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Between 2017 and 2018, e-cigarette use among middle and high school students increased by a shocking 70 percent, representing 1.5 million new smokers, according to data from the National Youth Tobacco Survey conducted by the Centers for Disease Control and Prevention (CDC).

Electronic cigarettes are battery-powered vaporizers that create an aerosol usually containing nicotine, flavorings, and various additives. Experts originally believed that smoking e-cigarettes (or “vaping)” was less harmful than using regular cigarettes. However, a series of recent incidents, in which otherwise healthy young adults developed severe lung ailments, is changing this attitude.

Unlike traditional cigarette use, which has largely been trending down for decades, use of e-cigarettes has grown. From 2012 to 2016, e-cigarette unit sales in the U.S. increased by 132 percent, from 667 units to 1,547 units per 100,000 people. New data suggests that sales of JUUL—a USB-shaped e-cigarette device popular among teens—increased by approximately 600 percent during 2016-2017 and even more through 2018. Cigarette smoking, on the other hand, recently reached its lowest level ever recorded.

The sharp uptick in e-cigarette use among teens is especially troublesome as it has led to a net increase in overall tobacco use despite declining cigarette sales. Between 2017 and 2018, use of tobacco products increased by 38.3 percent among high school students and by 28.6 percent among middle school students, according to the National Youth Tobacco Survey. E-cigarette use among the adult population, on the other hand, remained flat in 2017 at 4.6 percent.

In 2018, e-cigarettes were the most commonly used tobacco product among middle and high school students at 13.5 percent, followed by traditional cigarettes (5.2 percent), cigars (4.9 percent), chewing tobacco (3.0 percent), and hookah (2.8 percent). Among the adult population, regular cigarettes still dominate people’s tastes at 16.1 percent, followed by e-cigarettes (4.6), and smokeless tobacco (4.1 percent), according to data from the Centers for Disease Control and Prevention, BRFSS Survey.

One reason e-cigarettes are gaining ground among young adults is that they are significantly less expensive than traditional cigarettes. Smoking a pack of cigarettes a day comes out to almost $2,300 a year on average, while the figure could be as low as a few hundred dollars with e-cigarettes. The CDC reports that increasing the price of tobacco products is the single most effective way to reduce consumption, especially among young adults who are two to three times more price sensitive to tobacco prices than adults.

Tobacco companies today offer such a wide range of products that appeal to a variety of preferences—a trend that’s a major challenge in slowing the growth of overall tobacco product use. For example, while e-cigarettes are most popular among teens, this analysis finds that among adults, the current use of e-cigarettes is positively correlated with the proportion of whites in a metropolitan area (correlation of 23 percent), while it is actually negatively correlated with the proportion of blacks (-7 percent), who, on average, prefer regular cigarettes (a positive correlation of 17 percent).

The analysis also finds a statistically significant relationship between the usage of electronic cigarettes and depression. This is consistent with CDC data reporting that among adults who report serious psychological distress, more than 40 percent used any tobacco product, compared with less than 20 percent of the population without serious mental distress.

The relationship between tobacco use and mental illness may suggest that those who suffer from psychological ailments are more likely to use e-cigarettes to alleviate stress; worse so, one could postulate that the actual use of e-cigarettes or other tobacco products increases the likelihood of mental health issues. Furthermore, this analysis discovered that smaller metropolitan areas are experiencing higher e-cigarette usage compared to larger ones. Coupled with smaller budgets for awareness campaigns and mental health care, small metropolitan areas might be the most vulnerable to the surge in e-cigarettes.

Given large differences across U.S. metropolitan areas and the skyrocketing e-cigarette usage, researchers at HeyTutor wanted to find areas with the highest e-cigarette smoking rates and identify communities, which could be most vulnerable to lung ailments experienced across the nation. The researchers used data from the Centers for Disease and Control Prevention (SMART Survey), data from the U.S. Census American Community Survey, and the National Youth Tobacco Survey in its analysis. Due to data limitations, the metro-level data shown is for adults only. Here are the metropolitan areas with the highest e-cigarette usage.