Juul Faces Market Withdrawal in the US: Implications and Controversies

On June 23, the US Food and Drug Administration (FDA) announced that all Juul products must be removed from the US market. This decision significantly expanded the existing ban on the company's nicotine e-cigarettes among teenagers to include adults as well. The following day, Juul appealed to the federal court to temporarily halt the ban and questioned the decision. The court agreed to temporarily suspend the ban, and currently, Juul products are still being sold in the US.

Lynn Kozlowski, a professor at the State University of New York at Buffalo's School of Public Health and Health Professions, has been researching nicotine and tobacco addiction for several decades. In this Q&A, he addresses the recent controversy surrounding Juul products and how they fit into broader discussions among adults and young people about e-cigarettes, tobacco use, and public health.

Why does the US Food and Drug Administration want to stop the sale of Juul products?

According to the FDA, the decision to remove certain flavored electronic cigarette products from the market is a preventative measure due to the lack of "sufficient evidence of product toxicology profiles" to ensure public health and safety. The FDA also noted that it has not received any information indicating that Juul products pose an imminent danger.

In a statement, FDA Commissioner Robert M. Califf addressed the impact of Juul products on youth e-cigarette use. This decision comes as some are hoping for new bans on Juul products and other adult e-cigarettes, in effort to decrease teen e-cigarette usage.

How do the health risks of electronic cigarettes compare to traditional smoking?

At least half of smokers die prematurely due to cancer, obstructive lung disease and cardiovascular diseases caused by smoking, which shorten their average lifespan by 10 years.

Currently, there is a lack of long-term epidemiological data on e-cigarettes. However, assessments conducted in the United States and the United Kingdom have concluded that while the harm from e-cigarettes may be much less than that of traditional cigarettes, they still pose some risks. Potential hazards include nicotine addiction and some cardiovascular risks, although it is estimated that these risks are lower than those associated with smoking cigarettes.

Can electronic cigarettes reduce the harm caused by traditional smoking?

I do not encourage anyone to vape if they do not need to. However, if someone smokes and e-cigarettes help them quit completely, they can be a useful tool in reducing smoking and health issues. Quitting smoking is indisputably good for your health. Research shows that if someone quits smoking before the age of 40, they can avoid 90% of their risk of death compared to continuing to smoke. If someone quits smoking before the age of 30, their health risks are almost the same as someone who has never smoked.

The Centers for Disease Control and Prevention states that there is limited evidence to suggest that e-cigarettes aid in smoking cessation. The U.S. Food and Drug Administration has approved some e-cigarettes for sale, noting that they can be a beneficial tool for smokers in significantly reducing their tobacco use or quitting altogether.

Recent research has shown that electronic cigarettes are more effective in aiding smokers to quit than nicotine replacement therapy. The UK National Health Service has approved electronic cigarettes as a recognized form of smoking cessation aid.

Is vaping still popular among teenagers as it was before?

Teen e-cigarette use is on the decline, according to data from the Centers for Disease Control and Prevention. In 2019, 27.5 percent of high school students reported having used e-cigarettes within the past month. That number dropped to 19.6 percent by 2020, and again to 11.3 percent by 2022. Just over a quarter of monthly users, or roughly 3 percent of high schoolers in 2022, reported using e-cigarettes daily.

Some of the reduction may be due to COVID-19, restrictions on young people's access, and government anti-vaping campaigns.

The widespread publicity around the serious respiratory illness caused by e-cigarettes, known as EVALI, is likely to deter many people from using them. However, research has ultimately shown that the illness is primarily caused by illicit THC-containing e-cigarette products sold on the black market.

Will teenagers who vape lead to a higher smoking rate among adolescents?

Although the decrease in teen e-cigarette use is encouraging, an important question worth asking is whether e-cigarettes directly lead to smoking later on.

Parents have valid reasons to be concerned that e-cigarettes may serve as a gateway to smoking. However, research does not necessarily support this strong causal relationship. Despite the recent surge in e-cigarette use across the country, smoking rates have actually decreased.

According to data from a national survey of nearly 40,000 participants in the US over the past few years, researchers have found that less than 1% of those who tried e-cigarettes for the first time became long-term smokers. Compared to those who first tried cigarettes or other tobacco products, people who first tried e-cigarettes were also less likely to become smokers.

Another large-scale study on American youth found that once researchers controlled for general risky behavior, the history of using e-cigarettes was only moderately or insignificantly associated with increased smoking rates.

How do you balance adult usage with teenage safety?

Even though e-cigarettes are not a major factor contributing to youth smoking, the use of e-cigarette products by young people is still a cause for concern, despite the ban on selling e-cigarettes to those under the age of 21 in 2019.

Completely banning products that may be helpful for adult smokers who want to quit is not the only way to reduce young people's access to these services. As an example, a proposal suggests moving the sales of all nicotine and tobacco products to stores that only allow entry for individuals of 21 years or older.

While products like Juul deserve research and regulation, it is important to remember the established deadline for verification and the ease of access for cigarettes - whether it is for adults or the many teenagers who start smoking every year and will become adult smokers. Persuading as many smokers to quit as possible will save lives.

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