Clinical Toxicology (2014), 52, 449–450 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 1556-3650 print / 1556-9519 online DOI: 10.3109/15563650.2014.918998
COMMENTARY
Electronic cigarettes: Another pediatric toxic hazard in the home? J. A. LOWRY
Clinical Toxicology Downloaded from informahealthcare.com by University of Queensland on 06/11/14 For personal use only.
Division of Clinical Pharmacology and Medical Toxicology, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri School of Medicine. Kansas City, MO, USA
Electronic cigarettes (e-cigarettes) have recently gained attention in the media as an alternative to traditional smoking due to its increased use and lack of regulation. Originally marketed as a tobacco reduction or smoking cessation product, recreational use of e-cigarettes in adolescents and adults has doubled from 2010 to 2012.1,2 Current use in Great Britain rose from 2.7% of adult smokers studied in 2010 to 6.7% in 2012.2 Alternatively, adolescent data reveal that 9.3% of ever cigarette users had reported never smoking conventional cigarettes.1 This trend in increased use has been associated with increased calls to the U.S. Poison Control Centers as evident in the article by Vakkalanka et al. in this issue.3 In their study, unintentional exposures in children less than 6 years of age accounted for the most calls to poison control centers compared with other age groups. While the majority of patients followed had no more than minor effects reported, moderate, and major effects were found in this study. One fatality was reported, and, unfortunately, the clinical effects were not accounted for this age. Additionally, poison center data are unable to verify dose resulting in an incomplete account for the seriousness of these exposures. Parents and clinicians should be alarmed at these numbers and recognize the potential risk of harm to children and adolescents. It is known that children under the age of 6 years account for the majority of calls to poison control centers. Potential toxic exposures are relatively common in this age group due to their curious nature and frequent hand-to-mouth behaviors. Anticipatory guidance for poisoning prevention starts at the 9-month well-child visit and should continue for adolescents. However, unintentional poisonings in young children occur despite our best efforts often because caregivers do not recognize that harm can occur. Many chemicals are present in tobacco products that, used chronically, can result in harm. However, acute tobacco
poisoning is largely due to the effects of nicotine. Nicotine binds to nicotinic acetylcholine receptors primarily in the autonomic nervous system. Early toxic signs and symptoms are reflective of nicotinic cholinergic excess. Vomiting is the most common symptom. However, high doses of nicotine can result cardiac and neurologic adverse effects with tachycardia, agitation, and seizures occurring early; progressing to late manifestations of bradycardia, dysrhythmias, lethargy, and paralysis. While e-cigarettes are believed to be a safer form of “smoking”, this does not equate to safer forms of nicotine. Nicotine concentrations in e-cigarette solutions vary as there is no standard dose for manufacturers. E-cigarette solutions have mean nicotine concentrations of 8.5–22.2 mg/mL.4 Refills are sold in 5, 10, or 20 mL vials. For most children and adults, this exceeds the estimated lethal dose for nicotine in humans of 1 mg/kg. With the additional flavors/scents (e.g., strawberry, licorice, and chocolate) and the optional child-resistant packaging, children are at risk for toxicity that is known to occur with ingestion and dermal exposure to nicotine. Nicotine cartridges are easily replaced by simply twisting it off from the battery. A new cartridge can be placed in the chamber or the old can be refilled. The cartridge can be opened with tweezers or a small screwdriver; however, no studies have assessed the ability to open these products with teeth. Few of these products have child-resistant packaging. While the potential risk to young children are real, current practice shows that adolescents are engaging in risky behaviors now. The National Youth Tobacco Survey (NYTS) demonstrates that adolescents in grades 6–12 have doubled their use of e-cigarettes from 2011 and 2012, from 3.3% to 6.8%.1 This is concerning. The absorbed nicotine yield from a traditional smoked cigarette is on the order of 0.05–3 mg/ cigarette. This is much less than the exposure from ingestion. However, systemic nicotine and cotinine concentrations are similar to traditional cigarette smokers in current e-cigarette smokers.5 Recent internet blogs suggest that e-cigarette smokers use on average 2 cartridges a day which is the equivalent of 40 traditional cigarettes. Thus, daily nicotine exposures may be higher with e-cigarettes than smokers anticipate. Nicotine is highly addictive.6 Dopamine, a
Received 22 April 2014; accepted 24 April 2014. Address correspondence to Jennifer Lowry, MD, Division of Clinical Pharmacology and Therapeutic Innovations, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City, MO 64108, USA. Tel: ⫹(816)-234-3059. Fax: ⫹(816)-855-1958. E-mail: [email protected]
449
Clinical Toxicology Downloaded from informahealthcare.com by University of Queensland on 06/11/14 For personal use only.
