The Dangers of E-Cigarette Exposure in Children

According to a report from The Lund Report on September 7th, several thousand children are exposed to liquid nicotine in e-cigarettes each year, which is also known as e-cigs. Even a few drops of this substance can be deadly for young children.

Hospital toxicologist Ryan Marino closely observed the severe reactions that children experienced due to nicotine poisoning from e-cigarette liquid. A young boy, brought to the emergency room, exhibited severe symptoms of nausea, diarrhea, and vomiting, necessitating intravenous fluid administration to treat dehydration.

Children may also feel dizzy, pass out, and experience a sudden drop in blood pressure. Marino, from Case Western Reserve University School of Medicine, said that in the most severe cases he has witnessed, doctors had to put another boy on a ventilator in the intensive care unit because he was unable to breathe.

Despite the Child Nicotine Poisoning Prevention Act, which was implemented in 2016 and required child-resistant packaging for e-cigarette liquid bottles, the poison center reports a record high number of nicotine exposure cases related to e-cigarettes in 2022. It is notable that the law does not mandate protective packaging for the devices themselves, a significant oversight according to medical professionals.

Marino argues that the design purpose of refillable e-cigarettes, to store liquid nicotine in a central reservoir, is dangerous for children. Even e-cigarettes that appear to be more child-friendly, as their nicotine is sealed within detachable pods, still pose a risk as the pods can be pried open. Some disposable e-cigarettes (currently the best-selling type on the market) allow users to "inhale" thousands of times, with nicotine levels equivalent to multiple packs of cigarettes.

Many e-cigarettes and liquid products appear to be designed to appeal to children, with soft packaging colors and names like "Candy King" and flavors like bubblegum and blueberry. Diane Calello, Executive and Medical Director of the New Jersey Poison Information Center, says that this makes e-cigarettes more enticing and dangerous compared to traditional cigarettes, which typically have lower levels of nicotine and a bitter taste that often prompts children to quickly spit them out. This highlights the need for educational measures to address this issue.

"Nicotine liquid is an impending accident," Carlo said,"It smells fragrant and has a high concentration."

Richard Blumenthal, a Democratic Senator from Connecticut and one of the co-sponsors of the 2016 legislation, has announced that he will advocate for expanding child safety packaging requirements to include disposable e-cigarettes and pod e-cigarettes.

In his statement, he voiced concern over the continued availability of flavored e-cigarette products on the market, asserting that each day these hazardous and, in some cases, potentially lethal products continue to lure children.

Although the FDA declined to comment on this article, the agency included a featured report on child nicotine poisoning in its "CTP Connect" newsletter on August 2nd.

According to the analysis by the FDA, the number of reports related to e-cigarettes submitted to the Poison Control Center has more than doubled since 2018. The Poison Control Center reports indicate that there were over 7,000 cases of e-cigarette-related exposures across all age groups from April 1, 2022, to March 31, 2023.

According to the FDA, 43 cases resulted in hospitalization, while an additional 582 cases received alternative forms of treatment. Approximately half of the poison control centers reported no information regarding whether the patients required medical care.

Nearly 90% of the cases involved children under the age of five, according to the report's authors. They further mentioned that considering not all cases are reported to poison control centers, their figures might underestimate the extent of this issue.

In 2014, a 1-year-old child died from nicotine poisoning related to an e-cigarette. The latest report by the FDA also mentioned a case of an adult who committed suicide due to e-cigarette poisoning.

A spokesperson of the e-cigarette industry stated that the company places great importance on safety.

All e-cigarette liquid bottles produced in the United States comply with American laws," said April Meyers, Chairperson and CEO of the Smokeless Alternative Trade Association, representing the e-cigarette industry. "The caps not only prevent children from opening them, but the flow of liquid is also restricted, allowing only a small amount to be distributed.

However, many e-cigarette products are manufactured overseas, and the United States is currently flooded with illegal e-cigarettes, with a majority of them originating from China.

Natalie Rine, Director of the Ohio Central Poison Control Center at Nationwide Children's Hospital, has stated that the number of children exposed to nicotine is steadily rising, especially among curious infants who put almost anything they can grab into their mouths. This trend may reflect the significant sales volume of e-cigarettes.

According to a report released by the Centers for Disease Control and Prevention (CDC) in the United States, e-cigarette sales have increased by 47% from January 2020 to December 2022. The sales have risen from 15.5 million units every four weeks to 22.7 million units.

"Parents believe this is not a significant risk," Marino said,"But with the spread of e-cigarettes, this risk is unlikely to dissipate quickly."

An effective strategy to decrease e-cigarette sales is to ban flavored products. California, Massachusetts, New Jersey, New York, Rhode Island, and Washington D.C have all prohibited flavored e-cigarettes, while Utah and Maryland have banned certain flavors. A study has revealed that states that implemented flavor bans experienced an overall decrease in e-cigarette sales by 25% to 31% compared to states where e-cigarettes were not prohibited.

Some doctors argue that the country needs to take more measures to protect children.

"If the numbers are increasing, then the law becomes ineffective," said Dr. Carl Baum, professor of pediatrics and emergency medicine at Yale School of Medicine.

Pediatrician Dr. Gary Smith stated that the lack of child safety requirements in e-cigarette devices is a major concern. Refillable e-cigarettes, in particular, can be relatively easy for children to open.

Although most poison control centers do not include brand information in their reports, disposable e-cigarettes, including Elfbar, Puff Bar, and Pop Vape, are some of the most common products mentioned in FDA analysis. Elfbar has now been renamed EB Design.

Smith, the president of the Child Injury Prevention Alliance, stated that expanding federal laws to include equipment would be a "significant step." The Child Injury Prevention Alliance is an advocacy organization based in Ohio, dedicated to preventing harm to children.

In addition, Smith stated that federal officials should restrict the nicotine concentration in e-cigarette juices to reduce their toxicity and prohibit the use of candy-like flavors and colors on packaging. "Public health measures should be comprehensive," said Smith.

Robert Glatt, an Assistant Professor of Emergency Medicine at Lenox Hill Hospital in New York City, has emphasized that even if children do not inhale aerosols from e-cigarettes, simply using them exposes their skin to nicotine, which can be absorbed into the bloodstream. Glatt also points out that e-cigarette liquids contain numerous harmful chemicals, including arsenic and lead, both of which are toxic in any amount; carcinogens such as formaldehyde and acetaldehyde; as well as benzene, a volatile organic compound found in car exhaust fumes.

According to Marc Auerbach, a pediatric emergency medicine professor at Yale Medical School, fortunately, children who inhale nicotine are exposed to much lower doses compared to those who ingest it, reducing the risk of serious harm.

According to a study by FDA, only about 2% of exposures were documented as having a moderate or significant impact.

Dr. Baume suggests that this can possibly be because children often come into contact with hazardous liquids (ranging from e-cigarette juice to household cleaning products or gasoline), which usually ends up spilling out a majority of the liquid. "They tend to end up wearing it, rather than ingesting it," Dr. Baume explained.

Despite having seen many children exposed to nicotine, Stephen Santon says that the human body has ways to protect itself from toxic substances. "Luckily, when children consume these e-cigarette nicotine products, they self-purify. They vomit a lot, which makes the mortality rate very low, but these children are still frequently sent to the emergency room due to nausea and vomiting," said Dr. Stephen Santon, an emergency medicine physician and medical director at the Kansas Poison Control Center.

The FDA urges parents and guardians of young children to keep e-cigarettes and e-cigarette liquids in a secure location out of reach, and to store them in their original containers.