Evaluating the effectiveness of recovery-oriented interventions for youth who vape nicotine: a systematic review protocol

Abstract

Introduction

The increase in nicotine vaping among youth has emerged as a critical public health concern. Vaping among youth is linked to adverse health outcomes, including nicotine addiction, cardiovascular and pulmonary diseases and mental health challenges. Recently, there has been a growing demand for research to expand on treatments to enhance the recovery process from vaping nicotine in youth. To this date, no comprehensive review identifies all interventions available for vaping recovery and compares their effectiveness in youth. This proposed systematic review seeks to identify all recovery-oriented interventions for youth aged 10–24 that facilitate vaping recovery and evaluate the measured effectiveness. This review will serve to support healthcare practitioners, nurses and policymakers to further understand recovery interventions and aid in improving vaping recovery among youth.

Method and analysis

This protocol, registered with PROSPERO, adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) framework, and the final review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to ensure quality and replicability. The review will comprise studies including youth aged 10–24 engaging in nicotine vaping. A comprehensive search will be conducted across MEDLINE, Embase, PsycINFO, Scopus and CINAHL, with no restrictions on the date range due to the recency of the topic. Two independent reviewers will screen the identified research for eligibility at the title and abstract levels, with any disagreements resolved by a third reviewer. The review will include randomised control trials and quasi-experimental studies. Full-text review and data extraction will be standardised and completed by the primary researcher. Additionally, studies will be assessed for quality and potential biases.

Ethics and dissemination

Given that this is a review of existing literature, no ethics approval is required. The focus on youth necessitates careful consideration of ethical standards. This review is committed to contributing responsibly to public health knowledge regarding youth vaping recovery. The results from this review will be disseminated through publication in an open-access, peer-reviewed journal and likely through posters and presentations at scientific conferences.

PROSPERO registration number

CRD42024543994.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• Adhering to the PRISMA guidelines, the methodology involves rigorous and unbiased screening of titles, abstracts and full texts.

• The PRISMA strategy minimises the potential for reviewer bias and ensures a thorough and objective assessment of the literature.

• A potential limitation lies in the scope of available literature due to the novelty of vaping as a topic.

• The heterogeneity of the interventions may make comparison between studies difficult.

Introduction

Rationale

The youth vaping epidemic is an emerging and critical area of public health concern.¹ Youth are the predominant population of individuals who vape and are subsequently exposed to adverse health risks.2,4 As vaping use has increased, there has been a corresponding increase in youth striving to enter vaping recovery.^{5 6} Vaping recovery is an individualised and iterative process in which an individual seeks to regain control over their vaping use disorder.⁷ This process may involve reducing consumption, switching to less harmful substances such as nicotine replacement therapies like gum or patches, nicotine-free vaping or adopting other harm reduction strategies like behavioural interventions.⁸ Recovery within this context must be evaluated to determine the effectiveness of available resources.^{4 9} Therefore, the purpose of this review is to synthesise available data on vaping recovery interventions, determine which are more effective and compare the effectiveness of these recovery-oriented interventions for youth aged 10–24, filling a significant knowledge gap.^{5 10}

Vaping refers to the act of inhaling vapour generated by a device known as an electronic cigarette (e-cigarette) or vape. Like traditional cigarettes, individuals can inhale on these battery-powered devices to receive an intake of vapour. These devices function by heating a liquid infused with nicotine, most commonly known as e-juice, to create the vapour.¹¹ While certain devices may contain other substances like marijuana, the review proposed will solely focus on devices that contain only nicotine, as this is the most prevalent form of vaping among youth.¹² Nicotine addiction through vaping is similar to that of cigarette smoking, with interactions through dopaminergic mechanisms and the mesolimbic system contributing to nicotine-dependent reward-related behaviours.¹³

Over the past decade, vaping has gained popularity among youth, being the less stigmatised, more fashionable and socially acceptable alternative to cigarettes.¹⁴ A study examining 1960 Connecticut students showed that roughly 51% of youth have tried vaping, a figure likely underestimated due to under-reporting.¹⁵ Additionally, more than half of youth who vape are experiencing some level of nicotine dependence.¹⁶ Studies show that vaping prevalence is highest among youth and young adults, being more than five times that of adults aged 25 or older.¹⁷ Additionally, more than half of new users have never smoked before.¹⁸ From 2017 to 2019, the prevalence of vaping doubled in Canada, with youth, young adults and individuals who never smoked accounting for the majority of this increase.¹⁷ Although the long-term use of vaping is currently underexplored, youth typically perceive it as a safer alternative to traditional cigarettes, contributing to its popularity.^{19 20} This growing trend of vaping use and dependence among youth raises the alarm for frontline health professionals such as nurses and physicians.²¹

