A study, published in JAMA Network Open, suggests that health officials might be underestimating the number of teens using electronic cigarettes or e-cigarettes.
Although the prevalence of vaping is high among adolescents, branding and brand loyalty are playing a major role in the perception of ‘smoking’ (including the use of e-cigarettes) and ‘vaping’ among high school students.
However, the extent to which JUUL, the manufacturer of a particular brand of e-cigarette products, has not been explored in population-based surveys. The company is being sued for fueling the youth e-cigarette epidemic because their sales and marketing strategy may, according to a Rutgers-led study, have influenced high school students’ perception of vaping to such a degree that some Juul users do not consider themselves e-cigarette users.
The ubiquity of the term “JUULing” has created challenges for measuring e-cigarette use, leading to a 2018 tobacco focused survey of 4,183 public high school students (grade 9 – 12) in New Jersey.
When researchers added JUUL specific questions to assess e-cigarette use they found that high school students reported higher use when JUUL was included in the measure of e-cigarette use (24.2%; 95% CI, 22.5%-25.9%) compared with current use assessed by use of e-cigarettes only (17.8%; 95% CI, 16.4%-19.4%) or JUUL use only (21.3%; 95% CI, 19.7%-23.0%).
The researchers found that in some cases, the addition of the JUUL specific question resulted in dramatic increases in youth e-cigarette estimates, particularly for female students and black students. For example, e-cigarette prevalence nearly doubled among black students when JUUL use was included. The study further showed that 88.8% (95% CI, 86.6%-91.1%) of current e-cigarette users reported JUUL as a brand they used.
Hispanic students (PR, 0.78; 95% CI, 0.69-0.89) and non-Hispanic students of other races (PR, 0.64; 95% CI, 0.51-0.81) were significantly less likely than non-Hispanic white students to be current e-cigarette users, and students in 12th grade were more likely than those in 9th grade to be current users (PR, 1.29; 95% CI, 1.11-1.48).
Current e-cigarette use was positively associated with current use of other tobacco products (PR, 2.57; 95% CI, 2.24-2.95), endorsing a tobacco brand on social media (PR, 1.43; 95% CI, 1.19-1.72), having tobacco-branded merchandise (PR, 1.70; 95% CI, 1.46-1.97), having close friends who used JUUL (PR, 3.81; 95% CI, 3.17-4.58), and seeing JUUL used on school grounds (PR, 1.43; 95% CI, 1.24-1.65).
“We’ve suspected that the brand JUUL contributed to the increase of e-cigarette use among teens, but I think we were surprised at the extent of the brand’s popularity among young people,” noted Mary Hrywna, an assistant professor at the Center for Tobacco Studies and the Rutgers School of Public Health who co-authored the study with Michelle B. Manderski, also from the Center and School of Public Health, and Cristine Delnevo, director of the Rutgers Center for Tobacco Studies.
Hrywna further added that “almost half of the current e-cigarette users said JUUL was the first e-cigarette product they tried and more than half of the high students reported seeing people use JUUL on school grounds.”
Lessons for Policymakers
Researchers also found that current and frequent e-cigarette use was highest among 12th graders and in fact one out of ten high school seniors reported using e-cigarettes on 20 or more days in the 30 days preceding the survey.
“This pattern of heavy e-cigarette use is consistent with nicotine addiction,” Delnevo explained. “It’s however not surprising given the high nicotine delivery of JUUL”.
“We need to think more carefully about how future questions are constructed when assessing e-cigarette use among teens,” Hrywna observed.
“Policymakers must understand how certain brands have driven e-cigarette use and carve out policies that address restrictions by age and location as well the high nicotine concentrations in these products if we hope to reduce these prevalence rates,” Hrywna concluded.
An unrelated study among 19,018 American students in grades 6 to 12 participating in the 2019 National Youth Tobacco Survey (conducted from February 15, 2019 to May 24, 2019), demonstrated that the prevalence of self-reported e-cigarette use was high among high school and middle school students, with many current e-cigarette users reporting frequent use and most of the exclusive e-cigarette users reporting use of flavored e-cigarettes. 
 Hrywna M, Bover Manderski MT, Delnevo CD. Prevalence of Electronic Cigarette Use Among Adolescents in New Jersey and Association With Social Factors. JAMA Netw Open. 2020;3(2):e1920961. Published 2020 Feb 5. doi:10.1001/jamanetworkopen.2019.20961
 Cullen KA, Gentzke AS, Sawdey MD, et al. e-Cigarette Use Among Youth in the United States, 2019 [published online ahead of print, 2019 Nov 5]. JAMA. 2019;e1918387. doi:10.1001/jama.2019.18387