Decades of public health efforts turned America’s young people against smoking. And then JUUL made it cool again. Abdul speaks with Lauren Etter, author of “The Devil’s Playbook,” about how a tool designed to help people quit hooked a whole new generation to nicotine.

Transcript

Dr. Abdul El-Sayed: COVID-19 cases continue to plummet, now down in every region of the country as the FDA approves childhood vaccines for children aged 5 to 11. In a rare move for a pharmaceutical company, Merck, the makers of a new COVID-19 pill, have agreed to share the formula for their drug with lower-income countries. Senate and House Democrats have agreed to a framework for the Build Back Better agenda, but bowing to centrists, Democrats are not including paid family leave or Medicare drug price negotiation. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. Let’s face it, public health has taken some hard knocks through this pandemic, whether it’s the challenge to communications, which we talked about last week, or the politicization, it’s been a tough few years. So it’s worth remembering some of our biggest wins. One of the biggest was the victory over cigarette smoking. Only half a century ago, television viewers could hear this:

[clip of TV commercial] According to this repeated nationwide survey, more doctors smoke Camels than any other cigarette.

Dr. Abdul El-Sayed: Can you imagine a cigarette company being brazen enough to advertise cigarettes with doctors today? It’s not just that big tobacco’s capacity to advertise, particularly to minors, has been virtually eliminated. It’s also that we’ve limited where they can sell cigarettes altogether. We’ve taxed them, banned smoking indoors, and even in some outdoor settings. Perhaps most of all, we changed the culture around cigarette smoking. In fact, smoking is one of the only things that society deems it OK to shame someone over. To be clear, shaming people doesn’t really help, but I’ve seen children walk up to absolute strangers smoking on the street and tell them how bad it is for them. Today, cigarette smoking rates are near an all-time low, and that’s meant literally millions of lives saved. People who would have died of lung cancer or lung failure, heart disease, stroke, or literally one of dozens of other diseases that smoking causes, they’re alive today, and we have public health to thank for that. But that doesn’t mean that the cigarette corporations have called it quits. No. Instead, they’ve opened new lines into the battle to get people hooked on smoking. But before we get to that, let me tell you a story about what happened on a flight that I took back in the before times, all the way in 2018, you know, when taking flights was common. I was flying between Detroit and New York, and I heard a voice behind me: yo, have you seen my JUUL? By his voice, I could tell that he was a young man and I could hear him rustling around his belongings. And then I felt a tap on my shoulder. We were mid-air, mind you, and it would have been illegal for him to take a drag of the e-cigarette, even if he did find it. I look back to see his face. Definitely a young man, probably in his early 20s. “Yo, you got a JUUL, man? I lost my JUUL.” No, man, I said. The kid started to sound more and more agitated as he looked desperately for his fix. It got so bad that the flight attendant had to come and ask him to sit quietly. It was at that point that I came to appreciate just how addictive the little vapes have become. If you’ve never seen a JUUL, they look innocent enough, literally like a USB cartridge. In fact, that’s how they charge. When loaded with a JUUL pod, a small packet of vaping liquid laced with a whopping load of nicotine, a simple drag activates the machine to vaporize liquid into the lungs, delivering that hit of nicotine that poor kid was after. JUUL had become by far the biggest player in the burgeoning e-cigarette game. Discreet and easy to hide from parents or teachers alike, and originally with flavors like creme brulee and mango, JUUL hooked millions of teens around the country. About a year after that flight, this happened:

[news clip] 450 people across the U.S. have developed ailments linked to tobacco and cannabis vaping. At least six have died.

Dr. Abdul El-Sayed: The syndrome, termed “vaping-associated acute lung injury” was a wake up call, alerting parents, teachers, and school administrators around the country to the epidemic of vaping in their midst and the dangers that could come with it. And though the outbreak was ultimately traced back to a specific ingredient that wasn’t actually included in JUUL vaping liquid, it led to a sea-change in industry regulation.

[news clip] President Trump is preparing to ban flavored e-cigarettes nationwide after a sixth person died from a vaping-related illness.

