Digital Repository Doctoral Projects Fall 2022 Preventing Vaping in Students Through Parental Education in a Northwest Utah Elementary School Ashlie T. Flynn Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Flynn, A. T. (2022). Preventing Vaping in Students Through Parental Education in a Northwest Utah Elementary School. 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. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 1 Preventing Vaping in Students Through Parental Education in a Northwest Utah Elementary School by Ashlie T. Flynn 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 _______________________________ ______________________________ Ashlie T. Flynn, DNP-FNP student, RN, BSN Date _______________________________ _____________________________ Angela Page, DNP, APRN, PPNP-BC Date Faculty Project Lead _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Angela Page 12/16/2022 12/16/2022 12/16/2022 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 2 Table of Contents Abstract ........................................................................................................................................... 4 Preventing Vaping in Students Through Parental Education ......................................................... 6 Background and Problem Statement ........................................................................................... 6 Diversity and Population of Project Site ..................................................................................... 8 Significance for Practice Reflective of Role-Specific Leadership ............................................. 8 Literature Review and Framework ................................................................................................. 9 Search Methods ........................................................................................................................... 9 Electronic Nicotine Delivery Systems ...................................................................................... 10 Reasons for Use ........................................................................................................................ 10 Regulation ................................................................................................................................. 11 Supply Sources.......................................................................................................................... 11 Perceived Benefits .................................................................................................................... 12 E-Cigarettes for conventional smoking cessation ................................................................. 12 Social..................................................................................................................................... 13 Risks .......................................................................................................................................... 13 Particulate Matter .................................................................................................................. 13 Cancer ................................................................................................................................... 14 Addiction............................................................................................................................... 14 E-Cigarettes or Vaping Product Use-Associated Lung Injury (EVALI) .............................. 14 Second and Third-Hand Smoke ............................................................................................ 15 Dripping ................................................................................................................................ 15 Marketing .................................................................................................................................. 16 Adolescent Implications and Misconceptions .......................................................................... 17 Parent Implications ................................................................................................................... 17 Framework and Project Application ............................................................................................. 18 Discussion ................................................................................................................................. 18 Implications for Practice ........................................................................................................... 19 Project Plan ................................................................................................................................... 19 Project Design ........................................................................................................................... 20 Needs Assessment of Project Site and Population .................................................................... 20 Cost Analysis and Sustainability of Project .............................................................................. 21 Project Outcomes ...................................................................................................................... 21 Consent Procedures and Ethical Considerations....................................................................... 22 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 3 Instrument(s) to Measure Implementation Effectiveness ......................................................... 22 Project Implementation ................................................................................................................. 23 Project Interventions ................................................................................................................. 23 Deliverables .............................................................................................................................. 24 Project Timeline ........................................................................................................................ 25 Project Evaluation ......................................................................................................................... 26 Data Maintenance and Security ................................................................................................ 26 Data Collection and Analysis.................................................................................................... 27 Graph 1...................................................................................................................................... 28 Findings..................................................................................................................................... 28 Strengths ................................................................................................................................... 29 Weaknesses ............................................................................................................................... 29 Discussion ..................................................................................................................................... 29 Translation of Evidence into Practice ....................................................................................... 