Fragrances in the workplace are not always ones we choose ourselves. Some people experience coughing or difficulty breathing around perfume worn by colleagues or visitors, or room air fresheners. How do such experiences appear in records of work-related illness?
A study published in 2017 by Justine Lew Weinberg and colleagues examined work-related asthma cases collected in California, USA, from 1993 to 2012. Fragrance-associated cases included both exacerbations of existing asthma and cases classified as new onset. The study offers evidence concerning one respiratory aspect of the various health problems referred to in Japan as fragrance-related harm.
Investigating work-relatedness through medical records and interviews
The study aimed to characterize asthma associated with workplace fragrance exposure, improve recognition, and inform prevention. It used surveillance data assembled from physician reports, workers’ compensation information, hospital records, and other sources. It was not a survey that randomly selected workers and clinically examined everyone.
Cases were confirmed using common criteria: a healthcare provider’s diagnosis consistent with asthma documented in medical records, and an association between symptoms and work. Where possible, telephone interviews supplemented records to establish which products people encountered and when symptoms began. Fragrance-associated cases were those with recorded exposure to perfume, cologne, scented body-care products, or air fresheners.
Here, confirmation means meeting surveillance criteria. The researchers did not independently examine everyone or conduct pulmonary function or product-specific challenge tests in every case. The study should be read as a standardized compilation of recorded diagnoses and their relationship to work.
Which population does the 3.8% refer to?
Among 7,163 confirmed work-related asthma cases over 20 years, 270, or 3.8%, were fragrance-associated. There were 242 associated with perfume and other body-care products and 32 with air fresheners; subtracting the four cases involving both gives 270.
The denominator for this 3.8% is the work-related asthma cases identified and confirmed by the surveillance system. It does not mean that 3.8% of the general population, or 3.8% of workers, develop asthma from fragrance. Nor did the study follow everyone exposed to fragrance, so it cannot compare the risk of developing asthma between exposed and unexposed people. Observation ended in 2012; this is not a current incidence estimate either.
Distinguishing exacerbation of existing asthma from new onset
Of the 270 fragrance-associated cases, 103 involved existing asthma aggravated by work, 63 were classified as new onset, and 104 were confirmed as work-related but could not be classified because information such as the timing of onset was insufficient. The 63 new-onset cases included eight with symptoms beginning after acute irritant exposure and 55 developing after a latency period.
This distinction matters. All 270 cannot be counted as people who first developed asthma because of fragrance. Equally, the records do not concern only exacerbations of existing asthma. The inclusion of new-onset cases was one reason the authors argued for prevention. However, classification does not establish which ingredient in each product was responsible.
Symptom burden and biases in the cases identified
Among interviewees, emergency visits and hospitalizations were reported in fragrance-associated cases, at proportions not significantly different from cases associated with other exposures. Among those answering the relevant interview question, 50% of fragrance-associated cases were still exposed at work, compared with 26% of other cases. The authors highlighted the difficulty of avoiding workplace exposure even when symptoms occur.
Women accounted for 94% of fragrance-associated cases. Office, healthcare, and education occupations also represented larger proportions of this group than of cases associated with other exposures. These are not comparisons of incidence across the entire workforce in each occupation. Interview information also showed that workers’ compensation claims had been denied in 30% of fragrance-associated cases versus 21% of other cases. The authors discussed possible underrecognition of work-relatedness. These comparisons alone, however, cannot determine women’s biological susceptibility or why claims were denied.
Telephone interviews were completed for only 39% of all cases. The remainder were confirmed from medical record information. Interviews offer an opportunity to establish products and onset in detail, while records alone may not identify the products involved. Fragrance-associated cases could therefore be missed. Conversely, there may be biases toward people more able to participate in interviews or obtain medical care, so missing cases cannot be corrected for uniformly.
The authors also noted that some cases might involve upper-airway disorders producing asthma-like symptoms. This does not mean that people’s experiences can be dismissed. It points to the need both to acknowledge distress and difficulties at work and to distinguish appropriately what is happening.
The authors proposed reducing workplace exposure
This was not an experiment testing causality or mechanisms for individual fragrance ingredients. Drawing on earlier research, the authors discussed airway irritation and sensitization, while acknowledging unresolved questions about inhaling mixtures and the quantities that elicit responses. These case data cannot establish a risk level common to all fragrances or an amount guaranteed to be safe.
The authors nevertheless proposed preventive workplace measures: policies limiting fragranced products, employee education, appropriate ventilation, and building maintenance. This approach involves reviewing the procurement of air fresheners and scented cleaning products, as well as perfume use, at workplace level. They also called for ingredient disclosure and more detailed clinical research.
These are the authors’ preventive proposals based on surveillance findings and previous studies. This study itself did not test how much each measure would reduce case numbers. Uniform effects cannot be asserted across different products and workplaces, but the proposals offer a way to address shared environments rather than leaving individuals simply to endure exposure.
Summary
California surveillance recorded 270 cases of asthma associated with workplace fragrances, distinguishing work-aggravated asthma, new onset, and cases that could not be classified for lack of information. The 3.8% figure is a proportion of identified work-related asthma cases, not incidence in the general population.
Alongside the need to investigate causal ingredients further, an important question raised by this research is how to reduce exposure where affected people work. Despite the limits of the records, it provides one basis for considering workplace fragrances as an issue for prevention and environmental management.
References
Authors: Justine Lew Weinberg, Jennifer Flattery, Robert Harrison
Article: Fragrances and work-related asthma–California surveillance data, 1993–2012
Journal: Journal of Asthma 54(10), 1041–1050 (2017)
DOI: 10.1080/02770903.2017.1299755
Full original article: Full-text PDF in CDC Stacks
Rights: © 2017 Taylor & Francis Group, LLC. The publicly available PDF does not display a Creative Commons license.
