Susan C. Walley, Karen M. Wilson, Jonathan P. Winickoff and Judith Groner
Pediatrics June 2019, 143 (6) e20182741; DOI: https://doi.org/10.1542/peds.2018-2741
Electronic cigarettes (e-cigarettes) and vape devices have rapidly become the most common tobacco products used by youth, driven in large part by marketing and advertising by e-cigarette companies. There is substantial evidence that adolescent e-cigarette use leads to use of combustible tobacco products. E-cigarette companies commonly advertise that e-cigarettes contain nicotine, flavoring chemicals, and humectants (propylene glycol and/or vegetable glycerin), but toxicants, ultrafine particles, and carcinogens have also been found in e-cigarette solutions and emissions, many of which are known to cause adverse health effects. Most major e-cigarette brands are owned by big tobacco companies that use similar marketing and advertising strategies to attract youth users as they did with traditional tobacco products. In this review, we provide an overview of e-cigarettes and vape devices with an emphasis on the impact for the pediatric population. We describe the vast array of e-cigarette devices and solutions, concern for nicotine addiction, and the scientific background on the known health harms. There are accompanying visual depictions to assist in identifying these products, including newer e-cigarette products and JUUL. Because current federal regulations are insufficient to protect youth from e-cigarette use, exposure, and nicotine addiction, there are recommendations for pediatricians and pediatric health care providers to counsel and advocate for a tobacco-free lifestyle for patients and families.
About 6.2 million U.S. middle and high school students were current (past 30-day) users of some type of tobacco product in 2019, according to new National Youth Tobacco Survey (NYTS) data released in today’s Morbidity and Mortality Weekly Report.
The survey found that about 1 in 3 high school students (4.7 million) and about 1 in 8 middle school students (1.5 million) are current tobacco users.
For the sixth year in a row, e-cigarettes were the most commonly used tobacco product among high school (27.5%) and middle school students (10.5%). Tobacco products used by middle and high school students were not limited to e-cigarettes, but also included cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco.
“Our Nation’s youth are becoming increasingly exposed to nicotine, a drug that is highly addictive and can harm brain development,” said CDC Director Robert R. Redfield, M.D. “Youth use of any tobacco product, including e-cigarettes, is unsafe. It is incumbent upon public health and healthcare professionals to educate Americans about the risks resulting from this epidemic among our youth.”
Many of these students are also using more than one tobacco product. Among current tobacco product users, about 1 in 3 middle and high school students (2.1 million) used two or more tobacco products. Among youth, symptoms of nicotine dependence are increased in multiple tobacco product users compared with single tobacco product users.
Data on youth tobacco-product use
In collaboration with the U.S. Food and Drug Administration, CDC analyzed data from the 2019 NYTS. NYTS has been conducted periodically during 1999–2009 and annually since 2011. From 1999 through 2018, NYTS had been conducted in middle and high schools via paper and pencil questionnaires. In 2019, NYTS, for the first time, was administered in schools using tablet computers.
Among high schoolers, e-cigarettes were the most commonly used (27.5%) tobacco product, followed by cigars (7.6%), cigarettes (5.8%), smokeless tobacco (4.8%), hookahs (3.4%), and pipe tobacco (1.1%).
Among middle schoolers, e-cigarettes (10.5%) were also the most commonly used tobacco product, followed by cigars (2.3%), cigarettes (2.3%), smokeless tobacco (1.8%), and hookahs (1.6%).
Among middle and high school students overall, the most commonly used tobacco product combination among multiple tobacco product users was e-cigarettes and cigars (17.2%), followed by e-cigarettes and cigarettes (13.3%), and e-cigarettes and smokeless tobacco (9.8%).
In 2019, among middle and high school students, more than half (57.8%) of current tobacco product users reported seriously thinking about quitting all tobacco products. In addition, 57.5% reported they had stopped using all tobacco products for one or more days because they were trying to quit. Increasing successful quit attempts could complement prevention efforts to reduce tobacco product use among youths.
“We are fully committed to preventing children from using harmful tobacco products, including e-cigarettes, and will continue to develop policies that will achieve that objective as soon as possible,” said Admiral Brett Giroir, M.D., HHS assistant secretary for health and acting FDA commissioner. “In addition, we will continue taking other actions to address this shocking epidemic of youth use, including aggressive enforcement and compliance efforts and evidence-based public education – which includes investing in campaigns to educate youth about the many dangers of e-cigarette use including addiction, behavioral disorders, and other health risks.”