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J. A. Lowry
neurotransmitter involved in mediating addiction, may be 30% higher in smokers versus nonsmokers.7 Additionally, Trauth et al.8 suggest that nicotine in adolescents produce immediate and long-term changes in the central nervous system resulting in behavioral changes. Further study of the NYTS cohort found that the use of e-cigarettes was associated with higher odds of cigarette smoking and higher odds of chronic use.9 Use of e-cigarettes may not discourage (and may, actually, encourage) cigarette use in adolescents. While the risks are different in young children compared with adolescents, appropriate regulation of e-cigarettes would go far in preventing harm from these exposures. Currently, e-cigarette advertising expenditures are on the rise with increased focus on national markets and television advertisements. Expenditures rose from $6.4 million in 2011 to over $18 million in 2012 with more than 80 brands advertised.10 The Food and Drug Administration has proposed to regulate (e.g., registration, product and ingredient listing, user fees for certain products, premarket requirements, and adulteration and misbranding provisions) e-cigarettes similar to tobacco products. Additionally, the FDA would seek to reduce initiation and increase cessation particularly for youth. Unfortunately, the proposal, submitted in October 2013, remains under review by the Office of Management and Budget. Further regulations are necessary and include restrictions on nicotine content, safety warnings, and use of child-resistant packaging for the devices and cartridges. There are clear benefits to the use of e-cigarettes. The harm from traditional cigarettes is known, and the effects of second-hand smoke to children and those with diseases such as asthma has markedly increased morbidity and mortality. While tobacco cessation would be ideal, it is not realistic. As such, safer forms of “smoking” are necessary. However, this does not negate our responsibility and recognition that lack
of oversight and regulations regarding the tobacco industry have resulted in great harm.
Declaration of interest The author report no declaration of interest. The author alone is responsible for the content and writing of the paper.
References 1. Corey C, Wang B, Johnson SE, Apelberg B, Husten C, King BA, et al. Centers for Disease Control and Prevention. Notes from the field: electronic cigarette use among middle and high school students: United States, 2011-2012. MMWR 2013; 62:729–730. 2. Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes: prevalence and attitudes in Great Britain. Nicotine Tob Res 2013; 15:1737–1744. 3. Vakkalanka JP, Hardison L Holstege C. Epidemiological Trends in Electronic Cigarette Exposures Reported to U.S. Poison Centers. Clin Toxicol 2014; 52:542–548. 4. Cameron JM, Howell, DN, White JR, Andrenyak DM, Layton ME, Roll JM. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tob Control 2014; 23:77–78. 5. Schroeder MJ, Hoffman AC. Electronic cigarettes and nicotine clinical pharmacology. Tob Control 2014; 23:ii30–ii35. 6. West R. Nicotine: a dependence-producing substance. Prog Clin Biol Res 1988; 261:237–259. 7. Salokangas RK, Vlikman H, Ilonen T, Taiminen T, Bergman J, Haaparanta M, et al. High levels of dopamine activity in the basal ganglia of cigarette smokers. Am J Psychiatry 2000; 157:632–634. 8. Trauth JA, Seidler FJ, Ali SF, Slotkin TA. Adolescent nicotine exposure produces immediate and long-term changes in CNS noradrenergic and dopaminergic function. Brain Res 2001; 892:269–280. 9. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US Adolescents. A cross-sectional study. JAMA Pediatr 2014; published online March 6, 2014. 10. Kim AE, Arnold KY, Makarenko O. E-cigarette advertising expenditures in the U.S., 2011-2012. Am J Prev Med 2014; 46:409–412.
