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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Curr Probl Pediatr Adolesc Health Care. 2022 May 6;52(6):101204. doi: 10.1016/j.cppeds.2022.101204

School-based programs to prevent adolescent e-cigarette use: A report card

Jessica Liu a, Shivani Mathur Gaiha b, Bonnie Halpern-Felsher b,*
PMCID: PMC9296568  NIHMSID: NIHMS1820190  PMID: 35534403

Abstract

Given high rates and known health consequences of adolescent e-cigarette use as well as adolescents′ susceptibility to nicotine addiction, school-based efforts to prevent and reduce adolescent e-cigarette use should continue to be developed, implemented, disseminated, and evaluated. This paper elaborates on best practices for developing and implementing prevention programs, including the importance of grounding programs in theories and frameworks that empower adolescents, including normative and interactive education, and having programs that are easily accessible and free of cost. Programs should also address key factors driving adolescent e-cigarette use, including discussing misperceptions, flavors, nicotine content, addiction, and the role that marketing plays in appealing to adolescents. The paper also discusses the gap areas of currently available prevention programs and highlights the need for evidence-based approaches and the importance of rigorous evaluation of programs.

Introduction

Electronic cigarette (e-cigarette) use among middle- and high-school students remains high,1 and varies in part by the current landscape of evolving e-cigarette products.2 Despite the evidence for negative e-cigarette health risks, adolescents are susceptible to using e-cigarettes for a number of reasons, including the appeal of flavors, peer influences, social media and industry marketing, and misperceptions of reduced harm of e-cigarettes compared to other tobacco products such as combustible cigarettes.3–6

E-cigarette use has been associated with adverse health effects such as cardiac and respiratory problems and secondhand exposure;7 e-cigarette aerosols also can contain cancer-causing chemicals.8 Nicotine is highly addictive, and nicotine’s impact on brain development can lead to negative effects on behavior, mental health, school outcomes, and coping skills.9,10 Recent studies have shown that adolescent use of e-cigarettes is associated with future initiation of combustible cigarettes.11–13

Research has found that adolescents are highly susceptible to nicotine addiction, especially given the high nicotine content in many e-cigarettes and pod-based e-liquids that contain at least the amount of nicotine found in a pack of combustible cigarettes.14,15 Further, the salt-based nicotine patented by JUUL but now found in many e-cigarettes feels less harsh when inhaled and allows for greater absorption and use, compared to cigarettes or older e-cigarette devices.16 A study examining adolescents’ addiction to nicotine from e-cigarettes identified that over half of the sample experienced some level of nicotine dependence.17 Another study found that adolescents were less likely to quit or reduce e-cigarette use if they were nicotine dependent.18

Given the high rates of e-cigarette use, known health consequences of e-cigarettes,19–21 and adolescent susceptibility to nicotine addiction, school-based e-cigarette education, prevention, and cessation programs should be made a priority for adolescents. This paper discusses the importance of school-based prevention programs and elaborates on the need for using theory in developing prevention programs. It then presents the components and best practices of various programs currently available to prevent and reduce adolescent e-cigarette use. Finally, it addresses programmatic gap areas, the importance of rigorous evaluation of programs, and need for evidence-based approaches.

Importance of school-based e-cigarette prevention programs

Schools and classrooms are particularly great settings for delivering e-cigarette prevention programs because a large portion of adolescents’ social lives take place and revolve around a school setting and with their peers.22–24 School-based programs allow for adolescents to learn alongside their peers to build collective efficacy around preventing or reducing e-cigarette use, while simultaneously building self-efficacy.25,26

There are three main types of school-based e-cigarette programs: prevention programs,27–33 secondary prevention programs (including Alternative-to-Suspension programs),34 and cessation interventions. E-cigarette prevention programs are often conducted in health education classrooms as a part of usual curriculum or in afterschool settings. Alternative-to-Suspension programs and cessation interventions are used when adolescents are caught using e-cigarettes on campus, or when adolescents self-identify that they are using and need help to quit. Often these Alternative-to-Suspension programs and cessation interventions are carried out by a school nurse, counselor, or health education teacher, both during and outside of school hours. This paper focuses on school-based prevention programs, and discusses Alternative-to-Suspension programs as a form of secondary prevention.