Many factors influence youth tobacco product use
Multiple factors influence youth initiation and use of tobacco products. Today’s report assessed several of these factors, including tobacco product advertising and promotions, flavored tobacco products, curiosity, and misperceptions of harm.
Tobacco product advertising and promotions: In 2019, nearly 9 in 10 middle and high school students (22.9 million) reported exposure to tobacco product advertisements or promotions from at least one source.
Flavored tobacco products: Nearly 7 in 10 (4.3 million) middle and high school students who currently use tobacco reported use of flavored tobacco products in 2019.
Curiosity: Among students who reported ever having tried e-cigarettes, the three most common reasons for use were “I was curious about them” (55.3%), “friend or family member used them” (30.8%), and “they are available in flavors, such as mint, candy, fruit, or chocolate” (22.4%). Among students who never used e-cigarettes, 39.1% were curious about using e-cigarettes and 37.0% were curious about smoking cigarettes.
Misperceptions of harm: Among all students, perceiving no harm or little harm from intermittent tobacco product use (use on some days but not every day) was 28.2% for e-cigarettes, 16.4% for hookahs, 11.5% for smokeless tobacco products, and 9.5% for cigarettes.
What more can be done about youth tobacco use?
Comprehensive, sustained, evidence-based tobacco control strategies, combined with FDA regulation of tobacco products, are important for preventing and reducing tobacco product use among U.S. youths.
Given the evolving variety and availability of tobacco products, surveillance for all forms of youth tobacco product use and associated factors is important to inform action at the national, state, and community levels.
CDC works 24/7 protecting America’s health, safety and security. Whether disease start at home or abroad, are curable or preventable, chronic or acute, or from human activity or deliberate attack, CDC responds to America’s most pressing health threats. CDC is headquartered in Atlanta and has experts located throughout the United States and the world.
By the time Juul’s co-creator stood before a tech audience in April 2016, ads for the e-cigarette aimed to distance the product from a toxic past: “Our company has its roots in Silicon Valley, not in fields of tobacco.”
But when James Monsees, a soon-to-be billionaire, projected a 30-year-old tobacco document on the screen behind him, he grinned. It was an internal memo from the research troves of R.J. Reynolds, the maker of Camel cigarettes. It was stamped “SECRET.”
“We also had another leg up,” Monsees said.
A review by the Los Angeles Times of more than 3,000 pages of internal Juul records, obtained by the Food and Drug Administration and released to a researcher through the Freedom of Information Act, found that the concept behind the formula that makes Juul so palatable and addictive dates back more than four decades — to Reynolds’ laboratories.
The key ingredient: nicotine salts.
Juul’s salts contain up to three times the amount of nicotine found in previous e-cigarettes. They use softening chemicals to allow people to take deeper drags without vomiting or burning their throats. And they were developed based on research conducted by the tobacco companies Juul claimed to be leaving behind.
In addition to the internal documents, The Times consulted more than a dozen tobacco researchers, policy experts and historians, and reviewed patent applications and publicly available videos of Juul’s founders discussing their product over the course of a decade. One of those videos has since been removed from YouTube.
Taken together, the evidence depicts a Silicon Valley start-up that purported to “deconstruct” Big Tobacco even as it emulated it, harvesting the industry’s technical savvy to launch a 21st century nicotine arms race.
In multiple conversations with The Times, Juul did not directly address assertions that the company embraced the very industry it sought to dismantle. A spokesperson for Juul acknowledged that the product intentionally “mimicked” the nicotine experience of a traditional cigarette, but explained that the formula was designed that way in order to satisfy the cravings of adult smokers, not children.
“We never designed our product to appeal to youth and do not want any non-nicotine users to try our products,” a spokesperson for Juul said in a statement to The Times. “We are working to urgently address underage use of vapor products, including Juul products, and earn the trust of regulators, policymakers, and other stakeholders.”
After extensive lobbying by the vaping industry and its allies, President Trump this month missed the deadline he set to ban vaping flavors, despite mounting public complaints over their attractiveness to teenagers, and it’s now unclear whether the administration will take any action. On Monday, California Atty. Gen. Xavier Becerra and Los Angeles officials announced a lawsuit against Juul, alleging it engaged in deceptive practices with kid-friendly advertising and a failure to issue health warnings.
