Juul's notorious youth-targeting ads have attracted heated criticism from public health officials and media since its emergence in 2015. But now, e-cigarette health expert, Robert Jackler, MD, professor and chair of otolaryngology at Stanford, is providing evidence to suggest that Juul's influence on the industry has shifted more than just the consumer base, it's changing the norms of e-cigarette production.
Before Juul, e-cigarettes companies made vaping products that contained 1 to 2 percent nicotine -- Juul's e-cigarette liquid, or e-liquid, contains as much as 5 percent nicotine. Now, other e-cigarette companies are following Juul's lead, and it's creating something Jackler calls the "nicotine arms race."
In a paper in Tobacco Control, Jackler, the senior author of the study, says that Juul is the instigator behind broadly increasing nicotine levels, and even provides evidence to suggest that the rise is contributing to addiction among adolescents.
I spoke with Jackler recently.
How has Juul changed the norms of e-cigarette production?
The astounding financial success of Juul... has led to an upswell of devices that emulate its high-tech appeal, small size and stealthiness.
Until recently, most e-cigarette liquids carried 1 to 2 percent nicotine, with a few considered 'super high' at 3 percent, intended for the two-pack-a-day smoker. In 2015, Juul introduced a 5 percent nicotine vaping liquid with a novel chemistry -- nicotine salts -- which improved palatability, enabling higher concentrations of nicotine without undue bitterness. Following Juul's phenomenal success, numerous knockoff devices were introduced that emulated, or even exceeded, Juul's very high nicotine level.
Also problematic, the nicotine percentage is inconsistently portrayed on labels. Juul, unlike most e-liquid brands, measures its nicotine content by weight rather than by volume. For example, the nicotine level in Juul's e-liquid is 5 percent by weight versus 5.9 percent by volume...
Do we know what the health ramifications of long-term, high-nicotine usage are?
The rapidly rising popularity of high-nicotine e-liquids threatens to addict a generation of youth. The epidemic of their use among American middle and high school students is reversing decades of public health efforts. Nicotine addiction is very hard to escape -- meaning that many youths will get addicted for their lifetime.
In terms of acute health risks, Juul and its high-nicotine emulators are more efficient at delivering nicotine than conventional cigarettes. This makes them potently addictive, especially to nicotine-naive teens. A youth would reach the addictive threshold by inhaling the vapor generated by merely using a quarter of a Juul pod per day.
More than 70 e-liquid brands sell high-nicotine products, meaning those with nicotine concentrations of 5 percent or higher by volume, in bulk -- 30 milliliters or more -- which is equivalent to more than 40 cigarette packs...
How can public health or government officials better regulate the sale of higher concentration nicotine solutions?
High-nicotine vapor products often come in sweet and fruity flavors, such as mango or gummy bear. One policy option would be to ban youth-appealing flavors from all nicotine-containing e-liquids and allow only unsweetened tobacco flavor to accompany nicotine. This would help to reduce the appeal of these products among youths while retaining a product acceptable to adult smokers seeking to transition from cigarettes.
Another regulatory option would be to cap the amount of nicotine permissible in e-cigarettes. The amount of nicotine in Juul pods that is sold in the United States (59 milligrams of nicotine per milliliter of e-liquid) would not be permitted in Europe or the United Kingdom, which have adopted limits of 20 milligrams of nicotine per milliliter of e-liquid. If the U.S. adopted this standard, it would almost certainly reduce the tendency of e-cigarettes to act as a gateway to youth nicotine addiction. However, it may also reduce their efficacy in cigarette-smoking cessation. As high-nicotine versions may well prove more efficacious in transitioning cigarette smokers to vapor, one option would be to allow sale of high-nicotine e-liquids only by doctor's prescription.
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