TY - JOUR
AU - FACS, Pirko Maguina, MD,
AB - Abstract Electronic cigarettes (e-cigarettes) are novel battery-operated devices that deliver nicotine as an inhaled aerosol. They originated from China in 2007 and their use has rapidly increased worldwide in the past decade, yet they remain largely unregulated. Reports of injuries associated with their use have appeared as unusual events in the news media and as case reports in the medical literature. This study was undertaken to explore e-cigarettes as a mechanism of burn injury. Referral records to three burn centers from January 2007 to July 2016 were searched to identify patients with injuries caused by e-cigarettes. Data were gathered from the electronic medical records (EMRs) of patients referred within the most recent 18 months. Thirty patients with burns resulting from e-cigarettes were identified. Twenty-nine were referred within the most recent 18 months. Only one was referred in the preceding 8 years. An explosion was identified by the patient as the inciting event in 26 of the 30 injuries (87%). Explosion of an isolated battery while it was carried on personal attire was reported in 10 cases. Explosion of a fully assembled e-cigarette was described in 16 cases. In seven of these 16 cases, the explosion occurred while the device was idle and carried on personal attire. In the other nine cases, the explosion occurred while the device was being operated. No injury occurred while batteries were charging. The mean age of injured patients was 30 years. The mean size of burn was 4% TBSA. The thighs, hands, and genitalia were the most common sites of injury. Twenty-six patients required hospital admission and nine required surgery. Serious burn injuries from e-cigarettes have recently occurred with greatly increased frequency. The increase in injuries appears out of proportion to the increased popularity of e-cigarettes. The most common pattern of injury is explosion when either the idle device or its batteries are carried on personal attire. Modern electronic cigarettes (e-cigarettes) were invented in 2003 by a Chinese pharmacist, Hon Lik, who hoped they would help him quit smoking. The devices deliver nicotine as an inhaled aerosol. They are called vaporizers, e-cigarettes, e-cigs, e-pens, e-hookahs, vapes, or mods. They are made by numerous small manufacturers, many based in China, and more recently they are also being made by large tobacco companies. They are distributed through the Internet, tobacco shops, and convenience stores. They consist of a cartridge with a liquid solution, a heating element, a microprocessor, and a battery (Figure 1). Some are activated by inhalation and some are manually activated. Once activated, the microprocessor turns on the heating element, which is a coil in contact with the liquid solution. The liquid solution is heated to its boiling point and becomes a vapor, which may be inhaled. The liquid solution consists of nicotine, flavoring, and a solvent—typically a combination of glycerin and polyethylene glycol. The heating element is powered by a battery, usually a rechargeable lithium battery. Figure 1. View largeDownload slide An electronic cigarette with the battery compartment open. Figure 1. View largeDownload slide An electronic cigarette with the battery compartment open. The medical community initially focused on the use of e-cigarettes in smoking cessation.1–3 Meanwhile, their use expanded in a very different direction—as an alternative to smoking and a recreational activity in its own right. Thus, their popularity exploded over the past decade.4,5 They were first sold in China in 2004 and by January 2014 they were being sold worldwide as 466 different brands.6 It is estimated that in 2014 they generated 7 billion dollars in global sales and were used by 2.5 million people in the United States.7 This great increase in popularity is most prevalent among youth. A recent survey supported by the U.S. FDA and the Centers for Disease Control and Prevention showed the e-cigarette use among high school students increased from 1.5% in 2011 to 16% in 2015.8 E-cigarettes have occasionally been reported to cause fires and explosions in the media, but rarely have they been reported to cause burn injuries. The U.S. Fire Administration (USFA) published a compilation of all media reports of fires and explosions caused by e-cigarettes through October 2014.9 Most fire explosions were reported to occur while batteries were charging and few burn injuries were identified. Similarly, the Center for Tobacco Products (a division of the FDA) has compiled voluntary reports of fires and explosions caused by e-cigarettes.10 In 4 years, from 2011 through 2015, the FDA received reports of only seven e-cigarette users who required treatment in a burn unit. The medical literature has also not reported many burn injuries from e-cigarettes. Only three cases have been published in the world, one in the United States and two in the United Kingdom.11–13 Recently, however, the authors received multiple referrals for burn injuries associated with e-cigarettes, prompting this study. METHODS A retrospective study was performed to review all cases of burns related to e-cigarettes referred to three burn centers in California: UC Davis Firefighters Burn Institute Regional Burn Center, UC San Diego Regional Burn Center, and Shriners Hospitals for Children Northern California. The study was approved by the University of California Institutional Review Board. All patient referrals at the three burn centers are logged in patient intake forms where demographic data are recorded, including the mechanism of injury. For the purposes of this study, all