Bowen and Monsees said they wanted to help smokers “move past cigarettes” with a “whole new experience that retains the positive aspect of smoking, like the ritual and everything, but makes it as healthy and socially acceptable as possible.”

After graduation, the pair launched two products, Ploom and Pax, for vaporizing loose leaf tobacco and cannabis, respectively. In 2015, they began focusing on a device for vaporizing liquid nicotine, or e-juice, and so was born the Juul. (Around this time, they also sold the Ploom brand to Japan Tobacco). In 2017, Juul Labs spun off Pax to become a separate company and hired Kevin Burns of Chobani to be CEO of Juul. In 2018—the same year that Juul accounted for some 66% of Nielsen-tracked e-cigarette sales in the US—they sold a 35% stake in the company to Altria. Today, as youth vaping in the US reaches what the FDA has called “epidemic” proportions, Monsees says that Juul “never wanted any non-nicotine users, and certainly not anyone underage.”

THE BIG QUESTION

Are e-cigarettes really less unhealthy than cigarettes?

Benowitz at the University of California is satisfied that they are—but, he concedes, a cigarette sets a pretty low bar. “There’s hardly anything that’s as harmful as a cigarette, in terms of the number and the concentrations of different toxins in cigarette smoke,” he says. “There’s no way that an e-cigarette is going to be as toxic.”

That said, e-cigarettes contain a cacophony of chemicals. One common ingredient, diacetyl, imparts a buttery flavor to e-juice, but has also been known to impart a condition called bronchiolitis obliterans. This incurable lung-obstructing disease got its nickname, “popcorn lung,” after workers in a microwave-popcorn manufacturing plant where diacetyl was used for flavor developed the condition. Benowitz says that most “legitimate” e-juice manufacturers are avoiding diacetyl, and that toxic flavorants like it could be regulated for safety.

E-cigarettes also often contain metal coils, which could impart particles of contaminants such as cadmium, chromium, or lead when heated. And some common carrier liquids, such as propylene glycol and glycerin, can also become toxic when thermally degraded—producing, for example, formaldehyde. Benowitz, who is currently studying the distinction between low- and high-voltage e-cigarettes to test his hypothesis that the higher-voltage variety are more hazardous, does note that these toxins, or “thermal degradation products,” are much lower with e-cigarettes than with regular smoking.

And these are just a few of the many potential contaminants. As vaping proliferates, so do sources of e-juice—and cannabis oil for vaping—with sketchy origins and unknown contents. As of Sept. 6, 450 cases of vaping-related respiratory illnesses had been reported across 33 US states, and health officials have in the past two months announced what are believed to be five vaping-related fatalities. State and federal officials attribute at least some of those to an oil derived from vitamin E that was used in vaped cannabis products, but a report by the Centers for Disease Control and Prevention (CDC) noted that “no consistent e-cigarette product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to pulmonary disease in patients.” The CDC has advised that people not use e-cigarette products while the investigation is ongoing. New York state’s health commissioner issued similar guidance.

Oh yes, nicotine

In addition to those many chemicals, the operative ingredient in most e-cigarettes—their raison d’etre—is the same as in old-fashioned cigarettes: nicotine. And although nicotine, a stimulant that occurs naturally in tobacco plants, doesn’t directly cause most of the harm associated with cigarettes, addiction to nicotine is what keeps smokers coming back. It’s powerful stuff.

Nicotine is known to have cardiovascular effects—narrowing the blood vessels and increasing heart rate and blood pressure. (Fun fact: It was used as an insecticide as early as the 17th century, but has since been left behind in favor of “more potent pesticides that are less harmful to mammals.” Ouch.)

It also gets into our heads. Inhaling nicotine sends it from the lungs to the blood to the brain within seconds. Once there, it has a variety of effects—many of them pleasurable, whether that’s calming an anxiety-ridden smoker or waking up a drowsy one. Nicotine triggers the release of dopamine, which can help regulate our mood and behavior, and frankly, feels good. This all contributes to nicotine’s highly addictive and risky nature—and even more so for people whose brains are still developing.

Exposure to nicotine during adolescence, which researchers describe as “an age of explosive development of both emotional and cognitive sides of the mind,” increases the risk of developing memory and attention impairment, as well as a variety of mental and behavioral problems—major depressive disorder, agoraphobia, and panic disorder among them. It’s also easier for adolescent brains to form habits than older brains.

So perhaps it shouldn’t surprise us that the e-cigarette (yes, that one) that has led to vape detectors in school bathrooms also contains among the highest levels of nicotine.

Rhymes with cool

The e-juice contained in a Juul pod, at 5% nicotine by weight, is among the strongest on the market. And yet, because it’s formulated with benzoic acid to lower the pH, “it’s easier to inhale, especially for a non-smoker,” says Benowitz.

And therein lies the problem with Juul. It’s wildly popular with a population that wasn’t smoking before: kids. In 2018, 21% of US high schoolers reported using e-cigarettes in the past 30 days, up from 1.5% in 2011, according to data from the CDC. Much of that increase since 2016 has been thanks to Juul’s popularity.

