CE: Tripti; MCP/240204; Total nos of Pages: 9;

MCP 240204

REVIEW

CURRENT
OPINION Air pollution in India and related adverse
respiratory health effects: past, present, and
future directions
Gopi C. Khilnani and Pawan Tiwari

Purpose of review
The review describes current status of air pollution in India, summarizes recent research on adverse health
effects of ambient and household air pollution, and outlines the ongoing efforts and future actions required
to improve air quality and reduce morbidity and mortality because of air pollution in India.
Recent findings
Global burden of disease data analysis reveals more than one million premature deaths attributable to
ambient air pollution in 2015 in India. More than one million additional deaths can be attributed to
household air pollution. Particulate matter with diameter 2.5 mm or less has been causatively linked with
most premature deaths. Acute respiratory tract infections, asthma, chronic obstructive pulmonary disease,
exacerbations of preexisting obstructive airway disease and lung cancer are proven adverse respiratory
effects of air pollution. Targeting air quality standards laid by WHO can significantly reduce morbidity and
mortality because of air pollution in India.
Summary
India is currently exposed to high levels of ambient and household air pollutants. Respiratory adverse
effects of air pollution are significant contributors to morbidity and premature mortality in India. Substantial
efforts are being made at legislative, administrative, and community levels to improve air quality. However,
much more needs to be done to change the ‘status quo’ and attain the target air quality standards.
Video abstract
http://links.lww.com/COPM/A24.
Keywords
air pollution, ambient air pollution, household air pollution, India, respiratory adverse effects

INTRODUCTION: THE PAST AS PROLOGUE world which led to improvement of environmental

Air pollution is as old, or probably older than
humanity itself. ‘Charaka Samhita’, ancient Indian
text (600 BC), described air pollution as, ‘The air
which is against the virtues of season, full of mois-
ture, speedy, hard, icy cool, hot dry, terribly roaring,
colliding from two or three sides, bad smelling, oily,
full of dirt, smoke, sand and steam creates diseases in
body and is polluted’ [1]. Contrary to common
belief, human activities in ancient Roman, Chinese,
and Indian civilizations probably caused long-term
increase in greenhouse emissions even in preindus-
trial ages [2].
However, the great surge in air pollution came
with rapid industrialization and urbanization in the
20th century. Following events like the Great London
Smog [3] and Donora Disaster, stringent air pollution
control measures were implemented in developed
standards. However, the same cannot be said about
developing countries. Currently, only one in 10 per-
sons in the world lives in a city compliant with WHO
air quality standards. The status of air pollution in
Delhi has been highlighted in media [4] and promi-
nent journal news articles [5]. Delhi recorded one of its
worst Air Quality Indices (AQI) during ‘Diwali’ (festival
of lights) because of excessive use of firecrackers in
2016, with carbon monoxide of 3524 mg/m3 and
Department of Pulmonary Medicine and Sleep Disorders, All India Insti-
tute of Medical Sciences, New Delhi, India
Correspondence to Professor Gopi C. Khilnani, Department of Pulmo-
nary Medicine and Sleep Disorders, All India Institute of Medical Scien-
ces, New Delhi 110029, India. E-mail: gckhil@gmail.com
Curr Opin Pulm Med 2017, 23:000–000
DOI:10.1097/MCP.0000000000000463

1070-5287 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-pulmonarymedicine.com

