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As politicians around the country call for bans on flavored e-cigarettes, a recent Yale study found that most adolescents do not understand caution labels on Juul products — e-cigarettes known for appealing flavors such as mango, crème and cucumber.

A survey of 3,170 high school students from four Connecticut high schools asked teenagers to identify the relative concentration of nicotine in Juul pods before and after being told it contains “5% strength,” per the packaging. Prior to receiving the information, roughly 40 percent responded that the pods contain a low or medium nicotine concentration, while the number soared to 60 percent after. In fact, five percent nicotine — which Juul cartridges contain — is one of the highest nicotine concentrations in any e-liquid sold in the U.S.

“It’s the first study that shows directly that most adolescents aren’t aware of the fact that Juuls — at least at the 5 percent level — contain a high nicotine concentration,” said first author of the study and psychology assistant professor at Oberlin College Meghan Morean.

In an interview with the News, Morean speculated that the 20 percent uptick could be attributed to vague phrasing on Juul packaging, which makes the nicotine content in the popular e-cigarettes sound small. For her part, psychiatry professor Grace Kong, who co-authored the study, noted that even researchers studying e-cigarettes have a hard time understanding Juul’s labeling.

The viral e-cigarette company has previously faced criticism for how it markets its products to the public. Last September, the U.S. Food and Drug Administration raided Juul Labs’ San Francisco headquarters and seized thousands of documents that detailed the company’s sales and marketing practices under suspicion the company targeted children with its advertisements.

“There’s some historical advertising that I’ve seen, especially on social media, that gives me pause as to how earnest some of these companies were in making sure that kids didn’t use their products,” said FDA commissioner Scott Gottlieb in a press release at the time.

Psychiatry professor and the study’s senior author Suchitra Krishnan-Sarin said that e-cigarettes may have a greater impact on teenagers than adults because the adolescent brain is more sensitive to nicotine. Nicotine is a neurotoxin that negatively impacts memory and impulse control in a developing brain, Krishnan-Sarin explained.

According to Morean, further research is needed to determine whether labeling nicotine concentrations differently — such as specifying milligrams of nicotine in a Juul pod — will help youth better understand nicotine strength.

“We’re collecting data right now on trying to address some of these other questions like, ‘Could we create new labels that could better convey nicotine strength or potential harm?’” Morean said.

Morean said she is also interested in investigating whether adults understand e-cigarette labels. If a survey of adults also indicate that they lack understanding of nicotine content in Juul pods, this may indicate a broader issue of inappropriate product labeling, Morean explained.

Juul Labs dominated over 70 percent of the e-cigarette market in 2018, according to Nielsen Holdings.

Ashley Qin | ashley.qin@yale.edu