Pediatric Exposure to E-Cigarettes, Nicotine, and Tobacco Products in the United States

Self-poisoning by E-cigarette and E-liquids: National Reports to French Poison Control Centers from July 2019 to December 2020: VIGIlance and VAPE: The VIGIVAPE Study

INTRODUCTION

Exposure to e-cigarette liquids, whether intentional or accidental, might lead to adverse events. This study aimed to describe the prevalence and characteristics of exposures to e-liquids reported to French Poison Control Centers.

METHODS

All e-liquids exposure cases reported to French Poison Control Centers from July 1, 2019, to December 31, 2020, were reviewed. Information was collected about the patient's characteristics, exposure circumstances, management and outcome.

RESULTS

About 919 cases of exposure to e-liquids were reported. Ages ranged from one month to 89 years, with a mean age of 16.6 ± 18.6 years and a median age of 4 years. The highest number of exposures-50.7%-concerned infants (0-4 years), 3.1% children (5-11 years), 5.9% adolescents (12-17 years), and 40.1% of cases concerned adults. The majority of cases were accidental (95.0%). Intentional exposures (4.9%) were mainly observed in patients older than 12 years of age (P < 0.001). The route of exposure was ingestion in 73.7% of the cases. A total of 455 exposures showed no symptoms or signs related to poisoning. High nicotine concentration in e-liquids was associated with an increase in hospital management (Odds-ratio from 1.77 to 2.60).

CONCLUSION

Involuntary exposures to e-liquids occurred more often in children under the age of five, mainly by ingestion. Unlike intentional ingestions, unintentional ingestions rarely resulted in severe adverse events. These findings highlight the importance of ongoing surveillance to prevent such exposures and associated injuries, emphasizing the need for effective regulation of these products.

The availability and distribution of vaping retailers across Ontario neighbourhoods, 2016-2019

OBJECTIVES

To characterize the distribution of vaping retailers and examine the association between neighbourhood income and vaping retailer availability in Ontario prior to and after regulatory changes to the vaping market in 2018.

METHODS

We quantified vaping access by number of vaping retailers for 19,964 dissemination areas (DAs) in Ontario and percentage of schools near a vaping retailer. We used mixed-effects regression models to examine the associations between vaping access and neighbourhood income in 2018 and 2019.

RESULTS

Between 2016 and 2019, the number of vaping retailers in Ontario increased by 22.6% (5999 to 7355), despite a mild drop from 2016 to 2018. In 2019, 59.7% of urban neighbourhoods had one or more vaping retailers within 1000 m of their geographic centre, and 79.4% of elementary, 82.8% of secondary, and 84.2% of post-secondary schools had at least one within 1000 m. Neighbourhood income was associated with access to vaping retailers, with a greater number in low-income regions. In 2019, neighbourhoods in the lowest income quintile had over twice the number of vaping retailers per capita within 1000 m compared to the highest income quintile (adjusted incidence rate ratio 2.40; 95% CI 2.24-2.58). Increases over time in access to vaping retailers did not differ by geographic region, neighbourhood income quintile, or school type.

CONCLUSION

We observed a substantial increase in access to vaping retailers in Ontario including proximity to elementary and secondary schools following the 2018 provincial marketing regulations and federal nicotine regulations. Access to vaping was greatest in low-income neighbourhoods and may contribute to established inequities in vaping-related adverse events.

Acute Pediatric Liquid Nicotine Ingestions

Electronic cigarette and vaping device use in the household represents a possible source of unintentional nicotine exposure to pediatric patients. Although most ingestions of nicotine may be mild, there is a potential for significant toxicity. Nicotine toxicity can present similarly to many other types of ingestions, which makes the history an important piece of the encounter. Treatment of nicotine toxicity is primarily supportive care directed at the presenting signs and symptoms. There is no antidotal therapy for nicotine toxicity. This review covers information that can assist clinicians who might treat a pediatric patient presenting with significant nicotine toxicity after the accidental ingestion of liquid nicotine products. [Pediatr Ann. 2023;52(5):e187-e191.].

E-cigarettes and youth: an unresolved Public Health concern

The use of electronic cigarettes (e-cigarette) and vaping devices started as a potential aid for cessation and reducing the harmful consequences of cigarette smoking, mainly in the adult population. Today e-cigarette use is highly increasing in vulnerable populations, especially young and pregnant women, due to the misconception of its harmless use.

Despite the growing acknowledgment in e-cigarette as a potential harmful device, and due to mixed information found concerning its beneficial aid for smokers, along with an insufficient clinical study done in human models, it is important to further evaluate the possible benefits and risks of non-combusting, vaping nicotine or non-nicotine delivery devices.

In this review we tried to summarize the latest updated information found in the literature, concentrating mainly in the variety of adverse effects of e-cigarette use and its contribution for recent and future health concerns.

Acute injury or illness related to the inhalation of vaping aerosols among children and adolescents across Canada: A cross-sectional survey of Canadian paediatricians

Background

Vaping prevalence rates have increased among Canadian youth. Evidence suggests that vaping poses significant health risks to children and adolescents.

Objectives

The objectives of the study were to investigate epidemiological characteristics of acute injury/illness cases due to the inhalation of vaping aerosols among children and adolescents across Canada and to explore factors contributing to severe cases.

Methods

Data from the 2019 Canadian Paediatric Surveillance Program cross-sectional survey on vaping-related injury/illness were used. Analyses focused on injury/illness cases (n=71) among children and adolescents aged 0 to 17 years who presented to participating paediatricians for a harm related to the inhalation of vaping aerosols. We conducted descriptive analyses and performed logistic regression to explore associations between severe presentations requiring hospitalization or intensive care unit (ICU) admission and selected case characteristics.

Results

Of the 71 reported injury/illness cases related to inhalation of vaping aerosols, 56% of patients were male, and 68% were aged 15 to 17 years. Nicotine vaping was reported in 42% of cases, and cannabis vaping in 24%. Fifty-four per cent presented with respiratory distress, 18% with symptoms of nicotine toxicity, and 41% required hospitalization and/or admission to the ICU. Cases presenting with respiratory distress were more likely to be hospitalized/admitted to the ICU (odds ratio [OR]=5.37, 95% confidence interval [CI]:1.76 to 16.39).

Conclusions

The inhalation of vaping aerosols among children and adolescents may contribute to acute injury/illness. Clear associations between study variables and severe cases could not be established due to a small sample size. Additional research is needed to determine predictors and preventable risk factors of severe vaping-related injuries.

