Differences in JUUL Appeal Among Past and Current Youth JUUL Users

Abstract

Introduction

JUUL, a closed system e-cigarette with disposable pods, is popular among youth, with positive attributes of this product linked to current use by youth. However, many youth try JUUL and do not continue using; understanding differences in the appeal of this device between current users and those who chose not to continue use can inform regulation and prevention efforts. The aim of the current study is to compare JUUL appeal in youth among past users (ie, used, but not in past month) and current users (ie, used in past month).

Methods

A cross-sectional survey was conducted in four Connecticut high schools in Spring 2018. This survey assessed JUUL use and reasons for liking/disliking JUUL, including its' pharmacological effects (eg, nicotine “buzz”), product characteristics (eg, flavors), peer influence, appeal compared to other e-cigarettes, and concealability. Logistic regressions were conducted to examine differences in liking/disliking JUUL by use status (past vs. current).

Results

Among JUUL users (N = 1374; 43% of total sample), 30.4% were past users and 69.6% were current users. Compared to current users, past users were less likely to like JUUL for positive pharmacological effects (eg, nicotine “buzz”), product characteristics (eg, flavors), and peer use and more likely to dislike JUUL for the adverse pharmacological effects (eg, headache), product characteristics (eg, flavors), and for “other” reasons (open-ended response; eg, perceived harm).

Conclusions

Findings suggest that altering JUUL appeal through regulating nicotine content and flavors may be key in policy aimed at shifting youth to become past JUUL users.

Implications

This study investigates how current and past youth JUUL users differ in their report of the appeal of JUUL. Past users are less likely to report experiencing positive pharmacological effects and product characteristics of JUUL and are less likely to report appeal due to peer use. Understanding how appeal of JUUL may differ among past and current users can aid in our understanding of how to regulate these products so that they are less appealing to current youth users.

Introduction

E-cigarette use among adolescents in the United States is at an all-time high. National data showed that 27.5% of youth reported current e-cigarette use in 2019, a significant increase from 20.8% in 2018 and 11.7% in 2017.¹ This rapid increase in e-cigarette use over the past several years is attributable to the increased prevalence of pod-type e-cigarettes, most notably, JUUL.² JUUL is a rechargeable, closed-system e-cigarette that uses disposable pods containing flavored e-liquids with high concentrations of nicotine salt (initially available at 5% nicotine concentration; a 3% concentration was introduced in August 2018). Compared to other e-cigarettes, 5% nicotine strength JUUL contains a higher nicotine concentration resulting in faster nicotine delivery and a pharmacokinetic profile similar to combustible cigarettes.³ The most recent publicly available data on JUUL sales indicate that JUUL comprised almost three-quarters of the market share of U.S. e-cigarettes in August 2018—a dramatic increase from 13.6% in the first quarter of 2017.⁴ Many devices have been developed to mirror the pharmacological profile of JUUL using nicotine salt with similar or higher nicotine strengths.⁵

JUUL has higher rates of use among youth compared to adults,⁶ and there are concerns that JUUL may be specifically appealing to youth as a function of its sleek design, appealing flavors, and the ease with which it can be concealed.^2,7 A recent examination of current youth JUUL users supports these concerns and also suggests that JUUL may be appealing to youth because of its' high nicotine levels.⁸ Current youth JUUL users in this study reported liking the “buzz” from JUUL, the increased ability to concentrate, the nicotine level of the device, the available flavors, and the ease with which the device can be concealed. Notably, liking the “buzz,” increased ability to concentrate, and concealability all were associated with increased frequency of past month use among current users.⁸

In prior examinations of reasons for e-cigarette use among youth e-cigarette users, flavors, concealability relative to other products, and peer use were all predictors of future use.⁹ This was conducted prior to JUUL's availability and subsequent rapid rise to dominance of the e-cigarette marketplace. Existing research on JUUL compares ever youth users to other e-cigarette device users,² examines flavor use among current youth users¹⁰ and association between appeal and frequency of JUUL use among current youth users.⁸ Little is known about the appeal (or lack thereof) of JUUL for youth that has tried JUUL but is not current (ie, past-month) users. For example, does JUUL use not persist among this group because the product is not reinforcing, its flavors are not appealing, or the product cost is prohibitive? Or, do past and current JUUL users, both find flavor selection similarly appealing suggesting that flavors may not be the feature that sustains use? Understanding similarities and differences in appeal among past and current JUUL users has important implications regarding who may be at risk for continued use, what features of JUUL are associated with current use and what features are associated with past youth, and how JUUL could be regulated to reduce its appeal with the aim of reducing current use of this product among youth. Prior work by our group examined reasons for JUUL appeal and associations with frequency of use among current JUUL users.⁸ To extend this, the aim of the current study is to compare reasons for appeal and dislike of JUUL among current and past JUUL users to distinguish what features of JUUL are either positively or negatively associated with past use.

To address this question, we utilized school wide survey data from high school students to compare the reported appeal between youth who tried JUUL in their lifetime but do not report currently using JUUL (ie, past users) and current (ie, past month) JUUL users. We hypothesize that past JUUL users will report greater endorsement of reasons for disliking JUUL and lower endorsement of reasons for liking JUUL compared to current users.

Method

Procedures

Twenty-minute, anonymous, computerized surveys assessing tobacco product use were conducted in four high schools (grades 9–12) in Connecticut (May–October 2018). This survey was one in a series of longitudinal surveys assessing tobacco use among youth in a cohort of schools and the first survey in this series to specifically address JUUL use. Initial survey content was developed based on focus groups conducted with middle and high school youth and each wave of the survey is updated by content experts to adapt questions based on concepts identified in earlier surveys and introduce questions based on the changing marketplace for new and emerging tobacco products. Details of survey administration have been reported previously,⁸ but briefly schools were from distinct District Reference Groups, school groupings based on socioeconomic status. Students were informed participation was voluntary and anonymous. Survey completion was considered assent/consent. Students received a stylus for participating. The research was approved by the Yale Institutional Review Board and participating schools.

Participants

3170 students (52.4% female, mean age 15.9 [SD = 1.29], 60.4% Non-Hispanic (NH) white) who attended school on the days of the survey administration completed the survey (response rate: 85.0%).

Measures

Demographics

We assessed sex (female, male), age, and race (coded as NH white, NH black, Hispanic, NH Multi-race, and NH Other Race).

JUUL Use

Adolescents viewed a picture of a JUUL device and JUUL pods aside a product description (ie, “rechargeable with USB charger; has pods that insert in device”) and were asked if they had ever tried the device (no/yes). Adolescents who answered “no” were coded as “never users.” Adolescents who answered “yes” were classified as “lifetime users” and asked, “Approximately how many days out of the past 30 days did you use a JUUL?” (0–30 days). JUUL lifetime users were classified as “current users” if they used JUUL on ≥1 day/past month and classified as “past users” if they used JUUL on 0 days/past month. This definition of current use is consistent with other reporting on youth e-cigarette use.^1,8,11 All JUUL users were queried about JUUL flavors they had ever tried (ie, mango, cool mint, fruit medley, cool cucumber, crème brulee, classic menthol, classic tobacco, and Virginia tobacco).

Reasons for Liking/Disliking JUUL

All JUUL users were asked, “What do you like about using a JUUL? (Select all that apply).” Response options were grouped into six constructs: (1) positive pharmacological effects (ie, “It gives me a buzz,” “It helps me concentrate,” “It gives me energy,” “It helps me control my appetite,” and “It helps me lose weight”); (2) positive product characteristics (ie, “I like the flavors,” “I like the size of the JUUL,” “I like the nicotine level,” “It is easy to change pods,” and “I like the shape of the JUUL”); (3) peer influence (ie, “My friends use it”); (4) comparison to other e-cigarettes (ie, “I believe that it's less harmful than other e-cigarettes,” and “I like that it produces less vapor than other e-cigs”); (5) concealability (ie, “It is easy to hide from my parents,” “It is easy to hide from my teachers”); and (6) “other” (with the option to write in an open-ended response). Respondents did not have to select any of the response options if they desired.

All JUUL users were asked, “What do you dislike about using a JUUL? (Select all that apply)” Response options were grouped into five constructs⁸; (1) adverse pharmacological effects (ie, “It gives me a headache,” “It makes me jittery or shaky,” and “The headrush is too strong”); (2) negative product characteristics (ie, “The pods are expensive,” “Nicotine is too high,” “I don't like the flavors,” and “There aren't many flavor options”); (3) peer influence (ie, “My friends don't use it”); (4) “none of the above”; and (5) “other” (with the option to write in a response).

