Signs and Symptoms

• Onset varies between 15 minutes and 10 hours.
• The general symptoms are dizziness, generalized weakness, and prostration.
• GI symptoms include severe nausea, vomiting, and abdominal pain.
• CV symptoms: bradycardia/tachycardia and hypertension/hypotension
• Neurologic: headache, tremor, and seizure
• Somatic: muscular cramping, fasciculations, weakness, and respiratory muscle weakness

Treatment

• Primary goal is separating the patient from the exposure—removal of clothes that have been exposed or are wet, copious washing of the victim’s skin is critical to stop continued exposure.
• Anti-emetic and hydration as needed for fluid losses; benzodiazepines can be used for persistent vomiting and for comfort.
• Green tobacco sickness is usually a self-limiting condition—recovery occurs in one to three days.
• Prevention is paramount and consists of gloves, long sleeves, water-impermeable clothing, along with the ability and opportunity to wash skin with soap and water during work if contaminated with tobacco sap or dew.³
• Although not recommended, many tobacco workers self-treat by starting to smoke or chew tobacco to build a nicotine tolerance.

Tobacco Leaf Use Primer

Selected forms of tobacco—cigars, which are rolls of cured tobacco wrapped in tobacco leaf or paper that contain tobacco or tobacco extract, and cigarettes, which are uniform in size and usually contain less than one gram of tobacco each. U.S. cigarettes are made from different blends of unfermented tobaccos and wrapped with paper; chewing tobacco comes from loose leaves and is sold in various forms: pellets /“bits,” plugs (tobacco leaf pressed with a sweetener, usually licorice), twists (leaf tobacco rolled and twisted), and chaw—shredded and chewed leaf. These are placed in the mouth, usually between the cheek and lower lip, and may be chewed. Snuff is toasted and powdered for inhalation.¹⁰

Other Uses

• In various cultures, tobacco leaves (or their extracts) are used medicinally for bronchitis, tonsillitis, toothaches, wounds, sore throat, stomach infections, and arthritis.¹⁴
• Nicotine is used as a pesticide in many places in the world (in the United States, one product no longer available was Black Leaf 40).
• Blowing tobacco smoke up the rectum of a drowned person was a resuscitative technique widely used in the 1700s with variable success.^1,6 This is no longer recommended.

Dr. Hack is chief of the division of medical toxicology and vice chair for research at East Carolina University in Greenville, North Carolina.

References

1. Bamji A. Blowing smoke up your arse: drowning, resuscitation, and public health in eighteenth-century Venice. Bull Hist Med. 2020;94(1):29-63.
2. Gehlbach SH, Williams WA, Perry LD, et al. Nicotine absorption by workers harvesting green tobacco. Lancet. 1975;1:478-480.
3. Occupational Safety and Health Administration. Green Tobacco Sickness. Accessed September 15, 2024.
4. Jassbi AR, Zare S, Asadollahi M, et al. Ecological roles and biological activities of specialized metabolites from the genus Nicotiana. Chem Rev. 2017;117(19):12227–12280.
5. Koob GF, Arends MA, Le Moal M. Drugs, Addiction, and the Brain. Waltham, Mass.:Elsevier;2014.
6. Lawrence G. Tobacco smoke enemas. Lancet. 2002;359(9315):1442.
7. McBride JS, Altman DG, Klein M, et al. Green tobacco sickness. Tob Control. 1998;7(3):294-298.
8. McKnight RH, Spiller HA. Green Tobacco Sickness in Children and Adolescents. Public Health Rep. 2005;120(6):602-605.
9. Mishra S, Mishra MB. Tobacco: its historical, cultural, oral, and periodontal health association. J Int Soc Prev Community Dent. 2013;3(1):12-18.
10. National Cancer Institute. NCI Dictionary of Cancer Terms: chewing tobacco [ND]. Accessed September 15, 2024.
11. Popova V, Ivanova T, Stoyanova A, et al. GC-MS composition and olfactory profile of concretes from the flowers of four Nicotiana species. Molecules. 2020;25(11):2617.
12. Shahbandeh M. Statista. Global tobacco production 1990-2022. Published February 13, 2024. Accessed September 15, 2024.
13. National Archives. Founders Online: From George Washington to Robert Cary and Company, 20 September. Published September 20, 1765. Accessed September 15, 2024.
14. Zou X, Bk A, Abu-Izneid T, et al. Current advances of functional phytochemicals in Nicotiana plant and related potential value of tobacco processing waste: a review. Biomed Pharmacother. 2021;143:112191.

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