30 Implications for Practice and Future Scholarship ..................................................................... 30 Sustainability......................................................................................................................... 31 Dissemination ....................................................................................................................... 31 Conclusion ................................................................................................................................ 31 References ..................................................................................................................................... 33 Appendix A ................................................................................................................................... 39 Appendix B ................................................................................................................................... 42 Appendix C ................................................................................................................................... 47 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 4 Abstract Purpose: In 2019, 8.0% of sixth graders in Tooele County, Utah, reported ever using e-cigarettes (State of Utah, 2019). Due to the high e-cigarette use among adolescents in Tooele County, and the association of parental attitudes with adolescent e-cigarette use, there is a need for parental education regarding the adverse health effects of e-cigarette and nicotine use in adolescence. The primary goal of this DNP project was to raise parental awareness and concern about the prevalence of e-cigarette use in adolescence, as well as the harmful effects of nicotine on the developing brain, and to encourage open conversation regarding e-cigarette use between parents and their children. Methodology: Parents attended an evidence-based e-cigarette prevention program via Zoom meeting or a pre-recorded video and participated in a pre-and post-survey. The survey assessed parental knowledge of e-cigarettes, nicotine, and concern about adolescent e-cigarette use. The surveys were anonymous, confidential, and adapted with permission from a previously published e-cigarette prevention program study. Results: Data analysis showed increased parental awareness and knowledge of e-cigarettes, nicotine, and addiction. An increase in parental concern about adolescent e-cigarette use was also evident. Implications for practice: A strong parent-child bond and parent involvement decrease adolescents' desire to use e-cigarettes (Kurji et al., 2021). An evidence-based e-cigarette prevention education video was created for use in the future to increase parental awareness and overall concern regarding adolescent e-cigarette use. Future quality improvement projects could focus on providing similar education to 5th-grade students and increasing parental involvement. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 5 Keywords: vaping, e-cigarette, nicotine, parent, parental knowledge, adolescent, adolescence, primary prevention, parental concern, parental awareness PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 6 Preventing Vaping in Students Through Parental Education in a Northwest Utah Elementary School Electronic Nicotine Delivery Systems (ENDS) vaporize e-liquid to deliver nicotine to the user (US Food and Drug Administration, 2020). Nicotine is the addictive substance in tobacco and has toxic side effects at high doses (Harrell et al., 2014). ENDS are also known as "vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), and e-pipes" (US Food and Drug Administration, 2020, p. 1). The chemicals used in e-liquid have adverse effects on the cardiovascular, immune, reproductive, and respiratory systems and normal adolescent growth and development (Sapru et al., 2020). Recent studies show that 12%-16% of young adults and adolescents report having used a vaping device (Lui & Halpern-Felscher, 2018). In Tooele County, the number of adolescents who report a lifetime use of e-cigarettes is significantly higher than the state average. In 2019, 8.0% of sixth graders in Tooele County used e-cigarettes, compared to 5.2% in Utah (State of Utah, 2019). Parents are often misinformed about vaping consequences and prevalence (Kurji et al., 2021). This project aims to identify and address the misconceptions about vaping using an education protocol directed at the parents of students in an elementary school in the Tooele County School District. The protocol aims to increase parental awareness of vaping and positive parental influence on young people. Background and Problem Statement E-cigarettes are battery-powered handheld devices that produce an inhalable aerosol to simulate tobacco smoking. Regarding the ingredients in e-liquid, Besaratinia & Tommasi (2020) stated: PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 7 The liquid, also referred to as 'e-liquid/e-juice', contains a mixture of propylene glycol, glycerin, flavors, nicotine at variable concentrations…and other substances and additives…such as tetrahydrocannabinol (THC) and cannabinoid (CBD) oils. Of note, THC is the primary psychoactive mind-altering compound in marijuana that produces the infamous 'high'. (p. 663) In the United States, vaping products were introduced in 2007 (Harrell et al., 2014). Since then, vaping rates have increased significantly. A significant rise in use has been identified in adolescent never-smokers (Besaratinia & Tommasi, 2020). In 2016, the top reasons reported by adolescents for using e-cigarettes were use by a friend or family member (39%), desirable e-liquid flavors (31%), and a belief that they are less harmful than other forms of tobacco (17%). Between 2011 and 2015, e-cigarette use among young people increased substantially. The United States Surgeon General has declared e-cigarette use among adolescents a public health concern (Tsai et al., 2018). In the United States in 2016, e-cigarettes were the most used tobacco product in children aged 10-18 (Tsai et al., 2018). Vaping use in adolescents is higher than in the adult population (Sapru et al., 2020). "The number of adolescents who have used an e-cigarette in the past 30 days increased from 1.5% in 2010 to 26.7% in 2018" (Sapru et al., 2020, p. 9). In the Tooele County School District in 2019, 8% of sixth graders reported using vaping products, compared with 5.2% percent of sixth graders in Utah. In the same year in Tooele County, 23.9% of eighth-grade students reported using vaping products, compared with 15.2% of eighth-grade students throughout Utah (State of Utah, 2019). Kurji et al. (2021) found that a strong parent-child bond and parent involvement can decrease adolescents' desire to use e-cigarettes. Some parents lack education about e-cigarette PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 8 use, believing it is not harmful. Many parents are unaware of their child's e-cigarette use or choose not to address the issue with their child (Kurji et al., 2021). The use of e-cigarettes in the Tooele County School District is higher than the state average and steadily increasing (State of Utah, 2019). As of November 21, 2019, the Center for Disease Control and Prevention (CDC) reported 2,290 cases of vaping-related lung injury and 47 vaping-related deaths in ages 13 to 75 (Radcliffe, 2019). Increased parental