Digital Repository Doctoral Projects Fall 2021 Decreasing Vaping Among Adolescents Using a School-Based Prevention Toolkit for Educators Deseret Allen Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Allen, D. (2021) Decreasing Vaping Among Adolescents Using a School-Based Prevention Toolkit for Educators. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Decreasing Vaping Among Adolescents Using a School-Based Prevention Toolkit for Educators by Deseret Allen A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah December 12, 2021 Jessica Bartlett, DNP, CNM, RN, IBCLC__(signature) Faculty Advisor/Committee Chair (Jessica Bartlett, DNP, CNM, RN, IBCLC) Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE (signature) Graduate Programs Director Running head: VAPING PREVENTION TOOLKIT FOR EDUCATORS 1 Decreasing Vaping Among Adolescents Using a School-Based Prevention Toolkit for Educators Deseret Allen Weber State University Annie Taylor Dee School of Nursing December 6, 2021VAPING PREVENTION TOOLKIT FOR EDUCATORS 2 Acknowledgments I would not have been able to accomplish this DNP project without the continued support of all those involved. My sincere gratitude and thanks to Dr. Jessica Bartlett DNP, CNM, RN, IBCLC my project lead and Dr. Mary Anne Reynolds PhD, ARN, ACNS-BC for their continued professional direction and mentorship to help this project overcome barriers, take shape, and come to fruition. A big thank you to Principal Heather Hardy, MAED at Snowcrest Junior High School for allowing me to enter her school and work with her teachers and students as we were emerging from COVID-19 school closers and lockdowns. She also provided invaluable information and feedback as a community partner. I also want to thank Mason Anderson, the health science teacher for welcoming me into his classroom. And finally, the biggest thank you of all, to my family for their love and support through this process. VAPING PREVENTION TOOLKIT FOR EDUCATORS 3 Abstract Vaping is detrimental to health, yet its use is rapidly expanding among adolescents. However, there is a lack of knowledge about vaping and how it affects health. It is important to educate adolescents to promote healthy decision-making and to prevent vaping initiation. The purpose of this Doctor of Nurse Practice project was to develop and implement a school-based vaping prevention toolkit to increase faculty knowledge and confidence in teaching vaping curriculum and to provide resources to educate students. A vaping prevention toolkit was developed that consisted of an educational module for teachers to increase personal knowledge about vaping, a 25-minute student education presentation, and a comprehensive resource list. Two educators and forty junior high students were introduced to the toolkit and asked to provide feedback on the perceived effectiveness of the toolkit. 100% of the students agreed that they had learned something new about vaping, and this information would positively influence their choice, not to vape. Both participating educators gained new knowledge about vaping and felt more prepared to discuss vaping with their students. Both agreed that the toolkit and resources were user-friendly and would be easy to incorporate into the classroom. Vaping rates among adolescence are a significant health care issue. Early education is one way to increase knowledge and encourage teens to avoid vaping. By using evidence-based resources, clinicians can take an active role in educating on the health risk and prevention associated with vaping in adolescence and influencing decision-making. Keywords: Smoking, tobacco, cessation, ENDSs, adolescents, vaping. VAPING PREVENTION TOOLKIT FOR EDUCATORS 4 Decreasing Vaping Among Adolescents Using a School-Based Prevention Toolkit for Educators Nicotine dependence is one of the most common forms of chemical dependence in the United States. This dependency or addiction typically occurs before the age of 18. There are an estimated 34.2 million adult smokers in the United States and 16 million Americans are living with a smoking-related disease. Among smokers age 18 and younger, more than 6 million may die prematurely from a smoking-related disease such as cardiovascular disease and lung cancer (Centers for Disease Control and Prevention [CDC], 2020b). The estimated total societal cost of smoking in the United States is over $300 billion a year. This includes $170 billion in medical treatment associated with the negative health outcomes related to smoking and $156 billion in lost productivity caused by premature death and exposure to secondhand smoke. After experiencing a substantial downward trend in the use of tobacco products by youth and young adults, there has been a concerning rise in the use of nicotine products and addiction in these age populations due to the advent of the electronic nicotine delivery systems (ENDS), also known as the e-cigarette or vaping. Since entering the market in 2007, the use of ENDS has rapidly expanded in popularity including children and adolescents (Drope, Cahn, Kennedy, Liber, Stoklosa, Henson, Douglas, and Drope, 2017). In the United States, youth are more likely than adults to use ENDS. In 2020, 3.6 million U.S. middle and high school students were using ENDS, equaling 4.7% of middle school students and 19.6% of high school students (CDC, 2020a). Between 2011 and 2015 there was a 900% increase in youth ENDS use (King, Jones, Baldwen, & Briss, 2020). This is concerning as these products contain an increasingly high level of nicotine when compared to traditional combustible cigarettes (Truth Initiative, 2020). The 2020 National Youth Tobacco Survey done by the Federal Food and Drug Administration (FDA) found that among high school ENDS users VAPING PREVENTION TOOLKIT FOR EDUCATORS 5 38.9% used ENDS frequently and 22.5% used ENDS daily showing a strong dependence on nicotine (FDA, 2020). Exposure to these highly addictive nicotine levels during adolescents is a serious health concern as the brain is still undergoing maturation until the age of 25. Nicotine can interfere with the normal development of the brain causing lasting effects on cognition abilities, mental health, and personality (Utah Department of Health, 2017). It also leads to poor lifestyle habits into adulthood resulting in acute and chronic health issues (Boudi, Patel, Boudi, & Chan, 2019). Adolescence is an especially vulnerable time when smoking in all forms is often initiated (Boudi et al., 2019). The aim of this project is to prevent ENDS use initiation among adolescents through the implementation of a school-based prevention toolkit for educators promoting learning and collaboration with students to change perceptions, attitudes, beliefs, and knowledge associated with the dangers of using ENDS. Literature Review Search Methods A web-based internet search was conducted using Medline and PubMed databases. Search terms included smoking, tobacco, smoking cessation, ENDS, adolescents, vaping, school-based education, and prevention. Inclusion was limited to peer-review journal articles published in English within the last 10 years. Important research gaps remain regarding the negative effects of ENDS and potential solutions to solving the increased use by adolescents. In general, evidence for smoking prevention among youth was evaluated which can be adapted to specifically address ENDS use