They look like flash drives (and can be charged on the USB port of a computer), come in sweet flavors like mango and fruit medley, and oh, yes – they deliver a strong dose of nicotine. Their popularity among American middle and high schoolers is raising alarm among public health and medical organizations, six of whom sent a letter to the FDA yesterday calling for strong and immediate action on the teen use of Juul e-cigarettes.

In the letter, the Campaign for Tobacco-Free Kids, Truth Initiative, American Academy of Pediatrics, American Cancer Society Cancer Action Network, American Heart Association and American Lung Association say that it is unacceptable that the FDA – which is responsible for regulating tobacco products – has yet to take action to address the skyrocketing youth use of the product.

Undermining decades of progress

“Juul is putting kids at risk of nicotine addiction and threatens to undermine decades of progress in reducing youth tobacco use,” the groups wrote. The manufacturer, Juul Labs, claims that each Juul cartridge of nicotine liquid (called a “Juul pod”) contains as much nicotine as a pack of cigarettes.

Several members of Congress are also calling on the FDA to take action on Juul. House Energy and Commerce Ranking Member Frank Pallone (D-NJ) recently wrote to the FDA, and a group of senators led by U.S. Sen. Dick Durbin (D-IL) wrote to the FDA and Juul’s manufacturer today.

Extensive media reports and educators have documented the skyrocketing popularity of Juul among middle and high school students across the U.S., as well as on college campuses. Educators report widespread use of Juul in school bathrooms, hallways and even classrooms, as reflected in recent news headlines: “Schools and Parents Fight a Juul E-Cigarette Epidemic” (The Wall Street Journal); “I Can’t Stop: Schools Struggle with Vaping Explosion” (The New York Times); “JUUL Smoking Craze Getting Teens Hooked on High Levels of Nicotine, Health Officials Fear” (The Washington Times); “Juuling: The most widespread phenomenon you’ve never heard of” (The Boston Globe); and “Juuling is the new teen vaping fad taking over school bathrooms” (The Milwaukee Journal-Sentinel).

Since its introduction in 2015, Juul sales have grown dramatically and now make up more than half the e-cigarette market in convenience stores and other mass-market retailers, according to industry analysts.

Many users don't realize Juul contains nicotine

The health groups’ letter comes as new research conducted by Truth Initiative, and published today in the journal Tobacco Control, reveals that while many young people are aware of Juul, 63 percent of current Juul users aged 15-24 did not know the product always contains nicotine. In addition, 25 percent of survey respondents who recognized Juul reported that use of the product is called “Juuling,” indicating they may not realize it is an e-cigarette or tobacco product.

The health and medical groups urged the FDA to take specific steps including, but not limited to:

• Immediately ordering the removal of any Juul flavors, including the popular “mango” and “cool cucumber” flavors, which were introduced after August 8, 2016 without first seeking required FDA review and authorization. Such review is required for new or changed products under the FDA’s 2016 rule extending the agency’s authority to e-cigarettes. According to Juul’s own social media posts, the “mango” and “cool cucumber” flavors were not introduced until 2017.
• Ordering the removal of Juul-like e-cigarette products that have recently been introduced by other manufacturers without required FDA review.
• Suspending internet sales of Juul until stronger rules are established to prevent sales to kids and step up enforcement to prevent underage sales by brick-and-mortar retailers.
• Reversing the FDA’s 2017 decision that allows e-cigarettes that were on the market as of August 8, 2016, to stay on the market until at least 2022 without undergoing review by the FDA. Health groups last month filed suit challenging the FDA’s delay, arguing it is unlawful and harms public health by leaving on the market products that appeal to kids.

“If Juul fails to take the steps necessary to curtail youth use before the start of the next school year in fall 2018, the FDA should take strong, additional enforcement action up to and including suspension of Juul sales until it does so,”  the letter further states.

A 2016 Surgeon General’s report concluded that youth use of nicotine in any form, including e-cigarettes, is unsafe, can cause addiction and can harm the developing adolescent brain. A January 2018 report by the National Academies of Sciences, Engineering and Medicine concluded, “There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.”