Dr. Abdul El-Sayed: It decimated companies like JUUL, which is curious because JUUL never set out to hook new nicotine users in the first place. At least not in the beginning. As we’ll hear more about from our guest today. No, JUUL, like e-cigarettes in general, was supposed to help cigarette smokers transition away from combustion cigarettes. And a few weeks back, the FDA took a major step on e-cigarettes:

[news clip] For the first time, the FDA authorized an electric cigarette, saying the device can help smokers cut back on conventional cigarettes. But this authorization only applies to the Vuse solo e-cigarette.

Dr. Abdul El-Sayed: In doing so, the FDA endorsed its first e-cigarette product, arguing that the benefit of providing current cigarette smokers an alternative, outweighs the harms of new nicotine addiction. To be sure, cigarette smoking is profoundly worse than vaping, but we’re still learning about the long-term consequences of vaping to our health. That said, the early research suggests that it’s far less dangerous in terms of lung or cardiovascular disease than smoking is. At the same time, though, nicotine addiction isn’t without its consequences. What’s worse, though, is that e-cigarette companies like JUUL haven’t been content with simply selling their product to former smokers. They’ve employed growth strategies particularly focused on hooking new users, as the story of JUUL demonstrates. Today, we’re taking a deep dive into the story. Together, we’ll explore how JUUL went from a cigarette alternative, to hooking a new generation of nicotine smokers, and the consequences that had. My interview with investigative reporter Lauren Etter, author of The Devil’s Playbook: Big Tobacco, JUUL, and the Addiction of a New Generation, after the break.

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Dr. Abdul El-Sayed: OK. Are you ready to get started?

Lauren Etter: Yeah. Let’s go.

Dr. Abdul El-Sayed: OK, let’s go. If you can introduce yourself for the tape.

Lauren Etter: Hi, I’m Lauren Etter. I am an investigative reporter at Bloomberg News, and the author of The Devil’s Playbook.

Dr. Abdul El-Sayed, narrating: Lauren Etter’s book, The Devil’s Playbook: Big Tobacco, JUUL, and the Addiction of a New Generation, details the rise and fall of JUUL. She traces how an old public health nemesis, Big Tobacco, found a way into a new generation on the back of JUL, and what it tells us about the fight against corporations whose bottom lines come at the cost of our health. Just a note, we taped this interview just before the FDA had approved its first e-cigarette.

Dr. Abdul El-Sayed: I want to jump right into the book because, you know, you cover something that was the biggest public health news until the biggest, biggest public health news took over, which was, you know, March of 2020. But this remains a longer-burning issue—and, you know, pun intended because, you know, we do that on the show—can you tell us a little bit about what inspired the writing of this book and you to look into JUUL and the broader history of tobacco in our country?

Lauren Etter: Sure. So as a reporter at Bloomberg, I write about all kinds of companies, big and small. And when the EVALI epidemic happened, this was when the mysterious outbreak of these lung injuries that appeared to be tied to vaping started occurring and teenagers started showing up in hospitals with the inability to breathe, I just thought that was really a fascinating public health topic. And at the same time, there was this growing youth usage issue of JUUL and of nicotine. So there are these two twin crises, right? The lung injury issue and the nicotine epidemic, essentially. And I just became fascinated by the idea that there is a Silicon Valley firm that found itself in the center of these two public health crises. So as I embarked on writing a book about JUUL, it quickly became clear that it was impossible to tell the complete story of JUUL and the issue of nicotine use in our country without really diving deep into the history of the tobacco industry, one of the most notorious industries in America that had sort of bedeviled this country for decades. So that’s why I ended up telling these twin stories of JUUL, but also of Altria, formerly known as Philip Morris and the maker of Marlboro cigarettes.

Dr. Abdul El-Sayed: What I really appreciated, right, is that this story sits at the intersection of a number of trends that keep popping up in our society, right? You’ve got the power of major corporations, you’ve got tech bro’s trying to disrupt an industry and then just doing the exact same thing that the non-tech bro’s who came before them did. And you’ve got this, you know, this major public health issue that has been a challenge in our society, frankly, since the founding. I want to sort of step back here. What is a JUUL, and what makes a JUUL so unique among vaping products?