education and awareness are needed to prevent e-cigarette use in adolescents in Tooele County. This quality improvement project aims to address e-cigarette use in school age students by implementing a nationally recognized, evidence-based parent education program. Diversity and Population of Project Site This project focuses on the parents of sixth-grade students in an elementary school in the Tooele County School District. In 2018, the school taught 396 students in kindergarten through sixth grade. Approximately 63 of those students were enrolled in sixth grade. The school ranks 390 out of 957 Utah schools based on testing scores. Minority enrollment in the school is 12%, lower than the state average of 26%. There are 34 teachers employed at the school (Public School Review, 2018). Significance for Practice Reflective of Role-Specific Leadership With 23.9% of eighth graders in the Tooele County School District reporting lifetime use of vaping products (State of Utah, 2019), the need for education and awareness is evident. It is beneficial for the Tooele County School District and the Tooele County Health Department to invest in education protocols to increase the awareness of vaping and provide primary prevention in elementary schools (Principal Andy Peterson, personal communication, September 23, 2021). PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 9 A literature review outlines the evidence needed to develop this education protocol and quality improvement project. Literature Review and Framework This literature review explores e-cigarette use among adolescents, misconceptions about e-cigarette use, and parental knowledge of e-cigarettes. This research will provide a foundation for developing an education protocol that increases parental knowledge of e-cigarettes. Themes emerged from this research to help guide the protocol development: (a) many misconceptions about vaping exist in parental and adolescent populations (Dinardo & Rome, 2021); (b) the long-term effects of vaping are not well-understood (American Lung Association, 2016); (c) vaping has been shown to have negative health consequences (American Lung Association, 2016); (d) vaping is thought by young people to be healthy and is creating addictions in adolescents who would not have smoked conventional cigarettes (Blaha, 2021); and (e) parental influence plays a crucial role in the prevention of vaping in the adolescent population (Truth Initiative, 2019). The framework used to guide this project is Lev Vygotsky's Social Development Theory. Search Methods Search terms for this project include vaping, e-cigarettes, electronic cigarettes, adolescents, parents, e-cigarettes or vaping product use-associated lung injury (EVALI), popcorn lung, fatalities, social status, social practice, nicotine, regulation, propylene glycol, education, prevention, and addiction. Databases used were Google Scholar, PubMed, UpToDate, Web of Science, EBSCO, and CINAHL. Database search exclusion criteria included journal articles more than six years old. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 10 Electronic Nicotine Delivery Systems Electronic Nicotine Delivery Systems (also known as vapes, vaporizers, vape pens, hookah pens, electronic cigarettes (e-cigarettes or e-cigs), and e-pipes) are devices used to deliver nicotine through the inhalation of a vaporized, flavored liquid (US Food and Drug Administration, 2020). The devices come in various shapes, colors, and sizes and contain a heating element, a place to hold liquid, and a battery (Centers for Disease Control and Prevention, 2021). Currently, over 7,000 flavors of e-liquid are available (Worku & Worku, 2019). Some devices look like everyday items, such as USB drives and pens. The device works by using the heating element to vaporize a liquid that contains nicotine (the addictive substance in tobacco products) (Centers for Disease Control and Prevention, 2021). Some devices release vapor upon inhalation, and others release vapor with the push of a button. An LED light indicates that the device is in use (Harrell et al., 2014). Users and bystanders inhale the vapor into their lungs, which can cause serious health consequences (Centers for Disease Control and Prevention, 2021). Reasons for Use The reasons people choose to start vaping are not well-understood. The two most noted reasons are curiosity and enjoyment. Other reasons are quitting conventional cigarette use and the ability to vape indoors (Ayers et al., 2017). However, indoor vaping is declining rapidly as 12 states have implemented no-vaping regulations where no-smoking regulations are in place (Majmundar et al., 2019). Recent Google searches show that the use of e-cigarettes to quit conventional cigarettes is also declining (Ayers et al., 2017). PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 11 Regulation There is very little federal regulation of e-cigarettes in the United States. Due to the lack of regulation and the large number of companies producing e-cigarettes, the e-liquid contents are inconsistent with the labeling. In some cases, the nicotine content was shown to be higher or lower than what was printed on the label, making it difficult to accurately evaluate the safety of e-cigarettes (Harrell et al., 2014). Manufacturers rarely list the contents of e-liquid on the label. E-cigarettes have not undergone the usual process of clinical trials and are thus misunderstood (Worku & Worku, 2019). According to the Public Health Law Center (2021), Utah has minimal e-cigarette regulations. The packaging is required to include a safety warning, a notification of certain additives, and nicotine levels. The packaging must be child-proof. The distribution of e-cigarettes to anyone under the age of 21 is prohibited. Possession of an e-cigarette under the age of 21 is also prohibited. Sales must happen face-to-face, except through vending machines and self-service centers. E-cigarettes can be purchased online after verifying a minimum age of 21. The minimum age for entry into a vape shop is 21 unless active-duty military or accompanied by an adult aged 18 or older. Vaping is prohibited where smoking is not permitted. Vaping is banned in cars where a person aged 15 or younger is present. Schools are required to enforce these regulations. Supply Sources How are adolescents getting their vaping supplies if Utah regulations state that individuals under 21 cannot purchase or possess an e-cigarette (Public Health Law Center, 2021)? "Some youth buy the e-cigarettes they use, either directly from retailers or other kids, or by giving money to others to buy for them. Others get their [e-cigarettes] for free from social PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 12 sources (usually other kids)" (Bach, 2021, p. 1). On December 20, 2019, the minimum purchase age was increased from 18 to 21 nationally. According to the National Youth Tobacco Survey (NYTS) (2021), 22.2% of young people who vape report purchasing their vaping device from a gas station or convenience store, and 17.5% report buying from a local vape shop. Bach (2021) found that despite regulations, 44.7% of vape shops in the United States report selling to underage people, and among high school students, 57.1% report getting e-cigarettes from a friend. The author also states that young people report successful online purchasing (using a fake birthdate) in 