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Juul can fit in the palm of your hand and barely leave a trace after vaping. Each Juul pod also packs as much nicotine as one to two packs of cigarettes.
Press Herald via Getty Images

Juul, the vape device teens are getting hooked on, explained

If you’ve seen people sucking on USB flash drives, they’re probably “Juuling.”

Elijah Stewart first heard about the Juul three years ago, during his sophomore year of high school.

Many of his friends had started sucking on the e-cigarette that resembles a USB flash drive. It was suddenly a lot more socially acceptable, even cool, “to Juul” than to smoke cigarettes.

Stewart was an occasional cigarette smoker when he began experimenting with Juul. Very quickly, he felt he was addicted. “After about a week, you feel like you need to puff on the Juul,” he says. “To some people it is like a baby pacifier, and they freak out when it’s not near.”

Stewart, who is 19 and studies engineering at Providence College, now wants to throw away his Juul. Every four or five days, he burns through a pod — which comes in eight flavors, including Creme Brûlée and Cool Cucumber, and delivers as much nicotine as up to two packs of cigarettes. The habit sets him back about $16 to $32 every month.

But quitting won’t be easy, he says, because Juul is everywhere. “If you were to go to any party, any social event, there would no doubt be a Juul.”

What Stewart is seeing on his campus in Rhode Island is part a dramatic shift happening across America: E-cigarettes have quietly eclipsed cigarette smoking among adolescents. The possibility of another generation getting hooked on nicotine is a nightmare scenario health regulators are scrambling to avoid.

No device right now is as worrisome as the Juul — because of both its explosion in popularity and the unusually heavy dose of nicotine it delivers. In 2017, the e-cigarette market expanded by 40 percent, to $1.16 billion, with a lot of that growth driven by Juul.

As of March, Juul made up more than half of all e-cigarette retail market sales in the US, according to Nielsen data. Considering it has only been on the market since 2015, and there are hundreds of other devices available to consumers, Juul’s market share is staggering.

“I don’t recall any fad, legal or illegal, catching on in this way,” says Meg Kenny, the assistant head of school at Burr and Burton Academy in Manchester, Vermont, who has worked in education for 20 years. Students at her school are Juuling in bathrooms, in class, and on the bus. Because it’s against the school’s rules, they hide the devices in ceiling tiles and in their bras and underwear.

“Ninety-five percent of the disciplinary infractions we dealt with in the fall and continue to deal with into the spring are all connected to the Juul,” she added.

While school administrators like Kenny are glad that cigarette smoke is disappearing from campuses, they’re concerned that students don’t understand the risks of using the Juul. What sets it apart from other e-cigarettes is that it hits the body with a tobacco cigarette-worthy dose of nicotine. We don’t know if Juul is more addictive than regular cigarettes but it’s certainly possible that teens getting into Juul now may be wading into a lifelong habit.

The long-term health impacts of e-cigarettes are still unknown and a recent case study, published in the journal Pediatrics, suggests there are risks. An 18-year-old woman was diagnosed with hypersensitivity pneumonitis, also known as “wet lung,” a few weeks after taking up vaping. The chemicals in the e-cigarettes, the doctors hypothesized, caused an allergic reaction in her lungs that led to respiratory failure and forced her on to a breathing machine until her lungs recovered.

Doctors and public health officials also worry about the immediate harmful side effects of nicotine on young people’s developing brains and bodies. The “nicotine in these products can rewire an adolescent’s brain, leading to years of addiction,” said Scott Gottlieb, the head of the Food and Drug Administration. And there’s strong evidence that vaping may encourage young people to try cigarettes.

That’s why Gottlieb announced in April that the agency is cracking down on Juul and other e-cigarette companies like it, which appear to be selling and marketing their products to youth. The agency is going after retailers that illegally sell these products to minors, and they’ve asked Juul’s makers, Juul Labs, to submit paperwork about their marketing practices and health impact.

But the FDA, under Gottlieb, also delayed the compliance deadline for the regulation of e-cigarettes until 2022. This gave e-cigarette manufacturers who had products on the market before 2016, including Juul Labs, a free pass when it came to filing public health and marketing applications before selling in the US.

“In this world, a delay of [five] years is a lifetime,” said Matt Myers, president of the Campaign for Tobacco-Free Kids. “And the data seems to indicate this product is being used by kids all across the country.”

So what can and should be done about e-cigarettes like Juul, a growing market that Myers calls the “Wild West”? Let’s break it down.

“You can essentially Juul wherever without drawing much attention”

The Juul e-cigarette looks like a thumb drive.
Boston Globe via Getty Images

E-cigarette sales have exploded over the past decade — and the devices have slowly been embraced by many in the public health community for their potential as a harm reduction tool to help smokers quit.

