Implementation of a youth and young adult e-cigarette cessation program within a dental clinic setting : A SToHN feasibility study

Abstract

Introduction:

While significant progress has been made to decrease tobacco smoking among youth and young adults, e-cigarettes threaten to reverse the progress. The purpose of this study was to test the feasibility of the ReACH Assessment of Knowledge for E-Cigarettes (RAKE) e-cigarette cessation program targeting youth and young adults in Texas.

Methods:

Seven dental practitioners and 12 patients participated in this pilot study. Patients aged 15 to 29 who reported current e-cigarette use were recruited by their dental practitioner. All participants completed pre-and post-assessments—practitioners receiving the RAKE training and patients the RAKE cessation intervention. Descriptive statistics were calculated.

Results:

After RAKE training, all practitioners reported the RAKE cessation program as useful and an important part of patient care. In addition, after completing the program (5A’s), 67% (n=9) patients reported that the program was helpful, and 100% (n=12) would recommend the program to other ENDS users.

Conclusions:

Practitioners and patients enhanced their knowledge of e-cigarettes and their harm to health. In addition, practitioners demonstrated their ability to implement the RAKE cessation program within the practice, and patients approved of the use of the program. This study illustrated the feasibility and acceptability of conducting an e-cigarette cessation study in dental practices and a critical need to develop and disseminate the program to young patients.

Introduction

Significant progress has been made in reducing the use of conventional cigarettes among young people. Specifically, conventional cigarette smoking among high school youth in the United States declined from 28% in 1996 to 8% in 2018.¹ Unfortunately, electronic cigarettes (e-cigarettes) continue to threaten the progress in reducing tobacco use. Today, e-cigarettes are the most popular tobacco product among youth and young adults, surpassing cigarettes.¹ One of the chief concerns regarding e-cigarette use is the potential for transition to conventional cigarette smoking. A recent meta-analysis found that youth who use e-cigarettes are 3.5 times more likely to initiate cigarette smoking as non-users.³

Use of tobacco products in youth and young adults poses many concerns. Not only are there notable systemic health effects of nicotine on young people, including its impact on mood and brain development, nicotine dependence also underlies the association between e-cigarette use and future initiation of cigarette smoking among youth and young adults.³ Other concerns associated with e-cigarette use is the mechanisms themselves when used. For example, the emergence of an e-cigarette or vaping use-associated lung injury (EVALI) has renewed concerns over the safety of vaping devices. Notably, vaping tetrahydrocannabinol (THC) and vitamin E acetate seem to be implicated in the EVALI epidemic.⁵

The FDA recognizes the need for e-cigarette cessation interventions for young people and to date, no approved cessation program to target this product exists⁶. One tobacco cessation program that has shown to be effective is the 5A’s (Ask, Advise, Assess, Assist, and Arrange)—a brief, practitioner-directed intervention.^7,8 A recent study showed that patients satisfied with the 5A’s counseling services were 5 times more likely to intend to quit using tobacco and 4 times as likely to recommend counseling to other tobacco users.⁹ The feasibility of e-cigarette cessation within clinical practice as part of regular patient care is crucial for patient success. In a 2016 study examining the feasibility of vascular surgeons providing smoking cessation to their patients, surgeons stated having a “standardized protocol with brief interventions as easy and doable within their clinical practice”.¹¹ Implementing a brief counseling intervention, such as the 5A’s, allows practitioners to integrate the counseling efficiently into their routine visits with their patients.

Formative research with dental practitioners and community members demonstrated the need for a dental practitioner-based e-cigarette cessation intervention¹⁰. Dental practitioners indicated they were interested in an e-cigarette cessation tool but lacked the skills to effectively counsel patients on how best to quit. Community members stated they were interested in learning about the harms of e-cigarette use from their dental practitioners yet had never received such information¹⁰.

Given the lack of e-cigarette–specific cessation programs directed at young people who use e-cigarettes (vape) and the results of this formative research, the study team developed the ReACH Assessment of Knowledge for E-cigarettes (RAKE) cessation program, which consists of 1) training for dental practitioners on e-cigarette cessation utilizing the 5A’s and 2) screening youth and young adult (15- to 29–year-olds) dental patients for e-cigarette use to administer the cessation program. The purpose of this pilot study was to test the feasibility of the RAKE dental practice-based e-cigarette cessation program targeting youth and young adults (15- to 29–year-olds) in Texas.

