Environmental Problems Affecting Health

Review
Indoor and Built
Environment Indoor Built Environ 2003;12:427–433 Accepted: May 14, 2003

Health Effects due to

Indoor Air Pollution
John A Hoskins
Reigate, Surrey, UK

Key Words the levels found the probability that they will cause
Air pollution E Health effects E Cancer E Biomass E cancer is extremely low. This is not to lessen the
Combustion E Radon problem. In a 1987 study, the U.S. Environmental
Protection Agency ranked indoor air pollution fourth
in cancer risk among the 13 top environmental
Abstract problems analysed.
The indoor micro-environment has its own pollutants
and pollution levels indoors may be higher than
those outdoors. This is particularly so when there are
combustion processes associated with cooking heating
Introduction
or smoking coupled with poor ventilation. About half
the world’s population have to rely for cooking; and
We spend most of our time indoors in an environment
associated space heating on simple household stoves
filled with things that can produce air pollution including
using unprocessed solid fuels that have high emission
many consumer products, gas appliances, cigarettes and
factors, with the consequence that they are exposed
furniture, and of course ourselves. The outdoor environ-
to high levels of health-damaging air pollutants.
ment, particularly the outdoors urban environment with
Cooking can produce very high concentrations of
its vehicular traffic, adds a contribution as do building
particles and biomass fuels emit hundreds of chemicals
materials [1–7]. Over most of the world cooking and
during small-scale combustion, such as in household
heating add a considerable contribution to the overall air
cooking or heating stoves. Tobacco smoke may add
pollution load in a dwelling [8]. Because of this indoor
to other biomass smoke and all these together cause
spaces are important micro-environments when consider-
considerable human ill health world-wide. Most
ing the impact of air pollution on health [9–11]. The
indoor air pollutants directly affect the respiratory and
problem is, in fact, compounded for the indoor environ-
cardiovascular systems and the severity of the effect
ment because pollution levels indoors are generally higher
varies according to both the intensity and the duration
than those outdoors.
of exposure, and also the health status of the population
The importance of the problem is that the WHO has said
exposed. The importance of this is that some members
that indoor air pollution in urban areas is responsible for
of the population may be at greater risk than others.
about 14 times more deaths than outdoor air pollution [12].
A number of the chemicals found in the indoor
In total indoor air pollution is estimated to be responsible
environment are classed as carcinogens although at
for 2.8 million deaths each year: some 5.5% of all deaths.

