appealing than those exposed to non-flavored e-cigarette advertisements." e-cigarette advertisements with warnings could strengthen e-cigarette harm perceptions, and lower the likelihood of buying e-cigarettes. some e-cigarette businesses that use cartridges state their products are 'eco-friendly' or 'green', despite the absence of any supporting studies. some writers contend that such marketing may raise sales and increase e-cigarette interest, particularly among minors. safety graphic from the january 2015 california department of public health's state health officer's report on e-cigarettes warning about harmful substances in e-cigarette vapor since about 2006, e-cigarettes have been widely marketed as a 'cleaner' type of recreational nicotine product than traditional cigarettes in the us, uk, and europe. tobacco manufactures have vigorously promoted the use of alternatives to traditional cigarettes with supposedly safer tobacco products, such as e-cigarettes, as a way to lower the harms of tobacco. the objective of the tobacco firms is to maintain their sales by using marketing tactics that de-emphasize the harms and focus attention on e-cigarettes as a "much safer alternative" to traditional cigarettes while publicizing flavors that are enticing to children. e-cigarettes are marketed to smoking and non-smoking men, women, and children as being safer than traditional cigarettes. a 2015 report states, "they are being marketed as safe for recreational use by the general population." unsupported or exaggerated assertions about safety and quitting smoking are recurring marketing strategies used to target smokers. although they are marketed as being safer than traditional cigarettes, the accuracy of this assertion is unknown, as of 2014. a 2017 review states, "there are no definite conclusions regarding the safety and long-term health effects of electronic cigarettes; however, there is evidence that they are being marketed online as a healthier alternative to traditional cigarettes." e-cigarettes are frequently presented as a healthier, less costly, and cleaner option than tobacco smoking; assertions that are supported with little scientific evidence, and as products change, these assertions may become irrelevant. in 2014, the forum of international respiratory societies released a position statement, stating "electronic cigarettes are nicotine delivery devices that have rapidly gained popularity because of marketing and the belief that they are safe and helpful for cessation of cigarette smoking. the health risks of these products, however, have not been adequately studied." e-cigarette marketing is of particular concern, because it is creating an illusion that e-cigarettes are safer and healthier than traditional cigarettes, whereas their safety is still a matter of ongoing debate. e-cigarettes are marketing as being safer than traditional cigarettes, but there is a lack of available evidence to adequately support that view. a 2018 review stated, "manufacturers of e-cigs claim that their products are nontoxic, but multiple adverse effects including pneumonia, wheezing and coughing have been associated with them." e-cigarettes are promoted as being safe to use in contrast to traditional cigarettes, though they are not absence of hazardous substances. a 2017 review stated, "there is a justifiable concern that any broad statement promoting e-cig safety may be unfounded considering the lack of inhalational toxicity data on the vast majority of the constituents in e-cigs. this is particularly true for individuals with existing lung disease such as asthma." a 2016 review states "various tobacco products are being commercially marketed such as 'reduced exposure,' 'light,' or 'nicotine-free' products including electronic cigarettes with different levels of nicotine, nitrosamines, and other toxic chemicals, claiming a reduced health hazard compared with regular brands. however, recent studies from our laboratory and others assessing the differential bbb toxicity of various cigarette products have challenged the claimed safety of these reduced or low-exposure cigarette brands." e-cigarettes are asserted as being safe to use. despite this, the us fda has stated that e-liquids used in the e-cigarettes contained nitrosamines, diethylene glycol, heavy metals, and other contaminants that are possibly toxic. the marketing of e-cigarettes as being safe to use in contrast to traditional cigarettes is under dispute, because the e-cigarette aerosols are a significant source of toxic heavy metals. the available evidence demonstrates that e-cigarette aerosol is not just "water vapour" as is frequently asserted in their marketing. a 2014 report evaluated 59 e-cigarette business retail websites in 2012 and concluded marketing on the sites regularly asserted that e-cigarettes generate merely "harmless water vapor." similar marketing techniques were being utilized in the uk. assertions that e-cigarettes and nicotine are safe and even healthy are commonly found in the media and on business websites, is an area of concern. e-cigarette businesses commonly promote that their products contain only water, nicotine, glycerin, propylene glycol, and flavoring but this assertion is misleading as researchers have found differing amounts of heavy metals in the vapor, including chromium, nickel, tin, silver, cadmium, mercury, and aluminum. the widespread assertion that e-cigarettes emit "only water vapor" is not true because the evidence demonstrates e-cigarette vapor contains possibly harmful chemicals such as nicotine, carbonyls, metals, and volatile organic compounds, in addition to particulate matter. e-cigarette companies have advertised that substances including glycerin are "fda approved" or "generally recognized as safe," but this classification is applicable to eating food rather than the inhalation of the e-cigarette aerosol. marketers of e-cigarettes have asserted that the "cancer causing chemicals found in tobacco cigarettes are not found in electronic cigarettes". a 2016 review stated, "despite widespread promotion that e-cigarettes are safer than regular cigarettes due to less tar production, there are multiple chemicals found in these products. these include nicotine, formaldehyde, acetaldehyde, lead, acetone, copper, and cadmium. these compounds can be addictive and/or carcinogenic. for example, formaldehyde is an international agency for research on cancer group 1 carcinogen." the makers and marketers of such products frequently assert that the products they offer are a safe substitute to smoking, especially because they do not generate carcinogenic smoke. despite this, "no studies have been conducted to determine that the vapor is not carcinogenic, and there are other potential risks associated with these devices," a 2012 world medical association report stated. as of 2014, the e-cigarettes that were being marketed may have used a significant number of interchangeable components that enabled users to alter the composition of the inhaled