among adolescents. Literature Review Combustible Tobacco Products Traditional combustible cigarettes are an extremely efficacious way of delivering the highly addictive substance, nicotine. They do so by burning the tobacco which generates ultra- VAPING PREVENTION TOOLKIT FOR EDUCATORS 6 fine particles that carry nicotine deep into the lungs during inhalation where it is rapidly absorbed. It then travels through the heart and reaches the brain within seconds. The combustible process of burning tobacco also produces other toxins and carcinogens that are inhaled deep into the lungs (Glantz & Bareham, 2018). Cigarette smoking has been linked to many preventable diseases including cancer, heart disease, lung disease including COPD, diabetes, and a weakened immune system. Smoking is the leading cause of preventable death in the United States, responsible for 480,000 deaths per year. This includes 42,000 deaths from secondhand smoke (Hall & Doran, 2016). Hall and Doran (2016), looked at the effects of reducing the prevalence of smoking and its measured influence on reducing healthcare costs in the United States. Their findings suggest that a 10% reduction in the nation’s smoking prevalence in one year is responsible for an average savings of $6.3 billion in health care costs the following year. States who have strict tobacco control policies contributing to lower rates of smoking prevalence also have lower healthcare costs overall. Enacting tobacco control policies has continued to be a challenge in the face of the tobacco industry, lobbyists, legal battles, and campaigns that create and promote doubt about the health risks associated with smoking. Two risk factors associated with smoking initiation include impulsivity and the inability to recognize and cope with negative emotions. This endorses beliefs of the socially enhancing effects of smoking, increasing the risk of initiation (Dir, Banks, Zapolski, McIntyre, & Hulvershorn, 2016). Common predictors of adolescent smoking initiation include increased age or grade, lower socioeconomic status, poor academic performance, sensation-seeking behavior or rebelliousness, receptivity to tobacco promotion efforts, those who have a family member or friend who smokes, and exposure to films depicting smoking. In contrast, higher self-esteem and VAPING PREVENTION TOOLKIT FOR EDUCATORS 7 greater parental involvement through monitoring and supervision help protect against smoking initiation (Wellman, Dugas, Dutczak, O’Loughlin, Datta, Lauzon, & O’Loughlin, 2016). A similar research study focusing on smoking initiation among youth showed that family engagement and parental monitoring are crucial in smoking prevention and uptake (Dietz, Arheart, Sly, Lee, & McClure, 2016). Electronic Nicotine Delivery Systems E-cigarettes were first developed in China in the early 2000s and then introduced in the United States in 2007. These electronic devices heat a liquid or wax that contains a variety of ingredients which may include nicotine, cannabis, tetrahydrocannabinol (THC), additives, and flavorings into an aerosol vapor that is then inhaled into the lungs. Previous to 2007, there had been a continued decline in the use of traditional cigarette smoking. However, the use of ENDS and other ENDS products exploded in the United States with the number of users increasing two-fold every year between 2008 and 2012. It was perceived that the use of ENDS through vaping would be a safer less toxic alternative to combustible cigarettes and could be used as an effective cessation method (Boudi et al., 2019). In 2013, Public Health England claimed that ENDS were 95% safer than traditional cigarettes (Truth Initiative, 2021). This is now proving to be inaccurate. This analysis did not take into account the potential for negative net public health impacts as many were concerned that ENDS may be used as a “gateway” to combustible smoking. Research suggests that currently, ENDS use represents more harm than benefit for the general population due to the substantial increase in use among youth and young adults (Soneji, Sung, Primack, Pierce, & Sargent, 2018). It is becoming more apparent that ENDS pose their own unique health risks and harm (Truth Initiative, 2021). VAPING PREVENTION TOOLKIT FOR EDUCATORS 8 The U.S FDA was given regulatory authority over tobacco through The Family Smoking Prevention and Tobacco Control Act of 2009. Unfortunately, these regulations only included certain forms of tobacco and nicotine-containing ENDS. Other types of ENDS and vaping products were excluded (Lawrence, Gostin, & Glasner, 2014). Many viewed ENDS as a harm-reduction approach to smoking and an effective method of smoking cessation. Others felt ENDS were a “Trojan horse” that would normalize smoking, reduce the number of individuals trying to quit, and seduce young people into smoking (Fairchild, Lee, Bayer, & Curran, 2018). Adults are using ENDS for convenience where smoking is prohibited or socially unacceptable. Often smokers are using combustible tobacco cigarettes in combination with ENDS with few positive health benefits or plans of cessation (Drope et al., 2017). ENDS or Vaping Product Use-Associated Lung Injury Wisconsin reported the first cluster of lung injuries to the CDC in August of 2019 and the ENDS or vaping product use–associated lung injury (EVALI) was identified. Hospitals began linking the use of ENDS to lung illnesses presenting with difficulty breathing, shortness of breath, chest pain, and gastrointestinal disorders. These issues resulted in lung damage and even death in otherwise young healthy individuals (Boudi, et al., 2019). As of February 2020, a total of 2,807 cases of EVALI have been confirmed among all 50 states. This has resulted in 68 deaths in people with a median age of 24 years old. Those 18 to 34 years old comprised 62% of all deaths and 16% were under the age of 18 (CDC, 2020b). Smoking Among Adolescents Many unhealthy behaviors develop during adolescence and are the cause of major public health concerns that contribute to costly social and physical health problems. Tobacco smoking, and the use of ENDS, not only affects current health with side effects including shortness of VAPING PREVENTION TOOLKIT FOR EDUCATORS 9 breath, cough, dry mouth, sore throat, headaches, dry eyes, tooth sensitivity, tooth enamel erosion, and loss of taste or smell, but can also lead to many poor health outcomes and disorders into adulthood such as cancer, heart disease, lung disease, and diabetes increasing overall morbidity and mortality (Das et al., 2016; Truth Initiative, 2021). As previously stated, there has been a concerning rise in the use of nicotine products and addiction among the adolescent population due to the advent of ENDS products. Between 2017 and 2018 ENDS use increased 75% among high school students and 50% among middle school students (CDC, 2020a). In 2020, 27.5% of U.S. high school students had used ENDS in the last 30 days (Truth Initiative, 2021). Many contributing factors are now being identified as a catalyst in the increased use of ENDS products among adolescents. Anand, McGinty, O’Brien, Guenthner, Hahn, and Martin (2015) completed a study aimed at examining the beliefs and attitudes of ENDSs use among high school students. 