Air pollution is a widespread environmental risk factor that poses a serious threat to global human health. It is a complicated mixture of particulate matters (PM₂.₅, and PM₁₀), gases including nitrogen dioxide (NO₂), sulfur dioxide (SO₂), ozone (O₃), carbon monoxide (CO), and a number of volatile organic compounds (VOCs), which mainly come from industrial emissions, vehicle exhaust, biomass combustion, and other human activities [1, 2]. Air pollution worldwide alone causes millions of deaths annually, which are mainly due to respiratory and cardiovascular disease. In addition to these established physical health outcomes, however, there is increasing evidence that air pollution also negatively influences mental health, causing a variety of psychiatric conditions and cognitive impairment [3, 4].

Long-term exposure to air pollution has been associated with a greater risk of depression, anxiety, bipolar disorder, psychosis, and even suicide [5-7]. According to previous epidemiological studies, air contamination raises the risk of dementia, Alzheimer's disease, and cerebral decline in the elderly population [8-11]. The most vulnerable individuals are children and young people because of their immature nervous system and increased liability per body weight, which can lead to sustained neuro-developmental and behavioral effects [4]. Neuroimaging and epidemiological research indicate that air pollution causes neuroinflammation and oxidative stress that impact brain areas responsible for emotion regulation, such as the hippocampus, amygdala, and prefrontal cortex [12, 13]. Such biological pathways yield a likely mechanism to connect exposure to pollutants with heightened internalizing symptoms, such as anxiety and depression [12].

Moreover, new research shows that air pollution adversely affects sleep patterns, contributing to poor sleep quality, insomnia, and sleep fragmentation. Pollutants, such as fine particulate matter (PM_2.5) and nitrogen dioxide (NO₂), can irritate the respiratory system, leading to sleep-disordered breathing and disrupted restorative sleep stages, which in turn cause daytime fatigue and cognitive impairments [14]. Chronic exposure to polluted air has also been associated with feelings of altered mood, irritability, anger, restlessness, and chronic sadness, many of which are symptoms that precede or exist with anxiety and depressive disorders. These impacts are hypothesized to stem from neuroinflammation, oxidative stress, or changes in stress hormones, which damage brain regions involved in emotional regulation [15]. In addition, the neurobehavioral outcomes highlighted above emphasize a more comprehensive psychological burden of air pollution beyond traditional psychiatric diagnoses.

International organizations, such as the World Health Organization (WHO), establish limits for safe concentrations of typical air pollutants, but many city dwellers remain exposed far above these thresholds, further amplifying health risks [1]. The United States Environmental Protection Agency (EPA) also places a high priority on integrating scientific evaluations to inform policy makers and promote public health [16]. Understanding the whole extent of air pollution health-related impacts, including its behavioral and psychological aspects, is necessary for comprehensive public health plans.

This study aims to investigate the relation between air pollution exposure with anxiety, depression, and behavioural changes among residents in Pakistan, a country facing significant air quality challenges. A cross-sectional online survey and strong statistical methods were utilized in this study to highlight the psychological burden of air pollution. By revealing these hidden effects, the study not only deepens the discussion on environmental health but also opens new directions for public health strategies that are more inclusive and responsive. It is important to address this gap in knowledge in order to develop interventions that not only mitigate the effects of pollution on the body but also on the psychological health of the affected people.

This cross-sectional study used a sample of 160 respondents, consisting of 35 (21.9%) males and 125 (78.1%) females. The participants were categorized into five age groups, and the majority were between the ages of 15–24 years (75.6%), followed by 25–34 years (13.1%), 35–44 years (5.6%), 45–54 years (3.1%), and 55 years or older (2.5%). To assess air pollution awareness among respondents, demographic information was further categorized by population density and level of education. As per the location of the survey participants, the majority resided in urban areas (89.4%), with fewer participants from rural areas (6.3%) and suburban areas (4.4%). Regarding educational background, most participants held an undergraduate degree (n = 103, 64.4%), followed by high school graduates (n = 27, 16.9%), postgraduate degree holders (n = 21, 13.1%), and those with less than high school education (n = 5, 3.1%), and other (n = 4, 2.5%) (Table 1).

