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ORIGINAL ARTICLE
Epidemiologic investigation of an occupational illness
of tobacco harvesters in southern Brazil, a worldwide
leader in tobacco production
Patrı´cia Bartholomay,1 Betine Pinto Moehlecke Iser,1
Patrı´cia Pereira Vasconcelos de Oliveira,1,2 Tania Esther Herc Holmer dos Santos,3
Deborah Carvalho Malta,2 Jeremy Sobel,4 Lenildo de Moura1,2
ABSTRACT
Objectives As part of smoking surveillance, the authors
conducted an epidemiologic investigation in southern
Brazil to identify the occurrence of Green Tobacco
Sickness and risk factors for illness and to recommend
control and prevention measures.
Methods A 1:2 caseecontrol study matched by
subjects’ smoking habits. The study population was
residents of Candela´ria, Rio Grande do Sul state, who
farm tobacco and provided a urine sample for cotinine
measurement by high-performance liquid
chromatography. Confirmed cases were persons
with compatible clinical presentation (headache,
nausea, vomit, dizziness or weakness) and cotinine
level >10 ng/ml. Controls were persons without
compatible signs or symptoms. The association measure
was the matched OR with 95% CIs and p<0.05.
Results Of 33 confirmed cases, 64% were men, average
age was 33 years (SD 611.8 years) and 57% were
landowners. Cases have had similar illness in the past
and were likelier to be workers hired by
farmerselandowners than controls. Multivariate analysis
yielded independent association between these variables
and illness, controlled for age and sex. Contact with
pesticides and working with wet tobacco leaves were
not associated with illness.
Conclusions The authors confirmed Green Tobacco
Sickness in southern Brazil; the authors recommend
investigation of its prevalence in tobacco-growing
regions and monitoring of and education about the
disease and its prevention by occupational health
authorities.
INTRODUCTION
Green Tobacco Sickness (GTS), an occupational
illness of tobacco harvesters, is an acute moderate
intoxication caused by dermal absorption of nico-
tine. Its principal signs and symptoms are head-
ache, nausea, vomiting, abdominal cramps,
dizziness and weakness.1 In some cases, the
condition presents more severe manifestations,
requiring more protracted medical attention and
hospitalisation.2 3
Published studies describe contact with moist
tobacco leaves and failure to use personal protective
equipment (PPE) during the harvest as risk factors
for illness.3e6 Other factors such as contact
between the tobacco plant and more absorptive
body surfaces (forehead, back and axilae),
consumption of alcoholic beverages and heat
exposure at the time of harvest are considered
facilitators of nicotine absorption.5 High levels of
nicotine in smokers have been described in the
literature as protective.
Diagnosis of GTS rests of the following triad:
occurrence of compatible signs and symptoms,
exposure to tobacco farming and elevated nicotine
levels demonstrated by cotinine level measurement.
The differential diagnosis includes pesticide intox-
ication and heat exhaustion. Cotinine is a nicotine
metabolite found in urine, blood and saliva that
serves as a useful marker for nicotine exposure
because its half-life (20 h) is longer than that of
nicotine (2 h).7
GTS was first described in the medical literature
in the 1970s in the USA and later in other coun-
tries, including India and Malaysia.3 8 There has
been no confirmed occurrence of GTS in Brazil,
although it is the largest tobacco grower in the
world, responsible for 13% of world production.9 10
To strengthen disease surveillance and imple-
mentation of the Framework Convention on
Tobacco Control in Brazil,11 the Brazilian Ministry
1Field Epidemiology Training
Program EPISUS, Health
Surveillance Secretariat,
Ministry of Health - Brazil,
Brasilia, Distrito Federal, Brazil
2Non-communicable Diseases
Coordination, Health
Surveillance Secretariat,
Ministry of Health - Brazil,
Brası´lia, Distrito Federal, Brazil
3Non-communicable Diseases
Coordination, State Center for
Health Surveillance, State
Health Secretariat, Porto Alegre,
Rio Grande do Sul, Brazil
4Center for Global Health
Center, Centers for Disease
Control and Prevention - CDC,
Atlanta, Georgia, USA
Correspondence to
Patrı´cia Bartholomay, Health
Surveillance Secretariat,
Ministry of Health - Brazil, Setor
Comercial Sul, Quadra 4, Bloco
A, Edifı´cio Principal, 1 andar,
CEP:70304-000, Brasilia, Distrito
Federal 70304000, Brazil;
patricia.bartholomay@saude.