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204
Obstructive, occupational, and environmental diseases
KEY POINTS
 Air pollution, both ambient and household, has
emerged as the most important environmental health
risks in India, accounting for nearly 2.4 million
premature deaths in 2015.
 Respiratory adverse effects of air pollution contribute
significantly to mortality and morbidity in India.
 Though a lot still needs to be done, ongoing
administrative, community, and personal actions hold
great potential for air pollution mitigation and
associated respiratory health effects.
particulate matter with diameter 2.5 mm or less of
1238 mg/m3 at some monitoring centers [6].
The current Indian scenario of air pollution
constitutes a ‘serious health emergency’. According
to the Global burden of disease study, India had
more than 1.09 million premature deaths in 2015,
attributable to ambient air pollution (AAP), with
&&
nearly 24% increase in last 10 years [7 ]. Household
air pollution (HAP) has an even greater attributable
mortality, with 1.04 million estimated deaths in
2010 [8]. Thus, air pollution causes nearly 6000
deaths/day in India.
Air pollution has adverse effects on cardiovas-
cular, respiratory, and virtually all organ systems
across all age groups. In this article, we review
adverse respiratory health effects of air pollution,
with emphasis on evidence related to India.
THE GATHERING STORM: CAUSES OF
WORSENING AIR POLLUTION IN MODERN
INDIA
Sources of AAP in India include both stationary and
mobile sources. Stationary sources are industrial
units, power plants and brick kilns. North India
has largest number of these brick kilns. Coal mines
and thermal electric plants are in central, Northern
and Eastern India. North India is also landlocked,
and devoid of mitigating effect of sea breezes. This
makes the north and north-eastern belt the most
polluted part of the country, with higher particulate
matter concentrations as compared with South
India; Indo gangetic region has the highest recorded
particulate matter concentrations [9,10]. Statewise
levels of ambient air pollutants are shown in Table 1.
Growing human population and urbanization
have led to increasing demand for transport vehicles.
Inadequate public transport, higher use of diesel
vehicles, and increased highway freight have contrib-
uted to AAP. As per 2011 Census, 30% households in
30 major cities had a two wheeler; in 19 cities, at least
2 www.co-pulmonarymedicine.com
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
10% households had a car or utility vehicle [13].
In Delhi, number of registered vehicles crossed
10 million in 2016, with 6.6 million two wheelers
and 3.3 million four wheelers. Other sources of urban
AAP include diesel driven electricity generators, road
dust, and waste burning. Periodic causes like fire-
cracker and crop residue burning are also important
[14,15]. Major sources of AAP with source apportion-
ment are shown in Table 2.
Nearly 74% of Indian population utilizes solid
cooking fuels, leading to HAP. Nearly 800 million
people depend on polluting cooking systems [19].
Even in major cities, 30% households have non-LPG
(liquified petroleum gas) cookstoves [13]. In rural
India, biomass accounts for nearly 90% of energy
source (wood, 56%; dung, 21%; crop residues, 16%).
High levels of emissions coupled with poor ventila-
tion makes indoor air even more toxic. Indoor peak
particulate matter with diameter 10 mm or less levels
can reach upto 30 000 mg/m3 [20]. Rural poor, espe-
cially women and children are the most affected.
HAP, predominantly from cooking fuels, also con-
tributes significantly to AAP [21].
All these have contributed to progressive wors-
ening of air quality in India. Of the 122 Indian cities
included in WHO AAP database (2016), 18 cities had
annual particulate matter with diameter 2.5 mm or
less of 100 mg/m3 or higher. Mean annual particulate
matter with diameter 2.5 mm or less levels in India are
62 mg/m3 (range 41–95), nearly six times the WHO
guidelines [22]. Population-weighted mean concen-
tration of particulate matter with diameter 2.5 mm or
less also remains high (74 3 mg/m3). Also, there has
been progressive increase in ambient particulate mat-
ter with diameter 2.5 mm or less (10%) and ozone (14–
&&
25%) as compared with 1990 [7 ]. Similarly, average
household particulate matter with diameter 2.5 mm
or less exposures have also been reported to be six to
10 times higher as compared with WHO standards
(337 mg/m3 for women, 204 mg/m3 for men, and
285 mg/m3 for children) [23]. Urban population in
India will grow from 30 to 50% by 2030. This, along
with growth in industrial, transportation, household,
and power generation sectors has potential to further
increase air pollution.
CLEAR AND PRESENT DANGER: THE
ADVERSE HEALTH EFFECTS OF AIR
POLLUTION
According to Global Burden of disease Study (2015),
AAP was the 5th leading cause of mortality world-
wide. In this study, ambient particulate matter with
diameter 2.5 mm or less attributable mortality was 4 2
million (95% uncertainty interval, uncertainty inter-
val 3.7–4.8 million). Disability-adjusted life years
Volume 23  Number 00  Month 2017
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204

Air pollution in India Khilnani and Tiwari

Table 1. Statewise Status of Ambient Air Quality in India

SO2 NO2 PM10

State or union territory 2011 2013 2011 2013 2011 2013

Andhra Pradesh 7 7 19 18 77 75
Assam 6 7 14 15 74 124
Bihar 5 – 47 – 174 –
Chandigarh 2 10 16 23 102 118
Chhattisgarh 12 2 27 28 173 101
Dadra and Nagar Haveli 8 8 19 21 24 44
Daman and Diu 7 8 20 20 24 44
Delhi 5 4 57 66 222 221
Goa 10 7 18 12 100 53
Gujarat 15 12 25 19 88 84
Haryana 13 11 25 24 146 178
Himachal Pradesh 3 2 12 14 88 91
Jammu and Kashmir 5 15 12 5 107 118
Jharkhand 23 22 39 41 197 151
Karnataka 11 9 21 18 71 82
Kerala 4 4 14 11 42 55
Madhya Pradesh 12 12 18 22 135 144
Maharashtra 18 16 33 31 111 101
Meghalaya 17 5 10 10 89 59
Mizoram 2 2 5 7 57 48
Manipur – – – – – –
Nagaland 2 2 6 5 82 93
Odisha 4 4 19 16 96 82
Punjab 10 10 25.7 25 156 153
Puducherry 7 6 16 14 42 43
Rajasthan 7 7 31 30 165 173
Sikkim – – – –
Tamil Nadu 10 12 22 22 77 69
Uttar Pradesh 13 10 30 27 163 182
Uttarakhand 21 23 24 26 158 142
West Bengal 11 10 56.6 65 127 162

Values expressed are annual average (mg/m3); Indian National Air Quality Standard are 50 mg/m3for SO2, 40 mg/m3for NO2, and 60 mg/m3for PM10 for
residential, industrial and other areas; Indian National Air Quality Standard are 20 mg/m3for SO2, 30 mg/m3for NO2, and 60 mg/m3for PM10 for ecologically
sensitive areas.
PM10, particulate matter with diameter 10 mm or less.
Adapted with permission [11,12].