94-97% of the attempts and that second-hand supplies have been found on Craigslist and eBay, requiring no verification to purchase. Perceived Benefits E-Cigarettes for conventional smoking cessation Though in lower concentrations, E-cigarettes contain harmful chemicals like conventional cigarettes (Harrell et al., 2014). Rahman et al. (2015) looked at the role of e-cigarettes in smoking cessation. Six studies and 1,242 participants were analyzed in a meta-analysis. They found that 224 (18%) participants reported conventional smoking cessation after using nicotine-containing e-cigarettes for at least six months. The use of e-cigarettes was associated with smoking cessation and reduced the number of cigarettes used. The study highlights the need for further research on the safety of using e-cigarettes in smoking cessation. Up to 70% of current tobacco users report concurrent use of e-cigarettes. It is predicted that e-cigarette use will supersede conventional cigarette use within the next decade (Worku & Worku, 2019). Current evidence suggests that e-cigarette emissions generally contain lower tobacco-specific pollutants than cigarette smoke. However, specific toxicants with harmful health effects PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 13 are found at elevated levels in e-cigarette emissions compared with cigarette smoke (Tan et al., 2015, p. 67). There is not enough data available to indicate the success and safety of e-cigarettes for smoking cessation (American Lung Association, 2016). In a study looking at smoking cessation success in e-cigarette users compared to nicotine-replacement users, 18% of e-cigarette users had stopped smoking after one year compared with 9% of nicotine-replacement users. However, 80% of e-cigarette users were still vaping after one year, compared to 9% of nicotine-replacement users (Dinardo & Rome, 2021). Social Another presumed benefit of e-cigarette use is increased social status (Tan et al., 2015). Young people perceive vaping as cool. When they vape, they aren't judged by people as harshly as when they smoke conventional cigarettes. Adolescents are motivated to try e-cigarettes because they are fun and new (Michaels, 2016). Risks Particulate Matter Due to the new nature of e-cigarettes, it is impossible to assess the long-term side effects of use accurately. E-cigarettes require deeper inhalation than conventional cigarettes, allowing for deeper penetration of harmful chemicals into the lungs (Harrell et al., 2014). Although less than traditional cigarettes, e-cigarettes have been found to contain particulate matter, which can work its way into the deep parts of the lungs and the bloodstream. The substances in e-liquid have been shown to cause a cough, dry throat, and decreased lung capacity (Worku & Worku, 2019). PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 14 Cancer Harell et al. (2014) found that e-liquid contains varying nicotine levels. Although it is unclear if nicotine causes cancer, it has been shown to promote the growth of pre-existing tumors. Previous users of conventional cigarettes consume more nicotine when using e-cigarettes. This indicates that previous smokers compensate for low nicotine levels in e-liquid by increasing the use of e-cigarettes or that the lack of the irritants in cigarette smoke allows for deep penetration of vapor into the lung. Four out of every twenty-one e-liquids have cytotoxic effects (effects that destroy body cells). Addiction "There is also concern in the public health community that as e-cigarettes gain popularity among youth, this could lead to increased nicotine dependence and other tobacco use" (Tan et al., 2015, p. 67). Nicotine has harmful neurocognitive effects and addictive properties, especially in the developing brains of adolescents (Dinardo & Rome, 2021). Nicotine is as addictive as heroin and cocaine, and many e-cigarette users get more nicotine from vaping than smoking. The use of e-cigarettes is causing addiction in young people who would not have used conventional cigarettes (Blaha, 2021). E-Cigarettes or Vaping Product Use-Associated Lung Injury (EVALI) Essa et al. (2020) studied an increase in cases of lung disease associated with vaping. The increased rates of mortality and morbidity related to vaping led to the coining of the term 'e-cigarettes or vaping product use-associated lung injury (EVALI).' "Some of the common symptoms of EVALI include fever, chills, and a headache. Respiratory symptoms include shortness of breath, cough, and chest pain. Gastrointestinal symptoms include nausea, vomiting, diarrhea, and abdominal pain" (Essa et al., 2020, p. 4). There are no clear guidelines for the PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 15 management of EVALI. The pathology of EVALI is not well-understood, but many imaging reports suggest a pneumonia-like process. EVALI can be fatal (Essa et al., 2020). As of November 21, 2019, the CDC reported 2,290 cases of vaping-related lung injury and 47 vaping-related deaths in ages 13 to 75 (Radcliffe, 2019). Propylene glycol is one of the significant components of e-liquid. When heated, propylene glycol can generate diacetyl, formaldehyde, and methylglyoxal. Methylglyoxal has recently been shown to cause necrosis (death) of tissue in the lining of the lungs, resulting in bronchiolitis obliterans (popcorn lung) (Azimi et al., 2021). Diacetyl has the same effect on lung tissue (American Lung Association, 2016). Over a decade ago, diacetyl was removed from butter-flavored popcorn after factory workers became sickened after inhaling the chemical. Now, people who vape inhale the same chemical directly into their lungs. Popcorn lung is a scarring of the tiny air sacs (alveoli) in the lungs. This results in a thickening and narrowing of the airway and decreased lung function and capacity (American Lung Association, 2016). If current trends continue, smoking-related diseases could lead to early death in one of thirteen American youth (Dinardo & Rome, 2021). Second and Third-Hand Smoke Second-hand smoke is the aerosol released from the e-cigarette. It tends to linger in the environment. The aerosol allows for the passive vaping of e-liquid chemicals by bystanders. Third-hand smoke is aerosol absorbed into surrounding surfaces, such as clothes, furniture, bedding, and carpet (Worku & Worky, 2019). Dripping Dinardo & Rome (2021) found that vaping devices can be taken apart and modified to allow for 'dripping.' Dripping produces a more intense vaping experience. The e-liquid is dripped PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 16 directly onto the heating coils, allowing more aerosol and nicotine release. This also causes the release of elevated amounts of harmful chemicals. One in four high school students who use vaping devices report having tried dripping (Dinardo & Rome, 2021). Marketing E-cigarette marketing is focused directly on adolescent populations, making vaping appear cool and harmless. Many campaigns claim that e-cigarette vapor is harmless, which is not true (Michaels, 2016). In 2014, sales of vaping products reached $6.5 billion worldwide (Keane et al., 2017). Since 2007, marketing for vape products has increased on television and in print. Expenditures on e-cigarette marketing increased from $3.6 million in 2010 to $125 million in 2014 (Essa et al., 2020). Vaping products are often placed in