18B.4 Safety and abuse potential

Last updated: September 2017

Suggested citation: Greenhalgh, EM, & Scollo, MM. InDepth 18B: Electronic cigarettes (e-cigarettes). In Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2017. Available from: http://www.tobaccoinaustralia.org.au/chapter-18-harm-reduction/indepth-18b-e-cigarettes

18B4.1 Safety risks

18B4.1.1 Explosions, fires and burns

As the popularity of e-cigarettes has increased, there have been growing reports of fires1 and burn injuries2-8 attributed to e-cigarette battery explosions. A 2017 review of burns associated with e-cigarette batteries found that the most frequent sites of injury involved the lower extremities and hands. Nearly half of the reported incidences required surgical management as a result of the depth of injury.2 There have also been case reports of such explosions causing fractures9 and ocular injuries.10 A man was reportedly killed in late 2014 when a charging e-cigarette exploded and ignited his oxygen equipment.11   

Following several fires, in 2015 the International Civil Aviation Organization prohibited airplane passengers and crew from carrying e-cigarettes and other battery-powered portable electronic smoking devices in checked baggage, and from recharging the devices in aircraft cabins.12   

Most of the reported explosions have occurred due to lithium-ion battery failure when the device was charging, largely due to the use of non-approved or faulty power adaptors. Although many e-cigarettes have a USB port, plugging an e-cigarette into a USB port or power adapter not supplied by the manufacturer can subject the battery to a higher current than is safe, leading to an explosion and/or fire.1   

18B4.1.2 Nicotine toxicity and accidental poisoning

The nicotine content of e-cigarettes typically ranges between 0 and 34mg/mL;13 although several studies have reported discrepancies between labelled and measured nicotine content.14, 15  At high enough doses, nicotine has acute toxicity.16 Vaping is unlikely to cause nicotine overdose or intoxication, since the amount consumed and absorbed is quite low and comparable to smoking.17-19 However, some e-liquid cartridges contain nicotine doses that are potentially toxic in adults and children if used in ways other than intended.20 In recent years there have been increasing numbers of calls to poison information centres due to unintended ingestion of the e-liquid,21, 22 particularly by children,23-25 with a baby in the US26 and a toddler in Israel27 reportedly dying after drinking from an e-cigarette refill bottle. There have also been limited reports of intentional intoxication by injection and ingestion and a small number of suicide attempts associated with the cartridges.28, 29 E-cigarettes may also leak, presenting a hazard as nicotine can be absorbed through the skin.30   

For further information, refer to Chapter 6, section 2

18B4.2 Abuse potential

18B4.2.1 Nicotine adddiction

Nicotine is among the most addictive of substances known.31, 32 Although e-cigarette users appear to be less dependent on their product than comparable smokers,33-35 most users still considered themselves to be addicted.34 E-cigarettes may deliver systemic nicotine concentrations in a similar range to,13, 36 or even in excess of,37 those delivered by combustible cigarettes.  

Nicotine addiction is discussed further in Chapter 6 - Addiction

References

1. U.S. Fire Administration. Electronic cigarette fires and explosions. 2014. Available from: https://www.usfa.fema.gov/downloads/pdf/publications/electronic_cigarettes.pdf

2. Harshman J, Vojvodic M, and Rogers AD. Burns associated with e-cigarette batteries: A case series and literature review. Canadian Journal of Emergency Medicine, 2017:1–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28566106

3. Jiwani AZ, Williams JF, Rizzo JA, Chung KK, King BT, et al. Thermal injury patterns associated with electronic cigarettes. International Journal of Burns and Trauma, 2017; 7(1):1–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28123861

4. Kumetz EA, Hurst ND, Cudnik RJ, and Rudinsky SL. Electronic cigarette explosion injuries: A case series. American Journal of Emergency Medicine, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27133537

