Description Read the attached case "JUUL and the Vaping Revolution". Review the article from (http ...
Description Read the attached case "JUUL and the Vaping Revolution". Review the article from (https://www.vox.com/2019/1/25/18194953/vape-juul-e...) about the marketing of JUUL, which includes images of its marketing campaigns. By early 2020, several states had sued JUUL. Read the article from (https://www.cbsnews.com/news/juul-ads-nickelodeon-cartoon-network-lawsuit-claims-2020-02-12/) about Massachusetts' lawsuit regarding JUUL's marketing to underage customers. In an APA-formatted paper of at least 4 pages, not including the cover page and references, discuss the following: Is there an ethical problem with JUUL's marketing tactics? Use the ethical marketing issues framework on pg. 291 of the textbook in your analysis. The U.S. Federal Trade Commission regulates advertising on the basis of two criteria: deception and unfairness. Is JUUL's marketing deceptive and unfair? Explain your reasoning. What should JUUL do regarding its marketing tactics? What ethical concepts lead to this recommendation? UNFORMATTED ATTACHMENT PREVIEW 9 - 6 1 9 -0 0 6 REV: JAN UARY 11, 2022 MICHAEL W. TOFFEL JOHN MASKO SARAH MEHTA JUUL and the Vaping Revolution Our Mission[:] Improve the lives of the world’s one billion adult smokers. — JUUL Labs’ Mission Statement (August 2018) 1 In November 2019, K.C. Crosthwaite had been CEO of San Francisco-based e-cigarette startup JUUL Labs for two months. A former VP at cigarette maker Altria Group (Altria), Crosthwaite had come to JUUL Labs to tackle challenges that had emerged since Altria invested $12.8 billion in December 2018 to acquire 35% of the company. 2 After launching in 2015, JUUL Labs’ flagship e-cigarette product had quickly become the undisputed face of the industry. The JUUL’s sleek look, appealing flavors, and novel nicotine delivery system had proven to be a powerful combination. JUUL Labs had quickly become the face of the rapidly growing e-cigarette industry, as it encouraged adult smokers to switch from combustible cigarettes to the JUUL—a less harmful alternative. Given JUUL’s success, Altria CEO Howard Willard called the company “a world leader in switching adult smokers” and referred to its products as “the best way to achieve tobacco harm reduction.” 3 By 2018, JUUL Labs reported $1 billion in revenue and claimed 70% of the e-cigarette market. 4 Troublingly, however, the JUUL’s popularity extended beyond adult smokers. Many teens (and a growing number of pre-teens) who had never smoked had begun “Juuling.” Amid uproar from parents and accusations that JUUL Labs had intentionally marketed to minors, several municipalities banned the sale of flavored e-liquids, and in some cases, all e-cigarettes. In the months preceding Crosthwaite’s appointment as CEO, JUUL Labs’ problems had only intensified. In April 2019, public health officials identified a mysterious spate of respiratory illnesses linked to several non-JUUL vaping e-liquids. 5 Concurrently, new research from the U.S. Centers for Disease Control and Prevention (CDC) indicated that more than a quarter (27%) of high school students were using e-cigarettes, nearly double the rate of just two years earlier, 6 causing alarm among parents, many health professionals, and growing pressure among regulators at the local, state, and federal levels. When JUUL Labs announced Crosthwaite’s appointment as CEO that September, the company also announced it was suspending all product advertising in the U.S. and that it would not lobby against possible federal regulations that would ban flavored e-cigarettes. 7 Just a few weeks later, Altria impaired the value of its JUUL Labs stake by $4.5 billion, nearly 30% of its investment. 8 And in November 2019, a report indicated that certain e-cigarette flavors, notably mint, were driving teen use. 9 “These results are unacceptable,” said Crosthwaite, “and that is why we must reset the vapor category Professor Michael W. Toffel and Case Researchers John Masko and Sarah Mehta (Case Research & Writing Group) prepared this case. This case was developed primarily from published sources. Funding for the development of this case was provided by Harvard Business School and not by the company. HBS cases are developed solely as the basis for class discussion. Cases are not intended to serve as endorsements, sources of primary data, or illustrations of effective or ineffective management. The authors acknowledge the assistance of Dr. Jonathan Winickoff, Massachusetts General Hospital, in providing information contained in the sections, “The Rise of the JUUL” and “Health Impacts of E-Cigarettes.” Copyright © 2019, 2020, 2022 President and Fellows of Harvard College. To order copies or request permission to reproduce materials, call 1-800545-7685, write Harvard Business School Publishing, Boston, MA 02163, or go to www.hbsp.harvard.edu. This publication may not be digitized, photocopied, or otherwise reproduced, posted, or transmitted, without the permission of Harvard Business School. This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. 