Notes from the field: calls to poison centers for exposures to electronic cigarettes — united states, september 2010-february 2014

Kevin Chatham Stephens, MD1, Royal Law, MPH2, Ethel Taylor, DVM2, Paul Melstrom, PhD3, Rebecca Bunnell, ScD3, Baoguang Wang, MD4, Benjamin Apelberg, PhD4, Joshua G. Schier, MD2 (Author affiliations at end of text)

Electronic nicotine delivery devices such as electronic cigarettes (e cigarettes) are battery powered devices that deliver nicotine, flavorings (e.g., fruit, mint, and chocolate), and other chemicals via an inhaled aerosol. E cigarettes that are marketed without a therapeutic claim by the product manufacturer are currently not regulated by the Food and Drug Administration (FDA) (1). In many states, there are no restrictions on the sale of e cigarettes to minors. Although e cigarette use is increasing among U.S. adolescents and adults (2,3), its overall impact on public health remains unclear. One area of concern is the potential of e cigarettes to cause acute nicotine toxicity (4). To assess the frequency of exposures to e cigarettes and characterize the reported adverse health effects associated with e cigarettes, CDC analyzed data on calls to U.S. poison centers (PCs) about human exposures to e cigarettes (exposure calls) for the period September 2010 (when new, unique codes were added specifically for capturing e cigarette calls) through February 2014. To provide a comparison to a conventional product with known toxicity, the number and characteristics of e cigarette exposure calls were compared with those of conventional tobacco cigarette exposure calls.

An e cigarette exposure call was defined as a call regarding an exposure to the e cigarette device itself or to the nicotine liquid, which typically is contained in a cartridge that the user inserts into the e cigarette. A cigarette exposure call was defined as a call regarding an exposure to tobacco cigarettes, but not cigarette butts. Calls involving multiple substance exposures (e.g., cigarettes and ethanol) were excluded. E cigarette exposure calls were compared with cigarette exposure calls by proportion of calls from health care facilities (versus residential and other non health care facilities), demographic characteristics, exposure routes, and report of adverse health effect. Statistical significance of differences (p<0.05) was assessed using chi square tests.

During the study period, PCs reported 2,405 e cigarette and 16,248 cigarette exposure calls from across the United States, the District of Columbia, and U.S. territories. E cigarette exposure calls per month increased from one in September 2010 to 215 in February 2014 (Figure). Cigarette exposure calls ranged from 301 to 512 calls per month and were more frequent in summer months, a pattern also observed with total call volume to PCs involving all exposures (5).

E cigarettes accounted for an increasing proportion of combined monthly e cigarette and cigarette exposure calls, increasing from 0.3&#37 in September 2010 to 41.7&#37 in February 2014. A greater proportion of e cigarette exposure calls came from health care facilities than cigarette exposure calls (12.8&#37 versus 5.9&#37 ) (p20 years (42.0&#37 ). E cigarette exposures were more likely to be reported as inhalations (16.8&#37 versus 2.0&#37 ), eye exposures (8.5&#37 versus 0.1&#37 ), and skin exposures (5.9&#37 versus 0.1&#37 ), and less likely to be reported as ingestions (68.9&#37 versus 97.8&#37 ) compared with cigarette exposures (p<0.001).

Among the 9,839 exposure calls with information about the severity of adverse health effects, e cigarette exposure calls were more likely to report an adverse health effect after exposure than cigarette exposure calls (57.8&#37 versus 36.0&#37 ) (p<0.001). The most common adverse health effects in e cigarette exposure calls were vomiting, nausea, and eye irritation. One suicide death from intravenous injection of nicotine liquid was reported to PCs.

Calls about exposures to e cigarettes, which were first marketed in the United States in 2007, now account for 41.7&#37 of combined monthly e cigarette and cigarette exposure calls to PCs. The proportion of calls from health care facilities, age distribution, exposure routes, and report of adverse health effects differed significantly between the two types of cigarette.

