Intentions and Attempts to Quit JUUL E-Cigarette Use

The Role of Perceived Harm and Addiction

Andréa L. Hobkirk, PhD; Brianna Hoglen, MPH; Tianhong Sheng, BS; Ava Kristich; Jessica M. Yingst, DrPH; Kenneth R. Houser, MS; Nicolle M. Krebs, MS; Sophia I. Allen, PhD; Candace R. Bordner, MS; Craig Livelsberger, BS; Jonathan Foulds, PhD

Disclosures

Prev Chronic Dis. 2022;19(2):E06

Abstract and Introduction

Abstract

Introduction: Research on electronic cigarette (e-cigarette) quit intentions and attempts is limited despite the potential health benefits of quitting, especially for long-term users. The current study aimed to investigate perceptions of harm and addictiveness and tobacco use characteristics associated with quit variables among users of a popular e-cigarette brand, JUUL.

Methods: We surveyed 301 US adult JUUL users on their tobacco use characteristics, perceptions of JUUL harm and addictiveness, and quit variables at 3 time points, from July 2019 to April 2020. We used logistic regression models to assess demographic characteristics, smoking characteristics, and perceptions of JUUL harm and addictiveness as correlates of e-cigarette quit intentions, attempts, importance, and confidence.

Results: Twenty-three percent of the sample had intentions to quit using JUUL within the year, and 22.6% reported making a lifetime quit attempt. The average rating of quit importance was 4.1 and quit confidence was 5.8 on a Likert scale of 1 to 10. More than 90% of the sample indicated that JUUL was at least moderately addictive, whereas less than one-quarter indicated that JUUL was as harmful or more harmful than smoking. Higher levels of perceived JUUL addictiveness were associated with more quit intentions, attempts, and importance. Higher levels of perceived JUUL harm compared with smoking were associated with more quit importance.

Conclusion: Our findings suggest that a small proportion of adult JUUL users are interested in quitting. Self-reported perceptions of JUUL's addiction potential may be related to more quit attempts. Findings highlight the need for evidence-based information on e-cigarette addictiveness and effective strategies for cessation.

Introduction

An estimated 8.1 million adults currently use electronic cigarettes (e-cigarettes) in the US.^[1] Unlike cigarettes, which use combustion to generate tobacco smoke, e-cigarettes aerosolize a nicotine-containing e-liquid for inhalation,^[2] resulting in lower intake of carcinogens and toxins for long-term e-cigarette users compared with smokers.^[3,4] Although replacing cigarettes with e-cigarettes likely reduces health risks in the short term for current smokers, e-liquids can contain high levels of nicotine and toxic compounds that may contribute to addiction and respiratory damage.^[5,6]

Adults' perceptions that e-cigarettes are harmful and addictive have increased over the past decade along with increased messaging about harms.^[7–9] For example, the Centers for Disease Control and Prevention website states that e-cigarettes contain toxic and carcinogenic chemicals, cause long-lasting changes in the brain, and are not a method for smoking cessation approved by the US Food and Drug Administration (FDA) (eg, cdc.gov/ecigarettes; drugabuse.gov/tobacconicotine-vaping). Data from several national surveys collected in the past decade revealed that the percentage of US adults who believe e-cigarettes are less harmful than cigarettes decreased, while the percentage who believe that e-cigarettes are addictive doubled.^[7–10]

Motivation for e-cigarette use cessation is rising in parallel with attention to the potential harms of e-cigarettes and the growing numbers of long-term e-cigarette users. Online and national surveys of adult e-cigarette users found that approximately 30% to 60% expressed some interest in quitting and 10% to 64% had made a previous e-cigarette quit attempt.^[11–13] However, research is limited on the factors associated with e-cigarette quit intentions and attempts, including the influence of harm or addiction perceptions.

