Article

The adult JUUL switching and smoking trajectories (ADJUSST) study: Methods and analysis of loss-to-follow-up

Authors:
  • Juul Labs, Inc.
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Abstract

Objectives: The Adult JUUL System User Switching and Smoking Trajectories (ADJUSST) study assessed the smoking and JUUL use trajectories of adults who purchased JUUL. In this paper, we describe study methods, characterize the sample, and assesses potential for bias due to loss to follow-up. Methods: We entered 55,414 US adults (≥ age 21) who purchased a JUUL Starter Kit for the first time (online or at retail) in 2018 into a naturalistic, longitudinal observational study, irrespective of baseline smoking status. Participants were invited for follow-ups 1, 2, 3, 6, 9, and 12 months later, focused on assessing past-30-day smoking and JUUL use. Analyses assessed potential bias due to non-response. Results: Over 90% of participants had a history of smoking; 62.8% were past-30-day smokers; 23.3% were former smokers. Participants' average age was 30; 75% were white. Most participants (77.6%) completed some follow-ups; 25% completed all follow-ups. Baseline differences among complete responders (N = 13,729), partial responders (N = 29,252), and complete non-responders (N = 12,433) were small. When recontacted, few 12-month non-responders said their non-response was due to smoking; many reported no past-30-day smoking. Conclusions: The study may elucidate smoking trajectories of adult JUUL users. The potential for bias due to loss to follow-up in ADJUSST was limited.

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... Finally, focusing on a single ENDS brand eliminates heterogeneity across different ENDS products, possibly allowing clearer focus on the association between risk perceptions and switching. A rich source of data for this question is the previously-described Adult JUUL Switching and Smoking Trajectories (ADJUSST) study [32] which enrolled a large national sample of adult established smokers who had first purchased a JUUL brand starter kit, and followed them over the subsequent year. Previous research on the ADJUSST study showed that, among established smokers, lighter baseline smoking behavior, more frequent JUUL use, and greater satisfaction with and dependence on JUUL were positively associated with later switching [33]. ...
... The current secondary analysis of the above ADJUSST study [32] focuses on risk perception and subsequent switching, among adult established smokers who had recently adopted JUUL brand ENDS with the purchase of a JUUL Starter Kit. We hypothesize that smokers who perceive JUUL to be less harmful than cigarettes are more likely to later switch away from smoking, consistent with psychological theory and prior research [31,34]. ...
... Data were drawn from the Adult JUUL Switching and Smoking Trajectories (ADJUSST) Study, which has been described in detail previously [32]. Briefly, N = 22,905 adult (21+) current established smokers were selected from the full ADJUSST sample (i.e. ...
Article
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Background Evidence indicates that electronic nicotine delivery systems (ENDS) pose lower risk than cigarettes; however, many smokers harbor misperceptions that ENDS are equally or more harmful, possibly deterring them from switching. This study examines whether comparative risk perceptions of JUUL vs. smoking are associated with subsequent switching, among smokers who recently purchased JUUL. Methods N = 16,996 current established smokers who recently purchased a JUUL Starter Kit were followed 6 times over 12 months. Comparative risk perceptions were assessed using both direct and indirect measures (i.e., contrasting JUUL and smoking directly in questions, and deriving from separate absolute scales). Repeated-measures logistic regression examined switching across follow-up (no smoking in past 30 days) as a function of baseline risk perceptions, adjusting for demographics and baseline smoking behavior. Results Perceiving JUUL as less harmful than smoking was associated with higher switching rates, using both direct (e.g., adjusted odds ratio [AOR] = 1.48 for “JUUL much less” vs. “more/much more harmful”) and indirect (AOR = 1.07, for each 10-unit increase in fraction; AOR = 1.51 for highest (6-100) vs. lowest (0 to < 1) fraction categories) comparative risk measures (all p < 0.0001). Among the subset smoking 10 + cigarettes per day, associations between risk perceptions and switching were more pronounced (AOR = 2.51 for “JUUL much less” vs. “more/much more harmful”; AOR = 1.81 for 6-100 vs. 0 to < 1 fraction, both p < 0.0001). Conclusions Smokers who perceive JUUL as less harmful than cigarettes have higher odds of switching. Future research should examine whether messaging which aligns comparative risk perceptions with current evidence can facilitate switching, especially among heavier smokers.
... The ADJUSST Study was a naturalistic observational prospective cohort study of US adults who had recently purchased their first JUUL Starter Kit (with JUUL 5.0% nicotine e-liquids) on their own through commercial channels between June and October 2018 Selya et al., 2021 ;Shiffman et al., 2021b ). Retail purchasers were invited via in-pack recruitment cards; online purchasers were invited via email. ...
... Participants were assessed at baseline, and subsequently invited by email to complete online assessments 1, 2, 3, 6, 9 and 12 month(s) thereafter. As previously reported, between two thirds and three quarters of participants completed each follow-up assessment Shiffman et al., 2021b ). Analysis of baseline differences -including differences in cigarette dependence -found that differences between those who missed or completed follow-ups were uniformly small in magnitude (e.g., effect size for baseline TDI cigarette dependence was R 2 = 0.0008), suggesting limited bias due to missing follow-ups. ...
... As in any longitudinal study, some participants did not complete all follow-ups, which may raise concern about non-response bias Thompson et al., 2019 ). However, previously-reported analyses suggest limited bias due to missed follow-ups in ADJUSST Shiffman et al., 2021b ). Participants with incomplete data did not differ materially at baseline from those with complete data (including on baseline cigarette dependence), and the most common reasons for missing data were mostly related to survey logistics (e.g., narrow time window for responding to survey invitations, dissatisfaction with compensation), mitigating concern about non-response bias. ...
Article
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Background: Electronic nicotine delivery systems (ENDS) are substitute sources of nicotine for adults who smoke cigarettes. Understanding changes in dependence as people switch from cigarettes to ENDS is relevant to public health. This study assessed changes in dependence among adults who switched completely or partially (dual users) from cigarettes to JUUL-brand ENDS over 12 months. Methods: US adults who smoke and purchased a JUUL Starter Kit (n = 17,619) completed a baseline assessment and were invited to 1-, 2-, 3-, 6-, 9- and 12-month follow-ups. Dependence on cigarettes at baseline and on JUUL at follow-ups was assessed with the Tobacco Dependence Index (TDI; Range 1-5). Analyses estimated the minimal important difference (MID) for the scale, compared JUUL dependence to baseline cigarette dependence and assessed changes in JUUL dependence over 1-year, including among those using JUUL at all follow-ups. Results: Participants who switched at month 2 had month 1 JUUL TDI scores 0.24 points greater than those who continued smoking (p<0.001); thus MID=0.24. Among both switchers and dual users overall, dependence on JUUL 1 and 12 months later was lower than baseline dependence on cigarettes (ps<0.001); participants who smoked every day showed more consistent and larger reductions. Among participants who persistently used JUUL without smoking, dependence increased 0.01 points per month (p<0.001), but was leveling off over time. Conclusions: Dependence on JUUL was lower than baseline cigarette dependence. Increases in JUUL dependence were small over 12 months of continual JUUL use. These data indicate that ENDS, including JUUL, have lower dependence potential than cigarettes.
