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E-cigarettes: an evidence update 12 as intended pose no risk of nicotine poisoning to users. However, e -liquids should be in ‘childproof’ packaging. Duration and frequency of puffs and mechanical characteristics of EC play a major role in determining nicotine content in vapour. Across the middle range of nicotine levels, in machine tests using a standard puffing schedule, n icotine content of e-liquid is related to nicotine content in vapour only weakly. EC use releases negligible levels of nicotine into ambient air with no identified health risks to bystanders. Use of a cigalike EC can increase blood nicotine levels by around 5 ng/ml within five minutes of use. This is comparable to delivery from oral NRT. Experienced EC users using the tank EC can achieve much higher blood nicotine levels over a longer duration, similar to those associated with smoking. The speed of nicotine absorption is generally slower than from cigarettes but faster than from NRT. Policy implications o General labelling of the strength of e-liquids, along the lines used for example indicating coffee strength, provides sufficient guidance to consumers. o Regulatory interventions should ensure optimal product safety but make sure EC are not regulated more strictly than cigarettes and can continue to evolve and improve their competitiveness against cigarettes. Summary of Chapter 10: Safety of e-cigarettes in light of new evidence Two recent worldwide media headlines asserted that EC use is dangerous. These were based on misinterpreted research findings. A high level of formaldehyde was found when e-liquid was over-heated to levels unpalatable to EC users, but there is no indication that EC users are exposed to dangerous levels of aldehydes; stressed mice poisoned with very high levels of nicotine twice daily for two weeks were more likely to lose weight and die when exposed to bacteria and viruses, but this has no relevance for human EC users. The ongoing negative media campaigns are a plausible explanation for the change in the perception of EC safety (see Chapter 8). None of the studies reviewed above alter the conclusion of Professor Britton’s 2014 review for PHE. While vaping may not be 100% safe, most of the chemicals causing smoking-related disease are absent and the chemicals which are present pose limited danger. It has been previously estimated that EC are around 95% safer than smoking. This appears to remain a reasonable estimate.