Nicotine Addiction and Intensity of e-Cigarette Use by Adolescents in the US, 2014 to 2021

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Abstract
Electronic cigarettes (e-cigarettes) are highly engineered drug delivery devices that create and sustain addiction. Early e-cigarettes did not deliver nicotine as efficiently as cigarettes because they delivered freebase nicotine that was hard to inhale. This situation changed with the 2015 introduction of Juul products (Juul Labs Inc),1 which added benzoic acid to the nicotine e-liquid to lower the pH level and form protonated nicotine. Protonated nicotine increases addictive potential by making it easier to inhale quantities of nicotine that are difficult for naive users to achieve with cigarettes or earlier e-cigarettes.2 By 2018, Juul held 75% of the market.3 After the US Food and Drug Administration partially banned cartridge-based flavored products in 2020,4 disposable flavored protonated nicotine e-cigarettes rapidly gained adolescent market share3,5; in 2021 middle and high school students used Puff Bar (Puff Bar [26.8%]), Vuse (R. J. Reynolds Vapor Company [10.5%]), SMOK (Shenzhen IVPS Technology Co Ltd [8.6%]), and Juul (6.8%).6

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