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. Author manuscript; available in PMC: 2024 Dec 1.
Published in final edited form as: Dev Psychobiol. 2023 Dec;65(8):e22440. doi: 10.1002/dev.22440

The Impact of Air Pollution on Neurocognitive Development: Adverse Effects and Health Disparities

Kim-Chi T Pham 1, Kimberly S Chiew 1
PMCID: PMC10683861  NIHMSID: NIHMS1940773  PMID: 38010305

Abstract

Air pollution is recognized as a major public health concern. The number of deaths related to ambient air pollution has increased in recent years and is projected to continue rising. Additionally, both short- and long-term air pollution exposure has been linked with deleterious effects on neurocognitive function and development. While air pollution poses as a threat to everyone, people of color and individuals of lower socioeconomic status are often exposed to elevated levels of air pollution as a function of systemic racism and classism. Further, given additional disparities in access to healthcare and other compounding stressors, adverse effects of air pollution on neurocognitive health are exacerbated among individuals who hold marginalized identities – making effects both less likely to be detected and treated. This review examines evidence of the effects of air pollution on neurocognitive development across the lifespan and incorporates an environmental justice perspective to highlight disparities in air pollution exposure across race and socioeconomic status. Lastly, upon the reviewed evidence, limitations of past research and recommendations for policy are discussed.

Keywords: air pollution, neurocognitive development, health disparities, environmental justice

Introduction

Addressing and mitigating poor air quality has been a long-standing environmental and public health issue. In the United States, the Clean Air Act (CAA), the first federal air quality law intended to limit air pollution, was enacted in 1963 (CAA, 1963). Over the past half-century, the CAA and other environment protection laws have helped to drastically reduce air pollution nationally. However, after decades of reduced emissions, the United States experienced a 5.7% increase in fine particulate matter (PM2.5) from 2016 to 2018 (Clay, Muller & Wang, 2021). Increases of natural gas emissions, nitrate production from motor vehicles, and wildfires in recent years have negatively impacted ambient air quality and contributed to these national increases of PM2.5 and other harmful air pollutants. Air pollution has been fully recognized as a significant public health problem (Kelly & Fussell, 2015), with increased levels of PM2.5 contributing to an estimated 9,700 premature deaths and $89 billion in damages in the U.S. alone (Clay, Muller & Wang, 2021). Exposure to fine particulate matter has also been associated with adverse effects on cognitive and brain development, with implications for physical and mental health outcomes (Bakolis et al., 2021; Genc et al., 2012; Zhang, Chen & Zhang, 2018). Further, there are widespread inequities present in exposure to air pollution and its resultant effects (Pratt et al., 2015; Zou et al., 2014). The present review outlines the effects of air pollution on neurocognition over development, the disproportionate impact of air pollution on historically marginalized groups, and recommendations for policy.

Air pollution represents a combination of diverse components, including particulate matter (PM), gases, organic compounds, and toxic metals (Costa et al., 2014; Genc et al., 2012) that can be found in both outdoor and indoor air. Although there are many types of air pollutants inside the Earth’s atmosphere (e.g., elevated levels of ozone, lead, sulfur dioxide, nitrogen dioxide, carbon monoxide), this review’s primary focus is the impact of PM2.5 and ultrafine particulate matter (UFPM), given these compounds’ ability to enter the circulatory system and penetrate organs, including the brain (Costa et al., 2014; Miller et al., 2021). Particulate matter is characterized by its size and aerodynamic features that affect biological properties (Genc et al., 2012; Oudin, 2020). Fine particulate matter is classified as < 2.5 μm and UFPM as < 0.1 μm (Genc et al., 2012) and is believed to be the most widespread and threatening air pollutant (Costa et al., 2014; Suades-González et al., 2015).

Across different research studies, multiple methods have been used to estimate exposure to air pollution and its constituent compounds. Many of the research studies in the present review rely on participants’ reported zip code or reported residential address, then use pollutant measurements from nearby municipal monitoring sites to provide an estimate of annual exposure. Over time, the models used to estimate pollution exposure from such measurements have evolved, incorporating algorithms such as land-use regression that draw on geographical characteristics of the terrain, climate patterns, and human land use to improve their predictive ability (Hoek et al., 2008). However, it has also been noted that these approaches have limitations in their ability to provide exact measures of personal air pollution exposure, including missing data, missing geographic areas (dependent on the location of monitoring sites), and failing to capture variations in pollutant exposure as a function of where people live versus work/study (Gray, Edwards, & Miranda, 2013). A more limited number of research studies in the present review have incorporated direct personal monitoring of air quality (i.e., at participants’ residential or school sites, or using devices carried by participants), used participant residential addresses to compare between individuals living relatively close versus far from major roadways to examine relative pollutant exposure, or used biomarkers of benzene collected from participant urine samples as a more direct marker of traffic-related pollution exposure (i.e., Kicinski et al., 2015). However, these approaches also have practical limitations, especially in large-scale population studies.

