Wicked Wizard Eliquid E – cigarettes: an evidence update A report commissioned by Public Health England
E cigarettes: an evidence update A report commissioned by Public Health England Key messages 1. Smokers who have tried other methods of quitting without success could be encouraged to try e cigarettes (EC) to stop smoking and stop smoking services should support smokers using EC to quit by offering them behavioural support. 2. Encouraging smokers who cannot or do not want to stop smoking to switch to EC could help reduce smoking related disease, death and health inequalities. 3. There is no evidence that EC are undermining the long-term decline in cigarette smoking among adults and youth, and may in fact be contributing to it. Despite some experimentation with EC among never smokers, EC are attracting very few people who have never smoked into regular EC use. 4. Recent studies support the Cochrane Review findings that EC can help people to quit smoking and reduce their cigarette consumption. There is also evidence that EC can encourage quitting or cigarette consumption reduction even among those not intending to quit or rejecting other support. More research is needed in this area. 5. When used as intended, EC pose no risk of nicotine poisoning to users, but e liquids should be in ‘childproof' packaging. The accuracy of nicotine content labelling currently raises no major concerns. 6. There has been an overall shift towards the inaccurate perception of EC being as harmful as cigarettes over the last year in contrast to the current expert estimate that using EC is around 95% safer than smoking. 7. Whilst protecting non-smoking children and ensuring the products on the market are as safe and effective as possible are clearly important goals, new regulations currently planned should also maximise the public health opportunities of EC. 8. Continued vigilance and research in this area are needed. Question & Answers Q- Are e cigarettes safe? A- The evidence indicates that they carry a fraction of the risk of smoking cigarettes but are not risk free. If a person is smoking tobacco then we know that they have a 50% of dying of a smoking related disease often in middle age. Q- Should I ask patients if they use an e cigarette? A- Yes, this should be asked as part of a medical history in addition to tobacco smoking history and other substances e.g. cannabis. It should also be recorded in the notes and any advice or referrals made. Some people will have ‘switched’ to e cigarette and stopped using tobacco and others may be using an e cigarette to ‘quit’ tobacco. Some may be using tobacco and an e cigarette depending on the circumstances and this is referred to as ‘dual use’. We should encourage all and especially the ‘quitter’ to accept a referral to local stop smoking services for support to aid their quit. Receiving behavioural support along with their e cigarette will improve their chances of quitting tobacco long term. Q- A patient who is keen to quit smoking and is struggling to be successful; he has tried a range of smoking cessation medication and asks if you think he should try an e cigarette? A- This report recommends supporting the decision of the patient to use an e cigarette and also to refer to the local stop smoking service for support. Q- Can they be used in hospitals? A- This will depend on each hospitals policy; many are currently reviewing their policy regarding smoke free sites taking into account NICE guidance and this report. Each trust will need to take into account the risk of fire from the electrical elements of e cigarettes and other substances e.g. oxygen. This report does not support a blanket ban in organisations. Q- Can e cigarettes be prescribed? A- New regulations come into force in 2016 when companies can apply for a medicines licence from the MHRA. This report supports having products available on prescription to support people quitting smoking and recommends that the license process may need streamlining as e cigarette manufacturers are often small companies unlike the pharmaceutical industry. Q- What e cigarettes they look like? 1 st Generation 2 nd Generation 3 rd Generation Written by Wendy Preston (27/08/15) The full Public Health England, review “E cigarettes: an evidence update” can be found via the link below: cigarettes-an-evidence-update
Nicotine poisoning describes the symptoms of the toxic effects of consuming nicotine, which can potentially be deadly, though serious or fatal overdoses are rare. Historically, most cases of nicotine poisoning have been the result of use of nicotine as an insecticide. More recent cases of poisoning typically appear to be in the form of Green Tobacco Sickness or due to accidental ingestion of tobacco or tobacco products or ingestion of nicotine-containing plants.
The estimated lower limit of a lethal dose of nicotine has been reported as between 500 and 1000 mg. Children may become ill following ingestion of one cigarette; ingestion of more than this may cause a child to become severely ill. The nicotine in the e liquid of an electronic cigarette can be hazardous to infants and children. In some cases children have become poisoned by topical medicinal creams which contain nicotine.
People who harvest or cultivate tobacco may experience Green Tobacco Sickness (GTS), a type of nicotine poisoning caused by dermal exposure to wet tobacco leaves. This occurs most commonly in young, inexperienced tobacco harvesters who do not consume tobacco.
