The "youth epidemic" is a result of JUUL and similar discreet products with high nicotine concentrations. A ban on e-liquid flavors other than tobacco will mainly affect open system products, and is in fact, supported by JUUL. Open system products allow for much lower nicotine concentrations, including zero nicotine products.
Prior to JUUL gaining significant popularity, an increase in youth use of e-cigarettes was directly correlated with a decrease in youth use of cigarettes. As e-cigarettes play a significant role in tobacco harm reduction, youth and young adults switching to vaping from smoking or initiating use of e-cigarettes instead of cigarettes, is a public health benefit. However, when youth initiate use of JUUL products, high levels of nicotine lead to addiction and other potential harms and the discreet device allows for undetected use.
Evidence suggests that youth initiation is strongly influenced by nicotine concentration and a restriction on non-tobacco flavors will not reduce the "youth epidemic."
UK has not experienced the same “youth epidemic.” In the United Kingdom, nicotine concentration is limited to 20mg/ml; however, there is little to no restriction on non-tobacco flavors. JUUL has a smaller market share than the most popular refillable vapes in the UK. However, in the United States, JUUL captures more than 70% of the sales in convenience stores and mass retailers and has an estimated 40% market share of the entire US e-cigarette industry. Unlike the US, vaping among young people in the UK remains low. A 2019 report from Public Health England found that only 1.7% of 11-18 year olds use e-cigarettes weekly or more, and among young people who have never smoked, only 0.2% of them use e-cigarettes regularly. This is despite the fact that UK actively promotes e-cigarettes as a reduced harm product.
Increase in sales of JUUL products from 2017-2019 correspond with increase in youth initiation. In September, preliminary data from the 2019 National Youth Tobacco Survey was released and reflects a youth initiation of 11.7% in 2017, 20.8% in 2018, and 27.5% in 2019. Data from Neilson shows that JUUL monthly sales increased approximately five-fold from the beginning of 2018 through June of 2019.
JUUL restricted flavors other than mint, menthol, and tobacco (considered traditional tobacco flavors), and as a result (i) youth transitioned to JUUL’s traditional tobacco flavors, (ii) youth use continued to increase, and (iii) the sale of JUUL products continued to increase. 2019 preliminary NYTS data includes popular flavors by high school users. In November 2018, JUUL limited sales of its flavored refill pods (except for mint, menthol, and tobacco) exclusively to its website instead of retail stores. As the survey reflects, youth use in traditional tobacco flavors increased, while non-tobacco flavors decreased.
Consumer satisfaction with JUUL products is greatly influenced by nicotine concentration. Reviews listed on JUUL's website include 4 times the number of reviews for 50mg/ml products than 30mg/ml and a higher average rating for 50mg/ml products. In regard to JUUL’s most popular non-tobacco flavor, Mango, the reviews are more than 7 times greater for 50mg/ml than 30mg/ml. The conclusion that youth use is directly related to high nicotine concentration is supported by JUUL’s decreased market share in UK where nicotine concentration is limited to 20mg/ml.In order to reduce youth use of e-cigarettes, a ban on JUUL and a nicotine concentration limit of 20mg/ml will have far greater success in reducing youth initiation without inhibiting the tobacco harm reduction potential of e-cigarettes for adults.