When Tom Lindsey’s foster son’s e-cigarette cartridge accidentally fell to the floor, they both dove for it. Lindsey got to it first, but that didn’t end the scuffle.

“He bites my hand just like Gollum,” Lindsey recalled.

That’s when it became clear to the retired Kauai corrections officer and long-time foster parent that e-cigarettes weren’t just a fad. Lindsey is so concerned about vaping’s ability to quickly hook Hawaii’s youth that he recently traveled to Oahu to attend a state summit on tobacco use prevention.

“I’m a dad — I’m supposed to be a gatekeeper at the house,” he said. “He knows it’s dangerous. I can’t keep him in a bubble.”

Since their entrée into the market about 10 years ago, vaping devices have exploded in popularity among Hawaii youth, particularly on the neighbor islands.

It’s become so prevalent that Hawaii has the highest reported vaping rate among middle schoolers and the second highest vaping rate among high schoolers in the nation, just behind Colorado, according to the most recent 2017 data available from the national Centers for Disease Control and Prevention.

Justin, a 17-year-old high school senior who requested that we only use his first name, began smoking e-cigarettes as a sophomore while attending a private school on Oahu. When he transferred to a public school, he found that many of his new classmates had the same habits.

“You gotta be pretty strong to quit, not gonna lie,” he said. “It’s harder than cigarettes.”

With one in four high schoolers admitting in surveys that they vaped at least once within the past month, Hawaii public health officials and advocates worry the trendy devices have created a new generation addicted to nicotine in Hawaii, a state that had made strides in kicking cigarette smoking habits.

The Trend May Have Roots In Asia

So how did Hawaii become vaping central for teenagers?

The islands got a head start on the trend, even before e-cigarette startup Juul launched in 2015.

“I’m speculating, but part of the reason is Hawaii’s proximity to Asia, because vaping was big in Korea, Japan and China before it came here,” said Pallav Pokhrel, an associate professor and researcher at the University of Hawaii Cancer Center who studies the effects of e-cigarette advertising on the attitudes and behaviors of young adults in Hawaii.

E-cigs proved to be a promising and irresistible new venture for small business owners and entrepreneurs, especially as the economy lagged on neighbor islands, says Kathryn Akioka, a tobacco treatment specialist at the Hamakua-Kohala Health Center on the Big Island.

“When the recession hit, the Big Island was the last to recover,” said Akioka. “You had adults looking for something to be able to go back to work. We saw vape shops pop up all over the place.”

Vape shops quickly expanded from kiosks at the mall to brick-and-mortar locations.

The do-it-yourself nature of mixing the vaping solutions for different devices also made it easy for more folks to open shop, she said. Sometimes they settled near schools, and many offered customized flavors like lilikoi and li hing mui that catered to local kids’ palates.

“That’s what made it easy for our small mom-and-pop stores to start producing their own e-liquids — they could order gallon-sized nicotine on the internet and they’d be mixing it,” said Akioka, who treats patients with respiratory issues.

By 2016, the Aloha State had among the highest number of vape shops per capita, according to a Quartz analysis of data from Yelp and the U.S. Census.

“The availability in combination with high hopes for the product and not knowing what it is I think made everything fall into place for this one particular product,” said Valerie Saiki, a Kauai coordinator for the Hawaii Public Health Institute.

Neighbor Island Effects

Maui, Kauai and Hawaii county teens were soon vaping more than their peers on Oahu.

By 2017, self-reported current use of e-cigarettes among high schoolers reached 35% on the Big Island, 31% on Kauai and 32% on Maui. The national average vaping rate among high schoolers in 2017 was 13%.

Middle schoolers also picked up the trend, particularly on the Big Island and Kauai.

In 2015, 16% of Big Island middle schoolers said they vaped at least once within the past month, and by 2017, that had grown to 23%.

During the same two-year period, the middle school vaping rate rose on Kauai from 13% to 19%. The Oahu rate remained around 15%.

Lindsey’s son was in middle school when he picked up the habit.

