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Promotion of JUUL on Twitter

      See Related Article on p. 582
      There is considerable literature on the relative advantages and disadvantages of e-cigarettes/electronic nicotine delivery systems (hence ''e-cigarettes'') [
      • Morean ME
      • Krishnan-Sarin S
      • O'Malley S
      Assessing nicotine dependence in adolescent E-cigarette users: The 4-item patient-reported outcomes measurement information system (PROMIS) nicotine dependence item bank for electronic cigarettes.
      ,
      • Staudt MR
      • Salit J
      • Kaner RJ
      • et al.
      Altered lung biology of healthy never smokers following acute inhalation of e-cigarettes.
      ,
      • McKeganey N
      • Barnard M
      Change and continuity in vaping and smoking by young people: A qualitative case study of a friendship group.
      ,
      • Salamanca JC
      • Meehan-Atrash J
      • Vreeke S
      • et al.
      E-cigarettes can emit formaldehyde at high levels under conditions that have been reported to be non-averse to users.
      ]. Proponents have argued that e-cigarettes are a safer alternative to traditional smoked tobacco [
      • Warner KE
      • Mendez D
      E-cigarettes: Comparing the possible risks of increasing smoking initiation with the potential benefits of increasing smoking cessation.
      ]. Conversely, opponents have argued that they can encourage nonsmokers to begin smoking tobacco and/or expose nonsmokers (and potentially, those nearby) to the risks associated with inhaling e-cigarette vapour, with uncertain long-term consequences [
      • Rehan HS
      • Maini J
      • Hungin APS
      Vaping versus smoking: A quest for efficacy and safety of e-cigarette.
      ,
      • Jancey J
      • Maycock B
      • McCausland K
      • Howat, P
      E-cigarettes: Implications for health promotion in the Asian Pacific region.
      ,
      • Soneji SS
      • Sung HY
      • Primack BA
      • et al.
      Quantifying population-level health benefits and harms of e-cigarette use in the United States.
      ].
      The first argument—that e-cigarettes can promote smoking cessation—positions these devices as a quitting aid. This approach corresponds with marketing e-cigarettes as relatively more advantageous than smoked tobacco due to lower health risks. The argument also implies that e-cigarettes should be marketed with information on how users can decrease nicotine intake over time to facilitate nicotine withdrawal, devoid of glamourised promotion. Conversely, marketing e-cigarettes with glamour, youthful images, and reference to multiple flavours weakens their position as a quitting aid and strengthens their position as a lifestyle device. This approach potentially increases the interest of nonsmokers and/or young people, who are likely to be exposed to the risks associated with e-cigarettes, without benefiting from reduced tobacco-smoking.
      Consistent with the different potential methods of marketing e-cigarettes discussed above, how e-cigarettes are marketed is likely to change their relative risks and benefits. If e-cigarettes are marketed as a lifestyle device, with the potential to attract the interest of nonsmokers and/or young people, the associated risks are likely to increase. Conversely, if e-cigarettes are largely marketed as a quitting aid, this can minimise the associated risks by not encouraging their use among nonsmokers.
      Among e-cigarettes, JUUL recently achieved prominence due to its rapid increase in market share, high-levels of brand recognition and use among adolescents [
      • Willett JG
      • Bennett M
      • Hair EC
      • et al.
      Recognition, use and perceptions of JUUL among youth and young adults.
      ]. With only moderate marketing expenditure, JUUL was transformed from a little-known brand to the largest retail e-cigarette brand in the United States. This followed innovative, engaging, and wide-reaching campaigns on Twitter, Instagram, and YouTube [
      • Huang J
      • Duan Z
      • Kwok J
      • et al.
      Vaping versus JUULing: How the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market.
      ]. The rapid growth of JUUL, largely due to social media promotion, makes JUUL particularly problematic, since non-smoking adolescents who use JUUL or other e-cigarettes would be exposed to the associated risks, without any benefit from reduced tobacco-smoking.
      The rapid rise of JUUL also demonstrates the important role of online marketing in adolescent use of this product, and its role in adolescent health. This was established by Chu et al. [
      • Chu KH
      • Colditz JB
      • Primack BA
      • et al.
      JUUL: Spreading online and offline.
      ] who present evidence in this issue on the role of Twitter in the promotion of JUUL, including among adolescents. Using a novel strategy to assess who is retweeting JUUL-related tweets, they found a substantial proportion to be adolescents. In previous research, we have found Twitter to be an influential channel to promote tobacco-smoking and alcohol products and messages [
      • Burton S
      • Soboleva A
      • Khan A
      Smoke spots: Promoting smoking with social media.
      ,
      • Dadich A
      • Burton S
      • Soboleva A
      Promotion of alcohol on Twitter.
      ,
      • Burton S
      • Dadich A
      • Soboleva A
      Competing voices: Marketing and counter-marketing alcohol on Twitter.
      ]. However, our analyses did not allow us to determine the proportion of adolescents who retweeted such content. Chu et al. thus make two important contributions to research on adolescent health. First, their study demonstrates that posts about devices such as JUUL are being shared online by adolescents—a finding that should alarm anyone concerned about the risks associated with e-cigarettes. Second, the methodology of Chu et al. enables others to estimate the age of Twitter users—and potentially, users of other social media platforms. The expanded use of their methodology has much to offer, allowing researchers to identify the postings of adolescents, who should not be exposed to the promotion of e-cigarettes, tobacco, or alcohol.
      The debate on the relative advantages and disadvantages of e-cigarettes will undoubtedly continue. Consider for instance, the diverging legislative paths of two nations that have adopted some of the toughest antismoking measures, internationally–namely, Australia and New Zealand. Despite their common history in acting against tobacco-smoking, these nations now have very different legislation regarding e-cigarettes. In New Zealand, nicotine vaping products and heated tobacco products can be legally sold [

      Ministry of Health. Vaping, Smokeless, Including Heated Tobacco. Available at: https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/vaping-smokeless-including-heated-tobacco. Accessed August 22nd, 2018.

