Probably the most urgent, and confusing, issue in the world of smoking prevention is the rising popularity of e-cigarettes. So much is unknown about the health risks, and that is worrisome to many health professionals, including those at the Centers for Disease Control and Prevention (CDC).

Part of the problem is the sheer number of different Electronic Nicotine Delivery Systems, collectively known as ENDS. They include at least 450 different brands of e-cigarettes, e-cigars, e-pipes, hookah pens, e-hookahs, and vape pens. The FDA defines ENDS as devices that allow users to inhale an aerosol (vapor) containing nicotine or other substances. Unlike traditional cigarettes, they are generally battery-operated and use a heating element to heat e-liquid from a refillable cartridge, releasing a chemical-filled aerosol.

According to the CDC, the use of e-cigarettes is skyrocketing, from less than 10% of current cigarette smokers in 2010, to more than 36% in 2013, and from 2.5% to 9.6% of former smokers. At the same time many countries such as Brazil, Singapore, Uruguay, and Norway have banned e-cigarettes, the United States has become the largest market, taking in almost 50% of sales worldwide.

Although there is evidence suggesting that electronic cigarettes may help to reduce the number of cigarettes smoked, no study has compared their efficacy to proven cessation therapies. In fact, according to the CDC, in 2013 76.8% of current e-cigarette users were also current cigarette smokers (i.e., dual users). And while e-cigarettes may be less harmful than regular cigarettes, that doesn’t make them safe. Many e-cigarettes deliver contaminants with known potential risks, including tobacco-specific nitrosamines, metals, formaldehyde, and aerosol particles large enough to penetrate into the lung.

While nicotine has adverse effects on health throughout a person’s life, adolescents have an increased risk because their brains are still developing and they are particularly sensitive to nicotine. According to a study presented in 2015 at the Society for Research on Nicotine and Tobacco among 2,100 11-12th graders, the 698 students who had used e-cigarettes had a 2-fold increased risk for bronchitic symptoms. The higher the frequency, the greater their risk.

A recent survey supported by the FDA and the Centers for Disease Control and Prevention shows current e-cigarette use among high school students has risen from 1.5 percent in 2011 to 16 percent in 2015, a more than 900 percent increase. Even more alarming, in 2011 less than 5% of high school students and less than 2% of middle schoolers had ever smoked an e-cigarette. Three years later those percentages had jumped to more than 27% and 10%, respectively.

More alarming, more than a quarter of a million middle and high school students who had never smoked regular cigarettes had smoked e-cigarettes, three times as many as 2011.

Prior to being prohibited in 1998, for decades, tobacco companies used sponsorships of sporting, entertainment and music events to promote cigarettes to huge audiences, including children. E-cigarette companies are now copying big tobacco’s playbook, with celebrity spokespeople that mimic the cigarette ads of old, complete with catchy slogans and celebrity endorsers. Even the generic nickname, “e-cig,” to say nothing of brand names like VaporFi, Halo Cigs, and South Beach Smoke, to name just a few, are made to sound cool to teenagers.

According to Dr. John Wiesman, Secretary of the Washington State Department of Health, for adults who already smoke, switching to e-cigarettes is probably less harmful than continuing to smoke, but they have to quit smoking cigarettes completely for that to be true. For young people, however, Dr. Wiesman plainly believes that “e-cigarette use is unsafe for their health and should not be done at all.”

Matthew L. Myers, President of the Campaign for Tobacco-Free Kids, is concerned that the progress made to prevent teenagers from smoking will be negated by the rising popularity of e-cigarettes. He notes that there has been substantial progress in reducing initiation and use of cigarettes by young people, mainly because smoking is finally no longer considered cool, chic or sexy. But the manufacturers are trying to change that.

It wasn’t until May of this year that the FDA finalized a rule extending its authority to all tobacco products, including e-cigarettes and hookah tobacco. In making the announcement, Sylvia Burwell, the U.S. Secretary of Health and Human Services, noted that cigarette smoking among those under 18 had fallen, but use of other nicotine products, including e-cigarettes, had taken a drastic leap and created a new generation of Americans who are at risk of addiction.

The new federal rule prohibits e-cigarettes, hookah tobacco or cigars from being sold to people under age 18, and completely prohibits them from being sold in almost all vending machines. It also outlaws the distribution of free samples. The FDA did not, however, restrict advertising, which means that TV commercials, radio spots, print ads, billboards, and sponsorship campaigns will continue.

Adding to the appeal of e-cigarettes, particularly among young people are the many different flavors that are sold and advertised. A 2009 federal law banned fruit- and candy-flavored cigarettes, but e-cigarettes are exempt, despite the fact that attorney generals from over two dozen states advised the FDA to ban flavors altogether.

Among U.S. middle and high school students who currently use e-cigarettes, 63% have used flavored e-cigarettes. That translates into 1.58 million U.S. young people under the age of 18. Additionally, a joint study by the FDA and the National Institutes of Health shows that in 2013-2014, nearly 80 percent of current youth tobacco users reported using a flavored tobacco product in the past 30 days – with the availability of appealing flavors consistently cited as a reason for use.

Flavorings used in electronic cigarettes are “generally recognized as safe” (GRAS) by the U.S. Food and Drug Administration (FDA) for ingestion, but have not been adequately tested for inhalation, although flavoring is linked to permanent scarring of the airways in the lungs

In conclusion, the CDC acknowledges that because very few clinical trials have been conducted to date, it is difficult to know the impact of current use of e-cigarettes, particularly among young people. That in itself is concerning.