Volume 211 - Issue 4
Unintended consequences of a cautious approach to e‐cigarette laws
Authors: Colin P Mendelsohn and Alex D Wodak
Med J Aust 2019; 211 (4): 190-190.e1. || doi: 10.5694/mja2.50263
Published online: 19 August 2019
Published online: 19 August 2019
To the Editor: We agree with Catalano and colleagues1 that nicotine liquid needs to be regulated. However, we feel that their letter overstates the risk from nicotine poisoning.
The authors state that the minimum potentially lethal dose of nicotine in humans is 60 mg, but the reference used for this claim actually estimates a far higher minimum lethal dose of 500–1000 mg.2
While it is correct to say that the “ingestion of even a small volume could cause serious harm or even death,” the reality is less worrying. The bioavailability of ingested nicotine is as little as 20% due to hepatic first pass metabolism.3 Furthermore, most cases of significant ingestion result in prompt vomiting.4
A recent review of all cases of nicotine exposure reported to the Australian Poisons Information Centres between 2009 and 2016 found that most cases resulted in only mild gastrointestinal symptoms.5
We agree with the recommendation to mandate safety labelling and childproof packaging to reduce risk. However, regulation needs to go further; legalising and enforcing quality and safety standards would help to ensure a safer product and minimise unwanted contamination, as found in a recent Australian study.6
Vaping has a potential role in reducing smoking‐related disease in Australia. A recent large randomised controlled trial demonstrated that vaping is nearly twice as effective as nicotine replacement therapy.7
Regulation needs to find a balance between reducing the risk to children and non‐smokers while making high quality reduced‐risk products available to smokers who are otherwise unable to quit. Overly restrictive regulations are likely to have a net negative effect on public health.
Competing interests
We are unpaid directors of the Australian Tobacco Harm Reduction Association (ATHRA), a health promotion charity established to reduce the harm from tobacco smoking (www.athra.org.au). ATHRA has received unconditional donations from e‐cigarette businesses in the past. Neither author has or has ever had a financial or commercial relationship with any e‐cigarette or tobacco company. [Correction added on 06 August 2019, after first online publication: new disclosures have been added.]
References
- Catalano C, Cranswick NE, Robinson J, et al. Unintended consequences of a cautious approach to e‐cigarette laws. Med J Aust 2019; 210: 143–144. https://www.mja.com.au/journal/2019/210/3/unintended-consequences-cautious-approach-e-cigarette-laws
- 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.
- Zins BJ, Sandborn WJ, Mays DC, et al. Pharmacokinetics of nicotine tartrate after single‐dose liquid enema, oral, and intravenous administration. J Clin Pharmacol 1997; 37: 426–436.
- Hughes A, Hendrickson RG. An epidemiologic and clinical description of e‐cigarette toxicity. Clin Toxicol (Phila) 2019; 57: 287–293.
- Wylie C, Heffernan A, Brown JA, et al. Exposures to e‐cigarettes and their refills: calls to Australian Poisons Information Centres, 2009–2016. Med J Aust 2019; 210: 126. https://www.mja.com.au/journal/2019/210/3/exposures-e-cigarettes-and-their-refills-calls-australian-poisons-information
- Chivers E, Janka MA, Franklin P, et al. Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia. Med J Aust 2019; 210: 127–128. https://www.mja.com.au/journal/2019/210/3/nicotine-and-other-potentially-harmful-compounds-nicotine-free-e-cigarette
- Hajek P, Phillips‐Waller A, Pfzulki D, et al. A randomised trial of e‐cigarettes versus nicotine replacement therapy. N Engl J Med 2019; 380: 629–637.
Linked content
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MJA Letter: Unintended consequences of a cautious approach to e‐cigarette laws
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MJA Letter: In Reply