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Underage Youth and Young Adult e-Cigarette Use and Access Before and During the Coronavirus Disease 2019 Pandemic

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Did underage youth and young adults (13-24 years) self-report changes in use and access to e-cigarettes during the coronavirus disease 2019 pandemic?

Findings  In this national, online, cross-sectional survey study of 2167 youth and young adults using e-cigarettes, 1198 respondents reported changing their amount of e-cigarette use, with 810 reducing or quitting e-cigarette use; e-cigarette access shifted to alternative retail stores and online. Reduced e-cigarette use or quitting was associated with adhering to shelter-in-place guidelines and was less likely if participants had used e-cigarettes more than 10 times or were nicotine dependent.

Meaning  Individuals younger than 21 years reported e-cigarette use and accessed e-cigarettes from online and retail stores during the coronavirus disease 2019 pandemic, suggesting a need to strengthen prevention of e-cigarette sales to such youth, including age verification, and provide cessation resources.


Importance  Understanding patterns of e-cigarette use and access during the coronavirus disease 2019 (COVID-19) pandemic is important because e-cigarettes may put users at risk for more severe respiratory effects and other health problems.

Objective  To examine whether underage youth and young adults who ever used e-cigarettes self-reported changes in access and use of e-cigarettes since the COVID-19 pandemic began.

Design, Setting, and Participants  A national, cross-sectional online survey study was conducted from May 6 to May 14, 2020. This sample of 4351 participants aged 13 to 24 years across the US included 2167 e-cigarette ever-users. Quota sampling was used to balance for age, sex, race/ethnicity, and 50% having ever used e-cigarettes.

Main Outcomes and Measures  Change in e-cigarette use (increase, decrease, quit, no change, and switch to another product) and access to e-cigarettes (easier or harder, and change in point-of-purchase) before and after the COVID-19 pandemic began, reasons for change, number of times e-cigarettes were used, nicotine dependence, and sociodemographic data.

Results  This study focused on 2167 e-cigarette ever-users among 4351 participants who completed the survey. Among 2167 e-cigarette users, a total of 1442 were younger than 21 years and 725 were aged 21 years or older; 1397 were female (64.5%) and 438 identified as lesbian, gay, bisexual, transgender, queer (20.2%). The survey completion rate was 40%. Since the COVID-19 pandemic began, 1198 of 2125 e-cigarette users (56.4%) changed their use: 388 individuals (32.4%) quit, 422 individuals (35.3%) reduced the amount of nicotine, 211 individuals (17.6%) increased nicotine use, 94 individuals (7.8%) increased cannabis use, and 82 individuals (6.9%) switched to other products. Participants reported that not being able to go to vape shops and product unavailability were the reasons accessing e-cigarettes was difficult after the pandemic began. Since the COVID-19 pandemic began, individuals reported purchasing from alternative retail stores (disposables, 150 of 632 [23.7%]; pod-based, 144 of 797 [18.1%]; and other e-cigarette, 125 of 560 [22.3%], ie, between 18.1% and 23.7%), purchasing online instead of retail (disposables, 115 of 632 [18.2%]; pod-based, 156 of 797 [19.6%]; and other e-cigarette, 111 of 560 [19.8%], ie, between 18.2% to 19.8%), and shifted to retail instead of online (disposables, 11 of 632 [1.7%]; pod-based, 17 of 797 [2.0%]; and other e-cigarette, 13 of 560 [2.3%], ie, between 1.7%-2.3%). Other individuals reported no change: from retail stores (disposables 262 of 632 [41.5%]; pod-based 344 of 797 [43.2%]; and other e-cigarette, 223 of 560 [39.8%], ie, between 39.8% and 43.2%) and online (disposables 94 of 632 [14.9%]; pod-based 136 of 797 [17.1%]; and other e-cigarette, 88 of 560 [15.8%], ie, between 14.9% and 17.1%). Underage youth reported e-cigarette deliveries from vape shops and/or dealers or friends who received such deliveries, and 63 of 229 (27.5%) self-reported accessing e-cigarettes without age verification. e-Cigarette users were 52% less likely to quit or reduce their use if they previously used e-cigarettes between 11 and 99 times (adjusted odds ratio, 0.48; 95% CI, 0.30-0.78), 68% less likely to quit if they previously used e-cigarettes more than 100 times (adjusted odds ratio, 0.32; 95% CI, 0.20-0.51), and 51% were less likely to quit if they were nicotine dependent (adjusted odds ratio, 0.49; 95% CI, 0.35-0.70).

