JUUL® (pronounced jewel) is one of the most popular vaping devices, particularly among youth. It’s promoted as an alternative to combustible cigarettes, and existing e-cigarettes or vaping devices.1
Most electronic nicotine delivery systems, including e-cigarettes, use cartridges or reservoirs filled with a liquid that contains nicotine, flavoring, and other chemicals. The liquid is heated by the e-cigarette device, turning it into a vapor that is inhaled. In January 2020, the FDA announced its enforcement policy to ban fruit flavors for e-cigarettes but allow continued sale of menthol flavored products.
JUUL had previously announced that it was suspending U.S. sales of non-tobacco, non-menthol-based flavors (mango, crème, fruit and cucumber), pending FDA review of the company's premarket tobacco product applications. However, between 2017 and 2019, there was a more than 20 percentage point increase in high school e-cigarette users who reported using mint/menthol flavors to nearly 64%. Exempting menthol flavoring seriously diminishes the overall effort to limit youth exposure to e-cigarettes.
JUUL works similar to other e-cigarettes but has several features that make it different and potentially more dangerous. Distinguishing features include:
The majority of adult smokers – more than 90% – began smoking when they were teenagers or younger. Research shows that the earlier in life a person tries tobacco products, the more likely they are to become a regular or daily user.3 The ease of concealment and previous variety of flavor options has made JUUL one of the most popular tobacco products among youth. Introduced in 2016, JUUL sales accounted for over 75% of all e-cigarette sales just two years later in October 2018.4 JUUL use is so prevalent that the brand-centric term for use – “JUULing” – has become a common synonym for any ENDS product use.
JUUL has one of the highest levels of nicotine among e-cigarettes on the market, although many young people are unaware that it contains nicotine at all.1,5 A 2018 Truth Initiative study published in Tobacco Control found that 63% of JUUL users did not know it contained nicotine.6
Once youth and young adults use e-cigarettes, they are more likely to move to combustible cigarettes. The National Academies of Sciences, Engineering, and Medicine (NASEM) concluded that there is substantial evidence that e-cigarettes use does increase the risk of smoking combustible cigarettes among youth and young adults.7
Since e-cigarettes have been on the market for just longer than a decade, long-term health effects are unknown. However, studies are beginning to show an adverse impact on the short-term effects. For example, effects such as rapid deterioration of vascular function, increased heart rate, and elevated diastolic blood pressure have been noted by researchers in recent years.8
E-cigarettes don’t burn tobacco, so the vapor they produce doesn’t contain the same harmful substances found in cigarette smoke – like tar and carbon monoxide. 9 However, e-cigarettes do contain many toxic substances, including high levels of nicotine, heavy metals like lead, volatile organic compounds, and cancer-causing agents.10
Most flavored e-cigarette liquids contain diacetyl and 2,3-pentanedione, flavoring chemicals which have been linked to serious and irreversible lung diseases like bronchiolitis obliterans, or “popcorn lung” disease, and related respiratory diseases. 10,11,12
Vitamin E acetate, an oil derived from vitamin E, has also been identified in many THC-containing vaping products examined following the 2019 outbreak of e-cigarette/vaping-associated lung injury (EVALI), a severe respiratory illness that has led to at least 55 deaths in 27 states in the U.S. 13, 14 Exogenous lipoid pneumonia, a rare form of pneumonia caused by inhalation or aspiration of a fatty substance, has been observed in several cases associated with this outbreak. 15
E-cigarette liquids and cartridges also contain microbial toxins like endotoxin and glucan, which have been linked to the development of airflow obstruction, reduced lung function, atopic and nonatopic asthma. 16 These risks aren’t limited to e-cigarette users – bystanders can breathe in aerosol when it is exhaled into the air. 17
Scientific studies have not shown that e-cigarettes help people quit smoking combustible cigarettes. In fact, the opposite is often true. The USPSTF concluded that there is insufficient evidence about the effectiveness of e-cigarettes as cessation aids to quit smoking combustible cigarettes when compared with no treatment or proven cessation treatments.18 In many cases, individuals trying to quit smoking combustible cigarettes by using e-cigarettes as a cessation aid will become dual users of both products.19
As family physicians, your advice is critical in getting patients to avoid using JUUL and other e-cigarettes, as well as traditional tobacco products.
The AAFP’s Quit Smoking Guide offers steps, techniques, and medicines you can use to help patients quit smoking.
Fact sheets developed by AAFP help you and your patients understand the risk of using this product.
1. Public Health Law Center at Mitchell Hamline School of Law. Public health concerns about youth & young adult use of JUUL. https://www.publichealthlawcenter.org/blogs/2018-02-19/public-health-concerns-about-youth-young-adult-use-juul.. Accessed June 25, 2018.
2. Belluz J. Juul, the vape device teens are getting hooked on, explained. www.vox.com/science-and-health/2018/5/1/17286638/juul-vaping-e-cigarette(www.vox.com). Accessed June 25, 2018.
3. Ambrose BK, Day HR, Rostron B, et al. Flavored tobacco product use among US youth aged 12-17 years, 2013-2014. JAMA. 2015;314(17):1871-1873.
4. Feirman SP, Lock D, Cohen JE, Holtgrave DR, Li T. Flavored tobacco products in the United States: a systematic review assessing use and attitudes. Nicotine Tob Res. 2016;18(5):739-740.
5. The National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Consensus study report. Highlights. www.nap.edu/resource/24952/012318ecigaretteHighlights.pdf(www.nap.edu). Accessed June 25, 2018.
6. Qasim H, Karim ZA, Rivera JO, Khasawneh FT, Alshbool FZ. Impact of electronic cigarettes on the cardiovascular system. J Am Heart Assoc. 2017;6(9).
7. Glantz SA, Bareham DW. Annual review of public health. E-cigarettes: use, effects on smoking, risks, and policy implications. www.annualreviews.org/doi/pdf/10.1146/annurev-publhealth-040617-013757(www.annualreviews.org). Accessed June 25, 2018.