294 Control 1998;7:294–298 Tob Control: first published as 10.1136/tc.7.3.294 on 1 September 1998. Downloaded from

REVIEW ARTICLE

Green tobacco sickness

JeVrey S McBride, David G Altman, Melissa Klein, Wain White

Abstract are well known. Less well known are the health Objective—To describe the health impact eVects of handling wet tobacco leaves. Green of harvesting tobacco and to suggest tobacco sickness (GTS) is a form of prevention and risk reduction strategies to that aVects workers who have direct avoid contracting green tobacco sickness contact with tobacco plants during cultivation (GTS). and harvesting. Symptoms of GTS are similar Data sources—A literature search of to those induced by pesticide exposure or heat Medline, Toxline, and Toxline65 with the exhaustion, and to nicotine intoxication terms “green”, “tobacco”, and “sickness” experienced by novice smokers. Thus, GTS covering the years 1966–1998. may be misdiagnosed by practitioners unfamil- Study selection—All studies, reviews, and iar with this condition.1–4 Although GTS has commentaries that provided information not been associated with mortality or on the health eVects of harvesting green long-term morbidity, it causes significant tobacco and disease prevention strategies. discomfort and lost productivity among Data synthesis—GTS occurs when to- tobacco workers.1 4–8 bacco workers hand-harvest, cut, or load Much of the research on GTS has focused tobacco plants, usually in the early morn- on American tobacco harvesters. Internation- ing or after a rainfall when tobacco plants ally, the eVects and prevalence of GTS are not are covered with moisture. GTS occurs well known. Foreign production of tobacco, through skin exposure to dissolved however, has increased rapidly in recent years nicotine from tobacco leaves. Symptoms and tobacco manufacturers and wholesalers of GTS include weakness, headache, nau- spend millions of dollars each year helping for-

sea, vomiting, dizziness, abdominal eign tobacco growers with state-of-the art http://tobaccocontrol.bmj.com/ cramps, diYculty, abnormal technology, growing techniques, seeds, fertilis- temperature, , diarrhoea, chills, ers, chemicals, and leaf-processing plants.910 fluctuations in blood pressure or heart As a result of this shift in the world tobacco rate, and increased and supply, we may see a subsequent shift in the salivation. The onset of the illness is three distribution of GTS. to 17 hours after exposure and the In the United States, there have been duration of illness is one to three days. published reports of GTS in Kentucky,237 Initial treatment includes cessation of Florida,11 Tennessee,4 and North Carolina.1 work, change of clothing, showering, fluid Internationally, GTS has been recorded in intake, and rest. In more extreme cases, India5 and Japan.12 Although much has been intravenous rehydration, anti-emetics, learned about GTS in the United States over

and dimenhydrinate are administered. the past 20 years, very little regulatory eVort on September 29, 2021 by guest. Protected copyright. Protective, water-resistant clothing; has been undertaken to address the potential chemical-resistant gloves, boots, and hazards of this disease. socks; working in dry conditions; and dimenhydrinate can reduce the likelihood Data sources and study selection of contracting GTS. All population-based studies, review articles, Conclusions—It is important to provide and commentaries concerning GTS were education to tobacco workers and employ- included, although literature on GTS is sparse. ers about GTS. An international public GTS is not included in several of the most awareness campaign about GTS timed to well-known medical dictionaries—for exam- Wake Forest University School of Medicine, coincide with the tobacco harvest, along ple, Stedman’s, Churchill’s, Dorland’s—and only Winston-Salem, North with enforced worker safety regulations, 18 journal articles were found in a comprehen- Carolina, USA should be undertaken to protect the health sive literature search covering the years J S McBride 1966–1998. This search of Medline, Toxline, D G Altman of individuals working in tobacco produc- M Klein tion. and Toxline65 used the terms “green”, W White ( 1998;7:294–298) “tobacco”, and “sickness.” To find additional studies and commentaries, the bibliographies Correspondence to: Keywords: green tobacco sickness, health education, DG Altman, Wake Forest occupational safety of identified articles were also reviewed. University School of Medicine, Department of Public Health Sciences, Data synthesis Medical Center Boulevard, Introduction SYMPTOMS Winston-Salem, North Carolina 27157–1063, USA. The health risks associated with During GTS onset, early symptoms often [email protected] tobacco and exposure to secondhand smoke include headache and nausea followed by Green tobacco sickness 295 Tob Control: first published as 10.1136/tc.7.3.294 on 1 September 1998. Downloaded from

