Digital Repository Doctoral Projects Fall 2022 E-Cigarette Intervention for Sixth-Grade Students Emily Rhodes Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Rhodes, E. (2022) E-Cigarette intervention for sixth-grade students 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. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS E-Cigarette Intervention for Sixth-Grade Students by Emily Rhodes 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 16, 2022 Emily Rhodes _______________________________ 12/16/2022 ______________________________ Emily Rhodes, DNP-FNP, RN Date Angela Page _______________________________ 12/16/2022 _____________________________ Angela Page, DNP, APRN, PPNP-BC Date DNP Project Faculty Lead 12/16/2022 _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Graduate Programs Director Date 1 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 2 Table of Contents Table of Contents .......................................................................................................................................... 2 Abstract ......................................................................................................................................................... 5 E-Cigarette Use Intervention for Sixth-Grade Students................................................................................ 7 Background and Problem Statement ........................................................................................................ 7 Problem Statement ............................................................................................................................... 9 Diversity of Population and Project Site ................................................................................................... 9 Significance for Practice Reflective of Role-Specific Leadership............................................................. 10 Literature Review........................................................................................................................................ 10 Search Methods ...................................................................................................................................... 10 Synthesis of the Literature ...................................................................................................................... 11 Developmental and Health Risks of Nicotine ..................................................................................... 11 Influences and Education ........................................................................................................................ 13 Marketing ............................................................................................................................................ 14 Peers and Family ................................................................................................................................. 14 Lack of Knowledge and Misconceptions ............................................................................................. 15 Regulations and Oversight .................................................................................................................. 16 Framework and Project Application ........................................................................................................... 16 Framework Implications for Practice ...................................................................................................... 17 Implications for Practice ......................................................................................................................... 18 Project Plan ................................................................................................................................................. 18 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 3 Project Design ......................................................................................................................................... 18 Project Site Needs Assessment and Population ..................................................................................... 19 Cost Analysis and Project Sustainability ................................................................................................. 19 Project Outcomes ................................................................................................................................... 20 Consent Procedures and Ethical Considerations .................................................................................... 20 Instruments to Measure the Intervention Effectiveness ........................................................................ 21 Project Implementation ............................................................................................................................... 21 Project Interventions .............................................................................................................................. 21 Project Timeline ...................................................................................................................................... 22 Project Evaluation ....................................................................................................................................... 22 Data Maintenance and Security.............................................................................................................. 23 Data Collection and Analysis ................................................................................................................... 23 Findings ................................................................................................................................................... 23 Question One ...................................................................................................................................... 24 Question Two ...................................................................................................................................... 24 Question Three ................................................................................................................................... 24 Question Four ..................................................................................................................................... 25 Question Five ...................................................................................................................................... 