The next time youre about to blast a fellow diner for lighting up in a restaurant, take a closer look.
What hes smoking may not be tobacco, but an electronic cigarette.
Popularity of the devices is growing, with their use among U.S. adults quadrupling in recent years.
Some may be using them to quit smoking. And new research shows they may be about as effective as nicotine patches at helping smokers quit.
But there are new concerns that children may be using e-cigarettes, and that in turn could lead them to tobacco.
E-cigarettes are battery-powered devices that deliver nicotine and other additives in an often flavored aerosol, according to the U.S. Centers for Disease Control and Prevention.
And while they do contain nicotine, the addictive ingredient in cigarettes, they dont have the chemicals in tobacco known to cause cancer, experts say.
Their use among middle- and high school students doubled between 2011 and 2012, the CDC reports. Some 1.8 million students had used e-cigarettes as of 2012, including 160,000 whod never smoked regular cigarettes.
The American Cancer Society warns that e-cigarettes can lead children to tobacco, which accounts for about one in five U.S. deaths the most preventable cause of death in the country, killing some 443,000 every year more than alcohol, AIDS, car accidents, suicide, homicide and illegal drugs combined.
And the American Academy of Pediatrics says the sale of candy cigarettes, cigars and other products that imitate smoking like e-cigarettes should be banned because theyve been shown to promote tobacco use by children and youth.
In youths, concerns include the potential negative impact of nicotine on adolescent brain development, as well as the risk for nicotine addiction and initiation of the use of conventional cigarettes or other tobacco products, researchers wrote in CDCs Morbidity and Mortality Weekly Review in September.
'It's cool' Carol Reeves, executive director of Greenville Family Partnership, said many youths who never smoked before are using e-cigarettes.
They think its cool and pleasurable. And they love the term vaping. Theres a whole culture around it, she said. Will they then smoke other cigarettes? Maybe.
The question is if these devices fall into the hands of children, will they addict these children to nicotine ... and get them on to cigarettes or other tobacco products? Dr. Len Lichtenfeld, the cancer societys deputy chief medical officer, told The Greenville News.
We dont know, he said. What we do know is that the uptake of these cigarettes has been increasing significantly.
Thomas Kiklas, co-founder of the trade group Tobacco Vapor Electronic Cigarette Association, disputes the CDCs findings. He said another study of 1,300 college students whose average age was 19 showed e-cigarettes werent a gateway to tobacco.
Some 4 million Americans now use e-cigarettes, which first came on the market in 2007, and sales of more than $1.5 billion are expected this year, he said.
Kiklas said it shouldnt come as a surprise that teens may be trying e-cigarettes because they have a natural curiosity about new products. But he added that its up to parents to regulate their childrens use of tobacco products.
The FDA has proposed a rule that would allow it to regulate e-cigarettes along with other tobacco products, according to the cancer society.
South Carolina banned the sale of e-cigarettes to minors last June. But that doesnt mean kids cant get hold of them.
Reeves, whose group works to stop alcohol, drug and tobacco use among youths, said the kids she knows who use e-cigarettes smoke, too.
Theyre using e-cigarettes around school, in the car, places where you cant smoke, because they want the nicotine, she said.
Still a habit Dr. Bill Schmidt, medical director of Greenville Health Systems Childrens Hospital, said e-cigarettes are another way to deliver an addictive drug.
Nicotine is so very addictive, he said. If you take the point of view that its a clean cigarette, that you dont get the tar and all that goes with it, perhaps it is. But youre still addicted. And I hate to see kids get addicted to it.
Its an easy jump from e-cigarettes to regular cigarettes, particularly if e-cigarettes arent available, Schmidt said.
Its supporting a habit, he said. I smoked cigarettes once, and I know how difficult it is to break that habit. They now have patches and drugs that can help people get off nicotine. Thats what they should be doing. Not just substituting another nicotine delivery system.
The American Medical Association recently called on the FDA to extend its tobacco regulations to include all non-pharmaceutical tobacco and nicotine products, including electronic cigarettes, pipes, cigars and hookahs to ensure safety and proper labeling and to deter sales to minors.
Very little data exists on the safety of these tobacco and nicotine products, and the FDA has warned that they are potentially addicting and contain harmful toxins, said AMA board member Dr. Albert Osbahr III.
And members of Congress wrote to the FDA in November, warning that e-cigarette companies are targeting youths with their advertising, using celebrities, cartoon characters and race car driver sponsorships.
We wrote to you in September to urge you to take action to regulate electronic cigarettes ... citing our concern that use of e-cigarettes among adolescents has increased rapidly, read the letter to FDA Commissioner Margaret Hamburg from Rep. Henry Waxman, D-Calif., and other members of the House.
We are now writing you to bring your attention to ... growing evidence that e-cigarette manufacturers are taking advantage of the absence of regulation to market their products to young smokers, they continued.
In fact, e-cigarette manufacturers appear to be using the same advertising and promotional techniques that were used by cigarette manufacturers to hook teenagers on their products.
The fruit, mint and candy flavorings also appeal to children, said Reeves.
Kiklas said his group supports restricting advertising of e-cigarettes to minors. But flavors can be helpful to people transitioning from cigarettes and arent aimed at children, he said, adding that cherry-flavored nicotine lozenges are on the market now.
More research About 18 percent of high school students and 4 percent of middle school students smoked cigarettes in 2011, according to the cancer society.
Tobacco use not only causes lung cancer, the leading cause of cancer death in America, the ACS reports, its responsible for at least 30 percent of all cancer deaths, including cancers of the mouth, throat, esophagus, stomach, kidney, pancreas and bladder.
It also causes heart disease, emphysema, aneurysms and stroke, has been linked to reproductive problems, birth defects and other health problems, according to the ACS.
And South Carolina with 3,480 cases of lung cancer and 2,712 deaths from the disease in 2010 ranks 15th nationally in lung cancer mortality, according to state health officials.
Reducing smoking over the past few decades has cut the incidence of those diseases, Schmidt said.
In my lifetime, weve seen something that caused just horrendous health problems start to be less and less of an issue, he said. Its a shame to see it go back again.
Kiklas said everything in life has a risk, and that e-cigarettes are far less harmful than cigarettes, which have more than 6,000 chemicals, many that are known carcinogens.
But Reeves said the verdict is still out on the impact of e-cigarettes on long-term health and that more research needs to be done.
We dont have enough data on the impact of nicotine on the body. We do know the young brain is addicted to nicotine very rapidly, she said. Our position is protecting the young.
In a recent article in The Lancet, researchers reported that e-cigarettes were about as effective as nicotine patches to help smokers quit and they had few adverse events. But they added that more research is urgently needed to clearly establish their overall benefits and harms at both individual and population levels.
Lichtenfeld said its possible that e-cigarettes may help people quit smoking, and if they are safe, they could be part of a structured program to stop, he said. But more research is needed to determine whether they are safe, he said.
We arent saying theyre not, he said. We are saying we dont know.
On the other hand, he said, using e-cigarettes also may make smoking seem acceptable again.
Until we know more about these cigarettes, I do not believe they should be sold to children under 18 either in stores or on the internet, he said. And we believe e-cigarettes should be regulated by the FDA.