E-cigarettes have grabbed headlines lately due to an outbreak of mysterious -- and in some cases fatal -- respiratory illness in people who have used the smokeless devices.

While the recent outbreak has politicians calling for e-cigarette bans, “vaping,” as it’s commonly known, has been a growing area of concern among public health professionals for years. Experts have been particularly concerned as vaping has increased dramatically among young people, putting them at risk of developing severe, potentially lifelong nicotine addictions.

One of those young people is “Daisy,” an Anchorage 16-year-old who has been vaping since she was 14.

“It’s not the best habit I have,” said Daisy, whose name has been changed to protect her privacy. “I’ve been quitting now for about a week.”

It’s not the national news that has her worried, she added -- it’s that this otherwise healthy teen is increasingly finding herself short of breath.

“I’m 16 and I get tired walking up a flight of stairs,” she said.

What is vaping?

E-cigarettes have been commercially available in the U.S. since the early 2000s but exploded in use over the last decade. By 2017, 2.8 percent of U.S. adults were e-cigarette users, according to the Centers for Disease Control and Prevention.

The pocket-sized devices use a tiny, battery-powered heating element to vaporize small amounts of liquid -- generally a mixture of propylene glycol, vegetable glycerin, water and flavoring, and often an ingredient like nicotine or THC. The vapor is absorbed in the lungs, so the active ingredient takes effect rapidly.

Because there’s no combustion and consequently no smoke, e-cigarettes quickly gained popularity as a portable, discreet, better-smelling and tasting alternative to tobacco. They have also been promoted as a less dangerous option for smokers who wanted to quit, including in presentations to schools and Tribes -- a claim that the Food and Drug Administration recently ordered e-cigarette manufacturer Juul to stop making.

New and under-researched

The trouble with vaping may not be what we know so much as what we don’t know.

Mass production of cigarettes led to a boom in popularity in the 20th century, along with a steep increase in the incidence of lung cancer. By the 1950s, researchers were taking a hard look at cigarettes. The U.S. National Library of Medicine’s PubMed.gov website today lists more than 30,000 scholarly articles dating back to 1886 about cigarette smoking alone, and new tobacco research is constantly underway.

Vaping, on the other hand, is a relatively young phenomenon that has been studied for just over a decade.

“With e-cigarettes, they are new, and they are still being researched, so we don’t have all the history,” said Cheley Grigsby, manager of the State of Alaska Tobacco Prevention and Control Program.

Even if e-cigarettes turn out to be a less dangerous alternative to smoking, Grigsby said, that doesn’t mean they’re healthy or risk-free. While research indicates that they may be a better choice for people who want to stop using tobacco, those who don’t smoke are warned not to start vaping.

Even without smoke, nicotine is unhealthy

While e-cigarettes don’t produce the carbon monoxide, hydrogen cyanide and carcinogenic tar that make cigarette smoke so toxic, they often contain tobacco’s addictive ingredient, nicotine. Today’s most popular brands contain nicotine salts, which are more concentrated, more potent, and potentially more addictive than early e-cigarettes. Juul was the first company to develop a vaping liquid containing nicotine salts, which propelled the brand to dominance in the e-cigarette market. One Juul pod contains as much nicotine as an entire pack of cigarettes.

Like vaping, nicotine on its own hasn’t been extensively studied, but it is known to present health risks. It’s incredibly addictive, it’s damaging to developing fetuses, it inhibits wound healing, and there’s evidence that it can be dangerous for people with heart disease. In 2017, UCLA researchers found that nonsmokers who started vaping nicotine showed signs of increased cardiac risk after using just one e-cigarette.

Even as a smoking cessation tool, vaping isn’t a miracle cure. One study found that smokers who replace tobacco with nicotine e-cigarettes were more likely to relapse. Another compared vaping with nicotine replacement therapy, finding that e-cigarette users were more successful at quitting traditional cigarettes but were almost nine times more likely than the nicotine replacement group to still be using their cessation tool a year later.

“Most of those who use e-cigarettes to quit smoking end up going back because they never break the nicotine habit,” Grigsby said.

E-cigarettes aren’t always what they seem

Lack of regulation is one theme that has emerged in the developing national story about vaping-related illnesses.

“It’s harder to regulate how much nicotine is in each one,” Grigsby said. “(Some e-cigarettes) have been marketed as having no nicotine and then when tested they’ve had nicotine in them.”

Even nicotine-free e-cigarettes may present risks. A recent study in the journal Radiology observed a negative impact on blood flow when non-smokers vaped a nicotine-free solution. Salon reported last year that many of the flavors used in “vape juice” have been FDA-approved for consumption in food or drink, but it’s unknown whether they’re safe to inhale. Vaping products have also been found to contain substances like formaldehyde and diacetyl, a chemical that causes a respiratory disease known as “popcorn lung.”

Critics say the FDA was slow to regulate the e-cigarette industry even as it boomed in popularity. Dr. Ned Sharpless, the agency’s acting commissioner, has said e-cigarette oversight is a “top priority.”

