Digital Repository Doctoral Projects Fall 2021 Decreasing Electronic Cigarette Use Among Adolescents Brian Maynard Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Maynard, B. (2021) Decreasing Electronic Cigarette Use Among Adolescents. 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 Electronic Cigarette Use Among Adolescents by Brian Maynard 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: DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLESCENTS Decreasing Electronic Cigarette Use Among Adolescents Brian Maynard Annie Taylor Dee School of Nursing Weber State University- Doctor of Nursing Practice DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 2 Acknowledgements A special thanks to all the Doctor of Nursing Practice faculty at Weber State, especially Dr. Jessica Bartlett and Dr. Mary Anne Reynolds. Thank you to Ogden High School and project consultants, Mrs. Ashley Bailey and Mr. Erik Thompson DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 3 Dedication An appreciation for all those healthcare providers who paved the way for me and those in my career who’ve taken the time to teach and show me the way. Lastly, a full-hearted thank you to my family: Michell, Caden, Alec, and Gabe. There is nothing more important than you. DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 4 Abstract Adolescent use of electronic cigarette (e-cig) products has continued to rise across the United States. These behaviors have led to acute and chronic health complications, the development of e-cig or vaping use-associated lung injury (EVALI), continued tobacco use into adulthood, and gateway drug use. The purpose of this Doctor of Nursing Practice project was to create a sustainable toolkit of information for high school educators to include in their curriculum and develop a web-based resource page for teachers, parents, and students. The toolkit included a 60-minute PowerPoint presentation on information related to e-cigs, their harmful health effects, and marketing tactics by tobacco companies towards youth. The toolkit also included a website link to resource information. Teachers evaluated the overall effectiveness of the program and their willingness to incorporate the toolkit into their curriculum. The teacher’s evaluation of the program noted a high rating in program effectiveness and willingness to incorporate the toolkit into their curriculum. Additionally, the website was visited by almost 80 individuals over 5 months. Screening for e-cig use and providing information and resources is an imperative part of the Nurse Practitioner’s role for adolescent health prevention. Providers can create or be involved with programs that highlight the negative health effects of e-cig use, dispel myths, and be a resource for community members inquiring about e-cig prevention and cessation. Keywords: electronic cigarette, vaping, adolescent, prevention DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 5 Electronic Cigarette Use Among Adolescents Over the last ten years, a growing health crisis has been the rise of electronic cigarette (e-cigs) usage among adolescents. In 2019, 27% of all high school students admitted to using an e-cig product within the last 30 days (Center for Disease Control and Prevention [CDC], 2020c). The use of e-cigs in 2011 among high school students was 1.5% but rose dramatically to 20.8% by 2018 (Gentzke et al., 2019). Young adult smokers are addicted to nicotine via e-cig use at an early age and continue their habits into adulthood (Primack, Soneji, Stoolmiller, Fine, & Sargent, 2015). Approximately 90% of today’s adult smokers used their first tobacco product before 18 years old (United States Food and Drug Administration, 2020). Continued use of e-cig or tobacco products into adulthood may result in acute and chronic health complications, developmental delays, and as a gateway to other drug use. Although programs exist from local health departments and schools regarding the harmful effects of e-cig use, students in Weber/Morgan county, mainly 10th and 12th graders, have higher experimental use (33% and 48.9%), continued vaping use (19.3% and 26.1%), and lower perceptions of risk than the state average (Utah Division of Substance Abuse and Mental Health, 2019). Current local prevention programs have been limited by implementation barriers, scattered information, and program sustainability. Specifically, the Ogden School District has continually been above national and state averages in experimentation and continued use from 6th to 12th-grade students. The goal of this project was achieved by creating and providing a sustainable educational toolbox for high school teachers. The information was obtained through national and state platform agencies and evidence-based research and consolidated into a PowerPoint presentation with an accompanying teaching manual. A webpage was also created for teachers, students, and DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 6 parents which contained information on e-cigs and their harmful effects. The webpage included links to resource information, videos, interactive gaming applications, and scholarship information. Search Methods A web-based search was performed using Google Scholar, Medline, PubMed databases, and Weber State University Stewart Library. Search terms included electronic cigarettes, adolescents, vaping, nicotine, tobacco marketing, tobacco-related health diseases, and electronic cigarette legislation. Limitations included obtaining longitudinal data since the prevalence of this outbreak is within the last ten years, limited studies specific to vaping use prevention among teenagers, and access to local school district data. Only reviews in English between 2013 to 2020 were used. Review of the Literature E-cigs, or vape products, go by many different names: e-hookahs, mods, vape pens, vapes, tank systems, and ENDS (electronic nicotine delivery system). They come in the shapes of traditional cigarettes, pipes, or everyday items such as USB sticks, watches, or pens. These battery-powered devices all use a heating process that aerosolizes the liquid, or