2Signs and symptoms
The LD50 of nicotine is 50 mg/kg for rats and 3 mg/kg for mice. 0.5-1.0 mg/kg can be a lethal dosage for adult humans, and 0.1 mg/kg for children. However the widely used human LD50 estimate of 0.5–1.0 mg/kg was questioned in a 2013 review, in light of several documented cases of humans surviving much higher doses; the 2013 review suggests that the lower limit causing fatal outcomes is 500–1000 mg of ingested nicotine, corresponding to 6.5–13 mg/kg orally. An accidental ingestion of only 6 mg may be lethal to children.
It is unlikely that a person would overdose on nicotine through smoking alone. The US Food and Drug Administration (FDA) stated in 2013: "There are no significant safety concerns associated with using more than one OTC NRT at the same time, or using an OTC NRT at the same time as another nicotine-containing product—including a cigarette." Ingestion of nicotine pharmaceuticals, tobacco products, or nicotine containing plants may also lead to poisoning. Smoking excessive amounts of tobacco has also led to poisoning; a case was reported where two brothers smoked 17 and 18 pipes of tobacco in succession and were both fatally poisoned. Spilling an extremely high concentration of nicotine onto the skin can result in intoxication or even death since nicotine readily passes into the bloodstream following skin contact.
The recent rise in the use of electronic cigarettes, many forms of which are designed to be refilled with nicotine-containing "e liquid" supplied in small plastic bottles, has renewed interest in nicotine overdoses, especially in the possibility of young children ingesting the liquids. A 2015 report on e cigarettes by Public Health England noted an "unconfirmed newspaper report of a fatal poisoning of a two-year old child" and two published case reports of children of similar age who had recovered after ingesting e liquid and vomiting. They also noted case reports of suicides by nicotine. Where adults drank liquid containing up to 1,500 mg of nicotine they recovered (helped by vomiting), but an ingestion apparently of about 10,000 mg was fatal, as was an injection. They commented that "Serious nicotine poisoning seems normally prevented by the fact that relatively low doses of nicotine cause nausea and vomiting, which stops users from further intake."
Signs and symptoms
Nicotine poisoning tends to produce symptoms that follow a biphasic pattern. The initial symptoms are mainly due to stimulatory effects and include nausea and vomiting, excessive salivation, abdominal pain, pallor, sweating, hypertension, tachycardia,ataxia, tremor, headache, dizziness, muscle fasciculations, and seizures. After the initial stimulatory phase, a later period of depressor effects can occur and may include symptoms of hypotension and bradycardia, central nervous system depression,coma, muscular weakness and/or paralysis, with difficulty breathing or respiratory failure.
The symptoms of nicotine poisoning are caused by excessive stimulation of nicotinic cholinergic neurons. Nicotine is an agonist at nicotinic acetylcholine receptor which are present in the central and autonomic nervous systems, and the neuromuscular junction. At low doses nicotine causes stimulatory effects on these receptors, however, higher doses or more sustained exposures can cause inhibitory effects leading to neuromuscular blockade.
It is sometimes reported that people poisoned by organophosphate insecticides experience the same symptoms as nicotine poisoning. Organophosphates inhibit an enzyme called acetylcholinesterase, causing a buildup of acetylcholine, excessive stimulation of all types of cholinergic neurons, and a wide range of symptoms. Nicotine is specific for nicotinic cholinergic receptors only and has some, but not all of the symptoms of organophosphate poisoning.
Increased nicotine or cotinine (the nicotine metabolite) is detected in urine or blood, or serum nicotine concentrations increase.
The initial treatment of nicotine poisoning may include the administration of activated charcoal to try to reduce gastrointestinal absorption. Treatment is mainly supportive and further care can include control of seizures with the administration of abenzodiazepine, intravenous fluids for hypotension, and administration of atropine for bradycardia. Respiratory failure may necessitate respiratory support with rapid sequence induction and mechanical ventilation. Hemodialysis, hemoperfusion or otherextracorporeal techniques do not remove nicotine from the blood and are therefore not useful in enhancing elimination. Acidifying the urine could theoretically enhance nicotine excretion, although this is not recommended as it may cause complications of metabolic acidosis.
The prognosis is typically good when medical care is provided and patients adequately treated are unlikely to have any long-term sequelae. However, severely affected patients with prolonged seizures or respiratory failure may have ongoing impairments secondary to the hypoxia. It has been stated that if a patient survives nicotine poisoning during the first 4 hours, they usually recover completely.