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Hypertension prevalence and living conditions related to air pollution: results of a national epidemiological study in Lebanon


Hypertension is a risk factor of several diseases, linked to high mortality and morbidity, particularly in developing countries. Some studies have linked indoor and outdoor pollution exposure items to hypertension, but results were inconsistent. Our objective was to assess the association of living conditions related to air pollution to hypertension in Lebanon, a Middle Eastern country. A national cross-sectional study was conducted all over Lebanon. Blood pressure and its related medications were assessed to be able to classify participants as hypertensive or not. Moreover, in addition to living conditions related to air pollution exposure, we assessed potential predictors of hypertension, including sociodemographic characteristics, self-reported health information and biological measurements. Furthermore, we assessed dose-effect relationship of air pollution items in relation with hypertension. Living conditions related to indoor and outdoor air pollution exposures were associated with hypertension, with or without taking biological values into account. Moreover, we found a dose-effect relationship of exposure with risk of disease (15% increase in risk of disease for every additional pollution exposure item), after adjustment for sociodemographics and biological characteristics (Ora = 1.15 [1.03–1.28]). Although additional studies would be necessary to confirm these findings, interventions should start to sensitize the population about the effect of air pollution on chronic diseases. The work on reducing pollution and improving air quality should be implemented to decrease the disease burden on the population and health system.

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  1. Alshaarawy O, Xiao J, Shankar A (2013) Association of serum cotinine levels and hypertension in never smokers. Hypertension 61(2):304–308.

  2. Baalbaki R, Al-Assaad K, Mehanna CJ, Saliba NA, Katurji M, Roumie M (2013) Road versus roadside particle size distribution in a hot Mediterranean summer—estimation of fleet emission factors. J Air Waste Manag Assoc 63(3):327–335.

  3. Barbour B, Saadeh N, Salameh PR (2012) Psychological distress in Lebanese young adults: constructing the screening tool ‘BDS-22’. Int J Cult Mental Health 5(2):94–108.

  4. Baumgartner J, Zhang Y, Schauer JJ, Huang W, Wang Y, Ezzati M (2014) Highway proximity and black carbon from cookstoves as a risk factor for higher blood pressure in rural China. Proc Natl Acad Sci U S A 111(36):13229–13234.

  5. Brook RD, Kousha T (2015) Air pollution and emergency department visits for hypertension in Edmonton and Calgary, Canada: a case-crossover study. Am J Hypertens 28(9):1121–1126.

  6. Brook RD, Newby DE, & Rajagopalan S (2017) Air pollution and cardiometabolic disease: an update and call for clinical trials. Am J Hypertens.

  7. Burroughs Pena MS, Rollins A (2017) Environmental exposures and cardiovascular disease: a challenge for health and development in low- and middle-income countries. Cardiol Clin 35(1):71–86.

  8. Cai, Y., Zhang, B., Ke, W., Feng, B., Lin, H., Xiao, J.,. .. Liu, T. (2016). Associations of short-term and long-term exposure to ambient air pollutants with hypertension: a systematic review and meta-analysis. Hypertension, 68(1), 62–70. doi:

  9. Ezejimofor MC, Uthman OA, Maduka O, Ezeabasili AC, Onwuchekwa AC, Ezejimofor BC, Kandala NB (2016) The burden of hypertension in an oil- and gas-polluted environment: a comparative cross-sectional study. Am J Hypertens 29(8):925–933.

  10. Farah R, Zeidan RK, Chahine MN, Asmar R, Chahine R, Salameh P, Hosseini H (2015) Prevalence of stroke symptoms among stroke-free residents: first national data from Lebanon. Int J Stroke 10(Suppl A100):83–88.

  11. Farah R, Zeidan RK, Chahine MN, Asmar R, Chahine R, Salameh P, Hosseini H (2016) Predictors of uncontrolled blood pressure in treated hypertensive individuals: first population-based study in Lebanon. J Clin Hypertens (Greenwich) 18(9):871–877.

  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(1):1202.

  13. Fuks K, Moebus S, Hertel S, Viehmann A, Nonnemacher M, Dragano N, Heinz Nixdorf Recall Study Investigative, G (2011) Long-term urban particulate air pollution, traffic noise, and arterial blood pressure. Environ Health Perspect 119(12):1706–1711.

  14. Fuks, K. B., Weinmayr, G., Foraster, M., Dratva, J., Hampel, R., Houthuijs, D.,. .. Hoffmann, B. (2014). Arterial blood pressure and long-term exposure to traffic-related air pollution: an analysis in the European study of cohorts for air pollution effects (ESCAPE). Environ Health Perspect, 122(9), 896–905. doi:

  15. Fuks KB, Weinmayr G, Hennig F, Tzivian L, Moebus S, Jakobs H, Heinz Nixdorf Recall Study Investigative, G (2016) Association of long-term exposure to local industry- and traffic-specific particulate matter with arterial blood pressure and incident hypertension. Int J Hyg Environ Health 219(6):527–535.