(DALYS) were 103.1 million (95% uncertainty inter-
val 90.8–115.1 million), representing 7.6% of total
global deaths and 4.2% of global DALYs. Ozone expo-
sure caused another 254000 (95% uncertainty inter-
val 97000–422000) deaths and a loss of 41 million
(95% uncertainty interval 1.6–6.8 million) DALYs.
Major causes of death were ischemic heart disease,
cerebrovascular diseases, chronic obstructive pulmo-
nary disease (COPD), lower respiratory infections
(LRIs), and lung cancer. Respiratory causes accounted
for 43% of mortality and 50% of DALYs because of
AAP. HAP was responsible for 2.8 million (95%
uncertainty interval 2.2–3.6 million) deaths and
85.6 million (95% uncertainty interval 66.7–106.1
million) DALYs in 2015. AAP and HAP combined
accounted for 6.4 million (95% uncertainty interval
&&
5.7–7.3 million) deaths [7 ]. In 2016, AAP accounted
for 7.5% (6.6–8.4) of deaths globally. Diseases with
highest proportion of AAP attributable burden were
LRI with 27.5% (21.4–34.4) and COPD with 26.8%
(16.1–38.6) of all deaths [24]. It is estimated that
global deaths due to AAP could double by 2050 [25].
India had estimated 1.0904 million (95% uncer-
tainty interval 0.936–1.254) deaths attributable to

1070-5287 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-pulmonarymedicine.com 3

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204
Obstructive, occupational, and environmental diseases
Table 2. Major sources of ambient air pollution in major Indian cities
Emission sources PM10
Transport or vehicles 7–43%
Road dust 8–57%
Diesel run electricity generators 4–14%
Domestic fuel burning 4–19%
48–89% (Delhi)
Waste burning 5–25%
Secondary particulates – 14–60%
Industries including power plants 1.2–25.6%
Measured ambient ozone levels did not exceed the hourly limit of 180 mg/m3 at any of the sampled sites across the six cities.
Based on Central Pollution Control Board study (2011) of ‘Air Quality Monitoring, Emission Inventory and Source Apportionment Study for Indian Cities’ including
Delhi, Mumbai, Chennai, Bangalore, Pune, and Kanpur.
NOx, nitrogen oxides; PM10, particulate matter 10 mm diameter; PM2.5, particulate matter 2.5 mm diameter; SOx, sulphur oxides.
Adapted with permission [16–18].
AAP with 29.6 million (25.9–33.6) DALYs lost in
2015, ranking second only to China. India ranked
the second according to deaths/100 000 people
(133.5, 95% uncertainty interval 112.8–154.9) and
DALYs/100 000 people (2922.1, 95% uncertainty
&&
interval 2527.3–3327.5) [7 ]. These were greater
than the Global burden of disease (2010) estimates,
in which approximately, 627 000 premature deaths
and 17.8 million DALYs were attributable to AAP [8].
In 2010, 1.04 million premature deaths and 31.4
million DALYs were attributable to HAP in India [8].
About 17% deaths from lung cancer and 33% of
deaths from COPD in low and middle-income coun-
tries could be attributed to HAP [26]. Of note, 60% of
premature deaths because of HAP occur in children
and women. Phased removal of solid fuel cookstove
emissions by 2050 may avoid 260 000 (13700–
268 000) annual premature deaths in India, China,
and Bangladesh [27].
Studies from various areas of India have reported
positive correlations between higher levels of AAP
and premature all cause and respiratory disease-
&
related mortality (Table 3) [28–34,35 ]. We have
previously reported increased mortality with increas-
ing particulate matter with diameter 10 mm or less
and NO2 concentrations in a time series analysis
(2003–2006) from Delhi [36]. Respiratory adverse
effects of AAP range from reduced lung functions
[37,38], increased prevalence of respiratory symp-
& &
toms, exacerbations of COPD [39 ], asthma [40 ],
and lung cancer [41]. Short-term exposures to AAP
have been correlated with mortality because of
cardiorespiratory diseases [42]. One of the first Indian
studies to demonstrate direct correlation of increased
ambient pollutant levels with emergency admissions
was by Pande et al. [43] in 2002. In this study
(n ¼ 12812), ambient carbon monoxide, nitrogen
oxides, and sulphur oxide were monitored daily.
4 www.co-pulmonarymedicine.com
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
PM2.5 NOx SOx
20–60% 18.5–94.6% 12–48%
<5% – –
8–28% 1.6–23.4% 0.18–22.9%
15–27% 0.96–12.6% 0.13–10.4%
14% (Delhi) 0.03–1.03 0.05–0.07%
– –
0.3–21% 2.2–42.8% 5.2–95.4%
Ambient levels of pollutants exceeded national
standards on most days. There were increased emer-
gency visits for asthma (21.3%), COPD (24.9%), and
acute coronary events (24.3%) with increased levels
of ambient pollutants [43].
HAP, in addition, has been attributed to acute
LRIs and increased risk of tuberculosis (TB) [26]. In a
recent meta-analysis on adverse health effects of HAP
on adult Indian women, pooled odds ratios were 2.37
[95% (confidence interval) CI 1.59–3.54] for chronic
bronchitis and 2.33 (95% CI 1.65–3.28) for TB. About
2.4 (95% CI 1.4–3.1) of 5.6 million cases of chronic
bronchitis as well as 0.3 (95% CI 0.2–0.4) of 0.76
million cases of TB, could be attributed to HAP
because of biomass cooking fuel [44]. In a recent
community based cross sectional survey from Chen-
nai (n ¼ 55 617), solid household fuel use was an
independent risk factor for TB in urban adults [45].
HAP was an independent risk factor for TB in a hospi-
tal based case–control study (n ¼ 178) from Pune [46].
Dose–response curve for acute LRI and HAP has
been demonstrated [26]. In a recent study from
Orissa (n ¼ 105 households), improved cookstove
use (ICS) usage was associated with significant
reduction in particulate matter with diameter
2.5 mm or less, polycyclic aromatic hydrocarbons,
organic carbon and nitrogen (P < 0.01) in household
air, though particulate matter levels were still higher
than WHO guidelines. ICS use also led to reduced
time in hospital with acute LRI [47]. Multicentric
trials on effect of LPG cookstoves on infant out-
comes including acute LRI are underway [48].
Prolonged exposure to AAP induces oxidative
stress and increase susceptibility to cardiac and
respiratory diseases. A recent study from Delhi
(n ¼ 85) demonstrated higher levels of oxidative
stress and inflammatory markers in serum of autor-
ickshaw drivers as compared with other groups
Volume 23  Number 00  Month 2017
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204

