Effects of a short school-based vaping prevention program for high school students

Abstract

Educational programs that address adolescents’ misperceptions of e-cigarette harms and benefits and increase refusal skills play an important role in preventing initiation and use. This study evaluates changes in adolescents’ e-cigarette perceptions, knowledge, refusal skills, and intentions to use following a real-world implementation of a school-based vaping-prevention curriculum. Study participants were 357 9th-12th grade students from one high school in Kentucky, United States who participated in a 60-minute vaping prevention curriculum from the Stanford REACH Lab’s Tobacco Prevention Toolkit. Participants completed pre- and post-program assessments regarding their e-cigarette knowledge, perceptions, refusal skills, and intentions to use e-cigarettes. Matched paired t-tests and McNemar tests of paired proportions were applied to assess changes in study outcomes. Following the curriculum, participants indicated statistically significant changes on all 15 survey items related to e-cigarette perceptions (p’s < 0.05). Participants demonstrated improved knowledge that e-cigarettes deliver nicotine in the form of an aerosol (p <.001), reported that if a friend offered them a vape it would be easier to say no (p <.001), and indicated they would be less likely to take the vape (p <.001) after receiving the curriculum. Other survey items related to knowledge, refusal skills, and intentions did not demonstrate significant changes. Overall, participation in a single session vaping-prevention curriculum was associated with several positive changes in high school students’ e-cigarettes knowledge, perceptions, refusal skills, and intentions. Future evaluations should examine how such changes affect long-term trajectories of e-cigarette use.

1. Introduction

Recent national surveys estimate that over 2.5 million U.S. middle and high school students are currently using e-cigarettes (Cooper et al., 2022). The popularity of e-cigarettes among adolescents is a cause for concern given associated health risks (Tsai et al., 2020) and adolescents’ heightened vulnerability to nicotine addiction (Yuan et al., 2015).

There are several factors associated with adolescents’ increased likelihood of initiation and use of e-cigarettes, including adolescents’ misperceptions about e-cigarette risks and benefits (Bernat et al., 2018, Zheng et al., 2021) and social pressures to use (Bernat et al., 2018, Kong et al., 2015). For example, many adolescents view e-cigarettes as a healthier alternative to cigarettes (Kong et al., 2015), while underestimating potential health risks (Bernat et al., 2018), nicotine content (Morean et al., 2019), and addictiveness (Bernat et al., 2018). Adolescents also turn to e-cigarettes for stress relief (Bernat et al., 2018), despite evidence that e-cigarette use may negatively impact mental health (Nguyen and Mital, 2022). Additionally, adolescents are particularly susceptible to peer influence (Sumter et al., 2009), with many young e-cigarette users highlighting peer pressure and social belonging as playing a role in their e-cigarette experimentation and use. These risk factors are compounded by ubiquitous e-cigarette advertising and promotion on social media designed to attract young users (Zheng et al., 2021).

High rates of adolescent e-cigarette use and established health harms stress the importance of developing and evaluating programs aimed at preventing e-cigarette initiation and use. Key strategies for such programs include improving adolescents’ knowledge of e-cigarette health risks, teaching refusal skills, and discussing marketing and social media tactics used by tobacco companies (Gaiha and Halpern-Felsher, 2021, Liu et al., 2022).

One program based on these strategies is a one-session vaping-prevention curriculum from the Stanford REACH Lab’s Tobacco Prevention Toolkit (Gaiha et al., 2021), which has been associated with improvements in adolescents’ e-cigarette knowledge, perceptions of health harms, and intentions to try when implemented in school settings (Gaiha et al., 2021). However, the curriculum’s impact on adolescents’ refusal skills and perceptions of tobacco companies have yet to be evaluated. The current study builds on prior evaluations of the vaping-prevention curriculum by examining its impact on these untested outcome domains, and also assesses changes in adolescents’ e-cigarette knowledge, perceptions, and intentions to try with a novel sample. Furthermore, this study is an evaluation of a real-world implementation of the curriculum, and as such is a valuable demonstration of program effectiveness in non-research settings.

