Juuling (Vaping): Increasing Regulation Due to Its Dangers

In 2003, the first commercially successful electronic cigarette debuted in China. Today, millions of consumers regularly use ENDS, especially, e-cigarettes. Juul e-cigarettes, apparently created to help adult smokers quit smoking more easily, are now the most popular “vaping device” among teens and young adults.

While the vast majority of adults can’t identify a Juul and report they’ve never tried one, the same can’t be said about most teens. Studies suggest that Juul devices and “vaping” can lead to problems with brain development, lung damage, increased risk for high blood pressure, and increased risk for nicotine/smoking addiction.

FDA Regulation and Warning

As of 2016, in the U.S, the U.S. Food and Drug Administration (FDA) now regulates the manufacture, import, packaging, labeling, advertising, promotion, sale, and distribution of ENDS (and other tobacco products).

In 2018, the FDA announced plans to change the way e-cigarettes, including Juuls, were marketed and sold. For example, new regulations mean that all e-cigarettes/ENDS cannot be sold to anyone under 18, or without a health warning statement on the package.

The FDA’s move came on the heels of some startling new statistics: e-cigarette use among high-school and middle-school kids rose from 77 percent and 50 percent, respectively, from 2017 to 2018. The estimates show that more than 3.5 million minors vaped at least once in 2018. Recent changes in regulations are intended to make the risks of e-cigs more apparent, and also to make them more difficult to buy, especially for adolescents.

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In September 2019, the Trump Administration released a statement that the FDA intends to finalize a new compliance policy that would prioritize enforcement of unauthorized non-tobacco-flavored e-cigarettes.

The intention behind the new legislation is to continue to “clear the market of flavored e-cigarettes to reverse the deeply concerning epidemic of youth e-cigarette use.” The ultimate goal of the Administration is to ban sales of all flavored e-cigarettes, which would include Juuls.

As of June 2019, San Francisco is the first major U.S. city to ban sales of all e-cigarettes. Then in early September, Michigan became the first state to announce they would prohibit sales of most flavored e-cigarettes. These prohibitions were put in place mostly “to curb the underage vaping epidemic.” The New York State Department of Health has also got on board with banning all flavored vapes, which would make New York the second state to do is if “emergy order” regulations do in fact go through.

In an effort to hold e-cig retailers and manufacturers accountable for marketing and sales practices that encourage use among adolescents, the FDA has issued more than 8,600 warning letters and more than 1,000 civil money penalties (fines) to retailers.

On September 9, 2019, the FDA “issued a warning letter to JUUL Labs Inc. for marketing unauthorized modified risk tobacco products by engaging in labeling, advertising, and/or other activities directed to consumers, including a presentation given to youth at a school.”

As part of its ongoing investigation, including a Congressional hearing, of e-cigarettes and other electronic nicotine delivery systems (ENDS), JUUL’s marketing and outreach to students, tribes, health insurance companies and employers has been called into question.

What Is a Juul?

If you don’t yet know much about e-cigarettes, you’re probably wondering, “What is a Juul vape, and what does Juuling mean?”

Some of the many terms used to describe electronic nicotine delivery systems (ENDS) include: vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), and e-pipes.

A Juul is a type of e-cigarette (short for electronic cigarette). According to the National Cancer Institute, it’s “a device that has the shape of a cigarette, cigar or pen and does not contain tobacco. It uses a battery and contains a solution of nicotine, flavorings, and other chemicals, some of which may be harmful.”

Juuling is a type of vaping, another way to describe the use of e-cigarettes that causes a nicotine solution to turn into an inhalable mist. E-cigarettes like Juuls contain heated nicotine extracted from tobacco, but they don’t contain tobacco itself. Vaping works by heating liquid and turning it into vapor which is inhaled and enters the lungs.

Although vaping devices were created to inhale nicotine, these devices and cartridges can be used to heat many substances, including cannabis-based oils.

