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Table 1.  Demographic Characteristics of the Study Sample
Demographic Characteristics of the Study Sample
Table 2.  Questions, Themes, Responses, and Representative Quotes
Questions, Themes, Responses, and Representative Quotes
1.
US Food & Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on new steps to address epidemic of youth e-cigarette use. Published September 11, 2018. Accessed September 8, 2019. https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-new-steps-address-epidemic-youth-e-cigarette-use
2.
Kaplan  S. Juul targeted schools and youth camps, House panel on vaping claims. Published July 25, 2019. Accessed September 8, 2019.https://www.nytimes.com/2019/07/25/health/juul-teens-vaping.html
3.
McGinley  L. Michigan becomes the first state to ban flavored e-cigarettes. Published September 3, 2019. Accessed September 8, 2019. https://www.washingtonpost.com/health/michigan-becomes-first-state-to-ban-flavored-e-cigarettes/2019/09/03/34f234c6-ce4c-11e9-8c1c-7c8ee785b855_story.html?noredirect=on
4.
King  BA, Gammon  DG, Marynak  KL, Rogers  T.  Electronic cigarette sales in the United States, 2013-2017.   JAMA. 2018;320(13):1379-1380. doi:10.1001/jama.2018.10488PubMedGoogle ScholarCrossref
5.
DeJonckheere  M, Nichols  LP, Moniz  MH,  et al.  MyVoice national text message survey of youth aged 14 to 24 years: study protocol.   JMIR Res Protoc. 2017;6(12):e247. doi:10.2196/resprot.8502PubMedGoogle Scholar
6.
US Food & Drug Administration. FDA notifies four companies to remove 44 flavored e-liquid and hookah tobacco products from the market for not having required marketing authorization. Published August 8, 2019. Accessed September 8, 2019. https://www.fda.gov/news-events/press-announcements/fda-notifies-four-companies-remove-44-flavored-e-liquid-and-hookah-tobacco-products-market-not
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    Research Letter
    May 4, 2020

    Youth Perceptions of Juul in the United States

    Author Affiliations
    • 1University of Michigan, Ann Arbor
    • 2Department of Family Medicine, University of Michigan Medical School, Ann Arbor
    • 3University of Michigan Medical School, Ann Arbor
    • 4University of Michigan School of Public Health, Ann Arbor
    • 5Department of Family Medicine, University of Michigan Medical School, Ann Arbor
    • 6Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
    JAMA Pediatr. Published online May 4, 2020. doi:10.1001/jamapediatrics.2020.0491

    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 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.

    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.

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    Article Information

    Corresponding Author: Tammy Chang, MD, MPH, MS, Department of Family Medicine, University of Michigan, 2800 Plymouth Rd, Bldg 14, Room G128, Ann Arbor, MI 48109 (tachang@med.umich.edu).

    Published Online: May 4, 2020. doi:10.1001/jamapediatrics.2020.0491

    Author Contributions: Dr Chang and Ms Waselewski had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Wood, Sonneville, Chang.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Wood, Waselewski, Chang.

    Critical revision of the manuscript for important intellectual content: Wood, Bryant, Sonneville.

    Statistical analysis: Wood, Waselewski, Bryant, Chang.

    Obtained funding: Chang.

    Administrative, technical, or material support: Wood, Waselewski, Sonneville, Chang.

    Supervision: Sonneville, Chang.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This research was funded by the Michigan Institute for Clinical & Health Research, the University of Michigan MCubed program, and the University of Michigan Department of Family Medicine.

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    US Food & Drug Administration. Statement from FDA Commissioner Scott Gottlieb, M.D., on new steps to address epidemic of youth e-cigarette use. Published September 11, 2018. Accessed September 8, 2019. https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-new-steps-address-epidemic-youth-e-cigarette-use
    2.
    Kaplan  S. Juul targeted schools and youth camps, House panel on vaping claims. Published July 25, 2019. Accessed September 8, 2019.https://www.nytimes.com/2019/07/25/health/juul-teens-vaping.html
    3.
    McGinley  L. Michigan becomes the first state to ban flavored e-cigarettes. Published September 3, 2019. Accessed September 8, 2019. https://www.washingtonpost.com/health/michigan-becomes-first-state-to-ban-flavored-e-cigarettes/2019/09/03/34f234c6-ce4c-11e9-8c1c-7c8ee785b855_story.html?noredirect=on
    4.
    King  BA, Gammon  DG, Marynak  KL, Rogers  T.  Electronic cigarette sales in the United States, 2013-2017.   JAMA. 2018;320(13):1379-1380. doi:10.1001/jama.2018.10488PubMedGoogle ScholarCrossref
    5.
    DeJonckheere  M, Nichols  LP, Moniz  MH,  et al.  MyVoice national text message survey of youth aged 14 to 24 years: study protocol.   JMIR Res Protoc. 2017;6(12):e247. doi:10.2196/resprot.8502PubMedGoogle Scholar
    6.
    US Food & Drug Administration. FDA notifies four companies to remove 44 flavored e-liquid and hookah tobacco products from the market for not having required marketing authorization. Published August 8, 2019. Accessed September 8, 2019. https://www.fda.gov/news-events/press-announcements/fda-notifies-four-companies-remove-44-flavored-e-liquid-and-hookah-tobacco-products-market-not
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