Methods

Practitioner Recruitment

The study (HSC20200543H) was reviewed and approved for Expedited Review by the Institutional Review Board (IRB) at the University of Texas Health San Antonio (UTHSA). The study team consulted with: the South Texas Oral Health Network (STOHN)—a practice-based research network (PBRN), a Coalition Coordinator from the San Antonio Council on Alcohol & Drug Awareness (SACADA), a private practitioner who specializes in orthodontics, and an assistant professor from the Center for Research to Advance Community Health (ReACH). Dental practitioner participants were recruited via emails and telephone calls through the STOHN PBRN between October 2020 and January 2021. Practitioners were given an information sheet and provided verbal informed consent. Patients reviewed and gave written informed consent to participate in the study.

A total of 7 dental practitioners (n=6 dentists and n=1 dental hygienists) were recruited into the pilot study. Practitioners were sent a link via REDCap to access the pre- and post-assessments as well as the RAKE training. The pre-assessment consisted of 28-items and captured their demographics, practice and patient characteristics, knowledge, attitudes, and perceptions of e-cigarettes as well as their perception of an e-cigarette cessation program. Practitioners then navigated to the training that could be downloaded onto their individual computers for access throughout the study. The training, if completed in one sitting, took approximately 30–40 minutes.

Intervention Description

The RAKE training component consisted of information on the prevalence, trends, and patterns of e-cigarette use; history and safety regulations; increases in the legal age to buy tobacco; components and mechanisms of action in the devices; chemical composition of the nicotine inhalant (“e-juice”); up-to-date best practices and screening guidance for assessing patient use of e-cigarettes; evidence-based information on oral health and systemic effects of e-cigarettes; evidence-based tobacco cessation strategies, including the 5A’s cessation counseling card; and information on evidence-based e-cigarette cessation products as they became available. Finally, practitioners took the 18-item post-training assessment to assess the acceptance, satisfaction, and usability of RAKE and items parallel to items of the pre-assessment addressing knowledge, attitudes, and behaviors (intention to utilize RAKE), e-cigarette education, and cessation training. Practitioners were encouraged to complete this post-assessment right after the training but could save and return with an individualized code if needed. Each assessment was estimated to take 10–15 minutes to complete.

Implementation in Dental Practices

Practitioners completed an initial 30-minute phone call or Zoom meeting with the study coordinator to discuss timeline, their role in the study, how to complete the human subject protection training, remuneration for their efforts as well as patient remuneration, the different surveys the patients would need to complete, and review any questions they had about the implementation of the RAKE cessation program into their clinics. Communication with practitioners occurred at least twice a month. Regular check-in emails consisted of a fact about e-cigarettes that practitioners could discuss with patients and any study updates on patient screening and enrollment. Each check-in lasted 10–15 minutes, reviewed recruitment strategies, and troubleshot the RAKE cessation program. Narratives from the check-in sessions regarding screening and recruitment techniques and optimal timings to provide the RAKE cessation program during the dental visit. Discussions centered around actionable changes for recruitment (i.e., increasing study signage around the clinic, reviewing patient charts to determine expected age range for the day, bringing up the study during cleanings and before dentist evaluation of patients) and any comments that patients made about the study/cessation program.

Once assessments and training were completed, practitioners recruited patients at their respective clinics using flyers posted in the clinic waiting rooms and utilized staff and fellow practitioners within the same clinic to advertise the study. A total of 12 patients (between 17 and 29 years of age) who reported current e-cigarette use were recruited through these efforts between February 2021 and July 2021.

Patient participants were asked to complete a 39-item pre-assessment and a 12-item post-assessment, collecting demographics and assessing e-cigarette knowledge, perceptions of harm, use, and addictiveness, dependency/addictiveness, and evaluation of the RAKE cessation program—acceptance, satisfaction, and usability. The pre-assessment took approximately 10 minutes to complete while the post-assessment took 5 minutes. Responses conveyed by the patients to the practitioners and any comments practitioners had about the cessation program were documented, and later grouped by commonality. After the pre-assessment, patients completed a5–7minute 5A’s RAKE cessation session with the practitioner. Patients then completed the short post-assessment as previously mentioned. Patients were remunerated $25 for completing both surveys, and practitioners were remunerated $50 per patient who completed the study.

Data Analysis

Study data were collected and managed using REDCap electronic data capture tools hosted at UTHSA (Harris et al., 2009; 2019). Descriptive statistics were calculated through the statistical SAS® software. Categorical variables were summarized by frequency and continuous variables by means and standard deviations.

Results

Practitioners

Practitioner participants were primarily female (71%, n=5), between the ages of 32 and 56 (M= 41 years, SD = 9.84), general dentists (86%, n=6), had between 11–20 years of professional experience (n=3, 43%), and worked in a single private practice setting (86%, n=6). All practitioners reported awareness of e-cigarettes but felt they had little knowledge about them (71%, n=5). One hundred percent (n=7) stated they were very willing to learn more about e-cigarettes; however, 29% (n=2) reported they were not very comfortable discussing e-cigarettes with adolescent patients.

