Intended for healthcare professionals

Observations Yankee Doodling

Start-up e-cigarette brand aims to “improve smokers’ lives”

BMJ 2018; 362 doi: (Published 06 July 2018) Cite this as: BMJ 2018;362:k2930
  1. Douglas Kamerow, senior scholar, Robert Graham Center for policy studies in primary care, professor of family medicine at Georgetown University, and associate editor, The BMJ
  1. dkamerow{at}

But the Juul “epidemic” in schools is very worrisome

Great news: the prevalence of cigarette smoking continues to decline in the US, now down to about 14% of the population.1 Quite a change from 42% in the early 1960s. Furthermore, high school students’ cigarette smoking rate has declined to a new low of 9%.1

These decreases may be, in part, because of the increased use of electronic nicotine delivery systems (ENDS), or e-cigarettes. And that, on the other hand, may not be good news, because e-cigarettes have become wildly popular with teenagers. As Time magazine recently said, “Vaping is the new smoking. Is that a good thing?”2

The most popular US e-cigarette is now a relatively new one called Juul. It has come out of nowhere to become the leading e-cigarette in the US by far. Nielsen surveys show that Juul’s market share in convenience store sales exceeded 50% in March this year.3

Unlike the other leading e-cigarettes in the US (Vuse, MarkTen, Blu), Juul is not owned by a major tobacco company. Founded by two engineers who were former smokers, Juul has been run like a Silicon Valley start-up company, with offices in a renovated warehouse in San Francisco. Cleverly named to evoke precious jewels and energy promoting joules, Juul was designed to be an un-cigarette. As opposed to the industry standard “cigalikes” that are cigarette shaped tubes, Juul looks like a sleek, black USB drive. Rechargeable in your laptop, Juuls use small, colorful pods to supply nicotine “e-juice,” which comes in a choice of eight flavors. All this is packaged in beautifully spare, white boxes more befitting an iPhone than a lowly cigarette.

Richard B Levine/SIPA USA/PA Images

Juul’s success is not just because of great design and packaging, however. Its “biggest breakthrough was chemical.”4 It is the first e-cigarette to use nicotine salts, which better mimic the rapid “hit” of a combustible cigarette when the vapor reaches the back of the throat.4 This may help explain its popularity and phenomenal growth rate.

Juul denies marketing to teenagers and says its mission is “to improve the lives of the world’s one billion adult smokers.”5 It has pledged $30m (£23m; €26m) over the next three years to prevent youth accessing its products, and the Juul website sales platform has a state of the art ID matching algorithm to prevent minors from purchasing them.5

But Juuls are wildly popular in US high schools, where “juuling” has become a verb and the latest cool thing. US newspapers have sounded the alarm: “The Juul is too cool,”3 “Schools and parents fight a Juul e-cigarette epidemic,”6 “‘I can’t stop’: schools struggle with vaping explosion.”7 These articles are full of personal testimonies from teenagers who cannot stop juuling. The concern is that Juul is producing a new generation of nicotine addicts.

The US Food and Drug Administration, which regulates tobacco products, is clamping down on illegal sales of e-cigarettes to minors, but kids are easily finding ways to circumvent the law, obtaining Juuls from dealers in their schools.4

I would take the company’s declarations that Juuls are an adult product aimed at improving lives more seriously if it didn’t offer flavors called mango, cool cucumber, fruit medley, and crème brûlée. How about just tobacco and maybe menthol flavors, like cigarettes? And if it really wanted to help smokers quit, maybe it should sell pods with decreasing concentrations of nicotine. Of course, that would eventually put it out of business, but with a billion smokers to reach, it would take a while.

Watch out, world. Juul is on the way.



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