A quick update on the e-cigarette and e-liquid poison scare stories..
Much has been made of the rapid rise in calls to US Poison Centers (chart by Clive Bates from AAPPC data)
Commentators have piled in, highlighting the rapid percentage rise between years. Some examples…
- CDC: New CDC study finds dramatic increase in e-cigarette-related calls to poison centers
- American Association of Poison Control Centers: AAPCC and Poison Centers Issue Warning About Electronic Cigarette Devices and Liquid Nicotine
- Campaign for Tobacco Free Kids: Poisoning Calls About E-Cigarettes and Liquid Nicotine More Than Doubled in 2014 – FDA Must Act to Protect Kids
- New York Times: Lethal Liquid Nicotine and Selling poison by the barrel
- The Guardian: E-cigarette poisoning figures soar as vaping habit spreads across UK (UK 139 calls in 2013, compared to 29 in 2012).
Poison reports in context
Two factors are likely to explain these observations: (1) the rapid rise in e-cigarette and e-liquid use – a good thing as it displaces smoking; (2) the increased fear about these products arising from the negative publicity and fear-mongering in the press and by ‘public health organisations’. But such rises have to be put in context… in the United States there were 2.6 million calls in 2013, and 0.06 percent of those related to nicotine. See American Association of Poison Control Centers Annual Report 2013 Table A17 (chart by Clive Bates from AAPPC data – plots the data points from 2013, 2014 alongside the top calls to poison centres – data in the appendix below)
The point is that poisons and risks of exposure are ubiquitous in society, and are associated with products from which society benefits. We do not ban them or over-regulate them, we find proportionate approaches to managing the risks.
Peak Poison
Calls to poison centers may also be affected by publicity – and there was quite a media blitz in March and early April 2014, leading to ‘peak poison’.
Source for graph: American Association of Poison Control Centers Annual Report 2013 Figure 6 p.1063.
How poisonous?
As well as being proportionate about the scale of exposure, there is also the question of how dangerous nicotine liquids actually are. Dr Bernd Mayer showed that conventional estimates of the toxicity (the dose that would kill 50% of subjects) was based on poor experiments undertaken in the 19th Century and that these likely exaggerated the toxicity by 10-20 times.
Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Arch Toxicol 2014; 88: 5–7. [link] [blog]
The trade association ECITA commissioned expert advice from consultants Bibra on how e-liquids should be classified under the European Classification, labelling and packaging of substances and mixtures (CLP) Regulation. The report is excellent: see ECITA’s summary: How Toxic is E-liquid…
European officials have been wrongly labelling e-liquid as extremely toxic. This is the view of ECITA, based on a report by toxicology consultants which has been verified by Professors Riccardo Polosa and Bernd Mayer, and Dr Jacques Le Houezec. The civil servants had been misclassifying e-liquid as either a CLP category 2 product, alongside strychnine, or a category 3 product, alongside formaldehyde. The new report demonstrates that the acute oral and dermal toxic hazards of the strongest consumer e-liquids only merit being classed as category 4 – along with washing-up liquid – while the vast majority of e-liquid (which has nicotine concentrations below 25mg/ml or 2.5%) does not require any type of formal hazard warning. ECITA will still mandate its members to provide clearly labelled e-liquid in child-proof containers.
Pragmatic approach – not a cause for panic
Instead of indulging in panic-stricken commentary or regulatory over-kill, there is a simple measure, which meets the requirement for a duty of care to consumers. Just ensure tamper proof containers are used, as set out in ISO 8317 – Child Resistant Packaging. Something the industry can easily do and increasingly does.
Of course, regulators could have mandated this by now if they were taking a pragmatic and proportionate approach to regulation under consumer protection legislation. Instead they are indulging in legally vulnerable and grandiose schemes like the FDA’s deeming regulation, EU Directive 2014/40/EU Article 20 or attempting to de facto outlaw these products by classifying them as medicines or poisons (Canada and Australia).
Appendix: calls to US poisons centers – data
| E-cigs & liquids 2013 | 1,543 |
| E-cigs and liquids 2014 | 3,957 |
| Analgesics | 298,633 |
| Cosmetics | 199,838 |
| Cleaning substances | 196,183 |
| Sedatives | 153,398 |
| Antidepressants | 109,110 |
| Foreign bodies | 103,737 |
| Cardiovascular drugs | 101,544 |
| Antihistamines | 99,176 |
| Topical preps | 89,287 |
| Pesticides | 85,033 |
| Alcohols | 70,258 |
Source (non-nicotine): 2013 Annual Report of the American Association of Poison Control Centers ’ National Poison Data System (Table 17A)
Source (nicotine): AAPPC E-Cigarette Devices and Liquid Nicotine
excellent, dear!