vape juice, which may contain nicotine, and many other products, allowing for the user's inhalation (CDC, 2020b). It is unknown how many chemicals exist in vape juice or are activated upon heating, but some researchers state it is less than the 4000 chemicals present in traditional cigarettes. Tobacco companies cite this information as “a healthier alternative” to traditional smoking. Manufacturers are not required to list all the active and inactive ingredients in their product, nor list what chemicals are created after heating the vape juice (Lestari, Humairo, & Agustina, 2018). DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 7 A known active ingredient in most e-cigs liquids is nicotine. Nicotine is rapidly absorbed within 10 seconds of inhalation and stimulates several parts of the brain resulting in an excited or “buzzed” type feeling and ending in a calming state when dopamine is released (Brunzell, Stafford, & Dixon, 2015). The adolescent brain is in constant development of mapping synaptic junctions and myelination of nerve sheaths. The introduction of a neurological insult, such as nicotine, to the frontal lobe during development can result in reduced cognitive processing manifesting as impaired planning, increased risk-taking, poor impulse control, and decreased memory. The pre-cortex frontal lobe reward-emotion impairment leads to greater susceptibility to addiction in those affected youth (U.S. Department of Health and Human Services, 2016). As nicotinic receptors within the midbrain dopamine neurons are stimulated by the nicotine in vape juice, the cue for continued addictive behaviors may continue (Krishnan-Sarin et al., 2017). Vaping Behavior Many social, mental, and environmental factors may contribute to the increasing rate of e-cig use. These include peer pressure, mental health susceptibility, parental influence, and marketing directed towards a younger age group. By nature, adolescents are identity-seeking and exploring areas of young adulthood components (Eleuteri, Saladino, & Verrastro, 2017). As they develop, they are a part of a peer crowd with strong influences on an individual's behaviors and risks. One central reoccurring reason teenagers stated their experimentation with e-cigs was curiosity. Over 60% of them believed they were only inhaling flavoring, not recognizing the active ingredient of nicotine in the product or the end effect of product vaporization particles (Douglass & Solecki, 2017). Hwang (2016) noted a significant impact on groups' behaviors concerning an individual’s choice to participate or not participate. The results indicated not so much a pressure to act, but that relating and identifying to those partaking in a particular DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 8 behavior made the individual at higher risk to mimic what they were viewing. The study also noted a trend in “re-normalizing” the perception of smoking by tobacco companies with vaping products' popularity. In addition to peer pressure, other factors contribute to a teen’s risk of e-cig use. Teens with mental health issues such as anxiety and depression are at higher risk of using tobacco, possibly related to poor decision making, impulse control issues, or inability to fully understand their actions. Additionally, those from a lower socioeconomic group, those with poor grades, low self-esteem, or inadequate parental involvement and support, are also at high risk (CDC, 2020a). Marketing Towards Youth Tobacco companies spend a considerable amount of time and money on advertisements explicitly directed towards youth to entice new and younger users. In 2016, tobacco companies spent $9.5 billion on advertising and promotional expenses: $26 million daily (CDC, 2020c). Companies promote their products through radio, television, and internet advertisements that use celebrities, sexual content, and independence to appeal these products to youth (Dunlop, Freeman, & Jones, 2016). E-cigs are advertised as healthy alternatives to cigarettes and packaged with attractive coloring, naming, and flavors such as bubble gum, peanut butter, chocolate, etc. Tobacco companies have created vape device components that can be customized and interchanged, an aspect that appeals to youth seeking their own personality and creativity (Wasowicz, Feleszko, & Goniewicz, 2015). Advertising and misinformation regarding e-cigs have an effect on the risk to youth using these products. A 2016 study noted that teenagers exposed to current advertisements of e-cigs were more likely to try the products within the next year, especially if offered by a friend. DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 9 Additionally, teens believed that e-cigs were allowed in tobacco-free areas, not thinking they were considered tobacco products, that they weren’t harmful to others around them, and were safer than cigarettes or less toxic (Farrelly et al., 2015). Tobacco companies highlight that vaping is not smoking because there is no solid product combustion to an aerosol, creating fewer byproducts to inhale and fewer chemicals expelled. This perception leads youth to believe vaping is less harmful, and the expelled smoke is mostly water vapor, thus safer for those around someone who vapes (TobaccoFreeCA, 2020). Vape juice is advertised as containing only four ingredients: nicotine, vegetable glycerin, propylene glycol, and various flavorings. However, studies have found other ingredients included in vape juice such as acetaldehyde, formaldehyde, acrolein, diacetyl, diethylene glycol, nickel, tin, lead, and cadmium. Many of these ingredients can cause liver disease, cell damage, lung injuries, high blood pressure, and vessel disease (American Lung Association, 2020). Although paid advertising of tobacco products is banned on social media sites, what constitutes paid advertising is a gray area. The rise in e-cig use prevalence shows that some of the marketing strategies are working (Singh et al., 2016). Dunlop, Freeman, and Jones (2016) noted that 46 tobacco companies had established 238 different Facebook pages, with over 1.9 million likes and 19,000 posts. The study