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JUUL Awareness, Trial, and Continued Use among Undergraduate Students in Mississippi Undergraduate Students.

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Abstract

JUUL e-cigarettes can rapidly deliver nicotine to the brain, are not complicated to maintain and use, and can be used discreetly. These features may be attractive to adult cigarette smokers looking for a product to replace cigarettes, but may also attract nonsmoking youth and young adults. JUUL has changed the e-cigarette landscape in a short span of time, yet little is known about JUUL use among young adults. The current study assessed awareness and nicotine perceptions of JUUL, and the prevalence of trial and frequency of use of JUUL among undergraduate students at three Mississippi universities. We also examined misclassification issues in survey assessment of e-cigarette and JUUL use.
Participants
Sample and population demographic characteristics of
each university (provided on the website for Institutional
Research) are presented in Table 1. The demographic
distributions within each universitys undergraduate
student population and the survey sample were
similar; however, African American students were
underrepresented in survey results for each of the three
universities.
JUUL Awareness and Nicotine Perceptions
Most students had seen or heard of JUUL, and more than
half of those who had heard of JUUL were aware that
one JUUL pod has an equivalent amount of nicotine to a
pack of cigarettes (see Table 2). Awareness tended to be
higher among males, white students, younger students,
non-daily smokers, and members of Greek organizations.
More than half of students (59.4%) who were aware of
JUUL had accurate perceptions of the amount of nicotine
in a JUUL pod. Males, younger students, non-daily
smokers, and members of Greek organizations were more
likely to have accurate nicotine perceptions, p<.05.
JUUL Use
More than a third of students (37.1%) reported having tried
JUULs; and trial was higher among males, students who
were not African American, first-year/sophomore students,
smokers, and students in the Greek system. Most trial
users also reported current past 30-day use. More than
half of trial users reported either daily or past week JUUL
use, 20.5% reported past 30-day use (but not in the past
week), and the remaining quarter had not used a JUUL
in the past 30 days (See Table 3). Males, smokers, and
students in the Greek system were more likely to report
daily or past week JUUL use than others, p<.05.
Continued use following JUUL trial was more likely than
continued use following trial of other forms of e-cigarettes.
Past 30-day use among trial users was more than three
times higher among students who had tried a JUUL
(74.4%) than those who had tried e-cigarettes but not a
JUUL (19.5%), p<.001. Conversely, more students who
had tried e-cigarettes, but not JUUL, discontinued use
more than six months ago (63.6%) versus those who had
discontinued JUUL use (8.7%), p<.001.
Assessment of JUUL and e-Cigarette Use
All respondents were asked about e-cigarette trial prior
to being presented with questions specific to JUUL. These
e-cigarette questions did not mention JUUL. To address
the possibility that some students did not consider JUULs
to be e-cigarettes, we examined responses to the earlier
question about e-cigarette trial among students who
later reported trial of the JUUL. Indeed, 9.9% of students
who reported JUUL trial did not report e-cigarette trial.
Females, non-smokers, and students in the Greek system
were more likely to report JUUL but not e-cigarette trial
(see Table 4).
Robert C. McMillen, PhD1,2, Emily McClelland, MS1, Julie Gorzkowski2
1Mississippi State University, 2American Academy of PediatricsJulius B. Richmond Center of Excellence
{JUUL} Awareness, Trial, and Continued Use among {Undergraduate Students} in Mississippi
Significance: JUUL e-cigarettes can rapidly deliver
nicotine to the brain, are not complicated to maintain and
use, and can be used discreetly. These features may be
attractive to adult cigarette smokers looking for a product
to replace cigarettes, but may also attract nonsmoking
youth and young adults. JUUL has changed the
e-cigarette landscape in a short span of time, yet little is
known about JUUL use among young adults. The current
study assessed awareness and nicotine perceptions of
JUUL, and the prevalence of trial and frequency of use of
JUUL among undergraduate students at three Mississippi
universities. We also examined misclassification issues in
survey assessment of e-cigarette and JUUL use.
Methods: A random sample of undergraduate students
completed a web-based survey on the Qualtrics platform.
Respondents were asked about e-cigarette trial and then
about JUUL awareness, trial, and use.
Results: Most students had seen or heard of the JUUL
(69.5%), and about half of those who had heard of the
JUUL were aware that one JUUL pod has an equivalent
amount of nicotine to a pack of cigarettes (59.4%). More
than a third of students reporting have tried JUULs
(37.1%); and more than half of trial users reported either
daily or past week JUUL use (55.6%), another 20.5%
reported past 30-day use but not in the past week, and
the remaining quarter had not used a JUUL in the past 30
days (23.9%). Males, smokers, and students in the Greek
system were more likely to report daily or past week
JUUL use than others, p<.05. On a measurement note,
9.9% of students who reported JUUL trial did not report
e-cigarette trial. Females (18.9%) were more likely than
males (4.1%) and nonsmokers (15.5%) were more likely
than some day smokers (3.3%) and daily smokers (0.0%)
to misclassify JUULs as not being ecigarettes, p<.05.