15.2% of the participants reported trying ENDS, 60% reported that ENDS were safe and had minimal health hazards and only 5.4% reported receiving any education from their school regarding ENDS. A similar study found that among youth and young adults, ENDS are considered a healthier alternative to traditional smoking. They also found a link between peer and social influences among youth. Those peer groups who are more open to, and accepting of, smoking behaviors are associated with a higher prevalence of ENDS use, which may further influence young people to initiate or continue conventional smoking (Chao, Hashimoto, & Kondo, 2019). One study examined the effect of TV advertisements on youth. It focused on future intention to use ENDS and the promotion of positive perceptions and beliefs through deceptive marketing. It showed that ENDS TV advertisements are targeted toward youth and are VAPING PREVENTION TOOLKIT FOR EDUCATORS 10 successfully persuading many adolescents to try these novel products. Advertisements often contain five prominent messages to consumers. That you can use ENDSs in places where smoking is not allowed, you can use ENDSs without affecting the people around you, they are a safer and less toxic alternative to regular cigarettes, and using them is a good way to express your independence. Those adolescents who viewed the TV advertisements reported a greater likelihood of future ENDS use when compared to those that did not (Farrelly, Duke, Crankshaw, Eggers, Lee, Nonnemaker, Kim, & Porter, 2015). One of the most popular and recognizable brands of vaping or ENDS products is JUUL. It is so popular that using these products is often referred to as “JUUL-ing” among youth. In October 2019, JUUL held 64.4% of the ENDS market. In 2018, the makers of Marlboro cigarettes acquired a 35% stake in the company for $12.8 billion. JUUL has spent over $1 million advertising its products on social media including Twitter, Instagram, and YouTube, in addition to paying “social influencers” to talk about JUUL in a positive light. Studies showed that 99% of all JUUL products contain nicotine. However, nearly two-thirds of users ages 15-21 were unaware that the products almost always contain nicotine. One JUUL pod is equivalent to that of an entire pack of traditional cigarettes (Truth Initiative, 2020). One study sought to determine if the use of flavorings in ENDS in addition to nicotine encouraged continued use and its impact on youth. It was concluded that flavoring enhances the rewarding and reinforcing value of ENDS with nicotine and increased the potential for long-term use among adults who smoke, which may aid in combustible smoking cessation. However, it also shows a liability in use among adolescents (Audrain-McGovern, Strasser, & Wileyto, 2016). The practice of using flavor additives in traditional combustible cigarettes has long since been illegal, except for menthol. However, ENDS are marketed in over 7,000 different flavor VAPING PREVENTION TOOLKIT FOR EDUCATORS 11 combinations. Many of these flavors are found in familiar candy and soft drinks that appeal to adolescents (Boudi et al., 2019). More than 8 out of 10 current youth ENDS users use flavored products (FDA, 2020). A longitudinal cohort study completed by Hammond, Reid, Cole, and Leatherdale (2017) demonstrates a strong association between ENDS use and future cigarette smoking behaviors including cigarette smoking initiation among adolescents. This is comparable to the findings of a meta-analysis completed by Zhong, Cao, Gong, Fei, and Wang (2016) which also showed that non-smoking adolescents and young adults who used ENDS doubled their odds of intention for future cigarette smoking use. The Adolescent Brain During adolescence or the teenage years, the pre-frontal cortex is undergoing significant changes. This area of the brain is responsible for planning, problem-solving, assessing risk, decision making, and social interactions. These changes can impact adolescent behavior making them more likely to participate in risky behaviors, place an over-emphasis on social rewards, and struggle to understand the emotions of others. Those in this adolescent age group can be challenging to educate and teach. They thrive in a nurturing environment and educational presentations should offer a variety of delivery methods to encourage students to think for themselves and keep the brain active (Starbuck, 2018). Adolescent learning should combine the abstract with the concrete. For example, text is abstract until the student makes meaning of it by connecting it to what they know through experience. Adolescent students learn best when they are alert but in a relaxed environment. Feeling anxious or anticipating a negative experience is not conducive to learning. This age group values strong emotional connections with the teacher, VAPING PREVENTION TOOLKIT FOR EDUCATORS 12 the subject, or the task, facilitating memory, retention, comprehension, and appreciation (Lieber, 2016). Solutions to the Clinical Problem A systematic review of interventions for adolescent substance abuse including smoking or tobacco use was conducted and found that school-based interventions were effective in decreasing the incidence of substance abuse (Das et al., 2016). A quasi-experimental study was conducted among 280 male students between the ages of 15 and 17 years old in Nowshahr, Iran, where 140 students were randomly chosen for inclusion in the experimental and control groups. After conducting a pre-test to collect data associated with risk factors for smoking and perceived barriers and benefits, a school-based educational smoking prevention program based on the Health Belief Model was administered to the experimental group. Four months post-intervention a post-test evaluation was completed by all participants. It was found that the prevalence of cigarette smoking decreased among the intervention group (Khazee-pool, Pashaei, Mansorian, Qorbani, Safari, & Shojaeizadeh, 2016). A similar quasi-experimental study was conducted by Nurumal, Zain, Mohamed, and Shorey (2019). Data was collected from 140 students among four primary schools in the Kuantan and Pahang districts of Malaysia. Each school was randomly assigned to the intervention or control groups. The intervention consisted of a school-based smoking prevention education program. Questionnaires were used to collect data at baseline and again three months post-intervention. At three months post-intervention, the percentage of nonsmokers remained 100% among the intervention group, and the mean scores of attitude, subject norms, and nonsmoking intention improved significantly. However, 2.9% of the participants in the control group reported smoking within the last seven days. VAPING PREVENTION TOOLKIT FOR EDUCATORS 13 An evaluation of the California Tobacco-Use Prevention Education (TUPE) program for adolescence within the school setting was conducted. Through a competitive grant process, schools can receive funding to provide these programs for grades 6 through 12. The study found that TUPE-funded schools were more likely to provide tobacco-specific health education programs, place a priority on tobacco prevention efforts, and prepare educators to address these topics. However, educators felt better prepared to discuss traditional tobacco products than emerging products such as ENDSs. Overall students receiving the anti-tobacco messages in the TUPE-funded schools were less likely to use tobacco products (McMenamin, Cummins, Zhuang, Gamst, Ruiz, Mayoral, & Zhu, 