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Three cases of attempted suicide by ingestion of nicotine liquid used in e-cigarettes
... Az e-cigaretta és az utántöltő folyadékok gyakran szabályokat nélkülöző gyártása folytán a közelmúltban világszerte megnövekedett a nikotin okozta mérgezések száma: az Egyesült Államokban bejelentett esetek több mint fele öt év alatti gyermekeknél fordult elő [11][12][13]. A patronokon feltüntetett nikotinkoncentráció sok esetben jelentősen -több mint a hibahatárnak számító 10%-kal -eltér a folyadékban mérttől [7]. ...
... A patronokon feltüntetett nikotinkoncentráció sok esetben jelentősen -több mint a hibahatárnak számító 10%-kal -eltér a folyadékban mérttől [7]. A bőrön keresztül felszívódó, illetve a véletlenül vagy öngyilkossági szándékkal lenyelt nikotin okozta mérgezések néhány esetben halállal jártak [12,13]. A tudomány által jelenleg széleskörűen elfogadott korábbi vizsgálatok becslése alapján felnőtteknek 40-60 mg, gyermekeknek már 6 mg nikotin véletlen lenyelése életveszélyes lehet [14]. ...
The decreasing proportion of smokers due to smoking restrictions have led producers to invent and disseminate electronic cigarettes (e-cigarettes) worldwide as a new form of nicotine enjoyment. This review summarizes the existing knowledge about e-cigarettes based on publications of PubMed, and on reviews and research data published by national and international scientific institutions. Present knowledge about the composition of e-cigarettes confirms that they are harmful products since their vapor is equally detrimental to the health of users and bystanders. Their benefits in smoking cessation still have not been justified by adequate scientific evidence, however, it has been proven that e-cigarettes uphold nicotine addiction and may increase the risk of starting conventional cigarette use by youth. In order to ensure the results of tobacco control policy and to assist smoking cessation, the same regulations are to be applied to e-cigarettes as to conventional tobacco products. Orv. Hetil., 2016, 157(25), 979-986.
... In addition, 4 attempted suicides by e-liquid ingestion have been recorded (Cervellin et al., 2013;Christensen et al., 2013). Reportedly, one individual attempted suicide by e-liquid ingestion on 2 occasions (ingesting 360 mg and 1500 mg of nicotine, respectively); both led to nausea and vomiting. ...
... Reportedly, one individual attempted suicide by e-liquid ingestion on 2 occasions (ingesting 360 mg and 1500 mg of nicotine, respectively); both led to nausea and vomiting. Another individual, aged 13 years, ingested 3 ml of nicotine of an unknown concentration and experienced similar symptoms (Christensen et al., 2013). Another individual apparently attempted suicide by injecting approximately 3 mg of nicotine solution mixed with liquid methadone in addition to orally ingesting roughly 34 mg of e-liquid (Cervellin et al., 2013). ...
Electronic cigarettes (ECIGs), also referred to as electronic nicotine delivery systems or "e-cigarettes," generally consist of a power source (usually a battery) and heating element (commonly referred to as an atomizer) that vaporizes a solution (e-liquid). The user inhales the resulting vapor. Electronic cigarettes have been increasing in popularity since they were introduced into the US market in 2007. Many questions remain about these products, and limited research has been conducted. This review describes the available research on what ECIGs are, effects of use, survey data on awareness and use, and the utility of ECIGs to help smokers quit using tobacco cigarettes. This review also describes arguments for and against ECIGs and concludes with steps to move research on ECIGs forward.
... However, one case of e-liquid spilling with no injury or side effects was reported. Previous studies have reported accidental and intentional nicotine poisoning cases among children and adults (22)(23). For the safety of vapers and the public, these problems can be solved by refilling e-liquids in childproof packaging and by standardising the bottle size for the maximum nicotine concentration of 20 mg/ml in ? 10 ml. ...
... Such risks are even higher in vaping than in smoking, where such poisonous nicotine levels rarely occur [38]. In fact, many successful and unsuccessful suicide attempts through intravenous and oral intake of the nicotine solution intended for e-cigarette cartridges have been reported [39][40][41]. ...
Cigarette smoking is a risk factor for respiratory disorders, cardiovascular diseases and even decrements in muscle function. Electronic cigarette use (vaping) is considered a healthier alternative to cigarette smoking and may help in smoking cessation. However, the effects of vaping are not clear yet and particularly the long-term effects of vaping are largely unknown. Some reports suggest that vaping maybe as harmful for e.g. respiratory function, as cigarette smoking. In this narrative review the effects of vaping and cigarette smoking on respiratory, cardiovascular and muscle function are compared. Overall, vaping has been found to cause similar effects as smoking on lung function and cardiovascular function. Future studies are needed to clarify the severity of smoking- and vaping-induced decrements on muscle function.
... Poisonings were caused by accidental (9/28) [138][139][140][141][142][143][144][145][146] or intentional ingestion (14/28) [147][148][149][150][151][152][153][154][155][156][157][158] of e-liquid, intravenous injection of e-liquid (4/28) [151,[159][160][161], or both ingestion and injection (1/28) [162]. ...
Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016–2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.
... Poisonings were caused by accidental (9/28) [138][139][140][141][142][143][144][145][146] or intentional ingestion (14/28) [147][148][149][150][151][152][153][154][155][156][157][158] of e-liquid, intravenous injection of e-liquid (4/28) [151,[159][160][161], or both ingestion and injection (1/28) [162]. ...
Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016–2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.
... A boost of plasma nicotine delivery was reported (3.5 ng/ml) which was less than traditional cigarettes [33]. Studies show that EC poses minimal risk of nicotine poisoning from the device as intended to be used, but e-liquid can be dangerous or lethal if ingested, particularly by small children [34,35]. ...