2. Method

The study design is a one arm pre-post analysis to evaluate changes in high school students’ e-cigarette knowledge, perceptions, refusal skills, and intentions to use following participation in a single session vaping-prevention curriculum from the Stanford REACH Lab’s Tobacco Prevention Toolkit. The session included a 35-minute presentation on e-cigarettes as well as interactive activities and quizzes. More information on the Toolkit is available at https://med.stanford.edu/tobaccopreventiontoolkit.html and (Gaiha et al., 2021).1

Participants were 600 9th-12th grade students from one high school in Kentucky, United States who participated in a school-wide implementation of the vaping prevention curriculum. The school sent a notification home with each student with information about the vaping prevention education being taught to the students. The curriculum was then administered from February through April 2022 during students’ English classes to ensure all students from each grade would have the opportunity to participate. Sessions were led by a community health nurse who had been trained in implementing the curriculum by members of the Tobacco Prevention Toolkit team. Training was based on an empirically validated approach which included (1) an information session, (2) website navigation demonstration, and (3) opportunities to practice presenting lessons (Lazaro et al., 2021). This study was approved by the IRB at Stanford University’s School of Medicine.

Participants completed an online survey immediately before and after the educational session (i.e., approximately 50 min apart). The survey asked for self-reported age, grade, sex, race/ethnicity, and past e-cigarette and cigarette use (see Table 1). Participating students also responded to questions pre- and post-education related to their e-cigarette perceptions, knowledge, refusal skills, and intentions to try e-cigarettes. All questions were shown to all study participants; however, ever users of e-cigarettes could select “have already tried this product” in response to the intention item measuring future likelihood of trying e-cigarettes. All perception and refusal variables were coded so that higher scores reflected an anti-e-cigarette profile. Knowledge variables were coded so that 1 indicated a correct response and 0 indicated an incorrect response.

Table 1.

Sociodemographic, E-cigarette, and Cigarette Use Information for All Participants and Those Linked Pre- and Post-Surveys.

	All Participants (N = 600)	Linked Participants (N = 357)
Age (M, SD)	16.0 (1.3)	16.0 (1.2)
Grade (n, %)
9th	190 (31.7)	103 (28.9)
10th	157 (26.2)	93 (26.1)
11th	152 (25.3)	99 (27.7)
12th	101 (16.8)	62 (17.4)
Sex (n, %)
Male	306 (51.0)	179 (50.1)
Female	260 (43.3)	161 (45.1)
Other	34 (5.7)	17 (4.8)
Race/Ethnicity (n, %)
Hispanic or Latino	42 (7.0)	24 (6.7)
American Indian/Alaska Native	9 (1.5)	2 (0.6)
Asian	24 (4.0)	17 (4.8)
Black or African American	41 (6.8)	18 (5.0)
Native Hawaiian	6 (1.0)	4 (1.1)
White	357 (59.5)	236 (66.1)
More than One Race	8 (1.3)	2 (0.6)
Mixed or Other	17 (2.8)	4 (1.1)
Not Sure	10 (1.7)	2 (0.06)
Missing Data	86 (14.3)	48 (13.4)
Ever Use (n, %)
E-cigarettes	117 (20.0)	58 (16.2)
Cigarettes	46 (7.7)	19 (5.3)
Past 30-Day Use (n, %)
E-cigarettes	117 (20.00)	58 (16.2)
Cigarettes	46 (7.7)	19 (5.3)

Note. M = mean, SD = standard deviation.

All survey items are available in Table 2 and Supplementary Table S1, and were based on curriculum content and adapted from prior surveys and evaluations related to these constructs (Gaiha et al., 2021, Kelder et al., 2020, McKelvey et al., 2018, Song et al., 2009). Survey items were pilot tested with youth and educators, with changes made until the survey was clear to pilot participants.

Table 2.

E-cigarette Perceptions, Knowledge, Refusal Skills, and Intentions at pre-test vs post-test among linked participants (N = 357).

