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Smoking cessation among US adults: use of e-cigarettes, including JUUL, and NRT use
  1. Minal Patel,
  2. Alison F Cuccia,
  3. Yitong Zhou,
  4. Elexis C Kierstead,
  5. Jodie Briggs,
  6. Barbara A Schillo
  1. Schroeder Institute, Truth Initiative, Washington, DC, USA
  1. Correspondence to Dr Minal Patel, Schroeder Institute, Truth Initiative, Washington, DC 20001, USA; mpatel{at}truthinitiative.org

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.

  • electronic nicotine delivery devices
  • cessation
  • nicotine
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Introduction

While adult smoking rates have declined substantially over the past two decades, smoking cessation remains a top priority for public health.1 2 Nicotine replacement therapies (NRTs) approved by the US Food and Drug Administration (FDA) are an effective, yet widely underutilised tool in reducing withdrawal and helping smokers quit.1 3–5 Electronic cigarettes (e-cigarettes), despite lacking FDA approval for cessation, have been viewed by some as a potential tool for tobacco users seeking to quit combustible tobacco use. In 2018, JUUL captured roughly three-quarters of the e-cigarette market,6 and promoted their product as a way for adult smokers to switch from cigarettes.7 Adult rates of e-cigarette use have remained relatively low at 3.2% however, and while some e-cigarette users report smoking cessation as a reason for use, reasons for initiation vary greatly across age groups and tobacco use status. Further research is needed as to how widely smokers are using e-cigarettes as tools to help them quit.8–10 Additionally, the rise of pod products such as JUUL may be further shifting the reasons for use.11

Using a nationally representative sample of US adults ages 18–64, this paper aims to explore whether current and former smokers report using JUUL and other e-cigarettes for cigarette smoking cessation.

Methods

Sample

Data were collected between 24 October 2018 and 17 December 2018 from the online Ipsos KnowledgePanel of non-institutionalised English-speaking or Spanish-speaking adults aged 18–64. Participants (n=2979) were recruited via an address-based sampling, to be nationally representative of the US population. Past 12-month JUUL users were additionally oversampled through an augmented sample from two sources: (1) a non-probability-based sample and (2) the Ipsos CHAT panel,12 to ensure sufficient sample sizes for JUUL subgroup analyses (n=436), for a total sample of 3415 US adults. The research was exempted by Advarra IRB (protocol number: Pro00029613).

Measures

E-cigarette use

Ever e-cigarette users were asked about ever and past 12-month use of e-cigarette rechargeable products, disposable ‘cigalike’ products and tank systems/box mod vaporisers. Individuals with past 12-month product category use were asked about past 12-month and past 30-day specific product or brand use, accompanied by a picture of the device. Specific products were identified primarily through Nielsen data,6 or identified as an emerging products.13 14 Rechargeable products included: JUUL, VUSE, myblu, Logic, Suorin and ‘other’. Disposable products included: Blu, NJOY, jak, Logic power and ‘other’. Tank system brands included Smok, Vaporesso, Kanger, Joyetech and ‘other’. Past 12-month and past 30-day e-cigarette use was defined as (1) only using JUUL, (2) only using any other e-cigarette products or brands (excluding JUUL) and (3) using both JUUL and other e-cigarette products or brands.

Cessation

Cessation attempts among current smokers (>100 lifetime cigarettes, past 30-day use) were measured by one item: ‘In the past 12 months, have you stopped smoking cigarettes for 1 day or longer because you were trying to quit?’ (yes/no). Former smokers (>100 lifetime cigarettes, no past 30-day use) were asked ‘About how long has it been since you completely quit smoking cigarettes’ (0–100 years). The subset of former smokers who quit in the last 4 years, since the end of 2014, were examined to understand cessation behaviour among those who quit since JUUL was available in the US.

Products used for cessation among all former smokers and current smokers with a quit attempt were assessed by the item: ‘Thinking back to (the last time you tried to quit/when you quit) cigarettes in the past 12 months, did you use any different tobacco products to help you quit?’ For former smokers, product use referred to the 12 months leading to their cessation. Response options included e-cigarette brands used in the past 12 months and other tobacco products.

All former smokers and current smokers with a quit attempt were asked separately about using NRT for cessation: ‘Thinking back to (the last time you tried to quit/when you quit) cigarettes in the past 12 months, did you use a nicotine patch, gum, inhaler, nasal spray or lozenge?/ (yes/no). Cessation methodology was defined through mutually exclusive groups combining use of (1) JUUL, (2) any one of the other e-cigarette products or brands and (3) NRT for cessation.

Analysis

Analyses were conducted in Stata/SE V.15.1. Survey weights combining the probability and non-probability samples were used to offset non-response bias and produce nationally representative estimates of the US adult population. Descriptive statistics were used to examine the prevalence of e-cigarettes and NRT use for cessation. Demographic differences by current and former smokers with a quit attempt were examined.

Results

Among former smokers with a quit attempt in the past 4 years (n=157), 21.2% used e-cigarettes and/or NRT to help them quit. JUUL was the least frequently used product category to quit smoking: 2.2% of former smokers used JUUL only, compared with 10.3% who used NRT only, and 6.9% who used other e-cigarettes only to quit (table 1). An additional 1.4% of former smokers reported JUUL use in combination with other methods including NRT and other e-cigarettes. Overall, 11.0% used NRT alone or in combination with e-cigarettes in a quit attempt.

