18.4 Safety risks and abuse potential of e-cigarettes

Last updated: August 2023 

Suggested citation: Jenkins, S, Winnall WR, Greenhalgh, EM, MacKenzie, R, & Scollo, MM. 18.4 Safety risks and abuse potential of e-cigarettes. In Greenhalgh, EM, Scollo, MM and Winstanley, MH [editors]. Tobacco in Australia: Facts and issues. Melbourne: Cancer Council Victoria; 2023. Available from: https://www.tobaccoinaustralia.org.au/chapter-18-e-cigarettes/18-4-safety-risks-and-abuse-potential-of-e-cigarettes 

 

This section examines:

18.4.1 Safety risks

18.4.1.1 Explosions, fires and burns

Numerous major reviews have concluded that e-cigarettes can cause burns and projectile injuries, which may be serious and sometimes fatal.1-3

E-cigarettes are usually powered by rechargeable lithium-ion batteries that pose a risk of chemical leaks and explosions and fires. Lithium-ion batteries contain flammable chemicals. If these chemicals leak due to damage or explosion, they can cause chemical burns or start fires from nearby flammable items. Lithium-ion battery explosions are rare, but may occur if these batteries are damaged, overheated, overcharged or poorly constructed.4 Unlike other products such as mobile phones and laptops, e-cigarettes usually contain cylindrical lithium-ion batteries installed in a cylindrical tube—one that is weakest at both ends. Battery failures generate increased pressure that “shoots” the batteries out of the tube like “rockets.”5 Injuries from battery explosions could include burns from exposure to the battery chemicals, burns from the fires caused by these explosions, traumatic wounds from projectiles and burns from hot or burning projectiles (see below).

Although e-cigarette manufacturers have tended to attribute blame for explosions to the user for charging the devices improperly, a 2017 report from the US Fire Administration found that only 25 per cent of explosions occurred during the charging process. Sixty-two per cent of the devices exploded when being carried in a pocket or when they were actively in use. The report notes that the shape and construction of e-cigarettes is itself problematic, concluding that:

“Lithium-ion batteries should not be used in e-cigarettes. While the number of batteries that explode and catch fire is statistically small, the catastrophic nature of the injuries that can occur warrants the use of another battery technology for e-cigarettes.”5

Nether-the-less, lithium-ion batteries remain a popular choice for e-cigarettes, including those sold in Australia.6

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.7

Thermal and chemical burns

After growing numbers of reports of fires and burn injuries attributed to e-cigarette battery explosions,5 , 8-11 a major review of international evidence conducted by the National Centre for Epidemiology and Public Health at the Australian National University concluded that there is conclusive evidence that e-cigarettes can cause burns and injuries, which can be severe and can result in death.1 An analysis of e-cigarette explosion and burn injuries presenting to US hospital emergency departments (EDs) between 2015 and 2017 concluded that past reports appear to substantially underestimate the actual number of these events. It estimated that there were 2035 presentations over this period—between 15 and 40 times more than previous estimates. The true number of injuries also likely exceeds these estimates, given that people with less severe injuries are less likely to present to an ED.12

Burns associated with e-cigarette batteries most commonly occur on the hands, thighs and genitalia.1 , 3 , 9-11 , 13 Nearly half of the reported incidences in a 2017 review of cases required surgical management as a result of the depth of injury.13 Chemical burns in eyes have also been reported.14

Projection of a damaged battery or flammable chemicals from an e-cigarette has been reported to start fires, resulting in injuries and deaths. A 2023 study found eight records of injury while smoking e-cigarettes whilst receiving supplemental oxygen therapy.15 A man was reportedly killed in late 2014 when a charging e-cigarette exploded and ignited his oxygen equipment.16

E-cigarette burns have also been reported in association with falls. In cases when a person has fallen over whilst using an e-cigarette, burns to the throat and oesophagus have been reported.17

