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Objectives Beekeepers are frequently exposed to bee venom and combustion smoke, leading to risks of systemic allergic reactions and respiratory hazards. This study assesses the prevalence of systemic allergic symptoms among beekeepers in Northeastern Italy and describes current management practices. Additionally, it characterises inhalation exposures to combustion smoke during apiary maintenance.Methods A cross-sectional survey collected data on sting exposure, allergic symptoms and smoke use practices. Combustion smoke exposure assessment was performed using Fourier transform infrared spectroscopy (Gasmet DX-4030) coupled with an ultrafine particle classifier (DiSCmini) to characterise emissions from commonly used fuels.Results Among 553 beekeepers surveyed, 21.3% reported systemic allergic reactions after bee sting, mostly males (66.7%). Of these (n=118), only 31.4% were confirmed sensitised to Apis mellifera and prescribed epinephrine autoinjector; 16.1% received venom immunotherapy, while others had no specific allergological assessment. Multivariate analysis showed that allergic symptoms during apiary work and extended local reactions increased the likelihood of systemic reactions fivefold. Almost all participants used smoke during inspections, with 39.1% frequently inhaling smoke; only 0.9% used respiratory protective equipment. Environmental monitoring detected multiple volatile organic compounds—including formaldehyde exceeding at different time points the threshold limit value-short term exposure limits—and high concentrations of ultrafine particles, particularly from hay and pellet combustion.Conclusions Systemic allergic reactions to bee venom are common but often undertreated in beekeepers. Combustion smoke is a significant respiratory hazard. Targeted interventions are needed to improve health outcomes and safety in this occupational group.