The electronic cigarette (EC) is battery-powered electronic nicotine delivery systems that appear very similar to a conventional cigarette. EC is a rising phenomenon that is becoming gradually more popular among smokers worldwide. Vapers report use of EC helps them to quit smoking, and to reduce cigarette consumption. Although available evidence indicates that EC is safer alternative to smoking there is emerging data that suggests otherwise and that considerable health benefits are likely in smokers who switch from tobacco to EC. The key motivation among most of the vapers is smoking cessation (SC), however some use it for recreational purposes. Progression is often related to EC resembling traditional cigarettes, curiosity, and experimentation. Studies indicate that the content of the nicotine in EC is equivalent to oral nicotine replacement therapy products and causes minimal possibility of poisoning. The inhaled compounds associated with EC results in cytotoxicity and affect various organs. The considerable risk associated with the use and abuse of nicotine refill bottles has been reported. Large scale research will help make EC more effective as smoking substitutes. Although previous data shows that EC can considerably decrease cigarette consumption without causing significant side effects, there is emerging data suggesting the potentially toxic consequences of EC, which necessitates the urgent need for further research in that regard. The focus of the present article is use, the safety of EC and its effectiveness to provide as a long-term substitute for SC.
... The toxicity of nicotine has been widely studied when inhaled, ingested and in transdermal use, but never when injected [7,13]. The population concerned by e-liquid intoxication consists of paediatric patients (close to 35% of reported events) principally unintentional ingestion [1,3,5,6] and adults with psychiatric illnesses using e-liquid in suicide attempts [8,[14][15][16][17][18]. E-liquid injection has been documented in only three cases. ...
Background
Concern about intoxication by e-liquid is growing as calls to poison control centers have increased since their introduction. Only three cases of intoxication by injection have been reported worldwide. Our case is unique because of the precise follow-up of a patient who survived a lethal dose of self-injected e-liquid, without other co-intoxication.
Case presentation
A 51-year-old male presented to the Emergency Department after injecting himself intravenously (IV) in the forearm with 10 mL of e-liquid (1000 mg of nicotine diluted in propylene glycol). An agitation phase was followed by coma and bradypnoea requiring mechanical ventilation. The patient developed a transitory neurological impairment with the appearance of tetraparesis, gaze palsy and myoclonus due to nicotinic syndrome. The arterial blood gas (ABG) analysis confirmed uncompensated lactic acidosis with an elevated anion gap, which is an expected effect of propylene glycol. The toxicology screen indicated the presence of nicotine and cotinine in the blood and excluded the presence of concomitant intoxication. The patient recovered without sequelae.
Conclusion
Even a small quantity of intravenous (IV) e-liquid can lead to an acute intoxication and fatal outcomes due to the toxic effects of nicotine. This case might help emergency doctors cope with acute intoxication by injection of e-liquid and increase their comprehension of the two main substances, nicotine and propylene glycol with overview of their pharmacodynamics and kinetic effects.
... In addition, there is strong evidence that the nicotine use has a role in neurodegeneration and im-paired brain develop-ment among the consumers primarily in the youths 16 . Moreover, some accidental and intentional poisoning cases of nicotine have been reported among the children and adults in the preceding e-cig related studies 17,18 . Furthermore, WHO does not recommend any nicotine-containing products usage due to its extremely addictive nature 19 . ...
E-cigarette (e-cig) is becoming a popular substitute for tobacco cigarette all over the world. The chief constituents of e-cig e-liquids are nicotine, propylene glycol, glycerine, and a couple of other flavouring constituents. The current study objective was to find out the discrepancy in the labelled vs actual nicotine concentration amid the Malaysian marketed e-liquids brands for consumer safety purpose. The study examined the 69 e-liquids samples that were selected from Malaysia market. The nicotine estimation was measured by Agilent 6890N Gas chromatography-mass spectrometry with 5973 mass selective detector (MSD). Out of 69 samples analysed for actual nicotine level, in 64 samples nicotine concentration was found to be as low from - 1 to -67.13% and in remaining 5 samples it contained higher from +2.8 to +24.70. A total of 60 (86.9%) samples were found to have significant discrepancies in labelled vs. actual nicotine concentration. The study concludes that high discrepancy in the labelled vs actual nicotine concentration was found among the Malaysian marketed e-liquids brands. Based on analysis results, there is an urgent need for regulation for these marketed nicotine e-liquids products in Malaysia. The study suggests that corresponding Malaysian tobacco regulatory authorities should instruct suppliers of e-liquids for flawless packaging for consumer safety reason.
... Poisoning from ingestion of refill liquids may also be intentional, as suicide attempts have been reported [160,161,164,168,169,[172][173][174][175]. Suicides have also been recorded, by intravenous injection and ingestion of refill liquids [176,177]. ...
The purpose of this study was to identify the potential risks to public health associated with the use of refillable electronic cigarettes and development of technical specifications for refill mechanisms
... Our finding that the majority of incidents reported in poison centers refer to unintentional exposure is also consistent with published data [14]. However, several incidents of intentional poisoning -suicide attempts-through ingestion have also been reported in the literature [15][16][17][18][19][20][21][22]. ...
Background
The use of e-cigarettes has increased during the past few years. Exposure to e-cigarette liquids, whether intentional or accidental, may lead to adverse events our aim was to assess factors associated with e-cigarette exposures across European Union Member States (EU MS). MethodsA retrospective analysis of exposures associated with e-cigarettes reported to national poison centers was performed covering incidents from 2012 to March 2015 from 10 EU MS. De-identified and anonymous raw data was acquired. ResultsIn total, 277 incidents were reported. Unintentional exposure was the most frequently cited type of exposure (71.3%), while e-cigarette refill vials were responsible for the majority of the reported incidents (87.3%). Two-thirds of all exposures (67.5%) occurred as ingestion of e-liquids, which was more frequent among children (≤ 5 years, 6–18 years) compared to adults (87.0% vs. 59.3% vs. 57.6%, p < 0.001 respectively), exposure via the respiratory (5.4% vs. 22.2% vs. 22.2%, p < 0.001) were more frequent among paediatric patients while ocular routes (2.2% vs. 3.7% vs. 11.4%, p = 0.021) were more frequent among adults. Logistic regression analyses indicated that paediatric incidents (≤ 5 years) were more likely to be through ingestion (adjusted Odds Ratio [aOR] = 4.36, 95% Confidence Interval [C.I.]: 1.87–10.18), but less likely to have a reported clinical effect (aOR = 0.41, 95% C.I.: 0.21–0.82). Conclusions
Our study highlighted parameters related to e-cigarette exposure incidents in 10 EU MS, the results of which indicate that consideration should be given to the design features which may mitigate risks, thereby protecting users, non-users and especially children.