For both items, “Other” open-ended responses were removed if they did not address a reason for either liking/disliking (eg, “I just tried it”). “Other” responses for either item were recoded if (a) the open-ended response indicated the opposite of the item (eg, a response of “I don't like it” reported for the “Liking” item) and (b) there was not already a response in the corresponding “Other” category.

Current Use of Other E-Cigarette Devices

Students also were asked “Approximately how many days out of the past 30 days did you use an [e-cigarette device]?” Separate questions assessed use of various e-cigarette devices including, disposable e-cigarettes, cig-a-likes, e-hookah, vape pen, pod system other than JUUL, and mods/advanced personal vaporizers. A picture and a brief description accompanied each device type. Students reporting any past month use were coded as currently using other e-cigarette devices.

Current Use of Non-E-Cigarette Tobacco Products

Students were asked “Approximately how many days out of the past 30 days did you use a [tobacco product]?” Separate questions assessed use of cigarettes, cigarillos, smokeless tobacco, hookah, and blunts, and questions included a picture and a brief description of each product. Students reporting past-30-day use of any of these products were coded as currently using other tobacco products.

Data Analysis

Chi-square tests and independent samples t tests were used to examine unadjusted differences between past and current JUUL users on demographic variables (age, sex, and race), current tobacco use, current other e-cigarette use, JUUL flavors used, total number of reasons for liking or disliking JUUL, and differences in the proportion of respondents endorsing each reason for liking/disliking JUUL.

Two logistic regressions were conducted to analyze the reasons for liking JUUL and reasons for disliking JUUL, respectively, as predictors of the likelihood of being a past JUUL user (compared to a current JUUL user). Both models adjusted for covariates including school, demographic factors (ie, sex, race [white vs. Non-white], age), current use of other tobacco products, and current use of other e-cigarettes. Reasons for liking/disliking JUUL were entered into the models as constructs (e.g., pharmacological effects, product characteristics, peer influence, comparison to other e-cigarettes [liking only], concealability [liking only], “other,”).⁸ Responses indicating “None of the Above” were not included in the disliking JUUL regression model as our study aim was to evaluate how reasons for disliking JUUL were associated with use status. Scores for each construct were calculated by averaging the endorsement of the “liking” or “disliking” the items comprising each construct.⁷ Constructs rather than individual items were entered to reduce variance inflation error of the independent variables. If any one construct was statistically significant (p ≤ .05) within a model, we conducted follow up adjusted logistic regression analyses to examine the individual items within each construct to identify which items in each construct may be driving the observed effects. All analyses were run using SPSS (version 26, IBM).

Results

Demographics

43.3% of the total sample reported lifetime use of JUUL. Of survey respondents who reported lifetime use of JUUL (n = 1374), 69.6% (n = 956) were current JUUL users and 30.4% (n = 418) were past users. Past JUUL users were more likely to be younger and non-users of tobacco products and other e-cigarette devices in the past 30 days (Table 1). Past users reported a lower average number of JUUL flavors tried and were less likely than current JUUL users to have tried each of the available JUUL flavors. Current JUUL users reported a mean of 13.6 (11.7) days of use in the past 30 days.

Table 1.

Demographic and Tobacco Product Use Characteristics

Characteristics	Past JUUL users (30.4%; n = 418)	Current JUUL users (69.6%; n = 956)
Female (%)	51.7	53.0
Race (%)
Non-Hispanic white	62.4	68.1
Hispanic	19.6	15.7
Non-Hispanic multi-race	10.0	9.5
Non-Hispanic black	6.0	3.7
Non-Hispanic other race	1.9	3.0
Age (M, SD)	15.9, 1.3	16.2, 1.3
# days/past 30 days JUUL use (M, SD)	N/A	13.6 (11.7)
Past-30-day use of other tobacco products (%)a	16.9	47.6
Cigarette	2.2%	10.9%
Cigarillo or little cigar	0.7%	7.0%
Large cigar	1.4%	5.1%
Blunt	15.3%	39.6%
Hookah	2.4%	5.2%
Smokeless tobacco	0.7%	3.3%
Past 30 day use of other e-cigarettes (%)b	16.0	67.1
Disposables, cig-a-like, e-hookah	4.3%	16.4%
Vape pen	9.8%	33.7%
Non-JUUL pod system	6.5%	49.0%
Mods or advanced personal vaporizers	6.0%	23.6%
Total number of JUUL flavors tried (M, SD)	2.6, 1.9	4.6, 2.4
JUUL flavors ever tried (%)
Mango	50.7	79.8
Cool mint	50.7	78.2
Fruit medley	28.0	62.8
Cool cucumber	22.2	61.2
Crème brulee	18.4	47.1
Classic menthol	9.8	34.7
Classic tobacco	6.9	29.7
Virginia tobacco	7.4	24.4
Don't know	22.5	7.8