also noted that YouTube videos similarly had over 6 million views regarding hookah, vaping tricks, and other tobacco suggestions. There are little to no restrictions on e-cig advertising on radio, T.V., or magazines. These products are portrayed as cool, sexy, and harmless to use (TobaccoFreeCA, 2020). Parental Factors Another significant influence on a teenager’s decision to smoke is the parental behavior they are exposed to. A longitudinal study of 1010 adolescents showed the risk was increased not DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 10 only during teen years but into adulthood if they were exposed to cigarette use in their homes. The more the parent smoked (occasional use to heavy use) reflected a higher percentage of adolescents who smoked. Approximately 8% of children with parents who were former smokers had tried tobacco in the last 12 months. Additionally, 23-29% of children whose parents were daily or substantial smokers had used tobacco during the previous 12 months (Vuolo & Staff, 2013). Combining a teen’s risk of peer involvement to vape and parental behavior may increase the odds of vaping experimentation or continued use during their adolescent years. Clinical Consequences Adolescents who use e-cigarettes are at risk of similar health problems related to tobacco, including various types of cancer and respiratory problems such as asthma and COPD. Lung cancer is a slowly progressing disease usually manifesting later in life. Epidemiologic studies have shown the earlier a person smokes in life, the higher risk of developing lung cancer. A person who began smoking before age 15 doubled their risk for lung cancer versus those who started smoking at age 20 (Hymowitz, 2012). Between 2009-2013, there were 660,000 new tobacco-related cancer diagnoses among all ages in the United States, and 343,000 died from those types of cancers. Among all cancer sites and cancer-related deaths, cancer of the lungs was the most prominent site (33%) and cause of death (50%) (Henley et al., 2016). Cancer doesn’t manifest until later years in life. Therefore, it is imperative to address tobacco use in the early years to prevent older age type chronic diseases. Tobacco use has been attributed to heart disease, stroke, myocardial infarction, peripheral vascular disease, and obesity. It also causes hypertension, tachycardia, nicotine addiction, and withdrawal symptoms, including irritability, anger, anxiety, and difficulty concentrating (TobaccoFreeCA, 2020). DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 11 Although many of these diseases are long-term vaping complications, there are also short-term effects noted among adolescents. Those who use e-cigs are at greater risk for cracked or broken teeth, tongue and cheek pain (Cho, 2017), wrinkled skin due to an increase in the release of free radicals, depletion of vitamin A and C, decreased wound healing due to vasoconstriction, hair loss or thinning related to interrupted blood flow to the hair follicles, yellow staining of the teeth, tooth enamel decay leading to increased sensitivity, gum loss, and periodontal infections related to bacterial adherence from flavoring products (Smith, 2020). Bystanders are not immune from the health consequences of vaping even if they are not involved in the process. Vape smoke is not “just water vapor” as advertised by many tobacco companies. Vape smoke has been found to contain particles such as carbonyls, nicotine, volatile organic compounds, benzene, and toluene (Lee, LeBouf, Son, Koutrakis, & Christiani, 2017). Exposure to many of these chemicals results in airway and eye irritation, chromosomal damage, or various cancers (Lee, LeBouf, Son, Koutrakis, & Christiani, 2017). Gateway drug use. In addition to increasing the risk of cigarette smoking in adulthood, e-cigs are emerging as a gateway to marijuana use. A 2019 study of 2630 adolescents noted 41% had used marijuana over the last 365 days; the preferred method was smoking (99%), edibles (63%), and vaping cannabis (44%). The rise in these statistics is consistent with the increase in e-cig use (Knapp et al., 2019). As states transition to cannabis legalization, the positive aspects of vaping such as healthier alternative, discreteness, more practical effect, better taste, and more socially accepted may increase the probability of trying cannabis at a younger age leading to potential addiction (Budney, Sargent, & Lee, 2015). E-cig or vaping use-associated lung injury (EVALI). A new disease being investigated by the CDC is lung injury as a result of e-cigs. In September 2019, forty-six states reported a DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 12 total of 805 patients with lung injuries after smoking nicotine or nicotine-containing THC products via e-cig devices within the last 90 days. All patients were ruled out for an infectious process or other causative diagnoses. Of the 805 patients, 12 resulted in death. The average hospital stay was six days, with the longest being noted at 158 days. The average age was 23 years old, with the youngest noted at 13 (Perrine et al., 2019). Although further research is required, a bronchial lavage study in 51 patients with e-cig induced lung injury noted vitamin E acetate in 94% of the patients. THC was observed in 94% of samples, while nicotine was also noted in 64% of the samples (Blount et al., 2020). Solutions One key to stopping e-cig use among high school students is prevention. Effective strategies proven to impact e-cig prevention in youths include comprehensive programs, accessible resources, and educator or parental engagement using established anti-vaping evidence-based information (U.S. Food and Drug Administration, 2020b). Prevention programs. Several prevention programs have been established highlighting the dangers of vaping, encouraging positive youth development, resisting media influences, and teaching critical thinking. Successful programs include parental involvement, maintaining an open dialogue with teens, dispelling myths surrounding vaping, providing correct information regarding the harmful effects of vaping, and recognizing policies