPD was uncertain
(57)
. A later 2015 review focusing on the elderly (those 65 or over)
found that chronic exposure to elevated levels of air pollution was related to the risk of having COPD
and asthma. Growing evidence also suggests adverse effects on lung function in the elderly
(58)
.
Two studies have looked at elderly Londoners who suffer from chronic obstructive pulmonary disease.
Pfeffer et al., (2019)
(59)
found that increased NOx (a gaseous pollutant often used as a tracer for traffic
pollution) led to more COPD exacerbations and slower recovery. Evangelopoulos et al., (2021)
(60)
supplied wearable pollution sensors to over 100 COPD suffers and found the increases in gaseous air
pollution was associated with more frequent exacerbations.
Analysis by Imperial College London
(61)
estimated that London’s poor air quality led to over 1,700
hospital admissions for asthma and serious lung conditions between 2017 - 2019. Within these,
exacerbation of asthma by air pollution led to around 700 hospital admissions in children from 2017 –
2019. This was 7% of all asthma admissions in children in the capital. The numbers for adults were
smaller (around 200 admissions from 2017 - 2019). Chronic obstructive pulmonary disease (COPD) is
more common in the elderly and is difficult to distinguish from asthma. Estimates for the elderly
therefore combined asthma and COPD. The study estimated that exacerbation of asthma and COPD by
air pollution lead to around 900 hospital admissions from 2017-2019 in the elderly in London.
However, improvements in air pollution were estimated to have reduced asthma admissions from air
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pollution by 30% in children since 2016. The equivalent reductions for asthma in adults and
COPD/asthma in the elderly were 27% and 26%, respectively.
Cancer
The Six Cities Study
(46)
was amongst the first to show an association between long term exposure to air
pollution and lung cancer in both smokers and non-smokers. A 2009 report by the UK Committee on
the Medical Effects of Air Pollution (COMEAP) recognised the relationship between air pollution
exposure and lung cancer and included recommendations for quantifying the impact
(62)
. In 2012 the
International Agency for Cancer Research (IARC) classified diesel exhaust as carcinogenic to humans
(group 1). This was followed in 2013 by similar classification for outdoor air pollution, specifically for
lung cancer. They also noted an association with bladder cancer
(63, 64)
. Airborne particulate matter was
looked at separately, and also classified as a class 1 carcinogen. This classification was shortly followed
by European study, using data from nine countries, including the UK, that showed associations
between particle pollution, both PM
2.5
and PM
10
and lung cancer
(65)
. In an important breakthrough in
2022, scientists at the Francis Crick Institute
(66)
in London announced the results of research that may
explain the way in which particle pollution could cause lung cancer in people that have never smoked,
by inducing an inflammatory environment in the lung that promotes the growth of cells carrying
cancer-causing mutations
(67)
.
Chronic illness
In addition to shortening lives, a new UK study, the largest of its kind to date, has found that people
living in polluted areas were more likely to be living with more than one long-term illness
(68)
. These
long-term problems affect people’s lives, and place significant burdens on our economy and health
services. The researchers looked at more than 360,000 people aged between 40 and 69 who had
health data in UK Biobank. Forty three percent had multiple long-term illness. There were clear
associations between air pollution (NO
2
and PM
2.5
) and the chances of multiple neurological,
respiratory, cardiovascular ill-health as well as associations with common mental health conditions
such as depression and anxiety, even after allowing for differences in income. Associations were seen
between the amount of exposure to PM
2.5
or NO
2
and the number of people with multiple long-term
illness, adding to the plausibility of the air pollution associations. There was an extra 20 percent
chance of multiple long-term illnesses for those living with PM
2.5
particle pollution that is worse than
the 2040 England target of 10 µg m
-3
. The study was, however, a snap-shot and was therefore not able
to examine if air pollution caused these long-term illnesses, or led to a deterioration.
A study of 13 million Canadians found that short-term increases in air pollution increased the risk of
emergency department visits for people with chronic illness including those with non-smoking related
lung cancers, COPD and diabetes
(69)
.
Evidence continues to accumulate indicating that air pollution is associated with an ever-wider range
of health endpoints, many of which are likely to have significant and as yet unquantified costs to
society and out health care systems. For example, recent work has associated long term air pollution
exposures with an increased risk of osteoporosis
(70)
.
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8 Impacts that run through the life course
In their first report on air pollution and health in 1970, the RCP
(56)
suggested that the development of
chronic illness later in life may stem from the damage caused by air pollution from childhood.
However, it was recognised that assessing these connections between harm caused during one phase
of life with impacts occurring many decades later was not possible at that time. Similarly, the RCP
(2016)
(2)
report highlighted the impacts of air pollution at different stages of our lives, but there were
few studies on how exposure to air pollution at one point in our lives could impact on long term
health. Such studies require individuals to be tracked over many decades and detailed information on
exposure over this extended period.
Three newer UK studies however support the idea of impacts that run through the life course.
The first
(71)
looked at children who experienced the London 1952 smog either in utero or during their
first year of life. Compared with similarly aged children in other UK cities, the Londoners had a 20
percent greater chance of developing asthma in childhood. Although on the margins of statistical
significance, there was a 10 percent increase in their rate of asthma as adults.
The second study
(72)
took at 1 percent sample of the 1970 English census and followed these
individuals in the census that followed. The probability of death between each census was mainly
associated with air pollution exposure in the previous decade, but smaller associations were found
between air pollution exposures and mortality over a period of more than 30 years. This was the case
for both cardiac and respiratory mortality.
The third study
(73)
considered the deaths of over 3.5 million people, aged over 35 between 1993 and
2012 in England and Wales. Associations were found with local domestic coal consumption in the
1950s and the risk of death in periods spanning up to 60 years, even having allowed for social class,
education, crowding and unemployment in 1951, as well as contemporary social factors. Mortality
risks included respiratory problems, including those like pneumonia acquired later in life, as well as
cardiac problems. Risks of dying were greatest for those born during 1952 and 1953 suggesting that
early life exposure to smog may present a life-long risk.
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9 A note on association and causation
Epidemiological analysis of air pollution and health data are generally based on observations and not
experiments. Statistical association, or apparent linkage, from these studies is not the same as
causation.
Confidence that an association is causal requires the triangulation of information from many studies.
Factors to be considered include the strength of the association, consistency across different types of
study and populations, that exposure comes before effect, a dose response relationship (more air
pollutant, more effect), biological plausibility, an absence of alternative plausible explanations and
evidence that the reducing the exposure decreases the risk. To inform policy it is therefore important
to draw together results from many studies through reviews and meta-analysis along with the work of
expert panels who pull together evidence from many sources. Our report refers to expert panels
including those convened by the World Health Organization, the UK Committee on the Medical Effects
of Air Pollution (COMEAP), the Royal College of Physicians (RCP), the Health Effects Institute (HEI) and
the International Agency for Research on Cancer (IARC).
10 Acknowledgements
We would like to thank Holly Walder for help with the scientific literature cited in this report; Dr Inga
Mills from the GLA for help to define the scope of this project; Dr Heather Walton, Prof Klea
Katsouyanni and Dr Dimitris Evangelopoulos for help with the section on association and causation
and Prof Frank Kelly for reviewing the final version of this report.
This report was funded by the GLA - PO 35000012269.
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Contact us:
Dr Gary Fuller, Environmental Research Group
Email: [email protected]
Imperial Projects
Email: [email protected]
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