Juul’s stated mission is “improving the lives of the one billion adult smokers.” Created by two former smokers and Stanford design graduates (one of whom also worked as a design engineer at Apple), the duo wanted to make a device that looked sleek and attractive:

When they could find no attractive alternative to cigarettes, [James Monsees and Adam Bowen] recognized a groundbreaking opportunity to apply industrial design to the smoking industry, which had not materially evolved in over one hundred years.

So they designed an e-cigarette that could easily be mistaken for a USB flash drive — and can fit in the palm of the hand.

The Juul has two components: the e-cigarette, which holds the battery and temperature regulation system; and the “pod,” which contains e-liquid — made up of nicotine, glycerol and propylene glycol, benzoic acid, and flavorants — and is inserted into the end of the e-cigarette device. Pods come in a variety of colors and flavors, from cucumber to creme brûlée, mango, and tobacco. Juul’s “starter kit,” the e-cigarette, USB charger, and four flavor pods, sells for about $50.

When you insert the pod into its cartridge and inhale through a mouthpiece on the end of the Juul, the device vaporizes the e-liquid. When the device runs out of power, you can insert it into your computer via a USB charger for a reboot.

With such a sleek design and enticing flavor options, it’s not difficult to see why these devices appeal to more than just older smokers.

Christophe Haubursin / Vox

“[Juul] is everything old vapes were not,” college student and Juul dabbler David* told me. “It’s very lightweight and portable, super easy to charge and refill, and it’s low-maintenance,” unlike other e-cigarette devices that require users to replace coils or atomizers.

But the biggest appeal for David is how discreet the device is. “You can essentially Juul wherever without drawing much attention.”

For Stewart, the student at Providence College, it’s also the flavors. “If they had bland flavors, then not as many people would [Juul].”

While Juul’s official marketing campaign appears to be targeted to adult smokers, young Juul users have taken it upon themselves to spread the word. Campaigns have sprung up on social media, including #doit4Juul on YouTube, Twitter, and Instagram, where enthusiasts share photos and videos doing tricks with the product. Meg Kenny told me teachers often catch students Juuling in photos they’ve shared on social media.

Juul delivers a hit of nicotine like a cigarette. That’s because of its “nicotine salts.”

Vaping devices, with Juul in the center.
AP

Another feature that sets Juul apart from many of the other e-cigarettes on the market is the nicotine punch it packs.

Each pod contains 59 milligrams of nicotine per milliliter of liquid. Juul claims one pod is equal to a pack of cigarettes in terms of nicotine, but tobacco experts told me the precise equivalency is difficult to determine because not all the nicotine released in cigarette smoke is inhaled, and some is trapped in the filter. Juul also contains three times the nicotine levels permitted in the European Union, which is why Juul can’t be sold there.

Juul’s creators ramped up the nicotine levels on purpose. They realized many of the e-cigarettes on the market don’t hit smokers’ systems in a way that’s comparable to cigarettes. (Typical e-cigarettes have nicotine levels ranging from 6 to 30 milligrams per milliliter.)

To address that gap, Juul vaporizes a liquid that contains nicotine salts. In Juul, these nicotine salts are absorbed into the body at almost the same speed as nicotine in regular cigarettes, a speed that comes from the use of freebase nicotine.

“This innovation in nicotine chemistry may be critical with regard to the addictiveness” of e-cigarette pods like Juul, according to an August 22 Perspective piece in the New England Journal of Medicine.

Unlike the freebase nicotine in regular cigarettes, which can be very irritating, nicotine salt goes down smoothly and doesn’t cause the unpleasant feeling in the chest and lungs that cigarette smoke does, said David Liddell Ashley, a former director of the office of science in the Center for Tobacco Products at the FDA.

The vapor also doesn’t have the nasty smell of cigarettes, and can emit a subtle whiff of fruit or other flavors when users vape.

“[That’s] my biggest concern,” Ashley added. With traditional cigarettes, users typically cough uncontrollably on their first puffs. With Juul, vapers can get the same nicotine effect but without the pesky irritation. “It may be much easier for a user to start on these products,” Ashley said.

Stewart says he also finds Juul more addicting. “It gives you a head rush that is stronger that is a drag of a cigarette.”

Juul seems to have taken off among young people, many of whom don’t know it contains nicotine

As regulators scramble over what to do about Juul, one thing has become clear: Many teens don’t seem to understand the potential harms of these devices.

An April study, published in BMJ’s Tobacco Control journal, suggests many young people know about Juul, though they aren’t aware of its potential harms. In the survey of youth ages 15 to 24, a quarter recognized Juul, and 10 percent reported both recognizing and trying the device. Alarmingly, most respondents were not aware that Juul pods always contain nicotine.