vomiting, weakness, pallor, dizziness, head- Cropping typically occurs in the summer aches, increased perspiration, chills, abdomi- and autumn months. Workers begin in the nal pain, diarrhoea, and increased early morning, when the tender green tobacco salivation.1–8 13–17 These eVects can be rather is wet with dew. GTS occurs primarily when extreme, and may also include severe people handle wet tobacco.1–3723 The prostration,31718 shortness of breath, and geographical clustering of GTS cases is occasional fluctuations in blood pressure or influenced by rainfall, temperature, and heart rate.1313 Among those susceptible, the humidity.17 24 In the process of cropping average length of the illness, with treatment, is tobacco, leaves and stalks are often cracked, between one and three days (median = 2.4 emitting a gummy substance that coats days).27 workers’ hands, skin, and clothing.11 After cur- Some of the symptoms of GTS are similar to ing, leaves are usually loaded into burlap sheets those of organosphosphate poisoning and heat in preparation for taking them to the auction exhaustion. However, many of the symptoms market. Some farmers are experimenting with of organosphosphate poisoning (including compressed bales of tobacco that can hold increased lacrimation, pulmonary oedema, and substantially more tobacco than a burlap miosis) have not been associated with GTS.8 sheet.25 Although tobacco is handled during The possibility that GTS symptoms are due to many stages of production, GTS occurs is lessened because the last primarily among workers who handle green application of pesticides normally occurs leaves and stalks in the field or during the several weeks before harvest.1811 and because process of transferring green tobacco to the GTS is known to occur among workers on curing barn.1 farms that do not use pesticides. Furthermore, cases of GTS were documented before Absorption of nicotine widespread pesticide use.11 GTS is a threat to those who harvest tobacco 26 Symptoms of heat exhaustion have been because nicotine, being soluble in water, can ruled out in many cases of GTS. Although be drawn out of tobacco by rain, dew, or tobacco is typically harvested during hot perspiration, and subsequently absorbed 513 weather, GTS symptoms have also appeared through the skin. As much as 9 mg nicotine 13 during cool conditions when harvesters may be contained in 100 ml of dew. Although reported feeling chilled rather than there is no accurate measurement of the overheated.1 Also, most of those stricken with amount of nicotine-laden dew to which GTS became ill after they had gone home for tobacco harvesters are exposed, Gehlbach and the day (median onset = 10 hours).2 colleagues suggested that 600 ml would be a conservative estimate.13 The percentage of

dew-laden nicotine absorbed transdermally, http://tobaccocontrol.bmj.com/ AETIOLOGY however, is not known. Despite this, many Exposure to nicotine studies have documented the increase of Burley and flue-cured tobacco are the two (a nicotine metabolite) in the urine of main types of tobacco grown in the United tobacco workers, after controlling for those States, accounting for 94% of all tobacco who reported regular tobacco usage.5 13–16 grown. Burley is grown primarily in Kentucky Absorption was found to be greatest among and Tennessee, whereas flue-cured tobacco is croppers who had the most contact with the grown largely in North Carolina, South Caro- wet leaves and least among stringers (those lina, Virginia, and Georgia.19 The amount of who tie burley tobacco leaves on poles for cur- nicotine present in a tobacco leaf depends on a ing) and tractor drivers. number of factors including genetics, soil, fer- Once the dew-laden tobacco is contacted, tilisation practices, weather, and cultivation croppers can absorb a great deal of nicotine in on September 29, 2021 by guest. Protected copyright. and harvesting techniques.820On average, bur- a relatively short period of time. It has been ley tobacco contains about 13% more nicotine reported that nausea and faintness can occur than flue-cured tobacco.21 Nicotine levels in within 15 minutes of skin contact,27 although dark varieties of tobacco—such as dark the US Centers for Disease Control and fire-cured, dark air-cured—are generally higher Prevention (CDC) reported that the median than burley.22 time from exposure to onset of GTS was 10 GTS occurs primarily among tobacco work- hours (ranging from three to 17 hours).2 ers who hand-harvest (“crop”) tobacco leaves in the field and handle the leaves as they are EVects of nicotine placed in barns for curing. The process of Once nicotine is absorbed, it is distributed cropping flue-cured tobacco usually consists of throughout the body, including into the brain. pulling and twisting loose green leaves from the The nausea and vomiting characteristic of GTS plant and collecting them in large bundles that is mediated by the direct action of nicotine on are held either in the hand or underneath the the emetic chemoreceptor trigger zone in the arm and against the body. For burley tobacco, medulla oblongata leading to reflex vomiting.28 the entire stalk is removed and the tobacco is Nicotine also excites sensory nerves from the typically held in the hand or on the forearm. gut and parasympathetic nerves in the gastroin- Hand harvesting can lead to skin abrasions, testinal tract, which lead to an overall increase in further increasing risk of contracting GTS. gastrointestinal secretion and motility. The Larger farm operators are increasingly using pharmacological eVects of nicotine on nicotinic mechanical harvesting equipment, thus reduc- receptors in the central and at ing dermal exposure to tobacco leaves. post-synaptic autonomic ganglia have been well 296 McBride, Altman, Klein, et al Tob Control: first published as 10.1136/tc.7.3.294 on 1 September 1998. Downloaded from