ß 2003 Sage Publications Dr J. A. Hoskins

DOI: 10.1177/1420326X03037109 27 Furzefield Crescent, Reigate
Accessible online at: Surrey RH2 7HQ, UK
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 Research has shown that the indoor levels of some syndrome, but there is as yet no clear evidence of any
pollutants, such as formaldehyde [13], chloroform [14] and exposure–effect relationship [22,23].
styrene [15], range from 2 to 50 times higher than outdoor Although the definition is vague BRI is often defined
levels. Overall, though, in many countries, pollutant as an illness related to indoor exposures to biological
concentrations indoors are similar to those outdoors, and/or chemical substances (e.g. fungi, bacteria, endotox-
with the ratio of indoor to outdoor concentration ins, mycotoxins, radon, CO, HCHO). It is experienced by
falling in the range 0.7–1.3. Higher levels of indoor some people working or living in a particular building and
pollution are usually the result of combustion processes it does not disappear after leaving it [24]. Illnesses include
associated with cooking or heating coupled with poor respiratory tract infections and diseases, legionnaires’
ventilation. Exposure to some pollutants such as environ- disease, and more controversially, cardiovascular diseases
mental tobacco smoke and radon occurs almost entirely and lung cancer.
indoors.
Indoor sources may lead to an accumulation of some
compounds that are rarely present in the ambient air. Factors that Affect Indoor Air Quality
Conversely the urban outdoor air is dominated by
the VOC mixture known as BTEX (benzene, toluene, The air quality inside buildings is affected by many
ethylbenzene, xylenes) comprised of the major petroleum factors. In an effort to conserve energy, modern building
constituents. Concentrations of combustion products in design has favoured tighter structures with lower rates
indoor air can be substantially higher than those outdoors of ventilation. By contrast, in some areas of the world only
when heating and cooking appliances are used. This natural ventilation is used; in other areas mechanical
is particularly true in countries where ovens and ventilation is common [25]. In spite of the move to tighter
braziers are used with imperfect kitchen and stove designs structures there is still continuous air exchange between
indoors and outdoors such that indoor concentrations
[16–18]. In many countries exposure to emissions from
of air pollutants are influenced by outdoor levels. The
cooking and heating may produce the highest indoor air
extent to which this occurs depends upon the rate
pollution exposures to many pollutants. Today about
of exchange between indoor and outdoor air; and these
half the population of the world has to rely for cooking
levels are subject to geographical, seasonal and diurnal
and associated space heating on simple household
variations [26].
stoves using unprocessed solid fuels that have high
Within buildings the factors that can have a negative
emission factors for a range of health-damaging air
effect on health and comfort range from chemical and
pollutants [18,19].
biological pollutants, to occupant perceptions of specific
Specific health effects are often claimed for individual
stresses such as temperature, humidity, artificial light,
pollutants, particularly causes of cancer from the presence
noise and vibration [27]. Important sources of chemical
of carcinogens in the air. Health effects from exposure to
pollutants indoors include not only outdoor air, but also
the whole mixture of pollutants are often held responsible
human body and human activities, plus emissions from
for vaguely defined syndromes or conditions such as sick
building materials, furnishings and appliances and use of
building syndrome (SBS) or building related illnesses consumer products. Microbial contamination is mostly
(BRI) [20,21]. related to the presence of humidity. The heating, ventilat-
Sick building syndrome is the occurrence of specific ing and air conditioning system can also act as a pollutant
symptoms with unspecified aetiology, that are experi- source, especially when it is not properly maintained. For
enced by people while working or living in a particular example, improper care of filters can lead to re-emission
building, but which disappear after they leave it. Symptoms of particulate contaminants. Biological contamination can
include mucous membrane, skin and eye irritation, chest proliferate in moist components of the system and be
tightness, fatigue, headache, malaise, lethargy, lack of con- distributed throughout the building.
centration, odour annoyance and influenza symptoms. One of the most important causes of indoor pollution is
SBS usually cannot be attributed to excessive exposure to combustion [28]. The level of pollution produced depends
any one contaminant or to a defective ventilation system on the fuel that is burnt and how it is burnt. The cleanest
although this is often claimed. A number of factors may be fuel is gas, although there are several types, but at the
involved and it is assumed that the interaction of these bottom of the energy ladder is biomass [29,30]. Although
factors, involving different reaction mechanisms, cause the part of human experience since the first controlled use of