      ]. However, in Australia, the sale, use, and possession of e-liquid nicotine, including in e-cigarettes, is illegal [

      NSW Ministry of Health. Electronic Cigarettes. Available at: http://www.health.nsw.gov.au/tobacco/Pages/e-cigarettes.aspx. Accessed August 22nd, 2018.

      ]. Despite this difference, both nations have banned the advertising of e-cigarettes, the sale of these devices to those under 18 years, and their use in areas where tobacco-smoking is prohibited. In balancing the related competing arguments about e-cigarettes, evidence such as that reported by Chu et al. [
      • Chu KH
      • Colditz JB
      • Primack BA
      • et al.
      JUUL: Spreading online and offline.
      ] demonstrates the need for public health policies that minimise the promotion of e-cigarettes to adolescents and nonsmokers. The absence of such policies might mean that the decreasing rates of tobacco-smoking are offset by a new wave of risk, as people who would never have smoked adopt e-cigarettes.

      References

        • Morean ME
        • Krishnan-Sarin S
        • O'Malley S
        Assessing nicotine dependence in adolescent E-cigarette users: The 4-item patient-reported outcomes measurement information system (PROMIS) nicotine dependence item bank for electronic cigarettes.
        Drug Alcohol Depend. 2018; (;188:60-3)
        • Staudt MR
        • Salit J
        • Kaner RJ
        • et al.
        Altered lung biology of healthy never smokers following acute inhalation of e-cigarettes.
        Respir Res. 2018; 19: 1-10
        • McKeganey N
        • Barnard M
        Change and continuity in vaping and smoking by young people: A qualitative case study of a friendship group.
        Int J Environ Res Public Health. 2018; 15: E1008
        • Salamanca JC
        • Meehan-Atrash J
        • Vreeke S
        • et al.
        E-cigarettes can emit formaldehyde at high levels under conditions that have been reported to be non-averse to users.
        Sci Rep. 2018; 8: 7559
        • Warner KE
        • Mendez D
        E-cigarettes: Comparing the possible risks of increasing smoking initiation with the potential benefits of increasing smoking cessation.
        Nicotine Tob Res. 2018; (Epub-ahead-of-print)
        • Rehan HS
        • Maini J
        • Hungin APS
        Vaping versus smoking: A quest for efficacy and safety of e-cigarette.
        Curr Drug Saf. 2018; (;13:92-101)
        • Jancey J
        • Maycock B
        • McCausland K
        • Howat, P
        E-cigarettes: Implications for health promotion in the Asian Pacific region.
        Asia Pac J Public Health. 2018; (; 30:321-7)
        • Soneji SS
        • Sung HY
        • Primack BA
        • et al.
        Quantifying population-level health benefits and harms of e-cigarette use in the United States.
        PLoS One. 2018; 13e0193328
        • Willett JG
        • Bennett M
        • Hair EC
        • et al.
        Recognition, use and perceptions of JUUL among youth and young adults.
        Tob Control. 2018; 0: 1-2
        • Huang J
        • Duan Z
        • Kwok J
        • et al.
        Vaping versus JUULing: How the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market.
        Tob Control. 2018; (Epub-ahead-of-print. doi: 10.1136/tobaccocontrol-2018-054382)
        • Chu KH
        • Colditz JB
        • Primack BA
        • et al.
        JUUL: Spreading online and offline.
        J Adolesc Health. 2018; 63 (582-6)
        • Burton S
        • Soboleva A
        • Khan A
        Smoke spots: Promoting smoking with social media.
        Tob Control. 2015; 24: 313-314
        • Dadich A
        • Burton S
        • Soboleva A
        Promotion of alcohol on Twitter.
        Med J Aust. 2013; 199: 327-329
        • Burton S
        • Dadich A
        • Soboleva A
        Competing voices: Marketing and counter-marketing alcohol on Twitter.
        J Nonprofit Public Sector Mark. 2013; 25: 186-209
      1. Ministry of Health. Vaping, Smokeless, Including Heated Tobacco. Available at: https://www.health.govt.nz/our-work/preventative-health-wellness/tobacco-control/vaping-smokeless-including-heated-tobacco. Accessed August 22nd, 2018.

      2. NSW Ministry of Health. Electronic Cigarettes. Available at: http://www.health.nsw.gov.au/tobacco/Pages/e-cigarettes.aspx. Accessed August 22nd, 2018.

      Linked Article

      • JUUL: Spreading Online and Offline
        Journal of Adolescent HealthVol. 63Issue 5
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          The increasing popularity of the JUUL electronic nicotine delivery system among youth poses several potential public health concerns. Social media can be used to better understand the spread of information related to JUUL. This study examined whether adolescents (age < 18) are following JUUL's official Twitter account and subsequently sharing (retweeting) JUUL's posts to their followers. We also assessed various patterns in which adolescents share information on JUUL with each other.
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