25 Strengths ................................................................................................................................................. 25 Weaknesses ............................................................................................................................................ 26 Discussion ................................................................................................................................................... 26 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 4 Translation of Evidence into Practice ..................................................................................................... 26 Implications for Practice and Future Scholarship ................................................................................... 27 Sustainability ........................................................................................................................................... 27 Dissemination ......................................................................................................................................... 27 Conclusion ............................................................................................................................................... 28 References ................................................................................................................................................... 29 Appendix A ................................................................................................................................................. 34 Appendix B ................................................................................................................................................. 35 Appendix C ................................................................................................................................................. 36 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 5 Abstract Lack of e-cigarette education and prevention efforts in adolescents can increase the use of ecigarettes, which often leads to nicotine addiction and adverse health, social and psychological consequences. Purpose: Lack of e-cigarette education and prevention efforts in adolescents can increase the use of e-cigarettes, leading to nicotine addiction and adverse health consequences. This project addressed educating sixth-grade students about e-cigarettes and their associated risks and ultimately aimed to decrease the number of students using e-cigarettes. Methodology: Sixth-grade students in a school district with high e-cigarette use were chosen as the focus population for e-cigarette use prevention efforts. The school administration was consulted in selecting an age-appropriate, evidence-based prevention intervention. The FNP/DNP-L student led the 35-minute program to 60 students over four consecutive weeks. In addition, to satisfy Internal Review Board (IRB) requirements, pre and post-surveys were administered to teachers to indirectly measure students' attitudes and knowledge of e-cigarette use and refusal skills. Results: Survey results showed a teacher-perceived increase in student knowledge of the addictive nature of e-cigarettes. The Teachers' perception also increased regarding students' attitudes of aversion and understanding of refusal skills. The program was also perceived to have met the needs of the students in e-cigarette use prevention. Implications for Practice: Education programs increase knowledge of e-cigarettes and support students in making healthy decisions and avoiding addiction. Teaching refusal skills can help adolescents confidently refuse e-cigarettes. Finally, implementing e-cigarette prevention programs in elementary schools is projected to decrease the use of e-cigarettes in adolescence. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS Keywords: e-cigarettes, knowledge, adolescents, substance use prevention, early intervention, nicotine addiction, health effects, health promotion, regulations, and oversight. 6 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 7 E-Cigarette Use Intervention for Sixth-Grade Students E-Cigarettes became available in the United States in 2007 (Jenssen & Walley, 2019). They are marketed as assistive devices for smokers to quit traditional combustible cigarettes. Ecigarettes aerosolize chemicals, flavorings, and additives that the user inhales (Gaiha et al., 2020). Since e-cigarettes became available, their use by middle and high school students increased from 11.7% in 2017 to 20.8% in 2018 nationally (Jenssen & Walley, 2019). The Department of Human Services (2019) reports rising rates of adolescent e-cigarette use in Utah, from 1.9% in 2011 to 12.4% in 2019. In addition, the Tooele, Utah School District has found that adolescent e-cigarette use has been above the state average since 2015; specifically, sixth graders in Tooele County rose from 3.8% in 2015 to 8.0% in 2019. Address the rise in use should use primary prevention focusing on education and peer-participation interventions that positively influence student choices and decrease adolescent e-cigarette use (Gaihna et al., 2021). Background and Problem Statement According to the US Surgeon General, adolescent nicotine use in the United States increased by 900% between 2011 and 2015. Further, he stated that adolescent nicotine use is an epidemic and a top health concern (US Department of Health and Human Services, 2016). After decades of anti-nicotine campaigns and falling use rates, the increase in use is alarming. Furthermore, the health effects of nicotine use in adolescents are concerning. A Jenssen and Walley (2019) study states that nicotine is more addictive when use begins in adolescence. In addition to addiction, e-cigarettes increase respiratory symptoms and asthma in users. Psychological effects of use include decreased impulse control, reduced ability to concentrate, reduced memory, and reduced ability to decide (Xie et al., 2020). Because of the rise in ecigarette use in Tooele County, intervention is needed to improve children's knowledge, E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 8 understanding, and refusal skills, which is projected to decrease future nicotine use and ecigarettes. Normal adolescent behavior includes low impulse control in many individuals; targeting youth through media, product design, and flavorings capitalizes on developmental stages (US Department of Health and Human Services, 2016). Many young people believe that flavored liquid and additives in e-cigarettes are not as dangerous as combustible cigarettes; in actuality, most e-cigarettes