619-006 JUUL and the Vaping Revolution in the U.S. and earn the trust of society by working cooperatively with regulators, attorneys general, public health officials, and other stakeholders to combat underage use.”10 As part of this “reset,” Crosthwaite announced that JUUL Labs would temporarily suspend all sales of mint pods and other flavors aside from tobacco and menthol. If the company was unable to reduce youth usage, it risked being unable to serve the adult market in the United States, as it would soon need Food and Drug Administration (FDA) approval to continue selling in the U.S. As JUUL Labs’ challenges mounted, Crosthwaite needed to decide how to reposition the company to achieve its mission of improving the lives of adult smokers. The E-Cigarette Industry Cigarette smoking had been popular in the U.S. since the early 20th century. At its peak in 1965, 42% of Americans used cigarettes. 11 Amid mounting evidence linking smoking to lung cancer and other health problems, those numbers declined over time, reaching 13.7% by 2018, though they remained higher in many other countries. 12 The main factor preventing smoking rates from falling further was the extreme addictiveness of nicotine, a chemical found in the tobacco leaf. Smoking cessation products, like nicotine skin patches and chewing gum containing nicotine, focused on satisfying smokers’ nicotine addiction without the harmful effects of inhaling the smoke and toxins produced by combustible cigarettes. The e-cigarette was first developed in China in the early 2000s by pharmacist and longtime smoker Hon Lik. Whereas combustible cigarettes burned tobacco to release nicotine, e-cigarettes used a heating coil to vaporize a liquid containing nicotine that the user then inhaled (or “vaped”). E-cigarettes came in four main types: cig-alikes, vape pens, vape mods, and pod mods (see Exhibit 1 for photos). All shared three major components—(1) a battery, (2) a chamber containing e-liquid (the nicotine solution); and (3) an atomizer that heated and vaporized the e-liquid. 13 E-cigarettes achieved early success in China and arrived on American shores in 2006.14 The three biggest tobacco companies in the U.S., Altria, Reynolds, and Lorillard, soon took an interest in the nascent e-cigarette market and started their own brands. As sales of the major tobacco companies’ ecigarettes rose in the early 2010s (see Exhibit 2), some customers came to prefer e-cigarettes that gave them more control over the amount of nicotine and flavor concentration delivered in each “hit.” In response, several boutique e-cigarette makers emerged along with a new vape shop retail industry, which spurred innovation in e-cigarette technology. By 2014, as many as 7,765 unique e-liquid flavors were on the market, along with 466 brands of e-cigarettes. 15 One of these innovators was PAX Labs, which introduced its popular JUUL e-cigarette in 2015 (see Exhibit 3). While e-cigarettes were initially sold online and at promotional booths in shopping centers, by the late 2000s, sales had shifted toward convenience stores and retailers, where they took up shelf space alongside combustible cigarettes. 16 By the mid-2010s, distribution of e-cigarettes had again shifted, this time toward local vape shops and smoke shops—single locations or small chains that acquired products from regional suppliers. By 2018, nearly one-third of e-cigarette products (devices, e-liquid refills, and other components) were sold by vape shops; another third were sold by convenience, food, and drug retail stores; and the remaining third were sold online. 17 The U.S. represented around 40% of the global e-cigarette market, a figure six times larger than second-place Japan. The U.K. occupied third place. 18 According to one source, the global population of adult vapers surpassed 40 million in 2018.19 2 This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. JUUL and the Vaping Revolution 619-006 E-Cigarette Users in the U.S. According to a 2018 poll, roughly 9% of the 200 million adults in the U.S. used e-cigarettes “regularly or occasionally,”20 while 13.7% of U.S. adults regularly smoked cigarettes. 