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Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X Journal of Pulmonary Respiratory Medicine ISSN: 2161-105X Journal of Pulmonary Respiratory Medicine Bazzi et al. J Pulm Respir Med 2018 8:6 DOI: 10.4172/2161-105X.1000478 Research article Open Access Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon Bazzi A 1 Zaatari G 1 Makki M 2 Tamim H 23 and Zein-El-Dine S 3 1 Department of Pathology and Laboratory Medicine Environmental Core Laboratory American University of Beirut Medical Center Beirut Lebanon 2 Clinical Research Institute American University of Beirut Medical Center Beirut Lebanon 3 Department of Internal Medicine Faculty of Medicine American University of Beirut Medical Center Beirut Lebanon Abstract Objective: Earlier studies associated the chronic exposure to the dust of tobacco leaves with increased occurrence of allergies skin rashes rhinitis nausea dizziness vomiting and various respiratory disorders in tobacco farmers and processors. We aimed to investigate if oriental tobacco farm households who store dried tobacco leaves inside their house are more likely to experience and report respiratory and allergic episodes or illnesses than households storing dried tobacco leaves outside the house. Methods: A cross-sectional study was conducted among tobacco farm households within the Caza of Bint Jbeil in South Lebanon. Demographic socioeconomic household characteristics and respiratory symptoms were assessed by separate sets of questions. The questionnaire assessed respiratory symptoms allergies’ and smoking habits using questions items adopted mainly from The European Community Respiratory Health Survey II. Results: A borderline association was found between storage status of tobacco leaves and respiratory symptoms OR 1.68 95 CI 0.93-3.03 p0.09. Overall 37.0 among those who stored tobacco leaves inside their house reported respiratory symptoms in comparison to 26.0 among those who stored tobacco leaves outside. Conclusions: The study fndings suggest that indoor storage of dried tobacco leaves can slightly contribute to aggravation of respiratory symptoms. Prospective cohort studies in tobacco farming communities would be useful in determining if indoor storage of dried tobacco leaves can lead to development of asthma and aggravation of symptoms especially among younger age group. Corresponding author: Salah Zein-El-Dine Department of Internal Medicine Faculty of Medicine American University of Beirut Medical Center Beirut Lebanon Tel: +961-1-350000 Ext: 4526 E-mail: sz01aub.edu.lb Received October 05 2018 Accepted November 09 2018 Published November 15 2018 Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Copyright: ©2018 Bazzi A et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License which permits unrestricted use distribution and reproduction in any medium provided the original author and source are credited. Keywords: Indoor storage Dried tobacco Respiratory symptoms Lebanon Introduction Earlier studies among tobacco workers and processers has associated the exposure to tobacco dust with diferent respiratory disorders such as occupational asthma 1 increased occurrence of chronic respiratory symptoms 12 including chronic cough phlegm dyspnea chest tightness snufe snivel and allergic rhinitis 2 wheezing attacks of shortness of breath with wheezing dyspnoea and rhinitis 3 chest tightness and wheezing 4 mild obstructive ventilation disturbances 5 and decreased lung function tests 1267 allergic alveolitis 8 and chronic bronchitis 9. Earlier studies have also associated the exposure to tobacco dust with acute episodes of nose and throat dryness as well as eye irritation during work shifs 1 skin allergies 210 as well as vomiting dizziness and headache 11. Risk from tobacco dust is believed to afect all people involved in tobacco production or live near tobacco-growing felds including processors farmers children pregnant women and older people 1213. Studies targeting oriental tobacco farm households mainly investigated the economic impact of oriental tobacco leave production in Turkey and Lebanon but not health efects 1415. Tis study is the frst to address the oriental tobacco farmers’ house as a work place that puts home attendees at increased risk for chronic respiratory diseases and allergies. Specifcally it intends to investigate the hypothesis that occupants of households who store dried tobacco leaves inside the house are more likely to experience and report respiratory and allergic episodes or illnesses than households storing dried tobacco leaves outside the house. Methods Study design Te study conducted a cross-sectional descriptive design of 258 representative tobacco farming households. Setting and study population Participating households represent 5.6 of active farmers located mainly within the Caza of Bint Jbeil South Lebanon. Tobacco farm households were distributed in the villages and towns of Rmaish 33.3 n86 Ramia 19.8 n51 Debel 15.9 n412 Dehayre 13.2 n34 Marwahin 7 n18 Yarin 6.2 n16 Kouzah 2.7 n7 and Al-Bistan 1.9 n5. Inclusion/exclusion criteria Inclusion criteria for this study included currently active households in tobacco farming with multiple family members and only those who