Figure (1) shows that participants were asked whether they noticed air pollution (smog, dust, or haze) in their area on a 5-point Likert scale ranging from 1 (Never) to 5 (Always). Most respondents favored frequently noticed air pollution (35.6%) or always (30.0%). Only 2.5% of participants declared that they never noticed air pollution. The mean response was 3.82(1.04), suggesting that, on average, participants noticed air pollution between “occasionally” and “frequently,” with a greater inclination towards “frequently.”

Figure (2) shows that the majority of people (70%) perceived a worsening of air quality over the past year, while 19.4% were not sure and 10.6% reported no worsening of air quality in their area. The mean response is 1.49, indicating that most participants perceived a decline in air quality. However, this awareness didn’t consistently translate into protective behavior, as shown in Fig. (3). Participants were inquired about the frequency of using a face mask or an air purifier to protect against air pollution on a 5-point Likert scale ranging from 1 (Never) to 5 (Always). A larger proportion of the participants responded Rarely (31.9%), followed by Occasionally (23.8%). Only 11.9% of participants declared “Always” using protective measures such as a face mask or an air purifier. The mean response was 2.78 (SD = 1.24), suggesting that participants, on average, adopted infrequent protective measures. This relatively low average is concerning, suggesting a general lack of consistent protective behavior against air pollution.

Figure (4) shows that the mental health impact of air pollution emerged as a significant concern. Participants were asked to rate the overall impact of air pollution on their mental health, compared to other stress factors (like work, personal life, etc.) on a Likert scale ranging from 1 (Minimal impact) to 5 (I don’t know). The majority of respondents selected significant impact (34.4%) or moderate impact (32.5%) of air pollution. Only 8.1% of participants reported “I don’t know”, indicating their uncertainty about the impact of air pollution on their psychological health. The mean response was 2.66 (SD = 1.10), suggesting that, on average, participants perceived the impact of air pollution as moderate to significant, with a slight tendency toward the moderate end. The relatively high proportion of participants reporting moderate to significant effects shows a concerning trend regarding the psychological burden of air pollution.

Results pertaining to the analysis of mental health outcomes show significant demographic variations in terms of age, gender, area, and level of education of the sample population in both the frequency of experiencing poor air quality and the perceived level of concern about air pollution’s health impact. Also, the p-values are presented in Table 2. Strong associations were found between demographic characteristics and mental health outcomes related to air pollution. In terms of the age factor, the younger adults (15–24 years) consistently reported higher levels of anxiety, fatigue, irritability, and sleep disturbances compared with the older groups, while the 25–34-year-old group expressed greater concern about the health impacts. Whereas, in terms of gender, females generally reported heightened anxiety, mood changes, irritability, and depressive symptoms compared to males, although in the case of fatigue, males expressed greater health concerns. According to the area of living, the urban residents were more likely than rural residents to report anxiety, mood disturbances, irritability, and depressive symptoms, and also expressed greater concern about the health consequences of air pollution, particularly regarding fatigue, sleep, and anger. While the educational differences were also notable, undergraduates showed higher levels of anxiety, fatigue concerns, sleep disturbance concerns, irritability, and depressive symptoms, but postgraduates tended to express concern rather than symptoms, particularly regarding mood changes.

The key findings of the stratified demographic analysis in Table 2 are depicted in Fig. (5).

Further evaluation of the survey variables was conducted by conducting a series of chi-square tests of independence. Table 3. shows that the individuals who frequently notice contaminated air in their area were more likely to report several indicators of psychological impact. Participants recognize a significant change in their mood or behavior, due to frequent awareness of air pollution (p < .001). A marginally significant association (p = .028) was also found between noticing air pollution and feelings of fatigue or exhaustion. Similarly, most respondents feel sad or depressed (p < .001), as well as report the worsening of their anxiety or depressive symptoms (p < .001) after exposure to smog, dust, and haze. This relationship suggests that increased perceptual awareness of poor air quality is linked to negative emotional states and mental health distress.

