By Dr. Mercola
We all know people who've struggled to stop smoking. Some have opted to quit "cold turkey" or relied on patches, but when e-cigs came along — electronic nicotine delivery systems or devices that emit doses in a vapor for users to inhale without the smoke — millions lined up to give them a try. The most inviting premise was its original design to help cigarette smokers taper off and eventually quit.
Since 2004, when the Chinese introduced e-cigs, the U.S. Centers for Disease Control and Prevention (CDC) estimates that by 2016, 3.2 percent of U.S. adults were e-cig users. More than 2 million middle school and high school-aged students had used in the previous 30 days. "Vaping" has overshadowed tobacco use among teenagers in the U.S., escalating by 900 percent between 2011 and 2015. For people 18 to 24 years of age, 40 percent had not been smokers before using the device.1
One of the newest e-cigs, made by Juul Labs Inc., has been making a big dent in the market. According to Bloomberg, the San Francisco-based startup is poised to rank its worth at $16 billion.2 While Israel is the only country where the vape pen is currently available outside the U.S., the company has plans to change that, The Verge notes:
"Since launching in 2015, the Juul has been a runaway success. Vapers appreciate the flat rectangular product design, discreet size and powerful pre-filled nicotine pods. Sucking on a Juul creates a similar sensation to smoking a cigarette.
As of … [June 2018] Juul had captured 68 percent of the U.S. e-cigarette market, according to Nielsen data … The company's growth has made it a bright spot in an ailing industry. Since January 2017, cigarettes' share of the smoking and vaping market has fallen by almost 4 percentage points. Juul's market share has jumped by roughly 3.5 percentage points in the same period."3
Morgan Stanley analyst Pamela Kaufman told investors that "Juul's success underscores the potential for disruptive technology to undermine U.S. tobacco's reliable business algorithm."4 Rival companies Philip Morris International Inc. (in the U.S), British American Tobacco Plc and Japan Tobacco Inc. have all seen their shares slump: 23 percent, 24 percent and 15 percent, respectively, just this year.
Business Insider says the product is so popular, its use has become a verb; it's not "smoking" anymore, it's "Juuling." But here's how the company has overtaken their rivals in a very competitive market: The Juul contains somewhere around twice the concentration of nicotine as cigarettes and other vape pens, so they pack an even more powerful nicotine punch.
What Juuls Deliver — More Than Users Bargained For
Presented as the "most satisfying" and "genuine alternative to cigarettes,"5 Juuls are described as delivering "a nicotine hit that's much more like smoking a cigarette than other e-cigs."6 The company's patented JuulSalts approach to nicotine delivery is due to compounds called nicotine salts, which develop in heat-dried tobacco leaves much like most cigarettes.7 Science reporter Rachel Becker explains in The Verge:
"These nicotine salts are less harsh to inhale than the straight-up, 'freebase' nicotine used in most regular nicotine vapes — the same kind of nicotine you get from smoking the air-dried tobacco used for pipes and cigars. Freebase nicotine can be absorbed through your mouth — but it's also much less pleasant to inhale because of its 'greater physiological (throat and chest) impact and toxicity,' according to a report for the tobacco industry from the 70s."8
Vapers who've tried Juuls agree they have a much stronger nicotine "hit" than other e-cigs. One ex-smoker found that once he started on Juuls, the vaping habit became "remarkably difficult to kick." Becker writes about The Verge's video director, Christian Mazza, a 15-year smoker who gave up cigarettes, then started vaping Juuls. His first reaction wasn't necessarily positive as he compared them with the low-nicotine e-cigs he started with, but after a while, he recalls:
"It just sort of took over, and everything else just got put away in a shelf — and the Juul became the daily driver … I don't know what's going on on a molecular level, but it hits smoother and it's a lot more satisfying when you're craving that nicotine."
In fact, the reality is that you could think of regular vapes like smoking a cigar, and the Juul pretty much like smoking a cigarette. JuulSalts make the nicotine easier to access. According to the company website, freebase nicotine is mixed with benzoic acid to make the e-liquid, which has a chemical reaction to produce the nicotine salts. JuulPod e-liquid cartridges contain up to twice the amount of nicotine as a pack of cigarettes, and they're just as easy to inhale.9,10
Making use even easier, The Boston Globe11 notes the Juul's built-in battery is charged via a magnetic USB adapter, takes an hour to charge and lasts for 200 puffs, or one full day of regular use. The fruity-, tobacco-, crème brulee-, mango- and mint-flavored pods contain 50 milligrams of nicotine and emit such a mild fragrance, they've been mistaken for a light perfume.
With the Juul device, the company offers a "starter" kit online for $49.99. It comes complete with a charger, a warranty and four flavored Juul pods. On the resale market, the starter kit might run around $80.
The Good, the Bad and the Addictive
For adults who hope to get over their cigarette addiction by indulging in an occasional nicotine hit via vaping, Juul company spokesperson Victoria Davis says they were created for that purpose: They're "intended for adult smokers only who want to switch from combustible cigarettes." However, University of California San Francisco professor Gideon St. Helen told Becker that while an e-cig may have its place, "You just don't want young people using it."