Perceptions of Harms and Benefits	N	Pre-TestM (SD)	Post-TestM (SD)	p-value	Cohen’s d
If I vape I will…a
Breathe in harmful chemicals	355	3.63 (0.72)	3.75 (0.60)	0.003	-0.15
Damage my lungs	355	3.59 (0.73)	3.74 (0.61)	<0.001	-0.18
Imagine you are vaping an e-cigarette in a room with your friend…b
How concerned are you about your vaping’s impact on the health of your friend?	351	2.71 (1.06)	3.10 (1.00)	<0.001	-0.46
Using E-cigarettes…a
Is safe since it has fewer chemicals than cigarettes	349	3.38 (0.75)	3.51 (0.80)	0.002	-0.16
Increases the risk of developing a lung or heart disease later in life	346	3.50 (0.72)	3.59 (0.73)	0.019	-0.11
Is harmful to the lungs	344	3.59 (0.68)	3.67 (0.63)	0.018	-0.11
Gives people more energy	345	3.08 (0.81)	3.16 (0.94)	0.041	-0.09
Reduces stress	344	2.67 (0.95)	3.18 (0.95)	<0.001	-0.50
Harms the environment	344	3.08 (0.89)	3.34 (0.84)	<0.001	-0.28
Can be harmful to others around me	343	3.34 (0.79)	3.58 (0.70)	<0.001	-0.30
Tobacco Companies…a
Are truthful about the addictiveness of their products	352	3.07 (0.93)	3.30 (0.97)	<0.001	-0.24
Are truthful about the health effects of their products	352	3.01 (0.98)	3.33 (0.92)	<0.001	-0.34
Perceptions of Addictiveness
How addictive do you think these products are?
E-cigarettesc	356	3.93 (1.26)	4.40 (1.04)	<0.001	-0.39
Cigarettesc	355	4.06 (1.28)	4.43 (1.01)	<0.001	-0.33
You have to use nicotine products daily to become addicteda	352	2.93 (0.92)	3.06 (0.99)	0.003	-0.15
Refusal Skills
If one of your friends were to offer you a vape…d
How easy would it be to say no to your friend?	355	3.68 (0.58)	3.76 (0.54)	<0.001	-0.20
How easy would it be to walk away from the situation?	354	3.62 (0.65)	3.66 (0.63)	0.09	-0.07
Knowledge	N	Pre-Test (%)	Post-Test (%)	p-value	Chi-Square
E-cigarettes are devices that deliver nicotine in the form of a…e	356	6.2%	75.6%	<0.001	237.32
You have to use nicotine products daily to become addictedf	353	78.5%	81.6%	0.16	1.96
What is the definition of addiction?g	342	7.3%	7.6%	1.00	0.00
Intentions to Try	N	Pre-TestM (SD)	Post-Test M (SD)	p-value	Cohen’s d
How likely is it that you will EVER try e-cigarettes?h	295	1.25 (0.61)	1.24 (0.70)	0.439	0.01
If one of your friends were to offer you a vape, would you try it?i	333	2.19 (0.53)	2.32 (0.64)	<0.001	-0.18

Note. ^aScale was 1 (Strongly Agree) to 4 (Strongly Disagree); ^b1 (Not at all concerned) to 4 (Extremely Concerned); ^c1 (Not at all addictive) to 5 (Extremely addictive); ^d1 (Very easy) to 4 (Very hard); ^e (“Aerosol” = 1; “Vapor”, “Liquid”, “Steam” = 0); ^f (“False” = 1; “True” = 0); ^g(“Uncontrollable desire to use something despite consequences” = 1; “The state/condition of not having any or enough of something”, “A situation in which someone must have something to survive”, “I don’t know” = 0); ^h1 (Very unlikely) to 4 (Very likely), participants who had already used e-cigarettes could select “have already tried the product;” ⁱ1 (Definitely not) to 4 (Definitely yes). For perception and refusal skills items, values were recoded so that higher scores reflect an anti-e-cigarette profile. M = Mean; SD = standard deviation.

The current study focused on participants with successfully linked pre- and post-curriculum surveys in order to assess changes in key study variables attributable to the one-session vaping prevention curriculum. To link pre- and post-curriculum surveys while maintaining confidentiality, participants created a self-determined identifying code based on a set of instructions on the surveys (i.e., first three letters of mother’s first name, number of month born, first three letters of favorite 5th grade teacher’s name). Pre- and post-curriculum tests were completed by 600 and 410 high school students, respectively (68.3% completion rate), and were successfully linked for 357 participants (59.5% of pre-tests; 87.1% of pre- and post-tests), yielding the analytic sample of N = 357 for the current study. Sociodemographic information for all study participants and for just the linked participants is provided in Table 1.