... The possibility of deliberate use of e-liquids in order to achieve a specific result or even death causes grave concern. In 2013, in Great Britain, three cases of intentional use of liquid nicotine in order to commit suicide were reported [39]. In the Internet there are even instructions on how to commit suicide with the help of liquid nicotine [40]. ...
Electronic cigarettes are more and more frequently used to deliver nicotine. They are used both by the users of regular cigarettes and those who to date have not smoked. The literature about potential impact of electronic nicotine delivery systems on health is constantly growing. Particular concern is expressed about toxicity of chemical compounds and elements delivered with the vapour of electronic cigarettes. It turns out that products that have positive image in media, actually are not so beneficial. Furthermore, they not only may cause damage to health but also death.
... In contrast, over-puffing on e-cig (intake of nicotine, similar to those occurring for tobacco cigarette) is a rare occurrence due partially to a phenomenon of self-titration NIC intake among smokers [8]. Nonetheless, high nicotine concentrations in e-liquids may potentially increase the risk of nicotine toxicity by inhalation and also by accidental/suicidal oral ingestion or intravenous injection [4,[9][10][11][12]. Intake/exposure to nicotine continues to be an area of public health concern, and major interest has recently been focused on e-cig with important implications for safety and regulation aspects related to high use among young people, tobacco smokers and ex-smokers. ...
Background:
Electronic cigarettes (e-cig) known as electronic nicotine devices recently gained popularity among smokers. Despite many studies investigating their safety and toxicity, few examined the delivery of e-cig-derived nicotine and its metabolites in alternative biological fluids.
Methods:
We performed a randomized, crossover, and controlled clinical trial in nine healthy smokers. Nicotine (NIC), cotinine (COT), and trans-3'-hydroxycotinine (3-HCOT) were measured in plasma and oral fluid by liquid chromatography-tandem mass spectrometry after consumption of two consecutive e-cig administrations or two consecutive tobacco cigarettes.
Results:
NIC and its metabolites were detected both in oral fluid and plasma following both administration conditions. Concentrations in oral fluid resulted various orders of magnitude higher than those observed in plasma. Oral fluid concentration of tobacco cigarette and e-cig-derived NIC peaked at 15 min after each administration and ranged between 1.0 and 1396 μg/L and from 0.3 to 860 μg/L; those of COT between 52.8 and 110 μg/L and from 33.8 to 94.7 μg/L; and those of 3-HCOT between 12.4 and 23.5 μg/L and from 8.5 to 24.4 μg/L. The oral fluid to plasma concentration ratio of both e-cig- and tobacco cigarette-derived NIC peaked at 15 min after both administrations and correlated with oral fluid NIC concentration.
Conclusions:
The obtained results support the measurement of NIC and metabolites in oral fluid in the assessment of intake after e-cig use and appear to be a suitable alternative to plasma when monitoring nicotine delivery from e-cig for clinical and toxicological studies.
... 3.1.9. Intentional misuse/suicidal attempts associated with EC Eight case reports involving nine individuals (8 adults and 1 adolescent ) are categorized as intentional or suicide attempts related to EC (Cervellin et al., 2013; Christensen et al., 2013; Valento, 2013; Eberlein et al., 2014; Schipper et al., 2014; Thornton et al., 2014; Bartschat et al., 2015; Chen et al., 2015). One case reported accidental overdose by intravenous injection of EC liquid combined with use of other recreational drugs. ...
The health risks associated with electronic cigarettes (ECs) are largely unknown. The purpose of this systematic review was to evaluate published case reports that deal with health effects attributed to EC use. An Internet search was conducted to identify case reports dealing with the effects of EC use on health. Twenty-six case reports representing 27 individuals (one study contained reports for two individuals) were published between April 2012 and January 2016, and these were grouped into categories of effect according to their health outcomes.
Of the 27 individuals, 25 had negative effects subsequent to use or exposure to ECs and their refill fluids, while two reported improvement in chronic immune and gastrointestinal conditions. Three categories of negative health effects were identified: systemic effects, nicotine poisoning, and mechanical injury. Thirteen cases reported EC effects on different systems including: respiratory (6), gastrointestinal or developing intestine of an infant (3), cardiovascular (2), neurological (1), and immune (1). Twelve cases involved nicotine poisoning resulting from accidental (N = 3), misuse/abuse (N = 1), or suicidal/intentional ingestion (N = 8); four of these involved children and three resulted in adult fatalities. Two cases reported mechanical injury caused by an EC battery explosion. Most case reports show that the health of children and adults can be negatively affected by EC products and that if death does not occur, negative effects can be reversed. Data further indicate that EC use can cause negative health effects in previously healthy individuals and exacerbate pre-existing conditions.
... [8]. For example, some recently reported non-fatal suicidal attempts from self-administration (per os) of e-liquid (maximum nicotine dose was equal up to 1500mg) caused only voluminous vomiting and abdominal pain [9]. Recent research estimates that L50 for per os nicotine administration ranges from 6.5 to 13 mg/kg (475-975 mg for an adult person), a much higher dose than previously estimated [7]. ...
Background:
Global use of electronic nicotine delivery systems (ENDS; also called electronic cigarettes, e-cigarettes) has increased dramatically in recent years. However, due to the limited safety studies and growing concerns on the potential toxicity from long term use of ENDS, many national and international governments have employed regulatory measures to curtail its use. One of the most significant challenges regulators of ENDS encounter is the lack of quality standards to assess ENDS, e-liquid (solution used with ENDS which contain nicotine--a highly toxic and addictive substance), and amount of nicotine delivery to aerosol during ENDS use.
