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Green Tobacco Sickness

Green tobacco sickness (GTS) is a condition that affects people who handle tobacco leaves. It is caused by nicotine toxicity, when it is absorbed through the skin.


Presentation

When workers harvest tobacco without the necessary protective clothing, they are subjected to nicotine poisoning, and thus suffer from green tobacco sickness (GTS). It typically manifests as vomiting, headache, and dizziness. Further symptoms such as abdominal discomfort may occur [1]. The onset of the illness is from a few hours to a few days after exposure to tobacco and may be self -limiting [2] [3]. It is estimated that in one tobacco season, as many as a one in four workers experience GTS [4].

There are several factors that are associated with an increased risk of GTS. The first is the time that a worker has spent handling tobacco. Compared to experienced handlers, inexperienced handlers are more susceptible, as nicotine tolerance is built with prolonged exposure. Secondly, it has also been found that children are particularly predisposed to GTS for several reasons. Children often have no knowledge of the harmful effects of direct contact with tobacco leaves, and hence may not exercise caution. Furthermore, children have a higher body surface area to weight ratio, thus amplifying the effective dose delivered. It is further postulated that adult workers who smoke tobacco for years acquire a tolerance towards nicotine [5]. Children are unlikely to have this advantage. Further investigations have shown that the younger the workers are, the greater their likelihood of developing GTS, and that both children and young adults are more easily affected by exogenous substances adversely [6] [7]. In addition, water causes the delivery of nicotine to the skin to become more efficient. As a result, rain, sweat and other sources of moisture further intensify the risk [8].

An important aspect of GTS is that it induces a significant amount of vomiting that may lead to dehydration. Dehydration in turn, along with elevated body temperature, if severe enough, may contribute to the emergence of heat exhaustion and heat stroke. These illnesses require medical intervention, and heat stroke has potentially fatal repercussions. Along with pre-existing signs of GTS, symptoms indicative of a heat illness, such as seizures, confusion, diaphoresis and syncope may follow.

Outdoor Worker
  • For more information on heat illness, please visit the Occupational Safety and Health Administration’s (OSHA’s) Campaign to Prevent Heat Illness in Outdoor Workers at .[osha.gov]
Fishing
  • Recommendations specific to agricultural work are available through a NIOSH website focused on the Agriculture, Forestry and Fishing Sectors (www.cdc.gov/niosh/agforfish).[osha.gov]
Persistent Vomiting
  • All 13 workers experienced worsening and persistent vomiting, headache, dizziness, and weakness throughout the evening.[ncbi.nlm.nih.gov]
Skin Lesion
Diplopia
  • A 25-year-old man who worked in a tobacco field for 14 hours with no protective measures experienced symptoms of GTS, and additionally, diplopia, after leaving the field. Upon hospital admission, diplopia was no longer observed.[ncbi.nlm.nih.gov]
  • Interestingly, diplopia at the initial stage of tobacco poisoning and horizontal nystagmus, which resolved on the 2nd day of hospital stay were observed. We believe that cases of GTS occur in Poland; however patients do not seek medical care.[ncbi.nlm.nih.gov]
Diplopia
  • A 25-year-old man who worked in a tobacco field for 14 hours with no protective measures experienced symptoms of GTS, and additionally, diplopia, after leaving the field. Upon hospital admission, diplopia was no longer observed.[ncbi.nlm.nih.gov]
  • Interestingly, diplopia at the initial stage of tobacco poisoning and horizontal nystagmus, which resolved on the 2nd day of hospital stay were observed. We believe that cases of GTS occur in Poland; however patients do not seek medical care.[ncbi.nlm.nih.gov]
Lacrimation
  • However, many of the symptoms of organosphosphate poisoning (including increased lacrimation, pulmonary oedema, and miosis) have not been associated with GTS. 8 The possibility that GTS symptoms are due to pesticide poisoning is lessened because the last[tobaccocontrol.bmj.com]
Seizure
  • Along with pre-existing signs of GTS, symptoms indicative of a heat illness, such as seizures, confusion, diaphoresis and syncope may follow.[symptoma.com]
  • A seizure in the tobacco field: green tobacco sickness. NC Med J. 2000; 61 :390–2. [ PubMed ] [ Google Scholar ][ncbi.nlm.nih.gov]
  • Severe poisonings can lead to seizures and respiratory depression. 2 Death may occur through respiratory failure. 1 Although highly toxic, death due to ingested tobacco is extremely rare due to the unpleasant flavour of tobacco, the vomit response and[tobaccoinaustralia.org.au]
  • Symptoms of Heat Exhaustion Headache, dizziness, or fainting Weakness and wet skin Irritability or confusion Thirst, nausea, or vomiting Symptoms of Heat Stroke May be confused, unable to think clearly, pass out, collapse, or have seizures (fits) Increased[osha.gov]
  • In its acute forms, Green Tobacco Sickness can cause seizures, vomiting and difficulty breathing.[inverse.com]

Workup

There are no set criteria for diagnosing green tobacco sickness, nor are there laboratory tests to aid the health worker. Moreover, the correct identification of GTS may be challenging due to its symptoms, that often mimic those of poisoning from synthetic substances used in pest control, as well as heat exhaustion and heat stroke. Inquiry about occupational history, specifically tobacco harvesting or handling, is thus imperative. It is also beneficial to ascertain the onset and duration of symptoms, as GTS has an acute presentation.