deliver significantly more nicotine than combustible cigarettes (Jones & Salzman, 2020). Recent data also shows the alarming trend that most adolescents addicted to nicotine-containing e-cigarettes will eventually switch to combustible cigarettes (Gaiha et al., 2021). Jenssen & Walley (2019) call for efforts to decrease e-cigarette use in school-aged children, preventing a new generation of nicotine users. They continue calling for community and state entities can support and enforce local regulations to reduce access to and free use of ecigarettes. The Food and Drug Administration (FDA) enacted the Deeming Rule in 2016, giving them regulatory authority over all nicotine products in the United States, including e-cigarettes. The rule mandates that all nicotine-containing products have nicotine labeling, and warnings must be on product packaging. Despite the need for change, the FDA delayed the enactment until 2022. There is no current FDA oversight on pre-market nicotine products. Some states have taken legislative action, added e-cigarettes to their smoke-free air laws, and increased age requirements to 21 years (Jenssen & Walley, 2019). Jackson, Janssen, and Gabrielli (2018) convey study findings showing that regulating the marketing and advertisements of e-cigarettes is arguably the most effective approach to prevention. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 9 Gaiha et al. (2020) and Maina et al. (2020) shared findings from studying evidence-based intervention programs to combat the rising e-cigarette use in adolescents. Findings support interventions that encourage active participation, peer-to-peer teaching, and interactive learning techniques to teach the risks and correct misconceptions regarding e-cigarettes. In addition, careful selection of the most appropriate intervention ensures that the intervention is suited to the developmental stage of the population, increasing the positive effects and decreasing reports of intention to try e-cigarettes (Gaiha et al., 2020; Maina et al., 2020). Problem Statement This Doctor of Nursing Practice (DNP)/Family Nurse Practitioner (FNP) quality improvement project aims to address e-cigarette prevention in sixth-grade students by implementing a nationally recognized, age-specific, evidence-based education program. Diversity of Population and Project Site The Elementary School is part of the Tooele School District in Utah. According to Public Schools Review (2018), the school has 396 students, 47 in the sixth grade. In the 2017-2018 school year, there were 34 teachers, zero of whom had more than three years of experience, compared with the state total of 80% of teachers having over three years of experience. Public School Review (2018) also states that enrollment in Elementary declined by 43% over the past five years. The diversity score for the school is 0.22. Minority students made up only 12% of the student body, which is lower than the average state diversity score of 0.42. Twenty-one percent of the students qualify for the reduced or free-lunch program, compared with the state average of 34%. Reading and math proficiency scores are above the state average. The elementary school is ranked in the top 30% of 959 Utah schools for scholastic performance (Public Schools Review, 2018). E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 10 Significance for Practice Reflective of Role-Specific Leadership Providing an e-cigarette intervention for sixth graders is a primary intervention that supports healthy choices. Providing facts about the health risks of using e-cigarettes supports the students in making informed decisions and lower rates of e-cigarette use (Rhode et al., 2018). The project was implemented in a high-risk county, as identified in the SHARP survey (2019). The program openly discussed the health risks, knowledge deficits, and targeted advertising practices used to increase adolescent e-cigarette use (Catch Global Foundation, 2021). The project supports the parents, schools, and healthcare providers in decreasing e-cigarette use, health risks, and nicotine addiction, allowing the students to live healthier lives. Literature Review The substantial rise in adolescent use of e-cigarettes has prompted research on the causes and risks of use in the population. While the duration of data is less than 15 years, many dangers are still evident. Researchers also agree on the addictive nature of nicotine in adolescents. Further, research indicates that advertising is tailored to adolescents, suggesting that federal oversight of e-cigarette products is lacking (Jenssen & Walley, 2019). Search Methods Data and literature searches were performed using CINHAL Complete, MEDLINE, Cochrane Library, Google Scholar, PubMed, and Wiley Online Library databases. Search terms include e-cigarette, adolescent knowledge, substance use prevention, early intervention, nicotine addiction, health effects, and health promotion. Fifty-six articles were considered for review. Following a review, themes resulting in the literature search include nicotine, knowledge, adolescents, substance use prevention, early intervention, nicotine addiction, health effects, health promotion, and regulations and oversight. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 11 Synthesis of the Literature E-cigarettes are commonly marketed as a safe alternative to computable cigarettes, but data is clear that they have many unadvertised risks. Research is clear that they are highly addictive and under-regulated in adolescents. Understanding the extent and specific knowledge deficits and social risk factors that increase usage rates has assisted organizations and professionals in designing and implementing prevention programs. Developmental and Health Risks of Nicotine Jenssen and Walley (2019) stated that e-cigarettes were introduced in the United States in 2007; consequently, the duration of data is short and currently inconclusive regarding long-term health consequences. The authors continue that the addictive nature of nicotine is welldocumented and is especially apparent in adolescent users. Effects on Development. The toxic effects of e-cigarette use are accentuated in the adolescent brain because of the stage of development, making individuals highly susceptible to harm from toxins and addictive substances (Jenssen & Walley, 2019). Tobore (2019) articulates that inhalation of the chemical toxins in e-liquid causes oxidative stress, altering mitochondrial function and protective mechanisms. Ultimately, the exposure changes the molecular system that proofreads DNA. As oxidative stress