Paired sample t-tests and McNemar tests of paired proportions (pairs are within subject’s pre and post survey responses) were applied to assess changes in study outcomes associated with participation in the curriculum. P-values are considered statistically significant at p <.05; however, in this paper they are provided for summary purposes rather than in their formal use in hypothesis-testing. To assess if students who were excluded from analysis (e.g., pre-survey could not be linked to a post-survey using the identifying code) were substantively different from those included in our analysis, we also quantified the comparability between the unlinked and linked participants using standardized mean differences (SMDs) of key pre-test study variables, and then replicated study analyses with the full sample (n = 600) using unpaired t-tests and two-proportions z-tests. We interpret standardized mean differences values of > 0.20 to be large differences between groups.

3. Results

Study results for linked participants (N = 357) are shown in Table 2. The educational session was associated with improvements on all 15 perceptions items (p’s < 0.05), including increased perceptions of e-cigarette and cigarette addictiveness (p’s < 0.001), decreased perceptions that e-cigarettes reduce stress (p <.001), and decreased agreement that tobacco companies are truthful regarding their products’ addictiveness and negative health effects (p’s < 0.001). Participants also reported increased agreement that they will damage their own lungs if they vape (p <.001), and that using e-cigarettes can be harmful to others around them (p <.001). Concerns about the impact of one’s own vaping on the health of a friend also increased after the curriculum (p <.001).

There was a notable improvement on one of the two refusal skill items. Following the curriculum, participants indicated that it would be easier to say no to a friend if offered a vape (p <.001), but there was a marginal increase in how easy it would be to walk away from the situation if offered a vape (p =.09). For knowledge items, a higher proportion of participants correctly identified that e-cigarettes deliver nicotine in the form of an aerosol (p <.001) following the curriculum, but changes in the two knowledge items related to addiction were non-significant. For intentions items, mean values for the item measuring likelihood of ever trying e-cigarettes were low on both pre- and post-tests (M_pre = 1.25; M_post = 1.24), and there was no meaningful change (p =.44). There was a reduction in participants’ willingness to try an e-cigarette if offered by a friend (p = < 0.001). See Table 2 for details.

Comparison of pre-curriculum survey responses between participants who were included (i.e., linked) vs excluded (i.e., unlinked) from study analyses revealed several differences in characteristics. Non-Hispanic Asian and non-Hispanic White students were more likely to be included in the linked analyses, whereas Non-Hispanic Black participants and participants selecting “unsure” for their race and ethnicity were less likely to be included. Participants included in the main analyses also reported higher pre-program survey scores on four perception items and one knowledge item relative to excluded participants. The perceptions items were “using e-cigarettes is safe” (smd = 0.358), “using e-cigarettes reduces stress” (smd = 0.228), “tobacco companies are truthful about the addictiveness of their products” (smd = 0.246), and “how addictive do you think [e-cigarettes] are?” (smd = 0.201). The knowledge item was “you must use nicotine daily to get addicted” (smd = 0.219).

Despite these differences between linked and unlinked participants, the general pattern of study results was similar when examining differences between pre- and post-curriculum survey results among the full sample (n = 600) compared to the main analytic sample (n = 357). Two exceptions included one knowledge item that became statistically significant (i.e., you must use nicotine daily to get addicted, p =.007), and one refusal skill item that was no longer statistically significant (i.e., how easy would it be to say no to your friend, p =.08). All other results were similar. See Supplementary Table S1 for more information.

4. Discussion

High school students participating in a one-session vaping prevention curriculum from the Stanford REACH Lab’s Tobacco Prevention Toolkit reported immediate positive changes in their perceptions of e-cigarettes and also showed some improvements in knowledge, refusal skills, and intentions to use. Most notably, the curriculum was associated with significant reductions in high school students’ beliefs that e-cigarettes reduce stress, a common misperception associated with initiation and use (Bernat et al., 2018). Participants also perceived e-cigarettes as more addictive and more damaging to their own and peers’ health after the curriculum. More students also correctly identified that e-cigarettes deliver nicotine in the form of an aerosol rather than a vapor, a common misconception that can obscure health risks (Ebrahimi Kalan et al., 2022).

