Fire-safe cigarettes

There were over 140,000 smoking-material (lighted tobacco products) fires in the US in 2006 which caused 780 deaths, 1600 injuries and $606 million in property damage. One-fourth of all structure fire deaths in the US involved smoking materials in 2006 [91]. Most fire deaths are associated with ignition of upholstered furniture, mattresses and bedding by dropped cigarettes. Sadly, one-quarter of fatalities from smoking-material fires were not the smokers whose cigarettes started the fires. There has been a reduction in smoking-material fires of 57 % from 1980 to 2006. Both the decline in cigarette consumption as well as standards and regulations that have made mattresses and upholstered furniture more resistant to ignition have contributed to this trend [91].

Smoking-material fires result from the intersection of human behavior, a source of ignition, and a supply of fuel. Prevention of such fires requires modifications of one or more of these factors. Fortunately, cigarette consumption has decreased over 40 % since 1980. Modification of smoking behavior includes emphasis on smoking out-of-doors, but efforts to modify smoking behavior are hampered by the relatively high prevalence of alcohol use among those at highest risk for death from residential fires. Newer furniture, mattresses and bedclothes are more fire resistant, but older models will be more prevalent in low-income housing where the risk of fire is greater. Because cigarettes are the most common source of ignition in fatal residential fires, US consumer safety movements since the 1970’s have focused on legislating mandatory production of firesafe cigarettes [30].

The first bill was introduced by Rep. Joseph Moakley (D-MA) in 1978, who continued his efforts in the US House of Representatives for another two decades. By the end of the 20 th century, it was clear that passage of Federal laws was progressing too slowly, so the emphasis was redirected toward state laws. In 2003, the first state law requiring all cigarettes to be low-ignition was passed in the state of New York. By the end of 2010, all states had either passed or enacted fire-safe cigarette legislation [51].

A fire-safe cigarette has a reduced tendency to burn when left unattended. To achieve this, most

manufacturers wrap cigarettes with two or three thin bands of less-porous paper. These bands act as “speed bumps” to slow down the rate at which the cigarette burns. If a fire-safe cigarette is left unattended, the burning tobacco will reach one of these speed bumps and extinguish itself. Fire-safe cigarettes meet an established cigarette fire safety performance standard (based on ASTM E2187, Standard Test Method for Measuring the Ignition Strength of Cigarettes) [91].

One year after the New York State law went into effect, researchers from the Harvard School of Public Health compared the physical properties of cigarettes sold in New York with cigarettes sold in Massachusetts and California. Although nearly 100 % of cigarettes purchased in MA and CA burned to the end, only 10 % of cigarettes in New York had a full burn. The quantity and quality of toxins present in cigarette smoke was not different amongst the products. Consumer acceptance was acceptable, as evidenced by the observation that tobacco tax income in New York State did not change after implementation of the law [52].

Children’s sleepwear

Regulation of the manufacture of children’s sleepwear exemplify the power of coalitions – including health care experts, safety advocacy groups, technical experts, and government agencies – in responding to the needs of the public. An all-too common cause of severe burn injury in children in the 1960’s was ignition of sleepwear7 (most often by stoves and matches) [99], leaving the young survivors with the scars and complications of third degree burns. One study found that the average sleepwear fire caused burns over nearly one-third of the child’s body surface, two-thirds of which was third degree in depth [134].

In 1971, the U. S. Secretary of Commerce delivered a flammability standard for children’s sleep-

7“Sleepwear” is defined as any article of clothing intended to be worn primarily for sleeping or activities related to sleeping. “Daywear” is defined as clothing designed to be worn during the day. However, it is now common to see daywear used at night in place of pajamas, nightgowns or other traditional night clothes.

wear in the Flammable Fabrics Act. In 1973 the responsibility for administration and enforcement of this act was passed to the U. S. Consumer Product Safety Commission (CPSC). The primary aim of the standard was to minimize the risk of ignition of children’s sleepwear; the secondary aim was to diminish the extent of injury by reducing the speed at which fire would spread after ignition occurred. The mandatory resistance to flammability was applied to all children’s sleepwear garments, sizes 0–6 × and 7–14. T meet the children’s sleepwear standard, the dry garment had to char fewer than seven inches on its bottom edge after exposed to flame for three seconds [118].

