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It's too easy to call JuulBan a public health victory

After the US Food and Drug Administration (FDA) announced last week that it would order the e-cigarette giant Juul Labs to stop selling its products

6} In the United States, my inbox was flooded with emails from public health groups praising this decision. The CEO of the American Lung Association called it "a long postponement and welcome." The CEO of the smoking cessation group, Truth Initiative, called this a "big public health victory."

These congratulatory statements revolve around Juul's protagonist, which federal regulators call theteenage nicotine addiction epidemic. In that sense, the ordered withdrawal from the US market was a victory. Finally, the regulatory agency held the company accountable and protected the children.

It took less than 48 hours for the federal court to issue an emergency stay. This allowed Juul to continue selling e-cigarettes while the lawyer was preparing a full appeal. In a court filing, Juul's lawyer called the FDA's decision "based on deficiencies in Juul's toxicological data," "arbitrary and capricious," and less dangerous for adult smokers. By helping to switch to the product, Juul argued that it would help public health.

This is a point that has often been lost in the last few years. Jewling isn't just about what happens in high school bathrooms. Adult smokers also use Juul to throw away cigarettes. For them, last week's decision was not a victory.

"Juul is the most thoroughly studied #ecig in history," said Jonathan Foulds, a professor of public health science at Pennsylvania State University, after the FDA's decision. Tweeted. "Because some" potentially harmful chemicals "can seep out of some pods, banning this life-saving evacuation route from smoking is an emergency staircase because the stairs are slippery. It's a bit like locking the door.

Like other tobacco products, e-cigarettes are not completely safe. Experts broadly agree that no one who is currently smoking should start smoking. However, for those who have already smoked, current studies show that e-cigarettes are a less risky way to consumenicotine, between deadly cigarettes and quitting nicotine altogether. It suggests that it could be a bridge.

Not long ago, the country's top tobacco regulators were cautiously optimistic about the promise. In 2017, then FDA Commissioner Dr. Scott Gottlieb and Mitchzeler, who was the director of the FDA's Tobacco Product Center until April, explained theframework for reducing tobacco-related deaths and illnesses.. In the United States, along with nicotine gum and patches, it involves promoting e-cigarettes as an off-lamp for adults who want to quit smoking.

Later, e-cigarettes began among teens, and Juul in particular spread like a wildfire in certain US middle and high schools. Concerns that children can understand have begun to cover everything else. The FDA has no choice but to act aggressively as the teenage e-cigarette problem snowballs and influentialparliamentarians, parent groups, and public health organizations begin to oppose Juul. did.

For clarity, Juul made more mistakes than the spaces listed here. (I wrote an entirebookabout them, andcovered them extensively for this magazine.) The first marketing campaign that the company repeatedly denied attracts children It was aimed at —at least it wasn't wiseIt was too easy and too long for underage customers to buy Juul products online or in stores. Juul executives sendtobacco company representatives to school to educate their children about the dangers of e-cigarettes, despite the tragic history oftobacco companies doing the same. did. Concerns about serious conflicts of interest. Juul has become more responsible in acting in recent years, but it's not hard to understand why it has attracted so much public attention.

The FDA's refusal did not focus on any of these very common mistakes. Instead, the agencyordered Juul to be removed from the market. "Insufficient and inconsistent data" raised concerns about genetic damage and chemical leaching from Juul's e-liquid pods. The FDA said there was no "imminent risk information" associated with Juul products, but concerns about health risks should be taken seriously.

Still, some public health experts wondered aloud whether politics also played a role. Clifford Douglas, director of the University of Michigan's Tobacco Research Network, said: he told theWashingtonpost.

A former Juul employee who knows the company's FDA application told me more frankly. "Many of these decisions are political," they said. "They are not necessarily evidence-based."

Zeller categorically denies that politics influenced the FDA's decision. "I know that many people who support harm reduction and e-cigarettes are very disappointed with this," he says. "I understand how others have reacted, but this is the way the system is supposed to work. It was a science-based decision by a subject expert. "

The question is what will be the effect of that decision. The impact among teens may be less than Juul's history suggests. In's latest federal study on teen vaping, about 6% of high school vaping people list Juul as their favorite brand, and 26% say they're the brand they rely on. Said it was a puff bar. Still on sale. If

Juul doesn't win its appeal and the product has to be removed from the market, many adult users will probably haveFDA-approvedanother e-cigarette. Will switch to. Or it remains for sale because it is on the verge of regulation. But if I learned anything by reporting on vaping, it means that vaping people are passionate and loyal to any product that helps them quit smoking. Therefore, it is not easy to remove one of the potentially largest brands from the market.

When I was reporting a book about Juul, some worked for Juul and others saw the vaping industry evolving from outside the company, but Juul's story missed the opportunity. I said it was one of the things I did. If the company Juul acted more responsibly, if it wasn't very popular with teens, if it didn't offend regulators, it didn't ignite the match that caused the political fire. If so, perhaps the product Juul could have made a real difference in public health.

As co-founder James Monsiesonce said, was it "one of the greatest opportunities for public health in human history"? A major study review published last yearfound that e-cigarettes gave about 3 additional smokers out of 100 cigarettes compared to traditional nicotine replacement therapies such as gums and patches. I concluded that I could help. This isn't a big difference, but it's a difference for both public health and the three fictitious smokers.

It's not that the FDA has made an easy choice in its hands, it's just that there is more nuance in the vaping debate than it is sometimes expressed. Zeller, on his part, wants the tobacco control community to be more proactive in looking for commonalities when it comes to vaping.

"I hope the people of pro-e-cigarettes did not completely deny the concerns that the other side has about unintended consequences, such as youth use and addiction." Zeller says. "But likewise, I hope the anti-cigarette people are more open-minded about the potential benefits of a well-regulated market."

The FDA's decision on Juul is , Is in that gray area. Casting Juul's withdrawal from the potential market as an uneased victory for public health, even if it is ultimately the right choice, based on nasty toxicological data and concerns about the use of minors. Feels oversimplified. There is also a loss associated with it.

Jamie Ducharme (