INTRODUCTION
Ammonia inhalant (AI) use is widespread by athletes as a possible means of temporarily enhancing athletic performance during training or competition (3,5). AI use is common among various athletes as a means of increasing focus or “psyching up,” and it has been speculated that AIs are most commonly used for their purported benefit of increasing muscular strength for short periods of time (3). Presently, there is no empirical evidence supporting this purported ergogenic effect. The use of AIs can most commonly be observed anecdotally among powerlifters, weightlifters, and track and field athletes (3), as well as within sports such as boxing, football, hockey, and mixed martial arts. It has also been speculated that interest in AI use has recently experienced a resurgence among athletes (5).
AIs are commonly referred to as smelling salts, ammonia capsules, or ammonia salts and historically have been used for the prevention and treatment of fainting, dizziness, and lightheadedness. Research on AI use, risk, and effectiveness among athletic populations is nonexistent, even though anecdotal reports indicate that their use is widespread (3,5). AI use has largely been advocated against by many health care professionals and organizations because AI use can complicate the evaluation of injury, especially mild head injuries and concussions.
Research investigating the use of AI among athletes is nonexistent. Although the nonergogenic use of AIs has been reported as early as the 13th century (5), there is no present research examining the prevalence of AI use among athletes. The paucity of research examining the effectiveness and/or extent of AI use necessitates that anecdotal reports and observation be the primary mechanisms that establish their popularity and extent of use among athletes. A certain level of knowledge should be maintained among those in the strength and conditioning community because the use of AIs often occurs concomitantly with strength training and competitive sports and possesses a certain degree of relative risk. There have been adverse reactions with AI use reported previously in the literature (3), and the use of any substance that has the potential for misuse by athletes must be understood by strength and conditioning staffs, coaches, and athletic trainers.
WHAT ARE AIs?
Ammonium carbonate, the active ingredient in AIs, is often combined with scents or perfumes, giving AIs the more accurate name of aromatic spirits of ammonia. Ammonium carbonate is characterized as a respiratory stimulant that exerts its physiological effect when inhaled or sniffed. When inhaled, it causes a rapid and extreme irritation of the lungs, nose, and mucus membranes of the nasal cavity. This causes a concomitant rapid inhalation reflex that causes involuntary inhalation (5). This reflex then stimulates the muscles that control breathing to work faster, accelerating respiration and stimulating a higher degree of consciousness.
Historically, AIs have been indicated for the use of treating fainting, lightheadedness, and dizziness. Today, the only approved use of AIs in the United States is for the treatment of fainting, and this use extends to the entire general population. According to Drug Information Online (http://www.drugs.com/mmx/smelling-salts.html. Accessed: March 1, 2010), AIs are classified as respiratory stimulants that act through peripheral irritation of the respiratory system (7). The use of AIs is most commonly observed among athletes immediately before or during competition. During training, their use often precedes or accompanies high-intensity strength training. Anecdotally, it is common to observe athletes use AIs before 1-repetition maximum (RM) attempts, especially movements such as the squat, deadlift, bench press, or power clean. Furthermore, AI use can also be observed before or during various sporting events. For example, it is not uncommon to observe athletes sniff AIs before the opening kickoff of a football game, in between rounds of a boxing match, or in locker rooms during breaks or intermissions of games.
For many reasons, health care professionals and sports medicine organizations advocate against the use of AI. In Canada, the sale of AIs has been stopped, and they are no longer available for purchase over-the-counter (6). Ammonia is a toxic substance, and AI inhalation merely provides symptom relief and does nothing, or potentially complicates, the underlying injury. For this reason, the use of AIs has fallen out of favor among sports medicine professionals and physicians. However, AI accessibility still makes their self-prescription by athletes widespread, often without the knowledge of the coaches or sports medicine team.
ARE THEY SAFE?
Although anecdotal reports indicate that AI use poses certain risks among the athletic population, AIs are generally considered safe for their indicated use in treating fainting. However, there is no empirical research establishing their safety or ergogenic benefit when used by athletes during training or competition. AIs are approved for use by the Food and Drug Administration and are available for purchase over-the-counter in the United States. The accessibility of AIs makes their potential misuse high among athletes. AIs are often found in most commercial first aid kits where they are indicated only for use with fainting. The use of AIs among athletes, based primarily on anecdotal reports, has been commonplace as a means of temporarily increasing consciousness, focus, and excitement before competition. Unfortunately, AIs have also been used by athletes, sports medicine professionals, and coaches as a way of “clearing an athlete's head” after injury. This practice is dangerous because AIs can lead to a rapid involuntary contraction of the head and neck that can exacerbate an underlying injury. AI use in this manner also complicates evaluation of the underlying head injury.