School-based tobacco prevention programs have shown mixed results in changing normative beliefs and actual behaviors.23,35–38 However, there are components of school-based tobacco prevention programs that have been effective such as interactive curricula, refusal skills activities, and content addressing health effects and industry marketing.39,40

Social and emotional learning (SEL) is also an important aspect of school-based programs, including e-cigarette prevention programs. SEL programs establish a classroom learning environment that enhances adolescents’ capacity to manage emotions, understand perspectives of others, establish goals, and use interpersonal skills.41 Core components of SEL programs include addressing social skills, identifying feelings, and learning coping or relaxation skills.42

Review of best practices

To understand what e-cigarette programs are doing well and where remaining gaps exist, we next describe components and best practices of existing prevention programs.43

Importance of Theory

Effective e-cigarette prevention programs are based on theories that promote positive behavior change and are situated within a framework of adolescent development and adolescent learning styles.44 Explicitly using theory and evidence-based frameworks in developing prevention programs helps to understand why risk behaviors happen, and provides a map of how to create better resources and strategies that have worked well in the past. The Theory of Planned Behavior, Social Cognitive Theory, and the Transtheoretical Model of Behavior Change45–47 are commonly used behavior change theories to inform substance use prevention.

Theories of behavior change

The Theory of Planned Behavior, proposed by Azjen in 1991, suggests that intentions, attitudes, subjective norms, and perceived behavioral control are important determinants of behavior.45,48 The Theory of Planned Behavior has been widely used to understand intentions and design interventions around tobacco use,45,48 and continues to be cited in the development of e-cigarette prevention programs.

Social Cognitive Theory, which emerged from Social Learning Theory, was developed by Bandura in the 1980s. This theory focuses on the dynamic and reciprocal determinism of individuals in relation to cognitive, behavioral, and environmental factors.45 Reciprocal determinism implies that all three of these domains interact to explain a behavior change.45 The core constructs of Social Cognitive Theory explain how individuals learn from modeled behaviors and support how educating adolescents about social norms can help build refusal skills to resist peer pressure and influence behavior change.45

The Transtheoretical Model of behavior change or Stages of Change model, developed by Prochaska and DiClemente in the 1980s, posits that health behavior changes through the progression of a number of stages, including precontemplation, contemplation, preparation, action, and maintenance.7,69 This theory has been used in smoking cessation to meet people at the stage they are at in the behavior change process for quitting.47,49

Frameworks to inform adolescent programs

Frameworks such as the Optimal Health Framework, Positive Youth Development, and Community-Based Participatory Research are also applied to many adolescent-focused programs to build engagement and foster participatory learning.44

The optimal health framework

The Optimal Health Framework argues that physical and social environments including parents, peers, schools, communities, and media, can influence adolescents’ engagement in unhealthy risk behaviors.50 Risk-taking behavior results from neurobiological development during adolescence, which is why adolescents seek out novel experiences and experimentation to help develop independence and self-identity.50 Programs informed by the Optimal Health Framework strive to improve the health and well-being of the whole person, lay the foundation for developmentally appropriate behavioral skills, consider adolescent risk taking as normative, and engage diverse communities and leaders to improve social determinants of health.50

Positive youth development

Positive Youth Development (PYD) encourages educators to engage and empower adolescents in the learning process in their journey into adulthood.44 PYD includes supports such as adult mentorship and community engagement opportunities (e.g., through adolescent-led projects).44 PYD aims to provide adolescents with relationships and experiences that facilitate development of self-regulation and other positive assets that buffer against involvement in substance use.44

Community-based participatory research

Community-based participatory research (CBPR) empowers community members including youth, educators, parents, and healthcare providers, to participate in the research process from beginning to end, as they share their knowledge and experiences to formulate research questions and processes that are culturally sensitive and relevant to drive social change. CBPR methods are also used to create and disseminate prevention programs, with the resulting curricula readily adapted by the communities involved in creating the curricula.51

