The small clouds are more noticeable than the people enveloped in the white smoke, visible on city streets and college campuses across America. They are caused by "vaping," the use of liquid nicotine from one of various types of so-called electronic cigarettes.
The users — or "vapers" — include the roughly 13 percent of high school students who admitted using e-cigarettes last year, a threefold increase to close to 2 million adolescents, according to the 2014 National Youth Tobacco Survey. The Centers for Disease Control and Prevention said that's the first survey to show more e-cigarette use than any tobacco product in that age group.
That trend has caught the attention of pediatricians and apparently the general public. The American Academy of Pediatrics this week called for a minimum age of 21 to buy products containing nicotine, including e-cigarettes. A recently released NPR-Truven Health Analytics Health Poll found 57 percent of American adults think e-cigarettes should be regulated like cigarettes by the Food and Drug Administration.
Health experts say parents should discourage use of vaping products because the safety or danger of e-cigarettes is as cloudy as the vapor they produce.
"We can't say definitively it's bad and you shouldn't use them," said Brittany Karzen, spokeswoman for the Utah Department of Health Tobacco Prevention Program, "but a lot of caution should be taken."
A CDC spokesman is more blunt. Youths should not be using any form of tobacco or nicotine, regardless of how it's delivered, Dr. Brian King, deputy director for research translation in the CDC's Office on Smoking and Health, told the Deseret News. "There's a lot we don't know, but we know enough to know they should not be using any of these products."
Nicotine is a chemical found in several plants, including tobacco. It stops insects from chewing tobacco crops and keeps tobacco users addicted. It can also be produced synthetically.
E-cigarettes, vape pens and related products deliver nicotine, flavorings and different chemicals by way of vapor instead of smoke. "Puffing activates the battery-powered heating device, which vaporizes the liquid in the cartridge. The resulting aerosol or vapor is then inhaled," according to the National Institutes of Health.
E-cigarettes owe their increasing popularity to different factors, experts say, from popularity of an ever-growing list of flavored "e-liquid" or "e-juice" to marketing of the devices as a quit-smoking aid. The supposition is that they may be less dangerous because e-cigarettes deliver less nicotine and are not lit, so they don't produce tar and other byproducts of burning tobacco that cause cancer.
On the other hand, nicotine is known to be both very addictive and a stimulant. It has been associated with heart disease, poisoning — sometimes of young children who get hold of a parent's e-liquid and drink it — and possibly birth defects.
"Today, while (e-cigarettes) are not quite the same and we hope these aren't as bad, we do know there are going to be some dangers associated because of the nicotine," Karzen said.
A Chinese pharmacist named Hon Lik is generally credited with creating the modern e-cigarette in 2003 and most of the devices are imported from China. Vapers have lots of choices — including disposable or reusable, pre-loaded or load-your-own-juice and more. The price range reflects that variety, from a few dollars to significantly more.
Right now, e-cigarettes are not federally regulated, though most states have restricted youth access to them, barring use age 19. Seven states and at least 400 communities include e-cigarettes in clean air legislation governing public spaces. Because no electronic smoking devices have been approved for therapeutic use, the National Park Service won't allow them. Vaping is also banned on U.S. airplanes and new rules won't allow vaping devices in checked luggage, either, because of fire potential.
But there are dueling views on the devices' health impact.
A recent World Health Organization report on possible and perceived hazards of e-cigarettes was sharply criticized by King's College London professor Ann McNeill and her colleagues, who said the review used "alarmist language to describe findings and to present opinion as though it were evidence." Their own research said e-cigarettes are 95 percent safer than traditional tobacco products because they don't contain the tar found in regular cigarettes.
But users do face risks associated with nicotine and with no regulation on what can be put into the e-liquids. "You don't know what's going into your body when you inhale," Karzen said, noting nicotine is the biggest concern in use by kids, because it's bad for the developing brain. It's also possible that vaping wires young minds for addiction.
What's listed on the packaging and what's actually in the e-cigarette often don't match, Karzen added. "There are pretty large discrepancies" between percentages listed on packaging and what testing shows.
Several recent news stories have noted that e-cigarette users sometimes vape marijuana oils.
The ultrafine particles in vaping aerosol are worrisome, too, King said. Some e-liquids contain organic compounds and heavy metals.
It's a common misconception that everyone's inhaling water vapor. In some devices it's true. But others contain no water vapor, Karzen said, and studies don't agree if what's inhaled is dangerous. She said it reminds her of what happened in the 1930s and '40s, when popularity outpaced knowledge about safety or risks of cigarettes.
