Self-reported history of stroke and long-term living conditions near air pollution sources: results of a national epidemiological study in Lebanon

  • Pascale Salameh
  • Rita Farah
  • Souheil Hallit
  • Rouba Karen Zeidan
  • Mirna N. Chahine
  • Roland Asmar
  • Hassan Hosseini


Stroke is a disease related to high mortality and morbidity, particularly in developing countries. Some studies have linked self-reported indoor and outdoor pollution to stroke and mini-stroke, while some others showed no association. Our objective was to assess this association in Lebanon, a Middle Eastern developing country. A national cross-sectional study was conducted all over Lebanon. In addition to self-reported items of pollution exposure, we assessed potential predictors of stroke and mini-stroke, including sociodemographic characteristics, self-reported health information, and biological measurements. Moreover, we assessed dose-effect relationship of pollution items in relation with stroke. Self-reported indoor pollution exposure was associated with stroke and mini-stroke, with or without taking biological values into account. Moreover, we found a dose-effect relationship of exposure with risk of disease, but this effect did not reach statistical significance after adjustment for sociodemographics and biological characteristics. No association was found for any outdoor pollution item. Although additional studies would be necessary to confirm these findings, sensitizing the population about the effect of pollution on chronic diseases, working on reducing pollution, and improving air quality should be implemented to decrease the burden of the disease on the population and health system.


Self-reported Living conditions Stroke history Indoor pollution Outdoor pollution Dose-effect Developing country 


Compliance with ethical standards

Conflict of interest

None to declare.