Lauren Etter: So a JUUL is essentially it’s called an electronic cigarette. What it is, is a little battery-operated device that looks like a flash drive, and in fact was modeled after a flash drive. It’s small, it fits in the palm of your hand. On the top of a JUUL, you pop in a little cartridge. It’s about the size of a, a little bigger than the size of a thumbnail. You pop the cartridge into the top of the JUUL and inside the cartridge is contained a nicotine liquid, a high, high-strength nicotine liquid that when you pop it in, you suck on it. You don’t even have to turn it on. You just put it in your mouth, you suck on it and the battery heats up, essentially, the liquid turns into a vapor. You inhale it and you get a very fast, potent nicotine hit.

Dr. Abdul El-Sayed: Hmm. And how much nicotine does head of JUUL deliver versus know, say, a puff on a cigarette?

Lauren Etter: Right. So it’s hard to, it’s hard to measure it like that because people inhale differently. They suck on it differently. But the equivalent measure for a single pod is a pack of cigarettes.

Dr. Abdul El-Sayed: Oh, wow.

Lauren Etter: So one, yeah, a one JUUL pod contains about the same amount of nicotine as a pack of traditional cigarettes, a pack of Marlboro Reds, for example.

Dr. Abdul El-Sayed: And how long is a pod designed to last? Is it something that you, you know, vape in an afternoon? Or is it something that you have sitting in your JUUL for a while, or . . . ?

Lauren Etter: It totally depends. So the thing about the JUUL that is also ingenious and also potentially dangerous for youth addiction issues is that there’s no on or off switch. And unlike a cigarette, you don’t have to light anything. You don’t have to pick up a lighter. You just simply pick up and start sucking. So it depends on how much you use the product. Some people go through half a pod a day, but it’s not uncommon at all for people to blow through multiple pods a day, two pods, three pods. And that’s what we were seeing at the height of the nicotine addiction issue with kids was that they were JUULing multiple pods a day. So they were ingesting large amounts of nicotine, more than, most people don’t smoke a pack of cigarettes a day. So they ended up ingesting a lot, high, high concentration, high quantities of nicotine. So you can, it just depends on how much you use it, but it’s very easy to use. You can use it pretty much anywhere. You can discretely use it in a bathroom or in a bedroom or in a classroom. And that’s why it became so insidious and became such a problem among teenagers in schools.

Dr. Abdul El-Sayed: Hmm. And just to set the context here, what was the state of of teen smoking when JUUL arrived on the scene?

Lauren Etter: So this is the issue that just shot this product to the front and center of the public health community. So after the tobacco wars in the 1990s, one of the hugest issues that the FDA and public health regulators wanted to tackle was youth smoking, because at the time of the Master Settlement Agreement—this was the big agreement that was signed between state attorneys general and the tobacco industry that basically said, OK, you’re not going to, tobacco industry, you’re not going to continue to go after kids, you’re not going to continue to market to kids, you’re not going to continue to try to essentially addict a new generation, and we need to prevent this health crisis by cutting off the next generation of smokers. So at the time that the master settlement agreement was signed in 1998, the rate of youth smoking was around 35%. That was an all-time high. So over those next years, really almost a decade and a half, the smoking rate, teen smoking rate had been declining year after year after year, and it was actually considered a public health coup that they had in fact, been able to tackle this very pernicious problem. So by the time that JUUL came around, when they launched their product in 2015, the youth smoking rate had declined to about 10%.

Dr. Abdul El-Sayed: Oh wow.

Lauren Etter: So again, a huge decline, a huge public health coup, and thinking that this issue had been settled. And then e-cigarettes arrived.

Dr. Abdul El-Sayed: And the thing that’s so pernicious about this is that the makers of JUUL, these tech bro’s who launched this, they thought they were doing something good, right?