This analysis might have underestimated the total number of e cigarette and cigarette exposures for several reasons. Calls involving e cigarettes or cigarettes and another exposure were excluded, and the code indicating a case of e cigarette exposure might have been underused initially. In addition, health care providers, including emergency department providers, and the public might not have reported all e cigarette or cigarette exposures to PCs. Given the rapid increase in e cigarette related exposures, of which 51.1&#37 were among young children, developing strategies to monitor and prevent future poisonings is critical. Health care providers the public health community e cigarette manufacturers, distributors, sellers, and marketers and the public should be aware that e cigarettes have the potential to cause acute adverse health effects and represent an emerging public health concern.

1EIS officer, CDC 2Division of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC 3Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, CDC 4Center for Tobacco Products, Food and Drug Administration (Corresponding author Kevin Chatham Stephens, xdc4 , 770 488 3400)

References

  1. Food and Drug Administration. News and events electronic cigarettes (e cigarettes). Silver Spring, Maryland US Department of Health and Human Services, Food and Drug Administration 2014. Available at
  2. CDC. Notes from the field electronic cigarette use among middle and high school students United States, 2011 2012. MMWR 2013 62 729 30.
  3. King BA, Alam S, Promoff G, Arrazola R, Dube SR. Awareness and ever use of electronic cigarettes among U.S. adults, 2010 2011. Nicotine Tob Res 2013 15 1623 7.
  4. Cobb NK, Byron MJ, Abrams DB, Shields PG. Novel nicotine delivery systems and public health the rise of the «e cigarette.» Am J Public Health 2010 100 2340 2.
  5. Mowry JB, Spyker DA, Cantilena LR Jr, Bailey JE, Ford M. 2012 annual report of the American Association of Poison Control Centers’ National Poison Data System (NPDS) 30th annual report. Clin Toxicol (Phila) 2013 51 949 1229.

E-cigarette television advertising to be investigated

The advertising watchdog’s probe into the advertising of e cigarettes has been welcomed by British American Tobacco (BAT), the biggest tobacco company to show a TV ad for e cigarettes in the UK.

The Committee of Advertising Practice (CAP) last week kicked off an eight week consultation which will look at introducing new rules to clear up «concern» and «confusion» in this area.

The consultation could lead to new rules protecting under 18s and it follows criticism over an e cigarette ad broadcast during ITV’s I’m a Celebrity Get Me Out Of Here! which attracted more than 1,100 complaints to the advertising watchdog.

Adverts for e cigarettes are currently subject to the general rules under the advertising code, such as whether they are harmful or offensive, in which case they could be banned.

But the advertising watchdog believes there needs to be specific rules in place in light of public concern over issues such as children taking part in «vaping», the inhaling of vapour from e cigarettes, along with uncertainty among advertisers about the rules.

The watchdog is also mindful that e cigarettes also carry an obvious association with tobacco advertising, which has been banned on TV since 1965.

Des Naugton, managing director of BAT owned Nicoventures which makes e cigarette brand Vype, said «In the light of the differing rules today, we are supportive of the e cigarette advertising consultation which is being led by the Committees of Advertising practice (CAP and Broadcast Committee of Advertising).

«We hope that it will result in clear and consistent rules for advertising e cigarettes across all media to ensure that they are marketed responsibly, whilst giving appropriate marketing freedoms to allow this important product category to develop further.»

Shahriar Coupal, secretary of CAP which is a sister body to the Advertising Standards Authority (ASA), said «The market for e cigarettes is fast growing and the existing rules haven’t been able to give advertisers the clarity they need. By proposing new specific rules, we’re providing a clear framework for responsible advertising. Given the potential association with tobacco products and the fact that many e cigarettes contain nicotine, it’s important we put in place strong responsibility rules to make sure that the public and particularly children are protected.»

The ASA recently banned an ad from e cigarette maker VIP, which featured a woman saying «I want you to get it out. I want to see it. Feel it. Hold it. Put it in my mouth.» The ad led to 1,156 complaints.

The introduction of new rules comes as the European Union also considers the future of e cigarette advertising. It has passed rules which mean that EU member states have to decide if e cigarettes are tobacco or medicine products.

According to Mintel, the market in e cigarettes ballooned by 340% to 193m in 2013. Last month, BAT launched a campaign for its Vype electronic cigarettes the first time a big tobacco company has marketed products on TV since cigar ads were banned in 1991.

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