A 2017 survey conducted by the Schroeder Institute at Truth Initiative found that 25 percent of teens aged 15 to 17 and 29 percent of young adults aged 18 to 24 recognized a Juul device. Between 10 and 12 percent reported both recognizing and having ever used a JUUL, and 8 to 10 percent reported recognition and past 30-day use. Overall, the survey found that young adults aged 18 to 24, especially males, were most likely to recognize and use Juuls regularly.

Juul Labs first released Juuls in 2015, stating that the company’s mission was to “eliminate cigarettes and help the more than one billion smokers worldwide switch to a better alternative.” But while Juuls may be intended to serve as part of a “harm reduction strategy” — a public health strategy that intends to reduce the negative effects of addictive substances, including nicotine/tobacco — there’s evidence that Juuls may be doing more harm than good.

Experts on the dangers of nicotine tell us: “It is not yet known whether electronic cigarettes are safe or if they can be used to help smokers quit smoking.” There’s still debate over whether Juul devices and other similar products offer more benefits to smokers than they cause harm. What we do know is that evidence suggests they aren’t totally harmless, especially when used by teens or young adults or for long periods of time.

For example: In September, 2019 doctors came forward stating that they had identified a previously unrecognized characteristic of vaping products that has been linked to development of respiratory illnesses across the U.S. It’s been found that within the lungs of people who are affected by “vaping associated lung injuries” there are large immune cells containing numerous oily droplets, called lipid-laden macrophages, which are not found in healthy people without these injuries. The presence of these macrophages in the lungs is now linked with symptoms including dry cough, chest pain, shortness of breath, as well as abdominal pain, nausea, and vomiting.

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Juuling vs. Vaping

How much nicotine does a Juul contain, and how does this compare to other e-cigarettes?

The amount of nicotine in e-cigarettes can vary. Juul devices come with a preset five percent nicotine content, similar to the amount found in cigarettes. Each nicotine cartridge inserted into the Juul (called a pod) gives about 200 puffs, providing about as much nicotine as a pack of cigarettes, according to the product’s website.

Juuls might not contain tobacco, but they deliver nicotine as efficiently as a combustible product (for instance, a cigarette). They cause nicotine to reach the lungs, affect the brain and can potentially increase the risk for nicotine addiction.

Here are the differences between vaping and Juuling?

• Juuling is a type of vaping. Juuling is said to provide a higher and faster dose of nicotine compared to other vaping products.
• Juuls contain a unique chemical composition compared to other vaping devices. Most vaping products on the market use propylene glycol and glycerin as the solvents that deliver nicotine, but Juuls contain organic nicotine salts, a combination of a nicotine and an organic acid.
• Nicotine salts allow for absorption of nicotine. PAX Labs claims that Juul products provide a nicotine concentration that is comparable with a traditional cigarette, plus they can deliver nicotine 1.25 to 2.7 times faster than competing vaping products.
• The look and ease of use of Juuls is also part of what makes them appealing. They feature a small, slim, high-tech design and use nicotine cartridges, or “Juul pods,” that come in a variety of flavors.
• A Juul looks just like a USB stick and is small enough to hide from parents and teachers. Juuls do not omit vapor into the air, so they are easy to use in public without anyone knowing,
• Some report that the nicotine delivered from Juuls feels “less harsh” on the throat and in the lungs compared to the nicotine from cigarettes, making the experience more pleasant, including among sensitive or new users.

Why Juuling Is Surging in Popularity

Juul is now considered a leader in the e-cigarette market, with roughly 45.7 percent of e-cigarette market unit shares, according to a 2018 Wells Fargo Equity report. Since 2017, two years after first release, sales of Juul kits increased 680 percent; sales of refills increased 710 percent.

• They’re convenient, easy to obtain and pleasant to use. Juuls are relatively inexpensive (about $29 to $49 for a starter kit, plus more money to keep replenishing pods), easy to obtain and have a “high tech” look. (Basically like a long thumb drive that can be recharged using a computer USB drive). They are also easy to conceal and use discreetly, since they don’t produce smoke, vapor or generate much smell. Plus, Juules come in appealing flavors like mint, mango, fruit and creme.
• Their use is encouraged by authorities. It’s likely that another reason Juuling and vaping are gaining popularity is because they are “supported” (or at least not demonized) by certain health authorities and organizations, including the American Cancer Society, American Public Health Association and Royal College of Physicians. Organizations such as these feel that e-cigarette use is ultimately better than smoking cigarettes/tobacco use. For example, in February 2018, the American Cancer Society (ACS) Board of Directors issued the following guidelines to smokers: “Smokers who can’t or won’t quit should be encouraged to switch to the least harmful form of tobacco product possible; switching to the exclusive use of e-cigarettes is preferable to continuing to smoke combustible products.”