Bolding indicates statistical difference (p < .05) between past users and current users. Current use is defined as using JUUL ≥ 1 days in the past 30 days and past use is defined as lifetime JUUL use, but no reported use in the past 30 days.

^aIndicates past 30 day use of cigarettes, little cigars or cigarillos, large cigars, blunt, hookah, or smokeless tobacco. Past month use of each individual product is listed below overall value.

^bIndicates past 30 day use of any e-cigarette device other than JUUL including disposables, cig-a-likes, and e-hookahs, vape pen or EGOs, non-JUUL pod systems, and mods or advanced personal vaporizers. Past month use of each individual product is listed below overall value.

Reasons for Liking and Disliking JUUL Among Past and Current Users

On average, past JUUL users reported 1.6 (SD: 1.9) total reasons for liking JUUL, significantly less (p < .001) than the average 3.3 (SD: 3.1) reasons reported by current JUUL users. There was no difference in total number of reasons for disliking JUUL between these groups with non-current users reporting 1.6 (SD: 1.7) and current users reporting 1.5 (SD: 1.3).

Top reasons for liking JUUL among past users were (1) “My friends use it” (29.4%), (2) “I like the flavors” (24.2%), and (3) “It gives me a buzz (21.5%). Notably, top reasons for liking JUUL were the same for current as non-current JUUL users, but past users had significantly lower endorsement of the items (Figure 1). Top reasons for disliking JUUL among past users were (1) “The pods are too expensive” (35.2%), (2) “The nicotine is too high” (27.0%), and (3) “It gives me a headache” (27.3%). Top reasons for disliking JUUL among current users were the same, but rates of endorsement significantly differed with current users having higher endorsement of “The pods are too expensive” and lower endorsement of “The nicotine is too high” and “It gives me a headache” (Figure 2).

Figure 1.

Reasons for liking JUUL among past and current youth JUUL users.Note: Asterisks (*) indicates significant differences (p< .05) between current and past JUUL users in response rate for each item.

Figure 2.

Reasons for disliking JUUL among past and current youth JUUL users.Note: Asterisks (*) indicates significant differences (p < .05) between current and past JUUL users in response rate for each item.

Past users had lower endorsement of most reasons for liking JUUL compared to current users. However, both groups had similar rates of endorsing liking JUUL because “It helps me lose weight,” “I believe it is less harmful than other e-cigarettes,” “My friends use it,” and “Other” (ie, open-ended) (Figure 1). In contrast, past users more frequently endorsed many reasons for disliking JUUL compared to current users with the exception of the following item: (1) “It makes me jittery or shaky” in which there was no difference between current and past users and the two items: (1) “The pods are expensive” and (2) “There aren't many flavor options” in which current users had significantly more endorsement than past users. (Figure 2).

Association Between Reasons for Liking/Disliking JUUL and Past Use

To understand the contribution of liking/disliking JUUL and the impact on use, logistic regressions were used to examine the association of liking/disliking and likelihood of being a past user with current use was set as the reference group. For reasons for liking JUUL, adjusted findings demonstrate that the response constructs: (1) positive pharmacological effects, (2) positive product characteristics, and (3) peer influence were associated with lower odds of being a past user (ps < .05). Follow up, adjusted regression models including the individual items from these constructs indicated that individual items, “It gives me a buzz” (ie, positive pharmacological effect), “It helps me concentrate” (ie, positive pharmacological effect), “I like the flavors” (ie, positive product characteristic), and “My friends use it” (ie, peer influence) were associated with lower odds of being a past user (Table 2).

Table 2.