Traditionally, e-cigarettes have been used to achieve smoking cessation; however, the motivations behind use in youth typically include taste, experimentation and relieving boredom.^{22 23} Susceptibility of using e-cigarettes has been linked to multiple factors such as previous use, having a peer who uses them and perceiving those who use them to be more popular.²⁴ In the last 5 years, the marketing of vaping has changed drastically, with many new devices emerging and the design of e-cigarettes closely aligning with aesthetics in the fashion industry.²⁵ Vaping among youth has been associated with many consequences, including association with both cardiovascular and pulmonary disease, leading to over 5000 hospitalisations in the USA in 2020, with hospitalisation rates steadily increasing.² In addition to the physical symptoms, vaping also leads to psychological effects such as addiction, anxiety, depression and potential impacts on brain development.³ Vaping poses various health risks to youth, and without much evidence on long-term use and an abundance of different devices, power settings and attachments, it is difficult to predict the long-term consequences.²⁶

Due to the increase in vaping consumption, there has been a rise in individuals attempting to quit vaping altogether and attain abstinence.⁶ Youth are increasingly seeking information on quitting and the effectiveness of nicotine replacement therapies. According to Palmer et al,²⁷ roughly 44% of youth aged 12–17 reported interest in vaping cessation, with 25% stating unsuccessful attempts throughout the year. For most youth, nicotine exposure initially stems from e-cigarette use. Unfortunately, the majority of existing cessation resources are primarily designed for traditional cigarette smokers.¹¹ Recovery from vaping encompasses more than just abstinence; it is an iterative, multi-stage and holistic process that must be client-centred and aids in developing healthy coping mechanisms.⁷ Vaping recovery is a dynamic process of change that can be cyclical or non-linear and aims towards achieving an improved quality of life in a person-centred or individual way.²⁸ Additionally, recovery may not always result in abstinence; instead, it involves a process aimed at achieving stable improvements in psychosocial functioning and purpose in life.²⁹ Young individuals may begin vaping for various reasons, such as social influences, curiosity or the appeal of flavoured options.³⁰ Youth typically rely on vaping to address emotional issues and stress in their challenging lives.³¹ Therefore, the approach to recovery must be specifically tailored to address the unique experiences and needs of youth, given their critical developmental stage.²⁷

Despite growing research on youth vaping, significant gaps in the literature remain. To this date, no paper has identified all available interventions for vaping recovery; there has been a growing demand for research to expand on treatments to enhance recovery from vaping and e-cigarettes.^{5 10} The alarming rise in youth prevalence and lack of existing reviews on vaping recovery stress the need for a systematic review. The review will synthesise existing literature, enabling healthcare providers to better understand and improve care for these youth. In response to the gap in the literature, this review will identify all available interventions for vaping recovery and assess for effectiveness measured to date of recovery-oriented interventions for youth aged 10–24.

Objectives

This review will address the research question, “What is the effectiveness of recovery-oriented interventions on vaping reduction and cessation among youth who vape?” The insights from this systematic review will serve to support healthcare practitioners, nurses and policymakers in designing informed, evidence-based interventions and policies to understand and effectively aid vaping recovery among youth. The comprehensive approach is essential for a thorough understanding of the recovery process in this demographic. In summary, this review aims to:

1. Identify the available recovery-oriented interventions for youth vaping recovery.

2. Amalgamate studies for a meta-analysis if feasible, based on the heterogeneity of studies.

3. Assess the effectiveness of recovery interventions available.

Methods and analysis

This systematic review has been registered with the International prospective register of systematic reviews (PROSPERO) CRD42024543994.³² The protocol has been reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol (PRISMA-P) framework as a guide, and the proposed systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to ensure quality and replicability.^{33 34}

Eligibility criteria

Study design

The inclusion and exclusion criteria for this systematic review and meta-analysis were designed using the Population, Intervention, Comparison and Outcome (PICO) framework to ensure a focused and relevant selection of studies.³⁵ (P) Studies including participants who are aged 10–24. This age range was chosen to incorporate all youth, from elementary school to postsecondary education and beyond. Boccio and Jackson’s³⁶ sample of Florida youth was used to justify this age range, with vaping peaking at age 14 in their sample and approximately 63% of individuals who vape initiating activity in high school or later. Additionally, this broad age range ensures that the study comprehensively covers the life stages where most behaviours and habits, such as vaping, are typically initiated and solidified and where individuals are seeking help to start the process of recovery.^{11 36} Studies focused on devices that only contain nicotine. (I) Studies focusing on recovery-oriented vaping interventions in youth within all settings. These interventions may include pharmacological treatments, counselling, behavioural therapies, educational programmes or any combination. (C) Studies that compare recovery approaches versus a control, such as pharmacological treatments versus standard care or behavioural approaches versus standard care. (O) The effectiveness of an individual entering recovery, with respect to their individual circumstances; this may include abstinence but could also reflect harm reduction such as decreasing the amount consumed or moving to a safer substance like nicotine-free vaping or nicotine replacement therapies like gum or patches.^{8 29}

