Nov 5, 2024

Journal of Medical Internet Research This paper is in the following e-collection/theme issue: June 27, 2023 Online Interest in Elf Bar in the United States: Google Health Trends Analysis Authors of this article: 2Department of Health, Human Performance and Recreation, University of Arkansas, Fayetteville, AR, United States *all authors contributed equally University of Arkansas Abstract Background: Despite the popularity of JUUL e-cigarettes, other brands (eg, Elf Bar) may be gaining digital attention. Objective: This study compared Google searches for Elf Bar and JUUL from 2022 to 2023 using Google Health Trends Application Programming Interface data. Methods: Using an infodemiology approach, we examined weekly trends in Google searches (per 10 million) for “Elf Bar” and “JUUL” at the US national and state levels from January 1, 2022, to December 31, 2023. Joinpoint regression was used to assess statistically significant trends in the search probabilities for “Elf Bar” and “JUUL” during the study period. Results: Elf Bar had less online interest than JUUL at the beginning of 2022. When the US Food and Drug Administration denied JUUL marketing authority on June 23, 2022, JUUL searches peaked at 2609.3 × 107 and fell to 83.9 × 107 on September 3, 2023. Elf Bar searches surpassed JUUL on July 10, 2022, and steadily increased, reaching 523.2 × 107 on December 4, 2022. Overall, Elf Bar’s weekly search probability increased by 1.6% (95% CI 1.5%-1.7%; P=.05) from January 2022 to December 2023, with the greatest increase between May 29 and June 19, 2022 (87.7%, 95% CI 35.9%-123.9%; P=.001). Elf Bar searches increased after JUUL’s suspension in Pennsylvania (1010%), Minnesota (872.5%), Connecticut (803.5%), New York (738.1%), and New Jersey (702.9%). Conclusions: Increasing trends in Google searches for Elf Bar indicate that there was a growing online interest in this brand in the United States in 2022. J Med Internet Res 2024;26:e50343 Introduction Defined by 4 distinct “generations,” the first e-cigarette products resembled traditional cigarettes and were referred to as “cig-a-likes” [ 1 ]. These devices evolved into vape pens (second generation) and modifiable tank-style systems (third generation). The current (fourth) generation of e-cigarette products now include cartridge-based and disposable devices. Cartridge-based devices include a prefilled “pod” that contains nicotine and flavors and can be discarded after use, and disposable devices are advertised to include a number of “puffs” (eg, 1500), after which they can be disposed [ 1 ]. Although youth and young adults’ use of e-cigarettes was increasing from 2011 to 2020 [ 2 ], it peaked in 2019, when the fourth-generation flash drive–shaped product, JUUL, controlled the e-cigarette market [ 3 - 5 ]. Although the use of e-cigarettes has declined since 2019, they continue to be popular among young audiences, with 2.13 million middle and high school students reporting current use in the United States in 2023 [ 6 ]. In January 2020, the Food and Drug Administration (FDA) announced that a sales restriction of cartridge-based e-cigarette flavors (other than mint and tobacco) would go into effect later that month [ 7 ]. This policy was suggested to decrease the popularity of cartridge-based e-cigarettes such as JUUL. JUUL Labs Inc has now settled in court regarding cases where they were accused of marketing their products to those younger than 21 years, the legal sales age for tobacco products [ 8 ]. Although this policy was posited to reduce use among youth and young adults, researchers have speculated that the FDA’s cartridge-based flavor restriction policy created a loophole for disposable devices, such as Puff Bar, that gained online attention after this policy was enacted [ 9 , 10 ]. On July 20, 2020, the FDA issued warning letters to 10 companies, including Puff Bar and other disposable e-cigarette brands, that they had not received the appropriate premarket authority to be marketed and sold in the United States [ 11 ]. After a short period of suspended sales, Puff Bar began selling their products again in March 2021, claiming that they used synthetic nicotine, which was not authorized for regulation by the FDA [ 12 ]; the FDA’s authority over nicotine products is defined in the Tobacco Control Act as products that were made, contained, or derived from tobacco [ 13 ]. Thus, on March 11, 2022, President Joe Biden closed this regulatory gap by signing a Congress-approved amendment (Docket No. FDA-2022-N-3261) that expanded the tobacco product definition to “products that contain nicotine from any source,” granting the FDA authority over synthetic nicotine products [ 12 ]. From 2021 to 2023, other brands of disposable e-cigarette devices, including Elf Bar, began to gain popularity in Great Britain and the United States, with 56.7% of US youths who reported current use of e-cigarettes indicating that they used Elf Bar most often in 2023 (compared with 15.5% for JUUL) [ 14 - 17 ]. Research indicates that discussion about Elf Bar and other emerging e-cigarette brands was increasing on Twitter in 2021, whereas discussion about JUUL was decreasing [ 18 ]. During this time, research suggests that disposable, nicotine salt–based e-cigarette products became the most popular e-cigarette devices on the market [ 15 ]. However, no research has explored the popularity of Elf Bar on a more widely available search engine, such as Google. Google Trends (GT) is a useful tool for measuring popularity (defined as online interest) of a wide range of topics including football players, disease prioritization, and the harms of drug use [ 19 - 21 ]. It has been used in prior tobacco-related research, to examine the online popularity of JUUL and Puff Bar [ 10 ], but it has not been used since the FDA’s expansion of the tobacco product definition to determine the online popularity of other e-cigarette products, such as Elf Bar. June 2022, the FDA announced the prohibition of JUUL sales in the US market [ 22 ], an order that was immediately appealed. Thus, although JUUL remained on the market, the popularity of this product continued to decline while newer disposable products that included flavors saw increases in use [ 9 , 10 , 23 ]. Although data suggest that there were shifts in e-cigarette product and brand use after the COVID-19 pandemic [ 15 ], and research has noted the popularity of Puff Bar [ 9 , 24 , 25 ], there remains a gap in literature about the online interest in other brands, particularly following the FDA’s order to suspend Puff Bar sales. It is possible that regulatory announcements could have created changes in online interest of e-cigarette products. With growing regulations that focus on particular brand or product characterizations (eg, cartridge-based systems and synthetic nicotine-containing products), there could be growing online popularity for other e-cigarette brands, such as Elf Bar, a brand that has been noted for its recent popularity in the United Kingdom and United States [ 16 , 17 ]. The purpose of this study is to explore the online interest in Elf Bar in the United States, compared with JUUL from 2022 to 2023 using Google Health Trends Application Programming Interface (GHT-API) data. Methods GHT-API Data GT is a popular data source that is widely used in public health research [ 26 ]. Given recent concerns about the data quality and accuracy of GT [ 27 - 29 ], some researchers have begun to use GHT-API, which provides raw probabilities of a short search session with no restrictions on the search volume index [ 30 , 31 ]. To collect and use the GHT-API data, researchers must have a valid API key supplied by Google. A detailed GHT-API technique and data features have already been published elsewhere [ 32 , 33 ]. Briefly, Google maintains a random sample of all Google search queries that can be obtained by researchers using the API. The GHT-API provides researchers with the relative share of all Google searches made by individuals within a specific geographic area and time range for given search terms. The API returns a scale proportion equal to the number of searches for specific search terms as a proportion of total searches multiplied by a constant of 10 million. Compared with traditional GT metrics, GHT-API facilitates more granular and unbiased analyses of temporal and spatial search trends pertinent to public health topics. Further research leveraging this promising data source may elucidate novel insights into online health information–seeking behaviors. To identify Google search terms, we examined GT search queries to identify the most popular queries related to “Elf Bar” and “JUUL” from 2022 to 2023. Given JUUL’s prior popularity [ 10 ], we included the term JUUL as a reference that would help interpret the popularity of Elf Bar as an emerging e-cigarette product. The study considered search queries labeled “Breakout” (indicates that the Google search term has grown by more than 5000%) [ 34 ]. Following