In October 2018, the U.S. Food and Drug Administration (FDA) held a surprise inspection of the headquarters of the Juul company, manufacturers of electronic cigarettes, where thousands of documents were seized on grounds that the company was engaged in practices aimed at inducing young people to consume these tobacco products ¹1. Christensen J. FDA seizes documents from e-cigarette maker Juul. CNN 2018. https://www.cnn.com/2018/10/02/health/fda-juul-e-cigarette-surprise-inspection-bn/index.html (acessado em 19/Dez/2018).
https://www.cnn.com/2018/10/02/health/fd... .

The raid was part of the response by the FDA to what can be considered an e-cigarette epidemic use among elementary and High School students in the United States. Among High School students, e-cigarette vaping increased from 1.5% in 2011 to 20.8% in 2018, and 2017 saw the most significant increase ²2. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among Middle and High School students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep 2018; 67:1276-7.. Among elementary school students, e-cigarette use increased from 0.6% in 2011 to 4.9% in 2018 ²2. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among Middle and High School students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep 2018; 67:1276-7.. In short, practically 1 in 5 American High School students use e-cigarettes, mostly products with diverse flavors and mainsly of the brand Juul ²2. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among Middle and High School students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep 2018; 67:1276-7.. The significant increase in 2017 is purportedly associated with this brand’s popularity on the American market ²2. Cullen KA, Ambrose BK, Gentzke AS, Apelberg BJ, Jamal A, King BA. Notes from the field: use of electronic cigarettes and any tobacco product among Middle and High School students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep 2018; 67:1276-7..

The reasons for the great popularity of these products among students are their format, the possibility of low-profile use, the high nicotine content, and attractive flavors ³3. King BA, Gammon DG, Marynak KL, Rogers T. Electronic cigarette sales in the United States, 2013-2017. JAMA 2018; 320:1379-80..

The small and rectangular shape of the product, presenting several colors, resembling a pen drive, and charged via USB port is attractive and discreet. The nicotine is loaded via “pods”, which contain the amount of nicotine equivalent to 20 conventional cigarettes (one pack) ⁴4. Hammond D, Wackowski OA, Reid JL, O'Connor RJ; International Tobacco Control Policy Evaluation Project (ITC) team. Use of Juul e-cigarettes among youth in the United States. Nicotine Tob Res 2018. [Epub ahead of print].^,55. Barrington-Trimis JL, Leventhal AM. Adolescents' use of "pod mod" e-cigarettes - urgent concerns. N Engl J Med 2018; 379:1099-102.

Compared to other e-cigarettes, the “pods” used by Juul have far higher addictive potential, causing a physiological sensation similar to that experienced by smokers of conventional cigarettes. The product uses nicotine treated with benzoic acid (resulting in the nicotine salts, its natural form in tobacco leaves) to deliver concentrations 10 times higher than in other e-cigarettes, which use freebase nicotine in their formulations ⁵5. Barrington-Trimis JL, Leventhal AM. Adolescents' use of "pod mod" e-cigarettes - urgent concerns. N Engl J Med 2018; 379:1099-102. Other manufacturers, possibly inspired by Juul’s commercial success, have also begun to adopt nicotine salts in their products ⁴4. Hammond D, Wackowski OA, Reid JL, O'Connor RJ; International Tobacco Control Policy Evaluation Project (ITC) team. Use of Juul e-cigarettes among youth in the United States. Nicotine Tob Res 2018. [Epub ahead of print]..

Interestingly, the tobacco industry has a history of manipulating nicotine levels in cigarettes, with techniques ranging from the addition of ammonia to cigarettes to increase the freebase nicotine to using modified tobacco strains that produce higher nicotine concentrations (Y-1 tobacco) ⁶6. Stevenson T, Proctor RN. The secret and soul of Marlboro. Am J Public Health 2008; 98:1184-94.^,77. Hanford D; Dow Jones News Service. Brown & Williamson used Y-1 tobacco, executive testifies. Truth Tobacco Industry Documents; 1998. https://www.industrydocumentslibrary.ucsf.edu/tobacco/docs/pyvd0172 (acessado em 19/Dez/2018).
https://www.industrydocumentslibrary.ucs... , but the use of these salts in e-cigarettes is unprecedented. One study suggests that Juul pods have greater addictive potential for young people than other e-cigarettes or even ordinary cigarettes ⁸8. McKelvey K, Baiocchi M, Halpern-Felsher B. Adolescents' and young adults' use and perceptions of pod-based electronic cigarettes. JAMA Netw Open 2018; 1:e183535..

Like other electronic smoking devices, Juul comes in various flavors such as creme brûlée, mango, and menthol, making these products even more attractive to young people, just as flavors are used in conventional cigarettes to facilitate initiation and thus nicotine addiction ⁹9. Scientific Committee on Emerging and Newly Identified Health Risks. Final opinion on additives used in tobacco products (Opinion 1): tobacco additives I. https://ec.europa.eu/health/sites/health/files/scientific_committees/emerging/docs/scenihr_o_051.pdf (acessado em 22/Dez/2017).
https://ec.europa.eu/health/sites/health... . In electronic cigarettes were described about 8,000 flavours ¹⁰10. Zhu S-H, Sun JY, Bonnevie E, Cummins SE, Gamst A, Yin L, et al. Four hundred and sixty brands of e-cigarettes and counting: implications for product regulation. Tob Control 2014; 23 Suppl 3:iii3-9..

