Youth Perceptions of Juul in the United States

Abstract

This mixed-methods cohort study uses responses to text-messaged, open-ended questions to examine US youths’ perceptions of Juul e-cigarettes.

The use of e-cigarettes among youths has reached epidemic proportions in the United States.¹ Juul is the most popular brand of e-cigarettes among youth, and it has been criticized for marketing that targets youths.² Concerns of serious short-term and long-term health outcomes from e-cigarette use have led to actions from the US Food and Drug Administration, states, and municipalities to ban or restrict the sale of e-cigarettes.^3,4 For policies to be effective in curtailing the use of Juul among youth, there must be a greater understanding of youths’ knowledge, beliefs, and motivations regarding this product. This study assesses the perspectives of a national sample of youths on the use of Juul (also known as juuling).

Methods

Respondents are part of the National MyVoice Cohort⁵ of youths aged 14 to 24 years. Youths were recruited on a rolling basis to match national demographic benchmarks, including age, sex, race/ethnicity, education, and region of the country, based on weighted samples from the American Community Survey. Online consent was obtained from participants prior to participation. This study was approved by the University of Michigan institutional review board, including a waiver of parental consent for minor participants. Demographic information was self-reported during online enrollment.

From January 25, 2019, to February 1, 2019, participants were sent 4 questions via text message about the e-cigarette brand Juul:

1. Have you ever heard of Juul?

2. Why do you think people your age juul?

3. Do you think juuling is dangerous? Why or why not?

4. Do you think juuling leads to using alcohol, cigarettes, or other drugs? Why or why not?

Open-ended responses were analyzed and coded independently by 2 investigators (G.G.W. and A.C.B.) using a modified grounded theory approach. Discrepancies were resolved by a third investigator (M.E.W.). Responses were coded in Excel version 16 (Microsoft), and SAS version 9.4 (SAS Institute) was used to calculate summary statistics.

Results

Among 1215 MyVoice participants, 1129 responded to the survey (a response rate of 92.9%). The demographic characteristics of these respondents are shown in Table 1. In brief, respondents were mostly female (n = 633 [56.3%]), with a mean (SD) age of 18.8 (2.9) years.

Table 1. Demographic Characteristics of the Study Sample.

Characteristic	Respondents, No. (%)
Age
No. of respondents	1129
Mean (SD), y	18.8 (2.9)
14-17 y	484 (42.9)
18-24 y	645 (57.1)
Sex
No. of respondents	1124
Male	409 (36.4)
Female	633 (56.3)
Other	82 (7.3)
Race/ethnicity
No. of respondents	1127a
Non-Hispanic
White	653 (57.9)
Black	102 (9.1)
Hispanic	151 (13.4)
Non-Hispanic other	221 (19.6)
Education
No. of respondents	1129
High school or less	695 (61.5)
Some college or technical school	282 (25)
College or technical school graduate	152 (13.4)
Free/reduced lunch eligibility
No. of respondents	1115a
Yes	392 (35.2)
No	723 (64.8)
Region
No. of respondents	1118a
Midwest	491 (43.9)
South	297 (26.6)
West	186 (16.6)
Northeast	144 (12.9)

^aSome participants did not provide all demographic information.

Table 2 summarizes major themes, with representative quotes by question and age group. Most youths in the sample (88%) had heard of Juul. Social reasons (eg, “Because it's trendy and cool!”) were the most commonly reported reason for why youths juul (62%), while only 5% of youths mentioned flavors as a driver of use. A large proportion of youths (79%) believed that juuling is dangerous (eg, “It's dangerous. You're breathing chemicals into your lungs, addictive ones too”) and that it leads to other substance use (72%), with cigarette use cited most commonly.

Table 2. Questions, Themes, Responses, and Representative Quotes.

