Juuling Is Fine, Actually (For Adults Who Want to Quit Smoking Cigarettes)

As far as we can tell so far, if you’re exclusively using a product like Juul that contains nicotine and that’s under FDA regulation, this does not appear to be linked to the lung injury that we’re hearing about in the news. Might there be other health risks down the line? Yes, potentially. But as it relates to cases of vaping-related lung injury, it does not appear that nicotine-containing products like Juul are responsible for those illnesses. It appears to be the result of the use of more counterfeit or illicitly purchased products that contain THC.

If I were you, I wouldn’t be too concerned about what we’re hearing in the news.

So I can keep on Juuling my 3 percent mint, is what you’re saying.

I’m not recommending what you should do, but I’m saying that you should not be concerned, as far as we know. Right now it doesn’t seem like nicotine-containing products are the culprit.

Our best evidence so far suggests that we’re starting to hone in on Vitamin E acetate as the culprit. I don’t think we can confidently say that that’s exactly what it is, because it might be an interaction between that ingredient and something else, or it might be just a common factor in these cases. We haven’t honed in on the specific chemical exposure that’s causing the illness. But the use of THC, specifically from a counterfeit brand—that appears to be driving these illnesses.

I think the the the CDC recommendations regarding this issue are actually really well written, because the first thing they say is, if you’re at all concerned about any of these issues, don’t vape. If you’re a smoker who has switched to vaping, don’t go back to smoking. And if you’re still going to purchase vaping products, make sure you’re not buying illicit products. You should probably avoid buying THC pods. That’s pretty good advice. If you’re concerned, don’t do it. But also don’t go back to smoking if you’re going to stop.

Please tell me if I’m actually dumb since I’m not a public health expert, but all of the bans passed by cities and states seem like an overreaction. What do you think?

So there really have been two main stories related to vaping that have kind of taken over the evening news and headlines, and I think they’re getting very conflated. On the one hand you have this vaping-related lung injury, which the CDC and public health officials need to respond to. It’s a concerning issue and they need to figure out what it is and to prevent it.

At the same time, you have news stories about youth use of e-cigarettes. So you have a lot of policymakers, public health officials, and local and state governments saying we need to step in and do something. And they’ve proposed these flavor bans and proposed banning e-cigarettes entirely.

The vaping related deaths that we’ve seen are serious. But there’s been, I think, 13 at this point. Compare that to nearly 500,000 deaths per year in the U.S. caused by smoking-related illnesses. It pales in comparison.

But I’ll say that these bans of e-cigarette or flavored products will not do anything to address the vaping-related lung injury cases, because these appear to be caused by illicit sales. Banning sales of e-cigarettes in corner stores or drugstores won’t address that outbreak, since it doesn’t appear that it’s being caused by products that are bought over the counter or regulated by the FDA.

I think that was more a response to the youth vaping and an attempt to to prevent access. Maybe that’s what the goal was. But sometimes you even hear some of the politicians talking about these bans as a way to prevent the outbreak that we’ve been seeing, and that just doesn’t really align with what the data are showing us.

From a harm reduction perspective, these bans seem particularly dangerous. If e-cigarettes and Juuls are helping adult smokers like me quit cigarettes, then banning them seems completely counter-productive.

Absolutely. And I actually feel very strongly about this. I think it’s inappropriate to ban e-cigarettes, because we know that they’re less risky than combusted cigarettes. I think it’s inappropriate to ban them while allowing more dangerous combusted tobacco products to remain on the shelf. These are heavily promoted in retail environments. The vaping related deaths that we’ve seen are serious, certainly. But there’s been, I think, 13 at this point. Compare that to the nearly 500,000 deaths per year in the U.S. that are caused by smoking-related illnesses. It pales in comparison. So to allow combusted tobacco products to flourish while banning a class of products that’s less risky just doesn’t seem appropriate.

It raised my eyebrows when I saw that Walmart is planning to stop the sale of e-cigarette products and yet continues to sell tobacco products.

Yes. And Rite-Aid did the same thing. And when they come out with their press releases or their explanations for why they did this, they always say something about how this is out of concern for public health and for youth. And frankly, I don’t believe that that’s accurate, because if they truly had concern for the public’s health, they would ban the tobacco products that are responsible for the death and disease caused by tobacco use, meaning cigarettes and even cigars. Those products are what’s driving the disease, the death, the disparities that we see when it comes to tobacco use and morbidity and mortality.

I think if this was truly about the appropriate public health response, they would go a step further. I think this might be more of a response to public outcry. And also, for retailers like Wal-Mart and Rite Aid, e-cigarettes are probably a relatively small percentage of their total sales. So I think they’re looking like the hero, but it probably doesn’t affect them too greatly from from a business perspective.

Maybe I’m just a cynic. But I think CVS was the real hero there. They banned all tobacco products from being sold several years ago. And this was when e-cigarettes weren’t a huge thing yet. And I think other stores that pull e-cigarettes from their shelves, you know, they’re claiming to be the hero. Well I think they could go much further.

Let’s talk about New York, where I live and where Governor Andrew Cuomo has announced a ban on the sale of all flavored e-cigarettes with the exception of tobacco and menthol. What do you think specifically of this particular ban?

This is a complex issue, and in all the conferences and meetings that I attend, this is something that comes up every time, and there is really heated debate about it. Because on the one hand, we know that flavors are appealing to youth. So if you ask youth what kinds of products they use, it is usually a flavored one, that’s how most of them start. So I can see the concern on that hand. On the other hand, a lot of smokers have successfully quit [by] using a flavored product, and many will tell you that it was the flavor that really kept them away from cigarettes. It was something that didn’t remind them of cigarettes, that was appealing but satisfied their nicotine addiction.

