The founders of Juul, Adam Bowen and James Monsees, have famously said they came up with their product while taking a smoke break at Stanford University in the early 2000s. By mimicking the ritual of smoking without the tobacco, they hoped to create an attractive nicotine vehicle for adults who wanted to quit cigarettes. As smokers themselves, they bet they’d know how to appeal to adults who shared the addiction.
They were right: By 2018, Juul had taken over between 40% and 68% of the e-cigarette market, depending on how you count. But the company is set to take a fall in the wake of what health officials have started calling vaping-associated pulmonary illness, or VAPI for short. With over 800 cases and a dozen deaths tied to vaping, the US Centers for Disease Control and Prevention (CDC) says that all adults should “[refrain] from using e-cigarette, or vaping, products, particularly those containing THC.”
For the masses of nicotine-addicted vapers, though, that’s easier said than done. The response from some has reportedly been to smoke cigarettes as an alternate nicotine source—exactly the opposite of what health care providers want.
But many physicians wouldn’t recommend continuing to vape, either, especially right now. “There’s not a defensible posture to encourage anyone to use an e-cigarette until we understand what the component is that’s causing this epidemic rise in these [VAPI] cases,” says Enid Neptune, a pulmonologist at Johns Hopkins University. Going cold turkey is an option, but certainly not a pleasant or particularly easy one.
So if you shouldn’t get your nicotine fix with an e-cig or a combustible cigarette, then how?
Neptune recommends current smokers and vapers who are addicted to e-cigarettes turn to nicotine replacement therapies that have already been approved by the US Food and Drug Administration. These are supplies like nicotine patches, gum, or lozenges that are available without a prescription to those older than 18. There are also prescription nicotine inhalers and drugs, which may be covered by insurance.
These products are all pretty good at helping people quit smoking cigarettes—a meta-review published in 2018 found that all kinds of nicotine replacement therapies (NRTs) increase smokers’ chances of quitting by 50% to 60% compared to going cold turkey. There’s no data yet on how they fare when compared to e-cigarettes. In the absence of these studies, though, health care providers are likely going to recommend vapers turn to NRTs to quit. At least they’re known to be safer than cigarettes.
The challenge presented by these VAPI cases reflects a broad issue with nicotine addiction: People don’t really want to quit. “[Nicotine replacement therapies] are approved to treat tobacco use and dependence, so any medical product needs to provide a pathway go get off of nicotine,” Gregory Conley, the president of the American Vaping Association, said in an email to Quartz. Vape shops offer e-juices that start with higher levels of nicotine that taper off to none at all. But that’s not what customers really want, he said. “Many have no interest in quitting nicotine altogether, or fear that if they stop using nicotine they’ll relapse back to smoking.”
Juul advertises that each of its 5% nicotine pods are designed to mimic the smoking duration (200 puffs) and nicotine content of a pack of 20 cigarettes. But it’s not totally clear that vaping delivers nicotine in the same manner as smoking cigarettes. A smoke break usually involves one cigarette over about five to 10 minutes. With an e-cigarette, you can just keep going—which means it’s easier for vapers to take in more nicotine at once. “It’s like an endless supply of Skittles on your desk,” says Karen Wilson, a pediatrician at Icahn School of Medicine at Mount Sinai in New York.
All this amounts to the fact that vapers may have a harder time weaning themselves off of e-cigarettes than smokers would have quitting cigarettes. And those trying to switch to a patch, lozenge, or gum may additionally miss the physical habit that Juul was designed to provide.
The problem is especially gnarly for those under 18 who got addicted to nicotine by vaping e-cigarettes: Legally, they can’t get access to NRTs without a prescription (although stores selling them may not verify for age). There are a lot of teen vapers—in 2018, more than 3.5 million teenagers reported having vaped in the last month—who don’t have legal access to any other nicotine vehicles if they want to follow the CDC’s recommendation. “There’s no guidance,” says Neptune. Her colleagues who work with children addicted to nicotine have had to customize treatments for each of their patients.
Plus, given the fact that sweet flavors are so appealing to teenagers, they may be vaping more—and therefore taking in more nicotine—than they’d ever want to smoke. Wilson has heard reports of her colleague’s patients who smoke the equivalent of four packs of cigarettes a day, or can’t sleep through the night without vaping. “We don’t hear that about cigarettes,” she says.
For now, Neptune says, the most important thing for current vapers to do is to find a way to quit that doesn’t involve using cigarettes. “We’re in the midst of this public health crisis with these devices,” she says.