—Mimi Nichter
When my book, Lighting Up: The Rise of Social Smoking on College Campuses, was published in 2015, the popularity of e-cigarettes was showing early but steady growth among the young adult market. Having first entered the U.S. market in 2007, sales of e-cigarettes began to double each year due in part to aggressive advertising which heralded e-cigarettes as significantly less harmful than smoking. Towards the end of data collection for the book, I interviewed several e-cigarette users, most of whom were smokers who were trying e-cigarettes as a trendy new product. Some perceived benefits included their affordability, the fact that they were considered a ‘clean smoke’—not ‘dirty and smelly like cigarettes’, and the acceptance of vaping in many spaces that had long been off limits to cigarette smokers. For those who smoked at higher levels, vaping seemed to alleviate some of the guilt, stigma, and marginalization associated with being a smoker, and was embraced by some as a positive step enabling harm reduction and eventual quitting.
In the past few years, vaping has become entrenched as an established part of the landscape of nicotine delivery devices. Recent data show that more than a quarter of high school seniors have used e-cigarettes in the last 30 days, and over 40% report having ever used e-cigarettes (Miech et al., 2019). Many of these students may continue vaping in college while others may initiate e-cigarette use in their freshmen year much in the same way as they initiated social smoking. Importantly, among all age cohorts, e-cigarette use is highest among young adults aged 18 to 24. Results from the National Health Interview Survey among a representative sample of young adults found that between 2017 and 2018, e-cigarette use jumped 46 percent, an increase which appears to be equally distributed across gender, across income levels, across most racial groups, and smokers and non-smokers (Dai et al. 2019).
In part, the phenomenal growth of vaping is due to JUUL, a high tech vaping device which currently has 75% of the U.S. e-cigarette market share. Following the introduction of Juul in 2015, the business of e-cigarettes was transformed. JUUL captured the youth and young adult market with its sleek, minimalist product which is virtually indistinguishable from a USB drive. In 2018, JUUL was valued at 38 million dollars and 35% was sold to the major tobacco company, Altria.
JUUL lab claims that their product delivers nicotine at levels and speeds similar to conventional cigarettes (Vallone et al. 2019). This claim has garnered concern about the addictive quality of the product, and the possible transition to smoking cigarettes particularly among youth and young adults. JUUL has a different formulation than other e-cigarettes and more closely simulates the buzz that one gets from a real cigarette. Of note, JUUL has one of the highest nicotine concentrations on the market, is more easily absorbed in the blood stream when compared to other e-cigs, and is less harsh and therefore easier to inhale. While these factors contribute to the popularity of the product, they also pose a substantial risk to nicotine addiction.
JUUL was the first major e-cigarette brand to incorporate social media into their marketing strategy. At present, e-cigarette brands do not face comprehensive marketing restrictions and digital marketing is unrestricted. Thus, e-cigarette companies like JUUL can aggressively market their product through social media sites, such as Instagram, Twitter and YouTube. Evidence suggests that exposure among youth and young adults to vaping on social media is extremely common. Recent research has found that JUUL Instagram posts directly compare JUUL use to other “everyday” addictions such as binging on Netflix or eating chocolate, which may serve to normalize JUUL as part of one’s life, and by extension as “no big deal” (Czaplicki et al. 2019).
While some public health researchers argue that vaping may facilitate harm reduction and quitting among smokers, recent findings among young adults suggests that few are vaping as a means to quit smoking. To the contrary, among those who smoke cigarettes, simultaneous use of e-cigarettes has been found to reduce the likelihood of quitting smoking as well as the likelihood of reducing their level of smoking (Olfson et al, 2019). In fact, social smokers who also frequently vaped report increases in their cigarette smoking, suggesting that dual use may lead to higher levels of addiction (Doran et al. 2017). While vaping may have fewer negative health consequences than smoking, concerns remain considering the association between vaping and future or continuation of smoking (Vallone et al. 2019)
Looking Forward
While statistics about the growing popularity of JUUL are alarming, there is evidence to suggest that reports of e-cigarette use are actually underreported. A 2016 survey conducted by Campus Health at the University of Arizona found that only 6% of students reported e-cigarette use. However, when the survey questionnaire was updated to query about whether students had vaped or used JUUL, almost 25% of students reported use. Similar to my findings about smoking where a majority of college students who socially smoked did not consider themselves to be smokers, research on vaping needs to be sensitive to the nuances of language, contexts of use, and self-characterizations of what it means to be a vaper.