21 Adults vaped for a range of reasons. One study reported that nearly half of vapers (46%) were ex-smokers who had given up smoking altogether, that 8% had never smoked before, and that the remaining 47% were “dual users” who both smoked and vaped. 22 By 2019, some 5.3 million middle and high school students in the U.S. (10.5% of middle school students and 29% of high school students) used e-cigarettes, including nearly one million daily users (see Exhibit 4). 23, 24 Non-tobacco flavors were important to young users, with 81% of 12- to 17-year-olds who had ever used e-cigarettes reporting that the first e-cigarette they tried was non-tobacco flavored (e.g., menthol, mint, fruit, candy, etc.). 25 Similarly, 76% of adults who frequently used e-cigarettes in 2015-2016 reported that the first e-cigarette they tried was non-tobacco flavored, up from 54% before 2011. 26 Marketing Early E-Cigarettes Early e-cigarette advertising, like sales, took place mostly online. By the early 2010s, however, as the industry moved into the hands of the major tobacco companies, advertising migrated to traditional channels, including magazines and television. (Because e-cigarettes were not deemed tobacco products at that time, they were not subjected to the U.S. tobacco product ban on television ads). 27 In 2010, local vape shops started to become major advertisers; between 2010 and 2012, advertising spend on smoking accessories rose from $2.7 million to $20.8 million. 28 Using television, radio, and print advertisements, vape shops appeared freer than the major U.S. tobacco companies to market to younger adults, often locating stores near college campuses and offering student discounts. 29 Vape shops and equipment companies were social media savvy, frequently advertising on Twitter. 30 Many industry observers claimed that e-cigarette companies’ advertising followed the playbook of their cigarette forbears, using ads to glamorize e-cigarette use, associate it with free choice and openness, and portray it as scientifically cutting-edge. They also touted its health benefits over smoking. 31 Some 10% of the ads for three common e-cigarettes were set in a club or party atmosphere, according to one study. 32 Some ads promoted cig-alike products as a way to rebel against an imposed smoke-free culture. 33 E-cigarettes were also marketed as more healthful than cigarettes and as potential smoking cessation tools. 34 Vape shops appeared even more brazen in youth marketing, with some posting advertisements for “back to school sales,” or advertising e-liquid flavors like “gummi bear.” 35 By 2014, 70% of middle and high school students had seen an e-cigarette advertisement. 36 The Rise of the JUUL The JUUL e-cigarette was the brainchild of product designers Adam Bowen and James Monsees, who met in the early 2000s while in graduate school at Stanford. In 2007, the duo founded a company called Ploom aimed at developing a customizable e-cigarette. 37 A Silicon Valley start-up, Ploom branded itself as the technology sector’s answer to the vaping boom or, as some put it, “the Apple of vaping.” 38 In 2012, Ploom released the Pax, a vaping device that could be used with either tobacco or marijuana. 39 The product’s packaging and appearance resembled the iPod. In 2015, Japan Tobacco International acquired the Ploom brand and Bowen and Monsees rebranded their company to PAX Labs and released the JUUL product.40 Designed for nicotine vaping, the JUUL e-cigarette resembled a long USB flash drive, charged via USB port (refer to Exhibit 3 for a photo). The JUUL used heat powered by a rechargeable battery to vaporize its e-liquid, held in small replaceable “pods.” The device’s inhalation sensor and heating element were combined in one component so that 3 This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. 619-006 JUUL and the Vaping Revolution inhalation activated the heating element to vaporize the liquid, a design JUUL Labs had patented. Unlike most e-cigarettes, the JUUL was discreet, concealable, and created a modest vapor cloud. 41 Consumers embraced the JUUL e-cigarette. Sales revenues quadrupled from $60 million in 2016 to $245 million in 2017, with gross margins around 70%. 42 In 2017, PAX Labs spun off JUUL Labs, a private company run by Bowen and Monsees. 43 The two hired Kevin Burns, formerly COO of Chobani, as JUUL Labs’ CEO, and undertook a $150 million financing round in late 2017. 