Daniel Pyle, Ph.D. TEEN VAPING EPIDEMIC: A RISING HEALTH CONCERN by Teshia Mikesell A project submitted in partial fulfillment of the requirements for the degree of MASTER OF EDUCATION IN CURRICULUM AND INSTRUCTION WEBER STATE UNIVERSITY Ogden, Utah June 17, 2020 Approved Stephanie Speicher, Ph.D. Chantel Cowan, District Curriculum Director TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 2 Acknowledgements I would like to thank all the professors and other education leaders who helped so much with this project. For Dr. Stephanie Speicher and all her time, great feedback, and support. For Dr. Daniel Pyle and his important feedback and encouragement. Also for Chantel Cowan, District Curriculum Director, for taking time out of her busy schedule to be on the committee for this project and for all her input. For my husband who has helped me and supported me on the good and bad days of completing my masters project. He continually gave me encouragement and tried helping me when I felt lost or confused. Finally for all my health students who participated in the survey. The data received from them was crucial in finishing the project. With the coronavirus pandemic, more than half of my students pulled through and completed the survey for me. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 3 Table of Contents NATURE OF THE PROBLEM.............................................................................. 7 Literature Review........................................................................................ 8 Increased Popularity ........................................................................ 8 Reasons Teens are Drawn to Vaping ............................................ 10 Health Concerns ............................................................................ 18 PURPOSE ............................................................................................................. 26 METHOD ............................................................................................................. 27 Participants ................................................................................................ 27 Procedures ................................................................................................. 28 Data Analysis ............................................................................................ 29 RESULTS ............................................................................................................. 31 How Teens Perceive Vaping’s Impact on their Health ............................. 31 How would Students Prefer to Learn about Vaping’s Impact on Health . 36 DISCUSSION ....................................................................................................... 40 How Teens Perceive Vaping’s Impact on their Health ............................. 40 How would Students Prefer to Learn about Vaping’s Impact on Health . 42 Limitations ................................................................................................ 45 Recommendations ..................................................................................... 46 Conclusion ................................................................................................ 47 REFERENCES ..................................................................................................... 48 APPENDICES ...................................................................................................... 56 Appendix A: Survey Instrument ............................................................... 57 TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 4 Appendix B: Information Letter to Parents .............................................. 60 Appendix C: Information Letter to Students ............................................ 61 Appendix D: Informed Consent ................................................................ 62 Appendix E: Figures 1-7 ........................................................................... 65 Appendix F: District Research Approval Form ........................................ 69 Appendix G: IRB Research Approval Form ............................................. 71 TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 5 List of Figures Figure 1. Frequency distribution of all respondents in regards to exposure to tobacco products in e-cigarettes and the likelihood it could lead to other addictions. ..... 32 Figure 2. Frequency distribution of all respondents in regards to e-cigarettes being harmless. .............................................................................................................. 33 Figure 3. Frequency distribution of all respondents in regards to e-cigarettes being a healthier alternative to traditional cigarettes... .................................................... 34 Figure 4. Frequency distribution of all respondents in regards to the smoke from e-cigarettes is just water and not harmful. .............................................................. 35 Figure 5. Frequency distribution of all respondents in regards to how much respondents thought people risk harming themselves if they used an e-cigarette regularly. .............................................................................................. 36 Figure 6. Frequency distribution of all respondents in regards to how interested they are in learning about vaping in health class. ....................................................... 37 Figure 7. Frequency distribution of all respondents in regards to what learning activities respondents would feel would be most beneficial in educating students about vaping. ......................................................................................... 38 TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 6 Abstract In recent years, vaping has become popular among teens. Research shows the increasing number of teens’ vaping across the nation. Teen’s need to be educated on the dangers of vaping so they can make informed decisions when it comes to vaping. Smoking has declined dramatically over the years. This has been done through education programs, campaigns, advertisements, and cessation groups. Now that vaping is on the rise, similar events need to take place to decrease the amount of users. To expand on prior research, a survey was done to understand what students knew about the harms of vaping on their health, and also to examine what educational strategies would be the best to use when teaching teen’s about the dangers of vaping. The survey examined 10th grade health students at a local high school. Results indicated that for the most part teen’s understand that vaping is harmful to their health. Students reported mixed results about whether vaping was a healthier alternative to traditional cigarettes or not. Results also determined that the best educational strategies to use when teaching the dangers of vaping was a classroom discussion, and watching videos that related facts about the dangers of vaping. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 7 NATURE OF THE PROBLEM In recent years, vaping has become increasingly popular among kids and teens (American Heart Association [AHA], 2018; Dai, Catley, Richter, Goggin, & Ellerbeck, 2018; Surgeon General’s Report [SGR], 2016). More than five million youth in the United States use e-cigarettes (FDA, 2019). The most commonly used tobacco product among youth are e-cigarettes, commonly referred to as e-cigs (AHA, 2018; SGR, 2016). In 2019, high numbers of 12th graders in Utah reported vaping (State of Utah Division of Substance Abuse and Mental Health, 2019). The number of vapers has increased dramatically since 2013 (SHARP Survey, 2013). As of 2019, more than 27% of high school students and 10% of middle school students were vaping (FDA, 2019). Before vaping was introduced, smoking had declined as a result of anti-smoking campaigns, policies, and educational programs (AHA 2018; CDC, 2018; Dai et al., 2018; Patrick et al., 2016). There are a number of reasons teens are drawn to vaping. One reason that teens are drawn to vaping is that they believe vaping is safe (Martinelli, 2019; Vaughn, 2019). Others believe vaping is considerably less harmful than traditional cigarettes (AHA, 2018; Hilton, Weishaar, Sweeting, Trevisan, & Katikireddi, 2016). Another reason teens are drawn to vaping is that teens view e-cigs as attractive and pleasing due to all the fun flavorings (AHA, 2018; Hilton et al., 2016; SGR, 2016; Patrick et al., 2016). Some teens view e-cigarettes as a way to quit smoking (AHA, 2018; Hilton et al., 2016; Patrick et al., 2016; SGR, 2016). Finally, social media posts showing ‘vape tricks’ have also prompted teens to experiment with e-cigs (Hilton et al., 2016). As vaping has become more prevalent, vaping-related health concerns are on the rise and health educators need to be prepared to address this issue with their students (AHA, 2019; Dai et al., 2018; Johnson & Pennington, 2015). One major health concern is that e-cigarettes contain the TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 8 addictive substance nicotine and other harmful chemicals (AHA, 2018; SGR, 2016). Exposure to tobacco products can lead to other addictions like marijuana, cocaine, or methamphetamine (AHA, 2018; Dai et al., 2018; SGR, 2016). Vaping at a young age also puts teens’ brain development at risk (AHA, 2018; Dai et al., 2018; SGR, 2016). Another alarming concern is the severe lung and respiratory problems being reported across the nation (Centers for Disease Control [CDC], 2019; U.S. Food & Drug Administration [FDA], 2019). Given the recent vaping-related health crisis, it is imperative that health teachers address the topic of vaping with their students (AHA, 2019; SGR, 2016). Literature Review Increased Popularity Vaping has become popular among teens (American Heart Association [AHA], 2018; Surgeon General’s Report [SGR], 2016). Every two years the state of Utah does a survey called Student Health and Risk Prevention (SHARP). Through the survey the state collects data about substance abuse, and mental health issues. In 2019, over 30% of 12th graders in Utah reported vaping (State of Utah Division of Substance Abuse and Mental Health, 2019). This percentage shows that vaping has increased since 2013, where less than 10% of 12th graders vaped (State of Utah Division of Substance Abuse and Mental Health, 2013). Younger students also indicated that they had vaped, at the following rates: 25% of 10th graders; 15% of 8th graders; and 5% of 6th graders (State of Utah Division of Substance Abuse and Mental Health, 2019). In contrast to vaping, teen cigarette smoking declined. In Utah, the number of students who reported having ever smoked a cigarette dropped in each of the surveyed grade levels from 2011 to 2019 (State of Utah Division of Substance Abuse and Mental Health, 2011; State of Utah Division of Substance Abuse and Mental Health, 2019, in press). In that time frame, TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 9 traditional cigarette smoking decreased by over 8% for 12th graders, 11.5% for 10th graders, 4.5% for 8th graders, and 4% for 6th graders (2011; 2019). Smoking traditional cigarettes in Utah has decreased over the years, but health officials are concerned that the vaping epidemic might start to increase traditional smoking again (AHA, 2018; CDC, 2018). As in Utah, vaping in the United States has increased over the years. The rise in vaping was documented via the “Monitoring the Future Survey” (MTF), that focuses on the nation’s trends with substance use. From 2017 to 2018 vaping increased among students at the following rates: 8th graders: 11%, 10th graders: 25%, 12th graders: 30% (Johnson et al., 2019). According to the 2018-2019 MTF, the following percentages of teens nationwide reported vaping: 12th graders: over 40%, 10th graders: 41%, 8th graders: 24.3% (Johnston et al., 2019; NIH, 2019; SHARP Survey, 2019). In 2015, over three million middle and high school students had used an e-cigarette in the past month (Dai, Catley, Richter, Goggin, & Ellerbeck, 2018; SGR, 2016). In 2018, the number of 10th and 12th graders who vaped was the largest increase the survey had reported for any substance (Johnson et al., 2019). Given vaping’s rise in popularity, the 