Question/theme	No. (%)a			Representative quote
	All	Age, y
		14-17	18-24
Have you ever heard of Juul?
Yes	979 (87.6)	445 (92.5)	534 (83.8)	“who hasn't?”
No	137 (12.3)	36 (7.5)	101 (15.9)	“Nope. Never heard of it”
Why do you think people your age juul?
Social reasons	658 (62.2)	307 (67.9)	351 (57.9)	“I think it's a social experience. It's part of being in a club”
				“…peer pressure. If your friends juul then you juul”
As an alternative to other substances	206 (19.5)	46 (10.2)	160 (26.4)	“…it's helped me quit smoking after 5 years”
				“…think it's a healthier alternative to smoking/vaping.”
Feels good/gives a buzz	176 (16.6)	88 (19.5)	88 (14.5)	“To get a high or for fun.”
Addiction	107 (10.1)	52 (11.5)	55 (9.1)	“because they tried it and now are hooked…”
A belief it is harmless	96 (9.1)	31 (6.9)	65 (10.7)	“…they thinks it's cool and that it has no harmful effects”
Flavors	50 (4.7)	22 (4.9)	28 (4.6)	“it's a trend now because of new fruity flavors…”
Do you think juuling is dangerous? Why or why not?
Yes	826 (78.7)	362 (81.2)	464 (77.0)
Nicotine content	339 (41.0)	155 (42.8)	184 (39.7)	“Yes- nicotine is very harmful to the body…”
				“yes…one Juul pod has enough nicotine for 20 cigarettes”
Affects physical health	298 (36.1)	138 (38.1)	160 (34.5)	“Yes, it causes COPD, lung cancer and popcorn lung”
				“yes because it has harmful cancer causing chemicals”
Addiction	278 (33.7)	135 (37.3)	143 (30.8)	“I think it's dangerous because it becomes an addiction”
No	66 (6.3)	29 (6.5)	37 (6.1)
Better than cigarettes	24 (36.4)	9 (31.0)	15 (40.5)	“No Because it safer than cigs”
Maybe	71 (6.8)	38 (8.5)	33 (5.5)
Understudied	14 (19.7)	6 (15.8)	8 (24.2)	“I can't really be sure. There's not much research”
Better than cigarettes	14 (19.7)	9 (23.7)	5 (15.2)	“Than what? I think it is less dangerous than smoking”
Do you think juuling leads to using alcohol, cigarettes, or other drugs? Why or why not?
Yes	727 (71.7)	318 (74.8)	409 (69.4)
Cigarettes	257 (35.4)	94 (29.6)	163 (39.9)	“Cigarettes bc nicotine is addictive”
Addictive behaviors	182 (25.0)	85 (26.7)	97 (23.7)	“Yes, people will try riskier and riskier things.”
No	234 (23.1)	92 (21.7)	142 (24.1)
Not associated	63 (26.9)	28 (30.4)	35 (24.7)	“no, all of those are a choice. I don't think they're related.”
Already more likely	58 (24.8)	18 (19.6)	40 (28.2)	“No because…people are already doing those things”

Abbreviation: COPD, chronic obstructive pulmonary disease.

^aCategory percentages may not add to 100% because codes are not mutually exclusive, and only major codes are represented.

Discussion

Our findings indicate that social influences, such as fitting into a peer group or experimentation, are an important factor in Juul use among youths. Policies designed to reduce e-cigarette use among youths will likely need to address these social drivers and youths’ age-appropriate interests in experimenting with substances that may give them a buzz or make them feel cool. Existing policies designed to limit use of e-cigarettes by youths that focus on restricting the sale of flavored products may be insufficient in overcoming these social influences.⁶

Despite a common belief among MyVoice youths that juuling may be dangerous and may serve as a gateway to other substances, rates of Juul use continue to rise.¹ These beliefs suggest that campaigns and educational programs focused on the dangers of juuling alone may not be effective in reducing this health epidemic. This study was unable to examine differences in opinions among users and nonusers of Juul and purposefully did not ask participants to disclose personal Juul usage, to protect confidentiality and minimize social desirability bias. However, firsthand experience with Juul may influence a participant’s knowledge and beliefs of the product and bias their responses. Future campaigns should acknowledge and tackle the social realities of youths today to effectively address the underlying reasons why youths use e-cigarettes despite perceived risks.