... The data were from the ADJUSST study, a longitudinal observational study of US adults who purchased a JSK (a JUUL device, a charging dock, and 4 e-liquid pods) between 2018 and 2019. 46 Those who purchased a JSK were invited to participate, either through a card inserted in the package (retail purchaser) or an email (online purchaser) in a longitudinal study that followed their cigarette smoking and JUUL use. Those who were (1) 21 years or older, (2) permanent residents of the US, (3) purchased the JSK for the first time within the past 5 days, and (4) not employees or family of employees of Juul Labs Inc, or PAX Labs Inc were eligible to participate. ...
... Each survey invitation noted that participants were eligible to participate whether or not they were using JUUL and whether or not they were smoking. More details of the ADJUSST study have been described by Shiffman et al. 46 The present study analyzed a cohort of baseline smokers to assess the association between their medico-socio-demographic characteristics and complete switching away from combustible cigarettes. For these analyses, smokers were defined as those who at baseline smoked in the past 30 days, report smoking 'every day' or 'some days', and had smoked 100 or more cigarettes in their lifetime; these are sometimes referred to as "established smokers." ...
... Survey nonresponse has the potential to cause biases if responders differ from non-responders. However, analyses by Shiffman et al 46 showed that (1) those with no follow-up data, (2) those with partial data, and (3) those who completed all 6 follow-ups did not show meaningful differences in their sociodemographic characteristics and baseline smoking history (R 2 or uncertainty coefficients ≤ 0.002). Also, the observed differences were small and did not consistently suggest that non-responders would have had lower switching rates (eg, they had lower cigarette dependence, which was associated with higher rates of switching). ...
Article
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Objectives: In this study, we examined complete switching away from cigarettes across various medico-socio-demographic subpopulations of adult smokers who purchased a JUUL Starter Kit (JSK) electronic nicotine delivery system. Methods: We analyzed trajectories of smoking over 12 months in 17,986 adult smokers who purchased a JSK. Populations of special interest were characterized by race/ethnicity, income, diagnoses of potentially smoking-related illness (SRI), depression, and anxiety. Results: Across all 16 subgroups examined, a consistent pattern of trends was observed where complete switching increased, and dual-use decreased over time. Non-Hispanic Asian race/ethnicity, low income, diagnoses of potential SRI, depression, and anxiety were associated with significantly lower switching rates; however, complete switching rates at month 12 were near 50% for all groups, and surpassed the dual-use rates in all subgroups except for those with potential SRI. Conclusions: Substantial rates of complete switching were consistently achieved across all medico-socio-demographic subgroups 12 months following the purchase of the JSK. The potential benefits of switching with JUUL on smokers are likely to be experienced by a wide range of adult smokers.
... The ADJUSST study methodology and further analyses of participants lost to follow-up have been detailed in the previous publication. [36] Measures ...
... However, 72% of the participants responded to 5 or more surveys and previous analyses on loss-to-follow-up demonstrated that the biases from survey nonresponse are limited. [36] Nonetheless, there is a possibility of selective loss-to-follow-up. Lastly, participants may also have used other tobacco products that were not assessed in this study. ...
Preprint
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OBJECTIVES: Electronic nicotine delivery systems (ENDS) can reduce tobacco-related risks for adults who smoke cigarettes (AWS) by facilitating complete switching away from combustible cigarettes. However, little is known about ENDS use and switching among subpopulations that have been disproportionately affected by smoking, which could contribute to reducing tobacco-related disparities. METHODS: AWS (age≥21 years) were recruited following their first purchase of a JUUL Starter Kit in 2018. Participants self-reported switching (no past-30-day cigarette smoking) at 1-, 2-, 3-, 6-, 9-, 12-, 15-, 18-, 21-, and 24-months follow-up assessments. Percent switched and percent with a substantial smoking reduction from baseline (≥50% decrease in cigarettes/day among those who continued smoking) were analyzed. Analyses focused on racial/ethnic minorities, persons with low income and education levels, sexual minorities, and those with mental and physical health conditions. RESULTS: Overall rates of switching away from cigarettes increased across follow-ups to 51.2% at Month 12 and 58.6% at Month 24. Among those who continued to smoke, 45.4% reported a substantial smoking reduction in Month 24. Rates of switching and substantial smoking reduction were similar between subgroups disproportionately affected by cigarette smoking and their referent counterparts, except for lower switch rates in individuals with physical health conditions. CONCLUSIONS: AWS demonstrated progressively increasing switching rates over two years after purchasing JUUL products. A similar trend was also observed across populations disproportionately affected by smoking. ENDS products such as JUUL may provide an opportunity to benefit population health and reduce tobacco-related disparities among AWS.
... The current secondary analysis of a previously-described longitudinal study (23) focuses on risk perception and subsequent switching, among adult established smokers who have recently adopted JUUL brand ENDS with the purchase of a JUUL Starter Kit. In assessing risk perceptions, this study considers both "direct relative risk," where the comparison between JUUL and smoking is explicit within the question and "indirect relative risk," where a measure of perceived risk is derived from participants' responses to separate items assessing absolute risk for smoking and for JUUL use (25)(26)(27). ...
... Data were drawn from the Adult JUUL Switching and Smoking Trajectories (ADJUSST) Study, which has been described in detail previously (23). Brie y, N = 22,905 adult (21+) current established smokers were selected from the full ADJUSST sample (i.e. ...
