International Journal of Hygiene and Environmental Health 218 (2015) 319323

Contents lists available at ScienceDirect

International Journal of Hygiene and

Environmental Health
journal homepage: www.elsevier.com/locate/ijheh

Effects of commuting mode on air pollution exposure and

cardiovascular health among young adults in Taipei, Taiwan
Wen-Te Liu a,b , Chih-Ming Ma c , I.-Jung Liu d , Bor-Cheng Han e , Hsiao-Chi Chuang a,b ,
Kai-Jen Chuang e,f,
a
Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
b
School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
c
Department of Cosmetic Application and Management, St. Marys Junior College of Medicine, Nursing and Management, Yilan, Taiwan
d
Department of Nursing, Cardinal Tien College of Healthcare & Management, New Taipei City, Taiwan
e
School of Public Health, College of Public Health and Nutrition, Taipei Medical University, Taipei, Taiwan
f
Department of Public Health, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan

a r t i c l e i n f o a b s t r a c t

Article history: The association between trafc-related air pollution and adverse cardiovascular effects has been well
Received 12 November 2014 documented; however, little is known about whether different commuting modes can modify the effects
Received in revised form of air pollution on the cardiovascular system in human subjects in urban areas with heavy trafc. We
30 December 2014
recruited 120 young, healthy subjects in Taipei, Taiwan. Each participant was classied with different
Accepted 9 January 2015
commuting modes according to his/her own commuting style. Three repeated measurements of heart
rate variability (HRV) indices {standard deviation of NN intervals (SDNN) and the square root of the mean
Keywords:
of the sum of the squares of differences between adjacent NN intervals (r-MSSD)}, particulate matter with
Air pollution
Trafc
an aerodynamic diameter 2.5 m (PM2.5 ), temperature, humidity and noise level were conducted for
Particulate matter each subject during 1-h morning commutes (09001000 h) in four different commuting modes, including
Subway an electrically powered subway, a gas-powered bus, a gasoline-powered car, and walking. Linear mixed-
Cardiovascular effect effects models were used to investigate the association of PM2.5 with HRV indices. The results showed
Epidemiology that decreases in the HRV indices were associated with increased levels of PM2.5 . The personal exposure
levels to PM2.5 were the highest in the walking mode. The effects of PM2.5 on cardiovascular endpoints
were the lowest in the subway mode compared to the effects in the walking mode. The participants in the
car and bus modes had reduced effects on their cardiovascular endpoints compared to the participants
in the walking mode. We concluded that trafc-related PM2.5 is associated with autonomic alteration.
Commuting modes can modify the effects of PM2.5 on HRV indices among young, healthy subjects.
2015 Elsevier GmbH. All rights reserved.

Introduction
The association of short-term exposure to trafc-related air
pollution with mortality (Madsen et al., 2012) or adverse cardio-
vascular effects (Krishnan et al., 2013; Peters et al., 2004; Riediker
et al., 2004; Wu et al., 2010) has been well documented in epidemi-
ological studies. Short-term exposure to trafc-related pollutants
can be a major contributor to total air pollution exposure among
commuters during rush hour trafc times. It has been reported
that air pollution levels are high and commuters are close to trafc
Corresponding author at: Department of Public Health, School of Medicine, Col-
lege of Medicine, Taipei Medical University, No.250, Wu-Hsing Street, Taipei 110,
Taiwan. Tel.: +886 2 2736 1661x6536; fax: +886 2 2738 4831.
E-mail addresses: d92841003@ntu.edu.tw, kjc@tmu.edu.tw (K.-J. Chuang).
emissions during rush hours when commuting (Kaur et al., 2007).
The World Health Organization reported that individuals in Europe
may spend 1 to 1.5 h commuting daily (World Health Organization,
2005). Therefore, exposure to trafc remains a major public health
issue in urban areas with heavy trafc around the world.
Exposure levels of trafc-related air pollution vary according
to the route, the various trafc loads and the mode of commut-
ing. Previous studies have shown that walkers (Kaur et al., 2007)
and cyclists (Kaur et al., 2007; McNabola et al., 2008; Thai et al.,
2008) had higher particulate matter (PM) exposures on routes with
high trafc loads compared to those on low trafc routes. Bus com-
muters experience three to four times higher PM concentrations in
diesel-powered buses than in gas-powered buses (Hammond et al.,
2006). Moreover, higher PM levels were demonstrated among com-
muters walking on sidewalks compared to commuters driving in
cars (Briggs et al., 2008).