Treatment

  • Antinausea medications were the most common treatments. Only 9% sought medical treatment; 7% lost work time.[ncbi.nlm.nih.gov]
  • GTS resembles pesticide poisoning, but treatment is quite different. Many farmworkers in tobacco today are Spanish-speaking immigrants from Mexico with limited experience in tobacco work.[ncbi.nlm.nih.gov]
  • Dimenhydrinate is a useful over-the-counter product for the treatment of this occupational illness in the tobacco-growing states of the Southeast.[ncbi.nlm.nih.gov]
  • In 1992, 47 persons (3 were under age 16 y) in the study region sought medical treatment for green tobacco sickness. Twelve persons were hospitalized and 2 required intensive-care treatment.[ncbi.nlm.nih.gov]
  • The need for medical treatment was also discounted. Addressing each of these beliefs is important in any program to prevent GTS among farmworkers.[ncbi.nlm.nih.gov]

Etiology

  • A brief discussion of the etiology and symptomatology of GTS is included. Dimenhydrinate is a useful over-the-counter product for the treatment of this occupational illness in the tobacco-growing states of the Southeast.[ncbi.nlm.nih.gov]
  • We use qualitative methods structured by the Explanatory Models of Illness approach to identify farmer beliefs about the etiology, onset, pathophysiology, course, and treatment of GTS.[ncbi.nlm.nih.gov]
  • In this article, we provide an overview of GTS among young people who work in tobacco, summarize reports documenting pediatric GTS cases, explain GTS etiology, and present three case studies of pediatric GTS in Kentucky.[ncbi.nlm.nih.gov]

Epidemiology

  • University, Korea. wisewine@dongguk.ac.kr Abstract PURPOSE: This study was carried out to investigate the epidemiological characteristics and changes of prevalence for green tobacco sickness (GTS) for 2 years.[e-epih.org]
  • Epidemiological and laboratory data indicate for the first time the occurrence of green tobacco sickness in Brazil.[ncbi.nlm.nih.gov]
  • Abstract This study describes epidemiological patterns of Green Tobacco Sickness (GTS) reported to a regional poison center July 24 through September 24, 1991, and investigates the feasibility of using such a center to expand the understanding of GTS.[ncbi.nlm.nih.gov]
  • STUDY OBJECTIVE: The characteristics of some populations make epidemiological measurement extremely difficult.[ncbi.nlm.nih.gov]
  • Jounal Epidemiology Community Health, 2001; 55:818–824. Suprapto, S. dan Julianty Pradono. Faktor Risiko Green Tobacco Sickness (GTS) pada Petani Pemetik Daun Tembakau di Desa Bansari, Kabupaten Temanggung. Jawa Tengah.[jurnal.ugm.ac.id]
Sex distribution
Age distribution

Pathophysiology

  • We use qualitative methods structured by the Explanatory Models of Illness approach to identify farmer beliefs about the etiology, onset, pathophysiology, course, and treatment of GTS.[ncbi.nlm.nih.gov]

Prevention

  • Little is known about preventing GTS. This analysis examines possible GTS preventive measures. METHODS: Data were collected from 36 patients with GTS and 40 controls who presented at clinics in eastern North Carolina in 1999 and 2000.[ncbi.nlm.nih.gov]
  • If health care providers understand the explanatory model held by farmworkers, they will be more effective at diagnosing and treating GTS and be better prepared to teach patients how to prevent future episodes.[ncbi.nlm.nih.gov]
  • MSF constitute a population at risk for GTS who have little control over work conditions to prevent GTS or seek treatment. Copyright 2000 Wiley-Liss, Inc.[ncbi.nlm.nih.gov]
  • OBJECTIVE: To describe the health impact of harvesting tobacco and to suggest prevention and risk reduction strategies to avoid contracting green tobacco sickness (GTS).[ncbi.nlm.nih.gov]
  • Addressing each of these beliefs is important in any program to prevent GTS among farmworkers.[ncbi.nlm.nih.gov]

References

Article

  1. Gehlbach SH, Williams WA, Perry LD, Woodall JS. Green tobacco sickness: an illness of tobacco harvesters. JAMA 1974;229(14):1880-1883.
  2. Arcury TA, Vallejos QM, Schulz MR, et al. Green tobacco sickness and skin integrity among migrant Latino farmworkers. Am J Ind Med. 2008;51(3):195–203.
  3. Schmitt NM, Schmitt J, Kouimintzis DJ, Kirch W. Health risks in tobacco farm workers: a review of the literature. J Public Health. 2007;15(4):255–264.
  4. Quandt SA, Arcury TA, Preisser JS, Bernert JT, Norton D. Environmental and behavioral predictors of salivary cotinine in Latino tobacco workers. J Occup Environ Med. 2001;43(10):844-852.
  5. Onuki M, Yokoyama K, Kimura K, et al. Assessment of urinary cotinine as a marker of nicotine absorption from tobacco leaves: a study on tobacco farmers in Malaysia. J Occup Health. 2003;45(3):140–145.
  6. Weaver VM, Buckley TJ, Groopman JD. Approaches to environmental exposure assessment in children. Environ Health Perspect. 1998;106(Suppl 3):827-832.
  7. Landrigan PJ, Kimmel CA, Correa A, Eskenazi B. Children’s health and the environment: public health issues and challenges for risk assessment. Environ Health Perspect. 2004;112(2):257-265.

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Last updated: 2019-06-28 10:42