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Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Page 2 of 7 Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X store tobacco leaves whether inside or outside the house premises. Excluded from this study were retired tobacco farmers as well as those who didn’t consent to the study. Farming process Oriental tobacco farming process involves a seedling stage where tobacco seeds are implanted within a small plot/garden in front or behind the house where it is sprayed heavily with herbicides fungicides or other pesticides. Mature seedlings with strong roots are then transferred to tobacco plots feld where it grows further and green leaves are individually harvested on a daily basis. In terms of duration the seedling cycle averages 60 days and starts as early as October and lasts as late as April whereas the tobacco leaves cycle averages 60 days and starts as early as May and lasts until late September. Harvested green leaves are organized in special threads based on their size and maturity. Te threaded leaves are held on wooden holders El Mancher under sun until the leaves become light brown in color and protected from morning dew with nylon covers during the night 16. Dried tobacco leaves are then stored indoors for an average of 4.4 months until it is shipped to Regie Libanaise des Tabacs et Tombacs. Prior to shipment the fattened leaves referred to as Mobsat are gathered in circular consecutive layers referred to as El Tadnik with the leave heads placed to the inside and neck to the outside until their moisture is fully evaporated without losing their color or features. Dried fattened leaves are packaged in boxes and then shipped to Regie Libanaise des Tabacs et Tombacs. Afer the yellow color of the leaves is fxed the threaded leaves are held on wooden holders in the assigned drying El Mancher so that the leaves become light brown in color under appropriate moisture 65- 70 and temperature 16-32°C and protected from morning dew with nylon covers during the night 16. Afer the drying stage the fattened leaves referred to as Mobsat are gathered in circular consecutive layers referred to as El Tadnik with the leave heads placed to the inside and neck to the outside until their moisture is fully evaporated without losing their color or features. Dried tobacco leaves are then stored until packaged in wooden boxes so that the head of the leaves is directed to the inside and then shipped to Regie Libanaise des Tabacs et Tombacs 16. In terms of duration the seedling cycle averages 60 days and starts as early as October and lasts as late as April whereas the tobacco leaves cycle averages 60 days and starts as early as May and lasts until late September. Outcomes Outcome variables included the storage location of dried tobacco leaves inside house/outside respondent history of breathing difculties any change in respiratory health status over the past year history of asthma or other respiratory disease by respondent or any other family member in the household. Information about respiratory symptoms included two items for wheezing fve items for shortness of breath one item for coughing and one item for phlegm. Te frequency of experiencing each respiratory symptom was assessed along with the change in severity of reported symptoms. Te history of respiratory nasal and skin allergies was also investigated among those specifed family members with chronic respiratory diseases. Data collection Data was collected using structured interviews. Follow-up phone interviews with representative participants were done to verify and confrm some of the study fndings. Tobacco farm households were visited during August to October 2013. Household interviews were carried out by an experienced feld surveyor knowledgeable of the area under study. All interviews were carried out in the presence of female and male heads of the households and other representative family members. Te interview ranged from 45 minutes up to 1.5 hour per household depending on family size the complexity of the health profle of each individual in the household participant’s interest level conversational style and the number of interruptions. A structured questionnaire was specifcally designed from multiple preexisting questionnaires to ft the purpose of the study 17-21. Information was collected about socio-demographic information of overall family member household