Managing intoxications with nicotine-containing e-liquids

INTRODUCTION

Nicotine is an addictive and poisonous agent. The recent development of e-cigarettes has caused a new demand for highly concentrated nicotine-containing solutions. These concentrated nicotine solutions have also increased the risk of nicotine overdoses.

AREAS COVERED

Essential factors for nicotine exposure are the concentration of the nicotine-containing e-liquid solution and its pharmacokinetics. Liquid nicotine refills contain nicotine in varying concentrations, which vary widely between and within products. The pharmacokinetics of nicotine are dependent on the route of administration, renal/hepatic clearance and urinary pH. The dose is another essential determinant of nicotine exposure. There is a considerable discrepancy between the generally accepted lethal dose and symptoms reported in case studies. Ingested doses correlate poorly to clinical symptoms. Symptoms of liquid nicotine toxicity vary from mild to severe between patients and are the result of overstimulation of nicotinic acetylcholine receptors, which may lead to fatal respiratory failure and cardiovascular collapse.

EXPERT OPINION

The literature on nicotine-containing e-liquid intoxications originating from vaping device refills are mainly case reports. Based on these case reports, we propose a treatment plan which is primarily symptomatic. Research should focus on providing insight on its toxicity, based on oral and transdermal pharmacokinetics and on toxicodynamics.

The chemistry and toxicology of vaping

Vaping is the process of inhaling and exhaling an aerosol produced by an e-cigarette, vape pen, or personal aerosolizer. When the device contains nicotine, the Food and Drug Administration (FDA) lists the product as an electronic nicotine delivery system or ENDS device. Similar electronic devices can be used to vape cannabis extracts. Over the past decade, the vaping market has increased exponentially, raising health concerns over the number of people exposed and a nationwide outbreak of cases of severe, sometimes fatal, lung dysfunction that arose suddenly in otherwise healthy individuals. In this review, we discuss the various vaping technologies, which are remarkably diverse, and summarize the use prevalence in the U.S. over time by youths and adults. We examine the complex chemistry of vape carrier solvents, flavoring chemicals, and transformation products. We review the health effects from epidemiological and laboratory studies and, finally, discuss the proposed mechanisms underlying some of these health effects. We conclude that since much of the research in this area is recent and vaping technologies are dynamic, our understanding of the health effects is insufficient. With the rapid growth of ENDS use, consumers and regulatory bodies need a better understanding of constituent-dependent toxicity to guide product use and regulatory decisions.

Nicotine Toxicity Secondary to Aftermarket Modifications to a Vaping Device

Electronic cigarettes continue to rise in popularity as a reportedly safe alternative to standard cigarette smoking. Their use has become common in our society and specifically in our young active duty population. This cigarette smoking alternative has come under recent scrutiny with the discovery of e-cigarette or vaping product use-associated lung injury. However, there is another potential risk associated with vaping: the relative ease at which vaping devices can be modified has allowed a growing community of users to invent novel ways of delivering higher concentrations of nicotine. Here, we describe two cases of active duty patients who presented to an emergency department with clinical nicotine toxicity after using a heavily modified e-cigarette.

Systematic Review of Human Poisoning and Toxic Exposures in Myanmar

The International Health Regulations (2005) promote national capacity in core institutions so that countries can better detect, respond to and recover from public health emergencies. In accordance with the ‘all hazards’ approach to public health risk, this systematic review examines poisoning and toxic exposures in Myanmar. A systematic literature search was undertaken to find articles pertaining to poisoning in Myanmar published between 1998 and 2020. A number of poisoning risks are identified in this review, including snakebites, heavy metals, drugs of abuse, agrochemicals and traditional medicine. Patterns of poisoning presented in the literature diverge from poisoning priorities reported in other lower-middle income countries in the region. The experience of professionals working in a Yangon-based poison treatment unit also indicate that frequently observed poisoning as a result of pharmaceuticals, methanol, and petroleum products was absent from the literature. Other notable gaps in the available research include assessments of the public health burden of poisoning through self-harm, household exposures to chemicals, paediatric risk and women’s occupational risk of poisoning. There is a limited amount of research available on poisoning outcomes and routes of exposure in Myanmar. Further investigation and research are warranted to provide a more complete assessment of poisoning risk and incidence.

The electronic cigarette epidemic in youth and young adults: A practical review

Electronic cigarettes are the most common form of nicotine delivery used by youth and young adults, and in 2018, the US Surgeon General declared this to be an epidemic. The developing adolescent brain is vulnerable to nicotine exposure, which can lead to long-lasting cognitive and mood disorders. Screening rates for vaping are low and lack of knowledge by adolescents, clinicians, parents, and caregivers is high. This article reviews the components of vaping, prevalence, adverse reactions, regulation, treatment, and prevention strategies related to vaping in youth and young adults.

Retrospective review of nicotine exposures in California from 2012 to 2018 and analysis of the impacts of e-cigarette regulations

OBJECTIVES

To review the association between US e-cigarette regulations and the number of reported nicotine exposures, and identify higher-risk products DESIGN: Retrospective review of de-identified medical records.

SETTING

California PARTICIPANTS: Cases reported to California Poison Control System in 2012-2018.

PRIMARY AND SECONDARY OUTCOME MEASURES

Suspected nicotine toxicity; route of exposure and product characteristics.

RESULTS

We examined 5277 exposures, of which 3033 involved combustible cigarettes, 1489 involved e-cigarettes and 818 involved other substances (ie, chewing tobacco, nicotine patches, nicotine lozenges, hookah, etc). Implementation of the Child Nicotine Poisoning Prevention Act of 2015 was not significantly associated with reduced exposures. Exposures for e-cigarettes increased significantly after the 2017 Food and Drug Administration Compliance Policy (p=0.003, coefficient (coeff)=0.61). Total exposures for all tobacco and nicotine products also increased significantly after the policy change (p=0.01, coeff=1.26). Nicotine exposure outcomes classified as being of minor and moderate severity increased significantly after implementation of the 2017 Compliance Policy (p=0.004, coeff=0.54 and p=0.002, coeff=0.56, respectively). Ingestion was the most common route of exposure (87.7%), followed by inhalation (8.1%), dermal (6.5%), ocular (2.1%) and other (intranasal, rectal, sublingual and unknown) routes (0.2%); some cases reported multiple routes of exposure. Exposure cases involving e-cigarettes fell into three problem categories: product design, labelling and the appeal of flavours.