Aim of the study:
Aims of the study were to (1) measure and compare nicotine concentration in e-liquids to values reported by manufacturers on packaging labels; (2) assess the precision of nicotine delivery from tank during aerosol formation. Methods: Nine popular Polish e-liquids (based on the market share data from October 2014) were purchased for the study. The labelled nicotine concentration for the selected e-liquids ranged between 11-25 mg/mL. All e-liquids were aerosolized in the laboratory using a smoking simulation machine (Palaczbot). Each e-liquid was aerosolized in a series of 6 consecutive bouts. A single bout consisted of 15 puffs with the following puff topography: 65 mL puff volume, 2.8 sec. puff duration, and 19 sec. interpuff interval. A total of 90 puffs were generated from each e-liquid. Nicotine content in the e-liquids and the aerosol generated were determined by gas chromatography with thermionic sensitive detection (GC-TSD).
Results:
For seven of nine analyzed e-liquids, the difference between measured and manufacturer labeled nicotine concentration was less than 10%. Nicotine dose in aerosol per bout ranged between 0.77-1.49 mg (equivalent to one-half the nicotine a smoker inhales from a single combustible cigarette).
Conclusions:
Our analysis showed the high consistency between the labeled and measured nicotine concentration for popular on the Polish market ENDS e-liquids. Also, our analysis demonstrates that the risk for nicotine overdose is likely minimal when ENDS are used in a similar manner as a combustible cigarette. However, due to the toxicity risk nicotine poses regulatory measures focused on safety and quality of e-liquids should continually be exercised.
... as in adult [15][16], adverse events mays suicide attempt does not succeed with 1500 mg [17] but succeeds with 10 000 mg (equivalent of 50 tanks of high concentration e-liquid [18]. All the e-liquid bottle caps need to be children resistant. ...
e-cigarettes remain controversial mainly because the lack of scientific evidence of short term and long term effects on tolerance and efficacy of a switch from tobacco to e-cigarette. Nevertheless the quality of e-cigarette and e-liquid is now improved. The main ingredients, propylene glycol, vegetal glycerine and nicotine are pharma grade quality in most e-liquid. Aroma and alcohol are of food grade. The high quality of ingredient has decreased the presence of impurities in e-liquids.The emission of e-cigarette does not content solids particles, carbon monoxide. Nitrosamine content is hundred times lower than in tobacco smoke. e-cigarette emission in normal use do not content any harmful product at significant level except nicotine. UK authorities enounce than e-cigarettes is at least 95% less toxic than tobacco use.It is important to improve the good use of the product. In countries where e-liquid containing nicotine is not allowed, "do-it-yourself" liquid are sometime toxic and impurities or inappropriate use. A major factor of misuse is the over burn of the product because of lack of liquid on the resistance of too high electric power. If e-cigarette will never be a safe product and will never be a product for non-smoker, for smoker e-cigarette is more than 20 times less dangerous than cigarette and most of tobacco cessation specialists in countries were nicotine containing e-cigarettes are available provide counselling for e-cigarette use to stop to smoke or to reduce smoking at the request of patients. According to existing knowledge, for patients with lung or others cancer who continue to smoke after use of e-cigarette is an alternative to quit tobacco after failure of medical procedures.
... Although e-liquids are intended to be vaporized and inhaled, the risks associated with ingestion should also be considered. Liquids can be ingested either after deposition of the vapor droplets in the upper aero-digestive tract during normal vaping, or accidentally [26], or intentionally in suicide attempts [27]. Assuming an ingestion of 10 mL of e-liquid, the risk of acute toxicity for components other than nicotine was not significant, because all the estimated concentrations were largely below the known LD50 for various animals (mainly rodents and guinea pigs). ...
We analyzed 42 models from 14 brands of refill liquids for e-cigarettes for the presence of micro-organisms, diethylene glycol, ethylene glycol, hydrocarbons, ethanol, aldehydes, tobacco-specific nitrosamines, and solvents. All the liquids under scrutiny complied with norms for the absence of yeast, mold, aerobic microbes, Staphylococcus aureus, and Pseudomonas aeruginosa. Diethylene glycol, ethylene glycol and ethanol were detected, but remained within limits authorized for food and pharmaceutical products. Terpenic compounds and aldehydes were found in the products, in particular formaldehyde and acrolein. No sample contained nitrosamines at levels above the limit of detection (1 μg/g). Residual solvents such as 1,3-butadiene, cyclohexane and acetone, to name a few, were found in some products. None of the products under scrutiny were totally exempt of potentially toxic compounds. However, for products other than nicotine, the oral acute toxicity of the e-liquids tested seems to be of minor concern. However, a minority of liquids, especially those with flavorings, showed particularly high ranges of chemicals, causing concerns about their potential toxicity in case of chronic oral exposure.
... istnieją doniesienia o podejmowaniu próby samobójstwa poprzez dożylne lub doustnie pobranie nikotyny obecnej w kartridżu e-papierosa. [25][26][27][28] w skutek czego może dojść do nagłego zatrzymania krążenia [25]. ...
Currently very popular in the market of tobacco products have gained electronic cigarettes (ang. E-cigarettes). These products are considered to be potentially less harmful in compared to traditional tobacco products. However, current reports indicate that the statements of the producers regarding to the composition of the e- liquids not always are sufficient, and consumers often do not have reliable information on the quality of the product used by them. This paper contain a review of previous reports on the composition of e-cigarettes and their impact on health. Most of the observed health effects was related to symptoms of the respiratory tract, mouth, throat, neurological complications and sensory organs. Particularly hazardous effects of the e-cigarettes were: pneumonia, congestive heart failure, confusion, convulsions, hypotension, aspiration pneumonia, face second-degree burns, blindness, chest pain and rapid heartbeat. In the literature there is no information relating to passive exposure by the aerosols released during e-cigarette smoking. Furthermore, the information regarding to the use of these products in the long term are not also available.
