Rise of ‘JUULing’ Among Youth Sparks Sharp Response

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August 06, 2018, 05:09 pm Chris Crawford – One particular brand of e-cigarette, known as JUUL, is drawing a lot of heat these days. Extremely popular among adolescents and young adults, the product is the focus of an FDA crackdown, multiple lawsuits and, most recently, an ongoing investigation by one state's attorney general.

According to former assistant surgeon general and family physician Douglas Kamerow, M.D., M.P.H., of Washington, D.C., it is JUUL's popularity among younger users that has driven the product's massive sales, with the device now accounting for almost 70 percent of convenience store e-cigarette business.

"It's shaped like a small, sleek USB drive -- easy to use and easy to conceal," Kamerow told AAFP News. "High-school and even middle-school students love its shape and ease of use and enjoy flavors such as mango, fruit medley and cool cucumber."

Each JUUL starter pack contains four pods of flavored e-juice that are formulated with nicotine salts from natural tobacco leaves instead of the free-base nicotine commonly used by other e-juice manufacturers, says the Public Health Law Center at Mitchell Hamline School of Law.

"Kids like the flavors and trade them back and forth, as the e-juice pods are removable," said Kamerow. "JUUL has higher nicotine concentrate than other e-cigarettes, so it may be more addictive than other e-cigarette products. There are many anecdotes about kids starting JUUL to be cool but ending up needing to use it every day."

The concentration of nicotine in each JUUL pod is about twice that of many other e-juice nicotine concentrations, listed at 5 percent nicotine by weight versus the more common 2.4 percent or less in other e-juices.

To combat the perception that JUUL's higher nicotine concentration is leading to more people becoming addicted to the product compared with its rival e-cigarettes,  JUUL Labs Inc. announced July 12 that it will add an option to buy e-juice pods with a 3 percent nicotine concentration by weight starting in August and becoming widely available in October in the product's mint and Virginia tobacco flavors.

JUUL Labs is also manufacturing reduced-nicotine versions of the product for distribution in the United Kingdom to comply with local regulations, Kamerow said.

What's particularly troubling about nicotine levels in JUULs is a study that found that 63 percent of JUUL users ages 15-24 didn't realize the device contains any nicotine, so they wouldn't be aware that they were inhaling an addictive chemical.

Kamerow pointed out that JUULs don't look like classic "cigalike" e-cigarettes, which are round and resemble traditional combustible cigarettes.

"JUUL is not just an e-cigarette in a different package," he explained. "It contains a different type of nicotine, using nicotine salts, that seems to better approximate the mouth feel of cigarettes than other e-cigarettes."

It should also be noted that products similar to JUUL, such as myblu and KandyPens, have also entered the U.S. market.

Center of Controversy

On April 24, FDA Commissioner Scott Gottlieb, M.D., said in a statement that the agency's Youth Tobacco Prevention Plan launched in July 2017 would expand to include several efforts to stop youth use of tobacco products, focusing particularly on e-cigarettes such as JUUL.

These actions included

• launching a large-scale, undercover crackdown on the sale of JUUL products to minors by both brick-and-mortar and online retailers;
  
• reaching out to eBay to remove listings for JUUL products on its website; and
  
• contacting the product's manufacturer, JUUL Labs Inc., with an official request for information to better understand its marketing efforts; research on the health, toxicological, behavioral or physiologic effects of the product; and how design features, ingredients or specifications appeal to youth.

Following the agency's action, three separate lawsuits -- two filed in  and one in New York -- have claimed the company deceptively marketed the JUUL product as safer than combustible cigarettes and as a viable method to quit smoking. The plaintiffs in these lawsuits contend that "JUULing" has, in fact, proved to be more addictive than using traditional cigarettes and say they're now addicted to the product.

Most recently, Massachusetts Attorney General Maura Healey announced during a July 24 press conference that her office was investigating JUUL Labs Inc. and online e-cigarette retailers that sell JUUL and JUUL-compatible products because of concerns that they are marketing and selling the devices to minors.

What the Research Shows

Kamerow noted that despite anecdotes about e-cigarettes helping users to stop smoking combustible cigarettes, there are no good-quality evidence-based studies showing this to be the case. In fact, some studies have shown that these electronic devices not only do not help users quit using tobacco -- they may actually increase their odds of smoking.

For example, a study published July 9 in the PLOS ONE journal found ENDS users who also smoked cigarettes were no more likely to quit smoking than smokers who don't use ENDS devices.

Similarly, the National Institute on Drug Abuse found 30.7 percent of teen e-cigarette users started smoking traditional cigarettes within six months of use compared to 8.1 percent of nonusers who took up smoking.

On the other hand, said Kamerow, there are plenty of nicotine-replacement therapy products that have better research behind them that family physicians can recommend. These include transdermal nicotine patches, nicotine gum and nicotine lozenges. Non-nicotine cessation options, including prescription drugs such as varenicline tartrate (Chantix) and bupropion hydrochloride (Zyban), are also available.

AAFP Fact Sheets and Other Resources

In addition to easy-to-use fact sheets the AAFP has developed for both physicians and patients, the Academy offers members a comprehensive fact sheet on ENDS, a Tobacco and Nicotine Cessation Toolkit, and its Ask and Act tobacco cessation program resources.

One more way family physicians can combat JUUL and ENDS use, said Kamerow, is by asking adolescent patients -- and/or telling their parents to ask their adolescent children -- whether they "vape" or "JUUL," not just whether they "smoke."

"We need to keep kids from using JUULs and other e-cigarettes, if possible," he urged. "That's why it's so important to educate parents and adolescents about this."

Related AAFP News Coverage
ENDS Not Effective as Tobacco Cessation Method, Says Study
(7/31/2018)

MMWR Report: Fewer Youth Say They Use Tobacco Products
(7/3/2018)

AAFP Voices Support for FDA Tobacco Regulation
Academy Comments on Tobacco Flavors, Cigars, Nicotine in Cigarettes
(6/26/2018)

Study Suggests E-cigarettes Cause More Harm Than Good
Some Adults May Quit Smoking Traditional Cigarettes, But More Teens and Young Adults Will Start
(3/30/2018)

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