A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL Susan C. Walley, MD, CTTS,a Karen M. Wilson, MD, MPH,b Jonathan P. Winickoff, MD, MPH,c Judith Groner, MDd Electronic cigarettes (e-cigarettes) and vape devices have rapidly become the abstract most common tobacco products used by youth, driven in large part by marketing and advertising by e-cigarette companies. There is substantial evidence that adolescent e-cigarette use leads to use of combustible tobacco products. E-cigarette companies commonly advertise that e-cigarettes contain nicotine, flavoring chemicals, and humectants (propylene glycol and/or vegetable glycerin), but toxicants, ultrafine particles, and carcinogens have also been found in e-cigarette solutions and emissions, many of which are known to cause adverse health effects. Most major e-cigarette brands are owned by big tobacco companies that use similar marketing and advertising aDivision of Pediatric Hospital Medicine, The University of strategies to attract youth users as they did with traditional tobacco products. Alabama at Birmingham and Children’s of Alabama, Birmingham, Alabama; bDivision of General Pediatrics, Icahn In this review, we provide an overview of e-cigarettes and vape devices with School of Medicine at Mount Sinai and Mount Sinai Kravis an emphasis on the impact for the pediatric population. We describe the vast Children’s Hospital, New York, New York; cDivision of General Academic Pediatrics, Harvard Medical School and array of e-cigarette devices and solutions, concern for nicotine addiction, and Massachusetts General Hospital, Boston, Massachusetts; the scientific background on the known health harms. There are and dDivision of Primary Care, College of Medicine, The Ohio State University and Nationwide Children’s Hospital, accompanying visual depictions to assist in identifying these products, Columbus, Ohio including newer e-cigarette products and JUUL. Because current federal fi Dr Walley conceptualized and drafted the initial regulations are insuf cient to protect youth from e-cigarette use, exposure, manuscript and reviewed the final manuscript; Drs and nicotine addiction, there are recommendations for pediatricians and Wilson, Winickoff, and Groner assisted in pediatric health care providers to counsel and advocate for a tobacco-free conceptualizing and drafting the initial manuscript and reviewed the final manuscript; and all authors lifestyle for patients and families. approved the final manuscript as submitted. DOI: https://doi.org/10.1542/peds.2018-2741 Accepted for publication Jan 7, 2019 DEFINITIONS Thirdhand aerosol: The nicotine and Address correspondence to Susan C. Walley, MD, toxicants that are present in the CTTS, The University of Alabama at Birmingham, Combustible tobacco product: A ’ environment, mainly on surfaces, Childrens of Alabama, 1600 7th Ave South, McWane tobacco product that involves the Suite 108, Birmingham, AL 35233. E-mail: swalley@ burning of the tobacco leaf for from the emissions of an e-cigarette peds.uab.edu after use. inhalation. This includes PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, conventional cigarettes, cigars, JUUL: A brand name of an e-cigarette 1098-4275). cigarillos, hookahs, and pipe tobacco. that is shaped like a flash drive, has Copyright © 2019 by the American Academy of Electronic cigarette (e-cigarette) prefilled cartridges (“pods”) with Pediatrics aerosol: Although often referred to as solutions that contain a high FINANCIAL DISCLOSURE: The authors have indicated vapor, the emission of an e-cigarette concentration of nicotine, and is they have no financial relationships relevant to this is more accurately described as an available in many youth-appearing article to disclose. aerosol, a suspension of particles flavors. FUNDING: No external funding. in gas. E-cigarettes and vape devices are POTENTIAL CONFLICT OF INTEREST: The authors have Secondhand aerosol: The emissions handheld devices designed to deliver indicated they have no potential conflicts of interest of e-cigarettes that nonusing emissions for inhalation by heating to disclose. bystanders are exposed to, a solution that commonly contains mainly from what is exhaled nicotine, a humectant, and flavoring To cite: Walley SC, Wilson KM, Winickoff JP, et al. A by the user during use of the chemicals. For the purpose of this Public Health Crisis: Electronic Cigarettes, Vape, and JUUL. Pediatrics. 