Outcome measures

Randomised control trials and quasi-experimental studies will be included to ensure breadth of the review. Additionally, only studies published in English will be included. No restrictions will be placed on the date range due to the recency of the topic.¹ Studies will be excluded if they use non-human subjects or are incomplete (eg, ongoing trials, abstracts). Studies that focus on youth with substance use disorders unrelated to vaping, such as alcohol, cannabis or other drugs, will be excluded. Additional notable studies that do not strictly fit into the inclusion/exclusion will be mentioned in a subsection of the discussion called studies considered but excluded. This approach ensures that relevant literature, which was excluded due to the rigorous application of the inclusion and exclusion criteria, is not overlooked and provides a complete overview of the evidence base. Lastly, noteworthy grey literature like theses, dissertations, conference papers and ongoing research will be searched for and incorporated to create a comprehensive view of existing evidence.³⁷

Information sources and search strategy

The review will begin with screening titles and abstracts from databases, including CINAHL, Scopus, MEDLINE, Embase and PsycINFO. Vaping-related terms: “vap*”, “e-cigarette*”; Recovery and cessation: “recover*”, “cessation”, “quit*”, “manage*”, “treat*”, “harm-reduction”, “abstinence”; Interventions: “Intervention”; Demographics: “adolescen*”, “teen*”, “youth”, “high school”, “young adult”, “college”, “university”, “student” and “post-secondary” will be used in various combinations to ensure all relevant literature is captured. Boolean operations (AND, OR, NOT) will be used to refine the search. The entire search strategy for Ovid (MEDLINE, Embase and PsycINFO) is listed in the table. The search strategy was created with the help of a university librarian to ensure relevant, and sufficient literature was present. A mock search using the strategy retrieved 1355 research articles after removing duplicates, a number adequate for the review (table 1).

Table 1. Search strategy^{33 34}.

Database	Search strategy
MEDLINE/Embase/PsycINFO (Ovid)	ALL<1946 to April 8, 2024>=
	1. ((vap* or e-cigarette*) adj3 (recover* or cessation or quit* or manage* or treat* or “harm reduction” or abstinence or intervention)).tw.
	2. Adolescent Behavior/ or Adolescent/ or Adolescent Health/
	3. (adolescen* or teen* or youth or “high school” or “young adult” or college or university or post-secondary or student*).tw.
	4. 2 or 3
	5. 1 and 4

Note. This table includes the exact search strategy used for MEDLINE, Embase and PsycINFO.

Study records

Data management

Covidence, the leading data management tool for conducting systematic reviews, will be used to manage references at all stages throughout the review and remove duplicates.³⁸ Covidence will be used to remove irrelevant studies and include literature that matches the inclusion and exclusion criteria. After all abstracts have been reviewed by the primary researcher and a research assistant to increase inter-rater reliability, all remaining papers will be retrieved for full-text review.³⁹

Selection process

Two reviewers will independently perform each phase of the review, including title and abstract screening, full-text assessment and data extraction to avoid data entry errors.³⁹ Both reviewers will be trained on how to use Covidence. Furthermore, a calibration phase involving 30 articles will be carried out to confirm consensus among team members regarding the inclusion and exclusion criteria. All disagreements regarding screening will be discussed among reviewers. Any remaining disagreements will be resolved by including a third-party doctoral-level reviewer to facilitate further discussion.

Data collection process and data items

The data extraction process will be completed using Covidence and exported into a data extraction table on Google Sheets to maximise organisation.⁴⁰ The following descriptive and analytical data will be collected from each full-text paper: (1) Basic Information: Authors full name, publication year, country of origin and Covidence reference ID; (2) Study Characteristics: Study design type, setting (clinical, educational) and study duration; (3) Participant Details: Mean age range, number of participants, sex, inclusion and exclusion criteria for participants and available participant demographic details (eg, ethnicity, socioeconomic status); (4) Intervention Details: Type of intervention, number of participants assigned to each study, duration and frequency of the intervention, control groups used and description of the comparison intervention (if available); (5) Outcome Measures: Primary and secondary outcomes measured, measurement tools and techniques, frequency of outcome measures and definitions of key terms (eg, what constitutes ‘recovery’ or ‘relapse’); (6) Results: Key findings related to the effectiveness of interventions, statistical analysis used and its findings (eg, p value, confidence intervals), any subgroup analysis (eg, differences in effectiveness based on age, sex); (7) Limitations: Any limitations identified by the authors; (8) Additional Information: If information from an included study is missing, there will be an attempt to contact the authors to obtain the information, which will be recorded in a correspondence log. Additionally, the recommended flow diagrams from the PRISMA guidelines will be used.^{33 34} Moreover, the data extraction phase will be piloted with a doctoral-level reviewer to ensure that all necessary data is captured.