  1. Alimohammadi, H., Fakhri, S., Derakhshanfar, H., Hosseini-Zijoud, S. M., Safari, S., & Hatamabadi, H. R. (2016). The effects of air pollution on ischemic stroke admission rate. Chonnam Medical Journal, 52(1), 53–58. Scholar
  2. Baalbaki, R., Al-Assaad, K., Mehanna, C. J., Saliba, N. A., Katurji, M., & Roumie, M. (2013). Road versus roadside particle size distribution in a hot Mediterranean summer—estimation of fleet emission factors. Journal of the Air & Waste Management Association (1995), 63(3), 327–335.CrossRefGoogle Scholar
  3. Barbour, B., Saadeh, N., & Salameh, P. R. (2012). Psychological distress in Lebanese young adults: constructing the screening tool ‘BDS-22’. International Journal of Culture and Mental Health, 5(2), 94–108.CrossRefGoogle Scholar
  4. Bennett, S., Woods, T., Liyanage, W. M., & Smith, D. L. (1991). A simplified general method for cluster-sample surveys of health in developing countries. World Health Statistics Quarterly, 44(3), 98–106.Google Scholar
  5. Bouyer, J. (2009). Epidémiologie: principes et méthodes quantitatives: Lavoisier.Google Scholar
  6. Central Administration of Statistics, Ministry of Social Affairs. Population. Available from:
  7. Central Administration of Statistics. List of Circumscriptions. Available from:
  8. Chiu, H.-F., Chang, C.-C., & Yang, C.-Y. (2014). Relationship between hemorrhagic stroke hospitalization and exposure to fine particulate air pollution in Taipei, Taiwan. Journal of Toxicology and Environmental Health, Part A, 77(19), 1154–1163.CrossRefGoogle Scholar
  9. Crichton, S., Barratt, B., Spiridou, A., Hoang, U., Liang, S. F., Kovalchuk, Y., et al. (2016). Associations between exhaust and non-exhaust particulate matter and stroke incidence by stroke subtype in South London. Science of the Total Environment, 568, 278–284. Scholar
  10. Dijkema, M. B., van Strien, R. T., van der Zee, S. C., Mallant, S. F., Fischer, P., Hoek, G., et al. (2016). Spatial variation in nitrogen dioxide concentrations and cardiopulmonary hospital admissions. Environmental Research, 151, 721–727. Scholar
  11. Farah, R., Zeidan, R. K., Chahine, M. N., Asmar, R., Chahine, R., Salameh, P., & Hosseini, H. (2015). Prevalence of stroke symptoms among stroke-free residents: first national data from Lebanon. International Journal of Stroke, 10(Suppl A100), 83–88. Scholar
  12. Fischer, F., & Kraemer, A. (2015). Meta-analysis of the association between second-hand smoke exposure and ischaemic heart diseases, COPD and stroke. BMC Public Health, 15, 1202. Scholar
  13. Franchini, M., & Mannucci, P. M. (2011). Thrombogenicity and cardiovascular effects of ambient air pollution. Blood, 118(9), 2405–2412. Scholar
  14. Gill, E. A., Curl, C. L., Adar, S. D., Allen, R. W., Auchincloss, A. H., O'Neill, M. S., et al. (2011). Air pollution and cardiovascular disease in the multi-ethnic study of atherosclerosis. Progress in Cardiovascular Diseases, 53(5), 353–360. Scholar
  15. Giorgini, P., Di Giosia, P., Grassi, D., Rubenfire, M., Brook, R. D., & Ferri, C. (2016). Air pollution exposure and blood pressure: an updated review of the literature. Current Pharmaceutical Design, 22(1), 28–51.CrossRefGoogle Scholar
  16. Hoffmann, B., Weinmayr, G., Hennig, F., Fuks, K., Moebus, S., Weimar, C., et al. (2015). Air quality, stroke, and coronary events: results of the Heinz Nixdorf Recall Study from the Ruhr Region. Deutsches Ärzteblatt International, 112(12), 195–201. Scholar
  17. Howard, V. J., McClure, L. A., Meschia, J. F., Pulley, L., Orr, S. C., & Friday, G. H. (2006). High prevalence of stroke symptoms among persons without a diagnosis of stroke or transient ischemic attack in a general population: the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Archives of Internal Medicine, 166(18), 1952–1958. Scholar
  18. Issa, C., Jomaa, L., Salamé, J., Waked, M., Barbour, B., & Zeidan, N. (2014). Females are more adherent to Lebanese Mediterranean diet than males among university students. Asian Pacific Journal of Health and Sciences, 1(4), 345–353.Google Scholar
  19. James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., et al. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the eighth joint National Committee (JNC 8). JAMA, 311(5), 507–520. Scholar
  20. Kulick, E. R., Wellenius, G. A., Kaufman, J. D., DeRosa, J. T., Kinney, P. L., Cheung, Y. K., Wright, C. B., Sacco, R. L., & Elkind, M. S. (2017). Long-term exposure to ambient air pollution and subclinical cerebrovascular disease in NOMAS (the northern Manhattan study). Stroke, 48(7), 1966–1968. Scholar
  21. Lahoud, N., Salameh, P., Saleh, N., & Hosseini, H. (2016). Prevalence of Lebanese stroke survivors: a comparative pilot study. Journal of Epidemiology and Global Health, 6(3), 169–176. Scholar
  22. Lee, M. S., Hang, J. Q., Zhang, F. Y., Dai, H. L., Su, L., & Christiani, D. C. (2012). In-home solid fuel use and cardiovascular disease: a cross-sectional analysis of the Shanghai Putuo study. Environmental Health, 11, 18. Scholar
  23. Lin, H., Guo, Y., Di, Q., Zheng, Y., Kowal, P., Xiao, J., et al. (2017). Ambient PM2.5 and stroke: effect modifiers and population attributable risk in six low- and middle-income countries. Stroke, 48(5), 1191–1197. Scholar
  24. Lin, L. Y., Chuang, H. C., Liu, I. J., Chen, H. W., & Chuang, K. J. (2013). Reducing indoor air pollution by air conditioning is associated with improvements in cardiovascular health among the general population. Science of the Total Environment, 463-464, 176–181. Scholar
  25. Martinelli, N., Olivieri, O., & Girelli, D. (2013). Air particulate matter and cardiovascular disease: a narrative review. European Journal of Internal Medicine, 24(4), 295–302. Scholar
  26. Moussa, M. R., Hussein, R. A., & El-Naggar, H. M. (2016). Environmental risk factors and the associated morbidity in a periurban area, Alexandria, Egypt. The Journal of the Egyptian Public Health Association, 91(1), 44–51. Scholar
