ReviewThe rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects
Introduction
Electronic cigarettes (e-cigarettes) first entered the U.S. market in 2006, acclaimed as a smoking cessation tool and a safer alternative to smoking (Cahn and Siegel, 2011; Hon, 2013). E-cigarettes have evolved from early generation cigarette lookalikes (cigalikes), to modifiable tank-style e-cigarettes, to the latest, more inconspicuous device type known as pod mods or “pods.” Among pod mods, the most well known is JUUL, which was first introduced in 2015. JUUL is currently the most popular retail e-cigarette brand in the USA, accounting for 76% of the retail e-cigarette market at the end of 2018 (Craver, 2019; Huang et al., 2019). JUUL has become so popular among youth that the term “JUULing” has become synonymous with “vaping” among teens and young adults (Teitell, 2017). JUUL devices are small, rechargeable, battery-powered e-cigarettes which aerosolize liquid solutions containing glycerol, propylene glycol, natural oils, extracts and flavor, nicotine, and benzoic acid (JUUL, 2019). Modern e-cigarettes and pod mod devices like JUUL have become a more socially acceptable alternative to combustible cigarettes among adolescents and young adults, and have become popular among this age group as a result of (1) sleek designs, (2) user-friendly functions, (3) less aversive smoking experiences, (4) desirable flavors, and (5) the ability to be used discreetly in places where smoking is forbidden (Allem et al., 2018; Barrington-Trimis and Leventhal, 2018; Kavuluru et al., 2019; Kinouani et al., 2017; McKeganey et al., 2018; Pepper et al., 2016; Ramamurthi et al., 2018; Yingst et al., 2018).
JUUL has been described as the “iPhone of e-cigarettes” (Radding, 2015) due to its modern and user-friendly design that requires only sliding a flavor pod (nicotine cartridge) into the device before use, a significant improvement over previous models of e-cigarettes (Barrington-Trimis and Leventhal, 2018). JUUL utilizes protonated nicotine, which the company claims provides a more satisfying experience to the user by reducing aversive experiences of taste, smell, and throat irritation (Barrington-Trimis and Leventhal, 2018; Bowen and Xing, 2015). The appealing flavorings available (e.g., mango, fruit medley, menthol) in JUUL (JUUL, 2019) can mask unwanted tastes and smells, and are often cited as a reason for experimentation among young JUUL users (Ayers et al., 2017;Chen, 2018 Kavuluru et al., 2019; Kong et al., 2015). The size of JUUL and its resemblance to a USB flash drive allow it to be easily concealed from authority figures and discreetly used in places where smoking is forbidden, also known as “stealth vaping” (Allem et al., 2018; Kavuluru et al., 2019; Ramamurthi et al., 2018; Yingst et al., 2018). Given the novel user experience, appealing flavors, and product design of JUUL and other pod mod devices, they may be more appealing to youth than prior e-cigarette products. In one recent report, 80% of 15–24 year olds who reported that they had ever tried JUUL were also past 30-day users (Willett et al., 2019), suggesting that youth who try JUUL are highly likely to continue using it.
This review examines the rise of use in e-cigarettes and pod mod devices such as JUUL, and discusses factors which are implicated in their initiation and sustainment of use. The perception of these products among adolescents and young adults will also be examined, as well as current research available regarding the potential benefits of e-cigarettes and pod mod devices as a harm reduction model for those who use combustible cigarettes. Alternatively, this review will also examine the risk of e-cigarette use as a “gateway” to combustible cigarette use and cannabis use. This review is meant to serve as an updated, meaningful summary of adolescent e-cigarette and pod mod use from a clinical perspective, with Table 1 as a general reference to commonly asked questions that many researchers, providers, educators, and families often have regarding e-cigarettes.
Section snippets
Methods
Pubmed, Scopus, and PsycINFO search was performed using search terms "Electronic Nicotine Delivery Systems," "e cigarettes," "e-cigarettes," “vaping,” “electronic cigarettes,” “JUUL,” “e-cigs,” and “vape pens.” Search results were filtered to only include those related to adolescents and young adults. Review of peer-reviewed articles included original research articles and review articles pertinent to adolescent e-cigarette, vaping, and pod mod use.