gov.br
Accepted 10 March 2012
Published Online First
26 April 2012
What this paper adds
GTS was first described in the medical literature in
the 1970s in the USA Until 2007, there has been no
confirmed occurrence of GTS in Brazil, although it is
the largest tobacco grower in the world. To
strengthen disease surveillance, the Brazilian
Ministry of Health conducted epidemiologic inves-
tigations with the purpose of identifying the
occurrence of this disease in two tobacco-farming
regions, each with a distinct mode of farming. Our
investigation took place in one county in southern
Brazil, in the region in which 96% of tobacco
production in Brazil took place. We confirmed the
occurrence of GTS and identified several risk
factors, demonstrating it is an occupational condi-
tion among tobacco farmers of this region. We
recommend studies of its prevalence in tobacco-
growing regions and monitoring and education
about the disease and its prevention by occupa-
tional health authorities.
514 Occup Environ Med 2012;69:514e518. doi:10.1136/oemed-2011-100307
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of Health conducted epidemiologic studies with the purpose of
identifying the occurrence of this disease in two tobacco-
farming regions, each with a distinct mode of farming. The first
investigation took place in northeastern Brazil, in the township
of Arapiraca, where tobacco has reportedly been grown since the
end of the 19th century.12
Our epidemiologic investigation took place in one county in
southern Brazil, in the region in which 96% of tobacco
production in Brazil takes place. The objective was to confirm
the occurrence of GTS, identify risk factors for illness and
recommend control and prevention measures.
METHODS
The investigation county was selected because it is located in
Rio Grande do Sul state, the principle tobacco-producing part of
Brazil, where harvest time coincided with the convenience of the
investigators and the ready availability of healthcare to resi-
dents.
To identify potential risk factors for illness to be included in
the investigation, we observed the tobacco production process in
situ. We conducted a 1:2 matched caseecontrol study of
potential risk factors during the period 17 November to 31
December 2009; this period included the local tobacco harvest.
Cases and controls were matched based on smoking status, to
control for the impact of smoking on the occurrence of GTS;
smoking is known to reduce GTS signs and symptoms,13 and
nicotine-induced vasoconstriction in smokers reduces dermal
nicotine absorption.3 A smoker was defined as a person who
reported smoking, regardless of the number of cigarettes smoked
daily.
Persons eligible to participate in the investigation were resi-
dents of the county of Candelária, who had worked in tobacco
farming in the 7 days preceding the interview. A suspect case
was defined as an individual presented with symptoms of acute
intoxication (headache, nausea, vomiting, dizziness or weak-
ness) in the 48 h preceding collection of a urine specimen. A
confirmed case was defined as a suspect case with a urinary
cotinine level >10 ng/ml. Controls were persons who presented
no signs or symptoms of acute intoxication (headache, nausea,
vomiting, dizziness or weakness) during the 7 days preceding
interview.
Case finding wasconducted with the support of the local
health services: three family health teams, one basic health unit,
one hospital and a team of community health agents. Addi-
tionally, we advertised the investigation during the Rural
Workers’ Unions radio program’s broadcast on local AM and FM
radio stations. Their main audience is farmers residing in the
county. For convenience, controls were systematically sought in
homes to the left and then to the right of case homes. When
more than one eligible potential control was identified in
a household, they were listed by alphabetical order, and the
control was selected using a random numbers table. Homes
without occupant present at the time of the team visit were
substituted.
Data were collected using a standardised questionnaire about
socioeconomic, individual and clinical characteristics, as well as
questions on tobacco and pesticide exposure. The questionnaire
was completed by the interviewer.
Association between biologically plausible exposures and
illness was subjected to univariate analysis, and those exposures
found to be statistically significantly associated with illness were
assessed for independence by conditional logistic regression
models. Data analysis was conducted in Epi-info 3.5.1. We
used the McNemar c2 test for categorical variables and the
KruskaleWallis test for continuous variables in non-matched
analyses. We calculated matched ORs and 95% CIs; p<0.05 was
considered statistically significant.