Davis insists that combating underage vaping is one of the company's highest priorities. "We cannot be more emphatic on this point: No young person or non-nicotine user should ever try Juul." But unfortunately, they do. Anti-smoking advocates say the company targets teens, but The Washington Times maintains it's a moot point because Juuls already have all the necessary elements for any age: They're flavored, their batteries can be recharged on a laptop in an hour and they fulfill the "cool factor."12
One high schooler is quoted as saying that while smoking is "gross … Juuling is really what's up."13 Another student enthuses, "People Juul at parties, Juul when they're driving — it's a social thing. They're Juuling all the time."14 But according to The New Yorker, "Teens have taken a technology that was supposed to help grownups stop smoking and invented a new kind of bad habit, molded in their own image."
What's more, while school personnel across the U.S. have been used to looking for telltale whiffs of cigarette smoke and glimpses of slender white shafts, e-cigs sneaked up on them because they're so easy for users to conceal. Juuls may or may not have been specifically designed look like a USB flash drive at first glance.
Interim superintendent Howard Colter at Cape Elizabeth High School in Maine noted, "They can pin them on to their shirt collar or bra strap and lean over and take a hit every now and then, and who's to know?"15
The U.S. Food and Drug Administration (FDA) has noticed, and in April 2018 issued a report with FDA Commissioner Scott Gottlieb's comprehensive prevention plan to "stop youth use of, and access to, JUUL and other e-cigarettes." Others have similar characteristics to Juul, he notes, but more types of e-cigs are emerging into the marketplace all the time. He asserts:
"In some cases, our kids are trying these products and liking them without even knowing they contain nicotine. And that's a problem, because as we know the nicotine in these products can rewire an adolescent's brain, leading to years of addiction. For this reason, the FDA must — and will — move quickly to reverse these disturbing trends, and, in particular, address the surging youth uptake of JUUL and other products."16
So What's so Bad About Juuls?
Truth Initiative, a nonprofit youth anti-smoking organization, conducted a survey that revealed several things that should make everyone, including teens, sit up and take notice. Again, a significant number of students say they were unaware before they tried it that Juuls actually contained nicotine. One girl admitted she thought they were healthier than cigarettes and that "it won't give you as much cancer, but finding out that one pod is equivalent to one pack of cigarettes was shocking."17
The New York Times referenced another student's admission after he'd been reprimanded three times: "I can't stop."18 The device's patent includes charts showing how its nicotine salts rival a Pall Mall cigarette in the amount of nicotine absorbed into the bloodstream. That alone is troubling, but Truth Initiative's CEO, Robin Koval, lists a few facts that have been established regarding e-cigs to date:
- Nicotine has effects on young people's cognitive development
- If addicted to nicotine at a younger age, young people are more susceptible to other addictions later on in life
- When addicted at a younger age, it's harder to quit nicotine, whether it's vaped or a smoking product
To a teenager's brain, particularly since it's not fully developed until around age 25, Business Insider notes potential vulnerability of their prefrontal cortex, the part of the brain involved in decision making, emotional control and impulse regulation. In short, nicotine, like any other drug, impacts developing brains more than those of adults.
"Brain imaging on adolescents suggest that those who begin smoking regularly at a young age have markedly reduced activity in the prefrontal cortex and perform less well on tasks related to memory and attention compared to people who don't smoke."19
Dr. Nicholas Chadi, a clinical pediatrics fellow at Boston Children's Hospital, says brain changes from nicotine include increased sensitivity to other drugs and greater impulsivity. Effects of teen vaping he's run across include intense nicotine cravings after only a few months of use and loss of hope they'll be able to quit. Further, Chadi references a Lancet study ranking nicotine as more addictive than alcohol or barbiturates.20 "Some start showing irritability or shakiness when they stop."21
While they may show less severe withdrawal symptoms compared to adults, teen symptoms may appear after only a few hundred e-cigs. One study shows that 85 percent of those who try to stop either smoking or vaping end up relapsing.22
Dr. John Ross, from Brigham and Women's Hospital and a Harvard Health Blog contributor, says long-term safety information on e-cigs doesn't yet exist, and while they're "almost certainly" less dangerous than smoking, the nicotine itself in e-cigarettes may also have negative health effects.
"Chronic nicotine exposure may lead to insulin resistance and [Type] 2 diabetes … Inhaled nicotine increases heart rate and blood pressure. Nicotine is highly addictive in its own right, and it may lead to changes in the brain that increase the risk of addiction to other drugs, especially in young people."23
Are E-Cigs Dangerous?
It's significant that Juul's labeling includes California's Proposition 65 warning that the product contains chemicals known to cause cancer, birth defects and/or other reproductive harm, and the website reiterates that the product contains addictive nicotine.
Perhaps to counter that, company spokesperson Christine Castro says an in-house research team is looking at youth prevention to engage educators and parents, offers its curriculum to schools for free and will even help compensate for costs linked to after-school activities and addiction counselors.