Traumatic injuries from explosions

Projectiles (such as batteries) from e-cigarette explosions are a cause of traumatic injuries, especially to the face.1 , 2 Blast injuries reported include tooth loss,18  fractures19 and eye injuries.20 Many occurred when the device was in users’ pockets.21 A review of the patterns of facial injuries found reports of fractures to jawbones, vertebrae, hard palates and nasal bones, as well as oral lacerations, tooth loss and oesophageal stricture (narrowing).22 One report details a fatal penetrating head injury caused by the explosion of the lithium-ion battery in the modified e-cigarette.23

18.4.1.2 Nicotine toxicity and accidental poisoning

Major reviews have concluded that exposure to e-liquids can lead to poisoning, including nicotine toxicity.1 , 2 , 24 A major international review conducted by the Centre for Epidemiology and Population Health found conclusive evidence that: 1) intentional or accidental exposure to nicotine e-liquids can lead to poisoning, which can be severe and can result in death, 2) a significant number of accidental poisonings occur in children under the age of six, and 3) the use of e-cigarettes can result in nicotine toxicity.1

Poisoning from accidental or intentional exposure to e-liquids may cause harm through nicotine toxicity or toxicity of other chemicals found in the e-liquids. Many of the symptoms reported to poison centres after exposure are consistent with nicotine toxicity (see below).

The nicotine content of e-liquids typically ranges between 0 and 34mg/mL25 but has been found as high as 134mg/ml.26 , 27 Several studies have reported discrepancies between labelled and measured nicotine content.28 , 29 At high enough doses, nicotine has acute toxicity.30 Vaping as intended is unlikely to cause nicotine overdose or intoxication, since the amount consumed and absorbed is approximately comparable to smoking.31-33 However, some e-liquids contain nicotine doses that are toxic and potentially lethal in adults and children if used in ways other than intended – such as drinking the e-liquid.34

The number of reports of exposures to e-cigarettes/e-liquids made to poison centres in the US has fluctuated in recent years. Reports increased during 2010–2014, and then decreased during 2015–2017, rising again in during 2017–2018 (from 2,320 to 2,901). From April 1st 2022 to March 31st 2023, there were 7,043 reports.35 Increasing use of e-cigarettes as well as the implementation of legislation requiring child-resistant packaging for liquid nicotine containers in the US36 may have influenced these changing numbers of exposure reports.

An analysis of calls to Australian Poisons Information Centres (PICs) from 2009 to 2016 showed rapidly increasing cases related to e-liquid exposures from 2013.37 32% of calls were on behalf of children exposed or potentially exposed to e-liquids. One infant has reported died in Australia after ingesting a concentrated nicotine solution.37 Calls to Australian PICs have reported doubled since 2020, with 501 calls made in 2021.38

Intentional or accidental exposure to e-liquids may cause toxicity through differing routes of exposure, including ingestion, inhalation, dermal (skin contact) and ocular exposures (eye splashes).39 A review of exposure reports in the medical literature from 2010 to 2022 found that 65–93% of child and infant exposures were through ingestion of e-liquids, often including their containers/ cartridges.39 Data from cases reported to US poison centres from April 1st 2022 to March 31st 2023 also show over 60% of accidental exposures occurring in children 5 years old and younger,35 consistent with reports from Europe.40 Eye exposure, on the other hand, was reported in a range of age groups in the US.41 Similar to reports in the US, Australian reports included exposure through ingestion, inhalation, skin and eyes.37

Exposure to e-liquids leads to many different symptoms that are often consistent with nicotine toxicity.39 , 42 Gastrointestinal symptoms included vomiting, nausea, abdominal pain and diarrhoea. Reported cardiovascular symptoms include tachycardia (fast heart rate) or bradycardia (slow heart rate), hypotension (low blood pressure), and cardiac arrest. Dermal effects (on skin) included pallor (paleness), erythema or flushing (redness), and irritation/pain. Reported neurologic symptoms included drowsiness, irritability, tremor, confusion, seizure or coma. Ocular (eye) symptoms were red eyes and irritation/pain, which can occur even when exposure does not occur through the eyes. Reported respiratory symptoms included cough, cyanosis (bluish skin) and respiratory depression (shallow breathing).39 The symptoms of exposure may be related to the route of exposure but many symptoms, like vomiting and nausea, are common to more than one route of exposure.39 Fatal cases of exposure have been reported; a baby in the US43 and a toddler in Israel44 died after drinking from an e-cigarette refill bottle. An 18-month old baby died in Melbourne after ingesting nicotine e-liquid from a bottle in 2018.45 There have also been limited reports of intentional intoxication by injection and ingestion and a small number of suicide attempts associated with the cartridges.46-48

