The astonishing popularity of the electronic cigarette brand Juul has spurred a "nicotine arms race," with e-cigarette and e-liquid manufacturers increasing their products' nicotine content to unprecedented levels, researchers said.
In a study in Tobacco Control, Robert K. Jackler, MD, and Divya Ramamurthi, MA, both of Stanford University in California, documented the proliferation of high-nicotine e-cigarette products and e-liquids following the financial success of Juul, which in less than 4 years has captured more than 70% of the e-cigarette market in the U.S., which is projected to reach $9 billion in 2019.
In an interview with MedPage Today, Jackler explained that before Juul entered the market, most e-cigarettes and vaping liquids had nicotine concentrations of no more than 1.5% to 2% (1.5-2 mg/mL), with 3%, nicotine vaping products are considered to have "super high" nicotine levels.
In June 2015, Juul entered the market with a novel e-liquid chemistry that utilizes nicotine salts instead of freebase nicotine and a nicotine content of 5% for most flavors sold.
"Basically they changed the formula to allow them to pack more nicotine into the [vaping] liquid without affecting the taste," Jackler said. "Juul is an amazingly efficient deliverer of nicotine. Each pod delivers around 200 puffs, and the company claims it releases a similar amount of nicotine as a pack of cigarettes."
He said the explosive growth in Juul use among adolescents, teens, and young adults -- which has been characterized as an "epidemic" by federal health officials -- has occurred with few young users recognizing the very high nicotine content.
In a recent online survey of Juul users ages 15 to 24, 63% said they did not even know the e-cigarette contained nicotine.
"There are now a ton of companies knocking off the pod-based Juul design, and there are also e-liquid bottles with 5% and 6% nicotine," Jackler said, calling the phenomenon a "nicotine arms race."
In their new study, Jackler and Ramamurthi conducted an online search to identify brands selling Juul copycat products and other e-cigarettes and e-liquids with nicotine concentrations of 5% and higher. Among the researchers' main findings:
- 14 brands marketed 15 Juul-compatible pods, with nicotine concentrations of up to 6.5%; most came in flavors that are considered attractive to youth
- 39 pod-based products (19 non-refillable, 17 refillable, and 3 disposable) came on the market after Juul's introduction
- The three disposable Juul-like devices offered nicotine strengths equivalent to or higher than Juul
- 71 U.S. e-liquid brands contained high-nicotine (≥5%) sold in bulk packaging (≥30mL)
Jackler said the recent proliferation of high nicotine concentration e-liquids sold in large-volume containers poses a new and under-recognized poisoning risk to young children, especially since many flavored vaping liquids are still packaged in ways that are highly appealing to children.
"There is a clear need to regulate the sale of higher-concentration nicotine solutions in now being sold in larger volumes," he said, adding that colorful bottles with images of fruits, desserts, and even cereal brands easily recognized by young children could be deadly to them.
He cited one example of a 30-cubic centimeter (cc) bottle of vaping liquid with 5.5% nicotine with a label resembling the breakfast cereal Fruit Loops. "One teaspoon would be enough to kill five toddlers, and the whole bottle would be enough to kill a preschool classroom," Jackler said. "My view is regulators should never allow 30-cc bottles of high-nicotine vaping liquid, let alone 30-cc bottles with pictures of gummy bears or Fruit Loops or brownies on them."
Child-resistant packaging for e-liquids is being required by an increasing number of American states, but with inconsistent standards and weak enforcement, Jackler and Ramamurthi noted in the study.
"While small quantities (≤1 mL) of concentrated nicotine solutions may be of lower risk when sold in hermetically closed pods, regulators should consider whether or not larger volumes of flavored high-nicotine liquids should remain allowed on the marketplace unfettered by regulation," the researchers wrote.
The researchers reported that they had no funding source or relevant relationships with industry related to the study.
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