By requiring that children’s sleepwear be flameresistant, these standards helped protect children from burns. A retrospective study of children admitted to the Shriners Burns Institute of Boston during the eight-year period 1969 through 1976 showed that the promulgation of flammability standards reduced the incidence of flame burns from the ignition of sleepwear (Fig. 6; [134]). The National Fire Protection Association (NFPA) estimated that the enactment of the flammability standards for sleepwear in 1971 resulted in a ten-fold decrease in childhood deaths caused by ignition of sleepwear [138].

However, in 1996 amendments to these standards allowed exemption of tight-fitting children’s sleepwear and infant garments sized 9 months or smaller.8 The rationale for relaxation of the standards was that there were decreased sales of sleepwear because daywear was being used for night clothes.9 CPSC was subsequently challenged by an alliance of stakeholders (Safe Children’s Sleepwear Coalition) with a mutual interest in the health and safety of children, including the NFPA’s Center for High-Risk Outreach, the American Burn Association and the Shriners Hospitals for Children [56]. In response to this challenge, the CPSC resolved to collect data prospectively using a National Burn Center Reporting System (NBCRS) starting in 2003. The NBCRS was a

8Current requirements are published in the Code of Federal Regulations, Title 16, Parts 1615 and 1616.

9Although difficult to quantify, the clothing industry’s perception of consumers was that sleepwear treated for reduction in flammability was less comfortable (and therefore less popular) than untreated cotton, such as that found in T-shirts.

Fig. 6. Sleepwear involvement in flame burns at the Boston Shriners Burns Institute 1969–76 [134]

surveillance system focused on clothing-related burn injuries to children treated in the U. S. in which children were injured by the ignition, melting or smoldering of clothing. Ninety-two burn centers in the U. S. participated.

The first report was issued in September 2004 [19]. This analysis scrutinized the cases of 213 victims of 209 incidents, which were submitted by 44 burn centers. Of the 209 reported incidents, only 36 involved clothing worn for sleeping, most of which was daywear.10 Of those incidents involving sleepwear, none involved tight-fitting sleepwear or infant garments sized 9 months or smaller.

Results from the second report were distributed in a memo dated January 12, 2007. These data were provided by 33 burns centers about 261 children injured in 253 incidents. In only 33 of these incidents were the children injured while wearing clothing that at some point was worn for sleeping. Nineteen of these 33 incidents involved daywear which was being worn for sleeping. Only 14 incidents involved sleepwear subject to the Standards for the Flammability of Children’s Sleepwear. As in the first report, there were no incidents involving tight-fitting sleepwear or infant garments sized 9 months or smaller.

The conclusion reached by the author of this memo, Patricia K. Adair in the Directorate for Engin-

10Daywear is subject to the Standard for the Flammability of Clothing Textiles, but is not subject to the flame-resistant requirements of the Standards for the Flammability of Children’s Sleepwear.

eering Sciences for CPSC, was that the analysis of data from March 2003 through December 2005 revealed no deaths or injuries attributable to the exempted infant size and tight-fitting sleepwear.

Thus the CPSC allowed remain the modifications to the standards. However, there are marketing responsibilities for retailers, distributors, and wholesalers who sell children’s sleepwear [219].

(1)They should not advertise, promote, or sell as children’s sleepwear, any garment which another party has indicated does not meet the requirements of the children’s sleepwear flammability standards and/or are not intended or suitable for use as sleepwear.

(2)They should place or advertise fabrics and garments covered by the children’s sleepwear standards in different parts of a department, store, catalog, or web site, from those in which fabrics and garments which may resemble but are not children’s sleepwear are sold or marketed.

(3)They should use store display signs, and/or catalog or web site notations that point out the difference between different types of fabrics and garments, for example, by indicating which are sleepwear items and which are not.

(4)They should avoid advertising or promoting garments or fabrics that do not comply with the children’s sleepwear standards in a manner that may cause consumers to view those items as children’s sleepwear or as being suitable for making such sleepwear.