  16. Giorgini P, Di Giosia P, Grassi D, Rubenfire M, Brook RD, Ferri C (2016) Air pollution exposure and blood pressure: an updated review of the literature. Curr Pharm Des 22(1):28–51

  17. Howard VJ, McClure LA, Meschia JF, Pulley L, Orr SC, Friday GH (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. Arch Intern Med 166(18):1952–1958.

  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 Pac J Health Sci 1(4):345–353

  19. James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, Ortiz E (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.

  20. Kingsley SL, Eliot MN, Whitsel EA, Wang Y, Coull BA, Hou L, Wellenius GA (2015) Residential proximity to major roadways and incident hypertension in post-menopausal women. Environ Res 142:522–528.

  21. Kulick ER, Wellenius GA, Kaufman JD, DeRosa JT, Kinney PL, Cheung YK, Wright CB, Sacco RL, Elkind MS (2017) Long-term exposure to ambient air pollution and subclinical cerebrovascular disease in NOMAS (the Northern Manhattan Study). Stroke 48(7):1966–1968.

  22. Lazarevic N, Dobson AJ, Barnett AG, Knibbs LD (2015) Long-term ambient air pollution exposure and self-reported morbidity in the Australian longitudinal study on women’s health: a cross-sectional study. BMJ Open 5(10):e008714.

  23. Lee WH, Choo JY, Son JY, Kim H (2016) Association between long-term exposure to air pollutants and prevalence of cardiovascular disease in 108 south Korean communities in 2008-2010: a cross-sectional study. Sci Total Environ 565:271–278.

  24. Li N, Li Z, Chen S, Yang N, Ren A, Ye R (2015) Effects of passive smoking on hypertension in rural Chinese nonsmoking women. J Hypertens 33(11):2210–2214.

  25. Lin H, Guo Y, Zheng Y, Di Q, Liu T, Xiao J, Wu F (2017) Long-term effects of ambient PM2.5 on hypertension and blood pressure and attributable risk among older Chinese adults. Hypertension 69(5):806–812.

  26. Liu C, Chen R, Zhao Y, Ma Z, Bi J, Liu Y, Li W (2017) Associations between ambient fine particulate air pollution and hypertension: a nationwide cross-sectional study in China. Sci Total Environ 584:869–874

  27. Mahmud A, Feely J (2004) Effects of passive smoking on blood pressure and aortic pressure waveform in healthy young adults—influence of gender. Br J Clin Pharmacol 57(1):37–43

  28. Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Bohm M, Task Force M (2013) 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 31(7):1281–1357.

  29. Martinelli N, Olivieri O, Girelli D (2013) Air particulate matter and cardiovascular disease: a narrative review. Eur J Intern Med 24(4):295–302.

  30. Moussa MR, Hussein RA, El-Naggar HM (2016) Environmental risk factors and the associated morbidity in a periurban area, Alexandria, Egypt. J Egypt Public Health Assoc 91(1):44–51.

  31. 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. Int J Occup Med Environ Health 28(4):641–661.

  32. Nogueira JB (2009) Air pollution and cardiovascular disease. Rev Port Cardiol 28(6):715–733

  33. O’Brien E, Asmar R, Beilin L, Imai Y, Mallion JM, Mancia G, European Society of Hypertension Working Group on Blood Pressure, M (2003) European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 21(5):821–848.

  34. Olasky SJ, Levy D, Moran A (2012) Second hand smoke and cardiovascular disease in low and middle income countries: a case for action. Glob Heart 7(2):151–160 e155.

  35. Peña MB, Romero KM, Velazquez EJ, Davila-Roman VG, Gilman RH, Wise RA, Checkley W (2015) Relationship between daily exposure to biomass fuel smoke and blood pressure in high-altitude PeruNovelty and significance. Hypertension 65(5):1134–1140.

  36. Pitchika A, Hampel R, Wolf K, Kraus U, Cyrys J, Babisch W, Schneider A (2017) Long-term associations of modeled and self-reported measures of exposure to air pollution and noise at residence on prevalent hypertension and blood pressure. Sci Total Environ 593-594:337–346.

  37. Qiao Q, Keinanen-Kiukaanniemi S, Rajala U, Uusimaki A, Kivela SL (1995) Random capillary whole blood glucose test as a screening test for diabetes mellitus in a middle-aged population. Scand J Clin Lab Invest 55(1):3–8.

