National Institute of Occupational Health

Research Project

Occupational Health Problems Of Tobacco Harvesters & Their Prevention

 

Ø    introduction, Collaborating Institute

Ø    Objectives

Ø    Subject, STUDY TYPE

Ø    Methodology 

Ø    RESULTS

Ø    CONCLUSIONS

 

 

 

 

 

Introduction

 

Portuguese introduced tobacco cultivation in India in 1605. Initially tobacco was grown in Kaira and Mehsana districts of Gujarat and later spread to other areas of the country. Commercial cultivation of Virginia tobacco in India in black soil was commenced in the year 1920. Flue curing was first successfully done in 1928 at Guntur, AP. After 1930 India found a place on the world tobacco map & during 1943-44, the excise duty on tobacco was introduced and since then tobacco remained as the important of excise revenue.With its rich agro- climatic diversity, India has the unique position of growing all types of tobacco which are broadly classified as: 

1.       

FCV Tobacco

Andhra Pradesh and Karnataka

2.       

Beedi Tobacco

Gujarat and Nipani area of Karnataka

3.       

Cigar and Cheroot

Tamil Nadu and West Bengal

4.       

Hookah Tobacco

Assam, West Bengal, Bihar, UP and Punjab

5.       

Chewing and Snuff

Tamil Nadu, West Bengal, Bihar, Assam, UP, Punjab and Gujarat

6.       

Natu, Burley, Lanka, HDBRG

Andhra Pradesh

7.       

Pika Tobacco

Orissa

Source : www.ctriindia.com 

India stands second in the world as far as production of all tobacco types constituting about 9% of total global production. India produces 600 million Kg. of all types of tobacco in 4 lakh hector area. It is the fourth largest exporter and exports about 123 million Kg. It is estimated that about seven lakh growers and five lakh curers are engaged in tobacco cultivation. The chief tobacco growing states in India are – Andhra Pradesh, Gujarat, Karnataka, West Bengal, Maharashtra, Tamil Nadu, Orissa, and Bihar. India produces several types of tobacco, which fall under two botanical species namely Nicotiana tabacum and Nicotiana rustica. India grows both the species, but by far the largest area is under N. tabacum.  

Tobacco harvesters are occupationally exposed to nicotine during tobacco cultivation. Occupational health problems associated with tobacco cultivation are known as "Green Tobacco Sickness" (GTS). It is mild and acute form of nicotine toxicity that affects tobacco workers through direct dermal contact with tobacco plants during cultivation and harvesting. Headache, nausea, vomiting, giddiness, loss of appetite, fatigue, weakness and sometimes fluctuations in blood pressure or heart rate characterize it. These symptoms are self-limited and relieved without medication. The GTS was first reported from U.S.A. in 1970 as “Cropper’s sickness”. Later on in 1974 it was reported by Gelbach et.al from USA as “Green Tobacco Sickness”. NIOH reported as “Green Symptoms” among Indian tobacco harvesters in 1976 & 1978. The prevalence of GTS among Indian tobacco harvesters in these studies was found fairly high in the harvesters of both the varieties i.e. non-Virginia (86.20%) and Virginia (53.29%). It was also observed in these studies that excretion rate of nicotine and its major metabolite cotinine in urine were increased about 3 to 4 times among exposed workers. The chronic health effects of tobacco smoking are well documented. These include chronic bronchitis, emphysema, malignancy of lung, coronary heart diseases, premature systole, paroxysmal atrial tachycardia, decrease in amplitude or inversion of T wave, rise in systolic and diastolic blood pressure, thromboangitis obliterans, tobacco amblyopia and reproductive effects like low birth weight, fetal abnormalities, pre-maturity, still birth, and abortion. There are no epidemiological studies evaluating chronic health effects of handling of green tobacco leaves among tobacco agricultural workers. Therefore, the present study has been carried out to detect chronic health effects due to tobacco cultivation.

 In tobacco cultivation there are different type of processes like sawing, transplanting of seedlings, topping of flowering buds, disbudding of axillary buds, harvesting of plant, separation of leaves, curing, grading etc. Usually the workers when they do not wear the gloves during the various agricultural processes like topping of plant, disbudding of axillary buds (suckers) and harvesting of plant, their hands get smeared with thick sticky plant sap and they have to wash their hands after each shift to remove this plant sap. 