But a new generation of nicotine addicts has already been established, and health experts warn that millions of teenagers who currently vape could ultimately turn to other products like cigarettes for their fix.
“Reynolds successfully engineered this formula, but it was Juul that ultimately vaporized it — and achieved what Big Tobacco never could,” said Robert Jackler, a Stanford University researcher focused on teenage e-cigarette use. “They studied Reynolds literature, took advantage of it, and addicted a new generation of American youth.”
Making nicotine more palatable
In February 1973, a researcher at Reynolds saw a conundrum: While cigarettes had wide appeal to adults, they would never become “the ‘in’ products” among youths.
For a teenager, the physical effects of smoking were “actually quite unpleasant,” Claude E. Teague Jr., who is now deceased, wrote in a confidential internal memo.
“Realistically, if our company is to survive and prosper, over the long term, we must get our share of the youth market,” he wrote. “There is certainly nothing immoral or unethical about our company attempting to attract those smokers.”
Reynolds had known for two decades that its product caused cancer. Still, one of the company’s top researchers, Frank G. Colby, pitched a design late in 1973 that would secure “a larger segment of the youth market” by packing “more ‘enjoyment’ or ‘kicks’ (nicotine)” and softening the chemical’s harsh effect on the throats of young smokers.
By boosting nicotine, the addictive chemical, the company could generate faster and more intense addictions among the youngest clients, securing decades of business. But a key challenge was to make nicotine palatable: The chemical had been used as an insecticide since colonial times, and three drops on the tongue could be lethal, according to Robert Proctor, a cigarette historian at Stanford. People couldn’t inhale hefty doses without vomiting.
Reynolds scientists eventually found a solution: Combine the high-pH nicotine with a low-pH acid. The result was a neutralized compound called a salt — nicotine salt.
To perfect the technique, the company enlisted one of its chemists, Thomas Perfetti, a 25-year-old with a newly minted PhD.
Perfetti got to workon a six-month investigation into nicotine salts. According to his laboratory notes, he stirred round-bottom flasks of various acids, then added nicotine, watching as the ingredients condensed into thick yellow oils. All were odorless except one, he wrote, which smelled like “green apples.”
Perfetti synthesized 30 different nicotine salt concoctions, then heated them — like a smoker would — in pursuit of the “maximum release of nicotine.” He also tested the salts’ ability to dissolve into a liquid — a trait that would decades later become central to vaping products like Juul.
On Jan. 18, 1979, Perfetti scribbled his signature on a 17-page final report. The results were stamped “CONFIDENTIAL.” He was soon promoted.
Ten years later, Reynolds was granted a patent for its salts, with Perfetti’s name listed among three inventors. Perfetti would go on to receive a Lifetime Achievement Award from the Tobacco Science Research Conference.
Perfetti, who has since retired from the company, confirmed the details of his research to The Times in a LinkedIn message, but declined to comment further.
Kaelan Hollon, a spokesperson for Reynolds, told The Times that the nicotine salts research was conducted as the company aimed to “reduce the risks” of smoking while “maintaining nicotine delivery.” Although the salts were patented, they were ultimately never used in a traditional Reynolds cigarette, she added.
About the same time, in 1988, Reynolds introduced one of the first-ever aerosol cigarettes: Premier. After five months, it was pulled from the market because of low sales, records show.
“It made me nauseous for the rest of the day,” one tobacco distributor told The Times in 1989, saying he was sending back thousands of dollars’ worth of the aerosol cigarettes to Reynolds.
At the time, the company was facing another obstacle to using its new research: the FDA’s mounting outrage over what health experts called its “deceptive”past. In 1998, Reynolds, along with three other companies, agreed to begin paying billions of dollars to compensate states for having knowingly propelled a smoking epidemic, which by then had led to the deaths of about 20 million Americans. According to Proctor, Reynolds’ Camel cigarettes have killed about 4 million.
Within this climate, the company was unable to combine its two technical triumphs — palatable salts and early vaping equipment.
“Reynolds succeeded in developing the technology, but never really succeeded in turning it into a transformative breakthrough,” said Matthew Myers, the president of the Campaign for Tobacco-Free Kids in Washington, D.C.
“Juul did that.”
‘Addiction is central to the business model’
In June 2005, two product design students at Stanford moseyed in front of a classroom to present their graduate thesis, titled “The Rational Future of Smoking.” It was, in a way, the birth of an industry.