Preprint
Full-text available
Background: Evidence indicates that electronic nicotine delivery systems (ENDS) pose lower risk than cigarettes; however, many smokers misperceive ENDS to be equally ormore harmful, possibly deterring them from switching. This study examines whether relative risk perceptions of JUUL vs. smoking are associated with subsequent switching, among smokers who recently initiated JUUL use. Methods: N=16,996 current established smokers who recently purchased a JUUL Starter Kit were followed 6 times over 12 months. Relative risk perceptions were assessed using both direct and indirect measures (i.e., contrasting JUUL and smoking directly in questions, and deriving from separate absolute scales). Repeated-measures logistic regression examined switching across follow-up (no smoking in past 30 days) as a function of baseline risk perceptions, adjusting for demographics and baseline smoking behavior. Results: Perceiving JUUL as less harmful than smoking was associated with higher switching rates, using both direct (e.g., odds ratio [OR]=1.48 for “JUUL much less” vs. “more/much more harmful”) and indirect (OR=1.07, for each 10-unit increase in ratio; OR=1.51 for highest (6-100) vs. lowest (0 to <1) ratio categories) relative risk measures (all p<.0001). Among the subset smoking 10+ cigarettes per day, associations between risk perceptions and switching were more pronounced (OR=2.51 for “JUUL much less” vs. “more/much more harmful”; OR=1.81 for 6-100 vs. 0 to <1 ratio, both p<.0001). Conclusions: Smokers who perceive JUUL as less harmful than cigarettes have higher odds of switching. Future research should examine whether messaging which aligns relative risk perceptions with current evidence can facilitate switching, especially among heavier smokers.
... The majority of Switchers (61.4%) reported using JUUL least 15 times per day (a time was de ned as 15 puffs or 10 minutes of use), and a similar majority (61.4%) reported using 20 + pods per month. To put this level usage into context, Supplement 2 reports the levels of JUUL usage reported in two samples: (1) a longitudinal cohort study of adult smokers who had purchased a JUUL Starter Kit two years earlier [42] and (2) a sample of adult JUUL users from the population-representative PATH data [43]. The comparisons show that the participants in the Switcher sample were more likely to use daily, and twice as likely to use 15 or more times per day and to use 20 + pods per month than the more representative samples. ...
... This likely re ects the pattern of unusually heavy use of JUUL in the Switcher sample. Their JUUL use was considerably higher than that seen in a large cohort of real-world purchasers of JUUL [42]. Compared to the broader JUUL purchaser sample, the Switcher sample was 40% more likely to use JUUL daily, twice as likely to use 15 + times per day, and > 2.5 times more likely to consume 20 + pods monthly. ...
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Introduction: More real-world evidence on exposure to harmful and potentially harmful constituents (HPHCs) and on biological effects when cigarette smokers switch to e-cigarettes would be useful. Methods: This cross-sectional, observational study assessed adults who had smoked ≥ 10 cigarettes/day for ≥ 10 years, comparing 124 continuing cigarette smokers (Smokers) to 140 former smokers who switched to JUUL-brand e-cigarettes exclusively for ≥ 6 months (Switchers). Assessments included biomarkers of exposure (BOEs) to select HPHCs, biomarkers of potential harm (BOPHs) related to smoking-related diseases, and psychometric assessments of tobacco dependence and respiratory symptoms. Planned analyses compared geometric means, adjusted for covariates; exploratory analyses adjusted for additional covariates. Results: Nicotine was higher in Switchers, who were heavy users of JUUL. All other BOEs, including NNAL and HPMA3 (primary endpoints), were significantly lower in Switchers than Smokers. Most BOPHs (sICAM-1 [primary], and e.g., white blood cell count, MCP1, HbA1c) were significantly lower in Switchers than Smokers; HDL was significantly higher. Switchers reported significantly lower tobacco dependence and respiratory symptoms than Smokers. Conclusions: Compared to continuing smokers, smokers who switched to JUUL had substantially lower exposures to multiple HPHCs, favorable differences in markers of inflammation, endothelial function, oxidative stress, and cardiovascular risk, and less respiratory symptoms.
... The Center for Tobacco Products requires information to assess the potential impact of a new product on current tobacco user behaviors, including who uses the product, how the product is used, and the effects of its use on the use of other tobacco products. Various study designs can be employed to provide this information, including randomized clinical trials, longitudinal cohort studies, and actual use studies (AUS) [3,[9][10][11][12][13][14][15]. ...
Article
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Background Introduction of new tobacco products in the United States, including those that may be lower on the risk continuum than traditional combustible cigarettes, requires premarket authorization by the US Food and Drug Administration and information on the potential impact of the products on consumer behaviors. Efficient recruitment and data capture processes are needed to collect relevant information in a near-to-real-world environment. Objective The aim of this pilot study was to develop and test a protocol for an actual use study of a new tobacco product. The product included in this study was a commercially available oral nicotine pouch. Through the process of study design and execution, learnings were garnered to inform the design, execution, analysis, and report writing of future full-scale actual use studies with tobacco products. Methods A small sample (n=100) of healthy adult daily smokers of 7 or more cigarettes per day were recruited to participate in an 8-week prospective observational study conducted at 4 geographically dispersed sites in the United States. A smartphone-based customized electronic diary (eDiary) was employed to capture daily tobacco product use, including 1 week of baseline smoking and 6 weeks during which participants were provided with oral nicotine pouches for use as desired. Results Online screening procedures with follow-up telephone interviews and on-site enrollment were successfully implemented. Of 100 participants, 97 completed the study, with more than half (59/99, 60%) identifying as dual- or poly-users of cigarettes and other types of tobacco products at baseline. There was more than 90% (91-93/99, 92%-94%) compliance with daily eDiary reporting, and the majority (92/99, 93%) of participants expressed satisfaction with the study processes. Product use data from the eDiary indicated that after an initial period of trial use, pouches per day increased among those continuing to use the products, while per day average cigarette consumption decreased for 82% (79/97) of all study participants. At the end of the week 6, 16% (15/97) of participants had reduced their cigarette consumption by more than half. Conclusions The design of this study, including recruiting, enrollment, eDiary use, and oversight, was successfully implemented through the application of a detailed protocol, a user-friendly eDiary, electronically administered questionnaires, and remote monitoring procedures. High-resolution information was obtained on prospective changes in tobacco product use patterns in the context of availability of a new tobacco product. Future, larger actual use studies will provide important evidence supporting the role that alternatives to combustible cigarettes may play in smoking reduction and/or cessation and lowering the population health burden of tobacco and nicotine-containing products.
