Impact of Prolonged Heavy Incense Smoke Exposure on Pulmonary Function Assessed by Spirometry in Chinese Temple Workers

Impact of Prolonged Heavy Incense Smoke Exposure on Pulmonary Function Assessed by Spirometry in Chinese Temple Workers | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Prolonged Heavy Incense Smoke Exposure on Pulmonary Function Assessed by Spirometry in Chinese Temple Workers Vether Fernhandho, Anita Halim, Sylvia Sagita Siahaan, Wahyuni Lukita Atmodjo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7488057/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Background Burning incense is a common practice in Chinese temples during religious ceremonies. The incense smoke contains cytotoxic substances such as Volatile Organic Compounds and PM2.5, which can harm respiratory cells and tissues and trigger inflammatory responses involving IL-6 and COX-2. However, there are limited studies that have specifically assessed the impact of prolonged exposure to heavy incense smoke on pulmonary function, as measured by spirometry, in Chinese temple workers. Research Objectives: To examine the impact of prolonged heavy incense smoke exposure on pulmonary function assessed by spirometry in Chinese temple workers. Methodology: This study used a cross-sectional, analytical comparative design with unpaired categorical data, conducted in January 2025. Participants were recruited through a research questionnaire, and specific inclusion and exclusion criteria were applied. They were informed about the spirometry testing process and performed the test under the supervision of trained enumerators. Data were processed and analysed using SPSS Statistics version 30.0, with chi-square tests applied to examine associations. Results Among 51 subjects, 82.4% exposed to heavy incense smoke showed decreased lung function. Spirometry indicated 56.9% had restrictive, 9.8% obstructive, and 33.3% normal lung function. Chi-square analysis revealed a significant association between heavy incense smoke exposure and reduced lung function (p < 0.001; OR = 8.56). Additionally, after stratification for incense exposure, male gender (p = 0.002; OR = 21) and smoking behaviour (p = 0.003; OR = 70) were also significantly associated. Conclusion A significant relationship was found between exposure to incense smoke and lung function. Chinese temple workers with heavy incense smoke exposure are 8.56 times more likely to have reduced lung function. Additional influencing factors to decreasing lung function in heavily exposed workers to incense smoke include smoking behaviour and gender. Incense exposure lung function Chinese temple workers Figures Figure 1 INTRODUCTION Burning incense is a widespread tradition among Chinese communities in Indonesia. It used to honour ancestors and deities considered sacred. The combustion releases compounds such as polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (including benzene, toluene, and ethylbenzene), and inorganic gases (such as CO, CO₂, NO₂, and SO₂), which can irritate the respiratory system.[ 1 – 3 ] Inhalation of these substances can provoke inflammation, affect lung tissues and impair normal lung function. This increases the risk of respiratory diseases, such as COPD and asthma.[ 3 – 5 ] In Indonesia, Chinese communities practising Buddhism, Confucianism, and Taoism often use incense in temples as part of worship to honour ancestors and deities. Studies show that people exposed to incense smoke tend to have reduced lung function compared to those who are not.[ 5 ] COPD and asthma are closely associated with decreased lung function. Patients with COPD and asthma often exhibit significant reductions in lung function. Decreased lung function is defined as a condition where the ratio of forced expiratory volume in one second (FEV₁) to forced vital capacity (FVC) is less than 70%. [ 6 – 8 ] Chronic Obstructive Pulmonary Disease (COPD) is a condition characterised by damage to the respiratory airways, particularly the lungs, leading to airway obstruction. Boers et al. report that COPD is the third leading cause of death worldwide, with an estimated 10.6% of the world population affected, equating to approximately 480 million cases. [ 8 ]In Indonesia, Nuhrayati et al. estimate that by 2024, approximately 3.18 million Indonesians will be afflicted with COPD. According to the 2013 National Basic Health Research (RISKEDNAS) data published by the Ministry of Health, the prevalence of COPD among smokers in Indonesia is documented at 3.7%, corresponding to roughly 9.2 million individuals living with the condition. [ 9 , 10 ] Asthma is a condition in which the airways become inflamed, thereby disrupting the breathing process. [ 11 ] The Indonesian Ministry of Health reported that in 2020, approximately 4.5% of the Indonesian population, or more than 12 million people, suffered from asthma. Individuals with asthma in populations with high smoking rates are more likely to experience exacerbations, with coughing occurring 2.9 times more often, shortness of breath 3.4 times more often, and wheezing 4.7 times more often. [ 12 , 13 ] Based on research by Adnyana et al., decreased lung function is associated with exposure to incense smoke. Lung function can be examined in several ways. [ 14 ] One method recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) is spirometry using the forced manoeuvres to measure FVC (Forced Vital Capacity) and FEV1 (Forced Expiratory Volume in 1 second). FVC measures the maximum capacity of air a subject can exhale after taking a maximal inspiration, while FEV1 measures the amount of air exhaled by the subject during the first second. These four lung capacities can be measured using a spirometer to assess lung function. [ 15 , 16 ] According to research conducted by Zhang et al. in Taiwan, children who are regularly exposed to incense smoke experience impaired lung function as measured by spirometry, which inhibits lung growth in children and increases the risk factors for lung disease. However, this study did not specifically find changes in lung function in the subjects.[ 16 ] Another study conducted by Guo et al. showed that temple workers in Taiwan tend to have higher levels of inflammatory biomarkers such as IL-1β, IL-6, IL-8, IL-17A, TNF-α, and PAI-1 compared to people who do not work in temples. These differences were observed while accounting for demographic conditions in both groups, those exposed to incense smoke and those not exposed. [ 17 ] Based on several reports from the studies mentioned above, it can be concluded that incense smoke exposure has an impact on the decline of lung function in communities that use incense compared to those not affected by incense smoke, as indicated by inflammatory biomarkers. Until now, there have been limited studies examining the effects of incense smoke exposure using spirometry on workers in Chinese temple who work for 6 hours per day, 5 days a week. Therefore, this study aims to investigate the impact of prolonged heavy incense smoke exposure on pulmonary function assessed by spirometry in Chinese temple workers and we hypothesized that smoke exposure has an impact on the decline of lung function on workers in Chinese temples who work for 6 hours per day, 5 days a week, measured using spirometry. METHODOLOGY A. Study Design and Subjects This study used an analytical, categorical, unpaired, cross-sectional design. The sample included Chinese temple workers exposed to incense smoke for 6 hours daily, 5 days a week, with at least 2 years of service. Workers were divided into a worship group (heavy incense smoke exposure) and a non-worship group (light exposure) based on their job roles. We conducted this study from January to June 2025, included recruitment and