Abstract
Although chemical exposures from cleaning and disinfectant products often go unnoticed or unrecognized, such exposures have been associated with asthma-related symptoms and exacerbations. The Environmental Working Group (EWG) website provides consumer information on a wide range of issues and products related to human health and the environment, including the use of cleaning and disinfectant products, 2,500 of which it has rated in terms of their effects on respiratory function and asthma. In discussing how the use of cleaning and disinfectant products and the frequency of their use may affect asthma control, the authors use the EWG ratings as well as data collected for a study they conducted on older adults with asthma.
Keywords: asthma, asthma control, cleaning products, disinfectants, Environmental Working Group, household cleaners
Limiting exposures by choosing safer cleaning and disinfectant products.
People are often unaware of the numerous chemical exposures they encounter daily—in the air they breathe, the water they drink, the food they eat, and the products they use to clean and disinfect their homes. Cleaning and disinfectant products can contain multiple chemicals including volatile organic compounds (VOCs), which are used as solvents, fragrances, or preservatives.1
When sprayed, cleaning and disinfectant products can aerosolize both asthma-associated VOCs and nonvolatile compounds, which then may be inhaled.1, 2 Such exposure to cleaning and disinfectant products has been shown to be related to adult-onset asthma, and occupational exposures have been shown to increase asthma-related symptoms and exacerbations.3, 4 While the precise biological mechanism by which cleaning and disinfectant products affect the respiratory system isn’t clear, studies have shown that they may function as both irritants and allergens,3 producing oxidative stress, inflammation, and irritation.
Residential exposure.
Although the occupational effects of cleaning and disinfectant products on adults with asthma have been widely explored, scant research has focused on the effects of residential exposure to these products on asthma control. Several recent European studies have investigated the relationship between use of cleaning and disinfectant products and asthma. One study involving 607 women (mean age, 44 years) in which analyses were adjusted for age, smoking (never, former, current), body mass index of 25 or higher, and occupational exposure to asthmagens reported that frequent bleach use at home was significantly associated with nonallergic asthma (adjusted odds ratio [aOR], 3.30; 95% confidence interval [CI], 1.53-7.13).5 For women who used bleach four to seven times per week, the association between bleach use and current asthma was borderline significant when adjusted for age (aOR, 1.70; 95% CI, 0.98-2.95; P = 0.06).5
Another study found that the risk of asthma increased not only with the use of cleaning and disinfectant products and the frequency of use, but also with the number of products used.6 Furthermore, a study that included 2,223 women ages 64 to 76 years found that weekly use of cleaning and disinfectant products by older women was associated with “poorly controlled” asthma.7
In this article, we describe the tools nurses and their patients can use to make smart choices about the cleaning and disinfectant products they use in their homes. We discuss how the Environmental Working Group (EWG) rates these products and report the findings of a recent study we conducted that identified cleaning and disinfectant products that could reduce asthma control in older adults.We also describe precautions people of all ages who have asthma or other respiratory conditions should take when deciding how to safely clean and disinfect their homes.
ENVIRONMENTAL WORKING GROUP RATINGS
One publicly available resource for accurate information about cleaning and disinfectant products is the EWG. The mission of the EWG, as stated on its website (www.ewg.org), is to provide research that empowers people “to make informed choices and live a healthy life in a healthy environment.” The EWG website includes consumer information on a wide range of issues and products that affect human health and the environment, including contaminants in water; pesticides in food; ingredients in personal care products such as shampoos, toothpastes, deodorants, and cosmetics; and cleaning and disinfectant products. The EWG’s Guide to Healthy Cleaning rates more than 2,500 products based on five categories: asthma and respiratory concerns, skin allergies and irritation, developmental and reproductive toxicity, cancer, and overall environmental impact.8
Within these categories, products are then assigned a rating of concern: low concern, some concern, moderate concern, or high concern. In addition, products are assigned an overall grade of A to F: A indicates that the product discloses its ingredients and has a very low toxicity to health and the environment, C indicates that the product discloses some ingredients and has no overt hazards, and F indicates that either the ingredients are not disclosed or the product is highly hazardous.9
To determine these ratings, EWG staff evaluate the ingredients listed on product labels and websites, material safety data sheets submitted to the Occupational Safety and Health Administration, U.S. and European toxicity data sources, and scientific literature.9
Ingredients, however, are not always disclosed because industries consider some formulations to be proprietary trade secrets, and scientific data on some chemicals and their cumulative or synergistic effects are inconclusive or nonexistent. The United States does not require a review of chemicals in cleaning products, nor are manufacturers required to list all ingredients.10
OUR STUDY OF CLEANING PRODUCT USE AND ASTHMA CONTROL IN OLDER ADULTS
We recently conducted a study to determine whether asthma control varied based on older adults’ cleaning practices (participant recruitment and data collection procedures are published elsewhere11). Between 2015 and 2020, we collected data on the cleaning practices of older adults with asthma and the cleaning and disinfectant products they used. We focused on older adults because much of the research on asthma has focused on children and adolescents, and very little has been published about asthma in older adults.