Clinical Toxicology vol. 52 no. 5 2014
COMMENTARY
Electronic cigarettes: Another pediatric toxic hazard in the home? J. A. LOWRY
Clinical Toxicology Downloaded from informahealthcare.com by University of Queensland on 06/11/14 For personal use only.
Division of Clinical Pharmacology and Medical Toxicology, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, University of Missouri School of Medicine. Kansas City, MO, USA
Electronic cigarettes (e-cigarettes) have recently gained attention in the media as an alternative to traditional smoking due to its increased use and lack of regulation. Originally marketed as a tobacco reduction or smoking cessation product, recreational use of e-cigarettes in adolescents and adults has doubled from 2010 to 2012.1,2 Current use in Great Britain rose from 2.7% of adult smokers studied in 2010 to 6.7% in 2012.2 Alternatively, adolescent data reveal that 9.3% of ever cigarette users had reported never smoking conventional cigarettes.1 This trend in increased use has been associated with increased calls to the U.S. Poison Control Centers as evident in the article by Vakkalanka et al. in this issue.3 In their study, unintentional exposures in children less than 6 years of age accounted for the most calls to poison control centers compared with other age groups. While the majority of patients followed had no more than minor effects reported, moderate, and major effects were found in this study. One fatality was reported, and, unfortunately, the clinical effects were not accounted for this age. Additionally, poison center data are unable to verify dose resulting in an incomplete account for the seriousness of these exposures. Parents and clinicians should be alarmed at these numbers and recognize the potential risk of harm to children and adolescents. It is known that children under the age of 6 years account for the majority of calls to poison control centers. Potential toxic exposures are relatively common in this age group due to their curious nature and frequent hand-to-mouth behaviors. Anticipatory guidance for poisoning prevention starts at the 9-month well-child visit and should continue for adolescents. However, unintentional poisonings in young children occur despite our best efforts often because caregivers do not recognize that harm can occur. Many chemicals are present in tobacco products that, used chronically, can result in harm. However, acute tobacco
poisoning is largely due to the effects of nicotine. Nicotine binds to nicotinic acetylcholine receptors primarily in the autonomic nervous system. Early toxic signs and symptoms are reflective of nicotinic cholinergic excess. Vomiting is the most common symptom. However, high doses of nicotine can result cardiac and neurologic adverse effects with tachycardia, agitation, and seizures occurring early; progressing to late manifestations of bradycardia, dysrhythmias, lethargy, and paralysis. While e-cigarettes are believed to be a safer form of “smoking”, this does not equate to safer forms of nicotine. Nicotine concentrations in e-cigarette solutions vary as there is no standard dose for manufacturers. E-cigarette solutions have mean nicotine concentrations of 8.5–22.2 mg/mL.4 Refills are sold in 5, 10, or 20 mL vials. For most children and adults, this exceeds the estimated lethal dose for nicotine in humans of 1 mg/kg. With the additional flavors/scents (e.g., strawberry, licorice, and chocolate) and the optional child-resistant packaging, children are at risk for toxicity that is known to occur with ingestion and dermal exposure to nicotine. Nicotine cartridges are easily replaced by simply twisting it off from the battery. A new cartridge can be placed in the chamber or the old can be refilled. The cartridge can be opened with tweezers or a small screwdriver; however, no studies have assessed the ability to open these products with teeth. Few of these products have child-resistant packaging. While the potential risk to young children are real, current practice shows that adolescents are engaging in risky behaviors now. The National Youth Tobacco Survey (NYTS) demonstrates that adolescents in grades 6–12 have doubled their use of e-cigarettes from 2011 and 2012, from 3.3% to 6.8%.1 This is concerning. The absorbed nicotine yield from a traditional smoked cigarette is on the order of 0.05–3 mg/ cigarette. This is much less than the exposure from ingestion. However, systemic nicotine and cotinine concentrations are similar to traditional cigarette smokers in current e-cigarette smokers.5 Recent internet blogs suggest that e-cigarette smokers use on average 2 cartridges a day which is the equivalent of 40 traditional cigarettes. Thus, daily nicotine exposures may be higher with e-cigarettes than smokers anticipate. Nicotine is highly addictive.6 Dopamine, a
Received 22 April 2014; accepted 24 April 2014. Address correspondence to Jennifer Lowry, MD, Division of Clinical Pharmacology and Therapeutic Innovations, Department of Pediatrics, Children’s Mercy Hospitals and Clinics, Kansas City, MO 64108, USA. Tel: ⫹(816)-234-3059. Fax: ⫹(816)-855-1958. E-mail: [email protected]
449
Clinical Toxicology Downloaded from informahealthcare.com by University of Queensland on 06/11/14 For personal use only.
