3.20 Tobacco poisoning

Last updated: March 2015
Suggested citation: Bellew, B, Greenhalgh, EM & Winstanley, MH. 3.20 Tobacco poisoning. In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2015. Available from http://www.tobaccoinaustralia.org.au/3-20-tobacco-poisoning

Smokers subject their bodies to continued exposures to low amounts of nicotine, leading to tolerance. However dizziness, nausea and vomiting may occur in response to tobacco use before tolerance is established.1 These symptoms also accompany cases of acute nicotine poisoning, which may occur through ingestion of tobacco or other products containing nicotine (such as pesticides or nicotine-replacement medications) or through absorption of nicotine through the skin, either from exposure to pesticides, unprocessed tobacco leaves (see 'green tobacco sickness' below), or nicotine replacement medications.1

Symptoms of mild nicotine poisoning may include nausea and vomiting, progressing with increased exposure to cholinergic syndrome, which includes diarrhoea, increased salivation, increased respira¬tory secretions, and bradycardia (slow heart rate). Severe poisonings can lead to seizures and respiratory depression.2 Death may occur through respiratory failure.1 Although highly toxic, death due to ingested tobacco is extremely rare due to the unpleasant flavour of tobacco, the vomit response and early metabolism of the nicotine.1

3.20.1 Ingestion

A study of cigarette or cigarette butt ingestion by children as reported to a state Poison Control Centre in the United States has shown that vomiting is the most common response, and that significant toxicity is rare.3 Cases have also been reported in which children have ingested or had transdermal exposure to nicotine replacement therapy patches, causing symptoms of nicotine poisoning and, in more severe cases, requiring hospitalisation.4 Reports of ingestion of novel smokeless nicotine products have also increased since the availability of these on the market in the US.5

Solutions containing nicotine from cigarettes have also been reported in suicide attempts.6,7,8

Nicotine is a scheduled poison in Australia, its distribution being controlled by state and territory drugs and poisons legislation, all of which refer to a nationally-accepted Standard for Uniform Scheduling of Drugs and Poisons devised by the Therapeutic Goods Administration of the Australian Government.9 In an exemption considered by many public health interests to be anomalous, tobacco prepared and packed for smoking is excluded from the standard. See Chapter 12 for further information.

3.20.2 Green tobacco sickness

Green tobacco sickness (GTS) affects individuals involved in tobacco farming, especially during the harvesting season.10, 11 GTS occurs when nicotine is absorbed through the skin from direct contact with tobacco leaves and enters the bloodstream. Sufferers commonly experience dizziness, nausea, headache and vomiting; less frequent symptoms include abdominal pain, shortness of breath, diarrhoea, altered heart rate and blood pressure, sweating and increased salivation.10, 11 Non-smokers are more likely to be affected by GTS than smokers,12 which has in some cases lead to tobacco growers encouraging workers to take up smoking.11 GTS is treated with rest and rehydration, and treatment of additional symptoms if required. The incidence of GTS is reduced by provision of appropriate protective clothing and other workplace safety measures.10 11

GTS is common, a recent international review reporting that 8–89% of tobacco harvesters may be affected in the course of a season, this wide variation probably being due to differences between study methodologies as well as a range of working conditions.11 There are an estimated 33 million tobacco farm workers in the world, a substantial proportion living in developing countries. Long-term health outcomes for individuals exposed to nicotine transdermally for extended periods of time are not known.11

3.20.3 Carbon monoxide poisoning

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1. US Department of Health and Human Services. The health consequences of smoking. Nicotine addiction. A report of the Surgeon General. Rockville, Maryland: Center for Health Promotion and Education, Office on Smoking and Health, DHHS Publication No (CDC) 88-8406, 1988. Available from: http://profiles.nlm.nih.gov/NN/B/B/Z/D/segments.html

2. US Department of Health and Human Services, The health consequences of smoking - 50 years of progress, 2014, US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health: Atlanta, GA.

3. McGee D, Brabson T, McCarthy J and Picciotti M. Four-year review of cigarette ingestions in children. Pediatric Emergency Care 1995;11:13-16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7739954

4. Woolf A, Burkhart K, Caraccio T and Litovitz T. Childhood poisoning involving transdermal nicotine patches. Pediatrics 1997;99:e4. Available from: http://pediatrics.aappublications.org/cgi/content/abstract/99/5/e4

5. Connolly G, Richter P, Aleguas A, Jr, Pechacek T, Stanfill S and Alpert H. Unintentional child poisonings through ingestion of conventional and novel tobacco products. Pediatrics 2010;125(5):896–9. Available from: http://pediatrics.aappublications.org/content/125/5/896.long

6. Corkery J, Button J, Vento A and Schifano F. Two UK suicides using nicotine extracted from tobacco employing instructions available on the Internet. Forensic Science International 2010;199((1–3)):e9–13. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20202767

7. Schneider S, Diederich N, Appenzeller B, Schartz A, Lorang C and Wennig R. Internet suicide guidelines: report of a life-threatening poisoning using tobacco extract. Journal of Emergency Medicine 2010;38(5):610–3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19272738

8. Solarino B, Rosenbaum F, Riesselmann B, Buschmann C and Tsokos M. Death due to ingestion of nicotine-containing solution: case report and review of the literature. Forensic Science International 2010;195((1–3)):e19–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19954906

9. Therapeutic Goods Administration. Standard for the uniform scheduling of drugs and poisons (SUSDP). Canberra, Australia: Department of Health and Ageing, 2007. Available from: http://www.tga.gov.au/ndpsc/susdp.htm

10. McBride JS, Altman DG, Klein M and White W. Green tobacco sickness. Tobacco Control 1998;7:294-8. Available from: http://tobaccocontrol.bmj.com/cgi/reprint/7/3/294

11. Schmitt N, Schmitt J, Kouimintzis D and Kirch W. Health risks in tobacco farm workers - a review of the literature. Journal of Public Health 2007;15:255-64. Available from: http://www.springerlink.com/content/rq0351564h1v60jp/

12. Arcury TA, Quandt SA and Preisser JS. Predictors of incidence and prevalence of green tobacco sickness among Latino farmworkers in North Carolina, USA. Journal of Epidemiology and Community Health 2001;55:818-24. Available from: http://jech.bmj.com/cgi/reprint/55/11/818