As the lights dimmed, the students, Adam Bowen and Monsees, projected an image onto a screen of a man puffing an early prototype of a vape pen — a precursor to Juul.
A video of the event shows the two students pitching their audience for 17 minutes on a device called Ploom, a vaporizer that would provide “a lot more effective way of releasing nicotine.” They illustrated the stigma of traditional cigarettes — using a South Park cartoon clip that called a smoker “Dirty Lung” and “Tar Breath.” They likened their nicotine pods to sleek Nespresso cartridges that were “a big hit in Europe.”
“We can take tobacco back to being a luxury good — and not so much a sort of drug-delivery device,” said Bowen, who went on to become Juul’s co-founder and chief technology officer.
Monsees said the pair had scrutinized the research behind Reynolds’ failed Premier model before designing their own. He projected a snapshot of chemistry charts from the company’s internal records.
“They’ve realized that they’re killing off their own client base, so they sunk several billion dollars into this already,” Monsees said.
When Bowen clicked to the final slide, a video began to play: A man peering into a video camera lens gave a testimonial, gripping the vaporizer prototype in his hand.
“This product is the greatest thing I have ever encountered in my life,” he said. “I will smoke this with enthusiasm, and develop a nicotine habit that will follow me to my grave.”
The class howled with laughter and broke into applause, launching Monsees and Bowen into a decade of product development. The Ploom device entered the market and would evolve into Pax, and in 2015, Juul.
Monsees would use a TEDx talk in Brussels to explain their effort to “deconstruct” smoking, and early Juul advertisements used a catchy drum beat to assure consumers: “We threw away everything we knew about cigarettes.”
Juul records show the start-up collected research done by tobacco experts about nicotine — work on using salts to control harshness, written by a former top scientist at Reynolds, as well as methods to maximize nicotine delivery, and piles of literature on nicotine’s impact on adolescent brains.
“Certainly, the nicotine salt chemistry was one of the big breakthroughs,” Monsees said onstage at a 2018 tech start-up conference called Disrupt.
Three days before Christmas in 2015, the maker of Juul, Pax Labs, patented its own nicotine salt recipe — making reference to U.S. Patent 4,830,028A, the Reynolds salts from 1989.
On page 15 of the patent, Pax said it had “unexpectedly discovered” the “efficient transfer of nicotine to the lungs of an individual and a rapid rise of nicotine absorption in the [blood] plasma.” The company’s patent used graphics to show that its effects surpassed that of Pall Mall — a popular Reynolds cigarette — as users’ blood nicotine levels spiked dramatically, then fell by almost half within 15 minutes.
The compound would later become trademarked: JUULSALTS™.
“Addiction is central to the business model,” said David Kessler, a pediatrician who headed the FDA from 1990 to 1997, during the agency’s tobacco investigation. “With their nicotine salts, Juul has found the Holy Grail.”
In response, Juul did not directly address that accusation, but said its product offered a “public health and commercial opportunity of historic proportions” for the millions of adult smokers who die each year from cigarettes.
The patent also detailed the role of pH-neutralizing acids in the formula — including at least four of the chemical compounds that Perfetti had created in the Reynolds lab 37 years earlier.
And included in the cache of files that the FDA obtained from Juul was a copy of the confidential Reynolds nicotine salts investigation.
Monsees and Bowen did not respond to multiple requests for comment.
A Juul spokesperson said: “RJ Reynolds’ old work in the field of traditional burn cigarettes was widely known,” noting that Juul followed routine disclosure procedures, such as citing Reynolds’ patents and publications, as required by the U.S. Patent Office.
The spokesperson also said that research shows that nicotine is absorbed more slowly from Juul pods than from traditional cigarettes.
Before Juul, most vaping fluids contained 1% to 3% nicotine, the latter described as “super high” and intended for two-packs-a-day smokers, according to Jackler, the Stanford researcher. Juul offers pods that contain 5% nicotine, according to the company’s website.
Juul disputed Jackler’s characterization, saying that there were higher nicotine concentrations in other brands, and said assertions that Juul’s pods had two to three times the nicotine strength of a cigarette were “false.”
From 2016 to 2017, Juul’s sales skyrocketed by more than 640%. Its cartridges were so palatable that teenagers sometimes raced one another to finish inhaling them. Many said they didn’t know the pods contained nicotine. Each 5% cartridge contained the nicotine equivalent of about 20 cigarettes.
