{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T21:20:58Z","timestamp":1781904058575,"version":"3.54.5"},"reference-count":23,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2021,3,2]],"date-time":"2021-03-02T00:00:00Z","timestamp":1614643200000},"content-version":"unspecified","delay-in-days":1,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100005188","name":"California Tobacco-Related Disease Research Program","doi-asserted-by":"crossref","award":["25IR-0025"],"award-info":[{"award-number":["25IR-0025"]}],"id":[{"id":"10.13039\/100005188","id-type":"DOI","asserted-by":"crossref"}]},{"DOI":"10.13039\/100005188","name":"California Tobacco-Related Disease Research Program","doi-asserted-by":"crossref","award":["26IR-0014"],"award-info":[{"award-number":["26IR-0014"]}],"id":[{"id":"10.13039\/100005188","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open"],"accepted":{"date-parts":[[2021,2,15]]},"published-print":{"date-parts":[[2021,3]]},"abstract":"<jats:sec>\n                  <jats:title>Objectives<\/jats:title>\n                  <jats:p>To review the association between US e-cigarette regulations and the number of reported nicotine exposures, and identify higher-risk products<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Design<\/jats:title>\n                  <jats:p>Retrospective review of de-identified medical records.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Setting<\/jats:title>\n                  <jats:p>California<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Participants<\/jats:title>\n                  <jats:p>Cases reported to California Poison Control System in 2012\u20132018.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Primary and secondary outcome measures<\/jats:title>\n                  <jats:p>Suspected nicotine toxicity; route of exposure and product characteristics.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>We examined 5277 exposures, of which 3033 involved combustible cigarettes, 1489 involved e-cigarettes and 818 involved other substances (ie, chewing tobacco, nicotine patches, nicotine lozenges, hookah, etc). Implementation of the Child Nicotine Poisoning Prevention Act of 2015 was not significantly associated with reduced exposures. Exposures for e-cigarettes increased significantly after the 2017 Food and Drug Administration Compliance Policy (p=0.003, coefficient (coeff)=0.61). Total exposures for all tobacco and nicotine products also increased significantly after the policy change (p=0.01, coeff=1.26). Nicotine exposure outcomes classified as being of minor and moderate severity increased significantly after implementation of the 2017 Compliance Policy (p=0.004, coeff=0.54 and p=0.002, coeff=0.56, respectively). Ingestion was the most common route of exposure (87.7%), followed by inhalation (8.1%), dermal (6.5%), ocular (2.1%) and other (intranasal, rectal, sublingual and unknown) routes (0.2%); some cases reported multiple routes of exposure. Exposure cases involving e-cigarettes fell into three problem categories: product design, labelling and the appeal of flavours.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusions<\/jats:title>\n                  <jats:p>Our analysis found that despite previous studies suggesting that the Child Nicotine Poisoning Prevention Act appeared to have reduced exposures for e-cigarettes, there was no significant change in exposures after its implementation. In contrast, there was a 30% increase in California e-cigarette exposures following the 2017 Compliance Policy. We conclude that current regulations are insufficient to reduce nicotine toxicities due to e-cigarette use.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjopen-2020-043133","type":"journal-article","created":{"date-parts":[[2021,3,2]],"date-time":"2021-03-02T10:59:14Z","timestamp":1614682754000},"page":"e043133","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":13,"title":["Retrospective review of nicotine exposures in California from 2012 to 2018 and analysis of the impacts of e-cigarette regulations"],"prefix":"10.1136","volume":"11","author":[{"given":"Gabrielle","family":"Driller","sequence":"first","affiliation":[{"name":"Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emily","family":"Plasencia","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4694-0826","authenticated-orcid":false,"given":"Dorie E","family":"Apollonio","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2021,3,2]]},"reference":[{"key":"2025101810443895000_11.3.e043133.1","unstructured":"American Association of Poison Control Centers (AAPCC) . E-Cigarettes and liquid nicotine, 2020. Available: https:\/\/aapcc.org\/track\/ecigarettes-liquid-nicotine [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.2","doi-asserted-by":"publisher","DOI":"10.1503\/cmaj.109-4818"},{"key":"2025101810443895000_11.3.e043133.3","doi-asserted-by":"crossref","first-page":"488","DOI":"10.1080\/15563650.2019.1661426","article-title":"Poisoning exposure cases involving e-cigarettes and e-liquid in the United States, 2010-2018","volume":"58","author":"Wang","year":"2020","journal-title":"Clin Toxicol"},{"key":"2025101810443895000_11.3.e043133.4","doi-asserted-by":"crossref","DOI":"10.1542\/peds.2016-0041","article-title":"Pediatric