Along with long-documented effects on respiratory and cardiac function (Brunekreef & Holgate, 2002), recognition that air pollution adversely affects the brain and nervous system has been growing in the past two decades (Genc et al., 2012). Converging observations across animal, in vitro, and human studies suggest that the biological mechanisms by which air pollution may harm neurocognitive development include increases in oxidative stress and neuroinflammation (reviewed in Costa et al., 2014; Costa et al., 2020). Early studies of post-mortem brain tissue from canines from the Mexico City area (characterized by high levels of air pollution) relative to control samples from a less-polluted region suggested that higher air pollution exposure might be linked to elevated neuroinflammation, DNA damage, and evidence of neurodegeneration in cortical and glial cells (Calderón-Garcidueñas et al. 2002, 2003). In vitro studies confirm cytotoxic effects of particulate matter exposure, resulting in elevated oxidative stress and inflammation (Block et al., 2004; Xu et al., 2020). Consistent with these findings in animal and in vitro models, studies in humans have reported higher levels of proinflammatory markers in cerebrospinal fluid of the brain as a function of air pollution exposure (Calderón-Garcidueñas et al., 2008).

Such changes at the cellular level may serve as mechanisms underlying observed adverse effects of air pollution on human health. Short-term exposure to harmful air is associated with increased risk of asthma-related emergency room visits (Dominici et al., 2006; Yang et al., 2019; Zheng et al., 2015), increased inflammation (Dauchet et al., 2018; Tsai et al., 2019), and short-term cognitive decline (Shehab & Pope, 2019). Chronic exposure to air pollution is associated with higher incidences of cardiovascular diseases (Brook et al., 2010; Chi et al., 2016; Rajagopalan, Al-Kindi, & Brook, 2018; Tonne et al., 2007), respiratory diseases (Katanoda et al., 2011; Kravitz-Wirtz et al., 2018; Raju et al., 2019), neurodegenerative disorders (Costa et al., 2017; Oudin, 2020; Power et al., 2016), and neurodevelopmental delays (Block et al., 2012; Clifford et al., 2016; Costa et al., 2017). Prolonged exposure to ambient air pollution has been linked to increased rates of depression (Gładka, Rymaszewska, & Zatoński, 2018; Kim et al., 2016), aggressive behavior (Burkhardt et al., 2020), and other mental health challenges (Miller et al., 2019; Tzivian et al., 2015).

While detrimental effects of air pollution on human health are well-established, its impact has been inequitably distributed, with some communities affected more than others. Global evidence (including studies from North American, South American, European, Asian, and African locations) indicate a link between socioeconomic status (SES) and exposure to air pollution: specifically, individuals that experience economic hardship are more likely to reside in areas with elevated levels of air pollution (Evans & Kantrowitz, 2002; Martins et al., 2004; Hajat, Hsia & O’Neill, 2015; Yang & Liu, 2018; Ofoezie et al., 2022). In the United States, Americans of color are disproportionately exposed to and negatively impacted by air pollutants relative to White Americans (Hadeed et al., 2021; Wooduff et al., 2003).

Taken together, this manuscript reviews recent evidence of the impact of air pollution (with a particular focus on PM2.5 and UFPM) on neurocognitive function and development and related health disparities. We largely focus on evidence from studies based in the United States, but also draw on findings from studies conducted globally. We note that the evidence reviewed generally indicates consistent findings regarding the adverse impact of air pollution across geographic regions, but that the present review does not systematically compare for differences in outcomes as a function of location. Additionally, given variability in the neurocognitive outcomes examined relative to air pollution exposure across studies in current literature, we review evidence from studies utilizing a broad range of cognitive, behavioral, and neural outcomes, including measures of cognitive performance from multiple domains (such as attention, memory, visual, verbal, and motor function) as well as related measures such as IQ and academic performance, sleep and behavioral outcomes (such as hyperactivity), and measures of brain structure, function, and connectivity. We use a lifespan perspective, examining adverse effects of air pollution at ages ranging from gestation to older adulthood, as well as intersecting influences of poverty and racism associated with disparities in the adverse effects of air pollution on cognition and neurodevelopment. Finally, on the basis of the reviewed evidence, we will present policy recommendations to address both the impact of air pollution generally as well as in terms of racial, ethnic, and socio-economic disparities. These policy recommendations are primarily framed within the United States context, given that the reviewed evidence is largely United States-based, as are the manuscript authors.

Impact of Air Pollution on Cognition and Behavior Over the Lifespan

A growing literature provides evidence that air pollution exposure adversely effects cognitive and behavioral outcomes across a broad range of domains and over the course of the lifespan. In the present section, we highlight key findings from this literature, organized chronologically from the prenatal and infant stage through adolescence to older adulthood.

The early years of life are critical for the development of cognitive processes, including attention, memory, language and motor functions, essential to adaptive behavior and daily activities (Johnson & Munakata, 2005; Kundakovic & Champagne, 2015). An ever-growing body of research has implicated air pollution as a harmful agent that disrupts cognitive functioning and development. There is mounting evidence that adverse cognitive outcomes are associated with exposure to fine particulate matter beginning in the prenatal period. Utilizing data from 1,109 mother-child dyads in Massachusetts, Harris and colleagues (2015) found that prenatal residential proximity to major roadways (i.e., higher exposure to traffic-related air pollutants) measured during the third trimester predicted lower verbal and nonverbal skills as well as poorer visuomotor abilities in middle childhood (at ~8 years of age), controlling for demographic and parental factors, neighborhood income, and predictors of indoor pollution. Furthermore, a systemic review of 126 recent epidemiological studies examining air pollution exposure and neuropsychological development during infancy and early childhood identified a significant association between air pollution during gestation and infant cognitive development (Suades-González et al., 2015). Specifically, exposure to high levels of PM2.5 during the prenatal period was linked to delayed global, verbal, and psychomotor development during infancy.