Article
Introduction: Menthol cigarettes and menthol-flavored electronic nicotine delivery systems (ENDS) are a current focus of US regulatory policy considerations. Informed policy requires understanding how ENDS flavor may influence smoking behavior, and whether this association varies by preferred cigarette flavor. Materials and methods: The analytic sample included 8,428 US adults who smoked cigarettes (AWS) in the Adult JUUL Switching and Smoking Trajectories Study and used tobacco- or menthol-flavored JUUL products. Repeated-measures logistic regressions assessed the time-varying association between primary JUUL flavor (menthol vs. tobacco) and switching (no past-30-day smoking) across four follow-ups in year 2 of the study, adjusting for sociodemographics and baseline smoking history. Analyses also examined interactions with cigarette flavor preference (menthol vs. non-menthol). Results: AWS smoking menthol cigarettes predominantly used menthol-flavored JUUL (∼70% of follow-ups) and had significantly higher switch rates (aOR[95%CI] = 1.30[1.09-1.55]). AWS primarily using menthol-flavored (vs. tobacco-flavored) JUUL had higher odds of switching (aOR = 1.24[1.08-1.43]). The association varied by preferred cigarette flavor: AWS who smoked non-menthol cigarettes had higher odds of switching when using menthol- (vs. tobacco-flavored) JUUL aOR = 1.21[1.05-1.40]). Among AWS who smoked menthol cigarettes, the difference in switching was not significant, but trended in the opposite direction (aOR = 0.94[0.79-1.11] for menthol- vs. tobacco-flavored JUUL). More generally, AWS who used cigarette-incongruent JUUL flavors (especially non-menthol cigarettes and Menthol-flavored JUUL) had higher odds of switching (aOR = 1.16[1.04-1.29]). Discussion: Some menthol-flavored ENDS may promote complete switching beyond that facilitated by tobacco-flavored ENDS. Cigarette-incongruent ENDS flavors, especially menthol-flavored ENDS among people who smoke non-menthol cigarettes, may facilitate increased switching.
Article
Background: This is authors' reply to the Commentary on our publication entitled "Adult smokers' Complete Switching Away from Cigarettes at 6, 9, and 12 Months after Initially Purchasing a JUUL e-Cigarette." Methods and results: Analyses addressed questions about follow-up rates and missed responses in the Adult JUUL Switching and Smoking Trajectories (ADJUSST) Study. Results demonstrate limited potential for selection bias, as participants who missed surveys were similar to those with complete data, and re-contact of participants who missed a follow-up indicated almost half were not smoking. Imputing smoking behavior for missing data would likely introduce bias and is not appropriate. The study demonstrated that JUUL products can facilitate high rates of complete switching away from cigarettes as suggested in previous experimental and observational studies. The ADJUSST cohort, including baseline nonsmokers, demonstrates a net reduction in smoking prevalence. Moreover, population modeling considering both benefits and harms demonstrated a net population benefit. Conclusion: While the ADJUSST Study is not without limitations, the findings are consistent with multiple streams of real-world evidence that indicate that ENDS can facilitate switching among adults who smoke, and provide population benefits.
Article
OBJECTIVES Electronic nicotine delivery systems (ENDS) can reduce tobacco-related health risks for adults who smoke cigarettes (AWS) by facilitating complete switching away from cigarettes. However, little is known about ENDS use and switching among subpopulations that have been disproportionately affected by smoking. METHODS AWS (age≥21 years) were recruited following their first purchase of a JUUL Starter Kit in 2018. Participants self-reported switching (no past-30-day cigarette smoking) at 1-, 2-, 3-, 6-, 9-, 12-, 15-, 18-, 21-, and 24-month follow-ups. Percent switched and percent with substantial smoking reduction (≥50% decrease in cigarettes/day among those who continued smoking) were calculated. Analyses focused on racial/ethnic minorities, persons with low income and education levels, sexual minorities, and those with mental and physical health conditions. RESULTS Overall rates of switching away from cigarettes increased across follow-ups to 51.2% (Month-12) to 58.6% (Month-24, 87% of whom used ENDS). Among those who continued to smoke at 24 months, 45.4% reduced cigarettes/day by ≥50%. Rates of switching and substantial smoking reduction were largely similar across subgroups, with some statistically significant, but small, differences in Month-24 switching rates(e.g. education, mental/physical health conditions; switch rate range: 42~57%). CONCLUSIONS AWS demonstrated progressively increasing switching rates over two years after purchasing JUUL products. Similar trends in switching and smoking reduction were observed across populations disproportionately affected by smoking. By facilitating switching and smoking reduction, ENDS products such as JUUL may provide an opportunity to reduce smoking-related harm among some populations disproportionately affected by smoking, potentially reducing tobacco-related health disparities. IMPLICATIONS ENDS have the potential to benefit population health if they can replace cigarettes. This benefit must extend to populations disproportionately affected by smoking. In this real-world study, 59% of JUUL purchasers reported complete switching two years later (no past-30-day smoking, with most continuing to use ENDS). Further, 45% of those who continued to smoke reduced cigarette consumption by at least half. These rates of switching and smoking reduction were largely comparable across populations disproportionately affected by smoking (defined, e.g., by ethnicity and income). ENDS can serve as an effective harm reduction strategy to complement current efforts to reduce tobacco-related disparities.
Article
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Background: Electronic nicotine delivery systems (ENDS) have the potential to benefit public health if smokers completely switch from cigarettes to ENDS. Methods: A cohort of adult smokers (age ≥ 21) who purchased a JUUL Starter Kit was followed for 12 months after the initial purchase. We defined "switching" as past-30-day abstinence from smoking (even if JUUL use had stopped), and analyzed factors associated with achievement and maintenance of self-reported repeated point-prevalence switching (RPPS) at three follow-ups, i.e., no past-30-day smoking at months 6, 9, and 12. Results: RPPS was reported by 21.6% of the 12,537 evaluable smokers. Smokers with lighter smoking history and lower cigarette dependence at baseline were more likely to report RPPS. RPPS was also associated with daily use of JUUL (Month-3: OR = 2.32, 95% CI = 2.02-2.68; Month-6: OR = 1.73, 95% CI = 1.42-2.10), and with greater subjective reinforcing effects from JUUL use (assessed by the mCEQ, Month-3: OR = 1.46, 95% CI = 1.38-1.56; Month-6: OR = 1.11; 95% CI = 1.02-1.20). Even among smokers who did not meet the criteria of RPPS (i.e., who smoked at least once), 35.5% reported past 30-day point-prevalence switching on at least one follow-up, and their cigarette consumption was substantially reduced compared to baseline. Conclusions: Approximately one-fifth of adult smokers reported 30-day point-prevalence abstinence at 6, 9, and 12 months after purchasing JUUL. Greater use of JUUL and stronger subjective reinforcing effects were associated with nonsmoking, validating the potential for ENDS to substitute for smoking, with potential for positive impacts on individual and population health.