Table 4 presents the relationship between the concern of respondents about the health impacts of air pollution and related perceptual and behavioral factors. A significant association was found (p = .013) between experiencing worsening air quality in one's area and concern about the health impacts of poor quality of air quality. Additionally, a significant relationship was identified between concern about air pollution's health effects and the use of protective behaviors, such as air purifiers or wearing face masks (p = .004). These results suggest that individuals who perceive air quality as deteriorating are more likely to exhibit concern about health consequences and to take self-protective actions.

The current survey-based study assessed the awareness of air pollution and its related mental health symptoms by using self-reported, custom-made questionnaire partly adapted from PHQ-4 and PHQ-9 criteria along with coping strategies among general population in Pakistan, offering crucial insights into how air pollution exposure impacts participant’s quality of life and what strategy they choose to mitigate it [17, 19] Using an online survey, the study involved 160 participants, predominantly 125 females followed by 35 males. Demographically, individuals were primarily students (64.4% pursuing undergraduate degrees), indicating a younger cohort aged 15-24 years, with a larger proportion residing in urban areas.

According to demographic factors, this study shows that the younger adults were the most anxious, depressed, with low mood and sleep changes, although they show lesser concern than the early-working-aged adults (25-34 years old). However, a stark contrast emerges when compared to previous studies in Bangladesh, Italy, and Brazil, in terms of age categories mentioned that older adults are more prone to mental and respiratory disorders due to air pollution [20-22]. Similarly, in terms of gender, it was found that a greater number of female participants reported anxiety, fatigue, irritability, and behavioral changes than males. But males showed more concern regarding their health due to poor air quality. The same finding was reported in the study of Al-Shidi, H.K., and colleagues [23]. In view of respondents' area of living, urban dwellers recognized elevated anxiety, anger, mood changes, and sadness. Also, they reported concern about health than the rural residents, which aligns with previous evidence [24, 25]. The level of education factor also determines the increased anxiousness, exhaustion, depressive symptoms, and fidgety behavior among undergraduates, but the concern regarding mental health was more in postgraduate students [26]. Participants' awareness of air contamination in their living areas was significant in the present study, as they frequently (35.6%) notice smog, haze, and dust in their everyday routine, though this is less than an online study conducted in Bangladesh, where 90% respondents reported air-polluted environments and associated health problems [20]. A majority (70%) of participants in the survey reported experiencing a worsening of poor air quality over the past year, which is validated by the 2024 report of Pakistan’s Air Quality Index (AQI) with an average of 164, placing it in the red zone and ranking it the third worst country with contaminated air. The PM2.5 concentration is 14.7 times the World Health Organization PM2.5 guideline value. The major urban cities top the list of unhealthy air, including Sialkot (119 AQI), Islamabad (117 AQI), followed by Lahore and Karachi, both at 96 AQI [26].

A significant to moderate impact of air pollution was found on an individual’s mental health symptoms as compared to other stress factors like personal life difficulties, trauma, workload, etc., and this aligns with previously reported data [27, 28]. The matter of fact is that this awareness didn’t consistently translate into protective behavior, as most participants, i.e., Pakistanis, were found to be using a face mask or air purifier “rarely” (31.9%) as protection from impure air, which is concerning and contradictory to the research from China [29]. That study revealed that the behavior of Chinese people was more promising, with 54.5% using all types of masks and 70.6% using anti-PM 2.5 masks to prevent unclean air hazards to their health [29, 30]. This highlights the need for awareness and the development of a habit of taking protective measures among Pakistanis to combat the health effects of polluted air [31].

The current evidence suggests a strong association between frequent detection of air pollution and the emergence of negative emotional states, indicating poor mental health indicators among participants. They recognize marked changes in their mood or behavior, and many reported suffering from sadness and depression, as also recognized by previous research [12, 32]. Similarly, most respondents experienced feelings of fatigue or exhaustion and reported worsening of their anxiety or depressive symptoms. This same significant pattern was mentioned by the CHARLS study [33, 34]. These relationships suggest that increased perceptual awareness of poor air quality is linked to mental health distress [35].

