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the 2013 review suggests that the lower limit resulting in fatal events is 5001000 mg of ingested nicotine, which is equivalent to 6.513 mg/kg orally.[98] Reports of serious adverse effects associated with acute nicotine toxicity that resulting in hospitalization were very uncommon.[99] Death from intentional nicotine poisoning is very uncommon.[66] Clear labeling of devices and e-liquid could reduce unintentional exposures.[68] Child-proof packaging and directions for safe handling of e-liquids could minimize some of the risks.[86] Some vaping companies willingly used child-proof packaging in response to the public danger.[61] In January 2016, the Child Nicotine Poisoning Prevention Act of 2015 was passed into law in the US,[100] which requires child-proof packaging.[101] The nicotine exposure rate in the US has since dropped by 18.9% from August 2016 to April 2017, following the Child Nicotine Poisoning Prevention Act of 2015, a federal law mandating child-resistant packaging for e-liquid, came into effect, on July 26, 2016.[71] The states in the US that did not already have a law, experienced a notable decline in the average number of exposures during the 9 months after the Child Nicotine Poisoning Prevention Act of 2015 came into effect compared to before it became law.[71] E-liquids have been observed in 2016 to include a press-and-turn feature similar to what is used for aspirin.[61] E-liquids that were normally available in bottles that were not regarded as child-resistant, have been reported in 2016.[61] There was inconsistent labeling of the actual nicotine content on e-liquid cartridges from some brands,[11] and some nicotine has been found in no nicotine' liquids.[28] A 2015 PHE report noted overall the labelling accuracy has improved.[102] Most inaccurately-labelled examples contained less nicotine than stated.[102] Due to nicotine content inconstancy, it is recommended that e-cigarette companies develop quality standards with respect to nicotine content.[20] Because of the lack of production standards and controls, the pureness of e-liquid are generally not dependable, and testing of some products has shown the existence of harmful substances.[86] The German Cancer Research Center in Germany released a report stating that e-cigarettes cannot be considered safe, in part due to technical flaws that have been found.[89] This includes leaking cartridges, accidental contact with nicotine when changing cartridges, and potential of unintended overdose.[89] The Therapeutic Goods Administration (TGA) of Australia has stated that, "Some overseas studies suggest that electronic cigarettes containing nicotine may be dangerous, delivering unreliable doses of nicotine (above or below the stated quantity), or containing toxic chemicals or carcinogens, or leaking nicotine

Mental health charities: Find support in your area The following charities can offer support for smokers and non-smokers who are struggling with mental health:

1 2 As a program of the California Department of Public Health, UNDO is one of the nations leading public health programs fighting to end Big Tobaccos deadly epidemic in California

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Heide Weishaar, Research Fellow, University of Glasgow This article was originally published on The Conversation

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