tobacco farming history proximity of farming plots to house premises storage location of dried tobacco leaves indoors/outdoors storage period of dried tobacco leaves whether the dried tobacco leaves storage room is also used as sleeping room by any family member storage room and overall house size in meter square indoor air cooling and heating methods presence of windows in the storage room frequency and time windows are opened household cleanliness and adopted on farm safety practices and wearing of personal protective equipment. Te experienced respiratory symptoms and allergies’ along with medications and smoking patterns of family members were assessed using Te European Community Respiratory Health Survey II abbreviated as ECRHS II 21. A separate questionnaire form was flled for each person in visited household respondent and any other family member with asthma or other physician diagnosed respiratory disease. Te questions were modifed to elicit as much as possible information about respiratory symptoms and allergies during the previous 12 months of the subject’s life. Te modifcations from the pre-existing scales were mainly in the response options. As applicable to the type of questions a two three four and fve response scale was used. For example history of breathing difculties was assessed using binary response. If positive its frequency was assessed using 3 response scale only rarely repeatedly but it always get completely better continuously so that the breathing is never quite right. Te change in respiratory health status over the past year was assessed using 3 response scale usual better than usual and worse than usual. Information assessed about asthma or chronic respiratory symptoms included two items for wheezing wheezing / whistling without having a cold unable to breath when the wheezing noise was present fve items for shortness of breath upon waking in the morning while at rest anytime when hurrying on level ground or walking up a slight hill following strenuous activity at any time when walking at own pace with other people of similar age on level ground and had to stop to breath one item for coughing waking up by cough attack one item for chest constriction upon wake up and one item for phlegm bring up any phlegm from the chest in the morning during the day or at night in the winter. Te frequency of each respiratory symptom was assessed using 5 response scale 0-none 1-less than one incident /month 2-one incident /month 3-two incidents /month and 3-more than 2 incidents /month. Change in severity of reported respiratory symptoms was assessed over the past 6 month period to account for the overlap in farming phases among visited tobacco farm households using 4 response scale 0- did not occur 1-no change 2-decrease 3-increase. Te history of respiratory nasal and skin allergies was also investigated among those specifed family members with chronic respiratory diseases using 3 response scale No Yes Don’t know. Respiratory allergies refected in coughing wheezing and shortness of breath were assessed using 9 items whenever they have a cold or respiratory infection upon change in weather occurring when usually not sick occurring during playing or running occurring afer playing or running when working around in a room where dried tobacco leaves are present when working around

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Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Page 3 of 7 Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X wood smoke while present in a room where carpets are being dusted or vacuumed when around furry animals or birds. Te Institutional Review Board at the American University of Beirut reviewed and approved this study. Statistical analysis Statistical Package for the Social Sciences SPSS version 23 was used for data entry and analysis. Descriptive analyses were carried out by calculating the number and percent for categorical variables whereas the mean and standard deviation ± SD were calculated for the continuous variables. Te bivariate analyses were performed using Chi- square test fsher’s exact test or independent sample t-test to assess the association between demographic socioeconomic household smoking factors and the storage status of dried tobacco leaves as appropriate. Moreover non-parametric Mann-Whitney test was used to assess the association between experienced respiratory symptoms and the storage status of dried tobacco leaves. Hierarchical binary logistic regression analysis using a forward selection procedure was conducted to examine the relationship between the reported respiratory symptoms and various potential predictors while imposing the storage status of dried tobacco leaves as main exposure. All determinants that are statistically and clinically signifcant were entered into the regression analysis. Statistical