increases in the body, cellular and metabolic changes give rise to respiratory, neurologic, psychologic, and metabolic diseases. Using e-cigarettes is also associated with a decreased ability to learn, remember, and perform academically. In addition, smoking e-cigarettes is associated with increased impulsivity and aggression. Finally, sleep quality, cognitive ability, and attention span changes are often seen in adolescents who use ecigarettes. Associated side effects can also include increased or worsening depression and suicidal ideation (Tobore, 2019). E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 12 Nicotine. Most e-cigarette liquids contain nicotine; however, the amount of nicotine an individual absorbs when inhaling vaporized e-cigarette liquids varies widely (DeVito & Krishnan-Sarin, 2018). St. Helen et al. (2017) studied nicotine amounts delivered from ecigarettes. They reported many variables affecting nicotine levels, including the flavor of the eliquid, showing varying levels of nicotine exposure. JUUL e-cigarettes are the most popular brand in the United States. However, Morean et al. (2019) found that 68.9% of 3170 adolescents surveyed reported being unaware that JUUL e-liquid contains 5% nicotine, making them a highlevel nicotine product. Addiction. Jenssen and Walley (2019) stated that there is "significant concern that ecigarettes have the potential to addict a new generation to nicotine and tobacco, slowing or reversing the decline in adolescent cigarette smoking that has occurred in the last 20 years" (Jenssen & Walley, 2019, p. 4). The policy statement by Jenssen and Walley (2019) was sponsored by the American Academy of Pediatrics (AAP), affirming the risk of addiction in adolescents when they use nicotine. The authors cite those adolescents who experiment and engage in risky behaviors, such as using e-cigarettes. In addition, the earlier children engage with addictive substances, the stronger the addiction, and breaking the addiction is more complex (Vogel et al., 2018). Jones and Salzman (2020) highlighted data that warn adolescents who become addicted to nicotine from e-cigarettes are 3.6 times more likely to transfer to combustible cigarettes later in life, assuming both risk profiles. Finally, Rhode et al. (2018) cite supporting studies showing that 90% of lifelong smokers start smoking before age 18. Chemical Toxins. E-cigarettes now have refillable tanks filled with the liquid to be vaporized, called e-liquid, which are available in over 8,000 flavors. Because the Federal Drug Administration does not yet regulate e-cigarettes and e-liquids, manufacturers do not have to E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 13 manifest all the chemicals in each product (Jenssen & Walley, 2019). Krishnan-Sarin et al. (2018) shared that the most common toxins in unmarked e-liquid include propylene glycol and glycerin. The chemicals suspend the nicotine and other chemicals in the liquid. Both chemical toxins act as visible smoke-like vapor when heated. Besides chemical toxins, metal particles are found in most vapors, originating from the e-liquid and the vaporizer heating element (CallahanLyon, 2014). There is little long-term data about the inhalation of propylene glycol and glycerin compounds, but both are known as eye and airway irritants. When heated, glycerin can produce acetaldehyde and acrolein, impairing immune function and triggering the airway's inflammatory response. Other toxins are often found in e-liquids, including formaldehyde, acetaldehyde, and benzaldehydes. In addition, E-liquids with a buttery or cinnamon flavor can emit diacetyl, the toxin known to cause "popcorn lung." The United Kingdom banned diacetyl products in 2016 because of the known dangers (Krishnan-Sarin et al., 2018). Influences and Education Many variables can affect adolescents' opinions about e-cigarettes. Among the most influential variables is marketing. Nine billion dollars was spent on e-cigarette marketing in 2019, much geared toward adolescents (Catch Global Foundation, 2021). Data shows that the higher the number of peers or family members who use e-cigarettes, the more likely the child is to begin using (Vogel et al., 2018; Helgertz, 2020). Lack of knowledge about the risks and facts about e-cigarettes also increases the rates of use (Rhode et al., 2018). With multiple variables that are constant in the lives of adolescents, the AAP calls for increased government oversight to decrease marketing influences and the availability of e-cigarettes in general (Jenssen & Walley, 2019). E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 14 Marketing Research is clear that media can increase adolescents' interest level in e-cigarettes. Hwang and O'Neil (2020) report that e-cigarette advertisements target adolescents. Between 2011 and 2013, adolescents were exposed to a 256% increase in e-cigarette advertisements. The authors also describe how manufacturers have designed e-cigarettes that do not resemble a cigarette or pen. The most popular brand in the United States is JUUL, which produces ecigarettes called "mod pods." The new devices resemble a USB flash drive and are smaller and less detectable to parents and authorities, increasing their popularity among adolescents (Gaiha et al., 2020; Hwang & O'Neil, 2020). Jones and Salzman (2020) report that by 2016, 78% of adolescent students had seen advertisements for e-cigarettes. The authors describe advertisements targeting teenagers with bright packaging that taught flavors like frosted sugar cookies and gummi bear. The tactics elicit attention and interest from adolescents because one of the most influential factors in initiation is the flavor of the e-liquid (Janssen &Walley, 2019). Peers and Family In a study about e-cigarette use in adolescents, Vogel et al. (2018) identified a strong correlation between e-cigarette use and one's family member providing the first e-cigarette. The authors also shared the study's outcome concerning peer influences, showing that adolescents are more likely to use e-cigarettes with peers because of social pressure and the desire for social acceptance (Vogel et al., 2018). In addition, Helgertz (2020) studied e-cigarette initiation in adolescents, finding that for young people who live with someone who uses e-cigarettes, the chance of initiating e-cigarette use is 3.28 times higher than those who do not live with a user. In E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 15 the same study, an additional impact was apparent when an adolescent's four closest friends used e-cigarettes, increasing