Young Children and e-Cigarette Poisoning

Kevin Chatham-Stephens, MD, MPH


October 20, 2014

Editorial Collaboration

Medscape &

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Hello. I am Dr Kevin Chatham-Stephens, with CDC's National Center for Environmental Health. I am speaking to you as part of the CDC Expert Commentary Series on Medscape. Today I would like to discuss electronic nicotine delivery systems and the potential for acute adverse health effects from these emerging devices.

Electronic nicotine delivery systems include a variety of devices, such as electronic cigarettes (e-cigarettes), e-hookahs, and modified or tank-style devices. These devices typically contain a battery, a liquid-filled cartridge, and a heating element. The liquid in these devices is often called e-liquid or e-juice. The devices typically deliver nicotine; flavorings such as fruit, mint, bubble gum, and chocolate; and other chemicals through an inhaled aerosol.

There are both single-use, disposable devices and reusable devices. Some reusable devices use cartridges prefilled with the e-liquid so that the user inserts a new cartridge when the previous cartridge is empty, whereas other reusable devices require users to refill the cartridge themselves with e-liquid from a bottle. Although most devices are designed to deliver nicotine, some devices can be modified to use other substances, such as marijuana oil.

In the United States, use of e-cigarettes has increased in adolescents over the past several years. The number of middle and high school students who reported ever using e-cigarettes more than doubled, from 3.3% in 2011 to 6.8% in 2012, with approximately 1.8 million US students reporting that they tried e-cigarettes in 2012.[1] With this increase in youth experimentation, there has been increasing focus on questions about the safety of these devices and the e-liquid. One of the major concerns about these products is the potential for acute nicotine poisoning, especially among children, owing to several factors:

The nicotine liquid colors and flavors, such as apple pie, banana split, and graham cracker, may appeal to children;

The lack of childproof containers for the nicotine liquid; and

The concentrated nature of the nicotine liquid.

The early signs of nicotine poisoning may include tachycardia, diaphoresis, nausea, and vomiting, and late signs include hypotension, seizures, respiratory depression, and death. Infants and toddlers, who engage in activities such as hand-to-mouth and curiosity-seeking behaviors, are at particular risk for ingestion of e-liquid.

In April, CDC released a study in the Morbidity and Mortality Weekly Report[2] documenting an increase in the number of calls to US poison centers involving exposures to e-cigarettes. The number of e-cigarette exposure calls increased from one call in September 2010 to 215 calls in February 2014. More than half of the 2400 e-cigarette calls involved children aged less than 6 years. Ingestion of the e-liquid accounted for 69% of exposures, inhalation of the vapor accounted for 17%, eye exposures accounted for 9%, and dermal exposures for 6%. The three most commonly reported adverse health events were vomiting, nausea, and eye irritation. In addition to our study, Bassett and colleagues,[3] from Einstein Medical Center in Philadelphia, recently reported in the New England Journal of Medicine the case of a 10-month old who ingested an unknown amount of e-liquid and developed vomiting, tachycardia, grunting respirations, and ataxia.

Given the increase in use of electronic nicotine delivery systems and the rising number of calls to poison centers, clinicians need to be aware of the risks related to these devices. Exposure to nicotine from electronic nicotine delivery systems may cause acute adverse health effects. Clinicians can obtain clinical guidance for managing exposures to these devices and e-liquid by calling their local poison control centers at (800) 222-1222. Reporting these exposures to poison control centers also enables CDC to more accurately document and characterize adverse health effects from electronic nicotine delivery systems and e-liquid by contributing to CDC's national surveillance activities.

To help prevent pediatric exposures, we suggest that healthcare providers counsel parents to treat electronic nicotine delivery devices and e-liquid like other potential poisons found in the home, such as pesticides, bleach, or medications, and keep them properly stored out of reach of children.

On a policy level, electronic nicotine delivery systems and e-liquid are currently unregulated in the United States.[4] However, the US Food and Drug Administration (FDA) has proposed regulations that would require manufacturers to register their products with the FDA, ban the distribution of free samples, establish a minimum age to purchase such products, and prohibit vending machine sales.

Kevin Chatham-Stephens, MD, MPH, is a pediatrician serving as an Epidemic Intelligence Service (EIS) Officer at CDC's National Center for Environmental Health.