signifcance was defned at the 0.05 level. Results In total 258 tobacco farmers were included in the study. Overall 77 of them 29.8 stored the dried tobacco leaves outside their house and 181 70.2 inside their house. Table 1 summarizes the demographic socioeconomic and household factors among the study sample and their association with the storage status of tobacco leaves. Moreover 67.4 of the farmers were aged above 40 years and 51.2 were males. As for educational level most has elementary and above level 49.0 illiterate participants represented 19.8 of the sample. Less than one third 30.6 of the participants had 26 to 50 years of experience in tobacco farming. Most participants were from large families counting between 6 and 12 members 44.2 and the majority 94.6 had an income above USD 30000 per year. Around 38.4 of the farmers lived in a house with an area of less than 150 m 2 . Close to two thirds 63.7 cultivated tobacco leaves in an outside area of less than 0.6 hectares. Overall 39.8 of them produced less than 500 kg of tobacco leaves per year while 21.5 produced above 1000 kg per year. Moreover 62.7 of the farmers used the charcoal and wood method to heat their indoor during winter time and 46.7 didn’t have any air conditioning method to cool and ventilate their houses during summer time. While 70.4 of the farmers implanted their tobacco leaves seeds in seedling plots only 12.6 purchased the seedlings to replant it into tobacco felds. Te average storage period of tobacco leaves is 4.4 months SD 0.9. Finally it was observed that 70.9 of the farmers are smokers. Comparison of these factors between farmers that stored the tobacco leaves inside or outside their house showed signifcant diferences only in family size P0.05 and heating method P0.03. Large families 6-12 members are less likely to store the tobacco leaves outside in comparison to the small families 1-5 members 35.1 versus 64.9 respectively. Additionally farmers that used charcoal and wood heating method reports using more the inside house storage 67.0 in comparison to farmers that uses other heating method 33.0. Other factors did not show any statistically signifcant diference between the two groups of farmers. Te prevalence of self-reported respiratory symptoms at the level of total family members of surveyed tobacco farm households were data not shown: 3 “wheezing” 3 “breathlessness with wheezing” 2 “shortness of breath upon waking in the morning” 2 “shortness of breath when hurrying on level ground or walking up a slight hill” 2 “shortness of breath following strenuous activity” 1 “shortness Storage status of tobacco leaves Total sample All Outside house n Inside house n P value n258 n77 29.8 n181 70.2 Demographic Gender Male 132 51.2 37 48.1 95 52.5 0.51 Female 126 48.8 40 51.9 86 47.5 Age ≤ 40 years 84 32.6 25 32.5 86 47.5 0.98 40 years 174 67.4 52 67.5 122 67.4 Education Illiterate 51 19.8 11 14.5 40 22.1 0.26 5 years of basic education 80 31.1 28 36.8 52 28.7 Elementary and up 126 49.0 89 49.2 89 49.2 Socioeconomic Experience in tobacco farming years 1-15 103 39.9 36 46.8 67 37.0 0.33 16-25 76 29.5 21 27.3 55 30.4 26-50 79 30.6 20 26.0 59 32.6 Family size members 1-5 144 55.8 50 64.9 94 51.9 0.05 6-12 114 44.2 27 35.1 87 48.1 Annual family income ≤ 30000 USD 14 5.4 5 6.5 9 5.0 0.76 30000 USD 244 94.6 72 93.5 172 95.0

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Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Page 4 of 7 Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X Household House size ≤ 150 m 2 96 38.4 31 43.1 65 36.5 0.42 151-200 m 2 92 36.8 27 37.5 65 36.5 200 m 2 62 24.8 14 19.4 48 27.0 Area in hectare cultivated with tobacco ≤ 0.6 163 63.7 54 71.1 109 60.6 0.11 0.6 93 36.3 22 28.9 54 71.1 Output of tobacco leaves/year kg 1-500 102 39.8 35 46.1 67 37.2 501-1000 99 38.7 28 36.8 71 39.4 0.35 1000 55 21.5 13 17.1 42 23.3 Indoor heating Charcoal and wood heating 160 62.7 36 47.4 120 67.0 0.03 Fuel heater 95 37.3 36 47.4 59 33.0 Indoor air conditioning No 120 46.7 31 40.8 89 49.2 0.22 Yes 137 53.3 45 59.2 92 50.8 Proximity of seedling plots to house Within garden in front/ behind house 178 70.4 53 72.6 125 69.4 0.62 Others 75 29.6 20 27.4 55 30.6 Proximity of tobacco feld to house Within garden in front/ behind house 32 12.6 7 9.5 25 14.0 0.33 Others 221 87.4 67 90.5 154 86.0 Storage period months Mean ± SD 4.4 ± 0.9 4.5 ± 0.7 4.3 ± 0.9 0.16 Smoking No smoker 75 29.1 23 29.9 52 28.7 0.85 Smokers 183 70.9 54 70.1 129 71.3 Table 1: Association between storage of dried tobacco leaves and demographic socioeconomic household factors. of breath while walking at own pace with other people of similar age on level ground and had to stop to breath” 3”ever waken-up by attack of cough” 3”ever waken up with feeling of tightness in chest at any time” 2 “ bring up any phlegm from the