Background

In recent years, use of electronic nicotine delivery systems (ENDS) has drastically increased, exceeding the prevalence of combustible tobacco use among youth in the USA.1 ENDS products are heavily marketed on television, radio and the internet, in print and at the point-of-sale,2–5 using strategies that may appeal to youth.6 Recent national data suggest exposure to ENDS marketing may be associated with increased use of the products among young people.5 7 Of public health concern are the findings suggesting negative health consequences associated with ENDS use and associations between ENDS use and future combustible tobacco use. Additionally, ENDS use is substantially higher among youth, a group for whom nicotine exposure is particularly harmful, compared with adults.1

A novel ENDS product, JUUL, was developed by PAX Labs and represents one of the latest efforts to innovate within the ENDS market. The slim, high-tech devices are charged through USB ports and use nicotine cartridges, or ‘pods’, that come in a variety of flavours. Through novel product design and use of organic nicotine salts extracted from tobacco leaves, rather than the ‘freebase formulations’8 of nicotine used in other ENDS, PAX Labs claims JUUL provides a nicotine concentration comparable with a traditional cigarette and delivers nicotine 1.25–2.7 times faster than competing ENDS. Since its introduction in early 2015, JUUL has experienced tremendous growth in market share. As of 24 February 2018, JUUL represented an astonishing 49.6% …