“What I hear on Kauai is kids are bored, but there’s so much to do. It’s their perspective,” said Lindsey, who lives on the Anahola Hawaiian Homestead on Kauai.

Since 2016, state law has prohibited anyone under 21 from purchasing e-cigarettes but it hasn’t had much effect.

Lindsey said his foster son, now 14, circumnavigated the law by ordering products online and delivering them to a neighbor’s house. He found out when his credit card company contacted him about possible fraudulent use of his card.

By using online tracking, teens know when to swipe the package before neighbors get home. Then they distribute it at school.

“No other product is as easily available and at a good price,” said Saiki, who conducts educational presentations at schools across Kauai. She’s heard electronic smoking devices, or ESDs, can run for as much as $60 each at school.

“When I talk to students directly in classrooms, they don’t hold back and tell me, ‘Oh yeah, somebody brings to school and they sell it,’” she said.

Lindsey’s foster son had outlined a distribution business plan of sorts in his school composition book. Ultimately, he was suspended from school.

“I don’t know if it’s the novelty of challenging authority or being enterprising,” Lindsey said. “It’s all of those things that we impress on them to be from the get-go in school — math, salesmanship, make money. I think the problem with them is they don’t have the start up (money), so they steal that, and then they’re on their way.”

Elimar Utrera, a senior at Konawaena High School, said he doesn’t vape, but he sees his classmates post on their social media accounts when they want to sell products.

“On my social media accounts, I follow some friends and on their stories, they put that they’re selling their vape machines,” he said. “People buy from other students. It’s very easy for people to get their hands on vaping devices.”

Utrera is a member of the Coalition for Tobacco-Free Hawaii’s state youth council, which he says is planning ways to promote the banning of flavored tobacco products, including e-cigarettes.

Data on Hawaii’s youth vaping rate for 2019 won’t come out until 2020, but nationally, the fraction of high schoolers who have vaped nicotine in the past month roughly doubled from 2017 to 2019.

Personalized Marketing

Pokhrel and his University of Hawaii Cancer Center researcher colleague Thomas Wills study e-cigarette use among adolescents and young adults.

They believe marketing contributed to Hawaii’s high youth vaping rate.

“What we’ve been finding is when you look at advertisements in magazines and newspapers, they’ve been decreasing, but social media-based marketing and informal marketing has been widespread,” Pokhrel said.

“Vaping enthusiasts,” or people who post promotional videos on Instagram and YouTube, are influential trendsetters and local Hawaii vape shops have been particularly active on social media platforms like Instagram and Facebook, according to research from the UH Cancer Center, which receives funding from the state’s tobacco tax revenue.

“E-cigarette marketing basically influences young adults to believe they are less harmful than cigarettes. That’s one conclusion we can draw,” Pokhrel said. “It also appears those exposed to marketing are more likely to initiate e-cigarette use over time.”

Along with ubiquitous online ads, heavy radio advertising by e-cigarette companies on the Big Island may have propelled its vaping rate.

In a 2017 survey of more than 600 high school and middle schoolers across the state, the Hawaii Public Health Institute found that 81% of Big Island teenagers heard e-cigarette advertising on the radio, compared to about 20% of teens who lived in each of the other Hawaii counties.

“We aren’t like Honolulu where there’s a bunch of different radio stations,” said Akioka. “We only have one to two stations that the kids listen to. The up-and-coming new Hawaiian music that younger crowds are listening to — those tend to be the stations they (vaping suppliers) targeted.”

“What was hideous was they’d say, ‘Come in and get your back to school supplies,’” added Sally Ancheta, HIPHI Big Island coordinator. “That was really marketing to parents, and that was one of our first red flags.”

Higher Use Among Native Hawaiians

While there are restrictions on advertising cigarettes, the lack of regulation on how vaping is marketed has also played a role in pushing up Hawaii’s high youth vaping rate, Wills said.

UH Cancer Center research shows Hawaii teens were most frequently exposed to advertising at the point of sale in convenience stores, gas stations, and other retailers. Pokhrel and Wills have also found that minors who were exposed to e-cigarette marketing are more likely to pick up an electronic smoking device later.