Lauren Etter: So definitely at the outset, they believed they were doing something good. So the state of play at the time that Adam Bowen and James Monsees came around, those were the founders of JUUL—they were at Stanford, it’s almost, you know, it’s a myth at this point or a tale that everybody knows well, rather, which is that they were at Stanford and they were at the design school. And this is the division of Stanford, where people come there to innovate everything, anything and everything. And so Adam and James, they were both casual smokers and they were standing outside of the design school one night and they were smoking and smoking, and they looked at each other and said, how idiotic is this? We are using this product that we know that kills us, and the design of the product is identical to the design, almost identical to the design of a cigarette from a century ago. It’s still the shredded tobacco, rolled in paper that you light on fire like a caveman, and you inhale, and then we now know that it kills you. So they thought to themselves, if this is a product that everybody wants so badly—because remember, there are 34 million adult smokers in America today, so still a billion smokers around the world, so this is a product that people still use, they’re addicted to it because of the nicotine—they thought, what if we can give to smokers what they really want, which is the nicotine and strip out all of the harmful properties of a cigarette, which is essentially the combustion. The lighting on fire of the material and inhaling that into your lungs is essentially what causes lung disease. So what if we can just give people what they want, which is nicotine, and give them, give it to them in a way that’s less deadly? So they did have a harm reduction element to their business model to start out in the beginning. And it’s one, it’s a worthy goal, and one that the public health community at large is continuing to tackle today. But there are lots of things that went wrong, and we can talk about all of those things, but they certainly started off with a mission to help give smokers an alternative to the deadly cigarette, and to allow them to continue getting their desired fix of nicotine.

Dr. Abdul El-Sayed: And then the question becomes All right, so where did their mission go from? Converting cigarette smokers to e-cigarettes to addicting, a whole new generation of young people to e-cigarettes to begin with?

Lauren Etter: So this is what is sort of at the heart of my story and in my book, which is this the collision of these two industries, Big Tobacco and Silicon Valley. So we know all about Big Tobacco and their sordid history of targeting teenagers and lying about the deadly nature of their product and covering that up for decades. We know all about that. We also know a lot about Silicon Valley as well. And what is that business model, what that business model is based on and essentially to be successful in Silicon Valley. You need to attract investors and investors. Venture capitalists care about only one thing about making money, and they want to invest in a company, a startup, a product that has a large number of potential users and that also can be scaled rapidly. So I believe what went wrong initially with Jewel was that they, instead of crafting a company that was truly designed to go after adult smokers and to potentially get regulatory approval before entering the market and do it in a in a more measured way, they took the Silicon Valley model and ran with it. So what that meant was the investors saw the investors who were interested in India or saw a massive market opportunity. They saw the one billion smokers, 34 million in America. If you could get even a fraction of those, you have a huge customer base already. And so as they started attracting Silicon Valley investors, there was really a lot of pressure on the company to grow quickly, to grow fast and to just blow it out. And which is exactly what they did. And another kind of wrinkle there that is kind of underlying all of this is that at the time that you will launch, there were no regulations on e-cigarettes. And that’s a whole other complicated topic that we can talk about. But what it meant was that there was the threat of regulation in the future. Everybody knew that the FDA was trying to figure out a regulatory scheme for e-cigarettes and it was going to come down the line, but it was still pretty much years away. So what that meant was investors wanted Jewel to grow as quickly as possible and to get their product into the market and to take over the market as quickly as possible before FDA regulations came down and potentially inhibited their growth. So there was the incentive there for Jewel to grow quickly to get its product out there as fast as possible and to just scale. And that’s exactly what happened. So I think by prioritizing growth over public health, that that’s where they began running into trouble.

Dr. Abdul El-Sayed: You know, they also engaged in a really, I want to say nefarious approach to marketing their product, which rather than, you know, investing in billboards, et cetera, they were more interested in getting their product into the hands of influencers. Can you talk about how that departure in marketing signaled the moment that they were really interested in sort of shifting tack?