Conclusions and Relevance  During the COVID-19 pandemic, youth e-cigarette users reported changes in e-cigarette use, point-of-purchase, and ability to purchase e-cigarettes without age verification. The US Food and Drug Administration and local policy makers may find these data useful to inform policies to prevent e-cigarette sales to underage youth.

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Article Information

Accepted for Publication: October 5, 2020.

Published: December 3, 2020. doi:10.1001/jamanetworkopen.2020.27572

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Gaiha SM et al. JAMA Network Open.

Corresponding Author: Bonnie Halpern-Felsher, PhD, Stanford University, 770 Welch Rd, Ste 100, Palo Alto, CA 94304 (

Author Contributions: Drs Gaiha and Halpern-Felsher had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Gaiha, Halpern-Felsher.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: All authors.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Gaiha.

Obtained funding: Halpern-Felsher.

Supervision: Halpern-Felsher.

Conflict of Interest Disclosures: Dr Halpern-Felsher is a paid expert scientist in some e-cigarette litigation and an unpaid scientific advisor and expert witness regarding some tobacco-related policies. Dr Halpern-Felsher reported grants from the National Institutes of Health and other funding from the Taube Family in support of her Taube Endowed Research Faculty Scholar during the conduct of the study. No other disclosures were reported.

Funding/Support: The research reported in this article was supported by the Taube Research Faculty Scholar Endowment (Dr Halpern-Felsher). Additional support was received from grant U54 HL147127 from the National Heart, Lung, and Blood Institute and the Food and Drug Administration Center for Tobacco Products.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Further Consolidated Appropriations Act, 2020. In: Sec. 603, Minimum age of sale of tobacco products (December 16, 2019):1492-1503.
Centers for Disease Control and Prevention. Quick facts on the risks of e-cigarettes for kids, teens, and young adults. Updated February 3, 2020. Accessed July 1, 2020.
Cullen  KA , Gentzke  AS , Sawdey  MD ,  et al.  e-Cigarette use among youth in the United States, 2019.   JAMA. 2019;322(21):2095-2103. doi:10.1001/jama.2019.18387 PubMedGoogle ScholarCrossref
Villarroel  MA , Cha  AE , Vahratian  A . Electronic cigarette use among US adults, 2018: NCHS data brief No.365. National Center for Health Statistics, Centers for Disease Control and Prevention, US Department of Health and Human Services. Published 2020. Accessed May 24, 2020.
Kim  M , Popova  L , Halpern-Felsher  B , Ling  PM .  Effects of e-cigarette advertisements on adolescents’ perceptions of cigarettes.   Health Commun. 2019;34(3):290-297. doi:10.1080/10410236.2017.1407230 PubMedGoogle ScholarCrossref
Kim  M , Ling  PM , Ramamurthi  D , Halpern-Felsher  B .  Youth’s perceptions of e-cigarette advertisements with cessation claims.   Tob Regul Sci. 2019;5(2):94-104. doi:10.18001/TRS.5.2.1 PubMedGoogle ScholarCrossref
McKelvey  K , Halpern-Felsher  B .  Youth say flavored e-cigarette ads are for them.   J Adolesc Health. 2018;62(2):S136-S137. doi:10.1016/j.jadohealth.2017.11.278 PubMedGoogle ScholarCrossref
Jackler  RK , Ramamurthi  D .  Unicorns cartoons: marketing sweet and creamy e-juice to youth.   Tob Control. 2017;26(4):471-475. doi:10.1136/tobaccocontrol-2016-053206 PubMedGoogle ScholarCrossref
Cullen  KA , Liu  ST , Bernat  JK ,  et al.  Flavored tobacco product use among middle and high school students—United States, 2014-2018.   MMWR Morb Mortal Wkly Rep. 2019;68(39):839-844. doi:10.15585/mmwr.mm6839a2 PubMedGoogle ScholarCrossref