CBPR creates community and empowers both adolescents and educators to directly advocate for issues that impact themselves. Impactful health education programs and curricula around e-cigarette prevention include modules that not only teach adolescents about the risks of tobacco, but also encourage adolescents to have social involvement and participation in this issue in their own communities.52 Additionally, by incorporating educators into the process of developing prevention materials, educators feel empowered to participate and use the curricula that they know either they or similar educators developed. For example, the Stanford Tobacco Prevention Toolkit uses CBPR to develop content through focus group discussions and working groups with parents, educators, researchers, and youth.53

Another example of using CBPR to develop an adolescent e-cigarette prevention program is creating a Youth Advisory Board (YAB). Tobacco prevention programs have created YABs to engage in CPBR, as well as incorporate elements of PYD.44 YABs are especially helpful when trying to understand the nuances of how to better tailor prevention materials to a specific community. Participation in a YAB also gives adolescents a sense of leadership in their schools and greater community.52

Based on the previously mentioned theories and frameworks, core components of e-cigarette prevention programs should thus include elements of socialemotional learning, self-efficacy building, and community engagement and leadership, and involve adolescents, their families, and communities.50

Normative education

Another best practice of e-cigarette prevention programs is to include normative education.54 In e-cigarette prevention programs, normative education corrects common misperceptions that adolescents have around e-cigarettes, for example, by addressing misinformation that e-cigarettes do not contain nicotine. This education can also include addressing beliefs around what constitutes nicotine addiction or susceptibility to marketing and allow for adolescents to reflect on their perceptions that underly their decisions to use e-cigarettes. Thus, prevention programs should address information, perceptions, and social norms regarding the appeal of flavors, peer influences, perceptions of harm, popularity of e-cigarettes, and marketing.55

Interactive content

Interactive content is defined as curricula that encourages discussions and activities, and foster games, role plays, and skill building including refusal skills. Interactions can occur between students and teachers or just among students.56 Interactive content is a hallmark of the PYD framework, as it directly engages with youth to share, communicate, create and provide inputs, rather than having youth be “talked at.” Such content may encourage learning outside of a traditional classroom setting, such as through an online role-playing simulation videogame,57 or by encouraging adolescents to steer peer-led initiatives or local advocacy in their community.58

Access and availability

E-cigarette prevention programs should be easily adaptable and accessible to help with wider dissemination and implementation of programs. Ideally programs should be available fully online or be web-based and completely free of cost. Further, being online means that the content can quickly be revised when new information becomes available, or adapted when new e-cigarette products enter the market.28 Thus, online videos,59 resources,27 and educational modules,60 that are free of cost and are easily accessible can help with widespread information diffusion on platforms targeted to adolescents. It is important to provide content in a familiar format for adolescents used to technology (e.g., TikTok videos), as prevention programs need to keep up with the attractive audio-visual content on platforms where they are also seeing e-cigarette products.61

Targeting age groups

E-cigarette prevention should begin early, even in elementary school, but definitely at least delivered to both middle and high school students, given the early ages in which adolescents first begin to use e-cigarettes.62 E-cigarette prevention programs should ideally be tailored towards these different age groups, and materials for middle school-aged and high school-aged adolescents should differ and be specific to that developmental period in adolescence.

Role of the tobacco industry in adolescent e-cigarette prevention

Under no circumstances should any adolescent substance use prevention program be developed and implemented by the tobacco or e-cigarette industry.39,63 Such program content and delivery will be adversely affected by bias towards commercial interests of the industry.39,63 Tobacco companies have had a history of using tobacco prevention programs as a guise for inherently promoting their own agenda and further promoting their products to adolescents.63 For example, the e-cigarette company JUUL has followed in these footsteps in an attempt to curb the backlash they were receiving for their direct appeal to adolescents.39

Teacher training

In order to have effective supervision of student e-cigarette use, school administrators should be trained to fully understand all aspects of e-cigarettes including their appearance and smell, their effects on both physical and mental health, and where adolescents use them at school.64–66 Such trainings of school administrators and educators are fundamental, given that e-cigarettes are easy to hide,3 do not smell like traditional tobacco products, and are being used in school spaces where adolescents and their e-cigarettes are harder to locate.