“I definitely consider this to be Big Tobacco 2.0,” says Bonnie Halpern-Felsher, a developmental psychologist and professor of pediatrics at Stanford University, who is the founder of the Tobacco Prevention Toolkit. “Kids weren’t smoking in this generation. They think cigarettes are gross. It’s not that e-cigarettes stopped us from having a generation of people addicted to cigarettes. They weren’t going there. We would have a generation maybe using marijuana or something else, but certainly not addicted to any tobacco product. And it’s because of e-cigarettes that that’s happening.”

Juul would insist that this is all unintentional, and that their market is cigarette smokers. “Don’t vape,” CEO Kevin Burns said on CBS This Morning in August. “Don’t use Juul. Don’t start using nicotine if you don’t have a pre-existing relationship with nicotine. Don’t use the product. You are not our target consumer.”

Perhaps not anymore, but a Stanford study (pdf) of the company’s advertising practices in 2015 and early 2016 shows a pop-colored campaign unfolding at music festivals, hip hotels, and parties—not to mention on Twitter and Instagram—with women in short shorts and red lipstick giving out free samples and fresh-faced models smiling on ads with the phrase “smoking evolved.”

Juul has since shut down its social media accounts—part of its apparent effort to reduce the appeal to kids—but the company doesn’t need them anymore. For a generation primed to love devices, Juul has basically created a nicotine-loaded iPhone.

In a 2018 tour de force about the rise of Juul among teens, the New Yorker’s Jia Tolentino pointed out that “Juuling and scrolling through Instagram offer strikingly similar forms of contemporary pleasure. Both provide stimulus when you’re tired and fidgety, and both tend to become mindless tics that fit neatly into rapidly diminishing amounts of free time. (You can take two Juul hits and double-tap a bunch of pics in about 10 seconds. You need an inefficient five minutes to burn a paper tube of tar and leaves into ash.)”

“It’s cool, it’s sleek, it’s stealth,” says Halpern-Felsher, who specializes in adolescents. “Young people in particular are using them just like when we pick up our phone constantly … 15 or 100 times a day without even realizing it.”

When I ask Halpern-Felsher whether she considers e-cigarettes to be a safer alternative to cigarettes, she responds: “Ooooh! The million-dollar question!

“If you’re talking about youth then there’s no comparison, because youth aren’t smoking cigarettes,” she says. “So it’s not a comparison of cigarettes versus e-cigarettes. It’s really a comparison of e-cigarettes versus fresh healthy air.”

RISK VS. REWARD

The risk-benefit analysis

Of course, the question of whether growing, non-smoking children are better off without access to e-cigarettes is an easy one. But for smokers who have struggled to quit, the issue is far more complex. Although even Juul executives admit that the long-term effects of e-cigarettes are unknown, researchers still laud their potential to wean smokers off cigarettes.

“I believe if we fully embrace harm reduction, we could make cigarettes obsolete in 10-15 years,” David Abrams, a professor at New York University’s College of Global Public Health, told CNBC in the July documentary Vaporized: America’s E-cigarette Addiction.

In a 2018 study, Abrams wrote that e-cigarettes have the potential to fall in a “sweet spot” for smokers, where high satisfaction and appeal intersect with reduced harm. Which is to say, even if a nicotine patch, lozenge, or gum is safer, they only work if smokers switch to them and then stick with them, or manage to quit entirely. (A recent study showed that about 14% of smokers using a single one of these methods were able to quit for six months or longer.)

This calculus echoes Big Tobacco’s messaging about “reduced risk” products. PMI, let us not forget, is here to “unsmoke the world” with the IQOS. “My objective is to replace cigarettes with the alternatives,” the company’s COO told Quartz in August.

When a city like San Francisco bans the sale of e-cigarettes, as its Board of Supervisors unanimously voted to do in June, it understandably sends a message that decision-makers are more concerned about children’s health than smokers’. But Benowitz points out that the “benefit versus risk equation”—the benefit of converting cigarette smokers to e-cigarettes, weighed against the risk of children vaping—depends on the smoking prevalence where one lives. In San Francisco, the adult smoking rate is 10%, compared with a national rate of 14% as of 2017. In a place like, say, Calhoun County, West Virginia, where an estimated 23% of adults smoke, removing access to safer alternatives could be devastating.

It’s also a socioeconomic issue, which means e-cigarette crackdowns can play into a narrative that the government is run by elitists who are out of touch with poor people’s problems—nicotine addiction among them. In the US, only 6.5% of college graduates smoke, compared with 27.3% of those who didn’t finish high school. And more than 25% of people with household incomes under $25,000 per year smoke, compared with less than 10% of those who earn incomes above $75,000.

Where are the regulators?

Of course, the San Francisco Board of Supervisors wouldn’t have to make this cost-benefit analysis at all if e-cigarettes were better regulated at the federal level.

