Objective To estimate the prevalence of JUUL use and identify demographic and psychosocial correlates of use among youth and young adults in the USA.
Methods A national, probability-based sample was recruited via address-based sampling, with subsamples recruited from an existing probability-based online panel. Participants (N=14 379) ages 15–34 were surveyed about JUUL use, tobacco use, electronic nicotine delivery system (ENDS) harm perceptions, sensation seeking and demographic characteristics. Data were collected February–May 2018. Χ2 analyses assessed differences in JUUL use by demographic and psychosocial characteristics. Logistic regressions identified significant correlates of ever and current JUUL use.
Results Overall, 6.0% reported ever JUUL use, and 3.3% reported past 30-day (ie, current) use. Rates were higher among participants aged 15–17 and 18–21 years, with 9.5% and 11.2% reporting ever use, and 6.1% and 7.7% reporting current use, respectively. Among current users aged 15–17 years, 55.8% reported use on 3 or more days in the past month, and over a quarter reported use on 10–30 days. Significant correlates of use included younger age, white race, greater financial comfort, perceptions of ENDS as less harmful than cigarettes, household ENDS use, high sensation seeking and current combustible tobacco use.
Conclusion JUUL use was significantly higher among young people, with those under 21 having significantly higher odds of ever and current use. Frequency of use patterns suggest youth may not be experimenting with the device but using it regularly. Given the high nicotine content of JUUL, there is concern over the potential for addiction and other serious health consequences among young people. Findings suggest strong regulatory actions are needed to prevent youth and young adult uptake.
- surveillance and monitoring
- electronic nicotine delivery devices
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
Despite the success of tobacco control efforts in dramatically decreasing the use of combustible cigarettes, particularly among young people, the increasing use of nicotine delivery devices remains a concern.1 Data from the 2017 Monitoring the Future study indicate 13.9% of youth had used an electronic nicotine delivery system (ENDS) in the past year, and 7.5% reported use in the past month.2 While evidence suggests exclusive ENDS use may result in fewer negative health consequences compared with combustible tobacco use, concerns remain given the associations between ENDS use and future combustible tobacco use among young people1 3 4 and the negative consequences of nicotine exposure on the developing adolescent brain, particularly with regard to addiction susceptibility.5 Moreover, recent population-level research also suggests that ENDS use is not associated with successful cigarette cessation or complete substitution.6 7
In an effort to identify at-risk segments of the population, several studies have attempted to identify correlates of ENDS use among youth and young adults. Demographic factors such as male gender, non-Hispanic white race/ethnicity and younger age have been found to be associated with greater odds of ENDS use.8–11 ENDS use has also been found to be significantly associated with cigarette use.1 8 10–13 Those who perceive ENDS as less harmful than cigarettes are more likely to express an openness to ENDS use,14 as well as report ENDS use among both young and adult populations.15 16
One ENDS that has become extremely popular over the last 2 years is called JUUL. JUUL was created by Pax Labs (now JUUL Labs) in 2015 and has quickly dominated the ENDS market, accounting for over 70% of the dollar share of ENDS as of 14 July 2018, compared with less than 5% of the dollar share in January 2017.17 This slim device that looks like a USB drive can fit in the palm of your hand, making it easy to carry and conceal. Moreover, JUUL is charged through a USB port and uses ‘JUULpods’ containing nicotine salts available in a variety of flavours including fruit medley, crème brulee and mango. According to the JUUL product website, one JUULpod contains the same amount of nicotine as a pack of cigarettes.18 Its discreet shape, high-tech characteristics, nicotine delivery and flavours coupled with the manufacturer’s social media marketing and promotional efforts have all added to the appeal of the product among young people. On 12 September 2018, the US Food and Drug Administration (FDA) commissioner Scott Gottlieb announced that the FDA considers youth ENDS use to be an ‘epidemic’, and gave leading ENDS manufacturers, including the makers of JUUL, 60 days to submit plans on restricting youth use or else face regulatory action, including a ban of flavoured ENDS products sold by those manufacturers.19 20
JUUL’s website claims that the product is an alternative to cigarettes designed to ‘satisfy adult smokers’.18 However, research suggests use of the device is common among young people.21 22 Recent estimates of JUUL use are limited due to the use of convenience samples drawn from online panels. The objective of the current study is to determine the prevalence of JUUL use, as well as demographic and psychosocial correlates of use, using a large, nationally representative, probability-based sample of youth and young adults, aged 15–34 years.