Practitioners’ current knowledge of e-cigarettes is shown in Figure 1. When asked if the RAKE program was useful and an important part of patient care, 28.6% (n=2) strongly agree, 57.1% (n=4) agree, and 14.3% (n=1) neither agree nor disagree with the statement. When asked whether they planned to utilize the information presented to them in the RAKE training component to counseling their patients on e-cigarettes or not, 85.7% (n=6) said they strongly agreed to do so. After completing the training, 100% (n=7) strongly agreed that the training is a useful and important part of patient care and would counsel patients.

Figure 1.

Practitioner Knowledge, Attitudes, & Beliefs Pre-RAKE Training

Overall, practitioners improved their knowledge, harm perceptions, beliefs, perceived addictiveness, and attitudes regarding e-cigarettes (see Figure 2). Before the RAKE training, practitioners reported they agreed (28.6%, n=2) or neither agreed nor disagreed (71.4%, n=5) that they had the knowledge and skills to conduct e-cigarette cessation counseling with their patients (M= 3.28, SD = 0.49). After receiving the training, most practitioners strongly agreed (85.7%, n=6; M= 4.85, SD = 0.37) that they had the knowledge and skills to conduct cessation counseling. One hundred percent (n=7) of practitioners stated that they were very comfortable discussing e-cigarettes with their adolescent patients since they completed the training.

Figure 2.

Practitioner Knowledge, Attitudes, & Beliefs Post-RAKE Training

Patients

Among the twelve patient participants in the study, the mean age was 23 years (ranging between 17 and 26 years of age), 7 were female (58.3%), 11 were Caucasian (91.7%), and 5 had some college education (41.7%). Four patients (33.3%) also had private dental insurance. Nearly half (45.5%, n=5) of participants did not wish to disclose their annual household income, while income responses ranged from $25,001 to over $100,000. When asked about how common e-cigarette use is among their age group, patients reported it was very common (75%, n=9) and that mainly between a few and some of their close friends (66.7%, n=8) used e-cigarettes (M= 2.75, SD = 0.97). Interestingly, half of the patients reported they thought it was probably not okay (50%, n=6) for people their age to use e-cigarettes, followed by definitely not (25%, n=3) and probably yes (25%, n=3).

All patients reported use within the last 30 days, where the highest frequency of use was more than 20 times per day (50%, n=6), and that the e-cigarette they used contained nicotine (100%, n=12). Half of the patients (50%, n=6) used e-cigarettes to help stop smoking conventional cigarettes and have tried to quit using e-cigarettes but couldn’t and found it really hard to quit. Eight patients (66.7%) felt they were addicted to e-cigarettes and reported ever having a strong craving to use e-cigarettes, and 91.7% (n=11) had ever felt like they really needed an e-cigarette (for other responses related to dependency on e-cigarettes, see Table 2). When assessing patients’ perceptions of e-cigarettes, 58.3% (n=7) said that they are very addictive, 41.7% (n=5) that they are somewhat addictive, and 41.7% (n=5) that they were somewhat harmful to health. Table 1 shows how patients perceive the risks of e-cigarettes and their use in both the pre-and post-surveys.

Table 2.

Patient Pre- and Post-Survey on Perception of E-cigarettes, % (n)

	True		False		Don’t Know
	Pre-Survey	Post-Survey	Pre-Survey	Post-Survey	Pre-Survey	Post-Survey
E-cigarettes usually contain nicotine, an addictive chemical.	100% (12)	100% (12)	0	0	0	0
E-cigarettes use liquid/salts that contain harmful chemicals.	58.3% (7)	91.7% (11)	8.3% (1)	0	33.3% (4)	8.3% (1)
E-cigarettes may harm teen brain development.	75% (9)	83.3% (10)	0	0	25% (3)	16.7% (2)
E-cigarettes have unknown long-term health effects.	66.7% (8)	91.7% (11)	8.3% (1)	8.3% (1)	25% (4)	0
E-cigarettes are not risk-free.	75% (9)	83.3% (10)	16.7% (2)	16.7% (2)	8.3% (1)	0
E-cigarettes use liquid/salts that is made from tobacco.	58.3% (7)	66.7% (8)	0	8.3% (1)	41.7% (5)	25% (3)

Table 1.