(Fig.-1 ) which requires soap & kerosene.

Fig.1 :  Disbudding of axillary buds and harvesting of tobacco plants

 NIOH also carried out intervention study at Gujarat in 1982. Two types of hand gloves were provided to non-Virginia tobacco harvesters who suffered from GTS. Use of both the types of gloves showed significant reduction in prevalence of GTS and in nicotine absorption as reflected by nicotine and cotinine excretion rate in urine. It was found that the use of rubber gloves afforded protection among 93% of the subjects, while with cotton gloves the proportion was some what less 78.5%. Both the types of gloves were found saturated and encrusted with thick plant sap during harvesting and such gloves were difficult to wash and clean after the use. Therefore an exploratory study with disposable polyethylene gloves was carried out during the process of disbudding of axillary buds. It was undertaken to find out efficacy of polyethylene gloves. The polyethylene gloves were found to be elastic enough to adapt the contours of the palm and fingers causing no interference in the work performance and could be worn for the whole day. The hands were also not smeared with thick sticky plant sap after the process of disbudding of axillary bud. They were found comfortable and acceptable to the workers, as it did not affect the productivity. Cost-wise also they were cheaper but due the problem of recycling of these smeared polyethylene gloves & also non biodegradable nature of polyethylene, trial with various type of seamless knitted gloves have been undertaken. There was need to test prototype and suggest suitable gloves for different processes of cultivation to prevent the absorption of nicotine through the skin.

Collaborating Institutes: 

Tribhuvandas Foundation, Anand, Ravishankar Maharaja Eye Hospital, Chikhodara, Self Employed Women Association, Anand and Ahmedabad, Beedi Tobacco Research Station (BTRS), Gujarat Agricultural University (GAU), Anand, Central Tobacco Research Institute (ICAR), Rajahmundri, A.P.

 

 

 

 

    

Objectives
 

1.                  To assess the chronic health effects of green tobacco leaves exposure during agricultural operation among tobacco harvesters. 

2.                  To evaluate the effectiveness of various types of gloves by recording work related symptoms & measuring the urinary excretion rate of nicotine/cotinine among the tobacco harvesters. 

3.                  To suggest suitable gloves for prevention of absorption of nicotine in different processes of tobacco cultivation. 

4.                  To create awareness about the occupational hazards of tobacco cultivation & its prevention.

 

 

 

         

Subject, STUDY TYPE

 

Subject Keys

 Tobacco Cultivation, Chronic health effects, Green Tobacco Sickness,, Nicotine Toxicity, Dermal absorption & Prevention
 

Study type EPI, FOR, HEA, LAB

 

 

 

 

 

 

 

Methodology

 

Data Generation on Chronic Health Effects of tobacco cultivation amongst Tobacco Harvesters: 

The study populations for exposed and control subjects were selected with the help of Tribhovandas Foundation, a Non Governmental Organization (NGO) in Anand. Data regarding total population and tobacco workers were obtained from each village. On the basis of this sampling frame random samples from each selected village were determined for estimated sample size. A total of 685 tobacco workers and 655 comparable controls with respect to age, sex, and socio-economic condition were examined from two villages where tobacco agriculture was not carried out. 

To detect the chronic health effects of tobacco cultivation, a specially designed questionnaire was used which included tobacco habits, occupational history and reproductive history. For each subject general medical examination, ECG and visual acuity were determined.  

Intervention Study – Trial and Evaluation of Effectiveness of Various Types of Gloves in Prevention of Nicotine Absorption and Supply of Selected Gloves to the Workers:
 
Creation of Awareness – Awareness amongst Tobacco Harvesters and Popularization of Preventive Measures through NGOs and Govt. Agencies: 

To create the awareness about the hazards of green tobacco exposure and usefulness of gloves in its prevention, posters in Telugu, Gujarati and Hindi and video films have been prepared. NGOs & Government agencies (Tribhuvandas Foundation, Anand, Ravishankar Maharaja Eye Hospital, Chikhodara, Self Employed Women Association, Anand and Ahmedabad, Beedi Tobacco Research Station (BTRS), Gujarat Agricultural University (GAU), Anand, Central Tobacco Research Institute (ICAR), Rajahmundri, A.P.) have been contacted for the distribution of this educational and preventive material.

