E-cigarette “vaping” liquids are a poisoning risk for children

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Australian children are at increasing risk of poisoning from unregulated e-cigarette liquids containing nicotine, according to new research from Australian Poisons Information Centres.

The research findings, “Exposures to e-cigarettes and their refills: calls to Australian Poisons Information Centres, 2009-2016”, published in the Medical Journal of Australia, warn the risk to children, especially young children, from e-cigarette liquid should not be underestimated.

E‐cigarette popularity has increased in Australia since they first became available as smoking cessation tools. An estimated 1.3% of the New South Wales population used them in 2015, and as many as 8.4% had experimented with them.

E-cigarettes, which convert nicotine-laced liquid into vapour instead of burning tobacco, have been recommended as safe smoking cessation tools in the UK. However in Australia liquid nicotine is an S4 restricted drug, and a prescription is required to legally import the nicotine‐containing e‐cigarettes. Their efficacy as cessation tools hasn’t been proven, and safety for users and members of their households have not been established. Imported products may not meet Australian standards, including having child‐resistant closures and appropriate labelling, high concentrations of nicotine solutions, and potentially harmful ingredients such as propylene glycol (a solvent to produce fog or smoke used in theatrical productions), polyester compounds, anti-freeze, or vegetable glycerine.

Australian Poisons Information Centres (PICs) play a valuable role as health care sentinels when new products such as e‐cigarettes are introduced. The research team undertook a retrospective analysis of calls made to PICs between 2009 and 2016.

The report found 202 cases of reported poisoning from e-cigarette liquid, with the numbers of calls about e‐cigarette exposures increasing considerably across the study period, despite the overall PIC call volume remaining stable. Most patients had only mild symptoms at the time of the call to the PIC, mainly gastrointestinal disturbances. According to the authors the potential risks, however, should not be underestimated.

 Just one millilitre of nicotine solution can be lethal if ingested by a child

Children were involved in 76 of the cases, 62 of which were toddlers. Almost all exposures of children to nicotine‐containing e‐cigarette liquid require their hospitalisation for monitoring of possible toxic effects. One of the paper’s authors, Carol Wylie, manager of the Queensland Poisons Information Centre, said this wasn’t a surprise, as children between one and four years old were most commonly involved in poisoning incidents across the board. She said that just one millilitre of a highly concentrated nicotine solution can be lethal if ingested by a child.

“Children have died as a consequence of swallowing these e-cigarette refills. There were no deaths during our study period but we know that there has been a death of an infant in Australia since then from e-cigarette liquid, and there have been deaths overseas. The numbers have definitely been increasing since 2013, the 2017 data (which wasn’t part of the report) is higher than 2016, so we know those numbers are creeping up.” Ms Wylie said.

The report found most child poisoning cases saw the children exposed through uncapped vials, sucking the mouthpiece, drinking from separated liquid containers, inhaling the liquid, eating the cartridge, or having the liquid splashed in their eyes. The actual number of cases is believed to be higher because the data relies on instances which were reported and people may not have gone to a hospital or GP after an incident.

Ms Wylie said it was a complex issue as to whether there would be more benefit than harm in legalising and therefore regulating e-cigarettes. “Presumably the instances of poisoning would go up if they were legalised, but conversely we might be able to have more impact on storage, safety and labelling. Ideally it would be nice to have products which were better labelled and had child safety caps and ingredients lists that were accurate,” she said.