• Electronic nicotine delivery devices
• Nicotine
• Packaging and Labelling
• Public policy

E-cigarettes are a poison hazard.1 A review of studies evaluating chemicals in electronic cigarette liquid nicotine (e-liquid) found nicotine concentrations as high as 87 mg/mL.2 The lethal dose of nicotine for adults is estimated to be 30–60 mg of nicotine,3 although this amount has been scrutinised.4 For children, a fatal dose of nicotine may be as little as 10 mg.5 As e-cigarettes grow in popularity,6 ,7 associated poisonings are increasing. Poisoning cases linked to e-cigarettes jumped 1500% from 29 in 2010 to 438 in 2012.8 ,9 Over this same time period, the proportion of these poisonings that occurred in children younger than 5 years old increased from 21% in 2010 to 39% in 2012.8 ,9

There are currently no regulations requiring child-resistant packaging or poison warning labels on e-cigarettes and e-liquid sold in the USA. Previous research found e-liquid cartridges lacked content and warning labels, evidence that the industry has not been proactive at preventing poisonings.10 Since child-resistant packaging for other products has not proven 100% effective at preventing poisonings,11 consumer education about the poisoning hazards of nicotine is also important. Cigarettes and other tobacco products are now required to devote 50% of their front and rear panels to a warning label,12 but no such rules exist for e-cigarettes or packages of liquid nicotine refills.

To assess the degree to which online retailers of e-liquid are acting to protect consumers from accidental poisoning, we surveyed a convenience sample of US internet retailers in June 2013. Retailers were identified from the top Google results for popular searches: “e-liquid”; “electronic cigarettes refill”; “e cigs refill” and “electronic liquid”. Both authors reviewed the text and photos from each site for information on package sizes, nicotine concentrations, poison hazard warnings and child-resistant packaging. Discrepancies were resolved by consensus. This study focused on the information being presented to consumers at the point of sale rather than the physical products themselves. As such, no products were purchased from sites for confirmation of sizes, concentrations, warning labels or child-resistant packaging.

Twenty-one online e-liquid retailers were identified for the study. The most common volumes of e-liquid available were 10 and 30 mL. Four sites sold e-liquid in 500 mL bottles or larger. Most sites offered e-liquid in six different nicotine concentrations, ranging from 0% to 3.6% nicotine (36 mg/mL). Two sites sold 75 mg/mL nicotine solutions meant for dilution and another site offered e-liquid with a nicotine concentration of 100 mg/mL.

Explicit warnings about the toxicity of nicotine were found on 13 sites (59%). However, only six sites (29%) posted hazard warnings on the home page. Seven sites (33%) only posted hazard warnings in downloadable user manuals for e-liquid or in lists of Frequently Asked Questions. None of the sites included messages on their home page about potential poisoning hazards to children or pets.

Only three sites (14%) stated that all bottles of e-liquid had child-resistant caps. One site offered child-resistant packages as an option that customers could select. Other online retailers may have sold e-liquid in child-resistant packages, but did not make that explicit on the site.

In April 2014, the Food and Drug Administration issued proposed rules to deem additional tobacco products, including e-cigarettes and component parts. Although the deeming regulations would mandate warning labels on e-cigarettes and component parts such as e-liquid, there was no mention in the proposed rule of child-resistant packaging. Every website in this study sold e-liquid containing potentially fatal doses of nicotine. The lack of prominent nicotine hazard warnings and evidence of child-resistant packaging online is a cause for concern. Purchasers of this product may be uninformed about the toxic nature of nicotine and the potential for fatal poisonings. Strong standards for packaging that include child-resistant containers and prominent hazard warnings would help prevent poisonings. Although manufacturing standards for e-liquid exist,13 public safety should not rely on industry self-regulation. Although this study focused on US websites, safe packaging and poison warnings are important wherever e-liquid is sold.