An e-cigarette is shown next to a laptop and phone. The e-cigarette looks like a USB flashdrive.
An e-cigarette looks much like a USB flash drive, which critics say makes it trendy, discreet and attractive to younger consumers. (For Spectrum Health Beat)

Coconut. Cucumber. Mint. Mango.

Sound like flavors that might entice your Baby Boomer uncle to give up his two-pack-a-day Marlboro Red habit?

Or more like something for a younger market? High school and middle school kids, perhaps?

The answer here matters, because it’ll go a long way in explaining how the U.S. has found itself neck-deep in a fast-creeping morass of e-cigarette abuse among teens.

From 2011 to present, use of e-cigarettes has jumped exponentially among teenagers. About 3.6 million youth—1 in 5 high schoolers, 1 in 20 middle schoolers—now vape.

And the troubles are worsening.

In recent weeks, federal and state health officials have issued warnings about the youth vaping epidemic and a mysterious, vaping-related pulmonary illness thus far responsible for killing 12 and sickening nearly 800, including teens and adults.

The causes remain unknown. Even so, it appears many of the users vaped products containing THC, the main psychoactive ingredient in marijuana, according to the Centers for Disease Control and Prevention.

The e-cigarette market went largely unregulated until the U.S. Food and Drug Administration took initial steps to wrangle it about three years ago.

The pace of regulation has since increased—the Trump administration recently laid out plans to target flavored vaping products—but much of the action has played out at the state level.

This past summer, Michigan Gov. Gretchen Whitmer made her state one of the first in the nation to issue a temporary ban on flavored e-cigarette products.

New tactics

The Campaign for Tobacco-free Kids has pegged the vaping epidemic as nothing short of a second wind from big tobacco—and it’s being achieved largely through flavored e-cigarettes.

Newer version of e-cigarettes are particularly concerning, with just one pod delivering the same amount of nicotine as 20 cigarettes.

Fruity flavors are fueling the epidemic, according to the FDA.

Newer companies have come to dominate the industry, with some brands marching their way into the popular lexicon of teens and young adults, a coveted market for tobacco companies.

“In the 2016 time period, if you had kids who graduated high school in 2015, their parents had no idea (about certain e-cigarettes),” said Shelley Schmidt, MD, a pulmonary and critical care specialist at Spectrum Health. “Then by 2017—every single kid knows about it.”

The success of e-cigarettes hasn’t gone unnoticed by the tobacco industry. Just last year, one of the biggest names in tobacco invested $13 billion in one of the biggest names in vaping.

In fact, one company now commands about 70 percent of the e-cigarette market.

After watching Big Tobacco lose its grip on the youth market in recent years—largely because of diligent public health campaigns—health officials have effectively seen e-cigarettes snatch up some of tobacco’s lost ground.

Dr. Schmidt said she focuses on three aspects of the e-cigarette industry to educate parents and children about its dangers: lung toxicity, nicotine addiction and the industry’s current business model.

Fancy marketing, fancy design

Researchers said e-cigarette companies have used social media, launch parties, traditional advertising and other channels to reach impressionable consumers.

Those researchers pegged the tactics as reminiscent of big tobacco’s, an industry that learned early on how propaganda and mass media could suit their aims.

E-cigarette juggernauts “aggressively marketed to the non-nicotine addicted population,” Dr. Schmidt said.

“It’s very easy to see there was an online marketing presence through YouTube, paid influencers to use their products,” she said. “(These brands) worked very hard, frankly, to get access to the non-nicotine-addicted populations.”

The CEO of one leading e-cigarette company resigned in September amid allegations that company used targeted marketing to reach youth consumers.

But equally troubling is the design of some devices.

In a word, they’re “stealthy,” Dr. Schmidt said.

Some devices look like a USB flash drive—sleek, modern, easy to use. Virtually tailor-made for today’s tech-savvy youngsters.

“If you’re a 55-year-old, pack-a-day smoker, you don’t care if your device looks like flash drive … that you can charge in front of your mother,” Dr. Schmidt said. “You don’t need it to be fancy.”

They’re often designed to look like anything but a smoking device.

In short: They’re “targeting a nicotine-naïve population with something that looks techie and cool and looks like everything else they deal with,” Dr. Schmidt said.

There’s an entire submarket designed for hiding vapes, she said.

“(They) create easy-to-hide vapes … like a highlighter, a sharpie pen,” she said. “It’s completely designed for deception.”

Nicotine addiction

From about 2006 to 2012, many brands of e-cigarettes were marketed largely as smoking alternatives, often to help traditional cigarette smokers kick the habit.

In those years, the products often had a lower nicotine content—about 0.2% to 2%, or sometimes up to 3%.

The nicotine content in newer versions? About 5%.

The makers were able to up the nicotine content by using nicotine salts, which differs from the freebase system used in other popular vaping models, Dr. Schmidt said.

Changing the product’s chemistry meant a puff on the newer devices wouldn’t burn the user’s throat.

“That means you can take a really long drag and it doesn’t irritate your tissue,” Dr. Schmidt said.

Among the host of ill effects nicotine has on the cardiovascular system and immunity, in high doses it can cause seizure, loss of consciousness and other problems, Dr. Schmidt said.

“Nicotine is not a harmless chemical in the body,” she said.

E-cigarettes simply have not been subjected to the same regulatory pressures as traditional tobacco.

“They’re really well-designed and well-positioned to create addictions in a nicotine-naive population,” Dr. Schmidt said. “I refer to them as a highly engineered nicotine-addiction device.”

There is also the issue of addiction itself.

The adolescent brain is still developing up to the age of 25, so it’s far more susceptible to being shaped by nicotine usage, Dr. Schmidt said.

Think of a young person’s brain as a series of perpetually changing roads, she said: Roads that go unused are paved over to make way for more important, permanent pathways.

Given the highly addictive properties of nicotine, a youngster’s brain will register the drug as a critically important pathway—so nicotine secures its place.

“It can pave it in there for life,” Dr. Schmidt said.

The effects of this are profound.

Nicotine-addicted individuals have lower academic performance and lower socioeconomic performance and they’re at increased risk of mental health issues and dangerous behaviors such as drug use.

“Nicotine is the fifth-most addictive chemical known to man,” Dr. Schmidt said. “It has a lot of long-term repercussions that are very scary.”

E-cigarettes, however, are an especially pernicious new tool for drug experimentation because of their design. It’s a short hop from nicotine to something more dangerous when you need only remove an e-cigarette’s nicotine pod and replace it with something worse.

“If you can introduce someone to a device and they’re comfortable with the device—and you just change the drug—you make it a much greater likelihood they’ll try other drugs,” Dr. Schmidt said.

Lung toxicity

Beyond the known dangers of vaping, the unknowns are perhaps most troubling.

Dr. Schmidt calls this “the bigger underbelly of the iceberg.”

“We don’t know what happens when the chemistry behind these chemicals comes together,” she said. “There’s a lot of science right now researching this.”

Health researchers are finding that vaping itself, even without nicotine, can affect the body by way of the various chemicals involved and the heating process.

“The lungs are not designed to take in heated vapor,” Dr. Schmidt said. “They’re way too delicate.”

Some of the ingredients used in the vaping process are propylene glycol and glycerol, diacetyl and heavy metals.

Even then, the regulatory and vetting processes in the manufacture of e-cigarettes simply aren’t as rigorous as you’d think, Dr. Schmidt said.

“It’s not an approval (like with medicine),” she said. “It’s like a registration. You can be FDA-registered—you tell them what you’re putting in it. There’s nobody double-checking it. You don’t have to provide any safety data.”