... As some e-cigarette liquids contain nicotine at a concentration of around 100 mg/mL, this presents the potential for lethal toxicity. [34][35][36] Additionally, instances of "no nicotine" solutions actually containing nicotine have been reported. 31 24 Heart rate Significant increase after 5 and 10 minutes of use 22,23 Blood counts No change in WBCs, lymphocytes and granulocytes 25,26 Exhaled nitric oxide (FeNO) Significant decrease shortly after use 27,28 Respiratory impedances (a marker of peripheral airway flow resistance) Significant (18%) increase 28 Airway resistance Significant increase, including nicotine free solutions 29,30 Exposure to Chemical Substances Other Than Nicotine ...
Electronic cigarettes (e-cigarettes) were introduced into the United States market in 2007 and have quickly become a popular source of nicotine for many patients. They are designed to simulate smoking by heating a nicotine containing solution producing an aerosol that the user inhales. The short and long term effects of e-cigarette use are still unclear, but their use is increasing. Some acute effects of e-cigarettes on heart rate, blood pressure and airway resistance are reported. Although there are some reports of improved cessation in a subset of users, there are also studies reporting decreased cessation in dual users of regular and e-cigarettes. Additionally, there is no current regulation of these devices, and this allows virtually anyone with a form of online payment to obtain them.
Copyright © 2015 Elsevier Inc. All rights reserved.
... All the cases have been successfully treated with activated charcoal. 17 Nicotine has also been reported as a potential chemical weapon, since it is highly toxic, it can be purchased without restriction, and there is no restriction for airline passengers. The Norwegian fanatic extremist and terrorist Anders Behring Breivik, before killing 77 people, published on-line a relatively simple process to convert hollow projectiles into chemical weapons, by injecting them with a biological or chemical toxin… and, after careful consideration of alternatives, including heroin, various insecticides and cyanide, he concluded that the ideal is nicotine. ...
There are increasing concerns about the escalating use of electronic cigarettes (e-cigarettes). In particular, smokers have been advised by important agencies such as the US Food and Drug Administration about the potential harm to the health of these products, being now considered as drug delivery devices. The leading issues supporting this statement include the repeated inhalation of propylene glycol that is used as a diluent in refills, accidental poisoning, as well as evidence that ecigarettes may promote continued smoking since their use may compromise quitting motivations. Some authors have minimized these risks, considering the potential advantages of these devices for public health. Here we describe the first case of nicotine poisoning due to both ingestion and intravenous injection of the content of an e-cigarette refill, incorrectly mixed with methadone, bottled in a generic vial.
... With the increase in EC use, there has been an increase in calls to poison centres following accidental exposures but these remain lower than calls following such exposure from tobacco and none resulted in any serious harm [92]. Several suicide attempts were recorded where adults drank up to 1,500mg of nicotine in e-liquid which resulted in vomiting but recovery within a few hours [93]. ...
AimsWe reviewed available research on the use, content and safety of electronic cigarettes (EC), and on their effects on users, to assess their potential for harm or benefit and to extract evidence that can guide future policy.Methods
Studies were identified by systematic database searches and screening references to February 2014.ResultsEC aerosol can contain some of the toxicants present in tobacco smoke, but at levels which are much lower. Long-term health effects of EC use are unknown but compared with cigarettes, EC are likely to be much less, if at all, harmful to users or bystanders. EC are increasingly popular among smokers, but to date there is no evidence of regular use by never-smokers or by non-smoking children. EC enable some users to reduce or quit smoking.Conclusions
Allowing EC to compete with cigarettes in the market-place might decrease smoking-related morbidity and mortality. Regulating EC as strictly as cigarettes, or even more strictly as some regulators propose, is not warranted on current evidence. Health professionals may consider advising smokers unable or unwilling to quit through other routes to switch to EC as a safer alternative to smoking and a possible pathway to complete cessation of nicotine use.
... [69][70][71] Three reported suicide attempts involving e-liquid ingestion were ultimately non-fatal, but one individual did commit suicide via e-liquid injection. 72,73 Secondhand vaping-Toxic chemicals in e-cigarette vapor are not only inhaled by ecigarette users; they are also released into the indoor environment. An early study reported no risk of harm to health via the inhalation route of environmental e-cigarette vapor, 74 but later studies found that use of e-cigarettes leads to emissions of aerosols, VOC's, flavoring substances, and nicotine, allowing for "passive vaping". ...
Background and objectives:
Cigarette smoking is common among cancer patients and is associated with negative outcomes. Electronic nicotine delivery systems ("e-cigarettes") are rapidly growing in popularity and use, but there is limited information on their safety or effectiveness in helping individuals quit smoking.
Data sources:
The authors searched PubMed, Web of Science, and additional sources for published empirical data on safety and use of electronic cigarettes as an aid to quit smoking.
Review methods:
We conducted a structured search of the current literature up to and including November 2013.
Results:
E-cigarettes currently vary widely in their contents and are sometimes inconsistent with labeling. Compared to tobacco cigarettes, available evidence suggests that e-cigarettes are often substantially lower in toxic content, cytotoxicity, associated adverse effects, and secondhand toxicity exposure. Data on the use of e-cigarettes for quitting smoking are suggestive but ultimately inconclusive.
Conclusions:
Clinicians are advised to be aware that the use of e-cigarettes, especially among cigarette smokers, is growing rapidly. These devices are unregulated, of unknown safety, and of uncertain benefit in quitting smoking.
Implications for practice:
In the absence of further data or regulation, oncologists are advised to discuss the known and unknown safety and efficacy information on e-cigarettes with interested patients and to encourage patients to first try FDA-approved pharmacotherapies for smoking cessation.
... Further support for this came from a recent presentation of three cases of attempted suicide by ingesting nicotine liquid used for e-cigarettes; none of the cases were fatal, with one of them ingesting 1,500 mg of nicotine. 9 Smokeless tobacco is an alternative form of nicotine intake which does not involve combustion. Still it contains tobacco and several contaminants present in it. ...