Conclusion: Awareness and trial of JUUL are high among
undergraduate students in Mississippi. Moreover, most
trial users report past 30-day use, in contrast to many
previous studies finding that most trial use is discontinued.
Daily/weekly use among more than 4 of ten nonsmokers
who tried JUUL raises concerns about nicotine addiction
among nonsmokers.
abstract results
Funding: This publication was made possible by the Office of Tobacco Control, Mississippi State
Department of Health and the Flight Attendant Medical Research Institute (FAMRI) under Award Number
#052302_CoE to the American Academy Pediatrics (AAP). The information, views, and opinions contained
herein are those of the authors and do not necessarily reflect the views and opinions of these organizations.
E-cigarettes are a rapidly evolving class of battery-
powered devices that heat nicotine, flavor additives, and
chemicals to the point of areolation. JUUL Labs developed
a novel approach to these products in 2015 producing
an e-cigarette that could approximate the ability of a
cigarette to rapidly deliver nicotine to the brain in a
device that is easy to maintain and use. The JUUL is a
pod-based, closed-system that uses a non-refillable pod of
nicotine solution. Each JUUL pod contains 59 milligrams of
nicotine, or 5% nicotine as displayed on the package. The
level of nicotine in each pod is equivalent to a pack of
cigarettes; significantly higher than the nicotine delivered
by other e-cigarettes currently on the market.
These features may be appealing to adult cigarette
smokers looking for a product to replace cigarettes, but
the tech sleekness; ease of discreet use (JUULs are small
and produce less noticeable aerosol plumes due to higher
level of propylene glycol compared to other e-cigarettes);
and availability in flavors may also attract non-smoking
youth and young adults. The potent delivery of nicotine
raises concerns that nicotine-naïve trial users are at risk
for nicotine addiction. A recent survey of U.S. adult JUUL
users found that 12.7% of users were never smokers when
they first used a JUUL.
Despite public health concerns and legal challenges, JUUL
e-cigarettes are becoming a widespread phenomenon.
JUUL is currently the best and fastest selling e-cigarette on
the market and represented 72.2 percent market share in
the four-week period ending August 11, 2018, according
to Nielsen data.
JUUL has changed the e-cigarette landscape in a short
span of time, yet little is known about JUUL use among
young adults. The current study investigates awareness
and use of JUUL among undergraduate students at three
Mississippi universities. Specifically, the current study
assessed awareness and nicotine perceptions of JUUL and
the prevalence of trial and continued past 30-day use,
as well as frequency of use among trial users. We also
examined misclassification issues in survey assessment
of e-cigarette and JUUL use. There is no standard
terminology for these diverse class of products25 and we
were interested in examining surveillance challenges to
estimating prevalence of e-cigarette use.
introduction
Design and sample
This study is a cross-sectional, web-based survey of
undergraduate students at three Mississippi universities. In
the spring semester of 2018, we administered a web-based
survey via Qualtrics survey software to students at three
Mississippi universities.
Procedures
The study population included undergraduate students
at these universities during April 2018 who were 18
years of age or older. The three universities provided
15,303, 16,741 and 10,596 undergraduate student e-mail
addresses, and 50% of the email addresses provided were
randomly sampled to take part in the survey. Completed
surveys were obtained from 593, 614, and 252 students,
respectively.
Students at each university received an initial e-mail asking
for their participation in the survey. Students who chose
to participate clicked on an embedded URL address that
linked students to the survey website. Respondents who did
not finish the survey or who did not start the survey after
the initial e-mail were sent two additional emails requesting
their participation. No more than three e-mails were sent
to any student in the sample. Precautions were taken to
protect the privacy of respondents.
Measures
E-cigarettes
Respondents were provided the following information
concerning e-cigarettes, “The next questions are about
electronic cigarettes, also known as e-cigarettes, vaping
devices, or hookah pens. E-cigarettes look like regular
cigarettes but are battery-powered and produce vapor
instead of smoke.” Then respondents were asked, “Have
you ever used an e-cigarette, even one or two puffs?”
Students who selected “Yes” were classified as trial
e-cigarette users. Trial e-cigarette users were asked, “When
did you last use an e-cigarette, even one or two times?”
