Table 1.

Frequently Asked Questions from Families and Clinicians.

“I have heard that e-cigarettes like JUUL are really popular at my child’s school, but I don’t know if my child has tried them. Should I talk to him/her about this? What should I say?”	Some families will be hesitant to discuss talking about e-cigarettes like JUUL out of concern that they may inadvertently encourage their child to start using the product, which is very unlikely to be true. You should talk with your child about why his or her peers may use e-cigarettes, the known and unknown health risks of e-cigarettes, and their association with an increased risk of cannabis and combustible cigarette smoking. Tell your child that cigarettes are still the most harmful tobacco product available, but that e-cigarettes are not safe. E-cigarettes like JUUL contain nicotine and can lead to addiction, meaning that it will be hard to stop using these products once they start.
“How much nicotine does a JUUL pod usually contain?”	Although combustible cigarettes and JUUL pods vary in nicotine content, JUUL reports that each JUUL pod contains a similar amount of nicotine as a pack of cigarettes (JUULpod Basics 2019).
“My son is in high school, how many other kids his age are using e-cigarettes? Are more kids using e-cigarettes than regular cigarettes?”	E-cigarettes are now more popular than cigarettes. In 2018, a nationwide study found that 21% percent of US high school seniors reported vaping in the past month, while 8% of high school seniors reported combustible cigarette use in the past month (Miech et al., 2018).
“Are devices like JUUL technically a tobacco product?”	Yes. The nicotine in e-cigarettes is derived from tobacco, and the FDA finalized a rule in 2016 which deemed e-cigarettes to be tobacco products under their control (United States Food and Drug Administration, 2016).
“Why are so many kids using e-cigarettes like JUUL?”	For many reasons; specifically for JUUL, it has a sleek, iPhone-like design, user-friendly functions, desirable flavors, and can be used discreetly in places where smoking is forbidden (such as schools). The social pressures and peer influence of use with e-cigarettes are significant.
“I have a friend at work who uses their e-cigarette to help reduce their cigarette use, but this doesn’t seem to be what my son or daughter is using it for, right?”	Less than 8% of adolescents who use e-cigarettes do so for combustible cigarette cessation (Tsai et al., 2018), in contrast to 85% of adults who do (Patel et al., 2016). Adolescents may use pod mod devices like JUUL as a result of evolving social norms, peer influences, appealing flavors, and decreased perceptions of risk, but less commonly for cigarette cessation.
“My daughter has been using her JUUL daily for the last six months. Is this a gateway drug to cigarettes and other substances?”	We don’t know if e-cigarette and pod mod devices like JUUL directly lead to cigarette or other substance use, but we do know that youth who use e-cigarettes are three times more likely to try cigarettes (Soneji et al., 2017), and four times more likely to try cannabis (Audrain-McGovern et al., 2018).
“My son said that other kids at school were using JUUL to smoke marijuana, is this true?”	Pod mod devices like JUUL provide a new method of inhaling cannabinoids or other psychoactive drugs (Giroud et al., 2015). In 2018, almost one in ten high school seniors vaped cannabis (Miech et al., 2018). Preparing cannabis in a JUUL or pod mod device can allow youth to smoke discreetly without the characteristic smell of cannabis that would otherwise lead them to be detected (Giroud et al., 2015; Hayes, 2018). However, vaping marijuana does appear to be a safer alternative to smoking it (Earleywine and Barnwell, 2007; Giroud et al., 2015).
“Do most high school students and young adults know what exactly is in the JUUL they are using?”	Most adolescents and young adults do not. In a recent survey, 63% did not know that nicotine is present in JUUL products (Willet et al., 2019), 19% believed that smoke from e-cigarettes was only water (Gorukanti et al., 2017), and 23% believed that e-cigarettes were not a tobacco product (Gorukanti et al., 2017).
“Are e-cigarettes like JUUL safer than combustible cigarettes?”	Yes, unlike traditional cigarettes, e-cigarettes are not combusted, which makes them substantially less harmful than traditional cigarettes (Courtney, 2015; Hecht, 1999). Studies have found that the vapor in e-cigarettes has a significantly reduced level (between 9–450 times) of toxic substances compared to combustible cigarettes (Goniewicz et al., 2014a).
“What are some of the health concerns related to using e-cigarettes like JUUL? What about the nicotine?”	Little is known about long-term effects (including those on brain development) as these are such new products (Chun et al., 2017; Sleiman et al., 2016). Nicotine receptors in the brain regulate critical aspects of brain development, and low doses of nicotine exposure can adversely affect brain development, leading to cognitive issues and development of more problematic levels of use (Dwyer et al., 2009; England et al., 2015; Goriounova and Mansvelder, 2012; Yuan et al., 2015). The most frequently reported short term adverse events associated with the use of e-cigarettes include throat and mouth irritation, headache, dry cough, and nausea, however these side effects are often self-limited and resolve over time (Courtney, 2015).
“Since JUUL is an electronic cigarette, does that mean that they have less nicotine than regular cigarettes?”	As a result of the nicotine salt formulation, JUUL can deliver high concentrations of nicotine by increasing the amount and rate of nicotine uptake (Bowen and Xing, 2015). Studies have found that nicotine exposure among youth who use e-cigarettes is just as high or higher than those who smoke combustible cigarettes (Goniewicz et al., 2018). Although nicotine exposure may be higher in JUUL, they are regarded as safer than traditional cigarettes since they are free from combustion.
“My daughter uses JUUL and regular cigarettes. She says that she is using JUUL to stop cigarette smoking. What should I do?”	Using both e-cigarettes and cigarettes is common, as 75% of adolescent e-cigarette users reported concurrent use of other forms of tobacco (Anand et al., 2015). However in youth, using both e-cigarettes and cigarettes is not often a temporary state, indicating that e-cigarettes may not be facilitating smoking cessation in the way that they are advertised among this age group (Barrington-Trimis et al., 2018). Youth who use e-cigarettes and cigarettes are more likely to continue using traditional cigarettes than to transition away from their use (Barrington-Trimis et al., 2018), and are more likely to develop a dependence on nicotine (Lee et al., 2013). There is limited data for treatments of tobacco use disorder (particularly e-cigarettes) among youth, but it is something that should be discussed with your child’s healthcare provider.
“My son uses JUUL because he says it is the only thing that can help with his stress and anxiety. It seems to help. What should I do?”	Although nicotine use may have favorable short-term effects in stress reduction and alleviating anxiety, exposure to nicotine during adolescence is associated with an increased risk of mood and attention symptoms (National Academies of Sciences, Engineering, and Medicine 2018). Outpatient follow-up with a mental health provider should be encouraged to help explore healthier and more appropriate ways to manage stress.