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Incense smoke: clinical, structural and molecular effects on airway disease
Ta-Chang Lin*1,2, Guha Krishnaswamy3 and David S Chi3
Address: 1Department of Environmental Engineering, National Cheng Kung University, Tainan, Taiwan, 2Sustainable Environment Research Center, National Cheng Kung University, Tainan, Taiwan and 3Department of Internal Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA Email: Ta-Chang Lin* - firstname.lastname@example.org; Guha Krishnaswamy - email@example.com; David S Chi - firstname.lastname@example.org * Corresponding author
Published: 25 April 2008 Clinical and Molecular Allergy 2008, 6:3 doi:10.1186/1476-7961-6-3
Received: 3 January 2008 Accepted: 25 April 2008
This article is available from: http://www.clinicalmolecularallergy.com/content/6/1/3 © 2008 Lin et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
In Asian countries where the Buddhism and Taoism are mainstream religions, incense burning is a daily practice. A typical composition of stick incense consists of 21% (by weight) of herbal and wood powder, 35% of fragrance material, 11% of adhesive powder, and 33% of bamboo stick. Incense smoke (fumes) contains particulate matter (PM), gas products and many organic compounds. On average, incense burning produces particulates greater than 45 mg/g burned as compared to 10 mg/ g burned for cigarettes. The gas products from burning incense include CO, CO2, NO2, SO2, and others. Incense burning also produces volatile organic compounds, such as benzene, toluene, and xylenes, as well as aldehydes and polycyclic aromatic hydrocarbons (PAHs). The air pollution in and around various temples has been documented to have harmful effects on health. When incense smoke pollutants are inhaled, they cause respiratory system dysfunction. Incense smoke is a risk factor for elevated cord blood IgE levels and has been indicated to cause allergic contact dermatitis. Incense smoke also has been associated with neoplasm and extracts of particulate matter from incense smoke are found to be mutagenic in the Ames Salmonella test with TA98 and activation. In order to prevent airway disease and other health problem, it is advisable that people should reduce the exposure time when they worship at the temple with heavy incense smokes, and ventilate their house when they burn incense at home.
Encyclopedia Britannica states that incense was employed to counteract disagreeable odors, drive away demons, manifest the presence of gods, and to gratify gods. Incense burning has been practiced for centuries. Early Christian churches used incense in the Eucharistic ceremony, in which it symbolized the ascent of the prayers of the faithful and the merits of the saints. Later, incense was employed sporadically in the Church of England. Elsewhere in both Eastern and Western Catholic Christendom, its use during divine worship and during
processions has been continuous . In Asian countries where the Buddhism and Taoism are mainstream religions, such as China, Thailand, and Taiwan, incense burning is a daily practice. In Taiwan, about half of its population (23 million) is Buddhist or Taoist. Most of them burn incense daily when they worship at home. The people in Taiwan also worship with incenses at temples regularly. In 2003, the Environmental Protection Agency in Taiwan reported that a total of 28.7 metric tons of incense was burned in 92 temples
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one end of a bamboo stick is first soaked in adhesive materials before it is coated with a mixture of fragrance. rope. C. The main difference between the first two forms is that the former has a slender bamboo base.4 cm. wood powders. Adhesive Powder is from the bark of Machilus nanmu Hemsl. (Magnoliaceae). var. The nature of incenses and incense burning There are various forms of incenses. and xylenes. among them stick incense is the most popular in Taiwan. Rheum officinale Baill. toluene. Asarum siebolidii Miq. tics of these incenses. Radix Aucklandia. Nardostachys chinensis