Rachel Lloyd was an avid cigarette smoker until she picked up her first Juul — the high-nicotine vape that skyrocketed in popularity after it hit the market in 2015, mostly among teens due to targeted marketing and flavors like fruit medley and creme brulee.
“I wasn’t even someone who wanted to quit smoking. I wanted to want to quit smoking, but I was so hopelessly addicted I honestly believed that the only motivating factor to quitting completely would have to be something like getting pregnant,” Lloyd, a 29-year-old in New Jersey, told BuzzFeed News. “For a somewhat unexplainable reason, I just eventually didn’t really care to smoke cigarettes anymore if I was always using my Juul.”
But now, as Juul faces a potential ban that would prevent its products from being sold in the US, some ex-smokers fear they’ll return to combustible cigarettes. People who use Juul devices say the experience just doesn't compare with the other nicotine delivery products on the market.
“Juul is not perfect, but it’s the closest we’ve gotten to an extremely effective smoking cessation tool, so their mistakes, whether it be in marketing or mishandling the backlash, seem forgivable to me,” said Lloyd, who shared that she’s tried at least 20 other vape brands, none of which kept her away from cigarettes like Juul has; she particularly likes the flavor and convenience of its refillable pods.
A few people told us they are even stocking up on Juul pods “out of sheer panic,” 45-year-old Daynah Burnett told us. The Washington state resident said she visited every corner store she could find when she heard about the ban; she now has about 40 boxes that should last her a year.
“I don’t plan to quit, because life has too few joys anymore — and I have too few rights!” Burnett said, adding that Juul helped her ditch cigarettes for good. “Let’s start with real gun control, then maybe you can have my Juuls.”
Many people who responded to a callout from BuzzFeed News asking for their thoughts on the FDA’s removal of Juul from the e-cigarette market feel the same. The company has been accused of marketing to children for years, often hooking young people who had never smoked before and didn't know the products contained nicotine.
The FDA — which began regulating the e-cigarette industry in 2016 — said on June 23 that it was removing Juul from the market after a nearly two-year review process. It determined that the company’s premarket application, which all e-cigarette companies must submit, lacked evidence that proved its device, as well as its tobacco- and menthol-flavored nicotine pods (other flavors were banned by the FDA in 2020), could protect public health. Specifically, the FDA said Juul had “insufficient and conflicting data” regarding “potentially harmful chemicals” leaking from its e-liquid pods.
The next day, the federal court granted Juul a temporary stay, allowing its products to continue being sold. Then on July 5, the FDA issued its own stay, stating that there are “scientific issues unique to Juul’s application that warrant additional review.”
In an argument brief filed in court and provided to BuzzFeed News, Juul said it actually provided 6,000 pages of aerosol data on four chemicals the FDA took issue with, and offered evidence that they aren’t found in the aerosol that users inhale.
“We believe that once the FDA does a complete review of all of the science and evidence presented — as required by law, and without political pressure — we should receive an authorization to market our products,” a company spokesperson told BuzzFeed News.
While researchers and doctors say e-cigarettes may help smokers avoid combustible cigarettes, the experts can’t ignore the appeal the products have for teens and the lack of data on its health effects.
Some ex-smokers worry that they’ll go back to smoking when the ban goes into effect.
“My fear if they stop selling Juul is that I would reach for a cigarette instead,” Mercedes Haass, a 61-year-old Texas resident, told us. “And I know that if I do that I’ll be a regular smoker within days.
“It will probably kill me.”
Does vaping really help people quit smoking cigarettes?
It’s not proven that vapes can actually help some people quit smoking cigarettes.
The FDA has yet to approve an e-cigarette as a smoking cessation device, although it has authorized 23 electronic nicotine delivery systems (ENDS) products “based on their potential to benefit adult smokers.” These products include vapes from companies Vuse, Logic, and Njoy. (Since the deadline to submit premarket applications in September 2020, the FDA has blocked more than 1 million ENDS products from being sold in the US.)