 

 

 

 

                  

Results
 

 

Data Generation on Chronic Health Effects of Nicotine Amongst Tobacco Harvesters 

A Total of 685 tobacco workers and 655 comparable controls with respect to age, sex and socio-economic condition were examined from five villages of Anand and Tarapur Talukas of Gujarat State. The distribution of exposed and control men and women workers by age and smoking habits are given in Table-1 and Table 2. Out of a total 685 exposed workers, 457 were men and 228 were women while out of 655 control workers 393 were men and 262 were women. The majority of exposed and control women workers were non-smokers. 

Findings related to hypertension among exposed and control workers are given in Table-3. The criterion for the hypertension was diastolic blood pressure equal to or more than 90 mm of Hg or systolic blood pressure equal to or more than 140 mm of Hg. The number of cases of hypertension is comparable in exposed and control groups and the difference is statistically non-significant. In Table-4 and 5 further analysis of hypertension with respect to age group is given. Some results, which are not comparable in exposed and control group may be due to small number of sample size. 

The E.C.G. findings are given in Table-6. The major observation in both the groups was ST-T changes. However, statistically the difference between both the groups was not significant.

 Visual acuity was examined by Snellen’s chart (Table-7). Subjects with visual acuity 6/18 to 6/60 were considered as having low vision. The difference between exposed and control men and women with low vision were non-significant and no case of tobacco amblyopia was found in the exposed group. Exposed subjects with visual acuity 6/18 to 6/60 were taken for the detailed eye examination at Nutan Eye Clinic, Anand & Sarvajanik Hospital Bochasan run by Ravishanker Maharaj Eye Hospital, Chikhodara. Ophthalmologists examined a total 86 subjects, 59 men & 27 women. 56 subjects, 36 men and 20 women with refractive errors were provided the spectacles. 

The reproductive abnormalities among exposed and control women workers are given in Table-8. Premature delivery, abortion and stillbirth were recorded in both the groups. However the difference in each condition was statistically non-significant in both the groups.

 Prevalence of GTS amongst women was 55.70% and men 42.66%.

 Intervention Study

 To prevent the absorption of nicotine by dermal route different varieties of seamless knitted gloves like Cotton, Cotton with PVC polka dots, Cotton + Polyester, only Polyester and Nylon (Fig.2) were provided to 80 tobacco harvesters.

 Fig.2 : Varieties of Seamless knitted gloves

 

(1) Cotton, (2) Cotton with PVC Polka Dots. (3) Cotton + Polyester, (4) Polyester, (5) Nylon 

The gloves were tested for their usefulness and durability during various processes of tobacco cultivation. Representative samples of urine have been collected from each group of workers before the use of gloves and after 15 days of work with the use of gloves. Workers were given two pairs of gloves initially and asked to wash the gloves same day after the use. They were also asked to use clean and completely dry gloves whenever they start the work next day. They were also instructed if their gloves were torn they should immediately ask for replacement with fresh pair. To estimate the nicotine and its major metabolite cotinine from urine samples of tobacco harvesters before and after the use of various type of gloves in various process of tobacco cultivation, method of urine sample extraction by solid phase extraction (SPE) using Drug Test cartridge with mix mode sorbent and reversed phase ion paired liquid chromatographic method have been developed. Concentration of nicotine and its major metabolite cotinine in representative urine samples of the workers before & after the use of different varieties of gloves is given in Table-9. Reduction of nicotine & cotinine in urine samples was found after the use of all the varieties of the gloves.  

Fig.3 shows the gloves completely smeared with plant sap after the use in both the shifts.  

Fig. 3 : Gloves smeared with plant sap after the work

 

Reports of all the varieties of gloves were taken for their durability and usefulness from the individual worker. Cotton and Cotton PVC Polka Dots gloves tore from the thumb and fingertips after 3 to 4 working days and they were replaced with new pair. Cotton + Polyester and Polyester gloves became thin after repeated washing and plant sap entered through the fingertips of the gloves after the week. It was observed that Nylon gloves were neither torn from the fingertips nor became thin after repeated wash and two pairs lasted for 30 working days. After the use of gloves, smearing of plant sap on the hands, abrasions on the palm, peeling of the skin around the nail (Fig.4) bitter taste in food due to plant sap and work related symptoms like headache and giddiness were completely prevented.