2017 MTF survey was updated to include more specific questions about vaping. These questions addressed topics such as vaping rates by grade level, who has vaped in the past 30 days, and who has vaped marijuana. Through these new questions, Johnson et al., (2019) found that marijuana vaping increased in 2018 as follows: 8th graders: 4.4%, 10th graders: 12.4%, 12th graders: 13.1%. The researchers also found that vaping ‘just flavoring’ amplified from 2017 (Johnson et al., 2019). Percentages of ‘just flavoring’ vapers increased among 8th graders by 3.2%, 10th graders increased 5.4%, and 12th graders increased 5.2% in one year’s time. Based on these findings, Johnson et al. (2019) raised concerns that the increase in vaping will reverse the many years of TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 10 progress our nation has made on reducing cigarette smoking among teens over the past few decades. Cigarette smoking among youth declined from 28% in 1996 to 8% in 2016 (Dai et al., 2018). Some of the things that helped de-normalize smoking were increasing cigarette prices, campaigns, smoke-free laws, cessation programs, and educating children (AHA, 2018). Along with Utah, nation-wide statistics for smoking traditional cigarettes was lower than 22% for 12th graders, 14% for 10th graders, and 10% for 8th graders (NIH, 2019; SHARP Survey, 2019). Health officials worry that vaping will “re-normalize” smoking again after all these efforts have been made over the years to reduce smoking (AHA, 2018; Dai et al., 2018; Patrick et al., 2016). It would be devastating to have smoking increase again because it is still the leading cause of preventable death in America (AHA, 2018; CDC, 2018). Health officials stated that smoking was declining, but now rates look like they are plateauing (AHA, 2018). In a study done by the National Institutes of Health, they gathered national demographic-based vaping data, including vaping trends by race and gender. Whites and Hispanics were more likely to ever use an e-cigarette compared to Blacks. Among all the races that reported ever using an e-cigarette, almost half had reported vaping in the past 30 days. A significant difference was found among Blacks who had ever reported vaping, in that they were more likely to continue using e-cigarettes than compared to Whites and Hispanics (NIH, 2016). Blacks were more likely to use e-cigarettes to help quit smoking (NIH, 2016). Whites were more likely than Hispanics to vape to save money (NIH, 2016). Reasons Teens are drawn to Vaping Vaping is appealing to teens for many reasons. To begin, teens believe vaping is safe. Research on teen vaping has shown that teens viewed e-cigarettes as considerably less harmful TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 11 than traditional cigarettes (AHA, 2018; CDC, 2016; Patrick et al., 2016; Hilton, Weishaar, Sweeting, Trevisan, & Katikireddi, 2016). The problem is that vaping has not been around long enough to know the long-term consequences (Vaughn, 2019). However, there is short term research that has proven vaping to not be safe (AHA, 2019; CDC, 2019; FDA, 2019). A big concern is that a lot of vape flavorings do contain nicotine or other harmful substances (Patrick et al., 2016; SGR, 2016; Vaughn, 2019). Even though a lot of e-liquids contain nicotine, which is very addictive, teens believe that they can smoke and quit when they want, and they think it is safe (Goriounova & Mansvelder, 2012). The Surgeon General’s Report (2016), noted that two-thirds of JUUL brand e-cig users aged 15-24 did not know that JUUL always contains nicotine (SGR, 2016; Truth Initiative, 2018). On some of the e-liquid packaging it will state 5% nicotine, but the problem with this is that since the package might say 5% nicotine, teens believe the rest of the liquid is made of water or vapor (Martinelli, 2019). Some packaging products and labels do not accurately tell customers what is in the e-liquids (Patrick et al., 2016). For example, some packaging that states that the e-liquid is nicotine free has been found to have nicotine in them (Patrick et al., 2016). There are not regulations on the e-liquids, and the FDA has not approved the liquids (FDA, 2019). Therefore, it is not clear what chemicals or drugs people might be vaping, and teens continue to believe it is safe. Gender and race also play a factor into why teens vape. According to Patrick et al. (2016), girls were more likely to vape because they wanted to experiment and boys were more likely to vape because of boredom and to have a good time with friends. Whites reported vaping for taste purposes compared to other races (Patrick et al., 2016). Blacks and others besides whites mainly reported vaping because it looked cool (Patrick et al., 2016). Students whose parents TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 12 were lower educated reported vaping to relax, and those with parents who graduated college reported vaping because of taste and to have a good time (Patrick et al., 2016). According to the SGR (2016), vaping was higher among youth who were White and Hispanic males, and those less likely were females and African-Americans. Among young adults 18-24 vaping was higher among less educated White and Hispanic, males (SGR, 2016). Martinelli (2019), indicated marketing companies cause people to think vaping will make them happier and improve their social status. This perpetuates the misconception among teens that vaping is not harmful. Marketing techniques exploit teens’ desire for social status, happiness, reward, etc. Teens are more motivated by rewards, than the risk factors (Goriounova & Mansvelder, 2012). Marketing companies for e-cigarettes know this, therefore this is how they market to teens. Teens believe they are just inhaling fun flavored gasses because of advertisement techniques that teach it is not as bad for their health like traditional cigarettes (Martinelli, 2019; Truth Initiative, 2018). A survey was conducted with just under 800 respondents from 9th and 10th grades regarding teens’ views about vaping (Goriounova & Mansvelder, 2012). About one in five teens believed the smoke from e-cigarettes was just water and not harmful (Goriounova & Mansvelder, 2012; Martinelli, 2019). From the same survey 23% of participants did not believe e-cigarettes were a tobacco product (Goriounova & Mansvelder, 2012). Almost 30% of teens did not view e-cigarettes as a product that produced smoke (Goriounova & Mansvelder, 2012). Lastly, over 40% of participants viewed e-cigarettes as safer than traditional cigarettes, and they felt that e-cigarettes were a product to help people quit smoking (Goriounova & Mansvelder, 2012). Many other studies have similarly found that teens view e-cigarettes as safer than traditional cigarettes, TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 13 and they believe it is a way to help people with smoking cessation (AHA, 2018; CDC, 2016; Goriounova & Mansvelder, 2012; Hilton et al., 2016; Patrick et al., 2016; SGR, 2016). There are a few reasons teens viewed e-cigarettes as a way to quit smoking (AHA, 2018; CDC, 2016; Goriounova & Mansvelder, 2012; Hilton et al., 2016; Patrick et al., 2016; SGR, 2016). E-cigarette companies have marketed their products stating it is a way to quit smoking (AHA, 2018; Truth Initiative, 2018). Patrick et al. (2016) found that even though teens view vaping as a way to quit smoking, it is not one of their top reasons for vaping. According to the AHA (2018), much more research needs to be done to prove that e-cigarettes are an effective way to quit smoking. Health officials like the AHA (2018), and Hilton et al. (2016), are worried that smoking will become normal again even though numbers have decreased over the years. The AHA (2018), also recommends not using e-cigarettes as a way to quit smoking because it has not been a proven effective way, but to find other proven methods to help smoking cessation. One reason the decline in smoking might reverse could be due to the variety of vape juices that contain nicotine. A focus group study conducted found that teens viewed e-cigs as attractive and pleasing due to all the fun flavorings (AHA, 2018; Hilton et al., 2016; Patrick et al., 2016). Vape companies advertise their flavors to attract young teens (Truth Initiative, 2018). Vape companies market their e-liquids to look like candy and other kid-friendly food items (Martinelli, 2019; Truth Initiative, 2018). Some examples of fun flavors e-cigarette companies sell are banana split, cotton candy, Kool-Aid, Sweet Tarts, Hawaiian Punch, Gummy Bears, Froot Loops, Skittles and more. All of these flavored items are popular among teens (Hilton et al., 2016; Tobacco-Free Kids, 2014). Lots of vape companies are coming under fire for selling flavored e-liquids that are targeted towards teens (FDA, 2018). A group of researchers did a study to see which flavor was TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 14 the most popular among teens who used JUUL and it was mango flavor (Leventhal, Miech, Barington-Trimis, 2019). JUUL, one of the biggest companies for e-cigarette sells, has quit selling all flavors except mint, menthol, and tobacco to help with the outburst of teen vaping (CNBC, 2019; Leventhal, Miech, Barington-Trimis, 2019). Now since JUUL has quit selling all flavors but mint, studies show that mint is the number one popular flavor among teens (CNBC, 2019; Leventhal, Miech, Barington-Trimis, 2019). Commentators from CNBC (2019) are concerned that if flavors get banned from the market, teens and other e-cigarette users will turn to the black market or start making their own. These flavors and liquids will not be regulated and no one will know what is in the liquids (CDC, 2019). Another reason e-cigarettes are popular is because they are easy to obtain (CDC, 2016; Hilton et al., 2016). A person needs to be over 18 to purchase e-cigarettes online. Teens reported that one of the top places they got e-cigarettes was online (FDA, 2018; Hilton et al., 2016; Martinelli, 2019). When ordering an e-cigarette online teens can lie about their age and buy an e-cigarette illegally. The other popular place teens were getting e-cigarettes was from their friends (Hilton et al., 2016). Despite the ease of purchasing e-cigarettes online, teens do not report that as a primary reason they are drawn to vaping (Patrick et al., 2016). The Food and Drug Administration (FDA), is responsible for protecting the public health (FDA, 2018). They make sure there is safety and security for products, medical devices, our food, etc. (FDA, 2018). Another big role they have is regulating the manufacturing, advertising, and delivery of tobacco products to protect the public, especially minors (FDA, 2018). In 2018, the FDA issued warning letters to over 1,300 to companies who illegally sold e-cigarette products to underage people. Warnings were also given to online companies in the big national sting for selling to minors and for advertising to teens in a kid-friendly way making vaping look TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 15 safe (FDA, 2018). The FDA (2018) is revisiting their compliance policy, and they want vape companies to submit applications for premarket authorizations to make sure they are not marketing to teens. Social media is one of the biggest advertisers for e-cigarettes (Patrick et al., 2016; Truth Initiative, 2018). Tobacco companies know that teens and young adults are the biggest users of social media (Kong, LaVallee, Rams, Ramamurthi & Krishnan-Sarin, 2019). They know that putting their ads on social media is the perfect way to target teens and young adults. JUUL has paid for campaigns on Twitter, YouTube, and Instagram (Truth Initiative, 2018). They want viewers to view vaping as cool, fun, relaxing, pleasurable, and having sex appeal (Patrick et al., 2016; Truth Initiative, 2018). JUUL tweets have skyrocketed. In 2015, the monthly average of tweets on Twitter about vaping was 765. In 2017, the monthly average jumped to 30,565 tweets (Truth Initiative, 2018). Advertising for e-cigarettes has been on the rise the last few years since there are no regulations yet. Thus, e-cigarette companies advertise as much as they can to hook the young generations before they might lose their opportunities to advertise so freely (FDA, 2018). The FDA (2018) and other organizations are in the process of passing laws and restrictions to stop vape companies from advertising so openly. Social media posts showing ‘vape tricks’ have also promoted teens to experiment with e-cigs (Hilton et al., 2016; Kong et al., 2019). A vape trick is the process of blowing out thick amounts of exhaled aerosol into shapes like rings. Vape tricks have become very attractive to youth (Kong et al., 2019). Kong et al. (2019), explained that there are even vape trick competitions with prizes to those who can do the best tricks. Kong et al. (2019) and Hilton et al. (2016) worry that vape tricks can appeal to youth and lead them to vaping and exposure to TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 16 nicotine. Despite their efforts, according to Patrick et al. (2016) the least common reasons for vaping were to look cool, or to fit in. YouTube has become a big advertiser for e-cigarettes (Kong et al., 2019; Truth Initiative, 2018). People aged 18-34 represent the largest demographic of YouTube users (Kong et al., 2019). Adolescents under 18 are even more likely to view YouTube than adults (Kong et al., 2019). There are a lot of tobacco and alcohol promoted videos on YouTube especially e-cigarettes (Kong et al., 2019; Truth Initiative, 2018). All the free and easy access to vape trick videos and e-cigarettes is another reason vaping is becoming popular among teens. On YouTube you can even find vape pens being promoted in music videos which have been viewed over a billion times (Kong et al., 2019). YouTube does set age limit restrictions, so teens cannot view inappropriate videos. Unfortunately, pro-tobacco videos can still be viewed by teens because the vaping videos do not fall under YouTube’s restricted videos for youth definition (Kong et al., 2019). Over half of the YouTube videos Kong et al. (2019) found while searching vaping topics were sponsored by e-cigarette companies. The other half of the videos were personal channels (Kong et al., 2019). In 1971, tobacco companies were banned from advertising cigarettes on TV, and radio stations (Truth Initiative, 2018). Today there are few federal restrictions on marketing e-cigarettes (Truth Initiative, 2018). In 2014, tobacco companies spent over $125 million on marketing (Truth Initiative, 2018). In 2017, 8.6 billion dollars were spent on marketing e-cigarettes (AHA, 2018). About half of U.S. teens aged 12-17 were exposed to these advertisements (AHA, 2018). Efforts by educators need to be even more dominant because of tobacco companies and their marketing strategies. One of the strategies tobacco companies are using to target teens is offering scholarships (Truth Initiative, 2018). E-cigarette companies are TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 17 offering scholarships asking students to write essays on topics about the potential benefits of vaping, and whether e-cigarettes reduce smoking’s negative effects (Truth Initiative, 2018). Tobacco companies were banned from sponsoring music, sports, and other events because their tactics were advertising to teens (Truth Initiative, 2018). The 1998 Master Settlement Agreement along with the Family Smoking Prevention and Tobacco Control Act were the reasons cigarette companies cannot sponsor music or sports events (Truth Initiative, 2018). E-cigarette companies have not been banned from these types of sponsorships. Thus, E-cigarette companies have sponsored many music festivals. For example, JUUL sponsored a 2018 music festival at Sundance Film Festival in Utah (Truth Initiative, 2018; Gardner & Saviss, 2018). E-cigarettes are also popular among teens because companies are coming out with a variety of shapes, and sizes of vape pens (AHA, 2018; Martinelli, 2019; SGR, 2016). They are becoming so small that they are easy to hide. There are e-cigarettes that look like a USB flash drive (Martinelli, 2019). You can plug them in and charge them using a computer or outlet. When the USB flash drive e-cigarette came out in 2016, JUUL the company who sold them, had a 600% surge in sales (SGR, 2016). On the JUUL website (2019), you can buy a USB e-cigarette for $5.99. JUUL is cheap compared to traditional cigarettes based on how much nicotine you get. A normal JUUL pod can contain as much nicotine as a pack of twenty cigarettes (Martinelli, 2019). There are also e-cigarettes that have minimal aerosol released which reduces the odor (SGR, 2016; Martinelli, 2019; Vaughn, 2019). Teens can easily hide the fact that they were vaping since they will not smell like smoke after using an e-cigarette (Hinton et al., 2016; Martinelli, 2019; SGR, 2016; Vaughn, 2019). Thus, vaping appeals to teens because it can be discreet. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 18 According to the Centers for Disease Control and Prevention (CDC, 2016), 39% of teens said the most common reason for using an e-cigarette was due to being used by a friend or family member. When friends and family used e-cigarettes teens were more likely to use them (CDC, 2016). In a similar study, the most common reasons for vaping were to experiment, taste, and boredom (Patrick et al., 2016). Both studies had different results on the top reasons why teens’ vape, which suggests there can be multiple different answers depending on what research you read. Health Concerns Overall, there are many reasons teens vape, but they tend to not think of the health concerns. Some concerns are that e-cigarettes contain harmful chemicals such as nicotine, which is very addictive (CDC, 2016; Johnson & Pennington, 2015). There are health risks when someone uses nicotine regularly, including heart disease, cancers of the lungs, and stroke (Johnson & Pennington, 2015). Some other dangerous things found in vape products are ultrafine particles; diacetyl, a chemical connected to severe lung disease; benzene, a chemical found in car exhaust; and heavy metals like tin, lead, and nickel. (AHA, 2018; SGR, 2016). Cancer causing chemicals and volatile organic compounds which are used as ingredients in paints, cleaners, fuels, and more are also found in e-cigarettes (AHA, 2018). The harmful substances contained in vaping liquids pose risks to people who are around the products as well as the vapers themselves. Those who are nearby someone vaping at risk for secondhand smoke (AHA, 2018). Adults and children have even reported being poisoned by e-liquids from swallowing, breathing, or absorbing it through their eyes or skin (AHA, 2018). In 2014, the CDC recorded the results from calls to the poison centers across the nation. The most common health effects recorded from e-cigarette exposure were vomiting, eye irritation, and TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 19 nausea (CDC, 2014). Thus, the aerosol released from an e-cigarette is not harmless (SGR, 2016). When someone vapes, the aerosol released can potentially expose themselves and others around them to the harmful substances previously mentioned (SGR, 2016). The chemicals used to make the variety of flavorings may also have health risks. E-cigarette flavorings are not regulated by the FDA (Johnson & Pennington, 2015). JUUL is also known to use nicotine salts (SGR, 2016). The salts allow high levels of nicotine to be inhaled more easily and possibly cause less irritation (SGR, 2016). Manufacturers of e-cigarettes claim they are healthier because the user is not inhaling tobacco smoke (Johnson & Pennington, 2015). When the FDA tested the vapor, toxic chemicals like carcinogens were found (Johnson & Pennington, 2015). Some types of flavorings, or e-cigarettes can expose the user to greater amounts of nicotine than a traditional cigarette (AHA, 2018). Not only can people vape nicotine and different flavorings, they can also use e-cigarettes to vape other drugs like marijuana (SGR, 2016). During teen years the prefrontal cortex (PFC) is still developing. PFC is the area of the brain is in charge of executive functions and attention performance. The brain is not fully developed until the early to mid-twenties (SGR, 2016). Brain exposure to nicotine can cause growth disruptions to the circuits connected to attention, learning, and proneness to addiction (AHA, 2018; CDC, 2016; Martinelli, 2019; Patrick et al., 2016; SGR, 2016). Nicotine exposure while the brain is still developing can be long-lasting (SGR, 2016). Exposure to nicotine can also cause lower impulse control and affect different mood disorders (SGR, 2016). Nicotine exposure in teens can cause changes in the central nervous system (Dai et al., 2018). It can also impact memory and attention (SGR, 2016). Smoking during teen years can increase a teen’s chances of developing psychiatric disorders and cognitive TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 20 impairment later in life. Teens are more likely to get addicted to nicotine faster than adults because they require less exposure to nicotine than adults do. (CDC, 2016; Dai et al., 2018; Martinelli, 2019). Due to teens’ brains still developing they find nicotine more rewarding, and less risky compared to adults (Goriounova & Mansvelder, 2012). Teen’s vaping at young ages risks their brain development (CDC, 2016; FDA, 2018; Martinelli, 2019; Patrick et al., 2016). Exposure to tobacco products can lead to other addiction like marijuana, cocaine, or methamphetamine (SGR, 2016; Dai et al., 2018; AHA, 2018; Goriounova & Mansvelder, 2012). For example, Dai et al., (2018) found that one in four teens who had ever vaped in their first wave of the study now reported vaping marijuana in the second wave of the study (Dai et al., 2018). Therefore, health educators need to inform teens of the dangers of nicotine and discourage youth from using tobacco in any form (SGR, 2016). Thousands of serious lung injuries have also been reported from e-cigarettes (AHA, 2018; Vaughn, 2019). The CDC (2019) only reports on hospitalizations from e-cigarette lung injuries and non-hospitalized reports are not counted. In the United States, there were 2,506 vaping related lung injury hospitalizations reported as of December 17, 2019 (CDC, 2019). The lung injury outbreak from e-cigarettes started in June 2019, but since 2017 there was a gradual increase of lung injury visits to the ER (CDC, 2019). However, the cases of lung injuries have started to decrease since September, 2019 with reasons presently unknown (CDC, 2019). Although researchers do not fully understand the exact cause of lung injuries, they do know that several patients have reported vaping THC (AHA, 2019; Aubrey & Wroth, 2019; CDC, 2019; FDA, 2019). THC is the psychoactive component in marijuana (AHA, 2019; CDC, 2019). One third of teens in 2016 who had ever vaped, reported vaping marijuana as well (SGR, TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 21 2016). More information is needed to know what specific products or substances cause lung injuries (AHA, 2019; CDC, 2019; FDA, 2019). It is also unknown if the lung injuries from vaping will be permanent or if people will be able to recover (Aubrey & Wroth, 2019, CDC, 2019). Scientists and medical professionals do not know the long-term effects of vaping (AHA, 2018; CDC, 2019; Vaughn, 2019). The CDC (2019) and the FDA (2019), reported that another factor in the lung injuries could be vitamin E acetate (Aubrey & Wroth, 2019). Vitamin E acetate is an additive, thickening agent in vaping products (CDC, 2019). This vitamin can be found in foods like cereal, fruits, vegetables, cosmetic products, etc. (CDC, 2019). This is usually not a harmful vitamin when eaten or applied to the skin properly (CDC, 2019). Vitamin E acetate has been found in the samples from patients with lung injuries (Aubrey & Wroth, 2019; CDC, 2019; FDA, 2019). Out of 51 people tested after a serious lung injury due to vaping, 48 of them had vitamin E acetate in fluid from their lungs (CDC, 2019; FDA, 2019). In many of the cases reported, patients suffered from breathing difficulty, chest pain, diarrhea, fevers, and fatigue (FDA, 2019). As of December 3, 2019, the CDC has gathered data on those hospitalized due to vaping (CDC, 2019). Among the more than 2,000 patients recorded for lung injuries, 67% were male, 78% were under 35 years old, and 16% were under 18 (CDC, 2019). The youngest age reported for lung injuries was 13 (CDC, 2019). The most commonly reported brand of e-liquids was ‘Dank Vapes’ at 56%, which could be one of the more dangerous brands (CDC, 2019; FDA, 2019). According to the CDC (2019) and FDA (2019), e-cigarettes caused 54 deaths in 27 states as of December 17, 2019. There are other deaths still being investigated to see if they are linked to vaping (CDC, 2019; FDA, 2019). Those who have died from vaping might have had other risk TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 22 factors involved such as advanced age, cardiac disease, pulmonary disease, or diabetes (CDC, 2019). From all confirmed deaths related to vaping the ages were from 17-75 years old, and the average age was 52 years old (CDC, 2019). Deaths and injuries are still being reported weekly from state health departments to the CDC (CDC, 2019). The FDA (2019), and many states across the country are in the process of passing laws and regulations for e-cigarettes (Public Health Law Center, 2019). All states have defined what an e-cigarette is in their laws (Public Health Law Center, 2019). Roughly just under half of the states have laws taxing e-cigarettes (Public Health Law Center, 2019). Just over half of the 50 states have laws requiring e-cigarette product labeling (Public Health Law Center, 2019). All 50 states except Pennsylvania as of September 15, 2019 restrict the sale of e-cigarettes to youth (Public Health Law Center, 2019; Truth Initiative, 2019). Presently, the minimum age for purchasing e-cigarettes varies by state, from age 18-21, but in July 2020 the minimum legal sales age will increase to 21 for all states (Public Health Law Center, 2019). In 2016, the FDA was successful in banning vending machines for e-cigarettes, free samples, and selling to teens underage (SGR, 2016). In 2016, they also got authority to regulate e-cigarettes, their marketing, labeling, etc. (FDA, 2019; Truth Initiative, 2019). Certain tobacco products, like e-cigarettes are required to do a premarket review before they are released to the public (FDA, 2019). The problem with this is not a lot of e-cigarette vendors are complying with the law and many warnings have been sent out, therefore almost all e-cigarettes on the market right now are illegal (Truth Initiative, 2019). In the state of Utah, any person 18 years old or younger who possesses an e-cigarette or tobacco in any form will be charged with a class C misdemeanor (Utah State Legislature, 2018). This consists of a minimum fine of $60 and to participate in a court-approved education program TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 23 on tobacco (Utah State Legislature, 2018). Any person under 18 in possession of an e-cigarette or tobacco product is subject to juvenile court, unless the incident happens on school grounds (Utah State Legislature, 2018). The person will be fined according to the law, and will also have to participate in a tobacco education program (Utah State Legislature, 2018). If a youth is caught at school with an e-cigarette, or tobacco product the school resource officer cannot issue a citation or referred to law enforcement, however they can be referred to evidence-based alternative interventions (Utah State Legislature, 2018). Thus, a student found in possession of an e-cigarette or tobacco product on school grounds is subject to district and school policies on how to handle the situation (Utah State Legislature, 2018). The AHA (2019), addressed ways parents can help discourage teens from smoking. These steps can also be applied and used by health educators, such as talking openly with teens about smoking and the dangers. Educators need to explain to kids and teens that it is more than just cigarettes. Hookah, e-cigarettes, and smokeless tobacco are all dangerous. Additionally, the AHA (2019) recommends preparing kids and teens for peer pressure. Educators and parents need to practice with kids and teens what they would do if a friend offers them an e-cigarette. The last step recommended is to set a good example. The people who smoke should quit, and be an advocate for not smoking (AHA, 2019; SGR, 2016). Educators need to be educated on the products so they can counsel teens that no tobacco product is safe. Smoking is the leading cause of preventable death in America. Every year in America 480,000 lives are lost because of smoking (AHA, 2018). Since smoking is the leading cause of preventable death, education at all levels needs to continue. Parents and communities need to rally together to prevent smoking behaviors. Not only do parents need to educate their children on the dangers of vaping, schools do as well. Teachers need to provide their students with TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 24 educational strategies to prevent them from vaping. Prevention is easier and cheaper than treatment later on (Martinelli, 2019). The FDA (2019), has made a few recommendations for teachers when teaching about e-cigarettes. Teachers need to be proactive in changing the social norms around e-cigarettes by having honest conversations and teaching the facts (FDA, 2019). Recent studies done on vaping have found that teens have some misconceptions about vaping that need to be corrected with facts (FDA, 2019). One of the misconceptions that needs to be corrected by educators is that teens think quitting whenever they want is easy (FDA, 2019). Educators need to make sure they are not comparing tobacco products and telling teens some are safer than others, because all tobacco products can be harmful to one’s health (FDA, 2019). Lastly, educators need to avoid showing appealing images of e-cigarettes (FDA, 2019). The best form of teaching is to present the facts to teens and let them decide for themselves, and avoid telling teens “You shouldn’t vape” (FDA, 2019). While the FDA provides some guidance on how to address vaping, teachers also need to know what teaching strategies would be most effective to use while creating curriculum. There was a study done that compared cooperative learning or working in groups vs. individualistic learning by themselves (Hsiung, 2012). In this study they randomly split the class of 42 students into two groups (Hsiung, 2012). Over the 18-week period the cooperative learning group performed substantially better in their homework and tests (Hsiung, 2012). Cooperative learning can improve academic achievement, student attitudes, and retention of the material (Ekima, Ifeoma, & Emmanuel 2013; Hsiung, 2012). Lessons where the instructor is the central focus with lecture and notes has been proven to be ineffective (Ekima, Ifeoma, & Emmanuel 2013; Hsiung, 2012). Therefore lessons about vaping need to be interactive and include student participation to TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 25 make it more meaningful to them. Thus, a curriculum that combines the FDA’s guidance on addressing teen vaping with a collective learning approach could help combat the teen vaping crisis. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 26 PURPOSE Over the years smoking has declined dramatically, but in the last few years the United States have seen a rise in teen tobacco use through vaping (American Heart Association, 2018, CDC, 2018; Dai et al., 2018; Patrick et al., 2016). Vaping has been reported as the number one tobacco product being used among teens (AHA, 2018; SGR, 2016). According to researchers, some common reasons teens are drawn to vaping is because of all the fun flavors, and they believe it is safe (AHA, 2018; Hilton et al., 2016; Patrick et al., 2016; SGR, 2016; Vaughn, 2019). Now that vaping has been around for a few years, vaping-related health concerns have increased (AHA, 2019; Dai et al., 2018; Johnson & Pennington, 2015). Exposure to vaping products can lead to addiction and brain development risks for teens (AHA, 2018; Dai et al., 2018; SGR, 2016). As new information comes out about vaping, health educators need to be prepared to address vaping with their students. The purpose of this study was to understand students’ perspectives of vaping. Knowing students’ perspectives will help health educators address the teen vaping crisis in the classroom. This study explored the following questions: a. How do teens perceive vaping’s impact on their health? b. How would students prefer to learn about vaping’s impact on health? TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 27 METHOD Where teen vaping and vaping-related health concerns have increased in recent years, there is a need for health educators to address vaping in the classroom. New information is continuing to evolve about vaping, and teens and health educator’s alike need to know the dangers. Using a survey, this descriptive study examined teens’ perceptions of vaping’s impact on their health, and how teens would prefer to learn about vaping’s impact on health. The results of this survey were used to inform the researcher on how to develop curriculum about vaping and the most beneficial way. The survey instrument included both Likert scaled and multiple choice items. A Likert scale was appropriate for this type of study because it measures people’s attitudes (Bishop & Herron, 2015; McLeod, 2019). A Likert scale also allows people to express whether they agree or disagree with each statement (Bishop & Herron, 2015; McLeod, 2019). Thus, using a Likert scale helped the researcher ascertain students’ attitudes and views on vaping. A few multiple choice questions were combined with the Likert scale questions. Multiple choice questions have fast processing times, respondents can focus on the content being asked, and it leaves out subjectivity (SurveyAnyplace, 2020). As such, multiple choice items are an efficient and effective way to survey students. Participants The study was conducted in a rural community high school. The participants were 10th grade students in mixed gender health classes. There were 101 students surveyed. Students’ identities were not be disclosed because the survey was confidential, and no personal information was recorded. Students were sent a link to their school canvas accounts to complete the survey through Qualtrics. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 28 Procedures After contacting the district, the following steps were followed to get approval from the district to conduct the survey. The researcher obtained approval from the Director of Assessment, Accountability & and Research. A research project request form was completed and submitted along with the survey. Once researcher had IRB approval and district approval, an information letter was sent electronically to all parents regarding the survey. Students enrolled in the researchers health classes were instructed by the researcher about the survey that was administered electronically. First an information letter was sent to parents along with an electronic consent form through email. At the bottom of the consent form there was a prompt for parents to click a Google Form Link to grant permission. Once they clicked the link it took them to a question asking if they give their student consent to participate in the survey. Parents typed their name in the short answer box provided. Google Form showed who responded so the researcher knew which students had permission to take the survey. Once electronic consent was given by the parent, an information letter was sent to the student with consent about the survey. Next students with parent permission were sent a link in canvas and email to Qualtrics where they needed to give assent to take the survey. Students needed to read the consent form sent to them first. Next, they clicked the link to go to the survey in Qualtrics. At the beginning of the survey students were asked to give assent. The first question asked students if they give assent to take the survey. If they clicked yes, then it will took them to the survey, if they clicked no, it did not allow them to see or take the survey. They were instructed to close the browser and not continue. Their names or information were not connected to the survey. When they clicked yes or no to give consent it did not ask for their name or any personal information. Information included in the email was the purpose of the study, when it would be conducted, and informing TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 