aerosol. provided that scientific evidence about the safety of e-cigarettes is largely inconclusive, marketing claims that use words such as safer to describe their products could contribute to confusion about their overall safety, especially among youth. promoting a product by claiming that it is healthier than tobacco smoking, the leading cause of preventable death, is therefore controversial and may only have merit when targeting smokers who are contemplating quitting or reducing use. independent e-cigarette businesses have directed marketing efforts at smokers, stating it is a safe nicotine product. statements that e-cigarettes are safe and beneficial in comparison to traditional cigarettes may hamper approaches to tobacco control. these products are being advertised as a harm reducing substitute. there is no evidence that the traditional cigarette brands are selling e-cigarettes as part of a plan to phase out traditional cigarettes, despite some stating to want to cooperate in "harm reduction". "perceived and marketed as a 'healthier alternative' to conventional cigarettes, few data exist regarding the safety of these devices and their efficacy in harm reduction and treatment of tobacco dependence; even less is known about their overall impact on population health," a 2014 review stated. e-cigarettes were initially presented as being safer than traditional cigarettes, but marketing approaches may be surpassing such claims by connecting e-cigarettes with words identified with healthy foods. some vaping brands assert that their devices will provide vitamins instead of nicotine. on social media sites these products are being advertised with images that include salads or split avocados. a 2018 review states that "the recent advent of 'vitamin vaping' and aggressive marketing by some e-cigarette companies that claim that vaping e-cigarettes containing a variety of vitamins (vitamins a, b12, c, and d) is worrying as at this current time, clinically determining the concentration of any given vitamin that is systemically absorbed by inhalation route is not possible." the manner in which e-cigarettes are marketed greatly influence the beliefs of the users regarding their harms and benefits and making choices to use such products. many cigarette smokers have turned to vaping because e-cigarette vendors have previously marketed their product as a cheaper and safer smokeless alternative to traditional cigarettes, and a possible smoking cessation tool. the us fda rejected these claims, and in september 2010 they informed the president of the electronic cigarette association that warning letters had been issued to five distributors of e-cigarettes for "violations of good manufacturing practices, making unsubstantiated drug claims, and using the devices as delivery mechanisms for active pharmaceutical ingredients." the marketing of such products as being safer than traditional cigarettes has resulted in a rise in their use in pregnant woman. marketing and other factors may differ in various countries, thus rates of use and the overall public health effects may not be identical. many circumstances associated with the public health impacts of large-scale availability and unimpeded marketing of e-cigarettes have been discussed, including impacts on starting to smoke in youth, giving up smoking, dual use in long-term smokers, and going back to smoking in previous smokers. fear exists that wide-scale promotion and use of e-cigarettes, fueled by an increase in the advertising of these products, may carry substantial public health risks. the rise in nicotine-containing products, primarily e-cigarettes, indicates that such products may be thought of as being safer in contrast to traditional cigarettes. despite this, there still are many questions with regard to the public health impacts of such products. claims related to pharmaceuticalization are made, presenting e-cigarettes as medical nicotine products. by switching from traditional cigarettes to nicotine products, traditional transnational tobacco businesses could make money from smokers, new users, and from people who are interested in quitting smoking. pharmaceuticalization constitutes the next stage of the tobacco industry, and another risk to public health. harm to bystanders widespread advertising and promotion included the assertion that vaping would present little risk to bystanders. in spite of that, "disadvantages and side effects have been reported in many articles, and the unfavorable effects of its secondhand vapor have been demonstrated in many studies." e-cigarettes are marketed as "free of primary and second-hand smoke risk" due to no carbon monoxide or tar is expected to be generated during use. however, the health impact of nicotine and other ingredients, is an area of concern. marketing efforts mislead people, who would be exposed to passive vapor, to perceive vaping as having been confirmed to be safe. a 2014 practice guideline by nps medicinewise states, "although data on health effects of passive vapour are currently lacking, the risks are argued to be small, but claims that e-cigarettes emit only water vapour are nevertheless incorrect. serum cotinine levels (a metabolite of nicotine) have been found to be similar in bystanders exposed to either e-cigarette vapour or cigarette smoke." addictiveness the us food and drug administration regulations require, among other things, a nicotine warning for advertisements, stating "warning: this product contains nicotine. nicotine is an addictive chemical." some manufacturers of e-cigarettes voluntarily carried health warnings in their advertisements. sellers in the us are not allowed to display advertisements for e-cigarettes or other electronic nicotine delivery systems (ends) without a health warning statement. e-cigarette packages and advertisements require health warnings under us law, stating "warning: this product contains nicotine. nicotine is an addictive chemical." according to a 2014 review, the advertising of vaping on television and radio is large-scale marketing of a habit-forming nicotine product, which is in support of its recreational use, to a new group of users who have not previously viewed this type of marketing. a 2019 world health organization report states that "apart from the known harmful effects of nicotine on the developing brain, nicotine is addictive and could lead people, particularly young people, to take up more harmful forms of nicotine or tobacco consumption. further, by using flavourings and branding strategies that appeal to young people, the industries involved in the manufacture and marketing of ends are employing tactics to expand their consumer base under the guise of contributing to public health work." to maintain continuing sales, independent e-cigarette businesses have directed marketing efforts at dedicated smokers, using the addictive substance nicotine. the assurance they give is that the nicotine being used is safe. another tactic used to imply the safety of these products is