Volume 211 - Issue 4
Unintended consequences of a cautious approach to e‐cigarette laws
Authors: Anthony C Catalano, Noel E Cranswick, Joanne Grindlay, Mick Creati, Margie H Danchin, Jeff Robinson, Nicola Williams and Amanda Gwee
Med J Aust 2019; 211 (4): 190-190.e1. || doi: 10.5694/mja2.50278
Published online: 19 August 2019
Published online: 19 August 2019
In reply
In reply: We thank Mendelsohn and Wodak for their comment on our letter.1
Although we acknowledge that there is a range of reported lethal nicotine doses in humans ranging from 0.5 mg/kg to 13 mg/kg,2,3 the value of 60 mg stated in our original letter is used in numerous studies and in toxicology textbooks.4,5 There have been documented paediatric deaths from accidental nicotine ingestion,6 with some articles suggesting that the lethal dose in a child may be as low as 10 mg.7 Of note, one case report described a lethal dose of 4.2 mg/kg in a 15‐month old child. Despite vomiting immediately after the ingestion, there was rapid progression to cardiac arrest and hypoxic brain injury.8 Therefore, with the risk of significant morbidity and mortality, a conservative approach to an accidental ingestion is needed.
Even if a lethal dose of 500 mg is applied — equating to about 8 mg/kg per dose in an adult with a weight of 70 kg — the volume of nicotine required to produce a lethal dose in a child would still be significantly smaller. With the reported nicotine concentrations in electronic nicotine delivery systems (ENDS) ranging from 0 mg/mL to 36 mg/mL,3 the ingestion of only 5 mL (one teaspoon) of a solution with a concentration of 18 mg/mL would be needed to produce a potentially lethal dose in a child who weighs 10 kg.
We advocate for the safe labelling and childproof packaging of ENDS products in Australia to prevent deaths from accidental ingestion. The fact remains that even a small amount of ingested liquid nicotine has the potential to cause serious harm to a child, at a time when ENDS products are both widely available and, at this point, unregulated.
Competing interests
No relevant disclosures.
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
- Solarino B, Rosenbaum F, Riebelman B, et al. Death due to ingestion of a nicotine‐containing solution: case report and review of the literature. Forensic Sci Int 2010; 195: e19–e22.
- American Academy of Paediatrics Policy Statement. Electronic nicotine delivery systems. Pediatrics 2015; 136: 1018–1026.
- Cameron JM, Howell DN, White JR, et al. Variable and potentially fatal amounts of nicotine in e‐cigarette nicotine solutions. Tob Control 2014; 23: 77–78.
- Goldfrank LR, Flomenbaum NE, Lewin NA. Goldfranks’ toxicologic emergencies, 6th ed. Stamford, CT: Appleton and Lange, 1998.
- Kamboj A, Spiller HA, Casavant MJ, et al. Pediatric exposure to e‐cigarettes, nicotine, and tobacco products in the United States. Pediatrics 2016; 137. pii: e20160041.
- Etter JF, Bullen C, Flouris AD, et al. Electronic nicotine delivery systems: a research agenda. Tob Control 2011; 20: 243–248.
- Seo A, Dong C, Yu H, Kang M. Accidental ingestion of e‐cigarette liquid nicotine in a 15‐month old child: an infant mortality case of nicotine intoxication. Korean J Pediatr 2016; 59: 490–493.
Linked content
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MJA Letter: Unintended consequences of a cautious approach to e‐cigarette laws
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MJA Letter: Unintended consequences of a cautious approach to e‐cigarette laws