 Fig. 4 : Clean hand after the use of nylon gloves

 

Use of gloves did not affect the speed of the work. Workers expressed that nylon gloves would be very useful for other processes of tobacco cultivation like harvesting and separation of leaves. Some workers have even shown willingness and readiness to work with gloves at their own cost. Manufacturer from Ankleshwar, Gujarat, was asked to manufacture seamless knitted nylon gloves of three different sizes viz. small, medium and large. Uptill now, we have distributed gloves to 7970 tobacco harvesters. Out of which 6729 workers of different villages of Anand and Kaira Districts, Research Stations of BTRS, Anand, Gujarat State, with the help of NGOs and Government Agencies and 1241 tobacco workers in Research Stations of CTRI and other villages of West Godavari District of Andhra Pradesh with the help of CTRI, Rajahmundry. 

Awareness amongst tobacco harvesters and popularization of preventive measures through NGOs and Govt. agencies 

To popularize the use of gloves among the tobacco workers, posters in different languages i.e. Gujarati, Telugu and Hindi and Video film on hazards of tobacco cultivation and its prevention have been prepared. These posters have been given to Tribhuvandas Foundation (TF) who has been engaged in the health care of village population of 640 villages of Anand and Kaira Districts, SEWA, Anand and Ahmedabad, Beedi Tobacco Research Station (GAU) and Education and Extension Department of GAU, Ahmedabad, CTRI, Rajahmundry, A.P., for the popularization of preventive measures.
 

Table-1          Distribution of Exposed and Control Men Workers by Age and Smoking Habits

 

Age group

(Yrs)

Total No. of workers

Smoking habits

Non-smoker

Smoker

Occasional smoker

Ex-smoker

E

C

E

C

E

C

E

C

E

C

15-19

15

15

10

(66.67)

11

(73.3)

4

(26.67)

3

(20.0)

-

1

(6.7)

1

(6.66)

-

20-29

101

77

38

(37.62)

45

(58.4)

56

(55.45)

28

(36.4)

1

(0.99)

1

(1.3)

6

(5.94)

3

(3.9)

30-39

131

107

29

(22.14)

27

(25.2)

90

(68.70)

66

(61.7)

1

(0.76)

2

(1.9)

11

(8.40)

12

(11.2)

40-49

99

97

12

(12.12)

27

(27.8)

73

(73.74)

61

(62.9)

-

-

14

(14.14)

9

(9.3)

50-59

40

45

3

(7.5)

5

(11.1)

33

(82.50)

27

(60.0)

-

-

4

(10.0)

13

(28.9)

60-69

48

41

3

(6.25)

3

(7.3)

39

(81.25)

26

(63.4)

-

-

6

(12.5)

12

(29.3)

70+

23

11

1

(4.35)

2

(18.2)

19

(82.61)

8

(72.7)

-

-

3

(13.04)

1

(9.1)

Total

457

393

96

(21.01)

120

(30.53)

314

(68.71)

219

(55.73)

2

(0.44)

4

(1.02)

45

(9.84)

50

(12.72)

 E = Exposed;            C= Control                 Figures in parenthesis indicate percentage.

 

Table-2          Distribution of Exposed and Control Women Workers by Age and Smoking Habits 

Age group

(Yrs)

Total No. of workers

Smoking habits

 

 

Non-smoker

Smoker

Ex-smoker

E

C

E

C

E

C

E

C

15-19

2

2

2

(100.0)

2

(100.0)

-

-

-

-

20-29

38

44

38

(100.0)

44

(100.0)

-

-

-

-

30-39

68

75

68

(100.0)

75

(100.0)

-

-

-

-

40-49

47

67

47

(100.0)

66

(98.5)

-

1

(1.5)

-

-

50-59

41

48

38

(92.68)

46

(95.8)

1

(2.44)

 

2

(4.88)

2

(4.2)

60-69

27

23

27

(100.0)

23

(100.0)

-

-

-

-

70+

5

3

5

(100.0)

3

(100.0)

-

-

-

-

Total

228

262

225

(98.68)

259

(98.86)

1

(0.44)

1

(0.38)

2

(0.88)

2

(0.76)

E = Exposed;             C= Control     Figures in parenthesis indicate percentage.