http://dx.doi.org/10.1016/j.ijheh.2015.01.003
1438-4639/ 2015 Elsevier GmbH. All rights reserved.
320 W.-T. Liu et al. / International Journal of Hygiene and Environmental Health 218 (2015) 319323
Although previous studies have investigated the effects of
trafc-related air pollution on cardiovascular events or air pollution
levels associated with different modes of commuting, few studies
have evaluated the differences in air pollution levels and cardio-
vascular endpoints related to trafc between different commuting
modes. Heart rate variability (HRV) is a quantitative biological mea-
surement of cardiac autonomic function and is analyzed in the
time or frequency domains. It reects autonomic modulation of the
rhythmic activity of the sinus node (Task Force, 1996). Decrease
in HRV has been demonstrated to be associated with increased
risk of mortality in healthy subjects and cardiac patients (Dekker
et al., 1997; Gerritsen et al., 2001; La Rovere et al., 2003). More-
over, air pollution has been reported to be associated HRV reduction
(Chuang et al., 2007; de Hartog et al., 2009; Huang et al., 2013;
Wu et al., 2010; Zanobetti et al., 2010). Therefore, we conducted a
panel study that simultaneously compared trafc-related air pollu-
tion levels with HRV indices between different commuting modes
to elucidate the associations between trafc-related air pollution
exposure and trafc-induced cardiovascular effects. The aim of this
study was to explore air pollution exposures and the adverse car-
diovascular effects of air pollutants encountered during different
modes of transport among commuters.
Methods
Participants and study design
We recruited a panel of 120 young, healthy students from
universities in Taipei, Taiwan. The following study participant
selection criteria were used: no history of smoking and no car-
diovascular diseases such as coronary artery disease, arrhythmia,
hypertension or diabetes mellitus. Each student was classied with
different commuting modes according to his/her own commuting
style. Three repeated measurements of HRV indices {standard
deviation of NN intervals (SDNN) and the square root of the mean
of the sum of the squares of differences between adjacent NN
intervals (r-MSSD)}, particulate matter with an aerodynamic
diameter 2.5 m (PM2.5 ), temperature, humidity and noise
level were conducted for each student during 1-hour morning
commutes (09001000 h) in four different commuting modes,
including an electrically powered subway, a gas-powered bus,
a gasoline-powered car, and walking. Air conditioning systems
were used in the bus, car, subway and subway station. Each of
the 120 students underwent three 1-hour measurements (each
measurement for each ride for a total of three rides per participant),
resulting in a total of 360 1-hour measurements between January
and March in the years 2012 to 2014. All of the students age,
sex, body mass index (BMI) and time-activity pattern information
was recorded with a questionnaire during their measurements.
This study was approved by the ethics committee of St. Marys
Medicine Nursing and Management College. Written informed
consent was obtained from each participant before the study.
HRV indices
We performed the 1-hour electrocardiography monitoring
using a PacerCorder 3-channel device (model 461A; Del Mar Medi-
cal Systems LLC, Irvine, CA, USA). A complete 5-min segment of the
NN interval was taken for the HRV indices analysis, including the
standard deviation of the normal-to-normal (NN) intervals (SDNN)
and the square root of the mean of the sum of the squares of
differences between adjacent NN intervals (r-MSSD). A total of 36
5-min HRV indices were recorded for each student during the three
repeated measurements (12 segments for each measurement) for
data analysis. We obtained 4320 5-min segments of HRV indices
from the 120 students in our data analysis.
Air pollution, noise and climate conditions
We performed a 1-hour continuous air pollution monitoring
during each measurement for each participant. PM <10 m in
aerodynamic diameter (PM10 ), PM <2.5 m in aerodynamic diam-
eter (PM2.5 ), temperature, and relative humidity were measured
continuously using a personal dust monitor (DUST-check portable
dust monitor, model 1.108; temperature and humidity sensor,
model 1.153FH, Grimm Labortechnik Ltd., Ainring, Germany),
which measured and recorded 1-minute mass concentrations
of PM10 and PM2.5 and temperature and relative humidity. The
detection limit for mass concentration is 0.1 g/m3 . Rupprecht
and Patashnick 1400a tapered element oscillating microbalance
samplers (Thermo Electron Corporation, East Greenbush, NY,
USA) were used to calibrate the mass concentrations of PM10 and
PM2.5 measured by DUST-check monitor before and after each
measurement. Total volatile organic compounds (TVOCs) were
measured continuously using a TVOCs monitor (SeeAiR, model
M5-201, Chen-Wei VR International Co., Ltd., Kaohsiung, Taiwan).
The detection limit for TVOCs concentration is 1ppb. Isobutylene
was used as the calibration gas before and after each measurement.
The noise level was measured using a portable noise dosimeter
(Logging Noise Dose Meter, Type 4443, Brel & Kjr, Nrum,
Denmark) that reports 1-minute continuous equivalent sound
levels (Leq) and time-weighted-averages (TWA) of noise doses. A
range of 30100 dBA was used to measure noise exposure with
1-minute readings conducted over 1 h. After sampling, the raw
data for the 1-minute PM10 , PM2.5 , TVOCs, temperature, humidity
and noise data were matched with the sampling time of the HRV
monitoring and then computed to 5-minute averages.
Statistical analysis
We used mixed-effects models to examine the associations
between air pollutants and log10 -transformed HRV indices by
running R statistical software version 2.15.1. The independent vari-
ables were the 5-minute mean PM10 , PM2.5 , and TVOCs values,
whereas the dependent variables were the log10 5-minute mean
SDNN and r-MSSD values. The mixed-effects models of the four
different commuting modes including an electrically powered sub-
way, a gas-powered bus, a gasoline-powered car, and walking were
adjusted for age, sex, body mass index (BMI), order of the mea-
surement, 5-minute temperature, 5-minute relative humidity and
5-minute noise level. The participant identity number was tted as
a random intercept term in all of the mixed-effects models. Inter-
individual and intra-individual variations in HRV were examined
by using autocorrelation function (ACF) and partial autocorrelation
function (PACF). No signicant autoregressive pattern or moving
average pattern was observed in all models. A one-way analysis of
variance (ANOVA) using Scheffes mean comparison test was used
to compare air pollution, noise, climate conditions and HRV indices
at 5-minute means between the four commuting modes. The air
pollution effects are expressed as percent changes by interquartile
range (IQR) changes using the formula: [10( IQR) 1] 100% for
the log 10-transformed HRV indices, in which is the estimated
regression coefcient.
Results
The average age of the 120 participants was 21.3 years (SD = 1.2
years), the average BMI was 22.7 kg/m2 (SD = 1.8 kg/m2 ), and the
male/female ratio was approximately 1:1. The mean values (SD)
 W.-T. Liu et al. / International Journal of Hygiene and Environmental Health 218 (2015) 319323 321