... 18 Intentional misuse in children A case of attempted suicide by a 13-year-old teen who ingested 3 mL of nicotine liquid (unknown concentration) was reported by Christensen. 26 The patient developed nausea and shivering 15 min after ingestion. Treatment included oral administration of activated charcoal, and symptoms improved 1 h after the ingestion. ...
To review the impact of electronic cigarettes (e-cigarettes) on children.
Five electronic databases were searched through 31 December 2013. Studies in English that included data for children younger than 18 years of age were included. In addition, relevant data from articles identified during searches of the e-cigarette literature, relevant state survey data and paediatric voluntary adverse event reports submitted to the US Food and Drug Administration (FDA) were reviewed and included.
Use of e-cigarettes by youth is increasing and is not limited to traditional cigarette smokers. Data regarding the reasons for youth e-cigarette initiation and ongoing use are limited. The effects of e-cigarette marketing and the availability of flavoured e-liquids on youth use are unknown. The abuse liability of e-cigarettes in youth is also not known. Unintentional exposures to e-cigarettes and e-liquids have been reported in children. The number of e-cigarette-related reports received by poison centres is increasing. No data are available on secondhand and thirdhand e-cigarette aerosol exposures in children.
Data on the impact of e-cigarettes on children are extremely limited. The available data indicate that youth awareness is high and use is increasing rapidly. The extent to which e-cigarette use in youth will result in nicotine dependence and subsequent use of other tobacco products is unknown. e-cigarettes present risks of unintentional nicotine exposure and are potential choking hazards. A greater understanding of the impact of e-cigarettes on children is needed and will be important in the evaluation of the effects of these products on the public health.
... 7 There are reports of completed and attempted suicide by intravenous injection and oral ingestion of liquid nicotine intended for e-cigarette cartridges. [8][9][10] The level of nicotine exposure from use of electronic cigarettes is highly variable. Studies have found wide ranges in nicotine levels, variability in aerosolisation, inaccurate product labelling, and inconsistent nicotine delivery during product use. ...
With the rapid increase in use of electronic nicotine delivery systems (ENDS), such as electronic cigarettes (e-cigarettes), users and non-users are exposed to the aerosol and product constituents. This is a review of published data on the human health effects of exposure to e-cigarettes and their components.
Literature searches were conducted through September 2013 using multiple electronic databases.
Forty-four articles are included in this analysis. E-cigarette aerosols may contain propylene glycol, glycerol, flavourings, other chemicals and, usually, nicotine. Aerosolised propylene glycol and glycerol produce mouth and throat irritation and dry cough. No data on the effects of flavouring inhalation were identified. Data on short-term health effects are limited and there are no adequate data on long-term effects. Aerosol exposure may be associated with respiratory function impairment, and serum cotinine levels are similar to those in traditional cigarette smokers. The high nicotine concentrations of some products increase exposure risks for non-users, particularly children. The dangers of secondhand and thirdhand aerosol exposure have not been thoroughly evaluated.
Scientific evidence regarding the human health effects of e-cigarettes is limited. While e-cigarette aerosol may contain fewer toxicants than cigarette smoke, studies evaluating whether e-cigarettes are less harmful than cigarettes are inconclusive. Some evidence suggests that e-cigarette use may facilitate smoking cessation, but definitive data are lacking. No e-cigarette has been approved by FDA as a cessation aid. Environmental concerns and issues regarding non-user exposure exist. The health impact of e-cigarettes, for users and the public, cannot be determined with currently available data.
... Although an unsubstantiated claim is often repeated that 30-60 mg of nicotine is fatal, several suicide attempts have been recorded where people drank up to 1500 mg of nicotine in e-liquid (i.e. 50× the presumed lethal dose) without any consequence other than abdominal pain and 'voluminous vomiting' [13]. A recent study managed to trace the statement concerning the lethal toxicity of nicotine to dubious self-experiments in the 19th century [14]. ...
Background and aims:
Electronic cigarettes (EC) may have a potential for public health benefit as a safer alternative to smoking, but questions have been raised about whether EC should be licensed as a medicine, with accurate labelling of nicotine content. This study determined the nicotine content of the cartridges of the most popular EC brands in the United Kingdom and the nicotine levels they deliver in the vapour, and estimated the safety and consistency of nicotine delivery across batches of the same product as a proxy for quality control for individual brands and within the industry.
Methods:
We studied five UK brands (six products) with high internet popularity.
Measurements:
Two samples of each brand were purchased 4 weeks apart, and analysed for nicotine content in the cartridges and nicotine delivery in vapour.
Results:
The nicotine content of cartridges within the same batch varied by up to 12% relative standard deviation (RSD) and the mean difference between different batches of the same brand ranged from 1% [95% confidence interval (CI) = -5 to 7%] to 20% (95% CI=14-25%) for five brands and 31% (95% CI=21-39%) for the sixth. The puffing schedule used in this study vaporized 10-81% of the nicotine present in the cartridges. The nicotine delivery from 300 puffs ranged from ∼2 mg to ∼15 mg and was not related significantly to the variation of nicotine content in e-liquid (r=0.06, P=0.92). None of the tested products allowed access to e-liquid or produced vapour nicotine concentrations as high as conventional cigarettes.
Conclusions:
There is very little risk of nicotine toxicity from major electronic cigarette (EC) brands in the United Kingdom. Variation in nicotine concentration in the vapour from a given brand is low. Nicotine concentration in e-liquid is not well related to nicotine in vapour. Other EC brands may be of lower quality and consumer protection regulation needs to be implemented, but in terms of accuracy of labelling of nicotine content and risks of nicotine overdose, regulation over and above such safeguards seems unnecessary.