Study goals.
The goals of our study were as follows11:
to develop a phenotyping algorithm for this population (an abstract that addresses this phenotyping has been published,12 and our manuscript on the subject is currently under review)
to explore the effects of asthma phenotypes and VOCs on asthma control
to produce a predictive model of asthma quality of life
Setting.
The Greater Louisville region in Louisville, Kentucky
Inclusion and exclusion criteria.
Participants were required to be nonsmokers, to be at least 60 years of age, and to have a confirmed diagnosis of asthma.11 Excluded were current smokers, former smokers who quit less than five years ago or had a smoking history of 20 pack-years or more, those who had a comorbid pulmonary disease or resided in a skilled nursing facility, and those with a prognostic index score of 10 or higher,11 which is predictive of a 42% four-year mortality risk.13
Recruitment.
Participants were recruited from pulmonologist and allergist offices; through social media, press releases, church newsletters, and flyers posted in clinics and senior citizen centers; and through local television and radio appearances.11
Initial screening and testing.
Potential participants were contacted by email or phone to determine potential eligibility.11 Those who passed the initial screening were scheduled for pulmonary function testing.
Demographics.
Participants were primarily female, White, college graduates, and retired or unemployed; most had health insurance, owned their own homes, were diagnosed with asthma as adults, and ranged in age from 60 to 96.11
Data collection.
Data were collected at baseline and at nine and 18 months postbaseline. Baseline data were collected at the Clinical Trials Unit of the University of Louisville and at participants’ homes.11 All nine- and 18-month data were collected at participants’ homes. Data were analyzed descriptively, and differences by Asthma Control Test (ACT)14 score groupings were analyzed using an independent-samples Kruskal-Wallis test, since the data were not normally distributed. The level of significance was set a priori at P ≤ 0.05.
Baseline physiological measures included pulmonary function testing, fractional exhaled nitric oxide, skin prick testing, and immunoglobulin E.11 Self-report measures included demographics, asthma control, asthma quality of life, asthma knowledge, and asthma self-efficacy.
A total of 185 participants completed baseline pulmonary function testing, questionnaires, sputum induction, skin prick testing, and had blood drawn for measuring vitamin D and immunoglobulin E.
Environmental data.
Within 30 days of enrollment, we collected baseline environmental data in participants’ homes, where we asked them about the cleaning and disinfectant products they used and how often they had used them in the past 14 days. During these visits, we were able to visually confirm the specific types of products used. We confirmed the products used by 148 (80%) ofthe 185 participants.
Our study focused only on the 148 participants for whom we could visually confirm specific cleaning and disinfectant products. We categorized these products on a scale of 1 to 4 in accordance with the EWG asthma and respiratory health concern ratings (low = 1, some = 2, moderate = 3, and high = 4).
An exposure scale.
Through conversations with study participants, we obtained specific information about their cleaning practices and the types of cleaning and disinfectant products they used, which enabled us to develop a scale that combined EWG asthma and respiratory impact ratings of the products with data on the frequency of use. The Cleaning Product Exposure Scale used the following formula to indicate the extent of each participant’s exposure to cleaning products:
EWG product asthma/respiratory rating × number of times shower/batbroom cleaned in past 2 weeks
Asthma control.