This combination has led to a considerable number of American schoolchildren addicted to nicotine. Considering that e-cigarettes can be the gateway to conventional cigarettes, since after one year of vaping these youngsters run a four times higher risk of starting to smoke regular cigarettes, and also increase the risk of future marijuana use ¹¹11. Soneji S, Barrington-Trimis JL, Wills TA, Leventhal AM, Unger JB, Gibson LA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: a systematic review and meta-analysis. JAMA Pediatr 2017; 171:788-97.^,1212. Primack BA, Shensa A, Sidani JE, Hoffman BL, Soneji S, Sargent JD, et al. Initiation of traditional cigarette smoking after electronic cigarette use among tobacco-naïve U.S. young adults. Am J Med 2018; 131:443.e1-443.e9^,1313. Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, Sussman S, Riggs NR, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA 2015; 314:700-7.^,1414. Watkins SL, Glantz SA, Chaffee BW. Association of noncigarette tobacco product use with future cigarette smoking among youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015. JAMA Pediatr 2018; 172:181-7.^,1515. Dai H, Catley D, Richter KP, Goggin K, Ellerbeck EF. Electronic cigarettes and future marijuana use: a longitudinal study. Pediatrics 2018; 141:pii:e20173787..

Another controversy that surrounds these products is their use in cessation treatment. Although some data suggest a possible increase in cessation rates, the published data are still not sufficient to claim that electronic cigarettes are an effective method to quit smoking ¹⁶16. Martins SR. Cigarros eletrônicos: o que sabemos? Estudo sobre a composição do vapor e danos à saúde, o papel na redução de danos e no tratamento da dependência de nicotina. http://www.inca.gov.br/bvscontrolecancer/publicacoes/cigarros_eletronicos.pdf (acessado em 19/Mai/2017).
http://www.inca.gov.br/bvscontrolecancer... . However, the UK House of Commons Science and Technology Committee recently released a report, according to which these products could be used for cessation and may be contributing to the reduction in the prevalence of smoking and that they pose less risk than conventional cigarettes ¹⁷17. McNeill A, Brose LS, Calder R, Hitchman SC. E-cigarettes: an evidence update. A report commissioned by Public Health England. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/457102/Ecigarettes_an_evidence_update_A_report_commissioned_by_Public_Health_England_FINAL.pdf (acessado em 23/Sep/2017).
https://www.gov.uk/government/uploads/sy... .

However, the report that backed the House of Commons’ position was harshly criticized in an editorial in The Lancet¹⁸18. E-cigarettes: Public Health England's evidence-based confusion. Lancet 2015; 386:829. on the following grounds: non-scientific references ¹⁹19. West R, Hajek P, Mcneill A, Brown J, Arnott D. Electronic cigarettes: what we know so far. A report to UK All Party Parliamentary Groups. http://www.smokinginengland.info/reports/ (acessado em 10/Out/2017).
http://www.smokinginengland.info/reports... , few references ¹⁸18. E-cigarettes: Public Health England's evidence-based confusion. Lancet 2015; 386:829., problems in the formation of the groups of expert consultants ¹⁸18. E-cigarettes: Public Health England's evidence-based confusion. Lancet 2015; 386:829., no attention to serious caveats in one reference ²⁰20. Nutt DJ, Phillips LD, Balfour D, Curran HV, Dockrell M, Foulds J, et al. Estimating the harms of nicotine-containing products using the MCDA Approach. Eur Addict Res 2014; 20:218-25., and conflicts of interests in the main reference ¹⁸18. E-cigarettes: Public Health England's evidence-based confusion. Lancet 2015; 386:829.. This indicates the size of the controversy still surrounding these products.

In Brazil, the prevalence of e-cigarette use is very low ²¹21. Cavalcante TM, Szklo AS, Perez CA, Thrasher JF, Szklo M, Ouimet J, et al. Conhecimento e uso de cigarros eletrônicos e percepção de risco no Brasil: resultados de um país com requisitos regulatórios rígidos. Cad Saúde Pública 2017; 33 Suppl 3:e00074416. due to the ban since 2009. However, online marketing of these products has been common despite the ban, even large department store chains sell e-cigarettes freely to children and adolescents; and even the sanctions and fines from the by Brazilian Health Regulatory Agency (Anvisa) do not seem inhibit these stores.

Data show that the decrease in smoking rates has stagnated in Brazil. Even more serious is that smoking prevalence among young people 18 to 24 years of age in the country’s state capitals increased from 7.4% to 8.5% ²²22. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Vigitel Brasil 2017: vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2017. Brasília: Ministério da Saúde; 2018. between 2016 and 2017.

One factor that may have contributed to the increase in the number of young smokers is the widespread marketing of e-cigarettes via internet.

Thus, these products can quickly reverse tobacco control policies if more stringent regulatory measures are not taken.

Even though the ban on electronic smoking devices may have effectively protected Brazil from the Juul epidemic among youth, stricter measures should be taken against the sale of such products, besides seeking the means to prevent large retail chains from continuing to challenge the national health authorities and to keep these products from undermining Brazil’s successful tobacco control policy.

Acknowledgments

The authors wishes to thank the Brazilian Health Regulatory Agency (Anvisa), the Oswaldo Cruz Foundation (Fiocruz) and Brazilian National Research Council (CNPq). The article expresses the author’s exclusive opinion and thinking, based on the currently available scientific evidence, and does not represent any guideline and/or institutional opinions of Anvisa, Fiocruz, the Brazilian Ministry of Health, or the Brazilian government.

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