There is also evidence that prenatal exposure to air pollutants can adversely affect sleep and behavioral outcomes during early childhood. Bose and colleagues (2019) examined gestational PM2.5 exposure, estimated from reported residential addresses, and sleep outcomes subsequently in childhood in a sample of parents and children from Mexico City, a geographic region characterized by high levels of air pollution (Calderón-Garcidueñas et al., 2016; Mahady et al., 2020). Bose et al. identified a sensitive period at 31-35 weeks of gestation (i.e., during the third trimester), during which PM2.5 exposure was significantly associated with decreased total hours of sleep later during the preschool years. The American Association of Sleep Medicine (AASM) recommends that children between the ages of three and five years old get 10-13 hours of sleep every day (Paruthi et al., 2016). However, the sample of children examined in Bose et al. (2019) averaged 7.8 hours of sleep a day, well below this recommendation, even when controlling for SES, mother’s body mass index, season, and maternal age. Bose et al. (2019) also found that prenatal PM2.5 exposure at 1-8 weeks (i.e., during the first trimester) was associated with lower sleep efficiency (defined as the percentage of time spent in bed asleep vs awake) during the children’s preschool years. The authors linked these poor sleep outcomes to heightened regional pollution exposure during pregnancy. Importantly, reduced sleep hours and poor sleep quality during this developmental stage can lead to challenges in cognitive function, weight problems, and behavioral maladjustment (Spruyt, 2019).

Exposure to high levels of air pollution during infancy are also associated with elevated rates of neurodevelopmental disorders such as attention deficit/hyperactivity disorder (ADHD) (Aghaei et al., 2019; Costa et al., 2020; Siddique et al., 2011; Thygesen et al., 2020). A 2016 meta-analysis of the relationship between early life exposure to air pollution and Autism Spectrum Disorder (ASD) risk provided limited evidence of toxicity for this association, with the strongest observed relationship between air pollution and ASD diagnosis for PM2.5 (Lam et al., 2016). Notably, this meta-analysis included both studies of prenatal as well as postnatal exposure, but did not systematically test for differences in the association between pollution and ASD diagnosis as a function of exposure period. Relatedly, longitudinal data from the Cincinnati Childhood Allergy and Air Pollution Study, which recruited Cincinnati-area children from families living near (< 400 metres) or far (> 1500 metres) from a major highway or bus route, indicates that exposure to higher levels of traffic-related air pollution during the first year of life predicts subsequent rates of hyperactivity, a key behavioral characteristic of ADHD, at ~7 years of age (Newman et al., 2013).

These studies together provide important evidence that exposure to air pollution during the prenatal period and early life is associated with adverse effects on cognitive and behavioral outcomes. However, given limited research literature investigating this relationship as well as heterogeneity in analysis approaches, observed results, and studied periods of exposure over the course of pregnancy, it is currently an open question whether specific critical periods during pregnancy exist whereby air pollution exposure presents a greater or lesser threat to cognitive development (Suades-González et al., 2015). Some studies of brain development have suggested that air pollution exposure during pregnancy might be most impactful on neural outcomes during the third trimester, as discussed in more detail below (see in The Impact of Air Pollution on Brain Health Over the Lifespan).

Along with evidence that poor air quality during early development is associated with adverse cognitive and behavioral outcomes, studies suggest that improving air quality might improve such outcomes as well as related metrics such as academic performance. Stafford (2015) conducted a natural quasi-experiment that included virtually every elementary school within a Texas school district and reported that students’ standardized test pass rates improved with mold removal (~3-4% increase), renovations to air ventilation (~2-3% increase), and roofing replacement (~3% increase) in the schools. These results remained significant even after controlling for confounding variables such as student attendance, school finances, and sociodemographic characteristics. On the basis of these observations, Stafford (2015) posited that renovations to improve schools’ indoor air quality may be a cost-effective way to improve students’ test scores, relative to other strategies such as reducing classroom sizes. While PM2.5 concentrations were not directly characterized in this study, Stafford’s results suggest a relationship between air quality and cognitive/academic performance to be explored further in future work. These findings also highlight one possible strategy for mitigating the impacts of poor air quality, an issue we return to later in the paper.