television shows, movies, and social media groups. Although ads for conventional cigarettes were banned in 1971, ads for e-cigarettes are prevalent in the media. "Marketing campaigns for vaping devices mimic the themes previously used successfully by the tobacco industry, e.g., freedom, rebellion, and glamour" (Dinardo & Rome, 2021, p. 792). The Juul vaping device was developed in 2005 and has since flooded the market. Their goal was to create a more smoking-like experience for vapors. They increased the nicotine in their devices and created a liquid that could be vaporized at lower temperatures. Juul designed a device that was small and easy to hide. Each Juul pod contains as much nicotine as 20 cigarettes. A Juul starter kit costs $49.99. Other brands of vaping devices can be purchased for $15-$35, with refill bottles costing $7 for 10 mL (Dinardo & Rome, 2021). Generally, a user will get approximately 1,000 puffs from a 10 mL bottle of e-liquid (Electric Tobacconist, n.d.) PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 17 Adolescent Implications and Misconceptions With vaping rates increasing rapidly in adolescent populations, there is concern that young people who would not have smoked otherwise are picking up the habit. The use of e-cigarettes in adolescent populations can lead to the future use of traditional tobacco products (Blaha, 2021). Michaels (2016) asserts that e-cigarette marketing is targeted at young people. More than 40% of 11th and 12th graders who vape have never smoked a traditional cigarette. Young people who use e-cigarettes are more than six times more likely to begin using traditional cigarettes (Michaels, 2016). Nicotine exposure during adolescence negatively affects learning, memory, reward processing, and emotional regulation (Dinardo & Rome, 2021). There are many vaping misconceptions among adolescent populations. For instance, young people believe that fruit-flavored e-liquid is less harmful than tobacco-flavored e-liquid. Many young people regard conventional smoking as dangerous, relating it to several health risks. However, they do not associate vaping with harm or health risks. They believe that vaping is much safer than conventional smoking. They view e-cigarettes as enjoyable, healthy, and fun (Dinardo & Rome, 2021). Parent Implications Despite rising rates of vaping, most parents remain unfamiliar with vaping. Only 44.2% of parents can identify an e-cigarette. Regarding school information, 73.5% of parents report never receiving information about vaping from their child's school. Less than half of administrative faculty at schools can identify a Juul device. Among parents aware of Juul, only 48.6% know that e-liquid contains nicotine (Truth Initiative, 2019). Parents can usually identify when their children are smoking but cannot recognize when they are vaping. The best way to prevent children from vaping is to enforce strict household PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 18 rules. Parents need the education to have a high-quality conversation with young people about vaping. Parents must set an example by maintaining a tobacco-free home (University of California San Francisco, 2020). Increasing parental awareness of vaping will curb the vaping epidemic in adolescent populations (Truth Initiative, 2019). Framework and Project Application This quality improvement project utilizes Lev Vygotsky's Social Development Theory as a framework for increasing vaping awareness in parents of sixth graders. Sprouts (2020) describes the theory as focusing on a child's development as influenced by social interactions and guidance from knowledgeable mentors. According to the theory, a child's development results from social interactions. The opportunity to practice skills aids in a child's development. The Zone of Proximal Development is where children learn from educated mentors. Here, children learn more with the help of mentors than they could learn alone (Culatta, 2021). The project will utilize this theory by focusing on the Zone of Proximal Development. Increasing parental knowledge of e-cigarettes will provide the students with an educated mentor, guidance, and the ability to make informed decisions regarding e-cigarettes. The parents will be encouraged to practice refusal skills with the children, increasing the child's ability to avoid e-cigarettes. Providing social interactions enhances child development by allowing the child to learn more than they could on their own (Sprouts, 2020). Discussion Evidence shows that parents play a crucial role in preventing vaping in adolescent populations (University of California San Francisco, 2020). Implementing an evidence-based education protocol for parents of sixth graders will promote primary prevention of vaping in adolescents, decreasing the health risks that arise from using e-cigarettes. Barriers to PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 19 implementation may include a lack of data and a lack of parent involvement. Additional research on parental knowledge gaps related to vaping can benefit organizations that wish to develop a similar education protocol. Implications for Practice Increased parental awareness of vaping and encouraging positive influences on adolescent groups will allow them to make educated decisions about vaping (Sprouts, 2020). This will reduce health concerns and addiction, increasing positive life experiences among young people (Dinardo & Rome, 2021). Doctoral-prepared nurse practitioners (DNP/FNP) aim to prevent disease and improve public health (American Association of Colleges of Nursing, 2006). This project supports the goals of nurse practitioners by preventing vaping in adolescent groups and decreasing the risk for health concerns and addiction in adolescent populations (American Association of Colleges of Nursing, 2006). Project Plan The student created this project to provide vaping prevention education to parents of sixth-grade students to decrease adolescent vaping rates. The project utilized the CATCH My Breath curriculum to educate parents on the prevalence and consequences of vaping in adolescents (Catch My Breath, 2021). The plan included teaching the curriculum to the parents of sixth graders at an elementary school in the Tooele County School District at a one-time evening seminar. The educational workshop was held in person and broadcasted through a synchronous Zoom meeting to meet the preferences of all parents. Following the presentation, the student uploaded a narrated slideshow containing the CATCH My Breath lesson to YouTube. The link was emailed to the parents of the sixth-grade students, requesting that they complete the surveys and the training. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 20 Project Design This quality improvement project aimed to increase parental awareness of the adolescent vaping prevalence and its consequences. The CATCH My Breath curriculum provided information to teach parents how to feel comfortable discussing vaping with their children. In addition, the presentation taught parents how to recognize when their child might be vaping. The curriculum educated the parents on the current marketing schemes and the lack of regulations surrounding e-cigarettes. Needs Assessment of Project Site and Population Curley (2020) found that a population's education and unemployment levels are directly related to health status. A higher education level increases the health status of the community and access to health care. According to the Tooele County Health Assessment (Tooele County Health Department, 2016), 20.6% of Tooele County residents have a bachelor's degree or higher, compared to the state of Utah at 30.6%. In Tooele County, adolescent vaping rates are significantly higher than the state average. In 2019, 8.0% of sixth graders in the county used e-cigarettes, compared to 5.2% in Utah (State of Utah, 2019). This project aimed to address the lack of education in Tooele County by providing vaping prevention education to parents in the community. The educational program directed its efforts at preventing elevated vaping rates among the young people in the county. This project directly affected a population of parents of sixth-grade students in an elementary school in the Tooele County School District. At the time of project implementation, the school taught 50 sixth-grade students (Principal Andy Peterson, personal communication, February 9, 2022). When these students leave elementary school, they attend junior high school PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 21 (Tooele County School District, 2015). The project, therefore, indirectly provided primary vaping prevention affecting the same students when they are in eighth grade. There were multiple project stakeholders. The sixth graders at the elementary school in the Tooele County School District were the indirect recipients of vaping prevention education. Their parents were the direct recipients of the education. The teachers at the school supported the education by distributing flyers with the details about the educational seminar. The Tooele County Health Department provided accurate information regarding vaping in the county. The director of assessment and research at the Tooele County School District provided approval to move forward with the project. The principal at the elementary school in the Tooele County School District assisted with arranging the educational seminar. Cost Analysis and Sustainability of Project Budgetary requirements for this project were minimal. The training lasted one hour, and the venue and resources were free for public use. The doctoral student purchased the Zoom subscription. The educational handouts were printed in color. The student purchased the educational handouts and the surveys. The Parent Teacher Association (PTA) will sustain the project in the future. The PTA will cover the future costs of web broadcasting and color packets for the parents. The program administrators were educated on the protocol. The training was easy to do as the curriculum is outlined and requires very little training. Project Outcomes The project goals were assessed using pre-and post-education surveys, utilizing a Likert-type scale and yes or no questions. The project outcomes were evaluated by measurement of the following objectives: PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 22 • Parents were able to identify an e-cigarette • Parents were aware of the presence of nicotine in e-liquid • Parents were aware of the consequences of nicotine Consent Procedures and Ethical Considerations The Institutional Review Board (IRB) at Weber State University confirmed that this project meets the standards for a quality improvement project. The Tooele County School District has approved this project. Pre-and post-surveys were used to assess the effectiveness of the education. The participants completed the survey using an online survey tool. No personal identifiers were collected in the surveys. The survey results were disseminated to the elementary school, the Tooele County School District, and the Tooele County Health Department. Autonomy was maintained by ensuring that participation was optional. Confidentiality was maintained by not recording any personal identifiers. This project maintained non-maleficence by obtaining IRB approval and recognizing that some drug prevention programs used in the past have increased drug use (Northpoint Recovery, 2018). This was addressed by utilizing a nationally recognized program specific to each age group, as the ineffective programs were generalized across all age groups. The program was based on other programs that have decreased drug and substance use (Coordinated Approach to Child Health, n.d.). Veracity was maintained by addressing that e-cigarettes may be helpful for the cessation of conventional cigarettes but that there is a lack of data supporting or refuting this idea (Rahman, 2015). Instrument(s) to Measure Implementation Effectiveness Project effectiveness was assessed using a survey (see Appendix A). The survey questions were initially used in a study on parental awareness of e-cigarettes published by Patel et al. (2019). Minimal alterations to the questions were necessary for this project. The word PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 23 "JUUL" was changed to "e-cigarette," and the last question was omitted as it was not applicable. The rights to alter and use these questions in the educational seminar were purchased through the Copyright Clearance Center (see Appendix B). The parents completed both pre-and post-education surveys. Project Implementation This project was implemented when the targeted sixth-grade elementary students' parents were educated using the CATCH My Breath vaping prevention curriculum. The education promoted parental vaping awareness and involvement. The sustainability of the vaping prevention program's parent education portion will manifest through the adoption of annual parental education presentations. The PTA at the target elementary school will sustain the annual education through PTA volunteers and the use of a recorded PowerPoint, discussed below. Project Interventions Project interventions included a professional, collaborative, evidence-based approach to facilitating buy-in from the Tooele County Health Department and the Tooele County School District. Early in the project, the Tooele County Health Department presented possible problem areas in the county. Adolescent e-cigarette use was discussed at this meeting as a significant problem in the community. Further research was performed to gain perspective on adolescent e-cigarette use in Tooele County. It was discovered that Tooele County has adolescent vaping rates significantly higher than the state average (State of Utah, 2019). This gap was pursued as the focus area for this project. Following this research, multiple research-based vaping prevention programs were explored. Two programs were selected for potential use-the Stanford Medicine vaping prevention course and the CATCH My Breath vaping prevention program. The elementary PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 24 school's principal in the Tooele County School District was provided information on both programs and given a choice between the programs. After a detailed discussion of the programs, the principal elected to utilize the CATCH My Breath program. The principal chose this program because it is age-specific and includes parent education to support what is taught in the school. Although the Stanford Medicine course is designed to be taught in a shorter time, it was not chosen because it lacks education specific to parents and elementary age groups. Through continued email