Should e-cigarette liquid safety be improved?

woman vaping in a restaurant

Calls to Australian Poisons Information Centres in recent years include cases where children inhaled e-cigarette liquids, ate cartridges or had liquids splashed in their eyes

Writing in the MJA this week, Carol Wylie, Aaron Heffernan, Jared A Brown, Rose Cairns, Ann‐Maree Lynch and Jeff Robinson outlined the increase in calls to Poisons Information Centres (PICs) between 2009 and 2016.

Only a handful of calls were made in 2009, while there were nearly 70 in 2016, though the overall PIC call volume remained stable at around 164,000 cases each year.

“Of 202 sequential e‐cigarette‐related cases, 38% were from relatives of children worried about their exposure to the liquid component of an e‐cigarette after children were found with uncapped vials, sucking the mouthpiece, drinking from separated liquid containers, inhaling the liquid, eating the cartridge, or having splashed liquid in their eyes,” the authors wrote.

“Adults and adolescents were the subjects of calls in 126 cases (62%), including calls about the potential side effects of routine use or accidental ingestion, or about skin or eye splash exposures.

“Twelve calls followed deliberate administration for self‐harm, ten by oral ingestion and two by injection.

“The reported median concentration of the 43 commercial nicotine solutions involved was 20.2 mg/mL, (range, 0.06–200 mg/mL), but confirmatory testing was not performed and actual concentrations may be higher than labelled, as noted recently.”

As pointed out by an accompanying piece in MJA InSight+ by Cate Swannell, another recent MJA article found that of 10 e-liquids which were labelled “nicotine free,” six turned out to contain nicotine after all – and in three, the level of the ingredient was similar to that found in low dose nicotine e-liquids.

The PIC study authors, led by Carol Wylie, say that the potential risks stemming from ingestion or other exposure to e-liquids “should not be underestimated”.

“We are aware that an infant recently died in Australia after ingesting a concentrated nicotine solution. Almost all exposures of children to nicotine‐containing e‐cigarette liquid require their hospitalisation for monitoring of possible toxic effects.”

The authors say the safety of nicotine-containing e-liquids – which are not legally available in Australia unless an e-cigarette user has a prescription permitting their importation – for both users and household members has not been established.

“Imported products may not conform to Australian standards, including having child‐resistant closures and appropriate labelling, and refill bottles containing highly concentrated nicotine solutions — one millilitre of which can be lethal if ingested by a child — can be purchased online.

“Our study can assist health care practitioners when advising patients about the use of e‐cigarettes, and our findings indicate that nicotine‐containing products should be stored where children cannot access them. We would welcome any move to improve the safety of electronic cigarettes, including changes to their labelling, storage, and packaging.”

Carol Wylie told Ms Swannell that the lack of regulation around imported e-liquids, and the resultant inability to determine the strength of the products, present a “real challenge for regulators”.

“We had [a call about] one product that was as strong as 200 mg of nicotine per mL,” she said. “You would not need very much in a 10 kg infant to be a problem. A mL would be enough to cause toxicity.”

She highlighted early symptoms of nicotine poisoning, which include nausea and vomiting; “sometimes palpitations, increased heart rate; some people get hypersalivation, and seizures have been reported”.

In more severe cases symptoms can include sedation, respiratory depression, hypotension, and bradycardia.

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