these techniques and using a valid GHT-API key, we collected the data for the search terms “Elf Bar” and “JUUL” in the United States from January 1, 2022, through December 31, 2023, a time at which Elf Bar was noted for its popularity among US youth [ 17 ]. Like previous studies [ 30 - 33 ], we collected multiple samples (using the same dates) of weekly and monthly data searches for “Elf Bar” and “JUUL” within the United States and averaged them to obtain better estimates of their true values. We conducted weekly and monthly searches at the state level for all 50 states between January 1 and October 16, 2022; however, 8 states (Alaska, Delaware, Montana, North Dakota, Rhode Island, South Dakota, Vermont, and Wyoming) and the District of Columbia were excluded because of insufficient data or suppression of the API by the GHT-API. These areas were not considered in the state-level analysis. Statistical Analysis To obtain GHT-API data, Python 3.11.0 (Python Software Foundation) was used. Excel (Microsoft Corp) was used to clean data, and the geofacet package for R version 4.2.1 (R Foundation for Statistical Computing) was used to create data visualizations. The coefficient of variance (COV) method was used to calculate the variability of data between samples. The COV can be calculated as the ratio of the SD to the mean: where μ is the mean probability of searches and σ is the SD. The COV measures how consistent the values of each sample are from the representative mean of the data samples. The lower the percentage COV value, the greater the homogeneity of the values in the data set. A total of 5 samples were collected with COV that were found to be less than 5% between the samples. Therefore, we used the mean of 5 samples for the analysis. The probabilities of weekly Google searches for “Elf Bar” and “JUUL,” from January 1, 2022, to December 31, 2023, were plotted to visualize the temporal trends. We calculated the percentage changes in Elf Bar after JUUL’s suspension in July 2022 for each state using the following formula: Weekly probabilities of the US public interest in Elf Bar and JUUL were calculated Using Joinpoint Regression Analysis Software (version 5.0.2; National Cancer Institute, May 2023). This joinpoint regression software uses regression modeling to assess trends while searching for temporal trend changes at time points known as joinpoints and estimating the regression function from previous joinpoints [ 35 ]. The number of joinpoints is calculated using a weighted Bayesian information criterion through the data-dependent selection method [ 36 ], and the analysis criteria were set to detect up to 5 joinpoints. This joinpoint regression analysis technique can capture nonlinear inflection points and trends in the data and provide a more nuanced understanding of the dynamics of information-seeking behavior on the internet. Weekly percentage changes between trend-change points were determined using 95% CIs. Results Overview Figure 1 shows that the search interest in the Elf Bar was lower (highest weekly probability: 17.3 × 107) than interest in the “JUUL” (highest weekly probability: 198.4 × 107) at the beginning of 2022. Starting from week 24 (June 12, 2022), Elf Bar search interest (169.1 × 107) exceeded “JUUL” (165.2 × 107) and continued to steadily increase. During week 25, the search probability of JUUL peaked at 2609.3 × 107. During that week (June 23, 2022), the US FDA denied JUUL marketing authority in the United States (temporarily suspending JUUL products from the US market). After this time, online interest in JUUL decreased, reaching an all-time low of 83.9 × 107 on September 3, 2023 (week 88). Alternatively, Elf Bar search interest surpassed that of JUUL, again, on week 28 (July 10, 2022) and steadily increased over time, with the highest weekly probability of 523.2 × 107 reported on week 49 (December 4, 2022). ‎ Figure 1. Weekly Google searches comparing “Elf Bar” and “JUUL” in 2022-2023 (105 weeks). FDA: Food and Drug Administration. Elf Bar Searches at the State Level Trends in monthly Elf Bar search volumes for 42 states from January 1, 2022, to December 31, 2023, are shown in Figure 2 . Overall, there was an upward trend in Elf Bar–related search volumes across all states after the JUUL suspension. West Virginia (866.4 × 107), Louisiana (579.2 × 107), Ohio (542.8 × 107), Mississippi (504.2 × 107), and Pennsylvania (480.6 × 107) had the highest mean search volume for Elf Bar, whereas Michigan (118.2 × 