“There really isn’t regulation,” says Azim Chowdhury, a regulatory attorney who has focused on tobacco law for the past decade, and counts mid-size vape companies among his clients.

The FDA has only regulated tobacco products since 2009, when Barack Obama signed the Tobacco Control Act into law—and that law only expanded to include what the FDA calls “electronic nicotine delivery systems,” or ENDS, in 2016. Even then, the FDA didn’t proceed with what Chowdhury describes as “basic rule-making” for e-cigarettes. For example, “there are no standards on what can be used or can’t be used in the e-liquid,” he says.

Under the TCA, e-cigarette (and e-juice) manufacturers do have to disclose their ingredients to the FDA. They must also adhere to the same rules and restrictions as cigarette manufacturers—for example, they’re not allowed to sell their products to minors, and they have to include warning labels on packaging. (“This product contains nicotine,” reads the warning on a Juul. “Nicotine is an addictive chemical.”)

But one rule that didn’t extend from cigarettes to vape products is the ban on fruit and candy flavors. While Michigan this month became the first US state to ban flavored nicotine vaping products, most people can still vape green apple candy, cookies-and-cream, and “holy cannoli” e-juice. (Fun fact: In 1963, a Pennsylvania inventor patented a battery-powered “smokeless non-tobacco cigarette” which heated liquid to allow users to “smoke their favorite food.”)

Anti-smoking activists point out that such flavors appeal to kids, while manufacturers argue they help ensure smokers’ adoption of vape products over cigarettes. In November, just before then-FDA commissioner Scott Gottlieb announced a plan to crack down on “kid-appealing flavors,” Juul pulled its mango, fruit, creme, and cucumber pods from retail stores, part of its “action plan” to reduce youth access and appeal. The flavors are still available on Juul’s website, where buyers go through an age-verification process that requires two-factor authentication and a social security number or photo ID.

Even with some protections in place, it’s clear that these products were widely accessible—and became wildly popular—before officials had the framework to regulate them, not unlike how city streets filled with Uber cars and Bird scooters before lawmakers figured out how to download the apps.

The 2016 update that added e-vapor products to the Tobacco Control Act also added a requirement that all ENDS manufacturers would have to submit applications called “premarket tobacco applications,” demonstrating a public health standard evaluating risks and benefits to smokers and non-smokers alike. Products already on the market were first given an August 2018 deadline for those applications. In July 2017, Gottlieb—then a new Trump appointee—extended the deadline to 2022. Public health organizations sued the FDA for delaying the reviews, and the deadline was moved to May 2020, a date Chowdhury says has left his clients scrambling to complete clinical studies required to satisfy the standards.  (Gottlieb resigned from his post at the FDA in March.)

And those are just the companies who want to play by the rules.

Vapor madness

Many of the recent stories of respiratory illness landing vapers in hospitals likely involve illicit products, according to CDC officials, who say that victims reported using both nicotine products and those they believed to contain cannabis-derived THC. It’s highly possible those products came from the black market—especially in Kings County, California, where several patients reported buying products from “pop-up shops.” Health officials are likewise focusing investigations on possible contaminants, rather than common e-juice ingredients.

“The patients had switched from regular retailers to the pop-up shops,” Nancy Gerking, Kings County’s assistant director of public health, told the Washington Post. Because they “found a difference between the potency of the products … they had to use twice as much, so they were taking twice as much of the product into their lungs.”

With harrowing reports of the teen craze for vaping and terrifying images of wheezing patients in hospital beds, it’s little wonder that concerned citizens—especially parents—are desperate for more restricted access. But critics say blanket bans like the one in San Francisco could do more harm than good, driving vapers back to cigarettes, or fueling an unmonitored black market. Says Chowdhury, “When has prohibition ever really worked?”

Big Tobacco 2.0 

While researchers work to learn more about these widely varied products’ long-term effects, Juul has embarked on a lobbying campaign that one senior congressional aide called “just crazy” in its scale. It’s buying full-page advertisements in the New York Times and putting its executives on network television to establish its position as a crusader against underage vaping.

An optimistic read of the industry’s current US status, whereby legitimate players are scrambling to complete studies and submit authorization forms to legally sell their products in a more regulated market, would be that the FDA is working hard and fast to keep Americans safe. A cynical read might be that the damage is done. An entire generation that had little use for cigarettes is now attuned to a hip, addictive alternative, and even an accelerated timeline for regulation can’t keep pace with the snowballing reports of health issues connected to vaping, or contend with the black market. When regulations do kick in, it’s highly possible that only companies with lots of lawyers, scientists, and lobbyists will have the resources to comply, paving the way for Big Tobacco 2.0. (PMI’s IQOS was the first ENDS product to receive a premarket tobacco application.)

It’s true that many researchers agree e-cigarettes and heated tobacco products are safer than cigarettes. But it’s also true that consumers have every reason to suspect tobacco companies of selling dangerous products, marketing them to children, and lying about their harmful effects. After all, they’ve done it before.