Table 1
Summary statistics for the participants characteristics, air pollution, heart rate variability and climate conditions using a 5-minute mean.

Subway Bus Car Walking ANOVA

p-value Scheffes test

Sex, no
Male 16 15 13 14
Female 14 15 17 16
Age, year
Mean SD 21.2 0.8 21.3 0.8 21.2 0.7 21.4 0.9 0.89
Range 1924 1924 1924 1924
BMI, kg/m2
Mean SD 22.8 1.8 23.0 1.7 22.1 1.8 22.9 1.6 0.91
Range 18.924.1 19.124.7 18.823.5 19.423.1
PM10 , g/m3
Mean SD 31.5 12.0 39.6 15.8 34.3 12.6 50.2 21.2
IQR 17.8 24.8 22.4 26.4 <0.05 S/B; S/W; C/W
Range 15.250.2 20.160.8 21.962.8 23.499.8
No 1080 1045 1069 1080
PM2.5 , g/m3
Mean SD 22.3 6.9 32.2 12.4 29.2 11.3 42.1 18.2
IQR 13.9 19.2 17.1 28.7 <0.05 S/B; S/W; C/W
Range 7.642.1 10.253.9 9.846.2 18.588.1
No 1080 1023 1002 995
TVOCs, ppb
Mean SD 55.2 18.2 77.5 41.8 69.1 36.8 100.5 32.8
IQR 23.2 42.9 37.4 72.1 S/B; S/W; C/W
Range 21.078.6 31.0139.8 26.0110.2 52.5210.2
No 1080 992 1018 943
Temperature, C
Mean SD 23.7 1.3 23.9 1.4 23.1 1.1 22.3 1.8 0.82
Range 20.324.2 19.825.5 19.624.3 18.223.1
Relative humidity, %
Mean SD 69.4 1.7 72.0 1.6 65.8 0.9 69.1 1.5 0.67
Range 61.170.8 64.077.5 58.271.4 60.183.0
Noise, dBA
Mean SD 66.0 7.8 72.5 11.3 63.1 8.6 81.2 12.5 <0.05 S/W; C/W
Range 58.481.9 63.597.2 51.184.3 76.2110.7
Log10 SDNN, msec
Mean SD 1.91 0.22 1.69 0.18 1.79 0.13 1.48 0.29 <0.05 S/B; S/W; C/W
Range 0.952.43 0.812.10 1.101.75 0.651.98
Log10 r-MSSD, msec
Mean SD 1.61 0.23 1.29 0.29 1.44 0.21 1.02 0.18 <0.05 S/B; S/W; C/W
Range 0.532.17 0.611.88 0.512.13 0.431.87