Urine samples from suspect cases and controls were tested for
cotinine by high-performance liquid chromatography, with
ultraviolet detector. The alkaline urine was extracted with an
dichloromethane.7 Cut-off levels were <20 ng/ml for non-
smokers and $20 ng/ml for smokers, as established by the
testing laboratory (Laboratório de Toxicologia da Pontifícia
Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil).
The lower limit of quantitative determination for the assay was
10 ng/ml and the lower limit of detection was 5 ng/ml.
The Ministry of Health determined in advance that the
proposed investigational activities fell within the scope of
normal measures of disease monitoring and response to an
urgent health event and that therefore they did not constitute
human subject research requiring National Ethics Committee
oversight. Verbal consent was obtained from all subjects as
a condition of enrolment. Confidentiality of personal data was
assured under Brazilian law, CNS Decree 196/96.
RESULTS
The investigation was conducted in the county of Candelária
(population 29 444), Rio Grande do Sul state.14 It is the fourth
most significant tobacco-producing county in the state; 7500
hectares are planted annually, yielding approximately 15 000
tons of tobacco each year. Production takes place in small plots
owned and farmed by w4000 families, which represent 54% of
the county’s population. Candelária and 18 other counties
produce 60% of the tobacco grown in the state of Rio Grande
do Sul.10
The harvest phase lasts about 4 months and entails the
greatest exposures of farmers to tobacco leaves through the
breaking of the leaves at harvest, carrying them in bundles to
storage and preparing leaves for drying in ovens. All persons
who met the study case and control definitions completed the
questionnaire and provided urine samples.
Forty-six persons met the suspect case definition, of which 33
(71.7%) were confirmed by cotinine-level test results. Of
confirmed cases, 17 (51.5%) were men, average age was 33 (SD
611.8 years), 25 (75.8%) were white complexion/race, six
(18.2%) mixed race and two (6.1%) black. Education level ranged
from 0 to 11 years (median, four). Twelve (36.4%) were smokers,
19 (57.6%) never-smokers and two (6.0%) were ex-smokers, for
at least 1 year (table 1). Of the 21 non-smokers and ex-smokers,
13 (61.9%) reported residing or working with a smoker, thus
being passive smokers.15 Regarding alcohol intake, 14 (42.4%)
reported alcoholic beverage consumptions, of which nine
(64.3%) reported consumption of alcohol at least once per week
(table 1).
The principal occupation of 81.8% of all subjects was farming,
with 57.6% being hired by a landowner, that is, they farmed
tobacco on land owned by someone else (table 1). The distri-
bution of cases was homogenous by workplace within the rural
tobacco-farming zone of the county. Rural county areas without
cases were those where rice was grown (figure 1).
Principal signs and symptoms among cases were nausea
(93.9%), dizziness and vomiting (72.7%), headache (66.7%),
abdominal cramps (57.6%), weakness (54.5%), tremor (18.1%)
and diarrhoea (12.1%). The median duration of signs and
symptoms was 21 h (range: 3e80 h). Of 24 persons who sought
medical treatment, two (8.3%) required observation for 24 h and
four (17.7%) required observation for up to 4 h.
Occup Environ Med 2012;69:514e518. doi:10.1136/oemed-2011-100307 515
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Of the 33 cases, 20 (60.6%) reported working with wet
tobacco and 24 (72.7%) reported that their clothes became wet
from dew, rain or sweat. Rainfall was low during the investi-
gation period, with rain on 4 days of the investigation period.
During the harvest, 97.0% of cases engaged in breaking
tobacco leaves, 33.3% stitched the collected leaves, 24.2% carried
bundled leaves and 15.1% stored leaves in ovens. Most (93.9%)
cases reported no contact with pesticides during the 7 days
before they experienced onset of symptoms of acute intoxica-
tion. Among the 28 cases who knew the date of the last appli-
cation of pesticides to the crops on which they worked, 78.6%
reported that pesticides had been applied more than 96 h before
the onset of signs and symptoms of illness.
Clothing most commonly used by confirmed cases included
flip-flop sandals (57.6%), long trousers (54.5%), long shirt
(63.6%) and hat (100.0%). Using cotton gloves was reported by
48.5% of cases. No farmer reported using PPE.