School administrators also need training to use the materials included in school-based e-cigarette prevention programs to ensure sustained implementation. Such educator trainings can be effective at increasing educators’ confidence and self-efficacy around managing the adolescent e-cigarette use epidemic on their school campuses.67 A recent study found that educators report wanting to receive this training, and that upon receiving the training they intended to continue using the e-cigarette prevention curriculum.67

Alternative-to-suspension programs

Although detention, suspension, and expulsion are disciplinary methods that schools have taken when catching students using tobacco products, this approach is not the most beneficial to adolescents in motivating them towards behavior change.68,69 Suspension programs have been inversely associated with achievement and positively associated with dropout, and can widen racial disparities within schools.70–72 This evidence points towards moving away from these suspension-based approaches and instead to Alternative-to-Suspension programs to help address adolescent e-cigarette use in schools. Alternative-to-Suspension programs include a combination of educational content, goal setting, and access to resources to help students quit using e-cigarettes.

Gaps in programs

Although many programs are incorporating many of the best practices discussed in this paper into their e-cigarette prevention programs, some gaps still exist. It is important that e-cigarette prevention be addressed separately from general tobacco prevention and cessation, as adolescents don’t always view e-cigarettes as tobacco products.73,74 What worked to reduce adolescent use of other tobacco products, such as combustible cigarettes, may not work for e-cigarettes due to differences in social norms and desirability, product design differences, an aggressive advertising landscape, appealing flavors, misperceptions of lower health risk of e-cigarettes compared to combustible cigarettes, and limited regulation of e-cigarettes.3,75,76 Several programs do not include the latest e-cigarette products that currently are the most popular products used by adolescents, such as education around disposables like Puff Bar, Vuse, or other newer products. Similarly, most programs do not highlight mint/menthol as e-cigarette flavors, when a previous evaluation study showed that prior use of mint/menthol flavors was associated with lower harmfulness and addictiveness perceptions.40

Need for more rigorous evaluation of programs

The literature lacks published studies evaluating existing e-cigarette prevention programs for adolescent e-cigarette use.43 Program evaluation can and has entailed different methods, including pre-post analyses,33,40 repeated cross-sectional studies,77 and randomized controlled trials.32,78

Cluster randomized controlled trials (CRCT) are considered the gold standard in evaluating school-based programs or interventions.79,80 The randomized nature of the method allows for a more rigorous design and causal interpretation of the results. Although CRCTs are the gold standard in school-based intervention evaluation, few programs have been evaluated through the CRCT method,60,81 highlighting the need for increased rigor in evaluating e-cigarette prevention programs. Qualitative or mixed-methods approaches are also integral in conducting specific community needs assessments and bolstering the findings of quantitative evaluations.

Recommendations

Existing e-cigarette prevention programs are supported by theory and follow best practices in e-cigarette education, but some gaps still exist. Programs should continually update their digital accessibility and interactive content to keep up with what adolescents are seeing in the advancing technology and media of their surrounding environments. Most importantly, programs need to focus on addressing the factors most likely to influence adolescent use of e-cigarettes, include more education around the impact on mental health, address new and emerging products such as disposable vapes and popular flavors, and empirically evaluate their programs. Programs should utilize a holistic or multi-systemic approach involving schools, parents, teachers and the greater community, such as through elements of PYD and CBPR.82

Conclusion

Alarming rates of adolescent e-cigarette use, industry tactics and targeted marketing, appealing flavors, high nicotine content leading to addiction, and other health effects of e-cigarettes are why high-quality prevention programs for adolescents are absolutely critical.83 It is important for e-cigarette prevention programs to incorporate theories and frameworks in the development, dissemination, and evaluation of their programs including Positive Youth Development (PYD) and Community Based Participatory Research (CBPR) to empower adolescents to make healthier behavioral choices. Prevention programs should be easily available online and free of cost, and contain an updated, stand-alone e-cigarette curriculum. Programs should also address key factors involved in adolescent e-cigarette use, such as marketing, flavors, and misperceptions. Table 1 provides a summary of these theories and components to be included in e-cigarette prevention programs, along with sample programs and program descriptions. Further, more rigorous empirical evaluation of e-cigarette programs is needed. The ongoing development, evaluation, and dissemination of innovative and creative prevention programs are critical in order address the current epidemic of adolescent use of e-cigarettes.