Given the changing landscape of e-cigarette harm messaging and regulations, and the media attention given to e-cigarettes, the primary objective of the current study was to investigate e-cigarette quit intentions and attempts by identifying associated factors and focusing on adult JUUL users. Of all e-cigarette brands, JUUL has received the most negative attention because of its popularity among adolescents and young adults and its relatively high levels of nicotine.^[14] Therefore, we hypothesized that perceptions of JUUL's addictive potential and harm relative to cigarettes would be associated with quit intentions and attempts.

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Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

Table 1. Demographic Characteristics, JUUL Use, JUUL Perceptions, and Quit Variables Across Smoking Status for a Sample of US Adult JUUL Users, 2019–2020 ^a
Characteristic	Never smoker (n = 81)	Current smoker (n = 55)	Former smoker (n = 165)	Total sample (N = 301)	P value^b
Demographic
Female sex, n (%)	35 (43.2)	13 (23.6)	61 (37.0)	109 (36.2)	.06
Age, mean (SD), y	28.8 (8.0)	35.2 (9.5)	32.3 (7.9)	31.9 (8.5)	<.001
JUUL use
No. of months have used e-cigarettes, mean (SD)	20.9 (21.8)	28.7 (22.4)	29.8 (24.6)	27.2 (23.7)	.02
No. of months have used JUUL, mean (SD)	13.5 (13.0)	13.4 (12.5)	14.0 (10.6)	13.8 (11.6)	.93
JUUL use days in past 30 days, mean (SD)	21.1 (8.6)	22.8 (8.7)	24.5 (8.3)	23.3 (8.6)	.01
JUUL use times per day, mean (SD)	10.3 (17.4)	16.2 (53.3)	11.2 (39.1)	11.8 (37.9)	.63
Where purchase JUUL, n (%)
Gas station	22 (27.2)	22 (40.0)	63 (38.2)	107 (35.5)	.06
Vape shop	28 (34.6)	9 (16.4)	52 (31.5)	89 (29.6)
Tobacco store	7 (8.6)	9 (16.4)	14 (8.5)	30 (10.0)
Online	23 (28.4)	11 (20.0)	30 (18.2)	64 (21.3)
Did not purchase	1 (1.2)	4 (7.3)	6 (3.6)	11 (3.7)
Nicotine concentration, n (%)
5% concentration	32 (42.7)	33 (63.5)	81 (51.9)	146 (51.6)	.07
3% concentration	31 (41.3)	11 (21.2)	42 (26.9)	84 (29.7)
Both	12 (16.0)	8 (15.4)	33 (21.2)	53 (18.7)
PSECDI total score, mean (SD)^c	8.0 (4.5)	9.1 (4.4)	8.4 (4.0)	8.4 (4.2)	.31
PSECDI dependence level, n (%)
Not dependent	17 (21.0)	8 (14.5)	20 (12.1)	45 (15.0)	.43
Low dependence	27 (33.3)	15 (27.3)	63 (38.2)	105 (34.9)
Medium dependence	25 (30.9)	19 (34.5)	53 (32.1)	97 (32.2)
High dependence	12 (14.8)	13 (23.6)	29 (17.6)	54 (17.9)
JUUL perceptions
How addictive, n (%)
Not at all addictive	14 (17.3)	4 (7.3)	6 (3.6)	24 (8.0)	.002
Moderately addictive	54 (66.7)	37 (67.3)	111 (67.3)	202 (67.1)
Very addictive	13 (16.0)	14 (25.5)	48 (29.1)	75 (24.9)
How harmful compared with smoking, n (%)
Much less harmful	30 (37.0)	8 (14.5)	43 (26.1)	81 (26.9)	.04
Less harmful	29 (35.8)	31 (56.4)	88 (53.3)	148 (49.2)
Just as harmful	18 (22.2)	13 (23.6)	31 (18.8)	62 (20.6)
Much more harmful	4 (4.9)	3 (5.5)	3 (1.8)	10 (3.3)
Quit variables
Quit attempts, n (%)
No	52 (64.2)	44 (80.0)	137 (83.0)	233 (77.4)	.004
Yes	29 (35.8)	11 (20.0)	28 (17.0)	68 (22.6)	.004
Quit intentions, n (%)
I'll quit JUUL within a year	17 (21.0)	10 (18.2)	41 (24.8)	68 (22.6)	.55
I will continue to use/don't know	64 (79.0)	45 (81.8)	124 (75.2)	233 (77.4)	.55
Quit importance, mean (SD)^d	4.1 (3.0)	4.1 (2.8)	4.2 (2.6)	4.1 (2.8)	.98
Quit confidence, mean (SD)^d	6.4 (2.7)	5.6 (2.8)	5.6 (2.7)	5.8 (2.7)	.07