44 In June 2018, the company announced that it was seeking $1.2 billion in venture capital, valuing it at $15 billion. 45 JUUL Labs’ e-cigarette unit market share reached 30% by 2018 (see Exhibit 5a). By 2019, its U.S. sales through retail outlets (not including online sales) reached $3.8 billion, and its dollar market share exceeded 70% in some months (see Exhibit 5b). 46 A major factor driving JUUL’s popularity was the chemistry of its e-liquid. E-cigarette makers had long struggled to develop products that could deliver the satisfying nicotine high provided by combustible cigarettes. 47 JUUL Labs introduced a unique pod formula that combined nicotine with benzoic acid—a process that increased the intensity of the “hit” while being gentler on the throat. 48 By rapidly delivering more nicotine to the bloodstream than other e-cigarettes, JUUL Labs’ patented technology better mimicked the experience of smoking cigarettes than did competing products. 49 In 2018, JUUL Labs sold eight flavors of JUUL pods to U.S. consumers: Virginia Tobacco, Classic Tobacco, Mint, Menthol, Fruit Medley, Mango, Cucumber, and Crème. 50 All contained 5% nicotine and five ingredients: glycerol, propylene glycol, nicotine, benzoic acid, and “food-grade flavoring.” 51,52 Starting in August 2018 Virginia Tobacco and Mint were also available with 3% nicotine, 53 allowing smokers “to explore what is best for them.” 54 When JUUL crossed the Atlantic in 2018, EU regulations forced the company to create 1.7% nicotine pods for the U.K., where it sold a similar set of flavors. 55 JUUL Labs sold its devices to new users in starter packs (which contained a JUUL device, a USB charger, and four different flavors of JUUL pods), retailing on the company website for $49.99.56 According to the company, each 5% nicotine pod provided the same amount of nicotine as a pack of cigarettes (20 cigarettes). 57 JUUL Labs sold four-packs of pods for $15.99, making the $3.99 cost of an individual pod cheaper than a pack of cigarettes, which ranged from $5.25 to $12.85 in the U.S. depending on state taxes. 58 Other companies sold JUUL-compatible pods in different flavors with nicotine strengths ranging from 4.0% to 6.5%. JUUL-compatible pods ranged from $2.50 to $3.00 each.59 JUUL Customers Data on JUUL’s customer base was sparse. In 2018, JUUL Labs sent a survey to nearly 89,000 people in the U.S. who had purchased from the JUUL online store, offering users $30 to complete the survey.60 Out of nearly 19,000 adult respondents, 87% reported being current or former smokers when they first tried JUUL; the remaining 13% had never smoked. Some 64% of respondents who had smoked cigarettes when they first tried JUUL reported that they had quit. Of JUUL users who were still smoking at the time of the survey, over half (56%) reported that they had cut their daily cigarette consumption in half. 61 Some experts questioned these results. Harvard Medical School Professor of Pediatrics Jonathan Winickoff, M.D., MPH noted that the study did not reveal how online store visitors were encouraged to complete the survey and that the analysis dropped respondents under age 21. Teen JUUL use Starting in 2016, a growing number of high school administrators became alarmed that use of the JUUL was rapidly gaining popularity among teens (refer to Exhibit 4). Surveys in 2018 reported that 25% of 15- to 24-year-olds recognized a JUUL in a photo and that 63% of 15–24year-olds were unaware that JUUL contained nicotine. 62, 63 By 2019, 59% of high school e-cigarette users stated that JUUL was their “usual brand.”64 On social media outlets including Snapchat, Instagram, 4 This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. JUUL and the Vaping Revolution 619-006 and YouTube, videos surfaced of students surreptitiously juuling in class or doing vaping tricks like “ghosting” (in which the user inhaled the vapor, exhaled it, and then inhaled it again). A Boston Globe article headline read: “‘Juuling’: The most widespread phenomenon you’ve never heard of,” and quoted a high school student describing JUUL’s allure: “It gives you a head rush. . . . The flavors are good. You can do tricks with it. You can ghost it. It looks cool.” 65 Many high schools were struggling with JUUL’s rapid ascent among their students. One Vermont private high school administrator wrote: “I don’t recall any fad, legal or illegal, catching on in this way. Ninety-five percent of the disciplinary infractions we dealt with in the fall and continue to deal with into the spring are all connected to the JUUL.” 66 A Washington, D.C.