Ingestion of Cigarettes and Cigarette Butts by Children -- Rhode Island, January 1994-July 1996

During 1995, the American Association of Poison Control Centers (AAPCC) received 7917 reports of potentially toxic exposures to tobacco products among children aged less than or equal to 6 years in the United States (1). Most cases of nicotine poisoning among children result from their ingestion of cigarettes or cigars (2). Acute nicotine poisoning is characterized by rapid onset of symptoms that may be severe when large amounts have been ingested (2). During January 1994-July 1996, the Rhode Island Poison Control Center (RIPCC) received 146 reports of ingestion of products containing nicotine by children aged less than or equal to 6 years. To characterize risk factors for and outcomes associated with ingestion of cigarettes and cigarette butts among children aged less than or equal to 6 years, the Rhode Island Department of Health (RIDH) analyzed data from the RIPCC and the 1996 Rhode Island Health Interview Survey (RIHIS). This report summarizes the findings of the study, which indicate that ingestion of cigarettes and cigarette butts by children aged less than or equal to 6 years resulted in minor toxic effects and occurred more frequently in households where smoking was permitted in the presence of children and where cigarettes and cigarette wastes were accessible to children.

Information about toxic exposures reported to the RIPCC is recorded on standardized forms published by the AAPCC. RIDH identified reports of ingestion of products containing nicotine among children aged less than or equal to 6 years during January 1994-July 1996. Data abstracted included age, sex, type of nicotine-containing product ingested, time of report, relationship between the person who made the report and the child, location where the ingestion occurred, symptoms, and whether the child visited a health-care facility (i.e., emergency department, doctor's office, or health maintenance organization {HMO} clinic). For reports with follow-up information (collected by Certified Specialists in Poison Information within 4 hours of the initial report), RIDH attempted to interview parents by telephone to obtain more detailed information about the household.

To identify risk factors for ingestion of cigarettes and cigarette butts, RIDH conducted a case-control study. Controls were determined using the 1996 RIHIS (a representative stratified random-digit-dialed survey of telephone-equipped households in Rhode Island) and included persons in households with at least one cigarette smoker (i.e., smoked cigarettes now) and at least one child aged less than or equal to 6 years. Factors assessed included history of ingestion of toxic substances, types of tobacco products used in the household, storage of cigarettes, location of ashtrays, household smoking policies, and type of child care. Of 123 parents identified as control sources, 67 (55%) completed a telephone interview. Odds ratios (ORs) and 95% confidence intervals (CIs) were used to measure the association between categorical variables and the ingestion of cigarettes or cigarette butts.

Of the 146 reports of children who ingested products containing nicotine, follow-up information was available for 90 (62%) and involved the ingestion of cigarettes or cigarette butts (an additional report with follow-up information involved the ingestion of pipe tobacco). The mean age of the 90 children was 11.7 months (range: 6-24 months); of these, 69 (77%) were aged 6-12 months (Table_1), and 48 (53%) were males. Fifty (56%) had ingested cigarettes, and 40 (44%) had ingested cigarette butts. Of the 50 children who had ingested cigarettes, 36 (72%) had ingested less than a whole cigarette. Of the 40 children who had ingested cigarette butts, 22 (55%) ingested less than a whole cigarette butt. A total of 32 (36%) of the episodes occurred during 7 a.m. to 10 a.m. (Table_1), but all reports were made within 30 minutes of either the onset of symptoms or when the reporting person recognized that a child had ingested cigarettes or cigarette butts. Most (81 {90%}) of the exposures were reported by parents, and 88 (98%) of the exposures occurred in the child's home (Table_1). Symptoms were reported in 30 (33.3%) of the children and included spontaneous vomiting (up to four episodes) (26 {87%}), nausea (two {7%}), pale or flushed appearance (two {7%}), lethargy (one {3%}), and gagging (one {3%}). Thirteen (14%) of the children had been taken to a health-care facility. All 30 children recovered fully within 12 hours.

Telephone interviews were completed with the parents of 35 (39%) of the 90 children (the parents of other children either could not be contacted or refused to participate). Based on these interviews and those of controls, children who ingested cigarettes or cigarette butts were more likely to live in homes where smoking occurred in the presence of children (25 {83%} versus 27 {52%}) (OR=4.6, 95% CI=1.4-17.6) or in which cigarettes (28 {80%} versus 22 {37%}) (OR=6.6, 95% CI=2.3-21.0) or ashtrays (30 {86%} versus 25 {45%}) (OR=7.3, 95% CI=2.3-27.6) were located within the children's reach. Smoking in the presence of children remained a significant risk factor for the ingestion of cigarettes or cigarette butts after controlling for the location of cigarettes (adjusted OR=7.8, 95% CI=2.0-30.2) and ashtrays (adjusted OR=5.9, 95% CI=1.6-22.6) within the household.