“Juul mimics the evil genius of the cigarette — but does it even better,” said Myers, the president of Tobacco-Free Kids. “They also pulled it off without any of the historical baggage, giving the deceptive illusion that it was safe.”
Anne Schuchat, the principal deputy director of the federal Centers for Disease Control and Prevention, told Congress during a hearing in September that doctors believe nicotine salts allow the addictive chemical to “cross the blood-brain barrier and lead to potentially more effect on the developing brain in adolescents.”
In a statement to The Times, Schuchat echoed her concern and said the salts “allow particularly high levels of nicotine to be inhaled more easily and with less irritation” than ingredients in previous e-cigarettes, and could enable nicotine dependence among youth.
On April 24, 2018, the FDA ordered Juul to submit documents related to its product design and marketing practices following reports of rampant use among youths who may not have understood Juul’s debilitating effects on the brain.
Later that year, FDA agents arrived at Juul’s headquarters and seized additional records. The FDA has released less than 10% of the requested documents, including Perfetti’s laboratory records, to a researcher at UC San Francisco. The agency said it withheld the remaining files to protect trade secrets and other material. As such, the records provide only a glimpse into the chemical research that Juul kept on hand as the company designed its product.
Today, Juul comprises about two-thirds of the vaping market.
In 2018, the largest tobacco company in the U.S., Altria — the parent company of Philip Morris USA, which makes Marlboro cigarettes — purchased a 35% stake in Juul.
After the purchase, several of the tobacco company’s employees also started working at Juul: Altria’s former head of regulatory affairs, Joe Murillo, as well as senior scientists and sales managers.
In September, Altria’s former chief growth officer, K.C. Crosthwaite, became Juul’s CEO.
Juul executives knew young people were flocking to its breakthrough e-cigarette shortly after it went on sale in 2015, a former manager tells Reuters. Its nicotine blend was so potent, engineers devised a kill switch to limit the dosage – but the idea was shelved.
The San Francisco startup that invented the groundbreaking Juul e-cigarette had a central goal during its development: captivating users with the first hit.
The company had concluded that consumers had largely rejected earlier e-cigarettes, former employees told Reuters, because the devices either failed to deliver enough nicotine or delivered it with a harsh taste. Developers of the Juul tackled both problems with a strategy they found scouring old tobacco-company research and patents: adding organic acids to nicotine, which allowed for a unique combination of smooth taste and a potent dose.
Employees tested new liquid-nicotine formulations on themselves or on strangers taking smoke breaks on the street. Sometimes, the mix packed too much punch – enough nicotine to make some testers’ hands shake or send them to the bathroom to vomit, a former company manager told Reuters.
In the end, it worked. The formula delivered nicotine to the bloodstream so efficiently, in fact, that the company’s engineers explored features to stop users from ingesting too much of the drug, too quickly. Juul’s founders applied for a patent in 2014 that described methods for alerting the user or disabling the device when the dose of a drug such as nicotine exceeds a certain threshold.
One idea was to shut down the device for a half-hour or more after a certain number of puffs, said Chenyue Xing, a former Juul scientist who helped patent its liquid-nicotine formula. The concern stemmed in part from the fact that a Juul – unlike a cigarette – never burns out, Xing said in an interview.
“You hope that they get what they want, and they stop,” she said. “We didn’t want to introduce a new product with a stronger addictive power.”
The company never produced an e-cigarette that limited nicotine intake. Xing was not directly involved in the engineering of the device and said she didn’t know why the firm did not adopt a dosage-control feature.
Juul Labs Inc is now the central player in a broader controversy sweeping the United States over the safety of its products along with those of a wave of high-nicotine imitators. The rise of Juul sales tracks closely with an epidemic of teenage nicotine use that has brought a hail of criticism and regulatory scrutiny on the company.
Congressional investigators, state attorneys general and health advocates have so far focused on whether Juul targeted young people through its marketing and the dessert-like flavors of some Juul nicotine liquids, such as creme brulee or mango. But a Reuters investigation has found that, from the company’s earliest days, insiders discussed and debated concerns over more fundamental attributes of the product: its potency and addictiveness.
The breakthrough “nicotine salts” formula that made the Juul e-cigarette so addictive – and ignited the company’s explosive market-share growth – made Juul especially attractive to teenagers and other new users who otherwise would never have smoked cigarettes, according to interviews with more than a dozen tobacco researchers, pediatricians, and a Reuters review of Juul patents and independent research on nicotine chemistry. The device delivers the drug more efficiently than a cigarette, according to emerging academic research into Juul’s formula and the company’s own patent documents.