29 them that a permission slip would be sent electronically for parents to sign. Informed consent and all contact with parents and students was conducted electronically. Informed consent and survey data were kept in a secure location for three years on the researcher’s district computer secured with a username and password. The data was only collected from students who have a signed consent form. Participation was voluntary. Students who complete the survey were awarded 15 points to their grade as an assignment. Those who wished not to participate in the study, or who did not bring back their consent forms signed were given an equal opportunity to earn the 15 points towards their grade. Students who did not participate watched a short 5-8 minute video about vaping and its dangers. The link was assigned to them through canvas. Once the video was over, students were required to answer 5-8 questions related to the video. The survey was conducted in May of 2020. The survey consisted of 11 questions about teens’ perceptions of vaping on their health and how students would prefer to learn about vaping in the classroom. The survey asked five questions related to research question number one, and six questions were asked related to research question two. When students returned signed consent electronically, they were sent a Qualtrics link in canvas where they could access the survey. The survey took about ten to fifteen minutes to complete. For those students who did not do the survey were given an alternative assignment which was previously mentioned and did it during the time the survey was open online in May. Data Analysis After the survey was completed the data was analyzed using percentages and averages for each question through Qualtrics survey. Qualtrics gave results on each question showing the percentages of how many students chose each answer. Survey results were divided based on the two research questions. All eleven questions related to teens’ perceptions of vaping on their TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 30 health and how educators can address the teen vaping crisis were analyzed with percentages. The data was kept secure on the researcher’s computer. The researcher was the only one who could log into the Qualtrics with the results. The username and password to log into Qualtrics survey was kept secure on the computer. The data was used to develop curriculum to teach about vaping. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 31 RESULTS Prior research has shown that there is a rising number of teen’s vaping and education designs need to be created to educate teens on the dangers of vaping. Survey research was conducted for this study to examine teen’s perception of vaping on their health, and the educational strategies needed to teach about the dangers of vaping. The response data were used to answer the research questions related to the purpose of the study to examine (a) how teens perceive vaping’s impact on their health, and (b) how would students prefer to learn about vaping’s impact on health. How Teens Perceive Vaping’s Impact on their Health The first part of the survey conducted was to understand a teen’s perception of vaping and the impact it has on their health. There were 101 respondents. Respondents were asked to rate levels of agreement from ‘strongly agree’ to ‘strongly disagree’, and ‘great risk’ to ‘no risk’ of their perception of vaping on their health. The first question in the survey was asking if the student gave ascent to do the survey. If they clicked yes it took them to the second question which was the first question asked about vaping. Results for questions 2-6 of the survey are demonstrated in Figure 1-5 below. In the second question, students were asked about exposure to tobacco products in e-cigarettes and if they thought this could lead to other addictions. A Likert scale type question was asked. 48% of respondents strongly agreed, which was the highest response to the question. The lowest response was 4% of respondents somewhat disagreed. Results of all respondents for question two are demonstrated in Figure 1. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 32 Q2 ‐ Exposure to tobacco products in electronic vapor products can lead to other addictions like marijuana, cocaine, or methamphetamine. Figure 1. Frequency distribution of all respondents in regards to exposure to tobacco products in e-cigarettes and the likelihood it could lead to other addictions. Question number three asked respondents if e-cigarettes are harmless. This question was asked because some of the previous research done indicated that some teens viewed e-cigarettes as not very harmful. The highest response was 67% of respondents strongly disagreed, and 22% somewhat disagreed. There was one outlier on the other end of the scale who responded that they strongly agree that e-cigarettes are harmless. Results for all respondents of question number three are found in Figure 2. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 33 Q3 ‐ E‐cigarettes are harmless. Figure 2. Frequency distribution of all respondents in regards to e-cigarettes being harmless. The next question on the survey asked respondents their views on whether e-cigarettes were a healthier alternative to traditional cigarettes. Respondents were asked to respond among five different choices starting with ‘strongly agree’ to strongly disagree. The results were mixed. The highest chosen response was 30% stated they somewhat agree, and the next closest was 27% neither agreed nor disagreed. 22% strongly disagreed, 16 % somewhat agreed, and only 5% strongly agreed. The research was done before the survey also indicated that a variety of teen’s also believed e-cigarettes were a healthier alternative to traditional cigarettes. The results are shown in Figure 3. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 34 Q4 ‐ E‐cigarettes are a healthier alternative to traditional cigarettes? Figure 3. Frequency distribution of all respondents in regards to e-cigarettes being a healthier alternative to traditional cigarettes. From the previous research done, about one in five teens believed the smoke from e-cigarettes was just water and not harmful (Goriounova & Mansvelder, 2012; Martinelli, 2019). Respondent’s data somewhat agreed with the national data. 10% neither agreed nor disagreed, and 1% somewhat agreed which is fairly close with national data. 62% of respondents strongly disagreed, and 27% somewhat disagreed that smoke from an e-cigarette was just water and not harmful. The results are demonstrated in Figure 4. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 35 Q5 ‐ The smoke from E‐cigarettes is just water and not harmful. Figure 4. Frequency distribution of all respondents in regards to the smoke from e-cigarettes is just water and not harmful. Respondents were asked to respond to how much they think people risk harming themselves if they use an e-cigarette regularly. Respondents had four options to choose from starting with ‘great risk’ down to ‘no risk’. More than half of respondents selected ‘great risk’ at 59%. No respondents chose ‘no risk’. The second highest response choice was ‘moderate risk’ at 31%. There are still 10% of students who think it is only slightly risky. Results of all respondents for question two are demonstrated in Figure 5. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 36 Q6 ‐ How much do you think people risk harming themselves if they use an electronic vapor product (including JUUL, e‐cigarettes, e‐cigars, e‐pipes, mods, personal vaporizers, vape pipes, vaping pipes, e‐hookahs, and hookah pens) regularly? Figure 5. Frequency distribution of all respondents in regards to how much respondents thought people risk harming themselves if they used an e-cigarette regularly. How would Students Prefer to Learn about Vaping’s Impact on Health The second part of the survey focused on how students would prefer to learn about vaping’s impact on health. Respondents were asked to rate levels of how interested or not interested they would be in learning about vaping. Some questions asked respondents about how effective, or not effective different learning strategies might be while learning about vaping in the classroom. Respondents were asked to check the options of how they learn the best. Below are the results of the respondents. There were mixed reactions from respondents on how interested they would be learning about vaping in health class. The highest answer to this question was 37% of respondents selected that they were moderately interested. The next closest were 24% saying they were slightly interested, and 18% said they were very interested. 15% were not interested at all in learning about vaping. Results of all respondents for question seven are demonstrated in Figure TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 37 6. Q7 ‐ How interested are you in learning about vaping in health class? Figure 6. Frequency distribution of all respondents in regards to how interested they are in learning about vaping in health class. There are many types of learning activities to use in the classroom. Respondents were asked to check all that apply to them on how they think learning about vaping would be most beneficial. The number one answer was that 26% of respondents believed a class discussion about the health concerns related to vaping would be the most beneficial learning activity. The second highest response was 23% responded that watching video clips stating facts about vaping would be the next most beneficial learning activity. Reading articles stating facts about vaping, student presentations, teacher lectures, working in groups, and working individually were all low responses. Results of all respondents for question eight are demonstrated in Figure 7. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 38 Q8 ‐ What learning activities do you feel would be most beneficial in educating students about vaping? (Check all that apply) Figure 7. Frequency distribution of all respondents in regards to what learning activities respondents would feel would be most beneficial in educating students about vaping. The next few questions on the survey asked more specific questions about how effective student learning would be with certain learning activities. The next question asked, “How effective would a classroom discussion be about vaping (would students pay attention, be honest about vaping, and learn new things from their peers)?” Interestingly 46% of respondents reported that it would be moderately effective for student learning. The next two highest responses were 22% said very effective, and 21% said slightly effective. 10% claimed it to be not effective at all and 1% said it would be extremely effective. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 39 Another question asked how effective it would be to correct teens’ misconceptions about vaping. This question was asked because the previously mentioned research stated that some teens’ had misconceptions about vaping. The highest chosen answer was 38% said it would be very effective to correct teens’ misconceptions about vaping, and the next highest response was 33% said it would be moderately effective. The rest of the responses were lower, for instance, 14% reported that it would be extremely effective, and 3% felt it would not be effective at all. Next, respondents were asked how effective researching facts about vaping would be. 42% conveyed that it would be moderately effective. The next highest response was 28% said researching facts would be very effective. 12% mentioned slightly effective, 9% extremely effective, and the least amount was 8% said it would not be effective at all. The last question of the survey wanted to know if it would be effective to do an assignment learning about the ways e-cigarette companies target teens. This question was asked because previous research that has been completed stated that e-cigarette companies target teens and this could be a reason teens might want to vape. 37% of respondents mentioned that doing this type of assignment would be moderately effective. 27% said it would be very effective, 22% said slightly effective, 11% reported it would be extremely effective, and only 3% said it would not be effective at all. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 40 DISCUSSION Prior research has shown us that teen vaping has increased dramatically over the last couple of years. Teens are drawn to vaping because they believe it is safe, and the tobacco companies are targeting teens with all their fun flavors. Health concerns are on the rise and educators need to be prepared to address this issue in the classroom. Curriculum needs to be developed to educate teens so they can make healthy, informed decisions. The purpose of this study was to (a) understand how teens perceive vaping’s impact on their health, and (b) how students would prefer to learn about vaping’s impact on their health. For the most part, the teens who participated in the survey viewed vaping as somewhat harmful with mixed emotions on whether vaping was safer than traditional cigarettes. Respondents gave input on what teaching strategies they thought would be best to use in the classroom on how to effectively teach about vaping and its dangers. How Teens Perceive Vaping’s Impact on their Health Results indicated that most teens agreed e-cigarettes are not harmless and that exposure to tobacco products in e-cigarettes can lead to other addictions. Very few students reported that they disagreed. Most respondents also agreed that vaping could cause moderate to great risk harming themselves if they vaped. Student’s responses were in line with previous research. The research mentions that exposure to tobacco products can lead to other addiction like marijuana, cocaine, or methamphetamine (SGR, 2016; Dai et al., 2018; AHA, 2018; Goriounova & Mansvelder, 2012). In reviewing the data results, most teens’ would agree with current research out there about e-cigarettes with tobacco products can lead to other addictions and it can be harmful to their health. This knowledge could come from teens’ previous knowledge about TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 41 tobacco in general that it is dangerous and addictive. Teens might also know that e-cigarettes are harmful due to the news, experience, friends, parents, etc. Even though the majority of respondents reported that e-cigarettes are harmful and can be addictive, there were mixed ideas on whether e-cigarettes were a healthier alternative to traditional cigarettes. Responses were fairly similar for the choice ‘somewhat agree’, ‘neither agree nor disagree’, ‘somewhat disagree’, and ‘strongly disagree’. These results show where some education and learning need to take place in the classroom. With the mixed results, this shows some confusion students might have about whether e-cigarettes are healthier than traditional cigarettes or not (AHA, 2018; CDC, 2016; Patrick et al., 2016; Hilton, Weishaar, Sweeting, Trevisan, & Katikireddi, 2016). However, there is short term research that has proven vaping to not be safe (AHA, 2019; CDC, 2019; FDA, 2019). These misconceptions need to be cleared up through designing curriculum that will educate students from the research on how e-cigarettes can be just as harmful as or more harmful than traditional cigarettes. Research has shown that teens believe vaping is considerably less harmful than traditional cigarettes (AHA, 2018; CDC, 2016; Patrick et al., 2016; Hilton, Weishaar, Sweeting, Trevisan, & Katikireddi, 2016). The results found in the vaping survey agree with previous research done among teens. Another reason the results might be mixed about e-cigarettes being a healthier option than a traditional cigarette is because of the marketing companies and the packaging. Research shows that tobacco companies and places that sell e-cigarettes target teens. A lot of flavored e-cigarette juices are not accurately portrayed on what is in them on the packaging labels (Patrick et al., 2016). Research shows that tobacco companies have marketed e-cigarettes as a way to quit smoking and that they are healthier than traditional cigarettes (AHA, 2018; Truth Initiative, 2018). Therefore, the results from the vaping survey confirm that marketing is affecting teens TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 42 and their views about vaping being a healthier alternative to traditional cigarettes. This is not true or accurate data being reported from tobacco companies. Results confirmed that most respondents agreed that the smoke from an e-cigarette is harmful and not just water. Interestingly, some of respondents answers are somewhat in line with the national data stating that one in five teens believed the smoke from e-cigarettes was just water and not harmful (Goriounova & Mansvelder, 2012; Martinelli, 2019). This is about 20% of our nation’s teens’. Respondent’s data somewhat agreed with the national data. 10% neither agreed nor disagreed meaning they did not know, or were in the middle of the two extremes. 1% somewhat agreed. This means that about 11% of respondents need further education and clarification which somewhat agrees with the national 20% of teen’s who believe it is just water. According to the vaping survey results, no one strongly agreed that smoke from an e-cigarette was just water and not harmful. Overall, it seems that most respondents would agree with the research that is out there about the dangers and harm that could come from the vapor from an e-cigarette. How Students would prefer to Learn about Vaping’s Impact on their Health For this study to help develop future curriculum about vaping, respondents were asked how they would prefer to learn about vaping’s impact on their health. Respondents were asked questions about what learning strategies would be the best to use. Students were also asked questions about how effective certain teaching strategies would be. Students were asked how interested they are in learning about vaping. The highest choice chosen was moderately interested. The other choices closest were very interested and slightly interested. There could be several factors why students are moderately interested in learning about vaping. Some assumptions could be that maybe since the majority of students know vaping TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 43 is harmful, they don’t care as much to learn about it. Some students might not be as interested to learn about it because they are vaping and do not care to know the impact vaping can have on them. Another assumption is that maybe talking about vaping is not a topic in health class they are interested in learning about, and maybe other health topics are more relevant to them. There is an interest in learning about vaping. Another possibility is maybe students think they know enough about it, and then after they are taught about vaping in health they will have enjoyed learning about it. Based on the results, the top two learning strategies respondents thought would be the most beneficial learning about vaping was a class discussion about the health concerns related to vaping and watching video clips stating facts about vaping. These results are following the FDA recommendations when teaching about vaping. The FDA (2019) stated, that teachers need to have honest conversations with their students and teach the facts. The FDA has also started developing a curriculum on how to teach teens about vaping. They have made short video clips stating facts about vaping and the dangers for teachers to use to help guide class discussions. The tools the FDA has created to teach about vaping is exactly how most of the respondents reported that they would want to learn about vaping. The third highest response was to learn in groups. This is also in substantiated in the research. Students who work in groups instead of alone can improve academic achievement, student attitudes, and retention of the material (Ekima, Ifeoma, & Emmanuel 2013; Hsiung, 2012). After asking students which strategies would be best to use while learning about vaping, then they were asked how effective some of the strategies would be. Some interesting results showed that the top strategies students said would be the most beneficial to use while learning about vaping they later stated that these strategies would be moderately effective. Respondents TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 44 rated a classroom discussion as moderately effective for student learning. In the previous question asked students stated that classroom discussions would be the best way to learn about vaping. The results are slightly mixed and a little confusing. Correcting teens’ misconceptions about vaping was ranked as a very effective way to educate teens. This goes along with what the FDA has recommended due to recent studies they have done (FDA, 2019). Their recent studies have found that teens’ have misconceptions about vaping and they need to be corrected with facts (FDA, 2019). For example, one of the misconceptions that needs to be corrected by educators is that teens think quitting whenever they want is easy (FDA, 2019). These misconceptions teens have about vaping could be effecting their desire to want to learn more about vaping, because they might think they know a lot about the topic, but they do not. Clearing up misconceptions through teaching teen’s facts will help them make more educated decisions when it comes to vaping. Respondents reported that researching facts about vaping would be moderately effective when it comes to learning. This was the lowest choice chosen earlier in the survey when respondents were asked which learning strategies they thought would be most beneficial. In conclusion, students believe there are other more effective learning strategies that they might like instead of research, but if students were asked to research facts about vaping they said it would be a moderately effective strategy to use. According to the students, the best way to learn the facts would be through a class discussion or watching short video clips that teach facts about vaping. Lastly, teens also thought that learning about the ways e-cigarette company’s target teens would be moderately effective to a very effective strategy. The FDA has a lesson they have developed that has students do some group activities to learn more about how e-cigarette TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 45 companies target teens (FDA, 2019). According to students, this would be a moderately effective activity. Earlier students did mention that working in groups would be one of their top three ways they would like to learn more about vaping. Therefore, this FDA lesson could be beneficial because they will be working in groups but also looking at how e-cigarette companies target teens. Overall, these new activities created by the FDA could be very beneficial in teaching teen’s the dangers of vaping. These lessons could also help give ideas to teachers trying to create a new curriculum about vaping or help them build off of what the FDA has already done. Limitations Results show that there is a need for a curriculum to be developed about the dangers of vaping. Students may have a general knowledge about vaping and think they know a lot, but more learning on the topic will help them make informed correct decisions when it comes to vaping. Results also showed some misconceptions teens’ have that need to be corrected through education. Results also show that curriculum developed based on class discussion and video clips stating facts about vaping would be great resources to use. One particular group of lessons that could be used that agrees with result data, are some lessons created by the FDA (FDA, 2019). The survey was done all online, and all communication was done through email with parents and students due to the Coronavirus Pandemic. All of the 4th term content and instruction was delivered online. The way the district wanted to do the grading system kept changing throughout the term. At first, most students were doing all their online work, and then once they realized the ease of the grading system a lot of students stopped trying as much and did less work. It would have been interesting to see how the results would have been different if we were still at school, and how many students would have had parent permission to do the survey. The TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 46 survey was conducted the last two weeks of the term right