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Ramamurthi D, Chau C, Berke HY, Tolba AM, Yuan L, Kanchan V, Santos G, Jackler RK. Flavour spectrum of the Puff family of disposable e-cigarettes. Tob Control 2023; 32:e71-e77. [PMID: 35017264 DOI: 10.1136/tobaccocontrol-2021-056780] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 12/22/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND In January 2020, the US Food and Drug Administration prohibited the sale of flavours (except for menthol and tobacco) in prefilled pod devices such as JUUL to decrease youth vaping. Excluded from the prohibition were disposable devices. OBJECTIVES To determine the scope and scale of flavours marketed by Puff Bar, a leading disposable brand, and related products. METHODS Disposable e-cigarette flavours were identified via online searches encompassing vendor websites, wholesale distributors, manufacturers (eg, made-in-china.com), and social media channel, Instagram, between June and August 2020. RESULTS The 'Puff' brand name and iconic cloud logo appear on a variety of products of differing sizes and nicotine e-liquid volumes. Among Puff Bar and its copycats (Puff-a-Likes), 139 flavours were identified. Fruit flavours predominated comprising 82.2% of the flavour varieties (fruit 50%, fruit and menthol/mint 23.6%, and fruity drinks 8.6%). A prevalent new flavour category which combines fruit with menthol/mint (Ice) was offered in 33 varieties such as Lychee Ice, Lush Ice and Banana Ice. Disposable e-cigarette brands are undertaking measures to escape tobacco regulation (eg, non-tobacco-sourced nicotine) and flavour limitations via post-market flavour additions to unflavoured nicotine e-liquid. CONCLUSIONS The proliferation of flavoured disposable e-cigarette products, many of which are designed to emulate popular pod devices, illustrates that narrowly limited flavour regulations covering only a single category are destined to fail. To be effective in youth protection, flavour regulations need to apply to all recreational nicotine-containing products and need to include measures to counter post-market flavour addition.
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Affiliation(s)
- Divya Ramamurthi
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Cindy Chau
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Hannah Y Berke
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Afnan M Tolba
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Lu Yuan
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Vedika Kanchan
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Giulia Santos
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
| | - Robert K Jackler
- Stanford Research into the Impact of Tobacco Advertising, Stanford University, Stanford, California, USA
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Gravely S, Meng G, Hammond D, Hyland A, Michael Cummings K, Borland R, Kasza KA, Yong HH, Thompson ME, Quah ACK, Ouimet J, Martin N, O'Connor RJ, East KA, McNeill A, Boudreau C, Levy DT, Sweanor DT, Fong GT. Differences in cigarette smoking quit attempts and cessation between adults who did and did not take up nicotine vaping: Findings from the ITC four country smoking and vaping surveys. Addict Behav 2022; 132:107339. [PMID: 35605409 PMCID: PMC9202449 DOI: 10.1016/j.addbeh.2022.107339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/10/2022] [Accepted: 04/17/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION There is mixed evidence as to whether nicotine vaping products (NVPs) can help adults who smoke transition away from cigarettes. This study investigated if self-reported attempts to quit smoking and smoking cessation, over a period of either 18 or 24 months, differed between respondents who initiated nicotine vaping versus those who did not. Outcome comparisons were made between those who: (1) initiated vaping vs. those who did not; (2) initiated daily or non-daily vaping vs. those who did not; and (3) initiated daily or non-daily vaping between surveys and continued to vape at follow-up (daily or non-daily) vs. those who did not initiate vaping. METHODS This cohort study included 3516 respondents from the ITC Four Country Smoking and Vaping Surveys (Australia, Canada, England, United Sates), recruited at Wave 1 (2016) or 2 (2018) and followed up at Wave 2 (18 months) and/or 3 (2020, 24 months). Adults who smoked daily at baseline and did not have a history of regular vaping were included. Initiation of vaping was defined as beginning to vape at least monthly between surveys. Respondents indicated whether they made an attempt to quit smoking between surveys. Smoking cessation was defined as those who self-reported no longer smoking cigarettes at follow-up. RESULTS Relative to those who did not initiate vaping, initiation of any daily vaping between surveys was associated with a greater likelihood of smokers making a cigarette quit attempt (p < 0.001) and quitting smoking (p < 0.001). Among smokers who attempted to quit smoking, initiation of daily vaping was associated with a greater likelihood of being abstinent from smoking at follow-up (p = 0.001). Respondents who initiated vaping between surveys and were vaping daily at follow up were significantly more likely to have attempted to quit smoking (p < 0.001) and to have quit smoking (p < 0.001) than those who did not initiate vaping. Respondents who initiated non-daily vaping did not differ significantly from those who did not initiate vaping on any of the outcome measures. CONCLUSIONS Daily NVP use was associated with increased attempts to quit smoking and abstinence from smoking cigarettes. These findings are consistent with the concept that complete cigarette substitution may be more likely to be achieved when smokers vape nicotine daily.