observation lung function by spirometry, at various Chinese temples in Tangerang. We determined the sample sizes in this study using the unpaired categorical calculation technique, and the minimum number of subjects required for this study was 44. B. Data Collection This study employed convenience sampling. Researchers obtained informed consent, conducted interviews using a questionnaire to control the inclusions, exclusions, and confounders in participants, measured height and weight to calculate BMI, and assessed lung function using spirometry under expert supervision. Data were then analyzed. Inclusion criteria: workers aged 21–65 at places of worship, exposed to incense smoke 6 hours a day, 5 days a week, with over 2 years of service. Exclusion criteria: recent alcohol consumption, third-trimester pregnancy, COPD, asthma, tuberculosis, recent flu or prolonged cough with fever, pacemaker use, recent surgery (chest, abdomen, eyes), and heavy smokers by the Brinkman index. To avoid bias in this study, we excluded heavy smoking subjects and we will analyze further for the gender to determine the confounding possibility. C. Statistical Analysis The study’s subject samples were divided into two groups: a worship group (heavy incense smoke exposure) and a non-worship group (light exposure). The dependent variable in this study was exposure to incense smoke. The independent variable was lung function quality. Possible confounding variables were gender and smoking. The data were organized using Microsoft Excel 2022, and we will exclude the missing data before analyzing using the Statistical Package for the Social Sciences (SPSS, version 30.0). The analysis used the chi-square test or Fisher’s exact test. This study was approved by the ethics committee of the Faculty of Medicine, Pelita Harapan University, with approval number 081/K-LKJ/ETIK/II/2025. RESULT This study employed a cross-sectional design with Fig. 1 . Shows the exclusion process for this study. In total, 51 participants from Chinese Temples were included in this study. The sampling method used in this study was convenience sampling. In Table 1 . Shows the characteristics of the study’s subject. All research subjects were divided into two groups: light incense smoke exposure and heavy incense smoke exposure. Based on the distribution of the research subjects' characteristics, it can be concluded that the subjects in this study were predominantly male, elderly, with a low body mass index, and non-smokers.. The examination results showed that 29 people had restrictive impairments, 5 had obstructive impairments, and 17 had normal results. Table 1 Subjects Characteristics Characteristics Non-Worship Area Worker (N = 17) Worship Area Worker (N = 34) Total p-Value Gender, n (%) 0.76 Male 9 (52.9%) 21 (61.8%) 30 (58.8%) Female 8 (47.1%) 13 (38.2%) 21 (41.2%) Age, Mean ± SD 51.94±14.93 51.85±11.69 51.88±12.71 < 0.001 Height (cm), median (IQR) 160 (141–165) 159.5 (136–179) 160 (136–179) < 0.001 Weight (Kg), Mean ± SD 62.46±11.06 62.02±16.37 62.17±14.70 < 0.001 Body Mass Index (BMI), n (%) 0.27 Underweight 5 (29.4%) 17 (50%) 22 (43.1%) Normal 12 (70.6%) 17 (50%) 29 (56.9%) Smoking Behaviour 0.76 Non-Smoker 11 (64.7%) 19 (55.9%) 30 (58.8%) Smoker 6 (35.3%) 15 (44.1%) 21 (41.2%) Brinkman Index 0.6 Non-Smoker 11 (64.7%) 19 (55.9%) 30 (58.8%) Mild 4 (23.5%) 7 (20.6%) 11 (21.6%) Moderate 2 (11.8%) 8 (23.5%) 10 (19.6%) Spirometry Result 0.004 Normal 11 (64.7%) 6 (17.6%) 17 (33.3%) Obstructive 1 (5.9%) 4 (11.8%) 5 (9.8%) Restrictive 5 (29.4%) 24 (70.6%) 29 (56.9%) FVC Actual (L), Mean ± SD 2.59±0.79 2.18±0.63 2.31±0.71 < 0.001 FVC Predicted (%), median (IQR) 82.53±16.36 66.75±15.75 72.01±17.48 < 0.001 FEV1 Actual (L), Mean ± SD 2.13±0.75 1.78±0.52 1.89±0.62 < 0.001 FEV1 Predicted (%), Mean ± SD 79.19±26.31 98.74±15.09 70.07±22.38 < 0.001 FEV1/FVC Ratio 81.55±11.87 83.06±13.19 82.55±12.67 < 0.001 FVC = Forced Vital Capacity; FEV1: Forced Expiratory Volume in the first second; FEV1/FVC Ratio = Tiffeneau-Pinelli index; Height and FVC predicted were presented with median and interquartile range (IQR) To determine the relationship between incense smoke and lung function, a bivariate analysis was conducted using the chi-square test on the variables of incense smoke and lung function, with the results presented in Table 2 . A significant relationship between incense smoke exposure and decreased lung function was found with a p-value < 0.001 and an odds ratio (OR) of 8.56. Based on this analysis, it can be concluded that workers with heavy incense smoke exposure have an 8.56 times higher risk of lung function decline compared to workers with light incense smoke exposure. Table 2 Analysis of The Relationship Between Exposure of Incense Smoke and Decreased Lung Function Incense Smoke Exposure Decreased Lung Function Total OR (CI 95%) p-value Yes No n % n % n % Heavy 28 82.4% 6 17.6% 34 100% 8.56 (2.26–32.32) 0.002 Low 6 35.3% 11 64.7% 17 100% Based on the test of the three confounding variables, shown in Table 3 , none of the confounding variables showed a significant relationship with the decline in lung function. Therefore, a stratification test will be conducted to examine the relationship between the confounding variables and both the independent and dependent variables. Table 3 Analysis of The Relationship Between The Confounding Variables and Decreased Lung Function Variable Decreased Lung Function Total OR (CI 95%) p-value Yes No n % n % n % Gender Male 20 66.7% 10 33.3% 30 58.8% 1 (0.31–3.26) 1 Female 14 66.7% 7 33.3% 21 41.2% Age Elder 24 70.6% 10 29.4% 34 66.7% 1.14 (0.34–3.89) Adult 10 58.8% 7 41.2% 17 33.3% 0.83 Smoking Behaviour Smoking 15 71.4% 6 28.6% 21 41.2% 1.45 (0.43–4.82) 0.76 Non-Smoking 19 63.3% 11 36.7% 30 58.5% Based on the stratification results in Table 4 , a significant relationship exists between gender and decreased lung function. In the male group, 18 individuals (85.7%) were categorized as having heavy lung exposure, while the light lung exposure group consisted of 3 individuals (14.3%). The values obtained were OR = 21; 95% CI = 2.87-153.75, and p = 0.002. In the female subject group, however, no significant relationship was found. In the incense smoke exposure group, 2 individuals (22.2%) showed decreased lung function, whereas in the light exposure group, 4 individuals (50%) did. From these two groups, the values obtained were OR = 3.33; 95% CI = 0.5-22.14, and p = 0.346. A significant relationship, with an OR value of 70, 95% CI = 3.65-1342.66, and a p-value of 0.002, was also found between smoking behaviour and decreased lung function in the group exposed to incense smoke. In the group who both smoke and are heavily exposed to incense smoke, there is a higher decrease in lung function, with 14 individuals (93.3%), compared to those with light exposure. Based on these results, it is concluded that gender and smoking behaviour are confounding variables that can be associated with decreased lung function in workers who are heavily exposed to incense smoke. Table 4 Stratification Analysis Between Confounding Variables with Incense Smoke Exposure and Decreased Lung Function Determinant Incense Smoke Exposure Decreased Lung Function Total OR (95% CI) p- value Yes No n % n % n % Stratified by Gender Male Heavy 18 90% 3 30% 21 70% 21 (2.87-153.75) 0.002 Light 2 10% 7 70% 9 30% Female Heavy 10 71.4% 3 42.9% 13 61.9% 3.33 (0.5-22.14) 0.346 Light 4 28.6% 4 57.1% 8 38.1% Stratified by Smoking History Smoking Heavy 14 93.3% 1 16.7% 15 71.4% 70 (3.65-1342.66) 0.002 Light 1 6.7% 5 83.3% 6 28.6% Non-Smokin Heavy 14 73.7% 5 45.5% 19 63.3% 3.36(0.7-16.08) 0.238 Light 5 26.3% 6 54.5% 11 36.7% DISCUSSION The primary objective of this study was to investigate the relationship between exposure to incense smoke