Article
Objectives Real-world evidence on exposure to harmful and potentially harmful constituents (HPHCs) and on biological effects in cigarette smokers who switch to electronic nicotine delivery systems (ENDS) can inform the health effects of switching. Aims and Methods This cross-sectional, observational study assessed adults who had smoked ≥10 cigarettes/day for ≥10 years, comparing 124 continuing cigarette smokers (Smokers) to 140 former smokers who switched to JUUL-brand ENDS exclusively for ≥6 months (Switchers). Assessments included biomarkers of exposure (BOEs) to select HPHCs, biomarkers of potential harm (BOPHs) related to smoking-related diseases, psychometric assessments of dependence on cigarettes and ENDS, respectively, and respiratory symptoms. Planned analyses compared geometric means, adjusted for demographic covariates; further analyses adjusted for additional lifestyle and smoking history covariates. Results Nicotine levels were significantly higher in Switchers (median time switched = 3 years), who were unusually heavy users of JUUL. All other BOEs, including NNAL and HPMA3 (primary endpoints), were significantly lower in Switchers than Smokers. Most BOPHs (sICAM-1 [primary], and eg, white blood cell count, MCP1, HbA1c) were significantly lower in Switchers than Smokers; HDL was significantly higher. Switchers reported significantly lower dependence on JUUL than Smokers did on cigarettes, and respiratory symptom scores were significantly lower among Switchers than Smokers. Conclusions Compared to continuing smokers, smokers who switched to JUUL had substantially lower exposures to multiple HPHCs, favorable differences in markers of inflammation, endothelial function, oxidative stress, and cardiovascular risk, and fewer respiratory symptoms. These findings suggest that switching from cigarettes to JUUL likely reduces smokers’ health risks. Implications Short-term confinement studies and randomized clinical trials demonstrate that adult smokers who switch completely to ENDS experience substantial reductions in exposure to many smoking-related toxicants. This study extends those findings to longer periods of switching to JUUL-brand ENDS (almost 3 years on average) under naturalistic use conditions in real-world settings and also found that switching to JUUL resulted in favorable differences in BOPHs more proximally related to smoking-induced disease, as well as in respiratory symptoms. Smokers who switch to ENDS reduce their exposure to toxicants, likely reducing their disease risk.
Article
Some smokers switch away from smoking using e-cigarettes, but guidelines recommend trying approved medications first. We analyzed switching in adult smokers using JUUL by their recent history of quit attempts and use of smoking cessation medications. Participants were 8511 adult (21+) established smokers (at baseline), in which 50.3% are daily smokers, in a longitudinal observational study who completed a survey 12 months after first purchasing a JUUL Starter Kit. At baseline, participants reported attempts to quit smoking in the prior year and use of pharmacotherapy (nicotine replacement therapy [NRT] or prescription medication) in their most recent attempt. The outcomes were switching (self-reported no past-30-day smoking) and 50%+ reductions in cigarette consumption. Multivariable analyses were adjusted for baseline covariates. Two thirds of the participants had made a quit attempt in the year before purchasing JUUL. Overall, 59% [58%, 60%] had switched at 12 months. Switching was more likely in those who had used NRT and who attempted quitting without medication versus those who used prescription medications or made no quit attempt. In adjusted multivariable analyses, only making a past-year quit attempt (vs. not) was associated with higher odds of switching (OR = 1.15 [1.04, 1.28]). Over 60% of dual users reduced cigarette consumption by ≥50%. These associations were largely similar in daily smokers. Twelve months after purchasing JUUL, almost all smokers reported either switching or reducing their smoking by 50%+, including those who had recently failed to quit smoking with approved pharmacotherapies. E-cigarettes provide an alternative route to abstinence from smoking for smokers with a history of cessation and cessation treatment failure.
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Background: Electronic nicotine delivery systems (ENDS) have the potential to benefit public health if smokers completely switch from cigarettes to ENDS. Methods: A cohort of adult smokers (age≥21) who purchased a JUUL Starter Kit was followed for 12 months after the initial purchase. We examined factors associated with achievement and maintenance of self-reported repeated point-prevalence switching (RPPS) at three follow-ups, i.e., no past-30-day smoking at months 6, 9, and 12. Results: RPPS was reported by 21.6% of the 12,537 evaluable smokers. Smokers with lighter baseline smoking history and lower baseline cigarette dependence were more likely to report RPPS. RPPS was also associated with patterns of and responses to JUUL use: Daily use of JUUL at month 3 (OR=2.25; 95% CI=1.96–2.60) and month 6 (OR=1.81; 95% CI=1.48–2.22) was associated with higher rates of RPPS, and as were greater subjective reinforcing effects from JUUL use (assessed by the mCEQ, month-3: OR=1.70, 95% CI=1.57–1.83; month-6: OR=1.15; 95% CI=1.06–1.25). Even among smokers who did not meet the criteria of RPPS (i.e., who smoked at least once), 35.5% reported past 30-day point-prevalence switching on at least one follow-up, and their cigarette consumption was substantially reduced compared to baseline. Conclusions: Approximately one-fifth of adult smokers reported 30-day point-prevalence abstinence at 6, 9, and 12 months after purchasing JUUL. Greater use of JUUL and stronger subjective reinforcing effects were associated with non-smoking, validating the potential for ENDS to substitute for smoking, with potential for positive impacts on individual and population health.
Article
OBJECTIVES Studies have assessed switching away from cigarettes among adult smokers who use electronic nicotine delivery systems (ENDS), but there is little data assessing differences in likelihood of switching or ENDS use characteristics by menthol smoking METHODS Adult (age≥21) established smokers who purchased a JUUL Starter Kit (N=15,036) completed baseline and 1-, 2-, 3-, 6-, 9- and 12-month assessments. Switching (no past-30-day cigarette smoking) and flavor use were assessed at each follow-up. Repeated-measure logistic regression models evaluated association of menthol smoking and switching across 1 year RESULTS Across the 6 follow-ups, more menthol smokers primarily used Menthol/Mint-flavored JUULpods (53.8%) than nonmenthol smokers (22.9%). Only 6.4% of menthol smokers primarily used Tobacco flavors (vs. 25.9% of nonmenthol smokers). Across all follow-ups menthol smokers (41.2% of sample) were more likely to switch than nonmenthol smokers (42.6% vs. 38.8%: OR[95% CI]=1.17[1.11, 1.23]); this association remained significant after adjustment for sociodemographic, smoking and JUUL use covariates (aOR[95% CI]=1.13[1.05, 1.21]). Nonmenthol smokers, but not menthol smokers, were significantly more likely to switch when primarily using Menthol/Mint-flavored (vs. Tobacco-flavored) JUULpods (aOR[95% CI]=1.14[1.04, 1.25]). Differences in baseline smoking characteristics between menthol and nonmenthol smokers were small in magnitude. CONCLUSIONS Adult menthol (vs. nonmenthol) smokers using JUUL were more likely to switch. More than twice as many menthol (vs. nonmenthol) smokers primarily used Menthol/Mint-flavor JUULpods; few menthol smokers used tobacco flavors. Given these pronounced differences in flavor preferences, availability of ENDS in menthol flavors may be particularly important for menthol smokers, but may also benefit some nonmenthol smokers.