A growing number of studies confirm that, as in this survey, a majority of respondents living in regions with high air pollution complain about irregular sleeping patterns and poor-quality sleep. PM₂.₅, NO₂, and O₃ are some of the harmful pollutants that have been known to reduce sleep efficiency and increase sleep latency, along with causing fragmented sleep architecture [36]. In one of the reviews, it has been discussed that air pollution disrupts melatonin regulation and inflammatory pathways, leading to poor sleep health and disruption of circadian rhythms [36, 37]. A cohort study conducted in China revealed that heightened concentrations of PM₂.₅ and NO₂ are associated with some symptoms of insomnia, such as trouble falling asleep and early waking habitually [38]. These subjective findings are bolstered by objective measures from actigraphy-based sleep studies that demonstrate decreases in sleep duration and sleep efficiency with exposure to pollutants [14]. Moreover, it is observed that circadian rhythm is disturbed due to altered melatonin production following pollutant exposure, causing delays in sleep onset and daytime fatigue [39]. These findings collectively strengthen the assertion that air pollution significantly influences sleep quality, a major concern with moderate positive significance (ρ = 0.40, p < 0.001) expressed by respondents in our survey.

It is becoming more apparent how air pollution can contribute to mental health issues, such as anxiety and depression. Research indicates that short-term exposure to air pollutants like SO₂, NO₂, PM₂.₅, and PM₁₀ is linked to increased outpatient and emergency department visits for anxiety and depressive episodes [40-42]. These observations demonstrate that the misery caused by polluted air is not restricted to subclinical thresholds, nor is it momentary, but rather long-lasting and severe enough to motivate seeking medical care. Sustained exposure is also critical, especially for older adults, as chronic exposure to pollutants increases the likelihood of developing anxiety and depression [6]. A systematic review provides additional support, noting that most studies reported biological alterations in the brain alongside mental health symptoms, underscoring the validity of considering air pollution as a potential psychiatric risk factor [12]. These findings corroborate the results of the survey, which showed that participants who reported consulting primary healthcare doctors to address emotional distress attributed to poor air quality, reinforcing the notion that the environment is directly shaping mental health care-seeking behaviors, and the chi-square value (p = .055) showed a significant relationship. Rating their health poorly due to air pollution increases the likelihood of experiencing depression, anxiety, and psychological distress (p < .001). This indicates that perceptions of negative air quality impact mental health and self-rated health in particular. It does support the idea that self-rated health acts as a mediator of the relationship between environmental exposure and mental well-being [43].

Monitoring the health of 422 Mexican-American adolescents for two years showed that exposure to air pollutants, such as NO₂ and CO, resulted in increased fatigue and emotional distress. These associations were strong for both symptoms occurring on the same day and the next day. Moreover, even when temperature and humidity were included as additional confounding factors, the results still showed a strong effect [44]. This showed the association between air quality and mood-related fatigue as well as energy levels in children and adolescents.

Additionally, this research indicates the coping strategies based on the personal choices of the participants to deal with the mental health implications of air pollution. A substantial portion (37.5%) of respondents choose to stay indoors to avoid the air pollutants from outdoor air, this aligns with the meta-analysis and review that previously mentioned the actions, such as reduced personal exposure to ambient air pollution by staying indoors, reducing outdoor air infiltration to indoors, cleaning indoor air with air filters, and limiting physical exertion outdoors on high air pollution days and near air pollution sources, reducing near-roadway exposure while commuting, utilizing air quality alert systems to plan activities, and wearing facemasks in prescribed circumstances which can be taken at the individual level to lower exposure-related health risks from air pollution [45, 46]. A reasonable number of respondents (19.4%) reported performing exercise regularly to address air pollution health consequences in the survey. This aligns with the comprehensive review, which includes studies of large samples of Korean and Swedish individuals who perform moderate to vigorous exercise >5 times/week, who experienced decreased risk of stroke and cardiovascular disease incidence, even when exposed to high levels of PM₂.₅ and PM₁₀ [47-49]. Quite a few people in the present investigation, i.e., 9.4% and 6.3%, chose meditation/mindfulness and use of medications, respectively, to prevent the negative health influences of contaminated air. This corresponds to the earlier qualitative analysis done that explains the effect of mindfulness on pro-environmental behavior [50]. Similarly, the specific medicine was not reported by the participants, and the use of air pollution-related mental symptoms-specific drugs is not much explored. Instead, one study reported that nonsteroidal anti-inflammatory drugs (NSAIDs), like aspirin, may lessen the adverse effects of air pollution exposure on lung function [51]. Lastly, subsequent majority (27.5%) of members answered using none of the mentioned coping strategies, suggesting the lack of seeking professional help like therapy, which points out that there might be insufficient mental health care services or a lack of promotion of available services in this situation. With regard to the air pollution-associated mental health symptoms, participants predominantly use behavioral strategies, especially avoidance, as their coping mechanism [45].

