Pod Mod: The New Era's Cutest Nicotine Addiction Device – Young People Are the Hidden Target!

NEJM in its scientific journal issue of 22 August 2018 featured, among its most important topics, the new-generation electronic cigarette Pod Mod was the subject. We previously explored how tobacco products, particularly cigarettes, have been marketed in different ways up to the present, and discussed what we consider today's newest public health crisis , electronic cigarettes, in articles describing their health effects and how they target young people (all our e-cigarette articles). So, regarding this new form that electronic cigarettes have taken in their evolution, what is Pod Mod, and what awaits young people?

During the years when electronic cigarettes became popular, adolescent e-cigarette use greatly surprised public health communities. In 2011, fewer than %2 of US high school students used e-cigarettes, but by 2015 this figure had reached %16 in a short time. By 2016, various US bodies, led by the Surgeon General, had made intensive efforts to address this problem. Public education campaigns and policies reduced high school e-cigarette use in 2016 to %11. A new development in technology and marketing may threaten this decline.

What Is Pod Mod?

Pod Mod is the name of a new type of electronic cigarette apparently gaining popularity. A Pod Mod resembles a small capsule. These small rechargeable devices aerosolize liquid solutions containing flavorings and other ingredients enclosed in cartridges (their operation can be likened to capsule coffee).

The popular e-cigarette brand Juul's pod-system electronic cigarette devices are reportedly frequently used by young people. Juul entered the e-cigarette market in 2015 and by 2017 was the most widely used electronic cigarette brand in the USA. According to Nielsen data, as of 27 January 2018, Juul controlled %49,6 of the US e-cigarette market. Reports also indicate that young people are not using pod mods as a transition product. Young people who have never used tobacco products and now use pod mods seem likely to open the door to new addictions as a consequence.

Salt Nicotine / Nicotine Salt

Juul and other pod mod electronic cigarette devices use protonated nicotine formulations derived from nicotine salts. Nicotine salt is a new form of nicotine that enables more efficient delivery. It allows stronger, higher-level nicotine inhalation. Nicotine salts contain certain hidden ingredients. The hidden ingredient they contain is known as benzoic acid.

According to the figures, nicotine salt solutions contain, compared with most e-cigarette products, 2 to 10 times the nicotine concentration. Juul's website states 0.7 ml nicotine per pod [concentration, 59 mg per milliliter (% 5)] — approximately equivalent to 20 regular cigarettes in amount. Examination of patents shows that combinations of salt-based nicotine and other additives provide a satisfying experience even at high nicotine concentrations. Another issue affecting young people seems to stem from this: delivering high nicotine levels with nicotine salt without unpleasant taste or sensation is an important factor in continued product use. Nicotine is scientifically proven to be addictive, and high intake opens the door to addiction. The finding that young Juul users aged 15 to 24 continue using the product at a rate of %80 supports these concerns.

Its easily concealed physical design also allows covert use among young people. Juul devices measure 9.4 cm x 1.52 cm x 0.76 cm and weigh only 100 grams. Their unobtrusive appearance resembles computer USB drives. Young people can therefore hide them easily and use them even at school.

Pod-system electronic cigarettes can appeal to a broad audience. Their stylish, modern design and resemblance to smart devices attract users. Juul can have customized covers and visual personal skins similar to those video gamers choose to represent game characters, and is marketed in appealing flavors such as "caramel", "fruit mushroom", "mango" and "cool mint".

Although e-cigarette solvents contain much less variety than regular cigarette smoke, e-cigarettes pose significant risks. Solvents may contain metals, volatile organic compounds and flavor additives that can be harmful when inhaled.

Nicotine adversely affects the developing brain, and the earlier the brain encounters concentrated nicotine, the stronger the addiction that develops. Adolescent nicotine exposure is associated with increased mood changes and attention problems. Given pod mods' high nicotine concentrations, nicotine-related health consequences may be worse than with most e-cigarette products. Surveys also showed that among young people aged 15-24, %63 did not know that all Juul products contain nicotine.

E-Cigarette Use May Increase the Risk of Conventional Cigarette Use

A joint report by the US National Academies of Sciences, Engineering, and Medicine concluded that adolescents and young adults using e-cigarettes were more likely to start regular cigarettes than nonusers, and that higher nicotine concentrations could increase this risk.

Because many devices are almost indistinguishable from USB drives, some schools have banned all USB drives. School districts have launched parent and teacher education programs to inform adults about pod mods and identify whether their children or students use them. Several school-based educational programs focus on preventing and stopping tobacco use and are considered promising by the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-Based Programs and Practices and other organizations.

On 18 April 2018, six public health organizations called on the US Food and Drug Administration (FDA), the federal agency responsible for regulating e-cigarettes, to act to prevent youth Juul and e-cigarette use. A coalition of 11 US senators also recently expressed similar concerns and called on the FDA to ban sales of e-cigarettes with "kid-friendly" flavors.

The FDA then acted on 24 April 2018, introducing restrictions targeting retailers selling e-cigarettes to minors and third-party Juul sales on the popular shopping website eBay. It also announced nationwide operations to examine information in detail and intervene.

In conclusion, we also argue that examining how and to what extent youth Pod Mod use affects conventional cigarette use is important. We believe schools should have zero tolerance for tobacco products on school grounds. We think these measures can provide a more useful starting point for developing evidence-based interventions addressing adolescent pod mod use. Knowing that comprehensive action is urgently needed against Pod Mod and other e-cigarette use, we advise doctors and parents to remain alert to this emerging public health concern.