In the JournalsPerspective

Many parents ignorant of e-cigarette poisoning risks to children

While e-cigarette use was found in 12.3% of households, often alongside regular cigarettes, many parents who used e-cigarettes were unaware of the potential health risks for children, such as nicotine poisoning, according to a recent survey.

“E-cigarettes generate little side-stream emissions, but the vapor exhaled by an e-cig user may contain nicotine, particles, heavy metals, and other constituents,” researcher Jane M. Garbutt, MB, ChB, from the department of pediatrics at Washington University School of Medicine, and colleagues wrote. “However, the health implications of bystander exposure to exhaled e-vapor remain unclear, particularly regarding children. More worrisome for children’s safety is the risk of acute nicotine toxicity through unintentional exposure to concentrated nicotine in e-liquid.”

To obtain information regarding parental knowledge of cigarette and their own personal use, Garbutt and colleagues distributed a questionnaire to 15 pediatric clinics in the St. Louis area. In addition to household use of cigarettes or e-cigarettes, parents/guardians (n = 658) were surveyed regarding their knowledge of the dangers of e-cigarette exposure for children through inhalation, skin absorption and ingestion.

Surveyed participants were asked if and where e-cigarettes were used in the home, how often they were used and what kinds of e-cigarette products were used. Participants also were surveyed regarding their pediatricians’ awareness of home use of e-cigarettes and the parent’s desire to receive information about e-cigarette safety from the pediatrician.

Forty-one percent of surveyed participants estimated that children viewed their daily e-cigarette use, with the most commonly used e-cigarette devices consisting of nicotine-containing (64.9%) and refillable (66.2%) devices; 57.1% of participants reported sweet-flavored e-liquids were occasionally used.

Furthermore, 36% of respondents said they neither locked up e-liquid bottles nor used childproof caps, while 19.7% used childproof caps, and 8.2% locked up e-liquid. Participants reported that e-liquid was most commonly stored in a drawer or cupboard (33.8%), a purse or bag (22.1%) and on an open counter or shelf (13%).

“Three percent of the people in our study said a child of theirs had tried to drink the e-liquid,” Garbutt said in a press release. “The easiest way to lower risk is to store e-liquid out of the reach of children. Open counters and shelves, unlocked drawers, and purses and bags aren’t safe storage places.”

The researchers said 47.2% of participants reported their pediatrician was unaware of e-cigarette use in the home, 5.6% had discussed e-cigarette use and safe storage of e-liquid with their pediatrician, yet 27.8% of participants said they would like to open this discussion. – by Bob Stott

Disclosure: The researchers report no relevant financial disclosures.

While e-cigarette use was found in 12.3% of households, often alongside regular cigarettes, many parents who used e-cigarettes were unaware of the potential health risks for children, such as nicotine poisoning, according to a recent survey.

“E-cigarettes generate little side-stream emissions, but the vapor exhaled by an e-cig user may contain nicotine, particles, heavy metals, and other constituents,” researcher Jane M. Garbutt, MB, ChB, from the department of pediatrics at Washington University School of Medicine, and colleagues wrote. “However, the health implications of bystander exposure to exhaled e-vapor remain unclear, particularly regarding children. More worrisome for children’s safety is the risk of acute nicotine toxicity through unintentional exposure to concentrated nicotine in e-liquid.”

To obtain information regarding parental knowledge of cigarette and their own personal use, Garbutt and colleagues distributed a questionnaire to 15 pediatric clinics in the St. Louis area. In addition to household use of cigarettes or e-cigarettes, parents/guardians (n = 658) were surveyed regarding their knowledge of the dangers of e-cigarette exposure for children through inhalation, skin absorption and ingestion.

Surveyed participants were asked if and where e-cigarettes were used in the home, how often they were used and what kinds of e-cigarette products were used. Participants also were surveyed regarding their pediatricians’ awareness of home use of e-cigarettes and the parent’s desire to receive information about e-cigarette safety from the pediatrician.

Forty-one percent of surveyed participants estimated that children viewed their daily e-cigarette use, with the most commonly used e-cigarette devices consisting of nicotine-containing (64.9%) and refillable (66.2%) devices; 57.1% of participants reported sweet-flavored e-liquids were occasionally used.