Electronic cigarettes are a popular, easily purchased, alternative source of nicotine that is considered safer than conventional tobacco. However, Intentional or accidental exposure to e‐liquid substances, mainly nicotine, can lead to serious, potentially fatal toxicity. Emergency and critical care physicians should keep in mind acute intoxication of this poison with a biphasic toxic syndrome. We highlight its potentially fatal outcome and suggest monitoring the adverse effects of nicotine according to a multimodal protocol integrating somatosensory evoked potentials, electroencephalography and neuroimaging data with anamnestic report and toxicological and laboratory data.
Background: Electronic cigarettes (e-cigarettes), the smokeless alternative to conventional tobacco cigarettes, have become increasingly popular. E-cigarettes vaporise e-liquid, a solution of highly concentrated nicotine, propylene glycol (PG) and vegetable glycerine (VG). With the popularity of e-cigarettes, e-liquid refills have become easily accessible and several cases of intoxication due to the ingestion of e-liquid have been reported. We provide an overview of these cases, their pathophysiology and patients’ characteristics.
Methods: We carried out a retrospective evaluation of the scientific literature reporting on cases of liquid nicotine intoxication, using the following inclusion criteria: (1) the article is or contains a case report, (2) describes an intoxication with e-liquid, (3) the substance contains nicotine, and (4) intake is oral, intravenous or subcutaneous.
Results: We found 26 case reports describing a total of 31 patients who suffered from e-liquid intoxication. All intoxications up to the age of six were reported as unintentional, whereas nearly all cases from ages 13 to 53 were due to suicide attempts. The three most prevalent symptoms of e-liquid intoxication were tachycardia, altered mental status and vomiting. Eleven cases resulted in the death of the patient. In the survivors, the highest plasma concentration of nicotine was 800 µg L⁻¹, while the lowest concentration in the non-survivors was 1600 µg L⁻¹.
Conclusions: There is a mismatch between the generally accepted lethal oral nicotine dose of 60 mg, resulting in approximately 180 µg L⁻¹ plasma concentration, and the 4.4- to 8.9-fold higher lethal plasma concentrations we found in cases of e-liquid intoxication. In these severe intoxications, plasma cotinine concentration does not act as a more reliable indicator of nicotine intoxication than nicotine itself. The ages of the patients display a bimodal distribution. In patients above the age of 10, intoxication results mainly from suicide attempts rather than accidental ingestion. The role of PG and VG in e-liquid intoxications is remarkably unclear. However, the similarity across nicotine and PG toxicity symptoms leads us to believe a cumulative effect cannot be excluded.
Introduction:
Smoking prevalence remains high in some vulnerable groups, including those who misuse substances, have a mental illness, are homeless or are involved with the criminal justice system. E-cigarette use is increasing and may support smoking cessation/reduction.
Methods:
Systematic review of quantitative and qualitative data on the effectiveness of e-cigarettes for smoking cessation/reduction among vulnerable groups. Databases searched were MEDLINE, EMBASE, PsychINFO, CINAHL, ASSIA, ProQuest Dissertations and Theses and Open Grey. Narrative synthesis of quantitative data and thematic synthesis of qualitative data.
Results:
2628 records and 46 full texts were screened; 9 studies were identified for inclusion. Due to low quality of evidence, it is uncertain whether e-cigarettes are effective for smoking cessation in vulnerable populations. A moderate quality study suggested e-cigarettes were as effective as nicotine replacement therapy. Four studies suggested significant smoking reduction, however three were uncontrolled and had sample sizes below 30. A prospective cohort study found no differences between e-cigarette users and non-users. No significant adverse events and minimal side effects were identified. Qualitative thematic synthesis revealed barriers and facilitators associated with each component of the COM-B (capability, opportunity, motivation, behaviour) model, including practical barriers; perceptions of effectiveness for cessation/reduction; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity.
Conclusion:
Further research is needed to identify the most appropriate device types for practicality and safety, level of support required in e-cigarette interventions, and to compare e-cigarettes with current best practice smoking cessation support among vulnerable groups.
Implications:
Smoking prevalence among people with mental illness, substance misuse, homelessness or criminal justice system involvement remains high. E-cigarettes could support cessation. This systematic review found limited quantitative evidence assessing effectiveness. No serious adverse events were identified. Qualitative thematic synthesis revealed barriers and facilitators mapping to each component of the COM-B (capability, opportunity, motivation, behaviour) model, including practical barriers; perceived effectiveness; design features contributing to automatic and reflective motivation; smoking bans facilitating practical opportunity; and social connectedness increasing social opportunity. Further research should consider appropriate devices for practicality and safety, concurrent support, and comparison with best practice smoking cessation support.
Nicotine is a potent neurotoxin alkaloid and is used in e-cigarette liquid. The LC/MS/MS method was linear over 0.01-1.0 mg/L (r(2) = 0.992-0.995). Limit of detection and limit of quantitation were 0.001 mg/L (S/N = 3) and 0.003 (S/N = 10). The inaccuracy and imprecision were <13.2%. The recoveries were >99.3%. A 39-year-old dentist was found dead lying on the floor under the couch in his dental clinic. The concentration of nicotine, cotinine, and trans-3'-hydroxycotinine (heart blood/peripheral blood) was analyzed as follows: 87.2/85.2 mg/L (ratio 1.0), 1.4/1.1 mg/L (ratio 1.3), and 0.012/0.0089 mg/L (ratio 1.3), respectively. The concentration of nicotine was determined to be 6734.8 mg/kg in gastric contents and 7262.0 mg/L in remaining e-liquid. Only, high concentration of nicotine was detected in the gastric contents as well as the two pieces of evidence collected from the death scene. This fatal case resulted from oral ingestion of e-cigarette liquid. It is estimated that at least 714 mg of nicotine was orally ingested.
Smoking is the leading cause of preventable morbidity and mortality globally. Electronic cigarettes are marketed both as nicotine substitutes and recreational devices. The popularity of electronic cigarettes has superseded other forms of nicotine replacement therapy. They are also popular in 'never smokers'. This review summarizes the available data regarding the cardiovascular effects of electronic cigarettes. The existing literature is limited and short-term with a lack of high-quality studies and adequate follow-up. The available literature suggests that electronic cigarettes have sympathomimetic effects related to nicotine exposure, however, electronic cigarettes also contain other chemicals that require further investigation. Sparse data suggest vascular injury may be another concern. Further research is needed before broad recommendations can be made.