Acute intoxication in previous years was reported by 69.7% of
cases, 56.5% reported illness every year in which they were
engaged in tobacco farming and 95.6% reported experiencing the
illness during the harvest.
In the caseecontrol study, 66 controls were matched to cases.
On univariate analysis, cases were likelier than controls to have
experienced acute intoxication symptoms in previous years
during tobacco harvest and to be hired workers. Among those
who reported illness in previous years, cases were likelier to have
been ill more than once. Among those who were engaged in
breaking the tobacco leaves, cases harvested a lesser portion of
leaves from the superior part of the plants (table 2). On
univariate analysis, illness was not associated with exposure to
wet leaves or clothes, using conventional clothes or accessories
for personal protection, consuming alcohol, working for the first
time in tobacco farming, male sex, age <33 and contact with
pesticides (table 2).
The following variables were included on conditional logistic
regression analysis: having acute intoxication symptoms after
contact with tobacco in previous years, being a hired farm
worker and harvesting superior tobacco leaves, all adjusted for
age and sex. This analysis yielded results consistent with those
of univariate analysis (table 3).
On non-matched analysis of continuous variables, there was
a statistically significant difference between average levels of
cotinine of cases and controls. Stratifying by smoking use
(smoker vs non-smoker), there was a statistically significant
difference between average levels of cotinine in cases and
control, who were non-smokers (table 4).
DISCUSSION
GTS is often mistaken for the clinically similar intoxication by
pesticides, which are used in several phases of tobacco farming.3
In our investigation, however, acute intoxicationcases occurred
during the harvest phase, which entails the least application of
pesticides. Thus, pesticide exposure was not related to illness.
Cotinine levels in individuals presenting GTS were heteroge-
neous, even when stratifying smokers versus non-smokers.
These differences could be explained by factors that modify
cotinine levels that have been described in the scientific litera-
ture. These include the time between last cigarette smoked and
urine collection, the number of cigarettes smoked per day,
nicotine tolerance, time from last exposure to sample collection
and body mass index.4 16e18 Even so, a statistically significant
difference was noted between cotinine levels of case-patients
and controls, resembling the findings of the stuy of Pereira et al,
although the type of tobacco to which cases were exposed was
different.12
The farm workers interviewed in this investigation considered
the use of conventional clothes and accessories during labour as
a form of protection against GTS. However, our results
demonstrate that these clothes conferred no protection. Use of
Table 1 Characteristics of cases and controls, Candela´ria/Rio Grande
do Sul State /Brazil, 2008, N¼99
Variable Cases (N[33) Controls (N[66)
n (%) n (%)
Male sex 17 (51.5) 36 (54.5)
Mean (6SD) Mean (6SD)
Age (years) 33 (11.8) 39.7 (14.1)
Complexion/race
White 25 (75.8) 42 (63.6)
mixed race 6 (18.2) 14 (21.2)
Black 2 (6.0) 10 (15.2)
Median (range) Median (range)
Education (years) 4 (0e11) 4 (0e11)
Smoking status
Smoker 12 (36.4) 24 (36.4)
Never-smoker 19 (57.6) 34 (51.5)
Ex-smoker (at least 1 year) 2 (6.0) 8 (12.1)
Consume alcohol
Yes 14 (42.4) 33 (50.0)
Principal occupation
Farming 27 (81.8) 55 (83.3)
Table 2 Univariate analysis of risk factors for Green Tobacco
Sickness, cases vs. controls, Candela´ria/Rio Grande do Sul State/Brazil,
2008, N¼99
mOR 95% CI p Value
Illness in previous years 3.10 1.18 to 8.09 0.01
Illness more than once 4.10 1.57 to 10.68 <0.01
Hired workers 3.36 1.01 to 11.18 0.03
Breaking superior tobacco leaves 0.04 0.00 to 0.34 <0.01
Exposure to wet leaves 2.15 0.92 to 5.03 0.07
Exposure to wet clothes 1.77 0.69 to 4.56 0.22
Using conventional clothes 2.19 0.57 to 8.36 0.23
Consuming alcohol 0.74 0.32 to 1.69 0.48
Working for the first time in tobacco
farming
2.73 0.22 to 33.00 0.41
Male sex 0.88 0.37 to 2.05 0.77
Age <33 years 2.00 0.80 to 4.98 0.13
Contact with pesticides 1.00 0.31 to 3.16 1
p Value: c2.
mOR, matched OR.
