SAN
FRANCISCO — Olivia Zacks, 17, recently took a drag of peach-flavored
vapor from a device that most people would call an e-cigarette.
But
Ms. Zacks, a high school senior, does not call it that. In fact, she
insists she has never even tried an e-cigarette. Like many teenagers,
Ms. Zacks calls such products “hookah pens” or “e-hookahs” or “vape
pipes.”
These
devices are part of a subgenre of the fast-growing e-cigarette market
and are being shrewdly marketed to avoid the stigma associated with
cigarettes of any kind. The products, which are exploding in popularity,
come in a rainbow of colors and candy-sweet flavors but, beneath the
surface, they are often virtually identical to e-cigarettes, right down
to their addictive nicotine and unregulated swirl of other chemicals.
The
emergence of e-hookahs and their ilk is frustrating public health
officials who are already struggling to measure the spread of
e-cigarettes, particularly among young people. The new products and new
names have health authorities wondering if they are significantly
underestimating use because they are asking the wrong questions when
they survey people about e-cigarettes.
Marketers
of e-hookahs and hookah pens say they are not trying to reach young
people. But they do say that they want to reach an audience that wants
no part of e-cigarettes and that their customers prefer the association
with traditional hookahs, or water pipes.
“The
technology and hardware is the same,” said Adam Querbach, head of sales
and marketing for Romman Inc. of Austin, Tex., which operates several
websites that sell hookahs as well as e-cigarettes and e-hookahs. “A lot
of the difference is branding.”
Sales of e-hookahs have grown “exponentially” in the last 18 months, Mr. Querbach said.
Public
health authorities worry that people are being drawn to products that
intentionally avoid the term “e-cigarette.” Of particular concern is use
among teenagers, many of whom appear to view e-cigarettes and e-hookahs
as entirely different products when, for all practical purposes, they
are often indistinguishable.
Indeed,
public health officials warn that they may be misjudging the use of
such products — whatever they are called — partly because of semantics. A
survey by the Centers for Disease Control and Prevention found that 10
percent of high school students nationwide said that they had tried
e-cigarettes in 2012, double the year before. But the C.D.C. conceded it
might have asked the wrong question: Many young people say they have
not and will not use an e-cigarette but do say they have tried hookah
pens, e-hookahs or vaping pens.
The
C.D.C. is sending a tobacco-use survey to 20,000 students nationwide
that asks about e-cigarette experimentation but does not identify the
devices by other names. The state of California, through a nonprofit
partner called WestEd, is asking virtually the same question of 400,000
students.
Brian
King, senior adviser to the Office on Smoking and Health at the C.D.C.,
said the agency was aware of the language problem. “The use of hookah
pens could lead us to underestimate overall use of nicotine-delivery
devices,” he said. A similar problem occurred when certain smokeless tobacco products were marketed as snus.
Other health officials are more blunt.
“Asking
about e-cigarettes is a waste of time. Twelve months ago, that was the
question to be asking,” said Janine Saunders, head of tobacco use
prevention education in Alameda County in Northern California.
E-Cigarettes That Don’t Look It
Like a cigarette, e-cigarettes, e-hookahs and
vape pens can be nicotine delivery devices. Unlike a cigarette, these
are unregulated by the F.D.A. They come in a medley of flavors, like
Belgian waffle, vanilla cupcake, and peppermint blast.
In
October, Ms. Saunders convened a student advisory board to discuss how
to approach “e-cigs.” “They said: ‘What’s an e-cig?’ “ Ms. Saunders
recalled, and she showed what she meant. “They said: ‘That’s a vape
pen.’ “
Health
officials worry that such views will lead to increased nicotine use
and, possibly, prompt some people to graduate to cigarettes. The Food
and Drug Administration is preparing to issue regulations that would
give the agency control over e-cigarettes, which have grown explosively
virtually free of any federal oversight. Sales of e-cigarettes more than
doubled last year from 2012, to $1.7 billion, according to Wells Fargo
Securities, and in the next decade, consumption of e-cigarettes could
outstrip that of conventional cigarettes. The number of stores that sell
them has quadrupled in just the last year, according to the Smoke Free Alternatives Trade Association, an e-cigarette industry trade group.
The
emergence of hookah pens and other products and nicknames seems to
suggest the market is growing well beyond smokers. Ms. Zacks was among
more than 300 Bay Area high school students who attended a conference
focused on health issues last month on the campus of the University of
California, Berkeley. Many students talked about wide use of e-hookahs
or vaping pens — saying as many as half of their classmates had tried
one — but said that there was little use of e-cigarettes.
Ms. Zacks said the devices were popular at her high school here. “E-cigarettes are for people trying to quit smoking,”
she said, explaining her understanding of the distinction. “Hookah pens
are for people doing tricks, like blowing smoke rings.”
James
Hennessey, a sophomore at Drake High School in San Anselmo, Calif., who
has tried a hookah pen several times, said e-hookahs were less
dangerous than e-cigarettes. He and several Drake students estimated
that 60 percent of their classmates had tried the devices, that they
could be purchased easily in local stores, and that they often were
present at parties or when people were hanging out.
“E-cigarettes have nicotine and hookah pens just have water vapor and flavor,” said Andrew Hamilton, a senior from Drake.
Actually,
it is possible for e-cigarettes or e-hookah devices to vary in nicotine
content, and even to have no nicotine. Mr. Querbach at Romman said that
75 percent of the demand initially was for liquids with no nicotine,
but that makers of the liquids were expanding their nicotine offerings.
Often, nicotine is precisely the point, along with flavor.
Take,
for example, the offerings of a store in San Francisco called King Kush
Clothing Plus, where high school students say they sometimes buy their
electronic inhalers. On a counter near the back, where tobacco products
are sold, are several racks of flavored liquids that can be used to
refill e-cigarettes or hookah pens. The flavors include cinnamon apple,
banana nut bread, vanilla cupcake, chocolate candy bar and coconut bomb.
They range in nicotine concentration from zero to 24 milligrams — about
as much as a pack of 20 ordinary cigarettes — but most of the products
have some nicotine. To use the refills, it is necessary to buy a hookah
pen, which vary widely in price — around $20 and upward.
It
is also possible to buy disposable versions, whether e-cigarettes or
hookah pens, that vary in nicotine content and flavor. At King Kush, the
Atmos ice lemonade-flavored disposable electronic portable hookah
promises 0.6 percent nicotine and 600 puffs before it expires.
Emily
Anne McDonald, an anthropologist at the University of California, San
Francisco who is studying e-cigarette use among young people, said the
lack of public education about the breadth of nicotine-vapor products
was creating a vacuum “so that young adults are getting information from
marketing and from each other.”
“We
need to understand what people are calling these before we send out
large surveys,” Dr. McDonald said. Otherwise the responses do not
reflect reality, “and then you’re back to the beginning.”
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