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
www.sagepublications.com Tel. þ44 1737 221360, Fax þ44 1737 221588
E-Mail j.a.hoskins@isbe.demon.co.uk
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 Research has shown that the indoor levels of some
pollutants, such as formaldehyde [13], chloroform [14] and
styrene [15], range from 2 to 50 times higher than outdoor
levels. Overall, though, in many countries, pollutant
concentrations indoors are similar to those outdoors,
with the ratio of indoor to outdoor concentration
falling in the range 0.7–1.3. Higher levels of indoor
pollution are usually the result of combustion processes
associated with cooking or heating coupled with poor
ventilation. Exposure to some pollutants such as environ-
mental tobacco smoke and radon occurs almost entirely
indoors.
Indoor sources may lead to an accumulation of some
compounds that are rarely present in the ambient air.
Conversely the urban outdoor air is dominated by
the VOC mixture known as BTEX (benzene, toluene,
ethylbenzene, xylenes) comprised of the major petroleum
constituents. Concentrations of combustion products in
indoor air can be substantially higher than those outdoors
when heating and cooking appliances are used. This
is particularly true in countries where ovens and
braziers are used with imperfect kitchen and stove designs
[16–18]. In many countries exposure to emissions from
cooking and heating may produce the highest indoor air
pollution exposures to many pollutants. Today about
half the population of the world has to rely for cooking
and associated space heating on simple household
stoves using unprocessed solid fuels that have high
emission factors for a range of health-damaging air
pollutants [18,19].
Specific health effects are often claimed for individual
pollutants, particularly causes of cancer from the presence
of carcinogens in the air. Health effects from exposure to
the whole mixture of pollutants are often held responsible
for vaguely defined syndromes or conditions such as sick
building syndrome (SBS) or building related illnesses
(BRI) [20,21].
Sick building syndrome is the occurrence of specific
symptoms with unspecified aetiology, that are experi-
enced by people while working or living in a particular
building, but which disappear after they leave it. Symptoms
include mucous membrane, skin and eye irritation, chest
tightness, fatigue, headache, malaise, lethargy, lack of con-
centration, odour annoyance and influenza symptoms.
SBS usually cannot be attributed to excessive exposure to
any one contaminant or to a defective ventilation system
although this is often claimed. A number of factors may be
involved and it is assumed that the interaction of these
factors, involving different reaction mechanisms, cause the
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syndrome, but there is as yet no clear evidence of any
exposure–effect relationship [22,23].
Although the definition is vague BRI is often defined
as an illness related to indoor exposures to biological
and/or chemical substances (e.g. fungi, bacteria, endotox-
ins, mycotoxins, radon, CO, HCHO). It is experienced by
some people working or living in a particular building and
it does not disappear after leaving it [24]. Illnesses include
respiratory tract infections and diseases, legionnaires’
disease, and more controversially, cardiovascular diseases
and lung cancer.
Factors that Affect Indoor Air Quality
The air quality inside buildings is affected by many
factors. In an effort to conserve energy, modern building
design has favoured tighter structures with lower rates
of ventilation. By contrast, in some areas of the world only
natural ventilation is used; in other areas mechanical
ventilation is common [25]. In spite of the move to tighter
structures there is still continuous air exchange between
indoors and outdoors such that indoor concentrations
of air pollutants are influenced by outdoor levels. The
extent to which this occurs depends upon the rate
of exchange between indoor and outdoor air; and these
levels are subject to geographical, seasonal and diurnal
variations [26].
Within buildings the factors that can have a negative
effect on health and comfort range from chemical and
biological pollutants, to occupant perceptions of specific
stresses such as temperature, humidity, artificial light,
noise and vibration [27]. Important sources of chemical
pollutants indoors include not only outdoor air, but also
human body and human activities, plus emissions from
building materials, furnishings and appliances and use of
consumer products. Microbial contamination is mostly
related to the presence of humidity. The heating, ventilat-
ing and air conditioning system can also act as a pollutant
source, especially when it is not properly maintained. For
example, improper care of filters can lead to re-emission
of particulate contaminants. Biological contamination can
proliferate in moist components of the system and be
distributed throughout the building.