So we shouldn’t necessarily take that option away from those who have successfully engaged in harm reduction. But a concern that I have with the flavor ban is that it could be lead to more of a black market, and that might result in the same health issues that we’re seeing with the THC products, with flavors being sold illicitly.

It just seems so misguided to me, so it’s good to hear from you that I am not actually coming out of left field here!

It does seem misguided. Again, I bring up other tobacco products. Cigarettes are far and away more harmful products than e-cigarettes, especially the kinds of e-cigarettes that are popular today. And if you look at cigars and cigarillos, those are heavily flavored with all kinds of fruit and mint and chocolate and dessert flavors. Why are we not acting on those products, which carry significantly more health risks?

I do think that teenagers who have never smoked a cigarette in their lives should not pick up a nicotine addiction. It is not a smart move! How do we balance that with the fact that vaping helps adult smokers quit? What do you think elected officials should be pursuing instead of these blanket bans?

You just asked for the million-dollar question. I think the crux of the debate is youth versus adult smokers, and finding that balance.

I don’t know if I can land on the exact right policy move, but I do think that we need to continue to restrict access to youth, so that includes making sure retailers are compliant with IDing, making sure that online sales for underage individuals aren’t happening. I think we do need to restrict marketing towards youth.

But at the same time, we should not close the off ramp from smoking. We shouldn’t restrict these products in such a way that smokers who want to switch have more difficulty finding them and using them. I think a lot of it comes down to appropriately educating the public. There’s still a lot of Americans, probably a lot of people around the world, that don’t believe that e-cigarettes are less risky. Some think they’re more risky or that they carry the same risk. And the science has told us that no, that’s not true. No. Combusted tobacco products expose users to carbon monoxide and tar and smoke. And that’s what’s really responsible for most of the death and disease caused by tobacco use.

This is going to require a multi-level approach—policy, education, restricting access. This is exactly what we’re talking about in the field now, how to make sure that the benefits outweigh the risks and what kinds of policy and public health approaches are the right ones to take to make sure of that. And I don’t think we’ve found an answer yet.

But it seems like these bans now are kind of a blunt weapon when what we really need are very targeted, precise efforts.

I think so, yeah. You were right in saying that people who definitely should not be using these products are people who have not smoked, because you can’t talk about reduced risk or harm reduction or lower risk products when the person never smoked. Because if they’re just using vaping products, they’re really introducing toxins and chemicals into their body that may not have been there to start. Vaping is not without health risks.

Personally, I think that the rates of teenage vaping have gotten a little bit out of control. But a silver lining is that smoking has never been lower among teenagers.

But yeah, for someone like you, a smoker who successfully switched, there’s conclusive evidence that that is reducing risk. So we want to encourage that for smokers who have extreme difficulty quitting. But how to communicate to the public that this is a much less risky product without young people thinking, “Oh, it’s safe.”

I remember being a teen and being stupid and impressionable. Part of me is just like, teens are always going to do dumb things.

I think teenagers will always forever engage in risky behaviors. Personally, I think that the rates of teenage vaping have gotten a little bit out of control. But what I think is a silver lining is that smoking has never been lower among teenagers. Smoking continues to decline. There was initially concern that vaping might normalize smoking, that it would be a gateway issue. If you look at the the prevalence data, it just doesn’t seem like it’s happening at the population level, because smoking continues to plummet among youth.

One thing that I think has led to confusion is that there doesn’t really seem to be a consensus among public health professionals about what should be done.

That’s correct.

Some say people should stop vaping immediately. Others who maybe come from a more harm reduction perspective are saying hold up, vaping has helped smokers quit which is a good thing. Can you talk about some of the disagreements in the public health field?

I think a lot of people in the public health field view vaping companies and vaping in general as Tobacco 2.0, and that’s totally understandable because in public health, we’ve worked for decades and decades and decades to eliminate smoking. We have this end game with an end game strategy that we’ve been working towards for so long, and vaping comes on the scene and is seen as a threat to that.

So I understand why there’s skepticism about vaping, but at the same time, what I sometimes have to remind even people in the public health community is that smoking, tobacco use, is still the leading cause of preventable death in the U.S., decades after knowing how deadly smoking is. And we recognize now that it’s not the nicotine that’s killing people. It’s highly addictive, but it’s the smoke, it’s the tar, it’s the carbon monoxide. That’s what causes the death and disease. So while some people view new nicotine products as a threat, others view it as a very promising strategy to help eliminate smoking. If we can deliver nicotine in the safest way possible, I personally think that that might help facilitate the smoking end game.

Just anecdotally talking to my friends who are also former smokers who’ve now switched to vaping, it has helped quite a bit. And yet now we’ll have to go to Jersey to get our Juul pods! Thank you, Andrew Cuomo.

I live in New Jersey, it’s not so bad over here.

I will have to become a big fan of New Jersey Transit soon enough.

You bring up a good point that in the face of really severe policy changes, you will have people trying to skirt around that policy, whether it’s going to buy it in a place where it’s legal or getting it illicitly. I think that that often happens. Some people, as flavors become unavailable, they may quit. That might be the impetus they need to quit. But I worry others may resort to other methods that could potentially worsen the problem.

Danny, you’ve given me a lot of peace of mind, and I will tell all of my friends and family who have emailed and texted and called me to tell me to stop vaping immediately that in fact it is perfectly fine and better than the alternative right now, so thank you.

I hope one day you’re able to quit vaping also, because I think that’s the goal. Even harm reduction proponents and advocates say the ideal scenario is to completely quit nicotine. And I hope that vaping for you was an off ramp from smoking and soon is an off ramp from nicotine. That’s the best case scenario, and I hope you get there one day.

It’s also not an inexpensive habit or replacement. My bank account also hopes for that, for me.

Absolutely.