18.4.2 Abuse potential

18.4.2.1 Nicotine addiction

Nicotine is among the most addictive of substances known.49 , 50 E-cigarettes may deliver systemic nicotine concentrations in a similar range to,25 , 51 or even in excess of,52 those delivered by combustible cigarettes.

Major evidence reviews have concluded that e-cigarettes containing nicotine are additive, particularly for non-smokers of conventional cigarettes.1 , 2

Nicotine absorption and dependency depends on factors associated with user habits and with the device/e-liquid. Nicotine flux (the rate at which nicotine is emitted from the e-cigarette) is associated with dependency.53 Device-related factors include the nicotine concentration of the e-liquid, the form of nicotine (with nicotine salts leading to higher blood levels of nicotine), the ratio of propylene glycol to glycerol, the type of device, the power settings used and the flavours present.54 Some policy makers have suggested reducing the nicotine concentration in e-liquid to reduce the addictive potential of the products. For example, in the EU, nicotine content is limited to 20 mg/ml.55 However, research suggests that among experienced user, such reductions may not translate to a reduction in nicotine absorption, possibly due to compensatory puffing.56-58  

Earlier studies found that e-cigarette users may be less dependent on their product than comparable smokers,59-61 although most users still considered themselves to be addicted.60 However, more recent studies have had mixed results, perhaps due to the changing nature of e-cigarettes or new users with differing habits. Results of some recent studies indicate that people who only use e-cigarettes, or dual users of e-cigarettes and conventional cigarettes, show similar levels of dependence to conventional cigarette users.62-65 This apparent increase in dependence may have been influenced by the amount of nicotine delivered by contemporary e-cigarette devices, which is reported to be higher than early ones, particularly when nicotine salts are used (see Section 18.5.3.1).54 , 66-69

Nicotine addiction is discussed further in Chapter 6 - Addiction.

18.4.2.2 Consuming other drugs in e-cigarette devices

E-cigarette devices provide the opportunity for discreet consumption of non-nicotine drugs, including illicit drugs such as opiates, amphetamines and ketamine. Little is known of the amount of these drugs that enter the body during e-cigarette use and of the safety of these practices. Cannabis appears to be the most popular of these drugs and has been studied more extensively than others.

Cannabis use in e-cigarette devices

E-cigarettes are being used to consume cannabis along with or instead of nicotine, particularly among young people.70 , 71 The active constituents of cannabis are cannabinoid molecules, some of which have psychotropic activity (can alter mood, perception, cognition and behaviour). Examples are tetrahydrocannabinol (THC) and cannabidiol (CBD). Cannabinoid-enriched or cannabis oil-enriched e-liquids72 are available for purchase online via Australian and international websites. “Dabbing” is a form of e-cigarette use where concentrated cannabis oils, known as butane hash oil, are heated for inhalation.73 Alternatively, users can reportedly download recipes and attempt to make their own cannabis e-liquid.74

Estimates of ever using an e-cigarette to use cannabis products in youth and young adult samples across North America range from 8 percent to 29 percent.2 A study using 2021 data from the International Cannabis Policy Study estimated that the prevalence of cannabis vaping (at least once over a 12-month period) in the US was 15.3%, Canada 10.7%, Australia 4.0% and in New Zealand 3.7%.75 In Australia, 82% of the surveyed people who used cannabis in e-cigarettes used flavoured cannabis-e-liquids, with fruity flavours being the most common.75 With the increasing legalisation of cannabis, the e-cigarette and cannabis industries and customer bases are likely to become increasingly intertwined.2