Lauren Etter: Sure. So the very, right out of the gate when JUUL launched, they created what they called their “vaporized campaign.” This was their marketing campaign that position JUUL as not an adult alternative to smoking, and not as a public health remedy—it was positioned as a flashy, cool gadget that if you used it, you would look like one of these cool models that they had starring in their ad campaigns. They were young looking they were often at parties, they were having fun, the ads that appeared in Times Square on the billboards were very flashy, using very bright colors and it made it seem like this is a really must-have kind of trendy gadget. And JUUL was even on runways with fashion models. You started seeing celebrities using it, and of course, they had the influencers. And so, and at the time—this is important to point out—at the time that their marketing campaign launched, they didn’t mention anything in their ads that this product contain nicotine and nicotine is highly addictive. A lot of people, including teenagers, had no idea that it even contained nicotine or what nicotine even was. So it just was rolled out into the market as another consumer product that you must have in order to be on trend. And so then that, combined with the use of social media, was a huge reason why JUUL ended up going viral. It went viral just like their ads did on Instagram and Twitter and Facebook. So it was kind of a combination of the advertising tactics and the use of social media that helped propel this product into the market in a very quick and in a very, in a very quick way.

Dr. Abdul El-Sayed, narrating: We’ll be back for more with Lauren Etter after this break.

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Dr. Abdul El-Sayed, narrating: And we’re back with more of my conversation with Lauren Etter.

Then it all kind of came full circle when one of the principal investors of JUUL was Altria, the company formerly known as Philip Morris. Can you talk about that moment and if it, you know, if it forced these two tech bro’s from Stanford to realize that, in fact, they had created a monster?

Lauren Etter: So, yeah, I mean, it was the ultimate irony when Altria invested in JUUL. They took a 35% stake in JUUL, they paid $12.8 billion for it. And this was in 2018. And in my book, I wrote that this is the moment that the glass shattered for JUUL. Because if you back up a little bit and you go back again to where Adam and James started and how they were trying to have this create this public health alternative for cigarettes, they also talked a lot about wanting to take on Big Tobacco and that they were the, you know, the antithesis to Big Tobacco and that they could, you know, they could provide something that Big Tobacco never would, and perhaps put them out of business. So there was a lot of swagger behind that, and it also kind of underscored the ethos that they wanted to kind of convey to the world that they were out there doing something better, that they weren’t a Big Tobacco company. So, but of course—and I write this in my book about how even from the very beginning, they had been quietly building relationships with the tobacco industry, because early on, when they first saw investors, people in Silicon Valley, venture capitalists didn’t want to touch the company with a 10-foot pole. Nobody wanted to be, do business with a tobacco company. It didn’t fall in line with sort of the ethics, quote unquote “ethics” in Silicon Valley, and so they had a hard time raising money. So they quickly realized that they needed to turn to the tobacco industry. They have deep pockets. This was an industry that was desperate to innovate the cigarette. And, so all along, there had been this kind of courtship between JUUL and various tobacco companies, but that’s not something that they touted at all. It was actually done very quietly. And so by the time that Altria came around in 2018 and made the big investment in JUUL, their, Altria had been fumbling for years trying to develop its own e-cigarette that could compete with JUUL. And Altria is among the worst innovators. They hadn’t developed anything significant or substantial since, really since the Marlboro Man in the 1950s, and they were desperate to come up with their own alternative, and they pretty much did a very bad job doing it. So they knew that they had to invest in JUUL in order to gain a foothold in this growing nicotine e-cigarette market. And JUUL was the leader at the time. JUUL had like 70% of the market. So when they invested $12.8 billion in Jewel, it was. It did a lot of things. It changed the conversation internally. A lot of employees felt very burned by that. They quickly felt a little bit better because the amount of money that they got as a result of the deal was pretty good. And, but it also shifted the public conversation surrounding JUUL. I mean, everybody was already mad at JUUL for creating the, you know, the youth epidemic. But then when they partnered with Altria, there was this sense of like, this is, there’s something more going on there that’s deeper, that’s more nefarious, that just didn’t sit right with public health regulators, and in fact pissed a lot of people off inside of the FDA, including the then-commissioner, Scott Gottlieb. But at the time, it was seen as a good deal for, it was an amazing deal for Adam and James and for the biggest shareholders in the company, and Altria at the time saw it as a pretty good deal, too. It turned out to be a horrible business decision and bad investment on behalf of Altria.

