The Emerging Method of Suicide by Electronic Cigarette Liquid: a Case Report

Transdermal Nicotine Poisoning: A Rare Case Report of Occupational Exposure

We report a case of accidental nicotine intoxication following transdermal exposure in a 22-year-old man with no medical history, who worked in a company manufacturing e-liquids for electronic cigarettes. He accidentally spilled 300 mL of pure nicotine solution (>99%) on his right leg without wearing protective clothing or a mask. Less than a minute later, he experienced dizziness, nausea, and headaches, followed by painful burning sensations in the affected area. He immediately removed his pants and washed his leg thoroughly with water. He presented to the emergency department two hours later, where he exhibited a respiratory rate of 25 cpm, a heart rate of 70 bpm, headaches, abdominal pain, pallor, and vomiting. He recovered without specific treatment five hours post-intoxication. Plasma levels of nicotine, cotinine, and hydroxycotinine were measured five hours after exposure using liquid chromatography-mass spectrometry. The concentrations found were 447 ng/mL for nicotine, 1254 ng/mL for cotinine, and 197 ng/mL for hydroxycotinine. Nicotine is an alkaloid that can be highly toxic, with doses of 30-60 mg being potentially fatal. Transdermal intoxication is rare, with very few cases reported in the literature. This case highlights the risk of acute intoxication through cutaneous exposure to nicotine-containing liquid products and the need for protective clothing when handling such products in a professional context.

Use of electronic vaping products and mental health among adolescent high school students in the United States: The moderating effect of sex

Although studies have investigated the association between conventional tobacco smoking and mental health outcomes among adolescents in the United States, few studies have examined the association between electronic vaping products (EVPs) and mental health among adolescents. This study aimed to investigate the cross-sectional association between EVPs use, symptoms of depression, and suicidal behaviors among adolescents. Data were pooled from the 2017 and 2019 Youth Risk Behavior Survey. An analytic sample of 14,285 adolescents (50.3% female) was analyzed using binary logistic regression. The outcome variables investigated were symptoms of depression, suicidal ideation, suicide plan, and suicide attempts, and the main explanatory variable was EVPs use. Of the 14,285 adolescents, 22.2%, 19.2%, and 58.8% were current, former and never users of EVPs, respectively. Controlling for other factors, current users of EVPs were significantly more likely to report having symptoms of depression (AOR = 1.82, 95% CI = 1.58-2.09), having suicidal ideation (AOR = 1.55, 95% CI = 1.30-1.86), making a suicide plan (AOR = 1.62, 95% CI = 1.34-1.97), or attempting suicide (AOR = 1.75, 95% CI = 1.41-2.18) when compared to never users of EVPs. Gender moderated the association between EVPs use, symptoms of depression, suicidal ideation, and suicide plan. Racial minority identity, sexual minority identity, sexual violence victimization, victim of school and cyberbullying, alcohol use, and cigarette smoking were all significantly associated with depression and suicidal behaviors. Study findings support the association between EVPs use and adolescent mental health. Future studies that employ longitudinal designs may offer more insight into the mechanisms underlying this association.

Association of Cigarette Type Initially Smoked With Suicidal Behaviors Among Adolescents in Korea From 2015 to 2018

IMPORTANCE

Assessment of whether past electronic cigarette (e-cigarette) use or initiating smoking with e-cigarettes is associated with suicidal behaviors among adolescents is needed to inform future research and public health interventions.

OBJECTIVE

To evaluate the association between starting smoking with e-cigarettes or conventional cigarettes and suicidal behaviors among Korean adolescents.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study analyzed data on adolescents in grades 7 through 12 who participated in the nationwide Korea Youth Risk Behavior Web-Based Survey between 2015 and 2018.

EXPOSURES

Type of cigarette initially smoked: electronic or conventional.

MAIN OUTCOMES AND MEASURES

Multiple logistic regression analysis was performed to examine the association between initial cigarette type and suicidal behaviors, including suicidal ideation and suicide planning and attempts. All participants completed questionnaires about their history of suicidal behavior and were categorized into groups according to the type of cigarette used at initiation of smoking and any subsequent change (or lack of change) in the type of cigarette used.

