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j.nurpra.2017.09.003

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Electronic Cigarettes: A Burn Case Series
Susan L. Smith, PhD, ARNP-C, Chadwick Smith, MD, Michael Cheatham, MD,
and Howard G. Smith, MD
ABSTRACT
This case series describes injuries and the associated morbidity resulting from electronic
cigarette (e-cigarette) use. E-cigarette use is a popular and dangerous fad. A single
institution case series is reviewed. Literature from 2011 to 2016 was identified from
the following databases: (a) Cumulative Index to Nursing and Allied Health Literature;
(b) Medline; and (c) the Cochrane Library. Nurse practitioners should provide patientcentered information describing the hazards of using e-cigarette. The cases described
detail the morbidity associated with e-cigarette use. The Health Belief Model serves as
a guide for education.
Keywords: burn, cigarette, debridement, electronic, graft, Health Belief Model
Ó 2017 Elsevier Inc. All rights reserved.
INTRODUCTION
E
lectronic cigarettes (e-cigarettes) provide an
alternative to traditional cigarette smoking,
assuming a wide variety forms and offering
battery-powered nicotine delivery systems that have
gained increasing popularity since their arrival in the
United States market in 2007. These devices are
widely advertised as a safe, even desirable, choice for
smoking cessation.1 However, recent statistics reveal
that the majority of e-cigarette users continue to
smoke cigarettes, with no intention of quitting.
Equally concerning is the steady increase in
e-cigarette use among tobacco-naive adolescents and
young adults.1,2 Emerging research has documented
known hazards associated with e-cigarette use that
include: thermal/chemical burn injuries, traumatic
injuries to the teeth and eyes, nicotine toxicity,
carcinogen exposure, pulmonary toxicity, and risks
from second-hand exposure.3 Unfortunately, the
literature is contradictory and findings are
inconsistent, making establishment of definitive
warnings and more restrictive regulations difficult to
establish.4
BACKGROUND
The World Health Organization attributes over 5
million deaths each year to tobacco use. With greater
than 1 billion smokers worldwide, tobacco use
remains a major cause of preventable death.5,6 In light
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of these devastating statistics, efforts to identify
effective methods for smoking cessation is an
international health care priority. Despite the
well-documented benefits of smoking cessation, only
3%-5% of smokers successfully abstain for 6 months
or more.5 Many products have been marketed over
the years to assist with cessation efforts. E-cigarettes
were introduced as a nicotine-free smoking
alternative using a device that was not initially
restricted in any way from public use. The realistic
smoking experience made e-cigarettes a desirable
and, reportedly, safe alternative.6,7
The first e-cigarette was developed in 2003 by
Hon Lik, a Chinese pharmacist. It was not until 2007
that e-cigarettes made their way into the US
marketplace.1 The basic e-cigarette device consists of
a battery unit, rechargeable lithium batteries, and a
heating coil or atomizer. The heating component
warms liquid containing flavors, nicotine, propylene
glycol, and glycerin (for the vapor). The devices can
be activated by inhaling or by pressing an ignition
switch. Disposable, closed, and open system modular
designs are common, in addition to the customizable
box style.8,9
Of the more than 10 million reported e-cigarette
users around the world, most are former or current
tobacco cigarette smokers.1,10 Use of the device
requires the “hand-to-mouth” motion that is second
nature to traditional smokers.9 In fact, e-cigarette use
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1
closely mimics many smoking behaviors, such as
holding, puffing, and creating a smoky vapor.6
Equally appealing to users appears to be the perceived
social acceptance of device use.10,11
Detailing all reported and speculated hazards
associated with e-cigarette use is beyond the scope of
this article. Emerging literature supports that inhalation of these toxins leads to significant
morbidity.9,12,13 The following is a brief description
of the harmful byproducts produced by use of the
device and the resultant illness. First, the vapor smoke
produced includes numerous noxious components.
