Juul A Public Health Threat?
Introduced in 2015, Juul electronic cigarettes have quickly skyrocketed in popularity among teens and college students across the United States, according to widespread news reports. Educators and students report an alarming level of Juul use in middle and high schools, making this an urgent public health problem.
JUUL Labs produces the JUUL device and JUULpods, which are inserted into the JUUL device. In appearance, the JUUL device looks quite similar to a USB flash drive, and can in fact be charged in the USB port of a computer. According to JUUL Labs, all JUULpods contain flavorings and 0.7mL e-liquid with 5% nicotine by weight, which they claim to be the equivalent amount of nicotine as a pack of cigarettes, or 200 puffs. JUULpods come in five flavors: Cool Mint, Crème Brulee, Fruit Medley, Virginia Tobacco, Mango, as well as three additional limited edition flavors: Cool Cucumber, Classic Tobacco, and Classic Menthol. Other companies manufacture “JUUL-compatible” pods in additional flavors; for example, the website Eonsmoke sells JUUL-compatible pods in Blueberry, Silky Strawberry, Mango, Cool Mint, Watermelon, Tobacco, and Caffé Latte flavors. There are also companies that produce JUUL “wraps” or “skins,” decals that wrap around the JUUL device and allow JUUL users to customize their device with unique colors and patterns (and may be an appealing way for younger users to disguise their device).
According to data from Wells Fargo, JUUL’s popularity has grown dramatically in the last year, with unit sales increasing more than 600 percent in 2017. In mid-2016, dollar sales share for JUUL products was less than 5 percent, the lowest compared to products sold by the main companies in Nielsen-tracked channels. But by the end of 2017, JUUL sales had surpassed all other companies’ products (see adjacent graph). As a result, JUUL is now more popular than the e-cigarette brands manufactured by the major tobacco companies (blu, Vuse, and MarkTen).
More recently, JUUL has updated its marketing code with the purported goal of limiting youth exposure to its advertising. Its current marketing materials focus primarily on its popular flavors and on messaging that encourages smokers to “make the satisfying switch.”
E-cigarettes are a diverse group of products containing a heating element that produces an aerosol from a liquid that users can inhale via a mouthpiece, and include a range of devices such as “cig-a-likes,” vape tank systems, and vape mods. Millions of Americans use e-cigarettes, and e-cigarette use is generally greatest among young adults and decreases with age. Use varies substantially across demographic groups, including age, gender, race, and ethnicity. For example, among youth and adults, use is typically greater among males than females.
Juul sales have grown dramatically and now make up more than half of the e-cigarette market. According to the most recent data from Wells Fargo, JUUL sales currently represent 68 percent of the market share.
Several factors have contributed to Juul’s rising popularity with teens:
- Juul e-cigarettes are sleek, high tech and easy to hide. They look just like USB flash drives and can be charged in the USB port of a computer. They don’t look like a traditional tobacco product. A Juul is small enough to fit in a closed hand;
- Juul comes in sweet flavors that appeal to youth, including mango, fruit medley, crème brulee, cool mint and cool cucumber. Research has shown that flavors play a key role in youth use of tobacco products, including e-cigarettes; and
- Juul appears to deliver nicotine more quickly, more effectively and at higher doses than other e-cigarettes, increasing users’ risk of addiction. The manufacturer claims each Juul cartridge of nicotine liquid (called a “Juul pod”) contains as much nicotine as a pack of cigarettes (about 200 puffs). However, research has found that many Juul users don’t know the product always contains nicotine, and many teens call use of the product “juuling,” indicating they may not realize it is an e-cigarette or tobacco product.
According to the National Youth Tobacco Survey, 11.7 percent of high school students and 3.3 percent of middle school students—over 2.1 million youth—were current e-cigarette users in 2017. However, a study from Truth Initiative found that a quarter of youth and young adult JUUL users don’t refer to JUUL use as “e-cigarette use” or “vaping,” but rather as “JUULing.” Therefore, it is possible that existing surveys may not be capturing the full spectrum of youth e-cigarette use. News articles, letters from school officials, and anecdotal evidence indicate that JUUL has gained popularity among youth and young adults across the country, from middle schools to college campuses. A 2018 study found that nearly one-fifth of youth (ages 12-17) surveyed reported having seen JUUL used in their school.
While smoking cigarettes among high school students has dropped, vaping nicotine continues to increase–in some states more than others. For example, according to the 2017 Healthy Kids Colorado Survey, only 7 percent of high school students currently smoke cigarettes, while 27 percent said they vape nicotine. The statewide school survey shows 87 percent of Colorado high school students think cigarette smoking is risky, but only 50 percent think those risks apply to vaping nicotine.
The availability of flavors may also contribute to JUUL’s popularity among youth. A national survey found that that 81 percent of youth aged 12-17 who had ever used e-cigarettes had used a flavored e-cigarette the first time they tried the product, and that 85.3 percent of current youth e-cigarette users had used a flavored e-cigarette in the past month. Moreover, 81.5 percent of current youth e-cigarette users said they used e-cigarettes “because they come in flavors I like.”
The number of youth using e-cigarettes, including JUUL, is alarming and raises serious concerns that E-cigarettes could be an entryway to nicotine addiction and use of regular cigarettes for some kids. Though there is insufficient research on the long-term effects of using e-cigarettes in general, and certainly not specific to JUUL, the use of such products still raises concerns because they contain nicotine. The company claims that the nicotine in JUUL is from “nicotine salts found in leaf tobacco, rather than freebase nicotine,” which they claim “accommodate cigarette-like strength nicotine levels.” 12 The health impact of that specific form of nicotine is yet unknown.
Juul is putting kids at risk of nicotine addiction and threatens to undermine decades of progress in reducing youth tobacco use:
- A 2016 Surgeon General’s report concluded that youth use of nicotine in any form, including e-cigarettes, is unsafe, can cause addiction and can harm the developing adolescent brain.
- A January 2018 report by the National Academies of Sciences, Engineering and Medicineconcluded, “There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.”
The alarming increase in youth use of Juul requires strong and immediate action by the Food and Drug Administration to protect kids. The FDA is responsible for regulating tobacco products, including e-cigarettes, and the FDA must take action to address the skyrocketing youth use of Juul.
A congressionally mandated report from the National Academies of Sciences, Engineering, and Medicine takes a comprehensive look at evidence on the human health effects of e-cigarettes. Although the research base is limited given the relatively short time e-cigarettes have been used, the committee that conducted the study identified and examined over 800 peer-reviewed scientific studies, reaching dozens of conclusions about a range of health impacts.
Whether e-cigarettes have an overall positive or negative impact on public health is currently unknown, the report says. More and better research on e-cigarettes’ short- and long-term effects on health and on their relationship to conventional smoking is needed to answer that question with clarity.
“E-cigarettes cannot be simply categorized as either beneficial or harmful,” said David Eaton, chair of the committee that wrote the report, and dean and vice provost of the Graduate School of the University of Washington, Seattle. “In some circumstances, such as their use by non-smoking adolescents and young adults, their adverse effects clearly warrant concern. In other cases, such as when adult smokers use them to quit smoking, they offer an opportunity to reduce smoking-related illness.”