Do JUUL and e-cigarette flavors change health risk perceptions of adolescents?

Nambi Ndugga is a policy analyst at Boston University School of Public Health. She tweets @joerianatalie.

Despite decades of progress in reducing the prevalence of tobacco smoking, we are now facing a new e-cigarette epidemic among youth in the United States. The prevalence of e-cigarette use among school-aged students has substantially increased between 2017 and 2019, from 3.3% to 10.9% among middle schoolers, and 11.7% to 27.5% among high school students. Within this population of users, fruit, menthol/mint, or sweet/dessert/candy flavors were the most popular.

This growing trend in e-cigarette use is concerning as most long-term tobacco product use is initiated during youth and young childhood. E-cigarettes contain high concentrations of nicotine and other additives that adversely affect people’s health. Nicotine exposure during adolescence increases the risk of future addiction and a transition to combustible tobacco products and harms the developing brain.

To address the growing trend in e-cigarette use, many states have implemented or are in the process of implementing bans and regulations on the sale, manufacturing, and use of flavored e-cigarettes. The bans vary in severity across states, with some states prohibiting the sales of all products, regardless of flavor, and others only placing bans on some flavored products. On January 2nd, 2020, the U.S. Food and Drug Administration issued enforcement policies against unauthorized flavored nicotine products (sweet and fruit flavors) but did not include menthol flavors.

As federal and state governing bodies determine the most effective ways to curtail e-cigarette use among youth, researchers have been studying the factors that have influenced this growing trend in e-cigarette use across the country.

Study Summary:

In 2018, Dr. Kiersten Strombotne from Boston University School of Public Health’s Health Law, Policy & Management Department, Jody Sindelar from Yale University, and John Buckell from the University of Oxford conducted an online national survey to determine whether youth perception of e-cigarette-associated health risks varied depending on flavor. They studied JUUL and other e-cigarette products and surveyed 1610 high-school students, aged 14-18 years old.

They first asked about students’ awareness of JUUL or e-cigarette products. Next, they used a ten-point Likert scale, with 0 being not likely and 10 being most likely, to measure students’ perceptions of health risks associated with the dedicated use of five e-cigarette or JUUL flavors: Virginia or classic tobacco, cool mint or classic menthol, fruit medley or mango, cool cucumber, and crème brulee. The health risks measured were the likelihood of lung cancer, second-hand vapor risk, risk of addiction, and level of healthiness.

Key findings were that 89% and 93% of students were aware of JUUL and e-cigarettes, respectively. On average, most of the respondents did not perceive JUULs or e-cigarettes to be healthy. They consistently scored the risk of lung cancer, second-hand vapor harm, and addictiveness at a five or higher on the Likert scale for both products. However, when assessed by flavor, students’ responses revealed differences in risk perception.

In comparison to the other flavors, students perceived fruit flavors to be more addictive, but also healthier and less likely to lead to lung cancer and second-hand vapor harm. Candy or sweet flavors demonstrated a similar risk pattern to fruit-flavored products, albeit they were considered less healthy. Menthol and mint flavors were considered the least likely to lead to lung cancer and second-hand vapor harm. They also scored in the middle to low range of addictiveness. Lastly, tobacco-flavored products were considered the least healthy and were associated with the highest risk of lung cancer and second-hand vapor harm.

Conclusions and Policy Implications:

The findings from this study correlate with the observed trends in sales and use of fruit, candy, mint, and menthol flavored e-cigarette products among youth. They also suggest that risk perception may unconsciously play a role in the appeal of flavored e-cigarette products among young users. For example, a recent JAMA study found that there was a significant increase of sales of menthol-flavored products in 2019, which adolescents associated with the lowest risk of lung cancer in the Strombotne, et al. study.

These findings have strong implications for e-cigarette policies that seek to stem the use of e-cigarettes among youth, perhaps calling into question the effectiveness of partial flavor bans that do not include mint or menthol-flavored products. Some health experts have stated that teens who can no longer buy banned pods would simply switch to products that are still on the market.

What’s more, the 2019 e-cigarette and vaping associated lung injury (EVALI) outbreak should serve as a wake-up call for legislators and public health officials to take the risks associated with e-cigarette use seriously. The average age of patients affected was 24 years old and 54% were users of e-cigarette nicotine products.

While more research is still needed to better understand the impact of flavors on the use and perception of e-cigarettes, Strombotne, et al.’s findings add to a growing body of work that can guide legislators and policymakers as they develop effective policies. So far, the research supports bans on all flavored e-cigarettes, including mint and menthol, as a means of protecting our youth.

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