The study sample is drawn from the Truth Longitudinal Cohort (TLC), a national, probability-based sample established to evaluate the national tobacco prevention mass media campaign, truth®. TLC sampling methods have been described elsewhere.23 Briefly, participants aged 15–21 years were recruited through address-based sampling in April 2014, with follow-up online surveys every 6 months. At baseline, the weighted response rate for the cohort was 38.7% (American Association of Public Opinion Research RR#3, with quota limits for those aged 18–21 years).24 The analytic sample for this study includes all participants from the TLC who completed wave 7 of data collection (n=9149), as well as two additional subsamples, one including participants aged 15–25 years (n=3225) and the other including participants aged 26–34 years (n=2005) for a total sample of N=14 379. Participants for these additional subsamples were recruited from GfK’s probability-based online panel, KnowledgePanel®.25 Data collection was conducted online from February to May 2018.
Ever JUUL use was measured with the item: ‘Have you ever smoked a JUUL vape?’, with responses 1=yes, 0=no. Current JUUL use was defined as those who had used the device in the past 30 days, and was measured with the item: ‘During the past 30 days, on how many days did you smoke a JUUL vape?’ Participants were prompted to enter the number of days between 0 and 30.
Current combustible tobacco use
Participants’ current use of combustible tobacco products was assessed with the following items: ‘During the past 30 days, on how many days did you smoke: 1) cigarettes (even 1 or 2 puffs); 2) large cigars, little cigars, or cigarillos (like Winchester, Swisher Sweets, Phillies Blunts, Dutch Masters, Black & Mild, or White Owl) (even 1 or 2 puffs); 3) hookah/shisha/waterpipe (with tobacco) (even 1 or 2 puffs); and 4) pipe (with tobacco) (even 1 or 2 puffs)?’ Participants responded with the number of days they had used each product, and those who indicated use of any product on at least 1 day in the past 30 days were coded as current combustible users.
ENDS harm perceptions
Perceptions regarding the relative harm of ENDS compared with cigarettes was assessed with the item: ‘Compared to regular cigarettes, do you think that e-cigarettes, e-hookah, vape pens, hookah pens, and vape pipes (including JUUL) are…’, with response options, 1=less harmful, 2=about the same harm, 3=more harmful, and 4=don’t know or refused.
The construct of sensation seeking was measured at baseline by calculating the average of the following items: (1) I would like to explore strange places; (2) I would like to take off on a trip with no preplanned routes or timetables; (3) I like to do frightening things; (4) I like wild parties; (5) I like new and exciting experiences, even if I have to break the rules; (6) I get restless when I spend too much time at home; (7) I prefer friends who are exciting and unpredictable and (8) I would like to try parachute-jumping. Response options included 1=strongly disagree, 2=disagree, 3=neither, 4=agree, and 5=strongly agree, and the variable was treated as a continuous variable.26
Household combustible and ENDS use
Use of combustible tobacco and/or ENDS among members of participants’ households was measured with the following item: ‘Does anyone you live with currently smoke any of the following tobacco products some days or every day?’ Response options included cigarettes, large cigars/little cigars/cigarillos, hookah, e-cigarettes, e-hookah/e-cigars/vape pens/hookah pens/vape pipe and no one I live with smokes. Responses were recoded to 0=no one I live with smokes, 1=only ENDS, 2=only combustible tobacco, and 3=both ENDS and combustible tobacco.
The following demographic characteristics were measured: age (15–17 years/18–21 years/22–24 years/25–34 years), gender (female/male), race/ethnicity (white/black/Hispanic/other), perceived financial situation (live comfortably/meet needs with a little left over/just meet basic expenses with nothing left over/don’t meet basic expenses),27 sexual orientation (heterosexual/lesbian, gay, bisexual (LGB)), and region (Northeast/South/Midwest/West). The first category listed in all categorical control variables was used as the reference group, with the expectation of age, where 25–34 years was the reference category.
