Epidemiological studies using pollutant gases (e.g., SO2) and particle characteristics (e.g., elemental carbon) indicate that products of fossil fuel combustion are important contributors to particulate matter (PM)-associated hospital admissions and mortality. Coal is one of the world’s most important fossil fuels, providing 40% of electricity worldwide. Besides individuals exposed to PM in ambient air, coal mining can cause adverse health effects in workers exposed to coal dusts at the workplace. Among the respiratory diseases, coal workers’ pneumoconiosis (CWP) has received the most attention because of its clear occupational association. The field of CWP research is one of the few areas in occupational health in which considerable epidemiological data are available. This offers a good opportunity to focus on the relationship between epidemiological data and physico-chemical and/or biological characteristics of coals. The objective of this review is to assess whether some physico-chemical parameters play a role in the observed regional differences in the prevalence of CWP among various coalmine regions. We mainly concentrate on the chemical interaction of two minerals, pyrite (FeS2) and calcite (CaCO3) in the coals and their role in causing occupational lung diseases (e.g., pneumoconiosis) and other environmental problems (e.g., acid mine drainage). Therefore, understanding the chemical interaction of the two minerals in the coal may lead to the identification of the causal components in coal dusts as well as in PM. Examples from U.S.A. coals are used to illustrate the chemical interaction and geological distribution of iron and calcium minerals in various coalmine regions and how the differences in levels of these types of minerals contribute to the observed regional differences in the prevalence of CWP. Molecular mechanisms leading to the CWP development are also discussed, particular in the aspects of oxidative stress and inflammation.