-area school reportedly removed the doors from its bathroom stalls to prevent students from juuling there, and teachers across the country complained of students vaping in class, exhaling into their shirts to avoid detection. 67 In some high schools and colleges, the JUUL inspired a cult following and even fan literature, with article titles like “The JUUL Manifesto” or “Who needs a boyfriend when you have a JUUL?”68 Distribution Like other e-cigarettes, JUUL was distributed through convenience stores (about 12,000 sold JUUL products in 2018) as well as at vape shops and online through JUUL Labs’ and others’ websites.69 Adults could buy the JUUL through traditional channels, but younger potential customers had to find ways to circumvent age restrictions. Since August 2017, the JUUL Labs website required U.S. customers to prove they were at least 21 (in the U.K., 18). The company verified user age via a public records search of the user’s entered name, partial social security number, and date of birth—or by inspecting a scanned photo ID image. 70 Some studies suggested that the ID check at convenience stores and retailers was lax. According to a 2018 study, 74% of 12- to 17-year-old users reported having purchased JUUL products at a physical retailer. 71 Anecdotal evidence suggested that some underage users also managed to buy JUUL online through third-party retailers, such as eBay or Alibaba, sometimes using prepaid debit cards to avoid detection. 72 In many cases, students also formed distribution networks at school. JUUL Marketing JUUL product launch The only major ad campaign in the JUUL’s early history occurred during the product launch in 2015, when PAX Labs spent $1.6 million on advertising, including $1 million on internet advertisements and $500,000 on radio spots. 73 Company executives recalled that this vaporized advertising campaign targeted a young adult audience. According to one account, which quoted former PAX Labs chief marketing officer Richard Mumby, “While other campaigns tend to be ‘overtly reliant on just the product,’ [PAX Labs’] effort features diverse 20-to-30-year-olds using the product. The ad’s background is set against a design of various shades of yellow, blue and pink with photos of the young men and women using Juul, typically dressed for a night out.”74 This ad campaign included a “Times Square Takeover” (where billboards featured young people using JUUL before bright-colored backgrounds) and a New York launch party targeting prominent New York socialites, featuring food prepared by a winner of the cooking reality show Top Chef and a “full vape bar.” 75 Photos taken at the launch party (see Exhibits 6a and 6b) featured JUUL-using partygoers who appeared to be in their teens or early twenties—close to the legal age for consuming tobacco products. As part of the launch, PAX Labs also sponsored tents and booths at cultural events geared toward younger audiences, including “pop-up ‘Juul bars’ . . . in Los Angeles, New York, and the Hamptons,” 76 free JUUL Starter Kits at a film festival in Brooklyn, New York, and a JUUL Vapor Lounge at a music festival in Los Angeles. 77 PAX Labs hosted two dozen such events. 78 The company also purchased online advertising through “ambassadors” who wrote sponsored articles promoting JUUL.79 According to a former employee, PAX Labs recognized its product’s popularity among young people 5 This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. 619-006 JUUL and the Vaping Revolution soon after the 2015 launch. 80 After several buyers placed bulk orders of JUULs on the company’s website, PAX Labs reportedly began to suspect that they were being resold to underage users. 81 (The company did not confirm these reports.) By late 2015, the company had discontinued the ad campaign. Marketing a growing brand After JUUL’s inaugural ad campaign, official marketing was mostly confined to the product’s website and social media accounts. In the early days of the JUUL website (late 2015 and early 2016), marketing efforts focused on JUUL’s non-tobacco flavors. One promotion in 2016 associated JUUL with fine dining: “JUUL’s medley of satisfying flavors makes it easy to pair with your favorite foods. We asked three chefs to try JUUL and create recipes inspired by their favorite pod flavors.” 