Why would The American Cancer Society encourage the use of vaping devices? The organization’s argument is that combustible tobacco products, primarily cigarettes, are the single greatest cause of cancer that we know, responsible for the deaths of about 7 million people worldwide each year. In the U.S., an estimated 98 percent of all tobacco-related deaths are caused by cigarette smoking.

In the ACS’s defense, they also recommend that “clinicians support all attempts to quit the use of combustible tobacco and work with smokers to eventually stop using ANY tobacco product, including e-cigarettes … the ACS strongly recommends that every effort be made to prevent the initiation of e-cigarettes by youth.”

Fortunately, the U.S. Centers for Disease Control and Prevention (CDC) released news in November 2018 that cigarette use among American adults is at a record low. However, it’s not clear how much e-cigs have been part of the solution, as experts give much more credit to recent smoke-free policies and rising prices of tobacco products.

Is Juuling Bad for You? 5 Dangers

So is Juuling bad for you, or is it a safer alternative for smokers and a helpful companion in the battle to quit?

Many seem to believe that the use of e-cigarettes is less harmful than smoking cigarettes, but the health effects of long-term use are still not known. And according to some study findings, there is reason to believe that e-cigarette use causes as much or more damage as conventional cigarettes.

Since their release, experts have been investigating the connection between a string of health issues and use of e-cigarettes or vaping devices. Some concerns with juuling/vaping now include:

1. Consumption & Addiction Among Teens/Young Adults

In May 2016, the FDA banned the sale of vaping products to children under 18 years old. But there’s still concern that teens are using e-cigarettes and Juuls in growing numbers. Juuls can be purchased at gas stations, convenience stores and smoke shops.

Experts also believe that young e-cigarette users face an increased risk for both starting to smoke and becoming long-term users of cigarettes and/or other combustible tobacco products.

In 2018 retailers became legally responsible for requiring age verification by photo ID for individuals under 27 in order to purchase any tobacco product. Several other provisions of the Tobacco Control Act are also now in effect, including a ban on free tobacco product samples and the prohibition of sales in vending machines.

2. Higher Risk for Cardiovascular Disease

Juuls contain nicotine, a stimulant that can increase heart rate and raise blood pressure. It’s also a risk factor for developing heart disease. That being said, certain health authorities feel that nicotine use via Juuling/vaping does not increase the risk for suffering from a heart attack.

One study found that e-cigarette exposure narrows arteries by 30 percent and decreases the blood vessels’ ability to widen.  Additionally, vaping/Juuling can stiffen the aorta, the main artery in the body that supplies oxygenated blood to the circulatory system. Aortic stiffness is considered an early warning sign of cardiac and vascular-related diseases, such as atherosclerosis, stroke and aneurysm.

A study published in Radiology in August, 2019 showed that vaping e-liquids (even those that don’t contain nicotine) just one time could cause changes in cardiovascular function. Vaping was found to temporarily impact blood vessel function in healthy people, such as by altering blood flow in major arteries in the legs. 

A separate study published in May, 2019 found evidence that inhaling e-cigarette flavors had certain toxic effects, such as decreasing cell survival and increasing markers of inflammation. 

More research is needed, but experts believe that frequent vaping over time may trigger processes that are known to contribute to development of cardiovascular diseases.

3. DNA Damage

Recent research shows that vaping may modify genetic material/DNA in the oral cells of users. In one study run by the Masonic Cancer Center at the University of Minnesota, researchers recruited five e-cigarette users and collected saliva samples before and after a 15-minute vaping session to analyze them for chemicals that are known to damage DNA.

