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Licensed Unlicensed Requires Authentication Published by De Gruyter April 22, 2020

Continuous exposure to ambient air pollution and chronic diseases: prevalence, burden, and economic costs

  • Seyed M. Karimi EMAIL logo , Ali Maziyaki , Samaneh Ahmadian Moghadam , Mahtab Jafarkhani , Hamid Zarei , Maziar Moradi-Lakeh and Hamid Pouran


Studies that assess the connection between the prevalence of chronic diseases and continuous exposure to air pollution are scarce in developing countries, mainly due to data limitations. Largely overcoming data limitations, this study aimed to investigate the association between the likelihood of reporting a set of chronic diseases (diabetes, cancer, stroke and myocardial infarction, asthma, and hypertension) and continuous exposure to carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), and coarse particulate matter (PM10). Using the estimated associations, the disease burden and economic costs of continuous exposure to air pollutants were also approximated. A 2011 Health Equity Assessment and Response Tool survey from Tehran, Iran, was used in the main analyses. A sample of 67,049 individuals who had not changed their place of residence for at least 2 years before the survey and reported all relevant socioeconomic information was selected. The individuals were assigned with the average monthly air pollutant levels of the nearest of 16 air quality monitors during the 2 years leading to the survey. Both single- and multi-pollutant analyses were conducted. The country’s annual household surveys from 2002 to 2011 were used to calculate the associated economic losses. The single-pollutant analysis showed that a one-unit increase in monthly CO (ppm), NO2 (ppb), O3 (ppb), and PM10 (μg/m3) during the 2 years was associated with 751 [confidence interval (CI): 512–990], 18 (CI: 12–24), 46 (CI: −27–120), and 24 (CI: 13–35) more reported chronic diseases in 100,000, respectively. The disease-specific analyses showed that a unit change in average monthly CO was associated with 329, 321, 232, and 129 more reported cases of diabetes, hypertension, stroke and myocardial infarction, and asthma in 100,000, respectively. The measured associations were greater in samples with older individuals. Also, a unit change in average monthly O3 was associated with 21 (in 100,000) more reported cases of asthma. The multi-pollutant analyses confirmed the results from single-pollutant analyses. The supplementary analyses showed that a one-unit decrease in monthly CO level could have been associated with about 208 (CI: 147–275) years of life gained or 15.195 (CI: 10.296–20.094) thousand US dollars (USD) in life-time labor market income gained per 100,000 30-plus-year-old Tehranis.

  1. Research funding: None declared.

  2. Competing interests: None declared.

  3. Informed consent: Not applicable.

  4. Ethical approval: Not applicable.


1. Bowe B, Xie Y, Li T, Yan Y, Xian H, Al-Aly Z. The 2016 global and national burden of diabetes mellitus attributable to PM2.5 air pollution. Lancet Planet Health 2018;2(7):e301–12.10.1016/S2542-5196(18)30140-2Search in Google Scholar

2. Coogan PF, White LF, Jerrett M, Brook RD, Su JG, Seto E, et al. Air pollution and incidence of hypertension and diabetes mellitus in black women living in Los Angeles. Circulation 2012;125(6):767–72.10.1161/CIRCULATIONAHA.111.052753Search in Google Scholar PubMed PubMed Central

3. Eze IC, Schaffner E, Fischer E, Schikowski T, Adam M, ImbodenM, et al. Long-term air pollution exposure and diabetes in a population-based Swiss cohort. Environ Int 2014;70:95–105.10.1016/j.envint.2014.05.014Search in Google Scholar PubMed

4. Hathout EH, Beeson WL, Ischander M, Rao R, Mace JW. Air pollution and type 1 diabetes in children. Pediatr Diabetes 2006;7(2):81–7.10.1111/j.1399-543X.2006.00150.xSearch in Google Scholar PubMed

5. Krämer U, Herder C, Sugiri D, Strassburger K, Schikowski T, Ranft U, et al. Traffic-related air pollution and incident type 2 diabetes: results from the SALIA cohort study. Environ Health Perspect 2010;118(9):1273–9.10.1289/ehp.0901689Search in Google Scholar PubMed PubMed Central

6. Malmqvist E, Jakobsson K, Tinnerberg H, Rignell-Hydbom A, Rylander L. Gestational diabetes and preeclampsia in association with air pollution at levels below current air quality guidelines. Environ Health Perspect 2013;121(4):488–93.10.1289/ehp.1205736Search in Google Scholar PubMed PubMed Central