elaborated29 and help to explain the toxic eVects Despite the relatively short duration of GTS, of nicotine. However, symptoms associated with the illness can be debilitating during its onset severe nicotine poisoning, such as convulsions, and progression. Clinical diagnosis of GTS is dyspnoea, and vascular collapse, are not based upon both the presence of symptoms typically seen in GTS cases.1 Symptoms that are described above and a history of harvesting ascribed to nicotine intoxication in novice tobacco. The diagnosis of GTS may be made smokers mimic green tobacco sickness—for by testing the blood or urine for nicotine (half- example, nausea, vomiting, increased heart rate, life = 3–4 hours) or cotinine (a nicotine chills. metabolite (half-life = 36 hours) that can also be detected in saliva).3 Although the level of EPIDEMIOLOGY cotinine has been used to distinguish between A few studies have estimated the incidence of tobacco users and non-users,5151623 the level GTS. Using United States and Kentucky cannot be used to distinguish between heavy Department of Agriculture data, the incidence tobacco users and persons with GTS, because of GTS was estimated to be 10/1000 workers nicotine/cotinine concentrations that represent (or 1%).3 In 1973, a study in North Carolina toxic levels have not been established.3 estimated a 9% prevalence of GTS—5400 of Little has been written about the treatment 60 000 workers.1 These estimates are not com- modalities available to those seeking relief from parable because case numbers were based on GTS. Although it can take as much as 10 hours self-reported data in North Carolina and on before GTS symptoms occur, the most hospital-treated cases in Kentucky. Thus, a common suggestion once symptoms occur is to true estimate of the prevalence of GTS is diY- avoid increased contact with green tobacco. cult to derive because reporting methods are This can be accomplished by ceasing work, not standardised and many cases likely go changing clothes, and showering. In addition, unreported. exposed workers are encouraged to increase Younger workers are more likely than older fluid intake, ingest dimenhydrinate workers to develop GTS.1–3 6 In one study, 58% (Dramamine), and rest.2618 The therapeutic of those suVering GTS were under age 29 and eVects of H1 blockers such as dimenhydrinate, 32% were between 14 and 19 years of age.6 however, are not mediated through an Likewise, it was found that younger people antagonistic action on the nicotinic (under age 30) were 3.1 times more likely to receptors. When symptoms are serious, develop GTS than older people.3 DiVerences physicians can administer intravenous hydra- by gender have also been found.1615Nearly all tion, anti-emetics, and H1 blockers (dimenhy- of those aVected by GTS are male1615 drinate).2 6–8 18 although women do not have any special