5. Nicoll KJ, Rose AM, Khan MA, Quaba O, and Lowrie AG. Thigh burns from exploding e-cigarette lithium ion batteries: First case series. Burns, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27118069

6. Ramirez JI, Ridgway CA, Lee JG, Potenza BM, Sen S, et al. The unrecognized epidemic of electronic cigarette burns. Journal of Burn Care and Research, 2017; 38(4):220–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28644205

7. Sheckter C, Chattopadhyay A, Paro J, and Karanas Y. Burns resulting from spontaneous combustion of electronic cigarettes: A case series. Burns Trauma, 2016; 4:35. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27995151

8. Treitl D, Solomon R, Davare DL, Sanchez R, and Kiffin C. Full and partial thickness burns from spontaneous combustion of e-cigarette lithium-ion batteries with review of literature. The Journal of Emergency Medicine, 2017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28501385

9. Norii T and Plate A. Electronic cigarette explosion resulting in a c1 and c2 fracture: A case report. Journal of Emergency Medicine, 2017; 52(1):86-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27712901

10. Paley GL, Echalier E, Eck TW, Hong AR, Farooq AV, et al. Corneoscleral laceration and ocular burns caused by electronic cigarette explosions. Cornea, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27191672

11. No authors listed. Man killed as e-cigarette 'explodes', merseyside fire service says. BBC News, 2014. Available from: http://www.bbc.com/news/uk-england-merseyside-28701515

12. International Civil Aviation Organization. New e-cigarette restrictions. 2015. Available from: http://www.icao.int/Newsroom/Pages/ICAO-Confirms-New-E-Cigarette-Restrictions.aspx

13. Schroeder MJ and Hoffman AC. Electronic cigarettes and nicotine clinical pharmacology. Tobacco Control, 2014; 23 (Suppl 2):ii30–5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24732160

14. Goniewicz M, Kuma T, Gawron M, Knysak J, and Kosmider L. Nicotine levels in electronic cigarettes. Nicotine & Tobacco Research, 2013; 15:158–66. Available from: http://ntr.oxfordjournals.org/content/early/2012/04/21/ntr.nts103

15. Buettner-Schmidt K, Miller DR, and Balasubramanian N. Electronic cigarette refill liquids: Child-resistant packaging, nicotine content, and sales to minors. Journal of Pediatric Nursing, 2016. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27079973

16. U.S. Department of Health and Human Services. The health consequences of smoking: 50 years of progress. A Report of the Surgeon General, Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf.

17. Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, and Voudris V. Evaluation of electronic cigarette use (vaping) topography and estimation of liquid consumption: Implications for research protocol standards definition and for public health authorities’ regulation. International Journal of Environmental Research and Public Health, 2013; 10(6):2500–14. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23778060

18. Nides MA, Leischow SJ, Bhatter M, and Simmons M. Nicotine blood levels and short-term smoking reduction with an electronic nicotine delivery system. American Journal of Health Behavior, 2014; 38(2):265–74. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24629555

19. Dawkins L and Corcoran O. Acute electronic cigarette use: Nicotine delivery and subjective effects in regular users. Psychopharmacology, 2014; 231(2):401–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23978909

20. Cameron JM, Howell DN, White JR, Andrenyak DM, Layton ME, et al. Variable and potentially fatal amounts of nicotine in e-cigarette nicotine solutions. Tobacco Control, 2014; 23(1):77–8. Available from: http://tobaccocontrol.bmj.com/content/23/1/77.short

21. Centers for Disease Control and Prevention. Press release: ‘New CDC study finds dramatic increase in e-cigarette-related calls to poison centers’. 2014. Available from: http://www.cdc.gov/media/releases/2014/p0403-e-cigarette-poison.html

22. Branley A. Health experts alarmed after rise in accidental poisoning from e-cigarettes. ABC News, 2014. Available from: http://www.abc.net.au/news/2014-08-27/accidental-poisoning-from-ecigarettes-on-the-rise/5699592>

