Soaring child poisonings from the fluid used in electronic cigarettes — especially in summer months — has prompted warnings about the risks of liquid nicotine exposure. The Centers for Disease Control and Prevention recently announced that reports of adverse e-cigarette exposure to U.S. poison control centers climbed from one in September 2010 to 1,351 in 2013. More than half of the e-cigarette exposures involved children under 5 years old. And 365 people in the 2013 reports to poison control centers were urged to go to hospitals, triple the number in 2012. Apart from a suicidal injection of e-cigarette liquid, no other fatalities have been reported in the U.S. But The Times of Israel reported last year that a 2-year-old girl died after drinking a small bottle of the fluid that her grandfather had used to refill his electronic device. The most common adverse health effects in e-cigarette exposure calls were vomiting, nausea and eye irritation, the CDC reported. One suicide death from intravenous injection of nicotine liquid was reported to poison control in Kansas. Small children typically can’t get the liquid out of the e-cigarette cartridges, product makers stress. But the cartridges are refilled with “juice,” often purchased in volumes of a gallon or more. Drinking only a teaspoon or so, the official said, could cause serious side effects or be lethal to a child. The nicotine in the liquid is the biggest concern, and the product is so new that scientists don’t yet know whether the ingredients are harmful, Dr. Lee Cantrell, director of the San Diego division of the California Poison Control System, told Promises Behavioral Health.
Fear for Children
“It’s not a matter of if a child will be seriously poisoned or killed,” Cantrell, who is also a professor of pharmacy at UC San Francisco, told the New York Times. “It’s a matter of when.” And young children aren’t the only ones whose health may suffer as a result of the influx of the devices. Cantrell and other public health officials fear that e-cigarettes will become a “gateway” drug to tobacco cigarettes. The concentration of nicotine in the juice can vary wildly due to a lack of standardization — from a boutique brand crafting small flavor batches (mac and cheese, anyone?) to corporate manufacturers selling online globally. “Nicotine itself is one of the most potent naturally occurring things there is,” Cantrell said. “There used to be over-the-counter nicotine products, sold for use as pesticide. But they were just too toxic.” (The nicotine was mixed with water to dilute it and then sprayed over whatever needed eliminating.)Young children are drawn to the liquid’s bright colors and flavorings, such as chocolate, tutti-frutti and bubble gum. Thus, public health officials cautioned users to secure the e-cigarette fluid out of reach. ‘‘We’re tremendously concerned,’’ James Perrin of the American Academy of Pediatrics told the Boston Globe. ‘‘This stuff is incredibly toxic, and it’s also not regulated in any way…. The public is really remarkably unaware of the serious dangers of this.’’ That may change as the Food and Drug Administration and other public health officials this year consider regulations surrounding the sale and marketing of the increasingly popular products. Critics of the Obama administration’s response to the explosion in e-cigarette use — including an editorial in the New York Times — say the FDA has been slow in taking action to safeguard the public from health risks. In addition to the accidental poisoning are concerns that the devices’ odorless vapor will mask drug use, particularly by young people, for whom marijuana has been found to cause damage to still-developing brains. Created as a tool to wean smokers off nicotine and free them from carcinogenic tobacco chemicals, electronic cigarettes were almost unheard of when they hit the U.S. in 2007. They’ve now rocketed into a $2-billion industry that is forecast to overtake tobacco cigarettes globally within a decade, according to Bonnie Herzog, Wells Fargo Securities’ senior tobacco industry analyst. With the market entry of Big Tobacco and its huge money, distribution systems and branding horsepower, industry growth may accelerate even faster, her team has told investors. The devices use a battery to heat the flavored liquid, creating a vapor steam that is inhaled. Legions of smokers say they’ve been able to kick tobacco cigarettes by tapering down the nicotine levels in their devices. Advocates of vaping stress that tobacco cigarettes have far more nicotine than the most potent e-cigarette. They also note the abysmally low quit rate for tobacco smokers and believe e-cigarettes offer a potentially huge public health win. And a study in the U.K. showed smokers are more successful at quitting when they use e-cigarettes. In discussing the proposed regulations, John Wiesehan, chief executive of e-cigarette maker Mistic, told CNN that the company avoids marketing to anyone under 18.
Huge Money Working Behind the Scenes
The entrance of Big Tobacco to the marketplace has only fueled distrust of the huge sums of money being poured into the marketing of e-cigarettes that, unlike tobacco, can be advertised on television. Amid the rocketing marketplace, from online storefront to your local gas station, public health officials have expressed alarm and warnings about exposure to children — be it handling, inhaling or ingesting the liquid that often carries nicotine. Nicotine-free vaping liquid was not identified in the findings; nicotine is the ingredient over which the FDA justifies its aim to regulate e-cigarette use as a tobacco byproduct. Anti-smoking activists such as leaders of the American Cancer Society and federal health officials are lobbying for strict regulation of the devices and fluids to prevent a new wave of tobacco use after steady declines. They argue that the verdict from scientists is still out as to whether the ingredients, often unknown due to a lack of labeling requirements, are harmful. Research is underway to determine risks of the e-cigarette vapor and its residue becoming so-called third-hand smoke. Intense attention to e-cigarettes followed last fall’s CDC finding that e-cigarettes had been tried by double the number of middle school and high school students from 2011 to 2012. About 1.78 million students reported using e-cigarettes as of 2012, according to the CDC. That same year, about 160,000 students who reported using e-cigarettes had never used tobacco cigarettes. “This is a serious concern because the overall impact of e-cigarette use on public health remains uncertain,” the CDC said. After months of debate and expectation, the FDA finally announced in April the specifics of its proposed regulation of electronic cigarettes. Under the proposed rules, the makers of e-cigarettes would have to abide by these requirements:
- Register with the FDA and report product and ingredient listings.
- Market new tobacco products only after FDA review.
- Make direct or implied claims of reduced risk only if the FDA confirms that scientific evidence supports the claim and that marketing of the product would benefit public health.
- Stop distributing free samples.
- Require identification to prevent sales to underage youth.
- Include health warnings.
- End vending machine sales, unless in a facility that never admits youth.
Mitch Zeller, director of the FDA’s Center for Tobacco Products, said tobacco-linked disease and death is one of the most critical public health challenges before the FDA. The proposed rules would give the agency additional tools to protect the public health in today’s rapidly evolving tobacco marketplace, including the review of new tobacco products and their health-related claims. The CDC’s report on poison control calls also suggested that the number of e-cigarette-related calls might be underestimated due to under-reporting and a lack of use or awareness of the e-cigarette classification for poison control centers. Also, the public might simply have not reported some events. “Given the rapid increase in e-cigarette-related exposures, of which 51.1% were among young children, developing strategies to monitor and prevent future poisonings is critical,” the CDC concluded. “Healthcare providers, the public health community, e-cigarette manufacturers, distributors, sellers and marketers, and the public should be aware that e-cigarettes have the potential to cause acute adverse health effects and represent an emerging public health concern.”