Air pollution in India Khilnani and Tiwari

Table 3. Summary of selected recent studies on ambient air pollution and adverse health effects from India
Author Year of
[reference] study Location Study description Reported pollutant levels Adverse health effects

Lawrence et al. 2012 Lucknow AAP and HAP monitoring Average PM10 ¼ 189 mg/m3; 46% had acute respiratory symptoms/
[28] Survey for cardiac and PM2.5 ¼ 226 mg/m3 asthma
respiratory symptoms HAP pollutants had positive
(n ¼ 197) correlation with AAP
Guttikunda 2008–2011 Delhi Estimation of AAP and Annual average 7350–16200 premature deaths;
et al. [29] Attributable mortality PM2.5 ¼ 123  87 mg/m3; Six million asthma attacks attributed to
PM10 ¼ 208  137 mg/m3 AAP
Nagpure et al. 1990-2010 Delhi Attributable mortality and - 18,229 excess deaths in 2010
[30] morbidity estimated using 50% because of respiratory causes
RiMAP model 26 525 hospital admissions because of
COPD
Tobollik et al. 2008–2011 Kerala Ambient pollutant concentrations Annual mean PM10 <60 mg/m3 6108 (95% CI): 4150–7791) of 81 636
[31] recorded natural deaths attributed to PM
Burden of disease estimated 50% mortality because of respiratory
causes
Parkhi et al. 2010, 2011 Delhi O3, NOx, CO, PM2.5, PM10 Peak 24 h PM10 ¼ 2070 ug/m3 Not reported
[32] monitored during and (2010); 600 ug/m3 (2011)
after Diwalia Peak 24 h PM2.5 was 1620 mg/
m3in 2010 and 390 mg/m3 in
2011
Kumar et al. 2012 Mumbai Air quality monitoring data Annual average SO2, NO2, Estimated total health cost USD8000
[33] interpolation and SPM were 10 mg/m3, million
Health impact and cost 35 mg/m3, and 260 mg/m3,
assessment respectively.
Etchie et al. 2013 Nagpur Ambient PM2.5 assessment Annual average PM2.5 3300 (95% CI 2600–4200)
[34] Hazard and survival analysis 34  17 mg/m3 premature deaths
91000 (95% CI: 68000–116000)
DALYs
Jain et al. 2001–2015 Varanasi Assessment of AAP Yearly " PM2.5 (1.5–3%); Estimated 5700 (2800–7500) annual
&
[35 ] pollutant levels 87% of daily PM2.5 exceeded premature deaths
Burden of disease national standard 33% deaths because of COPD, 19%
estimation because of ALRI; 1% because of
lung cancer attributed to AAP

AAP, ambient air pollution; ALRI, acute lower respiratory infections; CI, confidence interval; COPD, chronic obstructive pulmonary disease; HAP, household air
pollution; NO2, nitrogen dioxide; NOx, nitrogen oxides; O3, ozone; PM10, particulate matter 10 mm diameter; PM2.5, particulate matter 2.5 mm; RiMAP, risk
of mortality and morbidity due to air pollution model; SO2, sulphur dioxide; SPM, suspended particulate matter.
a
Diwali: a festival where firecrackers are burnt, usually lasting for a fortnight.

along with dysregulated protein metabolism involv-
ing phenylalanine, histidine, arginine, and proline
[49]. In animal studies on inflammatory responses
to biomass particulate matter samples from rural
Indian homes, acute exposure caused neutrophilic
inflammation, proinflammatory cytokine produc-
tion, and airway hyperresponsiveness. Subchronic
exposure, on the other hand, resulted in eosino-
philic inflammation, particulate matter-specific
antibody response, and alveolar destruction. This
demonstrates possible pathogenetic pathways for
HAP-induced chronic respiratory diseases [50].
There is no data based on cohort studies to ascer-
tain chronic health effects of air pollution from India,
though few studies are ongoing [51]. However, the
global burden of disease studies provide a robust
alternative estimate of morbidity and mortality.
CURRENT ACTIONS AND POLICY
DECISIONS: WORK IN PROGRESS
Study by Pande et al. [43] was considered by Supreme
Court of India while directing transition of public
transport in Delhi to compressed natural gas (CNG).
Currently, Delhi currently operates the world’s larg-
est fleet of CNG operated buses. Owing to significant
time lag in air quality reporting and limited partic-
ulate matter with diameter 2.5 mm or less monitor-
ing, Central Pollution Control Board convened an
Expert Committee (G.C.K. as member) for formula-
tion and implementation of real time AQI [52]. AQI
was launched in 2015 and currently covers 11 cities.
Table 4 shows Indian AQI standards as compared
with various guidelines [53–56]. Low cost high-
quality public transport network facilities like metro
are being extended to major cities. Public transport
utilizes CNG in Delhi and major cities. National
railway network operates predominantly on elec-
tricity. Legal and community awareness initiatives
have been taken to reduce trash and crop residues
burning.
Emissions norms for industries were introduced
under the Environment Protection Act of 1986.
These are enforced by the Central and State Pollu-
tion Control Boards. Measures to control air pollu-
tion emanating from industrial sources include

1070-5287 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved. www.co-pulmonarymedicine.com 5