Kong  G , Morean  ME , Cavallo  DA , Camenga  DR , Krishnan-Sarin  S .  Reasons for electronic cigarette experimentation and discontinuation among adolescents and young adults.   Nicotine Tob Res. 2015;17(7):847-854. doi:10.1093/ntr/ntu257 PubMedGoogle ScholarCrossref
McKelvey  K , Baiocchi  M , Halpern-Felsher  B .  Adolescents’ and young adults’ use and perceptions of pod-based electronic cigarettes.   JAMA Netw Open. 2018;1(6):e183535-e183535. doi:10.1001/jamanetworkopen.2018.3535 PubMedGoogle ScholarCrossref
McKelvey  K , Halpern-Felsher  B .  How and why California young adults are using different brands of pod-type electronic cigarettes in 2019: implications for researchers and regulators.   J Adolesc Health. 2020;67(1):46-52. doi:10.1016/j.jadohealth.2020.01.017 PubMedGoogle ScholarCrossref
Ramamurthi  D , Chau  C , Jackler  RK .  JUUL and other stealth vaporisers: hiding the habit from parents and teachers.   Tob Control. 2018;28(6):610-616. doi:10.1136/tobaccocontrol-2018-054455 PubMedGoogle ScholarCrossref
Ghosh  A , Coakley  RD , Ghio  AJ ,  et al.  Chronic e-cigarette use increases neutrophil elastase and matrix metalloprotease levels in the lung.   Am J Respir Crit Care Med. 2019;200(11):1392-1401. doi:10.1164/rccm.201903-0615OC PubMedGoogle ScholarCrossref
McConnell  R , Barrington-Trimis  JL , Wang  K ,  et al.  Electronic cigarette use and respiratory symptoms in adolescents.   Am J Respir Crit Care Med. 2017;195(8):1043-1049. doi:10.1164/rccm.201604-0804OC PubMedGoogle ScholarCrossref
Wills  TA , Pagano  I , Williams  RJ , Tam  EK .  e-Cigarette use and respiratory disorder in an adult sample.   Drug Alcohol Depend. 2019;194:363-370. doi:10.1016/j.drugalcdep.2018.10.004 PubMedGoogle ScholarCrossref
National Institute of Drug Abuse. COVID-19: potential implications for individuals with substance use disorders. Published April 6, 2020. Accessed May 20, 2020.
Javelle  E .  Electronic cigarette and vaping should be discouraged during the new coronavirus SARS-CoV-2 pandemic.   Arch Toxicol. 2020;94(6):2261-2262. doi:10.1007/s00204-020-02744-z PubMedGoogle ScholarCrossref
Gaiha  SM , Cheng  J , Halpern-Felsher  B .  Association between youth smoking, electronic cigarette use, and COVID-19.   J Adolesc Health. 2020;67(4):519-523. doi:10.1016/j.jadohealth.2020.07.002PubMedGoogle ScholarCrossref
Meyers  MJ , Delucchi  K , Halpern-Felsher  B .  Access to tobacco among California high school students: the role of family members, peers, and retail venues.   J Adolesc Health. 2017;61(3):385-388. doi:10.1016/j.jadohealth.2017.04.012 PubMedGoogle ScholarCrossref
Centers for Disease Control and Prevention. Historical NYTS data and documentation. Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion. Updated December 23, 2019. Accessed September 2, 2020.
Truth Initiative. Where are kids getting JUUL? Published May 29, 2018. Accessed June 12, 2020.
Qualtrics. ESOMAR 28: 28 Questions to help research buyers of online samples. Updated June 20, 2014. Accessed September 24, 2020.
American Association for Public Opinion Research.  Standard Definitions: Final Dispositions of Case Codes and Outcome Rates for Surveys. 9th ed. American Association for Public Opinion Research; 2016.
Gorukanti  A , Delucchi  K , Ling  P , Fisher-Travis  R , Halpern-Felsher  B .  Adolescents’ attitudes towards e-cigarette ingredients, safety, addictive properties, social norms, and regulation.   Prev Med. 2017;94:65-71. doi:10.1016/j.ypmed.2016.10.019 PubMedGoogle ScholarCrossref
Krishnan-Sarin  S , Jackson  A , Morean  M ,  et al.  E-cigarette devices used by high-school youth.   Drug Alcohol Depend. 2019;194:395-400. doi:10.1016/j.drugalcdep.2018.10.022 PubMedGoogle ScholarCrossref