One of the most important causes of indoor pollution is
combustion [28]. The level of pollution produced depends
on the fuel that is burnt and how it is burnt. The cleanest
fuel is gas, although there are several types, but at the
bottom of the energy ladder is biomass [29,30]. Although
part of human experience since the first controlled use of
Hoskins
fire, air pollution from simple open combustion of
biomass has been scientifically characterised only in the
last two decades, largely due to rising concerns about
wood-smoke pollution in developed countries [31]. Studies
have shown high emission factors for many important
pollutants, including respirable particulate matter, carbon
monoxide, polycylic aromatic hydrocarbons, such as
benzo[a]pyrene, and volatile organic compounds, such as
formaldehyde and benzene. Biomass fuels emit hundreds
of chemicals during small-scale combustion, such as in
household cooking or heating stoves. It has been shown
that such fuels produce 10–100 times more respirable parti-
culate matter per meal as the result of low (combustion
and heat-transfer) efficiencies. Although biomass makes
up only 10–15% of total human fuel use, compared to
modern fuels a much larger fraction is burned indoors,
since nearly one-half of humanity cooks and/or heats with
simple stoves burning traditional biomass fuels [12].
It is not known what fraction of biomass-burning
households cook indoors on un-vented stoves, although it
is clear that many hundreds of millions do so during some
or all seasons of the year. There is also little information
about the ventilation rates in the many thousands of
housing types in developing countries or countries in
transition. Unfortunately, relatively little monitoring
has been done in these indoor environments and none
of it has been done in a way to provide statistically valid
samples of large populations. The results that have
been obtained, nevertheless, are striking. Very high
concentrations of particles in indoor air can occur,
sometimes for short duration, such as during cooking
over solid fuel fires in rooms with poor ventilation.
The active and passive inhalation of tobacco smoke can
lead to reduced pulmonary function, to an increased
incidence of respiratory symptoms and infections, and
to an increased incidence of lung cancer. Tobacco smoke
is a fresh biomass smoke, which has been studied far
more than any other pollutant mixture. Since there are
similarities between ETS and biomass smoke from stoves,
as hundreds of the organic compounds they both contain
are similar it seems obvious that exposure to biomass
smoke from open stoves causes considerable human ill-
health world wide. In the second-hand form as ETS, it
is associated with adverse health impacts in adults
and children at particle concentrations similar to those at
which the epidemiological studies of health effects of
outdoor particulate matter have been conducted. It should
also be kept in mind that exposure to ETS and other air
pollutants can act synergistically to produce adverse health
effects [32].
Health Effects due to Indoor Air Pollution
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Health Effects
Since the early 1970s, interest in the health effects of
indoor air pollution has increased annually. Consequently,
a large body of literature is now available on diverse
aspects of indoor air pollution: sources, concentrations,
health effects and the engineering technology needed to
ameliorate the problem [33,34]. More recently it has
been realised that indoor air pollution from the use of
open fires for cooking and heating is a serious problem in
developing countries [12,35].
When it comes to health effects most indoor air
pollutants directly affect the respiratory and cardiovascu-
lar systems and the severity of effect varies according to
both the intensity and the duration of exposure, and also
with the health status of the population exposed [36–39].
The importance of this is that some members of the
population may be at greater risk than others. Many of
those who are especially susceptible to the health effects of
indoor pollutants are those who will spend nearly all
of their time indoors. These include infants and the elderly,
those with heart and lung diseases and people with asthma,
as well as hyper-responders and even the fitter members of
society who are exercising [40].
A lot of the work on the health effects of indoor air
pollution concentrates on a single pollutant, for example,
sulphur dioxide, particulate matter, carbon monoxide
or nitrogen dioxide. This specificity is particularly so
when the pollutant is a known human carcinogen such as
benz[a]pyrene, benzene or radon.
Although carcinogenicity may be a good reason for
studying individual pollutants as stand alone causes, the
fact that all pollutants differ in the health effects they
cause would seem to be an equally good reason for
discriminating between them. Thus, although we rarely
breathe any one pollutant in isolation some pollutants,
such as carbon monoxide, have such a dramatic effect on
health that they should be considered separately [41].
Carbon monoxide causes disruption of the chemistry in
several cell types, which, at low exposure levels, may be
reversible. There are other pollutants that can cause cell
damage and cell death, such as sulphur dioxide, nitrogen
dioxide and particulate matter, and particularly mineral
fibres. Cell death removes a cell but cell damage can have
more serious consequences for the organism. On the other
hand dead cells promote mitogenesis and this in its turn
may lead to mutagenesis. A high level of mutagenesis
may lead to inheritable changes in cell DNA and
eventually to cancer.
Indoor Built Environ 2003;12:427–433 429
 Carbon Monoxide
Acute exposure to high levels of carbon monoxide
can be life-threatening but the consequence of chronic
exposure to low levels is not really known [42,43]. In
general, average short-term CO concentrations at kerbside
locations in developed countries are about 60 mg
m3 for
30 min or 30 mg
m3 for 1 h. In kitchens with gas stoves,
short-term values of up to 15 mg
m3 have been measured.
