Respiratory disease and lung function in a tobacco industry

Tobacco Worker's Lung: A Neglected Subtype of Hypersensitivity Pneumonitis

Tobacco worker's lung (TWL) is a type of hypersensitivity pneumonitis (HP) affecting workers exposed to tobacco leaves and molds in the humidified environment of the tobacco production industry. Limited epidemiological data point to a prevalence of TWL that is not negligible and probably underestimated. As in other types of HP, an acute vs. chronic presentation depends on the pattern of the exposure. Therefore, the clinical presentation can vary from an acute influenza-like syndrome, mostly self-limiting with the removal of the exposure, to an insidious onset of cough, exertional dyspnea, fatigue and weight loss in chronic presentations, where fibrotic changes may be observed. The main treatment strategy is the removal of the exposure to tobacco dust and molds, while the main aim of corticosteroid therapy is to reduce morbidity and prevent complications, namely the development of pulmonary fibrosis and permanent lung dysfunction. Despite the fact that TWL is quite well described, preventive measures are not usually adopted in the tobacco production industry. We present here a state of the art review of this neglected, preventable, but still prevalent and occupational-related subtype of HP.

Occupational health hazards in women beedi rollers in Bihar, India

We studied the health problems of 197 female beedi rollers in Patna, Bihar, India to ascertain the effects of beedi rolling on health. The study found that more than 70% of the beedi rollers suffered from eye, gastrointestinal and nervous problems while more than 50% of the respondents suffered from respiratory problems, mostly throat burning and cough. More than 75% of the respondents faced osteological problems. Total RBC, WBC and platelet counts of the beedi rollers were significantly lower in comparison to the control subjects. Differential leucocyte count showed significantly risen lymphocytes and eosinophils and lowered neutrophils and monocytes in the beedi rollers as compared to the control group. Haemoglobin levels were lower among beedi rollers compared to the control group. SGPT (ALT) enzyme concentration, a parameter of liver dysfunction was significantly higher in the beedi rollers as compared to the control group. Thus, the study concluded that beedi rolling may cause significant health hazards.

Respiratory problems of workers in the zarda industry in Kolkata, India

This study was undertaken to assess the pulmonary and respiratory problems of workers in a zarda factory. A total of 70 permanent zarda workers (50 manufacturing workers and 20 office ones) were studied in a factory in Baguihati, Kolkata, India. The study included (a) completion of a questionnaire (on pulmonary and respiratory problems), (b) measurement of physical parameters, (c) spirometry and (d) measurement of peak expiratory flow rate. At the same time, the worksite was analyzed with an OSHA-recommended ergonomics checklist. Many zarda manufacturing workers complained of respiratory symptoms. Continuous exposure to the tobacco processing environment reduced the workers' lung volume and peak expiratory flow rates. Our study indicates that zarda manufacturing workers may have respiratory and pulmonary disorders related to exposure to tobacco dust in their work environment.

Respiratory effects in workers processing dried tobacco leaves

OBJECTIVES

The aim of this study was to examine the pollution level of the occupational environment and to investigate the effects of occupational exposure to tobacco dust on the respiratory system of tobacco workers. No such study has previously been conducted in Greece, which is one of the main tobacco-producing countries.

METHODS

A total of 1,020 seasonal and permanent tobacco workers (188 men and 832 women) were studied in a factory in Thessaloniki. The study included: 1) completion of a questionnaire (British Medical Research Council 1986), 2) spirometry and 3) rhinomanometry. At the same time, tobacco dust levels in the working environment were measured. As controls, 469 workers (87 men and 382 women) at a Thessaloniki hospital were used. Seventy six workers with nasal symptoms underwent: 1) special nasal provocation test with tobacco dust antigen, 2) skin prick tests, and 3) measurement of total IgE, specific IgE and specific IgG against tobacco protein.

