title: A framework for examining social stress and susceptibility to air pollution in respiratory health.
abstract: OBJECTIVE
  There is growing interest in disentangling the health effects of spatially clustered social and physical environmental exposures and in exploring potential synergies among them, with particular attention directed to the combined effects of psychosocial stress and air pollution. Both exposures may be elevated in lower-income urban communities, and it has been hypothesized that stress, which can influence immune function and susceptibility, may potentiate the effects of air pollution in respiratory disease onset and exacerbation. In this paper, we attempt to synthesize the relevant research from social and environmental epidemiology, toxicology, immunology, and exposure assessment to provide a useful framework for environmental health researchers aiming to investigate the health effects of environmental pollution in combination with social or psychological factors.
  
  
  RESULTS
  We review the existing epidemiologic and toxicologic evidence on synergistic effects of stress and pollution, and then describe the physiologic effects of stress and key issues related to measuring and evaluating stress as it relates to physical environmental exposures and susceptibility. Finally, we identify some of the major methodologic challenges ahead as we work toward disentangling the health effects of clustered social and physical exposures and accurately describing the interplay among these exposures.
  
  
  CONCLUSIONS
  There is still tremendous work to be done toward understanding the combined and potentially synergistic health effects of stress and pollution. As this research proceeds, we recommend careful attention to the relative temporalities of stress and pollution exposures, to nonlinearities in their independent and combined effects, to physiologic pathways not elucidated by epidemiologic methods, and to the relative spatial distributions of social and physical exposures at multiple geographic scales.
authors.affiliation: Department of Environmental Health, Harvard School of Public Health, Boston, MA 02215, USA. jcloughe@hsph.harvard.edu
authors.forename: Jane E
authors.initials: JE
authors.lastname: Clougherty
authors.forename: Laura D
authors.initials: LD
authors.lastname: Kubzansky
mesh_terms: D000397:Air Pollution; D006801:Humans; D007398:Interpersonal Relations; D008168:Lung / Q000187:drug effects* / Q000503:physiopathology; D013315:Stress, Psychological