to restrict the use and access to e-cig products. The programs are offered through PowerPoint presentations, online courses, written modules, and toolkits for educators. Several of these programs include The National Truth Initiative Program, The Real Cost Campaign, The Tobacco Prevention Took Kit from Stanford Medicine, and the CATCH My Breath Youth Program (Conner, Pelletier, Bayoumy, & Schwartz, 2019). DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 13 Comprehensive programs that vary to the appropriate developmental level are theory-driven and relevant to the community and cultural needs have the most successful outcomes (Nation et al., 2003). These programs, such as The National Truth Initiative Program (2019), speak to teens in their terms on platforms they are familiar with about vaping's real effects. They use social media, merchandising, and onsite event promotions to highlight their public education program. They seek to provide accurate and current data on the harmful effects of vaping, prevent any type of tobacco use, and provide resources and assistance to those trying to quit vaping. Since its inception, they have reached over 5 million adolescents and have prevented 450,000 of them from starting the smoking habit (The Truth Initiative, 2019) The Food and Drug Administration (FDA) launched the “The Real Cost” campaign in 2014 focusing on youth education that e-cigs, just like traditional tobacco products, put them at high risk for addiction and health consequences. The program is advertised via television and internet ads, social media, the FDA website, and high school posters and bulletins (Food and Drug Administration, 2020). Between 2014 to 2016, the campaigns reported the prevention of nearly 350,000 youths between ages 11-18 from initiating tobacco use (Brubach, 2019). Adolescents relate to social media and online influences, two major markets of the vaping industry. They use the internet for various reasons to include identity formation, autonomy, peer relations, and seeking out information. They want to fit in and feel accepted among their peers, they seek the independence and anonymity of exploration, and use web-based programs to stay connected to their offline relationships (Borca, Bina, Keller, Gilbert, & Begotti, 2015). To counter these industry influences, educators must create programs and messaging that separate the connection between vaping, social trends, social status, and reconsider those relationships to vaping (Stalgaitis, Djakaria, & Jordan, 2020). DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 14 The State of Utah has launched several online and interactive anti-smoking campaigns, including TobaccoFreeUtah.org, WayToQuit, OUTRAGE!, and Tobacco21. These programs provide information on quitting smoking, addressing the harmful effects of tobacco on an individual's health, and using platforms such as YouTube, social media, and radio with local celebrities to send their message (Utah Tobacco and Prevention Program, 2017). On a national level, several campaigns, such as the Truth Initiative and The Real Cost, also provide information about teen vaping use and its harmful effects while promoting these programs on T.V. and social media platforms. Other resources include interactive video games, such as smokeSCREEN (Yale Center for Health and Learning Games, 2018), that allow the participant to make choices that impact the game's progression and teach various behavioral skills while educating them at the same time. Success has been noted in using video game interaction programs to educate adolescents in other healthcare forums. Chu et al. (2015) looked at the impact of an interactive sexual education video game on teens. This game highlighted sexual boundaries for maturity levels, understanding of healthy relationships, situation outcome choices, education on sexual diseases and self-protection, and possible pregnancy outcomes. Among all participants, there was an increase in sexual education knowledge, external influences on sexual desires, and safe sex practices. A video-based game, such as Yale’s smokeSCREEN, is a web-based interactive program that can be used to address teen behaviors related to vaping use and social interactions. Parental Involvement. Parents play an active role in the prevention of teen vaping. The first step is educating themselves on what vaping is, the harmful effects of vaping, and tools on how to talk to their children about vaping. The CDC website provides PowerPoint presentations, fact sheets, DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 15 pictures, and other information to inform caregivers about e-cigs. Secondly, the CDC recommends parents set a positive behavior by quitting smoking, if they smoke, and creating a healthy and supportive smoke-free environment for teens. Additionally, the website provides information directly to youth, providing online assistance for tobacco cessation, tools for handling stressful situations, peer support, and information on all forms of tobacco products (CDC, 2019). Resource links. To increase learning uptake, how information is delivered and available should be culturally and socially relevant to the adolescent population (Chu et al., 2015). Eighty-two percent of high school students have a smartphone device with an average online use of six hours a day, and 82% of those students visit a social media platform daily (Twenge, Martin, & Spitzberg, 2019). Although adolescents seek health-related information more than before, limitations were observed on their results and their further investigation of a topic. General search engine information on teens' health-related topics resulted in over a million different links and information, making it difficult for adolescents to ascertain reliable information and usually choose one of the first nine links without searching further. A study in 2016 among adolescents seeking healthcare information found the search engine, Google was used 49% primarily as the initial method, 31% used a medical-specific website, and approximately 20% used social media platforms as a source for health information. Of