Williams et al studied the particulates present in
e-cigarette fluid and aerosol and found that the
mechanism’s design is responsible for much of the
metal and silicate pollutants produced. Tin particles
in the prefilled vapor cartomizers have escaped from
solder joints during testing and have been shown to
be cytotoxic.9 Iron, lead, nickel, chromium, and
silver are also present in the vapor, originating from
the wires. Of these, lead, nickel, and chromium are
included on the US Food and Drug Administration’s
“harmful and potentially harmful list.”14 In their
systematic review, Hua and Talbot reported that
respiratory compromise after e-cigarette encompasses
a broad spectrum of debilitating symptoms and
illnesses including: shortness of breath, cough,
bronchiolitis, and pneumonia.12
While the harmful effects of nicotine are well
established, the use of e-cigarettes as a nicotine
delivery system has given rise to many new safety
concerns. Benowitz and Burbank concluded that the
nicotine in e-cigarettes is potentially harmful to
patients with cardiovascular disease.15 Indeed, it is not
surprising that early data indicate a correlation exists
between e-cigarette use and the development of
atherosclerosis and symptoms consistent with
cardiovascular disease in otherwise healthy
individuals.16 Although it is generally known that
nicotine is a dangerously potent stimulant, the lack of
appreciation for the potential threat posed by
e-cigarette paraphernalia has left our most vulnerable
populations at risk. In 2013, the number of calls to
the US Centers for Disease Control and Prevention
to report accidental ingestion by young children had
risen dramatically, with this frightening trend
expected to continue.17 Adolescents and young
2
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adults are particularly vulnerable to the extensive
advertising funded by e-cigarette manufacturers and
the tobacco industry, especially through social media
and elsewhere on the internet, leaving them at risk of
becoming addicted to nicotine at an early age.18,19
The purpose of this case series report is to highlight yet another in the growing list of hazards
resulting from e-cigarette use. The volatility of the
device and the lithium batteries have been the cause
of an unquantified number of serious burn and
traumatic injuries. In fact, this “new” mechanism for
burn injuries is being reported in the literature
worldwide, yet little is known about the overall
detrimental impact of using these devices.20-24 This
case series adds to the experience of a single center,
highlighting not only the physical impact but also the
financial and social impact related to time away from
work and the expenses associated with extended
hospitalizations and surgical procedures.
RESULTS
Thermal Injuries: Case Series
A retrospective review of medical records was conducted to identify the reported occurrence of burn
injuries attributed to use of e-cigarettes in adult
patients admitted to a single burn center from
December 1, 2015 to October 31, 2016. There were
219 inpatient burn admissions during this period.
Our single center case series identified 10 adult
patients, all male, between age 20 and 47 years old.
The total body surface areas of the burn injuries
ranged from 0.5% to 15.6%, with a mean of 4.2%.
The average hospital length of stay for treatment of
the e-cigaretteerelated injuries was 4.9 days. Location of injuries included face, fingers, hands, wrists,
forearms, upper arms, thighs, knees, lower legs, feet,
and buttocks. The thigh and ipsilateral fingers were
the most common sites of injuries and skin grafts
were required by 80% of the patients.
Two patients were initially evaluated for their
injuries in our outpatient burn clinic. Five patients
were transferred to our facility for treatment. One
patient left after evaluation and debridement in the
emergency department. Initial management for
patients included nonsurgical debridement with
soap and water. After reviewing work by Nicoll
et al, our process was modified to include initial
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lavage with mineral oil to remove lithium
contamination, followed by standard nonsurgical
mechanical wound debridement.21 Silver
sulfadiazine cream was applied topically to all burns,
except those on the face. Antibiotic ointment was
applied to facial burns. One patient was admitted
from our clinic and taken to the operating room on
the same day; the remaining patients underwent
autografting between day 1 and day 4 of their
hospital stay (see Table 1).
