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June 1, 2020

Youth and Young Adult Use of Pod-Based Electronic Cigarettes From 2015 to 2019: A Systematic Review

Author Affiliations
  • 1Department of Media and Communication, Konkuk University, Seoul, South Korea
  • 2Harvard T. H. Chan School of Public Health, Department of Social and Behavioral Sciences, Boston, Massachusetts
  • 3Dana-Farber Cancer Institute, Population Sciences Division, Center for Community Based Research, Boston, Massachusetts
JAMA Pediatr. 2020;174(7):714-720. doi:10.1001/jamapediatrics.2020.0259
Key Points

Question  What are the factors associated with use of pod-based electronic cigarettes (e-cigarettes) and their potential association with youth and young adult health?

Findings  In this systematic review, pod-based e-cigarettes enhanced the delivery of nicotine and had greater dependence potential. Youth and young adult use can be attributed to social acceptability, convenient product features, and aggressive social media marketing.

Meaning  Health communications and restrictions on social media, marketing channels, product design, and youth access are needed to prevent youth uptake of pod-based e-cigarettes.


Importance  The use of electronic cigarettes (e-cigarettes) has rapidly increased among youth and young adults, but knowledge gaps exist on the potential health effects of using recently introduced pod-based e-cigarettes.

Objective  To conduct a systematic review of recent peer-reviewed scientific literature on pod-based e-cigarettes.

Evidence Review  A search of online databases, including PubMed, Web of Science, Embase, and EBSCO HOST, was conducted to identify pod-based e-cigarette–associated articles from June 2015 (the time when JUUL [JUUL Labs] was introduced) to June 2019. We included English-language articles that presented primary data on pod-based e-cigarettes.

Findings  Pod-based e-cigarettes represent a substantial evolution in design by increasing the efficient delivery of nicotine. While these products may contain less harmful constituents than other types of e-cigarettes and cigarettes, there is no evidence that the levels found are safe among youth. There is evidence for higher nicotine dependence associated with their use. Pod-based e-cigarette brands, compared with other e-cigarette brands, have targeted youth and young adults with social media marketing. There was less discussion about the use of these products as smoking cessation devices or their health risks on social media. The social acceptability and favorable perceptions of pod-based e-cigarettes may underlie the use of these products.

Conclusions and Relevance  The appeal and dependence potential of pod-based e-cigarettes for youth emphasize the need for stronger regulations on product design, social media, marketing channels, and youth access together with health communications that emphasize the risks of nicotine dependence.

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    1 Comment for this article
    Systematic Review Standards
    Lynley Pound, PhD | Thera-Business Inc.
    Systematic reviews are expected to systematically search all available evidence, appraise the quality of included studies, and objectively synthesize the evidence from the included studies (1). Lee and colleagues’ conducted a “systematic review” of literature on pod-based e-cigarettes (2). However, numerous methodological deficiencies suggest that this paper is not a systematic review nor are the conclusions based on a comprehensive and objective synthesis of the available evidence.

    This publication lacks several systematic review, a priori, requirements including no defined Key Question (KQ) and no predefined outcomes to be examined. These requirements are intended to ensure the reproducibility and
    objectivity of the review. Instead, this review was guided by a loose focus with corresponding outcomes not grounded in the evidence base or a protocol.

    Further, the reported search strategy was neither comprehensive nor reproducible. Using the reported search string provides far more records in Embase alone than disclosed by the authors from Embase and additional databases.

    Risk of bias, a critical systematic review element, was not assessed using standard tools such as ROBINS-I (3) or the Downs and Black checklist (4). The authors’ 5-point quality rating scale does not assess quality but, instead, simply categorizes the study by design. Therefore, a score of 4 or 5 might convey quality where quality is not measured.

    These and numerous other methodological flaws only underscore the non-generalizability of this publication’s findings. For example, conclusions on dependence from e-cigarettes are not reliable when based on a single study identified in the absence of an evidence-based KQ and clear inclusion criteria.

    Based on the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) 2 tool for rating methodological quality (5), this publication is graded as “critically low,” indicating more than one critical flaw — the review does not provide an accurate and comprehensive synthesis of available studies.

    Overall, given the flaws in the methods, results, and conclusions, this publication should not be considered as an accurate or comprehensive evaluation of evidence on youth and young adult use of pod-based e-cigarettes.

    Lynley D Pound, PhD, Red Thaddeus D Miguel, MD, MBA, Isabella Steffensen, PhD

    1. Mahtani KR, Jefferson T, Heneghan C, Nunan D, Aronson JK. What is a 'complex systematic review'? Criteria, definition, and examples. BMJ Evid Based Med. 2018;23(4):127-130.
    2. Lee SJ, Rees VW, Yossefy N, Emmons KM, Tan ASL. Youth and Young Adult Use of Pod-Based Electronic Cigarettes From 2015 to 2019: A Systematic Review. JAMA Pediatr. 2020.
    3. Sterne JA, Hernan MA, Reeves BC, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.
    4. Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health. 1998;52(6):377-384.
    5. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358:j4008.
    CONFLICT OF INTEREST: All authors report services from Reynolds American Inc (RAI) Services Company -- an indirect, wholly owned subsidiary of British American Tobacco p.l.c. This effort was sponsored by RAI Services Company. RAI Services Company had no role in the conception, analysis and writing of the present work or the decision to publish it.