There have been numerous reports of toxicity, sickness, and death as a result of ammonium exposure in large doses. Inhalation of high doses (in much greater concentrations than what is present in over-the-counter AIs) can cause severe lung damage (2). Complications with use of AIs among athletes is not common but have been reported (3). As early as 1920, it was reported that overuse of AIs caused a boxer to lose consciousness in between rounds. It was reported in The New York Times (October 8, 1920) that the boxer had inhaled enough ammonia to “revive a stricken horse.” Although cases such as this are very rare, other cases of adverse events with the use of AIs have been reported. Herrick and Herrick (3) have reported a case of anaphylaxis in a female powerlifter as a result of AI use. In this case, the athlete experienced an acute case of anaphylaxis during a competition after inhalation of an aromatic AI. In preparation for an attempt at a national powerlifting record, the lifter inhaled the contents of an AI and immediately began experiencing progressively worsening signs and symptoms of anaphylaxis (3).
There are certain differences and considerations that must be understood between the use of AIs before and during athletic competition. While the safety of AIs before competition or during training has not been investigated, their use during athletic competition should be prohibited by members of the coaching and sports medicine staff. AI use during competition may indicate that an athlete has suffered a head injury, may have lost consciousness at some point during their competition, or are experiencing headache, dizziness, or lightheadedness. Use of AIs in any of these situations may complicate subsequent evaluation of injury by making it more difficult for coaches and/or athletic trainers to identify if an athlete has suffered a head injury and putting the athlete at risk if they return to play (5). Athletes observed self-prescribing AIs during competition should minimally be questioned about their use or ideally screened for potential head injury or concussion. Recently, there has been increased media attention and scrutiny of concussion injuries in sports. Today, there is a better understanding of the impact of repeated concussions on athletes, especially as it pertains to chronic brain damage and long-term psychological and emotional health. There are numerous cases of ex-athletes suffering complications from mismanagement of concussions. Some of these athletes also report misuse of AIs in treating their concussions. National Football League (NFL) Hall of Famer Jim Brown described to NFLFanhouse.com (http://nfl.fanhouse.com/2010/03/01/jim-brown-actually-was-hurt-once. Accessed: March 1, 2010) returning to play after a concussion and specifically mentions “smelling salts” as a method of treatment. Ex-NFL player Andre Waters reportedly endured multiple concussions over his career but often did not report them. He stated in The New York Times (January 18, 2007) that he “stopped counting after 15 concussions” and that “I'd sniff some smelling salts, then go back in there.” He committed suicide in 2007, and physicians have concluded that he had sustained brain damage as a result of the numerous concussions he experienced during his career and that this lead to depression and ultimately his premature death.
Aside from the danger of masking the signs and symptoms of injury, other risks of AI use are present when used during training or competition. The use of AIs may predispose athletes to injury because they may cause athletes to do something that they are incapable of doing. In training, it is often observed that athletes will use AIs immediately before a high-intensity lift or during 1RM testing. This method of getting “psyched up” may be perceived to be helpful by athletes but may cause an athlete to attempt a lift at a level of intensity that they are not capable of completing, putting the athlete at increased risk of injury. AI use has also been reported to induce allergic reactions and is an irritant to the respiratory tract. Thus, it has the potential to exacerbate underlying asthma and trigger asthma attacks. Athletes with known asthma or other respiratory conditions should be prohibited from using AIs at any time.
There have also been reports of AI use resulting in death as a result of asphyxiation. One highly publicized report was of a 14-year boy whose death was caused by AI use and resulted in a $5 million award to the boy's family. Martin Lee Anderson was admitted to a community boot camp designed for young criminal offenders. During a group running drill, he fell to the ground and was administered AIs. It was determined later that the boy suffered from Sickle cell trait and that this condition was exacerbated by the AI use. An autopsy found that he died as a result of asphyxia because of repeated AI administration (1). Sickle cell trait is a condition that decreases the amount of oxygen carried in the blood and has been shown to be a risk factor for sudden death during physical activity (4). The National Collegiate Athletic Association recently introduced, in the NCAA News (April 13, 2010), a mandatory screening of student athletes for this condition beginning in the 2010-2011 academic year.
The use of AIs among athletes, although common, should not be approached without concern. Ammonia is a toxic substance in large doses. The use of AIs may offer a modest ergogenic effect, but there is no empirical research that is supportive of this. However, adverse events have occurred and been reported (1,3), and there are certain situations where AI use among athletes must be discouraged, most notably during athletic competition and among athletes with any preexisting medical condition.
CONCLUSION
The use of AIs during training and competition necessitates that the strength and conditioning professional be knowledgeable of their use. Whether AI use provides athletes with any scientifically proven ergogenic benefit cannot be answered given the lack of research examining AI use during training or competition. There is no research showing any increase in strength or athletic performance after their use (3). Research examining the safety and efficacy of AIs during training is needed and would be beneficial in establishing their potential safety and/or efficacy. Anecdotally, the use of AIs does seem to provide athletes with increased focus and effort. However, it is prudent to understand that because their effectiveness has not been documented among athletes, and the use of AIs should be approached with caution. There is no place for AI use in the care of an injured athlete, and their use should be discouraged. Furthermore, strength and conditioning personnel, coaches, and athletic trainers should also be keenly aware of potential self-utilization by athletes. It must also be understood that even when AIs are used for purposes for which they are indicated, their action is only treatment for their indicated purpose, their action merely treats a symptom, and should not replace appropriate medical evaluation to identify the cause of the symptom.
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