82 On social media, PAX Labs used celebrity endorsements and photos from users to sell the product. A 2016 tweet noted that pop singer Katy Perry was spotted holding a JUUL at the Golden Globe Awards.83 Other JUUL social media posts foregrounded sensuality and individuality, often featuring images of young adults and the tagline “share a #JUULmoment.” 84 The company continued to arrange one-off endorsements from social media “influencers” as late as 2017.85 Over time, JUUL Labs transitioned from emphasizing non-tobacco flavors, with little mention of smoking, to marketing JUUL as a smoking alternative. By September 2017, JUUL’s website contained the heading: “JUUL is for adult smokers seeking a satisfying alternative to cigarettes. JUUL was designed with smokers in mind. With its unique satisfaction profile, simple interface, flavor variety, and lack of lingering smell, JUUL stands out as a genuinely satisfying vapor alternative for smokers.”86 By mid-2018, when the FDA and at least one state Attorney General launched separate probes into JUUL Labs’ marketing practices, the company’s website seemed uniformly focused on older adult smokers, prominently featuring images and videos of older adults using JUUL. 87 Every page on the site now contained the banner: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.” The website claimed: “We support reasonable regulation of nicotine products and comply with all relevant laws and regulations.”88 JUUL Labs published a new “marketing & social media code” (see Exhibit 7), and launched the website www.juulfacts.com to handle public relations, headlined by the phrase: “If you don’t smoke or vape, don’t start.” 89,90 Monsees and other executives amplified that message. Underage use of JUUL, Monsees said, was “antithetical to the company’s mission.” 91 Chief Communications Officer Matt David added: “We have never marketed to anyone underage. . . . Like many Silicon Valley technology startups, our growth is not the result of marketing but rather a superior product disrupting an archaic industry. When adult smokers find an effective alternative to cigarettes, they tell other adult smokers.” 92 Free advertising from distributors and users Despite JUUL Labs’ modest ad spend to support its launch, a growing social media following, primarily among young users, promoted the brand. By February 2018, seven Instagram accounts dedicated to JUUL (including the official JUUL account and six fan accounts) attracted 278,172 followers. 93 Many were operated by companies that produced or sold JUUL products and accessories.94 As of March 2018, 35 JUUL-related videos on YouTube had over 100,000 views each. 95 Many were submitted by young users, including the YouTube drama, “Dude, Where’s my JUUL?”—a reference to the 2000 comedy film Dude, Where’s My Car?—which had over a million views. 96 Some videos showed users applying colorful “skins” to decorate (and potentially disguise) their JUULs. 97 While such social media exposure enhanced JUUL’s visibility, Burns lamented in 2018: “We have frustrations about how our product is glorified on social media.” 98 Health Impacts of E-Cigarettes Because e-cigarettes were a relatively new product, little research had been conducted on their longterm health effects, and in 2019 the public health community was divided on the issue. Proponents 6 This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. JUUL and the Vaping Revolution 619-006 viewed e-cigarettes as a “harm reduction strategy,” an approach that reduced the negative consequences of a behavior by encouraging a less harmful substitute. One common harm reduction strategy was giving heroin users methadone—a safer opioid—in a controlled setting. Some believed that e-cigarettes, like FDA-approved smoking alternatives (e.g., nicotine patches), reduced harm by providing smokers with nicotine without many of the harmful substances in combustible cigarettes.99 In the U.K., many experts actively encouraged vaping for smokers who wanted to quit. 100 On the other side of the debate were those who prioritized the precautionary principle, an axiom that stated: “[T]he introduction of a new product or process whose ultimate effects are disputed or unknown should be resisted.” 101 Adherents to the precautionary principle urged caution and argued that given their addictiveness, e-cigarettes should not be easily accessible. Winickoff made the following analogy: “Supporting adults to switch from heroin to methadone dispensed in a controlled environment is no doubt a net positive. But we would never say that it is a good idea to make methadone in flavors, and make it readily available at any corner store, as e-cigarettes are.” Harm: combustible cigarettes versus e-cigarettes Most experts agreed that vaping was less harmful than smoking. Cigarette smoking was associated with cardiovascular and respiratory disease and was the leading cause of preventable death in the U.S.102 But there was less consensus on the extent to which e-cigarettes reduced harm. Public Health England estimated that e-cigarettes were 95% safer than tobacco, but others disputed that figure. 