before the summer break. Surprisingly more than half of the students participated in the survey. On the contrary, doing the survey online could have been a strength to getting more respondents. Doing things online could have been more convenient for students, and for their parents to give them permission instead of a paper permission slip to return. Students could do the survey on their own time, and in an environment different than the classroom around classmates. Students possibly did not feel rushed doing it away from the school setting as well. Overall, getting 101 students to complete the survey during a pandemic at the end of a term was great. At this time as well a lot of students weren’t doing much work because of the ease of the grading system that was put in place to help students be successful during the pandemic. More information would need to be collected about the teaching strategies respondents felt would be the best to use while learning about vaping. For example, most respondents agreed that a classroom discussion on the facts about vaping would be the best learning strategy to use. Later on in the survey, respondents were asked how effective they thought a classroom discussion would be with student learning and the majority responded that it would be a moderately effective learning strategy. More follow-up questions would need to be asked about why classroom discussion would only be a moderately effective learning strategy. A follow-up could be done through another survey, class discussion, or a focus group. Recommendations There are some great lessons that have been developed about vaping. According to the survey results, the most beneficial lessons to use, or create would be classroom discussions, video clips with facts, and learning together in groups. To further this study, it would be interesting to do a pre-test of their knowledge on vaping using lessons that have already been TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 47 developed, or creating your own, then doing a post test. After the lessons were done it would be beneficial to do a post-test to measure student learning, and also ask students what their thoughts were on the learning strategies used in the lessons. The lessons should be focused on clearing up teens misconceptions, how e-cigarette companies are marketing to teens, and how e-cigarettes are harmful like traditional cigarettes. One idea is to use some lessons the FDA has developed on vaping as a future research project to see how impactful they are, and how much students learned. If only one recommendation were to be taken from this study, it would be to use lessons on vaping and either use them completely or build off of them. Before and after using the lessons always test student knowledge and their thoughts on how impactful the lessons were. If the lessons were not impactful, continue to build a curriculum that will enhance student learning and create the largest impact on them so they can make healthy, informed decisions about vaping. Conclusion Vaping has become an increasing problem especially among teens. Research shows that teens have some misconceptions about vaping, and they are being impacted by e-cigarette marketing tactics. Education programs need to be developed to help lower the number of teens who vape. Building lessons that focus on classroom discussions, watching video clips stating facts about e-cigarettes, and working in groups will be the most beneficial way to educate teens so they can make the most informed decisions when it comes to vaping. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 48 REFERENCES American Heart Association. (2019). 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(2016). Self-reported reasons for vaping among 8th, 10th, and 12th graders in the US: Nationally-representative results. Drug and alcohol dependence, 165, 275–278. doi:10.1016/j.drugalcdep.2016.05.017 Public Health Law Center. (2019). U.S. e-cigarette regulations-50 state review (2019). Retrieved from https://www.publichealthlawcenter.org/resources/us-e-cigarette-regulations-50- state-review Salako, E., Eze, I., & Adu, E. (2013). Effects of cooperative learning on junior secondary school students' knowledge and attitudes to multicultural education concepts in social studies. Education, 133(3), 303-309. Retrieved from https://link-gale-com. hal.weber.edu/apps/doc/A357760561/OVIC?u=ogde72764&sid=OVIC&xid=b597ff bb Setty, G. (2019, November 5). More than half of teens who vape use Juul and its mint pods are no. 1 flavor in high school, new study shows. CNBC. 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Retrieved from https://help.surveyanyplace.com/en/support/solutions/articles/35000042297-multiple-choice- question Tobacco-Free Kids. (2014, June 11). Nine e-juice flavors that sound just like kids’ favorite treats [Web log post]. Retrieved from https://www.tobaccofreekids.org/blog/2014_06_11_ecigarettes Truth Initiative. (2019). E-cigarettes: Facts, stats and regulations. Retrieved from https://truthinitiative.org/research-resources/emerging-tobacco-products/e-cigarettes-facts- stats-and-regulations Truth Initiative. (2018). 4 marketing tactics e-cigarette companies use to target youth. Retrieved from https://truthinitiative.org/research-resources/tobacco-industry-marketing/4- marketing-tactics-e-cigarette-companies-use-target. U.S. Food & Drug Administration. (2018). FDA takes new steps to address epidemic of youth e-cigarette use, including a historic action against more than 1,300 retailers and 5 major manufacturers for their roles perpetuating youth access. Retrieved from https://www.fda.gov/news-events/press-announcements/fda-takes-new-steps-address-epidemic- youth-e-cigarette-use-including-historic-action-against-more U.S. Food & Drug Administration. (2019). Lung illnesses associated with use of vaping products. Retrieved from https://www.fda.gov/news-events/public-health-focus/lung-illnesses- associated-use-vaping-products U.S. Food & Drug Administration. (2019). Teacher resource guide: Facts about e-cigarettes. Retrieved from https://www.scholastic.com/youthvapingrisks/ TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 55 U.S. Food & Drug Administration. (2018). What we do. Retrieved from https://www.fda.gov/about-fda/what-we-do#:~: text=The%20Food%20and%20Drug%20Administration,and%20products%20that %20emit%20radiation. Utah State Legislature. (2018). Title 76 Utah criminal code. Retrieved from https://le.utah.gov/xcode/Title76/Chapter10/76-10-S105.html?v=C76-10- S105_1800010118000101 Vaughn, E. (2019). How to talk to teens about vaping. Retrieved from https://www.npr.org/sections/health-shots/2019/10/06/766971966/how-to-talk-to-teens-about- vaping TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 56 APPENDICES Appendix A: Survey Instrument Appendix A: Survey Instrument Appendix B: Information Letter to Parents Appendix C: Information Letter to Students Appendix D: Informed Consent Appendix E: Figures 1-7 Appendix F: District Research Approval Form Appendix G: IRB Research Approval Form TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 57 Appendix A VAPING SURVEY You are invited to participate in a research study on vaping and how it can impact teens. You were selected as a possible subject because you are in between the ages of 14-18 in a health education class. The study is being conducted by Teshia Mikesell, a graduate student in the Department of Education at Weber State University. The purpose of this study is to better understand teens’ perceptions on vaping, knowledge/attitudes about vaping, and why teens vape. The following survey contains questions about vaping. Please answer to the best of your knowledge. Your answers will be kept private and your personal identity will not be disclosed at any time. This survey will take approximately 10-15 minutes to complete. You may skip any questions that make up feel uncomfortable. You may stop taking the survey at any time if you chose to. If you have any questions please contact Teshia Mikesell at TMikesell@tooeleschools.org, or Stephanie Speicher at stephaniespeicher@weber.edu. 1. Exposure to tobacco products in electronic vapor products can lead to other addictions like marijuana, cocaine, or methamphetamine. A. Strongly agree B. Somewhat agree C. Neither agree nor disagree D. Somewhat disagree E. Strongly disagree 2. E-cigarettes are harmless. A. Strongly agree B. Somewhat agree C. Neither agree nor disagree D. Somewhat disagree E. Strongly disagree 3. E-cigarettes are a healthier alternative to traditional cigarettes? A. Strongly agree B. Somewhat agree C. Neither agree nor disagree D. Somewhat disagree E. Strongly disagree TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 58 4. The smoke from E-cigarettes is just water and not harmful. A. Strongly agree B. Somewhat agree C. Neither agree nor disagree D. Somewhat disagree E. Strongly disagree 5. How much do you think people risk harming themselves if they use an electronic vapor product (including JUUL, e-cigarettes, e-cigars, e-pipes, mods, personal vaporizers, vape pipes, vaping pipes, e-hookahs, and hookah pens) regularly? A. Great risk B. Moderate risk C. Slight risk D. No risk 6. How interested are you in learning about vaping in health class? A. Extremely interested B. Very interested C. Moderately interested D. Slightly interested E. Not interested at all 7. What learning activities do you feel would be most beneficial in educating students about vaping? (Check all that apply) A. Class discussion about the health concerns related to vaping B. Watching video clips stating facts about vaping C. Reading articles stating facts about vaping D. Student presentations to the class about vaping and the dangers E. Teacher lecture about vaping F. Working in groups to learn more about vaping G. Working individually to learn more about vaping 8. How effective (effectiveness of student learning) would a classroom discussion be about vaping (would students pay attention, be honest about vaping, and learn new things from their peers)? A. Extremely effective B. Very Effective TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 59 C. Moderately effective D. Slightly effective E. Not effective at all 9. Would correcting teens’ misconceptions about vaping be an effective way to educate teens? A. Extremely effective B. Very effective C. Moderately effective D. Slightly effective E. Not effective at all 10. How effective would researching facts about vaping be for your learning? A. Extremely effective B. Very effective C. Moderately effective D. Slightly effective E. Not effective at all 11. How effective do you think it would be to do an assignment learning about the ways e-cigarette companies target teens? A. Extremely effective B. Very effective C. Moderately effective D. Slightly effective E. Not effective at all TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 60 Appendix B Dear Parents, I am currently working on a Masters of Education Degree in Curriculum and Instruction at Weber State University. For my final project, I have chosen what I consider to be a very relevant topic affecting today’s teenagers. I am researching how vaping has become popular in the recent years, why teens are drawn to vaping, and the health concerns related to vaping. To finish my Master’s degree, I am conducting a small research project that involves students within my Health classes, here at Stansbury High. I teach six Health classes. With the rising number of teen’s vaping it concerned me. I wanted to learn more about vaping so I could teach my students about the dangers of vaping. At SHS, we have also had a rise in teen’s vaping. Some teens view vaping as safe. I want to be able to educate my students about vaping and its dangers so they can make the best informed decision about vaping. They survey I am conducting will take anywhere from 5-15 minutes. The questions will ask about how teens perceive vaping’s impact on their health, and how would students prefer to learn about vaping’s impact on health? After the survey is completed, this data will give me great feedback from students to know how to best develop curriculum to teach about vaping in the future. I need, and would so appreciate, your signed permission to allow your student to participate in the study. The