the top 12 health subjects searched, smoking ranked 6th among all topics. The study did note teenagers were leerier to seek out any information that may be of a sensitive nature on social media sites (Wartella, Rideout, Montague, Beaudoin-Ryan, & Lauricella, 2016). DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 16 Educators. It is well-known and accepted the positive impacts that many teachers have on students regarding their academic performance, attitudes, behaviors, and skills learned into adulthood (Blazar, 2016). With education demands increasing, COVID-19 lingering over school districts, and increased student-to-teacher ratios, many teachers feel overwhelmed, anxious, and have left the profession (Cipriano, 2020). Having pre-designed kits with current information, links, and age-appropriate material can ease the burden of expanding the curriculum. Several anti-tobacco and vaping programs have been created for high school educators that inform students on the consequences of vaping, personal skills for behavior changes, and general marketing strategies and product information. One example is the Stanford Medicine tobacco prevention toolkit for educators and teens. This new six-module kit has information related to vaping products, e-cig ingredients, harmful effects, smoking and COVID-19 consequences, and youth self-improvement (Stanford School of Medicine, n.d.). This program has shown promising results in their preliminary evaluation of desired changes in knowledge, attitudes, and behaviors. A similar program used by many teachers, Catch-My-Breath, is a branch of the coordinated approach to child health (CATCH) program that is a community and school-based program. This program educates kids on healthy choices such as foods, exercise, and overall well-being. The anti-tobacco program consists of 4 modules for teachers and students, highlighting the dangers of vaping, marketing tactics, and refusal skills (Catch.org, n.d.). A pilot data result of 26 schools that implemented the CATCH My Breath noted: ● 91% of teachers agreed or strongly agreed that the lessons were culturally appropriate for their students DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 17 ● 91% of teachers agreed or strongly agreed that they felt confident in their ability to teach the curriculum ● 68% of teachers agreed or strongly agreed that their students enjoyed the lessons (Conner, Pelletier, Bayoumy, & Schwartz, 2019) A 16-month follow-up study at schools that implemented the Catch-My-Breath program noted a decrease in e-cig use and increased vaping knowledge (Kelder et al., 2020). Literature Review Summary A continuing epidemic has been the rise of e-cig use among adolescents, including teens at Ogden High School and the surrounding Weber County area. Teenagers become addicted to nicotine at a young age and continue their use into adulthood while experiencing similar adverse health effects as adults, including cancers, heart disease, respiratory complications, and withdrawal symptoms. Cognitive delays can also be related to nicotine effects in the developing brain. Secondary complications such as gateway drug use from e-cigs and EVALI disease have been attributed to adolescent e-cig use. Marketing strategies by tobacco companies target young adults via social media platforms and websites to re-normalize vaping as a healthier alternative to cigarette smoking, packaging vape products with colorful names, candy type flavoring, and advertising their products with popular celebrities. As adolescents continue to seek their identities, they rely heavily on peer influences, parental behaviors, and mimic what they see on T.V. and the internet. Successful e-cig prevention methods include educational resources and anti-smoking campaigns, internet-based resources with consolidated information links and social media interaction, interactive video games, parental involvement, and health educator-led in-school programs. Effective teaching strategies include involving teens in the process and lessening DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 18 authoritative or lecturing type programs. Successful program outcomes can be measured by students' involvement in prevention programs, visits or likes to various websites related to tobacco prevention or cessation, and the number of educators involved in teaching anti-vaping programs. Practice Change Expected Goals and Outcomes The overall goal was to create a collaborative toolkit of information that would increase teachers’ confidence and implementation of this information into their program and decrease e-cig use among students at Ogden High School. This was accomplished via prevention through education, consolidated resource information and links via social media platforms, and a created educational toolbox that can be easily accessed and used by teachers. Theoretical Framework The John Hopkins model for evidence-based change is a triad of three main elements: practice, research, and education. This model simplifies the evidence-based practice (EBP) for practicing clinicians by creating a culture of addressing a practice problem, analyzing the information (also known as the evidence phase), and implementing it into practice (known as the translation phase) (Appendix G). In practice, the problem question is developed and refined. Using the PICOT pneumonic may be helpful to guide the clinical research question. During the evidence phase, all internal and external sources of evidence are searched, appraised, summarized, and then synthesized. Each literature review determines whether the information is research or non-research, quantitative or qualitative, and its strength is related to the level of evidence. Lastly, the translation phase involves developing and implementing an action plan, evaluating outcomes and measures, and information dissemination techniques. This model is DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 19 acted on by internal factors, such as organizational culture and support, and external factors, such as legislation, quality metrics, and regulations (Dang & Dearholt, 2017, p. 