"It's the wild, wild west in terms of manufacturers and distribution," King said. "We don't know long-term effects for adults. We do know some potentially harmful ingredients have been identified, including nicotine, which harms the brain and creates fetal toxicity."
The FDA has said it will regulate electronic nicotine delivery devices, but not when or what rules will look like. The comment period got more than 135,000 before it closed over a year ago. But the agency is still involved in dozens of related studies and getting some of those results is expected to take a long time.
Meanwhile, Wells Fargo Securities predicted vaping will reach sales of $3.5 billion by the end of the year.
Quit aid or enabler?
Chandler Cutrer, 18, of Salt Lake City, is among those who both vape and smoke. He said he vapes for a lot of reasons, including the fact that it's acceptable where smoking is not. Like many young vapers, he's a "cloud chaser," doing tricks with the smoke vapor he exhales. "It's entertaining to watch and it takes a lot of skill to do it," he said.
But he also believes vaping is healthier than smoking. "I could feel cigarettes hurting my lungs more; they have way more chemicals in them and they smelled awful."
He said he now smokes only infrequently, which he credits to the e-cigarettes. He noted he tries to choose e-juice with the lowest level of nicotine possible and is fond of a flavor that reminds him of whipped cream and strawberries.
While vapers and e-cigarette proponents say the electronic devices are a stop-smoking tool, not everyone's convinced. Karzen calls it the stuff of anecdotes, not research. "Using it as a cessation product without knowing the real risks may be a pretty dangerous thing to do."
Anti-vaping groups are speaking up. CASA Columbia, a national nonprofit research and policy organization that focuses on substance abuse and addiction, just released a report that says "alternative non-combustible products that contain nicotine but not tobacco are not harmless, particularly to young people. Nicotine remains one of the most addictive and potent substances, regardless of whether it's delivered through a combustible cigarette, electronic cigarette, vape pen, hookah pipe or cigar."
King said that most who use e-cigarettes continue to use tobacco, too. "Just reducing the number doesn't reduce health risks," he said. "You have to quit completely." He said the best tools for quitting have been tested for efficacy and FDA approved.
The U.S. Preventive Service Task Force said it can't recommend e-cigarettes as a stop-smoking tool because current evidence is inadequate.
Gregory Conley, president of the American Vaping Association, questioned the task force's decision. “The task force should have at least had the integrity to advise doctors that vapor products may be a positive intervention for hardcore smokers who have tried and failed to quit with products like the nicotine gum, patch and medications," he said in a written statement.
“In the United Kingdom, Public Health England and over a dozen respected public health authorities have endorsed the use of vapor products by smokers looking to quit. Their rigorous assessment is based on a totality of the evidence, both from clinical trials and the real world. Every time groups like the USPSTF dismiss the benefits of vapor products, there are smokers that take their advice seriously and continue to smoke.”
Tastes like candy
Of the middle and high school students who tried tobacco in the past month, about 70 percent used at least one flavored product, a recent CDC Morbidity and Mortality Weekly Report said. The products most-often tried were flavored e-cigarettes, flavored hookah and flavored cigars. Nearly one in five high school students said they used at least one flavored product in the past month.
In a written statement, Matthew L. Myers, president of the Campaign for Tobacco-Free Kids, cited the report as evidence of "the urgent need for the FDA to issue its long-overdue final rule regulating all tobacco products, including electronic cigarettes and cigars, and to expand the current ban on candy- and fruit-flavored cigarettes to include all flavored tobacco products."
There are many popular "e-juice" flavors, including bubble gum, vanilla, cotton candy and cherry, some reportedly aimed at kids, said King. While some of the flavors are considered safe to eat, "we don't know the effects of inhaling flavorings and we don't want to just assume it is safe."
The Flavor and Extract Manufacturers Association of America in its safe-production manual warns workers about dangers of inhaling heated flavors, which the Center for Tobacco Control Research and Education cites as proof of health risk.
A special report by the Milwaukee Journal Sentinel noted a lack of standards for e-liquids or a requirement that manufacturers test them. Their own tests of various e-juice products documented the presence of chemicals "known to cause permanent and fatal lung disease" in some of the products, but which were not listed as ingredients. They also found varying levels of those chemicals and a dearth of certainty about how much is too much.
Health experts have a goal of a tobacco-free generation, which also means nicotine-free. Karzen said that rising popularity of e-cigarettes makes that goal harder to achieve.
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