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204

Obstructive, occupational, and environmental diseases

Table 4. Indian National Ambient Air Quality Standards as compared with WHO and other national Air Quality Standards

Pollutant Averaging Indian NAAQS WHO WHO WHO WHO European United States
(mg/m3) Time (2009) Guidelines ITG 3 ITG 2 ITG 1 Guidelines Guidelines

PM10 Annual 60 20 30 50 70 40 –
24 h 100 50 75 100 150 50 150
PM2.5 Annual 40 10 15 25 35 25 35
24 h 60 25 37.5 50 75 – 12–15
SO2 Annual 50 – – – – – –
24 h 80 20 50 125 125 –
NO2 Annual 40 40 – – – 40 100 (53 ppb)
24 h 80 200 – – – 200
COa 1h 4.0 30 30 40
8h 2.0 – – – – 10 10
Ozone 8h 100 100 – – 160 120 140 (0.07 ppm)
Lead Annual 0.5 0.5–1.0 – – - 0.5 0.15

NAAQS: National Ambient Air Quality Standards; ITG: interim target guidelines; PM10: particulate matter 10 mm diameter; PM2.5: particulate matter 2.5 mm
diameter; SO2: sulphur dioxide; NO2: nitrogen dioxide; CO: carbon monoxide.
a
(mg/m3).
Adapted with permission [51–54].

identification of critically polluted areas near indus-
trial townships, and specific action plans for
improvement of air quality in these areas. Environ-
mental clearances and environmental impact assess-
ment have been increasingly sought before
clearance of new development or industrial projects.
Submission of environment statement by industries
and provision of environment auditing are other
measures being initiated. In general, all polluting
industries have been gradually shifted out of highly
populated urban areas. Other measures include pro-
vision of utilization of low ash coal by power plants
(coal based). Utilization of by-products of industrial
activities like fly ash (from coal based thermal
power plants) and phosphogypsum (from fertilizer
industry) for construction activities are other such
measures.
For HAP mitigation, GOI Steering Committee
Report (2015) recommended multisectoral approach
[13]. WHO has recommended emission targets for
particulate matter with diameter 2.5 mm or less (0.23
and 0.80 mg/min) and carbon monoxide (0.16 and
0.59 g/min) in vented and unvented kitchens, respec-
tively [26]. ICS use has led to reduced emissions,
&&
albeit still higher than WHO standards [57 ]. There-
fore, HAP mitigation has gradually moved toward
provision of clean fuel like LPG. Table 5 enumerates
major steps being taken in India to curb air pollution.
DEMANDING A BETTER FUTURE
India needs to go back to the roots of the harmony
between man and nature envisaged in our culture.
Sustainable development goals have set air pollu-
tion-related indicators for monitoring progress. This
requires legislative, administrative, community,
and individual efforts. Owing to the federal gover-
nance structure in India, corroboration between
multiple central and state government agencies is
required to ensure appropriate air pollution control
measures. It has been proposed that the Ministry of
Health and Family Welfare be a coordinator to
ensure participation of various central and state
government departments. In critically polluted
areas, the Central Pollution control board (regulated
by The Ministry of Environment and Forests) is
gradually moving toward health impact assessment
along with air quality measurement. For addressing
AAP, ‘avoid-shift-improve’ framework has been pro-
posed. ‘Avoid’ refers to changes in town or land use
planning, financial disincentives (higher taxes on
fuels, congestion pricing, increasing parking fees),
limiting vehicle use, or declaring highly congested
areas vehicle free. ‘Shift’ refers to shifting to alterna-
tive cleaner modes of transport, including electric-
ity, CNG powered or nonmotorized vehicles like
bicycles. ‘Improve’ refers to tighter emission and
fuel standards [13]. Adopting more stringent norms
for particulate matter with diameter 2.5 mm or less
may save even more lives [60].
Relocation of industry and power plants from
densely populated areas and adoption of clean tech-
nology will reduce AAP. Proper street design, green
cover, and adoption of newer methods for cleaning
roads can avoid resuspension of road dust in air.
Enforcement of good construction practices, safe