Epidemiology and rising prevalence of use
Although there recently has been a significant decline in youth combustible cigarette use, the overall use of nicotine products among youth has increased as a result of e-cigarettes and pod mod devices such as JUUL (Miech et al., 2018; Mirbolouk et al., 2018). In the United States, past 30-day vaping among high school students has risen from 1.5% in 2011 to 11.7% in 2017 to 20.8% in 2018 (Cullen et al., 2018), whereas 30-day prevalence rates of combustible cigarette use among high school
Health concerns related to E-cigarettes and JUUL
Combustible cigarette smoking is the leading cause of preventable death (Courtney, 2015), and e-cigarettes are largely viewed as a safer alternative to combustible cigarettes (Cahn and Siegel, 2011). Unlike traditional cigarettes, e-cigarettes are free from the process of combustion, which releases pulmonary carcinogens including polycyclic aromatic hydrocarbons, N-nitrosamines, and other cytotoxic compounds that are inhaled by the user (Courtney, 2015; Hecht, 1999). An emerging product also
Cognitive influences: attitudes, knowledge, and misperceptions
Overall, youth are very open to using non-cigarette tobacco products such as e-cigarettes (Mays et al., 2015), and studies have indicated that perceptions of e-cigarettes as less risky, more popular, and more socially acceptable than combustible cigarettes have contributed to their increased use among youth (Ambrose et al., 2014; Anand et al., 2015; Berg et al., 2015; Chaffee et al., 2015; Choi and Forster, 2014; Copeland et al., 2017; Gorukanti et al., 2017; Kong et al., 2015; Mays et al., 2015
E-cigarettes may lead to combustible cigarette use among youth
The ultimate impact of e-cigarettes on public health will depend on their influence on the overall prevalence of cigarette smoking (National Academies of Sciences, Engineering, and Medicine, 2018). In contrast to adult e-cigarette users who are almost exclusively current and former cigarette smokers, many youth and young adult users had never used a tobacco product before initiating e-cigarette use (Barnett et al., 2015; Barrington-Trimis et al., 2015; Barrington-Trimis et al.; 2016; Camenga et
E-cigarettes and Cannabis use
The relationship between combustible cigarette use and the initiation, maintenance, and escalation of cannabis use is well-established (Agrawal et al., 2013; Peters et al., 2012), and research suggests that e-cigarettes may confer a similar risk (Azagba, 2018; Dai et al., 2018).
E-cigarette use at 14 years of age was associated with almost a four-fold increase in the odds of initiating and consistently using cannabis two years later (Audrain-McGovern et al., 2018). Nicotine exposure in
E-cigarettes, pod mod devices, and smoking cessation
More than half of youth who smoke combustible cigarettes are interested in quitting, and many adults who endorse e-cigarette use utilize the devices to quit smoking (Babb et al., 2017). Despite the urge to quit smoking, U.S. smokers report significant difficulty abstaining from nicotine use; within a given year, 34% of smokers will attempt to quit, but only 1% will remain tobacco free for at least one year (Stratton et al., 2001). In addition to the physiological addiction that occurs as a
E-cigarette regulation in the United States
Although e-cigarettes were not initially included in the Family Smoking Prevention and Tobacco Control of 2009, the FDA finalized a rule in 2016 that extended its regulatory authority to all tobacco products, including e-cigarettes (United States Food and Drug Administration, 2016). As a result, the new law required health warnings on e-cigarettes, and e-cigarettes were held to public health standards set by the law. Additionally, mounting pressure from the FDA and other public-health related
Conclusion
Youth are using e-cigarettes and pod mod devices such as JUUL now more than ever. Given the increasing prevalence of use among impressionable and vulnerable adolescent populations, there is concern that electronic cigarettes may be exposing a significant number of youth to nicotine who would have not otherwise be using tobacco. Although the use of e-cigarettes is generally considered safer in comparison to combustible cigarettes, concerns remain. The developing adolescent brain is susceptible
Contributors
Matthew C. Fadus formulated and wrote the manuscript. Tracy T. Smith provided significant guidance and helped edit and write the manuscript. Lindsay M, Squeglia provided significant guidance and helped edit and write the manuscript. All authors agree to the final submitted version of the manuscript.
Role of funding source
This study was supported by the National Institute on Drug Abuse R25 DA020537 (Back and Brady), K01 DA047433 (Smith), and U01 DA041093 (Squeglia and Gray); and the National Institute on Alcohol Abuse and Alcoholism R01AA027399 (Gray and Squeglia) and K23 AA025399 (Squeglia).
Conflict of interest
No conflict declared
Acknowledgements
The authors would like to thank Teri Lynn Herbert of the Medical University of South Carolina for her expertise and assistance with the literature search for this review.
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