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Affiliation(s)
| | - Gang Meng
- Department of Psychology, University of Waterloo, Canada
| | - David Hammond
- School of Public Health Sciences, University of Waterloo, Canada
| | - Andrew Hyland
- Department of Health Behavior, Division of Cancer Prevention & Population Sciences, Roswell Park Comprehensive Cancer Center, USA
| | - K Michael Cummings
- Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, USA
| | - Ron Borland
- Melbourne Centre for Behaviour Change, School of Psychological Sciences, University of Melbourne, Australia
| | - Karin A Kasza
- Department of Health Behavior, Division of Cancer Prevention & Population Sciences, Roswell Park Comprehensive Cancer Center, USA
| | - Hua-Hie Yong
- School of Psychology, Deakin University, Australia
| | - Mary E Thompson
- Department of Statistics and Actuarial Science, University of Waterloo, Canada
| | - Anne C K Quah
- Department of Psychology, University of Waterloo, Canada
| | - Janine Ouimet
- Department of Psychology, University of Waterloo, Canada
| | - Nadia Martin
- Department of Psychology, University of Waterloo, Canada
| | - Richard J O'Connor
- Department of Health Behavior, Division of Cancer Prevention & Population Sciences, Roswell Park Comprehensive Cancer Center, USA
| | - Katherine A East
- School of Public Health Sciences, University of Waterloo, Canada; Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, England
| | - Ann McNeill
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King's College London, England; Shaping Public Health Policies to Reduce Inequalities & Harm (SPECTRUM), UK
| | - Christian Boudreau
- Department of Statistics and Actuarial Science, University of Waterloo, Canada
| | - David T Levy
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, USA
| | | | - Geoffrey T Fong
- Department of Psychology, University of Waterloo, Canada; School of Public Health Sciences, University of Waterloo, Canada; Ontario Institute for Cancer Research, Canada
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Katz SJ, Cohen EL, Kinzer HT. "Can I hit that?" Vaping knowledge, attitudes and practices of college students. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022; 70:1778-1787. [PMID: 33048639 DOI: 10.1080/07448481.2020.1820512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/27/2020] [Accepted: 08/28/2020] [Indexed: 06/11/2023]
Abstract
Objective: Vaping rates among college students have been increasing significantly in recent years, due in large part to the diffusion of pod vaping devices (i.e., JUUL, Suorin) on American college campuses. In this study, we explore the ecological system of knowledge, attitudes, and practices in regards to this trend. Participants: Participants were 26 undergraduate students at the University of Minnesota. Method: Following a KAP (knowledge, attitudes, practices) approach, 8 focus groups were conducted in April/ May 2019. Results: Knowledge themes include awareness of the addictiveness of the devices and uncertainty regarding the health risks. Attitudinal themes include a dual perspective, wherein social use is acceptable, but everyday use is stigmatized. Practice themes included three evident stages: social connection, wherein the devices were used to achieve social advantage with peers; addiction, characterized by solitary, habitual use; and detachment, sometimes marked by a dramatic, public action filmed for social media. Conclusions: As we consider intervention points on college campuses, an understanding of knowledge, attitude, and practice themes can guide our approach. Recommendations for college vaping campaigns are discussed.
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Affiliation(s)
- Sherri Jean Katz
- Hubbard School of Journalism and Mass Communication, University of Minnesota, Minneapolis, MN
| | - Elisia L Cohen
- Hubbard School of Journalism and Mass Communication, University of Minnesota, Minneapolis, MN
| | - Hannah T Kinzer
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
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Harm perceptions, JUUL dependence, and other tobacco product use among young adults who use JUUL. Addict Behav 2022; 127:107210. [PMID: 34959076 DOI: 10.1016/j.addbeh.2021.107210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 01/02/2023]
Abstract
INTRODUCTION The study identified groups of JUUL using young adults based on their use patterns and compared harm perceptions, JUUL dependence, and other tobacco product use among these groups. METHODS Online cross-sectional survey data were gathered in March 2019 from 667 undergraduate students who used JUUL weekly (50.4% females, average age: 20.3 years) at a southwest U.S. university. RESULTS Latent class analysis identified four groups of young adults who used JUUL: 1) Light Social JUUL Using Young Adults (LS, 52.5%) who used JUUL occasionally with friends when drinking alcohol, 2) Daily Sensation Seekers (DSS, 16.2%) who used JUUL daily with alcohol, 3) Daily Activity Driven JUUL Using Young Adults (DAD, 26.0%) who used JUUL daily while drinking, watching media, or studying, and 4) Daily All Occasion JUUL Using Young Adults (DAO, 5.3%) who used JUUL heavily, daily and in various occasions. While all four groups reported some extent of JUUL dependence, DAO reported the highest dependence and were more likely than LS to have used cigarettes and other e-cigarettes besides JUUL. They also tended to believe different pod flavors could cause different types of lung damage while the other groups were unsure/disagreed with this belief. LS were more likely than DSS and DAD to believe that JUUL use indicated openness to new experiences. CONCLUSION Young adults with different JUUL use patterns perceived JUUL harms differently and faced varied risks of JUUL dependence and other tobacco product use. Effective cessation interventions should be adapted to meet the needs of these groups.