Reported by: W Lewander, MD, Rhode Island Hospital; H Wine, R Carnevale, Rhode Island Poison Control Center; J Lindenmayer, DVM, Dept of Community Health, Brown Univ, Providence; E Harvey, MS, C Hall-Walker, L Lambright, MPA, E Manzo, Project ASSIST, Rhode Island Dept of Health. Office on Smoking and Health and Div of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The investigation in Rhode Island documented ingestion of cigarettes or cigarette butts by children aged 6-24 months, an age range during which children are actively exploring their environment and are at increased risk for ingesting toxic substances (3). These ingestions were associated with only minor toxic clinical effects; however, previous reports have described severe toxicity among children who ingested cigarettes, cigarette butts, or snuff, including depressed respiration, cardiac arrhythmia, and convulsions (4-6). In Rhode Island, ingestion also was associated with smoking in the presence of children and easy accessability to cigarettes and cigarette butts, reflecting careless placement of these objects and/or lack of parent's knowledge about the potential toxicity of ingested tobacco products.

The findings in this report are subject to at least three limitations. First, the number of episodes most likely was underestimated because asymptomatic ingestions may not have been reported, ingestion was successfully treated by a health-care provider, or because some parents were unaware of the RIPCC. Second, the response rate for the case-control study was low; because children in homes where parents did not participate may have been more likely to have access to cigarettes or cigarette butts than children in homes of study participants, risk may have been underestimated. Finally, the study could not identify risk factors for the ingestion of other tobacco products because the use of tobacco products other than cigarettes was not included in the RIHIS.

The findings in this report will be used by RIDH and other public health agencies to develop approaches for decreasing exposures to cigarettes and cigarette butts among young children. These approaches may include public education about the potential toxicity of tobacco products, the health benefits of not smoking in the presence of children (i.e., the toxic effects of environmental tobacco smoke), and the safe storage and disposal of tobacco products (i.e., use of child-resistant containers). Tobacco products should be kept out of reach of children. However, if ingestion does occur, a poison-control center should be consulted to assess the risks for serious toxicity and review measures for appropriate treatment. In addition to preventing nicotine poisonings, avoiding the use of tobacco products in the presence of children should decrease the risk for infections from respiratory diseases in children (7); the risk that children will smoke in the future (8); and children's access to lighted cigarettes, matches, and cigarette lighters, thereby reducing fires started by children -- the leading cause of fire-related deaths among children aged less than 5 years (9).

References

1. Litovitz TL, Felberg L, Soloway RA, Ford M, Geller R. 1994 annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System. Am J Emerg Med 1995;13:551-97.

2. Ellenhorn MJ, Braceloux DG. Medical toxicology: diagnosis and treatment of human poisoning. New York: Elsevier, 1988:912-21.

3. Opheim KE, Raisey VA. Therapeutic drug monitoring in pediatric drug intoxications. The Drug Monitor 1985;7:148-58.

4. Malizia E, Andreucci G, Alfani F, Smeriglio M, Nicholai P. Acute intoxication with nicotine alkaloids and cannabinoids in children from ingestion of cigarettes. Hum Toxicol 1983;2:315-6.

5. Smolinske SC, Spoerke DG, Spiller SK, Wruk KM, Kulig K, Rumack BH. Cigarette and nicotine chewing gum toxicity in children. Hum Toxicol 1988;7:27-31.

6. Borys JD, Setzer SC, Ling JL. CNS depression in an infant after the ingestion of tobacco: a case report. Vet Hum Toxicol 1988;30:20-2.

7. Mannino DM, Siegel M, Husten C, Rose D, Etzel R. Environmental tobacco smoke exposure and health effects in children: results from the 1991 National Health Interview Survey. Tobacco Control 1996;5:13-8.

8. US Department of Health and Human Services. Preventing tobacco use among young people: a report of the Surgeon General. Atlanta, Georgia: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994.

9. Federal Emergency Management Agency. Fire in the United States: 1983-1990. Washington, DC: US Fire Administration, 1993; publication no. USFA/FA-140.

   
   
   Table_1
   Note: To print large tables and graphs users may have to change their printer settings to landscape and use a small font size.
   

   
   TABLE 1. Number and percentage of cigarette and cigarette butt ingestions by
   children aged <=6 years, by selected characteristics -- Rhode Island, January 1994-July 1996
   =============================================================================================
                          No.
   Characteristic      children     (%)
   ------------------------------------------
   Age group (mos) *
     6-12                 69       (76.7)
    13-19                 16       (17.8)
    20-24                  5        (5.6)
   
   Sex
    Female                42       (46.7)
    Male                  48       (53.3)
   
   Type of substance
    Cigarette             50       (55.6)
    Cigarette butt        40       (44.4)
   
   Hour of day
   occurred +
     7 a.m.-10 a.m.       32       (35.6)
    11 a.m.- 2 p.m.       17       (18.9)
     3 p.m.- 6 p.m.       24       (26.7)
     7 p.m.-10 p.m.       15       (16.7)
    10 p.m.- 1 a.m.        2        (2.2)
   
   Source of report
    Mother                71       (78.9)
    Father                10       (11.1)
    Other relative         3        (3.3)
    Health-care            5        (5.6)
    worker
    Rescue worker          1        (1.1)
   
   Site of exposure
    Own residence         88       (97.8)
    Other residence        1        (1.1)
    Public park            1        (1.1)
   
   Clinical symptoms
    Yes                   30       (33.3)
    No                    60       (66.7)
   
   Visited health-
   care facility
    Yes                   13       (14.4)
    No                    77       (85.6)
   
   Total                  90      (100.0)
   ---------------------------------------------------------------------------------------------
   * No cases were reported among children aged >=25 months.
   + No calls were made during 1 a.m.-7 a.m.
   =============================================================================================
   

   
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