In written answers to questions from Reuters, Juul said that it never intended to attract underage customers. The company acknowledged it needed to “earn back the trust of regulators, policymakers, key stakeholders and society at large” in light of a surge in youth vaping to “unacceptable” levels.
Juul declined to comment on why it never installed the features it considered to limit nicotine intake. It said it designed its products to mimic the experience of cigarettes because that was key to getting smokers to buy them. Citing studies it commissioned, the company said Juul users have far more success in quitting smoking than those who tried earlier e-cigarettes.
The firm seldom mentioned nicotine in early consumer marketing, which featured young, hip models and sold the product as a stylish alternative to cigarettes. But the company’s sales force – tasked with convincing reluctant retailers to give Juul shelf space – emphasized the device’s unique addictive power by showing store owners charts depicting how the Juul device delivers nicotine to the bloodstream as efficiently as a traditional cigarette, said Vincent Latronica, who headed sales and distribution for the company on the U.S. East Coast from 2014 until early 2016. That argument became a central selling point, Latronica said, allowing the young company to overcome retailer skepticism of early e-cigarettes and to break into sales channels long dominated by tobacco companies.
“Everyone wanted it,” Latronica said.
Juul did not answer questions from Reuters on why the company emphasized the addictive qualities of its product to retailers and downplayed them in advertisements to customers.
Flavors drive e-cigarette use among high schoolers
High school students like fruit, mint and candy flavors of e-cigarette nicotine liquids far more than tobacco flavors, survey data shows. Regulators have pressured Juul and other vaping device makers to stop offering flavors that appeal to children.
Inside the company, the first signs that Juul had a strong appeal to young people came almost immediately after the sleek device went on sale in 2015, according to the former company manager, who spoke on condition of anonymity. Employees started fielding calls from teenagers asking where they could buy more Juuls, along with the cartridge-like disposable “pods” that contain the liquid nicotine.
The calls and other early signs of teenage use kicked off an internal debate, the manager said in an interview. Some company leaders, including founder James Monsees, argued for immediate action to curb youth sales. Monsees served as chief executive and a company director at the time. The counter-argument came from other company directors, including healthcare entrepreneur Hoyoung Huh and other early investors, the former manager said. They argued the company couldn’t be blamed for youth nicotine addiction because it did not intentionally advertise or sell to teens, said the manager, who had direct knowledge of the internal discussions.
“Clearly, people internally had an issue with it,” the manager said, referring to sales of Juuls to teenagers. “But a lot of people had no problem with 500 percent year-over-year growth.”
Company leaders also clearly understood the long-term benefit of young users on its bottom line, the manager said. It was well-known that young customers were “the most profitable segment in the history of the tobacco industry” because research shows that nicotine users who start as teenagers are the most likely to become lifelong addicts.
In its written answers to Reuters, Juul said that Monsees “did not recall” the internal debate in 2015 over whether to take action to stop youth sales. Huh and other board members who served at the time of the company’s product launch did not respond to requests for comment. Board member Harold Handelsman declined to comment, citing pending lawsuits against the company.
Juul declined to make Monsees or company co-founder Adam Bowen available for interviews.
Following the product’s launch, it took nearly three years – and pressure from regulators and U.S. senators – before Juul in April 2018 announced what it called a “comprehensive strategy” of measures to curb youth sales. By that time, a leading U.S. government youth tobacco survey showed that more than 3 million U.S. high school students – one in five – had tried an e-cigarette in the prior month. More than a quarter of those vaped at least 20 days a month. The latest available data from the same survey, in September 2019, shows yet another increase: More than one in four high schoolers – 27.5% – reported using e-cigarettes in the previous month.
The measures to prevent youth sales and use came two days after the U.S. Food and Drug Administration (FDA) announced a nationwide crackdown on underage sales of Juul products. The company committed $30 million for youth prevention efforts, including distributing educational materials to retailers and conducting research into technologies to prevent youth sales.
Asked why the company did not act sooner, Juul noted two measures to curb youth sales that it took half a year earlier, in August and September of 2017: raising the minimum age for online purchases through Juul’s website to 21 even though some states allow retail sales to anyone over 18, and starting a “retail monitoring program.” The company repeated that it now needs to earn back the public’s trust and said the firm “reacted to the information that it had, and increased its youth prevention measures as more data came out over the years.”