Few students correctly identified the definition of addiction. This topic should be clarified in future sessions, particularly since adolescents often misunderstand what addiction means (Roditis et al., 2016). Results regarding students’ intentions to use e-cigarettes were mixed. The curriculum was not associated with significant changes in high schoolers’ self-reported likelihood of ever trying e-cigarettes. This may have in part been due to low levels of intentions reported on the pre-curriculum survey (i.e., floor effects) or lack of statistical power, and represents an area in need of further investigation. However, after the curriculum students did indicate they would be less likely to try an e-cigarette that was offered by a friend. These results likely reflect distinct aspects of decision-making related to risk behavior (e.g., Gerrard et al., 2008). Specifically, adolescents’ self-reported likelihood of trying e-cigarettes may represent a more deliberative dimension of decision-making, whereas accepting a vape offered by a friend may be guided by spontaneity or impulsivity (Gerrard et al., 2008). Given the salient role of peer influence in adolescent e-cigarette initiation and use (Bernat et al., 2018, Kong et al., 2015), reducing adolescents’ willingness for spontaneous or unplanned use of e-cigarettes in social situations represents an important target for mitigating overall risk. These findings suggest that future iterations of the curriculum should address both deliberative and spontaneous decision-making related to e-cigarette use in order to ensure that adolescents are adequately equipped to resist e-cigarette use in social situations.

It should also be noted that pre- and post-surveys were successfully linked for only 60% of students who completed pre-curriculum surveys, with comparison of linked vs unlinked participants revealing some important differences between groups. For example, we were more likely to successfully link surveys for Asian, Non-Hispanic or White, Non-Hispanic students relative to Black, Non-Hispanic students. Though the general pattern of results was similar between linked participants and the full sample, sociodemographic disparities in successful linkage indicate that more accessible and equitable linking procedures should be implemented in future studies to ensure that study findings accurately represent all participants. Furthermore, the relatively low completion rate for post-tests, particularly among 9th grade students, may be explained by some students running out of time during the allotted 60 min or disengaging from assessments. Curriculum developers should work closely with implementers to ensure that lessons, activities, and assessments can all be completed within the time-constraints inherent in school settings, especially for younger participants. Future evaluations of the curriculum should also apply more robust causal designs, such as randomized control trials, with larger samples to more rigorously examine its impact on adolescents’ e-cigarette outcomes. Furthermore, future studies should also include longitudinal follow-up assessments to evaluate sustained changes in study outcomes, as well as how changes in adolescents’ perceptions, knowledge, refusal skills, and intentions shape long-term trajectories of e-cigarette initiation and use. Such evaluations should also examine hetereogenous treatment effects based on key sociodemographic and behavioral factors (e.g., sex, race/ethnicity, e-cigarette use).

Despite these limitations, study results provide compelling evidence that a single educational session from the Stanford REACH Lab's Tobacco Prevention Toolkit is effective at promoting immediate positive changes in adolescents’ e-cigarette knowledge, perceptions, refusal skills, and intentions when implemented in real-world high school settings by community health professionals. These results support findings demonstrated by prior school-based evaluations (Gaiha et al., 2021), while expanding documented benefits to include improved perceptions of e-cigarette health harms and increased skepticism of tobacco company truthfulness about their products, as well as improved refusal skills. Overall, the findings support the continued implementation of school-based e-cigarette prevention programs (Liu et al., 2022).

Funding sources.

This study was supported by the Taube Research Faculty Scholar Endowment to Bonnie Halpern-Felsher and through additional support from a grant from the Tobacco-related Disease Research Program (TRDRP, grant number 27IR-0043), and a grant from the NIH/NCI (1R01CA263121-01) to Dr. Halpern-Felsher.

Dr. Halpern-Felsher is the Founder and Executive Director of the Stanford Tobacco Prevention Toolkit. She is also a paid expert scientist in some litigation against the e-cigarette industry and an unpaid scientific advisor and expert regarding some tobacco-related policies. The authors have no other conflicts of interest to disclose.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Data availability

Data will be made available on request.