CONCLUSIONS

Our analysis found that despite previous studies suggesting that the Child Nicotine Poisoning Prevention Act appeared to have reduced exposures for e-cigarettes, there was no significant change in exposures after its implementation. In contrast, there was a 30% increase in California e-cigarette exposures following the 2017 Compliance Policy. We conclude that current regulations are insufficient to reduce nicotine toxicities due to e-cigarette use.

Tweets About Acute Nicotine Toxicity Due to e-Liquid Exposure

Objectives

Intentional and unintentional exposures to electronic nicotine delivery system (ENDS) e-liquids can cause illness and death. In this study, we describe acute nicotine toxicity due to e-liquid exposure (ANTEE) information found on Twitter and contextualize ANTEE experiences to clarify conditions associated with exposure.

Methods

We obtained 20,180 ANTEE-relevant tweets from 2013-2018. We excluded retweets, suspected bots, non-English tweets, tweets not originating in the US, and advertisements. We coded relevant tweets qualitatively using domains for e-liquid exposure tweets and e-liquid-related non-exposure tweets (ie, posts reflecting hypothetical exposure, information about e-liquids).

Results

Content analyses were based on 1656 e-liquid exposure tweets and 1210 non-exposure tweets. More than half of exposure tweets (61.3%) were classified as accidental exposures; subjects were predominately young people, assumed to be under age 18 (40.5%), and self (27.7%). The most common exposure route was ingestion (61.1%). Of exposure tweets, 13.9% described health effects and 12.7% described seeking assistance. Most non-exposure tweets were classified as likely or hypothetical exposure (49.9%) or presentation of advice, information, or warnings (40.5%).

Conclusions

Tweets can serve as a novel and complementary data source for learning more about e-liquid exposures.

Vaping implications for children and youth

PURPOSE OF REVIEW

The development and uptake of E cigarettes are a relatively recent phenomenon. Because of aggressive marketing, attractive designs, enticing flavors and primarily reactionary legislation, we are now seeing soaring rates of adolescent vaping with associated consequences. This review explores how E cigarettes work, their health implications, epidemiology among youth and current regulatory strategies.

RECENT FINDINGS

Recently, the Center for Disease Control and Prevention reported that 27% of high school students had used a tobacco product within the last month, the majority being E-cigarettes in 20.8% of high school students. Vaping has managed to reverse a decades long trend of declining nicotine use among youth. Long-term addiction is not the only concern related to youth vaping; there are also increasing reports of short-term health consequences, such as seizures, acute nicotine toxicity, burns and lung injury.

SUMMARY

Industry has created and aggressively marketed a product that is enticing to adolescents. E cigarettes have sleek designs, desirable flavors and social acceptability with perceived safety among youth. This has resulted in epidemic E cigarette use in youth with resultant significant short-term and long-term health concerns. Legislation must include regulations that strictly avoid marketing and sales to youth, as well as reducing access to these products.

The Effects of Nicotine on Development

Recently, there has been a significant increase in the use of noncombustible nicotine-containing products, including electronic cigarettes (e-cigarettes). Of increasing popularity are e-cigarettes that can deliver high doses of nicotine over short periods of time. These devices have led to a rise in nicotine addiction in adolescent users who were nonsmokers. Use of noncombustible nicotine products by pregnant mothers is also increasing and can expose the developing fetus to nicotine, a known teratogen. In addition, young children are frequently exposed to secondhand and thirdhand nicotine aerosols generated by e-cigarettes, with little understanding of the effects these exposures can have on health. With the advent of these new nicotine-delivery systems, many concerns have arisen regarding the short- and long-term health effects of nicotine on childhood health during all stages of development. Although health studies on nicotine exposure alone are limited, educating policy makers and health care providers on the potential health effects of noncombustible nicotine is needed because public acceptance of these products has become so widespread. Most studies evaluating the effects of nicotine on health have been undertaken in the context of smoke exposure. Nevertheless, in vitro and in vivo preclinical studies strongly indicate that nicotine exposure alone can adversely affect the nervous, respiratory, immune, and cardiovascular systems, particularly when exposure occurs during critical developmental periods. In this review, we have included both preclinical and clinical studies to identify age-related health effects of nicotine exposure alone, examining the mechanisms underlying these effects.

Nicotine toxicity: Protecting children from e-cigarette exposure

Compared with children exposed to traditional cigarettes, those exposed to nicotine in e-cigarettes are 5.2 times more likely to be admitted to a healthcare facility and have 2.6 times the risk of a severe outcome. This article discusses nicotine toxicity in children accidentally exposed to e-cigarettes containing nicotine and reviews appropriate nursing interventions.

Special Considerations in Preschool Age

The diagnosis of asthma can be particularly difficult in young children, in whom wheezing is not always synonym with asthma. It is also difficult to predict which preschool children with wheeze will go on to be true asthmatics. In this chapter, we will characterize preschool wheezing and asthma and discuss early risk factors for the development of severe asthma. We will also review risk factors for severe acute wheezing in young children. Finally, we will describe the natural history and prognosis of wheezing and some of the attempts at early identification of children who will develop severe asthma.

Electronic nicotine delivery system (ENDS) liquid nicotine exposure in young children presenting to US emergency departments, 2018

Background

Increased use of electronic nicotine delivery systems (ENDS) in the United States (U.S.) has been related to acute adverse events from liquid nicotine exposure. Previous studies have reported on these events through 2017.

Findings

We used 2018 National Emergency Injury Surveillance System data to generate national estimates with 95% confidence intervals (CIs) of ENDS liquid nicotine-related poisonings among children under age 5 treated in U.S. hospital emergency departments (EDs). In 2018, an estimated 885 (95% CI: 397–1374) poisoning cases related to liquid nicotine among children under 5 were treated in U.S. EDs, which was a non-statistically signficant increase from 2017 (411 poisoning cases, 95% CI: 84–738). The most common route of exposure was through ingestion (99.4%). The majority of cases were treated and released from the hospital (90.0%), 8.9% of the cases left the hospital without being seen, and 1.1% of the cases were treated and admitted to the hospital.

Conclusions

This study provides updated national estimates of poisoning events related to liquid nicotine exposure that occurred in 2018 among children under age 5. Updated information from this study may complement public education efforts and prevent liquid nicotine exposure among children.

