Like many people, Bernd Mayer had encountered the widespread claims that 60 mg of nicotine is enough to kill an average-sized adult. But unlike most people, he didn’t accept it at face value. He went to look for the actual evidence.
After following a chain of “circular and often misleading references” he eventually found where the figure had come from: some dubious self-experiments conducted in the 19th century. He wrote a paper on his findings, questioning the accepted toxic dose and using other evidence to revise the figure to at least 500 mg for an average adult (about 6.5 mg per kg of body weight), noting that the real figure is almost certainly even higher than that.
However, his findings are often ignored in the continuing panic about e-liquid poisonings. In an article calling the e-liquid trade “selling poison by the barrel,” the New York Times’ Matt Richtel wrote that “A teaspoon of even highly diluted e-liquid can kill a small child.”
Mayer’s paper shows this extreme statement to be anything from an exaggeration to complete nonsense. If we call 6 mg/ml nicotine e-liquids “highly diluted,” a teaspoon would be just less than 30 mg, only standing a 50 percent chance of being fatal to a 4.55 kg child, which is less than the average weight of a three-month old baby. It would be serious, but you’d have to mix up your e-liquid with your breast milk or formula to have it happen.
The reason for this detour is that the risks of nicotine poisoning from e-liquid have been continually overstated: ready-to-vape e-liquid is poisonous, but not hugely so, and poses no more of a poisoning risk than many everyday products.
Don’t believe me? Take a look at these 10 poisoning statistics for normal household products that put the hysteria about e-liquid poisonings firmly into context.
How Many E-Liquid Poisonings Are There?
First, we need to know how many people are poisoned by e-liquid.
The UK’s National Poison Information Service’s (NPIS) annual report for 2013/14 lists 204 enquiries about e-liquid poisonings in the UK, but unlike the American Association of Poison Control Centres’ (AAPCC) reports figures are only provided for a very limited set of poisons. Since the full data generally isn’t made available, this post will have to mainly focus on the US figures (unless otherwise noted).
In 2013 (the most recent full report available), the AAPCC had a total of 1,540 calls about e-cigarette exposures, and although the full data hasn’t yet been released, there were 3,783 in 2014. However, not only is the 2014 one a preliminary figure, these also include mentions of e-liquid (even if it wasn’t the main cause of the suspected poisoning) and we can only compare it to 2013 figures for other substances (because the full 2014 statistics aren’t available yet).
The AAPCC reports class more serious cases as the exposures leading to moderate or major health outcomes, as well as those leading to death, and these criteria will be used for this post. However, much of the concern about e-liquid “poisonings” hasn’t distinguished between serious poisonings and somebody simply being worried enough to call a poison centre, so we’ll also be looking at the numbers of exposure calls.
From all the potential cases of e-liquid poisoning in the 2013 AAPCC report, just 3.2 percent had a serious outcome (and the vast majority of these were “moderate” outcomes). In the UK NPIS report, just 3 out of 204 had moderate or severe toxicity, putting the figure at about 1.5 percent of all calls.
1 – Cigarettes – 5,992 Exposures
This is the most obvious place to start, but it’s also the most important comparison: cigarettes lead to more exposure calls to poison control centres than e-cigarettes. Cigarettes compare even less favourably if you focus on kids aged 5 or under: over 90 percent of cigarette poisonings are in young children, compared to “slightly more than half” for e-cigarettes.
Less than 1 percent of all cases were serious, but this still equates to more individuals seriously poisoned for cigarettes than for e-cigarettes in 2013.
2 – Paracetamol – 6,105 Exposures (UK – 2013/14)
One of the few statistics available for the UK in 2013/14 related to telephone enquiries about paracetamol, with 6,105 in total (p15). This is almost 30 times larger than the number calling about e-cigarettes, and 434 of these had to be referred to a clinical toxicologist – over twice the number of total calls about e-liquids. Similarly, ibuprofen led to 2,569 enquiries and 77 referrals.
3 – Pens or Inks – 10,861 Exposures
There is a widespread poison in your home that looks like a pen. Nope, it’s not an eGo-style e-cigarette, it’s an actual pen.
Even if the 2015 e-liquid exposure figures for the US turn out to be double those from 2014 (which is unlikely, since there were just under 2,000 for the first seven months of the year), more people would still be potentially poisoned by pens, and about 70 percent of these were aged 5 or younger.
As you may expect, only a very small percentage of these were serious (0.21 percent), but, unlike for e-cigarettes, ink poisoning actually led to one death in the US in 2013.
4 – Bleaches – 47,311 Exposures
This is one of the classic comparisons when it comes to e-liquid poisoning, because it’s an undeniably poisonous substance found in almost every household. With over 47,000 calls about potential bleach poisonings in the US in 2013, and 3.3 percent of them being serious cases (a larger proportion than for e-liquid), it looks like making a huge fuss about e-liquid poisonings is an attempt to make a mountain out of a mole-hill, to say the least.
