Skyrocketing use of electronic smoking devices (ESDs) by Hawaii youth, who "vape" nicotine at much higher rates than the national average, has galvanized anti-smoking advocates who want e-cigarettes treated the same as combustible cigarettes under state law.

Health advocates tried and failed last legislative session to persuade lawmakers to impose higher taxes on the devices and associated supplies; require licenses for retailers; and restrict vaping at workplaces and other public places. E-cig users and sellers disputed health fears and praised ESDs as a safe alternative for long-term tobacco users trying to shake that lethal addiction. They maintain that the product, which typically is inhaled as a nicotine aerosol flavored as strawberry, cotton candy, bubble gum, mint, vanilla and countless other flavors, is not marketed to children, a claim that critics dispute.

Now, dual studies that document rising use among Hawaii middle-schoolers and high-schoolers, coupled with national news reports about the potential toxicity of liquid nicotine and other ingredients used in the largely unregulated industry, have reignited the debate. In particular, a study out of the University of Hawaii Cancer Center that indicates e-cigarettes lure young customers to a nicotine habit they might not otherwise acquire is fueling the renewed effort for more regulation.

"The findings coming out are disturbing and represent an erosion of the great strides we have been making in terms of tobacco use, especially among young people. The high use is normalizing behaviors that I think at the end of the day could prove to be very harmful, especially since we don’t know about all the chemicals and other harmful substances that are in these liquids," said Democratic state Rep. Della Au Bellati, who chairs the House Health Committee. "I think it’s a very serious public health issue that we have to address."

State Sen. Josh Green, a Hawaii island Democrat who chairs the Senate Health Committee, agreed, and, like Au Bellati, vowed to press again this upcoming legislative session for the type of bills that died late in last year’s session.

Green, who described the issue "as a priority for me personally, as a physician and a lawmaker," said he would focus on raising the age to acquire e-cigarettes to 21 statewide, following the model of Hawaii County; move to include electronic smoking devices in Hawaii Revised Statutes 328-J, the clean air law, which bans smoking at all public and private worksites; and strive to tax the sale of electronic smoking devices and supplies at the same rate as combustible tobacco products, to fund public health and anti-smoking prevention campaigns.

"From my perspective, the e-cig and tobacco industry are using e-cigs to addict a new generation to nicotine and if we don’t deal with it now, we are going to have a much bigger public health problem in the future," Green said. "We do not need a generation of young people becoming addicted to nicotine. It has no benefit in their lives. None."

Industry proponents such as Cory Smith, founder and CEO of Hawaii-based VOLCANO Fine Electronic Cigarettes, are not surprised that opponents are renewing their push to restrict the use of e-cigarettes, even among adults. Smith said he will continue to present his point of view to lawmakers, policymakers and the general public. The company’s website includes a blog with "call to action" updates urging customers to oppose attempts to restrict the industry throughout the country, including in Hawaii.

"It’s a very nuanced issue, and we should not be lumped into a regulatory framework designed for traditional tobacco cigarettes," said Smith. "I’m never going to make an argument that e-cigarette use is good for children. We don’t market our products to children. Our core group of users are committed long-term smokers who are looking for an alternative to traditional smoking. That’s our customer and that’s who we are marketing to. We’re not interested in creating new smokers or targeting children."

Smith said that his company strictly prohibited sales to minors even before the state Legislature passed such a law, which took effect in 2013. "We’ve had a policy since 2009 that we would strictly enforce carding and not get our product into children’s hands," he said.

For every report highlighting the risks of the devices, "I can cite studies that support the efficacy of the product as a smoking cessation device," Smith said.

He noted that even the Federal Drug Administration, which has grappled with the issue for some time, has yet to act "because the FDA has been very receptive to hearing both sides of the argument." Smith said he expects further regulation moving forward, but hopes the rules will be fair and applicable to the distinctive nature of the products, "not just calling them something they’re not."

Typical electronic smoking devices are metal tubes that use a battery-operated coil to heat a liquid solution containing nicotine, flavoring and propylene glycol. Users inhale the vaporized liquid, hence the name vaping, and get the sense of smoking without burning tobacco into cancer-causing tar. Nicotine is an addictive stimulant on its own, health officials and others point out.

"E-cigs were promoted as a cessation system for current smokers, but we’ve seen the opposite," said Green. "The number of smokers who use it to quit are dwarfed by the growing number of youth who never smoked before and now are becoming addicted to nicotine."

In the last month, the UH Cancer Center study, which was conducted among 14- and 15-year-olds in private and public schools, and a survey of students in public middle and high schools conducted by the education and health departments, illustrated just how many more Hawaii youngsters are trying ESDs. Both studies were conducted in 2013.

The public-school survey, conducted biennially with the Centers for Disease Control and Prevention, found ESD use had quadrupled among Hawaii middle-schoolers and tripled among high-schoolers from 2011 to 2013. Moreover, 10 percent of Hawaii high-schoolers and 5.5 percent of middle-schoolers described themselves as regular e-smokers, the survey found, compared to 4.5 percent and 1.1 percent nationally, respectively.

Meanwhile, the study by UH Cancer Center researchers, published in the journal Pediatrics, bolsters the view that e-cigarettes may be recruiting a new generation of young cigarette smokers who otherwise might not take up smoking at all, according to a summary of the research.

Nearly 30 percent of about 1,900 teens surveyed in Hawaii had tried e-cigarettes, and of those, 17 percent were using e-cigarettes only. The overall rate is about three times larger than previously reported in U.S. studies in 2011 and 2012; in addition, very few adolescents in the national studies use only e-cigarettes.

Dr. Thomas Wills, the interim director of the UH Cancer Center’s Prevention and Control Program, said in a news release that researchers are not sure why the rate of e-cigarette use is so high among Hawaii teens, but that aggressive marketing in public places, kid-friendly flavors such as mango and pineapple, and the fact that e-cigarettes cost less than combustible ones are among the likely factors.

Currently, sales of electronic smoking devices are restricted to people over 18, except in Hawaii County, where the age is 21. Many 18-year-olds are still in high school, and can easily buy the product for their underage friends, Green observed, which is one reason he wants to raise the age to 21 statewide.

For adults, there are no statewide restrictions that cover usage on private and public property, as conventional anti-smoking ordinances do. However, the departments of health, education and accounting and general services did take the lead in banning the use of ESDs in state government buildings, a policy that was broadly applied last October and mirrors the law for combustible cigarettes.

Health officials emphasized at the time that aerosols emitted from e-cigarettes contain nicotine and other toxins that are as harmful as those in secondhand smoke of conventional cigarettes.

Individual businesses and property owners can set their own smoke-free policies, and the health department’s Tobacco Prevention and Education Program offers a sample policy and signage for private businesses that want to prohibit use of electronic smoking devices in their sites.

Health officials worry that widespread use of the devices, including in locations where combustible cigarettes are banned, could undo decades of public health policy that made smoking socially unacceptable in many situations. Unlike tobacco smokers who try to quit by chewing nicotine gum or wearing a nicotine patch, e-cigarette users puff on devices that look like conventional cigarettes and emit aerosol that resembles smoke.

"Because these components resemble smoking so much it changes the social norm about smoking. That’s a real concern. It’s nothing to take lightly," said Lila Johnson, manager of the Tobacco Prevention and Education Program. "We know that smoking is deadly. We shouldn’t be encouraging it in any way, shape or form."