However, Bonnie Halpern-Felsher, Ph.D., a developmental psychologist and pediatrics professor at Stanford University School of Medicine, is of the mind that neither tobacco nor nicotine delivery device companies should be engaged in their own prevention work.24
Research at Portland State University25 "milked" the vapes from 11 different e-cigs with a syringe pump to examine the liquids and the aerosols produced by three of them. The "fruit medley" and "creme brulee" flavors had the most nicotine, but next to the lowest nicotine freebase levels.
Only a liquid called "Placid" had lower freebase nicotine levels, and far lower nicotine overall. In essence, "Juul packs a bigger nicotine punch in a more pleasant package than the other products the team tested."26 One of the chemistry professors involved in the study called Juul use a double-edged sword:
"If you've never smoked, and you try Juul for a few days, this is a recipe for addiction. You could make someone addicted who's never been a smoker — or, for someone who is addicted to nicotine, this could be a way to get off of cigarettes."27
In addition, it's important to understand that if you smoke e-cigarettes you may be exposing yourself to dangerous chemicals and toxic heavy metals with each puff, typically associated with cancers, heart disease and stroke. Other toxins detected in e-cigarette vapors include diacetyl, formaldehyde, diethylene glycol, tobacco-specific nitrosamine and highly reactive free radicals.28 In traditional cigarette smoke, these highly reactive free radicals are associated with cancer, chronic obstructive pulmonary disease and heart disease.
The History of Tobacco and How It Relates to E-Cigs
Tobacco smoking has been a thing for thousands of years. Native Americans grew tobacco long before Europeans showed up, and smoked pipes for religious and medical purposes as many as 2,000 years ago; the Mayans possibly engaged in it from 600 to 900 A.D., if ancient, stone-chiseled depictions of the practice mean anything.29
It was a cash crop for New World settlers in 1612, and by the 1800s, it was being chewed, smoked in a pipe and hand-rolled for easy inhalation. Cancer Council NSW (conducting and funding world-class cancer research), notes:
"In 1602, an anonymous English author published an essay titled '[Worke of Chimney Sweepers],' which stated that illnesses often seen in chimney sweepers were caused by soot, and that tobacco may have similar effects. This was one of the earliest known instances of smoking being linked to ill health."30
It took another 200 years for a German named Samuel Thomas von Soemmerring to notice that mouth cancers were a hallmark of some pipe smokers. In 1798, an American doctor wrote about the dangers of tobacco, but it wasn't until the 1920s that actual research and medical reports cautioned the public. In the '50s and '60s it was confirmed: Ingesting tobacco can spike a range of serious diseases.
With all that in mind, the medical world has been somewhat dumbfounded by the way e-cigs have completely changed the tobacco industry, which is why the science is absent in regard to what kind of damage, if any, habitual vapers can expect in regard to their health. The Verge observes:
"Needing more independent data is a common theme: vaping is so new that there's a ton we don't know about it yet, which means that people who use these products are mostly left to figure out the risks and benefits on their own. Thanks to a massive study of studies from the National Academy of Sciences, Engineering and Medicine, we know vaping probably exposes smokers to fewer toxic chemicals than smoking does and may cut their risk for short-term health problems, too."31
Vaping Juuls: The Bottom Line
A PLOS One study suggests there's a two- to seven-times greater possibility that vaping teens will move on to the real thing.32 But while experts say vaping can be a gateway to smoking in the traditional sense, one Juul spokesperson maintains that using e-cigs hasn't been proven as "causally related to cigarette use."
Interestingly, the National Academies doesn't comment on whether vaping helps people stop smoking (and a reported 70 percent of adult smokers say they want to quit33) any better than other FDA-approved recommendations, such as using nicotine patches, gum or lozenges.34 On the other hand, the Academies recently revealed incontrovertible evidence that using e-cigs creates a dependence on them.35
Vapers say that when they started, it was supposed to be a "transitional thing," but one couple admits they're still vaping two years later, and ask, "At what point does the transition get us off of nicotine completely?" To simply start vaping less is like telling smokers to smoke less, one Juuls user grouses, because the product, he says, is essentially designed to make you want to use it more. There's talk of the company rolling out lower-dose pods, but the company declined to comment on when or how.
Meanwhile, Juuls are patent-protected, and their expanding customer base is flourishing, which is going to make it hard for the powers-that-be at Juul to switch up the status quo in regard to how the product is made, because it's quite profitable. After all, Castro says, "The entire conception, premise, operations, mission of the company is to eliminate cigarettes and get adult smokers to switch to our vapor product."
One could compare it to putting a finger in a leaking dike, but before the first quarter of 2018 was out, 11 U.S. senators sent two letters to Juul Labs Inc., stating that the company's products undermine the fabric of the nation's efforts to curb tobacco use, and calling the company out for putting "an entire new generation of children at risk of nicotine addiction."36 Time will tell whether or not there's a positive response.