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Green Tobacco Sickness 294 Tobacco 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 nicotine prevention and risk reduction strategies to poisoning 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, breathing diYculty, abnormal technology, growing techniques, seeds, fertilis- temperature, pallor, 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 perspiration 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 (Tobacco Control 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 smoking 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 pesticide poisoning 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 cotinine (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.
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