  38. Ribeiro TS, Carvalho DP, Guimaraes MT, Campina NN, Lobarinhas MR, Lopes AL, Braga AL (2016) Prevalence of hypertension and its associated factors in contaminated areas of the Santos-Sao Vicente estuarine region and Bertioga, Brazil: 2006-2009. Environ Sci Pollut Res Int 23(19):19387–19396.

  39. Rumeau-Rouquette C, Bréart G, & Padieu R (1985) Méthodes en Epidémiologie: Echantillonnage, investigations, analyse

  40. Sarigiannis DA, Hansen U (2012) Considering the cumulative risk of mixtures of chemicals—a challenge for policy makers. Environ Health 11(Suppl 1):S18.

  41. Seki M, Inoue R, Ohkubo T, Kikuya M, Hara A, Metoki H, Hirose T, Tsubota-Utsugi M, Asayama K, Kanno A, Obara T, Hoshi H, Totsune K, Satoh H, Imai Y (2010) Association of environmental tobacco smoke exposure with elevated home blood pressure in Japanese women: the Ohasama study. J Hypertens 28(9):1814–1820.

  42. Sibai A, Tohme R, Mahfoud Z, Chaaya M, & Hwalla N (2009) Non-communicable diseases and behavioral risk factor survey: comparison of estimates based on cell phone interviews with face to face interviews. WHO Lebanon office. Beirut, Lebanon: Final report submitted to World Health Organization-Lebanon office

  43. Stankovic A, Nikolic M (2016) Long-term ambient air pollution exposure and risk of high blood pressure among citizens in Nis, Serbia. Clin Exp Hypertens 38(1):119–124.

  44. Stockfelt, L., Andersson, E. M., Molnar, P., Gidhagen, L., Segersson, D., Rosengren, A.,. .. Sallsten, G. (2017). Long-term effects of total and source-specific particulate air pollution on incident cardiovascular disease in Gothenburg, Sweden. Environ Res, 158, 61–71. doi:

  45. Tohme RA, Jurjus RA, Estephan A, Jurjus AR (2006) Knowledge and practices regarding atherothrombosis in the Lebanese population. Prev Control 2(4):165–173.

  46. Vijayan VK, Paramesh H, Salvi SS, Dalal AA (2015) Enhancing indoor air quality—the air filter advantage. Lung India 32(5):473–479.

  47. Wauters A, Dreyfuss C, Pochet S, Hendrick P, Berkenboom G, van de Borne P, Argacha JF (2013) Acute exposure to diesel exhaust impairs nitric oxide-mediated endothelial vasomotor function by increasing endothelial oxidative stress. Hypertension 62(2):352–358.

  48. Weaver AM, Wellenius GA, Wu WC, Hickson DA, Kamalesh M, Wang Y (2016) Residential proximity to major roadways is not associated with cardiac function in African Americans: results from the Jackson Heart Study. Int J Environ Res Public Health 13(6).

  49. Weaver AM, Wellenius GA, Wu WC, Hickson DA, Kamalesh M, Wang Y (2017) Residential distance to major roadways and cardiac structure in African Americans: cross-sectional results from the Jackson heart study. Environ Health 16(1):21.

  50. Yamamoto SS, Phalkey R, Malik AA (2014) A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: limited evidence from India and Pakistan. Int J Hyg Environ Health 217(2–3):133–144.

  51. Yang BY, Qian ZM, Vaughn MG, Nelson EJ, Dharmage SC, Heinrich J, Dong GH (2017) Is prehypertension more strongly associated with long-term ambient air pollution exposure than hypertension? Findings from the 33 Communities Chinese Health Study. Environ Pollut 229:696–704.

  52. Zeidan RK, Farah R, Chahine MN, Asmar R, Hosseini H, Salameh P, Pathak A (2016) Prevalence and correlates of coronary heart disease: first population-based study in Lebanon. Vasc Health Risk Manag 12:75–84.

  53. Zhang Z, Laden F, Forman JP, Hart JE (2016) Long-term exposure to particulate matter and self-reported hypertension: a prospective analysis in the Nurses’ Health Study. Environ Health Perspect 124(9):1414–1420.

  54. Zhong J, Cayir A, Trevisi L, Sanchez-Guerra M, Lin X, Peng C, Baccarelli AA (2016) Traffic-related air pollution, blood pressure, and adaptive response of mitochondrial abundance. Circulation 133(4):378–387.

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Correspondence to Souheil Hallit.

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Salameh, P., Chahine, M., Hallit, S. et al. Hypertension prevalence and living conditions related to air pollution: results of a national epidemiological study in Lebanon. Environ Sci Pollut Res 25, 11716–11728 (2018).

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  • Air pollution
  • Living conditions
  • Cumulative risk
  • Hypertension
  • Indoor
  • Outdoor
  • Developing country