genetic protection. Sex diVerences are COSTS http://tobaccocontrol.bmj.com/ probably due to the fact that women are largely Because nearly a quarter of those stricken with under-represented among tobacco croppers.2 GTS who sought medical treatment required Familial clustering of GTS has also been hospitalisation,26 significant hospital expendi- found.1724This may be less a function of genetic tures are associated with the condition. predisposition and more a function of the fact GTS-induced hospital expenses are estimated that in regions where there is little to average US$250 for outpatient treatment, mechanisation, such as on small family farms, $566 for hospital admission, and $2041 for families or groups of individuals must manually intensive care treatment.2 These figures do not harvest the crop under similar conditions, which include costs associated with lost income and in turn may lead to similar exposure patterns. productivity incurred by someone’s inability to Along these lines, GTS is known to recur among work. Because nearly half of Kentucky tobacco those susceptible to the illness.5781113Gehlbach harvesters are employed oV-farm (in work on September 29, 2021 by guest. Protected copyright. and colleagues reported that as many as 12 unrelated to farming),6 financial loss from recurrences over eight weeks have been reported missed work due to GTS is compounded by some workers.13 further. There is a discrepancy in the literature between the susceptibility of tobacco users and RISK REDUCTION non-users. In some studies, GTS was found to Despite the awareness of GTS among some be less likely to occur among those who were clinicians and tobacco workers, very little current tobacco users, perhaps resulting from widespread action has been taken to reduce the an increased tolerance to the eVects of risks associated with harvesting tobacco. If a nicotine.13813 This seemingly acquired worker becomes ill while working with tobacco tolerance, however, may not be completely and requires medical attention, the physician protective if the cropper’s typical nicotine should be informed of the exposure to nicotine exposure is significantly exceeded.235 In to aid in diagnosis, as it is common to misdiag- contrast, a few studies have suggested that nose GTS as pesticide poisoning or heat active smoking oVers no protection against exhaustion. GTS.14 15 One study found that tobacco users The use of protective, water-resistant in India actually had a higher prevalence of clothing and chemical-resistant gloves would “green symptoms” than non-tobacco users.14 reduce the amount of nicotine absorbed by workers in contact with green 23571415172330 DIAGNOSIS AND TREATMENT tobacco. Current occupational Because GTS is self-limiting and of short health regulations do not require this level of duration,1 treatment is not always necessary. protection. It has been suggested that croppers Green tobacco sickness 297 Tob Control: first published as 10.1136/tc.7.3.294 on 1 September 1998. Downloaded from

Green tobacco sickness

Toxic agent Nicotiana tabacum (nicotine) Exposure environment Tobacco workers hand harvesting, cutting, or loading tobacco plants during harvest; usually (but not necessarily) in the early morning or after rainfall when tobacco plants are covered with moisture. Exposure attributes Skin exposure (hands, forearms, thighs, backs, and feet) to dissolved nicotine from wet tobacco leaves. Dew from tobacco leaves often saturates workers’ clothing within minutes of beginning field work. Symptoms Most common: weakness, headache, nausea, vomiting, dizziness Other: abdominal cramps, breathing diYculty, abnormal temperature, pallor, diarrhoea, chills, fluctuations in blood pressure or heart rate, increased perspiration and salivation Illness onset Range of onset 3–17 hours; median onset 10 hours. Duration of illness (untreated) Mean duration of the illness is 2.4 days. Treatment Self: change clothing, showering, work cessation, fluid intake, rest, time Medical facility (if needed): Intravenous rehydration, anti-emetics, dimenhydrinate, supportive care Risk reduction Protective, water-resistant clothing; chemical-resistant gloves, boots, socks; avoid harvesting during rain or in the early morning; change clothing if wet; wash clothes if soaked with tobacco sap; dimenhydrinate (treatment and prophylactic); employee awareness—inform physician about exposure to nicotine. Public health response Educational outreach (timed to coincide with tobacco harvest)—informational mailings, flyers, bulletins, and news stories aimed at tobacco workers and healthcare providers. Economic impact US$250 for outpatient treatment; $566 for hospital admission; $2041 for intensive care. Plus lost income and productivity.