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Esquer C, Echeagaray O, Firouzi F, Savko C, Shain G, Bose P, Rieder A, Rokaw S, Witon-Paulo A, Gude N, Sussman MA. Fundamentals of vaping-associated pulmonary injury leading to severe respiratory distress. Life Sci Alliance 2021; 5:5/2/e202101246. [PMID: 34810278 PMCID: PMC8616545 DOI: 10.26508/lsa.202101246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/04/2021] [Accepted: 11/05/2021] [Indexed: 12/29/2022] Open
Abstract
Vaping of flavored liquids has been touted as safe alternative to traditional cigarette smoking with decreased health risks. The popularity of vaping has dramatically increased over the last decade, particularly among teenagers who incorporate vaping into their daily life as a social activity. Despite widespread and increasing adoption of vaping among young adults, there is little information on long-term consequences of vaping and potential health risks. This study demonstrates vaping-induced pulmonary injury using commercial JUUL pens with flavored vape juice using an inhalation exposure murine model. Profound pathological changes to upper airway, lung tissue architecture, and cellular structure are evident within 9 wk of exposure. Marked histologic changes include increased parenchyma tissue density, cellular infiltrates proximal to airway passages, alveolar rarefaction, increased collagen deposition, and bronchial thickening with elastin fiber disruption. Transcriptional reprogramming includes significant changes to gene families coding for xenobiotic response, glycerolipid metabolic processes, and oxidative stress. Cardiac systemic output is moderately but significantly impaired with pulmonary side ventricular chamber enlargement. This vaping-induced pulmonary injury model demonstrates mechanistic underpinnings of vaping-related pathologic injury.
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Affiliation(s)
- Carolina Esquer
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Oscar Echeagaray
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Fareheh Firouzi
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Clarissa Savko
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Grant Shain
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Pria Bose
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Abigail Rieder
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Sophie Rokaw
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Andrea Witon-Paulo
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Natalie Gude
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
| | - Mark A Sussman
- San Diego State University Integrated Regenerative Research Institute and Biology Department, San Diego State University, San Diego, CA, USA
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Conceptual model for the evaluation of attractiveness, addictiveness and toxicity of tobacco and related products: The example of JUUL e-cigarettes. Regul Toxicol Pharmacol 2021; 127:105077. [PMID: 34748878 DOI: 10.1016/j.yrtph.2021.105077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 09/06/2021] [Accepted: 11/02/2021] [Indexed: 11/21/2022]
Abstract
Many new tobacco and related products (nTRP) have emerged on the market, with unknown health risks. Here, we present a conceptual model containing the factors and relations between them that contribute to the nTRP's health effects. Factors that determine attractiveness, addictiveness and toxicity of nTRP were defined based on previous assessments, literature, and expert discussions. Our model will aid in identifying key risk factors contributing to increased risk of adverse health effects for a product in a qualitative manner. Additionally, it can gauge attractiveness for specific user groups, as a determinant for population prevalence of use. Our model can be used to identify aspects of nTRP that require attention for public information or product regulation. As an example, we applied this to JUUL, a popular e-cigarette in the US. Aspects of concern for JUUL are its attractive and discrete shape, user-friendly prefilled pods, flavors, high aerosol nicotine levels, and liquids containing nicotine salts instead of free-based nicotine. The addictiveness and especially attractiveness are sufficiently high to have a large potential impact on population health due to its contribution to use and hence exposure. Products and their use can change over time; therefore market research and monitoring are crucial.
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7
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Tattan-Birch H, Brown J, Shahab L, Jackson SE. Trends in use of e-cigarette device types and heated tobacco products from 2016 to 2020 in England. Sci Rep 2021; 11:13203. [PMID: 34168216 PMCID: PMC8225841 DOI: 10.1038/s41598-021-92617-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 05/28/2021] [Indexed: 01/19/2023] Open
Abstract
This study examined use trends of e-cigarette devices types, heated tobacco products (HTPs) and e-liquid nicotine concentrations in England from 2016 to 2020. Data were from a representative repeat cross-sectional survey of adults aged 16 or older. Bayesian logistic regression was used to estimate proportions and 95% credible intervals (CrIs). Of 75,355 participants, 5.3% (weighted = 5.5%) were currently using e-cigarettes or HTPs, with the majority (98.7%) using e-cigarettes. Among e-cigarette users, 53.7% (CrI 52.0-55.1%) used tank devices, 23.7% (22.4-25.1%) mods, 17.3% (16.1-18.4%) pods, and 5.4% (4.7-6.2%) disposables. Tanks were the most widely used device type throughout 2016-2020. Mods were second until 2020, when pods overtook them. Among all e-cigarette/HTP users, prevalence of HTP use remains rare (3.4% in 2016 versus 4.2% in 2020), whereas JUUL use has risen from 3.4% in 2018 to 11.8% in 2020. Across all years, nicotine concentrations of ≤ 6 mg/ml were most widely (41.0%; 39.4-42.4%) and ≥ 20 mg/ml least widely used (4.1%; 3.4-4.9%). Among e-cigarette/HTP users, ex-smokers were more likely than current smokers to use mod and tank e-cigarettes, but less likely to use pods, disposables, JUUL and HTPs. In conclusion, despite growing popularity of pods and HTPs worldwide, refillable tank e-cigarettes remain the most widely used device type in England.