RESULTS

Very high levels of total suspended dust were found in work site air (45.3-54.4 mg/m3). The prevalence of chronic bronchitis was 8.7 % versus 20.6 % in controls. Chronic obstructive pulmonary disease was found in 13 workers (1.3 %) and in 16 controls (3.4 %). FEV1 %pred, FVC %pred and the FEV1/FVC ratio were lower in controls, whereas FEF25-75 % %pred was lower in workers. There were no workers with bronchial asthma or extrinsic allergic alveolitis. Rhinitis was reported by 27.3 % of the workers versus 17.9 % of controls, whereas nasal flows were 563+/-211 versus 645 +/- 321 ml/sec, respectively. According to the results of skin prick tests, six workers were sensitized to dried tobacco leaf dust.

CONCLUSIONS

The results of our study do not support an association between the development of chronic diseases of the lower respiratory system and pollutants associated with the processing of dried tobacco leaves. In contrast, an association between disorders of the upper airways and tobacco dust in work sites is postulated.

Hyperresponsiveness to tobacco dust extract in sensitized guinea pig trachea

The role of pre-existing airway inflammation in the pathogenesis of occupational airway disease is poorly understood. Previously we studied an extract of tobacco dust (TDE) and determined that it causes concentration dependent contractions of nonsensitized guinea pig trachea (GPT). In the present study animals were sensitized using Ovalbumin (OA) and subsequently challenged with an aerosol of 2.5% OA on day 21. A control group of nonsensitized GPs were divided into rings in which the epithelium was retained (EPI+) or removed (EPI-). Concentration related contractions of sensitized and nonsensitized GPTs were elicited with TDE. Sensitized GPTs demonstrated a greater contractile response to TDE than did nonsensitized GPTs. In nonsensitized animals the EPI- GPTs demonstrated a lesser response to TDE than did the EPI+. Similar findings were demonstrated in sensitized GPTs with and without epithelium. When epithelium was removed, sensitized and nonsensitized GPTs behaved similarly. Moreover, sensitized GPTs without epithelium and nonsensitized with epithelium responded similarly. These findings suggest that presensitization with an unrelated antigen enhances the response to an occupational agent and that in sensitized animals at least part of the enhanced response is mediated by the epithelial layer.

Immunological and respiratory changes in tobacco workers

BACKGROUND

Tobacco workers develop respiratory changes following occupational exposure to tobacco dust.

METHODS

This study investigated 102 tobacco workers as well as a group of 30 matched control workers. Immunological testing, symptom questionnaire, and lung function measurements were performed in all workers.

RESULTS

Increased total IgE was found in 12.7% of tobacco workers but in none of the controls (P < 0.05). Increased specific IgE (tobacco allergen) was recorded in 26.7% of tobacco workers with positive skin tests to tobacco extract but in none of the controls (P < 0.05). Regression analysis of ventilatory tests in female tobacco workers indicated a significant association of FEF75 to employment and smoking among workers with positive skin tests to tobacco. There were, however, no other associations between positive immunologic findings and lung function abnormalities and symptoms.

CONCLUSIONS

Our study found increased immunological reactions in the tobacco workers. However, with the possible exception of lung function at low lung volume in female workers, these reactions do not appear to contribute significantly to the symptoms and lung function abnormalities seen in these workers. Am. J. Ind. Med. 45:76-83, 2004.

Respiratory findings in tobacco workers

OBJECTIVES

To screen for respiratory symptoms and lung function impairment in workers occupationally exposed to tobacco dust in a tobacco-processing plant.

PARTICIPANTS

One hundred twenty-one tobacco workers (97 women and 24 men) were included in the study. In addition, a group of 98 control workers (73 women and 25 men) were studied.

METHODS

Acute and chronic respiratory symptoms were recorded in all tobacco workers. Lung function was measured by recording the maximum expiratory flow-volume curves on which FVC, FEV(1), and flow rates at 50% of FVC (FEF(50)) and the last 25% of FVC (FEF(25)) were read.

