What Pediatric Providers Need to Know About JUUL and Other E-Cigarettes

Rise in JUUL Use

Pediatric providers have a unique opportunity to address the recent rise in e-cigarette use among teens and young adults. The FDA, labeling such use an epidemic, reported that more than 2 million middle and high school students were current e-cigarette users in 2017.(1) One product in particular, JUUL, has dramatically increased in popularity among young people and now dominates the e-cigarette market, with sales jumping more than 600% in just one year.(2) As of September 2018, JUUL sales comprise 73% of e-cigarette market share.(3)

Youth and young adults may not even be aware that most e-cigarettes, including JUULs, contain nicotine.

JUUL devices are small, resemble flash drives, and can be plugged into laptop USB drives for charging. These features make them easy to use discreetly and disguise. JUUL also comes in multiple flavors that appeal to youth. Teachers around the country have reported students using the product in schools and even sharing in classrooms. JUUL usage has become so popular among teens that its name has become a verb; one does not simply use an e-cigarette or vape, but instead “JUULs.”(4)

Any nicotine-containing product is inappropriate for use by youth. Research has consistently demonstrated the deleterious effects of nicotine on developing brains, priming young neural pathways for addiction not only to nicotine but potentially to other drugs as well.(5) Hooking young consumers on nicotine also ensures the tobacco industry has customers for generations into the future.

Youth and young adults may not even be aware that most e-cigarettes, including JUULs, contain nicotine. According to research by Truth Initiative, more than 60% of young JUUL users aged 15 to 24 did not know that the product always contains nicotine.(6)

How to Talk to Young Patients About JUUL

Pediatric providers are uniquely positioned to talk with young people about how tobacco products affect developing brains and how using tobacco at an early age can start youth on a journey of lifetime tobacco use. Five guidelines should be kept in mind:

1. Provide early guidance. Research suggests that, by middle school, many students have seen JUUL use either in person or on social media.(6) Providers should begin talking to young patients and their parents about tobacco even before middle school entry. By age 13, or when providers begin speaking to patients alone, more specific questions and education about product use are necessary.

2. Ask about specific products. When asking youth about tobacco use, it is important to specifically name products. Do you use tobacco? Do you smoke? Do you vape? Do you use e-cigarettes? Do you JUUL? Each of these questions may elicit a different answer. Asking about specific products helps to ensure that you capture an accurate picture of their use patterns and risk behaviors. Many young people seem to think of JUUL not as a tobacco product but as something different, and perhaps less dangerous.

3. Inform patients about nicotine content. Both published scientific research and anecdotal evidence suggest that young people are not aware of the amount of nicotine in JUUL devices.(6) Some think of it as just flavored vapor. But one JUUL pod contains the equivalent of 20 cigarettes, and the devices are engineered in such a way as to extract nicotine in a manner similar to combustible cigarettes—which together mean that users are consuming much more nicotine than they realize.(7-9)

4. Dispel myths about the addictiveness of nicotine. Rather than wagging a finger about reported use, providers should engage young patients in a discussion about the facts and myths surrounding JUUL and e-cigarettes. Young patients may not realize that nicotine is highly addictive. Although they may understand that cigarettes and other tobacco products are addictive, they may mistakenly believe that it is the tobacco, not the nicotine, that creates an addiction to the substance and think that as long as they do not smoke, that they are not likely to become addicted. When providers take the opportunity to dispel the myths around nicotine and tobacco, they can actively engage young people in their decision to reject tobacco by warning them that using an e-cigarette such as JUUL can quadruple the likelihood that they will go on to smoke cigarettes.(10)

5. Educate parents about the prevalence and dangers of e-cigarette use by youth. Parents should be alerted to the current patterns of e-cigarette use among youth, because they also may hold misconceptions about vaping products. They, too, may believe that e-cigarettes are safer, but “safer” does not mean that they are safe, particularly for youth and young adults. Parents need to understand that e-cigarettes are highly addictive to developing brains.

Conclusions

Pediatric providers are uniquely positioned to guide youth in healthy choices. The risk of lifelong addiction to tobacco from e-cigarette use is real. Efforts to reduce e-cigarette use among young people must be conducted across a variety of contexts including homes, schools, and legislatures as well as in healthcare clinics. Both anecdotal and research evidence suggests that young patients are amenable to conversations about tobacco use, and that when they are armed with the facts, they are more likely to consider stopping or never starting the use of tobacco.(11) When young lives are at risk, we must all answer the call.

References

1. U.S. Food and Drug Administration. Youth tobacco use: results from the National Youth Tobacco Survey. www.fda.gov/TobaccoProducts/PublicHealthEducation/ProtectingKidsfromTobacco/ucm405173.htm . Accessed October 16, 2018.

2. King BA, Gammon DG, Marynak KL, Rogers T. Electronic cigarette sales in the United States, 2013-2017. JAMA. 2018;320:1379-1380.

3. Herzog B, Kanada P. Nielsen: Tobacco ‘All Channel’ Data Through 9/8. Wells Fargo Securities; 2018.

4. Koval R, Willett J, Briggs J. Potential benefits and risks of high-nicotine e-cigarettes. JAMA. 2018;320:1429-1430.

5. England L, Bunnell R, Pechacek T, Tong V, McAfee T. Nicotine and the developing human: a neglected element in the electronic cigarette debate. Am J Prev Med. 2015;49:286-293.

6. Willett JG, Bennett M, Hair EC, et al. Recognition, use and perceptions of JUUL among youth and young adults. Tobacco Control. 2018;28(1):115-116.

7. Duell AK, Pankow JF, Peyton DH. Free-base nicotine determination in electronic cigarette liquids by (1)H NMR spectroscopy. Chem Res Toxicol. 2018;31(6):431-434.

8. Goniewicz ML, Hajek P, McRobbie H. Nicotine content of electronic cigarettes, its release in vapour and its consistency across batches: regulatory implications. Addiction. 2014;109:500-507.

9. Truth Initiative. E-cigarettes: facts, stats and regulations. 2018; https://truthinitiative.org/news/e-cigarettes-facts-stats-and-regulations. Accessed September 20, 2018.

10. Primack BA, Shensa A, Sidani JE, et al. Initiation of traditional cigarette smoking after electronic cigarette use among tobacco-naïve US young adults. Am J Med. 2018;131:443.

11. Hair EC, Cantrell J, Pitzer L, et al. Estimating the pathways of an antitobacco campaign. J Adolesc Health. 2018;63:401-406.