Poisoning exposure cases involving e-cigarettes and e-liquid in the United States, 2010-2018

Introduction: Poisoning exposure cases involving e-cigarettes have increased since 2010, coinciding with increasing rates of e-cigarette use in the United States (US). Given the increasing prevalence of e-cigarette use and ever-changing product designs, particularly the development of new products with high nicotine levels, it is important to conduct ongoing surveillance of poisoning exposure cases involving e-cigarettes. The objective of this study is to describe trends and characteristics of poisoning exposure cases involving e-cigarettes and e-liquids reported to poison control centers in the US.Methods: We analyzed e-cigarette exposure cases from the National Poison Data System (NPDS) during 2010-2018 by year and other characteristics.Results: The annual number of e-cigarette exposure cases increased greatly between 2010 and 2014, reaching a peak of 3742 in 2014, and then decreasing each year between 2015 and 2017. Between 2017 and 2018, the overall number of e-cigarette exposure cases increased by 25.0% (from 2320 to 2901). Approximately two-thirds (64.8%) of all cases were in children under age five, and 14.7% were in children aged 5-17 years or young adults aged 18-24 years. A small proportion of cases developed life-threatening symptoms (0.1%); and cases with more serious medical outcomes tended to be exposed to a higher e-liquid or nicotine quantity.Conclusions: Annual declines in e-cigarette exposure cases between 2015 and 2017 did not continue in 2018. The rapid changes in the occurrence of poisoning exposure cases involving e-cigarettes coupled with the development of new tobacco products and ever-evolving tobacco use landscape underscore the importance of continued surveillance of these poisoning exposure cases. Continuous monitoring of these poisoning exposure cases may inform efforts aimed at preventing e-cigarette poisoning exposures.

Electronic cigarette exposures reported to the British Columbia Drug and Poison Information Centre: an observational case series

BACKGROUND

Electronic nicotine delivery systems (ENDSs), including electronic cigarettes (e-cigarettes), are rapidly gaining popularity. The aim of this study was to use poison centre data to describe epidemiological trends in ENDS-related exposures.

METHODS

We conducted an observational case series study using records containing both coded fields and free-text narratives from the British Columbia Drug and Poison Information Centre for all calls involving exposure to ENDS received from 2012 to 2017. We described trends in exposures and exposed people, as well as clinical effects.

RESULTS

A total of 243 calls were recorded for 186 unique exposures to ENDS devices, e-juice, e-cigarette cartridges and other associated paraphernalia over the study period. Calls related to ENDS exposures increased nearly sixfold between 2013 and 2014 and did not decline subsequently. Exposures were most frequently documented in children aged 4 years or less (81 [43.5%]), with 58 (31.0%) in 1- and 2-year-olds. Seventy-two exposures (89%) in children aged 4 years or less were due to accidental ingestion, whereas adults aged 25 years or more called the poison centre following ENDS malfunctions (7 [23%], spills (4 [13%]) and exposure to e-juice mistaken for other substances (4 [13%]). Of the 186 exposed people, 87 (46.8%) reported symptoms.

INTERPRETATION

British Columbia experienced a sixfold increase in ENDS-related calls to the provincial poison centre between 2012 and 2017, driven by ingestions in young children. Regulatory approaches aimed at minimizing children's access to ENDS, clear labelling of nicotine concentration, and packaging that reduces the likelihood of spills, product confusion and malfunction should be considered.

Early-life exposure to electronic cigarettes: cause for concern

Electronic nicotine delivery systems, or ENDS, are devices that heat and aerosolise a solution of propylene glycol, glycerine, nicotine, and flavourings. They have only achieved widespread use in the past 5 years or so, and therefore evidence around their potential to effect health is scarce. Importantly, they are often viewed as safer than tobacco cigarettes, meaning that at-risk populations, including pregnant women, might be more inclined to use them. No human studies, however, have assessed the potential for maternal ENDS use to effect the health of a developing baby. Experimental research suggests that nicotine alone is likely to adversely affect the fetus. Further, there is a misconception that ENDS do not produce second-hand aerosols. This misconception might put infants and young children at risk because their parents are more likely to use ENDS around them than they are to use tobacco cigarettes. Emerging evidence also proposes that nicotine and other substances produced by ENDS can deposit onto surfaces, and subsequently be exposed to infants and children; a process known as third-hand exposure. Finally, ENDS are often refillable, and instances of accidental poisonings of children who drink nicotine-containing refills have occurred. Thus, there are a multitude of ways that, with respect to early-life exposures and health, ENDS are a cause for concern.

Young people's perspectives of e-cigarette use in the home

There is concern that the emergence of e-cigarettes could result in an increase in young people's intake of, and exposure to, nicotine. This UK study used friendship group interviews to elicit the perspectives of young people from socioeconomically contrasting backgrounds regarding e-cigarettes. Young people from both advantaged and disadvantaged backgrounds described similar e-cigarette practices in the home environment, and, for both health and sensory reasons, viewed these as preferable to tobacco smoking. Space-related practices of adult e-cigarette use in the home were revealed to be more malleable than those of tobacco use. Results also highlighted that e-cigarettes offered young people new opportunities for nicotine consumption in the home. Methods of storing e-cigarettes in domestic spaces posed safety risks to younger children and easy access to e-cigarettes for others.

National estimates of poisoning events related to liquid nicotine in young children treated in US hospital emergency departments, 2013-2017

Background

An estimated 2 million youth (in 2017) and 7.9 million adults (in 2015) reported currently using electronic nicotine delivery systems (ENDS). Reports of poisoning events related to liquid nicotine (e-liquids) in ENDS have been on the rise, but current, nationally-representative estimates of hospital-treated poisoning cases related to e-liquid nicotine exposure in the United States (US) are lacking.

Findings

We used National Electronic Injury Surveillance System (NEISS) data from 2013 to 2017 to calculate national estimates with 95% confidence intervals (CIs) of poisoning incidents related to e-liquid nicotine exposure. From 2013 to 2017, an estimated 4745 poisoning cases related to e-liquids among children under age five were treated in US hospital emergency departments; the number of cases increased from 181 (95% CI: 0-369) in 2013 to 1736 (95% CI, 871-2602) in 2015 and then decreased to 411 (95% CI, 84-738) in 2017. Most of the cases were treated and released; 4.1% were admitted to the hospital. The most common route of exposure was through ingestion (96.9%), and 2.6% of the cases were through dermal exposure. The highest amounts of e-liquids or nicotine ingested were 118.2mL, 1 bottle, and 100 mg, and the most common symptoms (63.6%) related to nicotine poisoning were nausea and vomiting.