Dr. Abdul El-Sayed: Before we get there, I want to ask, so at the height of this new e-cigarette epidemic, how many young people, we’ll say, you know, young people under the age of 18, had had been using e-cigarettes or using JUUL in particular?

Lauren Etter: So this is one of the most striking things when you look at how quickly JUUL just ripped through high schools and middle schools across the country. At the peak, which was in 2019, this is when, like the youth JUUL epidemic was at its height, there were over five million teenagers using e-cigarettes on a pretty regular basis. I think it was like 5.6 million middle school and high schoolers. There was about 27% of high school students reported using e-cigarettes, and JUUL was the most popular at the time. So this was not an insignificant problem.

Dr. Abdul El-Sayed: And do we know how many of them then transitioned to traditional cigarettes?

Lauren Etter: That’s, it’s kind of an open question. There is some research that does show that kids or teens who began using e-cigarettes go on to smoke cigarettes. So that is definitely a risk factor. There is research showing—I don’t have specific numbers on how many of those five million ended up going to use cigarettes—but there is research showing that if you use nicotine and e-cigarettes that you might be more predisposed to using combustible cigarettes later on in life. But the bigger question is just what is, what is the redeeming quality of having a teenager using nicotine? Nicotine is highly addictive. It’s about, it’s up there with cocaine and heroin. The other striking fact is that when you look at cigarette smokers, 99%, almost all cigarette smokers started smoking before they left high school. This is a teenage problem. This is a youth addiction problem, which is why health regulators had been wanting to go after it for so long. So now you end up with a different set of problems. While they might not be using cigarettes, which we know to be deadly, they’re using e-cigarettes, which is essentially just nicotine. So they’re becoming addicted to nicotine. And there’s a very large and robust conversation right now about what does that mean? How bad is it? Do we care if people are using nicotine if it’s not, you know, giving them lung cancer, that type of thing. So that’s part of a broader conversation. But yeah, there were over five million teenagers using nicotine. That number has dropped substantially, by the way.

Dr. Abdul El-Sayed: That is really good to hear. What is it dropped to?

Lauren Etter: Just over two million.

Dr. Abdul El-Sayed: OK, that’s, that’s really great. You know what that suggests, then, is that at least enough of them, you know, once regulation was put in place, at least enough of them were able to get off. But you can imagine, right, Altria’s play here is to say, well, we have two million people who are addicted to nicotine, how do we move them onto the harder substance? And so, you know, it was it a, it was a backdoor pathway for the resurgence of cigarettes. And, you know, just to remind our listeners of those numbers, we’re talking about 35% of young people smoking at the height in the late ’90s. Dropped about 10%, back up to 27% who are not smoking cigarettes but are now addicted to nicotine. And while the number has fallen, you’re talking about a whole generation of people who are now newly addicted to nicotine as a function of a product that was designed to get people to quit smoking in the first place. I want to just ask, right, because, you know, late 2019, there’s the onset of a new vaping-related lung injury outbreak. What do we understand about what caused that, and then what was the aftermath in terms of regulation of e-cigarettes?