The former manager’s account of the early debate over young users contradicts repeated statements from executives that the firm was caught off-guard by teenage addiction beginning last year – “completely surprised,” as Chief Administrative Officer Ashley Gould put it in a CNN interview.
That narrative is further undermined by two prominent tobacco researchers who told Reuters that they explicitly warned Juul’s founders and a top company scientist about the potential for youth e-cigarette abuse. Neal Benowitz at University of California-San Francisco, said he told Gal Cohen, the company’s director of scientific affairs, that widespread teen use could wreck the company’s business.
“Look, the one thing you have to do is make sure that this doesn’t get into the hands of young people,” Benowitz recalled telling Cohen about a year after the product launch. “If it spreads among kids, this product could be dead.”
Juul declined to comment on whether tobacco researchers warned company leaders about youth e-cigarette addiction. Cohen and Gould did not respond to requests for comment.
This inside account of Juul’s early inaction on youth addiction comes as the company faces mounting pressure from regulators. CEO Kevin Burns departed in September after a dizzying series of bad headlines for Juul and the industry: an outbreak of mysterious lung illnesses tied to vaping; an FDA warning about the company’s unauthorized health claims; and a proposed Trump administration ban on all e-cigarette flavors except those mimicking natural tobacco. Juul last month voluntarily halted online sales of flavors such as mango and fruit in the United States after earlier pulling them from retail stores. The company still sells the controversial flavors in many other markets globally.
The firestorm around Juul also led to the abandonment of merger talks between Philip Morris International Inc and Altria Group Inc, which has a 35% stake in Juul after a $12.8 billion investment last year. Altria last week had to write down that investment by $4.5 billion, citing the regulatory risks.
Altria declined to comment for this story, noting that it purchased its stake about a year ago, well after Juul developed its products.
Several state attorneys general and a U.S. congressional oversight committee are also investigating whether Juul marketed its products to underage users. Monsees and other company leaders have said they regret some of the company’s early marketing but maintain it targeted customers in their mid-20s to early 30s.
As youth e-cigarette use continues to rise – after a long decline in teenage cigarette smoking – doctors, scientists and researchers are grappling with how to treat nicotine addiction among teenagers. Emerging research suggests serious risks to the developing adolescent brain.
The combination of a “very, very addictive” product and a developing brain has dangerous implications, said Bonnie Halpern-Felsher, a professor of pediatrics at Stanford University’s medical school. “Rather than your brain getting pleasure from exercising or relationships, your brain becomes rewired to get pleasure from nicotine,” she said.
Juul did not comment on the research into how e-cigarettes harm teenagers. It said it has launched a “robust scientific program to assess the harm-reduction potential of Juul products, including their impact on the individual user” as part of a larger effort to comply with FDA regulations.
For William Smith, a high school senior in Newburyport, Mass., Juul became an obsession that occupied most of his waking hours, leading to near-failing grades and wild mood swings. He first tried it in the summer of 2017 while playing video games at a friend’s house and soon couldn’t shake the craving. A year later, he was vaping a pod or more every day – an amount of nicotine equivalent to a pack of 20 cigarettes.
“It honestly controlled me,” Smith said. “It’s almost like I was going insane.”
Tapping cigarette industry research
One late night in 2004, company founders Monsees and Bowen were brainstorming for their master’s thesis in product design at Stanford University. They went to smoke cigarettes outside the design school studio, as they often did, and started questioning how such a successful yet low-tech consumer product – a burning stick of plant material – could have changed so little over time, according to the origin story the founders have told in speeches, interviews and promotional videos.
Almost daily, educators across the country tell me that at least half of their students use e-cigarettes, mainly the Juul brand. Many of these young people show clear signs of addiction. They are agitated, emotional and unable to sit through an entire class period. They often need to leave class to “take a puff.”
National data about the pervasiveness of e-cigarettes show that it increased nearly 80% among high school students from 2017 to 2018. One in 5 report currently vaping.
But the vaping habit can start even earlier. Use among middle school students increased by almost 50% over the same time period, with 1 in 20 students reporting they had recently vaped.
Given that Juul Labs control about 70% of the e-cigarette market, allow me to borrow slang popular with teens and call this youth crisis what it is: A Juuling epidemic.