The total number of serious cases of bleach poisoning was 1,566, almost 32 times more than for e-liquid, and there were also two deaths.
5 – “Unit Dose” Liquid Laundry Detergent – 10,877 Exposures
The little single-wash pods of liquid laundry detergent poison almost three times as many people as e-liquid – perhaps it’s the “child-attractive” colours and packaging…
This comparison only gets worse, too, because around 8 percent of these are serious cases, leading to 866 serious poisonings, including two deaths.
6 – Reed Diffusers – 206 Exposures (UK – 2013/14)
Reed diffusers are little air fresheners filled with oil, which is soaked up into reeds before diffusing around the room. They might not cause many more poisonings than e-liquid (just 2 more in 2013/14), but the UK NPIS figures show that they should be about equally concerning. Additionally, based on four years’ worth of data, around 1.8 percent of exposures ended up with serious outcomes, compared to 1.5 percent for e-liquids.
Don’t be expecting a New York Times article calling attention to how “poisonous” reed diffuser liquids are any time soon, though.
7 – Superglue – 5,907 Exposures
Superglue is another commonly-found substance leading to more calls to poison control centres than e-cigs and liquids, and although almost all of those exposed are absolutely fine, 2.6 percent of cases were serious, in comparison to 3.2 percent for e-liquids.
Although a slightly smaller percentage of the cases are serious, the greater number of poisonings means there were 153 serious health outcomes due to superglue poisoning in 2013, compared to 49 for e-liquid.
8 – Aspirin – 19,054 Exposures
Acetylsalicylic acid might sound dangerous enough to poison over 19,000 people, but the fact that this is just ordinary aspirin should tell you that we aren’t dealing with something uniquely toxic here. Shockingly, though, including 26 deaths, there were 1,922 serious outcomes, accounting for about 10.1 percent of all exposure calls.
This means that in the US, in 2013, aspirin seriously poisoned over 39 times more people than e-liquid.
The data available for the UK also shows that the NPIS received 649 enquiries about aspirin poisonings, over three times as many as for e-liquids.
9 – Mouthwash (with Alcohol) – 7,278 Exposures
Not only are there almost twice as many exposure calls from alcohol-containing mouthwash as from e-liquid, 3.7 percent of them result in serious outcomes: equating to 268 serious cases of poisoning. This means there were over 5 times as many serious cases of poisoning from alcohol-containing mouthwash as from e-liquid in 2013.
Of course, mouthwash is a good thing – protecting your teeth and helping to keep your breath nice and fresh – so we don’t see too many attempts to stoke fear of mouthwash because of the very rare cases of poisoning. The benefits clearly outweigh the usually minor and unlikely risks.
So why the difference in how e-liquid poisonings are treated? Did somebody decide that having healthy teeth and fresh breath is more important than avoiding cancer, heart disease and the abundant health risks of smoking?
10 – Homeopathic Medicines – 9,833 Exposures
Although this is using an incredibly blunt instrument to make this point: the fact that poison control centres received almost 10,000 calls about homeopathic medicine exposures shows exactly why people merely calling in about an e-liquid exposure does not mean that this many people were actually poisoned.
For those not in the know, pretty much any homeopathic medicine can be most accurately described as “water.” Most shockingly, 34 of the exposure cases had moderate or major health consequences (likely due to contamination). This means that e-liquid only led to 44 percent more serious cases of poisoning than homeopathic medicines in 2013.
So, if you insist on causing a big fuss about e-liquid poisonings based on exposure calls, just remember: homeopathic medicines lead to over twice as many calls as e-liquids.
Putting E-Liquid Poisonings in Context
You might be wondering what the point in this whole exercise was. Even if fairly common products poison more people than e-liquid or lead to more exposure calls, e-liquid is still poisonous. That is definitely true, and ensuring you store your e-liquid safely and out of reach of children and pets is absolutely vital. This is all the more true if you’re mixing your own e-liquid.
The problem is that stories about e-liquid poisonings usually lack any appropriate context. They don’t sufficiently stress that they’re actually reporting exposure calls rather than poisonings, they don’t explain that almost all of these exposures didn’t lead to serious health outcomes, and they don’t really mention how many of the products we encounter everyday far exceed e-liquids when it comes to both exposures and serious outcomes.
As Paracelsus, the founder of toxicology, so crucially pointed out:
“All substances are poisons; there is none which is not a poison. The right dose differentiates a poison from a remedy.”
Some substances are poisonous in lower doses than others, but as Mayer found, nicotine isn’t the hugely potent poison it’s often claimed to be. All of these points – and examples like those given above – explain Public Health England’s conclusion on the poisonings “issue:”
“There is a risk […] of poisoning from ingestion of e-liquids. These risks appear to be comparable to similar […] potentially poisonous household substances.”
The take-home message is simple: don’t be careless with your juice, but don’t be fooled into thinking e-liquids pose a unique poisoning risk either.