103 Although e-cigarettes had fewer carcinogens than combustible cigarettes, critics argued, they still contained toxins, ultrafine particles, and nicotine. 104 Moreover, while some ingredients in vaping e-liquids were widely used in other forms—propylene glycol, for example, was used in soda, cosmetics, antifreeze, and artificial smoke at concerts—the effects of inhaling them were unknown. 105 That uncertainty also applied to chemicals used for flavoring. At least one, diacetyl (not used in JUUL), caused chronic lung diseases. 106 In addition, the scientific community had not yet determined the effects of emitted vapor on bystanders, though one study detected harmful pollutants in secondhand vapor. 107 In late 2018, the U.S. Surgeon General warned of the possibility of “harmful substances, including heavy metals . . . and ultrafine particles” in some e-cigarette vapors. 108 Efficacy of e-cigarettes for smoking cessation While anecdotal evidence suggested that many smokers had used e-cigarettes to stop smoking combustible cigarettes, most studies were too small or limited to draw wide conclusions. 109 As of September 2018, no e-cigarette had secured FDA approval as a smoking cessation aid. 110 One study found that when combined with counseling, ecigarettes led to nearly twice as much adult smoking cessation after one year compared to conventional nicotine replacement therapies such as the patch and nicotine gum (18% versus 9.9%, respectively). But among participants who quit smoking, only 9% of those who did so with traditional nicotine replacement products still used that product after one year, while 80% of those who quit smoking by using e-cigarettes were still vaping a year later. 111 Some experts linked recent declines in adult smoking rates in the U.S. to the rise of e-cigarettes. As one expert (who led a JUUL advisory board) concluded, “The only plausible explanation [for this decline] is e-cigarettes.” 112 A few population-level studies confirmed the correlation between increased vaping and smoking quit rates in the U.S., although such studies could not prove causation. 113 Risk to teenagers Critics of e-cigarettes often cited their potential harm to teenagers, who were especially at risk of nicotine addiction. 114 As Winickoff observed, “The most susceptible youth will lose autonomy over tobacco use after just a few times. So before they even know they’re addicted, they’ll first start wanting, then craving nicotine whenever they go too long between uses . . . and more exposure to nicotine at an early age will up-regulate nicotine receptors more rapidly in those developing centers of the brain than in adults.” 115 Moreover, noted Winickoff, “Nicotine creates a 7 This document is authorized for use only by Oluwasijibomi Osundina in MGMT 5900 taught by Jason Simmons, Johnson & Wales University from Jan 2023 to Jul 2023. For the exclusive use of O. Osundina, 2023. 619-006 JUUL and the Vaping Revolution biologic need that can be permanent.” 116 A 2018 study found that many young users did not consider themselves addicted, even as they exhibited classic addictive behaviors. 117 Some experts worried that vaping might be a “gateway” to combustible cigarettes, with one study finding that adolescents who vaped were 3.5 times more likely to start smoking after a six- to eighteenmonth period than never-vapers. 118 But the correlation between vaping and combustible cigarette use was not necessarily causal; at least some adolescents who vaped might have started smoking regardless. 119 Moreover, the U.S. adolescent smoking rate in 2018 and 2019 was among its lowest ever (refer to Exhibit 4). 120 Others worried that vaping nicotine might lead to vaping cannabis-derived THC. Regulating E-Cigarettes In the U.S., states and municipalities were the first to pass e-cigarette legislation. By 2018, nearly all states regulated the retail sale of e-cigarettes (e.g., setting age minimums and limiting samples or vending machine sales), and about half prohibited the use of e-cigarettes anywhere (or almost anywhere) smoking was prohibited. 121 Some states also imposed taxes on e-cigarettes, based eith
