Take a look around outside a crowded bar on a Friday night. Instead of lighting up Marlboros or American Spirits, the younger crowd has taken to tiny, USB-shaped devices known as Juul.
According to the Surgeon General, electronic cigarettes, also known as e-cigarettes, debuted in the U.S. marketplace around 2007. Since 2014, they have been the most commonly used tobacco product among American youth.
E-cigarette use among middle and high school students increased 900% during 2011-15. The Juul itself saw an influx of 600% in sales during 2016-17, giving it the greatest market share of any e-cigarette in the U.S., also according to the surgeon general.
Marketed primarily as a device used for smoking cessation, Juul has now become popular with youths given its flavor choices — including Mango and Crème Brulee — and the potential for the vapor to be easily concealable. However, doctors and dentists are not recommending the use of the device at all, given they do not know long term effects of Juul use.
Dr. Susan Morgan of the WVU Dental School has worked in smoking cessation for close to 20 years. In 2000, the electronic cigarette wasn’t available to consumers, but there were many West Virginians using tobacco who wanted to stop smoking. Around 70% of people coming into the clinic who were tobacco users expressed a desire to quit.
Morgan was trained at the Mayo Clinic in smoking cessation and was amazed at the program available and wanted to bring it back to West Virginia. Now, in the era of the electronic cigarette, Morgan sees a whole new set of challenges coming along with cessation.
“A couple years ago, probably about 16% of the nation smoked and West Virginia was up there in the 24, 25%, so we were running behind what the nation was doing. I think by the year 2020, the goal was that the nation would drop down to about 12% of smokers,” Morgan said.
That goal, she said, was within reach — until the boom of the electronic cigarette.
“I think that now that has absolutely created an epidemic,” she said. “An absolute epidemic of young people who are probably addicted to nicotine and the habit.”
Morgan said the science behind what lies ahead for e-cigarette users is questionable. She said there have been studies that show the vapor can cause cells to release inflammatory products, which can cause stress to the cells in the body, resulting in damage.
“I think the potential [for damage] is very much there,” she said. “I think that time is going to tell what happens, but with some of the early [e]-cigarettes … we know that there were carcinogens in those that were heavy metals that were found in the vapor.”
Morgan mentioned how the Center for Disease Control has urged caution with vaping. At the time of this report, there have been six deaths possibly linked to vaping.
Eight individuals were also hospitalized in Wisconsin with respiratory issues. Morgan said as far as dental issues go, some people have indicated that as nicotine is a stimulant, there have been higher instances of people grinding their teeth possibly from nicotine intake.
“My biggest concern is, I think, a lot of people picked up the Juul thinking that it says 5% or 3% on the outside of the packet. The first impression anybody that’s young or anybody looking for a product to buy is going to think ‘that’s a really low amount,’ ” Morgan said.
A low amount of what? Morgan said there’s no indication as to what that number is pointing to. Studies have found that one Juul pod is equal to 200 puffs of a cigarette — that can be equivalent to a pack, and some say, two packs of cigarettes.
“That’s a lot of nicotine for a young developing brain,” she said.
When nicotine hits the brain, it releases chemicals that give a person a sense of well-being. In a young person, if this reward center is being hit constantly with nicotine, the concern is what is happening long-term to that child.
“I think that’s the real fear,” Morgan said.
On Sept. 9, the Food and Drug Administration (FDA) sent Juul Labs Inc. a letter of warning and requested information on several issues, including “outreach and marketing practices, as part of ongoing investigation.”
A press release stated the letter identifies several statements, including statements discussed in testimony from a July 2019 Congressional hearing on Juul where a representative from the company claimed Juul was safer than analog smoking and “the FDA would approve it any day.” At the time of this report, the Trump administration announced it intended to remove all flavored e-cigarette liquid from purchase, working alongside the FDA
The FDA came out in 2016 saying it would regulate all e-cigarettes and tobacco products by 2018. Morgan said that didn’t happen and it was delayed to 2022.
Morgan said medical professionals don’t know the answer as to whether the Juul is as bad as picking up a pack of cigarettes. One thing she knows is she would not recommend using Juul for cessation to anyone.
“I think the more and more we learn about it, the more we’re going to know what to tell patients and to tell the public,” said Morgan.
Dr. James Frederick Littles, a radiation oncologist at Mon Health, shares similar sentiments with Morgan. Littles said cigarette companies have purchased e-cigarette companies.
“They did not want to miss out on that new, competitive revenue stream,” he said.
A class action lawsuit filed in West Virginia in late August reads, “Altria recently acquired a 35% stake in Juul.” Altria also owns Philip Morris, which sells Marlboro, the United States’ most popular brand of cigarettes. The lawsuit also claims that now that Juul has Altria’s infrastructure “progress in nicotine cessation stands to erode.”
The 65-page document claims Juul marketed to the plaintiff, a 16-year-old girl, and now she is addicted to nicotine.
“E-cigarettes, unfortunately, are a major public health concern,” Littles said.
He said he believes e-cigarettes could have been purposefully implanted as the “cool new thing.” Adults have moved from cigarettes to e-cigarettes thinking they were safer, so youth followed suit. However, doctors are unsure of this assumption.
“The other things that they’re putting in the cigarettes are propylene glycol and its hazard is unknown, from chronic inhalation, arsenic, lead, tin and nickel in addition to nicotine,” he said.
The brain continues to develop up until the mid-20s. Anytime blood flow is inhibited to the brain, which nicotine does, it can carry health issues along with it.
“Secondhand exposure to nicotine is unsafe for pregnancy. The burns that you can potentially get from the e-cigarettes — because there’s a heat source at the battery. You can get facial burns, hand burns, and other things from nicotine,” Littles said.
He also mentioned the cases of pneumonia detected across the country associated with e-cigarettes. Older adults might have other competing risk factors like blood pressure or diabetes.
“We already believe that they [e-cigarettes] are unsafe, given the cases across the country of young adults being hospitalized for pneumonia. Historically, pneumonia is very uncommon for healthy young adults,” he said.
Littles also mentioned that though propylene glycol is in some food, it’s also in antifreeze. Inhaling these elements and ultrafine particles for so many years could have adverse effects, but doctors are unsure of what those side effects will be, Littles said.
So, how do these products stay on the market with such evidence stacked against them? Littles uttered one word: “Lobby.”
“In the 1970s, tobacco companies were netting $4 billion dollars a year. If you’re netting $4 billion per year in the 1970s and ’80s, you can afford very expensive lobbyists to make sure you are less regulated than you need to be,” Littles said.
One of the things effective in other countries, like Canada, is a tobacco tax that might keep kids from smoking.
“Just making it cost prohibitive, but that’s one thing I believe the lobbyists fought tooth and nail against,” he said.
Littles said what physicians should do continuing on is educate the public as best they can and let people know e-cigarettes are believed to be unsafe.
“There are a plethora of ways that are approved by the FDA and the American Medical Association to stop smoking. E-cigarettes are not one of them,” he said.
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