The U.S. Department of Health and Human Services has launched a campaign to discourage e-cigarette vaping. While it targeted all e-cigarette vaping, the campaign makes a powerful visual reference to Juul, a device that can be recharged in a computer USB drive and has been reported to be gaining popularity among youth, even though Juul Labs created it for adults who want to stop smoking. The HHS campaign depicts seemingly emotionless teenagers with USB ports where their mouths should be.
The campaign is part of a long, successful history of fear-based campaigns that have effectively “denormalized” smoking. But, in the case of Juul, is it a new public health threat? Or is it a disruptive technology that threatens to make combustible tobacco products, which kill half of all smokers, obsolete? In short, could it help or hurt public health?
Harm reduction or harm extension?
I am a public health scholar who has studied the history, ethics and evidence in scientific and policy debates over the value of e-cigarettes as a harm reduction strategy. Harm reduction is a public health strategy that involves providing individuals with addiction safer but not necessarily safe substitutes. Providing clean needles to injecting drug users to prevent HIV, substituting methadone for heroin, and even offering seat belts are all examples of harm reduction tactics.
Juul entered the market in 2015 without the legacy of having previously manufactured combustible products. Juul Labs CEO describes the company’s mission as “to eliminate cigarettes and help the more than one billion smokers worldwide switch to a better alternative.” The company’s website invites visitors to “Learn about our mission to improve the lives of the world’s one billion adult smokers.”
The device itself is trim and high tech. It looks like a long, elegant thumb drive and easily fits in a user’s hand. It is relatively expensive. The Juul starter kit, which includes the device, charger and four nicotine pods, costs US$49.99 on the company’s website. On May 30, 2018, the company was offering a $20 discount for people who were willing to sign up.
Juul has improved nicotine delivery to users, meaning that they get more nicotine, faster, than they do with other vaping products. Most products on the market use propylene glycol and glycerin as the solvents that allow the delivery of nicotine. Distinguishing Juul is its use of nicotine salts, a combination of a nicotine base combined with a weak organic acid. Nicotine salts allow for absorption of nicotine in a fashion similar to combustible products. A recent study has suggested that the nicotine hit from Juul is also less harsh on the throat, which may produce a more pleasant experience for both seasoned smokers and new users.
Even without an aggressive marketing strategy, sales of Juul kits have increased 680 percent and sales of refills have increased 710 percent since 2017, according to RBC Capital Markets. Juul has quickly taken command of the e-cigarette market. On May 29, 2018, Wells Fargo Equity attributed 45.7 percent of e-cigarette market unit shares to Juul.
Nicotine: Addictive but not carcinogenic
Juul is increasingly viable as a safer alternative for smokers who are trying to quit. But it raises concerns about kids and e-cigarette experimentation.
For adults, nicotine is relatively benign; the tars resulting from tobacco combustion are deadly.
In 2000, the chair of a Public Health Service expert panel made the case that, if necessary, smokers could stay “on (nicotine replacement) medication for the rest of their lives because I know it saves lives.” According to the Royal College of Physicians, nicotine is not a carcinogen.
But nicotine is a stimulant that can increases both heart rate and blood pressure, suggesting that “it may contribute to cardiovascular disease.”
Nonetheless, over the counter nicotine replacement therapies have been established as safe and effective and are not associated with an increase in the risk of heart attacks.
Smoking has been established as a leading cause of cardiovascular disease and cancer. Thus, many in the public health and medical communities were prepared to accept lifelong dependence on nicotine replacement therapies like the patch and nicotine gum if they helped to sustain smoking cessation.
The American Cancer Society issued clinical guidelines acknowledging the potential of e-cigarettes to help smokers who have not been successful with going cold turkey or FDA approved nicotine replacement therapies. It notes that smokers who can’t or won’t quit “should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.”
A different story for teens
Nicotine does, however, pose risks to the developing adolescent brain.
The American Cancer Society states that “the use of products containing nicotine in any form among youth is unsafe and can harm brain development.” Public health experts and organizations supportive of e-cigarettes as a promising harm reduction strategy for smokers and staunch opponents of e-cigarettes agree that kids should not be using any type of product containing nicotine.
For this reason, Juul may represent a new kind of risk when it comes to kids. And because it is small and generates little aerosol, it is easy to conceal and use without attracting attention.
Juul has certainly captured teens’ attention. A Truth Initiative study found that, in a national sample of 1,012 people aged 15-17, 7 percent reported ever having used a Juul. Twenty-one percent of the kids in this age group also recognized a photograph of a Juul. Recognition (34 percent) and past 30-day use (11 percent) were higher among those in the sample who were more affluent. Kids who are just experimenting may not realize that Juul delivers nicotine as efficiently as a combustible product, potentially increasing their risk of addiction.
The backdrop of this growing attention is one in which data on children and vaping remains contested. On the one hand, a landmark 2018 National Academies of Science, Engineering, and Medicine report concluded that “there is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes amongst youth and young adults.”
On the other, several years of painstaking, systematic reviews have led Public Health England to conclude: “Despite some experimentation with these devices among never smokers, e-cigarettes are attracting very few young people who have never smoked in to regular use.” Both groups, it is important to underscore, agree that for adults, e-cigarettes are substantially safer than combustible products.
In May 2018, the former chair of the American Academy of Pediatrics Tobacco Consortium weighed in on the side of peril. Dr. Jonathan Winickoff described Juul in The New Yorker as nothing short of “bioterrorism” and declared that Juul already represents “a massive public-health disaster.”
Iowa Attorney General Tom Miller sees promise in Juul and other products that deliver nicotine electronically. Miller, a longtime consumer advocate, has argued that public health has an obligation to inform the public that e-cigarettes are substantially safer than combustible products. While Miller said that Juul gives “cause for concern” when it comes to kids “it has not reached panic or epidemic stages.”
Meanwhile, the evidence on whether e-cigarettes help smokers quit remains limited and hotly contested. A recent New England Journal of Medicine study has done little to quell controversy. Even as e-cigarettes continue to represent a increasing share of the tobacco market, smoking rates among adults and children continue to decline in both the U.K., where the lead public health agency has explicitly endorsed e-cigarettes, and the U.S.
Tobacco companies making their push
As companies like the Altria Group, which manufacturers Marlboro, and Imperial Tobacco Group, which produces Winston and Kool, are successful at mimicking Juul and “getting into the (nicotine) ‘salt game,’” this will certainly fuel public health concerns that kids or even adults who never smoked will try a product like Juul and eventually graduate to a deadly combustible cigarette. And, indeed, careful monitoring will remain an imperative.
When it comes to kids, even if they do not represent a step on the way to combustible products, any product that delivers nicotine as effectively as cigarettes will remain a public health concern. And all e-cigarettes will continue to demand vigorous public health interventions, such as the April 2018 Food and Drug Administration’s “undercover nationwide blitz to crack down on the sale of e-cigarettes.”
But in my view, neither rigorous monitoring nor muscular efforts to prevent sales to kids make products like Juul as dangerous as cigarettes, which remain the leading cause of preventable death in the U.S. Combustible products are a genuine cause for fear, for both smokers and kids alike.
The most vexing challenge that Juul poses may be to tolerance: How will we view adults looking to quit smoking who either cannot or will not give up the pleasures of nicotine? Will the old consensus that lifelong treatment is acceptable hold when it’s a recreational rather than a pharmaceutical product?