41-42). The John Hopkins model for evidence-based change was the framework for creating this educational toolkit. The first step in the project, practice, defined why adolescents are increasing their use of e-cigs, what beliefs they have about e-cigs, and the impacts contributing to their decisions. The next step in the project, the evidence phase, obtained up-to-date information and evidence related to current e-cig data, health complications, and existing programs in place to help support a practice change. This information was consolidated into a professional toolkit for teachers to use in their health class programs and assisted in the development of a website with various topics of e-cig information for teachers, parents, and teens to access. The last phase, translation, determines whether the created action plan is feasible and fits into the proposed framework for change at the high school. Programs should identify resources needed to implement the program and then evaluate the outcomes for change (White, Dudley-Brown, & Terhaar, 2019, p. 13-15). The evaluated change noted how many visitors accessed the website of resource links for anti-tobacco use and the willingness of educators to continue curriculum implementation. Setting/Population This project was completed on April 19 and 20, 2021 at Ogden High School located in Ogden, Utah. This school consists of 1,220 students in grades 10-12. These students comprise 50% Hispanic, 45% Caucasian, and 5% African American and Asian (National Center for Education Statistics, 2019). This school is located in the central part of Ogden and ranks in the bottom 50% state level in most academic categories and has an 82% graduation rate. Ogden DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 20 High School has 58 classroom teachers with an average student-to-teacher ratio of 21:1 (Public School Review, 2019). This school district serves a community with almost a 20% poverty rate, 16.4% uninsured rate, and median income of <$47,000 (United States Census Bureau, n.d.). Approximately 52% of Ogden High School students qualify for assistance programs such as provided meals (Public School Review, 2019). It has been shown that teenagers from socioeconomic depressed communities, such as Ogden City, have been found to have higher incidence rates of smoking (Moor et al., 2015). Implementation This project received institutional review board approval from Weber State University in April 2021 (Appendix F) and implementation was achieved via an agreement with Ogden High School (Appendix H), allowing a presentation of an evidence-based information program. The entire program was submitted to the principal of OHS, Shauna Haney, who approved the material and forwarded it to several health education teachers. The invitation was accepted by two health teachers: Ms. Ashley Bailey and Mr. Erik Thompson (See Appendix D). The presentation was taught to both educators and their students and the entire curriculum was given to those teachers afterward to continue program sustainability. The project was completed over five class periods to approximately 100 students and two teachers. Each class lasted approximately one hour and included students from the 10th to the 12th grade. The ethnicity and gender of individual students were not evaluated. One teacher, Mrs. Bailey, was present during the first day of classes and Mr. Thompson was present during the second day of classes. DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 21 The PowerPoint consisted of information consolidated from several anti-smoking platforms that addressed what e-cigs are, their harmful effects, marketing tactics, the “why” behind teen use, and the importance of preventative programs and parental involvement. By providing information to parents and teachers they can become more prepared and involved to have discussions with their adolescents (Chassiakos et al, 2016). Secondly, a website was created via the Wix website creator that consolidated scattered information and resources for students, teachers, and parents. By consolidating information for students and parents they can more easily and efficiently access pertinent information. During the presentation in April 2021, students were encouraged to use the interactive Kahoot application via cell phone or personal laptop to answer questions, provide feedback, and illicit conversation about various topics. Following the presentation, teachers were given an evaluation form using a Likert scale to determine the overall effectiveness of the presentation and their willingness to implement this program into their curriculum. Evaluation and Data Analysis Data Collection Data was collected via direct interaction with students, teachers, and indirect collection with webpage inquiries. First, a short interactive app, Kahoot, was administered to the students during the presentation to evaluate their knowledge and beliefs about e-cigs. Results were evaluated and compared to similar adolescent data. Teacher involvement was measured by the number of educators that viewed the presentation, obtained the curriculum, and completed a post-analysis evaluation. The post-analysis evaluation consisted of several questions, including a Likert scale rating of their comfort level to teach the information, willingness to continue the program, and overall acceptance of the DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 22 program content. To assess the effectiveness of providing resource information and links via a social media platform, the number of visitors to the webpage was monitored and evaluated. Any direct emails or communication via the website were answered promptly. Data Analysis During the presentation, the Kahoot app was used to evaluate the student’s current knowledge of e-cig information and use at OHS. 76% of students believe there is an e-cig problem at OHS, but the information was varied about the exact harmful effects of e-cig use. However, 78% of students do believe there is more to “just water vapor” as a byproduct of e-cig smoke (see Appendix C). Teachers were given evaluation forms to determine the overall