Adolescence is also a critical period for cognitive and behavioral development (Steinberg, 2005) but the impact of air pollution exposure on cognitive performance in adolescence has been understudied relative to its impact earlier in childhood. Kicinski et al. (2015) conducted an initial study investigating the association between traffic-related air pollution (characterized using biomarkers of benzene from urine samples as well as self-reported exposure to traffic) and performance on a series of neurobehavioral tasks (assessing sustained attention, short-term memory, and manual motor speed) in an adolescent sample (N=606) based in the Netherlands. They reported that increased traffic-related pollution exposure was associated with decreased sustained attention – specifically, for every one standard deviation (SD) increase in composite traffic-related air pollution exposure, they observed a 0.26 SD decrease in sustained attention performance (approximately one-third of the effect size of maternal education on attentional performance in this sample). On the other hand, Kusters et al. (2022) examined associations between prenatal and childhood air pollution exposure (using estimates based on residential address) and cognitive and behavioral outcomes (including processing speed, working memory, fluid reasoning, and IQ measures) in adolescents 13-16 years old (N=4683) from the Generation R longitudinal study conducted in the Netherlands. For the most part, these relationships were insignificant (or even positive, as observed between exposure to a small number of pollutant compounds and fluid reasoning as well as verbal IQ; these positive results were interpreted as reflecting negative residual confounds, selection bias, or chance). While further research needs to be done to characterize these relationships further, taken together, current findings indicate that air pollution is associated with adverse cognitive and behavioral outcomes during infancy and childhood in terms of lower verbal and nonverbal skills, visuomotor abilities, delayed psychomotor development, sleep, and academic performance, as well as poorer attentional performance in adolescence.

In addition to evidence indicating that ambient air pollution adversely impacts cognitive functioning in early life, numerous studies demonstrate that air pollution has negative effects on cognitive performance in adulthood as well. In a sample of 1,764 American adults ages 20-59 years in the Third National Health and Nutrition Examination Survey (NHANES-III), Chen and Schwartz (2009) observed cross-sectional associations between greater long-term exposure to air pollution (assessed using participants’ residential location at the time of study enrollment and measurements of annual PM10 levels to approximate long-term exposure to ambient air pollution; note that PM2.5 levels were not measured in this study) and reduced cognitive performance (measures of reaction time, visuomotor speed, sustained attention, perceptual functioning, and short-term memory). La Nauze and Severnini (2021) provided further cross-sectional evidence for the relation between air pollution and cognitive functioning: by examining performance on popular brain-training games as a function of users’ geographic location (measured by zip code) within the United States, they were able to characterize the relationship between PM2.5 exposure (estimated by zip code using monitoring data) and adult cognitive functioning across seven domains (verbal, attention, flexibility, memory, math, speed, and problem solving). Their results suggested that increasing levels of PM2.5 were associated with poorer cognitive performance, with the strongest deleterious effects observed on memory performance. Additionally, the inverse relationship between PM2.5 exposure and cognitive performance was strongest in low-performing individuals, suggesting that PM2.5 exposure might compound with other influences to exacerbate inequalities in cognitive performance. Finally, in this sample, the strongest negative relationship between air pollution exposure and cognitive performance was observed in young to middle-aged adults (under 50 years). Given that adults in this age range comprise a large portion of the workforce (Bureau of Labor Statistics, 2022), this finding implies that air pollution might impact group-level work performance, with major economic implications.

Adverse effects of air pollution on cognitive performance have also been observed in older adulthood. A recent systematic review identified multiple studies, both longitudinal and cross-sectional, demonstrating that elevated exposure to PM2.5 was negatively associated with verbal learning and working memory abilities in older adults globally (Clifford et al., 2016). Additionally, by reviewing global epidemiological and experimental data, Oudin (2020) identified that long-term air pollution exposure was associated with elevated risk of Alzheimer’s disease (AD), vascular dementia, and mild cognitive impairment in older adults. Delgado-Saborit et al. (2021) highlight further evidence, both longitudinal and cross-sectional, that chronic exposure to high levels of air pollution was associated with declining global cognition and visuo-spatial abilities in older adults at an accelerated rate beyond normative aging; this decline was also associated with increased risk of developing dementia. Given exponential growth of older adults as a proportion of the United States population (Vespa, 2018), the link between air pollution exposure and accelerated age-related cognitive decline is particularly important from a public health standpoint.

Taken together, this reviewed evidence demonstrates the negative impact of air pollution on cognitive functioning. These adverse effects can be observed in a wide range of cognitive domains across the lifespan, with widespread implications for daily behavior, academic and behavioral outcomes, as well as rates of cognitive decline and dementia later in life.

The Impact of Air Pollution on Brain Health Over the Lifespan

Along with adverse effects on cognition and behavior, air pollution exposure has been associated with alterations in the development of brain structure, function, and connectivity across the lifespan. Organized similarly to our review of cognitive and behavioral outcomes above, the present section reviews evidence regarding the impact of air pollution on brain health, spanning from the prenatal stage to older adulthood.

