OBJECTIVE: This study examines child poisonings resulting from ingestion of tobacco products throughout the nation and assesses the potential toxicity of novel smokeless tobacco products, which are of concern with their discreet form, candy-like appearance, and added flavorings that may be attractive to young children.
METHODS: Data representing all single-substance, accidental poisonings resulting from ingestion of tobacco products by children <6 years of age, reported to poison control centers, were examined. Age association with ingestion of smokeless tobacco versus other tobacco products was tested through logistic regression. Total nicotine content, pH, and un-ionized nicotine level were determined, and the latter was compared with values for moist snuff and cigarettes.
RESULTS: A total of 13705 tobacco product ingestion cases were reported, >70% of which involved infants <1 year of age. Smokeless tobacco products were the second most common tobacco products ingested by children, after cigarettes, and represented an increasing proportion of tobacco ingestions with each year of age from 0 to 5 years (odds ratio: 1.94 [95% confidence interval: 1.86–2.03]). A novel, dissolvable, smokeless tobacco product with discreet form, candy-like appearance, and added flavorings was found to contain an average of 0.83 mg of nicotine per pellet, with an average pH of 7.9, which resulted in an average of 42% of the nicotine in the un-ionized form.
CONCLUSION: In light of the novelty and potential harm of dissolvable nicotine products, public health authorities are advised to study these products to determine the appropriate regulatory approach.
WHAT'S KNOWN ON THIS SUBJECT:
Unintentional ingestion of tobacco products is a major reason for infant and child toxic exposures reported to poison control centers. The large majority (90%) of such accidental poisonings in the population involve children <6 years of age.
WHAT THIS STUDY ADDS:
This study examines child poisonings resulting from ingestion of tobacco products, particularly ingestion of smokeless tobacco products, through analysis of poison control center data. The potential toxicity of novel smokeless tobacco products to young children is assessed.
Recent estimates of product-related poisonings involving children, based on a national probability sample of US hospital emergency departments, underscore the insufficiency of existing child-resistant packaging and the need for additional child-poisoning prevention strategies.1 Unintentional ingestion of tobacco products is a major reason for infant and child toxic exposures reported to poison control centers throughout the nation.2 The large majority (90%) of such accidental poisonings in the population involve children <6 years of age.2 In addition to conventional smokeless tobacco products, novel smokeless tobacco products, including dissolvable, compressed, tobacco products called Camel Orbs (R.J. Reynolds Tobacco Company, Winston-Salem, NC), are now of major concern, with their discreet form, candy-like appearance, and added flavorings that may be attractive to young children.
Infants are susceptible to accidental tobacco ingestion because of a natural curiosity and a tendency for oral exploration.3,4 As taste discrimination develops, young children may be more attracted to flavored tobacco products.5 Ingestion of as little as 1 mg of nicotine by a small child can produce symptoms such as nausea and vomiting.6 Severe toxic effects of nicotine ingestion may include weakness, convulsions, unresponsiveness, and impaired respiration and ultimately may lead to respiratory arrest and death.6 The estimated minimal lethal pediatric dose is 1.0 mg of nicotine per kilogram of body weight.7
The present study examines child poisonings resulting from ingestion of tobacco products throughout the nation and trends in ingestion of smokeless tobacco products in particular. The potential toxicity of novel smokeless tobacco products to young children is assessed.
Case data from the National Poison Data System, compiled by the American Association of Poison Control Centers from reports of 61 regional poison control centers serving the nation, were examined. Age- and gender-specific case frequencies were computed for all single-substance, accidental poisonings resulting from ingestion of tobacco products by children <6 years of age during the period 2006–2008. Logistic regression analysis was performed by controlling for year of ingestion as a categorical variable and gender, to assess any age association with ingestion of smokeless tobacco versus other tobacco products (cigarettes, filter tips, cigars, other or unknown).
Multiple packs of 2 varieties of Camel Orbs (designated “Fresh” and “Mellow”), a novel, smokeless tobacco product sold in 3 test markets, were measured for nicotine content through gas chromatography-mass spectrometry8 and pH analyses, as described elsewhere.9 The proportion of nicotine in the un-ionized form was calculated by substituting measured pH and the appropriate pKa of nicotine (8.02) into the Henderson-Hasselbalch equation.10
Age- and gender-specific case frequencies for each tobacco product type, including smokeless tobacco (chewing tobacco and snuff), cigarettes and used filter tips, cigars, and others, are shown in Table 1. A total of 13 705 cases were reported for all types of tobacco products (Table 1). The majority (>70%) of ingestions were by infants <1 year of age (Table 1). Smokeless tobacco products represented an increasing proportion of tobacco ingestions with each year of age from 0 to 5 years (odds ratio: 1.94 [95% confidence interval: 1.86–2.03]). Year of ingestion was not statistically significant (P ≤ .127) in the model. Smokeless products were the second most common tobacco product ingested by children, after cigarettes. Orbs pellets sold in 3 test markets were found to contain an average of 0.83 mg of nicotine per pellet, with an average pH of 7.9, which resulted in an average of 42% of the nicotine in the un-ionized form.