In the past few months, a spate of vaping-related lung-injury illnesses and deaths have been reported. Ethnographic research is needed to explore adolescent and young adults’ perceptions of these vaping-related illnesses. To what extent has concern in the medical community and recent illnesses and deaths impacted the vaping behavior of young people? If it has been impacted, how? It is important to understand whether young men and women embrace a similar invulnerability to vaping-related illness as they did to smoking, including statements such as “I’ve been vaping/smoking for a year and nothing has happened, so I’m not concerned”, or “I’m not the type to get ill”, or ”I’m not really a vaper, I just do it every once in a while.” And, even if behavior has not changed, have discussions of possible consequences of vaping entered into popular discourse among youth? In relation to smoking among college students, it was rare to find young people who would tell their friends to quit. Does a similar logic apply to those who have friends who vape?
Drawing on themes which emerged during research on social smoking, a host of potentially important issues on vaping beg ethnographic research:
- What are the times and places deemed acceptable to vape?
- What is considered appropriate vaping etiquette?
- In what social contexts is vaping most likely? (parties, hanging out with friends, etc. or multiple contexts)?
- Do those who vape and also smoke cigarettes do so in different contexts? Do they smoke or vape depending on their emotional state?
- What does vaping go with? (i.e., smoking and drinking were considered to go together ‘perfectly’)
- First experiences with vaping
- Perceived benefits of vaping
- Data on the topography of vaping (i.e., how different people vape; how deeply one inhales, over what period of time a person vapes, etc.)
- Do perceptions of acceptability of vaping differ by gender? What are popular perceptions of women who vape? (With regard to smoking, many women considered the behavior to ‘look trashy’, although this was not found to impact behavior in social settings)
- Does vaping have a social stigma?
- Do young adults who engage in dual use mix smoking cigarettes with vaping as a form of harm reduction?
- To what extent do young adults who vape consider it to be addictive? (Reports of research show that young people are often unaware that products like JUUL contain nicotine)
- Do youth express concern that vaping may lead to smoking cigarettes?
- How is vaping looked out in relation to hookah (more or less dangerous for health; less addictive, etc.)?
- Do young adults who vape menthol and flavored e-cigarettes believe these are less harmful than vaping cigarette-flavored products?
Research focused on these issues is critical to an understanding of the lived experience of vaping. A concern expressed among tobacco researchers is that vaping is renormalizing a behavior (smoking) that had become de-normalized. In-depth studies of vaping behavior among youth and young adults are needed to better understand this phenomenon.
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Mimi Nichter is Professor in the School of Anthropology, University of Arizona where she holds joint appointments in the Norton School of Family and Consumer Sciences and the College of Public Health. She is the author of Fat Talk: What Girls and Their Parents Say About Dieting and Lighting Up: The Rise of Social Smoking on College Campuses (NYU Press, 2015).
Featured image from Vaping360
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References:
Czaplicki, L., Kostygina, G., Kim, Y. et al. Characterizing JUUL-related posts on Instagram. Tobacco Control; 2019; 0:1-6. Doi: 10.1136/tobaccocontrol-2018-054824.
Dai H. et al. Prevalence of e-Cigarette Use among Adults in the United States, 2014-2018 Journal of the American Medical Association (JAMA) 2019. DOI:10.1001/jama.2019,15331
Doran N., Brikmanis K., Petersen A. et al. Does e-cigarette use predict cigarette escalation? A longitudinal study of young adult non-daily smokers. Preventive Medicine 2017; 100-279-284. https://dii.org/10.1016/j.ypmed.2017.03
Miech, R., Johnston, L., O’Malley, P.M., et al. Trends in adolescent vaping, 2017-2019, The New England Journal of Medicine 2019; 381: 1490-1491.
Olfson, M., Wall, M., Liu S-M, et al. E-cigarette sue among young adults in the U.S. American Journal of Preventive Medicine 2019; 56(5):655-663.
Vallone, D., Bennett M., Xiao H., et al. Prevalence and correlates of JUUL use among a national sample of youth and young adults. Tobacco Control 2019, 28: 603-609. Doi: 10.1136/tobaccocontrol-2018-054693.