Article
Objectives: In this study, we assessed complete switching away from cigarette smoking among adult smokers who purchased a JUUL Starter Kit (JSK). Methods: Adult (age ≥ 21) established smokers (smoked ≥ 100 lifetime cigarettes) who purchased a JSK in 2018 were invited to complete online surveys 1, 2, 3, 6, 9 and 12 months after initial JSK purchase. Point prevalence of switching (no past 30-day smoking) was assessed at each follow-up. Repeated measures logistic regression models evaluated associations of sociodemographic factors, baseline smoking characteristics and time-varying JUUL System ("JUUL") use characteristics and switching across the 12-month period. Results: Respondents (N = 17,986) were 55.0% male, 78.3% white, mean age = 32.65 years (SD = 10.81), mean baseline cigarettes/day = 11.10 (SD = 8.16). The proportion self-reporting switching increased over time: one-month (27.2%[3718/13,650]), 2-month (36.4%[4926/13,533]), 3-month (41.0%[5434/13,257]), 6-month (46.6%[5411/11,621]), 9-month (49.4%[6017/12,186]), and 12-month (51.2%[6106/11,919]); 33.1% reported switching at both 9-month and 12-month follow-ups. In prospective analyses, smokers with lower cigarette dependence, shorter smoking history, lower cigarette consumption, more frequent JUUL use, greater satisfaction from initial JUUL use, and higher JUUL dependence were significantly more likely to switch. Conclusions: Rates of switching with JUUL increased over time. Over 50% of respondents reported complete switching away from cigarettes 12 months following purchase. Greater use of and dependence on JUUL predicted switching.
Article
Objectives: Many smokers who start using ENDS engage in dual use of cigarettes and ENDS. This paper examines time trends in dual use after a JUUL Starter Kit purchase, and changes in cigarette consumption among those remaining dual users. Methods: In the ADJUSST study, a cohort of adult smokers who purchased a JUUL Starter Kit were followed naturalistically 6 times over 12 months. Trends in dual use and reported complete switching away from cigarettes (ie, no past 30-day smoking), and changes in daily average cigarettes per day from baseline at 6 and 12 months were examined. Results: Dual use declined over time as complete switching increased. By 12 months, 43.2% reported dual using, and 51.2% reported switching away from cigarettes. Among dual users, approximately 60% reduced their cigarette consumption substantially (by ≥ 50%); average reductions in cigarette consumption were > 80%. Only a small minority (3%-10%) substantially increased cigarette consumption. Conclusions: Dual use of smoking and JUUL declines over time as switching away from smoking increases. This suggests that, for most smokers, dual use is a transitional state leading to switching completely away from cigarettes. Furthermore, dual use is often marked by substantial reductions in cigarette consumption.
Article
Objective: In this study, we assessed cigarette smoking over 12 months among adult former smokers who newly purchased a JUUL Starter Kit (JSK). Methods: Prevalence of past 30-day smoking and factors associated with smoking were assessed among adult (age ≥ 21) former established smokers, stratified as recent (quitting ≤ 12 months) and long-term quitters (> 12 months), who purchased a JSK and completed ≥ 1 of 6 follow-up assessments (N = 4786). Results: Recent quitters had higher rates (16.6%-19.9%) of past 30-day smoking than long-term quitters (6.4%-9.2%) across the 12-month period; smoking prevalence did not significantly increase over time in either subgroup. Few participants (6.5% of recent quitters, 2.8% of long-term quitters) reported smoking at both 9 and 12 months, a pattern that might indicate persistent smoking. Past 30-day JUUL use remained high (≥ 87%) across the 12 months. Participants who used JUUL more frequently were less likely to smoke. Conclusions: Among former smokers who purchased JUUL, prevalence rates of smoking were low and stable across the 12-month period, suggesting there was not a growing cohort of former smokers resuming smoking. Smoking was more common in recent quitters than long-term quitters. Greater use of JUUL was associated with reduced odds of smoking resumption.
Article
Objectives: Our objective was to improve understanding of the population health impact of electronic nicotine delivery systems (ENDS) availability in the US via computational modeling. Methods: We present an agent-based population health model (PHM) that simulates annual smoking, ENDS use, and associated mortality for individual agents representing the US population, both adults and youth, between 2000 and 2100. Model transitions were derived from key population surveys and a large longitudinal study of JUUL purchasers. The mortality impact of ENDS is modeled as excess risk relative to smoking. Outcomes are compared between a cigarettes-only Base Case and a Modified Case where ENDS are introduced in 2010. Model validation demonstrates that the PHM simulates population-level behavior and outcomes realistically. Results: The availability of ENDS in the US is projected to reduce smoking and prevent 2.5 million premature deaths by 2100 in the Modified Case. Sensitivity analyses show that a significant population health benefit occurs under all plausible scenarios. Conclusions: Our results suggest the availability of ENDS is likely to result in a significant health benefit to the US population as a whole, after accounting for both beneficial and harmful uses.
Article
This special issue addresses key topics relating to the public health impact of the use of electronic nicotine delivery devices (ENDS), particularly JUUL-brand ENDS. Smokers smoke for nicotine, but are harmed by the byproducts of combustion. ENDS can play a role in tobacco harm reduction offering a noncombustible alternative source of nicotine for adult smokers who would otherwise continue smoking. Papers presented here estimate the prevalence of ENDS and JUUL use among young and older adults, and document the 12-month smoking trajectories of adults who purchased a JUUL Starter Kit. Overall, smoking prevalence was halved, with most smokers switching completely as dual use declined. This held for subpopulations defined by demographics and psychiatric comorbidity. For those who did not switch, most significantly reduced (50%+) their cigarette consumption. Another study reports that dependence declines as smokers switch from smoking to using JUUL. The public health potential of ENDS is undermined by use of ENDS by nonsmokers, especially underage individuals. Some smoking was reported by adult former and never smokers, with little evidence of persistent smoking, and lower risk of smoking among those using JUUL more frequently. Regarding underage use, one paper reports that technology can ensure age-verification at point of sale. Population modeling integrating impacts on diverse populations indicates that availability of ENDS is expected to avert millions of premature deaths in the US. We believe these papers make a substantial contribution to the field of tobacco science and smoking control.