Cullen  KA , Ambrose  BK , Gentzke  AS , Apelberg  BJ , Jamal  A , King  BA .  Notes from the field: use of electronic cigarettes and any tobacco product among middle and high school students—United States, 2011-2018.   MMWR Morb Mortal Wkly Rep. 2018;67(45):1276-1277. doi:10.15585/mmwr.mm6745a5 PubMedGoogle ScholarCrossref
DiFranza  JR , Savageau  JA , Fletcher  K ,  et al.  Measuring the loss of autonomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study.   Arch Pediatr Adolesc Med. 2002;156(4):397-403. doi:10.1001/archpedi.156.4.397 PubMedGoogle ScholarCrossref
Wheeler  KC , Fletcher  KE , Wellman  RJ , Difranza  JR .  Screening adolescents for nicotine dependence: the Hooked on Nicotine Checklist.   J Adolesc Health. 2004;35(3):225-230. doi:10.1016/S1054-139X(03)00531-7 PubMedGoogle ScholarCrossref
Morean  ME , Kong  G , Cavallo  DA , Camenga  DR , Krishnan-Sarin  S .  Nicotine concentration of e-cigarettes used by adolescents.   Drug Alcohol Depend. 2016;167(167):224-227. doi:10.1016/j.drugalcdep.2016.06.031 PubMedGoogle ScholarCrossref
Morean  ME , Bold  KW , Kong  G ,  et al.  Adolescents’ awareness of the nicotine strength and e-cigarette status of JUUL e-cigarettes.   Drug Alcohol Depend. 2019;204:107512. doi:10.1016/j.drugalcdep.2019.05.032 PubMedGoogle Scholar
Williams  RS , Derrick  J , Ribisl  KM .  Electronic cigarette sales to minors via the internet.   JAMA Pediatr. 2015;169(3):e1563-e1563. doi:10.1001/jamapediatrics.2015.63 PubMedGoogle ScholarCrossref
Williams  RS , Derrick  J , Liebman  AK , LaFleur  K , Ribisl  KM .  Content analysis of age verification, purchase and delivery methods of internet e-cigarette vendors, 2013 and 2014.   Tob Control. 2018;27(3):287-293. doi:10.1136/tobaccocontrol-2016-053616 PubMedGoogle ScholarCrossref
Unger  JB , Bartsch  L .  Exposure to tobacco websites: associations with cigarette and e-cigarette use and susceptibility among adolescents.   Addict Behav. 2018;78:120-123. doi:10.1016/j.addbeh.2017.11.012 PubMedGoogle ScholarCrossref
Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC; 2017.
Callegaro  M , DiSogra  C.,   Computing response metrics for online panels.   Public Opinion Q. 2008;72(5):1008-1032. doi:10.1093/poq/nfn065Google ScholarCrossref
Family Smoking Prevention and Tobacco Control Act, 906(d), Pub. L. 111-31, 21 USC 387f. Published June 22, 2009. Accessed July 1, 2020.
Food and Drug Administration. Enforcement priorities for electronic nicotine delivery systems (ENDS) and other deemed products on the market without premarket authorization (revised): guidance for industry. Updated April 2020. Accessed July 1, 2020.
State of California. Business & Professions Code section 22963. In:2020.
Family Smoking Prevention and Tobacco Control Act, Section 907(a), Pub. L. 111-31, 21 USC 387g, (2009).
Food and Drug Administration. Warning letter: Provape Enterprise, Inc: MARCS-CMS 608866. Published July 31, 2020. Accessed September 24, 2020.
Food and Drug Administration. Warning letter: Vapor Plus OK: MARCS-CMS 608888. Published July 31, 2020. Accessed September 24, 2020.
Food and Drug Administration. Warning letter: MARCS-CMS 608397. Published July 31, 2020. Accessed September 24, 2020.
Czogala  J , Goniewicz  ML , Fidelus  B , Zielinska-Danch  W , Travers  MJ , Sobczak  A .  Secondhand exposure to vapors from electronic cigarettes.   Nicotine Tob Res. 2014;16(6):655-662. doi:10.1093/ntr/ntt203 PubMedGoogle ScholarCrossref
Drummond  MB , Upson  D .  Electronic cigarettes: potential harms and benefits.   Ann Am Thorac Soc. 2014;11(2):236-242. doi:10.1513/AnnalsATS.201311-391FR PubMedGoogle ScholarCrossref
Goniewicz  ML , Knysak  J , Gawron  M ,  et al.  Levels of selected carcinogens and toxicants in vapour from electronic cigarettes.   Tob Control. 2014;23(2):133-139. doi:10.1136/tobaccocontrol-2012-050859 PubMedGoogle ScholarCrossref
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