Electronic cigarettes (EC) are battery-powered nicotine delivery systems that have increased in popularity since they entered the US market. EC has been reported to contain less carcinogens than traditional cigarettes, cause less acute lung effects in healthy individuals, and may help with smoking cessation. It has also been viewed as a potential safer alternative for asthmatic smokers, but its effects on lung functions are unclear. However, EC do carry some harmful aspects as they contain formaldehyde and formaldehyde-forming hemiacetals as well as potentially toxic particulate matter that deposits on surfaces. EC are an increasingly popular device that could serve as a gateway into traditional cigarette smoking or illicit drugs. The popularity of EC has brought with it money from large tobacco corporations and mass marketing. Lack of regulation has generated product inconsistency and potential health hazards. This review highlights what is known and what still needs to be answered about EC.
Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
Objectives. The principal objective of this study is to evaluate effectiveness and safety of Varenicline as a smoking cessation treatment in a group of smokers with cardiovascular disease (CVD) in the clinical practice. Material and methods. A review was made of our database and the clinical records that achieved stable CVD (>2 months) were included. This is a descriptive, longitudinal study with retrospective collection
of the data. A total of 180 patients, all treated with varenicline, at standard dose of 1 mg every 12 h, for 12 weeks, plus psychological support and self-help material were incorporated. In all, 7 visits (baseline, 2nd and 4th weeks; 2nd, 3rd and 6th month and finally at 52 weeks) were carried out. Telephone calls were also made; the oral manifestation of abstinence was confirmed with measurement of CO in expired
air (<10 ppm). Results. Mean age of the participants was 58 years, with predominance of males (78%). Mean age at onset was 15.5 years, mean consumption of cigarettes 25/day. Mean on the Richmond test 8.1 and on the Fagerstrom test 7.5 points. A total of 83% smoked the 1st cigarette in less than half an hour. Abstinence rates at 12 w (52%); at 24 w (44%) and at 52 w (37%). Drop-out rate due to presence of adverse effects
was 7.6%. The most frequent undesired effects were, respectively: nauseas, headache, insomnia, vomits and unusual dreams. Conclusions. The participants had an elevated use of cigarettes/day and severe dependence. High motivation, with high score on the Richmond test. Varenicline has proven to be an effective drug treatment to achieve smoking cessation in smokers
Electronic cigarette smoking is gaining dramatic popularity and is steadily spreading among the adolescents, high income, urban population around the world. The aim of this study is to highlight the hazards of e-cigarette smoking on human health.
In this study, we identified 38 published studies through a systematic database searches including ISI-web of science and pub-med. We searched the related literature by using the key words including Electronic cigarette, E-cigarette, E-vapers, incidence, hazards. Studies in which electronic cigarette smoking hazards was investigated were included in the study. No limitations on publication status, study design of publication were implemented. Finally we included 28 publications and remaining 10 were excluded.
E-smoking can cause, nausea, vomiting, headache, dizziness, choking, burn injuries, upper respiratory tract irritation, dry cough, dryness of the eyes and mucous membrane, release of cytokines and pro-inflammatory mediators, allergic airway inflammation, decreased exhaled nitric oxide (FeNO) synthesis in the lungs, change in bronchial gene expression and risk of lung cancer.
Electronic cigarettes are swiftly promoted as an alternative to conventional cigarette smoking, although its use is highly controversial. Electronic cigarettes are not a smoking cessation product. Non-scientific claims about e-cigarettes are creating confusion in public perception about e-cigarette and people believe that e-cigarettes are safe and less addictive, but its use is unsafe and hazardous to human health. E-cigarette smoking should be regulated in the same way as traditional cigarettes and must be prohibited to children and adolescents.
Short summaryElectronic cigarettes are increasingly popular for smokers as an aid in the cessation of smoking. They are considered a less harmful alternative for traditional cigarettes. However, the liquid fillings of the electronic cigarettes (‘e-liquid’) contain high concentrations of nicotine which may cause potentially lethal poisoning when ingested.We present a case of nicotine poisoning in a 27 year-old male who attempted suicide by ingestion of a large amount of e-liquid. Given the increasing popularity of electronic cigarettes the frequency of nicotine intoxications is likely to rise in the next years. Physicians working in the Emergency Department and general practice should become familiar with this intoxication.
A systematic review was conducted to evaluate the impact of human factors (HF) on the risks associated with electronic cigarettes (e-cigarettes) and to identify research gaps. HF is the evaluation of human interactions with products and includes the analysis of user, environment and product complexity. Consideration of HF may mitigate known and potential hazards from the use and misuse of a consumer product, including e-cigarettes.
Five databases were searched through January 2014 and publications relevant to HF were incorporated. Voluntary adverse event (AE) reports submitted to the US Food and Drug Administration (FDA) and the package labelling of 12 e-cigarette products were analysed.
No studies specifically addressing the impact of HF on e-cigarette use risks were identified. Most e-cigarette users are smokers, but data on the user population are inconsistent. No articles focused specifically on e-cigarette use environments, storage conditions, product operational requirements, product complexities, user errors or misuse. Twelve published studies analysed e-cigarette labelling and concluded that labelling was inadequate or misleading. FDA labelling analysis revealed similar concerns described in the literature. AE reports related to design concerns are increasing and fatalities related to accidental exposure and misuse have occurred; however, no publications evaluating the relationship between AEs and HF were identified.
The HF impacting e-cigarette use and related hazards are inadequately characterised. Thorough analyses of user-product-environment interfaces, product complexities and AEs associated with typical and atypical use are needed to better incorporate HF engineering principles to inform and potentially reduce or mitigate the emerging hazards associated with e-cigarette products.
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