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 Zacks, a high school senior, doesn't call it that. In fact, she insists she has never even tried an e-cigarette. Like many teenagers, 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, 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, Texas, 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 past 18 months, 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 they had tried e-cigarettes in 2012, double the year before. But the CDC 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 CDC is currently sending out 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 CDC, 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.
In October, Saunders convened a student advisory board to discuss how to approach "e-cigs.""They said: 'What's an e-cig?'" 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 past 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. 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.
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 said 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 Drake senior.
Actually, it is possible for e-cigarettes or e-hookah devices to vary in nicotine content and even to have no nicotine. 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," McDonald said. Otherwise the responses do not reflect reality, "and then you're back to the beginning."
By MATT RICHTEL
The New York Times