chest frst thing in the morning during the day or at night in the winter”. None reported “shortness of breath while at rest at any time. Whereas the prevalence of self-reported nasal allergies is 1.2 and skin allergies is 0.28 at the level of total family members of surveyed tobacco farm households. Table 2 illustrates the reported respiratory symptoms of the family members of tobacco farmers and their association with the storage status of tobacco leaves. It was observed that 66.3 of the sample did not report any respiratory disease or symptom while only 5.0 reported asthma 16.7 reported respiratory problems other than asthma and 12.0 reported some symptoms of allergy. A borderline signifcant trend P0.09 was noted between reported respiratory disease and storage of dried tobacco leaves. Among family members of farmers who stored the tobacco leaves outside house 74.0 did not show any respiratory disease while 26.0 reported some respiratory problems. On the other hand 37.0 of the farmers who reported some respiratory diseases were storing tobacco leaves inside their house in comparison to 63.0 that did not show any respiratory symptoms. Te afected members were mostly the spouses 42.5 followed by the children or parents and siblings 35.0. Te mean age of the afected members was 37.2 years SD 19.5. Among family members of tobacco farmers that are using the inside house storage method 61.9 reported some wheezing or whistling without having a cold difculty in breathing when the wheezing noise was present and waking up with a feeling of tightness in the chest in comparison to 38.1 that did not report these symptoms. Around 54.8 described production of phlegm during winter time in comparison to 45.2 that did not report this specifc symptom. Farmers and their family members who used the outside storage are less likely to develop shortness of breath during morning walk 46.2 versus 53.8 respectively shortness of breath while at rest 15.4 versus 84.6 respectively and a shortness of breath while hurrying 46.2 versus. 53.8 respectively. None of the respiratory symptoms showed any statistically signifcant diference between the two groups of farmers that are using diferent storage methods. Hierarchical binary logistic regression in Table 3 estimates the efect of inside tobacco leaves storage on farmers and their family members’ respiratory diseases. Afer controlling for relevant factors it was shown that family members of farmers that are exposed to inside house storage of tobacco leaves OR1.68 p0.09 were more likely to report respiratory symptoms compared to those who stored tobacco leaves outside their house. Discussion Te percentage of the reported respiratory symptoms within the surveyed tobacco farm households are lower than the fndings reported in previous studies in Lebanon with the exception of self- reported asthma. For example Waked et al. estimated the prevalence of respiratory systems at the diferent Governate levels in Lebanon 22. Since the surveyed villages and towns in this pilot study administratively fall under Governate of Nabatieh the fndings of this pilot study are compared to values reported by Waked Salameh 22 at the same Governate level. Te 5 self-reported asthma in our study is higher than the 3.9 physician diagnosed asthma PDA reported by Waked and Salameh at Nabatieh Governate level 22. Tey also reported a percentage of 12.7 “ever wheezing symptoms”10.5 wheezing for 12 months” 5.7”wheezing on exercise” 15.4 “night cough” 10.5” productive cough for 12 months” and 3.5 “chronic productive cough” at same studied Governative 22. Te percentage

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Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Page 5 of 7 Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X Storage status of dried tobacco leaves All Outside house n Inside house n P value Total sample n258 n77 n181 Lifestyle Respiratory diseases Asthma or respiratory disease No 171 66.3 57 74.0 114 63.0 0.35 Asthma only 13 5.0 4 5.2 9 5.0 Respiratory problems other than asthma 43 16.7 10 13.0 33 18.2 Allergy only 31 12.0 6 7.8 25 13.8 Any respiratory disease No 171 66.3 57 74.0 114 63.0 0.09 Yes 87 33.7 20 26.0 67 37.0 N87 N20 N67 Demographic variables Affected members Respondent 18 22.5 5 26.3 13 21.3 0.12 Spouse 34 42.5 11 57.9 23 37.7 Child/sibling/parents 28 35.0 3 15.8 25 41.0 Age Mean ± SD 37.2 ± 19.5 40.1 ± 14.7 36.3 ± 20.8 0.75 Experienced respiratory symptoms Wheezing or whistling without having a cold No 19 34.5 3 23.1 16 38.1 0.51 Yes 36 65.5 10 76.9 26 61.9 Unable to breath when the wheezing noise was present No 20 36.4 4 30.8 16 38.1 0.75 Yes 35 63.6 9 69.2 26 61.9 Shortness of breath upon waking in the morning No 31 56.4 7 53.8 24 57.1 1 Yes 24 43.6 6 46.2 18 42.9 Shortness of breath while at rest anytime No 52 94.5 11 84.6 41 97.6 0.14 Yes 52 