communication with the principal, an implementation date was selected in March 2022. A parent letter was sent home with the sixth-grade students in February 2022. The letter included information about the CATCH My Breath program and the upcoming parent meeting, including in-person and Zoom options. An additional reminder email was sent to the parents on the day of the parent education meeting. The overarching project goal is the following: The CATCH My Breath curriculum is sustained through annual education directed at the sixth graders, and their parents, at the target school. During the meeting with the elementary school principal, he agreed to have the curriculum taught annually but was fearful that the teachers would feel overwhelmed if required to teach the classes. With sustainability through the school's PTA, the curriculum could be taught annually with minimal training. The curriculum is straightforward and includes short videos used to train the PTA president. Deliverables The parent education was provided at an in-person meeting with an alternate Zoom option. At the meeting, the parents completed a pre-assessment before the teaching. Unfortunately, there were no in-person participants and only seven online participants. The parents were given a parent toolkit handout as part of the CATCH My Breath education. The PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 25 CATCH My Breath program created the handout as a fundamental part of the curriculum. The handout included vaping facts, tips on increasing parental involvement, signs that a child may be vaping, an e-cigarette recognition activity, and ideas on starting a vaping discussion with an adolescent. A slideshow was presented at the educational event as part of the CATCH My Breath curriculum. The slideshow was pre-scripted by the CATCH My Breath program. Following the education, the parents completed a post-assessment containing the same questions. To adapt to low participation at the parent meeting, a recorded narration of the slideshow was created and offered as an alternative. The slideshow was uploaded to YouTube. The sixth-grade teachers sent an email to the parents, including links for the recorded slideshow and the pre-and post-education. The students were offered extra credit and candy for encouraging their parents to watch the slideshow and complete the surveys. The CATCH My Breath handout was not included in the narrated PowerPoint, as the information was sufficiently covered in the recording. Project Timeline In October 2021, the project was submitted to Weber State University for IRB approval, and IRB approval was obtained shortly after. Also in October 2021, the project was submitted to the Tooele County School District for approval. The project was approved by the school district in the same month. In January 2022, the event was scheduled with the elementary school principal. In February 2022, the event was publicized through a letter sent home with the sixth-grade students, addressed to their parents. In March 2022, the event was advertised through email, the educational event was held at an evening seminar at the elementary school, and the recorded slideshow was disseminated to the parents. The PTA president attended the last portion of the student education in March 2022, and sustainability was discussed in March and April PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 26 2022. The survey results were analyzed in May 2022. In June 2022, the PTA president was thoroughly trained on the curriculum. In January 2023, the project was disseminated (See Appendix C for project timeline). Project Evaluation A vaping prevention program (Catch My Breath, 2021) was offered to the parents of sixth graders after the students had received four education sessions regarding e-cigarettes. The parent educational program was presented first by an unsynchronized, unrecorded Zoom meeting. The same presentation was recorded and uploaded to YouTube, and a link was sent to the parents via email (Flynn, 2022). Five parents attended the synchronous Zoom presentation on June 18, 2022. Thirty-four individuals watched the recorded presentation on YouTube between March 14, 2022, and June 18, 2022. The parent participants took an 8-question pre- and post-Likert Scale survey after viewing the presentation, assessing their knowledge of e-cigarettes, nicotine's presence, and its effects on a growing brain (see Appendix A). Thirty-nine parents received the education via a live Zoom meeting or a recorded slideshow. Seventeen parents (44%) completed the pre-survey, and 13 parents (33%) completed the post-survey. Each parent counted as a participant. Data Maintenance and Security During the parental education via a live Zoom meeting, the survey was initially completed using TypeForm, a free, internet-based survey software. Following the meeting, the author discovered that TypeForm limits the number of surveys that can be completed on a free account. For this reason, subsequent surveys were conducted using the survey-generating website Qualtrics. The TypeForm responses were moved to Qualtrics by the author and permanently deleted from the TypeForm website. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 27 The parent surveys were completed anonymously, and no demographic information was collected. The survey results were stored on the password-protected Qualtrics website and a password-protected personal computer. The only person with access to the personal computer was the author. One year from project implementation (March 2023), the author will permanently delete the surveys from the Qualtrics website and personal computer. Proof of deletion will be delivered to the target school administration. Data Collection and Analysis The pre-and post-surveys were identical. The surveys analyzed parental knowledge of the presence of nicotine in e-cigarettes and the ability of nicotine to cause addiction. The parental understanding regarding the effects of nicotine on the developing brain and awareness were also measured, in addition to the concern about adolescent e-cigarette use, concern over their child's use, and the priority placed on the prevention of adolescent e-cigarette use (see Graph 1). PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 28 Graph 1 Note. Survey responses expressed as a rounded percentage Findings Overall, the findings supported the project outcomes. In the post-survey, the parents showed that they are aware that e-cigarettes contain nicotine and that nicotine leads to addiction and harms the developing brain. Parents demonstrated that they are concerned about general adolescent use and their own child's use. Prevention of e-cigarette use in adolescence was a PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 29 priority for parents. The provided education increased parental understanding of e-cigarettes and nicotine and the concern over e-cigarette use. Strengths Four strengths were identified in this project. First, the education was disseminated using two methods (a live Zoom meeting and a pre-recorded, evidence-based slideshow posted to YouTube), allowing greater access. Second, the asynchronous YouTube presentation allowed parents to watch at their convenience. Third, the teachers and students supported parent participation, encouraging the parents to participate in the education and surveys. Fourth, the