Attempting to commit suicide with E-Liquids: Witless!

Even if some won’t feel too comfortable about it, today’s blogpost concentrates on a taboo of our society: The desire to wilfully end one’s own life without assistance.

People committed suicide throughout history. About one of the most famous we can already read from Plutarch: Cleopatra, who arranged to be bitten by a poisonous snake.

There are many other prominent examples of suicide:

• Ernest Hemingway (shot himself),
• Karen Carpenter (anorexia),
• Jim Morrison (drugs),
• Jennifer Nitsch (leap out of the window),
• Hannelore Kohl (sleeping pills),
• Sid Vicious (heroin overdose).

The European Parliament and in particular the European Commission and the European Council seem to fear the possibility of an accidental or intentional fatal nicotine intoxication due to a high nicotine concentration in E-liquid. For this reason, the negotiating parties of the trilogue agreed to a number of rules for the proposed tobacco directive in order to make this impossible:

• Nicotine concentration limit defined at 20mg/ml
• E-liquid refill containers restricted to 10ml
• Disposable electronic cigarettes and single use cartridges limited to 2ml
• Refillable devices need to have some mechanism that avoid spilling – technical specs to be defined by Commission

It should be noted that the European Commission and the European Council are ignoring not only the small number of (harmless in most cases) accidental nicotine poisoning due to E-liquid over the last years, but also the current data situation concerning the slight poisonous effect of nicotine.

The facts

An article concerning three suicide attempts was published in the scientific journal „Clinical Toxicology“ by Lars B. Christensen et al. in May 2013.

[important]Case 1. Woman, age 36, admitted to a psychiatric ward, who had ingested 20 mL of nicotine liquid labelled as containing 18 mg to commit suicide. The Poisons Information Center was contacted 10 minutes after intake.
What is surprising is even though the patient ingested 360 mg nicotine, she presented no symptoms.
Medical treatment: The patient was admitted to the emergency ward for treatment with activated charcoal. [/important]

[important]Case 2. The same woman as in case 1 was admitted to the emergency ward after ingestion of 50 mL of nicotine liquid labelled as containing 30 mg of nicotine/mL, to commit suicide.
What is very surprising is even though the patient ingested 1500mg nicotine, two hours after ingestion the symptoms present were abdominal pain, nausea, and voluminous vomiting.
Medicinal treatment: Activated charcoal and observation for 6 hours. [/important]

[important]Case 3. Male, age 13, ingested 3 mL of nicotine liquid, no information about concentration, to commit suicide. Fifteen minutes after ingestion symptoms were nausea and shivering.
Medical treatment: Activated charcoal and 1 hour after ingestion symptoms were decreasing. [/important]

Three cases… In one case the patient ingested 1500mg nicotine and thus more than 25 times the presumedly lethal dose of 30 to 60 mg. The only symptoms were nausea, abdominal pain, shivering and voluminous vomiting.

Toxicity of nicotine

Although the unsubstantiated claim is often repeated by scientists, physicians and tobacco control advocates that 30–60 mg of nicotine are fatal, there is little concern that e-cigarettes can harm their users by delivering toxic nicotine levels.
There have been numerous recorded incidents of accidental or intentional nicotine poisoning in the last decades – they show that the LD50 of 30-60 mg nicotine has to be wrong.

A recent study of Prof. Dr. Mayer (Department of Pharmacology and Toxicology, Karl-Franzens University Graz) managed to trace the statement concerning the lethal toxicity of nicotine back to self-experiments in the 19th century. He published his results in the scientific journal „Archives of Toxicology“ in August 2013.

Fulltext: How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century

Due to a mistake in the 19th century, generations of researchers repeated these findings uncritically ever since. The conclusion of Prof. Dr. Mayer is clear:

[important]Nicotine is a toxic compound that should be handled with care, but the frequent warnings of potential fatalities caused by ingestion of small amounts of tobacco products or diluted nicotine-containing solutions are unjustified and need to be revised in light of overwhelming data indicating that more than 0.5 g (500mg) of oral nicotine is required to kill an adult.

(emphasis by me)[/important]

More toxicity of nicotine

Prof. Dr. Goniewicz et al. published a research report in the scientific journal „Addiction“ in December 2013, which is focused exactly on this subject:

Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications

The study determined the nicotine content of the cartridges of the most popular EC brands in the United Kingdom (18 to 24 mg nicotine) and the nicotine levels they deliver in the vapour, and estimated the safety and consistency of nicotine delivery across batches of the same product as a proxy for quality control for individual brands and within the industry:

[important]There is very little risk of nicotine toxicity from major electronic cigarette (EC) brands in the United Kingdom. Variation in nicotine concentration in the vapour from a given brand is low. Nicotine concentration in e-liquid is not well related to nicotine in vapour. Other EC brands may be of lower quality and consumer protection regulation needs to be implemented, but in terms of accuracy of labelling of nicotine content and risks of nicotine overdose, regulation over and above such safeguards seems unnecessary.

(emphasis by me)[/important]

In the full text of the study, Prof. Dr. Goniewicz made no bones about the toxicity of nicotine:

[important]Although an unsubstantiated claim is often repeated that 30–60 mg of nicotine is fatal, several suicide attempts have been recorded where people drank up to 1500 mg of nicotine in e-liquid (i.e. 50× the presumed lethal dose) without any consequence other than abdominal pain and ‘voluminous vomiting’ [13]. A recent study managed to trace the statement concerning the lethal toxicity of nicotine to dubious self-experiments in the 19th century. It has been repeated uncritically ever since. Given the low toxicity of nicotine at the doses observed and the fact that, long before any dangerous levels of nicotine concentration could be reached, an over-enthusiastic user would be warned by nausea, there is little concern that e-cigarettes can harm their users by delivering toxic nicotine levels.

(emphasis by me)[/important]

and the corresponding appropriate regulations:

[important]Our finding that the nicotine content of e-liquid has little, if any, relationship to nicotine content in vapour (let alone nicotine intake by users) suggests that a pharmaceutical level of accuracy of labelling of the nicotine content in EC cartridges is also unlikely to be informative for the user. It would appear that a general indication of strength such as that used, for example, on the packaging of coffee, would provide sufficient guidance to buyers.

(emphasis by me)[/important]

As Prof. Dr. Goniewicz states, the currently available E-liquid poses no serious threat to the health of human beings. An excessive regulation is therefore completely daft and unnecessary.

My conclusion:

Regulation of ECigarettes should be done with a sensible and light touch. The proposed regulation of the EU goes to far. The EU might as well regulate selling household cleaners in bottles of max. 20 ml…. Or painkillers like „Paracetamol“ in packages which contain a maximum up to two pills.

Lessons learned:

If someone wanted to commit suicide, he or she should not use an E-liquid. Execpt from nausea, abdominal pain, shivering and voluminous vomiting it will not have any effect.

An attempt to commit suicide by means of E-liquid is witless in various aspects.

Jens Mellin

German version of this text: Suizidversuche mit Liquid – Sinnlos

References:

1 F. Lee Cantrell – „Adverse Effects of e-Cigarette Exposures“

2 Clinical Toxicology -Lars B. Christensen „85.Three cases of attempted suicide by ingestion of nicotine liquid used in e-cigarettes“

3 Archives of Toxicology – Bernd Mayer „How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century“

4 Addiction – Maciej L. Goniewicz „Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications„