Quitting Juul may be harder than quitting cigarettes

As the outbreak of vaping-related respiratory illness keeps growing — with the death toll now at 26 — health officials are advising everyone to avoid vaping products (particularly those containing THC).

The outbreak, which to date involves mainly people under the age of 35 , has been a wake-up call about the risks of vaping, both acute and long-term — particularly for habitual users.

It’s also revealed another unsettling problem: We have no clear evidence on how to help young people quit.

“We don’t have any literature,” Suchitra Krishnan-Sarin, a Yale professor of psychiatry who studies adolescent tobacco use, told Vox. “There are no published [studies] on vaping cessation in youth.”

Yet young people are far and away the heaviest users of nicotine e-cigarettes. And the trend belies a tragic irony: E-cigarettes were initially marketed as a way to help adult smokers quit. It’s not clear how many youths are actually addicted to their devices — but stories and Reddit communities suggest it’s a problem.

So what can teens, and parents who want to help them, do in the absence of evidence?

There’s a robust literature on what works — and what doesn’t — to help youth get off cigarettes. Krishnan-Sarin says for now, she and other tobacco and addiction experts are extrapolating from that research to help patients who want to quit vaping. But there’s a twist: The experience of quitting nicotine vaping may actually turn out to be quite different from stopping smoking. Quitting vaping may actually be harder.

Why quitting vaping may be more difficult than ditching cigarettes

There’s a pretty strong case that vaping is a different beast from quitting smoking — that it may actually be harder to stop vaping. “There are unique aspects of e-cigarette devices, particularly ones like Juul, that may facilitate addiction,” said Rachel Grana Mayne, the program director in the Tobacco Control and Research Branch at the National Institutes of Health. “Many of these devices contain high concentrations of nicotine and are smoother to inhale.”

Each Juul pod, for example, carries 59 milligrams of nicotine per milliliter of liquid. Juul Labs — maker of the bestselling cigarette on the US market — claims one pod is equal to a pack of cigarettes in terms of nicotine. Considering you can get through a pod in less than a few hours of chronic use, that’s a lot of nicotine.

The nicotine in these products also goes down more smoothly than regular cigarettes. The reason: Juul vaporizes a liquid that contains nicotine salts. Unlike the nicotine in regular cigarettes, which can be irritating to the throat and lungs, nicotine salt doesn’t cause those unpleasant feelings. “This innovation in nicotine chemistry may be critical with regard to the addictiveness” of e-cigarette pods like Juul, according to a perspective piece in the New England Journal of Medicine.

There are other features of vaping that could make it more difficult to quit. The vapor doesn’t have the nasty smell of cigarettes and can instead emit a subtle scent of fruit or other flavors when users vape — or no odor at all. “Vaping doesn’t have the negative effects cigarettes have,” said Megan Jacobs, a managing director at the nonprofit public health organization Truth Initiative. “Those reminders every time you [smoke] that aren’t there for vaping.”

It’s also much easier to vape in public than it is to smoke. “Over the years, we put effort into making sure smoking is taboo, and many kids are not used being exposed to smoking cues on a daily basis,” Krishnan-Sarin said. With e-cigarettes, “[You’re] exposed to vaping cues every day. I think it’s going to be more difficult [to quit] — we need to understand the cues.”

Still, Grana Mayne warned, “We don’t have data yet that allows us to directly compare the experience of addiction to e-cigarettes to other vapes or cigarettes and tobacco products.” Yet, there’s good reason to believe it may turn out to be more challenging.

The best advice on how to quit now

So what to do if you want to stop vaping? Again, the best quitting e-cigarette advice comes from hundreds of randomized trials over the past several decades on stopping smoking. And it’s centered on three core components:

1) Changing your behaviors — Overcoming the habits associated with using nicotine-based products, which means finding new ways to cope with stress, deal with cravings, and reduce your exposure to vaping. “It also means understanding and recognizing what triggers you to want to use the products and coming up with a plan to have an alternative to vaping in place,” said Jacobs. These should be activities that are in no way associated with vaping, such as participating in sports teams or spending time around people who don’t vape.

2) Getting social support in place — Surround yourself with people who are supportive of the quitting process. The experts advised telling everybody in your life that you’ve decided to stop vaping, and asking those who use e-cigarettes not to vape around you. “Having a nice support system that knows they’ll be going through this and makes sure people don’t enable them to go back to nicotine use [is important],” said Steven Sussman, a University of Southern California preventive medicine professor focused on tobacco.

3) Nicotine-replacement therapy — Think nicotine patches, gums, nasal sprays, or lozenges. They’ve been shown to help increase the chances of quitting nicotine by reducing cravings and helping people overcome the physiological effects of addiction. But they’re only approved for people over the age of 18, and, Sussman cautioned, there’s no good research suggesting they work in young people. “[Researchers have] done 14 trials with nicotine-containing products,” Sussman explained. “The overwhelming evidence right now is that pharmacological adjuncts don’t work with teens.” Still, doctors may sometimes prescribe them for people who are younger and suffering nicotine withdrawal symptoms anyway.

Step one, though, is setting a quit date and sticking with it. In the lead-up to that day, get rid of anything that reminds you of vaping, including all vaping products.

Truth Initiative

You might also try a text-based tool if you think that might help, such as the This Is Quitting app from the Truth Initiative. The program focuses on social support and skill-building to help people stop vaping by sending users daily texts tailored to their age and the product they’re trying to ditch.

According to Jacobs, 54,000 young people have signed up since it launched nationally in January. (To access the program, youth and young adults can text “DITCHJUUL” to 88709 on the cell phones. Parents looking to help young people quit and adult vapers trying to quit can text “QUIT” to (202) 899-7550.) Smokefree.gov and the National Cancer Institute also have teen sections focused on helping young people stop vaping.

What concerned parents shouldn’t do

Finally, the tobacco experts had a couple of words of advice for parents concerned about their kids: Don’t fear-monger.

“Fear-mongering never works with kids,” said Krishnan-Sarin. That means no exaggerating about what we know about the health effects of vaping. Instead, she advised, “Take the approach of helping them understand these are products, which contain chemicals — chemicals that could be having an influence on their physiology.”

Krishnan-Sarin is referring to the fact that, in addition to the potential harm vaping may be doing to the developing lungs, nicotine itself carries numerous health risks — which is why it’s never recommended for young people. It’s highly addictive, and when the brain is still developing — up until age 25 — exposure can prime youth to being more sensitive to substance use disorders later. So instead of taking a punitive approach, she added, “Connect them with science.”

And don’t forget: Quitting is hard — for teens and adults alike. “Nicotine is a powerful psychotropic drug that people really underestimate because it is legal,” said Susanne Tanski, a pediatrics professor at the Geisel School of Medicine at Dartmouth. “Parents need to support their kids through their quit, tolerate moodiness and snarkiness — and continue to support them. It’s not easy on the parent side either.”

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