NOx

reacts with ammonia, moisture, and other compounds to form nitric acid vapor and related particles. Small particles can penetrate deeply into sensitive lung tissue and damage it, causing premature death in extreme cases. Inhalation of such particles may cause or worsen respiratory diseases, such as emphysema or bronchitis, or may also aggravate existing heart disease.

NOx reacts with volatile organic compounds in the presence of sunlight to form ozone. Ozone can cause adverse effects such as damage to lung tissue and reduction in lung function mostly in susceptible populations (children, elderly, asthmatics). Ozone can be transported by wind currents and cause health impacts far from the original sources. The American Lung Association estimates that nearly 50 percent of United States inhabitants live in counties that are not in ozone compliance.

NOx also readily reacts with common organic chemicals, and even ozone, to form a wide variety of toxic products: nitroarenes, nitrosamines and also the nitrate radical some of which may cause biological mutations. Recently another pathway, via NOx, to ozone has been found that predominantly occurs in coastal areas via formation of nitryl chloride when NOx comes into contact with salt mist.

NOx emissions also causes global cooling through the formation of OH groups that destroy methane molecules, countering the effect of greenhouse gases. The effect can be significant. For instance, according to the OECD "the large emissions from ship traffic lead to significant increases in hydroxyl, which is the major oxidant in the lower atmosphere. Since reaction with OH is a major way of removing methane from the atmosphere, ship emissions decrease methane concentrations. (Reductions in methane lifetimes due to shipping-based  emissions vary between 1.5% and 5% in different calculations)." "In summary, most studies so far indicate that ship emissions actually lead to a net global cooling. This net global cooling effect is not being experienced in other transport sectors. However, it should be stressed that the uncertainties with this conclusion are large, in particular for indirect effects, and global temperature is only a first measure of the extent of climate change in any event."