2018). The Education Against Tobacco (EAT) program consists of a network of 3500 medical students and physicians who volunteer across 14 countries to educate 50,000 adolescents each year with smoking prevention programs. Lisboa, Bernardes-Souza, Xavier, Almeida, Correa, and Brinker (2019) conducted a randomized control trial to measure the long-term effectiveness of the EAT curriculum in Brazil. The trial was conducted among 2,348 adolescents in grades 7 through 11 at public secondary schools. The experimental design included measurements at baseline, 6, and 12 months post-intervention. From baseline to 12 months the smoking prevalence among the control group increased from 11% to 20.9% and from 14.1% to 15.6% in the intervention group demonstrating decreased smoking initiation among those students in the intervention group. Evidence Summary This systematic review of literature examined the issue of smoking initiation among adolescents and the influence of ENDS causing the dangerous upward trend in nicotine use that is plaguing the U.S. Adolescence is a very vulnerable time in growth and development and VAPING PREVENTION TOOLKIT FOR EDUCATORS 14 many of these adolescents are being influenced by advertising, social media, peer pressure, novel products and flavorings, and role models that smoke. This leads them to experimentation and initiation of ENDS and other tobacco products (Anand et al., 2015; Chao, et al., 2019; Farrelly et al., 2015). The use of these nicotine products can have lasting effects on brain development leading to acute and chronic health outcomes and poor lifestyle choices into adulthood including nicotine dependency and addiction (Utah Department of Health, 2017). The literature presents school-based smoking prevention programs as an effective method to educate adolescents about the dangers of smoking including ENDS products. These programs can help change attitudes, beliefs, and perceptions that lead to smoking initiation. They can also include resources to help adolescents build positive self-esteem and learn healthy ways to cope with stress and negative emotions (Bektas, Ozturk, & Armstron, 2010). Theoretical Framework The Social Learning Theory of Albert Bandura emphasizes the ability to learn new behaviors through our environment by observing and then modeling or imitating the behaviors, attitudes, and emotions of others. Studies demonstrate that children are more likely to smoke if the behavior is considered positive in their society or if they have a parent or role model that smokes. The Social Learning Theory explains what needs to happen for an observable behavior to be learned. The first phase of learning through observation is attention to the model behavior. The second stage is retention or the way the behavior is retrieved to make sense of the information. The third stage is reproduction which encompasses the physical and psychomotor skills along with modeled beliefs to fully reproduce the modeled behavior. The final stage is motivation or attaining goals and acknowledging the achievements to motivate oneself to display newly learned behavior (Bektas et al., 2010). VAPING PREVENTION TOOLKIT FOR EDUCATORS 15 This theory was applied to the student education modules in the school-based ENDS use preventive toolkit for educators. Bright colors, catchy campaign posters, visually stimulating images, and interactive questions were used to capture the attention of the adolescent population toward the intended learned behavior. Various statistics and negative health consequence scenarios including disadvantages of smoking and the social problems expected by smokers helped to develop a negative attitude toward smoking behaviors. It is intended that information will be retained, recalled, and retrieved to trigger the established negative attitude toward smoking if the adolescent is ever exposed to the risky behavior. As noted by Bandura, beliefs are as important as behavior during the reproduction phase of learning. A negative self-concept does not allow children to cope with stressful situations appropriately and in a healthy way, leading to negative behaviors like smoking. The student education module provided a list of online resources for teens that encourages building a positive self-concept, addressing healthy ways to cope with stress, understanding emotions, being able to say no, and how to act with assertiveness. Students were motivated to avoid smoking behaviors through increased knowledge and information about the disadvantages of smoking on them and their environment. As they develop social skills, they will be more confident on how to behave when offered to use ENDS products (Bektas et al., 2010). Project Implementation Plan Expected Outcomes/Goals The goal of this project was to develop and implement a school-based ENDS use prevention toolkit for educators that increases faculty knowledge and confidence concerning ENDS education and curriculum. This will facilitate and encourage learning and collaboration with students to have a positive influence on decision-making before smoking initiation by VAPING PREVENTION TOOLKIT FOR EDUCATORS 16 changing attitudes, perceptions, and correcting misinformation. The aim of this project was to educate faculty members about ENDS products, implement a comprehensive school-based ENDS use prevention toolkit for educators, inform students about the dangers of ENDS use, gain faculty and student participation and feedback to organize a well-rounded prevention toolkit that meets the needs of the students and faculty, and ensure a sustainable program for continued use. Outcome measures included the number of students and educators who were introduced to the educational information within the toolkit and their feedback on perceived effectiveness and potential improvements. Setting and Population A pilot school-based ENDS use prevention toolkit for educators was developed and implemented among two faculty members and 40 eighth-grade students attending Snowcrest Junior High in Eden, Utah. Snowcrest Junior High is part of the Weber County School District and is a small rural school that has approximately 325 students in grades seventh through ninth (Public School Review, 2020). The school is within the boundaries of the Weber-Morgan Health District. In 2019, data collected by the Utah Department of Health showed that 7% of those aged 12-13, 10.1% aged 14-15, and 15.1% aged 16-17 were using ENDS (Utah Department of Health, 2019). Among Utah’s 13 health districts, the Weber-Morgan Health district represents the highest rates of youth ENDS use. In 2017, data collected from students living within the Weber-Morgan County health district showed that 15% of the 8th, 10th, and 12th graders surveyed reported vaping or the use of electronic cigarettes. This was twice that of adults in the same district. By comparison, only 3.3 % of students reported using traditional combustible cigarettes (Utah Department of Health, 2017). In 2019, Weber-Morgan County Health district showed a youth VAPING PREVENTION TOOLKIT FOR EDUCATORS 17 ENDS use rate of 18.4%, higher than Utah’s total average of 12.4 % (IBIS, 2019). It was also noted that Weber County has a higher concentration of retailers that sell ENDS products and supplies (Utah Department of Health, 2017). Project Related Barriers This project involved the participation