“The actual true science behind [Juul] and the concentrate and how the nicotine is derived — that’s not common knowledge to [students],” Kenny said. “And I think that’s the work that we have to do and with our students and families. When we’ve intervened and had meetings with parents, they’re even confused as to what’s in the product. ‘Is there really nicotine in it? My kid just told me it’s flavored oil.’”

To get to the bottom of why teens hold these views, the FDA took the unusual step in April of demanding Juul submit documents about its marketing and research and what it knows about Juul use among young people. The move was part of FDA’s new Youth Tobacco Prevention Plan. In May, the agency followed up by sending requests for information to four other e-cigarette makers, which also appear to be marketed at young people.

“We don’t yet fully understand why these products are so popular among youth,” said Gottlieb in a statement. “But it’s imperative that we figure it out, and fast. These documents may help us get there.”

The FDA has also started an undercover sting investigation of e-cigarette retailers, including gas stations, convenience stores, and online retailers, sending warning letters to anyone who is violating the law against selling these devices to kids under 18 (or even 21 in some states). If retailers don’t comply, they face escalating fines for their violations.

This may not go far enough. While e-cigarette makers, like regular cigarette makers, aren’t supposed to sell their products to minors, companies can design and market their devices in ways that appeal directly to youth.

Managing the public health impact of e-cigarettes has left regulators hamstrung

Public health authorities generally agree that e-cigarettes and other cigarette alternatives are less harmful than conventional smoking for individual smokers, but their long-term public health consequences are still unknown.

For example, these devices may save the lives of smokers at a time when one in five deaths in the US is still linked to traditional cigarettes. They may also entice more young people to use them, or even to smoke, at a time when smoking rates have been declining. (We know that most people who currently use e-cigarettes continue to smoke.)

This tension between helping smokers while minimizing harm to public health is a big reason why health and regulatory agencies have been hamstrung over how to regulate products like Juul.

Last summer, the FDA delayed the compliance deadline for the regulation of e-cigarette products to 2022. This gave the industry five more years to file public health applications that show that their products are safe alternatives to conventional cigarettes and that they weren’t unduly targeting minors. The FDA’s Gottlieb positioned the delay as a way to give manufacturers time to get in step with the new laws while ensuring smokers had access to cigarette alternatives that could save their lives.

Some public health advocates viewed the move as a giveaway for the vaping industry, and a chance for e-cigarette makers to further expand their market share among kids at a time when e-cigarette in teens has eclipsed conventional cigarette use. For these reasons, health groups sued the FDA over the delay and sent a letter to Gottlieb asking the FDA to begin to regulate e-cigarette products like other cigarettes immediately. (Something to look out for is whether e-cigarettes in young people becomes a big dark spot on Gottlieb’s otherwise respectable track record.)

In the absence of a tougher federal response, cities may start cracking down: San Francisco voters just approved a proposition to ban the sale of flavored tobacco products, including e-cigarette liquids. A group of senators also sent a letter to Juul with a series of questions about their products, including the health impact of their products and when they’d stop selling flavors that appeal to kids. And the researchers writing in NEJM argue “schools should emphasize zero-tolerance policies for the possession of any tobacco products on school grounds.”

“[Juul’s success] could be the first sign of a very important new category,” said University of Waterloo public health researcher David Hammond. But the more appealing and cigarette-like an e-cigarette is, the better it competes with cigarettes, and the more it helps people quit them. “On the flip side — the more likely it is to recruit new people into the market in terms of youth,” he said.

Juul is certainly not the only super-subtle and slick e-cigarette device that may entice young people. A bunch of copycats have sprung up, and unlike Juul, they very openly target kids. Check out the KandyPens website, and how it explodes with images of young models and rappers.

The FDA says it will continue exercising its regulatory authority to crack down on these manufacturers ahead of that 2022 deadline by warning and fining retailers. E-cigarette makers are also required to register the ingredients in their products, list any nicotine content on their packages, and remove “modified risk claims,” among other regulations.

Juul has also said it’ll work with federal and state health regulators to fight underage use, and a company spokesperson told Vox it “strongly condemn[s] the use of our product by minors,” defined as 18 or 21, depending on the state.

“Our company’s mission is to eliminate cigarettes and help the more than one billion smokers worldwide switch to a better alternative,” said Juul Labs chief executive officer Kevin Burns in an April 25 statement. “At the same time, we are committed to deterring young people, as well as adults who do not currently smoke, from using our products. We cannot be more emphatic on this point: No young person or non-nicotine user should ever try Juul.”

But the free market, and vaping culture, may be evolving faster than any health regulator.

“The nightmare scenario for public health is that this product brings kids into the market, addicts them to nicotine, and leads to smoking,” Hammond said. For now, it’s not clear whether this is happening. But there seems to be good reason it could.

*David did not want his full name and identity revealed to protect his privacy.


For more on Juul and e-cigarettes, please listen to the May 3, 2018 episode of Today Explained.

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