Logistic Regressions Examining Differences in Reasons for Liking JUUL by JUUL Use Status (Past vs. Current Use)

Model including constructs (ref. current JUUL use)
Independent variables	AOR	95% CI		p-value
Female (ref. male)	1.53	1.13	2.06	.01
Age	0.94	0.83	1.06	.31
White (ref. non-white)	1.56	1.05	2.32	.03
Current non-e-cigarette tobacco use	0.55	0.38	0.80	.002
Current e-cigarette use (Other than JUUL)	0.13	0.09	0.18	<.001
Positive pharmacological effects (construct)	0.34	0.13	0.88	.03
Positive product characteristics (construct)	0.21	0.09	0.50	.001
Comparison to other e-cigarettes (construct)	0.95	0.46	1.95	.89
Concealability (construct)	1.19	0.62	2.30	.60
Peer Influence (construct)	0.70	0.51	0.95	.02
Other (construct)	0.69	0.29	1.64	.40
Post-hoc models to evaluate individual items from significant constructs (ref. current JUUL use)
Independent variables	AOR	95%CI		p-value
Model 1: Construct: Positive pharmacological characteristics
“It gives me energy”	1.53	0.87	2.70	.14
“It gives me a buzz”	0.46	0.33	0.63	<.001
“It helps me concentrate”	0.53	0.32	0.90	.02
“It helps me to lose weight”	1.70	0.63	4.58	.30
“It helps me control my appetite”	0.72	0.34	1.52	.39
Model 2: Construct: Positive product characteristics
“I like the shape of the JUUL”	1.07	0.51	2.21	.86
“I like the size of the JUUL”	0.54	0.28	1.04	.07
“I like the flavors”	0.69	0.49	0.95	.03
“I like the nicotine level”	0.65	0.32	1.32	.23
“It is easy to change pods”	0.70	0.39	1.27	.24
Model 3: Construct: Peer influence
“My friends use it”	0.66	0.49	0.89	.01

AOR = adjusted odds ratio.

Bolding indicates significant values (p < .05). For all models, all independent variables were entered into the multinomial logistic regression model simultaneously. Across all models, sex, race, age, use of non-e-cigarette other tobacco products, use of other e-cigarettes, and school (not shown) were included as covariates. Covariates did not differ across models, so values from the initial model are included to demonstrate directionality and significance.

When examining what reasons endorsed for disliking JUUL were associated with being a past JUUL user with current use as the reference group, adjusted findings show that the response categories: (1) adverse pharmacological effects and (2) the open-ended response category “Other” was associated with higher odds of being a past user and the response category negative product characteristics were associated with lower odds of being a past user. Follow up, adjusted regression models including the individual items from each construct indicated that individual items, “It gives me a headache” (ie, adverse pharmacological effect), “I don't like the flavors” (i.e. negative product characteristics) was associated with higher odds of past use, while “The pods are expensive” (ie, negative product characteristics) was associated with lower odds of past use (Table 3). In other words, past users were more likely to report headache, dislike of flavors, and “other” as reasons for disliking JUUL, but less likely than current users to report disliking the price of pods. Responses that comprised the open-ended “Other” option varied, but repeated themes seen in open-ended responses included disliking JUUL because it is perceived as harmful to health (eg, “It is bad for you”; “Its unhealthy”) and disliking JUUL because of negative physical feelings (e.g. “It gives me a cough” and “It gives me a stomachache”).

Table 3.

Logistic Regressions Examining Differences in Reasons for Disliking JUUL by JUUL use Status (Past vs. Current Use)

Model including constructs (ref. current JUUL use)
Independent variables	AOR	95% CI		p-value
Female (ref. male)	1.49	1.12	1.98	.01
Age	0.96	0.86	1.08	.62
White (ref. non-white)	1.72	1.18	2.51	.04
Current non-e-cigarette tobacco use	0.51	0.36	0.73	<.001
Current e-cigarette use (other than JUUL)	0.12	0.09	0.17	<.001
Adverse pharmacological effects (construct)	2.60	1.49	4.56	.001
Negative product characteristics (construct)	0.49	0.27	0.89	.02
Peer influence (construct)	1.87	0.84	4.18	.013
Other (construct)	2.63	1.56	4.45	<.001
Post-hoc models to evaluate individual items from significant constructs (ref. current JUUL use)
Independent variables	AOR	95% CI		p-value
Model 1: Construct: Adverse pharmacological characteristics
“The nicotine is too high”	0.95	0.68	1.34	.77
“It gives me a headache”	1.48	1.03	2.13	.04
“It makes me jittery or shaky”	1.08	0.65	1.78	.77
“The head rush is too strong”	1.46	0.88	2.43	.15
Model 2: Construct: Negative product characteristics
“The pods are expensive”	0.61	0.46	0.82	.001
“I don't like the flavors”	1.81	1.08	3.05	.03
“There aren't many flavor options”	0.89	0.58	1.38	.060

AOR = adjusted odds ratio.