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Affiliation(s)
- Harry Tattan-Birch
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, Fitzrovia, London, WC1E 7HB, UK.
| | - Jamie Brown
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, Fitzrovia, London, WC1E 7HB, UK
| | - Lion Shahab
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, Fitzrovia, London, WC1E 7HB, UK
| | - Sarah E Jackson
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, 1-19 Torrington Place, Fitzrovia, London, WC1E 7HB, UK
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Newcombe KV, Dobbs PD, Oehlers JS, Dunlap CM, Cheney MK. College Students' Reasons for Using JUULs. Am J Health Promot 2021; 35:835-840. [PMID: 33535769 DOI: 10.1177/0890117121992292] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To identify reasons that college students use JUUL and explore associations between reasons for using JUUL and social and behavioral (tobacco use) factors. DESIGN On-line, cross-sectional survey. SETTING Large southwestern university in the US. SUBJECTS Undergraduate students (n = 605) who owned JUUL and used it weekly. MEASURES The study measured age of JUUL initiation, JUUL dependence, and use of other e-cigarettes and other tobacco products. Participants described reasons for JUUL use as brief open-ended responses. ANALYSIS Responses were categorized by 2 researchers using an inductive procedure. Logistic regressions examined associations between demographics and use frequency and categorized reasons for using JUUL. RESULTS Four reasons for using JUUL emerged: self-help (48.4%), social (30.4%), experience (42.8%), and substance use/addiction (42.3%). Daily JUUL users were 1.66 (95% CI: 1.05-2.63) times as likely to use JUUL for self-help than those who used JUUL 1-3 days/week. Those who had never tried a cigarette were twice (OR = 2.08; 95% CI: 1.22-3.54) as likely as cigarette-first users to use JUUL for social reasons. Males (OR = 1.87; 95% CI: 1.32-2.65) had higher odds of using JUUL for the experience than females, and JUUL and other e-cigarettes users were 4.37 (95% CI: 1.83-10.45) times as likely as JUUL-only users to use JUUL due to substance use/addiction. CONCLUSION JUUL users report unique reasons for use (e.g., addiction) not previously reported for older models of e-cigarette devices.
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Affiliation(s)
- Kyra V Newcombe
- Department of Health and Exercise Science, 6187University of Oklahoma, Norman, OK, USA
| | - Page D Dobbs
- Health, Human Performance and Recreation Department, 6187University of Arkansas, Fayetteville, AR, USA
| | - Julia S Oehlers
- Department of Health and Exercise Science, 6187University of Oklahoma, Norman, OK, USA
| | - Chris M Dunlap
- Department of Health and Exercise Science, 6187University of Oklahoma, Norman, OK, USA
| | - Marshall K Cheney
- Department of Health and Exercise Science, 6187University of Oklahoma, Norman, OK, USA
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Bandi P, Cahn Z, Goding Sauer A, Douglas CE, Drope J, Jemal A, Fedewa SA. Trends in E-Cigarette Use by Age Group and Combustible Cigarette Smoking Histories, U.S. Adults, 2014-2018. Am J Prev Med 2021; 60:151-158. [PMID: 33032869 DOI: 10.1016/j.amepre.2020.07.026] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 07/10/2020] [Accepted: 07/16/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The trends in e-cigarette prevalence and population count of users according to cigarette smoking histories are unknown. These data are needed to inform public health actions against a rapidly changing U.S. e-cigarette market. METHODS Data collected between 2014 and 2018 (analyzed in 2020) from cross-sectional, nationally representative National Health Interview Surveys were used to estimate current e-cigarette prevalence, adjusted prevalence differences (percentage points), and population counts of users. Analyses were stratified by age group (younger, 18-29 years, n=25,445; middle age, 30-49 years, n=47,745; older, ≥50 years, n=79,517) and cigarette smoking histories (current smokers, recent quitters [quit <1 year ago], near-term quitters [quit 1-8 years ago], long-term quitters [quit >8 years ago], never smokers). RESULTS Among younger adults, e-cigarette use increased in all groups of smokers, with notable increases between 2014 and 2018 among never smokers (1.3%-3.3%, adjusted prevalence difference=2%, p<0.001) and near-term quitters (9.1%-19.2%, adjusted prevalence difference=8.8%, p=0.024). Conversely, the only substantial increase in e-cigarette use between 2014 and 2018 among middle-aged (5.8%-14.4%, adjusted prevalence difference=8.2%, p<0.001) and older (6.3%-9.5%, adjusted prevalence difference=3.3%, p=0.045) adults was among near-term quitters. The largest absolute population increase in e-cigarette users between 2014 and 2018 was among younger-adult never smokers (0.49-1.35 million), followed by near-term quitters among middle-aged (0.36-0.95 million), younger (0.23-0.57 million), and older (0.35-0.50 million) adults. CONCLUSIONS The continuous increase among younger-adult never smokers suggests a rise in primary nicotine initiation with e-cigarettes. The concomitant increase among near-term quitters of all age groups suggests continuing e-cigarette use among smokers who may have switched from cigarettes previously.