Figure 1 Green Tobacco Sickness cases, Candela´ria/Rio Grande do Sul
State/Brazil, 2008.
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cotton gloves was reported as a measure to protect hands from
physical injury and facilitate their cleaning after work; no farm
worker reported spontaneously that they were used as PPE. Use
of proper PPE would be difficult for tobacco farmers, given that
it must be impermeable and tolerable to users at the high
ambient temperatures characteristic of harvest season.4 While
PPE use has been recommended by other authors, it must be
acceptable to the workers.
Tobacco farming in southern Brazil is a family enterprise,
entailing the participation of all family members. This differs
from the situation in the USA, where GTS is described in male
foreign migrant workers from Latin countries and in the first
reported outbreak of GTS in Brazil, from a region where the
activity is more common among men than women.3 5 12 All
family members are involved in the breaking of leaves at harvest,
the activity entailing the greatest exposure to nicotine. Our
conditional logistic regression analysis confirmed this finding,
controlled for the age and sex of the subjects.
Trape-Cardoso et al19 report that leaves from the upper
portion of the plant possess higher concentration of nicotine
than the remainder of the plant. We observed that farmers
collecting leaves from the upper portion of the plant were less
likely to experience illness than those who collected leaves from
other parts of the plant. This could be explained by the upper
leaves being larger, requiring a lesser number of leaves to fill
a drying oven, with the pickers consequently having reduced
time of exposure to leaves; this is supported by other reports in
the literature. Tobacco farmers relate that the smell of tobacco is
stronger during the picking of lower leaves, due to the proximity
to the soil, presumably due to reduced air circulation by the
ground, facilitating the stimulation of nausea, one of the signs of
acute intoxication.20 Furthermore, picking lower leaves requires
a greater effort, presumably associated with greater perspiration
and consequently increased nicotine absorption.
We observed that worker, who were hired, as opposed to those
who owned the land, were likelier to experience illness, similar
to findings that Latino workers in the USA were at greatest risk
for presenting with GTS.5 21 It is possible that this may be
related to the lesser ability that these persons had to choose their
working hours. Farmereowners reported that they avoided
working during the hottest hours of the day and at the times
that tobacco leaves were wet, circumstances they recognise as
associated with the illness.
Although the association between GTS and exposure to wet
tobacco leaves or working with wet clothes is well documented,22
we did not demonstrate this type of association.5 6 16 23 This may
be due to the low power of the study, especially since the
investigators heard many reports by farm workers about the
occurrence of illness after contact with wet leaves or in wet
clothes. Additionally, the occurrence of rain on only 4 days during
the investigation period was considered exceptionally low
compared with previous harvest seasons.
We believe that the true magnitude of illness in the region is
greater than that shown in our investigation. Local farmers
consider the signs and symptoms of GTS as inevitably related to
their work and report frequently opting for self-treatment,
rather than seeking medical care, in order to quickly return to
work. This is likely encouraged by the self-limiting nature of the
illness.
Possible limitations of our study include memory and infor-
mation biases occurring during interviews with tobacco farmers,
principally among controls. We believe that selection bias may
have occurred because controls were not recruited on the same
days as cases, but this was likely minimised by the fact that
weather conditions did not vary during the investigation period
and that cotinine levels are not cumulative. The number of cases
and controls in our study was a limiting factor, not permitting
the inclusion of more than three independent variables in
conditional logistic regression models. Our study did not control
for environmental tobacco smoke. It is possible that this expo-
sure could have increased cotinine levels in some cases and
controls.
Our investigation confirmed the occurrence of green leaf
tobacco sickness in southern Brazil, demonstrating it is an
occupational condition among tobacco farmers of this region.
In many studies of GTS from other countries, variation
persists in the clinical elements of the case definition,3 19 limiting
comparisons of disease incidence and prevalence between studies
that used a cohort design. The combination of clinical presen-
tation with cotinine level measurement in urine, blood or saliva
should allow more precise estimates; we recommend including
cotinine measurement in similar studies in the future.