The biggest debate in the present world about air pollution is its leading causes and possible mitigation strategies to cope with potential health risks and glitches [52]. The multiple survey responses demonstrated that participants selected vehicle emissions (83.15%), construction activities (54.4%), and industrial emissions (41.9%) as the top three causes of air pollutants, an existence with past studies in Pakistan that referred to the same outcomes [53, 54]. A plethora of prior studies also outlined these principal contributors to air quality deterioration. Research conducted in Iran cited a number of different emission sources, but motor vehicles and industrial processes contribute the major proportion of air pollution in Iran [55]. Geopolitical neighbors of Pakistan in South Asia, like India and Afghanistan, also cited the causes of air pollution. The main contributors to India's particulate air pollution include industrial and vehicular emissions, construction dust and debris, and waste burning etc [56]. Similarly, the primary sources of ambient air pollution in Afghanistan encompass motor vehicles, agricultural burning, and industrial activities [57]. A sparse participant pool chose crop burning (n=47) and other causes (n=9), i.e., damaged roads dust, timber cutting, hotel places smoke as pollutant-generating activities. These observations reinforce earlier scientific literature [58-60].

In response to the noxious air pollutants arising from emission sources, a range of advised mitigation approaches has been developed [61]. According to the collected data, participants shared several intervention strategies to counteract these toxic atmospheric pollutants. 95% of survey takers preferred improved transportation to control vehicle emissions, while 60% of respondents recommended strict government regulations on industrial emissions. These perspectives resonate with previously structured recommendations, including the benefits of effective vehicle management and emission control through regular maintenance [62]. It has been emphasized that policymakers should collaborate closely with regulatory bodies, industries, and local communities to implement environmentally responsible practices more efficiently [63]. The remaining mentioned secondary contributors are crop burning and construction activities, for participants opted for awareness campaigns and increasing green spaces across Pakistan. Initiatives, such as reducing air pollution from urban residential buildings and enhancing green spaces, have also been recognized for their role in filtering airborne particles [64, 65]. Increased plantation, in particular, plays a significant role in reducing city air pollution [66]. Besides that, public awareness campaigns regarding the health threats posed by air pollution present both challenges and opportunities, underscoring the need for comprehensive communication strategies to enhance environmental health literacy [67]. In addition to resisting the air contamination caused by issues such as damaged roads, dust, smoke from hotels, and the burning of garbage, it is essential to implement waste classification to enhance air quality in municipal solid waste management [68]. Implementing effective sanitation to prevent disease transmission, safeguards the air-polluted environment, enhances the quality of life, and promotes the overall well-being of the community [69].

This study serves as a preliminary investigation into the intricate and strong relationship between air quality decline and mental health. It concludes that prolonged exposure and perceptual awareness of smog, haze, and dust were associated with elevated symptoms of depression, irritability, anxiety, fatigue, and sleep disturbances, which contribute to a decreased quality of life and overall well-being in the Pakistani population. Despite this psychological burden, the protective behavior of the participants, i.e., the use of masks or air purification, was inconsistently practiced, highlighting a critical public health gap. In order to understand this critical issue, future longitudinal studies are required to establish causality and guide appropriate interventions. The findings of this study can be taken as baseline evidence highlighting an emerging public health concern rather than prescription policy recommendations.