To determine participants’ level of asthma control over the past four weeks, we asked them to complete the five-item ACT.11, 14 Based on their ACT scores, participants’ asthma control was categorized as follows15:
“very poorly controlled” (≤ 15); 27% of participants
“not well controlled” (16 to 19); 28.4% of participants
“well controlled” (≥ 20); 44.6% of participants
OUR STUDY FINDINGS
Cleaning frequency.
Over the previous 14 days, participants had scrubbed their shower or tub a mean (SD) of 3.1 (3.9) days. Those with very poorly controlled asthma reported scrubbing their shower or tub a mean of 4.8 (5) days, significantly (P = 0.026) more often than those whose asthma was either not well controlled (mean, 2.1 [2.4] days) or well controlled (mean, 2.7 [3.5] days).
Commonly used cleaning and disinfectant products.
Most participants (91.2%) used commercial cleaning and disinfectant products, the most common of which were Scrubbing Bubbles all-purpose cleaner (n = 38), Lysol products (n = 15), Comet powder with bleach (n = 10), and Kaboom Shower, Tub, and Tile Cleaner (n = 8). Most cleaning and disinfectant products (60%) were categorized by the EWG as having moderate asthma and respiratory health concerns. (See Table 1 for the full list of products used by study participants and their EWG ratings.8) Vinegar and baking soda, used alone or in combination, were the most common noncommercial cleaners used (n = 12) and were categorized as having low asthma and respiratory health concerns.
Table 1.
Commercial Cleaning and Disinfectant Products Used by Study Participants with Asthma and Their EWG Ratings8
| Products | EWG Asthma/Respiratory Concerns | EWG Rating |
|---|---|---|
| Ajax Powder Cleanser with Bleach | Moderate | F |
| Clorox Bleach | Moderate | F |
| Clorox Clean-up Cleaner with Bleach | Moderate | F |
| Clorox Disinfecting Wipes | Moderate | F |
| Clorox Spray | Moderate | D |
| Clorox Bathroom Bleach Foamer | Moderate | F |
| Clorox Green Works | No Data, Some | D |
| Clorox Toilet Bowl Cleaner with Bleach | Moderate | F |
| Clorox Toilet Wand | No Data | F |
| CLR Mold & Mildew Stain Remover | Some | A |
| Comet Powder with Bleach | Moderate | F |
| Dawn | No Data, Some | D |
| Dawn with Lemon | No Data, Some | D |
| Fabuloso All Purpose Cleaner | Some | F |
| Fantastik All Purpose Cleaner | Moderate | C |
| Formula 409 Multi-Surface Cleaner | Moderate | D |
| Kaboom Shower, Tub, and Tile Cleaner | Moderate | D |
| Kirkland Household Surface Wipes | Moderate | F |
| Lysol Aerosol Bathroom Cleaner | Moderate | F |
| Lysol Hydrogen Peroxide Multi-Purpose Cleaner | Some | A |
| Lysol Bathroom Cleaner Spray | Moderate | F |
| Lysol Disinfectant Spray | Moderate | F |
| Lysol Power Cleaner | Some | B |
| Lysol Professional Disinfectant Basin Tub & Tile Cleaner | Some | B |
| Mr. Clean Bathroom Cleaner | Moderate | F |
| Mr. Clean Multipurpose Spray Cleaner | Moderate | F |
| Mr. Clean Disinfecting Bathroom Spray | Some | C |
| Mr. Clean Liquid Muscle Multi-Purpose cleaner | Some | D |
| Mr. Clean White Pads/Magic Eraser | Some | F |
| Pine-Sol Original All-Purpose Cleaner | No Data, Some | D |
| Scrub Free Bath Cleaner Plus Oxi Clean | No Data | F |
| Scrubbing Bubbles All-Purpose Cleaner | Moderate | F |
| Soft Scrub All Purpose Cleaner with Bleach | Moderate | F |
| Soft Scrub with Baking Soda Cleanser | Some | C |
| Spic and Span Spray Cleaner with Lavender | Some | F |
| Tilex Fresh Shower Daily Cleaner | No Data | D |
| Tilex Mold and Mildew Remover | Moderate | F |
A or B = low toxicity to health, ingredients disclosed; C = no overt health hazards, some ingredients disclosed; D = some toxic ingredients identified or few ingredients disclosed; F = highly toxic or no ingredients disclosed.