2019;143(6):e20182741 product. review, the term “e-cigarette” will be Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 143, number 6, June 2019:e20182741 STATE-OF-THE-ART REVIEW ARTICLE used; however, these devices are more commonly referred to by the public and users as vapes, pod systems, mods, and tanks as well as by brand names such as JUUL. In the scientific literature, e-cigarettes are commonly referred to as electronic nicotine delivery systems. Because they commonly contain nicotine, which is derived from the tobacco plant, e-cigarettes are tobacco products.1 The awareness, marketing, advertising, and use of e-cigarettes FIGURE 1 have dramatically increased E-cigarette components. (Adapted from E-Cigarette Use Among Youth and Young Adults: A Report of since their introduction into the Surgeon General. US Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Chronic Disease Prevention and Health Promotion; Office on Smoking the US marketplace. The e-cigarette and Health. Atlanta, GA: US Department of Health and Human Services; 2016:12.) was introduced into the US market from China around 2006, where it “ waspatentedasan electronic When a user inhales from the third-generation products to assist in ”2,3 atomizing cigarette. By 2010, mouthpiece, the heating coil is describing their wide variability there were several brands of activated to aerosolize the e-cigarette (Fig 2). The first-generation e-cigarettes that were sold in US solution to form an emission, e-cigarette products usually have the 2 markets. In 2011, e-cigarettes were which is best described as an appearance of a cigarette and are added to the National Youth aerosol but is commonly called referred to as “cigalikes.” First- Tobacco Survey (NYTS) on tobacco- a vapor. A video clip showing the generation e-cigarettes are often product use, and since 2014, the use of an e-cigarette can be found disposable or have a reloadable e-cigarette has been the most online.5 cartridge for repeated uses. Second- frequently used tobacco product generation e-cigarettes are known as 4 by youth. There have been substantial changes vapes or vape pens and have and evolution of e-cigarettes, and arefillable reservoir for the electronic thus e-cigarette devices have often cigarette liquid (e-liquid). Third- E-CIGARETTE DEVICES AND been described as first-, second-, and generation e-cigarettes are frequently CONSTITUENTS referred to as “mods” or tank systems Basic Operation because the wattage and voltage can be modified. More recently, there has fi Part of the dif culty in the research been a wave of products that bear no and regulation of e-cigarettes is the resemblance to traditional cigarettes diversity and rapid change in or even previous generations of nomenclature, design, and technology, e-cigarettes, which, for purposes of not only of the devices but also in the this review, will be referred to as e-cigarette solution. Despite this fourth-generation e-cigarettes. variation, the majority of these Fourth-generation products are products have similar design sold under the names JUUL (Fig 3), characteristics, which include the FIGURE 2 Suorin, and SMPO. following components (Fig 1): E-cigarette design variability. Seen on the far 1. a mouthpiece; left is a conventional cigarette. The earlier E-cigarette Solution fi e-cigarettes ( rst generation) have a similar E-cigarette solutions, often known as 2. a sensor or user-actuated button shape as a conventional cigarette (second, to activate the heating coil (seen in third, and fourth from the left). The second- e-juice or e-liquid, are even more Fig 1); generation e-cigarettes (fifthandsixthfrom diverse than the devices. The the left) have refillable clear reservoirs for solutions are commonly advertised as 3. a battery; the e-liquid and are often known as vape containing 3 types of chemicals: pens. The third-generation e-cigarettes (far 4. a heating coil or atomizer; and 2 right) often have the ability to modify wattage a humectant, nicotine, and flavors. 5. a reservoir or tank. and voltage and are thus known as mods. The 2 humectants used most often Downloaded from www.aappublications.org/news by guest on September 28, 2021 2 WALLEY et al Glucose, fructose, and sucrose Additional JUUL pods can be levels were also detected in 22% to purchased in packs of 4 for 53% of a set of e-liquid samples.11 $15.99.17The JUUL website reports Other substances, such as marijuana their mission is to "improve the lives and methamphetamine, can also be of the world's one billion adult vaped from some e-cigarette smokers by eliminating cigarettes."18 devices.12 They state on their Web site that they do not sell to youth ,21 years of age; JUUL and Other Vaping Products however, previous marketing campaigns were clearly targeted at JUUL is a brand of e-cigarette a youthful demographic, and the that has recently received significant flavors are appealing to youth. In FIGURE 3 media attention because of its December 2018, JUUL sold a 35% JUUL and JUUL pods. rapid uptake by adolescents.13 stake to the tobacco company Altria, Part of the appeal of JUUL is formerly known as Philip Morris, for the small sleek shape and the $13 billion, evoking additional are propylene glycol (PG) and ability to use the device concerns about the company’s vegetable glycerin; both are generally surreptitiously. The JUUL device strategy to address use by recognized as safe for ingestion, looks like a flash drive (Fig 3) and teenagers.19 but there is little evidence about is rechargeable via a USB port.7 their safety for long-term inhalation.