23. England LJ, Bunnell RE, Pechacek TF, Tong VT, and McAfee TA. Nicotine and the developing human: A neglected element in the electronic cigarette debate. American Journal of Preventive Medicine, 2015; 49(2):286–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25794473

24. Hagen K. E-cigarettes poisoning Victorian toddlers. The Age, 2014. Available from: http://www.theage.com.au/national/ecigarettes-poisoning-victorian-toddlers-20140606-39ohu.html?skin=text-only

25. Kamboj A, Spiller HA, Casavant MJ, Chounthirath T, and Smith GA. Pediatric exposure to e-cigarettes, nicotine, and tobacco products in the United States. Pediatrics, 2016; 137(6). Available from: http://www.ncbi.nlm.nih.gov/pubmed/27244861

26. Withnall A. First 'e-cigarette child death': New York baby dies after drinking liquid nicotine. The Independent, 2014. Available from: http://www.independent.co.uk/news/world/americas/first-ecigarette-child-death-new-york-baby-dies-after-drinking-liquid-nicotine-9924229.html

27. Winer S. Police investigating toddler’s death from nicotine overdose. The Times of Israel, 2013. Available from: http://www.timesofisrael.com/police-investigating-toddler-death-from-nicotine-overdose/

28. Cervellin G, Luci M, Bellini C, and Lippi G. Bad news about an old poison. A case of nicotine poisoning due to both ingestion and injection of the content of an electronic cigarette refill. Emergency Care Journal, 2013; 9(2):18. Available from: http://ftp.oncologyreviews.org/index.php/ecj/article/view/ecj.2013.e18

29. Christensen LB, van’t Veen T, and Bang J. Three cases of attempted suicide by ingestion of nicotine liquid used in e-cigarettes. XXXIII International Congress of the European Association of Poisons Centres and Clinical Toxicologists (EAPCCT), 2013. Available from: http://www.e-cigarette-research.info/doku.php/research:documents:f87h87fv

30. National Institure for Health and Care Excellence. Tobacco: Harm-reduction approaches to smoking. NICE Public Health Guidance 45, 2013. Available from: http://www.nice.org.uk/guidance/ph45/resources/guidance-tobacco-harmreduction-approaches-to-smoking-pdf

31. Royal College of Physicians of London. Nicotine addiction in Britain. A report of the Tobacco Advisory Group of the Royal College of Physicians, London: Royal College of Physicians of London, 2000. Available from: http://www.rcplondon.ac.uk/pubs/books/nicotine/.

32. Benowitz N. Nicotine addiction. New England Journal of Medicine, 2010; 362(24):2295–303. Available from: http://content.nejm.org/cgi/content/full/362/24/2295

33. Etter JF and Eissenberg T. Dependence levels in users of electronic cigarettes, nicotine gums and tobacco cigarettes. Drug and Alcohol Dependence, 2015; 147:68–75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25561385

34. Liu G, Wasserman E, Kong L, and Foulds J. A comparison of nicotine dependence among exclusive e-cigarette and cigarette users in the path study. Preventive Medicine, 2017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28389330

35. Rostron BL, Schroeder MJ, and Ambrose BK. Dependence symptoms and cessation intentions among US adult daily cigarette, cigar, and e-cigarette users, 2012–2013. BMC Public Health, 2016; 16(1):814. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27538489

36. Shahab L, Goniewicz ML, Blount BC, Brown J, McNeill A, et al. Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users: A cross-sectional study. Annals of Internal Medicine, 2017. Available from: http://www.ncbi.nlm.nih.gov/pubmed/28166548

37. Ramoa CP, Hiler MM, Spindle TR, Lopez AA, Karaoghlanian N, et al. Electronic cigarette nicotine delivery can exceed that of combustible cigarettes: A preliminary report. Tobacco Control, 2016; 25(e1):e6–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26324250

  

 

      Previous Chapter Next Chapter