In a letter dated January 4, 2007, Dr. Russell Roegner, Associate Executive Director of Epidemiology at the U. S. Consumer Product Safety Commission, noted that the study on clothing-related burn injuries to children had ended. The result of data analysis led the CPSC staff to conclude that because more than half of children’s clothing fires involved flammable liquids, they had initiated a new project on flammable liquids. To date, the results of the new project on flammable liquids have not been distributed, aside from the publication on Sept 20, 2008, of a public information safety alert on the dangers of flammable liquids [221].

In summary, the chronicle of Standards for the Flammability of Children’s Sleepwear has ups and downs. Clearly, the institution of these standards back in the early 1970’s led to a dramatic reduction in

a devastating form of childhood injury. The relaxation of these standards twenty years later shows the effects of the erosion of consumer support as well as the power of industry pressure. The inability of the US burn care community to demonstrate convincingly that the relaxation of standards left no mark on the incidence of childhood burns was indeed an illustration of the need for comprehensive, accurate national databases.

Acid assaults

Although most burns are unintentional injuries, a small proportion occur because of assaults [86]. Chemical attacks have been reported in several countries, including Bangladesh, Cambodia, China, India, Jamaica, Nepal, Nigeria, Pakistan, Saudi Arabia, South Africa, Uganda, UK, and US. Across the world, male victims are more commonly reported; many of these are associated with robbery or violent crime. Alkali is the agent most commonly used in the US, but elsewhere the injuries sustained are due to acids [125].

The highest incidence of chemical burns in the world is in Bangladesh [26]. The perpetrators are often scorned suitors, but disagreements over property boundaries and animal ownership are also common instigations. Acids are favored over alkalis because they can be easily obtained from car batteries, jewelry workshops and leather tanneries [199]. The face and eyes are the usual target, with the intent being to disfigure or blind or both. Because of the scarcity of treatment options available to the victims, they often unfortunately suffer permanent mutilation, physical disability, psychological devastation, abandonment, and destitution. In the districts wherein such attacks occur, disempowerment of women and gender discrimination are common. Sadly, few perpetrators are punished for their crimes.

One shining light of an effective prevention program for these horrifying injuries is the Acid Survivors Foundation (ASF) of Bangladesh which has been working to reduce acid attacks on children and women since 1999. ASF has been raising public awareness, building institutional capacity and lobbying, working with other nongovernmental organizations, the media, celebrities and student groups to elevate community consciousness. It has also fos-

tered advocacy and lobbying efforts with the government to ensure the passage and enforcement of laws and to create systems to provide service to acid survivors. As a result, the number of victims has dropped from 490 in 2002 to 171 in 2008 (Fig. 7). Based on the success of ASF, similar organizations have been formed in Cambodia, India, Pakistan and Uganda.

Burns first aid treatment

The goal of injury prevention is to reduce the burden of injuries upon a community. Primary prevention seeks to do this by preventing the injuries from occurring in the first place. However, even with the most effective primary prevention programs in place, burn injuries will continue to occur. Secondary prevention, therefore, is designed to minimize the damage done when a burn occurs.

Appropriate first aid treatment of burns plays a role in determining outcome by limiting tissue damage and therefore curtailing the depth of the burn. In some cases, particularly with scald burns, appropriate first aid may avert the need for surgical excision and grafting [152, 204]. Appropriate first aid treatment of burns is cool, running water within the temperature range of 50 °F to 60 °F as soon as possible after the injury has occurred. Colder water, particular in victims with larger body surface area burns, may induce hypothermia. Application of ice causes vasoconstriction of the dermal plexus and exacerbates the depth of thermal injury [41, 42, 100, 155, 176, 177].

However, the knowledge of appropriate first aid treatment of burns is widespread neither in the community nor among health care workers. Fewer than 40 % of admissions to a regional burn center in Western Australia were treated appropriately following the burn injuries. Twenty per cent used no first aid techniques, and the remainder applied substances such as honey and toothpaste [178]. Similar surveys in Hungary and Vietnam revealed that only approximately one-quarter of patients had received appropriate burns first aid [153, 158]. A survey of understanding of appropriate burns first aid treatment among health care workers showed even more disheartening results, with fewer than 20 % of those surveyed able to answer correctly all questions put to them about burns first aid [178].