428 Indoor Built Environ 2003;12:427–433 Hoskins

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fire, air pollution from simple open combustion of Health Effects
biomass has been scientifically characterised only in the
last two decades, largely due to rising concerns about Since the early 1970s, interest in the health effects of
wood-smoke pollution in developed countries [31]. Studies indoor air pollution has increased annually. Consequently,
have shown high emission factors for many important a large body of literature is now available on diverse
pollutants, including respirable particulate matter, carbon aspects of indoor air pollution: sources, concentrations,
monoxide, polycylic aromatic hydrocarbons, such as health effects and the engineering technology needed to
benzo[a]pyrene, and volatile organic compounds, such as ameliorate the problem [33,34]. More recently it has
formaldehyde and benzene. Biomass fuels emit hundreds been realised that indoor air pollution from the use of
of chemicals during small-scale combustion, such as in open fires for cooking and heating is a serious problem in
household cooking or heating stoves. It has been shown developing countries [12,35].
that such fuels produce 10–100 times more respirable parti- When it comes to health effects most indoor air
culate matter per meal as the result of low (combustion pollutants directly affect the respiratory and cardiovascu-
and heat-transfer) efficiencies. Although biomass makes lar systems and the severity of effect varies according to
up only 10–15% of total human fuel use, compared to both the intensity and the duration of exposure, and also
modern fuels a much larger fraction is burned indoors, with the health status of the population exposed [36–39].
since nearly one-half of humanity cooks and/or heats with The importance of this is that some members of the
simple stoves burning traditional biomass fuels [12]. population may be at greater risk than others. Many of
It is not known what fraction of biomass-burning those who are especially susceptible to the health effects of
households cook indoors on un-vented stoves, although it indoor pollutants are those who will spend nearly all
is clear that many hundreds of millions do so during some of their time indoors. These include infants and the elderly,
or all seasons of the year. There is also little information those with heart and lung diseases and people with asthma,
about the ventilation rates in the many thousands of as well as hyper-responders and even the fitter members of
housing types in developing countries or countries in society who are exercising [40].
transition. Unfortunately, relatively little monitoring A lot of the work on the health effects of indoor air
has been done in these indoor environments and none
pollution concentrates on a single pollutant, for example,
of it has been done in a way to provide statistically valid
sulphur dioxide, particulate matter, carbon monoxide
samples of large populations. The results that have
or nitrogen dioxide. This specificity is particularly so
been obtained, nevertheless, are striking. Very high
when the pollutant is a known human carcinogen such as
concentrations of particles in indoor air can occur,
benz[a]pyrene, benzene or radon.
sometimes for short duration, such as during cooking
Although carcinogenicity may be a good reason for
over solid fuel fires in rooms with poor ventilation.
studying individual pollutants as stand alone causes, the
The active and passive inhalation of tobacco smoke can
fact that all pollutants differ in the health effects they
lead to reduced pulmonary function, to an increased
cause would seem to be an equally good reason for
incidence of respiratory symptoms and infections, and
discriminating between them. Thus, although we rarely
to an increased incidence of lung cancer. Tobacco smoke
breathe any one pollutant in isolation some pollutants,
is a fresh biomass smoke, which has been studied far
such as carbon monoxide, have such a dramatic effect on
more than any other pollutant mixture. Since there are
health that they should be considered separately [41].
similarities between ETS and biomass smoke from stoves,
as hundreds of the organic compounds they both contain Carbon monoxide causes disruption of the chemistry in
are similar it seems obvious that exposure to biomass several cell types, which, at low exposure levels, may be
smoke from open stoves causes considerable human ill- reversible. There are other pollutants that can cause cell
health world wide. In the second-hand form as ETS, it damage and cell death, such as sulphur dioxide, nitrogen
is associated with adverse health impacts in adults dioxide and particulate matter, and particularly mineral
and children at particle concentrations similar to those at fibres. Cell death removes a cell but cell damage can have
which the epidemiological studies of health effects of more serious consequences for the organism. On the other
outdoor particulate matter have been conducted. It should hand dead cells promote mitogenesis and this in its turn
also be kept in mind that exposure to ETS and other air may lead to mutagenesis. A high level of mutagenesis
pollutants can act synergistically to produce adverse health may lead to inheritable changes in cell DNA and
effects [32]. eventually to cancer.