Some experts think the FDA has no intention to consider vapes a legit quitting tool any time soon (the UK’s National Health Service does). That’s because the government is currently taking a “prohibitionist” approach when it comes to tobacco products, rather than one of harm reduction, said Gregory Conley, president of the American Vaping Association, an industry group. The FDA is also separately proposing to slash the amount of nicotine in traditional cigarettes to reduce their addictiveness as well as lessen youth use and smoking-related deaths.
Juul claims that its products have helped more than 2 million adults quit cigarettes, potentially resulting in over a million saved lives. For context, there were an estimated 8.1 million adults in the US using e-cigarettes in 2018, the CDC estimates, and about 34 million were smoking cigarettes.
A company spokesperson told us that Juul devices are not intended to help adult smokers “quit” but rather help them stay away from combustibles: “It would be best if no one used any nicotine product. Anyone who smokes should quit. However, adult smokers who have not successfully quit should completely switch to potentially less harmful noncombustible nicotine products.”
But Conley believes this isn’t a “Juul problem — it’s an FDA one.”
“[The agency] is run by people with a drug mindset where there’s ‘safe’ and there’s ‘unsafe.’ There’s no middle ground,” Conley said. “The end result of making products less appealing and less satisfying to adult smokers is more people continuing to smoke cigarettes. And that's a disaster for public health.”
Research has found that one Juul pod (5% cartridge) contains about 40 milligrams of nicotine, which is equal to about one pack of cigarettes.
Some research suggests that vaping may help people quit smoking, but they still have cravings for and use the nicotine delivery devices.
“You do run into this double-edged sword where you kind of swap one addiction out for the other,” said Andrew Hyland, chair of the Department of Health Behavior at Roswell Park Comprehensive Cancer Center and director of the New York State Smokers’ Quitline.
A review of 50 randomized controlled trials including over 12,400 smokers found “moderate certainty evidence” that quit rates over at least six months were higher in people who used nicotine e-cigarettes compared to those who used nicotine replacement therapies (NRTs), including patches, gum, varenicline (a pill to help people stop smoking), counseling, and nicotine-free cigarettes.
In absolute terms, the researchers estimated that for every 100 people using vapes to quit smoking, 10 might be successful; for those using NRTs, six of 100 people might be successful.
Heather Rohn, 41, can relate. “I was a 15-plus-year smoker, and nothing worked to stop. When I say I’ve tried it all, I mean ALL: the patch, the gum, laser, hypnotism, cold turkey, prescription medications. You name it,” the Ohio resident said. “The only thing that has helped is the Juul.” Rohn has been off cigarettes for almost three years now.
A 2019 randomized controlled trial of 886 smokers in the UK looking to ditch cigarettes came to a similar conclusion: The one-year quit rate among people who used nicotine e-cigarettes was about double that (18% versus 9.9%) of those who used NRTs, including patches, gum, nasal spray, mouth spray, and inhalators — or any combination thereof. (Both groups were also offered behavioral support.)
The e-cigarette group also experienced less severe cravings and withdrawal symptoms such as irritability, restlessness, and issues concentrating during their first week of abstinence.
A separate study published in 2021 found that smokers who started vaping daily and had no intention to quit cigarettes were still eight times more likely to stop smoking altogether compared to those who didn’t vape.
Meanwhile, other studies suggest the opposite, that smokers who vape to help quit cigarettes aren’t successful in their attempts and are still vulnerable to relapse. More research indicated that smokers who used e-cigarettes, FDA-approved NRTs, or no product at all similarly failed to fully quit cigarettes one to two years later.
“Do I think e-cigarettes have a place in helping adults quit smoking? Yes, but not the way that it's been done,” said Bonnie Halpern-Felsher, a pediatrics professor at Stanford who studies tobacco use in adolescents and young adults and is the founder of the Tobacco Prevention Toolkit. “It has to be behind this proverbial firewall so young people can't get them … and we need better evidence and ways to help adults quit.”