TABLE 1.

Summary of Best Practices for E-cigarette Prevention Programs, and Illustrative Programs that Include these Best Practices.*.

Best Practice Example Program(s) Description
Theory-based smokeSCREEN1 (Theory of Planned Behavior CATCH My Breath2 (Social Cognitive Theory) ASPIRE3 (Transtheoretical Model)
   Stanford Tobacco Prevention Toolkit4 (Social Cognitive Theory)		 Explicitly states and cites the theory of behavior change in program description on website or published scientific papers or uses another theory in developing their curriculum.
Framework-based Rise Above5 (Positive Youth Development) Stanford Tobacco Prevention Toolkit4 (Community Based Participatory Research; Positive Youth Development) Inclusion of units on “Building Healthy Relationships” and “Boosting Inner Strength” to provide adolescents with relationships and experiences that facilitate development of self-regulation.
   Inclusion of Toolkit Youth Action Board; Health educators, parents, youth, and doctors help develop programs/curricula.
Social and Emotional Learning Rise Above5 Inclusion of units on “Mastering Your Thoughts and Feelings” and “Boosting Your Greatest Inner
   Strength” to enhance adolescents’ capacity to manage emotions and use interpersonal skills.
Normative Education Project ALERT6
   Stanford Tobacco Prevention Toolkit4 		Inclusion of content that addresses misinformation around e-cigarette harms and teaches adolescents about susceptibility to industry marketing.
Includes refusal skills activities The Rise of Vaping Video7 Inclusion of activity guide for practicing refusal skills with adolescents.
Interactive Content smokeSCREEN1
   Stanford Tobacco Prevention Toolkit4 		Entire program is a role-play video game app.
   PowerPoint slide decks are visually appealing and animated; modules include Kahoots (an online interactive quiz platform) and many other activities.
Fully free, online Project ALERT6
   Stanford Tobacco Prevention Toolkit4
   CATCH My Breath2 		Entire program is made fully available online at no cost, can easily download from website
Includes content on flavors CATCH My Breath2
   Project ALERT6
   Stanford Tobacco Prevention Toolkit4 		Inclusion of content that addresses how flavors are directly appealing to youth
Updated with new/ emerging products Stanford Tobacco Prevention Toolkit4 Includes lecture on PuffBar and disposable vapes, and continually updates materials when new tobacco products enter the market
Stand-alone E-cigarette Component Stanford Tobacco Prevention Toolkit4
   CATCH My Breath2 		Contains separate curriculum for e-cigarettes that is not part of the general tobacco curricula
Targeted Age Groups Stanford Tobacco Prevention Toolkit4 Separate curricula for middle school and high school students
Teacher Training Stanford Tobacco Prevention Toolkit4
   Stanford Tobacco Prevention Toolkit4 		Provides opportunities for tailored teacher trainings on how to use the Toolkit curricula
Alternative-to-Suspension INDEPTH8
   Healthy Futures9 		Four, 50 min sessions that each address a different tobacco-related issue, led by a trained facilitator
   1, 2, or 4 session curriculum that covers health effects of vaping, addiction, and messaging.
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*

Note — these are just sample programs; other programs may also contain these components.

Funding source

In writing this paper, Dr. Halpern-Felsher was supported by the Taube Research Faculty Scholar Endowment, a grant from the Tobacco-related Disease Research Program (TRDRP, grant number 27IR-0043), and a grant from the NIH/NCI (1R01CA263121-01). J. Liu was funded by the Cancer Prevention Fellowship from the National Cancer Institute and Harvard T.H. Chan School of Public Health — National Institutes of Health grant number 2T32CA057711-27. Dr. Gaiha was supported by the National Cancer Institute of the National Institutes of Health under Award Number K99CA267477 and the Stanford Maternal and Child Health Research Institute Instructor K Support Award. The funders had no role in the design or conduct of the study, including the data collection, data management, analyses, interpretation of the data, or the manuscript preparation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Footnotes

Financial disclosure

All authors have indicated they have no financial relationships relevant to this article to disclose.

Declaration of Competing Interest

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

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