Exposure to PM2.5 during pregnancy, estimated using measurements of pollutant compound concentrations and traffic exposure by birth county, has been linked to low birthweight (Bell et al., 2010) which increases risk of neurological disorders, intellectual impairment, and other developmental challenges (Martinussen et al., 2005). Bell et al. (2010) further suggested that the relationship between PM2.5 exposure and low birth weight may be more robust for exposure during the third trimester. Additionally, Nawrot et al. (2018) reported that PM2.5 exposure during the third trimester, estimated from monitoring site data using residential address, influenced methylation of circadian pathway genes in both parent and fetus. Given the critical role of circadian rhythms (internal processes that regulate the sleep-wake cycle) in biological, psychological, and social development (Foster, 2020), such disruption can have serious health implications, including elevated risk of premature birth (Kajeepeta et al., 2014, Reschke et al., 2018), adverse experiences at birth (van den Berg et al., 2017), and neurological disorders (Nawrot et al., 2018). Ambient PM2.5 exposure is also associated with alterations in brain structure and function during development (Bell et al., 2005; Block et al., 2012; Calderón-Garcidueñas et al., 2016; Costa et al., 2017). A recent systematic review (de Prado Bert et al., 2018) of effects of air pollution exposure on the brain over the course of development suggested that children with greater exposure to PM2.5 displayed reduced white matter structure throughout the brain, including in the frontal, parietal, and temporal lobes, which in turn were associated with deficits in attention, short-term memory, and learning abilities, as well as deleterious effects on behavioral and psychomotor development in children. While not directly measuring for differences in the relative impact of air pollution on the brain as a function of prenatal period exposure, de Prado Bert et al. (2018) also suggest that the third trimester of pregnancy might be particularly critical given that neuron myelination starts during this period and follows specific spatiotemporal ordering (Baumann & Pham-Dinh, 2001) that may be disrupted by exposure to toxins (Maiuolo et al., 2019). However, as when considering cognitive and behavioral outcomes, additional research is needed to pinpoint critical periods during pregnancy where brain development and neural outcomes may be most vulnerable to the impact of air pollution exposure.

While early life is a critical period for brain development, large-scale functional networks of the brain continue to mature through childhood and adolescence; evidence suggests that the impact of air pollution on neurodevelopment also continues through this period. Pujol et al. (2016) used functional magnetic resonance imaging (fMRI) to examine effects of traffic pollution exposure on functional brain connectivity during a sensory task in a Barcelona-based sample of children ages 8-12 years. Increased exposure to traffic-related air pollution, measured directly at children’s school sites during class time for two 1-week periods separated by 6 months, was associated with reduced integration and segregation in brain networks supporting both internally- and externally-guided cognition (the default mode network and task-related networks; Fox et al., 2005), as well as poorer attention and motor task performance. Herting and colleagues (2019) conducted a systematic review of structural and function MRI studies to evaluate how early-life exposure to ambient air pollution affects neurodevelopment, and identified that higher levels of outdoor air pollution were associated with abnormalities (both decreases and increases) in white matter, cortical and subcortical gray matter, and brain volume within pre-adolescent children (under 13 years old). Finally, Miller and colleagues (2021) examined longitudinal effects of PM2.5 and early life stress (ELS), as well as their interaction, on adolescent brain development in a sample of 115 San Francisco and San Jose Bay Area adolescents. PM2.5 exposure was estimated for each participant using satellite-derived estimates of PM2.5 concentrations relative to reported residential address. Miller et al. identified changes in brain volume associated with both independent and interactive effects of ELS severity and PM2.5 levels; further, adverse effects of PM2.5 were attenuated in adolescents with histories of more severe ELS. Together, the results of these studies demonstrate the negative impact of air pollution on brain development and associated cognitive function during childhood and adolescence.

In contrast to literature examining effects of air pollution on neurodevelopment in childhood and adolescence, relatively few studies have examined effects of air pollution on brain health in older adulthood. In one such study, Hedges and colleagues (2019) evaluated the cross-sectional relation between estimated exposure to atmospheric toxins, based on reported residential address, and hippocampal volume in a United Kingdom-based sample of adults between 40-69 years. The study observed reduced left hippocampal volume with increasing exposure to PM2.5; these effects were significant even when controlling for age, sex, body-mass index, overall health, alcohol use, smoking, education attainment, and socioeconomic status. These findings are particularly alarming given the vital role of the hippocampus in learning and memory, and observations of reduced cognitive function in association with hippocampal volume reductions in cognitive aging, dementia, and neuropsychiatric diseases (Hedges et al., 2019). Relatedly, Chen and colleagues (2015) longitudinally examined the adverse effects of ambient PM2.5 (estimated using residential history and monitoring data) on brain matter in a sample of 1,403 older women (age range: 71-89 years) in the United States-based Women’s Health Initiative Memory Study (WHIMS). Chen et al. observed that in this sample, greater long-term exposure to PM2.5 predicted significant reductions in frontal lobe, temporal lobe, and corpus callosum white matter volume, independent of demographic factors, SES, lifestyle factors, and geographical region (although notably, in contrast to Hedges et al. (2019), Chen et al. (2015) did not observe a significant relationship between PM2.5 exposure and hippocampal volume). Finally, exposure to particulate matter and environmental nanoparticles has been identified as a risk factor for the development of neuroinflammation and neurodegeneration in older adulthood (Calderón-Garcidueñas et al., 2016; Costa et al., 2017). In recent years, there has been increasing evidence linking air pollution to diseases of the central nervous system (CNS), including stroke, Alzheimer’s disease, Parkinson’s disease, and neurodevelopmental disorders (Block et al., 2012; Genc et al., 2012). Taken together, these findings indicate that air pollution has deleterious effects on brain health and development at all stages of the lifespan, with widespread health, economic, and human costs.

