Lung health begins before disease: the role of social and environmental determinants

In recent years, pulmonology has gradually broadened its scope, evolving from a discipline focused on the diagnosis and treatment of diseases to a broader perspective centered on prevention and the determinants of respiratory health.

In fact, a growing number of studies show that lung function does not depend solely on genetic or behavioral factors, but is strongly influenced by environmental and social conditions that affect individuals throughout their lives.

A study published in the British journal Thorax (https://thorax.bmj.com/content/early/ 2026/01/05/thorax-2025-223714) highlights that factors such as pollution, malnutrition, and working conditions influence the trajectory of lung function starting in childhood, increasing the risk of developing chronic respiratory diseases in adulthood. Social inequalities are strongly associated with poorer respiratory outcomes.

Lung Function as a Trajectory

Respiratory function is not a static parameter but the result of a dynamic trajectory that begins in the earliest stages of life.

This trajectory can be outlined in three main phases:

1. Lung development (childhood and adolescence)

2. Plateau phase (young adulthood)

3. Physiological decline (late adulthood)

Alterations in any of these phases can lead to a reduction in functional reserve and increase the risk of developing chronic respiratory diseases.

Environmental determinants

Among environmental factors, air pollution is one of the main determinants of respiratory health.

Chronic exposure to pollutants such as:

· fine particulate matter (PM2.5)

· nitrogen dioxide (NO₂)

· ozone (O₃)

is associated with:

· reduced lung growth in children

· increased risk of asthma

· accelerated decline in respiratory function

· higher incidence of COPD and other chronic diseases.

The impact is particularly significant in urban areas with high traffic density and among the most vulnerable populations.

The role of social conditions

Alongside environmental factors, social determinants of health play a fundamental role.

These include:

· socioeconomic status

· access to healthcare services

· housing conditions

· dietary quality

· education.

People living in socioeconomically disadvantaged settings often experience:

· greater exposure to pollutants

· less access to preventive care

· higher prevalence of behavioral risk factors

· later diagnoses.

This translates into a higher likelihood of developing respiratory diseases and worse clinical outcomes.

Childhood and Lung Development

One of the most significant findings from recent studies concerns the importance of the early stages of life.

Factors such as:

· prenatal exposure to pollutants

· secondhand smoke

· early respiratory infections

· malnutrition

can permanently affect lung development.

Suboptimal lung growth during childhood can lead to reduced respiratory function in adulthood, increasing the risk of:

· persistent asthma

· early-onset COPD

· greater susceptibility to infections.

Workplace environment and respiratory risk

Occupational exposures represent another key factor.

Exposure to:

· industrial dust

· chemicals

· fumes and vapors

is associated with various conditions, including:

· occupational asthma

· COPD

· interstitial lung diseases.

Working conditions are often linked to socioeconomic status, contributing to the reinforcement of inequalities in respiratory health.

An integrated model: environment, society, and biology

The most recent evidence suggests that respiratory health is the result of the interaction between:

· biological factors

· environmental exposures

· social conditions.

This integrated model moves beyond the traditional single-risk-factor approach and introduces the concept of “cumulative exposure” over the course of a lifetime.

Implications for prevention

This new perspective has important implications for clinical practice and public health.

Preventing respiratory diseases requires interventions at multiple levels:

1. Individual level

· smoking cessation

· reduction of exposure to pollutants

· vaccinations and early follow-up

2. Environmental level

· improvement of air quality

· reduction of emissions

· monitoring of indoor environments

3. Social and political level

· reduction of inequalities

· equitable access to care

· environmental and occupational protection policies

Respiratory diseases do not begin with diagnosis, but much earlier, often in childhood or even during the prenatal period. Social and environmental determinants are therefore an essential component of respiratory pathophysiology.

Integrating these factors into clinical practice means shifting from disease-centered medicine to risk- and prevention-centered medicine throughout the entire lifespan.

The latest evidence indicates that lung function is the result of a complex, multifactorial process influenced by the environment, society, and biology.

Protecting respiratory health therefore means intervening not only with the patient but also with the context in which they live.

The pulmonology of the future will increasingly be an integrated, preventive, and public health-oriented discipline, capable of addressing the challenges posed by the global determinants of disease.