That smoking tobacco products is unhealthy comes as no surprise to any individual with a pulse.  It is impossible for me to imagine someone thinking that inhaling smoke into their lungs could be anything less than harmful.  Firefighters wear sixty pounds of respiration gear for the sole purpose of not inhaling smoke.  But I digress.

e-cig by Lindsay Fox (CC BY 2.0) (ecigarettereviewed.com)

Electronic cigarettes (e-cigs) have been theorized for quite some time, but not until around 2010 did they start to make a commercial impact (in the US, at least).  In short, e-cigs are a device resembling the size and shape of a cigarette and use battery power to vaporize a solution of nicotine.  These nicotine solutions are typically 1-3% nicotine in propylene glycol, a viscous, non-toxic liquid found in many, many things.  Users then just puff away, inhaling a thick vapor containing nicotine, much like tobacco smoke, but without the tar and hundreds of other potential carcinogens.

So are these e-cigs better for someone than regular cigarettes?  Without a doubt, in my mind.  That whole inhaling smoke thing again.  Users can also tailor their nicotine concentration, and ween themselves off of nicotine by gradually decreasing the concentration, if they so desire.  Is it still addictive?  Of course it is.  Otherwise tobacco companies wouldn’t be buying e-cig companies.  Case in point, the Altria Group (aka Philip Morris) just purchase e-cig company Green Smoke for $110 million.  And every major tobacco player is adding an e-cig line.  They know that even if people use e-cigs, they are still likely hooked for life.  It’s much like Pharma; the ideal drug is one that you manufacture for $1, sell for $100, and a person takes it every day for the rest of their life.

Nicotine refill by Lindsay Fox (CC BY 2.0) (ecigarettereviewed.com)

So what’s my problem?  I’ve obviously got one, otherwise I’ve just typed 400 words for nothing.  My problem is with the e-cig nicotine solution refills.  The refills are typically containers of between 5 and 30 mL of 1% – 3% nicotine.  This equates to nicotine concentrations of 10 – 30 mg/mL.  So in the smallest refill of 5 mL (1 teaspoon), there exists between 50 to 150 mg of nicotine.  The amount needed to kill an average adult, within about an hour, is roughly 40-60 mg.*** This amount is less than cyanide or arsenic!

*** The reported 40-60 mg lethal dose of nicotine is what has been used by toxicologists for years. I suspect, as do others, that this figure is on the low side. Unfortunately, with increased availability and exposure, we’ll get a better idea of what a lethal dose is. However, for a small child, 60 mg sounds reasonable. -JOB 8/2/14

Nicotine poisoning is biphasic.  First there is the typical stimulant effects, including hyptertension, tachycardia, dizziness, and naseau.  Then the depressant effects kick in, including hypotension, CNS depression, then respiratory failure.  Good times.  Did I mention that nicotine also readily absorbs through the skin?  That’s how those transdermal nicotine patches work.  So just spilling the nicotine solution on your skin can cause distress.  Now, do I think adults are going to start chugging this stuff?  Not really, but in my line of work of postmortem toxicology I see stupid stuff like that all the time.  And there is a case of a person that committed suicide by injecting themselves with a refill solution (1, case 432).  [Many have told me that he would have found another way, and that could be true, but this was the method he chose.  I can’t change that fact.]

But adults do what adults want to do.  What concerns me is children.  Especially when these nicotine solutions come in all sorts of flavors, such as cherry, berry, cotton candy, and even ice cream with pretzels.  The aroma, packaging, and flavor (propylene glycol is mildly sweet) could make it attractive to a toddler.  And remember, 5 mL (1 teaspoon) isn’t much – just a sip, really – and will kill a child.  And despite warnings about “keep away from children”, bad things happen, such as this.  The comments in that article are funny, especially “a bag of premium coffee left open is just as toxic to a toddler.”  Hmmm, 1 teaspoon liquid nicotine solution or 1 teaspoon of coffee grounds?  I’ll take the coffee grounds, thank you very much.

A few stats to back up my fears, using data from the National Poison Data System (1, 2):

• 2011 – 256 exposures from e-cigs/refills, 84 (32%) in children 5 or under
• 2012 – 438 exposures from e-cigs/refills, 172 (39%) in children 5 or under
• Total exposures up 70% and exposures in children 5 and under up 105%, from 2011.

There is no 2013 data yet.  E-cigs are increasing in popularity, so numbers will obviously be rising each year, but that’s kind of the point.

Now don’t get me wrong, deadly things exist all over the place, but they aren’t usually cherry flavored, and most likely won’t kill a child with one sip.  What’s needed is more awareness, education, and oversight as to who (what age) can purchase these devices and refills.  As of now there is no federal age restriction, and few state restrictions.  Though that is being discussed as we speak (read?).  [For the record, I live in a state where anyone, of any age, can purchase e-cigs.]

The take home message is nicotine is a deadly poison, the dose makes the poison, and don’t let the small nicotine % fool you.

Update 3/26/14:
Please don’t tell me that toothpaste and crayons elicit more calls to poison control centers than e-cig nicotine solutions.  I’ve seen the data.  Eating 5 grams of toothpaste or a crayon will not kill you.  Ingesting 5 grams (mL) of an e-cig nicotine solution will.  It’s simple: keep e-cigs and e-cig nicotine solutions out of reach of children, much like you would, or should, any household poison or prescription medication.  If you need suggestions or guidance, please call your local poison control center.  That’s what they are there for.

References:
1. Bronstein, Alvin C., Daniel A. Spyker, Louis R. Cantilena, Barry H. Rumack, and Richard C. Dart. “2011 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 29th Annual Report.” Clinical Toxicology 50.10 (2012): 911-1164.
2. Mowry, James B., Daniel A. Spyker, Louis R. Cantilena, J. Elise Bailey, and Marsha Ford. “2012 Annual Report of the American Association of Poison Control Centers’ National Poison Data System (NPDS): 30th Annual Report.” Clinical Toxicology 51.10 (2013): 949-1229.