Bastal. (Hamamelidaceae). Figure 2 shows five major forms of Asian incense. most incense is made from a combination of fragrant gums. Magnolia liliiflora Desr.3 gm). including sticks. herbs and spices. cones. (Santalaceae). respectively). such as length and diameter of the bamboo stick (average 39. (Umbelliferae).Clinical and Molecular Allergy 2008. NO2. Taiwan Incense burning during Lunar New Year in the LongShang Temple in Taipei. The air pollution in and around various temples has been documented [4-12]. Currently. Apaprently. (Lauraceae). Juniperus chinensis L. Cinnamomum cassia Bl. Hsing Shan. rocks/charcoal. (Compositae). If household incense burning is included. and Ocimum basilicum L. It is estimated that at least a total of 3. while the latter is without a central base. the dense incense smoke inflicted irritation in the eyes of a worshiper (photo by T. This coating process is repeated two more times. While the exact content of incense sticks is a commercial secret. length and diameter of the incense coated part (average 28. Gui Shan. as well as aldehydes and polycyclic aromatic hydrocarbons (PAHs). Incenses are then dried under the sun. To make incenses. are very similar . the burning extinguishes itself at the tip of the bare bamboo part of the stick. Some of these materials are also used in Chinese traditional medicine. Lao Shan. resins. it emits smoke (fumes) containing particulate matter (PM). SO2. The effects of incense smoke on airway disease and health also have been reported.86 kg/temple/ day. (Myrtaceae). 6:3 http://www.5 and 0.clinicalmolecularallergy. incense burning usually involves three or more sticks simultaneously. Foeniculum vulgare Mill. powders. such as benzene. It is therefore difficult. and musk xylene. This article will review: the nature of incenses and incense burning. and Liao Shan. incense sticks have several commercially available types. Kaizuka Hort. joss sticks. coils. Herbal and wood powders used in incense making include Glycyrrhiza uralensis Fisch. (Polygonaceae). (Primulaceae). When incense is burning. Depending on its makers and local custom. such as Chen Shan (Shan means incense). Lin). the physical characteris- Figure in Temple burning during Lunar New Year in the Long-Shang Incense 1 Taipei. Eugenia caryophyllata Thumb. (Labiatae) . However. Incense burning also produces volatile organic compounds. (Cupressaceae). musk ketone. It will take from 50 to 90 minutes to burn a stick of incense. if not impossible. a huge amount of incense is burned in temples (Figure 1). onto which the mixture of incense ingredients is attached. gas products and many organic compounds. Santalum album L. gas products and other organic compounds. Once the incense coating section has burned completely. and 33% of bamboo stick . 35% of fragrance material. and smudge bundles . there are 11. (Valerianaceae). and weight of the whole stick (average 1. A typical composition of stick incense consists of 21% (by weight) of herbal and wood powder. The gas products from burning incense include CO. pollutants emitted from incense burning. (Leguminosae). Major types of air pollutants in incense smoke and their toxicological effects People who are exposed to incense fumes always inhale the whole complex mixture that contains particulate matter. and others.503 registered temples in Taiwan . (Aristolochiaceae). It is equivalent to 0. (Lauraceae).com/content/6/1/3 in Kao-Hsiong City . which mostly are absorbed on particle matter. and effects of incense smoke on airway disease and health.7 cm. Musk ambrette. CO2. Traditionally. herbal and wood powders. Fragrance materials used in incense source from Lysimachia foenum-graecum. the incense consumption in Taiwan may even double or triple that estimated amount and it may indicate an environmental hazardous situation. respectively). During the Lunar New Year and other religious festivals. 11% of adhesive powder.580 tons of incense is consumed yearly in the temples in Taiwan. to single out the Page 2 of 9 (page number not for citation purposes) . Taiwan.5 and 2. Liquidambar formosana Hance.