All analyses were conducted in Stata SE V.15.1.28 Descriptive and χ2 statistics assessed the prevalence of ever and past 30-day (ie, current) JUUL use among the full sample, and by demographic characteristics. Logistic regression models assessed JUUL ever and current use as predicted by current combustible tobacco use, ENDS harm perceptions, sensation seeking, household combustible and ENDS use, and all demographic characteristics. All independent variables were included in a single mode in order to assess the relative effect of each, controlling for the others. Models used poststratification weights in order to generalise to the national population of people aged 15–34 years.23 Missing data were list-wise deleted, resulting in a analytic sample of n=13 357.
Table 1 presents the prevalence of ever and current JUUL use, overall and by demographic characteristics. Among the total sample, 6.0% reported ever use of JUUL and 3.3% reported current use. Significant differences in ever and current JUUL use were observed by age. The prevalence of ever and current use among youth aged 15–17 years was 9.5% and 6.1%, respectively. Young adults aged 18–21 years had the highest prevalence, with 11.2% reporting ever JUUL use and 7.7% reporting current use. The oldest age group assessed, those aged 25–34 years, had the lowest prevalence, with rates of 3.2% for ever use and 0.8% for current JUUL use. Significant differences in the prevalence of ever JUUL use were also observed by race/ethnicity, sexual orientation, household combustible and/or ENDS use, current combustible tobacco use and ENDS harm perceptions. A greater proportion of whites and Hispanics, those reporting a sexual orientation of LGB, those reporting someone in their household uses ENDS, current combustible tobacco users and those who perceived ENDS to be less harmful than cigarettes reported ever JUUL use, compared with the other categories in each variable. Rates of current JUUL use significantly differed by gender, perceived financial situation, sexual orientation, household combustible and/or ENDS use, current combustible tobacco use and ENDS harm perceptions. A greater proportion of males, those who report living comfortably with regard to their financial situation, LGB, those reporting someone in their household uses ENDS, current combustible tobacco users and those who perceived ENDS to be less harmful than cigarettes reported current JUUL use, compared with the other categories in each variable.
Table 1 also presents current use of ENDS and combustible tobacco use, overall and by demographic characteristics. Among the total sample, 10% reported current use of ENDS and 17% reported current use of combustible tobacco. Significant differences in rates of current ENDS use were observed by age, gender, perceived financial situation, sexual orientation, household combustible and/or ENDS use, ENDS harm perceptions and tobacco use. The prevalence of current ENDS use was greater among those aged 18–21 years, males, those who reported they do not have enough income to meet basic expenses, those who identify as LGB, those reporting someone in their household uses ENDS, those who believe ENDS are less harmful than cigarettes and those who are current combustible tobacco users, compared with the other categories in each variable.
Significant differences in the prevalence of current combustible tobacco use were observed by age, race/ethnicity, gender, perceived financial situation, sexual orientation, region, household combustible tobacco and ENDS use, and ENDS harm perceptions. The prevalence of current combustible tobacco use was greater among those aged 25–24 years, those who reported black/African-American race, males, those who reported they do not have enough income to meet basic expenses, those who identify as LGB, those living in the Northeast or South, those who reported someone in their household uses both ENDS and combustible tobacco, and those who reported ENDS were less harmful than cigarette, compared with the other categories in each variable.
The number of days current JUUL users reported use of the device in the past 30 days is presented in figure 1. Overall, 55.7% of current JUUL users reported use on 3 or more days in the past 30 days, while 44.3% reported use on 1 or 2 days. Similar patterns were observed among those aged 15–17 years and 18–21 years, with 55.8% and 57.1% of current users reporting use on 3 or more days in the past 30 days, respectively. Among current users aged 15–17 years, 25.3% reported use on 10–30 days in the past 30, and 28.5% of current users aged 18–21 years also reported this frequency of use. Among those aged 22–24 years, the majority of current JUUL users (64.6%) reported use on 1 or 2 days in the past 30 days. Among those who reported current ENDS use, approximately 60% reported use on 3 or more days in the past 30 days, while 40% reported use on 1 or 2 days. Similar patterns were observed for current ENDS users aged 18–21 years. However, a slightly higher proportion of current ENDS users aged 15–17 years reported use on 1 or 2 days in the past month (48%). Among all current combustible tobacco users, 68% reported use on 3 or more days in the past 30 days. Among current combustible tobacco users aged 15–17 years, 44% reported use on 3 or more days in the past 30 days, while among those aged 18–21 years, 59% reported use on 3 or more days.
