Biodiesels have been promoted as a greener alternative to diesel with decreased emissions and health effects. To investigate the scientific basis of the suggested environmental and health benefits offered by biodiesel, this review examines the current state of knowledge and key uncertainties of pollutant profiles of biodiesel engine exhaust and the associated the respiratory and cardiovascular outcomes. The ease and low cost of biodiesel production has facilitated greater distribution and commercial use. The pollutant profile of biodiesel engine exhaust is distinct from diesel, characterised by increased NOx and aldehyde emissions but decreased CO and CO2. Lower engine-out particulate matter mass concentrations have also been observed over a range of feedstocks. However, these reduced emissions have been attributable to a shift towards smaller sized particulate emissions. The toxicity of biodiesel engine exhaust has been investigated in vitro using various lung cell, in vivo evaluating responses induced in animals and through several human exposure studies. Discrepancies exist across results reported by in vitro and in vivo studies, which may be attributable to differences in biodiesel feedstocks, engine characteristics, operating conditions or use of aftertreatment systems across test scenarios. The limited human testing further suggests short-term exposure to biodiesel engine exhaust is associated with cardiopulmonary outcomes that are comparable to diesel. Additional information about the health effects of biodiesel engine exhaust exposure is required for effective public health policy.