of minors and limited the data collection and evaluation methods available without parental notification and consent. This would have greatly reduced the feasibility of implementation within the health classes at Snowcrest Junior High. With the current coronavirus (COVID-19) pandemic including lockdowns and school closures, it was difficult to find schools to allow educators and students to participate which drastically changed the scope of this project. It was always unclear if students would be remaining in the classroom or if online learning would be utilized more. Fortunately, this toolkit is easily adapted to online learning if needed. Pre-Implementation The DNP project was determined to be exempt after review by the Institutional Review Board (IRB) at Weber State University. The DNP project focused on implementing a pilot school-based ENDS use prevention toolkit for educators. In collaboration with the principal at Snowcrest Junior High School, it was decided that the pilot toolkit with educational resources for faculty and students would be developed by the DNP project leader through evidence-based research and assessment of current toolkits from organizations such as the CDC, the American Lung Association (ALA), and Tobacco Free Utah. As these toolkits have extensive information and strategies, a condensed version was developed for a quick 25-minute information-dense student-oriented presentation to be taught during a 40-minute health science class. VAPING PREVENTION TOOLKIT FOR EDUCATORS 18 The potential impact of prevention programs is limited by those individuals who are delivering the information. If it is not being done effectively or it is being delivered by faculty that are not knowledgeable or may feel ill-prepared and uncomfortable to discuss such topics, the desired outcomes may not be met (McMenamin et al., 2018). To avoid this barrier the toolkit also included a self-taught educator presentation for faculty to familiarize themselves with ENDS products to feel more knowledgeable, comfortable, and confident in teaching ENDS use prevention curriculum. An extensive list of online resources for further information, education, and smoking cessation methods was also included. Key stakeholders including the principal of Snowcrest Junior high and the health science teacher were involved in the development of a comprehensive ENDS use prevention toolkit to ensure successful implementation, outcomes, and future sustainability. Stakeholders intermittently reviewed the developing toolkit resources and participated by sharing feedback on content and delivery methods with the DNP project leader. To combine all the toolkit content into a user-friendly and easily accessible platform a webpage was created, designed, and developed using the free builder site wix.com (see Appendix A). Information was organized in sections for the educator and the student modules (see Appendix B and C). Each section included the educational PowerPoint presentation with a video of the slides with a voiced lecture and an option to view just the slides. Faculty then have the option to go to the site and view the educator module for their educational development and then use the student module to present the material to students. This can be done by playing the video to the students or the teacher can use the slides only option to teach the students themselves. The final section on the webpage is a comprehensive list of online resources for educators and students for further information, education, or smoking cessation methods (see Appendix D). All information can be easily VAPING PREVENTION TOOLKIT FOR EDUCATORS 19 downloaded by the educator. Once the final toolkit resources and content were approved by all key stakeholders it was decided that the DNP project leader would present the student education module during two health science classes consisting of a total of 40 students in the eighth grade, in May of 2021. Implementation The completed webpage was introduced to the principal and health science teacher for review of all toolkit information including the educator module, student module, and comprehensive resource guide. They were emailed the link to the webpage and the educator survey. They were then asked to review the toolkit resources and provide feedback on the perceived effectiveness through the use of a Likert scale survey and open-ended questions. This feedback was then used to assess the need for potential improvements to the educational content and delivery methods to ensure optimal efficacy, and promote sustainability (see Appendix E) (IHI, 2020). The DNP project leader attended two health science classes at Snowcrest Junior High to introduce the class participants to the student ENDS use prevention presentation module. The DNP project leader began the presentation with a short interactive “ice-breaker” game to help the students relax and feel more comfortable in the new setting and build a relationship of trust. The 25-minute educational module was then presented followed by a question-and-answer opportunity for the students. After the presentation was completed, the students were asked to provide feedback on the education materials. This information was then used for any needed adjustments to the toolkit’s student-oriented educational materials or delivery methods as part of the plan-do-study-act (PDSA) cycle (Finkelman, 2018). Ideally, this prevention toolkit will be VAPING PREVENTION TOOLKIT FOR EDUCATORS 20 used and shared with other schools or other community groups such as parents, boy/girl scouts, Big Brother and Big Sister, or youth church groups. Evaluation and Data Analysis Data Collection The project data was collected after the webpage with the toolkit modules was shared with educators to review and evaluate. They then completed an email survey. The students were introduced to the student module for ENDS use prevention by the DNP project leader and were asked to provide feedback. This was accomplished through an informal interview process done by the health science teacher. Opportunistic sampling was carried out on those students who were attending the health classes during that time, and their faculty. The educator survey was developed to evaluate the perceptions of the usefulness, adaptability, and effectiveness of the toolkit in helping the teachers be more prepared to teach ENDS use prevention curriculum. The survey also evaluated the teacher’s attitudes and perceptions on the vaping epidemic and the importance of offering ENDS use prevention education in a school setting. The educator survey consisted of six questions which were rated on a Likert scale from strongly disagree to strongly agree. It also included two open-ended questions for more specific feedback on the strengths and weaknesses of the toolkit (see Appendix E). The student interview process was done immediately following the presentation. The health teacher asked three questions of the students using language that was appropriate to their age group. “Did you learn something new about vaping”, “did you learn something that would positively influence you not to smoke or vape”, and “do you have any advice or feedback to improve the presentation to better meet the needs of your age group”? To maintain anonymity VAPING PREVENTION TOOLKIT FOR EDUCATORS 21 the students recorded their responses on a 3 x 5 notecard and