Article
Objectives: In this study, we prospectively assessed changes in smoking a year after US adults' first-time purchase of a JUUL Starter Kit (JSK). Methods: Descriptive analyses assessed transitions in smoking status at 12 months among adult (age ≥21) JSK purchasers providing baseline and 12-month follow-up data (N = 27,164 [49.0% of baseline]), stratified by baseline smoking status. Baseline regular use of other ENDS was also considered. Results: Purchasers included baseline past 30-day smokers (65.2%), former smokers (12.0%), and never smokers (9.7%); over 90% were ever-smokers. One year later, the majority (58%) of those smoking at baseline reported no longer smoking. Former smokers or never smokers who were smoking at 12 months represented less than 2% of respondents. Former and current smokers who were regularly using other ENDS at baseline were less likely to report smoking at 12 months. Conclusions: Past 30-day smoking prevalence in a large longitudinal study of first-time JSK purchasers fell by more than half over 12 months. Analyzing the sample composition at purchase and transitions within subgroups defined by smoking status allows for a detailed understanding to help inform assessments of the population health impact of ENDS.
Article
Objectives: We assessed adult never smokers' trajectories of smoking over 12 months after a first-time JUUL Starter Kit (JSK) purchase. Methods: Adult (≥ 21) never smokers (N = 3853) who purchased a JSK were recruited into an observational naturalistic study. Analyses distinguished those who had previously used ENDS (NS+E, N = 2848) from those who had not (NS-NE, N = 1005). Participants were invited to complete follow-up assessments at 1, 2, 3, 6, 9, and 12 months. "Smoking" was defined as any past-30-day smoking ("even a puff"). Results: Past-30-day smoking was reported by 5.01% of NS+E at month one, and 7.56% at month 12; for NS-NE, these were 10.23% and 12.35%. In both groups, < 5% reported smoking at both 9 and 12 months. Across follow-ups, 25%-49% of those reporting having smoked then said they were now smoking "not at all"; the remainder reported low frequency (10-12 days-per-month) and quantity (2-4 cigarettes-per-day) of smoking. Past-30-day use of JUUL remained at ≥ 80% across follow-ups. Each additional day-per-month of JUUL use decreased the odds of smoking by 1%. Conclusions: Some adult never smokers who purchased a JSK reported smoking during the suceeding year; smoking was light and intermittent. Participants who used JUUL more frequently were less likely to smoke.
Article
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Objectives: In this study, we examined complete switching away from cigarettes across various medico-socio-demographic subpopulations of adult smokers who purchased a JUUL Starter Kit (JSK) electronic nicotine delivery system. Methods: We analyzed trajectories of smoking over 12 months in 17,986 adult smokers who purchased a JSK. Populations of special interest were characterized by race/ethnicity, income, diagnoses of potentially smoking-related illness (SRI), depression, and anxiety. Results: Across all 16 subgroups examined, a consistent pattern of trends was observed where complete switching increased, and dual-use decreased over time. Non-Hispanic Asian race/ethnicity, low income, diagnoses of potential SRI, depression, and anxiety were associated with significantly lower switching rates; however, complete switching rates at month 12 were near 50% for all groups, and surpassed the dual-use rates in all subgroups except for those with potential SRI. Conclusions: Substantial rates of complete switching were consistently achieved across all medico-socio-demographic subgroups 12 months following the purchase of the JSK. The potential benefits of switching with JUUL on smokers are likely to be experienced by a wide range of adult smokers.
Article
Objectives: In this paper, we estimate the prevalence of electronic nicotine delivery systems (ENDS) and JUUL brand ENDS use among adults in the US, overall and by smoking history. Methods: We obtained 2019 cross-sectional online surveys assessing smoking, use of any ENDS, and JUUL specifically, in a national probability sample of 11,833 US adults. Data were analyzed for young adults (YA; aged 18-24) and older adults (OA; aged 25+). Results: Past 30-day ENDS prevalence was 8.0% in YA and 4.7% in OA; equivalent JUUL figures were 3.1% and 1.2%. ENDS/JUUL use was more prevalent among current and former smokers than never smokers, where prevalence was ≤ 2% (YA: 2.0%/0.9%; OA: 0.9%/0.1%). JUUL use was higher among recent (< 1 year) quitters than among long-term (≥ 1 year) quitters. Among those who had ever used both ENDS and other tobacco, strong majorities reported using other tobacco first. Among JUUL users who also had used other tobacco ≥ 95% had used other tobacco first. Conclusions: Past-30-day ENDS use (including JUUL) was ≤ 8% among young adults and ≤ 5% in older adults. Most (> 98%) ENDS and JUUL users were current or former smokers, which is relevant to assessment of the population impact of these products.
Article
Objectives: In this study, we assessed complete switching away from cigarette smoking among adult smokers who purchased a JUUL Starter Kit (JSK). Methods: Adult (age ≥ 21) established smokers (smoked ≥ 100 lifetime cigarettes) who purchased a JSK in 2018 were invited to complete online surveys 1, 2, 3, 6, 9 and 12 months after initial JSK purchase. Point prevalence of switching (no past 30-day smoking) was assessed at each follow-up. Repeated measures logistic regression models evaluated associations of sociodemographic factors, baseline smoking characteristics and time-varying JUUL System ("JUUL") use characteristics and switching across the 12-month period. Results: Respondents (N = 17,986) were 55.0% male, 78.3% white, mean age = 32.65 years (SD = 10.81), mean baseline cigarettes/day = 11.10 (SD = 8.16). The proportion self-reporting switching increased over time: one-month (27.2%[3718/13,650]), 2-month (36.4%[4926/13,533]), 3-month (41.0%[5434/13,257]), 6-month (46.6%[5411/11,621]), 9-month (49.4%[6017/12,186]), and 12-month (51.2%[6106/11,919]); 33.1% reported switching at both 9-month and 12-month follow-ups. In prospective analyses, smokers with lower cigarette dependence, shorter smoking history, lower cigarette consumption, more frequent JUUL use, greater satisfaction from initial JUUL use, and higher JUUL dependence were significantly more likely to switch. Conclusions: Rates of switching with JUUL increased over time. Over 50% of respondents reported complete switching away from cigarettes 12 months following purchase. Greater use of and dependence on JUUL predicted switching.