Conclusions

This study provides national estimates of poisoning cases associated with nicotine exposure from e-liquids among children under age five. Findings on e-liquid volume or nicotine dose, when available, provide important insights into exposures associated with toxicity in children. Since NEISS data do not include product codes specific to ENDS or provide information on poisoning severity, we used general keywords to capture these events, which might underestimate the population burden. Information from this study may complement efforts, such as public education, to prevent unintended exposure to nicotine in e-liquids among children.

Impact of Presence of Children on Indoor Tobacco Restrictions in Households of Urban and Rural Adult Tobacco Users

OBJECTIVES

Secondhand smoke exposure in children is changing as a result of new public policy and electronic nicotine products (e-cigarettes). We examined factors related to self-imposed indoor household tobacco restrictions, with emphasis on children in the household and associations with combustible and noncombustible product use.

METHODS

A cross-sectional survey of urban and rural Ohio adult tobacco users classified participants as exclusive combustible users, smokeless tobacco (SLT) users, e-cigarette users, or dual users. They were further stratified according to combustible or noncombustible product use and the presence of indoor tobacco use restrictions. Multiple logistic regression determined factors associated with indoor tobacco restrictions.

RESULTS

A total of 1210 tobacco users participated, including 25.7% with children living in the home. Half allowed combustible and two thirds allowed noncombustible tobacco use indoors. Urban location (odds ratio [OR] = 1.58), younger age (OR = 0.88 per 5 year), male sex (OR = 1.40), college education (OR = 1.40), household income of more than $15,000 (OR = 1.78), and being married (OR = 2.43) were associated with a higher likelihood of banning combustible products indoors. SLT (OR = 8.12) and e-cigarette (OR = 5.85) users were more likely to have indoor bans compared to combustible users. Children in the household (OR = 1.89), older age (OR = 1.12 per 5 years), and nonwhite race (OR = 1.68) were associated with a higher likelihood of banning noncombustible products indoors. Combustible (OR = 4.54) and e-cigarette (OR = 3.04) users were more likely than SLT users to have indoor bans.

CONCLUSIONS

Indoor restrictions on tobacco use remain infrequent in homes with children and are associated with user type and socioeconomic factors. Public policy should target modifiable risk factors for in-home secondhand smoke exposure.

The toxicity of E-cigarettes and children's respiratory health

Electronic cigarettes (E-cig), also referred to as Electronic Nicotine Delivery System (ENDS), were initially developed in 2003 to reduce the harmful effects of tobacco smoking. Since then, E-cig have become widely available in many countries and are used by many young people who would be unlikely to take up cigarette smoking. However, the adverse effects on child health remain largely unknown. E-cigs are available through regulated sale in many countries, but easily accessible by the internet in others. Adverse effects may be ascribed to the nicotine itself, to the accompanying substances in the aerosol (often referred to as vapour) or to temperature modifications of the content. There is a lack of human studies to assess respiratory effects of nicotine exposure to the unborn or young child. Also assessing the effects of the vaping content apart from nicotine is challenging, with the huge variety of exposure by frequency, duration and content, but experimental studies are on the way that may indicate the level of harm by such products. This article will summarize what is currently known about the use of E-cigs in children and in pregnancy, and discuss adverse effects of direct or in utero exposure to E-cig on the respiratory health of children. We thereby hope to provide a background for discussing potential harms to the respiratory system of children by E-cig exposure in pregnancy and early post-natal life, in a setting where an increasing proportion of adolescent and young adults use E-cigs, marketed to be 95% less harmful than conventional cigarettes.

Adults' Perceptions of Nicotine Harm to Children

BACKGROUND

Given the changing landscape of tobacco products in recent years, the array of products through which children could be exposed to nicotine has grown substantially. Thus, it is particularly important to understand adults' perceptions of the harms of nicotine to children and to identify any sociodemographic factors related to inaccurate risk perceptions.

METHODS

Data were drawn from 2015 to 2016 US nationally representative surveys (n = 11 959). Using multinomial logistic regression analyses, we examined whether race, sex, education, tobacco product use, and having a minor child in the home are associated with the level of perceived harmfulness of nicotine to children.

RESULTS

Although the majority of respondents characterized nicotine as "definitely harmful" to children, there were notable subgroup differences. Compared with women, men had significantly lower odds of characterizing nicotine as "definitely harmful" to children. Tobacco product users had significantly lower odds of endorsing "definitely harmful" or "don't know" than nonusers. African American non-Hispanic individuals, Hispanic individuals, and "other" non-Hispanic individuals had significantly lower odds of endorsing "definitely harmful" or "maybe harmful" than white individuals.

CONCLUSIONS

Although most adults perceive nicotine exposure as harmful for children, there are important differences based on sex, racial and/or ethnic background, and tobacco use status. The results reveal the need for public health efforts to better understand and target inaccurate risk perceptions among specific subgroups.

Weighing the Risks and Benefits of Electronic Cigarette Use in High-Risk Populations

This article reviews the current evidence on electronic cigarette (e-cigarette) safety and efficacy for smoking cessation, with a focus on smokers with cardiovascular disease, pulmonary disease, or serious mental illness. In the United States, adult smokers use e-cigarettes primarily to quit or reduce cigarette smoking. An understanding of the potential risks and benefits of e-cigarette use may help clinicians counsel smokers about the potential impact of e-cigarettes on health.

E-Cigarette and Liquid Nicotine Exposures Among Young Children

OBJECTIVES

To investigate exposures to liquid nicotine (including electronic cigarette devices and liquids) among children <6 years old in the United States and evaluate the impact of legislation requiring child-resistant packaging for liquid nicotine containers.

METHODS

Liquid nicotine exposure data from the National Poison Data System for January 2012 through April 2017 were analyzed.

RESULTS

There were 8269 liquid nicotine exposures among children <6 years old reported to US poison control centers during the study period. Most (92.5%) children were exposed through ingestion and 83.9% were children <3 years old. Among children exposed to liquid nicotine, 35.1% were treated and released from a health care facility, and 1.4% were admitted. The annual exposure rate per 100 000 children increased by 1398.2% from 0.7 in 2012 to 10.4 in 2015, and subsequently decreased by 19.8% from 2015 to 8.3 in 2016. Among states without a preexisting law requiring child-resistant packaging for liquid nicotine containers, there was a significant decrease in the mean number of exposures during the 9 months before compared with the 9 months after the federal child-resistant packaging law went into effect, averaging 4.4 (95% confidence interval: -7.1 to -1.7) fewer exposures per state after implementation of the law.