Adapted from McKnight.7 should avoid harvesting in the rain or should nitude of GTS is not well understood. begin harvesting after the dew evaporates.1 Plas- Unfortunately, surveillance systems have been tic aprons and rainsuits, in addition to boots and instituted in only a few states and most socks,15 have been used to reduce exposure to published research on GTS is descriptive stud- nicotine.23 These actions must be weighed ies. Treatment is discussed rarely and the mag- against the increased risk of heat stress caused nitude of GTS has not been assessed in by wearing impermeable clothing in hot suYcient detail. Much of the research cites the weather.15 16 Additionally, dimenhydrinate is same few studies completed many years ago, useful in treating GTS once onset has occurred most of which were conducted in the United and as a prophylactic measure before harvesting States. As the expands tobacco.18 The CDC advises tobacco farm production capabilities to the developing operators to inform their employees of the world, greater numbers of workers will be hazards associated with harvesting wet tobacco exposed to GTS and thus international studies and the importance of safe work practices in of GTS are badly needed. For example, world- 230 preventing GTS, but it is unclear how many wide output of flue-cured tobacco has nearly operators take such action. Mechanisation of tripled over the past 30 years, although the tobacco harvesting will reduce skin contact with American contribution to the world market has wet tobacco leaves and represents a potential dropped nearly 35%.32 method for prevention, although equipment for In addition, there has been no research to http://tobaccocontrol.bmj.com/ mechanical harvesting is not accessible to determine whether repeatedly contracting smaller farm operations. GTS over an extended period of time will increase the risk of cardiovascular disease, can- PUBLIC HEALTH RESPONSE cer, or other diseases. Similarly, the eVects of Very little regulatory eVort has been showering and frequent changes of clothing on undertaken to address the potential hazards of the development of GTS have not been GTS. Currently, there is no legal requirement adequately evaluated. Some workers in India that workers be informed about the hazards of and Kentucky thought that it was impractical 31 nicotine exposure. In Kentucky in 1992, for and uncomfortable to wear the recommended example, an Occupational Health Nurses in protective clothing and thus additional preven- Agricultural Communities study of GTS was tion strategies need to be evaluated. Because undertaken to educate tobacco workers and tobacco workers sometimes call control on September 29, 2021 by guest. Protected copyright. healthcare providers about the dangers centres when experiencing this illness,6 2 inherent in tobacco harvesting. The improved surveillance through these centres is educational eVort included targeted informa- needed. Part of the problem stems from the tional mailings and news stories in the local fact that treatment costs for GTS may be a sig- media, coinciding with the tobacco harvest. nificant barrier for poorer workers, especially Following a public awareness campaign, the those without insurance. Ballard and 1993 incidence of hospital-treated GTS colleagues point out that the number of increased from the previous year, probably due migrant and foreign workers harvesting to the heightened awareness about GTS on the tobacco in the United States is increasing.3 part of tobacco workers and healthcare provid- Because most of the recent research has ers. This study suggests that in the absence of focused on reports from hospital-treated an educational intervention, the magnitude of cases,324 GTS incidence is likely to be GTS may not be fully recognised. underestimated. Furthermore, one study found that even though people may be aware of Conclusions a treatment center’s existence, they may not be The table summarises what is currently known aware of the services that the centre provides.17 about GTS. The toxic agent, exposure As a result, those most in need are unable to environment, exposure attributes, symptoms, obtain treatment. illness onset, duration of illness, treatment, risk Considering that tobacco is grown in more reduction, potential public health responses, than 100 countries and 25 producers account and economic impact are identified. The mag- for 90% of global production,33 an international 298 McBride, Altman, Klein, et al Tob Control: first published as 10.1136/tc.7.3.294 on 1 September 1998. Downloaded from