6 www.co-pulmonarymedicine.com Volume 23  Number 00  Month 2017

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
CE: Tripti; MCP/240204; Total nos of Pages: 9;
Table 5. Important Policies and Actions taken in India to combat Air Pollution
Actions
Air (Prevention and Control of Pollution) Act
The Environment (Protection) Act
Motor Vehicle Act
Supreme Court Verdict for CNG adoption
by public transport buses
BHARAT Emission Norms adopted
Revised National Air Quality Standards
NAMP
AQI initiated
Odd–even experiment in Delhi
India signed Paris Accord
Ujjwala Yojna
Graded Response Action Plan in
Delhi National Capital Region
National Action Agenda
AQI, air quality index; CNG, compressed natural gas; CO, carbon monoxide; CPCB, Central Pollution Control Board; GOI, Government of India; LPG, liquified
petroleum gas; NH3, ammonia; NO2, nitrogen dioxide; PM10, particulate matter 10 mm diameter; PM2.5, particulate matter 2.5 mm diameter; SO2, sulphur
dioxide.
disposal along with recycling of construction and
demolition waste is also required. Phasing out old
technology, implementing emission standards, and
promoting alternative building material may limit
AAP from local industries using coal or agriculture
residues.
Daily AQI-based graded public response systems
are the need of the hour. These should include
warnings for high-risk groups, school holidays, lim-
itation of usage of personal automobiles, increasing
frequency of public transport, and provision of sub-
sidized public transport. Daily reporting of cardio-
vascular and respiratory admissions and deaths
during periods of high pollution by hospitals will
create public awareness, and improve our under-
standing of short-term effects of air pollution.
HAP mitigation requires a community level
approach. These include assured access to clean
fuels, stringent implementation of indoor emission
standards, and public awareness programmes. These
can only be achieved via continuous fiscal support
and robust distribution systems. Healthcare pro-
viders need to be trained to educate their patients
on harm reduction strategies from air pollution.
1070-5287 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
MCP 240204
Air pollution in India Khilnani and Tiwari
Year Remarks
1981 Act formulated; National Air Quality Monitoring Programme
(NAMP) started under CPCB
1986 Enacted after Bhopal Gas Tragedy
Strengthened 1981 act
1988 Limitation on automobile emissions
1998 Significant short-term improvement in AQI in Delhi
2000 Adopted from European Emission Norms
Currently BHARAT 4; BHARAT 6 adoption by 2020
2009 Standards revised for 12 pollutants including SO2, NO2,
PM10, PM2.5, Ozone, Lead, Arsenic, Nickel, CO, NH3,
Benzene, and Benzo[a]pyrene (particulate phase)
1980s onwards 629 stations; 264 cities currently
2015 11 cities covered, nine parameters, real time reporting
2016 Mixed results [58,59 ]
&
#Hourly average PM2.5 and PM10 (upto 74%) during
majority of trial hours [59 ]
&
2017 Self-committed targets for reducing emissions
2016–2017 onwards Provision of free clean cooking fuel (LPG) to 50 million poor
households; 20 million already benefitted
2017 onwards Environment Pollution Control Authority constituted including
authorities from Central, State and local governments
AQI-based pollution control and public interventions
2016–17 to 2019–2020 Comprehensive plan to reduce AAP and HAP
Robust large epidemiologic and clinical research
on adverse effects of air pollution is needed.
CONCLUSION
Air pollution in India is unacceptably high, and
has emerged as the most important environmental
contributor to morbidity and mortality. Respiratory
adverse effects of air pollution are acute LRIs,
asthma, COPD, exacerbation of preexisting respira-
tory diseases, TB and lung cancer. Administrative
and community-based actions hold great potential
in mitigation of air pollution and associated respi-
ratory adverse effects.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
www.co-pulmonarymedicine.com 7
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204
Obstructive, occupational, and environmental diseases
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. James GA. Ethical perspectives on environmental issues in India. Delhi: APH
Publishing; 1999.
2. Sapart CJ, Monteil G, Prokopiou M, et al. Natural and anthropogenic variations
in methane sources during the past two millennia. Nature 2012; 490:85–88.
3. Bell ML, Davis DL. Reassessment of the lethal London fog of 1952: novel
indicators of acute and chronic consequences of acute exposure to air
pollution. Environ Health Perspect 2001; 109(Suppl 3):389–394.
4. All you need to know about Delhi air pollution [Internet]. http://www.
hindustantimes.com/. 2016 [cited 1 October 2017]. Available from: http://
www.hindustantimes.com/delhi/all-you-wanted-to-know-about-delhi-air-
pollution-cleared-up-here/story-V7EkSU7xtNdnlimBYxGg6K.html. [Accessed
1 October 2017]
5. Pulmonary Perspectives: High levels of air pollution in Delhi and adverse
health effects. [Internet]. www.mdedge.com/chestphysician/. 2017 [cited 1
October 2017]. Available from: http://www.mdedge.com/chestphysician/ar-
ticle/131214/society-news/pulmonary-perspectives-high-levels-air-pollution-
delhi. [Accessed 1 October 2017]
6. Central Pollution Control Board, Delhi Deepawali Monitoring Report 2016
[cited October 2017]. Available from: http://cpcb.nic.in/Deepawali_
2016.pdf. [Accessed 1 October 2017]
7. Cohen AJ, Brauer M, Burnett R, 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;
389:1907–1918.
The study estimates global burden of disease attributable to AAP. It provides the
latest estimates of AAP attributable all cause and respiratory cause mortality and
disability adjusted life years for India.
8. Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of
disease and injury attributable to 67 risk factors and risk factor clusters in 21
regions, 1990–2010: a systematic analysis for the Global Burden of Disease
Study 2010. Lancet 2012; 380:2224–2260.
9. Sharma D, Kulshrestha UC. Spatial and temporal patterns of air pollutants in
rural and urban areas of India. Environ Pollut 2014; 195:276–281.
10. Cheng Z, Luo L, Wang S, et al. Status and characteristics of ambient PM2.5
pollution in global megacities. Environ Int 2016; 89–90:212–221.
11. Central Pollution Control Board. National Ambient Air Quality Status and
Trends for year 2011. 2014. [Cited 24 October 2017]. Available from: http://
cpcb.nic.in/divisionsofheadoffice/pams/NAAQStatus_Trend_Report_2011.
pdf. [Accessed 24 October 2017]
12. Central Statistics Office, Social Statistics Division. Statistics Related to
Climate Change - India [2015] [cited 24 October 2017]. Available from:
http://www.mospi.gov.in/sites/default/files/publication_reports/climate-
ChangeStat2015.pdf. [Accessed 24 October 2017]
13. Ministry of Health and Family Welfare, Government of India. Report of the
Steering Committee on Air Pollution and Health Related Issues, Ministry
of Health and Family Welfare, Government of India. 2015. [Internet].
August 2015 [cited 28 September 2017]. Available from: http://www.
mohfw.nic.in/sites/default/files/5412023661450432724_0.pdf. [Accessed
28 September 2017]
14. Yerramsetti VS, Sharma AR, Gauravarapu Navlur N, et al. The impact
assessment of Diwali fireworks emissions on the air quality of a tropical urban
site, Hyderabad, India, during three consecutive years. Environ Monit Assess
2013; 185:7309–7325.
15. Pachauri T, Singla V, Satsangi A, et al. Characterization of major pollution
events (dust, haze, and two festival events) at Agra, India. Environ Sci Pollut
Res 2013; 20:5737–5752.
16. Central Pollution Control Board. Air quality monitoring, emission inventory and
source apportionment study for Indian cities: National Summary Report. 2011
[cited 24 October 2017]. Available from: http://cpcb.nic.in/FinalNational-
Summary.pdf. [Accessed 24 October 2017]
17. Guttikunda SK, Goel R, Pant P. Nature of air pollution, emission sources, and
management in the Indian cities. Atmos Environ 2014; 95:501–510.
18. Gargava P, Rajagopalan V. Source apportionment studies in six Indian cities:
drawing broad inferences for urban PM10 reductions. Air Qual Atmosphere
Health 2016; 9:471–481.
19. World Health Organisation. Burning opportunity: clean household energy for
health, sustainable development, and wellbeing of women and children. 2016
[cited 2 October 2017]; Available from: http://apps.who.int/iris/bitstream/
10665/204717/1/9789241565233_eng.pdf. [Accessed 2 October 2017]
20. Torres-Duque C, Maldonado D, Pérez-Padilla R, et al. Forum of International
Respiratory Studies (FIRS) Task Force on Health Effects of Biomass Ex-
posure: Biomass fuels and respiratory diseases: a review of the evidence.
Proc Am Thorac Soc 2008; 5:577–590.
21. Chafe ZA, Brauer M, Klimont Z, et al. Household cooking with solid fuels
contributes to ambient PM2.5 air pollution and the burden of disease. Environ
Health Perspect 2014; 122:1314–1320.
8 www.co-pulmonarymedicine.com
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
22. World Health Organisation. WHO Global Urban Ambient Air Pollution Da-
tabase (update 2016). WHO [Internet]. WHO. [Cited 27 September 2107].
Available from: http://www.who.int/phe/health_topics/outdoorair/databases/
cities/en/. [Accessed 22 September 2017]
23. Balakrishnan K, Ghosh S, Ganguli B, et al. State and national household
concentrations of PM2.5 from solid cookfuel use: Results from measurements
and modeling in India for estimation of the global burden of disease. Environ
Health 2013; 12:77.
24. Abajobir AA, Abate KH, Abbafati C, et al. Global, regional, and national
comparative risk assessment of 84 behavioural, environmental and occupa-
tional, and metabolic risks or clusters of risks, 1990–2016: a systematic
analysis for the Global Burden of Disease Study 2016. Lancet 2017;
390:1345–1422.
25. Lelieveld J, Evans JS, Fnais M, et al. The contribution of outdoor air pollution
sources to premature mortality on a global scale. Nature 2015; 525:
367–371.
26. Bruce N, Pope D, Rehfuess E, et al. WHO indoor air quality guidelines
on household fuel combustion: strategy implications of new evidence on
interventions and exposure–risk functions. Atmos Environ 2015; 106:
451–457.
27. Lacey FG, Henze DK, Lee CJ, et al. Transient climate and ambient health
impacts due to national solid fuel cookstove emissions. Proc Natl Acad Sci
2017; 114:1269–1274.
28. Lawrence A, Fatima N. Urban air pollution & its assessment in Lucknow city:
the second largest city of North India. Sci Total Environ 2014; 488–
487:447–455.
29. Guttikunda SK, Goel R. Health impacts of particulate pollution in a megacity:
Delhi, India. Environ Dev 2013; 6:8–20.
30. Nagpure AS, Gurjar BR, Martel J. Human health risks in national capital
territory of Delhi due to air pollution. Atmospheric Pollut Res 2014;
5:371–380.
31. Tobollik M, Razum O, Wintermeyer D, et al. Burden of outdoor air pollution in
Kerala, India: a first health risk assessment at state level. Int J Environ Res
Public Health 2015; 12:10602–10619.
32. Parkhi N, Chate D, Ghude SD, et al. Large inter annual variation in air quality
during the annual festival ‘Diwali’ in an Indian megacity. J Environ Sci China
2016; 43:265–272.
33. Kumar A, Gupta I, Brandt J, et al. Air quality mapping using GIS and economic
evaluation of health impact for Mumbai City, India. J Air Waste Manag Assoc
1995 2016; 66:470–481.
34. Etchie TO, Sivanesan S, Adewuyi GO, et al. The health burden and economic
