Intended for healthcare professionals

Observations Yankee Doodling

Popular e-cigarette Juul comes under attack

BMJ 2019; 365 doi: (Published 18 June 2019) Cite this as: BMJ 2019;365:l4249
  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}

Public health authorities and medical groups are dismayed by Juul’s penetration

Juul, the wildly popular e-cigarette the size of a flash drive, continues to grow in market share and controversy in the US. Its easy concealability, fruit flavors, and youthful social media models attracted a large teenage following. The highly addictive nicotine-salt formula has kept them coming back for more.1

Introduced in 2015, Juul is now estimated to control 70% of the US market. It has left other brands (many owned by tobacco companies) in the dust. Altria, the US arm of Phillip Morris, for example, brought out its own e-cigarette brand, Mark Ten, in 2014, but sales were meager despite high expectations. Altria/Phillip Morris continues to sell its Iqos “heat, not burn” tobacco product in Europe and is close to gaining approval to sell it in the US, but it hasn’t really caught on anywhere.

With US sales of conventional cigarettes decreasing and profits sustained only by increased prices, Big Tobacco had to do something. Some have tried to team up with Juul. The Wall Street Journal reported that first British American Tobacco (maker of Camel, Newport, Kent, and others) and then Altria (Marlboro and others) tried to buy Juul.2 That failed, but after protracted negotiations Altria acquired a 35% minority stake in Juul for $12.8bn (£10.2bn; €11.4bn) last year. So much for Juul not being a cigarette company.

Juul insists that it is not marketing its products to young people. It has strengthened its website and retail underage purchasing controls, removed fruity flavors from retail settings, discontinued its Facebook and Instagram accounts, and launched two huge advertising campaigns: one in support of national legislation to raise the smoking and vaping age to 21 and one featuring clearly adult smokers testifying about how Juul has allowed them to switch from conventional cigarettes.

These are all reactions to negative publicity and to new regulations from the US Food and Drug Administration ordering sales of flavored e-cigarettes to be restricted and for more age surveillance. Public health authorities and medical groups are up in arms about Juul’s penetration in the youth market. The latest attack on the company comes from the state of North Carolina, which recently filed a lawsuit against Juul, asking it to remove mint flavored Juuls from stores and to restrict online purchases to tobacco and menthol flavors only.3 In addition, the lawsuit would force Juul’s advertising and marketing policies to align with restrictions on conventional cigarettes. E-cigarettes currently have no such restrictions in the US. It seems likely that other states will soon, so to speak, follow suit.

Another threat to Juul is the 2022 deadline imposed by the FDA for e-cigarette companies to provide evidence that they are less harmful than conventional cigarettes. Juul is actively recruiting scientists to perform this research for them, with mixed results. Researchers don’t want to be tainted by tobacco money, especially now that Altria is a co-owner of the company.4

It will be intriguing to see whether Juul can survive regulatory and public criticism long enough to prove what most scientists think: e-cigarettes are probably safer than conventional cigarettes, and we could save a lot of lives if we could get smokers to switch. But not at the cost of a new generation of non-smokers becoming addicted to nicotine products.



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