public awareness campaign on GTS should be 14 Ghosh S, Saiyed HN, Gokani VN, et al. Occupational health problems among workers handling Virginia tobacco. Int undertaken, and more aggressive worker protec- Arch Environ Health 1986;58:47–52. tion regulations should be promulgated. Health- 15 Ghosh S, Gokani VN, Parikh JR, et al. Protection against “green symptoms” from tobacco in Indian harvesters: a care providers in tobacco-growing regions preliminary intervention study. Arch Environ Health 1987; should document in medical records whether or 42:121–3. 16 Ghosh S, Gokani VN, Doctor PB, et al. Intervention against not moisture was present while workers were “green symptoms” among Indian tobacco harvesters. Arch handling tobacco, the number of hours worked Environ Health 1991;46:316–17. 17 McKnight RH, Dawson SK, Westneat SC, et al. Delay before symptom onset, and the specific ways in among the general public in telephoning a poison center. which tobacco was handled.6 The challenge for Vet Hum Toxicol 1996;38:92–5. 18 Ives TJ. Use of dimenhydrinate in the treatment of green public health professionals is to ensure that as tobacco sickness. Drug Intelligence Clin Pharm 1983; market forces and tobacco company practices 17:548–9. change the landscape of tobacco production, we 19 Grise VN. US tobacco farming trends. Tobacco situation and outlook (US Department of Agriculture) 1995;TBS- monitor, and reduce, the largely hidden 230(Dec):34–7. problem of GTS. 20 Chaplin JF, Miner GS, Production factors aVecting chemi- cal components of the tobacco leaf. Recent Adv Tobacco Sci 1980;6:3–63. This report was supported by grant NIH RO1 CA67838-02 21 Tso TC. Production, physiology, and biochemistry of the tobacco from the National Cancer Institute. plant. Beltsville, : Ideals, 1990. 22 Burton HR, Dye NK, Bush LP. Relationship between tobacco-specific nitrosamines and nitrate from diVerent 1 Gehlbach SH, Williams WA, Perry LD, et al. Green-tobacco air-cured tobacco varieties. J Agric Food Chem 1994; sickness: an illness of tobacco harvesters. JAMA 1974; 42:2007–11. 229:1880–3. 23 Gehlbach SH, Williams WA, Freeman JI. Protective 2 Boylan, BB, Brandt V, Muehlbauer J, et al. Green tobacco clothing as a means of reducing nicotine absorption in sickness in tobacco harvesters—Kentucky, 1992. MMWR tobacco harvesters. Arch Environ Health 1979;34:111–14. 1993;42:237–40. 24 McKnight RH, Kryscio RJ, Mays JR, et al. Spatial and tem- 3 Ballard T, Ehlers J, Freund E, et al. Green tobacco sickness: poral clustering of an occupational poisoning: the example occupational nicotine poisoning in tobacco workers. Arch of green tobacco sickness. Stat Med 1996;15:747–57. Environ Health 1995;50:384–9. 4 Edmonson WD, Smith BD, Morgan HJ. Green tobacco 25 Sosnowski T. Baling. Tobacco Int 1997;Oct:56–8. sickness ( in a young farmer). J Tenn Med Assoc 26 Goldfrank L, Melinek M, Blum A. Nicotine. Hosp Phys 1996;89:85–6. 1980;1:22–35. 5 Ghosh SK, Parikh JR, Gokani VN, et al. Studies on occupa- 27 Faulkner JM. Nicotine poisoning by absorption through the tional health problems during agricultural operation of skin. JAMA 1933;100:1664–5. Indian tobacco workers. J Occup Med 1979;21:45–7. 28 Svenson CK. Clinical pharmacokinetics of nicotine. Clin 6 McKnight R, Levine EJ, Rodgers GC. Detection of green Pharmacokinet 1987;12:30–40. tobacco sickness by a regional . Ve t 29 Taylor P. Agents acting at the and Hum Toxicol 1994;36:505–10. autonomic ganglia. In: Hardman JG, Gilman AG, Limbird 7 McKnight RH, Koetke CA, Donnelly C. Familial clusters of LE, eds. Goodman & Gilman’s the pharmacological basis of green tobacco sickness. J Agromed 1996;3:51–9. therapeutics. New York: McGraw-Hill, 1996. 8 Hipke M. Green tobacco sickness. Southern Med J 30 US Department of Health and Human Services. NIOSH 1993;86:989–92. issues warning to tobacco harvesters. Atlanta, Georgia: Cent- 9 Geiger B. Tobacco a winner in health care reform. Philadel- ers for Disease Control and Prevention, National Institute phia Inquirer 1994 Aug 19:A2. for Occupational Safety and Health, 1993. 10 Williams B. Brazil: the new tobacco capital. Winston-Salem 31 OYce of the Federal Register, Code of Federal Regulations. (North Carolina) J 1995 Apr 17:B1. Occupational safety and health administration standards. 11 Weizenrecker R, Deal WB. Tobacco cropper’s sickness. JFla Washington, DC: OYce of the Federal Register, National Med Assoc 1970;57:13–14. Archives and Records Administration, 1992. http://tobaccocontrol.bmj.com/ 12 Misumi J, Koyama W, Miura H. Two cases of “green 32 Obermayer JB. In support of tobacco: quotas and price sup- tobacco sickness” in the tobacco harvesters and the ports perpetuate an arcane system that has vanished for absorption of nicotine through the skin in the rat. Jpn J other crops. Raleigh (North Carolina) News and Observer Indust Health 1983;25:3–9. 1996;Jun 23:1F. 13 Gehlbach SH, Williams WA, Perry LD, et al. Nicotine 33 World Health Organisation. Tobacco or health: a global status absorption by workers harvesting green tobacco. Lancet report. Geneva, Switzerland: World Health Organisation, 1975;i:478–80. 1997. on September 29, 2021 by guest. Protected copyright.