Use of cannabis in e-cigarette devices has caused a serious and sometimes fatal respiratory disease called EVALI (E-cigarette or Vaping Associated Lung Injury). There is evidence to suspect the addition of vitamin E acetate to cannabis e-cigarettes has been the cause of this condition. More information is available in Section 18.6.5.4. Aside from EVALI, the health effects of short- or long-term cannabis use in e-cigarettes have not been extensively studied.72

Use of other drugs in e-cigarette devices

E-cigarettes can also be used to consume other types of drugs by inhalation.74 A review of e-cigarettes as an illicit drug delivery system found evidence of current use of e-cigarettes to consume almost all illicit drug types analysed. The authors highlighted that such use (via an easy to administer route and tool) may lead to higher levels and unusual patterns of drug use (continuous versus acute administration), potential increases in young adult use, addiction and toxicity, and paediatric accidental exposure.76

Data on the prevalence of this type of use is limited. An online survey of UK adults in 2017 found that of the respondents that had used an e-cigarette device, more than one-third (39.5%) had ever used them to consume recreational drugs, and more than one-quarter (27.4%) reported current use. The most common drug consumed was cannabis (lifetime use 65.7%). Lifetime use was also high for MDMA/“ecstasy” (42.8%), cocaine powder (39.8%), mephedrone (30.9%), crack cocaine (30.5%), synthetic cannabinoid receptor agonists (28.4%), fentanyl (26.7%), heroin (25.8%), alpha-PVP (alpha-pyrrolidinopentiophenone) (25.8%), typtamines (25.4%), NBOMe (2, 5-dimethoxy-4-bromophenethylamine) (25%) and ketamine (24.6%).77 Given this was a convenience sample, these numbers would be poor estimates of prevalence. Similar results were found in a small 2020 to 2021 study using convenience sampling from the US, which also noted reports of poly-substance use in e-cigarette devices.78 A review of scientific literature and media reports suggest that there is an underreporting of opiate vaping overdoses.79

“Wellness vaping”

E-cigarettes containing vitamins and other supplements are available for sale in Australia and elsewhere.80 Common advertised ingredients include essential oils, vitamins A, B12 and C, as well as caffeine, taurine and co-enzyme Q (a vitamin-like substance found in human cells). Many of these products have combinations of these supplements. Australian and international websites selling these “wellness vapes” make unfounded claims about the benefits of their use as well as their safety and environmental impact. The US Food and Drug Administration (FDA) have warned about the illegal sales of wellness vapes that claim to have health or wellbeing benefits, such as improving mental clarity, treating tumours or asthma.81

18.4.2.3 “Dripping”

E-cigarettes typically deliver e-liquid to the heating coil via saturated wicking material; however, “dripping” involves users putting a few drops of e-liquid directly onto the e-cigarette’s coil and then immediately inhaling the vapour that is produced.82 Limited evidence suggests that dripping can expose users to higher amounts of nicotine and toxic chemicals such as aldehydes.73 , 83 Higher amounts of nicotine raises concerns about greater dependency and acute toxic effects from nicotine exposure.73 One study of e-cigarette users found that those who frequently used dripping and those using higher nicotine strengths had a greater likelihood of higher perceived addiction than e-cigarette users who did not have these habits.84   

A study in Colorado found that among high school students who had ever used e-cigarettes, about one-quarter (26.1%) had used the product for dripping.82 However, the study was criticised for inadequately defining and measuring the concept.85 Further research is needed regarding the use and health effects of dripping, both for consumer information and to inform regulations.86  

18.4.3 Environmental impact

Last updated: February 2023

Cigarette manufacturing has a substantial environmental impact (see Section 10.15), and cigarette butt litter remains a major environmental pollutant that poisons waterways and wildlife and causes bushfires (see Section 10.16). There is also a growing awareness87-93 that “[f]rom mining to manufacturing, the e-cigarette product lifecycle presents novel environmental harms compared with traditional cigarettes.”94

E-cigarettes can be broadly categorised into three types:

  • the open or refillable system which includes box mods, pens and refillable pods;
  • closed pod systems which use disposable pods;
  • single-use products which have a built-in e-liquid cartridge that cannot be replaced or refilled.