effectiveness of the presentation and program, how well the students were engaged during the program, and the willingness to incorporate the program into their curriculum (Appendix A). On a Likert scale rating of 1-5, with 1 being strongly disagreed and 5 strongly agreeing, the average score of program effectiveness was 5, student engagement was 4.5, and willingness to incorporate the program into their curriculum was 5. Free text recommendations included more student involvement during the program to reiterate information and engage students. Additionally, teachers were given a template for student evaluation of program effectiveness and knowledge to use within their curriculum (See Appendix B). This form and its use were not included in this presentation due to research policies among minors. Lastly, the project-created website was monitored for visitors and direct inquires to the project leader. As of September 1, 2021, there have been approximately 78 visitors to the created website of resource information. Website traffic was highest around April, the same time as the presentation at OHS. Most access points were a direct web address link, but several were DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 23 through Facebook or another social media platform. The website was accessed from users mainly within a Northern Utah IP address site, but several were noted from within Idaho and as far away as Alaska. No direct emails or inquiries were obtained. Discussion Project Barriers Several pre-implementation challenges were identified: COVID, project sustainability, and locating consultants to work with. With the COVID-19 outbreak in early 2020, how classes are administered had changed. Many were online and schools were limiting access to the classroom, making resources and available personnel difficult to reach. There were delays in establishing communication with Ogden High School and its administration, delaying the opportunity to secure a mentoring agreement for this project. Language Barrier Several barriers were identified during and after the project implementation. Ogden High School consists of a high percentage of Hispanic students, some of which don’t speak English. The project was not created with a bilingual approach, therefore, excluding an unknown number of students who were present in the class. The created website of resources and links also needed to be adjusted to include both English and Spanish information for students and parents. Additionally, some students within the school are behind academically and struggle with age-level reading and writing skills. The classroom presentation included student involvement with reading situations and basic math examples, but some students were unable to complete the exercises. DNP Leader Role DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 24 The DNP leader has a responsibility to address local health problems and collaborate with community organizations to help identify, address, and support programs that tackle these issues. They are challenged to critically evaluate the complete body of science and evidence available to answer important nursing-related questions and solve nursing practice problems. This project recognized a problem in a social-economic depressed community of Ogden – specifically among high school students, created a program that addresses the issue of vaping, taught the teachers how to implement this program, maintain sustainability, and analyze its effectiveness. The created website is also a self-sufficient resource for anyone to access. Conclusion E-cig use among adolescents is a growing epidemic throughout the United States, including locally at Ogden High School. The number of teens who have experimented or currently use e-cigs at Ogden High School is above the state average. They are experiencing health complications, similar to adults, and developing unique medical conditions such as EVALI. The developing brain in an adolescent is at more risk for addiction, increasing the risk of continued tobacco use into adulthood. Many teens view e-cigs as healthier alternatives to traditional smoking, are uneducated on the ingredients of e-cig liquid, more susceptible to follow peer's actions, by nature are curious and seeking to explore, and are heavily marketed by large tobacco companies. Knowing these factors, prevention through education is a crucial approach to thwarting e-cig use. Prevention also includes parental and school involvement. Educating caregivers and providing information and talking points from evidence-based established programs will open the dialogue of e-cig use with adolescents, its harmful effects, and provide a supportive environment for children. Providing up-to-date information in terms and on platforms familiar to teens has more success DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 25 than traditional authoritative didactic lessons. Also, providing links and information about vaping on a single site or social media page will increase the likelihood of a student seeking out and following through on obtaining vape information. Lastly, educating teachers and creating a sustainable anti-vaping curriculum that can be taught consistently within the school will, hopefully, lead to an overall decrease in adolescent e-cig use. The overall expectation is decreased e-cig use among teenagers at Ogden High School and the implementation of the toolkit into the teacher’s curriculum. These interventions were measured in the short term via the number of students receiving the education, the number of visitors to the established information link site, and how many teachers receive the curriculum education. The long-term goal, not measured in this project, will be the overall decrease in e-cig use via the SHARP survey in 2021. DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 26 References American Lung Association. (2020, July 13). What's in an e-cigarette. Retrieved from https://www.lung.org/quit-smoking/e-cigarettes-vaping/whats-in-an-e-cigarette Blount, B. C., Karwowski, M. P., Shields, P. G., Espinosa, M. M., Blasini, L. V., Gardner, M., … Cowan, E. (2020). Vitamin e acetate in bronchoalveolar-lavage fluid associated with EVALI. The New England Journal of Medicine, 382(8), 697-705. Retrieved from DOI: 10.1056/NEJMoa1916433 Borca, G., Bina, M., Keller, P. S., Gilbert, L. R., & Begotti, T. (2015). 