and lung function in workers at Chinese community places of worship. Lung function testing was conducted using a spirometry device with a forced spirometry manoeuvre. The test was performed a minimum of three times and a maximum of seven times, following spirometry testing procedures. The study was conducted on 51 Chinese temple workers. The characteristics of the subjects in Table 1 revealed that the majority were male, comprising 30 (58.8%), while the female respondents numbered 21 (41.2%), with an age range of 21 to 65 years. There were 17 subjects with light incense smoke exposure and 34 subjects with heavy incense smoke exposure. The spirometry tests for subjects exposed to heavy incense smoke (Non-worship area worker) revealed that 24 subjects (70.6%) experienced restrictive lung function impairment. Meanwhile, the group with light incense smoke exposure (Worship area worker) mostly showed normal lung function, with 11 subjects (65.7%) having normal lung function. Based on Table 2 , there is a statistically significant relationship between the variable of incense smoke exposure and lung function, with a p-value of 0.002 and an OR value of 8.56. Based on this analysis, it can be concluded that workers with heavy exposure to incense smoke have an 8.56 times higher risk of experiencing decreased lung function compared to workers with light exposure. The majority of the type of lung function decline experienced by the subjects was restrictive impairment, with 29 subjects showing restrictive impairment, 17 subjects having normal lung function, and 5 subjects experiencing obstructive impairment. A study conducted by Khathlan et al. found that people working in environments using bakhour incense had a higher prevalence of decreased lung function compared to those not exposed, with an OR = 1.72; 95% CI = 1.21–3.85. The decline in lung function in this bakhour incense shop was attributed to exposure to particulate matter in the study subjects, resulting in impaired lung function. [ 18 ] Based on the bivariate test results for the variables of gender and lung function, showed in Table 3 , no relationship was found between the two variables (p-value = 1, OR = 1). However, after stratifying the gender variable by incense smoke exposure and lung function decline, it was found that male subjects exposed to incense smoke had a higher decline in lung function compared to females, with a total of 18 (90%) subjects experiencing decreased lung function (p-value = 0.002, OR = 21). Based on these results, it can be interpreted that males exposed to incense smoke have a 21 times higher risk of lung function decline compared to females. This finding is consistent with the study by Meng et al. , which showed that male subjects had a higher incidence of lung function decline than females. Their stratified research results reported a prevalence of lung function decline of 30% in the group exposed to incense smoke, while the group not exposed had a prevalence of 10.9%, with a p-value of 0.03.This can be explained by physiological differences between males and females. Males have a larger vital lung capacity compared to females, which causes males to inhale more irritants such as carbon gases and similar substances than females, leading to higher exposure to toxic gases in males. [ 19 , 20 ] Additionally, the relationship between smoking behaviour and lung function decline, based on the distribution of subject characteristics shown in the Table 1 , in both incense smoke exposure groups, the smoking behaviour of subjects was dominated by non-smokers, with 11 (64.7%) in the light exposure group and 19 (55.9%) in the heavy exposure group. Bivariate testing for smoking behaviour and lung function found no statistically significant relationship (p = 0.76, OR = 1.45). However, after stratifying smoking behaviour with incense smoke exposure and lung function decline, as shown in Table 4 , it was found that subjects who smoked and had heavy incense smoke exposure had a much higher lung function decline, 14 (93.3%), compared to the light exposure group, with only 1 (16.7%). This stratification was statistically significant with p = 0.002 and OR = 70. This finding aligns with the 2018 study by Rawashdeh et al. , which showed that smoking has a negative correlation with lung function. Their research found that subjects who smoked continuously over a long period had much worse lung function compared to those who smoked for only one year or did not smoke at all. [ 21 ] This consistent research finding supports the hypothesis that workers in Chinese temples who are exposed to heavier incense smoke (in the Worship area) have a higher risk of decreased lung function compared to those with lighter exposure (in the Non-Worship area). This is due to differences in the intensity of incense smoke exposure, which causes inflammatory reactions in the lungs and oxidative stress. Exposure to ultrafine particles (PM2.5) combined with carbon monoxide (CO), nitrogen oxides (NOx), harmful polycyclic aromatic hydrocarbons (PAHs), and volatile organic compounds (VOCs), such as benzene and isoprene, leads to decreased lung function. [ 22 – 24 ] The significant relationship between male exposure to incense smoke and the decline in lung function can be explained by physiological differences between males and females. Males have a physiological condition of larger vital lung capacity compared to females, which causes males to inhale more irritants such as carbon gases and similar substances than females, resulting in higher exposure to these toxic gases in male subjects. [ 25 ] Smoking is a behaviour already proven to be related to lung function decline. Cigarettes contain nicotine, carbon monoxide, tar, and other substances that trigger inflammatory reactions and secretion in the respiratory tract, which ultimately lead to decreased lung function. In smokers, this adds an additional source of inhaled factors that promote further decline in lung function. [ 21 ] Those workers who work in the worship area need to use more proper protective equipment when doing their jobs. Particulate matter (PM 2.5) and other irritants in the smoke produced when burning incense will continuously expose the worship worker when they handle the incense in the worship area. The Chinese temples also needed to improve the ventilation quality in the worship area so that the incense smoke could circulate more effectively throughout the temple. The limitations of this study included the possibility of temporal bias due to the distance between data collection, which could have allowed for higher exposure to incense smoke on certain religious days compared to other days. Additionally, we were unable to determine the exact exposure of the study’s subjects. So, we concluded from this study that workers with heavy exposure to incense smoke had an impact on their lung function. Workers who had heavy incense smoke exposure have an 8.56 times higher risk of lung function decline compared to workers with light incense smoke exposure. Declarations Ethics approval and consent to participate This study protocols were approved by the Faculty of Medicine Pelita Harapan University Ethical Board under study number 081/K-LKJ/ETIK/II/2025. All participants have consented to participate in this study. Consent for publication Not Applicable Competing interests The authors declare no competing interests Clinical trial Not applicable Funding Information This study received no funding. Author Contribution Vether Fernhandho, Wahyuni Lukita Atmodjo, and Sylvia Sagita Siahaan wrote the main manuscript text together. Anita Halim supervised and advised in the figures, tables, and statistics in this study. All authors reviewed the manuscript. Acknowledgement We would like to acknowledge Mr. Oey Bun Sen for his assistance in collecting the data for this study. Additionally, this study would not have been possible without the aid of Pelita Harapan University and all the Chinese temples included in this study. Data Availability The data used to support the findings of this study are available from the corresponding author upon request. References Chen KC, Tsai SW, Shie RH, Zeng C, Yang HY. Indoor Air Pollution Increases the Risk of Lung Cancer. 