107), Massachusetts (144.5 × 107), New Hampshire (167.2 × 107), Texas (196.5 × 107), and Illinois (198.1 × 107) had the lowest. However, after the JUUL suspension in July 2022, changes in the percentages in Elf Bar searches were highest in Pennsylvania (1010%), Minnesota (872.5%), Connecticut (803.5%), New York (738.1%), and New Jersey (702.9%), whereas states such as Hawaii (–13.1%), Virginia (76.5%), Nebraska (76.6%), Louisiana (80.2%), and Idaho (95.2%) recorded the lowest search interest (see Figure 3 ). ‎ Figure 2. “Elf Bar” weekly search volume from January 1, 2022, to December 31, 2023. The API suppressed data and excluded 8 states (Alaska, Delaware, Montana, North Dakota, Rhode Island, South Dakota, Vermont, and Wyoming) and the District of Columbia with small populations and data uncertainty. API: application programming interface. ‎ Figure 3. Percentage change in mean search volumes of Elf Bar after JUUL suspension in June 2022. Trends in Elf Bar and JUUL Searches From January 1, 2022, to December 31, 2023, three joinpoints for Elf Bar and JUUL were identified, indicating 3 distinct trends or changes in weekly searches that all demonstrated a significant search interest during the study period ( Figure 4 ). Overall, there was an average increase of 1.6% (95% CI 1.5-1.7; P<.001) in Elf Bar’s weekly search probability and an average decrease of –0.5% (95% CI –0.8 to –0.2; P<.001) in JUUL’s weekly search probability ( Table 1 ). ‎ Figure 4. Joinpoint analysis of the weekly search trend of Elf Bar and JUUL from January 1, 2022, to December 31, 2023. *Significant at P<.05. Three joinpoints identified. Table 1. Joinpoint analysis of the weekly search trend of Elf Bar and JUUL. Search term and perioda References Ozga JE, Felicione NJ, Douglas A, Childers M, Blank MD. Electronic cigarette terminology: where does one generation end and the next begin? Nicotine Tob Res. 2022;24(3):421-424. [ FREE Full text ] [ CrossRef ] [ Medline ] Preventing tobacco use among youth and young adults: a report of the surgeon general. U.S. Department of Health and Human Services. 2012. URL: http://www.surgeongeneral.gov/library [accessed 2021-02-15] Wang TW, Neff LJ, Park-Lee E, Ren C, Cullen KA, King BA. E-cigarette use among middle and high school students—United States, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(37):1310-1312. [ FREE Full text ] [ CrossRef ] [ Medline ] Chu K, Colditz JB, Primack BA, Shensa A, Allem J, Miller E, et al. JUUL: spreading online and offline. J Adolesc Health. 2018;63(5):582-586. [ FREE Full text ] [ CrossRef ] [ Medline ] Huang J, Duan Z, Kwok J, Binns S, Vera LE, Kim Y, et al. Vaping versus JUULing: how the extraordinary growth and marketing of JUUL transformed the US retail e-cigarette market. Tob Control. 2019;28(2):146-151. [ FREE Full text ] [ CrossRef ] [ Medline ] Birdsey J, Cornelius M, Jamal A, Park-Lee E, Cooper MR, Wang J, et al. Tobacco product use among U.S. middle and high school students—National Youth Tobacco Survey, 2023. MMWR Morb Mortal Wkly Rep. 2023;72(44):1173-1182. [ FREE Full text ] [ CrossRef ] [ Medline ] FDA finalizes enforcement policy on unauthorized flavored cartridge-based e-cigarettes that appeal to children, including fruitmint. U.S. Food and Drug Administration. 2020. URL: https:/​/www.​fda.gov/​news-events/​press-announcements/​fda-finalizes-enforcement-policy-unauthorized-flavored-cartridge-based-e-cigarettes-appeal-children [accessed 2022-11-17] The People of the State of New York vs. JUUL Labs Inc. Index No. 452168/19(2023). Office of the New York State Attorney General. URL: https://ag.ny.gov/sites/default/files/settlements-agreements/NY%20JUUL%20Final.pdf [accessed 2024-02-14] Chu KH, Hershey TB, Hoffman BL, Wolynn R, Colditz JB, Sidani JE, et al. Puff bars, tobacco policy evasion, and nicotine dependence: content analysis of tweets. J Med Internet Res. 2022;24(3):e27894. [ FREE Full text ] [ CrossRef ] [ Medline ] Dai H, Hao J. Online popularity of JUUL and Puff Bars in the USA: 2019-2020. Tob Control. 2022;31(1):7-10. [ CrossRef ] [ Medline ] FDA notifies companies, including Puff Bar, to remove flavored disposable e-cigarettes and youth-appealing e-liquids from market for not having required authorization | FDA. U.S. Food and Drug Administration. 2020. URL: https:/​/www.​fda.gov/​news-events/​press-announcements/​fda-notifies-companies-including-puff-bar-remove-flavored-disposable-e-cigarettes-and-youth [accessed 2020-08-12] What is synthetic nicotine and what does it mean for the youth vaping epidemic? Truth Initative. 