As little as a teaspoon of liquid nicotine used in electronic cigarettes can be enough to kill a child.
In liquid form, the nicotine is far easier for children to quickly swallow than in traditional cigarettes. But even skin exposure can result in vomiting and seizures.
And although geared for adults, small bottles of liquid nicotine are sold in flavors with the alluring smells of gummy bear, bubble gum, chocolate and cherry.
“Children can’t read the labels, and it smells good,” said Julie Weber, a pharmacist and director of the Missouri Poison Center at SSM Cardinal Glennon Children’s Medical Center in St. Louis. “But just a small amount is a problem.”
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With the popularity of e-cigarettes on the rise and no federal regulations in sight, Missouri lawmakers are voicing concern that a tragedy is a matter of when, not if. In December, they point out, a 1-year-old child in New York died after ingesting liquid nicotine.
The Missouri House is considering whether the state should bypass the feds and mandate child-proof packaging on liquid nicotine products sold in the state. A committee approved the idea last week.
“We have child-proof containers on everything from vitamins to ibuprofen,” said Rep. Sheila Solon, a Blue Springs Republican sponsoring the child-proofing bill. “So it’s just common sense that we place child-proof packaging on highly toxic liquid nicotine.”
The rate of calls to poison control centers regarding liquid nicotine rose from one per month in 2010 to 215 per month last year, according to the Centers for Disease Control and Prevention.
Weber said Missouri has also seen a spike. There were 46 calls in 2013 involving liquid nicotine and children younger than 6 years old. That number jumped to 125 last year, she said.
“We recently had an 11-month-old that got into a liquid product and developed, within 20 minutes, vomiting and actually had a seizure that required admission to an intensive care unit,” Weber said.
The surge in poisonings reflects, in part, the booming e-cigarette industry. Sales of e-cigarettes totaled roughly $1.7 billion in 2013, double that of 2012, according to Bloomberg.
But it also reflects a shift in the technology.
E-cigarettes are battery-powered devices that can resemble traditional cigarettes. They heat a liquid solution, creating vapor that users inhale to get nicotine. Part of their allure is that they give the user the sensation of inhaling smoke without actually producing the smoke of regular cigarettes.
In addition to the disposable devices that resemble cigarettes, there are also reusable models that can be refilled with a liquid combination of nicotine, solvents and a flavoring. Those liquid refills are the target of the Missouri legislation.
Jennifer Lowry, a pediatrician and section chief for medical toxicology at Children’s Mercy Hospital in Kansas City, said that because there are no U.S. Food and Drug Administration regulations on e-cigarettes, “we don’t know how much nicotine is in each of these bottles.”
The amount of nicotine, she said, can vary greatly.
At a recent hearing, no one testified in opposition to Solon’s legislation. A.J. Moll, spokesman for the e-cigarette advocacy group Bistate Regional Advocates for Vaping Education, said his organization is “100 percent behind safety caps.”
“E-liquids are adult products, and like all adult consumables, they should be kept out of the reach of children,” Moll said.
But he added that his organization can’t fully support the current version of the bill because it allows the state department of health to adopt rules to carry out the legislation. The fear, he said, is the department could push for rules that “hinder consumer choice.”
Enthusiasts see e-cigarettes as a powerful technology that could break many smokers from the deadly grip of tobacco. But they face a growing movement to regulate the devices — an effort driven by fear that they could just be another path to nicotine addiction.
The FDA recently proposed guidelines for regulating e-cigarettes that included a ban on their sale to minors and a requirement that companies list ingredients and nicotine strength. But because of the long rule-making process, any federal regulations could still be years away.
Missouri jumped into the debate last year by banning the sale of e-cigarettes to minors.
But health advocates — including the American Cancer Society, American Heart Association, American Lung Association and Tobacco Free Missouri — opposed the move because it also exempted the product from the state’s tobacco laws. The fear, they said at the time, is that the ban would make the e-cigarette industry more difficult to control if the health risks associated with the product become more apparent.
Solon said she’d prefer for the federal government to mandate child-proof packaging, but if it won’t states will have to take the lead.
A similar child-proof packaging law was implemented last year in New York.
“This is an easy problem to solve,” Solon said. “We can’t just wait around until another child dies. We need to act now.”