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I, Pengaruh Jenis Kelamin dan Masa Kerja Terhadap Tingkat Ventilasi. 2020. https://doi.org/ https://doi.org/10.29407/judika.v4i2.15385 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 05 Sep, 2025 Editor assigned by journal 03 Sep, 2025 Submission checks completed at journal 03 Sep, 2025 First submitted to journal 29 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7488057","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509657370,"identity":"74488251-6904-46e0-a4d8-1d24714f08f3","order_by":0,"name":"Vether Fernhandho","email":"data:image/png;base64,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","orcid":"","institution":"Pelita Harapan University","correspondingAuthor":true,"prefix":"","firstName":"Vether","middleName":"","lastName":"Fernhandho","suffix":""},{"id":509657371,"identity":"93f7df3b-dc6d-4dcf-b681-ebafefc894f4","order_by":1,"name":"Anita Halim","email":"","orcid":"","institution":"Pelita Harapan University","correspondingAuthor":false,"prefix":"","firstName":"Anita","middleName":"","lastName":"Halim","suffix":""},{"id":509657372,"identity":"9cfd9213-1e0e-4612-b8e6-82474983213c","order_by":2,"name":"Sylvia Sagita Siahaan","email":"","orcid":"","institution":"Pelita Harapan University","correspondingAuthor":false,"prefix":"","firstName":"Sylvia","middleName":"Sagita","lastName":"Siahaan","suffix":""},{"id":509657373,"identity":"2d89ddfd-b937-4ace-ad37-3389912b8cf5","order_by":3,"name":"Wahyuni Lukita Atmodjo","email":"","orcid":"","institution":"Pelita Harapan University","correspondingAuthor":false,"prefix":"","firstName":"Wahyuni","middleName":"Lukita","lastName":"Atmodjo","suffix":""}],"badges":[],"createdAt":"2025-08-29 11:08:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7488057/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7488057/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90891726,"identity":"63ad5510-1526-4b06-9b4b-0f769acdfcf2","added_by":"auto","created_at":"2025-09-09 11:12:32","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":83268,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy's Exclusion Flow Chart\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7488057/v1/303f032202b94ee3db94ac8b.png"},{"id":90894082,"identity":"85c4b3d4-471a-4a1f-b5c9-063cfa0932f8","added_by":"auto","created_at":"2025-09-09 11:28:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1009863,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7488057/v1/4747ea3d-c3c0-4ab4-9e3b-d2b85e86a282.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Prolonged Heavy Incense Smoke Exposure on Pulmonary Function Assessed by Spirometry in Chinese Temple Workers","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBurning incense is a widespread tradition among Chinese communities in Indonesia. It used to honour ancestors and deities considered sacred. The combustion releases compounds such as polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (including benzene, toluene, and ethylbenzene), and inorganic gases (such as CO, CO₂, NO₂, and SO₂), which can irritate the respiratory system.[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] Inhalation of these substances can provoke inflammation, affect lung tissues and impair normal lung function. This increases the risk of respiratory diseases, such as COPD and asthma.[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn Indonesia, Chinese communities practising Buddhism, Confucianism, and Taoism often use incense in temples as part of worship to honour ancestors and deities. Studies show that people exposed to incense smoke tend to have reduced lung function compared to those who are not.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eCOPD and asthma are closely associated with decreased lung function. Patients with COPD and asthma often exhibit significant reductions in lung function. Decreased lung function is defined as a condition where the ratio of forced expiratory volume in one second (FEV₁) to forced vital capacity (FVC) is less than 70%. [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eChronic Obstructive Pulmonary Disease (COPD) is a condition characterised by damage to the respiratory airways, particularly the lungs, leading to airway obstruction. Boers et al. report that COPD is the third leading cause of death worldwide, with an estimated 10.6% of the world population affected, equating to approximately 480\u0026nbsp;million cases. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]In Indonesia, Nuhrayati et al. estimate that by 2024, approximately 3.18\u0026nbsp;million Indonesians will be afflicted with COPD. According to the 2013 National Basic Health Research (RISKEDNAS) data published by the Ministry of Health, the prevalence of COPD among smokers in Indonesia is documented at 3.7%, corresponding to roughly 9.2\u0026nbsp;million individuals living with the condition. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAsthma is a condition in which the airways become inflamed, thereby disrupting the breathing process. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] The Indonesian Ministry of Health reported that in 2020, approximately 4.5% of the Indonesian population, or more than 12\u0026nbsp;million people, suffered from asthma. Individuals with asthma in populations with high smoking rates are more likely to experience exacerbations, with coughing occurring 2.9 times more often, shortness of breath 3.4 times more often, and wheezing 4.7 times more often. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eBased on research by Adnyana et al., decreased lung function is associated with exposure to incense smoke. Lung function can be examined in several ways. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] One method recommended by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) is spirometry using the forced manoeuvres to measure FVC (Forced Vital Capacity) and FEV1 (Forced Expiratory Volume in 1 second). FVC measures the maximum capacity of air a subject can exhale after taking a maximal inspiration, while FEV1 measures the amount of air exhaled by the subject during the first second. These four lung capacities can be measured using a spirometer to assess lung function. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAccording to research conducted by Zhang et al. in Taiwan, children who are regularly exposed to incense smoke experience impaired lung function as measured by spirometry, which inhibits lung growth in children and increases the risk factors for lung disease. However, this study did not specifically find changes in lung function in the subjects.[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] Another study conducted by Guo et al. showed that temple workers in Taiwan tend to have higher levels of inflammatory biomarkers such as IL-1β, IL-6, IL-8, IL-17A, TNF-α, and PAI-1 compared to people who do not work in temples. These differences were observed while accounting for demographic conditions in both groups, those exposed to incense smoke and those not exposed. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eBased on several reports from the studies mentioned above, it can be concluded that incense smoke exposure has an impact on the decline of lung function in communities that use incense compared to those not affected by incense smoke, as indicated by inflammatory biomarkers.