costs averted by ambient PM2.5 pollution reductions in Nagpur, India. Environ
Int 2017; 102:145–156.
35. Jain V, Dey S, Chowdhury S, Ambient PM2. 5 exposure and premature
& mortality burden in the holy city Varanasi, India. Environ Pollut 2017;
226:182–189.
The study reports concentration of ambient air pollutants and attributable mortality
from Varanasi, India.
36. Rajarathnam U, Sehgal M, Nairy S, et al. HEI Health Review Committee: Part
2. Time-series study on air pollution and mortality in Delhi. Res Rep Health Eff
Inst 2011; 157:47–74.
37. Adam M, Schikowski T, Carsin AE, et al. Adult lung function and long-term air
pollution exposure. ESCAPE: a multicentre cohort study and meta-analysis.
Eur Respir J 2015; 45:38–50.
38. Das P, Chatterjee P. Association of ambient air quality with pulmonary
function of youngster footballers. Asian J Sports Med 2014; 5:39–46.
39. DeVries R, Kriebel D, Sama S. Outdoor air pollution and COPD-related
& emergency department visits, hospital admissions, and mortality: a meta-
analysis. COPD 2017; 14:113–121.
Meta-analysis on increased risk of hospital admissions because of COPD exacer-
bation because of AAP.
40. Orellano P, Quaranta N, Reynoso J, et al. Effect of outdoor air pollution on
& asthma exacerbations in children and adults: systematic review and multilevel
meta-analysis. PloS One 2017; 12:e0174050.
Meta-analysis on increased risk of asthma exacerbations in children and adults
because of AAP.
41. Chen G, Wan X, Yang G, et al. Traffic-related air pollution and lung cancer: a
meta-analysis. Thorac Cancer 2015; 6:307–318.
42. Zhang Y, Wang SG, Ma YX, et al. Association between Ambient Air Pollution
and Hospital Emergency Admissions for Respiratory and Cardiovascular
Diseases in Beijing: a Time Series Study. Biomed Environ Sci BES 2015;
28:352–363.
43. Pande JN, Bhatta N, Biswas D, et al. Outdoor air pollution and emergency
room visits at a hospital in Delhi. Indian J Chest Dis Allied Sci 2002;
44:13–19.
44. Sehgal M, Rizwan SA, Krishnan A. Disease burden due to biomass cooking-
fuel-related household air pollution among women in India. Glob Health Action
2014; 7:25326.
45. Dhanaraj B, Papanna MK, Adinarayanan S, et al. Prevalence and risk factors
for adult pulmonary tuberculosis in a metropolitan city of South India. Plos One
2015; 10:e0124260.
46. Jubulis J, Kinikar A, Ithape M, et al. Modifiable risk factors associated with
tuberculosis disease in children in Pune, India. Int J Tuberc Lung Dis 2014;
18:198–204.
Volume 23  Number 00  Month 2017
CE: Tripti; MCP/240204; Total nos of Pages: 9;
MCP 240204
47. Lewis JJ, Hollingsworth JW, Chartier RT, et al. Biogas stoves reduce firewood
use, household air pollution, and hospital visits in Odisha, India. Environ Sci
Technol 2017; 51:560–569.
48. Household Air Pollution and Health: A Multicountry LPG Intervention Trial.
[Internet]. [Cited 30 September 2017]. Available from: https://clinicaltrials.-
gov/ct2/show/NCT02944682. [Accessed 30 September 2017]
49. Pradhan SN, Das A, Meena R, et al. Biofluid metabotyping of occupationally
exposed subjects to air pollution demonstrates high oxidative stress and
deregulated amino acid metabolism. Sci Rep 2016; 6:35972.
50. Sussan TE, Ingole V, Kim JH, et al. Source of biomass cooking fuel determines
pulmonary response to household air pollution. Am J Respir Cell Mol Biol
2014; 50:538–548.
51. Balakrishnan K, Sambandam S, Ramaswamy P, et al. Establishing integrated
rural–urban cohorts to assess air pollution-related health effects in pregnant
women, children and adults in Southern India: an overview of objectives,
design and methods in the Tamil Nadu Air Pollution and Health Effects
(TAPHE) study. BMJ Open 2015; 5:e008090.
52. National Air Quality Index. Central Pollution Control Board; 2015 [cited 1
October 2017] p. 1–54. Available from: http://cpcb.nic.in/FINAL-REPOR-
T_AQI_.pdf. [Accessed 1 October 2017]
53. Central Pollution Control Board. Environmental Standards, National Ambient
Air Quality Standards [Internet]. [Cited 3 October 2017]. Available
from: http://www.cpcb.nic.in/National_Ambient_Air_Quality_Standards.php.
[Accessed 3 October 2017]
1070-5287 Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Air pollution in India Khilnani and Tiwari
54. World Health Organisation. Air quality guidelines – global update 2005
[Internet]. WHO. [Cited 3 October 2017]. Available from: http://
www.who.int/phe/health_topics/outdoorair/outdoorair_aqg/en/. [Accessed
3 October 2017]
55. European Commission. Standards – Air Quality – Environment – European
Commission [Internet]. [Cited 3 October 2017]. Available from: http://ec.eur-
opa.eu/environment/air/quality/standards.htm
56. United States Environment Protection Agency. NAAQS Table [Internet]. US
EPA. 2014 [Cited 3 October 2017]. Available from: https://www.epa.gov/
criteria-air-pollutants/naaqs-table
57. Quansah R, Semple S, Ochieng CA, et al. Effectiveness of interventions to
&& reduce household air pollution and/or improve health in homes using solid fuel
in low-and-middle income countries: a systematic review and meta-analysis.
Environ Int 2017; 103:73–90.
The study provides evidence of inadequacy of improved cookstoves in achieving
WHO recommended indoor air quality.
58. Sehgal M, Gautam SK. Odd even story of Delhi traffic and air pollution. Int J
Environ Stud 2016; 73:170–172.
59. Kumar P, Gulia S, Harrison RM, et al. The influence of odd–even car trial on
& fine and coarse particles in Delhi. Environ Pollut 2017; 225:20–30.
The study reports the influence of odd–even car trial on AAP in Delhi.
60. Giannadaki D, Lelieveld J, Pozzer A. Implementing the US air quality standard
for PM2.5 worldwide can prevent millions of premature deaths per year.
Environ Health 2016; 15:88.
www.co-pulmonarymedicine.com 9