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INTRODUCTION

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HISTORY AND EPIDEMIOLOGY

Nicotine is the principal alkaloid derived from plants of the genus Nicotiana, collectively known as the tobacco plant, in the family Solanaceae. Other fruits and vegetables from the Solanaceae family, such as tomatoes, potatoes, eggplant, and cauliflower, also contain nicotine in amounts ranging from 3.8 to 100 ng/g.29 The source of greatest toxicologic importance in human use is Nicotiana tabacum, and the primary method of exposure is cigarette smoking.

The tobacco plant is native to the Americas, and its use most likely predates the Mayan empire. In 1492, Christopher Columbus and his crew were given tobacco by the Arawaks but reportedly threw it away, not knowing any use for it. Ramon Pane, a monk who accompanied Columbus on his second voyage to America, is credited with introducing tobacco to Europe.99

Because of the highly addictive properties of nicotine, the global disease burden related to cigarette use today is staggering. Cigarette smoking increases rates of illnesses, such as chronic obstructive pulmonary disease (COPD), cardiovascular disease, pulmonary infections, macular degeneration, and cancers, and tobacco use causes more than 5 million deaths worldwide per year.101 Chronic nicotine exposure causes cardiovascular damage related to catecholamine release and vasoconstriction and directly promotes angiogenesis, neuroteratogenicity, and possibly some cancers.64 However, there are more than 3,000 components to tobacco smoke, and nicotine per se may not be the crucial determinant of the total health burden associated with its use.

Although the long-term effects of tobacco dependency are significant, this chapter is concerned with the sources, effects, and management of acute toxicity referable to nicotinic receptor stimulation and cholinergic activation. Compared with other xenobiotics, exposure to nicotine-containing products is a relatively rare cause of acute poisoning. For example, reviews of case data from the National Poison Data System (NPDS) suggest that cigarettes are by far the most common vehicle implicated in acute nicotine exposures and poisoning in the United States,22 yet over a period of 27 years from 1983 to 2009, tobacco products accounted for 217,340 calls, or 0.37%, of all pediatric exposures reported to poison control centers in the United States2 and accounted for only 0.7% of all unintentional poisoning cases in children treated in US hospital emergency departments.36 More current data suggest that electronic cigarettes and liquid nicotine exposures are on the rise. In 2014, pediatric exposures to e-cigarettes and liquid nicotine accounted for approximately 59% of all calls reporting these exposures, a percentage that rose to 70% in 2015.41 Consequential poisoning occurs, but most patients with nicotine exposure from tobacco products have a benign course, with only mild to moderate symptoms, and an infrequent need for hospitalization.

The frequency and severity of nicotine poisoning is changing with the rise of e-cigarette use, and associated increase in topical and oral exposures of more highly concentrated liquid nicotine ...

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