the forms from January 2007 through July 2016 were reviewed. E-cigarettes first became available in the United States in 2007 and thus no forms were reviewed prior to 2007. Patients whose mechanism of injury involved an e-cigarette were identified and data were extracted from their electronic medical records. Data collection included patient age and gender, extent and pattern of burn, required treatment, date of injury, and details about the mechanism of injury (including whether or not an explosion occurred and whether the e-cigarette was charging, operating, or idle). Data analysis was performed using the Microsoft Excel 2010 function calculator. RESULTS Thirty patients were identified with burn injuries resulting from e-cigarettes. No injuries were identified in the 7 years from January 2007 through January 2014. One injury occurred in February 2014 and no other injuries were identified that year. Twenty-nine injuries were identified in 18 months from February 2015 through July 2016. Concerning the mechanism of injury, an explosion was identified by the patient as the inciting event in 26 of the 30 injuries (87%). Explosion of an isolated battery occurred in 10 cases (33%). Explosion of a fully assembled e-cigarette was described in 16 cases. In seven of these 16 cases, the explosion occurred while the device was idle and carried on personal attire. In the other 9 of these 16 cases, the explosion occurred while the e-cigarette was in use—either being activated for vapor delivery (five cases) or between activations (four cases). In four of the total 30 cases, an explosion was not described as the underlying event; all four of these injuries occurred while the device was idle and it is not clear whether the device exploded or whether there was some other underlying cause of spontaneous ignition. In the 10 cases where isolated battery explosion occurred, some patients stated that the battery came in contact with a metallic foreign object and some patients stated that the explosion occurred without an inciting event. No injuries were reported to occur while batteries were charging. The thigh was injured in 19 patients, a hand was injured in 16, the genitalia were injured in 4, the face was injured in 4, and the torso was injured in 4. The burn size ranged from less than 1 to 8% of the TBSA, with a mean of 4% TBSA. Twenty-six patients (87%) were admitted to the hospital for wound care and pain control. The length of admission ranged from 2 to 31 days with a median of 5.5 days, a mean of 7.6 days, and an SD of 5.7 days. Nine patients (30%) received surgical intervention. Seven were treated with tangential excision and split thickness skin grafting. Two underwent surgical repair of facial trauma. The other 21 patients healed without surgical intervention. The mean patient age was 30 years. Twenty four of the 30 patients (80%) were men. DISCUSSION E-cigarettes have come into widespread use without being subject to quality standards such as those usually applied to similar consumer products. Some devices now being distributed may explode or burst into flame and cause serious burn injuries, as evidenced by the patients in our study. Almost all injuries in our study occurred in the most recent 18 months—from February 2015 to July 2016. This represents an average of almost two cases per month compared with only one case over the prior 8 years. The reason for this sudden change is unclear and merits further exploration. The expanding popularity of e-cigarettes in the United States has proceeded largely unregulated. The U.S. Department of Justice Bureau of Alcohol, Tobacco, Firearms, and Explosives does not regulate e-cigarettes because they are not classified as cigarettes under the Jenkins Act or the PACT Act, which govern trafficking of cigarettes and tobacco products. The U.S. Consumer Product Safety Commission has stated that it does not have jurisdiction over e-cigarettes. Underwriters Laboratories (UL, an independent safety company that tests, inspects, and certifies electronic products) has not developed standards that apply to e-cigarettes or their batteries. Indeed, there are no requirements that e-cigarettes be subject to product safety testing by any nationally recognized organization. The U.S. FDA, which regulates nicotine replacement products like gum and patches, has not previously regulated e-cigarettes because they are distributed as recreational products, not smoking cessation products. This year the FDA will begin regulating e-cigarettes as a result of a new rule, yet the newly effective regulation is strictly aimed at preventing youth access to e-cigarettes.8 In the future the FDA will further regulate e-cigarette marketing. However, this will not take effect for another 3 years, and it is unclear whether the FDA will regulate the safety of e-cigarette devices or merely regulate e-cigarette vapors. If the FDA will not regulate the safety of the devices themselves, with their potential for injury, then who will? The most common mechanism of injury in our study was explosion. Explosions occurred with roughly equal frequency while an e-cigarette was in use, while a fully assembled e-cigarette was being carried idle on personal attire, and while an isolated battery was being carried on personal attire. The precise cause of each explosion was not identified in our study, but patients described batteries as the cause of explosion in the majority of cases (Figure 2). Rechargeable lithium ion batteries are by far the most commonly used batteries in e-cigarettes and they are known to explode and ignite.14 Therefore, rechargeable lithium batteries are suspected to be the underlying mechanism