Since we used a caseecontrol study design, we cannot esti-
mate incidence or prevalence of disease in southern Brazil; this is
true of the only other study on this disease in Brazil.12 Studies
permittingthe determination of GTS prevalence should be
conducted in tobacco-growing populations in Brazil, so that the
magnitude of the problem can be known. Furthermore, moni-
toring of the disease by occupational health authorities is
necessary, so that appropriate education of the affected popu-
lations with regard to control measures, such as use of PPE
appropriate for tobacco farming, may take place.
Signs and symptoms of GTS usually resolve within a day, but
we do not know whether there are chronic effects associated
Table 3 Conditional logistic regression analysis of risk factors for
Green Tobacco Sickness, Candela´ria/Rio Grande do Sul State/Brazil,
2008, N¼99
mOR 95% CI p Value
Model 1
Illness in previous years* 3.67 1.30 to 10.30 0.01
Male sex 0.78 0.27 to 2.20 0.64
Age <33 years 2.92 0.98 to 8.70 0.05
Model 2
Hired worker* 4.50 1.21 to 16.70 0.02
Male sex 0.67 0.25 to 1.79 0.43
Age <33 years 2.88 0.99 to 8.31 0.05
Model 3
Breaking superior tobacco leaves* 0.03 0.00 to 0.31 <0.01
Male sex 0.76 0.21 to 2.71 0.67
Age <33 years 3.10 0.77 to 12.37 0.10
p Value: c2.
mOR, matched OR.
*variable being tested.
Table 4 Average levels of cotinine in cases and controls, Candela´ria/
Rio Grande do Sul State/Brazil, 2008
Urinary cotinine (ng/ml) p Value
Average (SD)
Case (n¼33) Control (n¼66) 0.03*
432 (476) 353 (548)
Smoker
Case (n¼12) Control (n¼24) 0.54*
742 (530) 851 (65)
Non-smoker
Case (n¼21) Control (n¼42) <0.01*
255 (344) 68 (75)
Non-smokers: individuals who never smoked or smoked for more than 1 year.
*KruskaleWallis test non-matched analyses.
Occup Environ Med 2012;69:514e518. doi:10.1136/oemed-2011-100307 517
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with daily transdermal nicotine absorption over years in the
course of tobacco farming activities. Studies are needed to
investigate potential chronic effects in these workers, who are
exposed to high doses of nicotine in the course of their working
lives.
Acknowledgements We thank the following entities and persons: the State
Center for Health Surveillance of Rio Grande do Sul, the Central State Laboratory
(LACEN) of Rio Grande do Sul, the Municipal Secretariat of Health of Candela´ria and
the Benevolent Hospital Society of Candela´ria for essential support; the Union of
Rural Workers of Candela´ria, Rio Grande do Sul for assistance during field work;
Eduardo Marques Maca´rio and Wildo Navegantes de Arau´jo for scientific advice and
Carlos Eduardo Leite for help with laboratory testing.
Contributors PBO collected the data, participated in the design, performed the
statistical analysis and drafted the manuscript with approval of the final version; BPMI
collected the data, participated in the design and helped to draft the manuscript;
PPVdO, TEHHdS and DCM participated in the design and helped to draft the
manuscript; JS participated in the design, performed the statistical analysis and
helped to draft the manuscript and LdM participated in the design and coordination to
draft the manuscript.
Competing interest None declared.
Patient consent The work described in this paper was conducted as part of a public
health response to an outbreak of acute toxicity in tobacco workers. Oral consent was
required for all individuals at the moment of the interviews.
Ethics approval A public health response to an outbreak of acute toxicity in tobacco
workers. These activities were reviewed in advance by the officials within the Ministry
of Health of Brazil charged with determining whether actions by public health workers
fall under the jurisdiction of a research ethics committee.
Provenance and peer review Not commissioned; externally peer reviewed.
REFERENCES
1. Parikh JR, Gokani VN, Doctor PB, et al. Acute and chronic health effects due to
green tobacco exposure in agricultural workers. Am J Ind Med 2005;47:494e9.
2. Arcury TA, Quandt SA, Preisser JS. Predictors of incidence and prevalence of green
tobacco sickness among Latino farmworkers in North Carolina, USA. J Epidemiol
Community Health 2001;55:818e24.
3. Schmitt NM, Schmitt J, Kouimintzis DJ, et al. Health risks in tobacco farm workers -
a review of the literature. J Public Health 2007;15:255e64.
