EDITORIAL| VOLUME 2, ISSUE 7, P465, JULY 01, 2018

Juuling adolescents: a new health concern

• The Lancet Child & Adolescent Health

Published:July, 2018DOI:https://doi.org/10.1016/S2352-4642(18)30182-2

 

 

Since electronic cigarettes (e-cigarettes) first became available in the mid-2000s, their use—so-called vaping—has risen rapidly in many countries, not only among adult tobacco smokers but also in never smokers, both adult and adolescent. E-cigarettes are now the most commonly used nicotine-containing product among youths in the USA. Evidence about the health effects of their use in adolescents has been building. Vaping is known to increase the risk of young people transitioning to smoking conventional cigarettes; in those who make such a transition, there is also evidence to suggest that e-cigarette use increases the frequency and intensity of subsequent combustible cigarette smoking. In 2016, the US Surgeon General's report on e-cigarettes highlighted how nicotine exposure during adolescence can cause addiction and harm the developing adolescent brain. There are still gaps in our knowledge about e-cigarettes that need to be filled, including data on their long-term health effects. As these data are gathered, evidence on emerging trends in electronic nicotine delivery systems is also needed, including one concerning new trend called juuling.

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Juuling is becoming popular among adolescents in the USA, particularly in middle schools and high schools. The term comes from a brand of products called JUUL that seem to appeal to young people. A JUUL vaporizer looks like a USB flash drive and is charged by being plugged into a computer, properties that make it difficult for teachers and parents to distinguish it from other technology. It uses cartridges called pods that are filled with liquid containing a cigarette pack's worth of nicotine. The manufacturer claims that it delivers nicotine 1·25–2·7 times faster than other electronic nicotine delivery systems and provides a nicotine concentration similar to a traditional cigarette. Like other e-cigarettes, JUUL comes in several flavors that are appealing to youths, including mango and mint. Other brands that have similar characteristics such as myblu and KandyPens are also emerging. Despite strict regulations on the marketing of tobacco products, such regulations are less clear for e-cigarettes, and the promotion of JUUL is largely by youths themselves via images and videos on social media platforms such as Instagram and Snapchat. Such exposure is difficult to counter and worrying given that peer influence is particularly powerful in this age group. At present, the product is popular in more affluent US neighborhoods because of the cost of a vaporizer (US$34·99) and a four-pack of pods ($15·99). However, some young people are dealing in devices and pods at lower prices because of the ability to buy in bulk online.

 

The US Food and Drug Administration (FDA) is aware of JUUL being sold illegally to children under the age of 18 years in shops and online retailers. It has been conducting a nationwide crackdown since the beginning of March and has uncovered 40 breaches of US law. Warning letters have been sent to the retailers stating that failure to correct the violations could lead to federal enforcement actions, including monetary penalties. Importantly, the FDA is also trying to learn more about the appeal and marketing of JUUL. An official request for information has been sent to JUUL Labs requesting documents related to product marketing and research on health, including youth initiation and whether certain product design features, ingredients, or specifications appeal to different age groups.

In April, a research letter published in Tobacco Control described the results of an online survey about JUUL in young people aged 15–24 years in the USA. Of the 1012 respondents, almost 80% who reported ever using JUUL had also used the product in the past 30 days, indicating that they might be regular users. Furthermore, only 25% of individuals who recognized the product and 37% of past 30-day users were aware that JUUL always contains nicotine. This misconception is concerning; new health initiatives should be rolled out to raise public awareness about these devices, their contents, and nicotine and its addictive properties.

Given the trends observed in the use of e-cigarettes, the popularity of juuling is likely to spread beyond the USA, especially via social media. National health agencies in other countries need to be aware and ready to conduct surveillance to monitor uptake in their own jurisdictions. In the USA, the FDA's continued regulatory and fact-finding actions will be crucial to curb juuling. Stronger legislation is needed to prevent underage access to new electronic nicotine delivery technologies, and to combat product features and marketing that appeal to young people.