Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

112 III. SUBSTANCES OF ABUSEto relapse after they have been abstinent for 3 months, the potential for relapseremains present for many years (Ockene, Hymowitz, Lagus, & Shaten, 1991).CLINICAL FEATURESUnder normal circumstances, cigarette smoking and other forms of tobacco usedo not cause obvious states of intoxication, nor does their chronic use lead toorganic brain damage, although acute effects of nicotine may affect vigilanceand memory (U.S. Department of Health and Human Services, 1988). Overdosetypically is not a problem, and acute effects of nicotine on health havereceived less attention than chronic effects in the medical literature.A number of poisonings and deaths from ingestion of nicotine, primarilyinvolving nicotine-containing pesticides, have been reported, and acute intoxicationhas been observed in children after swallowing tobacco materials (U.S.Department of Health and Human Services, 1988). The lethal oral dose of nicotinein adults has been estimated at 40–60 mg (U.S. Department of Healthand Human Services, 1988). Nicotine intoxication produces nausea, vomiting,abdominal pain, diarrhea, headaches, sweating, and pallor. More severe intoxicationresults in dizziness, weakness, and confusion, progressing to convulsions,hypotension, and coma. Death is usually due to paralysis of respiratory musclesand/or central respiratory control (U.S. Department of Health and Human Services,1988).As noted previously, the chronic effects of cigarette smoking take a massivetoll. The role of cigarette smoking in the pathogenesis of coronary heartdisease, lung and other cancers, and chronic obstructive lung disease, as well asmany other forms of illness, has been dramatically documented in a series ofreports by U.S. surgeons general dating back to 1964 (U.S. Public Health Service,1964). Cigarette smoking has been cited as the chief avoidable cause ofdeath and morbidity in our society, and the number one public health problemof our time (U.S. Department of Health and Human Services, 1989b).The problems of cigarette smoking and tobacco-related diseases are notlimited to the United States. Worldwide, approximately 1.1 billion people ages15 and older smoke; 300 million live in developed countries, and 800 million indeveloping countries. About one-third of the world’s adults smoke. Four millionpeople die yearly from tobacco-related disease, one death every 8 seconds.If current trends continue, the toll will rise to 10 million by 2030, one deathevery 3 seconds (World Health Organization, 1999).The acute effects of nicotine also are important, having been implicated insudden heart attack death and stroke (Black, 1990). Cigarette smoking andother forms of tobacco use are contraindicated in patients with heart disease,hypertension, diabetes, chronic obstructive lung disease, and diseases of the gastrointestinaltract, for fear that nicotine and other components of tobacco will