7. Zhai D, Guo Y, Smith G, Krewski D, Walker M, Wen SW. Maternal exposure to moderate ambient carbon monoxide is associated with decreased risk of preeclampsia. Am J Obstet Gynecol 2012;207(1):57e1–9.10.1016/j.ajog.2012.03.022Search in Google Scholar PubMed

8. Beelen R, Hoek G, van den Brandt PA, Goldbohm RA, Fischer P, Schouten LJ, et al. Long-term exposure to traffic-related air pollution and lung cancer risk. Epidemiology 2008;19(5):702–10.10.1097/EDE.0b013e318181b3caSearch in Google Scholar PubMed

9. Cesaroni G, Badaloni C, Gariazzo C, Stafoggia M, Sozzi R, Davoli M, et al. Long-term exposure to urban air pollution and mortality in a cohort of more than a million adults in Rome. Environ Health Perspect 2013;121(3):324–31.10.1289/ehp.1205862Search in Google Scholar PubMed PubMed Central

10. Hamra GB, Laden F, Cohen AJ, Raaschou-Nielsen O, Brauer M, Loomis D. Lung cancer and exposure to nitrogen dioxide and traffic: a systematic review and meta-analysis. Environ Health Perspect 2015;123(3):1107–12.10.1289/ehp.1408882Search in Google Scholar PubMed PubMed Central

11. Pope III CA, Burnett RT, Thun MJ, Calle EE, Krewski D, Ito K, et al. Lung cancer, cardiopulmonary mortality, and long-term exposure to fine particulate air pollution. J Am Med Assoc 2002;287(9):1132–41.10.1001/jama.287.9.1132Search in Google Scholar

12. Raaschou-Nielsen O, Andersen ZJ, Beelen R, Samoli E, StafoggiaM, Weinmayr G, et al. Air pollution and lung cancer incidence in 17 European cohorts: prospective analyses from the European Study of Cohorts for Air Pollution Effects (ESCAPE). Lancet, Oncol 2013;14(9):813–22.10.1016/S1470-2045(13)70279-1Search in Google Scholar

13. Turner MC, Krewski D, Diver WR, Pope III CA, Burnett RT, JerrettM, et al. Ambient air pollution and cancer mortality in the cancer prevention study II. Environ Health Perspect 2017;125(8):087013.10.1289/EHP1249Search in Google Scholar PubMed PubMed Central

14. Han MH, Yi HJ, Kim YS, Ko Y, Kim YS. Association between diurnal variation of ozone concentration and stroke occurrence: 24-hour time series study. PLoS One 2016;11(3):e0152433.10.1371/journal.pone.0152433Search in Google Scholar PubMed PubMed Central

15. Maheswaran R, Pearson T, Beevers SD, Campbell MJ, Wolfe CD. Outdoor air pollution, subtypes and severity of ischemic stroke – a small-area level ecological study. Int J Health Geogr 2014;13(1):23.10.1186/1476-072X-13-23Search in Google Scholar PubMed PubMed Central

16. Sørensen M, Lühdorf P, Ketzel M, Andersen ZJ, Tjønneland A, Overvad K, et al. Combined effects of road traffic noise and ambient air pollution in relation to risk for stroke? Environ Res 2014;133(201408):49–55.10.1016/j.envres.2014.05.011Search in Google Scholar PubMed

17. Villeneuve PJ, Chen L, Stieb D, Rowe BH. Associations between outdoor air pollution and emergency department visits for stroke in Edmonton, Canada. Eur J Epidemiol 2006;21(9):689–700.10.1007/s10654-006-9050-9Search in Google Scholar PubMed

18. Weichenthal S, Lavigne E, Evans G, Pollitt K, Burnett RT. Ambient PM2.5 and risk of emergency room visits for myocardial infarction: impact of regional PM2.5 oxidative potential: a case-crossover study. Environ Health 2016;15:46.10.1186/s12940-016-0129-9Search in Google Scholar PubMed PubMed Central

19. Xu X, Sun Y, Ha S, Talbott EO, Lissaker CT. Association between ozone exposure and onset of stroke in Allegheny County, Pennsylvania, USA, 1994–2000. Neuroepidemiology 2013;41(1):2–6.10.1159/000345138Search in Google Scholar PubMed

20. Alotaibi R, Bechle M, Marshall JD, Ramani T, Zietsman J, Nieuwenhuijsen MJ, et al. Traffic-related air pollution and the burden of childhood asthma in the contiguous United States in 2000 and 2010. Environ Int 2019;127(201906):858–67.10.1016/j.envint.2019.03.041Search in Google Scholar PubMed