project successfully communicated nicotine and e-cigarette use risks, specifically in adolescents. Weaknesses Four weaknesses were identified in this project. First, motivating parents to participate in the presentation and surveys was challenging. Second, not all participants completed the pre-and post-surveys, limiting the obtained data. Third, more participants finished the pre-survey (17) than the post-survey (13), complicating the accuracy of the data. Fourth, internet access is necessary to view the pre-recorded slideshow on YouTube, making it difficult for individuals without internet access. Discussion In 2019, 8.0% of sixth graders in Tooele County reported ever using an e-cigarette. This is higher than 5.2% for Utah (State of Utah, 2019). Parents play a vital role in preventing adolescent vaping (University of California San Francisco, 2020). An evidence-based education protocol was implemented to educate and empower parents of sixth graders. Following the education, parents demonstrate an increased understanding of e-cigarettes and nicotine and increased concern over e-cigarette use. These results support the primary goal of the project, PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 30 which is to raise parental awareness and concern about the prevalence of e-cigarette use in adolescence, as well as the harmful effects of nicotine on the developing brain, and to encourage open conversation regarding e-cigarette use between parents and their children. Translation of Evidence into Practice This project supports evidence that parents play a crucial role in discouraging adolescent vaping (University of California San Francisco, 2020). Parent involvement and a substantial parent-child bond decrease adolescents' desire to use e-cigarettes (Kurji et al., 2021). Despite playing a vital role in vaping prevention, parents are often misinformed or uneducated regarding e-cigarettes. Often, parents cannot identify an e-cigarette, and they are unaware that e-cigarettes can contain nicotine or of the effects of nicotine on the adolescent mind and body (Truth Initiative, 2019). This project provides parents with important information regarding e-cigarettes, empowering them to recognize e-cigarette use and have an open conversation about e-cigarettes with their children. Parents gained new knowledge, allowing them to transfer it to their children. Implications for Practice and Future Scholarship The lack of parental education about e-cigarettes implies that healthcare providers can help educate and empower parents. Healthcare providers can include education about e-cigarettes in the anticipatory guidance section of well-child checks, allowing open dialogue and education about e-cigarettes. An evidence-based e-cigarette prevention education video can be used in future quality improvement projects and sustainability efforts. Future quality improvement projects can focus on providing similar education to 5th-grade students and increasing parental involvement. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 31 Sustainability The PTA at the elementary school will sustain the project in the future. The PTA will be able to teach the course with minimal training. The CATCH My Breath curriculum has training modules that are accessible and user-friendly. Instructions and links to the necessary resources were emailed to the PTA president. She was also provided with the evidence-based e-cigarette prevention education video, which they plan to use in the annual education. The PTA president will assign a board member to teach the parent course. Dissemination The project results will be disseminated to the principal of the elementary school in the Tooele County School District. The principal has changed since the completion of the project. The results will be disseminated to the new principal of the school. The PTA will also be provided with the results. In addition, they will be sent to John Contreras at the Tooele County Health Department. John Contreras is the deputy director and epidemiologist at the health department. He also works with a local college's Master of Public Health (MPH) program. This project will provide him with evidence that will be useful in the MPH program. Conclusion Tooele County has adolescent vaping rates significantly higher than the state average (State of Utah, 2019). Increased parental education and awareness are needed to prevent e-cigarette use in adolescents in Tooele County. The adolescent decision not to vape is heavily influenced by parental involvement and a strong parent-child bond (Kurji et al., 2021). However, parents are often misinformed or uneducated regarding e-cigarettes and nicotine (Truth Initiative, 2019). This project educated parents, increasing their knowledge of e-cigarettes and nicotine and amplifying parental concern over e-cigarette use. PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 32 Since completing this project, JUUL, one of the leading e-cigarette brands among teenagers, has been banned in the United States. Juul was primarily marketed to adolescent age groups. On June 23, 2022, the Food and Drug Administration (FDA) ruled that Juul be removed from shelves. Other nicotine-containing brands remain on the market (Richtel & Jacobs, 2022). PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 33 References American Association of Colleges of Nursing. (2006, October). The essentials of doctoral education for advanced nursing practice. https://www.aacnnursing.org/DNP/DNP-Essentials American Lung Association. (2016, July 6). Each breath: A blog by the American Lung Association. 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Sage Open Medicine, 7, 1-10. https://doi.org/10.1177/2050312119871405 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 39 Appendix A Parental Knowledge of E-cigarettes Survey Parents will be shown a picture of an e-cigarette and asked the following questions: 1. Can you identify this device? Vaping device/e-cigarette USB drive Power bank Pencil lead Medical device Candy Don't know 2. Have you seen or heard of e-cigarettes? Yes No 3. To the best of your knowledge, how often do e-cigarettes, as designed, contain nicotine? Always Very often Sometimes Rarely Never Don't know PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 40 Please indicate your level of agreement with the following statements. 4. Nicotine causes addiction Strongly agree Agree Neither agree/disagree Disagree Strongly disagree 5. Nicotine harms the developing brain Strongly agree Agree Neither agree/disagree Disagree Strongly disagree Please rate your level of concern regarding e-cigarette use in the following situations: 6. General adolescent use Very concerned Somewhat concerned Not at all concerned PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 41 7. Your own child's use Very concerned Somewhat concerned Not at all concerned 8. What priority do you place on the prevention of your own child's use of e-cigarettes? Very high Somewhat high Medium Low Very low PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 42 Appendix B PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 43 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 44 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 45 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 46 PRIMARY PREVENTION OF VAPING THROUGH PARENTAL EDUCATION 47 Appendix C