E-cig poisonings spike; APhA calls for stricter regulations

Poison-control centers nationwide are reporting a spike in calls concerning ingestion of liquid nicotine used in electronic cigarettes (e-cigarettes). The American Association of Poison Control Centers (AAPCC) reported 3,638 exposures to liquid nicotine and e-cigarettes for the first 11 months of 2014. That was more than double the number of exposures reported in 2013 and eight times the exposures in 2012.

See also: E-cigs: Healthy tobacco alternative? Definitely not 

In December, a one-year-old boy in upstate New York became the first person known to die from ingestion of liquid nicotine.

“The safety of liquid nicotine and its components is an issue,” said Mitchel C. Rothholz, chief strategy officer for the American Pharmacy Association (APhA). “The product needs to be secured well away from kids.”

The APhA House of Delegates wants more than safer storage for liquid nicotine. The body voted to oppose the sale of e-cigarettes and other vaporized nicotine products in pharmacies.

APhA opposes the use of e-cigarettes and other vaporized nicotine products in areas subject to current clean air regulation for combustible tobacco products, until and unless scientific data can support the health and safety of vaporized nicotine products. APhA also called on the FDA to require the full disclosure of all ingredients in e-cigarettes and other vaporized nicotine products, both in the vapor state and in the pre-use state.

Stricter regulation needed

The pharmacy association joins other health organizations calling for stricter regulation of e-cigarettes. The American Medical Association, the American Association for Cancer Research, the American Society for Clinical Oncology, and other groups have called for stricter regulation of e-cigarettes and more research into the health implications of what the e-cigarette industry calls “vaping.”

The healthcare community more often refers to electronic nicotine delivery systems, or ENDS, when discussing e-cigarettes. Regardless of the name, the devices vaporize liquid nicotine, which is typically colored, flavored, and sweetened to enhance consumer appeal.

What about the kids?

A national interest group, the American Vaping Association, points to e-cigarettes as an effective smoking cessation aid. Yet the CDC noted that the use of e-cigarettes has more than doubled among middle school and high school students.

See also: New study links se-cigs to conventional cigarette use among teens

Bright colors and candy-like flavors also appeal to young children. More than half the poison-center calls concerning liquid nicotine involve children under the age of six.

AAPCC President Jay Schauben, PharmD, noted that as little as a teaspoon of liquid nicotine can be lethal to a child, and smaller amounts can induce severe illness.

E-cigarette refill containers typically contain between 5 and 500 mL of liquid nicotine. They are not available with safety caps or other packaging designed to discourage children from accessing the contents.

FDA is considering regulation of e-cigarettes and their components, including liquid nicotine, but the products are effectively unregulated at the federal level.

To the ED

Standard poison-center nicotine protocols call for immediate transport to the nearest emergency department for all pediatric ingestions of liquid nicotine.

Asymptomatic children should remain under observation for at least four hours.

Symptomatic children should remain under observation until symptoms resolve.

Anti-emetics such as ondansetron (Zofran; GlaxoSmithKline) and IV rehydration may be used to control vomiting and may require serum electrolyte monitoring.

Poisonings on the increase

Because devices that vaporize nicotine are relatively new, there is little solid research into the health effects on the user - or on bystanders who may inhale second-hand vapor. Long-term research on the health impact of inhaling vaporized nicotine is entirely absent. But accidental poisoning is on the rise.

The Centers for Disease Control and Prevention reported 215 calls to poison-control centers for liquid nicotine during the month of Feb. 2013. That compares to one call per month in 2010.

A spokesman said the 2013 report represents CDC’s latest findings on liquid nicotine. Individual poison-control centers have more current data.

“We have seen an increase in calls from seven in 2001 and nine in 2012 to 21 in 2013 and 84 in 2014,” said Zane Horowitz, MD, medical director for the Oregon Poison Control Center and professor in the department of emergency medicine at Oregon Health Sciences University in Portland, Ore. “Of those 84 calls for e-cigarette liquid exposure, 64 were children accidentally drinking this product.”

In a California report released at the end of January, it was noted that e-cigarette-related calls to poison centers involving children five years and younger jumped from seven cases in 2012 to 154 cases in 2014, accounting for 60% of all calls for e-cig poisoning.