Increased levels of DNA-damaging compounds, including formaldehyde, acrolein and methylglyoxal, turned up in the saliva after vaping. Compared with people who don’t vape, four of the five e-cigarette users showed signs of increased DNA damage. The researchers believe this may increase the risk of developing into cancer.

4. Respiratory/Lung Damage

Surveys show that it’s the flavors of Juuls and similar vaping products that draw young users in. In fact, research conducted at the Yale University School of Medicine found that teenagers preferred sweet-flavored e-cigarettes that didn’t contain nicotine over e-cigs with nicotine but no sweetness. Unfortunately, these flavors change chemistry when combined with vape fluid and are capable of creating undisclosed chemicals.

In order to create unique vaping flavors, manufacturers use flavoring compounds such as diacetyl, acetoin and 2,3-pentanedione. Studies show these chemicals can wreak havoc on the respiratory system and contribute to health problems like bronchiolitis, severe respiratory illness and irritation to the eyes, skin, mucus membranes and lungs.

According to a 2018 report published by the American Physiological Society (APS), these chemical components seem to be capable of becoming embedded in the lungs, causing inflammation and leaving the lungs vulnerable to infection. Recent research showed an increase in markers of inflammation, mucus production and altered lung function in people using e-cigarettes containing propylene, propylene plus nicotine and flavoring groups for three days.

Those who have been affected report experiencing shortness of breath, coughing, fatigue, chest pains and weight loss in the weeks/months following vaping. It’s not yet know exactly what compounds in e-cigs are causing these symptoms, but it’s speculated that fungi and bacteria in some popular brands of e-cigarette liquid, as well as flavoring agents, are to blame.

In California, trace amounts of pesticides and fungicides were found on some THC vaping products, which may be playing a role. Experts speculate that vitamin E derivatives found in some vaping products may also be capable of irritating the lungs when vaped. It’s now believed that many cases of vaping-related lung illnesses are due to people vaping cannabis products that contain high levels of vitamin E acetate, a thickening agent for vaping liquid. “Vitamin E acetate is now a key focus of the department’s inquiry”, according to a September, 2019 New York Times article.

As mentioned above, lung scans from patients with vaping-related lung illnesses have revealed that vaping seems to lead to development of oily droplets in the lungs called lipid-laden macrophages.  These macrophages are a type of cell from the immune system that gather at sites of infection. Starting in July, 2019, doctors at the University of Utah began to uncover this marker in patients complaining of pneumonia-like symptoms who had a history of vaping. In the following two months they found that 10 out of 10 patients with vaping-related lung symptoms that they tested were found to have this marker.

5. Fertility Problems and Reduced Pregnancy Outcomes

A 2019 study published in the Journal of the Endocrine Society that was conducted on mice found evidence that e-cigarette usage may impair fertility and pregnancy outcomes. This is troubling news, considering that surveys suggest many young and pregnant women are now using e-cigarettes as a safer alternative to smoking cigarettes.

In the study it was found that after female mice were exposed to e-cigarette vapors they experienced decreased embryo implantation and a significant delay in the onset of pregnancy with the first litter. Female offspring exposed to e-cigarettes in utero also failed to gain as much weight as control mice by the 8.5 month mark. One of the study’s authors reported that “E-cigarette usage throughout pregnancy changed the long-term health and metabolism of female offspring—imparting lifelong, second-generation effects on the growing fetus.”

If You’re Already Vaping as a Tool to Quit Smoking

What does the science say — is vaping really safer than smoking? 

• It’s generally accepted that vaping is a better alternative to smoking cigarettes, but it’s still far from a healthy habit and has been linked with a number of health concerns.
• Agents used in vaping products might be generally safe to consume, but we don’t know exactly how their chemical structure and effects change when they are heated and inhaled, which can still potentially lead to serious lung irritation. 
• Vaping products that contain nicotine can still have addictive qualities, so you’ll still likely deal with withdrawal effects when stopping, such as irritability, anxiety, jitters, changes in appetite, headaches and so on.
• According to the FDA, there’s no evidence that any e-cigarette is totally safe or effective at helping smokers quit. The American Heart Association therefore tells that e-cigs should only be used as a last resort way to quit.