94.5 2 15.4 1 2.4 Shortness of breath when hurrying on level ground or walking up a slight hill No 32 58.2 7 53.8 23 41.8 0.76 Yes 23 41.8 6 46.2 17 40.5 Shortness of breath following strenuous activity at anytime No 28 50.9 5 38.5 23 54.8 0.36 Yes 27 49.1 8 61.5 19 45.2 Shortness of breath when walking at own pace with other people of similar age on level ground and had to stop to breath No 36 66.7 7 53.8 29 70.7 0.34 Yes 19 34.5 6 46.2 13 31.0 Waking up by coughing attack No 14 25.5 5 38.5 9 21.4 0.28 Yes 41 74.5 8 61.5 33 78.6 Waking up with a feeling of tightness in the chest No 20 36.4 4 30.8 16 38.1 0.75 Yes 35 63.6 9 69.2 26 61.9 Bring up any phlegm from the chest in the morning during the day or at night in the winter No 25 45.5 6 46.2 19 45.2 1 Yes 30 54.5 7 53.8 23 54.8 Table 2: Association between storage of dried tobacco leaves and respiratory diseases. of self-reported allergies nasal allergies and skin allergies or eczema in this study are also lower than the fndings by Waked and Salameh 22 where 21.1 had allergic rhinitis and 7.0 had atopic eczema at the Nabatieh Governate level. On the other hand in South America mainly in Southern Brazil Fiori et al. reported wheezing prevalence of 11 among tobacco farm workers 23. Tis is the frst study that attempted at quantifying the efect of indoor house storage of dried tobacco leaves on respiratory symptoms in tobacco farm house-holds planting oriental tobacco leaves. Identifying exposure status and data in the farming community is a challenging task. Genetics human behavior farming activities and frequency of exposure to the diferent farming asthmogens/irritants other indoor environmental toxicants or irritants are likely to infuence the development and/or aggravation of respiratory symptoms. Te study reported a positive association between indoor tobacco leaves storage and exacerbation of respiratory symptoms nevertheless it did not reach statistical signifcance. Around 87 of the farmers sufering from a pre-existing respiratory illness equivalent to 5 of the surveyed households reported symptoms when working around in a room where dried tobacco leaves are stored. Te study by Hoppin et al. 24 also found little evidence of positive association between prevalence of asthma and concurrent farming activities. Chloros et al. study of 1020 seasonal and permanent tobacco workers do not support an association between the development

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Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Page 6 of 7 Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X Predictors OR 95CI P value Storage status of dried tobacco leaves 1.68 0.93-3.03 0.09 Variables entered in the model are: Storage status of dried tobacco leaves Age Gender Education level Experience in tobacco farming family size annual income house size indoor heating indoor air conditioning Storage period number of smokers Table 3: Multivariate analysis for the predictors of any respiratory disease having the storage status of dried tobacco as main exposure. of chronic diseases of the lower respiratory system and pollutants associated with the processing of dried tobacco leaves in a factory in Tessaloniki in Greece 25. Te fndings of our study are partly explained by the common practice of household of opening windows during the day thereby minimizing indoor accumulation of dusts and particulates and minimizing exposure to such indoor pollutants. Almost all open windows at least once per day for more than 4 hours to aerate the room where dried tobacco leaves are stored. Te fnding that a higher percent of those reporting respiratory symptoms store dried tobacco leaves outside their home can be explained by the reverse causality i.e. those who are aware of their respiratory symptoms triggers are more likely to store it outside . Follow up phone interviews with around 10 participants in February 2013 further confrmed that dried tobacco leaves are stored outside occupied home premises whenever alternative places are present/ or can be arranged primarily to maintain house cleanliness and those who are aware of their respiratory and allergic diseases store it outside to minimize the aggravation of their respiratory symptoms and allergies. Moreover our fndings are expected to be underestimated due to the healthy-worker efect since our study included healthy and active tobacco farmers and excluded non-active farmers with potential health problems. Close to two thirds 60 of participating farmers had more than 16 years of experience in tobacco farming versus 40 with less than 16 years of experience. Moreover 32.6 were 40 years old or less which may have contributed to the healthy worker and healthy survivor efect. Te long years of experience as a proxy indicator of chronic exposure to dried tobacco leaves among adults is likely to