Disparities in Exposure to and Impact of Air Pollution

While there is mounting evidence that environmental contaminants pose a threat to all of us, exposure to low air quality does not affect everyone to the same extent. In particular, growing evidence indicates that exposure to air pollution might vary as a function of race and socioeconomic status as a result of systemic racism and classism. These differences in air pollution exposure compound with other group disparities in health, education systems, and other factors to amplify disparities in related health outcomes, including those in the neurocognitive domain. These compounding disparities and the need to address them has been recognized as a fundamental issue of environmental justice by the Environmental Protection Agency (EPA) and other federal agencies in the United States (https://www.epa.gov/ej-research). Below, we review evidence of racial/ethnic and SES-related disparities in air pollution exposure and impact, and advocate for evidence-based policy changes to reduce both air pollution exposure as well as disparities in its impact. Given that our policy recommendations below are targeted towards the United States, we primarily focus on evidence of United States-based disparities, although note that studies have suggested that similar racial/ethnic- and socioeconomic status-related disparities in air pollution exposure exist globally, including in France (Havard et al., 2009), Ghana (Rooney et al., 2012), India (Kopas et al., 2020), and China (Yang et al., 2022) and that calls have been made for more comprehensive studies of pollution-related health disparities outside the United States as well as comparatively (Jerrett, 2009).

Decades of research has demonstrated that exposure to air pollutants varies as a function of socioeconomic status (SES): specifically, lower-SES communities have often been the target of policies resulting in greater concentrations of air pollution (Ferguson et al., 2020) such as higher exposure to traffic and industrial emissions (Havard et al., 2009). A study conducted in North Carolina revealed that neighborhood-level concentration of fine particulate matter, estimated using air quality monitoring data and numerical output, was significantly associated with three SES-related factors: median household income, percentage of people living below the poverty line, and percentage of people with less than a high school education within the population (Gray, Edwards & Miranda, 2013). Further, Hajat et al. (2013) reported that in the Multi-Ethnic Study of Atherosclerosis (MESA), a large population-based study conducted in several regions of the United States, increased SES at both the neighborhood- and individual-level was significantly inversely correlated with air pollutant concentration levels (estimated for each participant’s home address using a combination of air quality monitoring data, personal sampling, measures of housing quality, and geographic covariates), even after adjusting for demographic variables and metropolitan area. This relationship was larger for neighborhood-level SES, although relationships between pollutant levels and both SES measures were significant. The significant inverse relationship between neighborhood-level SES and air pollutant levels may be understood as the product of policy decisions leading to elevated traffic and industrial emissions exposure in lower-SES neighborhoods; the similar relationship observed for individual-level SES may also reflect such community-level influences as well as related factors at the individual level (i.e., housing quality and direct proximity to roadways; but Hajat et al. also note that the extent to which individual- and neighborhood-level SES variables in the MESA dataset capture shared variance remains unclear given differences in their data collection).

In addition to the disparities in exposure and adverse effects of air pollution across socioeconomic status, people of color are also disproportionately impacted by air pollution. Nationally, this can be understood as a legacy of the United States’ longstanding history of racist segregation policies, corresponding disparities in neighborhood development, and broader structural violence towards racial and ethnic minorities (Namin et al., 2020; Smith & Stovall, 2008; Woo et al., 2019). Using census block group data from American urban areas, Ash and Fetter (2004) reported that Black and African American populations are higher in cities with higher levels of air pollution; and within those cities, Black populations are higher in heavily polluted neighborhoods, as are Latino populations. Using urban census tract data from across the United States, Zou and colleagues (2014) provided further evidence that on average, African Americans, Native Americans and Indigenous people, along with Asian Americans and Pacific Islanders (AAPI), are exposed to greater levels of air pollutants than White Americans.

While there is mounting evidence that socioeconomic status and systemic race/ethnicity-based discrimination each predict ambient air pollution exposure independently, effects of economic and racial-ethnic disparities can also compound. Grineski, Bolin, and Boone (2007) uncovered that in the Phoenix metropolitan area, neighborhood-level SES was negatively associated with estimated carbon monoxide (CO) levels, indicating that neighborhoods with lower SES had higher levels of CO. Grineski et al. also reported that racial/ethnic neighborhood composition was a significant and positive predictor of exposure to CO pollution: specifically, neighborhoods with higher proportions of Native Americans and Latino immigrants had higher levels of CO, independent of SES. Housing tenure was also a significant predictor of CO exposure: areas with higher proportion of renters (relative to homeowners) had higher levels of CO. These results are especially concerning given that the Phoenix Metropolitan area is the fifth largest metropolitan area in the U.S., one of the fastest growing areas in the country, and has failed to meet EPA standards for atmospheric pollutants for decades (Grineski, Bolin, & Boone, 2007). These findings indicate that while poor air quality poses a health threat to everyone in a given region, historically marginalized communities might be particularly exposed to the harmful effects of air pollution.

In addition to increased exposure to air pollution at the neighborhood level, low-income and historically marginalized communities may also be exposed to elevated air pollution within the household. Poverty is strongly related to increased exposure to household air pollutants including greater use of high-emission fuel sources, such as biomass and coal, for cooking, heating and lighting (Hadeed et al., 2021). Additionally, individuals from low-SES and historically marginalized communities might spend more time indoors, given reduced access to recreational spaces and opportunities as well as perceived neighborhood concerns, placing them at greater vulnerability to indoor pollutants, such as cigarette smoke and household chemicals (Ferguson et al., 2020; Woo et al., 2019). Housing in such communities might also be more poorly ventilated and in poorer condition, contributing to greater risk of indoor air pollution exposure (Tieskens et al., 2021).