Exposure scores, which ranged from 0 to 42 (mean, 7.7 [10.2]), with higher numbers indicating higher potential frequency of chemical exposure, were significantly (P = 0.012) higher for those with very poorly controlled asthma (mean, 12.5 [13.5]; median, 6) than for those with not well controlled (mean, 5.1 [5.5]; median, 4) or well controlled asthma (mean, 6.5 [9.3]; median, 3), indicating that participants with very poorly controlled asthma were cleaning more often within a 14-day period and using products with a more detrimental effect on their asthma control.
PURCHASING CONSIDERATIONS AND ASTHMA CONTROL
Asthma is a complex diagnosis, and health care providers are still uncertain as to how it develops. Once asthma is diagnosed, however, steps can be taken to reduce asthma triggers in the home and prevent asthma exacerbations. (See Table 216, 17 and Online Resources for Safer Cleaning Practices for People with Asthma.) Learning the negative effects of VOCs on asthma outcomes is an important step in reducing asthma triggers in the home.
Table 2.
| Action | Why? | How? |
|---|---|---|
| Avoid spray cleaners. | It’s better to use solid or liquid cleaning products. Sprays can release aerosols that can cause irritation if inhaled. | Use as little of the spray product as possible and open windows to provide good ventilation when cleaning. |
| Avoid scented products. | While scented products may smell good, they can trigger an asthma exacerbation. | Remove scented products from your home and plan to purchase unscented alternatives. |
| Use a damp cloth for cleaning. | A damp cloth can trap particles and prevent them from becoming airborne. | Use cotton rags or microfiber cloths. |
| Consider using products that are asthma and allergy friendly. | Asthma- and allergy-friendly products have lower levels of volatile organic compounds and are usually fragrance-free. | The following can be safely used: • Baking soda on a damp sponge or wet rag is effective for cleaning most surfaces. • Club soda and baking soda can be used as a spot remover. • Salt loosens burned-on food and is a good kitchen cleanser. • White or apple cider vinegar removes mold and mineral deposits. • Vinegar mixed with water can be used to clean windows. |
Online Resources for Safer Cleaning Practices for People with Asthma.
American Lung Association
Asthma and Allergy Foundation of America
www.aafa.org/indoor-air-quality
Asthma and Allergy Friendly Certification Program
www.asthmaandallergyfriendly.com/USA
Environmental Protection Agency Identifying Greener Cleaning Products
www.epa.gov/greenerproducts/identifying-greener-cleaning-products
National Center for Healthy Housing Healthy Homes Guide to Cleaning and Disinfection
Tools health care professionals and their patients can use to assist in reducing asthma triggers include the EWG’s Guide to Healthy Cleaning (www.ewg.org/guides/cleaners) and the U.S. Environmental Protection Agency Safer Choice program (www.epa.gov/saferchoice). Both provide resources that can guide purchase options, provide lists of products determined to be “green” or safe, and assist in a purposeful review of the chemical exposures present in the home.
For patients with asthma, the first step is to create an inventory of products used for routine cleaning and the various places they’re stored in the home. Once this list is in hand, ratings for each cleaning product can be accessed using the EWG’s Guide to Healthy Cleaning.
As we found in our study of older adults with asthma, exposure to specific cleaning products and frequency of use are related to very poorly controlled asthma in older adults. Although our study focused on older adults, the EWG asthma and respiratory health concern ratings for cleaning and disinfectant products apply to people of all ages. To ensure that homes are a safe haven for all household members, it’s important to take stock of household cleaning products and identify which are safe to use and which can be eliminated. A clear understanding of the negative effects of certain cleaning and disinfectant products can influence patients’ purchasing habits and have a positive effect on their respiratory health and that of their household members. ▾
Acknowledgments
This work was supported by the National Institutes of Health, National Institute on Aging (award number R01AG047297). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors acknowledge the work of Diane Endicott, MS, BSN, RN, and Carol Norton, MUP, in collecting study data. The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.