Many models, brands and flavours exist within each category.95    

There are, however, common aspects of e-cigarettes varieties. Their construction involves “new classes of plastics, metals, cartridges, lithium-ion batteries, concentrated nicotine solutions” and sophisticated but low-cost electronics that are used in “significantly more environmentally intensive manufacturing processes than products that are primarily made of plant material and plastic filters, as combustible cigarettes.”88

Inconsistent and selective US regulation has skewed the e-cigarette market. In January 2020 the FDA announced regulations prohibiting the sale of flavoured (with the exception of menthol and cigarette flavours) closed pod system e-cigarettes, such as market leader Juul. This measure also exempted all flavours of e-liquids used to refill open-system e-cigarette and the relatively new single-use e-cigarette sector led by Puff Bar. This has led to a predictable impact on sales. Single-use e-cigarettes went from 10.3% of total sales in August 2019 10 19.8% by May 2020, and increased by 1000% among high school students in the US.96 Between February 2020 and March 2021 total monthly sales in the US increased by 46.3% to 21.7 million e-cigarettes and sales of prefilled cartridges (pods) increased by 15.2%, from 12.0 million to 13.8 million. In the same period, sales of single-use e-cigarettes went from 2.8 million to 7.8 million, an increase of 181.6%, and a growth in overall market share from  18.8% to 36.1%.97

The continuing strength of Juul and the shift to single-use e-cigarettes98 has significant implications for the environmental impacts of e-cigarette waste. The Juul stick, its main component, can be used repeatedly but the plastic-e-liquid pods it requires are single-use. Single-use e-cigarettes contain e-waste components similar to open- and closed-system e-cigarettes, however, they can be used for a limited time (about 400 puffs or 20–40 cigarettes' worth of aerosol) before being used up and repurchased, creating greater net waste.94

E-cigarette waste should be considered electronic-waste94 and, as such, should not be disposed of in regular rubbish bins. The lithium-ion batteries found in e-cigarettes contain flammable and combustible liquid electrolytes that can cause fires and explosions if the battery overheats (see Section 18.4.1.1).99 Lithium-ion batteries that are disposed of in household waste and recycling can cause fires in waste management facilities, waste disposal vehicles and landfills.100 Used pods and single-use e-cigarettes also contain often significant levels of residual nicotine, which potentially makes them both e-waste and biohazard waste.93

As is the case with traditional combustible cigarettes, users of e-cigarettes are often uncertain about how to dispose of use components. A 2020 US survey found that 51% of young e-cigarette users disposed of pods or empty single-use e-cigarettes into general rubbish bins, 17% put them into regular recycling bins not designed for e-cigarettes and 10% reported that they threw them onto the ground.91  

The e-liquid in e-cigarettes contains nicotine, heavy metals, such as lead and mercury, and other hazardous chemicals that can leach into the soil and waterways when disposed of in landfills or littered.101 The lithium-ion batteries and plastics in single-use e-cigarettes also degrade, leaking further chemicals and microplastics into the environment.102 , 103 E-cigarettes are also not biodegradable.91

The nicotine contained in e-cigarettes can be toxic if ingested or absorbed by the skin, particularly for children and animals (see Section 18.4.1.2). Littered e-cigarettes could expose small children and animals to the risk of poisoning and pose choking hazards. i  

18.4.3.1 Public perceptions

A US survey conducted in 2019 found high levels of recognition of the environmental harms presented by e-cigarettes among young people. The majority of respondents recognised that empty e-cigarettes, pods, cartridges and refills are litter (86.9%), the danger of disposing of e-cigarette waste in general rubbish (75.8%), and that e-cigarettes are not biodegradable (65.7%).  Most respondents also knew that e-cigarettes and related materials contain substances that are toxic to humans (84.1%) and harmful to animals (89.8%). However, recognition of the danger of disposing e-cigarette waste in general rubbish was less common among respondents who had ever used e-cigarettes compared to never-users (71.0% vs. 81.4%). Respondents also indicated that they wanted an appropriate and convenient method to recycle e-cigarette devices; 75.7% of device owners reported that they had considered recycling e-cigarettes. Though more than half (57.8%) of past month e-cigarette users reported that it was inconvenient to responsibly dispose of e-cigarette waste.91