attenuate the observed hypothesized relationship in-between indoor storage of dried tobacco leaves and reporting of respiratory symptoms towards null hypothesis or no association 26-28. It is possible that the persistent exposure to dried tobacco leaves inside the house might make it difcult to “detect” an association between exposure and the mild phase of the disease 26-28. It is also possible that early life exposure in childhood to tobacco farming lifestyle might have a protective efect during immune maturation against asthma hay fever and allergic sensitization through specifc regulatory pathways T cells 29. Tis study is not without limitations where it is based on self- reported respiratory and allergic symptoms by study participants which can be less valid measure than physician diagnosed asthma corroborated with objective diagnostic test results. Nevertheless we do not anticipate major efect of this point as the self-report of asthma was verifed against the prescribed medications at the time of the interview data not shown 30. Another limitation is the small sample size which might have afected the power of the study to detect statistical signifcance as well as failure to include other potential confounders in multivariate analyses. Conclusion From a public health perspective the indoor storage of dried tobacco leaves can be a risk factor for asthma severity or aggravation of respiratory symptoms in both adults and children. Te low percent of reported respiratory symptoms can be explained by the limited storage period 91.3 days inside home 15 healthy worker and healthy survivor efect reverse causation protective measures taken to store dried leaves outside occupied premises to maintain house cleanliness and minimize efect of dried leaves smell and dust on those with respiratory symptoms. As risk factors for incidence of asthma can be diferent from risk factors for asthma severity prospective cohort studies in tobacco farming communities would be useful in determining if indoor storage of dried tobacco leaves can lead to development of asthma and aggravation of symptoms especially among younger age group. Funding IDRC project number 104639-999070777-006 Competing Interests The authors declare that they have no competing interests. References 1. Mustajbegovic J Zuskin E Schachter EN Kern J Luburic-Milas M et al. 2003 Respiratory fndings in tobacco workers. Chest 123: 1740-1748. 2. Zhang Y Chen J Chen Y Dong J Wei Q et al. 2005 Environmental mycological study and allergic respiratory disease among tobacco processing workers. J Occup Health 47: 181-187. 3. Viegi G Paggiaro PL Begliomini E Vaghetti E Paoletti P et al. 1986 Respiratory effects of occupational exposure to tobacco dust. Brit J Indus Med 43: 802-808. 4. Valic F Beritic D Butkovic D 1976 Respiratory response to tobacco dust exposure. Am Rev Respir Dis 113: 751-755. 5. Ignacak A Guzik TJ Gorski L Czerniawska-Mysik G Adamek-Guzik T 2002 Infuence of tobacco dust on the respiratory system and selected immunological parameters. Przeglad lekarski 59: 789-792. 6. Mukhtar MS Rao GM Gamra NS Afan AM Zendah MI 1991 Respiratory effects of occupational exposure to tobacco dust. Respiration 58: 271-276. 7. Mengesha YA Bekele A 1998 Relative chronic effects of different occupational dusts on respiratory indices and health of workers in three Ethiopian factories. Am J Indus Med 34: 373-380. 8. Huuskonen MS Husman K Jarvisalo J Korhonen O Kotimaa M et al. 1984 Extrinsic allergic alveolitis in the tobacco industry. Br J Ind Med 41:77-83. 9. Bhisey RA Bagwe AN Mahimkar MB Buch SC 1999 Biological monitoring of bidi industry workers occupationally exposed to tobacco. Toxicol Lett 108: 259-265. 10. Gleich GJ Welsh PW Yunginger JW Hyatt RE Catlett JB 1980 Allergy to tobacco: An occupational hazard. The New Eng J Med 302: 617-619. 11. Ghosh SK Parikh JR Gokani VN Rao NM Doctor PB 1985 Occupational health problems among tobacco processing workers: A preliminary study. Arch Environment Health 40: 318-321. 12. Riquinho DL Hennington EA 2012 Health environment and working conditions in tobacco cultivation: A review of the literature. Cien Saude Colet 17: 1587-1600. 13. Lecours N Almeida GE Abdallah JM Novotny TE 2012 Environmental health impacts of tobacco farming: A review of the literature. Tobacco control 21: 191- 196. 14. Gumus SG 2008 Economic analysis of oriental tobacco in turkey. Bulgarian J Agri Sci 14: 470-475. 15. Bazzi A Darwish MR Israwi F Kabbani N 2008 Raw tobacco price subsidy: Implications for farm income and natural productive resources. 16. Srour AZ 2002 The role of reggee The lebanese tobacco and tombac company in tobacco cultivation in lebanon: Between the present and the past. 17. Arcury TA Quandt SA 1998 Chronic agricultural chemical exposure among migrant and seasonal farmworks. Society Nat Res 11: 829-843.