Bolding indicates significant values (p < .05). For all models, all independent variables were entered into the multinomial logistic regression model simultaneously. Across all models, sex, race, age, use of non-e-cigarette other tobacco products, use of other e-cigarettes, and school (not shown) were included as covariates. Covariates did not differ across models, so values from the initial model are included to demonstrate directionality and significance.

Discussion

This study examined how JUUL appeal differs among past and current youth users. As hypothesized, when compared with current users, past users endorsed a lower number of reasons for liking JUUL, had significantly lower endorsement of most reasons for liking JUUL, and significantly higher endorsement of most reasons for disliking JUUL, suggesting that past users, had a more negative experience of JUUL. Adjusting for race, age, and sex, we observed that liking the positive pharmacological and product characteristics of JUUL and reporting liking JUUL because friends use it was associated with lower odds of being a past user, suggesting past users are less likely to endorse these aspects of JUUL appeal. Regarding reasons for disliking JUUL, reporting adverse pharmacological characteristics and reporting an “other” reason was associated with higher odds of being a past user.

These findings suggest that past users experienced less positive pharmacological and product characteristics of JUUL than current users and more negative effects. Regarding pharmacological characteristics, when examining individual items, past use was associated with lower odds of liking the “buzz” and how it improves concentration, and higher odds of disliking how it gives a headache. Past users may experience less positive pharmacological characteristics of JUUL (eg, “buzz”), but more adverse pharmacological characteristics associated with nicotine use (eg, headache) and therefore do not continue to use. This explanation is well-supported in the tobacco literature, which suggests that pleasant experiences in response to early experimentation with cigarette smoking, specifically nicotine “buzz,” plays a strong role in the transition to regular cigarette smoking^12–14 and, generally, positive initial experience with tobacco products are predictive of recent tobacco use.¹⁵ Preclinical studies suggest that adolescents are particularly sensitive to the neuronal effects of nicotine, and that the balance between the rewarding and aversive effects of nicotine may underlie their enhanced sensitivity to nicotine addiction.¹⁶ Further, there are well-established genetic differences to the appetitive effects of nicotine,^17,18 which could also be partially responsible for differences in responses to nicotine levels in JUUL among past and current youth users; future studies need to examine these possibilities.

Our evidence suggests that reducing nicotine content to reduce nicotine “buzz” may be one way to limit progression to current use. In August 2018 JUUL introduced 3% nicotine-strength pods in limited availability and widely in October 2018. Although we did not ask about JUUL nicotine content used, we can assume that during data collection, most if not all students reporting JUUL use had experience with the 5% JUUL. However, future research is urgently needed to determine if this 3% concentration is low enough to reduce nicotine “buzz” among youth (who are sensitive to low levels of nicotine)^16,19 and prevent current use, or if more youth can use this lower concentration and become current users because it produces less adverse physical and pharmacological symptoms (ie, headache).

Regarding product characteristics, when examining individual items, past use was associated with lower odds of reporting liking the JUUL flavors and higher likelihood of disliking flavors. These findings suggest that, of all product characteristics, flavors may be most impactful in distinguishing current and past users. In our sample, past users had less experience across all eight available flavors. It could be that past users may have stopped use before sampling flavors they enjoyed or that they had less access to flavors. As of February 2020, the Food & Drug Administration (FDA) has restricted the sale of flavored vaping cartridges (such as those used in JUUL) to only menthol and tobacco flavors. Prior to this, in late 2018 (after data collection), JUUL had made voluntary restrictions to flavor sales in the United States, including limiting in-store sales to tobacco, mint, and menthol flavors and by late 2019, voluntarily restricted all flavor sales (online and in store) in the United States to menthol, and tobacco. It will be important to evaluate how these regulations restricting flavors mitigate appeal and, potentially, use of JUUL. Additionally, regarding product characteristics, disliking price point of JUUL was associated with a lower likelihood of being a past user. One explanation for this is that current users have purchased JUUL more and thus have spent more on JUUL than past users. This would be in line with prior findings suggesting disliking price was associated with increased frequency of JUUL use.⁸