place them in a dropbox as they exited the classroom. Data Analysis Project analysis included descriptive statistics to quantify and describe the responses from both the student and educator groups. Frequency distributions were utilized to measure outcomes and quality indicators for the students including effective education and influence on smoking intention by changing attitudes, perceptions, and correcting misinformation. Educator quality outcomes include increased knowledge and confidence in presenting ENDS prevention education and curriculum. Results A total of 40 (n=40) students participated in the educational presentation. The student responses summarized in Appendix F show that the presentation was highly successful in imparting new knowledge and information that positively impacted ENDS use intention. When asked yes or no, “Did you learn something new about vaping?” all student participants (n=40, 100%) stated, “yes”. When asked yes or no, “Did you learn something that would positively influence you not to smoke or vape?” all student participants (n=40, 100%) stated, “yes”. The student participants were then asked “Do you have any advice or feedback to improve the presentation to better meet the needs of your age group?” Thirty-seven students (92.5%) did not offer any feedback for improvement, implying it was effective in its current format. Three students (7.5%) left comments for improvement with a general theme of including more visual pictures of the effects of vaping (see Appendix F). Two educators, the principal and health class faculty member, participated in the evaluation of the webpage that includes all the toolkit resources. The educator survey responses VAPING PREVENTION TOOLKIT FOR EDUCATORS 22 show a positive perception toward the toolkit for vaping prevention. Using the Likert scale, both participating educators marked “Agree” or “Strongly Agree” that, “this website is user-friendly and easy to navigate”, “I learned something new about ENDS, vaping, and nicotine use among youth”, “I feel the information in this educational toolkit would be easy to incorporate and use in the classroom” and “after reviewing the information in the educator module, I feel more confident and knowledgeable to teach or discuss the topic of ENDS, vaping, and the dangers of nicotine use.” Feedback from the open-ended questions on the strengths, weaknesses, and recommendations for changes to the toolkit was minimal. Comments included “great as is” and “very direct and informative” (see Appendix F). Discussion, Recommendations, Conclusions Discussion The role of the DNP nurse leader included identifying the problem, presenting an evidence-based solution, collaboration with community partners, stakeholders, and other team members, toolkit development and implementation, and data analysis and evaluation. The results of this pilot educational toolkit are encouraging, showing the effectiveness of school-based smoking prevention programs that address both faculty and student needs. Important educational information was effectively delivered to adolescents which positively influenced future smoking intention and educators were able to increase knowledge and confidence in presenting ENDS curriculum. The results demonstrate the positive impact of education to change attitudes, perceptions, and correct misinformation. It also indicates educators are more willing to participate in ENDS use prevention curriculum for students when they feel knowledgeable, confident, and prepared. Adaptability and sustainability are key to the success VAPING PREVENTION TOOLKIT FOR EDUCATORS 23 of this project. The webpage materials can be used in a variety of ways and adapted by the educator to meet their needs and the needs of their students. Sustainability Both participating educators informally expressed future intentions to continue to use the presentation to educate students in the classroom. There were also discussions to include parents in the educational presentations to increase their knowledge and awareness of the issue. The principal of Snowcrest Junior High School also expressed a desire to share the toolkit with other schools. The toolkit resources via the webpage will remain accessible and the contents are easily downloaded for convenient use by educators. There is no anticipated monetary cost to sustain this school-based toolkit. Only individuals’ time and effort. In the long term, this will positively impact and influence healthier lifestyles and better health outcomes. Limitations and Recommendations Potential limitations should be considered due to the highly favorable responses from students and educators. As the presentation took place during a health class with other peers the students may have been inclined to respond more favorably. Also, the educator and student populations who participated were very small and a larger group may glean more meaningful data to ensure the results were not inflated. The COVID-19 pandemic made entering schools and participating with more students and faculty difficult. The setting of this project is in a small rural community with middle to upper socioeconomic levels and low ethnic and cultural diversity. Data may vary with greater inclusion of socioeconomic status, ethnicity, and cultural diversity. The educators who participated had positive responses to the toolkit. However, they did not use the resources to teach students as the DNP project leader delivered the prevention presentation to the students. Perceptions may change slightly when actually using the toolkit in VAPING PREVENTION TOOLKIT FOR EDUCATORS 24 their classrooms to teach students. Recommendations for future advancements include expanding the educator and student population to gain a greater sample size including diversity in socioeconomic status, race, and culture. Further evaluation of the educator portions of the toolkit should be analyzed by having the educators participate in the presentation of the information to the students, and then again surveying their perceptions and attitudes on the effectiveness of the toolkit. Implications There are clear opportunities to address the youth vaping epidemic. However, the question still exists, what is the most effective way to do this? The results of this pilot project are encouraging for the use of school-based smoking prevention programs to get correct educational information to our adolescent populations in junior high school before smoking initiation occurs. This prevents early nicotine dependence and addiction, adverse effects on brain development, and negative health outcomes. Future implications may include the potential for toolkit expansion with more information and resources, expanding faculty and student participation within Snowcrest Junior High, including parents in the educational presentations, and outreach to other schools or community youth groups. Conclusion Smoking continues to be the leading cause of preventable death in the United States (Hall & Doran, 2016). As the use of ENDS products is still relatively new, we are still learning about the health outcomes associated with their use. One unanticipated outcome was the explosion of ENDS use among adolescents due to ease of access, appealing flavors, attractive advertisements, perception of safety, and limited regulatory policies (Anand et al., 2015; Chao, et al., 2019; Farrelly et al., 