their use rate by 7.09 times that of other adolescents (Helgertz, 2020). Lack of Knowledge and Misconceptions Smith et al. (2016) suggest the misconceptions that e-cigarettes are safer than combustible cigarettes may be from the data. Data show that tar, carbon monoxide, and ash from traditional cigarettes are harmful. Because e-cigarettes were introduced in 2007, long-term health effects are still yet to discovered. Rhode et al. (2018) studied knowledge and beliefs about ecigarettes, determining that individuals who used e-cigarettes were more likely to discount risks of addiction and harm than those who had never used e-cigarettes. The Rhode et al. (2018) study is critical because it highlights the influence of peers. The results showed that three out of five adolescents who try smoking become daily users. The authors continue that when adolescents were surveyed, they found that students who believed e-cigarettes lead to addiction were less likely to start using (p<0.05). Many pediatric healthcare providers lack knowledge and have misconceptions regarding e-cigarettes. For example, when a group of pediatricians was surveyed by Gorzkowski et al. (2016), only 81% reported knowing that most e-liquid contained nicotine, only 51% described them as addictive, and only 43% of the pediatricians knew that e-liquid comes in child-friendly flavors. Ninety-two percent of the providers felt uninformed about the health effects of ecigarettes, but only 14% reported reading a scholarly paper about e-cigarettes. Providers who are not confident in their knowledge will not initiate a dialogue about the topic. The study also claims that adolescent e-cigarettes use is not met with competence or evidence-based information. A lack of knowledge and confidence in educating young patients has created a gap in prevention measures from health providers. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 16 Regulations and Oversight Jenssen and Walley (2019) highlight the US Surgeon General calling the phenomenal increase in adolescent e-cigarette use an epidemic problem. Still, the FDA is delaying enforcement of the Deeming Rule till 2022. The Deeming Rule extends FDA oversite to all tobacco products and will require manufacturers of e-cigarettes to apply with the FDA for the right to sell their products in the United States. In January 2020, the Federal Food, Drug, and Cosmetic Act (FDCA) also issued a policy mandating companies cease manufacturing e-liquid flavors that appeal to children. The amendment also raised the age to purchase nicotine products, including e-cigarettes, from 18 to 21 (Jenssen & Walley, 2019). There are high risks when adolescents use e-cigarettes; the AAP published a report by Jenssen and Walley (2019) supporting several legislative changes, including reducing access to e-cigarettes. The AAP endorses the Food and Drug Administration (FDA) regulating e-cigarette products with a ban on internet sales of e-cigarette products and advertising of e-cigarettes. Further, the AAP supports taxing e-cigarettes like traditional tobacco products. Finally, the AAP recommends that the FDA incorporate e-cigarettes into tobacco-free laws (Jenssen & Walley, 2019). While states can enact age and use restrictions within their borders, federal legislation must change the targeted nature of e-cigarette products and advertising. The AAP supports controlling online purchases of e-cigarette products. Hwang and O'Neil (2020) found that 78.2% of adolescents who are current e-cigarette users have their own devices and reported that products are readily available online. Framework and Project Application McEwen and Wills (2019) described Pender's Health Promotion Model (HPM) as a theoretical guide for learning. Further, the model promotes health through education and a E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 17 commitment to a plan. Pender's model considers an individual's personality and sociocultural, biological, and psychological factors when planning a health promotion. Focusing on health as a goal instead of ridding oneself of illness is a hallmark of Pender's model. Applying the HPM to sixth graders presents a unique challenge because the population is transitioning and developing socially, emotionally, and psychologically. Srof & VelsorFriedrich, (2006) explain that sixth graders are entering a phase when they will begin making autonomous decisions that affect their health. Environmental influences are incredibly influential in their behaviors and choices. Understanding a holistic view of child development will aid in selecting the most appropriate intervention and implementation. The HPM is seen in the CATCH My Breath program in several ways. First, the program is specifically adjusted to match the developmental stages of children. Using the sixth-grade program will ensure developmentally appropriate content and activities. Second, the program focuses on increasing knowledge of e-cigarettes. Finally, CATCH My Breath uses peer influences in the learning process. As a result, the HPM improves learning and prevention of risk behaviors (Srof & Velsor-Friedrich, 2006). Framework Implications for Practice Prevention of risk behavior, sharing knowledge, and empowering patients to make healthy choices are primary responsibilities of the DNP. Ensuring individuals have accurate information and skills to make informed health decisions is a core function of primary health providers. Decreasing e-cigarette use in adolescents supports social, cognitive, and physiological health. Avoiding e-cigarette use allows children to live without addiction and risk poor health choices. Implementation of the e-cigarette use intervention is a preventative action leading to better health outcomes. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 18 Implications for Practice E e-cigarettes are associated with many health risks, mental changes, and lifelong nicotine addiction (Jenssen & Walley, 2019). Healthcare providers must educate themselves and their patients about this rapidly growing problem. Prevention is a central role of healthcare providers, including helping to prevent adolescent e-cigarette use. Data from Gorzkowski et al. (2016) shows that providers need to improve their knowledge about e-cigarettes and increase screenings of their patients for e-cigarette risks and use. Project Plan The intervention provided to the students was selected in consultation with the community mentors. The program selected was evidence-based and proven to be age-appropriate for sixth graders. The program was delivered over four sessions focusing on risks, advertising, and refusal skills. Plans were made for the sustainability of the project. Consideration was also taken to obtain parental permission for each child to participate in the program. Project Design The prevention program selected by the school principal was CATCH My Breath. The program has vast support from the Substance Abuse and Mental Health Service Administration (SAMHSA) (2020). The support of this intervention program for school-aged children focuses on educating students on the health risks of e-cigarettes, misconceptions, and refusal techniques. The project was implemented over four interactive sessions in the school. Each session presented was 30 to 40 minutes. The program was designed by CATCH Global Foundation (2021) and is evidence-based and age-appropriate for sixth-grade students (SAMHSA, 2020). The program also included training modules for presenters, thereby supporting the sustainable nature of the E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 19 program. In addition, CATCH My Breath modules fill Common Core standards in science, health, and art (CATCH Global Foundation, 2021). Project Site Needs Assessment and Population Despite recent increases in sixth graders in Tooele County, there was no e-cigarette education or prevention programs in the elementary school (Personal conversation with A. Peterson, September 25, 2021). Rhode et al. (2018) and Smith et al. (2016) reported that adolescents' leading causes of e-cigarette use are misconceptions and lack of education. Filling the education gap in school can be accomplished by using an evidence-based e-cigarette prevention program. The CATCH My Breath program is offered and spotlighted by SAMHSA (2020) as a widely used program with high efficacy. The same publication established the following outcomes seen from the use of CATCH My Breath: • Decreased last 30-day use rates and lifetime use rates. • More favorable perception of an e-cigarette-free lifestyle. • Increased knowledge of nicotine vaping. • A general decrease in tobacco use. Cost Analysis and Project Sustainability Budgetary needs for this project were minimal. However, CATCH My Breath has garnered significant financial support to offer it free to public schools nationwide (SAMHSA, 2020). The program is accessible and affordable, supporting greater access to the program. Most of the investment made by the deliverer is in preparation time. The cost of supplies for the poster project in session three was less than $20 for markers, poster board, and glue. Advertising and E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 20 communication with the parents were accomplished via email sent by the school. The ultra-low cost of executing this program allows anyone in any financial situation to deliver this program. Sustainability will be facilitated by the Tooele School District and Westminster College Master of Public Health (MPH). The ultra-low-cost program allows service organizations to access the materials. John Contreras, Ph.D., works with the Tooele County Health Department and Westminster's MPH program and has committed to helping maintain the program in the coming years (Personal Communication J. Contreras, September 25, 2021). In addition, the elementary school PTA has committed to supporting the continuation of the intervention. The optimal choice is the PTA because of the personal investment and connection to the student body. Project Outcomes The desired outcomes of this project were to increase knowledge of the dangers of ecigarette use, increase students' aversion to e-cigarettes, help students develop refusal skills, and support a decrease in use on the school campus. The students participated in the CATCH My Breath program once a week for four weeks. First, the students were presented with facts and risks of e-cigarette use, followed by refusal techniques. Next, time was focused on identifying advertising techniques used by the tobacco industry. The final topic supported the desired outcome by encouraging the children to share the warnings they created and articulate their stance on using e-cigarettes. Finally, the faculty were surveyed about their perceptions of how successfully the desired outcomes were met. Consent Procedures and Ethical Considerations The Weber State University Internal Review Board (IRB) approved the project and the evaluation tools (Appendix A). The Tooele School District IRB approved the project plan, E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 21 evaluation tools, and parent letter. Approval was based on the project plan and the submitted application. The IRB approvals were also based on ethical standards and the commitment to protect all participants. Therefore, no personal information was collected from the focus population or the students. During the sessions, the students were instructed not to put their names on any writing activities. In addition, the writing assignments were not collected or graded to protect the children's anonymity and privacy. Instruments to Measure the Intervention Effectiveness The teachers completed a pre-and post-intervention survey conveying their perception of the student's attitudes and knowledge about e-cigarettes (Appendix B). The surveys showed a marked increase in the student's positive perceptions, attitudes, and understanding following the program. According to the observing teachers, all the outcomes were reached. Results were shared with the school administration, the Project Lead, Tooele County Health Department, and the Tooele County School District. Project Implementation Implementing this program will deliver four separate modules over four consecutive weeks in the classroom setting. The implementation will occur in concert with the schedule of the teachers. The modules will be delivered in person, using small group learning, peer leaders, and modules from Catch My Breath to provide an evidence-based framework. The project will be fully implemented when all modules have been delivered, and the final survey is completed. Project Interventions Implementing the project aligns with the project's goals by providing the students with facts about e-cigarettes, learning that nicotine is addictive, and showing age-appropriate ecigarette refusal skills. The four-session program meets articulated goals for knowledge, E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 22 developing refusal skills, dispelling myths regarding e-cigarettes, and increasing selfactualization. The students were instructed on facts about e-cigarettes, organized into small groups for interactive