e-Cigs: A Big Threat for the Littlest Kids

Robert A. Bassett, DO


May 27, 2014

Editorial Collaboration

Medscape &

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Hi. My name is Robb Bassett. I'm an emergency medicine physician and medical toxicologist here at the Philadelphia Poison Control Center at The Children's Hospital of Philadelphia.

I'm here today to talk to you about an emerging health threat: nicotine poisoning. Years of antitobacco campaigning and public health legislation have resulted in a new market for smokeless nicotine products. The main delivery device is known as the electronic (e-) cigarette. The basic premise is that a heat source is applied to liquid nicotine, atomizing or vaporizing it. This allows the user to inhale it and provides a sensation similar to that of smoking.

Proponents of this technology promote it as a healthy alternative to smoking. They evidence this by citing a reduction in chemicals and carcinogens. The truth is that there are some preliminary data that suggest even using e-cigarettes may have detrimental effects in the lungs. We simply don't have the long-term data to know for sure whether any benefit exists from switching from cigarettes to e-cigarettes.

Certainly there is some logic that says: If e-cigarettes can be used as a bridge to not only smoking cessation but nicotine cessation, the long-term benefits may outweigh the short-term risks. The reality is that that's not always the norm. Many people end up trying e-cigarettes and trading one addiction for another, and they never completely wean off nicotine altogether. Additionally, this unregulated market has opened up a whole new generation to nicotine products that might not have otherwise tried tobacco.

What has this led to? This has led to the ubiquitous availability of highly concentrated nicotine products, exposure to which can result in severe toxicity. To understand nicotine toxicity, we have to know nicotine. Nicotine is a potent, plant-derived parasympathomimetic alkaloid. I know: a mouthful. Essentially, it's an agonist of the nicotinic acetylcholine receptor.

At low doses, this results in stimulation of the reticular activating system as well as dopamine release. As the dose increases, we start to see cardiovascular effects, things like hypertension or tachycardia. Seizures are a mainstay of central nervous system toxicity. As we get into supertherapeutic and toxic dosing, we can start to see loss of receptor specificity, so we can get presentations that are more similar to the classic cholinergic toxidrome and include bronchorrhea, excessive secretions, and profound gastrointestinal disturbance. At very high or extreme doses, nicotine can result in neuromuscular blockade, analogous to organic phosphate poisoning or even nerve agent exposure, which leads to respiratory failure and even death.

Why are we talking about this now? Hasn't this been around for a long time? Of course, the answer is yes. Historically in kids, nicotine toxicity has come in the form of exploratory ingestions with tobacco. Traditionally, there has actually been sort of a protective mechanism or rate-limiting step built in. In other words, tobacco is so noxious to the gastrointestinal system that it is, quite frankly, hard for a child who is actively becoming nauseous and vomiting to ingest enough to be severely toxic.

Of note, if a child were to consume a first-generation e-cigarette that had a self-contained small liquid nicotine cartridge, it would often pass through their gastrointestinal tract completely and be eliminated before they were ever able to release enough nicotine to become severely toxic.

Where are we today? In the spring of 2014, the US Food and Drug Administration only regulates therapeutic nicotine products. Unfortunately, there's no regulation of the recreational nicotine market, which includes brand or trade names that you may recognize, like Nicorette® gum or Nicotrol® inhalers. Why is this a problem? There is no incentive to implement costly consumer protection. For example, we don't see consumer warning labels on any of these products discussing the risks associated with nicotine use or any other ingredients that might be included in the product. There's certainly no child-protective packaging on any of these products.

Finally, there is no quality control. There are no guarantees that the consumer is actually getting what they think they're getting. To boot, the manufacturers are placing very attractive and appealing cartoon-like labels on these products or adding sweet-smelling or pleasant-tasting flavors like lemonade. What do we get? These essentially become child magnets. It is no surprise that the number of nicotine exposures in children reported to the National Poison Data System in fact tripled from last year to this year.[1]

We know exposures are up, but why is this so toxic? The primary reason is the high concentrations. These products are marketed in 1.8%, 2.4%, or even 10% solutions. In terms of nicotine content, these are orders of magnitude higher than traditional tobacco products.

The best way to demonstrate the seriousness and highlight the lethality of this is to demonstrate how a small volume can be dangerous. We know that the lethal dose, 50% or LD50, of nicotine is between 1 and 10 mg/kg. In a volume like this -- this is a 1.8% solution sample that I picked up at my local vape shop -- that is 18 mg/mL of nicotine. For the sake of easy math, let's round that to 20 mg/mL. We know that the potential lethal dose is 10 mg/kg. In a solution like this, approximately 20 mg/mL, a dose of 0.5 mL/kg could be lethal. A small 15-mL vial like this -- simply 1 tablespoon -- could be lethal to a 30-kg (65-lb) child.

When I show parents that this alarmingly small volume could be deadly to their child, they say, "I had no idea how dangerous this is." It's true. Liquid concentrated nicotine easily has the potential to be the most deadly substance in your house.

In conclusion, please discuss with your patients and your parents the potential hazards of having liquid nicotine in the household. Please talk to your legislators. Talk to your policy makers. Encourage them to consider strategies to mitigate the risks of the commercial sale of these products.