Intended for healthcare professionals


Air pollution moves up the global health agenda

BMJ 2018; 363 doi: (Published 27 November 2018) Cite this as: BMJ 2018;363:k4933

This article has a correction. Please see:

  1. Natalia Linou, policy specialist1,
  2. Jessica Beagley, policy research manager2,
  3. Suvi Huikuri, consultant1,
  4. Nina Renshaw, policy and advocacy director3
  1. 1United Nations Development Programme, New York, NY, USA
  2. 2NCD Alliance, London, UK
  3. 3NCD Alliance, Geneva, Switzerland
  1. Correspondence to: Natalia Linou Natalia.linou{at}

UN recognises air pollution as a key risk factor for NCDs

The international community working on the prevention and control of non-communicable diseases (NCDs) has historically focused on four disease groups (diabetes, cancer, cardiovascular diseases, and chronic respiratory diseases) and four risk factors (tobacco use, harmful use of alcohol, unhealthy diets, and physical inactivity). The United Nations high level meeting on NCDs, held in September 2018, signalled a shift from this four-by-four approach to a five-by-five response, adding mental health conditions and key environmental risk factors to the lists.

The opportunities and implications of this shift in scope are substantial: from an exclusive focus on what are often considered purely behavioural risk factors to a wider consideration of environmental determinants of health, including indoor and outdoor air pollution, water and soil pollution, and climate change.1

Aligned with this expansion of NCD priorities at the United Nations, the World Health Organization now officially recognises air pollution as a fifth risk factor for NCDs.2 As the first WHO global conference on air pollution and health in October made clear, the epidemiological imperative to tackle air pollution as part of NCD prevention is irrefutable: air pollution causes 5.6 million deaths from NCDs annually.3 It causes 24% of all deaths from stroke and 43%, 29%, and 25% of all deaths and disease from chronic obstructive pulmonary disease, lung cancer, and ischaemic heart disease respectively.4

Looking beyond the individual

This much needed mandate to bring the environmental health and NCD communities closer together, is important for at least two additional reasons. Firstly, recognition of air pollution as a leading NCD risk factor calls into question the ubiquitous individual lifestyle explanations for the rise of NCDs; these explanations are not only victim blaming but ignore key structural and contextual factors.

Although there is strong evidence that the regulatory and policy environment (smoke-free laws, trade subsidies, alcohol licencing laws, and marketing regulations) as well as social inequities and the built environment shape the distribution of NCDs, too often clinicians and policy makers focus on individual choices and behaviours.5 The inclusion of air pollution and recognition of wider environmental determinants within the NCD agenda strengthens calls for rebalancing attention towards the structural determinants of health and health inequities.

Secondly, this shift will support advocacy on environmental issues by applying lessons from the NCD community to emerging environmental challenges, including climate change. Tactics that are being used by the fossil fuel industry, from withholding evidence or funding organisations with the sole purpose of refuting scientific research, are reminiscent of those used by tobacco companies.

This is not surprising since tobacco and oil companies have employed the same public relations firms and research institutions since the 1950s.6 The NCD community already has guidelines and best practices that could be deployed to tackle environmental challenges. For example, effective measures to counter interference from tobacco companies, and increasingly the alcohol and sugar sweetened beverage industries, could be applied to the fossil fuel industry.

The potential to improve health by redirecting government subsidies away from harmful industries and towards the achievement of the sustainable development goals is similarly large. In 2015, 6.5% of global gross domestic product was used to subsidise fossil fuels7; this money could have been used to accelerate the achievement of universal health coverage.8 One estimate suggests that in 2014, G20 governments spent $444bn in subsidies to fossil fuel companies, resulting in health costs of six times this amount (roughly $2.76tn).9 The NCD community is equipped to advocate for fiscal policies that can simultaneously advance the health of both people and planet.

Joining forces

There is already a strong push towards closer collaboration between the health, development, and climate change communities, along with research into how attention to environmental determinants of NCDs can advance multiple health and development goals. One international research initiative, for example, is studying how urban environments and policies in Latin America affect the health of city residents, including how expanding public transportation could simultaneously increase physical activity, reduce emissions, and cut traffic related air pollution.10

Similarly, efforts by the EAT-Lancet Commission on Food, Planet, Health to produce targets for what constitutes both a healthy diet and a sustainable food system, will also encourage the transformations required to tackle our most pressing health and environmental challenges.

Health and development solutions that are good for both planet and people are urgently needed, and we must collectively redouble our efforts. We hope that the inclusion of air pollution within a five-by-five UN framework for NCDs will help bridge the gaps between the environmental justice, climate change, and health equity movements, and bring new energy and partnerships to bear on increasingly urgent global priorities.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have none to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.