Tobacco Skin Green Tobacco Sickness

Introduction – epidemiology

Green tobacco sickness (GTS) is acute nicotine poisoning due to the transdermal absorption of nicotine [Quandt et al., 2001; Arcury et al., 2003]. Transdermal nicotine absorption occurs through contact with the green tobacco plant during planting, cultivating, harvesting and curing [Arcury and Quandt, 2006]. In a recent study by Arcury and colleauges at Wake Forest University, the incidence density for GTS was estimated to be 1.88 days for every 100 days of exposure, and that the prevalence for the agricultural season was 24.2%.

UCONN studied GTS within the shade tobacco workers and found while flu like symptoms were prevalent amongst workers, GTS diagnosis was inconclusive [Trape et al. Shade tobacco and green tobacco sickness in Connecticut. J Occup Environ Med. 2003 Jun;45(6):656-61.].

The following table shows the incidence of other GTS-related symptoms found in the study cohort:

Characteristics of GTS

• Usually occurs in the afternoon or evening (several hours after exposure).
• Either stimulate or desensitize receptors in the autonomic ganglia and peripheral nerve endings, causing nausea, vomiting, and variable effects on blood pressure and heart rate.
• Increases release of epinephrine by the adrenal gland, causing increased blood pressure and heart rate.
• Acts directly on brain causing generalized stimulation, tremor, and activation of emetic hemoreceptor trigger zone, causing vomiting.
• Generally, GTS is diagnosed if a patient is experiencing nausea or vomiting, AND headache or dizziness, and has worked in tobacco that day or the previous day.
• Other symptoms may include abdominal cramps, headache, prostration, difficulty breathing, abdominal pain, diarrhea, and fluctuations in blood pressure or heart rate.
• GTS is normally self-limiting, but a case may be severe enough to result in dehydration. Emergency medical care may be needed.
• Season time: There is a 10.9% chance of a worker having GTS in the late season versus a 3.6% chance in the early season.
• Clothing protection: Wearing rubberized nylon rain suits effectively prevents nicotine absorption in tobacco workers, although they are hot and uncomfortable.
• Glove protection: Use of rubber gloves provides protection against nicotine absorption among 93% of tobacco workers, while cotton gloves protect 78.5% of tobacco workers. Rubber gloves are less comfortable but more durable than cotton gloves.
• Working in wet clothes: The chance of having GTS for those wearing wet clothes over 25% of the time is twice as high as it is for those wearing wet clothes less than 25% of the time.
• Smoking: Nicotine from non-skin sources such as smoking may reduce trans-dermal nicotine adsorption by regulating vasodilation.

Over half of tobacco workers report taking no precautions to prevent GTS.

• 96.4% of those who reported GTS took one or more actions to treat the symptoms.
• Typical treatments used by farmworkers are shown to the right.
• The most common prevention methods include smoking, wearing protective gloves/clothing, changing out of wet clothing, drinking lemon juice, and various herbal remedies. Although smoking appears to lower the number of GTS cases, it’s inadvisable because of a greater health risk associated with tobacco use.

GTS protection and treatment methods for tobacco farmworkers:

• If possible, avoid handling wet tobacco.
• Plastic or rubber protective aprons or rain suits will reduce dermal nicotine absorption, but watch for signs of heat stress.
• Chemical resistant gloves, such as those recommended for pesticide mixing, will protect workers’ hands from nicotine absorption. See glove pictures below.
• Changing into dry clothes after a worker’s clothing becomes completely wet with moisture from the tobacco plants will help reduce nicotine absorption.
• Over-the-counter medicines may help treat symptoms of GTS, but they should only be taken while not working because their side effects may be dangerous in the workplace.
• Cleansing the skin with cold water (hot water may hasten the absorption of nicotine) to remove tobacco sap may help alleviate symptoms.

• Generally, medication is prescribed that alleviates nausea and vomiting (anti emetics).
• Prochlorperazine or dimenhydrinate had previously been recommended for fast relief, but it has been more recently inferred that GTS is due to nicotinic stimulation of ganglionic cholinergic receptors. Therefore, the antihistamine dimenhydrinate (producing anticholinergic effects) or oral diphenhydramine have been thought to be effective in alleviating symptoms.