Abbreviation: PSECDI, Penn State Electronic Cigarette Dependence Index.
^aData source: A 30-minute survey was developed by the study team and administered at 3 time points: July 2019, January 2020, and April 2020.
^b P values determined from variable comparisons across smoking status using 1-way analyses of variance and χ² tests.
^cScores range from 0 to 20, where higher scores indicate greater dependence. Levels of dependence were categorized as not dependent (0–3), low dependence (4–8), medium dependence (9–12), and high dependence (≥13) (17).
^dA 10-point Likert scale ranging from "not at all" to "very." Scores categorized into low (1–3), medium (4–7), and high (8–10) to simplify analysis.

Table 2. Results of Logistic Regression Models of JUUL Addictiveness Perception Among US Adult JUUL Users (N = 301), 2019–2020 ^a
Variable	χ² P value	Odds ratio (95% CI)
Variable	χ² P value	Moderately vs not at all	Very vs not at all
Age	.001	1.05 (0.10–1.12)	0.98 (0.09–1.05)
Sex
Male	.004	0.95 (0.03–1.12)	0.34 (0.01–1.06)
Female	.004	1 [Reference]	1 [Reference]
Smoking status
Current	.002	1.42 (0.04–5.49)	4.02 (0.08–20.19)
Former		4.13 (1.43–11.94)^b	11.66 (3.25–41.88)^c
Never		1 [Reference]	1 [Reference]
PSECDI dependence level^d
Low	<.001	1.69 (0.06–4.60)	5.46 (0.94–31.55)
Medium		6.31 (1.57–25.39)^b	38.33 (5.33–275.41)^c
High		2,356,778 (1,077,123–5,156,700)^c,e	44,203,672 (2,020,259–9,671,854)^c,e
Not dependent		1 [Reference]	1 [Reference]

Abbreviation: PSECDI, Penn State Electronic Cigarette Dependence Index.
^aA 30-minute survey was developed by the study team and administered at 3 time points: July 2019, January 2020, and April 2020. The question on addictiveness was, "Overall, how addictive do you believe using a JUUL is?" with response options "not at all addictive," "moderately addictive," and "very addictive" Estimates of each variable level were determined by using binomial and multinomial logistic regression models. Akaike information criterion = 432.9; residual deviance = 400.9.
^b P < .01; determined by χ² test.
^c P < .001; determined by χ² test.
^dScores range from 0 to 20, where higher scores indicate greater dependence. Levels of dependence were categorized as not dependent (0–3), low dependence (4–8), medium dependence (9–12), and high dependence (≥13) (17).
^eThe odds ratios for high dependence are large because we modeled the log-odds as a linear function of each variable and, therefore, applied an exponential function to the odds ratio calculations. These estimates are reliable and not biased by outliers.