 

Table-3 Findings related to hypertension among exposed and control workers. 

Workers examined

Normal

Hypertension

Systolic³140

and/or

Diastolic³90

 

Total

Men

Women

Men

Women

Men

Women

Exposed

685

457

(66.72)

228

(33.28)

376

(82.28)

187

(82.02)

81

(17.72)

41

(17.98)

Control

655

393

(60.0)

262

(40.0)

323

(82.19)

214

(81.68)

70

(17.81)

48

(18.32)

 

E = Exposed;   C= Control       Figures in parenthesis indicate percentage.

 

Table-4          Detailed Analysis Related to Hypertension in Exposed & Control Men Workers According to Age group

 

Age

Group

(Yrs)

Total No. of Exposed & Control workers

Normal

Total cases of Hypertension (Systolic ³ 140 or Diastolic ³ 90)

Mild

(Systolic 140 to 159 Diastolic 90 to 99)

Moderate

(Systolic 160

to 179

 Diastolic 100 to 109)

Severe

(Systolic 180

 to 209

Diastolic 110

 to 119)

Very severe

(Systolic 210

or Higher Diastolic 120

or Higher

 

E

C

E

C

E

C

E

C

E

C

E

C

E

C

15-19

15

15

15

(100)

13

(86.67)

-

2

(13.33)

-

2

(13.33)

-

-

-

-

-

-

20-29

101

77

93

(92.08)

68

(88.31)

8

(7.92)

9

(11.69)

7

(6.93)

9

(11.69)

1

(0.99)

-

-

-

-

-

30-39

131

107

117

(89.31)

93

(86.92)

14

(10.69)

14

(13.08)

13

(9.92)

10

(9.35)

1

(0.77)

3

(2.80)

-

1

(0.93)

-

-

40-49

99

97

83

(83.84)

79

(81.44)

16

(16.16)

18

(18.56)

14

(14.14)

12

(12.37)

2

(2.02)

3

(3.09)

-

2

(2.06)

-

1

(1.03)

50-59

40

45

29

(72.5)

38

(84.44)

11

(27.50)

7

(15.56)

7

(17.50)

6

(13.33)

3

(7.50)

1

(2.22)

1

(2.5)

-

-

-

60-69

48

41

30

(62.5)

25

(60.98)

18

(37.50)

16

(39.02)

9

(18.75)

13

(31.71)

6

(12.50)

1

(2.44)

1

(2.08)

2

(4.88)

2

(4.17)

-

70+

23

11

9

(39.13)

7

(63.64)

14

(60.87)

4

(36.36)

8

(34.78)

4

(36.36)

5

(21.74)

-

 

1

(4.35)

-

-

-

Total

457

393

376

(82.28)

323

(82.19)

81

(17.72)

70

(17.81)

58

(12.69)

56

(14.25)

18

(3.94)

8

(2.04)

3

(0.65)

5

(1.27)

2

(0.44)

1

(0.25)

E = Exposed;    C= Control         Figures in parenthesis indicate percentage
 

 

Table-5          Detailed Analysis Related to Hypertension in Exposed & Control Women Workers According to Age group

 

Age

Group

(Yrs)

Total No. of Exposed & Control workers

Normal

Total cases of Hypertension (Systolic ³ 140 or Diastolic ³ 90)

Mild

(Systolic 140 to 159 Diastolic 90 to 99)

Moderate

(Systolic 160

to 179

 Diastolic 100 to 109)

Severe

(Systolic 180

 to 209

Diastolic 110

 to 119)

 

E

C

E

C

E

C

E

C

E

C

E

C

15-19

2

2

2

(100.00)

2

(100.00)

-

-

-

-

-

-

-

-

20-29

38

44

36

(94.74)

39

(88.6)

2

(5.26)

5

(11.36)

1

(2.63)

3

(6.82)

-

2

(4.55)

1

(2.63)

-

30-39

68

75

65

(95.59)

66

(88.00)

3

(4.41)

9

(12.00)

2

(2.94)

8

(10.67)

-

1

(1.33)

1

(1.47)

-

40-49

47

67

41

(87.23)

52

(77.61)

6

(12.77)

15

(22.39)

