BRUSSELS — The American agency in charge of public health, the US Food and Drug Administration (FDA), has banned the sale of Juul brand e-cigarettes in the United States. In the opinion of Pierre Bizel, PhD, a member of the Belgian National Coalition Against Tobacco, the intent of these products is above all to increase the number of smokers. There is no scientific evidence that e-cigarettes help eliminate tobacco consumption.

To justify its decision, the FDA determined that Juul Labs, with its USB stick-shaped vapes and its flavored nicotine refill cartridges, had not demonstrated that the marketing of its products was “appropriate for the protection of public health.” The San Francisco-based startup has been accused of having played a major role in the spike in vaping among adolescents, with ads and marketing campaigns targeting high school students in particular.

In 2021, Juul Labs paid $51,000 to devote the entire May-June issue of the American Journal of Health Behavior to the publication of 11 studies it had funded to demonstrate that its products helped smokers stop their tobacco consumption. Although all the articles had been peer-reviewed (a twelfth article was rejected), the legitimacy of the process was questioned by academics. The American Prospect described this edition as “taking academic corruption to a new level.”

A 2021 study that appeared in Tobacco Control revealed that fewer than half of the clinical trials sponsored by Juul Labs were published correctly. Facing pressure from the authorities, the company in 2019 suspended sales of the flavored refill cartridges that are popular among young people and agreed to review its marketing strategy.

MediQuality interviewed Bizel, who is also the lifestyle habits director at the Hainaut Health Observatory in Havré, Belgium.

MediQuality: So, is the Juul e-cigarette widely recognized today as a Trojan horse to lure young smokers?

Bizel: Absolutely. Of course, here in Belgium, the Juul product was pulled from the market in 2019. But it is clearly an e-cigarette and pod manufactured to appeal especially to young people. It looks like a USB stick and can be recharged on your laptop, with separate pods that offer different flavors. It is obviously designed to attract teens and young adults. This type of product is not targeted at responsible adult smokers looking for a way to quit.

These e-cigarettes can only serve to create dependency as early as possible and then increase the number of smokers. Like other products currently available, such as Puffs, the objective remains the same: these fluorescent or candy pink disposable e-cigarettes, which produce almost no smoke and are very discreet, have a very high nicotine content and hook the consumer into regular use. It is, after all, a product manufactured by nicotine sellers.

The Belgian Alliance for a Tobacco-Free Society considers e-cigarettes to be, first and foremost, devices for winning new customers. And, according to the recent opinion issued by the Belgian Superior Health Council on this subject, these are “not innocuous products.” They are not harmless products, and so young people need to be protected from them.

This device can certainly play a role in quitting [smoking], but only in a specific context, with support, as is required for any therapeutic weaning with the help of medication. Otherwise, effectiveness will be very low. Without counseling, without a physician, without behavioral support, relapse is almost certain. The device can be a tool, like many other tools, provided that it is used in a therapeutic context. Unfortunately, no manufacturer of e-cigarettes — Juul or any of the others — has applied for marketing authorization for this type of product for the purpose of eliminating tobacco consumption. Therefore, drug agencies from different countries have not been able to evaluate their possible positive effect on eliminating tobacco consumption and approve them.

Regardless of which aerosol resembling a cigarette might be presented, no manufacturer can say that these are devices to help quit smoking. The manufacturers are promoting the device as another way of smoking or an alternative, but it isn’t officially a tool to stop smoking. And we academics or researchers are the ones attempting to determine the possible virtues of a product that has not, in fact, been declared as an aid to stop tobacco consumption. There is ambiguity in this.

MediQuality: Would the only acceptable e-cigarette be a device with proven efficacy sold in a pharmacy?

Bizel: Yes, but that is not at all the goal of the manufacturers’ strategy. Their objective is to bypass the medical sector, the tobacco addiction specialists, and the ‘quit smoking’ helplines, and to have a consumer product that will produce the maximum number of nicotine-dependent smokers. They are not at all interested in becoming established in the therapeutic sector. That’s why we are clearly stating that the only guarantee of efficacy is for there to be supervision, tapered dosing, etc.

This is a market seeking long-term dependence, because there is no time limit for those who are currently using the product. It should also be pointed out that 70% of e-cigarette users also smoke regular tobacco, as shown by the national health survey conducted by the Belgian public health institute Sciensano and a survey by the Belgian Cancer Foundation. They are dual users. This raises questions about the efficacy of e-cigarettes as a way to stop smoking, because if they were so effective, their users would give up tobacco. In actual fact, e-cigarettes increase the total amount of nicotine ingested, which in turn increases the number of products in circulation and the manufacturers’ profits. If we look at the bigger picture, e-cigarettes are not changing anything in terms of cigarette sales, either in Belgium or on a global scale. The same amount of conventional tobacco is still being sold. And this new product enables manufacturers to profit on both counts.

MediQuality: Is the Juul e-cigarette gone for good?

Bizel: It would surprise me if the Juul e-cigarette were to come back on the market. But other e-cigarettes remain widely available. Another very interesting measure recently adopted in the United States is to reduce the amount of nicotine in each cigarette. The reduction is sizeable, since it amounts to 90% of the nominal content. That’s significant. But this reduction will have to be verified to make sure it has been implemented correctly, especially given the variety of types of nicotine — nicotine salt, freebase nicotine, etc. This measure should contribute considerably to the denormalization of cigarettes. The initiative is part of an ambitious health program aimed at reducing the number of deaths due to cancer, which US President Joe Biden has promised to decrease by 50% over a 25-year period. But there needs to be a reaction from the five big tobacco companies, so it’s not going to happen overnight.

This article was translated from MediQuality.

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