Additionally, we also observed an association of peer influence and JUUL use status suggesting that past use is associated with lower odds of liking JUUL because friends use. Past users could either not have as many friends that use JUUL or may not as susceptible to peer influences as current users. Regardless, this facet of appeal suggests peer influence may be an important component to sustaining use. Prior work among current users demonstrated peer influence was inversely associated with frequency of JUUL use in the past month.⁸ Taken together with our findings, it may be peer influence is important in regards to sampling and maintenance of e-cigarette use, which has been observed in other examinations of e-cigarettes.^9,20

Our examination of disliking JUUL among users demonstrated that not only do past users report significantly higher rates of endorsement of reasons for disking JUUL, but past users are more likely to report an “Other” reasons to dislike JUUL compared to current users. These reasons varied, but repeated themes were harm perceptions (eg, “It is bad for you”) and negative physical effects (eg, “It gives me a stomachache”). Regarding harm perceptions, this may suggest that regulatory actions aimed at increasing youth knowledge of e-cigarette harms could reduce current JUUL use, which is especially relevant given research suggesting youth knowledge of e-cigarettes are often non-evidence based²¹ and that perception of harm is related to use.²² This may be an important component in understanding why past users do not continue use.

It is also important to highlight that past JUUL users were less likely to be users of other e-cigarettes and tobacco products compared to current JUUL users. This could also suggest that past users may find tobacco products less appealing generally, potentially for similar reasons as reported for JUUL (ie, lack of positive pharmacological effects; adverse pharmacological effects) or use these products less as a result of less access to these products.

Limitations

This study was conducted in a sample of youth from Connecticut, which may not be representative of the general population. However, evidence from our regional studies has closely corresponded with national survey data.^2,23 Questions assessing liking/disliking of JUUL may not have captured all potential reasons for JUUL use, however, we included open-ended choices with the aim of capturing any reasons for liking/disliking not listed. Although we allowed for write-in responses, students may have been more likely to select predetermined response options rather than developing their own. At the time of the study, only 5% nicotine-strength JUUL pods were widely available, and JUUL was available in eight flavors, including fruit and dessert flavors. Currently, JUUL is widely available in both 5% and 3% nicotine-strength and only in menthol and tobacco flavors. Importantly, products similar to JUUL in design and delivery are available and these products come in a wide range of flavors/ nicotine concentrations, and many have a lower price.⁵ Our findings may have implications regarding the appeal of these products.

It is worth noting that past JUUL users may vary in experience with JUUL; some being youth who experimented with JUUL and did not continue using and some who used regularly and quit (either intentionally or due to an unforeseen reason like losing JUUL access). Future research should investigate differences among these types of past users. Our data are cross-sectional, and longitudinal studies are needed to understand changes in use patterns over time among youth. Limitations notwithstanding, our findings about experiences of JUUL among current and past users provide important information about product appeal that can be used to inform regulations and what facets of appeal may be most predictive of use.

Conclusions

Our study examined how past youth users of JUUL differ from current users in their perceptions of liking and disliking JUUL, the most prominent and popular e-cigarette available at the time of our study. We observed that past users had a lower number of reasons for liking JUUL, lower endorsement of most reasons for liking JUUL and higher endorsement of most reasons for disliking JUUL compared to current users. Understanding how past users experience with JUUL differs from those who report current use may help target aspects of JUUL that are most associated with current use to help with regulations of appealing features of JUUL. Findings suggest that regulations focused on lowering nicotine content to reduce positive pharmacological effects (such as the nicotine “buzz” and increased concentration), availability of flavors, and reducing peer use are avenues of reducing current JUUL use among youth.

Funding

This work was supported by the National Institute on Drug Abuse (NIDA) (K12DA000167 [KB], T32DA007238 [AJ, DD], R25DA0352163 [AJ]) and the Food & Drug Administration's Center for Tobacco Products (CTP) (P50DA036151, U54DA036151). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or the Food and Drug Administration.

Declaration of Interests

The authors have no conflicts of interest to disclose.