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Updated figures suggest that air pollution is the main environmental cause of death in the world (Cohen et al. 2017; Burnett et al. 2018). Most epidemiological research so far has been on air as a whole (e.g. TRAP, traffic-related air pollution), or on single (‘‘criterion’’) pollutants such as oxides of nitrogen (NOx) or particulate matter (PM). However, concerns have been raised on causality and the effects of specific pollutants at low or very low doses, and therefore on the rationale for regulatory policies (Tollefson 2018; Goldman and Dominici 2019). Uncertainties also concern the differences between pollution due to gasoline versus diesel. The identification of hazardous environmental pollutants—including air pollutants—is complex, particularly in relation to non-communicable diseases (Snyder et al. 2013; Prüss-Ustün et al. 2017; Vineis 2018). Obviously, chronic air pollution exposure cannot be randomized towards identifying adverse health effects. Air pollution exposure is also not associated itself with genetic traits, and subsequently its causal effects cannot be assessed by Mendelian Randomization, in contrast to other risk factors such as body mass index (Pierce et al. 2018). Prospective cohorts are therefore the gold standard in air pollution research and the source of risk-burden estimation. However, observational studies are faced with confounding. Additional contributors to the complexity of identifying hazardous pollutants are the diversity of hazards that may exist and their reciprocal correlations, the typically low levels of environmental contaminants combined with generally low effect sizes, long latency periods with unknown windows of susceptibility, and largely unknown modes of action. The unravelling of environmental causes of disease is also limited by the technical difficulties in defining, and accurately measuring exposures, and by considerable spatial, temporal, and intra-individual variation. The complex and partially unknown interactions with underlying genetic and other factors that modulate susceptibility and response to environmental exposures, further complicate the process of understanding environmental hazards.

Long-term effects of air pollution: an exposome meet-in-the-middle approach