RESULTS

There was a high prevalence of chronic respiratory symptoms among these workers, and this prevalence was significantly higher in exposed female workers than in female or male control workers (p < 0.01 and p < 0.05, respectively). Occupational asthma was recorded in 6 female tobacco workers (6.2%) and in none of the control subjects (p < 0.05). None of the male workers were found to have occupational asthma. There was also a high prevalence of acute symptoms that were noted during the work shift (particularly for nose and throat dryness, as well as eye irritation). Among these tobacco workers, the odds ratios for respiratory symptoms were frequently significant for employment and smoking among male tobacco workers but were not significant in general for female tobacco workers. The ventilatory capacity data in tobacco workers showed statistically significant reductions in FEV(1), FEF(50), and FEF(25) in relation to predicted values. These reductions were demonstrated in smokers as well as in nonsmokers. Regression analysis suggested that there were significant changes according to employment status for FVC, FEV(1), and FEF(25) in female tobacco workers. Measurements of ventilatory capacity during the course of the work shift in 38 female tobacco workers demonstrated significant mean acute reductions in FEV(1) (-5.7%), in FEF(50) (-15.7%), and in FEF(25) (-23.4%).

CONCLUSIONS

Our data indicate that tobacco workers may develop respiratory disorders related to tobacco dust in their work environment.

Pharmacologic effects of tobacco dust extract on isolated Guinea pig trachea

STUDY OBJECTIVE

To determine the effects of tobacco dust extract (TDE) on isolated guinea pig tracheal smooth muscle.

DESIGN

A controlled, in vitro smooth-muscle study of the effect of pharmacologic agents on TDE.

METHODS

The effect of TDE on isolated guinea pig tracheal smooth muscle was tested using water-soluble extracts of dust obtained from machines in a cigarette manufacturing plant. Dose-related contractions of nonsensitized guinea pig trachea were demonstrated using these extracts. The dust extracts contained significant quantities of bacterial components (eg, endotoxin). Pharmacologic studies were performed by pretreating guinea pig tracheal tissue with drugs known to modulate smooth-muscle contraction: atropine, indomethacin, pyrilamine, nordihydroguaretic acid, acivicin, bromophenacyl bromide, 3,4,5-trimethoxybenzoic acid-8-(diethylamino)octyl ester, captopril, and capsaicin.

RESULTS

Atropine strikingly reduced the contractile effects of these extracts. Inhibition of contraction by blocking other mediators was less complete. There was no inhibition of contraction by hexamethonium (10(-4) mol/L, 10(-5) mol/L, 10(-6) mol/L), suggesting that nicotine was not the major contractile mediator of TDE. A separate analysis using different molecular weight fractions of TDE indicated that the constrictor activity appears to be primarily in the fraction with a molecular weight < 10 kd. Additionally, the constrictor effect resided entirely in the nonlipid fraction of the extract. We suggest that TDE causes dose-related airway smooth-muscle constriction by nonimmunologic mechanisms involving a variety of airway mediators and possibly cholinergic receptors.

CONCLUSIONS

The bronchoconstrictor activity of TDE resides primarily in its low molecular weight, nonlipid fraction, and hexamethonium studies suggest that this agent is not nicotine.

Respiratory health of cigar factory workers

OBJECTIVES

To determine whether occupational exposure to raw tobacco causes respiratory or allergic diseases, an excess of respiratory symptoms, a decrease in lung function, or parenchymal changes in chest radiography among Finnish cigar workers.

METHODS

This cross sectional study included all Finnish cigar workers (n = 106) exposed to raw tobacco and also a group of unexposed matched referents. Data were collected with a self administered questionnaire, flow volume spirometry, measurements of diffusing capacity of the lung for carbon monoxide, chest radiography and skin prick tests. A questionnaire was also sent to former workers of the factory.