Article
Objectives: Many smokers who start using ENDS engage in dual use of cigarettes and ENDS. This paper examines time trends in dual use after a JUUL Starter Kit purchase, and changes in cigarette consumption among those remaining dual users. Methods: In the ADJUSST study, a cohort of adult smokers who purchased a JUUL Starter Kit were followed naturalistically 6 times over 12 months. Trends in dual use and reported complete switching away from cigarettes (ie, no past 30-day smoking), and changes in daily average cigarettes per day from baseline at 6 and 12 months were examined. Results: Dual use declined over time as complete switching increased. By 12 months, 43.2% reported dual using, and 51.2% reported switching away from cigarettes. Among dual users, approximately 60% reduced their cigarette consumption substantially (by ≥ 50%); average reductions in cigarette consumption were > 80%. Only a small minority (3%-10%) substantially increased cigarette consumption. Conclusions: Dual use of smoking and JUUL declines over time as switching away from smoking increases. This suggests that, for most smokers, dual use is a transitional state leading to switching completely away from cigarettes. Furthermore, dual use is often marked by substantial reductions in cigarette consumption.
Article
Objective: In this study, we assessed cigarette smoking over 12 months among adult former smokers who newly purchased a JUUL Starter Kit (JSK). Methods: Prevalence of past 30-day smoking and factors associated with smoking were assessed among adult (age ≥ 21) former established smokers, stratified as recent (quitting ≤ 12 months) and long-term quitters (> 12 months), who purchased a JSK and completed ≥ 1 of 6 follow-up assessments (N = 4786). Results: Recent quitters had higher rates (16.6%-19.9%) of past 30-day smoking than long-term quitters (6.4%-9.2%) across the 12-month period; smoking prevalence did not significantly increase over time in either subgroup. Few participants (6.5% of recent quitters, 2.8% of long-term quitters) reported smoking at both 9 and 12 months, a pattern that might indicate persistent smoking. Past 30-day JUUL use remained high (≥ 87%) across the 12 months. Participants who used JUUL more frequently were less likely to smoke. Conclusions: Among former smokers who purchased JUUL, prevalence rates of smoking were low and stable across the 12-month period, suggesting there was not a growing cohort of former smokers resuming smoking. Smoking was more common in recent quitters than long-term quitters. Greater use of JUUL was associated with reduced odds of smoking resumption.
Article
Objectives: In this study, we prospectively assessed changes in smoking a year after US adults' first-time purchase of a JUUL Starter Kit (JSK). Methods: Descriptive analyses assessed transitions in smoking status at 12 months among adult (age ≥21) JSK purchasers providing baseline and 12-month follow-up data (N = 27,164 [49.0% of baseline]), stratified by baseline smoking status. Baseline regular use of other ENDS was also considered. Results: Purchasers included baseline past 30-day smokers (65.2%), former smokers (12.0%), and never smokers (9.7%); over 90% were ever-smokers. One year later, the majority (58%) of those smoking at baseline reported no longer smoking. Former smokers or never smokers who were smoking at 12 months represented less than 2% of respondents. Former and current smokers who were regularly using other ENDS at baseline were less likely to report smoking at 12 months. Conclusions: Past 30-day smoking prevalence in a large longitudinal study of first-time JSK purchasers fell by more than half over 12 months. Analyzing the sample composition at purchase and transitions within subgroups defined by smoking status allows for a detailed understanding to help inform assessments of the population health impact of ENDS.
Article
Objectives: We assessed adult never smokers' trajectories of smoking over 12 months after a first-time JUUL Starter Kit (JSK) purchase. Methods: Adult (≥ 21) never smokers (N = 3853) who purchased a JSK were recruited into an observational naturalistic study. Analyses distinguished those who had previously used ENDS (NS+E, N = 2848) from those who had not (NS-NE, N = 1005). Participants were invited to complete follow-up assessments at 1, 2, 3, 6, 9, and 12 months. "Smoking" was defined as any past-30-day smoking ("even a puff"). Results: Past-30-day smoking was reported by 5.01% of NS+E at month one, and 7.56% at month 12; for NS-NE, these were 10.23% and 12.35%. In both groups, < 5% reported smoking at both 9 and 12 months. Across follow-ups, 25%-49% of those reporting having smoked then said they were now smoking "not at all"; the remainder reported low frequency (10-12 days-per-month) and quantity (2-4 cigarettes-per-day) of smoking. Past-30-day use of JUUL remained at ≥ 80% across follow-ups. Each additional day-per-month of JUUL use decreased the odds of smoking by 1%. Conclusions: Some adult never smokers who purchased a JSK reported smoking during the suceeding year; smoking was light and intermittent. Participants who used JUUL more frequently were less likely to smoke.
Article
Background: Understanding the population impact of e-cigarettes requires determining their effect on cigarette smoking cessation. Methods: Using the U.S. Population Assessment of Tobacco and Health (PATH) cohort, we examined smoking cessation among adult current cigarette smokers at Wave 1 with follow-up data at Waves 2 and 3 (n=9,724). Results: By Wave 3 (2015/2016), 17.3% of smokers had quit smoking. Smokers using e-cigarettes daily or who increased to daily use over the 3 waves were 2-4 times more likely to have quit in the short (<1 year) and long-term (1+ years) compared with never e-cigarette users (p<0.001). E-cigarette use in the last quit attempt was associated with a higher likelihood of short-term (<1 year) quitting at Wave 3 (aRRR:1.33; 95% CI:1.04,1.71) compared with smokers who did not use an e-cigarette in their last quit attempt. Non-current (no use in any wave) e-cigarette users and users who were unstable in use frequency were 33% and 47% less likely to quit in the short-term, respectively (p<0.001). Flavored (vs. non-flavored) and using a rechargeable (vs. disposable) e-cigarette device was associated with an increased likelihood of both short- and long-term quitting. Conclusion: Smoking cessation was more likely among frequent e-cigarette users, users of e-cigarettes in last quit attempt, and users of flavored and rechargeable devices. Less frequent, unstable, past or never e-cigarette users were less likely to quit smoking. Monitoring the relationship between patterns of e-cigarette and cigarette use is complex but critical for gauging the potential of e-cigarettes as a harm reduction tool. Implications: This study suggests that consistent and frequent e-cigarette use over time is associated with cigarette smoking cessation among adults in the US. In addition, findings suggest that flavored e-cigarette use and use of rechargeable e-cigarette devices can facilitate smoking cessation. These results underscore the importance of carefully defining and characterizing e-cigarette exposure patterns, potential confounders, and use of e-cigarettes to quit smoking, as well as variations in length of the smoking cessation.