3

(6.38)

13

(19.40)

2

(4.26)

2

(2.99)

1

(2.13)

-

50-59

41

48

27

(65.85)

37

(77.08)

14

(34.15)

11

(22.92)

11

(26.83)

9

(18.75)

2

(4.88)

1

(2.08)

1

(2.44)

1

(2.08)

60-69

27

23

14

(51.85)

18

(78.26)

13

(48.15)

5

(21.74)

9

(33.33)

2

(8.70)

2

(7.41)

2

(8.70)

2

(7.41)

1

(4.35)

70+

5

3

2

(40.00)

--

3

(60.00)

3

(100.0)

2

(40.0)

-

1

(20.0)

3

(100.0)

-

 

-

Total

228

262

187 (82.02)

214

(81.68)

41

(17.98)

48

(18.32)

28

(12.28)

35

(13.36)

7

(3.07)

11

(4.20)

6

(2.63)

2

(0.76)

E = Exposed;    C= Control         Figures in parenthesis indicate percentage

 


 

Table-6           ECG Findings  ST-T changes in Exposed and Control Workers 

Groups

Workers examined

No. of workers with ST-T Changes

Total

Men

Women

Men

Women

Exposed

678

454

(66.96)

224

(33.04)

6

(1.32)

18

(8.03)

Control

655

391

(59.69)

262

(40.31)

11

(2.81)

15

(5.72)

Figures in parenthesis indicate percentage

 

Table-7 Findings Related to Visual Acuity in Exposed and Control Workers 

Workers examined

Visual Acuity

6/6 – 6/12

Visual Acuity

6/18 – 6/60

 

Total

Men

Women

Men

Women

Men

Women

Exposed

685

454

(66.72)

228

(33.28)

332

(73.13)

169

 (74.13)

122

(26.87)

59

(25.87)

Control

655

393

(60.00)

262

(40.00)

297

(75.57)

178

(67.94)

96

(24.43)

84

(32.06)

Figures in parenthesis indicate percentage

 

 

Table-8        Findings Related to Reproductive Abnormalities in Exposed and Control Women workers. 

Women workers

Reproductive abnormalities

Premature deliveries

Abortion

Still birth

Exposed

228

17

(7.45)

23

(10.08)

20

(8.77)

Control

262

15
5.72)

41

(15.64)

13

(4.96)

Figures in parenthesis indicate percentages 


 

 

Table-9       Concentration of nicotine and cotinine in urine samples of tobacco harvesters before and after the use of varieties of gloves (Mean ± sem) 

Variety of Gloves

No. of Subjects

Concentration of Nicotine( µg/ml)

 

Concentration of cotinine( µg/ml)

 

 

M

W

Total

Without

With

%
Reduction

Without

With

% Reduction

Nylon

3

18

21

3.58 ± 0.81

1.42± 0.37

60

7.32±1.09

3.45±0.65

53

Cotton

6

9

15

2.59±0.62

1.29±0.29

50

5.54±1.14

2.98±0.46

46

CPD

2

4

6

3.74±1.60

2.1±0.77

44

6.56±1.51

4.32±1.08

34

CP

0

7

7

1.83±0.64

1.11±0.38

39

2.68±0.50

1.53±0.50

43

Polyester

7

2

9

1.63±0.64

0.91±0.33

44

3.96±0.94

2.25±0.60

43

Total

18

40

58

 

 

 

 

 

 

 

 

 

 

 

             

 Conclusions 

 

The present epidemiological study in Gujarat does not suggest any significant chronic health effects in Indian tobacco cultivators due to the occupational exposure.

 Green tobacco sickness occurs in tobacco cultivators. However its severity depends on several factors like variety of tobacco smoking habit, humidity, ambient temperature as well as various processes of cultivation. In Gujarat mainly sun curing is done and because of that workers are not exposed to hazardous constituents of tobacco. In Indian tobacco GTS can be considered as mild form of nicotine toxicity, which does not result in serious health effects, sickness absence or loss of wages.  The workers do not need the hospitalization during green tobacco sickness. 

Varieties of seamless knitted hand gloves were tested to prevent the absorption of nicotine through dermal route. All the varieties prevented the absorption of nicotine, but nylon gloves were found durable and suitable in all the processes of tobacco cultivation.