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 Carbon Monoxide Volatile Organic Compounds are not the only mixture
Acute exposure to high levels of carbon monoxide studied. Environmental tobacco smoke (ETS) is widely
can be life-threatening but the consequence of chronic considered as an important factor in indoor air quality
exposure to low levels is not really known [42,43]. In [52,53]. However, something that is often forgotten is that
general, average short-term CO concentrations at kerbside ETS is not ubiquitous. If no one is or has been smoking in
locations in developed countries are about 60 mg
m3 for an indoor environment there can be no exposure to ETS.
30 min or 30 mg
m3 for 1 h. In kitchens with gas stoves, ETS can be considered as a mixture of particle and vapour
short-term values of up to 15 mg
m3 have been measured. phases. Together these are complex mixtures of several
High values have also been measured in bars and pubs, thousand chemicals, including known carcinogens such as
where smoking is common, with average concentrations nitrosamines and benzene. One of the most commonly
of 10–20 mg
m3 and peak levels up to 30 mg
m3 [44]. used indicators of environmental pollution by tobacco
smoke is the concentration of PM10. This measurement of
Nitrogen Dioxide the particulate phase is 2–3 times higher in houses with
Nitrogen dioxide is an insidious pollutant that causes smokers than in other houses [54].
lung damage and for which there may be no threshold of One commonly encountered volatile organic chemical
that is not usually considered, as a VOC is formaldehyde.
action [33,45,46]. In countries that cook and heat by gas
In five developed European countries HCHO concen-
(used in 20–80% of houses in some countries) indoor levels
trations in indoor air were reported to range from
of NO2 can be surprisingly high. In a UK study (noted
9 to 70 mg
m3. Higher values are occasionally encoun-
with others in [47]), the average NO2 concentrations (over
tered, especially in dwellings with urea-formaldehyde foam
a week) were in the range of 9.4–596 mg
m3 in kitchens,
insulation [55]. Although this is less used nowadays as
for houses with gas cookers and 1l.3–353.4 mg
m3 in
a building material formaldehyde is often encountered
dwellings with electric cookers. Corresponding levels
indoors as a residual chemical from the manufacture of
outdoors were 26.3–45.1 mg
m3. These exposure levels
insulation boards [56,57]. Since formaldehyde has been
may have an effect on respiratory function [48]. If cooking
shown to be carcinogenic in rats, much of the interest in
ranges are unvented people may be exposed to even
its presence arises through fears that it may also be a
higher NO2 levels. In addition, short-term measurements
human carcinogen.
reveal NO2 concentrations that may be five-fold higher
As noted above a quartet of chemicals ubiquitous in the
than those averaged over several days. Peak values of up to
built environment is the petrol (gasoline) mixture of
3800 mg
m3 for 1 min have been measured in the
aromatics BTEX. For reasons known only to politicians
Netherlands in kitchens with unvented gas cooking
and financiers this excites little comment, although it
ranges [44,49].
may be a major part of the total VOC level. However, the
minor constituent, benzene, is a known human carcinogen
Volatile Organic Compounds (VOCs) and is therefore usually discussed as such. A recent study
All indoor environments contain a range of organic of environmental levels of benzene [58] noted that these
compounds, the more volatile ones are commonly grouped were three orders of magnitude lower than the lowest
together for convenience as VOCs [50]. Most of these are exposures reported to be associated with observed adverse
present at very low concentrations have no measurable or, effects.
at the worst, insignificant health effects. However, when
high levels do occur they may have health effects that Radon
range from sensory irritation to behavioural, neurotoxic, Then there is the one pollutant whose radioactivity sets
hepatoxic and genotoxic effects [51]. Exposures sufficient it apart from all other indoor pollutants. The evidence is
to cause health effects are more often associated with good that it is a human carcinogen and this is its only
occupational exposure but such exposure can be in the property that causes concern. In general, average indoor
home when large quantities of solvents or solvent-based levels of radon are 20–70 Bq
m3 [59], although they may
materials are used for building and maintenance. Several be ten times higher in certain areas.
of the VOCs that cause concern do so because they are real So, there are reasons for studying individual pollutants
or suspected human carcinogens. These, like the inorganic in isolation and other reasons for looking at them
gases and some other pollutants, are generally considered altogether. Leaving aside industrial and occupational
individually. exposure, which may be to a single pollutant and may be