2022. URL: https:/​/truthinitiative.​org/​research-resources/​emerging-tobacco-products/​what-synthetic-nicotine-and-what-does-it-mean-youth [accessed 2022-11-17] Family smoking prevention and tobacco control act—an overview. U.S. Food and Drug Administration. URL: https:/​/www.​fda.gov/​tobacco-products/​rules-regulations-and-guidance/​family-smoking-prevention-and-tobacco-control-act-overview [accessed 2021-01-25] Tattan-Birch H, Jackson S, Kock L, Dockrell M, Brown J. Rapid growth in disposable e-cigarette vaping among young adults in Great Britain from 2021 to 2022: a repeat cross-sectional survey. Addiction. 2023;118(2):382-386. [ FREE Full text ] [ CrossRef ] [ Medline ] Hammond D, Reid JL. Trends in vaping and nicotine product use among youth in Canada, England and the USA between 2017 and 2022: evidence to inform policy. Tob Control. 2023. [ CrossRef ] [ Medline ] Results from the annual National Youth Tobacco Survey. U.S. Food and Drug Administration. URL: https://www.fda.gov/tobacco-products/youth-and-tobacco/results-annual-national-youth-tobacco-survey [accessed 2024-06-13] East K, Taylor EV, Simonavičius E, Reid JL, Burkhalter R, McNeill A, et al. Use of 'Elf Bar' among youth and young adults who currently vape in England: cross-sectional associations with demographics, dependence indicators and reasons for use. Addiction. Mar 21, 2024. [ CrossRef ] [ Medline ] Tang Q, Zhou R, Xie Z, Li D. Monitoring and identifying emerging e-cigarette brands and flavors on Twitter: observational study. JMIR Form Res. 2022;6(12):e42241. [ FREE Full text ] [ CrossRef ] [ Medline ] Bitirim Y. An evaluation on popularity of the prioritized diseases using Google Trends. J Med Imaging Health Inform. 2019;9(4):682-687. [ CrossRef ] Jankowski W, Hoffmann M. Can Google searches predict the popularity and harm of psychoactive agents? J Med Internet Res. 2016;18(2):e38. [ FREE Full text ] [ CrossRef ] [ Medline ] Malagón-Selma P, Debón A, Domenech J. Measuring the popularity of football players with Google Trends. PLoS One. 2023;18(8):e0289213. [ FREE Full text ] [ CrossRef ] [ Medline ] Wise J. FDA orders JUUL to remove all its e-cigarettes from US market. BMJ. 2022;377:o1568. [ CrossRef ] [ Medline ] Allem J, Dormanesh A, Majmundar A, Rivera V, Chu M, Unger JB, et al. Leading topics in Twitter discourse on JUUL and Puff Bar products: content analysis. J Med Internet Res. 2021;23(7):e26510. [ FREE Full text ] [ CrossRef ] [ Medline ] Tan ASL, Weinreich E. #PuffBar: how do top videos on TikTok portray Puff Bars? Tob Control. 2021;30(6):712-713. [ FREE Full text ] [ CrossRef ] [ Medline ] Rosenthal H, Chow N, Mehta S, Pham D, Milanaik R. Puff Bars: a dangerous trend in adolescent disposable e-cigarette use. Curr Opin Pediatr. 2022;34(3):288-294. [ CrossRef ] [ Medline ] Nuti SV, Wayda B, Ranasinghe I, Wang S, Dreyer RP, Chen SI, et al. The use of Google Trends in health care research: a systematic review. PLoS One. 2014;9(10):e109583. [ FREE Full text ] [ CrossRef ] [ Medline ] Cebrián E, Domenech J. Is Google Trends a quality data source? Applied Economics Letters. 2022;30(6):811-815. [ FREE Full text ] [ CrossRef ] Rovetta A. Reliability of Google Trends: analysis of the limits and potential of web infoveillance during COVID-19 pandemic and for future research. Front Res Metr Anal. 2021;6:670226. [ FREE Full text ] [ CrossRef ] [ Medline ] Arora VS, McKee M, Stuckler D. Google Trends: opportunities and limitations in health and health policy research. Health Policy. 2019;123(3):338-341. [ CrossRef ] [ Medline ] Raubenheimer JE, Riordan BC, Merrill JE, Winter T, Ward RM, Scarf D, et al. Hey Google! will New Zealand vote to legalise cannabis? Using Google Trends data to predict the outcome of the 2020 New Zealand cannabis referendum. Int J Drug Policy. 2021;90:103083. [ CrossRef ] [ Medline ] Riddell CA, Farkas K, Neumann K, Santaularia NJ, Ahern J, Mason SM. US shelter in place policies and child abuse Google search volume during the COVID-19 pandemic. Prev Med. 2022;163:107215. [ FREE Full text ] [ CrossRef ] [ Medline ] Raubenheimer JE. A practical algorithm for extracting multiple data samples from Google Trends extended for health. Am J Epidemiol. 2022;191(9):1666-1669. [ CrossRef ] [ Medline ] Neumann K, Mason SM, Farkas K, Santaularia NJ, Ahern J, Riddell CA. Harnessing Google health trends data for epidemiologic research. Am J Epidemiol. 2023;192(3):430-437. [ FREE Full text ] [ CrossRef ] [ Medline ]