Major forms of incense are shown.5 to 5 µm. as compared to 10 mg/g burned for the cigarettes . including cooking. Mannix et al. reported that burning incense could generate large quantities of PM. Lin et al. respectively. On average.clinicalmolecularallergy. hospital admissions. In a study of the indoor air pollution in Taiwan.5) . So far. and lung dysfunction [20-25]. cone. and other residential activities. Particles in the range 10 to 2.5 µm are known as the thoracic coarse particles (PM10-2.026 particles/second.  found that incense burning had size integrated source emission rates of 0. hence causing no immediate threat. Coarse particles are those greater than 10 µm in diameter. Particles less than 10 µm in diameter (PM10) pose a health concern because when inhaled they can accumulate in the respiratory system. Particulate matter (PM) From practical considerations of the health effects.1 µm are called ultrafine particles . The combustion of incense. They are too large to enter the human respiratory system. coil. 1. health effects contributed by a certain component in the fumes. it is difficult to single out the health effects of incense particles alone. wood. For example. Particles less than 0. (photo by T. including mortality. C. For indoor particles ranging from 0. cigarette.316 and 73 µg/m3. Lin).27]. it produces PM greater than 45 mg/g burned.5 µm size range and below [4-6. incense burning. respiratory symptoms. and stick. Nevertheless. Particles less than 2. for the mean indoor and outdoor total suspended particulate (TSP) concentrations at one Taiwanese temple . products from the incense. measured 1.4.5) are referred to as fine particles and are believed to pose the largest health risks because they can go as deep as the alveoli [17. it's still helpful to know the composition of incense smoke in terms of types of pollutants and the corresponding toxicological effects – even though these cited effects were obtained from non-incense studies on air pollutants in general.038 ± 0.28-30]. there hasn't been any report about the ill effects on human health directly caused by the particles per se in the incense smoke. 6:3 http://www.18]. It is important to know Since people who are exposed to incense smoke always inhale a complex mixture of both gaseous and particulate Page 3 of 9 (page number not for citation purposes) . joss stick.5 exposure was associated with respiratory morbidity [26. 62–92% is from indoor sources.com/content/6/1/3 Figure 2 Forms of incense Forms of incense. Liao et al. Epidemiological studies have reported associations between air particulate matter (especially the fine particles) and several acute health effects. especially in the 2.13. air particulates are usually categorized according to how deep they can penetrate into the human respiratory system. including powder.5 µm in diameter (PM2. there hasn't been any report about the ill effects on human health directly caused by the particles per se in the incense smoke.Clinical and Molecular Allergy 2008. and candles is important or even major sources of residential indoor particulate matter. The USEPA 2004 Air Quality Criteria for Particulate Matter conclusion states that PM102.
Clinical and Molecular Allergy 2008. In Taiwan. Wood dust that carries formaldehyde enhances the toxicity of formaldehyde when the wood dust is intercepted and dissolved in water in the nasal cavity .8. and isoprene. odorless. The top five individual PAHs having the highest concentrations (particlebound + gas phase) were identified as acenaphthylene (3. cigarette. Eggert and Hansen reported that DEP emission from various incense could be as high as 16.14. respectively . It can be emitted into the air during incense burning. They found that. respiratory illnesses. choking. Acute symptoms of VOC exposures are: eye irritation/watering.  burned incense in a large environmental chamber.45].6. and the unsaturated aldehydes. eyes and the upper respiratory tract. indicating that incense was possibly the most significant source . incense. PAHs were found in sedimented dusts. tasteless.092 µg/m3. Löfroth et al. throat irritation.365 µg/m3 in concentration and 13.1. dizziness. Diethylphthalate (DEP) In India. the measured benzene concentrations of all tested incense were significantly higher than the standard.  found that smoking and incense burning generates CO.1 ug and 25. wood. especially those particulates with size of 3. In a study of one Swiss church. Inhalation of CO in low concentrations can cause headaches. Burning incense is also known to generate aerosols and formaldehyde [37-39. lung irritation.2 ug of particle-bound PAHs. 2. 2. isoprene and benzene. such as hydrocarbons. while high concentrations can be fatal . 