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to high doses, with the possible exception of nitrogen Taiwan [69] where it is an undoubted cause of cancer. In
dioxide the pollutants found indoors that cause concern some areas of China and India, household coal use leads to
with regard to their possible health effects are those which high indoor concentrations of fluorine, which causes
have the potential for such an exposure to result in cancer. fluorosis but not cancer, [28] and arsenic [70] with
consequent health effects. Other inorganic materials that
can pollute the indoor environment include the various
Cancer Causing Chemicals in Indoor Air types of asbestos and other mineral fibres. Diseases from
these include lung cancer and mesothelioma but almost
Cancer as a disease has been described since the earliest always as a result of occupational exposure [7173].
medical records were kept. The earliest known descriptions The only natural radioactive element to cause concern
of which appear in Egyptian papyri and were written is radon. It is a proven lung carcinogen in both animals
around 1600 B.C. but are believed to date from sources and man but the risks it poses, at least in the domestic
as early as 2500 B.C. One describes surgery, while the rather than occupational setting, are still unclear.
other outlines pharmacological, mechanical and magical
treatments.
The Risks from Carcinogens in the Indoor Environment
However, the causes of cancer belong to more recent
In a 1987 study, the U.S. Environmental Protection
times and the recognition of environmental cancers
Agency (EPA) ranked indoor air pollution fourth in
was not made until the eighteenth century. Although
cancer risk among the 13 top environmental problems
many occupations such as mining give rise to cancerous
analysed. Indoor radon ranked first in this list. The risk
conditions it is probable that in the past conditions were so
posed by the level of radon found in dwellings is still hotly
bad that few lived long enough for a tumour to develop.
debated with the ecologists finding an inverse relationship
Although cancers can occur at any time throughout life
between lung cancer and radon levels [74] or that there
they are particularly known as a disease of old age. It
was only in the twentieth century that large numbers of is little correlation [75] and the epidemiologists promoting
the population lived to old age, say, beyond the seventh a linear no-threshold model which contradicts these
decade. Ascribing the cause of cancer to exposure to findings [76,77].
pollution of one sort or another was something that However, what may be so in America, is not necessarily
probably only came about in the last fifty years or so. so in the rest of the world. Relatively few studies, for
Epidemiological studies in the 1950s looked at differences example, have been conducted to determine the health
in lung cancer rates between rural and urban areas. Such effects of indoor exposures to air pollutants in developing
studies have continued up to the present time classifying countries, although data has become available in recent
exposure according to levels of various pollutants such as years to obtain some preliminary information on the
benz[a]pyrene, particulates and sulphur dioxide/sulphate type and very approximate magnitude of effects [28]. The
levels. one major difference between rich and poor nations
that are responsible for differences in observed health
The Hazard – Carcinogens in the Indoor Environment effects is the way in which they generate energy. When
A number of the chemicals found in the indoor energy generation is produced remote from the areas
environment are classed as carcinogens, although not all where people live, it has little impact on personal health. If
of them are well documented as human carcinogens. The energy generation for heating, lighting and cooking is
list of organic compounds that may be found in the indoor confined to the dwelling-place and is almost entirely
environment is small and includes formaldehyde [60,61], accomplished by direct combustion, then a greater or
certain polycylic aromatic hydrocarbons (PAHs) [62], lesser effect on health is to be expected depending on the
benzene [58,63] and 1,3-butadiene [64]. Tobacco smoke quality of the fuel that is burnt. The lower the fuel is down
including ETS contains, among many other compounds, the energy ladder, the greater the pollution it causes and
benzene, nitrosoamines and PAHs [65]. the greater the incidence of cancer caused by inhaling the
Several inorganic compounds are classified as carci polluted emissions. Lung cancer is a probable consequence
nogens including, among others, arsenic, nickel and chro- of biomass burning [16] although not all studies find an
mium in their elemental form or as compounds [66,67]. association while coal for cooking and heating has been
Arsenic is a major problem in well water in many areas of shown in many Chinese studies to yield a statistically
the world including Bangladesh, West Bengal [68] and positive relationship with coal smoke and disease [78–80].

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 Conclusion pollution, although high ambient levels obviously
adversely affect the indoor environment. Moving from
Air pollution is responsible for much morbidity and poverty to wealth does not mean an escape from pollution,
mortality in the world. Its heterogeneous nature, though, but rather exchanging some elements of it for others:
means that few generalisations about its cause and effects radon has never been shown to be a problem in poor and
can be made. Higher levels of pollution are associated with draughty housing. Paradoxically, a wealthy lifestyle
poverty and most pollution comes from combustion of one promotes greater concern about pollution, but in reality
sort or another. For the global population as a whole, it means appreciably less ill health and death from
indoor pollution is more important than outdoor environmental causes.

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