High values have also been measured in bars and pubs,
where smoking is common, with average concentrations
of 10–20 mg
m3 and peak levels up to 30 mg
m3 [44].
Nitrogen Dioxide
Nitrogen dioxide is an insidious pollutant that causes
lung damage and for which there may be no threshold of
action [33,45,46]. In countries that cook and heat by gas
(used in 20–80% of houses in some countries) indoor levels
of NO2 can be surprisingly high. In a UK study (noted
with others in [47]), the average NO2 concentrations (over
a week) were in the range of 9.4–596 mg
m3 in kitchens,
for houses with gas cookers and 1l.3–353.4 mg
m3 in
dwellings with electric cookers. Corresponding levels
outdoors were 26.3–45.1 mg
m3. These exposure levels
may have an effect on respiratory function [48]. If cooking
ranges are unvented people may be exposed to even
higher NO2 levels. In addition, short-term measurements
reveal NO2 concentrations that may be five-fold higher
than those averaged over several days. Peak values of up to
3800 mg
m3 for 1 min have been measured in the
Netherlands in kitchens with unvented gas cooking
ranges [44,49].
Volatile Organic Compounds (VOCs)
All indoor environments contain a range of organic
compounds, the more volatile ones are commonly grouped
together for convenience as VOCs [50]. Most of these are
present at very low concentrations have no measurable or,
at the worst, insignificant health effects. However, when
high levels do occur they may have health effects that
range from sensory irritation to behavioural, neurotoxic,
hepatoxic and genotoxic effects [51]. Exposures sufficient
to cause health effects are more often associated with
occupational exposure but such exposure can be in the
home when large quantities of solvents or solvent-based
materials are used for building and maintenance. Several
of the VOCs that cause concern do so because they are real
or suspected human carcinogens. These, like the inorganic
gases and some other pollutants, are generally considered
individually.
430 Indoor Built Environ 2003;12:427–433
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Volatile Organic Compounds are not the only mixture
studied. Environmental tobacco smoke (ETS) is widely
considered as an important factor in indoor air quality
[52,53]. However, something that is often forgotten is that
ETS is not ubiquitous. If no one is or has been smoking in
an indoor environment there can be no exposure to ETS.
ETS can be considered as a mixture of particle and vapour
phases. Together these are complex mixtures of several
thousand chemicals, including known carcinogens such as
nitrosamines and benzene. One of the most commonly
used indicators of environmental pollution by tobacco
smoke is the concentration of PM10. This measurement of
the particulate phase is 2–3 times higher in houses with
smokers than in other houses [54].
One commonly encountered volatile organic chemical
that is not usually considered, as a VOC is formaldehyde.
In five developed European countries HCHO concen-
trations in indoor air were reported to range from
9 to 70 mg
m3. Higher values are occasionally encoun-
tered, especially in dwellings with urea-formaldehyde foam
insulation [55]. Although this is less used nowadays as
a building material formaldehyde is often encountered
indoors as a residual chemical from the manufacture of
insulation boards [56,57]. Since formaldehyde has been
shown to be carcinogenic in rats, much of the interest in
its presence arises through fears that it may also be a
human carcinogen.
As noted above a quartet of chemicals ubiquitous in the
built environment is the petrol (gasoline) mixture of
aromatics BTEX. For reasons known only to politicians
and financiers this excites little comment, although it
may be a major part of the total VOC level. However, the
minor constituent, benzene, is a known human carcinogen
and is therefore usually discussed as such. A recent study
of environmental levels of benzene [58] noted that these
were three orders of magnitude lower than the lowest
exposures reported to be associated with observed adverse
effects.
Radon
Then there is the one pollutant whose radioactivity sets
it apart from all other indoor pollutants. The evidence is
good that it is a human carcinogen and this is its only
property that causes concern. In general, average indoor
levels of radon are 20–70 Bq
m3 [59], although they may
be ten times higher in certain areas.
So, there are reasons for studying individual pollutants
in isolation and other reasons for looking at them
altogether. Leaving aside industrial and occupational
exposure, which may be to a single pollutant and may be
Hoskins
to high doses, with the possible exception of nitrogen
dioxide the pollutants found indoors that cause concern
with regard to their possible health effects are those which
have the potential for such an exposure to result in cancer.
Cancer Causing Chemicals in Indoor Air
Cancer as a disease has been described since the earliest
medical records were kept. The earliest known descriptions
of which appear in Egyptian papyri and were written
around 1600 B.C. but are believed to date from sources
as early as 2500 B.C. One describes surgery, while the
other outlines pharmacological, mechanical and magical
treatments.