1999) are 16. the halogenated aliphatic.com/content/6/1/3 that addition of calcium carbonate in incense can effectively suppress the particulate emission by as much as 40%. Lee et al. and coughing . central nervous system damage . . Volatile organic compounds Volatile organic compounds (VOCs) are chemicals that have low boiling points and therefore evaporate easily at room temperature. Gaseous emissions 2. bronchial constriction.582 µg/unit of incense .1–3. dizziness. respectively. nose irritation. A temple was reported to have mean total-PAH concentrations of 6. respectively. 6:3 http://www. 17. acenaphthene (349 ng/m3). In a comparison study of incense burning. 2. aldehydes also affect nasal mucous membranes and oral passages. headaches. in which incense was burned. and asthma exacerbation. especially the low molecular weight. yet poisonous gas generally formed during incomplete combustion of organic substances.258 ng/m3 and 231 ng/m3 in its indoor and outdoor air. 2. by a factor of 200–300. hence reduces the blood's capacity to transport oxygen. aggravation of existing cardiovascular diseases. while the benzene and toluene levels recommended by the Indoor Air Quality Objectives for Office Buildings in Hong Kong (HKIAQO. Epidemiological studies have correlated wood dust and formaldehyde with nasal cancer [44. and fossil fuels.3 µm. Sulfur dioxide (SO2) and nitrogen dioxide (NO2) Health effects of exposures to sulfur dioxide. Lin and Tang investigated the content of particulates in Chinese incense smoke and found that acrolein.2. In addition to irritating skin.7 µm and 2.6 mg of particles per gram of incense burned.1 and 1. formaldehyde and acetaldehyde were predominantly adsorbed on particulates. Polycyclic aromatic hydrocarbons The smoke emitted by incense burning has been found to contain polycyclic aromatic hydrocarbons (PAHs) [7. kidney damage. fluoranthene (243 ng/m3) and phenanthrene (181 ng/m3) . reported that both wood dust and formaldehyde can impair mucociliary clearance . temples are typically heavily polluted by incense smoke. naphthalene (1. It appears that different types of incense produce various amounts of PAHs. liver damage.clinicalmolecularallergy.583 ng/m3).5. Aldehydes Most materials produce aldehydes and ketones during combustion. especially during special festivals.264 ng/m3).8 mg and 43. diethylphthalate is used extensively in the incense stick industry as a binder of perfumes.54]. effects on pulmonary function. It also has been shown that burning incense is associated with increased levels of PAHs in homes [47.36. Chronic symptoms of VOC exposure are: cancer. Carbon monoxide (CO) Carbon monoxide is a colorless.3–4. 2. Lung and Hu reported that two kinds of incense sticks generated. 2. nausea/vomiting. indicating that PAH concentrations of the temple's inside air were 27 times higher than that of its outside air. Common VOCs include benzene. and nitrogen dioxide can include reduced work capacity. and 19. and alterations in the lung's defense system . Page 4 of 9 (page number not for citation purposes) . hence calcium carbonate may make the incense safer to use . toluene. CO combines with haemoglobin much more readily than oxygen.4. Aldehydes are volatile organic compounds typically characterized by their irritating properties.40].47-52]. Exposures to formaldehyde are of concern because formaldehyde is a potent sensory irritant and is classified as a probable human carcinogen . producing a burning sensation.3. Black et al. xylenes. weakness and nausea. such as the Chinese New Year or the birthdays of worshiped gods.
musk ketones. Thus. their results indicate Effects of incense smoke on airway disease and health Like second hand smoke. Rats were exposed to Arabian mix incense. The adjusted odds ratios calculated for acute irritative symptoms in Page 5 of 9 (page number not for citation purposes) . and some of volatile organic compounds. Ma'amoul. surveyed 35. Ho et al. The rats were given 50 ppm DEP (w/v). temple workers relative to the controls are 4.e. when incense smoke pollutants are inhaled.. and a lung cancer casecontrol study of 189 female patients and 197 district matched controls. Lee et al. lung tissues were removed and processed for electron microscopy. the control group. 