Here's a quick quiz: what do the following have in common?: Pink Bubble Gum, Peanut Butter Cup, Strawberry Shortcake, Gummi Bear, Mountain Dew Burst and Banana Split Dreams? Are they (A) an assortment of candy, gum and soda given out at children's birthday parties; (B) names of soaps, shampoos and body creams used by pre-teens; or (C) flavors of liquid nicotine used in the reusable types of e-cigarettes?
If you guessed (C) you are correct. These are flavors of liquid nicotine, sometimes called e-liquid or e-juice, which is heated to create a vapor. The e-cigarette user (a.k.a. "vaper") inhales a blend of water vapor and nicotine mixed with flavorings and other chemical additives. Liquid nicotine is sold legally in stores and online in hundreds of flavors and a range of nicotine concentrations, including very high potency in containers of various sizes.
Discussion of e-cigarettes -- and there will be plenty of it, given the U.S. Food and Drug Administration's first proposed regulations, released on Thursday -- naturally focuses on the effects of inhaling the vapor. But liquid nicotine can be harmful to the nervous system when accidentally ingested or absorbed through the skin. It can cause other harmful effects as well, including rapid heartbeat, elevated blood pressure, vomiting, abdominal cramping, dizziness and confusion. This concentrated liquid is significantly toxic even in very small doses, particularly for children. At higher doses it can cause seizures and death.
Last month the American Association of Poison Control Centers issued a warning about electronic cigarette devices and liquid nicotine because of a 300% increase – just from 2012 to 2013 – in calls to poison centers about accidental poisonings by liquid nicotine. Slightly more than half of the calls involved children under the age of six. Some children required hospital emergency room visits – not surprising when you consider that the nicotine comes in sweet candy-like scents and flavors kids love. A field report detailing calls to poison centers going back several years was published by the U.S. Centers for Disease Control and Prevention.
Internal records of the poison control center at Children's Hospital of Philadelphia, which contributed to that report, show 19 calls involving liquid refills, 13 of them for children under six. The most common symptoms were nausea and vomiting, but one was severe toxicity. Three were cases of product confusion: administering e-juice instead of eye or ear drops. A handful of fires have been reported elsewhere as well.
E-cigarette companies, many of which are owned by the big tobacco manufacturers, have scoffed at the recent reports of increased poison center calls. Jason Healy, president of Blu eCigs, which is owned by Lorillard Inc., the third-largest tobacco company in the United States, called the CDC report part of "an ongoing attack on the e-cigs industry by various anti-smoking groups." According to Healy, "the product is for adult smokers, and therefore the responsibility for children's safety falls on the parents, just like bleaches and prescription medications. The focus should be on parenting and education, and not regulation."
Neither e-cigarettes nor e-nicotine are currently regulated. While cities like Philadelphia have passed local laws – led by New Jersey, which took statewide action in 2010 – to prohibit selling e-cigarettes to children and using them in locations where ordinary cigarettes are banned, the U.S. Food and Drug Administration (FDA) is only now proposing regulations for the first time that must go through a public comment period before being revised and finalized.
The health implications of e-cigarettes are hotly debated even within the public health community. Advocates see them as a largely benign, life-saving alternative to tobacco that can help some people kick the habit. Others think they may be a gateway to regular cigarettes for nonsmokers, especially teens, that carry health risks of their own.
There is clear evidence that advertising and promotional activities used by tobacco companies in years past caused teens and young adults to start smoking – and e-cigarettes companies are using the same tactics to sell e-cigs to youth. Because the non-reuseable types are made to look like traditional cigarettes–NJOY's newest product has a soft tip and paper-like covering, closely replicating a conventional cigarette– anti-smoking advocates worry they may re-popularize smoking.
Regardless, e-cigarettes are not without some known harms. Nicotine is a highly addictive drug, particularly in young people; potentially harmful irritants, genotoxins, and animal carcinogens have been documented in some e-cigarette liquids; and now there is the poison centers' evidence of an increasing number of accidental nicotine poisonings.
There are public health leaders on both sides of the debate who agree on reasonable regulations. The FDA should limit the amount of liquid nicotine in any container sold to consumers, stop sales on the Internet, and require childproof packaging. It should ban marketing and sales to minors, including sponsorship, free samples, use of cartoon characters and use of labels and flavoring that appeal to children. It will be good news if it is shown that e-cigarettes saves lives by reducing the number of people who smoke ordinary cigarettes and die of tobacco-related disease. But there is scant evidence of that so far. And they must be safely manufactured, responsibly marketed, and appropriately regulated regardless.
More information about e-cigarettes in Philadelphia is here.