Despite overwhelming evidence that vaping devices are far less harmful than combustible cigarettes, JUUL’s meteoric path to capturing nearly 70 percent of the U.S. e-cigarette market has sparked mixed feelings among the public and scientific communities.
Proponents of e-cigs’ health benefits worry that the company’s roaring success among underage high-schoolers may outweigh the scores of existing smokers who are quitting in favor of a healthier life through JUUL. Meanwhile, a coalition of nicotine prohibitionists has labeled JUUL as a “public health disaster”—a campaign running counter to all evidence, as exposed by John Tierney in City Journal’s latest summer edition.
A vast review of scientific literature by the National Academies of Science, Engineering and Medicine (NASEM) in January found the evidence on e-cigs’ public health benefits to be inconclusive. Though containing far less toxicants and carcinogens than cigarettes, their aggregate health effects, the study found, hinges on the balance between smoking adults lured to quit and young non-smokers who take them up and end up using them as a gateway to cigarettes.
On both of those counts, however, a surface look at global smoking data shows the United States may not be a reliable test case for the potential health effects of e-cigarette use globally.
On cigarette consumption per capita, the United States ranks below most other markets JUUL is eyeing—70th out of 183 countries for which World Health Organization data was available in 2016, with roughly only 2.8 cigarettes smoked per person and day. In terms of smoking rates, the United States appears even further down the ranks of comparable countries: only 17 percent of declared smokers among people aged 15 or older. In Greece, that figure is close to 1 in 2, and in Croatia it nears 37 percent.
In the EU as a whole, 21 out of 27 member countries consume more cigarettes annually than the United States. With a unified regulatory framework for tobacco-related products, JUUL’s entry into the EU market would match far higher rates of smokers consuming far more cigarettes on average with a drastically healthier product currently unavailable.
JUUL can win over more smokers in countries where tobacco has proved the most deadly. In 2012, the latest year for which the World Health Organization compiled data on cancer fatalities, 0.052% of Hungarians died to lung cancer, for which smoking is the principal cause at 85 percent of deaths. This compares to a much lower 0.038% in the US, where for all the public opprobrium on tobacco, cases of smoking-induced fatalities are relatable to fewer families.
With a range of available e-cig brands in European markets but none offering the nicotine content of JUUL pods—nearly indistinguishable from the puff of a cigarette—, JUUL is also likely to shut off the flow of e-cig users who resume smoking after an unsatisfactory experience.
There is also some reason to believe JUUL will be picked up in lower numbers by European non-smoking teens. A Center for Disease Control Prevention survey from May 2018 found US vaping rates in 2016 had stalled in high-schools and declined in middle-schools, suggesting there may be a fad element to the JUUL craze that has begun to fade.
Higher smoking rates across all age groups in Europe likely reflect a stronger pull factor towards traditional smoking too. In the United States, conversely, JUUL’s outstanding success with underage high-schoolers can be at least partly understood as their way to get around an imperious social stigma with a discreet, fashionable gadget.
With smoking generally deemed “sexier” and less socially frowned upon than in the United States, impressionable teens in Europe are already likelier to fall for traditional cigarettes instead of the healthier proxy, with less room for e-cigs to become the intermediate culprit. If teen smoking rates remain higher in Europe after the range of alternatives widens, critics will have only preexisting societal conditions to blame, with JUUL playing next to no role.
Additionally, JUUL’s viral use among high-school-aged Americans relies largely on the network effects afforded by mass social media platforms that are not as popular in Europe. At 79 percent and 73 percent respectively, teen and young adult use of Snapchat and Instagram in the United States is by far the highest in the world. While the United States houses nearly 15 percent of the world’s Instagram user population, the platform barely penetrates a third of the Internet in Europe.
In countries with higher cigarette consumption and fewer societal factors that can make JUULing go viral among vulnerable youth, the company will likely face higher take-up rates among existing smokers and less of a gateway effect among non-smoking teens. The two will combine to weigh the balance decisively towards vastly beneficial net effects on public health.
Thankfully, JUUL has set its sights on achieving just that with its latest round of financing, estimated to cash in $1.2 billion in venture capital and bring the firm’s valuation on par with Silicon Valley hallmarks such as Snapchat and Lyft. This week, the UK will become JUUL’s first EU market, with devices sold across 250 vendors for the equivalent of $40.
To be sure, the EU’s Tobacco Products Directive has only allowed a lighter version of the US prototype with 1.7 percent nicotine, relative to 5 percent in pods sold stateside, somewhat lowering the incentive barriers to returning smokers and for existing ones to take up JUUL. However, the UK government’s proactive approach to the vaping transition was likely the triggering factor to JUUL tackling the UK first.
In February, a Public Health England’s review of scientific evidence similar to NASEM’s was rather more emphatic: it found e-cigs to be 95 percent less harmful, with 20,000 people transitioning every year. The same arm of the UK’s Health Department has advocated for e-cigs to be sold and permitted to use in hospitals, as well as subject to quit-smoking aid prescription.
If JUUL successfully raises the capital to launch a truly global consumer product, it is likely to drive more smokers away from the habit and fewer non-smoking teens into it. That is good news for healthcare spending and for smokers worldwide who are desperate to quit.
Jorge González-Gallarza is a policy associate at E21. Follow him on Twitter here.
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