4. 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;45:140e5.
5. Quandt SA, Arcury TA, Preisser JS, et al. Migrant farmworkers and green tobacco
sickness: new issues for an understudied disease. Am J Ind Med 2000;37:307e15.
6. McBride JS, Altman DG, Klein M, et al. Green tobacco sickness. Tob Control
1998;7:294e8.
7. Cattaneoa R, Alegretti AP, Sagebin FR, et al. Validac¸a˜o de me´todo para
determinac¸a˜o de cotinina urina´ria por cromatografia lı´quida de alta eficieˆncia. Revista
Brasileira de Toxicologia 2007;19:21e7.
8. Weizenecker R, Deal WB. Tobacco cropper’s sickness. J Fla Med Assoc
1970;57:13e14.
9. Temporao JG. Public Health and tobacco control in Brazil (In Portuguese). Cad
Saude Publica 2005;21:671.
10. Piovesan A. Fumicultura Nos Municı´pios Gau´chos. Porto Alegre: Corag, 2008.
11. Brasil. Ministe´rio da Sau´de, Instituto Nacional de Caˆncer. Convenc¸a˜o Quadro
Para o Controle do Tabaco. Semina´rio Internacional Sobre a Convenc¸a˜o Quadro Para
o Controle do Tabaco. Brası´lia: Caˆmara dos Deputados, 2003.
12. Oliveira PP, Sihler CB, Moura L, et al. First reported outbreak of green tobacco
sickness in Brazil. Cad Sau´de Pu´blica 2010;26:2263e9.
13. Arcury TA, Quandt SA, Preisser JS, et al. High levels of transdermal nicotine
exposure produce green tobacco sickness in Latino farmworkers. Nicotine Tob Res
2003;5:315e21.
14. IBGE. Instituto Brasileiro de Geografia e Estatı´stica. Brası´lia: Ministe´rio do Planejamento,
Orc¸amento e Gesta˜o, 2000. http://www.ibge.gov.br/home (accessed 2 Feb 2009).
15. INCA. Instituto Nacional do Caˆncer. Tabagismo Passivo. Brası´lia: Minsite´rio da
Sau´de, 2009. http://www.inca.gov.br/tabagismo/frameset.asp?item¼passivo&;
link¼tabagismo.htm (accessed 2 Feb 2009).
16. McKnight RH, Spiller HA. Green tobacco sickness in children and adolescents.
Public Health Rep 2005;120:602e5.
17. Figueiredo VC, Szklo M, Szklo AS, et al. Determinants of salivary cotinine level:
a population-based study in Brazil. Rev Saude Publica 2007;41:954e62.
18. Gehlbach SH, Williams WA, Perry LD, et al. Nicotine absorption by workers
harvesting green tobacco. Lancet 1975;1:478e80.
19. Trape-Cardoso M, Bracker A, Dauser D, et al. Cotinine levels and green tobacco
sickness among shade-tobacco workers. J Agromedicine 2005;10:27e37.
20. Simmons S, Quandt SA, Arcury TA, eds. Learning About Green Tobacco Sickness:
Juan’s Experience. Winston-Salem, North Carolina: Wake Forest University School of
Medicine, 2001.
21. Arcury TA, Quandt SA. Delivery of health services to migrant and seasonal
farmworkers. Annu Rev Public Health 2007;28:345e63.
22. Curwin BD, Hein MJ, Sanderson WT, et al. Nicotine exposure and decontamination
on tobacco harvesters’ hands. Ann Occup Hyg 2005;49:407e13.
23. Anon. From the Centers for Disease Control and Prevention. Green tobacco sickness
in tobacco harvesterseKentucky, 1992. JAMA 1993;269:2722e4.
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Environment
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tobacco production
southern Brazil, a worldwide leader in
occupational illness of tobacco harvesters in 
Epidemiologic investigation of an
Carvalho Malta, Jeremy Sobel and Lenildo de Moura
DeborahVasconcelos de Oliveira, Tania Esther Herc Holmer dos Santos, 
Patrícia Bartholomay, Betine Pinto Moehlecke Iser, Patrícia Pereira
doi: 10.1136/oemed-2011-1003072012
2012 69: 514-518 originally published online April 26,Occup Environ Med 
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