Furthermore, 36% of respondents said they neither locked up e-liquid bottles nor used childproof caps, while 19.7% used childproof caps, and 8.2% locked up e-liquid. Participants reported that e-liquid was most commonly stored in a drawer or cupboard (33.8%), a purse or bag (22.1%) and on an open counter or shelf (13%).

“Three percent of the people in our study said a child of theirs had tried to drink the e-liquid,” Garbutt said in a press release. “The easiest way to lower risk is to store e-liquid out of the reach of children. Open counters and shelves, unlocked drawers, and purses and bags aren’t safe storage places.”

The researchers said 47.2% of participants reported their pediatrician was unaware of e-cigarette use in the home, 5.6% had discussed e-cigarette use and safe storage of e-liquid with their pediatrician, yet 27.8% of participants said they would like to open this discussion. – by Bob Stott

Disclosure: The researchers report no relevant financial disclosures.

    Perspective
    James D. Sargent

    James D. Sargent

    Garbutt and colleagues surveyed a regional sample of parents from pediatric practices in Missouri about their e-cigarette use and their knowledge about the dangers liquid nicotine could pose to children in their households. They found that about 10% of households had someone using e-cigarettes and that the majority of them used rechargeable devices and had liquid nicotine (commonly referred to as e-juice), around the house. Most were aware it was poisonous if ingested, but few understood that it can be absorbed through skin and few took precautions to keep the liquid out of the reach of children.

    The nicotine concentration in e-juice ranges from 15 mg to 180 mg nicotine in each teaspoon of solution. E-cigarette shops buy pharmaceutical-grade nicotine and dilute it with propylene glycol to get the right strength. Then they add flavoring. “Grape freeze,” “simply mango” and “bubblegum jungle” are just a few of the many flavors available on the market. It’s the flavors that make liquid nicotine a prime candidate for ingestion by infants and young children.

    E-juice poisonings in children would be largely prevented by regulation that applies what we have learned about keeping children safe from other drugs. Think about acetaminophen, the drug most doctors recommend to treat fever in young children and supplied as a solution that can be administered to infants using a medicine dropper. The most important principle to prevent poisoning is to distribute the poison in a child-resistant bottle, engineered to be tough to open for children aged younger than 5 years. Second, the drug should come in bottles that contain nonlethal doses. So even if a child gets into the bottle and drinks the entire contents, she will not end up dead. Third, there should be a prominently displayed warning label that includes the dermal absorption hazard, a statement that the amount of nicotine in e-liquids can pose a serious risk, especially for small children, and that care should be taken to keep products out of the reach of children and pets.

    The Consumer Product Safety Commission implements the Poison Prevention Packaging Act, which requires household substances to be packaged in child-resistant packaging. Since 1970, when the regulation took effect, there have been remarkable declines in reported deaths from ingestions by children of toxic household products including medications. However, the tobacco industry successfully lobbied to have tobacco products specifically exempted from the jurisdiction of the CPSC.

    The Child Nicotine Poisoning Prevention Act of 2014 would remove that exemption for e-liquid (https://www.congress.gov/bill/114th-congress/senate-bill/142). That bill has garnered strong support from pediatric societies, but has not passed the House or Senate at this time.

    A more likely avenue for accomplishing the same thing is through FDA regulation by the Center for Tobacco Products, which is in the process of deeming e-cigarettes so that they fall under FDA regulatory authority. The FDA is actively seeking input from the public through the docket process on how best to label and distribute e-liquid. Docket FDA-2015-N-1514 seeks “comments, data, research results, or other information that may inform regulatory actions FDA might take with respect to nicotine exposure warnings and child-resistant packaging for liquid nicotine and nicotine-containing e-liquid(s) that are made or derived from tobacco and intended for human consumption.”

    The docket is available for public comment at http://www.regulations.gov/#!documentDetail;D=FDA-2015-N-1514-0090 until the end of September, and pediatricians are encouraged to contribute to that public conversation based on their experiences with e-liquid poisonings and their prior contributions in decreasing risk of ingestion of other drugs.

    It looks like e-cigarettes are here to stay. It is important for pediatricians to help the FDA craft regulations for these products that will keep children from poisoning themselves and minimize the chances adolescents will use these products.

    • James D. Sargent, MD
    • Professor of pediatrics Geisel School of Medicine at Dartmouth Co-Director, Cancer Control Research Program Norris Cotton Cancer Center

    Disclosures: Sargent reports no relevant financial disclosures.