Trial users were asked about frequency of use rather than
past 30-day use in order to avoid equating any level of
past 30-day use with current use.26 Those who selected
“Earlier today,” or “Not today, but sometime during the
past 7 days,” were classified as daily or weekly users;
students who replied, “Not during the past 7 days, but
sometime during the past 30 days” were classified as past
30-day users; and those who reported that last use of an
e-cigarette was more than 30 days ago were classified
as having not used an e-cigarette in past 30 days. Any
trial user who reported use within the past 30 days was
considered to have continued use and to be a past 30-day
user.
JUUL
Students may not consider JUUL devices to be e-cigarettes,
but rather view JUUL as a new class of product. To
address this possibility, questions about JUUL were asked
independently of previous responses to e-cigarettes
methods
questions. That is, all respondents were asked about JUUL
trial, not just the students who had previously reported
e-cigarette trial. The survey allowed the possibility for a
student to not report e-cigarette use, but to later in the
survey report JUUL use.
Following questions about e-cigarettes, all respondents
were provided an image of the JUUL and this statement,
“The JUUL nicotine-delivery device looks like a USB flash
drive.” and asked, “Have you ever seen or heard of the
JUUL before this study?” Those who replied yes were
asked, “Are you aware that the amount of nicotine in
one JUUL pod is equivalent to a pack of cigarettes?”
to assess nicotine perceptions of JUUL. To assess JUUL
use, respondents who had seen or heard of the JUUL
were asked, “Have you ever used a JUUL, even one or
two puffs?” Those who selected “Yes” were classified as
trial JUUL users. Past 30-day JUUL use among trial users
was assessed using the same protocol as past 30-day
e-cigarette use.
Demographic variables and smoking status
Self-reported gender, race, year in school, cigarette
smoking status, and membership in a Greek organization
were included as covariates in analyses. Respondents were
asked, “Have you ever tried cigarette smoking, even one or
two puffs?” Those who reported no were classified as non-
smokers. Those who reported yes were asked, “How old
were you when you smoked a whole cigarette for the first
time?” Those who reported, “I have never smoked a whole
cigarette” were classified as non-smokers. Those who
reported yes were asked, “On how many of the last 30
days did you smoke cigarettes?” Students who reported, “I
did not smoke cigarettes at all in the past 30 days” were
classified as non-smokers. Those who reported smoking
on at least one day but not all 30 days were classified as
nondaily smokers, whereas those who reported, “I smoked
cigarettes every day in the past 30 days” were classified as
daily smokers.
Data analysis
Sample demographics from each university are presented
alongside population distributions (provided by the
Institutional Research website for each university) in order
to assess the representativeness of each sample. Descriptive
analyses for JUUL awareness, trial, and use provide
prevalence estimates, while Chi-squared tests compare
these outcome variables across demographic variables
and by cigarette smoking status. Chi-squared tests also
compared the percentage of trial users who continued as
past 30-day users among those who had tried e-cigarettes,
but not JUULs, and those who had tried JUULs.
To examine misclassification issues in survey assessment
of e-cigarette and JUUL use, frequency analysis provided
the percent of students who reported JUUL use, but not
e-cigarette use, while Chi-squared tests compared these
outcome variables across demographic variables and by
cigarette smoking status.
Awareness of JUUL is high and more than a third of students
report JUUL trial. Moreover, most trial users report past
30-day or more frequent use, in striking contrast to many
previous studies finding that most trial e-cigarette use is
discontinued and only a small percentage of trial users are
current users. Furthermore, continued use of JUUL among trial
users in this sample was three times higher than in previous
annual surveys of e-cigarette use among this population.
In 2017, approximately a quarter of trial e-cigarette users
continued as past 30-day users, whereas more than three-
quarters of JUUL trial users did so in 2018. This finding
suggests that many JUUL users may not be experimenting
with the device, but using it regularly.
These findings, along with sales data indicating an increasing
market share, illustrate the rapid pace with which JUUL is
becoming ingrained into the social climate of youth and
young adults. Although the FDA has recently begun to
address the rising popularity of these products among youth,
public health efforts to curb use among nonsmokers will likely
face substantial challenges as use becomes more prevalent.
Another challenge facing survey surveillance concerns
terminology. As previously stated, one in ten students who
reported JUUL use did not report e-cigarette use earlier in the
survey, suggesting that these respondents did not consider
JUUL use to be e-cigarette use. Researchers need to carefully
consider terminology when designing surveys about these
products.
Limitations
1. The response rates for each university were low. However,
the demographic distribution of each sample closely matched
that of the undergraduate students as a whole, with one
exception. The under-representation of African American
students, who are less likely to use e-cigarettes, may have
inflated estimates of JUUL use.