Despite what some Juul users say, experts aren’t convinced combustible cigarette use will spike if Juul is banned, mostly because cigarettes just aren’t cool anymore, especially among younger people. Not to mention there are many other products like Juul still on the market.
“The newness factor is no longer there, and the social environment around sharing devices has changed as well,” Conley said.
Cigarettes are terrible for health, but it’s too early to tell for vapes
No tobacco product comes without risks. Anything you inhale that’s not air will produce some level of injury to your lungs, according to Dr. Panagis Galiatsatos, a pulmonologist and spokesperson for the American Lung Association.
Cigarettes are responsible for more than 480,000 deaths in the US each year, or about 1,300 deaths every day, according to the CDC. They have about 600 ingredients that when burned, morph into more than 7,000 toxic chemicals, including formaldehyde, carbon monoxide, and lead; about 69 of these chemicals are known to cause cancer.
E-cigarettes, on the other hand, are more of an enigma.
The company’s website says Juul’s e-liquids comprise mostly “pharmaceutical grade propylene glycol and glycerol,” which can be harmful to the lungs. When heated, the liquid creates an aerosol that carries nicotine, benzoic acid, and flavorings made of natural and artificial ingredients. Concentrations of its ingredients besides nicotine are largely unknown.
In 2019, e-cigarette or vaping use–associated lung injury, better known as EVALI, hospitalized thousands of people in the US and caused 68 deaths. The outbreak involved counterfeit THC-containing vapes that used the additive vitamin E acetate, which is safe to ingest or apply to your skin, but not inhale. (This additive is not found in Juul.)
The deaths prompted Nico, age 20, to quit both vapes and combustible cigarettes, which he started using simultaneously. “I was left with no choice but to go through withdrawals, and I haven’t started again. I’ve had a few cigs here and there, but not enough to get addicted again.”
The CDC says e-cigarette aerosols in general can contain “potentially harmful substances” like volatile organic compounds that affect the respiratory system, heavy metals like nickel, tin, and lead, and diacetyl, a type of flavoring linked to lung disease.
Still, vapes expose people to fewer harmful chemicals than combustible cigarettes do, the CDC and other experts say. After all, most of the damage comes from the burning of these chemicals, not the chemicals themselves.
E-cigarette toxicity is poorly understood because the majority of ingredients have not been tested for “inhalation toxicology,” according to a statement from the American Heart Association. While many of the chemicals are on the FDA’s Generally Regarded as Safe (GRAS) list, they were initially included as food components, so their effects on health once inhaled are unknown.
The problem, too, is that it takes decades for smokers of any kind to develop a disease, and vapes have really only been around in the US since about 2007. It’s also hard to tease out e-cigarettes’ health effects because most studies have been done on adult users who were former or current cigarette smokers.
One 2022 study published in the American Journal of Respiratory and Critical Care Medicine found that vape users between the ages of 18 and 24, regardless of former cigarette use, were more likely to develop wheezing or any respiratory symptom within a year of use.
But studies don’t always capture the individual experience.
TJ Lind, a 27-year-old New Yorker, told us his health has improved since switching from cigarettes to Juul in 2017 after smoking a pack a day for over five years. “I get less winded when working out or climbing flights of stairs, everything tastes better, and the biggest thing I immediately noticed is that I got my sense of smell back, which I didn't even realize had mostly gone missing from smoking!” he said.
The Juul ban worries him, though, because if other e-cigarette companies face similar backlash, he’ll “feel forced to pick up regular smoking again.” In the meantime, Lind said, his doctor supports his switch to Juul, although they prefer he avoid tobacco products altogether.
Other medical professionals agree.
“Our goal for someone who wants to become tobacco independent is to get them off of all products so at the end of the day they’re just breathing in air,” Galiatsatos said. “I recognize we can have conversations over safety, but I'm a lung doctor, I don't want either of them going to the lungs.
“With that said, I hold no stigma or judgment; that's not my place or decision,” he said. ●