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Affiliation(s)
- Priti Bandi
- Data Science, American Cancer Society, Atlanta, Georgia.
| | - Zachary Cahn
- Data Science, American Cancer Society, Atlanta, Georgia
| | | | - Clifford E Douglas
- Center for Tobacco Control, American Cancer Society, Atlanta, Georgia; University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Jeffrey Drope
- Data Science, American Cancer Society, Atlanta, Georgia; Health Policy & Administration, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Ahmedin Jemal
- Data Science, American Cancer Society, Atlanta, Georgia
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10
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Pulvers K, Correa JB, Krebs P, El Shahawy O, Marez C, Doran N, Myers M. JUUL E-Cigarette Quit Attempts and Cessation Perceptions in College Student JUUL E-Cigarette Users. Am J Health Promot 2020; 35:624-632. [PMID: 33353369 DOI: 10.1177/0890117120982408] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This study describes the frequency of JUUL e-cigarette (referred to as JUUL) quit attempts and identifies characteristics associated with confidence in quitting and perceived difficulty quitting JUUL. DESIGN Cross-sectional study from a self-administered online survey. SETTING Two public southern California universities. PARTICIPANTS A total of 1,001 undergraduate students completed the survey from February to May 2019. MEASURES Self-report measures about JUUL included use, history of quit attempts, time to first use, perceived difficulty with cessation/reduction, and confidence in quitting. ANALYSIS Binary logistic regressions were used to identify demographic and tobacco-related behavioral correlates of JUUL cessation-related perceptions and behaviors. RESULTS Nearly half of ever-JUUL users (47.8%) reported a JUUL quit attempt. Adjusting for demographic factors and other tobacco product use, shorter time to first JUUL use after waking was associated with lower confidence in quitting JUUL (aOR = 0.02, 0.00-0.13) and greater perceived difficulty in quitting JUUL (aOR = 8.08, 2.15-30.35). Previous JUUL quit attempt history was also associated with greater odds of perceived difficulty quitting JUUL (aOR = 5.97, 1.74-20.53). CONCLUSIONS History of JUUL quit attempts among college students was common. Those who had previously tried quitting were more likely to perceive difficulty with cessation. Time to first JUUL use, a marker of dependence, was linked with greater perceived cessation difficulty and lower confidence in quitting. These findings suggest that there is a need for cessation and relapse prevention support for college student JUUL users.
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Affiliation(s)
- Kim Pulvers
- Department of Psychology, 383559California State University San Marcos, San Marcos, CA, USA
| | - John B Correa
- VA San Diego Healthcare System, 19979University of California, San Diego, La Jolla, CA, USA
| | - Paul Krebs
- VA San Diego Healthcare System, 19979University of California, San Diego, La Jolla, CA, USA
| | - Omar El Shahawy
- Population Health Department, 12296New York University School of Medicine, New York, NY, USA
| | - Crystal Marez
- Department of Psychology, 383559California State University San Marcos, San Marcos, CA, USA
| | - Neal Doran
- VA San Diego Healthcare System, 19979University of California, San Diego, La Jolla, CA, USA
| | - Mark Myers
- VA San Diego Healthcare System, 19979University of California, San Diego, La Jolla, CA, USA
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11
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Patterson JG, LaPolt DT, Miranda AR, Zettler PJ, Berman M, Roberts ME, Keller-Hamilton B, Ferketich AK. Switching stories: user testimonials on juul.com continue to contradict JUUL's switch ≠ cessation narrative. Tob Control 2020; 30:e37-e40. [PMID: 33154067 DOI: 10.1136/tobaccocontrol-2020-055816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND In January 2019, electronic nicotine delivery systems (ENDS) market leader Juul Labs (JUUL) launched an advertising campaign encouraging adult smokers to 'make the switch' from combustible cigarettes to JUUL. Our primary aim was to describe consumer perceptions of JUUL as communicated by members of JUUL's online social community via testimonials promoted on JUUL's website. METHODS User testimonials that were displayed on the JUUL website in December 2019 and January 2020 were collected and coded by three reviewers. A total of 220 testimonials were coded for primary and secondary themes (eight codes within four broader themes). RESULTS Testimonial writers were, on average, 43.0 years old (range 28 to 74) and reported using JUUL for an average of 21.8 months (range 9 to 59 months). The most prominent theme, present in nearly half of the testimonials, was a description of how to use JUUL, with a mention of JUUL's benefits and tips on how to use the product. Nearly four in 10 statements encouraged smokers to give JUUL a try or noted that JUUL is a better product compared with cigarettes. About one in 10 statements focused on switching from smoking cigarettes to using JUUL. CONCLUSION This study presents a foundation for understanding how adult users describe JUUL, including their experiences using JUUL to 'switch' or stop smoking. Currently, the effectiveness of ENDS for smoking cessation is not supported by substantial evidence; however, if cessation is defined as 'quitting combustible tobacco products', then regulators should be aware that switch and cessation messages may not be distinct.