Only thigh burns required autografts; burns
involving the hands (limited to the fingers) and
burns to the feet were mostly partial thickness in
depth and closed with local wound care. One foot
wound, resulting from a piece of metal from the
device, was a small, full-thickness injury and eventually closed without surgical intervention. Surgical
debridement for e-cigarette burns involved excision
down to fat in many cases. Due to the depth of the
burns, 2 of the 8 patients who underwent autografting experienced graft loss, but none required
regrafting. Burn wound closure was achieved by 6
weeks for those patients who followed up in the
outpatient burn clinic.
The results of this retrospective medical records
review revealed a homogeneous population of
otherwise healthy males whose e-cigarette use was
recreational, rather than a substitute for traditional
cigarette smoking. The morbidity of these injuries
was significant, with pain, both from the burn injury
itself and as a consequence of surgical treatment.
Additional lifelong morbidity resulted from permanent scar formation. The financial repercussions from
lost earnings were difficult to quantify but were
evidenced by a delay or inability to return to work
(see Table 1).
In 2014, the US Centers for Disease Control and
Prevention found that 5.5 million working adults
were e-cigarette users. Demographic data for this
population reveal that the majority are white males,
age 18-24 years, lacking health care insurance, have
an income of less than $35,000 annually, and are
current traditional cigarette smokers.14 Our study
population demographics are consistent with these
findings. Our findings provide insight into the impact
on a single hospital and the community it serves
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attributable to 1 mechanism of harm resulting from
e-cigarette use.
DISCUSSION
“Thermal runaway” is the term used to describe the
battery fire and resultant explosion from e-cigarettes.25
Damaged or overcharged batteries and those in
contact with low-resistance conductors, such as
metallic objects, may trigger ignition and cause an
explosion. Because of this volatility, contact with
items commonly carried in pant pockets, such as cell
phones, coins, or keys, should be avoided. Manufacturers recommend that e-cigarettes only be carried
when housed in a nonconductive case.20
Nicoll et al described injuries from e-cigarette
lithium battery explosions as both thermal and
chemical.21 The higher pH noted with these injuries
is attributable to lithium contamination. The end
result is production of a strong alkali burn. Alkalis are
especially devastating, as the strong base denatures
protein and breaks down fat.21,22 When combined
with the thermal burn of the fire itself and burning
clothing, these mixed etiology burns are deep,
frequently requiring surgical intervention.21
Described as a “rocket in your pocket,” the
explosions cause the release of dangerous chemicals,
but the spark alone can have devastating consequences.21 E-cigarette explosions lead to complex
injuries as a result of mechanical forces and both
thermal and chemical burn injuries. Upon exploding,
the device itself morphs into projectiles composed of
metal, plastic, rubber, or ceramics components. The
lithium battery, often instigates and then adds to the
destruction by producing toxic vapors and fiery
explosions emitting flames capable of igniting
clothing, leading to serious thermal injury.23
Interest in the impact of e-cigarettes on public
health developed after admission of several patients to
our burn center with e-cigaretteerelated burns. The
resultant injuries all presented in a stereotypical
“mixed-etiology” pattern, resulting from the combined effects of the chemical and thermal components contributing to device explosion.25 Our clinical
observations support that trauma associated with the
force of the explosion and burning clothing (causing
prolonged duration of contact) significantly
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Table 1. Synopsis of E-cigarette Burn Injuries
Age (y)
Gender
Burn Size
Mechanism of
Injury
Skin
Graft
Length of
Stay
E-cigarette
explosion while
driving tractor
trailer and fell into
his lap
Yes
4 weeks
Facial lacerations
from broken
glasses
3 days
Yes
4 weeks
Prolonged healing
to burn on foot
4 days
Complications
45
M
1%; thigh,
hand,
buttock
47
M
5.25%; hand, E-cigarette
foot, thigh
exploded in front
pant pocket; hot
metal fell into his
shoe
28
M
15.6%; face,
trunk, arms,
hands,
ankles, feet
Pouring liquid
nicotine for use in
e-cigarette when
there was a flash;
the liquid spilled
and he was
engulfed in flames
Yes
Moved out
of state
