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Clinical Summary

Nicotine is a naturally occurring alkaloid found primarily in tobacco. Nicotine delivery methods include cigarettes, pipe and cigar tobacco, smokeless tobacco, electronic cigarettes, nicotine gum, and lozenges. Long-term complications of nicotine use include coronary artery disease, stroke, peripheral vascular disease, thromboangiitis obliterans (Fig. 27.22A), chronic obstructive lung disease, and oropharyngeal and pulmonary malignancies. Lighting a cigarette while using supplemental oxygen may cause flash burns (Fig. 27.23). Cigarette smoking also causes staining of nails and teeth due to both direct staining from tar and nicotine as well as vascular vasoconstriction mediated by the nicotine and carbon monoxide present in tobacco smoke (Fig. 27.22B). More recently, the increased use of electronic cigarettes (vaping) has resulted in a rise in e-cigarette– and vaping-associated lung injury (EVALI) with typical manifestations of bilateral ground-glass opacities on chest CT (Figs. 27.25 and 27.26).

FIGURE 27.22A

Tobacco Use Disorder—Thromboangiitis Obliterans. Fingertips of a patient with chronic nicotine use with Buerger disease. Recurrent inflammation and thrombosis are associated with tobacco use. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.22B

Tobacco Use Disorder—Stained Fingers and Nails. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.23

Tobacco Use Disorder—Flash Facial Burns. Facial burns due to rapid combustion of a cigarette while using oxygen. The burns are typically confined to the face and do not involve the supraglottic structures or trachea. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.24

Tobacco Use Disorder—Electronic Cigarette Explosion Burns. Thermal burns to first web space and fingers when an electronic cigarette exploded in the user’s hand. (Photo contributor: Lawrence B. Stack, MD.)

FIGURE 27.25

Vaping-Associated Pulmonary Injury (VAPI)—Chest X-Ray. An anteroposterior chest radiograph that reveals bilateral airspace opacities. These findings in the context of vaping and excluding other causes are suspicious for VAPI. (Photo contributor: Kaitlyn R. Works, MD.)

FIGURE 27.26

Vaping-Associated Pulmonary Injury—Axial Chest CT. The chest CT of the patient in Figure 27.25 reveals bibasilar dependent consolidations with diffuse patch ground-glass opacities. These findings in the context of vaping and excluding other causes are suspicious for VAPI. (Photo contributor: Kaitlyn R. Works, MD.)

Management and Disposition

Treatment of complications of nicotine use disorder is largely supportive and depends on the specific manifestations presenting. Flash cigarette burns to the face prompt evaluation for airway compromise. Optimal treatment of EVALI is not known, although empiric antibiotics are recommended in addition ...

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