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Citation: Bazzi A Zaatari G Makki M Tamim H Zein-El-Dine S 2018 Relation of Indoor Storage of Dried Tobacco Leaves to Reporting of Respiratory Symptoms: Case of Tobacco Farms Households in South Lebanon. J Pulm Respir Med 8: 478. doi: 10.4172/2161-105X.1000478 Page 7 of 7 Volume 8 • Issue 6 • 1000478 J Pulm Respir Med an open access journal ISSN: 2161-105X 18. Thompson B Coronado GD Grossman JE Puschel K Solomon CC et al. 2003 Pesticide take-home pathway among children of agricultural workers: Study design methods and baseline fndings. J Occup Environment Med 45: 42-53. 19. Quandt SA Hernandez-Valero MA Grzywacz JG Hovey JD Gonzales M et al. 2006 Workplace household and personal predictors of pesticide exposure for farmworkers. Environment Health Perspect 114: 943-952. 20. Rao P Gentry AL Quandt SA Davis SW Snively BM et al. 2006 Pesticide safety behaviors in Latino farmworker family households. Am J Indus Med 49: 271-280. 21. Janson C Anto J Burney P Chinn S de Marco R et al. 2001 The European community respiratory health survey: What are the main results so far European community respiratory health survey II. The Euro Resp J 18: 598- 611. 22. Waked M Salameh P 2008 Risk factors for asthma and allergic diseases in school children across Lebanon. J Asthma allergy 2: 1-7. 23. Fiori NS Fassa AG Faria NM Meucci RD Miranda VI et al. 2015 Wheezing in tobacco farm workers in southern Brazil. Am J Indus Med 58: 1217-1228. 24. Hoppin JA Umbach DM London SJ Henneberger PK Kullman GJ et al. 2009 Pesticide use and adult-onset asthma among male farmers in the agricultural health study. The Euro Resp J 34: 1296-1303. 25. Chloros D Sichletidis L Kyriazis G Vlachogianni E Kottakis I et al. 2004 Respiratory effects in workers processing dried tobacco leaves. Allergol Immunopathol 32: 344-351. 26. Le Moual N Siroux V Pin I Kauffmann F Kennedy SM et al. 2005 Asthma severity and exposure to occupational asthmogens. Am J Respir Crit Care Med 172: 440-445. 27. Malo JL 2005 Asthma may be more severe if it is work-related. Am J Respir Crit Care Med 172: 406-407. 28. Le Moual N Varraso R Zock JP Henneberger P Speizer FE et al. 2013 Are operating room nurses at higher risk of severe persistent asthma the nurses’ health study. J Occup Environ Med 55: 973-977. 29. Lluis A Depner M Gaugler B Saas P Casaca VI et al. 2014 Increased regulatory T-cell numbers are associated with farm milk exposure and lower atopic sensitization and asthma in childhood. J Allergy Clin Immunol 133: 551- 559. 30. Furu K Karlstad O Skurtveit S Haberg SE Nafstad P et al. 2011 High validity of mother-reported use of antiasthmatics among children: A comparison with a population-based prescription database. J Clin Epidemiol 64: 878-884.

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