Vaping proponents would have you believe that e-cigarette use among youth is responsible for fewer of them smoking traditional cigarettes. This is simply not the case.
Statistics show significant declines in conventional cigarette use among youth from 1996 to 2016. But e-cigarettes weren’t sold in the U.S. until 2007, and Juul entered the U.S. market in 2015 as part of another company before becoming independent in 2017. The dramatic increase in youth vaping began that same year.
The e-cigarette industry has created this vaping epidemic among the young. It actively markets dangerous nicotine delivery devices to adolescents while trying to confuse the reality surrounding the use of these nicotine products.
The increase in e-cigarette use among young people has also been largely attributed to the youth-oriented flavors, misperceptions about nicotine levels and risk, and the patented and unique salt-based nicotine.
E-cigarettes are the entry point for adolescent tobacco use. The overwhelming majority of youth who use e-cigarettes have never smoked conventional cigarettes or used other forms of tobacco. As their need for nicotine increases, they are likely to incorporate conventional cigarettes into their routine.
Nicotine is highly addictive. Each Juul pod, which contains the nicotine liquid that is aerosolized and inhaled, has the same amount of nicotine as is found in one to two packs of cigarettes. And the changes occurring in the still-developing brains of youth make them especially susceptible to addiction.
Research also shows that the chemicals found in e-cigarettes and the flavors used in them are harmful and can result in heart and lung disease and be poisonous, among other health consequences. The products are so new the long-term consequences are unknown, a fact the CEO of Juul labs has admitted.
Vaping proponents also argue that the flavors in e-cigarettes play a role in helping adults switch from traditional cigarettes to e-cigarettes. However, studies have repeatedly shown that young people use e-cigarettes because of the flavors. If flavors didn’t exist, they say they wouldn’t vape.
Many of the more than 15,000 unique e-cigarette flavors have silly names, such as Honey Doo Doo, Booger Sugar and Barney Pebbles. Names that aren’t exactly aimed at an adult audience. Kids are also attracted to the mint and menthol flavors, long thought to be the purview of adults.
Cities and localities in California and at least five other states have restricted the sale of flavored tobacco products. In addition, the Food and Drug Administration and states including California and Hawaii have proposed statewide regulation to eliminate the sale of flavored cigars and flavored tobacco used in e-cigarettes and for hookah smoking. Unfortunately, mint and menthol are often exempted from these policies.
Juul continues to argue that its products are aimed at helping adults quit smoking. If executives at Juul, or any other e-cigarette company, truly viewed their products as “tobacco cessation aids,” they would try to help the user withdraw from nicotine by offering pods with increasingly lower nicotine levels, which could help them taper off use. No such products are offered. They also would apply to the FDA to obtain authorization to sell their products as a cessation device, rather than as a tobacco product. No such action has occurred.
Juul also claims that it is not targeting youth, but its actions say otherwise. During last month’s congressional hearings on Juul’s role in the youth vaping and nicotine epidemic, the company’s “prevention and education efforts” were shown to be an attempt to mislead and encourage youth to use its products.
Another concern is Juul’s recent hiring of Dr. Mark Rubinstein, an adolescent-medicine physician and prominent nicotine researcher I trained in tobacco control research. Rubinstein is known for his work on the dangers nicotine poses to the adolescent brain. Juul publicly says it hired Rubinstein to enhance its youth-vaping prevention efforts.
But given Juul’s history of deceptive marketing practices and educational efforts that promote rather than deter use, many in the research community are skeptical. Rubinstein, a specialist on the effects of nicotine in adolescents, is now working in an industry he recently took to task. His joining Juul is very surprising, disappointing and troubling.
E-cigarette companies seem to be following in the dishonest path of traditional cigarette companies by employing marketing that doesn’t accurately reflect the harm vaping can do. (Just last week, the FDA announced it was investigating 127 reports of seizures or other neurological symptoms possibly related to using e-cigarettes.)
The youth e-cigarette movement needs to be stopped. Doing so will require a complicated multistep process that should start with the FDA, states and local agencies enforcing strict policies that cut back on nicotine levels allowed in vaping pods, eliminate the sale of all e-cigarette flavors and ban marketing to youth.
Bonnie Halpern-Felsher is a professor of pediatrics at Stanford University and founder and executive director of the Tobacco Prevention Toolkit, an online curriculum that educates youth about tobacco products.