2015). The use of nicotine is highly addictive, potentially harming brain VAPING PREVENTION TOOLKIT FOR EDUCATORS 25 development in adolescents (Utah Department of Health, 2017). The results of this pilot project suggest the use of a school-based ENDS use prevention toolkit for educators is an effective way to educate adolescents during a crucial time before the initiation of smoking or ENDS use (Das et al., 2016). It also suggests that providing resources for educators to feel more knowledgeable, prepared, and confident to address ENDS use curriculum will increase their participation in prevention education for students. This collaboration can lead to fewer numbers of adolescents using ENDS products, promoting better health outcomes. VAPING PREVENTION TOOLKIT FOR EDUCATORS 26 References Anand, V., McGinty, K. L., O’Brien, K., Guenthner, G., Hahn, E., & Martin, C. A. (2015). ENDS use and beliefs among urban public high school students in North Carolina. Journal of Adolescent Health, 57, 46-51. Audrian-McGovern, J., Strasser, A. & Wileyto, E. P. (2016). The impact of flavoring on the rewarding and reinforcing value of ENDSs with nicotine among young adult smokers. Drug and Alcohol Dependence, 166, 263-267. Bektas, M., Ozturk, C., & Armstrong, M. (2010). An approach to children’s smoking behaviors using social cognitive learning theory. Asian Pacific Journal of Cancer Prevention, 11, 1143-1149. Boudi, F. B., Patel, S., Boudi, A., & Chan, C. (2019). Vitamin E acetate as a plausible cause of acute vaping-related illness. Cureus, 11(12), 1-5. Centers for Disease Control and Prevention (2020). Smoking and tobacco use: Current cigarette smoking among adults in the United States. Retrieved from http://www.ihi.org/education/InPersonTraining/ImprovementProject/Pages/default.aspx Centers for Disease Control and Prevention (2020a). Outbreak of lung injury associated with the use of ENDS, or vaping, products. Retrieved from https://www.cdc.gov/tobacco/basic_information/ENDSs/severe-lung-disease.html Center for Disease Control and Prevention (2020b). Smoking & tobacco use: About electronic cigarettes. Retrieved from: https://www.cdc.gov/tobacco/basic_information/ENDSs/index.htm VAPING PREVENTION TOOLKIT FOR EDUCATORS 27 Chao, D., Hashimoto, H., & Kondo, N. (2019). Social Influence of ENDS smoking prevalence on smoking behaviours among high-school teenagers: Macrosimulation experiments. PloS ONE, 14(8), 1-7. Das, J. K., Salam, R. A., Arshad, A., Finkelstein, Y., & Bhutta, Z. A. (2016). Interventions for adolescent substance abuse: An overview of systemic reviews. Journal of Adolescent Health, 59, S61-S75. Dietz, N. A., Arheart, K. L., Sly, D. F., Lee, D. J., & McClure, L. A. (2016). Correlates of smoking among youth: The role of parents, friends, attitudes/beliefs, and demographics. Tobacco Induced Diseases, 14(9). https://doi.org/10.1186/s12971-016-0072-0 Dino, G., Horn, K., Abdulkadri, A., Kalsekar, I., & Branstetter, S. (2008). Cost-effectiveness analysis of the not on tobacco program for adolescent smoking cessation. Prevention Science, 9(1), 38-46. Dir, A. L., Banks, D. E., Zapalski, T. C. B., McIntyre, E., & Hulvershorn, L. A. (2016). Negative urgency and emotion regulation predict positive smoking expectancies in non-smoking youth. Addictive Behaviors, 58, 47-52. Drope, J., Cahn, Z., Kennedy, R., Liber, A., Stoklosa, M., Henson. R., Douglas, C. E., & Drope, J. (2017). Key issues surrounding the health impacts of electronic nicotine delivery systems (ENDS) and other sources of nicotine. Cancer Journal for Clinicians, 67(6), 450-449. Fairchild, A. L., Lee, J. S., Bayer, R., and Curran, J. (2018). ENDS and the harm-reduction continuum. New England Journal of Medicine, 378(3), 216-219. Farrelly, M. C., Duke, J. C., Crankshaw, E. C., Eggers, M. E., Lee, Y. O., Nonnemaker, J. M., Kim, A. E., & Porter, L. (2015). A randomized trial of the effect of ENDS TV VAPING PREVENTION TOOLKIT FOR EDUCATORS 28 advertisements on intentions to use ENDSs. American Journal of Preventative Medicine, 49(5), 686-698. Federal Food and Drug Administration. (2020). Youth tobacco use: Results from the national youth tobacco survey. Retrieved from https://www.fda.gov/tobacco-products/youth-and-tobacco/ youth-tobacco-use-results-national-youth-tobacco-survey Finkleman, A. (2018). Quality improvement: A guide for integration in nursing. Burlington, MA: Jones and Bartlett Publishing. Glantz, S. A., & Bareham, D. W. (2018). ENDSs: Use, effects on smoking, risk, and policy implications. Annual Review of Public Health, 39, 215-135. Hall, W., & Doran, C. (2016). How much can the USA reduce health care costs by reducing smoking? PLoS Medicine, 13(5), 1-3. Hammond, D., Reid, J. L., Cole, A. G., & Leatherdale, S. T. (2017). Electronic cigarette use and smoking initiation among youth: A longitudinal cohort study. Canadian Medical Association Journal, 189(43), 1328-1336. Improvement for Healthcare Improvement [IHI]. (2020). The improvement project. Retrieved from http://www.ihi.org/education/InPersonTraining/ImprovementProject/Pages/default.aspx Khazaee-Pool, M., Pashaei, T., Mansorian, M., Qorbani, M., Safari, O., & Shojaeizadeh, D. (2016). School-based smoking prevention programs for middle school students in Nowshahr-Iran: A randomized controlled trial. International Journal of Pediatrics, 4(11), 3859-3874. VAPING PREVENTION TOOLKIT FOR EDUCATORS 29 King, B. A., Jones, C. M., Baldwin, G.T., & Briss, P. A. (2020). The EVALI and youth vaping epidemics-implications for public health. New England Journal of Medicine, 2020(382), 689-691. Lawrence, O. G., Gostin, J. D., & Glasner, J. D. (2014). ENDSs, vaping, and youth. JAMA. 312(6), 595-596. Lieber, C.M. (2016). Adolescent development and how adolescents learn. Retrieved from: https://www.asdn.org/wp-content/uploads/AdolescentFactsfromREAL_2016.pdf Lisboa, O. C., Bernardes-Souza, B., Xavier, L. E. D., Almeida, M.R., Correa, P. C. R. P, & Brinker T. J. (2019). A smoking prevention program delivered by medical students to secondary schools in Brazil called “education against tobacco”: Randomized controlled trial. Journal of Medical Internet Research, 21(2), e12854. McMenamin, S. B., Cummins, S. E., Zhuang, Y-L., Gamst, A. C., Ruiz, C. G., Mayoral, A., & Zhu, S-H. (2018). Evaluation of the tobacco-use prevention education (TUPE) program in California. PLOS ONE, 13(11), 1-16. Miech, R., Patrick, M. E., O’Malley, P. M., & Johnston, L. D. (2017). What are kids vaping? Results from a national survey of US adolescents. Tobacco Control, 26, 386-391. Nurumal, M. S., Zain, S. H. M., Mohamed, M. H. N., & Shorey, S. (2019). Effectiveness of school-based smoking prevention education program (SPEP) among nonsmoking adolescents: quasi-experimental study. The Journal of School Nursing: The official publication of the National Association of School Nurses, 1059840519871641. Advance online publication. https://doi.org/10.1177/1059840519871641 VAPING PREVENTION TOOLKIT FOR EDUCATORS 30 Public Health Indicator Based Information System (IBIS) (2020). Community snapshot for Weber-Morgan local health district. Retrieved from: https://ibis.health.utah.gov/ibisph-view/ community/snapshot/report/AllIndicators/GeoLHD/12.html?PageName= Public School Review (2020). Snowcrest Junior High School. Retrieved from: https://www.publicschoolreview.com/snowcrest-junior-high-school-profile Reavy, K. (2016). Inquiry and