“I assure you that we are working as hard and expeditiously as possible to protect the public's health from the harms associated with e-cigarette use,” Sharpless wrote in a recent statement on the FDA website.

Vaping is popular with -- and unhealthy for -- young people

Daisy vaped for the first time at age 14, when a friend offered her a puff of mango-flavored vaping liquid.

“I did it to be cool, but then I actually got myself addicted,” she said.

It took about two weeks of social vaping for Daisy to find herself hooked.

“I knew there was nicotine; I just thought, ‘Oh, I’m not going to get addicted,’” she said. Soon she was vaping two Juul pods a day, getting them from friends’ older brothers and sisters who could buy them legally.

E-cigarette makers deny deliberately marketing to kids. But with a veritable buffet of sweet and fruity flavors, paid promotion by social media influencers, and minimal regulation, vaping quickly caught on among teenagers. Between 2017 and 2018, the number of middle and high school students using e-cigarettes increased more than 70 percent, to 3.6 million. More than two-thirds of them use flavored e-cigarettes, according to the Food and Drug Administration.

Nicotine isn’t healthy at any age, but it’s especially bad before the brain is fully formed, which happens around age 24.

“Nicotine actually kind of rewires it and actually makes (kids) more susceptible to addiction,” Grigsby said. “This is why access is such a big deal. If we can keep people from trying tobacco and nicotine products until they’re older, they’re less likely to become addicted to them.”

According to CDC data, nine out of 10 smokers start using cigarettes by age 18. And kids and teens who vape are three times more likely to become cigarette smokers, say researchers at Dartmouth College’s Geisel School of Medicine.

Daisy said almost everyone in her social group vapes -- and it’s definitely perceived differently than using tobacco.

“If you see somebody vaping on social media or something, it’s cool: ‘That’s a nice vape,’” she said. “But if I see a teenager smoking a cigarette, I’m like, ‘That’s f---ing nasty.’”

By comparison, she said, vaping seems clean and safe. And that’s exactly the problem, according to Grigsby.

“Kids don’t think they’re dangerous,” Grigsby said. “And kids are kids -- they’re invincible, right? They’re trying new things during this age.”

What’s more, many teens don’t even realize they’re inhaling a highly addictive substance.

“There was this myth that youth in particular, high school students, did not think there was nicotine in (e-cigarettes) and there was just water vapor,” Grigsby said. “It’s not water vapor. There are chemicals there. Youth didn’t even know what they were inhaling.” A recent study in the journal Pediatrics found that 40 percent of teens who reported using “nicotine-free” products had, in fact, been consuming nicotine.

In addition to the brain, nicotine can impact lung development in young people -- and it may not be just those who vape who are at risk. One in three teens reported being exposed to secondhand vapor in the last year, according to the Journal of American Medicine.

What’s a parent to do?

First and foremost, Grigsby said: Start a conversation about e-cigarettes, even if you don’t think they’re at risk.

Vaping is low-profile enough that some kids are getting away with doing it in school. Daisy said she used to take her vape to the bathroom during the school day, favoring a mint-flavored Juul pod that wasn’t as easy for teachers to sniff out as the fruity versions favored by some other teen vape users.

“It’s hard to tell when the kids are using them,” Grigsby said. “They look like a USB drive or something that kids would have normally.”

Grigsby said she recommends The Vape Talk, a free resource from the American Lung Association that helps parents educate themselves about vaping and prepare to have “the vape talk” with their kids. The State of Alaska also has its own teen-focused social marketing campaign, Not Buying It, that’s intended to help young people think more critically about the marketing messages around vaping. Teens may not realize they’re not getting the whole story about vaping and how it can harm them, Grigsby said.

What if you find out that your kids are vaping?

When Daisy’s parents found out she was vaping, they hit the ceiling.

“It has gotten me in so much trouble,” she said. That’s another reason she’s trying to quit -- she recently got her driver’s license and she knows her parents will take away her car keys if she keeps vaping. (She also did the math and figured out that with what she’d been spending on vape cartridges, she could have saved up and bought a car of her own instead.)

Daisy said she wished her parents realized that when she vapes, it’s not because she wants to disobey them; it’s because she has become addicted to nicotine. She said she understands their fears, but what she really needs right now is empathy.

“Parents need to understand addiction,” she said. “Be supportive and help educate your kids. Try to be there for them.”

Adults can find free smoking cessation resources through Alaska’s Tobacco Quit Line, online online at AlaskaQuitLine.com or by phone at 1-800-QUIT-NOW. But when it comes to helping kids quit, there are some special considerations. Some common smoking cessation tools aren’t available to kids because their brain development is ongoing. Grigsby urged parents to contact their child’s pediatrician for help coming up with a safe plan to help break the addiction.

For additional resources see www.anthc.org/vaping.

This story was sponsored by Alaska Native Tribal Health Consortium, a statewide nonprofit Tribal health organization designed to meet the unique health needs of more than 175,000 Alaska Native and American Indian people living in Alaska.

This story was produced by the creative services department of the Anchorage Daily News in collaboration with Alaska Native Tribal Health Consortium. The ADN newsroom was not involved in its production.