Results of the logistic regression models are presented in table 2. Compared with those aged 25–34 years, those in the younger age categories had significantly greater odds of ever (OR range=1.52–4.68, p<0.05) and current JUUL use (OR range=3.59–16.19, p<0.01). Those who identified as black/African-American has significantly lower odds of both ever (OR=0.43, p<0.01) and current JUUL use (OR=0.45, p<0.05) compared with whites. Regarding perceived financial situation, those reporting less financial comfort had significantly lower odds of ever (OR=0.55, p<0.01) and current JUUL use (OR range=0.38–0.54, p<0.01) compared with those reporting they live comfortably. Results also suggest significant regional differences in JUUL use, with those in the Midwest having significantly lower odds of ever (OR=0.67, p<0.05) and current JUUL use (OR=0.69, p<0.05), and those in the South having significantly lower odds of current use (OR=0.69, p<0.05), compared with those in the Northeast. Those residing in the West did not significantly differ from those in the Northeast with regard to odds of ever or current JUUL use (p>0.05). Compared with those with no household combustible tobacco or ENDS use, those who reported someone in their household exclusively uses an ENDS had significantly greater odds of being ever (OR=2.86, p<0.01) and current JUUL users (OR=4.10, p<0.01). Likewise, those who have household members who use an ENDS in combination with other combustible tobacco also had greater odds of being an ever (OR=2.07, p<0.01) and current (OR=2.87, p<0.01) JUUL user. Perceptions that ENDS are more or as harmful as cigarettes were significantly and negatively associated with both ever (OR range=0.43–0.58, p<0.01) and current (OR range=0.34–0.39, p<0.01) JUUL use, compared with those who perceived ENDS to be less harmful. Sensation seeking was also significantly associated with JUUL use, with greater sensation seeking associated with greater odds of ever (OR=1.76, p<0.01) and current JUUL use (OR=2.16, p<0.01). Finally, those reporting current combustible tobacco use had significantly greater odds of ever (OR=2.93, P<0.01) and current JUUL use (OR=4.91, p<0.01), compared with non-current smokers.
Overall, study results indicate 6.0% of youth and young adults have ever used a JUUL, and 3.3% have used the product in the past 30 days. The prevalence of JUUL use is highest among young adults aged 18–21 years, with 11.2% reporting ever use and 7.7% reporting current use; a finding that is consistent with patterns of overall ENDS use in the USA.1 27 This young adult period, ages 18–21 years, is a formative period of life where substance use experimentation can facilitate behaviours that will persist throughout adulthood, particularly for progression to regular tobacco use, as well as an age group that has been particularly targeted by the tobacco industry.29 30 Despite JUUL being illegal to sell to those under age 18 (and under 21 in some jurisdictions), and JUUL’s marketing claims that it does not aim to attract youth users,18 the prevalence of ever JUUL use among those aged 15–17 years reaches almost 10% which is higher than both of the older age categories. This is further highlighted with the results suggesting those aged 15–17 years have over 16 times greater odds of reporting current use of JUUL, compared with those in the oldest age group.
Findings indicate that those aged 25–34 years were much less likely to report ever use (3.2%) or current use (0.8%) of JUUL. This pattern is consistent with national surveillance data which demonstrate that ENDS use as a broad category declines with age.31 Some suggest that JUUL may serve as an effective cessation tool for adult smokers given its high level and efficiency of nicotine delivery.32 Although that may be the case, there are no peer-reviewed published studies demonstrating the efficacy of JUUL to help smokers quit. Moreover, since older subgroups are more likely to use regular cigarettes, the lower prevalence of JUUL use among older participants may indicate that this device is not being used as either a cigarette alternative or a cessation tool.
Patterns of current JUUL use are consistent with national estimates of overall ENDS use.33 Among all current JUUL users, over half used the device on 3 or more days in the past 30 days, and this pattern was consistent among youth (15–17 years old) and younger adult (18–21 years old) current users. Over a quarter of youth JUUL users use the product on 10–30 days in the past month, suggesting youth may not be just experimenting with the device, but becoming regular users. JUUL Labs claim the device has the ability to deliver nicotine at levels and speeds similar to a conventional cigarette18 34 which raises concerns about the potential for increased nicotine addiction and transitions to combustible products among JUUL users.