Nonetheless, appropriate burn first aid can be successfully taught. Public information campaigns in Vorarlberg, Austria, and Jamshedpur, India, have led to an improved understanding of appropriate burns first aid in the community [36, 82]. A multimedia educational campaign about burns first aid in Auckland, New Zealand, resulted in a reduction of in-patient admissions and surgical procedures [205]. Although such public education campaigns are at least temporarily effective, their long-term results are not yet known.

Burn care systems

Systems for care of injuries within communities is yet another component of secondary prevention. For ex-

ample, establishment of trauma care systems in the US has successfully reduced mortality from blunt and penetrating injuries [121]. Although burn centers have been functioning for nearly six decades, there is unfortunately a dearth of evidence that supports their effectiveness at reducing morbidity and mortality. Nonetheless, the bulk of expert opinion defends the need to establish within each region a tertiary care center that can provide acute and rehabilitative care for burn victims, as well as interaction with community and pre-hospital primary care systems that are responsible for prevention and first aid [191].

Nearly half a million burns are treated by licensed health care providers each year in the US [14]. There are approximately 4000 deaths a year in the US from residential fires (3500) and due to other causes (500 from motor vehicle and aircraft crashes, scalds, chemical and electrical injuries). The majority of deaths (75 %) occur at the scene, typically from smoke inhalation; however, 40,000 burn patients are admitted to hospitals in the US each year. These injured patients live within a population of over 300 million people scattered over more than 3.5 million square miles. There has to be a system in place to provide regional care for burn injuries throughout the US, whether that be with numerous small burn units that are geographically close to the patients they serve, or with large regional centers that function efficiently and effectively because of economy of scale [95].

Although emergency care for serious burns is available to most residents of the US, the care of minor burns is often provided at primary care facilities. In North Carolina in a recent study, 92 % of burn injuries were treated by Emergency Physicians; 4 % were admitted and only 4 % were transferred to burn centers [57]. Alternatively, specialty hospitals that lack burn centers may provide care to burn patients in consultation with the nearest burn center [192].

In 2008, there were 128 burn centers in the United States including 51 centers verified by the American Burn Association. Over 45 % of the US population lives within two hours by ground transport of a verified burn center. Nearly 80 % of the population lives within two hours of a verified center. Regional variation in access to verified burn centers by both ground and rotary air transport was significant. The greatest proportion of the population with

access was lowest in the southern United States and highest in the northeast region [113].

Fortunately, even at US burn centers the proportion of patients with life-threatening burns is relatively low. The average mortality rate throughout the 62 US burn centers contributing to the ABA NBR was only 4 % during the decade 1999–2008 [16]. Seventyseven percent of patients at burn centers were hospitalized for care of burns less than 10 % of their body surface area; the mortality in this subset of patients was only 0.6 % [16]. This is true in other HIC, such as Taiwan, ROC, where the overall mortality rate among hospitalized burn patients from 1997 to 2003 was only 3 % and the LA50 was 80 % TBSA [221].

However, the profile of injury severity and mortality is distinctly different in LMIC. For instance, during the years 1992 to 2000, the mean burn size of over 11,000 patients admitted to a single burn center in Delhi was 50 % TBSA, much greater than the 12 % TBSA mean burn size of patients whose records were recorded in the ABA NBR during a similar period. Additionally, mortality was also 50 % during this period of time in Delhi, compared to only 5 % at US burn centers [7, 13]. Such contrasts reflect more on the socioeconomic differences between LMIC and HIC, as well as on the limitation of resources available to burn centers in developing countries. Nonetheless, it is notable that this same burn center in Delhi has reduced the mortality rate from 50 % down to 40 % during the subsequent time period 2001 to 2007 [7]. Although the improvement in survival may be related to the rising economic status of India, it is also a tribute to the devotion and dedication of doctors and nurses at resource-restricted burn centers.

The ability of health care systems to provide burn care to a region depends on the availability of human resources (staff and training) and physical resources (infrastructure, supplies and equipment). Resources essential for burn services at all facilities (including out-patient clinics and care provided by non-med- ical providers) consist of training necessary to assess burn wound depth and capability (training and supplies) to apply clean or sterile dressings. Other resources are essential for higher levels of facilities (such as specialist or tertiary care centers), involving the capacity for debridement and skin grafting (Table 5; [141]).