Intended for healthcare professionals

Observations Yankee Doodling

The poisonous “juice” in e-cigarettes

BMJ 2014; 348 doi: (Published 01 April 2014) Cite this as: BMJ 2014;348:g2504
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, and associate editor, BMJ
  1. dkamerow{at}

Yet another reason to oppose their unregulated use

Since we last tuned in,1 electronic cigarettes have continued to grow in popularity and sales. They are widely available in convenience stores and, increasingly, in specialty “vaper” shops. Although e-cigarettes are now regulated in Europe, we are still awaiting national regulation in the United States by the Food and Drug Administration (FDA).

One can envisage three possible scenarios in which e-cigarettes are used: one good, two bad. Potentially, they could be useful to help tobacco smokers quit, replacing cigarettes and slowly dialing down nicotine levels, much as other nicotine delivery devices (gum, patches, inhalers, and so on) do. That would be a good thing, although the research that is starting to accumulate about this therapeutic use of e-cigarettes is so far not promising.2

Secondly, e-cigarettes could be used to maintain a tobacco habit by allowing smokers nicotine intake in tobacco free areas, such as the workplace or home, because the vapor emitted from e-cigarettes is odorless and presumed to be not toxic. This is not so good for public health, as one of the most important incentives for quitting smoking has been the dramatic increase in places that prohibit it.

Thirdly, and most distressing, e-cigarettes could be used to initiate nicotine use and perhaps lead to tobacco smoking. With their many flavors and nicotine levels, they are easy to use and appealing to vapers of all ages, including adolescents. Friends report that an e-cigarette is the new status item in middle schools here, where they are easily concealed and used in bathrooms and outdoor breaks. Will this lead to an end or reversal of the long term downward trend in tobacco use? Time will tell.

But the latest trend in e-cigarettes is perhaps more frightening still. Most early e-cigarettes were disposable appliances designed to look and feel like cigarettes; they even had a little LED light at the end that lit up when you inhaled. You used them up and then threw them away. What we’re seeing now, however, is larger vaporizing systems. Their batteries can be recharged with the USB port of your computer and the vaporizer refilled with nicotine liquid (called “juice”) in your choice of flavor at your preferred nicotine concentration.

It is the e-liquid that is the scary part of this. Manufactured worldwide, from China to the back rooms of neighborhood “vape joints” (as they are cleverly called), nicotine juice is brewed from pure nicotine, a solvent (usually propylene glycol or vegetable glycerin, or both), and flavours. You pick the flavor from literally hundreds available: vanilla, raspberry, bubble gum, even tobacco. The nicotine concentrations of the e-liquids range from zero for the neophyte (or after you’ve tapered down, presumably) up to 36 mg/mL (for heavy smokers).

The problem is that nicotine is a poison, and the e-liquid is easily absorbed in several ways: inhalation, certainly, but also through ingestion and even skin contact. Add in the fact that the “juices” come in cute little bottles of colored, great smelling liquids and you have the makings of a terrific attraction for toddlers and young children. Unsurprisingly, US poison control centers are reporting threefold increases in calls about e-liquid poisonings. A slug of 36 mg/mL of e-liquid can make a child very sick. No deaths have been reported yet, but it is only a matter of time. Higher concentrations of e-liquid, available wholesale in gallon jugs on the internet for home brewing, are deadlier yet. And children aren’t the only victims. Emergency rooms are reporting adults showing up with cardiac symptoms after spilling e-liquid on their skin.3

I stopped by an e-cigarette store and lounge that just opened in my neighborhood to take a look at what’s available. The proprietor, vaping as he talked (it really is odorless), pooh-poohed the original “cigarette lookalike” e-cigarettes because they are disposable and environmentally unsound. He wouldn’t sell them. Instead, he led me to e-cigarette kits with a rechargeable battery, charger, and juice for $35 (£21; €25) to $50. Next to them was a display of e-juice refills in various sizes, colors, and concentrations.

I asked him about the dangers of the e-liquids, and he blandly replied that people should treat them like drugs and keep them out of the reach of children. I asked if the bottles had child-proof tops. He said that some did and some did not. I asked if there were “poison” labels on the bottles. He said no, but they did say that they were for adult use only, and he only sold to people aged 18 or older. I asked what would happen if you spilled it on yourself, and he said, “You know, like when you were caught smoking as a kid and your parents made you smoke a pack all at once: you get sick and throw up.”

This is a pretty frightening situation. We’ve got unlabelled, easily opened, cherry flavored bottles of poison being sold at the corner store, and no one is doing anything about it. I can’t think of a similar poison available without a prescription. Maybe hydrochloric acid at the hardware store, but it doesn’t come in cute little colored bottles and smell like strawberries. And to top it off, USA Today reported that the absolute latest fashion is using the e-cigarette vaporizer delivery system to smoke marijuana without the telltale odor.4

It is way past time for the FDA to start regulating nicotine liquid poisons and all their various delivery systems.


Cite this as: BMJ 2014;348:g2504


  • Competing interests: I work part-time for the American Academy of Family Physicians, which has an interest in promoting family doctors and primary care.

  • Provenance and peer review: Commissioned; not peer reviewed.

  • DK is a former US assistant surgeon general.


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