Lauren Etter: So this is sort of a sore subject in the vaping world, in the vaping community, because what happened was there was this outbreak of lung injuries that started in 2018, 2019—2019, excuse me. And kids were showing up to emergency rooms unable to breathe, and it took some, it took some sleuthing to find out with the commonalities of these children that were showing up in the emergency rooms was they all vape. And so almost immediately, the public health officials, the CDC and the FDA put out warnings saying: this is a vaping-related disease, don’t vape. But after several weeks and months of further investigation, what the CDC found out was that it was primarily, most likely linked to vaping of THC pods. So essentially, some of these THC pods that the kids were getting off of the black market primarily contained an ingredient called vitamin E acetate. It’s like a gooey kind of material that people in the black market were cutting in their products to make it, the product go farther and to make it kind of more syrupy. And so it turned out that it was actually largely the vitamin E acetate, the vaping of that that was causing this lung injury. So but by this time, after weeks and months had passed, it had gotten out in the media and in the general public that this was a vaping-related disease. JUUL suffered as a result because people started getting spooked that this was a, this was a disease that was being caused by using JUUL. And only later did the CDC clarify, saying that most of the cases were tied to this bootlegged product. Now I will point out, and I continue to point out, that the CDC has not ruled out that vaping in general and nicotine, vaping nicotine products only was a small percentage of those cases. But the vast majority of them were these bootlegged THC products. So but the damage had been done. Once the FD—once the CDC came out and kind of clarified the market hep for JUUL  had already started to tank. Kind of the public perception of the products, the perception of risk of this product had kind of shifted, and the people in the pro-vaping community said that the CDC did a disservice to people who are turning to vaping to help them quit smoking and kind of tarnished the reputation of the e-cigarette industry. But it really was kind of a rolling investigation at the time, and there was, for a while, there was a fear that here was this suddenly, there’s this strange disease, this illness, happens to come at the same time that JUUL has just taken over the market and that teens are becoming increasingly addicted to. So it’s very bad timing for JUUL and but it did cause a lot of lasting damage to the company that they have continued to try and recover from.

Dr. Abdul El-Sayed: And as a part of this, there was a lot of movement around banning flavored vapes. Can you talk about the consequences that that has had on JUUL, and on the vaping industry?

Lauren Etter: Yes, absolutely. So the flavors, of course, have been one of the kind of gateways for kids right? At the very beginning of the e-cigarette industry they were launching—and this is not only JUUL—they were launching flavors in all kinds of crazy, with crazy names, you know, and flavors like cotton candy and lollipop and juice box and peanut butter and jelly—like all these flavors that appeared to be designed to attract children. JUUL had a bunch of flavors that they sold. They had, like mango and creme brulee, and mint—not menthol, mint—it tastes like a a peppermint, for example, was their most popular flavor. So at the time, the FDA started cracking down on flavors, saying that these are resulting in youth initiation and we need to take the flavors off the market, and under the Trump administration, they did act. They in fact, Trump wrote this executive order and it ended up becoming the law that there are no flavored pods that can be, no more flavored pods on the market, essentially. So you could still buy flavors if you get like the the big refillable pod mods and stuff like that, that you can get those in vape stores. But the pods that you like click into a device like a JUUL that you can get a 7-Eleven and convenience stores, all of those flavors were removed from the market. And so JUUL, JUUL had already actually, knowing that this controversy was going to only escalate, had already removed a lot of its flavors from the market voluntarily, like the mango and the dessert flavors and stuff like that. But they had still mint on the market. And they eventually took mint off the market, and it was about 70% of JUUL’s market. So it was huge, it was a huge hit to the company by removing their most popular flavor, mint, along with these other flavors. So now if you go to buy a JUUL, you can get it in two flavors: tobacco and menthol. And so menthol is a huge market for them today, and that’s another controversial topic that a lot of people want to see menthol taken off the market as well.

Dr. Abdul El-Sayed: So this story is extremely well told in your book, The Devil’s Playbook, and I hope folks will check it out just to understand, you know, that history repeats itself, and we always have to be on the lookout for the next shiny object that folks who say they’re going to disrupt the current sector try and throw at us. I’ll leave you the final question: where do we go from here?