learning, and showed new skills and knowledge through program activities. The deliverables were the IRB approvals, the parent letter (Appendix B), and the surveys (Appendix A). During the last two sessions of the program, the students designed and created anti-e-cigarette slogans and posters that they presented to their fellow students. The student slogans and posters were a deliverable representing student learning and understanding of the teaching. No record of the posters was included because the IRB approval did not permit the collection of any student submissions. Student slogans and posters were then hung in the school's hallway to be viewed by other students. Project Timeline The project timeline includes the research and development phase, community involvement, scheduling, permissions process, and implementation. In addition, the dates and status of each task are indicated (see Appendix C). Finally, the timeline reflects accommodations made to fit the schedule of the school. Specifically, the project was implemented in March 2022 to avoid the final two months of school per the administration's request. Project Evaluation The project was evaluated using pre- and post-intervention surveys completed by the teachers. The surveys were designed using a Likert scale. The collected data reflected teachers' perceptions of their students' experiences and opinions. The surveys showed improvement in knowledge and skills as identified in the goals of the project. The outcomes of the project encouraged the continuation of the program in the future. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 23 Data Maintenance and Security Names or personal information were not collected from teachers or students. Paper surveys remained in the personal possession of the FNP/DNP-L. The surveys will be professionally shredded by the FNP/DNP-L one year after the project, with evidence of shredding sent to the school district. Unnamed student art projects created during project week three were displayed in the school and left in the teacher's possession. Data Collection and Analysis Project outcomes were measured using pre-and post-intervention surveys completed by the sixth-grade teachers. The pre-and post-five-point Likert scale surveys were identical and comprised five questions where "1" represented "strongly disagree," and "5" represented "strongly agree." The surveys were tallied, recorded, and analyzed. Findings The teachers were the direct population and were surveyed before and after the project implementation. A five-question survey was used to determine teachers' perceptions of students' knowledge and opinions. The project goals were completed by assessing the pre-and postintervention survey data. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 24 Question One Question one asked teachers if students demonstrated knowledge of the dangers of ecigarettes. The pre-intervention ratings were group one reported "agree" while group two said they disagreed. Following the intervention, both groups answered: "Strongly agree." Question one was crucial to meeting the first and second goals of the project to increase student knowledge. Further, this question shows that the local presentation of the CMB program supported the students' understanding of the dangers of e-cigarettes so they could make informed decisions. Question Two Question two asked about students' attitudes of aversion to e-cigarette use. Both teachers perceived increased aversion in the students. Group one reported that they "agreed" before and "strongly agreed" following the program. Group two showed an increased perception of aversion from "neutral" before and "strongly agree" following the program. The increased attitude of aversion to e-cigarette use was reported by both groups, which correlates with nationwide data from participants of the CMB program, showing a 45% decrease in use following the completion of the program (Kelder et al., 2020). Question Three Question three queried the teachers about the student's e-cigarette refusal skills. The project's third goal was for students to learn and develop e-cigarette refusal skills. Perceptions of both groups rose from "disagree" and "agree" to "strongly agree," indicating that the goal was successfully met. This local presentation of the CMB program demonstrated that refusing ecigarettes is a skill that increases confidence and normalcy in refusing harmful substances. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 25 Question Four Question four was the only question that did not show a confident improvement in both groups. Group B answered "neutral" both before and following the intervention. One possible reason is that they may never have witnessed e-cigarette use at the school, so they could not say use had decreased. Group A showed increased positive perception, so the standard deviation for this question increased. The neutral response by group B may be able to be omitted; by so doing, the standard deviation would decrease. Question Five Question five addressed if the program had met the needs of the faculty in being a student and parent-centered program. Both groups increased to "strongly agree." A vital component of the projects was supporting the faculty in providing age-appropriate, targeted materials to the students. Evidence that the program was student-centered and parent-centered endorsed the goal of sustained delivery of the project each year. The local population confirmed the CMB program as age-appropriate and student-centered, which correlates with nationwide data (Kelder et al., 2021). Strengths Outcome data supported that the goals of the project were met. First, the CMB curriculum is available to all public schools at no cost so that outcomes can be reproduced in other settings. The project provided peer-guided practice of refusal skills, strengthening children's learning (Kelder et al., 2020). Finally, the project was reported to be age-appropriate and family and student-centered. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 26 Weaknesses Outcomes data were based on the perception of the teachers. Surveying students would have been ideal, but protective measures made that approach prohibitive. Lastly, the inclusion of comments and creative projects created by the students may have enriched the display of learning activities. Discussion The project outcomes show that the goals of the project were realized in educating the students about health dangers, increasing students' aversion to e-cigarettes while helping them develop refusal skills, and decreasing e-cigarette use on the school campus. The data from the project was completed and collected at 100 percent. While the data showed substantial improvement in surveyed topics, a larger population would strengthen outcome data. The outcomes show that future program implementation by the PTA can be successful and continue to accomplish program goals. Dissemination of the positive results to the school principal and the health department can increase support for the program in the coming years. Translation of Evidence into Practice Educating adolescents about the risks of using e-cigarettes is consistent with primary prevention and quality-improvement efforts. The CMB program used in this project has shown high success rates in primary prevention. The outcomes support the conclusion that the program had a comparable effect on the target population. Decreasing adolescent use of e-cigarettes supports healthcare providers by strengthening anticipatory guidance efforts to avoid addictive substances. Encouraging multiple entities to support this intervention can reinforce the new knowledge. A complimentary project was implemented was completed by another DNP/FNP-L to educate parents about e-cigarette use in adolescents. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 27 Implications for Practice and Future Scholarship The outcomes support that educating sixth graders about e-cigarettes is age-appropriate and effective. Therefore, considering the positive project outcomes, it is reasonable to increase the population size to whom the program is made available. In addition, the program can be supported, encouraged, and delivered by healthcare providers, public health professionals, and school personnel to increase the interprofessional nature of this quality improvement effort. Also, sharing the positive response and outcomes from this project through written summary and data sharing can encourage the school district and the health department to engage adolescents in this e-cigarette. Sustainability The plan to sustain the changes implemented with this project includes yearly delivery of the CMB program by the PTA at the school. The president, Lori Parker, signed an agreement to continue the program. As a result, the PTA board has accepted the responsibility to deliver the CMB program yearly at the school. In addition, the PTA will register on the CATCH website and access all needed training and presentation tools to provide the intervention on future occasions. Dissemination The project outcomes will be disseminated to the new elementary school principal, Kelly Staten, as Andy Petersen is no longer the principal at the school. In addition, Dr. John Contreras will receive the summary and data for the county health department. The outcomes section articulated previously, as well as the project poster that will summarize all aspects of the project, will be shared with Principal Staten and Dr. Contreras. Finally, the project will be disseminated E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 28 through a poster presentation at the SIGMA Nu Nu Chapter Research/Project meeting in the spring of 2023. Conclusion Using e-cigarettes is dangerous to the health of adolescents and is associated with high rates of addiction. After implementing the CMB program in a Northwest Utah elementary school, surveys showed increased knowledge regarding the risks and health dangers of using ecigarettes, including the risk of addiction. Surveys also showed an increased aversion to using ecigarettes and increased refusal skills. Finally, surveys confirmed that the program was age appropriate and student-centered for the sixth graders. The project increased the likelihood that the students would abstain from e-cigarette use, avoiding nicotine addiction through informed decision-making. 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(2019). Student health and risk prevention (SHARP) survey: Results for Tooele County LSAA., Division of Substance Abuse and Mental Health. Vogel, E. A., Ramo, D. E., & Rubinstein, M. L. (2018). Prevalence and correlates of adolescents' e-cigarette use frequency and dependence. Drug and Alcohol Dependence, 188, 109112. https://doi.org/10.1016/j.drugalcdep.2018.03.051 Xie, C., Xie, Z., & Li, D. (2020). Association of electronic cigarette use with self-reported difficulty concentrating, remembering, or making decisions in US youth. TobaccoInduced Diseases. https://doi.org/10.18332/tid/130925 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS 34 Appendix A RE: Nicotine Vaping Prevention Program Date: Dear Parents, Since Tooele County has an adolescent rate higher than the state average for the abuse of ecigarettes, Rose Springs Elementary School will be sponsoring a nicotine vaping prevention program called "CATCH My Breath." The CATCH My Breath program is used by more than one million school children each year, resulting in a 45% decrease in e-cigarette use in seventh-grade participants. This program will be presented in four sessions during regular school hours by a nurse, Emily Rhodes, RN, BSN, who is earning her Doctor of Nursing Practice Degree and Family Nurse Practitioner Certification from Weber State University. The students will not be interviewed or surveyed. The goal is to educate students and prevent the increasing adolescent use of these harmful products. The following information will be emphasized: ● Dangers of nicotine use and electronic cigarette vapor ● E-cigarettes do not simply use water vapor ● E-cigarette liquid contains nicotine ● Nicotine is addictive ● Nicotine refusal techniques will be taught and practiced *Parents can access the entire program and materials at www.CatchMyBreath.org. Each student must obtain parental permission to participate in this helpful presentation. Thank you. _____________________________________________________________________________ -PARENTAL PERMISSIONI DO give my student permission to participate in the e-cigarette prevention program. I DO NOT give permission for my student to participate in the e-cigarette prevention program. Student Name: _____________________________ Date: _________ Homeroom Teacher: _________________________ Parent Name: ___________________________ Parent Signature: _______________________________ *Please return the permission slip to school with your student by March 2, 2022. *Failure to respond to this request will prevent your student's participation in this critical seminar. E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS Appendix B 35 E-CIGARETTE INTERVENTION FOR FIFTH AND SIXTH GRADE STUDENTS Appendix C Project Timeline 36