Reducing the dangers of e‐cigarettes for children: opportunities for regulation and consumer education

The importance of packaging, storage, and product design must be reflected by legislation

Electronic nicotine delivery systems (ENDS), including e‐cigarettes, are devices that heat a liquid (e‐liquid) that usually includes propylene glycol or vegetable glycerine, nicotine, and other constituents, such as colourants and flavourings. Nicotine is a naturally occurring toxin in tobacco plants that affects mammalian nervous and cardiovascular systems.1 E‐liquids containing nicotine are a poisoning risk because small amounts of nicotine can induce vomiting, cause seizures, and be lethal, particularly if ingested by young children.2 As Chivers and colleagues3 report in this issue of the MJA, e‐liquids may also contain a range of other toxic and dangerous constituents, including insecticides. In Australia and overseas, ENDS products are subject to regulations similar to those for tobacco products, including minimum age of purchase and restrictions on advertising.4 However, mitigating the risk of poisoning by ENDS products and their e‐liquids has not been the primary object of legislation.

ENDS devices differ greatly in design,5 and the variations influence the risk of poisoning. ENDS products can be categorised into closed and open systems. Closed systems, including many e‐cigarettes, are pre‐filled with e‐liquid in disposable canisters (“pods”); exposure to the e‐liquid requires that the device or canister be physically compromised. In open systems, including “tanks”, users must add e‐liquid to the device reservoir. E‐liquids for open systems are generally sold in transparent bottles that display brightly coloured liquid. Some companies market containers with labels similar to those of child‐friendly foods, such as candy or confectionery, do not include sufficient health warnings, and are not child‐resistant.6,7

The United States ENDS market, estimated to be worth $US5.5 billion in 2018, is dominated by open systems ($US3.5 billion, including $US850 million in online sales).8 The Australian vapour product retail market in 2017 was estimated be worth $AU50.1 million, also primarily open systems ($AU46.8 million); 79% of retail purchases were made online.9 One US study identified worrying deficiencies in the online supply of e‐liquids, including inadequate systems for verifying the age of buyers, the lack of instructions about how to use or store the products, and delivered products that were leaky.10

ENDS e‐liquids contribute to both unintentional and intentional (suicidal) nicotine poisonings,11 as discussed by Wylie and colleagues in this issue.12 Those most at risk of unintentional poisoning are children under 5 years of age, particularly following ingestion of fluids from e‐liquid bottles.13 The importance of e‐liquid and e‐cigarette manufacturing, packaging, storage, and product design must be reflected by legislation.

Safe manufacturing, delivery, and storage of e‐liquids and e‐cigarettes

Product standards can ensure that only high quality constituents free of contamination, including by residual pesticides, are employed in the manufacture of e‐liquids. The delivery of e‐liquids to households from online distributors should require that an adult signs for their receipt, and the contents should be clearly indicated on the outside of the package, together with warnings that they are poisonous. E‐liquids and devices should be stored so that they are inaccessible to young children, ideally in locked spaces, consistent with best practice for medication storage.

Packaging and labels

Thirty‐one countries have regulations requiring child‐safe packaging for e‐liquid products, mostly member nations of the European Union.4 The US Poison Prevention Packaging Act of 1970 requires that hazardous substances be packaged in such a manner that it is difficult for young children to access them; e‐liquid packaging and e‐cigarette devices and canisters should therefore be difficult to open for children under 5, and they should also be shatterproof to reduce the likelihood of leaks.

E‐liquid packaging should be required to include health warning labels and detailed product descriptions (including the quantity of nicotine), to clearly indicate (in symbols and words) that the e‐liquid should not be ingested, to advise that toxic amounts of nicotine can be absorbed by skin, and to provide guidance on how to respond to e‐liquid spills or ingestion.

As already standard for combustible cigarettes in Australia and some other countries, plain and standardised packaging for e‐cigarettes and e‐liquids containers could be made mandatory. Standard sizes might facilitate health warning label design. At the very least, packaging with images of food, candy, or anything that appeals to young people should be banned.

Product design

Maximum nicotine concentrations and volumes of e‐liquid could be defined by regulation to reduce the risk of poisoning by ingestion or absorption. It could be further required that e‐liquids have a standard unappealing colour, or be bottled in opaque containers that are less attractive to children. Limiting the flavours of e‐liquids may further reduce the appeal of e‐liquids to children.

Public health surveillance and education

Surveillance of poisonings by e‐liquids and e‐cigarettes should be improved to monitor the numerous problems we have discussed. Awareness among both adults and children of the dangers of e‐cigarettes and e‐liquids should also be assessed. Finally, health educators should devise campaigns in partnership with medical professionals to communicate the dangers of e‐liquid poisoning, including messages that health care providers can share with their patients about the appropriate use and re‐filling of devices, and about e‐liquid storage.