Direct evidence that Juul increases nicotine addiction, especially among kids

John Pierce and his colleagues at UCSD just published “Daily E-cigarette Use and the Surge in JUUL Sales: 2017-2019” that shows shows that after Juul came on the market there was a 3.6-fold higher rate of progression to daily e-cigarette use — a marker of addiction — among 14-17 year olds compared to 3 years earlier, before Juul came on the market. This effect was largest among younger users (figure above), seriously challenging FDA’s “public health goal” of ensuring access to Juul for adults while protecting kids.

Juul adds acid to the e-liquid to make the nicotine easier to inhale (so-called protenated nicotine) by making the aerosol less alkaline.

They concluded

The surge in sales of JUUL e-cigarette from 2017 to 2019 was accompanied by increased daily e-cigarette use that was most marked among adolescents aged 14 to 17 years at baseline. Members of this youngest age group who became daily e-cigarette users had dependence scores that were not different to older adults nor different from adult daily cigarette smokers. This recent upswing in tobacco use in the young has resulted in initiation levels that are somewhat similar to those seen in the early 1990s, before the introduction of many effective tobacco control measures.

Despite having received Juul’s application nearly two years ago (on July 29, 2020), FDA has not made a decision on whether to continue allowing Juul to be sold. This new paper adds to the case that FDA should deny that application.

Here is the abstract:

Objectives: To identify how the 2017 rapid surge in sales of JUUL e-cigarettes affected usage among US youth and young adults.

Methods: Annual surveys in the Population Assessment of Tobacco and Health Study assess tobacco use by product and brand among the US population. We identified 2 cohorts aged 14 to 34 years, 1 with baseline survey in 2014 before the rapid surge of JUUL and the other in 2017 as the surge in JUUL sales was occurring. For 5 age groups, we compared 2-year incidence of first tobacco use and of new-onset daily tobacco use by product, and report levels of dependence.

Results: Sociodemographic variables and rates of experimentation with any tobacco product were similar between cohorts. Among baseline nondaily tobacco users, only those aged 14 to 17 years had an increase in the 2-year incidence of new daily tobacco use (2014 cohort = 4.8%, 95% confidence interval 4.3, 5.5 vs 2017 cohort = 6.3%, 95% confidence interval 5.8-7.0) to rates approaching those in the 1990s. In 2019, three-quarters of new daily tobacco users aged 14 to 17 vaped daily and had e-cigarette dependence scores similar to daily cigarette smokers and older adult e-cigarette vapers. We estimate that about 600 000 Americans aged <21 years used JUUL products daily in 2019, a rate 2.5 times those aged 25 to 34 years.

Conclusions: The surge in US JUUL sales was associated with a sharp rise in daily e-cigarette vaping and daily tobacco use among US youth, not young adults.

The full citation is: Pierce JP, Zhang J, Crotty Alexander LE, Leas EC, Kealey S, White MM, Strong DR, Trinidad DR, McMenamin SB, Chen R, Benmarhnia T, Messer K. Daily E-cigarette Use and the Surge in JUUL Sales: 2017-2019. Pediatrics. 2022 May 30:e2021055379. doi: 10.1542/peds.2021-055379. Epub ahead of print. PMID: 35634883. It is available here.

Published by Stanton Glantz

Stanton Glantz is a retired Professor of Medicine who served on the University of California San Francisco faculty for 45 years. He conducts research on tobacco and cannabis control and cardiovascular disease/

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