This increased exposure to air pollution compounds with other health disparities to amplify adverse pollution-related health outcomes for vulnerable communities. People from lower SES groups tend to have worse overall health than individuals of high-SES, which could make them more susceptible to the damaging effects of air pollution (Bell et al., 2005). Additionally, people of color and lower-SES individuals experience elevated levels of psychosocial stress related to discrimination; this stress exposure has been shown to predict poorer health outcomes including heightened vulnerability to air pollution’s adverse effects (Block et al., 2012, Nardone et al., 2018). Multi-directional relationships between increased susceptibility, heightened exposure to polluted air, financial hardship, and discrimination-based stress may have cumulative effects on people’s overall physical and socioemotional well-being. Furthermore, poor people tend to have less access to health care – and lower quality care – than people of higher socioeconomic status, which might make addressing the physical effects of exposure to air pollution even more difficult (Kravitz-Wirtz et al., 2018).

Differences in air pollution exposure may also have contributed to disparities in wide-ranging outcomes related to the Coronavirus disease 19 (COVID-19) pandemic (Brandt et al., 2020). While the evolving nature of the pandemic, confounding socioeconomic variables, geographic differences, and underestimation of case and mortality data present challenges to quantification of the relationship between air pollution exposure and COVID-19 outcomes, a recent review indicated a significant positive association between air pollution and averse COVID-19 health outcomes globally in 91% of papers included (Bhaskar et al., 2023). A growing literature indicates broader racial disparities in COVID-19-related outcomes; in the United States, this has included disparities in case rates (Credit, 2020; Ramprasad et al., 2022), hospitalization (Ogedegbe et al., 2020; Romano et al., 2021), mortality (Alcendor, 2020; Parpia et al., 2021), and “long COVID”, characterized by symptoms persisting for three months or more after COVID-19 infection (Jacobs et al., 2023). The detrimental effects of air pollution on health and disparities in these effects may have contributed to disparities in COVID-19 outcomes. It is likewise possible that disparities in COVID-19 outcomes and related ongoing adverse health outcomes (including long COVID and elevated risk of other subsequent adverse health events including stroke and cardiac disease post-infection; Ahmed et al., 2022; Xie et al., 2022) may position marginalized communities to be further negatively affected by ongoing air pollution exposure, but to our knowledge this bidirectional relationship has not been explored in the literature and remains an important question for future research. Thus, compounding effects of COVID-19, air pollution, and systemic racism and classism on brain health and cognitive function have yet to be fully characterized.

The U.S. Environmental Protection Agency (EPA) has recognized that race-, ethnicity-, and income-based discrimination plays a role in the inequitable distribution of environmental health burden: addressing such disparities has been identified by the EPA as a major goal and an issue of environmental justice (USEPA, 2022). Uneven urban development and residential segregation have pushed people of color into communities with fewer public goods (Grineski, Bolin & Boone, 2007), including green spaces (Nardone et al., 2021), opportunities for outdoor recreation (Winter et al., 2020), and pharmacies (Qato et al., 2014), as well as increased industrial and freeway exposure (Woghiren-Akinnifesi , 2013; Houston et al., 2004). This is in spite of the fact that people of color have been identified as consuming fewer goods and services and having a smaller “carbon footprint” on average, relative to white people (Tessum et al., 2019). This body of research illustrates the disparities in benefit and burden existing in the consumption of goods and exposure to air pollutants across race/ethnicity and SES (Zou et al., 2014), as well as interactions between race/ethnicity and SES in predicting exposure to harmful air pollutants (Ash & Fetter, 2004; Brochu et al., 2011).

Although environmental justice and equity issues have garnered the interest of researchers, policy holders, advocacy groups, and the general public, very few studies have assessed the cumulative risks of holding historically marginalized identities (i.e., racial-ethnic minorities in the U.S. and/or being of low-SES) in addition to heightened exposure to ambient air pollutants on human health (Smith & Laribi, 2022). One recent study (Schulz et al., 2020) examined the joint effects of race-based residential segregation, neighborhood socioeconomic factors, and environmental pollutant exposure (estimated using air quality monitoring and modeling data) in the Detroit Metropolitan Area and reported that race-based residential segregation was associated with increased rates of all-cause mortality (all deaths that occurred within a population, regardless of the cause). This effect was mediated by education attainment level, income inequality across the area, and exposure to PM2.5. Additionally, there were significant associations between each individual pathway and the all-cause mortality rate, indicating that each factor can partially explain regional-level all-cause mortality rates. Despite these indicators that historic marginalization, SES, and pollution exposure interact with one another to predict all-cause mortality, their cumulative risk on other specific health consequences, such as neurocognitive outcomes, remains to be fully examined. A recent pilot study (Medrano et al., 2022) provides an important step in this direction by investigating cognitive performance as a function of real-time measured personal exposure to PM2.5 (measured using personal monitoring devices carried by participants for a three-day period) and zip code-aggregated Social Vulnerability indices, and reported initial evidence that higher real-time PM2.5 exposure was negatively associated with cognitive performance as well as with socioeconomic metrics (higher parental education and income). Medrano et al.’s study was limited by use of a relatively small convenience sample (N=30 families with a child between the ages of 7 and 11 years old) and a constrained timeline; additional studies with larger, more diverse samples measured over longer periods of time will be beneficial in disentangling the cumulative impacts of air pollution and social vulnerability on neurocognitive outcomes.