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Affiliation(s)
- Joanne G Patterson
- The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, Ohio, USA
| | - Devin T LaPolt
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Alexis R Miranda
- College of Public Health, The Ohio State University, Columbus, Ohio, USA
| | - Patricia J Zettler
- The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, Ohio, USA.,Moritz College of Law, The Ohio State University, Columbus, Ohio, USA.,The Ohio State University Drug Enforcement and Policy Center, Columbus, OH, United States
| | - Micah Berman
- The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, Ohio, USA.,Moritz College of Law, The Ohio State University, Columbus, Ohio, USA.,College of Public Health, Division of Health Services Management and Policy, The Ohio State University, Columbus, Ohio, USA
| | - Megan E Roberts
- The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, Ohio, USA.,College of Public Health, Division of Health Behavior and Health Promotion, The Ohio State University, Columbus, Ohio, USA
| | - Brittney Keller-Hamilton
- The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, Ohio, USA
| | - Amy K Ferketich
- The Ohio State University Comprehensive Cancer Center Arthur G James Cancer Hospital and Richard J Solove Research Institute, Columbus, Ohio, USA.,College of Public Health, Division of Epidemiology, The Ohio State University, Columbus, Ohio, USA
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12
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Dobbs PD, Branscum P, Wilkerson AH. Intention to Use E-Cigarettes to Quit Smoking: A Reasoned Action Approach. AMERICAN JOURNAL OF HEALTH EDUCATION 2020. [DOI: 10.1080/19325037.2020.1822238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Patel M, Cuccia AF, Zhou Y, Kierstead EC, Briggs J, Schillo BA. Smoking cessation among US adults: use of e-cigarettes, including JUUL, and NRT use. Tob Control 2020; 30:693-695. [PMID: 32958602 DOI: 10.1136/tobaccocontrol-2020-056013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/01/2020] [Accepted: 08/04/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Electronic cigarettes (e-cigarettes) are a common tobacco product in the US. Despite lacking Food and Drug Administration (FDA) approval for cessation, e-cigarettes, including JUUL, a popular device, have been viewed by some as a potential tool for tobacco users seeking to quit combustible tobacco use. It is unknown how current and former smokers report using these products for cigarette smoking cessation. METHODS Online surveys were collected from a probability-based panel of US adults aged 18-64, with an oversample of past 12-month JUUL users (n=3415). Weighted past 12-month and past 30-day use of popular e-cigarette brands were measured. Former smokers with a quit attempt in the past 4 years and current smokers with a quit attempt in the past 12 months were asked about methods for smoking cessation, including e-cigarettes and nicotine replacement therapies (NRTs) use. RESULTS Among former smokers (n=157), 21.2% used e-cigarettes and/or NRTs to help them quit. Specifically, 2.2% used JUUL only, compared with 10.3% who used NRTs only, and 6.9% used other e-cigarettes only to quit. Among current smokers with a quit attempt (n=308), 24.0% used any product (NRT or e-cigarettes) to quit, and only 1.1% used JUUL only. Current smokers reported relatively low use of NRTs only (10.1%), other e-cigarettes only (5.6%) and other e-cigarettes and NRTs (5.1%). CONCLUSIONS Data suggest that few smokers in the US use e-cigarettes, and JUUL specifically, for cessation, and NRTs use is relatively low. All e-cigarettes should undergo FDA review to minimise recreational use and understand their cessation efficacy.
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Affiliation(s)
- Minal Patel
- Schroeder Institute, Truth Initiative, Washington, DC, USA
| | | | - Yitong Zhou
- Schroeder Institute, Truth Initiative, Washington, DC, USA
| | | | - Jodie Briggs
- Schroeder Institute, Truth Initiative, Washington, DC, USA
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14
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Benson R, Hu M, Chen AT, Nag S, Zhu SH, Conway M. Investigating the Attitudes of Adolescents and Young Adults Towards JUUL: Computational Study Using Twitter Data. JMIR Public Health Surveill 2020; 6:e19975. [PMID: 32876579 PMCID: PMC7495253 DOI: 10.2196/19975] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/17/2020] [Accepted: 08/10/2020] [Indexed: 01/22/2023] Open
Abstract
Background Increases in electronic nicotine delivery system (ENDS) use among high school students from 2017 to 2019 appear to be associated with the increasing popularity of the ENDS device JUUL. Objective We employed a content analysis approach in conjunction with natural language processing methods using Twitter data to understand salient themes regarding JUUL use on Twitter, sentiment towards JUUL, and underage JUUL use. Methods Between July 2018 and August 2019, 11,556 unique tweets containing a JUUL-related keyword were collected. We manually annotated 4000 tweets for JUUL-related themes of use and sentiment. We used 3 machine learning algorithms to classify positive and negative JUUL sentiments as well as underage JUUL mentions. Results Of the annotated tweets, 78.80% (3152/4000) contained a specific mention of JUUL. Only 1.43% (45/3152) of tweets mentioned using JUUL as a method of smoking cessation, and only 6.85% (216/3152) of tweets mentioned the potential health effects of JUUL use. Of the machine learning methods used, the random forest classifier was the best performing algorithm among all 3 classification tasks (ie, positive sentiment, negative sentiment, and underage JUUL mentions). Conclusions Our findings suggest that a vast majority of Twitter users are not using JUUL to aid in smoking cessation nor do they mention the potential health benefits or detriments of JUUL use. Using machine learning algorithms to identify tweets containing underage JUUL mentions can support the timely surveillance of JUUL habits and opinions, further assisting youth-targeted public health intervention strategies.