\u003c/p\u003e\u003cp\u003eUntil now, there have been limited studies examining the effects of incense smoke exposure using spirometry on workers in Chinese temple who work for 6 hours per day, 5 days a week. Therefore, this study aims to investigate the impact of prolonged heavy incense smoke exposure on pulmonary function assessed by spirometry in Chinese temple workers and we hypothesized that smoke exposure has an impact on the decline of lung function on workers in Chinese temples who work for 6 hours per day, 5 days a week, measured using spirometry.\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003ch2\u003eA. Study Design and Subjects\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study used an analytical, categorical, unpaired, cross-sectional design. The sample included Chinese temple workers exposed to incense smoke for 6 hours daily, 5 days a week, with at least 2 years of service. Workers were divided into a worship group (heavy incense smoke exposure) and a non-worship group (light exposure) based on their job roles. We conducted this study from January to June 2025, included recruitment and observation lung function by spirometry, at various Chinese temples in Tangerang.\u003c/p\u003e\u003cp\u003eWe determined the sample sizes in this study using the unpaired categorical calculation technique, and the minimum number of subjects required for this study was 44.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eB. Data Collection\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThis study employed convenience sampling. Researchers obtained informed consent, conducted interviews using a questionnaire to control the inclusions, exclusions, and confounders in participants, measured height and weight to calculate BMI, and assessed lung function using spirometry under expert supervision. Data were then analyzed.\u003c/p\u003e\u003cp\u003eInclusion criteria: workers aged 21\u0026ndash;65 at places of worship, exposed to incense smoke 6 hours a day, 5 days a week, with over 2 years of service. Exclusion criteria: recent alcohol consumption, third-trimester pregnancy, COPD, asthma, tuberculosis, recent flu or prolonged cough with fever, pacemaker use, recent surgery (chest, abdomen, eyes), and heavy smokers by the Brinkman index. To avoid bias in this study, we excluded heavy smoking subjects and we will analyze further for the gender to determine the confounding possibility.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eC. Statistical Analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe study\u0026rsquo;s subject samples were divided into two groups: a worship group (heavy incense smoke exposure) and a non-worship group (light exposure). The dependent variable in this study was exposure to incense smoke. The independent variable was lung function quality. Possible confounding variables were gender and smoking. The data were organized using Microsoft Excel 2022, and we will exclude the missing data before analyzing using the Statistical Package for the Social Sciences (SPSS, version 30.0). The analysis used the chi-square test or Fisher\u0026rsquo;s exact test. This study was approved by the ethics committee of the Faculty of Medicine, Pelita Harapan University, with approval number 081/K-LKJ/ETIK/II/2025.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULT","content":"\u003cp\u003e\u003c/p\u003e\u003cp\u003eThis study employed a cross-sectional design with Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Shows the exclusion process for this study. In total, 51 participants from Chinese Temples were included in this study. The sampling method used in this study was convenience sampling. In Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Shows the characteristics of the study\u0026rsquo;s subject. All research subjects were divided into two groups: light incense smoke exposure and heavy incense smoke exposure. Based on the distribution of the research subjects' characteristics, it can be concluded that the subjects in this study were predominantly male, elderly, with a low body mass index, and non-smokers.. The examination results showed that 29 people had restrictive impairments, 5 had obstructive impairments, and 17 had normal results.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSubjects Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-Worship Area Worker (N\u0026thinsp;=\u0026thinsp;17)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWorship Area Worker\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;34)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (52.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21 (61.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (58.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (47.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (38.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (41.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge, Mean \u0026plusmn; SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e51.94\u0026plusmn;14.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.85\u0026plusmn;11.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51.88\u0026plusmn;12.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHeight (cm), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160 (141\u0026ndash;165)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e159.5 (136\u0026ndash;179)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e160 (136\u0026ndash;179)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeight (Kg), Mean \u0026plusmn; SD\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.46\u0026plusmn;11.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.02\u0026plusmn;16.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e62.17\u0026plusmn;14.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBody Mass Index (BMI), n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnderweight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (29.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 (43.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (70.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (50%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (56.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSmoking Behaviour\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (64.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (55.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (58.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (35.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (44.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (41.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBrinkman Index\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Smoker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (64.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (55.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30 (58.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMild\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (23.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (20.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (21.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (23.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (19.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSpirometry Result\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (64.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (17.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (33.3%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eObstructive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (5.