  27. Nasser, Z., Salameh, P., Nasser, W., Abou Abbas, L., Elias, E., & Leveque, A. (2015). Outdoor particulate matter (PM) and associated cardiovascular diseases in the Middle East. International Journal of Occupational Medicine and Environmental Health, 28(4), 641–661. Scholar
  28. Nogueira, J. B. (2009). Air pollution and cardiovascular disease. Revista Portuguesa de Cardiologia, 28(6), 715–733.Google Scholar
  29. O’Brien, E., Asmar, R., Beilin, L., Imai, Y., Mallion, J. M., Mancia, G., et al. (2003). European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. Journal of Hypertension, 21(5), 821–848. Scholar
  30. Olasky, S. J., Levy, D., & Moran, A. (2012). Second hand smoke and cardiovascular disease in low and middle income countries: a case for action. Global Heart, 7(2), 151–160 e155. Scholar
  31. Onor, I. O., Stirling, D. L., Williams, S. R., Bediako, D., Borghol, A., Harris, M. B., et al. (2017). Clinical effects of cigarette smoking: epidemiologic impact and review of pharmacotherapy options. International Journal of Environmental Research and Public Health, 14(10), 1147.CrossRefGoogle Scholar
  32. Qiao, Q., Keinanen-Kiukaanniemi, S., Rajala, U., Uusimaki, A., & Kivela, S. L. (1995). Random capillary whole blood glucose test as a screening test for diabetes mellitus in a middle-aged population. Scandinavian Journal of Clinical and Laboratory Investigation, 55(1), 3–8.CrossRefGoogle Scholar
  33. Qu, W., Yan, Z., Qu, G., & Ikram, M. (2015). Household solid fuel use and cardiovascular disease in rural areas in Shanxi, China. Iran Journal of Public Health, 44(5), 625–638.Google Scholar
  34. Rumeau-Rouquette, C., Bréart, G., & Padieu, R. (1985). Méthodes en Epidémiologie: Echantillonnage, investigations, analyse.Google Scholar
  35. Salameh, P., Chahine, M., Hallit, S., Farah, R., Zeidan, R. K., Asmar, R., et al. (2018). Hypertension prevalence and living conditions related to air pollution: Results of a national epidemiological study in Lebanon. Environmental Science and Pollution Research. 
  36. Sarigiannis, D. A., & Hansen, U. (2012). Considering the cumulative risk of mixtures of chemicals—a challenge for policy makers. Environmental Health, 11(Suppl 1), S18. Scholar
  37. Scheers, H., Jacobs, L., Casas, L., Nemery, B., & Nawrot, T. S. (2015). Long-term exposure to particulate matter air pollution is a risk factor for stroke: meta-analytical evidence. Stroke, 46(11), 3058–3066. Scholar
  38. Stafoggia, M., Cesaroni, G., Peters, A., Andersen, Z. J., Badaloni, C., Beelen, R., et al. (2014). Long-term exposure to ambient air pollution and incidence of cerebrovascular events: results from 11 European cohorts within the ESCAPE project. Environmental Health Perspectives, 122(9), 919–925. Scholar
  39. Stockfelt, L., Andersson, E. M., Molnar, P., Gidhagen, L., Segersson, D., Rosengren, A., et al. (2017). Long-term effects of total and source-specific particulate air pollution on incident cardiovascular disease in Gothenburg, Sweden. Environmental Research, 158, 61–71. Scholar
  40. Tohme, R. A., Jurjus, R. A., Estephan, A., & Jurjus, A. R. (2006). Knowledge and practices regarding atherothrombosis in the Lebanese population. Prevention and Control, 2(4), 165–173.CrossRefGoogle Scholar
  41. Vijayan, V. K., Paramesh, H., Salvi, S. S., & Dalal, A. A. (2015). Enhancing indoor air quality—the air filter advantage. Lung India, 32(5), 473–479. Scholar
  42. Wang, Y., Eliot, M. N., & Wellenius, G. A. (2014). Short-term changes in ambient particulate matter and risk of stroke: a systematic review and meta-analysis. Journal of the American Heart Association, 3(4), e000983. Scholar
  43. WHO. Global recommendations on physical activity for health. Available from:
  44. Wilker, E. H., Mostofsky, E., Lue, S. H., Gold, D., Schwartz, J., Wellenius, G. A., & Mittleman, M. A. (2013). Residential proximity to high-traffic roadways and poststroke mortality. Journal of Stroke and Cerebrovascular Diseases, 22(8), e366–e372. Scholar
  45. World Health Organization. Waist circumference and Waist-hip ratio: report of a WHO expert consultation. Geneva 2008. Available from:
  46. Yamamoto, S. S., Phalkey, R., & Malik, A. A. (2014). A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: limited evidence from India and Pakistan. International Journal of Hygiene and Environmental Health, 217(2–3), 133–144. Scholar
  47. Zeidan, R. K., Farah, R., Chahine, M. N., Asmar, R., Hosseini, H., Salameh, P., & Pathak, A. (2016). Prevalence and correlates of coronary heart disease: first population-based study in Lebanon. Vascular Health and Risk Management, 12, 75–84. Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Pascale Salameh
    • 1
    • 2
    • 3
  • Rita Farah
    • 2
    • 3
  • Souheil Hallit
    • 2
    • 3
    • 4
    • 5
    • 6
    • 7
  • Rouba Karen Zeidan
    • 3
    • 8
  • Mirna N. Chahine
    • 1
    • 9
  • Roland Asmar
    • 1
    • 9
  • Hassan Hosseini
    • 10
  1. 1.Faculty of Medical SciencesLebanese UniversityHadathLebanon
  2. 2.Faculty of PharmacyLebanese UniversityHadathLebanon
  3. 3.Faculty of Public HealthINSPECT-LB (Institut National de Santé Publique, d’Epidémiologie Clinique et de Toxocologie – Liban)FanarLebanon
  4. 4.Faculty of PharmacySaint-Joseph UniversityBeirutLebanon
  5. 5.Faculty of Medicine and Medical SciencesHoly Spirit University of KaslikKaslikLebanon
  6. 6.Research DepartmentPsychiatric Hospital of the CrossJal EddibLebanon
  7. 7.Occupational Health Environment Research Team, U1219 BPH Bordeaux Population Health Research Center Inserm - Université de BordeauxBordeauxFrance
  8. 8.Faculty of Public Health 2Lebanese UniversityFanarLebanon
  9. 9.Foundation-Medical Research Institutes, F-MRIBeirutLebanon
  10. 10.Department of NeurologyHenri Mondor Hospital AP-HPCreteilFrance

Personalised recommendations