1. In their study of the association of indoor and outdoor environmental exposures and physician-diagnosed asthma.com/content/6/1/3 Diethylphthalate (DEP). In 1966. The controlled rats received normal diet and plain water. They concluded that working in a temple increases the risk for the development of acute irritative respiratory symptoms. chronic cough symptoms were significantly more common among the temple workers than those from the nonincense burning church. Furthermore. have used rats to study the effect of incense smoke on the lung. Taiwan. or a combined dose of 50 ppm DEP (w/v) + EtOH (5% v/v) in water ad libitum for a period of 120 days and were maintained on normal diet. Taiwan. or pneumonia among the primary school children. among the other chemical factors. and musk ambrette. Neutrophil infiltration into the alveolar lumena was found to accompany degenerative and necrotic changes of the alveolar lining cells.Clinical and Molecular Allergy 2008. In order to determine whether indoor environmental factors affected respiratory dysfunction. an Arabian incense . Similar ultrastructural pulmonary changes have also been reported in rats exposed to Bakhour. is a suspect carcinogen. even after adjusting for lifetime smoking amount. studied the interactive toxicity of DEP with ethyl alcohol (EtOH) in young male Sprague-Dawley rats. chronic sputum. but it significantly reduced risk among smokers. have surveyed 4. No interaction of DEP with EtOH was found. chronic bronchitis. Yang et al. several epidemiological studies have suggested that they do cause health problems. and less alcohol. While it is relatively difficult to directly study the effect of incense smoke pollutants on health. for 14-weeks at a rate of 4 grams/day in the exposure chamber. Incense burning also did not affect lung cancer risk among non-smokers. wheezing. significantly altered lipid and enzyme levels in the liver and serum were found in the DEP-fed group. including nose and throat irritation .164 elementary school children in several rural areas in Kaohsiung. runny nose. Since people working in temples may be exposed to high levels of air pollutants from incense burning.036 6.14 for nose irritation. pollutants emitted from incense burning in a close environment are harmful to human health. they will cause respiratory dysfunction. allergic rhinitis.to 15-year-old school children in Taiwan. particulate matters. Alveolar walls also revealed deposition of collagen fibrils which contributed in its thickening. Airway dysfunction Most obviously. 6:3 http://www. used as a plasticizer and a detergent base. In another study. their non-smoking mothers. It is interesting to note that in several epidemiological studies. They found that 74. musk xylenes. They suggested a likely explanation for this unexpected finding: incense burning was associated with certain dietary habits. analyzed data from an air pollution cross-sectional study of 346 primary school children and their 293 non-smoking mothers. Koo et al. They found that. It was noticed that alveolar pneumocytes of the exposed animals had significant ultrastructural changes which involved the cell organelles and surfactant material of type II cells. They found that there was no association between exposure to incense burning and respiratory symptoms like chronic cough. Sturton et al reported a high incidence of nasopharyngeal carcinoma in Hong Kong in male patients who burn incense as compared with the other malignant cases that were used as controls. They concluded that exposure to Ma'amoul incense could induce ultrastructural pulmonary changes which may imply compromised respiratory efficiency . They proposed a possible explanation for their finding. aldehydes. incense burning had shown no harmful effect. However. more fresh fish. have investigated the prevalence of chronic respiratory symptoms and acute irritative symptoms among 109 temple workers in Kaohsiung.5 for throat irritation and 4.clinicalmolecularallergy. more retinol. polycyclic aromatic hydrocarbons. which have been associated with lower lung cancer risk in this population.5% of the studied nasopharyngeal cancer cases and 52% of all other malignant cases were exposed to incense smoke and suggested the possibility that incense smoke may be a factor in the etiology of this malignant disease . i. asthma. Sonde et al. Alarifi et al. cigarette smoking and incense use might have been decreased in families with children with atopic disease and thus had less atopic asthma . 5% EtOH (v/v). At the end of the exposure period. incense burning and mosquito repellant burning were significantly associated with cough symptoms . diethylphthalate (DEP) are toxic to the lung and allergenic to the skin and eyes. As mentioned above. It was concluded that DEP alone leads to severe impairment of lipid metabolism coupled with toxic injury to the liver . They reported that daily cigarette consumption in families and incense burning at home showed negative effects to the occurrence of childhood asthma. or district matched controls.