Table 3. Results of Logistic Regression Models of Perceived Harm of JUUL, Compared With Smoking, Among US Adult JUUL Users (N = 301), 2019–2020 ^a
Variable	χ² P value	Odds ratio (95% CI)
Variable	χ² P value	Less vs much less harmful	Just as much vs much less harmful	Much more vs much less harmful
Sex
Male	.01	1.20 (0.66–2.17)	0.72 (0.35–1.47)	0.26 (0.06–1.09)
Female	.01	1 [Reference]	1 [Reference]	1 [Reference]
Smoking status
Current	.02	4.56 (1.75–11.88)^b	3.81 (1.26–11.52)^c	3.78 (0.64–22.45)
Former		2.55 (1.32–4.94)^b	1.71 (0.77–3.78)	0.65 (0.12–3.46)
Never		1 [Reference]	1 [Reference]	1 [Reference]
Days of JUUL use in past 30 days	.09	0.98 (0.94–1.01)	0.96 (0.92–1.00)	0.92 (0.85–0.99)^c
Months of e-cigarette use, square root	.046	0.90 (0.79–1.02)	0.83 (0.70–0.97)^c	1.12 (0.83–1.51)

^aA 30-minute survey was developed by the study team and administered at 3 time points: July 2019, January 2020, and April 2020. The question on harm perception was, "Compared to smoking, would you say that JUUL use is … " with response options "much less harmful," "less harmful," "just as harmful," or "much more harmful." Estimates of each variable level were determined by using binomial and multinomial logistic regression models. Akaike information criterion = 688.6; residual deviance = 652.6.
^b P < .01; determined by χ² test.
^c P < .001; determined by χ² test.

Table 4. Results of Logistic Regression Models of Quit Intentions Among US Adult JUUL Users (N = 301), 2019–2020 ^a
Variable	χ² P value	I'll quit vs I'll continue
Perceived addictiveness of JUUL
Moderately addictive	<.001	3.36 (0.88–22.35)
Very addictive		12.46 (2.92–88.24)^b
Not at all		1 [Reference]
Perceived harm of JUUL, compared with smoking
Less harmful	.14	0.68 (0.33–1.47)
Just as much harm		0.86 (0.36–2.03)
Much more harm		3.37 (0.77–15.91)
Much less harm		1 [Reference]
JUUL use times per day, log	.03	0.70 (0.49–0.97)^c
Months of JUUL use	.51	1.08 (0.85–1.38)
Months of e-cigarette use	.05	0.85 (0.72–1.00)
Survey time point
Time point 2	.06	2.26 (1.01–5.48)
Time point 3		2.75 (1.16–7.00)^c
Time point 1		1 [Reference]

^aA 30-minute survey was developed by the study team and administered at 3 time points: July 2019, January 2020, and April 2020. The question on quit intentions was, "Are you planning to continue using your JUUL electronic cigarette for at least the next year, or quit within that time frame?" with response options "I'll quit using JUUL within a year," "I plan to continue using the JUUL," or "Don't know." Estimates of each variable level were determined by using binomial and multinomial logistic regression models. Akaike information criterion = 306.5; residual deviance = 284.5.
^b P < .01.
^c P < .05.

Table 5. Results of Logistic Regression Models of Quit Attempts Among US Adult JUUL Users (N = 301), 2019–2020 ^a
Variable	χ² P value	Yes vs no
Perceived addictiveness of JUUL
Moderately addictive	.03	5.64 (0.99–107.16)
Very addictive		10.56 (1.62–212.12)^b
Not at all		1 [Reference]
Perceived harm of JUUL, compared with smoking
Less harmful	.10	0.68 (0.30–1.52)
Just as much harm		1.83 (0.76–4.49)
Much more harm		0.97 (0.17–5.26)
Much less harm		1 [Reference]
Smoking status
Current	.007	0.35 (0.14–0.87)^b
Former		0.32 (0.15–0.66)^c
Never		1 [Reference]
PSECDI dependence level^d
Low	<.001	2.96 (0.81–14.52)
Medium		15.16 (4.26–75.04)^e
High		8.85 (2.18–47.39)^c
Not dependent		1 [Reference]
Days of JUUL use in past 30 days	.002	0.94 (0.90–0.98)^c

Abbreviation: PSECDI, Penn State Electronic Cigarette Dependence Index.
^aA 30-minute survey was developed by the study team and administered at 3 time points: July 2019, January 2020, and April 2020. The question on quit attempt was, "Have you ever tried to quit using your JUUL electronic cigarette?" with response options no or yes. Estimates of each variable level were determined by using binomial and multinomial logistic regression models. Akaike information criterion = 280.9; residual deviance = 256.9.
^b P < .05.
^c P < .01.
^dScores range from 0 to 20, where higher scores indicate greater dependence. Levels of dependence were categorized as not dependent (0–3), low dependence (4–8), medium dependence (9–12), and high dependence (≥13) (17).
^e P < .001.