2. The survey could not differentiate between students who
used JUUL e-cigarettes exclusively and those who used JUUL
and other types of e-cigarettes. Students who reported JUUL
trial but not e-cigarette trial likely only had tried pod-based
systems. However, students who reported both e-cigarette
and JUUL trial may have tried both JUUL and other forms
of e-cigarettes or may have tried the JUUL e-cigarette
exclusively, but recognized this product as an e-cigarette
when responding to the e-cigarette trial question.
3. Several other pod-based systems entered the market from
the time we designed the survey to the time in which we
concluded data collection. Our survey asked about JUUL by
brand name and did not address other brands of pod-based
systems. Estimates may not accurately describe trial and use
for pod-based systems in general.
4. These findings are from undergraduate students in
Mississippi and may not be representative of students outside
of the state.
Conclusion
Awareness and trial use of JUUL are high. Moreover, most
trial users report daily or past week use, in contrast to many
previous studies finding that most trial use is discontinued.
Universities and policy makers need to be aware of JUUL
use among undergraduates, particularly those who are non-
smokers.
conclusions
Freshman
Sophomore
Junior
Senior and Beyond
Female
Male
Black
White
Other
Population
23.9%
21.0%
22.4%
32.7%
49.2%
50.8%
20.2%
72.1%
7.8%
Sample
24.6%
20.7%
29.3%
25.4%
47.6%
52.4%
6.1%
85.8%
8.1%
Population
26.0%
22.3%
23.2%
28.5%
54.8%
45.2%
12.5%
78.0%
9.6%
Sample
28.3%
19.7%
23.6%
28.3%
55.5%
44.5%
5.6%
85.6%
8.8%
Population
20.8%
16.5%
25.0%
37.6%
62.8%
37.2%
28.6%
60.9%
10.5%
Sample
12.9%
17.9%
27.5%
41.8%
65.4%
33.8%
13.8%
76.4%
9.8%
Universities
Overall
Gender
Male
Female
Race
White
African American
Other
Year
First Year
Sophomore
Junior
Senior
Cigarette Smoking
Nonsmoker
Smokes on Some Days
Daily Smoker
Member of a Greek Organization
Yes
No
69.5%
p<.001
74.5%
64.7%
p<.001
75.4%
21.2%
60.2%
p<.001
80.4%
80.0%
65.0%
57.3%
p<.001
64.6%
89.9%
61.0%
p<.001
95.9%
56.7%
Had heard or seen
of the JUUL (n=1,371)
Aware that one JUUL pod has
an equivalent amount of nicotine
to a pack of cigarettes (n=951)
59.4%
p<.001
68.9%
50.9%
n/a
60.9%
n/a
52.7%
p=.004
64.2%
66.0%
55.4%
51.8%
p<.001
52.9%
75.9%
66.7%
p<.001
71.7%
49.5%
Overall
Gender
Male
Female
Race
White
African American
Other
Year
First Year
Sophomore
Junior
Senior
Cigarette Smoking
Nonsmoker
Smokes on Some Days
Daily Smoker
Member of a Greek Organization
Yes
No
37.1%
p<.001
48.0%
27.2%
p<.001
40.4%
4.4%
33.3%
p<.001
47.1%
46.2%
32.3%
26.7%
p<.001
27.4%
71.5%
44.1%
p<.001
68.3%
21.6%
Trial Use
(n=1,459) Current JUUL use among trial users (n=507)
55.6%
60.4%
48.8%
55.4%
n/a
56.1%
60.9%
54.9%
55.5%
49.0%
43.5%
72.7%
57.7%
61.5%
45.4%
Daily or
weekly user Past 30-day user, but
not in the past week Has not used in
past 30 days
20.5%
15.7%
27.4%
20.5%
n/a
19.5%
17.4%
20.5%
21.8%
24.0%
24.7%
15.2%
15.4%
22.1%
18.9%
23.9%
p=.004
23.9%
23.9%
ns
24.1%
n/a
24.4%
ns
21.7%
24.6%
22.7%
26.9%
p<.001
31.8%
12.1%
26.9%
p<.001
16.4%
35.7%
table 1: population and sample characteri cs
table 2: juul awareness
table 3: juul trial and current use
Overall
Gender
Male
Female
Race
White
African American
Other
Year
First Year
Sophomore
Junior
Senior
Cigarette Smoking
Nonsmoker
Smokes on Some Days
Daily Smoker
Member of a Greek Organization
Yes
No
9.9%
p<.001
4.1%
18.9%
ns
10.0%
n/a
9.8%
ns
9.9%
5.7%
13.4%
10.6%
p<.001
15.5%
3.0%
0.0%
p=.049
12.0%
6.6%
Did not report
e-cigarette trial (n=507)
table 4: reports of e-cigarette
trial among juul trial users
p o s t e r d e s i g n e d b y :
{m i r a n d a r o b e r t s o n }
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