Statistics from the Hawaii Department of Health show 37% of Native Hawaiian high schoolers reported ever using e-cigarettes — more than 10 percentage points higher than the state average.

When asked why young Hawaiians might be disproportionately using e-cigarettes more than their peers, Wills conducted a separate analysis of the data for Civil Beat. Upon closer look, he found that Native Hawaiian teens had slightly higher levels of exposure to the advertising than their peers.

It may be that friendships also influence teens, because research from the UH Cancer Center shows Native Hawaiians teens have more friends who vape, says Wills.

“That’s what we see empirically, and that’s the strongest type of exposure that increases the probability of use,” Wills said. “That’s one thing that clearly accounts for the elevation among Native Hawaiians.”

Wills says numerous studies have shown that Native Hawaiian and Pacific Islander youth have disproportionately higher rates of use of some types of substances, and socioeconomic inequities often play a role in the data. Vaping could mirror that trend.

“We looked at the kinds of stresses on teens in Hawaii and the pretty consistent observation is that Native Hawaiian kids report that their families are under more financial stress,” Wills said. “They have stressors but they also have strengths, and the strength is clearly family support.”

Sean Anderson, owner of Black Lava Vape on the Big Island, rejected the idea that marketing has encouraged island teens to pick up vaping.

“Just because a product exists and somebody finds it, that is not marketing,” Anderson said. “There’s not one e-juice manufacturer that advertises specific flavors or products. That just doesn’t happen — it never has. As far as vape shops go, we advertise our brand.”

Advertising aside, when asked if the simple presence of vaping shops online can have an influence on youth, Anderson said it wasn’t a fair question.

“This is still the United States, right?” he asked. “I’ve been open for six years, and Facebook or Instagram and YouTube have never allowed the vape industry to advertise any products on there, ever.”

Vaping Injuries

A growing number of lung injuries potentially related to vaping, including two cases reported in Hawaii, has sparked a national investigation into the products.

No specific ingredient has been identified as the culprit, but the Food and Drug Administration says most samples that have been tested  involved vaping products containing THC. State health officials have advised everyone of all ages to drop their vape pens until it’s sorted out.

Akioka said she has seen patients in Hawaii with something called wet lung.

“It’s like having a chemical injury or burns to the inside of your lungs, and they’re inhaling hot chemicals,” she said, likening it to the effects of mustard gas and its use in World War I. “They’re doing mini-chemical warfare on our kids.”

Unless e-cigarettes companies can demonstrate to the U.S. Food and Drug Administration that vaping is “appropriate for the protection of public health” by May 2020, the products could be pulled from the market.

In response, some states have placed temporary bans on flavored tobacco products. Hawaii lawmakers have considered similar policy moves in the past.

Local vape retailers like Anderson say those policies would hurt their adult customer base who they say effectively use the products to quit traditional cigarettes.

Anderson said he has traveled to Oahu to meet with Hawaii lawmakers to discuss how to get the products out of the hands of minors.

“It sucks,” he said. “I have reached out to the state of Hawaii, the cancer center, to legislators, to try to get together to figure out how to stop teens getting their hands on the products and they don’t want to have anything to do with us.”

Anderson said he’d be in support of a law that requires online shops to have an age verification system. He’d also support getting rid of online sales entirely and increasing a fine for under-age possession of vaping devices.

“Let’s just stop online sales,” he said. “But really the biggest thing, don’t make it a $250 fine, make it a $10,000 fine.”

The U.S. Food and Drug Administration in 2016 extended its regulatory authority to include electronic nicotine delivery systems to its tobacco product purview, but does not regulate or track the ingredients within the products themselves.

Justin, the high school senior, said he gradually increased the amount of nicotine he vaped. When he started vaping “50s” e-liquids, that was when he felt the tug of addiction.

“Sometimes when I’m driving, or sometimes I’m in class or if I’m stressing out about an assignment, I go to the bathroom to vape — I’m not gonna lie,” Justin said. “I use it as a stress reliever. Any time something’s up, I do it.”

While he said he quit earlier this year, he still gets cravings.