The present findings raise concern in light of the recent increase in the prevalence of smokeless tobacco use among adolescents (average increase of 6% per year from 2002 to 2006) and the proliferation of new forms of smokeless tobacco products, including new flavored brands.11 In 2009, the R.J. Reynolds Tobacco Company introduced a novel, dissolvable, compressed tobacco product called Camel Orbs, which according to the promotional literature contains 1 mg of nicotine per pellet, as well as Camel Sticks with 3.1 mg of nicotine per stick and Camel Strips with 0.6 mg of nicotine per strip. Orbs are flavored with cinnamon or mint and resemble popular candies such as Tic Tacs (Ferrero, Somerset, NJ) or M&Ms (Mars Incorporated, McLean, VA) more than conventional tobacco products (Fig 1). Such products are designed and marketed not for smoking cessation but rather as temporary substitutes for cigarettes when smoking is not allowed.
We found the average pH of an Orbs pellet to be 7.9, which is more alkaline than cigarette tobacco (pH < 6.0) and results in an average of 42% of the nicotine in the un-ionized form, compared with averages of 28–30% for moist snuff and <10% for cigarettes.12,13 Un-ionized nicotine is absorbed more rapidly in the mouth, which might enhance toxicity.6 Furthermore, the discreet form of Orbs might make ingestion of nicotine, a highly addictive drug, easy and attractive for adolescents.
At least 1 case of ingestion of Orbs by a 3-year-old child (Oregon Poison Control Center, personal written and oral communication, July 27, 2009) and 2 cases of mild poisonings in children 2 and 3 years of age resulting from ingestion of snus (a flavored, oral, tobacco product packed in small paper pouches and sold without explicit warning to protect against child ingestion) (Indiana Poison Control Center, personal written communication, May 13, 2009) have been reported. The R.J. Reynolds Tobacco Company claims that Orbs packaging is child-resistant, but adults might take multiple pellets out of the container for convenience and unknowingly leave them where infants or children might find and ingest them.
The newly signed Family Smoking Prevention and Tobacco Control Act, which provides the Food and Drug Administration with certain authority to regulate tobacco products, prohibits cigarette constituents or additives that provide a characterizing flavor to the tobacco or tobacco smoke. This prohibition does not apply to other tobacco products. Because reports of toxic exposure to tobacco products are monitored, public health officials and poison control centers should be alert to reports of ingestion of novel products that claim to be tobacco products but more closely resemble candies or foods. In light of the novelty and potential harm of these dissolvable nicotine products, federal and other public health authorities are advised to study these products to determine the appropriate regulatory approach, on the basis of their potential to cause poisonings and to create addiction among youths.
We are grateful to Angela Kuo for performing the gas chromatography-mass spectrometry and pH analysis of the Camel Orbs samples. Use of trade names is for informational purposes only and in no way implies endorsement by the U.S. Government, the U.S. Department of Health and Human Services, or CDC. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of CDC.
- Accepted January 7, 2010.
- Address correspondence to Hillel R. Alpert, ScM, Harvard School of Public Health, Division of Public Health Practice, Landmark Building, Floor 3E, 401 Park Dr, Boston, MA 02215. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
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As Increased Rate of Autism Identified in Los Angeles: A child born in Los Angeles is four times as likely to be diagnosed with autism as a child born anywhere else in California according to an article in The Wall Street Journal (Beck M, February 1, 2010). While pockets of increased rates of autism are appearing around the country, a few recent studies, including one in the Journal of Health and Place, looked at the Los Angeles area as one such pocket to try to explain why. The good news is that vaccines are not the reason. On the other hand, local environmental and social factors that are still not well characterized appear to play key roles. In the Los Angeles area, for example, social influences, such as the sharing of information about this disorder, may lead more parents to ask about it and have pediatricians more prone to be on the lookout for it. The studies cited in this article attribute the increase to everything from family affluence to the work of autism advocacy groups to air and water pollution. Whether these differences in Los Angeles or elsewhere in the country represent variations in local awareness, record keeping, or actual higher risk remains to be determined.
Noted by JFL, MD
- Copyright © 2010 by the American Academy of Pediatrics