CONCLUSIONS

Pediatric exposures to liquid nicotine have decreased since January 2015, which may, in part, be attributable to legislation requiring child-resistant packaging and greater public awareness of risks associated with electronic cigarette products. Liquid nicotine continues to pose a serious risk for young children. Additional regulation of these products is warranted.

The Association between Potential Exposure to Magazine Ads with Voluntary Health Warnings and the Perceived Harmfulness of Electronic Nicotine Delivery Systems (ENDS)

(1) Background: Several brands of electronic nicotine delivery systems (ENDS) carry voluntary health warning messages. This study examined how potential exposure to ENDS magazine ads with these voluntary health warnings were associated with the perceived harmfulness of ENDS. (2) Methods: Risk perception measures and self-reported exposure to ENDS ads were obtained from the 2014 Georgia State University (GSU) Tobacco Products and Risk Perceptions Survey of a nationally representative sample of U.S. adults. We examined the association between potential exposure to magazine ads with warnings and the perceived harms of ENDS relative to cigarettes, using binary logistic regressions and controlling for general ENDS ad exposure and socio-demographic characteristics. (3) Results: Potential exposure to ENDS magazine ads with warnings was associated with a lower probability of considering ENDS to be more or equally harmful compared to cigarettes, particularly among non-smokers (OR = 0.16; 95% CI: 0.04–0.77). In addition, ad exposure, ENDS use history, race/ethnicity, gender, education, and income were also associated with harm perceptions. (4) Conclusions: This study did not find evidence that magazine ads with warnings increased misperceptions that ENDS are equally or more harmful than cigarettes. With more ENDS advertisements carrying warnings, more research is needed to determine how the warnings in advertisements convey relative harm information to consumers and the public.

Regulating Cannabis Manufacturing: Applying Public Health Best Practices from Tobacco Control

State legalization and regulation of cannabis, despite continued federal illegality, is a massive shift in regulatory approach. Manufactured cannabis, including concentrates, extracts, edibles, tinctures, topicals and other products, has received less attention than more commonly used dried flower, but represents emerging regulatory challenges due to additives, potency, consumption methods, and abuse and misuse potential. In November 2017, the California Department of Public Health (CDPH) released initial cannabis manufacturing regulations as part of a new state regulatory structure. As the largest U.S. medical cannabis market (and largest legal adult use market in the world beginning in 2018), California's regulatory approach will potentially influence national and global policy. Comparing CDPH's initial regulations to tobacco control best practices reveals that, while the regulations recognize the need to protect public health, prioritizing public health over business interests requires stronger approaches to labeling, packaging, and product formulations. Based on tobacco best practices, we recommend that cannabis regulations incorporate large and proportionately sized informational labels, a prominent universal cannabis symbol, rotating and pictorial health warnings, mandatory plain packaging, a comprehensive ban on characterizing flavors and addictive additives, and strict limits on the potency of inhalable products and those easily confused with non-cannabis products.

E-cigarettes: Impact of E-Liquid Components and Device Characteristics on Nicotine Exposure

BACKGROUND

Electronic cigarette (e-cigarette) use has increased substantially in recent years. While e-cigarettes have been proposed as a potentially effective smoking cessation tool, dualuse in smokers is common and e-cigarettes are widely used by non-smokers, including youth and young-adult non-smokers. Nicotine, the primary addictive component in cigarettes, is present at varying levels in many e-liquids. E-cigarettes may lead to initiation of nicotine use in adult and youth non-smokers, re-initiation of nicotine dependence in ex-smokers or increased severity of nicotine dependence in dual-users of cigarettes and e-cigarettes. As such, there are important clinical and policy implications to understanding factors impacting nicotine exposure from e-cigarettes. However, the broad and rapidly changing range of e-liquid constituents and e-cigarette hardware which could impact nicotine exposure presents a challenge. Recent changes in regulatory oversight of e-cigarettes underscore the importance of synthesizing current knowledge on common factors which may impact nicotine exposure.

METHODS

This review focuses on factors which may impact nicotine exposure by changing e-cigarette use behavior, puff topography, altering the nicotine yield (amount of nicotine exiting the e-cigarette mouth piece including nicotine exhaled as vapor) or more directly by altering nicotine absorption and bioavailability.

RESULTS

Topics reviewed include e-liquid components or characteristics including flavor additives (e.g., menthol), base e-liquid ingredients (propylene glycol, vegetable glycerin), components commonly used to dissolve flavorants (e.g., ethanol), and resulting properties of the e-liquid (e.g., pH), e-cigarette device characteristics (e.g., wattage, temperature, model) and user behavior (e.g., puff topography) which may impact nicotine exposure.

CONCLUSION

E-liquid characteristics and components, e-cigarette hardware and settings, and user behavior can all contribute substantially to nicotine exposure from e-cigarettes.

Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine

Answer questions and earn CME/CNE Over the last decade, the use of electronic nicotine delivery systems (ENDS), including the electronic cigarette or e-cigarette, has grown rapidly. More youth now use ENDS than any tobacco product. This extensive research review shows that there are scientifically sound, sometimes competing arguments about ENDS that are not immediately and/or completely resolvable. However, the preponderance of the scientific evidence to date suggests that current-generation ENDS products are demonstrably less harmful than combustible tobacco products such as conventional cigarettes in several key ways, including by generating far lower levels of carcinogens and other toxic compounds than combustible products or those that contain tobacco. To place ENDS in context, the authors begin by reviewing the trends in use of major nicotine-containing products. Because nicotine is the common core-and highly addictive-constituent across all tobacco products, its toxicology is examined. With its long history as the only nicotine product widely accepted as being relatively safe, nicotine-replacement therapy (NRT) is also examined. A section is also included that examines snus, the most debated potential harm-reduction product before ENDS. Between discussions of NRT and snus, ENDS are extensively examined: what they are, knowledge about their level of "harm," their relationship to smoking cessation, the so-called gateway effect, and dual use/poly-use. CA Cancer J Clin 2017;67:449-471. © 2017 American Cancer Society.

Tobacco-related Poison Events Involving Young Children in the US, 2001-2016

Objective

In this paper, we describe trends in tobacco-related poison exposure calls (calls) involving young children in the US.

Methods

Data were from the National Poison Data System between January 1, 2001 and October 31, 2016. We analyzed data on calls involving children younger than 5 years old. We describe trends in calls over time and call frequency by age, tobacco product type, level of care, and other characteristics of calls.