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Retrieved from https://www.smokescreengame.org/ DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 35 Appendix A- Teacher evaluation form This survey is part of a research study, it has been reviewed by the IRB, participation is voluntary, and completing the form indicates consent Electronic cigarettes- High School Student program Electronic cigarette (e-cig) use, also known as vaping, has risen dramatically over the last several years among high school students. By increasing knowledge, involving parents and teachers, dispelling myths, and exposing aggressive marketing tactics by tobacco companies the incidence of teen use may decrease. Brian Maynard, student- Weber State Doctor of Nursing Practice Program brianmaynard@mail.weber.edu E-cigarette teacher toolkit evaluation Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree Overall, this program was effective 1 2 3 4 5 Overall, this program will engage the students 1 2 3 4 5 I feel I can incorporate this program 1 2 3 4 5 Any other suggestions/recommendations: Thank you for taking the time to complete this survey. DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 36 Appendix B- Student Evaluation Form This survey is part of a research study, it has been reviewed by the IRB, participation is voluntary, and completing the form indicates consent Electronic cigarettes- High School Student program Electronic cigarette (e-cig) use, also known as vaping, has increased dramatically over the last several years among teenagers. This interactive program is designed to address what students already know about vaping, reasons teenagers may use, dispel the myths surrounding e-cigs, the short-term and long-term effects of vaping, and how big tobacco companies are aggressively marketing youth. Brian Maynard, student- Weber State University Doctor of Nursing Practice brianmaynard@mail.weber.edu Student Questionnaire False I don’t know True E-cigs are healthier than cigarettes 1 2 3 Nicotine causes cancer 1 2 3 Vape byproduct is more than just water 1 2 3 As of 2020, vape juice manufacturers are not required to list all the ingredients 1 2 3 The legal age to purchase an e-cig in Utah is 19 years old 1 2 3 1-30ml bottle of 3mg nicotine vape juice equals about 12 cigarettes 1 2 3 E-cig coils hit a max temperature of 224 degrees Fahrenheit 1 2 3 I have friends that use e-cigs: ______________ ____________ Yes No DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 37 Appendix C- Student Kahoot results These questions were presented to students during the PowerPoint presentation. Below are the results of the five classes. Percent of students that answered the question correctly 98 students total Class 1-(16) Class 2-(19) Class 3- (20) Class 4- (21) Class 5-(22) T of F- Do you think e cigs are a problem at your school- 76% 75% (12) 100% 80% (16) 48% (10) 77% (17) What is the average % of 12th graders at OHS that have ever vaped -34.2% 50% (8) 21% (4) 30% (6) 43% (9) 27% (6) T or F- Vape smoke contains more than just water – 78% 75% (12) 53% (10) 85% (17) 86% (18) 91% (20) T of F – E cigs are healthier than traditional cigarettes – 25% 31% (5) 21% (4) 5% (1) 43% (9) 23% (5) What age does the brain stop developing- 57% 80% (13) 37% (7) 45% (9) 48% (10) 73% (16) In 2019, how much of a profit did JUUL make – 20% 0% 32% (6) 35% (7) 14% (3) 18% (4) What is the most popular vape flavor on the market – 6% 0% 5% (1) 10% (2) 14% (3) 0% DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 38 Appendix D- Consult/preceptor agreement DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 39 Appendix E Final Presentation Completion Form This is to certify that Brian Maynard, a Doctor of Nursing Practice (DNP) student in the Weber State University Annie Taylor Dee School of Nursing, has successfully presented his/her project entitled “Decreasing E-cig Use Among High School Adolescents” and it has been approved as meeting the requirement for the Degree of Doctor of Nursing Practice. Project Leader: Jessica Bartlett Date: November 16, 2021 Project Consultant: Ashley Bailey (electronic signature) Date: 11/20/2021 DNP Graduate Program Director: Melissa Neville Norton Date: 11/16/2021 School of Nursing Chair: Sally Cantwell Date: 11/16/2021 *This document is placed in student file. DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 40 Appendix F- IRB Approval April 2, 2021 Mary Anne Reynolds Mary Anne Reynolds, Brian Maynard Students, Master of Science in Nursing Re: Exempt - Initial - IRB-AY20-21-270 Maynard- Decrease in E-cig use among adolescents Dear Mary Anne Reynolds: Weber State Institutional Review Board has rendered the decision below for Maynard- Decrease in E-cig use among adolescents. Decision: Exempt Approval: April 2, 2021 Expiration: -- Subjects are considered adults, signatures/consent are required, and they may choose not to participate. Anonymity and confidentiality are addressed appropriately, and the type of information gathered could not "reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects' financial standing, employability, or reputation" (Code of Federal Regulations 45 CFR 46, Subpart D). You may proceed at this time; you have one year to complete the study. Please remember that any anticipated changes to the project and approved procedures must be submitted to the IRB prior to implementation. Any unanticipated problems that arise during any stage of the project require a written report to the IRB and possible suspension of the project. If you have any question please contact your review committee chair or irb@weber.edu. Sincerely, Weber State Institutional Review Board DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 41 Appendix G- John Hopkins Nursing Evidence-Based Practice Model DECREASING ELECTRONIC CIGARETTE USE AMONG ADOLSECENTS 42 Appendix H- Ogden School District Approval