Not known
11 days
36
M
4.5%;
fingers,
thigh, knee
E-cigarette
exploded in his
front pant pocket
Yes
4 weeks
None
6 days
33
M
3%; thigh,
fingers
E-cigarette
exploded in his
front pant pocket
No
Lost to
follow-up
Not known
< 1 day
20
M
0.5%; hand,
fingers
E-cigarette
exploded in his
hand
No
No time off
taken
None
Outpatient
47
M
1%; thigh,
hand
E-cigarette
exploded in his
front pant pocket
Yes
No
Ongoing back pain 4 days
28
M
3%; thigh,
hand
E-cigarette
exploded in his
front pant pocket
while in his car
Yes
No
5 days
Back pain after
jumping out car
window due to fire
35
M
5.6%; thigh,
hand
E-cigarette
exploded in his
front pant pocket;
was trying to stop
smoking
Yes
5 weeks
Neuropathic pain
7 days
27
M
2.5%; thigh
E-cigarette
batteries exploded
in his pocket
Yes
3 weeks
None
5 days
contributes to the unique presentation of these
devastating cutaneous injuries.22 This theory is
supported by Herlin et al in their letter to the editor
describing increased reports of pain after initial lavage
and cleaning of thigh burns resulting from e-cigarette
4
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Work
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explosions.24 They described the exothermic reaction
that occurs when water is added to the lithium
particles deposited from the battery during device
explosion. The thigh burns were classified as both
flame and chemical burns.10
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Ramirez et al described significant increases in
e-cigarette burn injuries at 3 burns centers since 2015.
Their retrospective review revealed that the explosions reportedly occurred when the device was either
being used, or more commonly, when being carried
in clothing and while idle. None were reported as
occurring while the battery was charging. The majority of the burn injuries affected the thigh and hand,
with burns involving the torso, genitalia, and face also
noted.8 In addition to burns, facial injuries from
e-cigarette device explosions have been reported to
cause extensive ocular and dental trauma.23,26
IMPLICATIONS FOR NURSING PRACTICE
Regardless of whether defective batteries, improper
manufacturing, or toxic chemical exposure are to
blame, e-cigarettes pose a real threat to the health of
the device users, innocent bystanders, and family
members alike.27 Education on smoking cessation is a
well-established component of routine health visits.
Nurse practitioners (NPs) are effective and trusted
care providers with extensive knowledge in health
maintenance and disease prevention, with a proven
history in wellness promotion.28 The rapidly growing
popularity of e-cigarettes and the evolving body of
knowledge detailing the related hazards serve as
criteria for including these devices in patient-centered
education. The Health Belief Model provides NPs
with an effective framework for developing individualized discussions aimed at engaging patients in the
process for establishing positive behavior changes
directed toward the goal of cessation from all forms of
cigarette and tobacco use.29
Smoking beliefs and behaviors have been examined extensively in order to improve knowledge
about associated health hazards and to decrease
overall use. Advanced practice nurses routinely offer
smoking cessation counseling and education to their
patients during health care encounters further individualizing approaches after a thorough history and
physical, with the addition of diagnostic tests, as
indicated based on results and risk assessment.28
E-cigarettes are relative newcomers to the
constellation of smoking-related products. The list of
known device-related risks is evolving and necessitates a revised and updated approach.30,31
We propose the Health Belief Model (HBM) as an
supplemental and complementary template for
development of patient-centered education on the
dangers of e-cigarette use. Originally designed as a tool
for the US Public Health Service to predict and
explain health-related behaviors, the model has been
used extensively to evaluate the effect of perceptions
on adherence to health care advice.29 Thomas et al
summarized that the HBM provides patients with
motivation to make changes based on acceptance that
their behavior places them at a risk for serious
consequences and that they are capable of making
changes that will improve their health.32 The model
can provide a guide for understanding e-cigarette use
through individual perceptions, pertinent modifying
factors, and an assessment of the likelihood of
action.30-32
Details of the key perceptions impacting health
beliefs and motivating behavior changes related to
tobacco and e-cigarette use are described in Table 2.