Table 6. Results of Logistic Regression Models of Quit Importance and Quit Confidence Among US Adult JUUL Users (N = 301), 2019–2020 ^a
Variable	χ² P value	Moderate vs low	High vs low
Quit importance^b
Survey time point
Time point 2	.04	2.21 (1.07–4.56)^c	1.16 (0.41–3.33)
Time point 3		3.40 (1.56–7.42)^d	1.29 (0.42–3.99)
Time point 1		1 [Reference]	1 [Reference]
Age	.09	0.99 (0.96–1.02)	1.04 (0.99–1.09)
Place of JUUL purchase
Vape shop	.03	1.03 (0.50–2.10)	1.20 (0.42–3.38)
Tobacco store		0.75 (0.28–2.02)	0.62 (0.15–2.48)
Online		0.54 (0.25–1.18)	0.19 (0.42–0.81)^c
Did not purchase		0.33 (0.05–2.01)	3.97 (0.70–22.45)
Gas station		1 [Reference]	1 [Reference]
Perceived addictiveness of JUUL
Moderately addictive	.02	1.80 (0.58–5.64)	1.95 (0.18–21.27)
Very addictive		1.33 (0.35–5.04)	7.05 (0.54–92.91)
Not at all addictive		1 [Reference]	1 [Reference]
Perceived harm of JUUL, compared with smoking
Less harmful	<.001	4.08 (1.96–8.47)^e	1.65 (0.53–5.16)
Just as much harm		4.30 (1.79–10.35)^d	5.84 (1.71–19.92)^d
Much more harm		11.21 (0.95–131.79)	28.20 (2.46–323.29)^d
Much less harm		1 [Reference]	1 [Reference]
PSECDI dependence level^f
Low	.002	3.70 (1.41–9.72)^d	3.10 (0.59–16.28)
Medium		4.96 (1.78–13.81)^d	13.75 (2.48–76.26)^d
High		4.47 (1.36–14.66)^c	10.43 (1.66–65.42)^c
Not dependent		1 [Reference]	1 [Reference]
Days of JUUL use in past 30 days	.001	0.96 (0.92–0.99)^c	0.90 (0.85–0.96)^e
Months of e-cigarette use	.006	0.81 (0.71–0.93)^d	0.84 (0.70–1.00)
Quit confidence^g
PSECDI dependence level^f
Low	<.001	2.00 (0.63–6.33)	0.68 (0.23–2.02)
Medium		0.98 (0.33–2.90)	0.14 (0.04–0.41)^e
High		0.50 (0.16–1.56)^c	0.08 (0.02–0.26)^e
Not dependent		1 [Reference]	1 [Reference]

Abbreviation: PSECDI, Penn State Electronic Cigarette Dependence Index.
^aA 30-minute survey was developed by the study team and administered at 3 time points: July 2019, January 2020, and April 2020. Estimates of each variable level were determined by using binomial and multinomial logistic regression models.
^bThe question on quit importance was, "How important is it for you to quit electronic cigarette use now?" Akaike information criterion = 552.5; residual deviance = 480.5.
^c P < .05; determined by χ² test.
^d P < .01; determined by χ² test.
^e P < .001; determined by χ² test.
^fScores range from 0 to 20, where higher scores indicate greater dependence. Levels of dependence were categorized as not dependent (0–3), low dependence (4–8), medium dependence (9–12), and high dependence (≥13) (17).
^gThe question on quit confidence was, "How confident are you that you could quit electronic cigarette use now?" Akaike information criterion = 605.5; residual deviance = 589.5.