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Affiliation(s)
- Ryzen Benson
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Mengke Hu
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
| | - Annie T Chen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle, WA, United States
| | - Subhadeep Nag
- University Information Technology Infrastructure and Operations, University of Utah, Salt Lake City, UT, United States
| | - Shu-Hong Zhu
- Department of Family Medicine & Public Health, University of California, San Diego, La Jolla, CA, United States
| | - Mike Conway
- Department of Biomedical Informatics, University of Utah, Salt Lake City, UT, United States
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15
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Chen-Sankey JC, Tan ASL, Moran MB, Soneji S, Lee SJ, Choi K. Sources of awareness, perceptions, and use of JUUL e-cigarettes among adult cigarette smokers. PLoS One 2020; 15:e0238377. [PMID: 32870924 PMCID: PMC7462288 DOI: 10.1371/journal.pone.0238377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 08/14/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Given JUUL e-cigarettes’ potential for smoking cessation and its drastically increased sales in the U.S., more evidence is needed to understand the antecedents of JUUL use among adult cigarette smokers. This study assessed the relationships between awareness sources, perceptions about using JUUL, and JUUL use behavior. Methods In an online study with adult smokers who were aware of JUUL e-cigarettes (n = 341), respondents reported their sources for learning about JUUL, perceptions of using JUUL versus Vuse (a competitor brand), and ever and past-30-day (current) JUUL use. Multivariable logistic regressions were used to examine the associations between awareness sources, perceptions, and JUUL use, adjusting for covariates. Results Learning about JUUL through internet ads was associated with positive perceptions about JUUL compared to Vuse, including JUUL was more fun to use (AOR = 2.04, 95% CI = 1.21, 3.42) and tastier (AOR = 1.96, 95% CI = 1.19, 3.22). Perceiving JUUL as being tastier (AOR = 2.07, 95% CI = 1.23, 3.49), more helpful for quitting smoking (AOR = 2.07, 95% CI = 1.22, 3.53), and cooler (AOR = 2.07, 95% CI = 1.21, 3.56) than Vuse was associated with ever using JUUL. Only perceiving JUUL as being tastier (AOR = 1.98, 95% CI = 1.10, 3.59) than Vuse was associated with current use of JUUL. Discussion Adult smokers may be more likely to focus on the sensory and social experience of using JUUL rather than JUUL’s smoking cessation benefits. These positive perceptions are likely to be influenced by internet ads in general instead of JUUL’s official marketing outlets. They are also more likely to sustain JUUL use than JUUL’s perceived smoking cessation benefits.
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Affiliation(s)
- Julia Cen Chen-Sankey
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, MD, United States of America
- * E-mail:
| | - Andy S. L. Tan
- Annenberg School for Communication, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Meghan Bridgid Moran
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Samir Soneji
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
| | - Stella J. Lee
- Department of Media and Communication, Konkuk University, Seoul, Republic of Korea
| | - Kelvin Choi
- Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, MD, United States of America
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Lee SJ, Rees VW, Yossefy N, Emmons KM, Tan ASL. Youth and Young Adult Use of Pod-Based Electronic Cigarettes From 2015 to 2019: A Systematic Review. JAMA Pediatr 2020; 174:714-720. [PMID: 32478809 PMCID: PMC7863733 DOI: 10.1001/jamapediatrics.2020.0259] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The use of electronic cigarettes (e-cigarettes) has rapidly increased among youth and young adults, but knowledge gaps exist on the potential health effects of using recently introduced pod-based e-cigarettes. OBJECTIVE To conduct a systematic review of recent peer-reviewed scientific literature on pod-based e-cigarettes. EVIDENCE REVIEW A search of online databases, including PubMed, Web of Science, Embase, and EBSCO HOST, was conducted to identify pod-based e-cigarette-associated articles from June 2015 (the time when JUUL [JUUL Labs] was introduced) to June 2019. We included English-language articles that presented primary data on pod-based e-cigarettes. FINDINGS Pod-based e-cigarettes represent a substantial evolution in design by increasing the efficient delivery of nicotine. While these products may contain less harmful constituents than other types of e-cigarettes and cigarettes, there is no evidence that the levels found are safe among youth. There is evidence for higher nicotine dependence associated with their use. Pod-based e-cigarette brands, compared with other e-cigarette brands, have targeted youth and young adults with social media marketing. There was less discussion about the use of these products as smoking cessation devices or their health risks on social media. The social acceptability and favorable perceptions of pod-based e-cigarettes may underlie the use of these products. CONCLUSIONS AND RELEVANCE The appeal and dependence potential of pod-based e-cigarettes for youth emphasize the need for stronger regulations on product design, social media, marketing channels, and youth access together with health communications that emphasize the risks of nicotine dependence.