in most if not all explosions we identified. It should be noted, however, that other batteries may be used in e-cigarettes and the precise nature of the battery involved in each case was not identified in our study. It is also possible that the e-cigarette heating element was a source of some explosions in our study or the cause of spontaneous ignition in the cases where an explosion was not explicitly identified. It is unclear in these four cases whether no explosion actually occurred or whether the patient simply failed to identify an explosion when interviewed by the medical team; that is a limitation of this retrospective study. Figure 2. View largeDownload slide A battery that exploded in a patient's pocket. This was a spare battery belonging to the e-cigarette depicted in Figure 1. Figure 2. View largeDownload slide A battery that exploded in a patient's pocket. This was a spare battery belonging to the e-cigarette depicted in Figure 1. The USFA is the only national organization to have expressed concern about fires and explosions caused by e-cigarettes. It conducted a review of fires and explosions involving e-cigarettes in October 2014.9 That review involved an Internet search for news media reports and identified a total of 25 incidents nationally, going back to 2009. Seven of these incidents resulted in burn injuries. Conducting a similar search for news media reports in January 2016, we identified another 25 incidents in the 15 months since the USFA study.15–36 Thirteen of these resulted in burn injuries.26–36 Thus, in 2015 there were as many fires and explosions associated with e-cigarettes reported in the U.S. news media as there were in the previous 6 years, and even more burn injuries. This increase in media reporting is paralleled by the increased frequency of burn injury referrals identified in our study. Other burn centers have also identified an increased frequency of referrals in recent months for injuries associated with e-cigarettes (personal communication with burn center directors at University of California Irvine, University of South Alabama, and University of North Carolina). This study describes a newly developing problem: personal injury. The USFA study previously identified e-cigarettes as a source of fires and explosions, but the frequency with which these devices cause structure fires is small compared with the thousands of fires caused by traditional cigarettes.37 Personal injury from e-cigarettes, on the other hand, appears to be rapidly growing. The underlying cause of this growing problem is not clear and may be related to a new defect in e-cigarettes. The USFA identified battery charging as the primary cause of most e-cigarette fires it studied—that was the mechanism in 22 of 25 incidents. In our study, on the other hand, no injury occurred while a device was charging. All injuries occurred while devices were in use or while they were idle and carried on personal attire. The more recent media reports that we reviewed identified a pattern like the one in our case study—with a high incidence of injuries while e-cigarettes were idle or in use, rather than while batteries were charging. The findings of our study suggest that personal injury from e-cigarettes will only continue to grow until the underlying cause is identified and addressed. Some in the medical community have expressed concerns about e-cigarettes. These concerns have mostly focused on the effects of their vapors. Several medical studies have investigated the potential of e-cigarettes as smoking cessation aids.3,38,39 Others have investigated the potential toxicity of e-cigarette vapors.40 Others have addressed their potential for increasing nicotine addiction and tobacco use in adolescents.41–43 Others still have addressed their potential as tobacco replacement in the context of a public health harm reduction strategy.1,2,44 Regardless of these concerns from the medical community, e-cigarettes have become very popular as recreational products. Our current medical concern is now with their potential for causing burn injuries. The average cost to care for these injuries in our burn unit was approximately $120,000 per patient. This does not include any charges for treatment outside the burn unit, for transportation to the burn unit, or for any operations that were required. It also does not include the cost of time lost from work. Regulation of these devices is surely overdue. The increasing frequency with which burn injuries are resulting from e-cigarettes warrants that public attention and government regulation be turned to product safety. CONCLUSIONS E-cigarettes can cause burn injuries. The most common pattern of injury appears to be battery explosion when the unit is idle. Battery explosions can lead to ignition of clothing. The body areas most commonly burned in our study were the thighs, genitals, and hands. Greater awareness of this problem is needed to improve safety regulations and burn injury prevention. REFERENCES 1. Bullen C, McRobbie H, Thornley S, Glover M, Lin R, Laugesen M Effect of an electronic nicotine delivery device (e cigarette) on desire to smoke and withdrawal, user preferences and nicotine delivery: randomised cross-over trial. Tob Control  2010; 19: 98– 103. Google Scholar CrossRef Search ADS PubMed  2. 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TI - The Unrecognized Epidemic of Electronic Cigarette Burns
JF - Journal of Burn Care & Research
DO - 10.1097/BCR.0000000000000472
DA - 2017-07-01
UR - https://www.deepdyve.com/lp/oxford-university-press/the-unrecognized-epidemic-of-electronic-cigarette-burns-lgjsHUDgWb
SP - 220
EP - 224
VL - 38
IS - 4
DP - DeepDyve
ER -