Here’s what you need to know about Juul, the e-cigarette brand that contains double the nicotine and is vaped from a device that looks like a USB drive.

Forty years ago, nearly 29 percent of high school seniors reported smoking cigarettes daily, according to the U.S. Department of Health and Human Services. By 2018, less than 1 in 25 high schoolers smokes daily.

The Centers for Disease Control and Prevention (CDC) reports a similar decline, with 4.3 percent fewer middle schoolers and 15.8 percent fewer high schoolers admitting to smoking cigarettes between 2011 and 2018.

However, as cigarette smoking seems to be on the decline, another method of nicotine use has managed to hook today’s youth.

The same CDC report that discussed the decline of cigarette use revealed an increase in vaping.

In 2018, 4.9 percent of middle schoolers reported using electronic cigarettes, and 20.8 percent of high schoolers reported the same.

“By their senior year, over 25 percent of high schoolers are current e-cigarette users,” Dr. Jonathan Winickoff, a pediatrician at Massachusetts General Hospital in Boston and member of the American Academy of Pediatrics (AAP) Section on Tobacco Control, told Healthline.

When it comes to tobacco use, cigarettes are considered a combusted or burned product. The cigarette has to be lit, the tobacco burned, and the smoke inhaled.

Vaping, on the other hand, involves no combustion or burning. Instead, vaping products release an aerosol that is inhaled.

While many people make the mistake of assuming this aerosol is as harmless as water vapor, it actually consists of fine particles containing toxic chemicals, many of which have been linked to cancer, as well as respiratory and heart diseases.

Vaping devices, which include e-cigarettes and vape pens, were first introduced to the commercial market in 2007. They typically have to be plugged in or powered by battery so a heating component can warm an e-liquid cartridge that then releases the aerosol to be inhaled in the lungs.

“A lot of these cartridges are actually marketed as health products,” Winickoff explained. “They have ‘healthy’ flavors, things like mango and berry that are associated with high antioxidants. But they’re just flavors. There are no actual health benefits.”

The CDC has found that these flavors are a big part of the reason teens are latching onto these products. Even worse, Winickoff told Healthline about a study where 60 percent of kids believed that pods used in Juuls (a specific brand of e-cigarette) were nicotine-free — when the reality is that 99 percent of these products contain nicotine.

In 2018, Juuls accounted for about 40 percent of the e-cigarette market, grossing 150 million in retail sales the last quarter alone. The appeal of this product specifically is that they don’t look like e-cigarettes. Juuls are small, can be mistaken for a USB drive, and are easily concealed in a person’s hand.

In other words, this is a product teens are able to use more discreetly, without drawing as much attention from their parents and teachers.

With the introduction of Juuling, e-cigarette use among teens is on the rise. So much so that both Time and The Washington Post reported on Juuling and what parents need to be aware of.

“These products are really creating a resurgence,” Winickoff said. “All the work that happened, all the public health campaigns, the billions of dollars spent to try to eliminate tobacco use for kids has been undone. Now we have millions of adolescents currently addicted to nicotine.”

A large number of people believe e-cigarettes are simply a safer way to consume nicotine, and that nicotine isn’t harmful by itself. But that’s not true.

Research has found numerous negative impacts of nicotine alone: on metabolism, increased cancer risks and respiratory problems, as well as more asthma attacks and symptoms experienced by those who vape.

“We know based on Juul’s own published testing that these products contain carcinogens. Group 1 carcinogens — the most potent carcinogens known,” Winickoff revealed.

There’s also another risk that parents should be aware of when it comes to teens and e-cigarette use — the addiction may be harder to kick.

According to AAP, Juul pods contain nearly double the concentration of nicotine compared to other e-cigarette cartridges. This is especially concerning because the risk for addiction is already higher among teens.

Winickoff explained, “The younger the developing brain is exposed to nicotine, the stronger and more rapid the addiction. The earlier you become addicted, the harder it is to quit.”

But that’s not all. According to Winickoff, addiction to nicotine at a young age actually causes brain remodeling, changing the threshold for addiction to other substances.

In other words, kids who use nicotine earlier are more likely to fall in love with other drugs later on.

The risks of Juuling and vaping for kids are real, making it all the more important for parents to begin addressing these issues before their children decide to try these products.

A licensed clinical psychologist from Connecticut, Dr. Elaine Ducharme, PhD, told Heathline, “Parents really need to start talking to their kids in elementary school about this issue.”

She offered these tips for engaging in those discussions:

  1. Educate yourself first. Get the facts on these products so you know what you’re talking about when you approach the discussion with your kids.
  2. Be a role model. Parents are responsible for shaping many of their children’s ideas and behaviors, so set the tone with your own actions.
  3. Establish a safe environment where your kids can talk about their feelings and opinions without feeling judged.
  4. Really listen and let them tell you what they know.
  5. It can sometimes be helpful to give them something to read that you can then discuss together.
  6. Help them figure out ways to handle situations where they may be pressured to engage in these behaviors.
  7. Create a plan, even specific things for them to say like, “I have asthma and my doctor says I could become very ill if I try this,” or, “I just don’t think it looks cool.”
  8. Help them understand that using willpower to stand up to peers is really hard, but willpower is like a muscle — the more you use it, the stronger it gets.

Winickoff had this to add, “What the research says about tobacco use, which we can apply to Juuling and vaping, is that parents expressing how they feel about these products — their strong negative opinions — actually can make a difference. Kids may protest, but they do internalize their parent’s belief system.”

Winickoff says this is true even if a parent uses the product themselves. Talking about the negatives of that product, and about how the addiction has taken hold and why parents can’t quit (even though they want to) can still send a strong message to teens about why they shouldn’t start.

While the legal age for purchasing these products is 18 in some states and 21 in others, Winickoff explained that many kids are ordering them online — simply checking a box to verify they are of legal age. For this reason, parents should pay attention to their teen’s online purchases and packages that may arrive in the mail.

Juul pods also look very similar to an average USB flash drive. Examine any questionable device closely.

If you discover that your teen is already Juuling, Winickoff is clear that it’s important to recognize this as more than just a “bad habit.” It’s a medical problem that requires a major response from the family, the child’s pediatrician, and possibly a therapist to help get that teen out from under the nicotine addiction.

“It’s not easy to get kids to stop. Their body craves it. They need it just to get through the day. I can tell you from anecdotal experience just from my office, I’ve had a terrible time getting kids to give up electronic cigarettes. It’s that young brain and extra susceptibility. They’re locked in.”

Ducharme added, “If the situation seems out of control, it’s time to speak with a psychologist or other mental health professional trained in working with teens and addictions.”

Currently, there aren’t any addiction programs specifically geared toward teens and nicotine use, which makes prevention and enforcement of existing rules all the more important.

Winickoff recommends advocating for zero-tolerance policies in schools and tobacco-free zones around every school, middle grade through college. He also recommends parents get involved in the Tobacco 21 movement, which aims to increase the legal age for purchasing tobacco products to 21. So far, six states have adopted such laws.

With the help of active and informed parents, yours could be next.

Editor’s note: This piece was originally reported on August 17, 2018. Its current publication date reflects an update, which includes a medical review by Alana Biggers, MD, MPH.