Recommendations for Policy

The evidence reviewed here indicates that air pollution has major and adverse effects on neurocognitive development. Further, there are disparities in these effects, with some communities impacted more than others. A number of potential actions will help to address these issues. First, as noted by Clay, Muller & Wang (2021), ambient air pollution has increased since 2016 and this might be largely due to increased vehicle emissions. One strategy to address this increase might be to expand electric vehicle rebate programs, encouraging purchase and use of lower-emission vehicles. Additionally, increased investment into public transit infrastructure might increase its usage, thus decreasing air pollution by lowering vehicle emissions output. Investment in sustainable energy sources more broadly will also reduce air pollution by promoting transition away from use of high-emission fossil fuels.

In addition to these strategies to reduce emissions output generally, recommendations have also been put forward to specifically address the problem of inequity in pollution exposure and related health outcomes. While many previous environmental interventions have disproportionately benefited high-income communities, The Union of Concerned Scientists, a nonprofit advocacy organization, has recommended prioritizing investments in electric transit and school buses serving communities of color and lower income to decrease emissions exposure in these communities, decreasing racial and income disparities in pollution impact (Pinto de Moura, 2019). Additionally, while electric vehicle rebate programs could encourage purchase of lower-emission vehicles generally, such programs could prioritize low- to moderate-income individuals in particular, helping to mitigate disparities in pollution impact as well.

Furthermore, given that green space is lacking in marginalized communities and improves air quality (Jennings et al., 2015; Wen et al., 2013), prioritizing the development of green spaces in such communities could also help reduce disparities in pollution exposure and related health outcomes. Increases in green space also offer many other health benefits for communities: along with reducing air pollution, green space also decreases noise and heat pollution (Andersson et al., 2015; Douglas et al., 2017), promotes stress recovery and positive mental health outcomes (Bratman et al., 2019; Nutsford & Pearson, 2013), and is negatively associated with neighborhood-level crime (Bogar et al., 2016; McCabe, 2014). In addition to these recommendations to reduce disparities in exposure to and the impact of air pollution specifically, these considerations can be considered part of the larger need to address structural disparities disadvantaging marginalized communities (Rigolon et al., 2021).

In addition to strategies improving outdoor air quality, steps to improve indoor air quality are important as well. As demonstrated by Stafford (2015), ventilation systems renovations improving indoor air quality in schools have been associated with significant improvements in students’ cognitive, behavioral, and academic outcomes. Removal of harmful indoor contaminants (e.g., mold, asbestos), renovating air ventilation systems, and updating roofing and wall panels are all proven cost-efficient ways to reduce indoor air pollution and improve air quality. In addition to support for such improvements in older buildings, regulatory standards for indoor air quality should be developed and enforced. Current air quality regulations generally do not go beyond addressing outdoor air conditions, despite indoor air pollution posing a serious threat to public health (Roselund, 2020).

Finally, government agencies should both aim to better enforce current regulations and develop future environmental policies. Many large sources of air pollutants, such as factories and coal mines, are not properly regulated and penalized for failing to meet federal air quality standards (Payne-Sturges et al., 2019). Additionally, state governments and individual organizations need to be held accountable for failing to provide and regulate safe air for their residents (Melnick, 2010; Jacob & Winner, 2009). The 2022 Supreme Court decision curtailing EPA authority to reduce greenhouse gas emissions from power plants (Huang, 2022) is a concerning step in the wrong direction regarding such regulatory authority.

Conclusion

Air pollution has been fully recognized as a public health concern. Scientists have established a clear link between air pollution and negative health outcomes. As reviewed in the present manuscript, prenatal exposure to fine particulate matter can impact fetal programming and early development, while air pollution exposure during infancy and childhood is associated with poorer outcomes in a wide range of neurocognitive measures. Air pollution also adversely affects health outcomes in adulthood, including elevated rates of Alzheimer’s disease, dementia, and cognitive impairment in older adults.

Further, environmental justice advocates and environmental inequity researchers have brought to light the disproportionate exposure and harmful effects of air pollution amongst people of color and low socioeconomic status. Despite historically contributing the least to environmental pollutants, people of color and low-income individuals are experiencing the most damaging and lasting effects of air pollution and climate change more broadly. We all deserve the right to clean air and we should all be invested in climate change policy. Given the economic and human costs of air contaminants, it is imperative that local and federal legislators prioritize recommendations such as those we have outlined here to ensure that every person has access to clean and safe air.

Acknowledgements

K.S.C. is supported by the National Institute of Mental Health (R15MH117690) and a Young Investigator Award from the Brain & Behavior Research Foundation.

Footnotes

Conflict of Interest Disclosure

The authors have no conflicts of interest to disclose.

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