450
J. A. Lowry
neurotransmitter involved in mediating addiction, may be 30% higher in smokers versus nonsmokers.7 Additionally, Trauth et al.8 suggest that nicotine in adolescents produce immediate and long-term changes in the central nervous system resulting in behavioral changes. Further study of the NYTS cohort found that the use of e-cigarettes was associated with higher odds of cigarette smoking and higher odds of chronic use.9 Use of e-cigarettes may not discourage (and may, actually, encourage) cigarette use in adolescents. While the risks are different in young children compared with adolescents, appropriate regulation of e-cigarettes would go far in preventing harm from these exposures. Currently, e-cigarette advertising expenditures are on the rise with increased focus on national markets and television advertisements. Expenditures rose from $6.4 million in 2011 to over $18 million in 2012 with more than 80 brands advertised.10 The Food and Drug Administration has proposed to regulate (e.g., registration, product and ingredient listing, user fees for certain products, premarket requirements, and adulteration and misbranding provisions) e-cigarettes similar to tobacco products. Additionally, the FDA would seek to reduce initiation and increase cessation particularly for youth. Unfortunately, the proposal, submitted in October 2013, remains under review by the Office of Management and Budget. Further regulations are necessary and include restrictions on nicotine content, safety warnings, and use of child-resistant packaging for the devices and cartridges. There are clear benefits to the use of e-cigarettes. The harm from traditional cigarettes is known, and the effects of second-hand smoke to children and those with diseases such as asthma has markedly increased morbidity and mortality. While tobacco cessation would be ideal, it is not realistic. As such, safer forms of “smoking” are necessary. However, this does not negate our responsibility and recognition that lack
of oversight and regulations regarding the tobacco industry have resulted in great harm.
Declaration of interest The author report no declaration of interest. The author alone is responsible for the content and writing of the paper.
References 1. Corey C, Wang B, Johnson SE, Apelberg B, Husten C, King BA, et al. Centers for Disease Control and Prevention. Notes from the field: electronic cigarette use among middle and high school students: United States, 2011-2012. MMWR 2013; 62:729–730. 2. Dockrell M, Morrison R, Bauld L, McNeill A. E-cigarettes: prevalence and attitudes in Great Britain. Nicotine Tob Res 2013; 15:1737–1744. 3. Vakkalanka JP, Hardison L Holstege C. Epidemiological Trends in Electronic Cigarette Exposures Reported to U.S. Poison Centers. Clin Toxicol 2014; 52:542–548. 4. Cameron JM, Howell, DN, White JR, Andrenyak DM, Layton ME, Roll JM. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tob Control 2014; 23:77–78. 5. Schroeder MJ, Hoffman AC. Electronic cigarettes and nicotine clinical pharmacology. Tob Control 2014; 23:ii30–ii35. 6. West R. Nicotine: a dependence-producing substance. Prog Clin Biol Res 1988; 261:237–259. 7. Salokangas RK, Vlikman H, Ilonen T, Taiminen T, Bergman J, Haaparanta M, et al. High levels of dopamine activity in the basal ganglia of cigarette smokers. Am J Psychiatry 2000; 157:632–634. 8. Trauth JA, Seidler FJ, Ali SF, Slotkin TA. Adolescent nicotine exposure produces immediate and long-term changes in CNS noradrenergic and dopaminergic function. Brain Res 2001; 892:269–280. 9. Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US Adolescents. A cross-sectional study. JAMA Pediatr 2014; published online March 6, 2014. 10. Kim AE, Arnold KY, Makarenko O. E-cigarette advertising expenditures in the U.S., 2011-2012. Am J Prev Med 2014; 46:409–412.
Clinical Toxicology vol. 52 no. 5 2014