Well done Clive! I’ve been posting a similar proportional analysis for months in forums and reply to news articles. What I lacked you have provided, that being the toxicological evidence to further demonstrate that not only is the incidence of exposure far less than troublesome, but the effects of that exposure are far less likely to cause harm than the scaremongering headlines would lead one to believe. Thank you for the work!
Robert hi ,
as Mayer points out- if nicotine really had a LD 50 that was in the same league as things like cyanide – then why have there been so many documented cases of people ingesting many times the theoretically lethal dose, and yet suffering no apparent , lasting, harm?
BTW
Steven jay Gould used to tell a wonderfull true story about a widely distributed and used foundational level science text book ,first published back in the late 50s, that included a nice clear diagram of some important (but ‘ basic’ )statistical and related life science fundamentals. As it happened by chance that diagram had some serious , glaring errors – Over the next few decades new authors of similar text books in the same subject area ,simply reproduced and reproduced that same blatantly erroneous diagram- they had simply not actually looked at it. This lasted until about 1990.
In case you didn’t hear it already on of the ecig forum members was persistant with local authorities about the death of a child of nic poisoning in New York and after some weeks of getting the run around he was told a cause of death cannot be confirmed because it is cofidential under New York law. As far as I can find there has never been a confirmed case of death by accidental e liquid poisoning anywhere.
The calls to poison centers are only going to go up if people follow the advice in the CDPH brochure “How to Protect You’re Family from E-Cigarettes,” which advises people to immediately call the poison contol center if any of the fluid is swallowed, gets in the eyes, or on the skin. If it were truly that poisionous shouldn’t you try to wash it off before calling? Millions of open system users spill tiny amounts of nicotine fluid on their hands and in their mouths without incident. Later in the same brochure they recommend using other forms of “poisonous” nicotine for smoking cessation, which apparently don’t require a quick call to the poison center if they’re mishandled.
A better measure of nicotine ‘poisonings’ would be hospital admissions (or at the very least, actual examination/treatment by a GP ). Are there any figures re people who have actually required treatment, and how many have suffered any lasting ill effects?
Suspect that the answer would be very few, or nobody that we know for sure.
The 2013 US data gives the following outcomes:
none: 367
Minor: 422
Moderate: 47
Major:2
Death: 0
The missing reports would presumably fall into the none/minor category (otherwise they would be not be unreported)
Oh.. and the UK data is 204 exposures with the outcomes
“Where the clinical features were known at the time of
the enquiry, 103 patients had no features of toxicity and
94 had features of only mild toxicity (four unknown).
Two patients had moderate toxicity (one aged 13 months),
while another had severe toxicity and was sent to
an intensive care unit. Features of toxicity included
conjunctivitis, irritation of the oral cavity, anxiety, vomiting,
hyperventilation and changes in heart rate.”
from http://www.npis.org/NPISAnnualReport2013-14.pdf
Tom hi, the figure for calls to US poison information centres about cleaning substances is given as 193,183′. Do you have a break up as to how many of those calls ended in hospilisation, or long term ill efects or death. My hypothesis is that the figure for cleaning substances would be ,proportinately , much higher than for nicotine.
PS sorry about the spill chick, auto corrects in my posts, am a long way from my normal ‘office’ .
Hmm… little complicated…
Cleaning substances (household), category totals
Mentions: 195,862
Number of single exposures: 175,594
Outcomes
None: 32,897
Minor: 38,313
Moderate: 5,298
Major: 263
Death: 14
Tom hi
It looks like the figures , for household cleaning substances suggest that about one in seven hundred reported cases result in major harm plus some deaths ? And that about one in two thousand ecig cases results in major harm,but no known deaths?
We know what motivated the NY Times and CDC director Tom Frieden to knowingly and intentionally scare the public to believe e-cigs have poisoned thousands of children.
But it would be helpful to know who/what prompted many different Poison Control Centers to issue fear mongering press releases and local e-cig call data (but not data on 99.9% of other calls) to further confuse and scare the public about e-cigs.
Directors of Poison Control Centers are supposed to objectively inform the public about actual poisonings and poisoning risks, not to scare the public about products that have saved the lives of millions of smokers (while ignoring the many far greater poisoning threats).
The ‘peak poison’ may also indicate that the negative publicity did some good, and raised awareness of the fact that e-liquids should be kept out of the reach of children. Black propaganda is a far from ideal educational tool, however.
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