of the log10 -HRV indices were 1.69 msec (0.24) for the SDNN and
1.38 msec (0.26) for the r-MSSD.
Table 1 summarizes the participants characteristics, air pollu-
tion levels, heart rate variability and climate conditions during the
study periods for the 120 participants during the different modes
of commuting. The participants had relatively higher air pollution
exposure levels and lower HRV index responses in the walking
mode compared to the car and bus modes (ANOVA, p-value <0.05).
The levels of PM10 , PM2.5 and TVOCs in the walking mode were 1.6-
fold, 1.9-fold and 1.8-fold higher than those in the subway mode,
respectively. The levels of these pollutants in the walking mode
were approximately 1.5-fold and 1.3-fold higher than those in the
car and bus modes, respectively. In accordance with the air pollu-
tion levels, the SDNN and r-MSSD values in the walking mode were
23 and 37% lower than in the subway mode, 17 and 29% lower than
in the car mode and 12 and 21% lower than in the bus mode, respec-
tively. The climate conditions were moderately pleasant, with a
temperature range of 18.2 to 25.5 C and a relative humidity ran-
ging from 58.2 to 83.0%. The mean noise levels remained under 90
dBA in all of the commuting modes.
The Pearsons correlation analysis showed that PM2.5 was sig-
nicantly (p < 0.05) correlated with TVOCs in the walking mode
(r = 0.73), the bus mode (r = 0.61) and the car mode (r = 0.59). PM10
showed a weak correlation (p < 0.10) with PM2.5 (r = 0.46) and
TVOCs (r = 0.46) in the subway mode. There were no signicant
differences in temperature and humidity between the four com-
muting modes.
Table 2 lists the associations of HRV indices with PM10 , PM2.5 and
TVOCs among all of the commuters (Model 1) or the commuters
in the four different commuting modes (Models 25) estimated
by single-pollutant mixed-effects models. In general, the models
showed that decreased HRV indices were signicantly associated
with increased PM10 , PM2.5 and TVOC levels. Decreased HRV indices
were more strongly associated with PM2.5 than with TVOCs and
PM10 . The greatest effect of PM2.5 on the SDNN was observed among
the subjects in the walking mode (Model 5 with PM2.5 ), whereas
small decreases in the SDNN with PM2.5 exposure were observed
among the subjects in the subway mode (Model 2 with PM2.5 ). A
similar pattern was found in the association between PM2.5 expo-
sure and decreased r-MSSD values (Models 8 and 11 with PM2.5 ).
Two-pollutant mixed-effects models were performed for PM2.5
and the TVOCs; only PM2.5 was signicantly associated with a
decreased SDNN (-9.7%, 95% condence interval = 13.2, 6.2%)
and r-MSSD (8.1%, 95% condence interval = 10.5, 5.7%) after
adjusting for these variables among the subjects in the walking
mode (data not shown). We also performed two pollutant mixed-
effects models for PM10 and PM2.5 for the subjects in the walking
mode and found that only PM2.5 was signicantly associated with a
decreased SDNN (10.6%, 95% condence interval = 12.9, 8.3%)
and r-MSSD (9.3%, 95% condence interval = 11.7, 6.9%).
322 W.-T. Liu et al. / International Journal of Hygiene and Environmental Health 218 (2015) 319323
Table 2
Percent changes in heart rate variability indices for an interquartile range change of air pollution concentrations in single-pollutant mixed-effects models.
PM10
SDNN
Model 1: With all subjects 3.5 (4,9, 2.1)
Model 2: Subjects in subway mode 1.3 (1.4, 2.7)
Model 3: Subjects in car mode 1.1 (1.9, 0.8)
Model 4: Subjects in bus mode 3.2 (5.9, 0.5)
Model 5: Subjects in walking mode 5.6 (7.6, 3.6)
r-MSSD
Model 7: With all subjects 2.9 (3,8, 2.0)
Model 8: Subjects in subway mode 1.1 (2.6, 0.4)
Model 9: Subjects in car mode 0.8 (1.7, 0.1)
Model 10: Subjects in bus mode 2.8 (4.4, 1.2)