Footnotes
For eight additional nursing continuing professional development activities on the topic of asthma, go to www.nursingcenter.com.
Contributor Information
Barbara J. Polivka, Associate dean of research and a professor at the University of Kansas, Kansas City.
Luz Huntington-Moskos, Assistant professor at the University of Louisville, Louisville, KY.
Rodney Folz, Chief, pulmonary, critical care, and sleep medicine at Houston Methodist Lung Center, Houston Methodist Hospital.
Russel Barnett, Lecturer, University of Louisville, Louisville, KY.
REFERENCES
- 1.Bello A, et al. Quantitative assessment of airborne exposures generated during common cleaning tasks: a pilot study. Environ Health 2010;9:76. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Clausen PA, et al. Chemicals inhaled from spray cleaning and disinfection products and their respiratory effects: a comprehensive review. Int J Hyg Environ Health 2020;229:113592. [DOI] [PubMed] [Google Scholar]
- 3.Folletti I, et al. Update on asthma and cleaning agents. Curr Opin Allergy Clin Immunol 2017;17(2):90–5. [DOI] [PubMed] [Google Scholar]
- 4.Su FC, et al. Clustering asthma symptoms and cleaning and disinfecting activities and evaluating their associations among healthcare workers. Int J Hyg Environ Health 2019;222(5):873–83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Matulonga B, et al. Women using bleach for home cleaning are at increased risk of non-allergic asthma. Respir Med 2016;117:264–71. [DOI] [PubMed] [Google Scholar]
- 6.Lemire P, et al. Domestic exposure to irritant cleaning agents and asthma in women. Environ Int 2020;144:106017. [DOI] [PubMed] [Google Scholar]
- 7.Dumas O, et al. Household cleaning and poor asthma control among elderly women. J Allergy Clin Immunol Pract 2021;9(6):2358–65.e4. [DOI] [PubMed] [Google Scholar]
- 8.Environmental Working Group. EWG’s guide to healthy cleaning, n.d. https://www.ewg.org/guides/cleaners.
- 9.Environmental Working Group. About EWG’s guide to healthy cleaning, n.d. https://www.ewg.org/guides/cleaners/content/methodology.
- 10.U.S. Environmental Protection Agency. Frequently asked questions on safer choice. Are cleaning product manufacturers required by law to list all their ingredients? https://www.epa.gov/saferchoice/frequently-asked-questions-safer-choice#pane-12.
- 11.Polivka BJ, et al. Identifying phenotypes and factors impacting outcomes in older adults with asthma: a research protocol and recruitment results. Res Nurs Health 2018;41(4):336–45. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Folz RJ, et al. Phenotyping older adults with asthma via clinical cluster analysis [conference abstract]. Am J Respir Grit Care Med 2018;197:A1345. 10.1164/ajrccm-conference.2018.197.1_MeetingAbstracts.A1345. [DOI] [Google Scholar]
- 13.Lee SJ, et al. Development and validation of a prognostic index for 4-year mortality in older adults. JAMA 2006;295(7):801–8. [DOI] [PubMed] [Google Scholar]
- 14.Schatz M, et al. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol 2006;117(3):549–56. [DOI] [PubMed] [Google Scholar]
- 15.Castner J, et al. Home environment allergen exposure scale in older adult cohort with asthma. Can J Public Health 2021;112(1):97–106. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Asthma and Allergy Foundation of America. Asthma triggers: air pollution—indoor air quality, n.d. https://www.aafa.org/indoor-air-quality. [Google Scholar]
- 17.Asthma and Allergy Foundation of America. Asthma and allergy friendly certification program, n.d. https://www.asthmaandallergyfriendly.com/USA. [Google Scholar]