Ways to Stop Juuling and Vaping

Fortunately, recent studies suggest that even though e-cigarettes continue to represent an increasing share of the tobacco market, cigarette smoking rates among both adults and children continue to decline in countries, including the U.S and U.K.

If you’re already using vaping as a tool to quit smoking, what steps can you take to start tapering off of vaping and quitting altogether? 

Talk to your doctor about medications, patches and so on that may help you wean off of nicotine with fewer side effects. Look into other strategies that are proven tools to help you quit smoking, such as meditation. 

If you are someone who uses a Juul, another vaping device or who smokes cigarettes, these tips can offer help when it comes to quitting:

• Try mind-body practices, including mindfulness meditation. There’s strong evidence that mind-body practices like yoga, meditation, tai chi, hypnotherapy, biofeedback and guided imagery help with quitting smoking. They offer help with stress management, chronic fatigue, chronic pain and symptoms tied to withdrawal.
• Group relaxation training. One way to learn mind-body practices is in a group setting, such as a support group, or during a private session led by a coach/therapist. You can learn to better deal with cravings and triggers by starting counseling or therapy, especially with a specialist in cognitive behavioral therapy.
• Nicotine gum/patches or other replacements. Over-the-counter nicotine replacement therapies are somewhat controversial as they continue to fill the physical need without addressing the psychological and behavioral sides of a nicotine addiction. However, research suggests they are able to help ease the process of quitting and are much less addictive. You can visit Quit.com for information about these products and tips that may help increase quitting success.
• Seek an online program. The American Lung Association’s Freedom From Smoking program is an example of an online group support resources that also offers tips and help with techniques shown to assist smoking cessation. Smokefree.gov is another good resource for finding help.
• Consider trying black pepper essential oil: This oil may help reduce cravings for nicotine and decrease withdrawal effects, according to certain studies. Black pepper oil can actually be vaped in order to provide a similar sensation to smoking. In one study, 48 cigarette smokers were randomly assigned to one of three conditions: one group of smokers puffed on a device that delivered a vapor from essential oil of black pepper; a second group puffed on the device with a mint/menthol cartridge, and a third group used a device containing an empty cartridge. Craving for cigarettes was significantly reduced in the group using black pepper oil compared to the other control conditions. Negative effects and somatic symptoms of anxiety were also alleviated in the black pepper oil group. Additionally, intensity of sensations in the chest was significantly higher for the black pepper group, which mimicked the feeling of smoking and seemed to help satisfy the smoker’s urge. 

Authorities can also continue to help stop the use of Juuls/vaping products by making efforts to reduce the toxicity, addictiveness and appeal of tobacco products currently on the market.

Government authorities can implement policies and public health measures known to prevent the initiation and use of all tobacco products. For example, the ACS recommends establishing “appropriate taxation, retail policies (for example, raising the minimum age of purchase to 21), tobacco and e-cigarette aerosol-free policies and funding of evidence-based prevention and cessation programs.”

In 2019 the FDA created its Youth Tobacco Prevention Plan, which focuses on three crucial areas to prevent youth use of tobacco products, especially e-cigarettes. The plan focuses on:

1. Preventing youth access to tobacco products. The FDA will carry out regular retailer inspections, as well as surveillance on websites, social media, and in publications.
2. Curbing the marketing of tobacco products aimed at youth
3. Educating teens and their families about the dangers of tobacco products

Final Thoughts

• A Juul is a type of e-cigarette (electronic cigarette) that features the shape of a small USB drive. It contains nicotine but does not contain tobacco. It uses a battery and contains a solution of nicotine, flavorings and other chemicals, some of which may be harmful.
• Juuling is considered a type of vaping. Vaping is the use of e-cigarettes to mist a nicotine solution so it can be inhaled. Juul devices deliver similar amounts of nicotines as cigarettes and can still be additive, despite some groups saying they are safer than cigarettes.
• Dangers of Juul devices include: increased use among teens and young adults, potentially contributing to brain development problems, increasing risk for cardiovascular problems, causing DNA damage and causing lung and respiratory problems.