Results

During 2001-2016, there were 123,876 calls involving young children. During the study period, calls increased for most product types; e-cigarette-related calls increased from 7 in 2010 to 2558 in 2015. In calls with information on level of care (92.2%), 278 children were admitted to an intensive care unit, 497 were admitted to a hospital noncritical care unit, and 19,834 were treated and released.

Conclusions

Tobacco-related poison events commonly occur in the US and can have serious health consequences. More than 123,000 events among young children were reported during 2001-2016, but this likely represents a small portion of actual tobacco-related poison events due to underreporting. It is critical to continue to monitor tobacco-related poison events and develop strategies to prevent tobacco-related harm.

Characteristics and outcomes of e-cigarette exposure incidents reported to 10 European Poison Centers: a retrospective data analysis

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).

METHODS

A 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.

RESULTS

In 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.

Alcohol's Harm to Children: Findings from the 2015 United States National Alcohol's Harm to Others Survey

OBJECTIVES

To examine the prevalence and severity of alcohol's harm to children in the US and the relationship of the harmer to the child, and to examine caregivers' sociodemographic characteristics, alcohol use, and exposure to harm due to a drinking spouse/partner or other family member as risk factors for alcohol's harm to children.

STUDY DESIGN

We report data on 764 caregivers (defined as persons with parental responsibility for at least 1 child aged ≤17 years) from the 2015 National Alcohol's Harm to Others Survey, a dual-frame national sample of US adults.

RESULTS

Overall 7.4% of caregivers reported alcohol's harm to children in the past year. Risk factors for alcohol's harm to children included the caregiver's own experience of alcohol's harm from a spouse/partner or other family member. Caregivers with a heavy drinker in the household were significantly more likely to report harm to children. A caregiver's own heavy drinking was not a significant risk factor for children in his or her care.

CONCLUSIONS

Alcohol places a substantial burden on children in the US. Although a caregiver's own drinking can harm children, other drinkers also increase the risk of alcohol's harm to children. Screening caregivers to determine whether there is a heavy drinker in the household may help reduce alcohol's harm in the family without stigmatizing caregivers, who themselves may not be heavy drinkers.

MicroRNA expression profiling defines the impact of electronic cigarettes on human airway epithelial cells

While all forms of tobacco exposure have negative health effects, the significance of exposure to electronic cigarettes (eCig) is not fully understood. Here, we studied the global effects of eCig on the micro RNA (miRNA) transcriptome in human lung epithelial cells. Primary human bronchial epithelial (NHBE) cells differentiated at air-liquid interface were exposed to eCig liquid. Exposure of NHBE to any eCig liquid resulted in the induction of oxidative stress-response genes including GCLM, GCLC, GPX2, NQO1 and HO-1. Vaporization of, and/or the presence of nicotine in, eCig liquid was associated with a greater response. We identified 578 miRNAs dysregulated by eCig exposure in NHBE, and 125 miRNA affected by vaporization of eCig liquid. Nicotine containing eCig vapor displayed the most profound effects upon miRNA expression. We selected 8 miRNAs (29A, 140, 126, 374A, 26A-2, 147B, 941 and 589) for further study. We validated increased expression of multiple miRNAs, including miR126, following eCig exposure. We also found significant reduction in the expression of two miR126 target genes, MYC and MRGPRX3, following exposure. These data demonstrated that eCig exposure has profound effects upon gene expression in human lung epithelial cells, some of which are epigenetically programmed at the level of miRNA regulation.

MicroRNA expression profiling defines the impact of electronic cigarettes on human airway epithelial cells

While all forms of tobacco exposure have negative health effects, the significance of exposure to electronic cigarettes (eCig) is not fully understood. Here, we studied the global effects of eCig on the micro RNA (miRNA) transcriptome in human lung epithelial cells. Primary human bronchial epithelial (NHBE) cells differentiated at air-liquid interface were exposed to eCig liquid. Exposure of NHBE to any eCig liquid resulted in the induction of oxidative stress-response genes including GCLM, GCLC, GPX2, NQO1 and HO-1. Vaporization of, and/or the presence of nicotine in, eCig liquid was associated with a greater response. We identified 578 miRNAs dysregulated by eCig exposure in NHBE, and 125 miRNA affected by vaporization of eCig liquid. Nicotine containing eCig vapor displayed the most profound effects upon miRNA expression. We selected 8 miRNAs (29A, 140, 126, 374A, 26A-2, 147B, 941 and 589) for further study. We validated increased expression of multiple miRNAs, including miR126, following eCig exposure. We also found significant reduction in the expression of two miR126 target genes, MYC and MRGPRX3, following exposure. These data demonstrated that eCig exposure has profound effects upon gene expression in human lung epithelial cells, some of which are epigenetically programmed at the level of miRNA regulation.

Tobacco, e-cigarettes, and child health

PURPOSE OF THE REVIEW

The availability of the Children's Health Exposure Assessment Resource funded by the National Institute of Environmental Health Sciences provides new opportunities for exploring the role of tobacco smoke exposure in causing harm to children.

RECENT FINDINGS

Children of smokers are exposed to nicotine and other harmful tobacco smoke chemicals in utero as well as in their environment. This passive exposure to tobacco smoke has a variety of negative effects on children. In-utero exposure to tobacco smoke causes poor birth outcomes and influences lung, cardiovascular, and brain development, placing children at increased risk of a number of adverse health outcomes later in life, such as obesity, behavioral problems, and cardiovascular disease. Furthermore, most smokers start in their adolescence, an age of increased nicotine addiction risk. Biomarkers of tobacco exposure helps clarify the role tobacco chemicals play in influencing health both in childhood and beyond. Although electronic cigarettes (e-cigarettes) appear to be a nicotine delivery device of reduced harm, it appears to be a gateway to the use of combustible cigarette smoking in adolescents.

SUMMARY

Pediatric researchers interested in elucidating the role of tobacco smoke exposure in adverse outcomes in children should incorporate biomarkers of tobacco exposure in their studies.

Emerging exposures of developmental toxicants

PURPOSE OF REVIEW

The purpose of this review is to identify emerging developmental toxicants that are understudied in children's health. Exposures may arise from new products designed to improve utility, to reduce toxicity, or to replace undesirable chemicals. Exposures to less-toxic chemicals may also be significant if they are very commonly used, thereby generating widespread exposure. Sources of exposure include the workplace, personal, home, and office products; food, water, and air.

