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Campaign for fragrance-free health care in the U.S.

Nurses can improve indoor air quality by controlling synthetic fragrances

From the Massachusetts Nurse Newsletter
April 2006 Edition

By Peggy Wolff, MS, APRN, HNC


Indoor air quality in health care settings is under scrutiny by numerous environmental health and nursing organizations because patients, nurses and others have experienced health problems in those settings. Health Care Without Harm, the Environmental Working Group, the American Nurses Association, the Maryland State Nurses Association, the University of Maryland School of Nursing and the MNA are leaders in the movement to improve health care environments. Research has documented a direct connection between impaired health status and some chemical exposures. Harmful chemicals in the health care workplace include PVCs; disinfectants (ethylene oxide and glutaraldehyde); products containing DEHP; natural rubber latex; mercury; and pesticides to name just a few.

Some individuals and groups of individuals are especially affected by fragrance exposure.

Infants and children with immature immune systems and elders with weakened immune systems are particularly susceptible to harmful chemicals. In addition, people with asthma, allergies, migraines, compromised immune systems, and those who have been chemically injured are particularly vulnerable. Some patients are expressing frustration because their right to access health care is affected by toxic chemicals in health care environments. Sometimes they even have to choose between not getting health care and being exposed to harmful chemicals. Individuals of reproductive age are at heightened risk of chemical body burden that can be transmitted to the unborn, while new mothers are torn between the positive and negative effects of breastfeeding their infants because hazardous chemicals are consistently being detected in the breast milk of a majority of women.

Nurses may be at even greater risk than patients because they experience cumulative exposure. For an increasing number of nurses, fragrance use in their workplace is a barrier to employment. The Job Accommodation Network (JAN), a group concerned with employment rights for people with disabilities, has reported a sharp increase in the number of complaints related to fragrance and work. Between 1992 and 1995, JAN handled 37 cases related to fragrance while between 1995-2000, 567 cases were handled. Lessenger reported a case of a medical assistant developing acute anaphylactic reaction after being sprayed by perfume and cautions health care providers that this type of assault is becoming more common.

This article focuses on the harmful chemicals in synthetic fragrance, another important and prevalent cause of poor indoor air quality in health care settings. The following questions will be answered: What are the health effects of fragrance exposure? What are some of the harmful chemicals commonly found in fragrance? What can you as a nurse do about this problem? What does a model fragrance policy look like? How would I go about advocating for or implementing such a policy? What are the key resources?

Health effects of synthetic fragrance
At present one in five people in the U.S. experience adverse health effects from fragrance exposure. These effects range from mild to serious with fatalities reported in a very small number of cases. Each and every system of the body may be adversely affected. An example related to the respiratory system occurs when a person has a flare up in their asthma or even has an asthma attack when exposed to fragrance. In one study 72% of asthmatics had negative reactions to perfumes. Few nurses are aware that fragrance can cause respiratory problems. Respiratory problems can occur because fragrance is a known respiratory irritant. High levels of respiratory irritants can cause asthma or asthma-like conditions according to Betty Bridges, RN, owner of an informative web site on fragrance and health. In one tragic situation, a nurse practitioner died due to complications from an allergic reaction to perfume in 2002 at Inova Fairfax Hospital. Many symptoms such as irritability, impaired concentration, headaches, ataxia, and dizziness may develop when the central nervous system is involved. The most common site for allergic reactions to fragrance is the skin, with between five and 20% of the population experiencing such effects. Dermatitis, itchy or burning skin may occur. Cosmetics and fragranced products can also pose high risks for breast cancer and other illnesses. See shaded box at left for the Environmental Protection Agency’s list of adverse health effects associated with fragrance chemicals.

Harmful chemicals in synthetic fragrance and their health effects
What is in fragrance that could lead to this myriad of symptoms/health problems? For the past 50 years, 80-90 percent of fragrances have been synthesized from petroleum, not from natural sources, as advertisers might like us to believe. A few of the commonly found harmful chemicals in fragranced products are acetone, benzene, phenol, toluene, benzyl acetate, and limonene. See box at left for some of the health effects associated with each of these chemicals. Only a small sampling of chemicals and some of their health effects are provided because of space constraints.

Harmful health effects of fragrance are caused not only by the chemicals mentioned above and a few thousand other individual chemicals, but each fragrance may well contain hundreds of different chemicals in combination. Only a small minority of individual chemicals have been tested for respiratory and neurotoxic effects and rarely have chemical combinations been tested for their health effects. Since fragrance ingredients are protected under trade secret laws, the consumer is kept in the dark about many of the harmful chemicals that make up fragrance.

Irritants in fragrance can initiate a sensitizing process “as the immune system ‘learns’ to recognize materials that will later prompt a reaction when re-exposure occurs. Breakdown products of limonene, a-pinene, and benzaldehyde are known sensitizers commonly found in fragrance. Phthalates and synthetic musk compounds are two groups of chemicals frequently found in fragrance products that are known to cause serious and long-term health effects. Phthalates have been shown to cause endocrine disruption and are frequently found in fragrance products. Synthetic musk compounds used in fragrance can accumulate in fat tissue and be found in breast milk. These same compounds have also been shown to contribute to water contamination, harming aquatic and other wildlife.

Where is fragrance found?
Fragrance is ubiquitous in our society. In addition to being in obvious products like perfume and cologne, fragrance is in most personal care, laundry and cleaning products unless labeled “fragrance free.” Fragrance may also be in bath tissue, candles, markers, and numerous other widely used products. Air “fresheners” usually contain synthetic fragrance; rather than freshening the air, they significantly compromise air quality.

What can you do about fragrances?

  1. Avoid personal care, laundry and cleaning products that contain fragrance. Read labels carefully to see if the products are fragrance-free. Scent-free products may contain masking fragrances.
  2. Request that other nurses on your unit avoid fragrance and fragrance products. Provide them with a list of fragrance-free products that are readily available and with little, if any, increase in cost. A list of fragrance-free products is available in the brochure, “The Hidden Dangers of Fragrances” mentioned in the next paragraph.
  3. Distribute copies of the brochure, “The Hidden Dangers of Fragrances.” A sample brochure is available by sending a self-addressed stamped envelope to the Environmental Health Coalition of Western Massachusetts, P.O. Box 187, Northampton, MA 01061-0187.
  4. Inquire whether your health care setting has a policy or statement related to fragrance.
  5. If your setting has a policy/statement, please email the name of the facility, its location, and, if available, the policy/statement to the address below. A list of large health care facilities with fragrance-related policies will be available on-line at
  6. If your setting does not have a fragrance policy/statement, consider creating one based on the model described in the article below.

Reprinted with permission of the Maryland Nurses Association. Originally published in The Maryland Nurse, Feb.-March, 2006, 7-9.

Peggy Wolff, MS, APRN, HNC, is a licensed psychiatric-mental health nurse for more than 30 years and co-developer of the American Holistic Nurses Association’s certificate program in holistic nursing. She specializes in working with people with environmental illnesses. An author of numerous articles on environmental health, she completed Health Care Without Harm’s "RN No Harm Training Program." She can be reached at