Unravelling the Risk of Poisoning From Nicotine-Containing Tobacco Products in Children Less Than Five Years of Age

For decades, young children in the United States have been accidentally poisoned by traditional tobacco products and the yearly incidence has slowly increased. More poisonings have accompanied the introduction of new products such as e-cigarettes and dissolvable tobacco, with renewed public attention. Using toxicological principles of human health risk assessment, published data from prior exposures, and information about the content and characteristics of specific products, I estimated the acute toxicological risk from exposure to various types and quantities of tobacco products for children <5 years old. Approximate reference levels for a non-lethal oral dose of nicotine were derived: A higher level potentially requiring medical care (0.2 mg per kg) and a lower level not potentially requiring medical care (0.04 mg per kg). A weight-based oral lowest lethal dose (LDLO) of 1-14 mg per kg in children <5 years old is estimated from the cited LDLOs in adults. I provide tables relating e-liquid concentration and volume to the oral LDLO in children <5 years old by weight and describing the amount of other tobacco products expected to result in lethality. Communications about safe storage practices should focus on the benefits of keeping any nicotine-containing product out of the reach of young children, and adults can be reminded to always reengage child-resistant closures on packages and call a poison center for accidental exposures. Healthcare providers, families, or any member of the public can also make reports about unexpected health or safety concerns related to tobacco products to the FDA using its online Safety Reporting Portal at https://www.fda.gov/TobaccoProducts/PublicHealthScienceResearch/ucm377563.htm. Tobacco products, particularly electronic nicotine delivery system (ENDS) liquids are highly toxic to children <5 years old in small amounts. Given that the concentration of nicotine in ENDS is 3 to 72 mg per mL, the lethal dose (LDLO) is expected to be 13-40 mL in a bottle containing a solution of 3 mg per mL liquid nicotine but may be as low as ½-2 mL in a bottle containing a highly concentrated solution of 72 mg per mL liquid nicotine. Features such as flow restrictors, child-resistant closures, and communication of safe storage practices to parents can help to lessen the morbidity and mortality from poisoning.