Table 2. Education to Impact Perceptions of Electronic Cigarette Use on Health Beliefs6,8,9,15e19,24,26,28,30,31,33,34
Susceptibility
All users are at risk for harm from the liquid and metal components
Risk to family members through second-hand exposures, fires, and accidental ingestion of nicotine
Advertisement, especially through social media campaigns, specifically aimed at adolescents and young adults
Severity
Known link between traditional cigarette smoking and cancer
Nicotine use and cardiovascular disease
Harm to children through accidental nicotine ingestion
Pulmonary damage and worsening lung function caused by the inhaled toxins and byproducts
Devastating burn injuries, damage to teeth and eyes resulting from device explosion
Barriers
Misunderstandings and uncertainty about device safety
Smoking electronic cigarettes perceived as a desirable adjunct in smoking cessation
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These perceptions are presented as a starting point for
future NP-led patient education initiatives to increase
awareness of the dangers of e-cigarette use and may
prove effective in reducing all types of smoking and
tobacco use.29,32 Cues to action will vary
individually, but may include an acute decline in
health, an approaching birthday, or even the birth of
a child.29,33 Guidance aimed at eliminating use of
these devices must address components of wellness
promotion and injury prevention.28
Numerous counseling approaches to e-cigarette
use are possible, and must be guided by the unique
attributes of each patient. Pronchow offered the
“5A’s” model as the foundation on which NPs can
build their plan for attack against this emerging threat.
When inquiring about use, NPs must be aware of the
wide variety of e-cigarettes that are available and
remain vigilant in order to avoid erroneous assessment
of patient use and to dispel any misconceptions.13
Both the HBM and the “5A’s” model encourage
developing a strategy based on the patient’s specific
needs.13,29,33-35
CONCLUSION
The purpose of this retrospective case series is to
describe a single burn center’s experience with burn
injuries resulting from e-cigarettes. The population
demographics, extent of burns, wound treatment,
and surgical procedures are described. The length of
stay and time for return to work are offered as
indications of the social and economic impact
attributable to this mechanism of injury. The overarching goal is to add to the growing body of
knowledge validating the hazards of e-cigarette use
and to develop strategies for NPs to address device
use during health care encounters.
Our small case series revealed serious injuries
with significant and long-term implications for the
victims of e-cigarette explosions. Limitations of our
investigation include the small sample size and
single-center perspective. Furthermore, study
follow-up was limited to 1 year, so long-term
sequelae are not known. A serious, and most impactful limitation is the lack of consensus on the
safety of e-cigarettes and the implications of longterm use. These case series findings support that
serious injury can result from device use, which
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warrants ongoing investigation, increasing
restrictions, and focused patient education.
The popularity of e-cigarettes has continued on its
meteoric rise since their invention in 2003. These
trendy devices have been supported by both the
smoking and health care industries as a safe and
desirable alternative to traditional tobacco use.
However, several potential hazards have been linked
to these devices that may lead to devastating,
life-altering consequences. The long-term health
implications of e-cigarette use remain to be seen and
the current literature remains misleading and contradictory. The best approach to patient education is
establishing an open dialogue. Health care visits are
the appropriate venue for individualized discussions
about the known hazards of smoking and the
emerging literature describing the dangers of e-cigarette use for both the smoker and innocent bystanders
(including family, coworkers, and friends).
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All authors are affiliated with Orlando Health Physicians Group,
Orlando, FL. Susan Smith, PhD, ARNP-C, FAANP, is a
senior nurse practitioner with the Burn Surgery Service. She can
be reached at susan.smith4@orlandohealth.com. Chadwick
Smith, MD, FACS, is surgical critical care fellowship program
director of the Trauma Intensive Care Unit. Michael Cheatham,
MD, FACS, FCCM, is chairman of the Orlando Health
Surgical Group. Howard Smith, MD, FACS, is director of Burn
Surgical Services. In compliance with national ethical guidelines,
the authors report no relationships with business or industry that
would pose a conflict of interest.
1555-4155/17/$ see front matter
© 2017 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.nurpra.2017.09.003
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