RESULTS

A total of 255 887 Korean adolescents (51.2% male; mean (SD) age, 15.0 [1.8] years) were included in the primary analysis. Among 131 094 male adolescents, 3310 boys (2.5%) initially used e-cigarettes and 27 368 boys (20.9%) initially used conventional cigarettes. Among 124 793 female adolescents, 952 girls (0.8%) initially used e-cigarettes and 9296 girls (7.4%) initially used conventional cigarettes. Of those who initially used e-cigarettes, 178 of 3310 boys (5.4%) and 134 of 952 girls (14.1%) attempted suicide. Of those who initially used conventional cigarettes, 946 of 27 368 boys (3.5%) and 911 of 9296 girls (9.8%) attempted suicide. Adolescents who initially used e-cigarettes had a higher risk of suicidal behaviors, including suicide planning (boys: adjusted odds ratio [AOR], 1.63 [95% CI, 1.40-1.89]; P < .001; girls: AOR, 1.55 [95% CI, 1.23-1.95]; P < .001) and suicide attempts (boys: AOR, 1.55 [95% CI, 1.28-1.87]; P < .001; girls, AOR, 1.64 [95% CI, 1.29-2.10]; P < .001) compared with those who initially used conventional cigarettes. Changing from e-cigarettes to conventional cigarettes was associated with a higher risk of suicide attempts among both boys (AOR, 1.89; 95% CI, 1.39-2.57; P < .001) and girls (AOR, 2.36; 95% CI, 1.53-3.64; P < .001) compared with changing from conventional cigarettes to e-cigarettes.

CONCLUSIONS AND RELEVANCE

In this study, the initial use of e-cigarettes vs conventional cigarettes was associated with suicidal behaviors among adolescents. In future research on the association of e-cigarette use with adolescent mental health and interventions for suicide prevention, the type of cigarette initially used and changing the cigarette type should be considered.

Severe neurological nicotine intoxication by e-cigarette liquids: Systematic literature review

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.

Predictive Factors Associated With Methods of Suicide: The Korean National Investigations of Suicide Victims (The KNIGHTS Study)

Background: Because the suicide mortality depends on the lethality of suicide methods, the identification and prediction of suicide methods are important for suicide prevention. Methods: Examination data of suicide decedents were collected based on police reports. Suicide decedents were divided into groups according to the suicide methods (hanging, gas poisoning, pesticide poisoning, jumping, drug poisoning, and drowning) they used. Predictive factors for each suicide method in comparison to other suicide methods were identified. Results: Among 23,647 subjects, hanging was the most common method of suicide. Regarding gas poisoning, the history of previous suicide attempt was a risk factor and being age of 65 or older was a protective factor. Being age of 65 or older showed a highly strong association with suicide by pesticide poisoning. Being age of 18 or younger and the presence of schizophrenia were associated with jumping. A history of psychiatric outpatient treatment was a risk factor for drug poisoning. Regarding suicide by drowning, schizophrenia was a risk factor, while being age of 65 or older was a protective factor. Limitations: Only eight out of a total of 17 regions in South Korea were examined and included in the data of this study. Also, the methods of suicide were defined as one method that directly caused the death, which could undermine other less fatal methods used. Conclusions: There were differences in predictive factors according to the method of suicide. Predicting the method of suicide in people at high risk for suicide stands to be an important strategy for suicide prevention in clinical settings.

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

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.

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.

The Evolving Landscape of e-Cigarettes: A Systematic Review of Recent Evidence

Smoking continues to be a burden to economies and health-care systems across the world. One proposed solution to the problem has been e-cigarettes; however, because they are a relatively new product in the market, little is known about their potential health impacts. Furthermore, e-cigarettes continue to evolve at a rapid rate, making it necessary to regularly review and summarize available studies. Although e-cigarettes are marketed as a smoking cessation tool by some manufacturers, the reality is that many nonsmokers, including youth, are using them. This review focuses on two major demographic groups (smokers and nonsmokers) and evaluates the most recent data (early 2017 to mid 2019) regarding the potential health effects of e-cigarettes. We assessed peer-reviewed studies on the health impacts of e-cigarettes, with a particular focus on common questions asked by policy makers, clinicians, and scientists: (1) What are the effects of e-cigarettes compared with air/not smoking?; (2) Is there any direct evidence of harm or benefit to humans?; (3) Is there a risk from secondhand exposure?; (4) What are the risks and/or benefits of e-cigarettes compared with tobacco cigarette use?; (5) Are there risks or benefits to specific populations (eg, people with COPD or asthma, pregnant women [and their offspring])?; (6) What are the effects of flavoring chemicals?; (7) What are the effects of including nicotine in e-liquids?; (8) How often is nicotine concentration labeling incorrect?; and (9) What are the risks when e-cigarettes explode?

Nicotine intoxication by e-cigarette liquids: a study of case reports and pathophysiology

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.

Molecular mechanisms for nicotine intoxication

Nicotine, one of the more than 4700 ingredients in tobacco smoke, is a neurotoxin and once used as pesticides in agriculture. Although its use in agriculture is prohibited in many countries, nicotine intoxication is still a problem among the workers in tobacco farms, and young children as well as adults due to the accidental or suicidal ingestions of nicotine products. Understanding the mechanism of nicotine intoxication is important not only for the prevention and treatment but also for the appropriate regulatory approaches. Here, we review pharmacokinetics of nicotine and the molecular mechanisms for acute and chronic intoxication from nicotine that might be relevant to the central and the peripheral nervous system. We include green tobacco sickness, acute intoxication from popular nicotine products, circadian rhythm changes, chronic intoxication from nicotine through prenatal nicotine exposure, newborn behaviors, and sudden infant death syndrome.