Patient E-Cigarette Dependency, % (n)

	Yes	No
Have you ever felt you were addicted to e-cigarettes?	66.7% (8)	33.3% (4)
Do you ever have strong cravings to use e-cigarettes?	66.7% (8)	33.3% (4)
Have you ever felt like you really needed an e-cigarette?	91.7% (11)	8.3% (1)
Is it hard to keep from using an e-cigarette in places you are not supposed to, like school or work?	41.7% (5)	58.3% (7)
When you tried to stop using e-cigarettes… or if you haven’t used e-cigarettes in awhile…
Did you find it hard to concentrate?	66.7% (8)	33.3% (4)
Did you feel more irritable?a	45.5% (5)	54.5% (6)
Did you feel a strong urge to use an e-cigarette?	66.7% (8)	33.3% (4)
Did you feel nervous, restless, or anxious because you couldn’t use an e-cigarette?	50% (6)	50% (6)

^aOne participant did not answer “Do you feel more irritable” question.

Patient Acceptability

Before counseling, just over half of all patients (58.3%, n=7) reported that an e-cigarette quitting program would not be helpful to them. After receiving the 5A’s from their dental provider during their appointment, most respondents (83.3%, n=10) stated that e-cigarette use was definitely not or probably not okay within their age group. Most notably, 75% (n=9) of patients reported that they learned new information about e-cigarettes from their dental provider, 100% (n=12) would recommend the RAKE cessation program to other people who use e-cigarettes, and 90% (n=10) of responders (2 missing responses) answered that the RAKE cessation program was helpful to them.

Discussion

As one of the standard counseling protocols for tobacco cessation, the 5A’s adapted for e-cigarettes in this study showed to be feasible within clinical practice. As shown in Appendix A, the 5A’s utilized for this study provided questions, topics, and check boxes to assist practitioners in reviewing quickly during their sessions. The American Dental Association recommends the 5A’s for cessation counseling to best consider tobacco use and oral health implications.¹²

Overall, both practitioners and patients in this study showed changes in knowledge, attitudes, and perceptions related to e-cigarette use after completing the RAKE cessation program. As previously mentioned, dental practitioners discussed their progress in recruitment and completion of study procedures. These discussions with the study coordinator indicated the implementation of the study withing the practice: when patients were being screened, when the RAKE cessation program was being completed, and the overall receptiveness of the program. The study team relied on their experience to adapt and implement the cessation intervention that made sense for their patients and the clinic. This kind of implementation review allows the study team to make real-time adjustments to the cessation program’s timing as needed to best suit clinic practices. Providing up-to-date, evidence-based training for dental practitioners with online access at their convenience showed that the program can be utilized quickly and efficiently. Practitioners who gained new knowledge about e-cigarettes and the resources available showed increased confidence to implement the cessation program within their clinics.

Patients also provided feedback to their providers to help the study team increase the RAKE cessation program’s acceptability. Some suggestions from patients included: adding videos from former e-cigarette users discussing the benefits of quitting and why they should have quit earlier, a discussion between patients and providers about the financial cost of both long-term use and savings if ceasing use, adding graphics to show the dangers and injuries that have been reported in the news if devices malfunction and live presentations at schools to encourage student engagement through a Q&A. These suggestions could be utilized as the RAKE program continues to develop and be implemented in and out of dental settings. Cessation programs, including those made specifically for e-cigarettes, may become readily accepted among youth and young adults who also see that their use could pose issues for them.

Limitations

Study limitations included screening, recruitment, and training during the SARS-CoV2 pandemic. At the time of funding, the pandemic began to spread throughout Texas. This led the study team to revamp study protocols and make the procedures as easy as possible for practitioners to implement into their practice. However, challenges arose as practices limited patients coming in and modified their clinic flow to get patients in and out efficiently, thus minimizing the ability to add external procedures for the study. In addition, despite getting patients to return for their appointments, many were outside of the target age group for this study. Several dental practices had also shut down (permanently or temporarily) during the peak of the pandemic, leading to limited practitioners available to participate in the study.

Another limitation was recruiting minors into the study. Though the study team received a Certificate of Confidentiality from NIH to ensure participants under the age of 21 who reported use of e-cigarettes were assured of their participation as confidential (as it is illegal to purchase an e-cigarette due to the Federal Tobacco 21 Law), patients hesitated to participate in the study. In addition, practitioners reported that patients they knew used e-cigarettes within the age group were unwilling to admit use, especially if their parent brought them to the appointment. Future studies should examine the relationship between patients and practitioners in establishing rapport and encouraging discussion on sensitive topics, such as e-cigarette use.

While statistical findings were descriptive, the sample size was not large enough to produce statistically significant or complex analyses. Nevertheless, findings were suitable for the conditions of the pilot study. Given the recruitment shortcomings, the next steps are to test further implementation of the RAKE cessation program among a larger sample of dental clinics and add resources for patients who want to quit e-cigarette use that may go beyond the 5A’s, including more frequent contact of cessation support.