Lauren Etter: So we are at an inflection point right now. The FDA is currently deciding whether or not to approve JUUL, essentially, to allow JUUL to continue to be marketed. They are evaluating what’s called the pre-market authorization application. And if the FDA does not grant that application to JUUL, JUUL will be taken off the market and the company could go bankrupt. So there’s that issue, the ball is in the FDA’s court right now in terms of JUUL’s future. In terms of the larger question about the role of nicotine in America and how do we treat e-cigarettes, do we turn to them as an alternative for cigarette smoking to help get adult smokers off smoking—it’s a very live and controversial debate right now. I don’t think that, I personally don’t think that we’re going to see JUUL go away. I think it’s going to remain a product that’s part of this growing nicotine category. I think we’re going to see more nicotine users because you already are seeing a lot of new products: nicotine pouches, nicotine toothpicks, there’s all sorts of nicotine gums, candies, lozenges. The market for nicotine is only going to grow. So while the cigarette industry might be dying, I believe the nicotine industry is only going to continue to grow. And so I think as a society, we need to decide, I mean, there are a lot of people in the pro-vaping community who say, who cares if we use nicotine? It’s not deadly. And I think that’s the important thing to point out. Nicotine is not what kills people in cigarettes, it’s the combustion. And there actually aren’t that many adverse health effects to using nicotine, other than it’s highly, highly addictive. So you’re left with this product that has these deep roots in American society that is highly addictive, that people love to use and that are addicted to, and how do we treat that product in a consumer market in the market for cessation drugs, that type of thing. But there’s lots of thorny questions tied up in there, and there are no easy answers.

Dr. Abdul El-Sayed: Well, Lauren, we really appreciate you sharing very thick and deep research that you’ve done on JUUL as a business and e-cigarettes as a broader trend in society, and sharing your perspective with us here, and definitely giving us some some really helpful answers. That was Lauren Etter. She is the author of “The Devil’s Playbook” and also an investigative reporter at Bloomberg News. Thank you so much for joining us today.

Lauren Etter: Thanks for having me.

Dr. Abdul El-Sayed: As usual, here’s what I’m watching right now. Let’s start with some good news today: first cases continue to fall precipitously, down 57% from the delta surge’s September high. That’s great. And what makes it even better is that the CDC and FDA are preparing to approve vaccines for kids, which have the potential to increase our collective immunity even further. That is, of course, if people take them. Now, you all know, I’m no big fan of Big Pharma, but you’ve got to give credit where credit’s due. Pharmaceutical company Merck did something unheralded. They’re the makers of the new COVID pill, molnupiravir. They agreed voluntarily to a royalty-free licensing deal through the global nonprofit Medicines Patent Pool to allow the drug to be manufactured for 105 low-income countries. The drug, which reduces risk of hospitalization and death for people with early symptomatic COVID-19, could be a game changer in COVID-19 management. Now, if we could only get the vaccine manufacturers to do the same thing: Pfizer, Moderna? You all hear me? In less great news, Joe Manchin and Kyrsten Sinema are senators of the United States of America. What they do this time? Well, they forced Democrats drop two of the most promising pieces of Biden’s Build Back Better agenda, which is now just to build back, kind of. They’re, forcing Democrats to drop prescription drug negotiation, which is unsurprising considering Manchin’s Daughter is the CEO of Mylan. You know, the company that spiked the price of EpiPens. And Sinema is raking in the Pharma PAC contributions: $482,550 in corporate PAC contributions this cycle ALONE, to be exact. And then there’s paid family leave, because I guess neither of them care about parents. I don’t even know at this point. To be fair, Build Back Better is an incredibly important bill. It would fundamentally change the framework of American social investment. And yet Joe Manchin in Kyrsten Sinema. That’s it for today. On our way out, do me a favor and go to your podcast app and rate and review our show. It goes a long way to getting it to other folks. And if you really like us, go on over to the Crooked Media store and pick up some merch. We’ve got our new logo tees and mugs, our Safe and Effective shirts and our Science Always Wins shirts and dad caps. Oh, and if you haven’t already? Don’t forget to get your flu shot.

American has is a product of Crooked Media. Our producer is Austin Fisher. Our associate producer is Olivia Martinez. Veronica Simonetti mixers and masters the show. Production support from Tara Terpstra, Lyra Smith, and Ari Schwartz. The theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Sarah Geismer, Sandy Girard, and me: Dr. Abdul El-Sayed, your host. Thanks for listening.