Model 11: Subjects in walking mode 4.7 (7.7, 1.7)
Note: The values are presented as percent changes and 95% condence intervals for interquartile range changes after adjusting for sex, age, BMI, order of the measurement,
temperature, relative humidity and noise in the models.
Discussion
Differences in air pollution exposure among four commuting
modes
This is the rst study to report that particulate and gaseous air
pollutants had an effect on reducing HRV among young, healthy
subjects using four different commuting modes, including a sub-
way, a gas-powered bus, a gasoline-powered car, and walking in
urban environments during rush hours. We found that subjects in
the walking mode had higher air pollution exposures than the sub-
jects in the bus, car or subway modes. The subjects in the bus mode
were exposed to slightly higher PM levels compared to the subjects
in the car mode. These ndings are consistent with previous studies
showing a higher PM exposure among walkers and cyclists (Kaur
et al., 2007; McNabola et al., 2008; Thai et al., 2008). Briggs et al.
(2008) investigated the effects of walking and driving on particu-
late air pollutants and found that commuters in the walking mode
were exposed to 4.7-fold and 2.2-fold higher commuting exposure
levels to coarse particles (PM102.5 ) and PM2.5 than commuters in
the driving mode. Zuurbier et al. (2009) explored differences in
commuters exposure to trafc-related air pollution in diesel and
electric buses, gasoline- and diesel-fueled cars, and bicycles. The
results showed that particle number counts were the highest in
diesel buses and cyclists and the lowest in electric buses. Passen-
gers in diesel buses had higher PM10 exposure levels compared
to gasoline-car passengers. Both of these studies suggested that
the in-vehicle ltration system might help to prevent the pene-
tration of air pollution present in the outdoor environment. Chan
et al. (2002) examined commuters exposure to particulate air pol-
lution while commuting in public transportation modes, including
railway transport (subway), non-air-conditioned roadway trans-
port (bus), air-conditioned roadway transport (taxi and bus) and
marine transport (ferry). They reported that PM10 and PM2.5 expo-
sure levels in non-air-conditioned roadway transport were the
highest, followed by marine transport, air-conditioned roadway
transport and railway transport. They recommended railway and
air-conditioned vehicles as a substitute for non-air-conditioned
vehicles. It is possible that the ventilation status of the vehicle can
be an important factor for trafc-related air pollution exposure. The
reduction of in-vehicle exposure appeared to occur largely because
the ltration system reduced the penetration of air pollutants from
the outside and allowed the vehicle to become an independent and
relatively clean micro-environment.
Air pollution exposure and cardiovascular health
Our study demonstrated that PM2.5 exposure in the walking
mode could induce greater effects on decreased HRV indices com-
pared to those in the car, bus or subway modes. Decrease in HRV has
PM2.5 TVOCs
6.4 (9.1, 3.7) 2.9 (5.6, 0.2)
1.7 (-3.2, -0.2) 0.1 (-1.3, 1.1)
5.8 (-9.8, 1.8) 1.5 (2.2, 0.8)
7.5 (12.4, 2.6) 2.3 (3.3, 1.3)
11.6 (18.4, 4.8) 6.4 (8.6, 4.2)
5.8 (8.2, 3.4) 2.0 (3.6, 0.4)
0.9 (2.4, 0.6) 2.1 (4.3, 0.1)
4.9 (5.7, 4.1) 1.3 (2.0, 0.6)
6.1 (9.5, 2.7) 1.9 (2.3, 1.5)
9.5 (16.4, 2.6) 6.8 (7.9, 5.7)
been reported as a strong predictor of cardiac mortality (Gerritsen
et al., 2001; La Rovere et al., 2003). Autonomic nervous system
changes in HRV may also increase the likelihood of sudden cardiac
death (Task Force, 1996). The association between trafc-related
air pollution and decreased HRV indices has been documented in
previous studies (Chuang et al., 2007; de Hartog et al., 2009; Huang