Table 1

Weighted proportions of former smokers who quit in the last 4 years (n=157) and current smokers with a quit attempt (n=308) who have used e-cigarettes, including JUUL and/or NRT for smoking cessation

Among current smokers who attempted to quit in the past year (n=308), 24.0% used e-cigarettes and/or NRT to quit, and only 1.1% used JUUL only. The products frequently used by current smokers included NRT only (10.1%), other e-cigarettes (5.6%) and other e-cigarettes and NRT (5.1%). Overall, 16.2% used NRT alone or in combination with e-cigarettes in a quit attempt.

Demographic characteristics of the full sample, current smokers with a quit attempt and former smokers with a quit attempt in the past 4 years are presented in online supplementary table 1. Additional analyses showed that JUUL was more frequently used by younger adults aged 18–24 (3%, p<0.001) compared with other age groups (results not shown). Current, exclusive JUUL users were more likely to be aged 18–24 (2.6%, p<0.001), have some college education (1.0%, p<0.001) and be current smokers (1.9%, p<0.001). Among JUUL users aged 18–24, most (56.8%) had never smoked cigarettes.

Discussion

Findings from this nationally representative survey of US adults indicate that e-cigarettes, and JUUL specifically, are not often used for quit attempts by adults. Overall, 13.9% of current smokers and 10.9% of former smokers in our sample who recently quit had used any e-cigarettes in a quit attempt. Further, only 3.3% of current smokers with a quit attempt, and 3.6% of recent former smokers, had used JUUL in a quit attempt. Our findings show that e-cigarettes are used less commonly than other methods for cessation, with previous research indicating approximately 15% of smokers reporting giving up cigarettes all at once, or quitting ‘cold turkey’.5 The effectiveness of these products as a cessation tool are mixed, with long-term effects unknown.15 While some studies have shown that e-cigarettes do not help smokers quit,16–20 others have shown that e-cigarettes can aid in cessation, particularly with more frequent use.21–25 A thorough review of the effectiveness of these products by the National Academies of Science and Medicine found that there was limited evidence that e-cigarettes would serve as cessation aids. However, there was moderate evidence from observational studies that use of these products in higher frequency could increase likelihood of cessation.15 The most promising evidence regarding e-cigarette use as a cessation device comes from a randomised control trial in the UK that demonstrated that e-cigarettes support cigarette cessation with behaviour counselling; however, this approach is unrealistic at the population level, given that most smokers are unlikely to participate in the behavioural counselling portion required to support cessation using e-cigarettes.26

Regardless of their efficacy in helping smokers quit, our study shows that few adult smokers in the US are using e-cigarettes for cessation. Instead, evidence suggests that e-cigarettes are primarily being used by youth and young adults.27 28 The FDA must act quickly to regulate e-cigarettes and minimise youth access and appeal, while continuing to explore the long-term effects of these products for smokers.

Only 16.2% of current smokers with a quit attempt and 11.0% of recent former smokers used NRT during cessation, which is lower than previous estimates.5 29 These findings further highlight that smokers may be turning away from effective cessation aids, as rates of using NRT and other FDA-approved medications have remained stagnant in recent years and are underutilised.30 This is of concern, as NRT has been proven to increase rates of quitting compared with controls.31 32 The relatively low use of NRT or e-cigarettes is less common than is often assumed.

This study is not without its limitations. First, we were unable to assess prescription drug use, such as Chantix or bupropion, in past quit attempts. Additionally, the survey did not assess other cessation methods, such as quit lines, gradually cutting back or consulting with a medical professional. Second, in order to sufficiently capture JUUL users, we required an opt-in panel to supplement our sample. However, sample weights were used to correct for this additional sample. Third, given the small proportion who used e-cigarettes in cessation attempts, we were unable to model for determinants of e-cigarettes use for cessation. Finally, this study did not examine nicotine addiction and how the use of other tobacco products may impact cessation methods. Given sample size limitations, this study did not control for other tobacco product use.

In an unregulated environment, the disease burden of the tobacco epidemic will continue to increase. While some argue that e-cigarettes have the potential to help smokers quit, findings here indicate that e-cigarettes, including JUUL, the most popular e-cigarette during the study collection period, are being used primarily by youth and young adults for reasons other than cessation. The FDA should establish strong regulatory action to prevent youth and young adults’ e-cigarette use and prevent unauthorised cessation claims in order to reduce tobacco use now and prevent use among future generations.

What this paper adds

  • Although smoking cessation remains a top priority for publichealth in the US, nicotine replacement therapies (NRTs) arewidely underutilized despite their proven efficacy.

  • Electronic cigarettes (e-cigarettes), and specifically thepopular device JUUL, are not approved by the US Food andDrug Administration (FDA) as cessation tools, despite theirpromotion to help smokers “switch” from combustibletobacco products.

  • Though some adult e-cigarette users report using e-cigarettesto quit smoking, it is unknown how widely smokers use ecigarettes in quit attempts.

  • This study show that e-cigarettes, and JUUL specifically, arenot widely used among recent former smokers and currentsmokers with a quit attempt.

References

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Footnotes

  • Contributors MP conceptualised the study with AC and BS. YZ and AC analysed the data with supervision from MP. All authors were involved in study conceptualisation and design of analyses, collaborated on the interpretation of findings and placement in context, drafted the manuscript and were responsible for review and refinement of the manuscript’s content.

  • Funding This study was funded by Truth Initiative.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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