RECENT FINDINGS

We describe eight exposure categories that contain numerous potential developmental toxicants. References are discussed if reported in PubMed during the past decade at least 10 times more frequently than in 1990-2000. Examples included phthalates, phenols, sunscreens, pesticides, halogenated flame retardants, perfluoroalkyl coatings, nanoparticles, e-cigarettes, and dietary polyphenols. Replacements are often close structural homologs of their precursors. We suggest biomonitoring as preferred means of exposure assessment to emerging chemicals. Some existing analytic methods would require minimal modification to measure these exposures, but others require toxicokinetic and analytic investigation.

SUMMARY

A deliberate strategy for biomonitoring of emerging replacement chemicals is warranted, especially in view of concerns regarding developmental toxicity. To prevent adverse health effects, it is important to characterize such exposures before they become widely disseminated.

E-cigarettes: An update on considerations for the otolaryngologist

PURPOSE

We provide an update in the literature and national regulations regarding electronic cigarettes with special attention to the pediatric population.

BACKGROUND

Electronic nicotine delivery systems (ENDS) are handheld battery operated devices that vaporize nicotine-containing liquids for inhalation. Use of these products has dramatically increased over the last several years, particularly among the youth. ENDS are being marketed with advertising techniques and flavors which appeal to the adolescent and young adult population. More reports of accidental pediatric exposures are being documented, as are suicides from abuse of liquid nicotine. Federal regulation has only now become required of these devices.

CONCLUSION

Use of e cigarettes among adolescents increases each year. Government oversight is needed to protect our children from the re-normalization of tobacco. Otolaryngologists should be prepared to counsel their patients and families regarding the latest in ENDS use.

Measurements of dermal uptake of nicotine directly from air and clothing

In this preliminary study, we have investigated whether dermal uptake of nicotine directly from air or indirectly from clothing can be a meaningful exposure pathway. Two participants wearing only shorts and a third participant wearing clean cotton clothes were exposed to environmental tobacco smoke (ETS), generated by mechanically "smoking" cigarettes, for three hours in a chamber while breathing clean air from head-enveloping hoods. The average nicotine concentration (420 μg/m³ ) was comparable to the highest levels reported for smoking sections of pubs. Urine samples were collected immediately before exposure and 60 hour post-exposure for bare-skinned participants. For the clothed participant, post-exposure urine samples were collected for 24 hour. This participant then entered the chamber for another three-hour exposure wearing a hood and clothes, including a shirt that had been exposed for five days to elevated nicotine levels. The urine samples were analyzed for nicotine and two metabolites-cotinine and 3OH-cotinine. Peak urinary cotinine and 3OH-cotinine concentrations for the bare-skinned participants were comparable to levels measured among non-smokers in hospitality environments before smoking bans. The amount of dermally absorbed nicotine for each bare-skinned participant was conservatively estimated at 570 μg, but may have been larger. For the participant wearing clean clothes, uptake was ~20 μg, and while wearing a shirt previously exposed to nicotine, uptake was ~80 μg. This study demonstrates meaningful dermal uptake of nicotine directly from air or from nicotine-exposed clothes. The findings are especially relevant for children in homes with smoking or vaping.

Adolescent Risk Behaviors and Use of Electronic Vapor Products and Cigarettes

BACKGROUND

Adolescent use of tobacco in any form is unsafe; yet the use of electronic cigarettes and other electronic vapor products (EVPs) has increased in recent years among this age group. We assessed the prevalence and frequency of cigarette smoking and EVP use among high school students, and associations between health-risk behaviors and both cigarette smoking and EVP use.

METHODS

We used 2015 national Youth Risk Behavior Survey data (N = 15 624) to classify students into 4 mutually exclusive categories of smoking and EVP use based on 30-day use: nonuse, cigarette smoking only, EVP use only, and dual use. Prevalence of cigarette smoking and EVP use were assessed overall and by student demographics and frequency of use. Prevalence ratios were calculated to identify associations with health risk-behaviors.

RESULTS

In 2015, 73.5% of high school students did not smoke cigarettes or use EVPs, 3.2% smoked cigarettes only, 15.8% used EVPs only, and 7.5% were dual users. Frequency of cigarette smoking and EVP use was greater among dual users than cigarette-only smokers and EVP-only users. Cigarette-only smokers, EVP-only users, and dual users were more likely than nonusers to engage in several injury, violence, and substance use behaviors; have ≥4 lifetime sexual partners; be currently sexually active; and drink soda ≥3 times/day. Only dual users were more likely than nonusers not to use a condom at last sexual intercourse.

CONCLUSIONS

EVP use, alone and concurrent with cigarette smoking, is associated with health-risk behaviors among high school students.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Child-resistant and tamper-resistant packaging: A systematic review to inform tobacco packaging regulation

OBJECTIVE

We aimed to investigate the effects of special packaging (child-resistant, adult-friendly) and tamper-resistant packaging on health and behavioral outcomes in order to identify research gaps and implications for packaging standards for tobacco products.

METHODS

We searched seven databases for keywords related to special and tamper-resistant packaging, consulted experts, and reviewed citations of potentially relevant studies. 733 unique papers were identified. Two coders independently screened each title and abstract for eligibility. They then reviewed the full text of the remaining papers for a second round of eligibility screening. Included studies investigated a causal relationship between type of packaging or packaging regulation and behavioral or health outcomes and had a study population composed of consumers. Studies were excluded on the basis of publication type, if they were not peer-reviewed, and if they had low external validity. Two reviewers independently coded each paper for study and methodological characteristics and limitations. Discrepancies were discussed and resolved.

RESULTS

The review included eight studies: four assessing people's ability to access the contents of different packaging types and four evaluating the impact of packaging requirements on health-related outcomes. Child-resistant packaging was generally more difficult to open than non-child-resistant packaging. Child-resistant packaging requirements have been associated with reductions in child mortality.

CONCLUSIONS

Child-resistant packaging holds the expectation to reduce tobacco product poisonings among children under six.

Electronic Cigarette Toxicity

Electronic cigarettes (e-cigarettes) are often advertised as a healthier product when compared with traditional cigarettes. Currently, there are limited data to support this and only a threat of federal regulation from the US Food and Drug Administration. Calls to poison control centers about e-cigarette toxicity, especially in children, and case reports of toxic exposures have increased over the past 3 years. This research letter reports the frequency of hazardous exposures to e-cigarettes and characterizes the reported adverse health effects associated with e-cigarette toxicity.