18.4.3.2 Manufacturers’ response to e-cigarette waste

The manufacturers of e-cigarettes are aware of environmental issues associated with e-cigarette disposal but have to date failed to provide consumers with advice on appropriate disposal, unlike other electronic products, or taken responsibility for waste by-product.88 , 91 , 94 , 96

18.4.3.3 Policy response

Regulation of e-cigarettes has been slow to keep up with their rapid growth in popularity. Proposed regulation in the US has been diluted and delayed since 2010 and the deadline for the US Food and Drug Administration to assess manufacturers’ Premarket Tobacco Applications was pushed back on several occasions. This has left manufacturers to continue to produce e-cigarettes with minimal health or environmental oversight.88 In the UK, e-cigarette disposal and recycling is meant to follow guidelines set out in the Waste Electrical and Electronic Equipment Regulations, which require companies to process waste, but the onus for compliance is placed on consumers who are responsible for the costs and efforts of sending waste by-products back to manufacturers.88    

 In Australia, the prevalence of e-cigarette use continues to grow (see Section 18.3.1), and concerns about the disposal of e-cigarette components and their environmental impact are part of ongoing discussions of e-cigarette regulation.

 Under Australian law, e-cigarettes and e-liquids that contain nicotine can only be sold to people with a valid prescription, and cannot be sold from retail outlets other than pharmacies (see Section 18.13) for further information. The Pharmaceutical Society of Australia (PSA) provides the following advice to pharmacists about how they should advise patients who are dispensed nicotine vaping products from their pharmacies.

“Safe disposal

Nicotine vaping products and vaping devices are hazardous waste.

Open systems

Advise patients to return any unused nicotine vaping products (and empty nicotine vaping product containers that may contain residual nicotine) to the pharmacy for appropriate disposal through the return of unwanted medicines (RUM) program. Advise patients to switch vaping devices ‘off’ and remove rechargeable batteries prior to disposing in the household rubbish.

Rechargeable batteries can be disposed of according to local council recommendations.

Closed systems

Contact your local council for information about disposal of household quantities of closed system [single-use] ‘disposable’ vaping devices.

If the waste must be stored prior to disposal, advise patients to store it securely and out of reach of children.”104

Since the publication of the PSA’s guidelines, it was reported that the Battery Stewardship Council has advised that its battery collection points are not able to accept single-use e-cigarettes with an encapsulated battery. If the e-cigarette contains a battery that can be safely removed from the device, the separated battery can be disposed of at a battery collection point.105 Consequently, there is currently no safe way to dispose of single-use e-cigarettes. It seems unlikely that people would take their e-cigarette components to council recycling/waste management centres. In addition,  many e-cigarette users in Australia obtain their e-cigarettes from sources other than pharmacies;106 non-nicotine e-cigarettes can be sold to adults aged 18+ in retail stores in most states/territories (see Section 18.13).  These products also create considerable litter, e-waste and hazardous chemical waste in Australia.

Clear regulation at all levels of government is needed to establish standards for effective disposal and/or recycling of e-cigarettes and their components. There is also discussion of applying an extended producer responsibility (EPR) approach107 to e-cigarettes, which has also been a suggested response to cigarette butt waste (see Section 10.16.3).91 An EPR approach would make manufacturers responsible for the full life cycle of e-cigarettes and mitigate the “looming environmental threat”88 posed by e-cigarette use and disposal. Effective industry EPR should also remove the economic costs of waste management from governments.108 The implementation an EPR scheme to e-cigarettes or other tobacco products should be carefully considered with regards to government obligations under the World Health Organization’s Framework Convention on Tobacco Control Article 5.3, to protect public health policies from tobacco industry interference.109



i Cigarette manufacturing also has a substantial environmental impact (see section 10.15), and cigarette butt litter remains a major environmental pollutant that poisons waterways and wildlife and causes bushfires (see section 10.16).

 

Relevant news and research

For recent news items and research on this topic, click  here. ( Last updated June 2024)

 

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