et al., 2013; Wu et al., 2010; Zanobetti et al., 2010). The possible
mechanism of this association is the passage of inhaled particles
into the lungs and blood circulation, activating pulmonary neu-
ral reexes and initiating cardiac arrhythmias (Brook et al., 2010).
Only a few studies have investigated the association of air pollu-
tion with health endpoints in different commuting or ventilation
modes. McCreanor et al. (2007) recruited 60 adults with either mild
or moderate asthma to investigate the association between trafc-
related air pollutants and lung function on different streets. The
results showed that the participants with 2 h of walking had higher
air pollution exposure and inammatory responses and lower lung
functioning on the street with heavy trafc than on the street in a
park. Chuang et al. (2013) recruited a panel of 60 healthy subjects
to commute for 2 h by car using different operation modes of an air
conditioning system (AC). They found that great decreases in HRV
indices were associated with increased levels of in-car PM2.5 with
the AC turned off. The participants showed only slight decreases in
HRV indices with the AC turned on. The present study found that
air pollution exposure and decrement in HRV indices among com-
muters in the subway mode were the lowest, followed by the car
mode, the bus mode and the walking mode. Accordingly, our nd-
ings provide further support that an effective ventilation system
during commuting/transporting is an important factor for both air
pollution exposure and cardiovascular health promotion.
Study limitations
It should be noted that the lack of information on other air
pollutants, such as carbon monoxide and nitrogen dioxide, may
confound the observed associations between PM, TVOCs and HRV
indices and may bias our analyses toward either positive or null
results (Zeka and Schwartz, 2004). Moreover, we were not able to
exclude the confounding effect of respiration on the HRV indices
because the association of the participants breathing patterns with
vagal cardiac outow was not measured in our study (Yasuma and
Hayano, 2004). Physical activity and stress might alter breathing
patterns and heart rate and then inuence HRV measurements in
the walking mode.
Implications for public health policy
This study found that exposure to air pollutants was signicantly
lower among commuters in the subway than among commuters
 W.-T. Liu et al. / International Journal of Hygiene and Environmental Health 218 (2015) 319323
who walked. The use of a public rapid transit system is therefore
benecial for both total air quality improvement and commuter
health improvement. Although commuters in gas-powered buses
with an AC system also had a lower air pollution exposure and
HRV decrement compared to commuters who walked, the frequent
door opening and closing may decrease the efciency of the AC
system and increase the air pollution concentration in the bus. The
drivers may have a lower PM exposure than the bus passengers and
walkers; however, the tail-pipe emissions from large numbers of
cars can have a large impact on air quality in urban environments.
Therefore, we encourage policy makers to increase the construction
of public rapid transit systems in urban environments with heavy
trafc. Commuters are also encouraged to commute using public
rapid transit systems instead of walking during rush hours.
Acknowledgments
This study was supported by grants (NSC 101-2314-B-038-053-
MY3 and 103TMU-SHH-01-3) from the National Science Council
of Taiwan and the Taipei Medical University. The funders had no
role in the study design, data collection and analysis, decision to
publish, or preparation of the manuscript.
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