Incense burning smoke has also been associated with dermatological problems. particularly when animals are exposed transplacentally . side-stream cigarette smoke.5–10 and subsequently transferred to fetal blood and modulated the fetal immune system with IgE production. culminating in airway inflammation and remodeling. investigated a group of children of ages 10 years and under in Los Angeles County. investigated risk factors for the two most common types of brain tumors in children. As indicated in the previous section. This suggests that incense burning can cause indoor air pollution and thus cancer akin to that from cigarette smoking . Ger et al. Activation of resident and recruited inflammatory cells can lead to elaboration of a plethora of mediators. only beer was associated with a significantly increased risk of either tumor type . However. incense smoke cause morphological changes of alveolar pneumocytes and infiltration of neutrophils into alveolar lumena in experimental rats [61. left shoulder and abdomen. They found that increased brain tumor risk was associated with maternal contact with nitrosamine-containing substances such as burning incense.Clinical and Molecular Allergy 2008. McCredie et al. Th2 cytokines by regulating IgE class switching as well as inducing humoral immunity. although incense was identified as a major source of exposure to nitrogen dioxide and airborne carcinogens. would aggravate allergic respiratory disease. may contribute to the development of the Th1-Th2 imbalance [72-75]. Furthermore. it had no effect on lung cancer risk among nonsmokers and. studied umbilical cord blood IgE (cIgE) in 334 mother and neonate pairs. Numerous factors. who had practiced incense ceremony for about 15 years. A 48 h closed path testing revealed perfume in the incense was the cause. and was found to have itchy depigmented macules on his dorsum manus.5–10 in the sample collected at one temple in Taiwan. the authors have not yet proved the relationships between incense burning. Incense smoke contains various N-nitroso compounds. and face makeup .5 and PM2.com/content/6/1/3 that diet can be a significant confounder of epidemiological studies on air pollution and respiratory health . 3. Lead exposure could stimulate the IgE production . Recent studies suggest that a dominance of the Th2 type cytokines (IL-4. Allergy and Dermatological Effects Lin et al. and the interaction between the innate and adaptive immune systems may lead to inflammatory changes and airway remodeling . activation and survival in tissue. They attributed the findings to the relatively healthy diets among smoking women who burned incense versus those who did not. Lowengart et al. To study the causes of leukemia. 6:3 http://www. It is speculated that lead emitted from incense burning could be absorbed on PM2. IL-10 and IL-13) may be pivotal to asthma pathogenesis [67-71]. cord blood lead. found that smoking was the most important risk factor associated with lung cancer. reported a 63year-old patient. when they conducted four epidemiological studies in Hong Kong over 15 years. Preston-Martin et al.clinicalmolecularallergy. Similarly. It was suggested that the perfume and airborne particles from the burning incense contacted the skin and caused the allergic contact dermatitis accompanied by depigmentation . The concentrations of lead have been detected at 0.14 and 0. the same group also reported cases of contact dermatitis due to long-term exposure to musk ambrette vaporized from incense burning . Bunin et al. which have been shown to be potent nervous system carcinogens. They found that incense burning was a risk factor for elevated cIgE . carried out a population-based case-control study of perinatal and early postnatal risk factors for malignant brain tumors in New South Wales children. the risk was greater for more frequent users . while exposure to incense smoke and frying pan fumes were not significant risk factors . more intriguingly. A similar conclusion was reported by Koo et al.5 and PM2. Hayakawa et al. respectively. The mothers and fathers of acute leukemia cases and their individually matched controls were interviewed regarding specific occupational and home exposures as well as other potential risk factors associated with leukemia. In studying risk factors associated with lung cancer in Hong Kong.62]. IL-5. They found that.21 mg/g in PM2. In addition. Neoplasm Extracts of particulate matter from incense smoke are found to be mutagenic in the Ames Salmonella test with Page 6 of 9 (page number not for citation purposes) . investigated the relationship between various risk factors and lung cancer by histological types. astrocytic glioma and primitive neuroectodermal tumor (PNET) and found that among the products (including incense) studied that contain Nnitroso compounds. ChanYeung et al. others such as IL5 are essential to eosinophil hematopoiesis. and cord blood IgE levels . conflicting data on the effect of incense burning smoke on neoplasm have also been reported. While cytokines such as IL-4 and IL-13 are crucial to production of IgE by B lymphocytes. and reported that no association was found between childhood brain tumors and incense burning . including incense smoke. However. TA98 and activation. Similarly. Several studies have shown there is no association between incense smoke and cancer. it significantly reduced risk among the smokers . studied mothers of 209 young brain tumor patients and 209 control subjects. 2. Analysis of the data from the 123 matched pairs showed an increased risk of leukemia for children whose parents burned incense at home.
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