Outcomes and prioritisation

The primary outcome of interest for this review measuring the effectiveness of recovery-oriented interventions for youth who vape nicotine will include reduction or cessation of vaping, positive or negative attitudes towards vaping, future intentions to not engage in the use of nicotine vapes and changes in mental health outcomes (eg, depression, anxiety). This outcome will be measured by the rate of successful entry into the recovery process and the duration at which the individual remains in recovery at the longest follow-up available in the studies. The comparison will focus on the number of participants who achieve recovery in the intervention group relative to those in the control group. The secondary outcome for this review will measure if an individual has attained abstinence, has moved to a safer substance or has implemented harm reduction. Raw numbers will be extracted if possible, but if not publicly available, effect sizes and their confidence intervals will be used instead.

Risk of bias in individual studies

Studies included in the data extraction phase will be assessed for risk of bias in conjunction with their study design to ensure familiarity with the study. For randomised control trials, The JBI Critical Appraisal Tool for Assessment of Risk of Bias for Randomized Controlled Trials will be used; for quasi-experimental studies, the JBI Checklist for Quasi-Experimental Studies will be used. Both tools will be used to assess the risk of bias at the study level and overall methodological quality.^{41 42} The JBI critical appraisal tools were chosen to evaluate bias and rigour as they have been recently updated in 2023 revisions and go beyond assessing the overall quality of a study; the new versions allow for judgements specific to the domains of bias in which the question is contained.⁴¹

Data synthesis

Quantitative synthesis using meta-analysis will be considered if studies exhibit sufficient homogeneity in their design, interventions, participant characteristics and reported outcomes.⁴³ Review Manager (RevMan) will be used to conduct the meta-analysis, applying a random-effects model due to the expected variability among studies.⁴⁴ The primary statistical measures include risk ratios for dichotomous outcomes and mean differences for continuous outcomes. Homogeneity will be assessed by creating a forest plot.⁴³ Additionally, the I² statistic will be used to further assess the heterogeneity among studies, interpreting values as small (25%), moderate (50%) or large (75%).⁴⁵ This assessment will guide us in conducting further subgroup analyses to explore the effects of variables like age and intervention type, as well as sensitivity analyses to evaluate the robustness of the findings. Regardless of whether a meta-analysis is feasible or not due to significant heterogeneity or data inconsistency, a narrative synthesis will be still conducted, organising findings by intervention type in tables to outline effectiveness. The narrative synthesis will also identify gaps in the current literature and provide a contextual understanding of the research body available.^{33 34}

Metabias(es)

A funnel plot will be employed to address publication bias if a sufficient number of studies are included in the meta-analysis. The plots will be inspected for asymmetry, which is often indicative of publication bias. Additionally, an Egger’s test will be used to quantitatively assess the presence of publication bias if appropriate.⁴⁶ The outcomes reported in published studies will be compared with those outlined in the study protocols or trial registries, where available, to identify selective reporting. This comparison will be used to identify any discrepancies between planned and reported outcomes, indicating potential reporting bias.⁴⁷

Confidence in cumulative evidence

The quality of evidence from randomised control trials will be appraised using the Grading of Recommendations, Assessment, Development, and Evaluations framework to ensure a comprehensive analysis. The framework will be used to evaluate the potential for publication bias, accuracy of the literature and consistency.⁴⁸

Patient and public involvement

None.

Ethics and dissemination

This review is conducted on published work and does not require ethics approval. The findings will be published in an open-access, peer-reviewed journal and used as a guide for clinicians, researchers and policymakers to further their understanding of vaping recovery. In undertaking this systematic review and meta-analysis, it is essential to address ethical considerations, particularly focusing on the vulnerability of youth. As a vulnerable population, youth require special attention due to their developmental stage and susceptibility to external influences.⁴⁹ The included studies must demonstrate ethical conduct, notably regarding consent and safeguarding of this group. While systematic reviews typically analyse pre-existing data and may not individually require ethical approval, ensuring all included studies adhere to ethical standards and have received appropriate ethical clearance is especially important. Additionally, given the significant public health implications of vaping among youth, this research carries a responsibility to contribute positively and accurately to the body of knowledge. This responsibility involves ensuring that findings are communicated responsibly and used to inform public health policies and interventions that genuinely benefit the population. The findings of this review will be shared by publishing in an open-access, peer-reviewed journal and may also be presented through posters and discussions at scientific conferences.

The funding agencies did not influence the design of the review, the decision to publish or the preparation of the manuscript.