RESULTS

There were no significant differences between the groups in the prevalence of respiratory symptoms and chest radiography findings. Nine of 102 tobacco workers had pulmonary fibrosis of at least 1/0 (according to the International Labour Organisation (ILO) 1980 classification) and the corresponding figure was five for the referents. The tobacco workers tended to have a low forced vital capacity (FVC), and they had impaired forced expiratory volume in 1 second and lower means of the maximal expiratory flow at 25% of the FVC significantly more often than the referents. Diffusing capacity tended to be lower among the referents. The referents more often had atopy and earlier atopic diseases than the exposed workers. These results indicate the possibility of selection among the exposed workers.

CONCLUSIONS

No excess of prevalence of respiratory symptoms in the tobacco workers was found. According to the questionnaire episodes of allergic alveolitis may have occurred in the cigar factory workers. However, in the absence of impairments in lung function and radiological changes it was not possible to distinguish humidifier fever and allergic alveolitis. In exposure conditions that include humidification of the air humidifier, fever and allergic alveolitis constitute a risk for tobacco workers. No effects were shown of exposure to tobacco dust on lung function.

Respiratory disorders and atopy in cotton, wool, and other textile mill workers in Denmark

A cross-sectional study of respiratory disorders and atopy in Danish textile industry workers was conducted to survey respiratory symptoms throughout the textile industry, to estimate the association of these disorders with atopy, and to study dose-response relationships within the cotton industry. Workers at cotton mills, a wool mill, and a man-made fiber (MMF) mill were examined. Four hundred nine (90%) of the 445 workers participated in this survey, i.e., 253, 62, and 94 workers at the cotton mills, the wool mill, and the MMF mill, respectively. An interview designed to assess the prevalence of common respiratory and allergic symptoms was given to all workers willing to participate, and blood samples were drawn. Lung function measurements determined a baseline FEV1, FVC and the change in FEV1 and FVC during work hours on a Monday. The working environment was examined for dust, bacteria, endotoxins, and molds, and the exposure was estimated for each participant. The mean personal samples of airborne respirable dust and respirable endotoxin were highest in the cotton industry, i.e., 0.17-0.50 mg/m3 and 9.0-126 ng/m3 respectively, whereas mold spores were found in the highest concentrations in the wool mill: 280-791 colony-forming units (cfu)/m3. Only small concentrations of microorganisms were found in the MMF mill. The mean change in FEV1% and FVC% was greatest among atopic individuals in both cotton and wool industry and other textile industries although the differences were not significant. FEV1% and FVC% in the cotton workers were significantly associated with the cumulative exposure to respirable endotoxin. Byssinosis was diagnosed only in the cotton industry. We found a dose-response relationship between endotoxin exposure and byssinosis, and a significant association between A-1-A serum concentrations less than or equal to 35 mumol/liter and byssinosis, a finding we are further evaluating in subsequent studies.

Dust exposure, eye redness, eye cytology and mucous membrane irritation in a tobacco industry

In a study of 75 workers employed in a tobacco factory producing cheroots we measured cellular contents of tear fluid, redness of eyes, discomfort, total (0-5.7 mg/m3) and respirable dust in the breathing zone and total ambient dust by stationary sampling (0.08-1.0 mg/m3). A matched group of 50 office workers in a telephone company (total ambient dust concentration between 0.08-0.13 mg/m3) was similarly examined as referents. We found a difference between the two companies with regard to cell counts, with tobacco workers having the largest numbers except for lymphocytes. Among tobacco workers we furthermore found that the number of cuboidal and columnar epithelial cells increased during the day. The increase of cuboidal cells, however, occurred mainly in a small group of tobacco workers exposed to the highest concentrations of tobacco dust (mean = 1.26 mg/m3). No difference in the sensation of eye irritation was found between companies, but increased irritation in the morning was associated with increased exposure to total dust during the workshift among tobacco workers. A dose-dependent difference in photographically measured eye redness was found among the tobacco workers. It could not be explained by differences in tobacco smoking, sex, age, sleeping habits or use of glasses. Irritation of lips and upper airways as reported by questionnaire were more common in tobacco workers than in referents. In conclusion the tobacco workers, more often than the referents, had complaints and objective changes in the mucous membranes of the eyes. These may be related to tobacco dust exposure.