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Affiliation(s)
- Stella Juhyun Lee
- Department of Media and Communication, Konkuk University, Seoul, South Korea
| | - Vaughan W. Rees
- Harvard T. H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts
| | - Noam Yossefy
- Harvard T. H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts
| | - Karen M. Emmons
- Harvard T. H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts
| | - Andy S. L. Tan
- Harvard T. H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts,Dana-Farber Cancer Institute, Population Sciences Division, Center for Community Based Research, Boston, Massachusetts
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Vallone DM, Cuccia AF, Briggs J, Xiao H, Schillo BA, Hair EC. Electronic Cigarette and JUUL Use Among Adolescents and Young Adults. JAMA Pediatr 2020; 174:277-286. [PMID: 31961395 PMCID: PMC6990671 DOI: 10.1001/jamapediatrics.2019.5436] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE The increasing use rates of electronic cigarettes (e-cigarettes) among young people in the United States have been largely associated with the emergence of high-nicotine-delivery device JUUL. Relevant data are needed to monitor e-cigarette, specifically JUUL, use to help inform intervention efforts. OBJECTIVE To estimate the prevalence, patterns, and factors associated over time with e-cigarette use among adolescents and younger adults in the United States. DESIGN, SETTING, AND PARTICIPANTS Two nationally representative longitudinal samples of adolescents and younger adults aged 15 to 34 years were drawn from the Truth Longitudinal Cohort, a national, probability-based cohort. Participants in this cohort were recruited through address-based sampling, and subsamples were recruited from a probability-based online panel. The present cohort study used data from follow-up online surveys, specifically, wave 7 (N = 14 379; collected from February 15, 2018, to May 25, 2018) and wave 8 (N = 12 114; collected from February 10, 2019, to May 17, 2019). Respondents reported their use of e-cigarettes, JUUL, and combustible tobacco products as well as their harm perceptions, household smoking status, sensation-seeking, friends' e-cigarette use, and demographic information. MAIN OUTCOMES AND MEASURES The main outcomes were ever and current (past 30 days) JUUL use. χ2 Analyses assessed differences in JUUL use by psychosocial and demographic characteristics. Logistic regression models identified the significant factors associated with wave 8 ever and current JUUL use among wave 7 e-cigarette-naive participants. RESULTS A total of 14 379 participants (mean [SD] age, 24.3 [0.09] years; 8142 female [51.0%]) were included in wave 7 and 12 114 (mean [SD] age, 24.5 [0.10] years; 6835 female [50.1%]) in wave 8. JUUL use statistically significantly increased from wave 7 to wave 8 among ever users (6.0% [n = 1105] to 13.5% [2111]; P < .001) and current users (3.3% [680] to 6.1% [993]; P < .001). JUUL use increased among every age group and was highest among those aged 18 to 20 years (23.9% [491] ever users and 12.8% [340] current users) and 21 to 24 years (18.1% [360] ever users and 8.2% [207] current users). Users reported a higher prevalence of frequent use in wave 8 compared with wave 7 (37.6% vs 26.1%; P < .01). Significant factors associated with future JUUL use among e-cigarette-naive participants included younger age, combustible tobacco use, lower harm perceptions, sensation seeking, and friends' e-cigarette use. CONCLUSIONS AND RELEVANCE This study found that the e-cigarette device JUUL appears to be associated with the youth e-cigarette epidemic, attracting new users and facilitating frequent use with their highly addictive nicotine content and appealing flavors. Findings of this study underscore the critical need for increased e-cigarette product regulation at the federal, state, and local levels.
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Affiliation(s)
- Donna M. Vallone
- Schroeder Institute, Truth Initiative, Washington, District of Columbia,Bloomberg School of Public Health, Department of Health, Behavior, and Society, Johns Hopkins University, Baltimore, Maryland,College of Global Public Health, New York University, New York
| | - Alison F. Cuccia
- Schroeder Institute, Truth Initiative, Washington, District of Columbia
| | - Jodie Briggs
- Schroeder Institute, Truth Initiative, Washington, District of Columbia
| | - Haijun Xiao
- Schroeder Institute, Truth Initiative, Washington, District of Columbia
| | | | - Elizabeth C. Hair
- Schroeder Institute, Truth Initiative, Washington, District of Columbia,Bloomberg School of Public Health, Department of Health, Behavior, and Society, Johns Hopkins University, Baltimore, Maryland
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18
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Levy DT, Sweanor D, Sanchez-Romero LM, O'Connor R, Goniewicz ML, Borland R. Altria-Juul Labs deal: why did it occur and what does it mean for the US nicotine delivery product market. Tob Control 2019; 29:e171-e174. [PMID: 31484802 PMCID: PMC7279136 DOI: 10.1136/tobaccocontrol-2019-055081] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 11/24/2022]
Affiliation(s)
- David T Levy
- Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, District of Columbia, USA
| | - David Sweanor
- Faculty of Law and Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Richard O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Maciej Lukasz Goniewicz
- Cancer Prevention and Population Sciences, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Ron Borland
- School of Psychological Sciences, University of Melbourne, Melbourne, Victoria, Australia
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