21. Greenberg N, Carel RS, Derazne E, Tiktinsky A, Tzur D, Portnov BA. Modeling long-term effects attributed to nitrogen dioxide (NO2) and sulfur dioxide (SO2) exposure on asthma morbidity in a nationwide cohort in Israel. J Toxicol Environ Health A 2017;80(6):326–37.10.1080/15287394.2017.1313800Search in Google Scholar

22. Guarnieri M, Balmes JR. Outdoor air pollution and asthma. Lancet 2014;383(9928):1581–92.10.1016/S0140-6736(14)60617-6Search in Google Scholar

23. Cai Y, Zhang B, Ke W, Feng B, Lin H, Xiao J, et al. Associations of short-term and long-term exposure to ambient air pollutants with hypertension: a systematic review and meta-analysis. Hypertension 2016;68(1):62–70.10.1161/HYPERTENSIONAHA.116.07218Search in Google Scholar

24. Dong GH, Qian Z, Xaverius PK, Trevathan E, Maalouf S, Parker J, et al. Association between long-term air pollution and increased blood pressure and hypertension in China. Hypertension 2013;61(3):578–84.10.1161/HYPERTENSIONAHA.111.00003Search in Google Scholar

25. Yin P, Chen R, Wang L, Meng X, Liu C, Niu Y, et al. Ambient ozone pollution and daily mortality: a nationwide study in 272 Chinese cities. Environ Health Perspect 2017;125(11):117006.10.1289/EHP1849Search in Google Scholar

26. Heger M, Sarraf M. Air pollution in Tehran: health costs, sources, and policies. The World Bank Environment and Natural Resources Global Practice Discussion Paper 06; 2018.10.1596/29909Search in Google Scholar

27. Tsiouri V, Kakosimos KE, Kumar P. Concentrations, sources and exposure risks associated with particulate matter in the Middle East Area-a review. Air Qual Atmos Health 2015;8(1):67–80.10.1007/s11869-014-0277-4Search in Google Scholar

28. GBD 2017 Risk Factors Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159)1923–94.10.1016/S0140-6736(18)32225-6Search in Google Scholar

29. Roshani M, Ahadi S. Tehran Air Quality Report 2018. Tehran Air Quality Control Company 2019, Report QM98/02/01(U)/1.Search in Google Scholar

30. WHO. WHO air quality guidelines for particulate matter, ozone, nitrogen dioxide and sulfur dioxide, Global update 2005, Summary of Risk Assessment. Switzerland; 2006.Search in Google Scholar

31. EPA NAAQS Table:, United States Environmental Protection Agency.Search in Google Scholar

32. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392(10159):1736–88.10.1016/S0140-6736(18)32203-7Search in Google Scholar

33. Niccoli T, Partridge L. Ageing as a risk factor for disease. Curr Biol 2013;22(7):R741–52.10.1016/j.cub.2012.07.024Search in Google Scholar PubMed

34. Gualtieri T, Hicks RE. An immunoreactive theory of selective male affliction. Behav Brain Sci 1985;8(3):427–41.10.4324/9780203450499-13Search in Google Scholar

35. Hansen D, Møller H, Olsen J. Severe periconceptional life events and the sex ratio in offspring: follow up study based on five national registers. Br Med J 1999;319(7209):548–9.10.1136/bmj.319.7209.548Search in Google Scholar PubMed PubMed Central

36. Kraemer S. The fragile male. Br Med J 2000;321(7276):1609–12.10.1136/bmj.321.7276.1609Search in Google Scholar PubMed PubMed Central

37. Adamsen C, Schroeder S, LeMire S, Carter P. Education, income, and employment and prevalence of chronic disease among American Indian/Alaska Native elders. Prev Chronic Dis 2018;15:E37. doi: 10.5888/pcd15.170387.10.5888/pcd15.170387Search in Google Scholar PubMed PubMed Central

38. Choi AI, Weekley CC, Chen SC, Li S, Tamura MK, Norris KC, et al. Association of educational attainment with chronic disease and mortality: the Kidney Early Evaluation Program (KEEP). Am J Kidney Dis 2011;58(2):228–34.10.1053/j.ajkd.2011.02.388Search in Google Scholar PubMed PubMed Central

39. Bertrand M, Duflo E, Mullainathan S. How much should we trust differences-in-differences estimates? Q J Econ 2004;119(1):249–75.10.3386/w8841Search in Google Scholar

40. Murray CJ, Lopez AD. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Geneva: World Health Organization; 1996.Search in Google Scholar

Received: 2019-12-25
Accepted: 2020-03-17
Published Online: 2020-04-22
Published in Print: 2020-11-18

©2020 Walter de Gruyter GmbH, Berlin/Boston

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