Effect modification by a healthy lifestyle on association between ambient air pollutant exposure and cardiovascular disease risk: A systematic review and meta-analysis
- VernacularTitle:大气污染物暴露与心血管疾病风险的关联及健康生活方式的调节效应：一项系统评价与meta分析
- Author:
Ziyu WANG
1
;
Xiaoqian YAN
1
;
Fanlei KONG
2
;
Haipeng WANG
2
;
Yufang GUO
1
Author Information
- Publication Type:Investigation
- Keywords: healthy lifestyle; air pollutant; cardiovascular disease; meta-analysis
- From: Journal of Environmental and Occupational Medicine 2026;43(6):744-753
- CountryChina
- Language:Chinese
- Abstract: Background Ambient air pollution is a major environmental risk factor for cardiovascular disease (CVD). However, epidemiological evidence regarding the modifying effect of a healthy lifestyle on the association between air pollution and CVD remains inconsistent. Objective To investigate the modifying effect of a healthy lifestyle on the association between exposure to air pollutants and CVD risk, to provide evidence for targeted prevention strategies. Methods Databases including PubMed, Web of Science, Embase, the Cochrane Library, CNKI, and Wanfang were systematically searched for epidemiological studies published from January 2011 to August 2025. The quality of included studies was assessed, and relevant data were extracted. A meta-analysis was performed to examine the association between air pollutant exposure and CVD outcomes, as well as the modifying effect of a healthy lifestyle. Results A total of 24 studies were included. The meta-analysis demonstrated that each 10 μg·m−3 increase in the concentration of ultrafine particulate matter (PM1), fine particulate matter (PM2.5), inhalable particulate matter (PM10), nitrogen dioxide (NO2), sulfur dioxide (SO2), and ozone (O3) was associated with pooled relative risks (RRs) for CVD morbidity of 1.176 (95%CI: 1.007, 1.373), 1.167 (95%CI: 1.035, 1.315), 1.030 (95%CI: 1.012, 1.048), 1.093 (95%CI: 1.039, 1.150), 1.014 (95%CI: 0.996, 1.032), and 1.216 (95%CI: 0.901, 1.641), respectively; each 10 mg·m−3 increase in the concentration of carbon monoxide (CO) was associated with a pooled RR for CVD morbidity of 1.005 (95%CI: 1.005, 1.006). For CVD mortality, each 10 μg·m−3 increase in PM2.5, PM10, and NO2 yielded pooled RRs of 1.188 (95%CI: 1.032, 1.367), 1.137 (95%CI: 0.953, 1.357), and 1.038 (95%CI: 1.011, 1.066), respectively; for SO2 and O3, where only a single study was available, RRs were 1.068 (95%CI: 1.030, 1.108) and 1.010 (95%CI: 0.996, 1.024) per 10 μg·m−3 increase, respectively; for CO, where also only a single study was available, the RR was 1.002 (95%CI: 1.001, 1.003) per 10 mg·m−3 increase. Adherence to a healthy lifestyle significantly modified the PM2.5-associated CVD risk. Specifically, compared to healthy behaviors, unhealthy factors including smoking, low-quality diet, and physical inactivity exacerbated this risk, with relative effect sizes (RES; ratio of hazard ratios of the unhealthy group to the healthy group) of 1.016 (95%CI: 1.013, 1.020), 1.008 (95%CI: 1.003, 1.013), and 1.058 (95%CI: 1.055, 1.062), respectively. Furthermore, a combined healthy lifestyle demonstrated a superior modifying effect compared to any single lifestyle factor, which significantly attenuated the PM2.5-associated CVD risk (P for interaction < 0.05). Conclusion Long-term exposure to ambient PM2.5 significantly increases CVD risk. However, adherence to a combined healthy lifestyle can effectively mitigate these adverse effects, offering substantially greater cardiovascular protection than maintaining any single healthy habit.