However, the causes of cancer belong to more recent
times and the recognition of environmental cancers
was not made until the eighteenth century. Although
many occupations such as mining give rise to cancerous
conditions it is probable that in the past conditions were so
bad that few lived long enough for a tumour to develop.
Although cancers can occur at any time throughout life
they are particularly known as a disease of old age. It
was only in the twentieth century that large numbers of
the population lived to old age, say, beyond the seventh
decade. Ascribing the cause of cancer to exposure to
pollution of one sort or another was something that
probably only came about in the last fifty years or so.
Epidemiological studies in the 1950s looked at differences
in lung cancer rates between rural and urban areas. Such
studies have continued up to the present time classifying
exposure according to levels of various pollutants such as
benz[a]pyrene, particulates and sulphur dioxide/sulphate
levels.
The Hazard – Carcinogens in the Indoor Environment
A number of the chemicals found in the indoor
environment are classed as carcinogens, although not all
of them are well documented as human carcinogens. The
list of organic compounds that may be found in the indoor
environment is small and includes formaldehyde [60,61],
certain polycylic aromatic hydrocarbons (PAHs) [62],
benzene [58,63] and 1,3-butadiene [64]. Tobacco smoke
including ETS contains, among many other compounds,
benzene, nitrosoamines and PAHs [65].
Several inorganic compounds are classified as carci
nogens including, among others, arsenic, nickel and chro-
mium in their elemental form or as compounds [66,67].
Arsenic is a major problem in well water in many areas of
the world including Bangladesh, West Bengal [68] and
Health Effects due to Indoor Air Pollution
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Taiwan [69] where it is an undoubted cause of cancer. In
some areas of China and India, household coal use leads to
high indoor concentrations of fluorine, which causes
fluorosis but not cancer, [28] and arsenic [70] with
consequent health effects. Other inorganic materials that
can pollute the indoor environment include the various
types of asbestos and other mineral fibres. Diseases from
these include lung cancer and mesothelioma but almost
always as a result of occupational exposure [7173].
The only natural radioactive element to cause concern
is radon. It is a proven lung carcinogen in both animals
and man but the risks it poses, at least in the domestic
rather than occupational setting, are still unclear.
The Risks from Carcinogens in the Indoor Environment
In a 1987 study, the U.S. Environmental Protection
Agency (EPA) ranked indoor air pollution fourth in
cancer risk among the 13 top environmental problems
analysed. Indoor radon ranked first in this list. The risk
posed by the level of radon found in dwellings is still hotly
debated with the ecologists finding an inverse relationship
between lung cancer and radon levels [74] or that there
is little correlation [75] and the epidemiologists promoting
a linear no-threshold model which contradicts these
findings [76,77].
However, what may be so in America, is not necessarily
so in the rest of the world. Relatively few studies, for
example, have been conducted to determine the health
effects of indoor exposures to air pollutants in developing
countries, although data has become available in recent
years to obtain some preliminary information on the
type and very approximate magnitude of effects [28]. The
one major difference between rich and poor nations
that are responsible for differences in observed health
effects is the way in which they generate energy. When
energy generation is produced remote from the areas
where people live, it has little impact on personal health. If
energy generation for heating, lighting and cooking is
confined to the dwelling-place and is almost entirely
accomplished by direct combustion, then a greater or
lesser effect on health is to be expected depending on the
quality of the fuel that is burnt. The lower the fuel is down
the energy ladder, the greater the pollution it causes and
the greater the incidence of cancer caused by inhaling the
polluted emissions. Lung cancer is a probable consequence
of biomass burning [16] although not all studies find an
association while coal for cooking and heating has been
shown in many Chinese studies to yield a statistically
positive relationship with coal smoke and disease [78–80].
Indoor Built Environ 2003;12:427–433 431
 Conclusion
Air pollution is responsible for much morbidity and
mortality in the world. Its heterogeneous nature, though,
means that few generalisations about its cause and effects
can be made. Higher levels of pollution are associated with
poverty and most pollution comes from combustion of one
sort or another. For the global population as a whole,
indoor pollution is more important than outdoor
pollution, although high ambient levels obviously
adversely affect the indoor environment. Moving from
poverty to wealth does not mean an escape from pollution,
but rather exchanging some elements of it for others:
radon has never been shown to be a problem in poor and
draughty housing. Paradoxically, a wealthy lifestyle
promotes greater concern about pollution, but in reality
it means appreciably less ill health and death from
environmental causes.

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