leadership: A resource for the DNP project. Philadelphia: F.A. Davis. Soneji, S. S., Sung, H-Y., Primack, B. A., Pierce, J. P., & Sargent, J. D. (2018). Quantifying population-level health benefits and harms of ENDS use in the United States. PLoS ONE, 13(3), 1-19. Starbuck, J. (2018). Adolescences and learning-The teenage brain. Retrieved from: https://www.cambridge.org/elt/blog/2018/09/04/adolescence-learning-teenage-brain/ Truth Initiative (2021). ENDSs: Facts, stats, and regulation. Retrieved from: https://truthinitiative.org/research-resources/emerging-tobacco-products/ENDSs-facts-stats- and-regulations Utah Department of Health (2017). Utah Health Status Update: Vaping Trends Among Utah Youth and Adults Retrieved from https://ibis.health.utah.gov/ibisph-view/ pdf/opha/publication/hsu/2017/1712_Vaping.pdf Utah Department of Health (2019). Tobacco prevention and control in Utah. Retrieved from: https://tobaccofreeutah.org/wp-content/uploads/leg-rep-19-final.pdf Wellman, R. J., Dugas, E. N., Dutczack, H., O’Loughlin, E. K., Datta, G. D., Lauzon, B., & O’Loughlin, J. (2016). Predictors of the onset of cigarette smoking: A systematic review VAPING PREVENTION TOOLKIT FOR EDUCATORS 31 of longitudinal population-based studies in youth. American Journal of Preventative Medicine, 51(5), 767-778. Zhong, J., Coe, S., Gong, W., Fei, F., & Wang, M. (2016). Electronic cigarettes use and intention to cigarette smoking among never-smoking adolescents and young adults: A meta-analysis. International Journal of Environmental Research and Public Health, 13, 465-474. VAPING PREVENTION TOOLKIT FOR EDUCATORS 32 Appendix A Webpage Link with View https://desdayallen.wixsite.com/vapingtoolkit VAPING PREVENTION TOOLKIT FOR EDUCATORS 33 Appendix B Educator Module PowerPoint Slides VAPING PREVENTION TOOLKIT FOR EDUCATORS 34 VAPING PREVENTION TOOLKIT FOR EDUCATORS 35 VAPING PREVENTION TOOLKIT FOR EDUCATORS 36 VAPING PREVENTION TOOLKIT FOR EDUCATORS 37 Appendix C Student PowerPoint Module VAPING PREVENTION TOOLKIT FOR EDUCATORS 38 VAPING PREVENTION TOOLKIT FOR EDUCATORS 39 VAPING PREVENTION TOOLKIT FOR EDUCATORS 40 VAPING PREVENTION TOOLKIT FOR EDUCATORS 41 VAPING PREVENTION TOOLKIT FOR EDUCATORS 42 Appendix D Resource Guide Tobacco Free Utah https://tobaccofreeutah.org/ Weber-Morgan Health Department http://www.webermorganhealth.org/health-promotion/tobacco-prevention/ Weber-Morgan Health Department Governing Youth Council http://www.webermorganhealth.org/health-promotion/GYC/ Centers for Disease Control and Prevention https://www.cdc.gov/tobacco/basic_information/ENDSs/Quick-Facts-on-the-Risks-of-ENDSs-for- Kids-Teens-and-Young-Adults.html U.S. Federal Food and Drug Administration https://www.fda.gov/tobacco-products/youth-and-tobacco/fdas-youth-tobacco-prevention-plan https://www.fda.gov/tobacco-products/public-health-education/real-cost-campaign Truth Initiative https://truthinitiative.org/ Safer ≠ Safe https://www.thetruth.com/article/safer-safe “Catch My Breath” ENDS Prevention Program https://catchinfo.org/modules/ENDSs/ Peers Foundation: Vaping awareness and Nicotine Prevention Game Show https://peersfoundation.org/programs/vaping-prevention/ American Heart Association https://www2.heart.org/site/DocServer/Building_Community_Support_AHA-AASA_ Vaping_Toolkit.pdf American Lung Association: “Get your Head Out of the Clouds” https://www.lung.org/quit-smoking/end-youth-vaping American Cancer Association VAPING PREVENTION TOOLKIT FOR EDUCATORS 43 https://www.cancer.org/latest-news/faq-vaping-and-your-kids.html Campaign for Tobacco-Free Kids https://www.tobaccofreekids.org/what-we-do/industry-watch/ENDSs Youth Now: Educator Resources https://www.youthnow.me/schools/educators/ Tobacco Free Earth https://tobaccofree.org/quitting Stanford Medicine: Tobacco Prevention Toolkit https://med.stanford.edu/tobaccopreventiontoolkit.html Youth Engagement Alliance for Tobacco Control https://youthengagementalliance.org/resources/ Mayo Clinic: “Become an Ex” https://www.becomeanex.org/ U.S. Department for Health and Human Services: “The Real Cost” https://teen.smokefree.gov/quit-vaping/how-to-quit-vaping https://therealcost.betobaccofree.hhs.gov/vapes https://www.scholastic.com/youthvapingrisks/index.html Way to Quit https://waytoquit.org or youth can visit https://mylifemyquit.com/ American Lung Association “Not-On-Tobacco” https://www.lung.org/quit-smoking/helping-teens-quit Vaping Prevention Resources and Tools to Help Student Quit: Truth Initiative https://get.everfi.com/k12-vaping-know-the-truth/? utm_source=google&utm_medium=cpc&utmcampaign Quit Assist https://www.quitassist.com VAPING PREVENTION TOOLKIT FOR EDUCATORS 44 Appendix E Educator Survey 1. Before participating in this education module I felt confident and knowledgeable about the topic of ENDSs, vaping, and the harmful effects of nicotine? Strongly Agree Agree Neutral Disagree Strongly Disagree 2. This website is user-friendly and easy to navigate? Strongly Agree Agree Neutral Disagree Strongly Disagree 3. I learned something new about ENDSs, vaping, and nicotine use among youth? Strongly Agree Agree Neutral Disagree Strongly Disagree 4. I feel that ENDS and vaping use among youth is an important societal issue to address? Strongly Agree Agree Neutral Disagree Strongly Disagree 5. I feel the information in this educational toolkit would be easy to incorporate and use in the classroom? Strongly Agree Agree Neutral Disagree Strongly Disagree 6. After reviewing the information in the educator module I feel more confident and knowledgeable to teach or discuss the topic of ENDSs, vaping, and the dangers of nicotine use? Strongly Agree Agree Neutral Disagree Strongly Disagree 7. Please share your opinion on the strengths of this education toolkit. 8. Please share any ideas on how this toolkit could be improved for the educator and the student. VAPING PREVENTION TOOLKIT FOR EDUCATORS 45 Appendix F Results Tables Table F1 Table F2 Educator Survey Responses Likert Scale: Strongly Agree Agree Neutral Disagree Strongly Disagree Question Educator #1 Responses Educator #2 Responses 1. Before participating in this education module I felt confident and knowledgeable about the topic of ENDSs, vaping, and the harmful effects of nicotine? Agree Strongly Agree 2. This website is user-friendly and easy to navigate? Strongly agree Strongly Agree VAPING PREVENTION TOOLKIT FOR EDUCATORS 46 3. I learned something new about ENDSs, vaping, and nicotine use among youth? Strongly Agree Agree 4. I feel that ENDS and vaping use among youth is an important societal issue to address? Strongly Agree Strongly Agree 5. I feel the information in this educational toolkit would be easy to incorporate and use in the classroom? Strongly Agree Agree 6. After reviewing the information in the educator module I feel more confident and knowledgeable to teach or discuss the topic of ENDSs, vaping, and the dangers of nicotine use? Agree Agree 7. Please share your opinion on the strengths of this education toolkit. “Very direct and informative” “Great information for students” “I plan to show this presentation to students who are found vaping on school grounds” 8. Please share any ideas on how this toolkit could be improved for the educator and the student. “Great as is, I plan to use this presentation with my students” “Great as is” “Use of interactive questions and activities can support student learning”