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (11.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (9.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRestrictive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (29.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (70.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29 (56.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFVC Actual (L), Mean \u0026plusmn; SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.59\u0026plusmn;0.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.18\u0026plusmn;0.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.31\u0026plusmn;0.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFVC Predicted (%), median (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82.53\u0026plusmn;16.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.75\u0026plusmn;15.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e72.01\u0026plusmn;17.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1 Actual (L), Mean \u0026plusmn; SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.13\u0026plusmn;0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.78\u0026plusmn;0.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.89\u0026plusmn;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1 Predicted (%), Mean \u0026plusmn; SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e79.19\u0026plusmn;26.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98.74\u0026plusmn;15.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.07\u0026plusmn;22.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1/FVC Ratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81.55\u0026plusmn;11.87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.06\u0026plusmn;13.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.55\u0026plusmn;12.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eFVC\u0026thinsp;=\u0026thinsp;Forced Vital Capacity; FEV1: Forced Expiratory Volume in the first second; FEV1/FVC Ratio\u0026thinsp;=\u0026thinsp;Tiffeneau-Pinelli index; Height and FVC predicted were presented with median and interquartile range (IQR)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo determine the relationship between incense smoke and lung function, a bivariate analysis was conducted using the chi-square test on the variables of incense smoke and lung function, with the results presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A significant relationship between incense smoke exposure and decreased lung function was found with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and an odds ratio (OR) of 8.56. Based on this analysis, it can be concluded that workers with heavy incense smoke exposure have an 8.56 times higher risk of lung function decline compared to workers with light incense smoke exposure.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of The Relationship Between Exposure of Incense Smoke and Decreased Lung Function\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIncense Smoke Exposure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eDecreased Lung Function\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003cp\u003e(CI 95%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeavy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e8.56 (2.26\u0026ndash;32.32)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e64.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e100%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBased on the test of the three confounding variables, shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, none of the confounding variables showed a significant relationship with the decline in lung function. Therefore, a stratification test will be conducted to examine the relationship between the confounding variables and both the independent and dependent variables.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAnalysis of The Relationship Between The Confounding Variables and Decreased Lung Function\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eDecreased Lung Function\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c7\" namest=\"c6\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eOR\u003c/p\u003e\u003cp\u003e(CI 95%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e58.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1 (0.31\u0026ndash;3.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e41.2%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eElder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e70.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e29.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e66.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.14 (0.34\u0026ndash;3.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdult\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e58.8%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e41.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e33.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.83\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSmoking Behaviour\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e71.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e28.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e41.2%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e1.45 (0.43\u0026ndash;4.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.76\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNon-Smoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e36.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e58.5%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eBased on the stratification results in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, a significant relationship exists between gender and decreased lung function. In the male group, 18 individuals (85.7%) were categorized as having heavy lung exposure, while the light lung exposure group consisted of 3 individuals (14.3%). The values obtained were OR\u0026thinsp;=\u0026thinsp;21; 95% CI\u0026thinsp;=\u0026thinsp;2.87-153.75, and p\u0026thinsp;=\u0026thinsp;0.002.\u003c/p\u003e\u003cp\u003eIn the female subject group, however, no significant relationship was found. In the incense smoke exposure group, 2 individuals (22.2%) showed decreased lung function, whereas in the light exposure group, 4 individuals (50%) did. From these two groups, the values obtained were OR\u0026thinsp;=\u0026thinsp;3.33; 95% CI\u0026thinsp;=\u0026thinsp;0.5-22.14, and p\u0026thinsp;=\u0026thinsp;0.346.\u003c/p\u003e\u003cp\u003eA significant relationship, with an OR value of 70, 95% CI\u0026thinsp;=\u0026thinsp;3.65-1342.66, and a p-value of 0.002, was also found between smoking behaviour and decreased lung function in the group exposed to incense smoke. In the group who both smoke and are heavily exposed to incense smoke, there is a higher decrease in lung function, with 14 individuals (93.3%), compared to those with light exposure. Based on these results, it is concluded that gender and smoking behaviour are confounding variables that can be associated with decreased lung function in workers who are heavily exposed to incense smoke.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStratification Analysis Between Confounding Variables with Incense Smoke Exposure and Decreased Lung Function\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026minus;\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eDeterminant\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eIncense Smoke Exposure\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eDecreased Lung Function\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c8\" namest=\"c7\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-\u003cem\u003evalue\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStratified by Gender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeavy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e70%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e21 (2.87-153.75)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e70%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e30%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeavy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e42.