The product’s addiction potential is of particular concern given the relatively modest differences between the estimates of ever and current JUUL use. Findings indicate only 2–4 percentage point differences which suggests that most young people who try the products are continuing to use them more routinely. This is inconsistent with recent surveillance estimates of the total ENDS category which have demonstrated marked variations between ever and current use.2 Although JUUL is a relatively new addition to the ENDS category, estimates of ever use were several-fold higher than current use estimates even when ENDS were first introduced into the market.2 Evidence indicates that many young people who experiment with JUUL are transitioning to more frequent use.
Data from the current study also identify several significant correlates of ever and current JUUL use, including younger age, white non-Hispanic race/ethnicity, greater financial comfort, perceptions of ENDS as less harmful than cigarettes, household ENDS use, higher sensation seeking and current combustible tobacco use. Not surprisingly, those who perceive ENDS (including JUUL) to be less harmful than cigarettes are more likely to be JUUL users which is consistent with prior ENDS literature.16 35 36 Existing research also indicates youth report family member and friends’ use of ENDS as a primary reason for first trying the device.35 This may, in part, explain why household ENDS use is associated with greater likelihood of JUUL use. Data from the current study also demonstrate that JUUL use is associated with current combustible tobacco use which adds to the growing body of research identifying significant associations between ENDS and cigarette use.1 Youth and young adults with greater financial resources may be more likely to afford a JUUL device given the relatively high price of a JUUL starter kit at $50.18 However, this group is also less likely to smoke and raises the question of whether JUUL is exposing those who may not have ever smoked to potential nicotine addiction.
While rates of JUUL use are highest among the younger segments of the sample, the data only reflect use patterns from February through May 2018. The most recent Nielsen sales data for JUUL indicate dramatic increases since then; JUUL now accounts for 40% more of the market share than it did in February 2018.17 37 This rapid increase warrants serious steps to establish ongoing surveillance of JUUL use.
This study is not without limitations. While the present study assessed the frequency of JUUL use, the amount or number of JUULpods used was not measured. Although JUUL Labs claims that one JUULpod is equivalent to one pack of cigarettes, or approximately 200 puffs, these estimates have not been independently validated.18 Moreover, this study does not include participants older than 34 years. Further research is needed to establish prevalence and patterns of use among the entire population in the USA, as well as identify how best to measure pods used over time. This information can provide evidence as to the relationship between nicotine exposure among JUUL users and potential negative health consequences, particularly among youth and younger adults. Nonetheless, the significant strength of this study is based on the large, nationally representative, probability-based sample from a recent data collection.
Findings provide the first, national estimates of the prevalence and correlates of JUUL use among youth and young adults in the USA. Given the rapid uptake of this product, strong regulatory efforts are needed to prevent further increases in JUUL prevalence among young people. More specifically, we recommend that the FDA immediately begin to exercise its premarket review and approval authorities to prevent the marketing of products known to appeal to youth; that it move to prohibit internet sales of all tobacco products (including ENDS); and that it prohibit the distribution of branded merchandise and other promotional material for all tobacco products (including ENDS). Regulatory actions should also include prohibition of flavoured ENDS unless a manufacturer demonstrates that the product will primarily be marketed and used by smokers to completely switch. Further surveillance efforts are also required to monitor how and to what extent this product may be expanding nicotine addiction among young people rather than reducing exposure to the ever-expanding tobacco product landscape.
What this paper adds
Use of electronic nicotine delivery system (ENDS) remains popular among young people in the USA, and recent research suggests associations between ENDS use and later combustible tobacco use.
JUUL is a novel ENDS that has quickly dominated the market.
Studies of convenience samples and social media conversations suggest JUUL to be a popular ENDS, particularly among young people. However, a national estimate of the prevalence of JUUL use has not yet been established.
The present study uses a national, probability-based sample of youth and young adults in the USA to estimate the prevalence and correlates of ever and current JUUL use.
Contributors DMV and ECH designed the study. HX and LP performed the analysis. DMV and MB wrote the paper.
Funding This study was funded by Truth Initiative.
Competing interests None declared.
Patient consent Not required.
Ethics approval Advarra Institutional Review Board (formerly Chesapeake IRB).
Provenance and peer review Not commissioned; externally peer reviewed.