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Researchers respond to alarming rise in teen vaping.

At 17, Karin Felsher noticed a risky new trend among her high school classmates. Hiding under tables in science class or exhaling into their back-packs, students were widely using a new e-cigarette called JUUL—and educators and parents were none the wiser.

Karin’s mom, Bonnie Halpern-Felsher, PhD, was a Stanford researcher studying tobacco use in teens. Karin tipped her off to the alarming new phenomenon.

Since then, e-cigarettes have grown into an epidemic among adolescents and a multi-billion-dollar industry for manufacturers like JUUL.

“With at least 20 percent of high school students reporting some use of e-cigarettes in the last year and not understanding the harms and nicotine in there, it was important for me to do something about it,” explains Halpern-Felsher, professor of pediatrics at Stanford University School of Medicine.

Halpern-Felsher immediately incorporated the topic into the Tobacco Prevention Toolkit, a free set of online materials that informs teens of the dangers of tobacco and nicotine, as well as explains adolescent brain development and nicotine addiction. Halpern-Felsher launched the toolkit in October 2016 for young people and their teachers. Today, the toolkit is being used by educators in every state (and five countries) and has reached at least 300,000 youth across the country in just the past year.

“A few years into creating the toolkit, cigarette use among teens was below 10 percent,” says Halpern-Felsher. “I had spent 20 years of my career trying to prevent tobacco use to suddenly have this new product appear. Now we’re heading backwards in our tobacco prevention and control efforts.”

How JUUL Became Cool

What changed? JUUL, the most popular brand of e-cigarettes, went on sale in 2015 and now accounts for 75 percent of U.S. e-cigarette sales. JUUL is a pod-based system that appeals to youth with a variety of sweet flavors such as mint, mango, and fruit medley. The pods snap into sleek devices that resemble USB flash drives and can be charged in a laptop, making them convenient for teens to hide in plain sight.

They’re also accessible. Karin says JUUL was easy to get in her high school, and it’s even easier on her college campus. “You can Venmo $2 to someone for two puffs from their JUUL.”

JUUL is marketed as a safer, trendy alternative to cigarettes. However, the long-term effects of vaping, or JUULing, are still unknown. Made up of a cocktail of chemicals that researchers haven’t yet studied, JUUL delivers nearly as much nicotine as two packs of cigarettes in one pod.

“There’s a culture around JUUL,” Karin says. “It’s a total rebellion.”

JUUL denies that its products are marketed to teens. But a group of researchers at Stanford University cries foul. Stanford Research Into the Impact of Tobacco Advertising, led by Robert Jackler, MD, has intensely studied the JUUL phenomenon and archived 1,400 JUUL advertisements online. Many show attractive young models gazing flirtatiously at the camera or dancing exuberantly. Early on, JUUL also heavily marketed on youth-oriented sites such as Instagram.

For Halpern-Felsher, it’s no wonder they’re getting addicted. “In youth with their developing brains—and that brain is a fabulous thing—it makes them so much more at risk around addiction,” she says.

Research shows that the nicotine in e-cigarettes also primes the adolescent brain for other addictions like cigarettes and cocaine.

This is all good for the manufacturers who benefit from a new generation of users who will get addicted and become lifelong consumers, Halpern-Felsher says. Veteran tobacco and companies like Altria, the maker of Marlboro, and Reynolds American also win, since their hold is growing on the e-cigarette market. Recently, Altria purchased a third of JUUL.

Taking Action

Lawmakers responded by launching an investigation into JUUL’s advertising practices and the deal with Altria.

Halpern-Felsher has taken matters into her own hands. She co-authored several studies on teens’ JUUL use and found that teens believe JUUL is less harmful and addictive than other nicotine products. She also testifies before state and federal agencies about the need to regulate tobacco products including e-cigarettes to prevent them from getting into the hands of youth.

CVS Health Foundation has been a generous supporter of the Tobacco Prevention Toolkit. They made it possible to include modules on hookah and smokeless tobacco; increase content throughout the toolkit, especially about e-cigarettes and JUUL; and disseminate and train educators to use the toolkit. Additional funding is needed to share the toolkit more broadly in the United States and abroad.

“Our approach is to educate youth about the manipulation of tobacco marketing,” says Halpern-Felsher. “When I say to them that there are 400,000 smokers dying each year and the tobacco industry is looking to you to replace the next smoker who dies, it really wakes them up.”


The Tobacco Prevention Toolkit and trainings are free of charge to parents and educators. Visit

This work has been supported by the CVS Health Foundation, the Stanford Maternal and Child Health Research Institute, and other generous donors.

This article originally appeared in the Spring 2019 issue of Packard Children’s News.