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e61.9%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3.33 (0.5-22.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.346\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28.6%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e57.1%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e38.1%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eStratified by Smoking History\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSmoking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeavy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e16.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e71.4%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e70 (3.65-1342.66)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e83.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e28.6%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNon-Smokin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHeavy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73.7%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e45.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e63.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026minus;\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e3.36(0.7-16.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.238\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e26.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e54.5%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e36.7%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe primary objective of this study was to investigate the relationship between exposure to incense smoke and lung function in workers at Chinese community places of worship. Lung function testing was conducted using a spirometry device with a forced spirometry manoeuvre. The test was performed a minimum of three times and a maximum of seven times, following spirometry testing procedures.\u003c/p\u003e\u003cp\u003eThe study was conducted on 51 Chinese temple workers. The characteristics of the subjects in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e revealed that the majority were male, comprising 30 (58.8%), while the female respondents numbered 21 (41.2%), with an age range of 21 to 65 years. There were 17 subjects with light incense smoke exposure and 34 subjects with heavy incense smoke exposure. The spirometry tests for subjects exposed to heavy incense smoke (Non-worship area worker) revealed that 24 subjects (70.6%) experienced restrictive lung function impairment. Meanwhile, the group with light incense smoke exposure (Worship area worker) mostly showed normal lung function, with 11 subjects (65.7%) having normal lung function.\u003c/p\u003e\u003cp\u003eBased on Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, there is a statistically significant relationship between the variable of incense smoke exposure and lung function, with a p-value of 0.002 and an OR value of 8.56. Based on this analysis, it can be concluded that workers with heavy exposure to incense smoke have an 8.56 times higher risk of experiencing decreased lung function compared to workers with light exposure. The majority of the type of lung function decline experienced by the subjects was restrictive impairment, with 29 subjects showing restrictive impairment, 17 subjects having normal lung function, and 5 subjects experiencing obstructive impairment.\u003c/p\u003e\u003cp\u003eA study conducted by \u003cb\u003eKhathlan et al.\u003c/b\u003e found that people working in environments using bakhour incense had a higher prevalence of decreased lung function compared to those not exposed, with an OR\u0026thinsp;=\u0026thinsp;1.72; 95% CI\u0026thinsp;=\u0026thinsp;1.21\u0026ndash;3.85. The decline in lung function in this bakhour incense shop was attributed to exposure to particulate matter in the study subjects, resulting in impaired lung function. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eBased on the bivariate test results for the variables of gender and lung function, showed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, no relationship was found between the two variables (p-value\u0026thinsp;=\u0026thinsp;1, OR\u0026thinsp;=\u0026thinsp;1). However, after stratifying the gender variable by incense smoke exposure and lung function decline, it was found that male subjects exposed to incense smoke had a higher decline in lung function compared to females, with a total of 18 (90%) subjects experiencing decreased lung function (p-value\u0026thinsp;=\u0026thinsp;0.002, OR\u0026thinsp;=\u0026thinsp;21). Based on these results, it can be interpreted that males exposed to incense smoke have a 21 times higher risk of lung function decline compared to females.\u003c/p\u003e\u003cp\u003eThis finding is consistent with the study by \u003cb\u003eMeng et al.\u003c/b\u003e, which showed that male subjects had a higher incidence of lung function decline than females. Their stratified research results reported a prevalence of lung function decline of 30% in the group exposed to incense smoke, while the group not exposed had a prevalence of 10.9%, with a p-value of 0.03.This can be explained by physiological differences between males and females. Males have a larger vital lung capacity compared to females, which causes males to inhale more irritants such as carbon gases and similar substances than females, leading to higher exposure to toxic gases in males. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAdditionally, the relationship between smoking behaviour and lung function decline, based on the distribution of subject characteristics shown in the Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, in both incense smoke exposure groups, the smoking behaviour of subjects was dominated by non-smokers, with 11 (64.7%) in the light exposure group and 19 (55.9%) in the heavy exposure group.\u003c/p\u003e\u003cp\u003eBivariate testing for smoking behaviour and lung function found no statistically significant relationship (p\u0026thinsp;=\u0026thinsp;0.76, OR\u0026thinsp;=\u0026thinsp;1.45). However, after stratifying smoking behaviour with incense smoke exposure and lung function decline, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, it was found that subjects who smoked and had heavy incense smoke exposure had a much higher lung function decline, 14 (93.3%), compared to the light exposure group, with only 1 (16.7%). This stratification was statistically significant with p\u0026thinsp;=\u0026thinsp;0.002 and OR\u0026thinsp;=\u0026thinsp;70.\u003c/p\u003e\u003cp\u003eThis finding aligns with the 2018 study by \u003cb\u003eRawashdeh et al.\u003c/b\u003e, which showed that smoking has a negative correlation with lung function. Their research found that subjects who smoked continuously over a long period had much worse lung function compared to those who smoked for only one year or did not smoke at all. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis consistent research finding supports the hypothesis that workers in Chinese temples who are exposed to heavier incense smoke (in the Worship area) have a higher risk of decreased lung function compared to those with lighter exposure (in the Non-Worship area). This is due to differences in the intensity of incense smoke exposure, which causes inflammatory reactions in the lungs and oxidative stress. Exposure to ultrafine particles (PM2.5) combined with carbon monoxide (CO), nitrogen oxides (NOx), harmful polycyclic aromatic hydrocarbons (PAHs), and volatile organic compounds (VOCs), such as benzene and isoprene, leads to decreased lung function. [\u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe significant relationship between male exposure to incense smoke and the decline in lung function can be explained by physiological differences between males and females. Males have a physiological condition of larger vital lung capacity compared to females, which causes males to inhale more irritants such as carbon gases and similar substances than females, resulting in higher exposure to these toxic gases in male subjects. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eSmoking is a behaviour already proven to be related to lung function decline. Cigarettes contain nicotine, carbon monoxide, tar, and other substances that trigger inflammatory reactions and secretion in the respiratory tract, which ultimately lead to decreased lung function. In smokers, this adds an additional source of inhaled factors that promote further decline in lung function. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThose workers who work in the worship area need to use more proper protective equipment when doing their jobs. Particulate matter (PM 2.5) and other irritants in the smoke produced when burning incense will continuously expose the worship worker when they handle the incense in the worship area. The Chinese temples also needed to improve the ventilation quality in the worship area so that the incense smoke could circulate more effectively throughout the temple.\u003c/p\u003e\u003cp\u003eThe limitations of this study included the possibility of temporal bias due to the distance between data collection, which could have allowed for higher exposure to incense smoke on certain religious days compared to other days. Additionally, we were unable to determine the exact exposure of the study\u0026rsquo;s subjects.\u003c/p\u003e\u003cp\u003eSo, we concluded from this study that workers with heavy exposure to incense smoke had an impact on their lung function. Workers who had heavy incense smoke exposure have an 8.56 times higher risk of lung function decline compared to workers with light incense smoke exposure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study protocols were approved by the Faculty of Medicine Pelita Harapan University Ethical Board under study number 081/K-LKJ/ETIK/II/2025. All participants have consented to participate in this study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot Applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eClinical trial\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding Information\u003c/h2\u003e\u003cp\u003eThis study received no funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVether Fernhandho, Wahyuni Lukita Atmodjo, and Sylvia Sagita Siahaan wrote the main manuscript text together. Anita Halim supervised and advised in the figures, tables, and statistics in this study. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge Mr. Oey Bun Sen for his assistance in collecting the data for this study. Additionally, this study would not have been possible without the aid of Pelita Harapan University and all the Chinese temples included in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChen KC, Tsai SW, Shie RH, Zeng C, Yang HY. Indoor Air Pollution Increases the Risk of Lung Cancer. 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I, Pengaruh Jenis Kelamin dan Masa Kerja Terhadap Tingkat Ventilasi. 2020. https://doi.org/\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.29407/judika.v4i2.15385\u003c/span\u003e\u003cspan address=\"10.29407/judika.v4i2.15385\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Incense exposure, lung function, Chinese temple workers","lastPublishedDoi":"10.21203/rs.3.rs-7488057/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7488057/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eBurning incense is a common practice in Chinese temples during religious ceremonies. The incense smoke contains cytotoxic substances such as Volatile Organic Compounds and PM2.5, which can harm respiratory cells and tissues and trigger inflammatory responses involving IL-6 and COX-2. However, there are limited studies that have specifically assessed the impact of prolonged exposure to heavy incense smoke on pulmonary function, as measured by spirometry, in Chinese temple workers.\u003c/p\u003e\u003ch2\u003eResearch Objectives:\u003c/h2\u003e\u003cp\u003eTo examine the impact of prolonged heavy incense smoke exposure on pulmonary function assessed by spirometry in Chinese temple workers.\u003c/p\u003e\u003ch2\u003eMethodology:\u003c/h2\u003e\u003cp\u003eThis study used a cross-sectional, analytical comparative design with unpaired categorical data, conducted in January 2025. Participants were recruited through a research questionnaire, and specific inclusion and exclusion criteria were applied. They were informed about the spirometry testing process and performed the test under the supervision of trained enumerators. Data were processed and analysed using SPSS Statistics version 30.0, with chi-square tests applied to examine associations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong 51 subjects, 82.4% exposed to heavy incense smoke showed decreased lung function. Spirometry indicated 56.9% had restrictive, 9.8% obstructive, and 33.3% normal lung function. Chi-square analysis revealed a significant association between heavy incense smoke exposure and reduced lung function (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; OR\u0026thinsp;=\u0026thinsp;8.56). Additionally, after stratification for incense exposure, male gender (p\u0026thinsp;=\u0026thinsp;0.002; OR\u0026thinsp;=\u0026thinsp;21) and smoking behaviour (p\u0026thinsp;=\u0026thinsp;0.003; OR\u0026thinsp;=\u0026thinsp;70) were also significantly associated.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eA significant relationship was found between exposure to incense smoke and lung function. Chinese temple workers with heavy incense smoke exposure are 8.56 times more likely to have reduced lung function. Additional influencing factors to decreasing lung function in heavily exposed workers to incense smoke include smoking behaviour and gender.\u003c/p\u003e","manuscriptTitle":"Impact of Prolonged Heavy Incense Smoke Exposure on Pulmonary Function Assessed by Spirometry in Chinese Temple Workers","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-09 11:12:28","doi":"10.21203/rs.3.rs-7488057/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-05T06:52:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T11:27:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-03T11:27:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pulmonary Medicine","date":"2025-08-29T11:05:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pulmonary-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pulm","sideBox":"Learn more about [BMC Pulmonary Medicine](http://bmcpulmmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pulm/default.aspx","title":"BMC Pulmonary Medicine","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"277c00a6-87f2-4e16-8b54-83fb332d4b6e","owner":[],"postedDate":"September 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-20T12:53:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-09 11:12:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7488057","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7488057","identity":"rs-7488057","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}