exposure to e-cigarettes, nicotine, and tobacco products in the United States","volume":"137","author":"Kamboj","year":"2016","journal-title":"Pediatrics"},{"key":"2025101810443895000_11.3.e043133.5","doi-asserted-by":"crossref","first-page":"121","DOI":"10.5935\/0103-507X.20180018","article-title":"Symptomatic bradycardia due to nicotine intoxication","volume":"30","author":"Paik","year":"2018","journal-title":"Rev Bras Ter Intensiva"},{"key":"2025101810443895000_11.3.e043133.6","doi-asserted-by":"crossref","first-page":"24","DOI":"10.4103\/0971-5851.151771","article-title":"Harmful effects of nicotine","volume":"36","author":"Mishra","year":"2015","journal-title":"Indian J Med Paediatr Oncol"},{"key":"2025101810443895000_11.3.e043133.7","doi-asserted-by":"publisher","DOI":"10.1016\/j.mcna.2004.06.004"},{"key":"2025101810443895000_11.3.e043133.8","unstructured":"Centers for Disease Control and Prevention . Nicotine: immediately dangerous to life or health concentrations (idlh), 2014. Available: https:\/\/www.cdc.gov\/niosh\/idlh\/54115.html [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.9","unstructured":"JUUL Labs Inc . Discover more about juulpods & flavors, 2019. Available: https:\/\/www.juul.com\/resources\/What-is-JUUL-Vape-Liquid-All-JUUL-Pod-Flavors?&ag=CA [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.10","unstructured":"Centers for Disease Control and Prevention . Sales of juul e-cigarettes skyrocket, posing danger to youth, 2018. Available: https:\/\/www.cdc.gov\/media\/releases\/2018\/p1002-e-Cigarettes-sales-danger-youth.html [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.11","unstructured":"S.142 - child nicotine poisoning prevention act of 2015. 114th Congress (2015-2016) ed 2016."},{"key":"2025101810443895000_11.3.e043133.12","unstructured":"Kaplan S . Lawmakers say puff bar used pandemic to market to teens. The New York Times, 2020."},{"key":"2025101810443895000_11.3.e043133.13","doi-asserted-by":"publisher","DOI":"10.1542\/peds.2017-3361"},{"key":"2025101810443895000_11.3.e043133.14","unstructured":"US Food and Drug Administration . Enforcement priorities for electronic nicotine delivery system (ends) and other deemed products on the market without premarket authorization: guidance for industry guidance document, 2020. Available: https:\/\/www.fda.gov\/regulatory-information\/search-fda-guidance-documents\/enforcement-priorities-electronic-nicotine-delivery-system-ends-and-other-deemed-products-market [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.15","unstructured":"US Food and Drug Administration . Fda takes significant steps to protect Americans from dangers of tobacco through new regulation, 2016. Available: https:\/\/www.fda.gov\/news-events\/press-announcements\/fda-takes-significant-steps-protect-americans-dangers-tobacco-through-new-regulation [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.16","unstructured":"US Food and Drug Administration . Extension of certain tobacco product compliance deadlines related to the final deeming rule; withdrawal of guidance, 2020. Available: https:\/\/www.federalregister.gov\/documents\/2020\/04\/30\/2020-09163\/extension-of-certain-tobacco-product-compliance-deadlines-related-to-the-final-deeming-rule [Accessed 2 Feb 2021]."},{"key":"2025101810443895000_11.3.e043133.17","doi-asserted-by":"crossref","first-page":"785","DOI":"10.2105\/AJPH.2020.305667","article-title":"Flavored e-cigarette sales in the United States under self-regulation from January 2015 through October 2019","volume":"110","author":"Liber","year":"2020","journal-title":"Am J Public Health"},{"key":"2025101810443895000_11.3.e043133.18","doi-asserted-by":"publisher","DOI":"10.15585\/mmwr.mm6937e2"},{"key":"2025101810443895000_11.3.e043133.19","doi-asserted-by":"publisher","DOI":"10.1093\/ntr\/ntu223"},{"key":"2025101810443895000_11.3.e043133.20","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2019.103208"},{"key":"2025101810443895000_11.3.e043133.21","doi-asserted-by":"publisher","DOI":"10.1016\/j.jbi.2008.08.010"},{"key":"2025101810443895000_11.3.e043133.22","doi-asserted-by":"publisher","DOI":"10.1177\/1536867x1501500208"},{"key":"2025101810443895000_11.3.e043133.23","unstructured":"Maa J . California is ground zero of the vaping epidemic, 2019. Available: https:\/\/www.sfchronicle.com\/opinion\/openforum\/article\/California-is-ground-zero-of-the-vaping-epidemic-14903076.php [Accessed 2 Feb 2021]."}],"container-title":["BMJ Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjopen-2020-043133","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,18]],"date-time":"2025-10-18T17:45:00Z","timestamp":1760809500000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmjopen.bmj.com\/lookup\/doi\/10.1136\/bmjopen-2020-043133"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,3]]},"references-count":23,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2021,3,2]]},"published-print":{"date-parts":[[2021,3]]}},"alternative-id":["10.1136\/bmjopen-2020-043133"],"URL":"https:\/\/doi.org\/10.1136\/bmjopen-2020-043133","relation":{},"ISSN":["2044-6055","2044-6055"],"issn-type":[{"value":"2044-6055","type":"print"},{"value":"2044-6055","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,3]]}}}