only information I will be using from your student will be their responses to the survey. These results will be kept completely confidential. Your son/daughter’s identity will not be revealed to anyone not directly involved in conducting the research, nor will his/her identity be revealed in any publication, document, or computer database. I believe as teachers, we should always be improving our craft. The information gathered from this project will be useful in creating the most optimal learning environment for academic achievement and overall classroom experience for your student. At SHS, it is always our priority to work towards creating the most successful classroom environment as possible for your student to achieve. Participation is voluntary and refusal to participate will involve no penalty or loss of benefits to which your student is otherwise entitled. Completing the survey will be an assignment for students to complete. If students do not have permission to participate an alternative assignment of equal opportunity has been created for those students to receive class points as well. To include the results and input from your son/daughter in this study, we must obtain your written consent. If you are willing to have your child participate in this research project, please sign a copy of the enclosed Parent/Guardian Consent Form from Weber State University. Please sign and return if you consent to having your student participate in the study. Thank you. It’s a pleasure teaching here at SHS with such great families and students. All the best, Teshia Mikesell Health Teacher TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 61 Appendix C Dear Students, I am currently working on a Masters of Education Degree in Curriculum and Instruction at Weber State University. For my final project, I have chosen what I consider to be a very relevant topic affecting today’s teenagers. I am researching how vaping has become popular in the recent years, why teens are drawn to vaping, and the health concerns related to vaping. To finish my Master’s degree, I am conducting a small research project that involves students within my Health classes, here at Stansbury High. I teach six Health classes. With the rising number of teen’s vaping it concerned me. I wanted to learn more about vaping so I could teach my students about the dangers of vaping. At SHS, we have also had a rise in teen’s vaping. Some teens view vaping as safe. I want to be able to educate my students about vaping and its dangers so they can make the best informed decision about vaping. They survey I am conducting will take anywhere from 5-15 minutes. The questions will ask about how teens perceive vaping’s impact on their health, and how would students prefer to learn about vaping’s impact on health? After the survey is completed, this data will give me great feedback from you to know how to best develop curriculum to teach about vaping in the future. I need, and would so appreciate, your signed permission from your parents and yourself to allow you to participate in the study. The only information I will be using from you will be your responses to the survey. These results will be kept completely confidential. Your identity will not be revealed to anyone not directly involved in conducting the research, nor will your identity be revealed in any publication, document, or computer database. I believe as teachers, we should always be improving our craft. The information gathered from this project will be useful in creating the most optimal learning environment for academic achievement and overall classroom experience for your student. At SHS, it is always our priority to work towards creating the most successful classroom environment as possible for you to achieve. Participation is voluntary and refusal to participate will involve no penalty or loss of benefits. Completing the survey will be an assignment for you to complete. If you do not have permission to participate an alternative assignment of equal opportunity has been created for you to receive class points as well. To include the results and input from you in this study, we must obtain your parents written consent and your assent. If you are willing to participate in this research project, please click on the link sent to you in your email through aspire and also in canvas to give assent (your willingness to do the survey) by clicking ok at the beginning and then the survey will begin. Thank you. It’s a pleasure teaching here at SHS with such great families and students. All the best, Teshia Mikesell Health Teacher TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 62 Appendix D WEBER STATE UNIVERSITY INFORMED CONSENT Vaping Survey You are invited to participate in a research study of a vaping survey. You were selected as a possible subject because you are a student in a health class. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The study is being conducted by Teshia Mikesell and the Department of Education at Weber State University. STUDY PURPOSE The purpose of this study is to understand student’s perspective of vaping. Knowing students’ perspectives will help health educators address the teen vaping crisis in the classroom. This study will explore the following questions: 1. How do teens perceive vaping on their health? 2. How would students prefer to learn about vaping’s impact on health? This study does NOT involve any use of drug or devices. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of approximate 160 students that are participating with different backgrounds, socioeconomic status, gender, and school standing in this research. PROCEDURES FOR THE STUDY: If you agree to be in the study, you will do the following things: You will take an 11 question survey related to teens’ perspective on vaping on their health and the best educational strategies to use to teach about vaping. In between May 1st‐ May 21st you will have access to take this survey. It will take anywhere from 5‐10 minutes. You will be sent a Qualtrics link through Aspire and Canvas. The survey will be performed from your home, or where ever you have computer access since we are not at school. This will be a onetime survey. This can be done on your phone, tablet, or computer. RISKS OF TAKING PART IN THE STUDY: Students participating in the vaping survey could potentially experience some stress. Students could be stressed not knowing how to answer each question. Students could feel stressed if they don't know a lot about teens' vaping perceptions, knowledge, attitudes, or why teens choose to vape. There is also potential that there may be other risks that is currently unforeseeable. For example, the risks of completing the survey and being uncomfortable answering the questions, the risk of uncertainty, or the risks of possible loss of confidentiality. ** There may be other risks that are currently unforeseeable. BENEFITS OF TAKING PART IN THE STUDY TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 63 You will not receive payment for taking part in this study. You will receive class points for doing this assignment. ALTERNATIVES TO TAKING PART IN THE STUDY: Instead of being in the study, you have these options: To receive class points, you will watch a video about vaping and answer 5 questions. This will be an assignment available on canvas during the time of the survey. A notification will be sent to you on canvas to complete the alternative assignment if permission was not granted by your guardian. COSTS/ COMPENSATION FOR INJURY In the event of physical injury resulting from your participation in this research, necessary medical treatment will be provided to you and billed as part of your medical expenses. Costs not covered by your health care insurer will be your responsibility. Also, it is your responsibility to determine the extent of your health care coverage. There is no program in place for other monetary compensation for such injuries. However, you are not giving up any legal rights or benefits to which you are otherwise entitled. If you are participating in research which is not conducted at a medical facility, you will be responsible for seeking medical care and for the expenses associated with any care received. CONFIDENTIALITY Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published. The data will be kept secure on the researcher’s computer. The researcher is the only one who can log into the google survey with the results. Username and password to log into google survey will be kept secure on the computer. Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and her research associates, the Weber State University Institutional Review Board or its designees, the study sponsor, Weber State University Department of Education, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA‐regulated research and research involving positron‐emission scanning], the National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH], etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS For questions about the study, contact the researcher Teshia Mikesell at 435‐218‐8649 or the researcher’s mentor Stephanie Speicher at 801‐626‐6214. For questions about your rights as a research participant or to discuss problems, complaints or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. VOLUNTARY NATURE OF STUDY TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 64 Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with Weber State University. SUBJECT’S CONSENT In consideration of all of the above, I give my child consent to participate in this research study. If you give consent and desire for your student to participate, click the link below. If you do not consent, please close your browser. To sign this document it will be electronically. Please click the link below. It will take you to a Google From and ask you to type your name here to give consent to the above information. Please type your student’s name as well of who you are giving permission. After typing your name in the link below your child will be granted permission to do the survey. https://docs.google.com/forms/d/e/1FAIpQLScplDkhmkL‐xMV6Nf1XDaIM2ZeKDc90WOKKyFcgsWf421na_ g/viewform?usp=sf_link If you desire a copy of this informed consent document to keep for my records, please download this page. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 65 Appendix E Q2 ‐ Exposure to tobacco products in electronic vapor products can lead to other addictions like marijuana, cocaine, or methamphetamine. Figure 1. Frequency distribution of all respondents in regards to exposure to tobacco products in e-cigarettes and the likelihood it could lead to other addictions. Q3 ‐ E‐cigarettes are harmless. Figure 2. Frequency distribution of all respondents in regards to e-cigarettes being harmless. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 66 Q4 ‐ E‐cigarettes are a healthier alternative to traditional cigarettes? Figure 3. Frequency distribution of all respondents in regards to e-cigarettes being a healthier alternative to traditional cigarettes. Q5 ‐ The smoke from E‐cigarettes is just water and not harmful. Figure 4. Frequency distribution of all respondents in regards to the smoke from e-cigarettes is just water and not harmful. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 67 Q6 ‐ How much do you think people risk harming themselves if they use an electronic vapor product (including JUUL, e‐cigarettes, e‐cigars, e‐pipes, mods, personal vaporizers, vape pipes, vaping pipes, e‐hookahs, and hookah pens) regularly? Figure 5. Frequency distribution of all respondents in regards to how much respondents thought people risk harming themselves if they used an e-cigarette regularly. Q7 ‐ How interested are you in learning about vaping in health class? Figure 6. Frequency distribution of all respondents in regards to how interested they are in learning about vaping in health class. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 68 Q8 ‐ What learning activities do you feel would be most beneficial in educating students about vaping? (Check all that apply) Figure 7. Frequency distribution of all respondents in regards to what learning activities respondents would feel would be most beneficial in educating students about vaping. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 69 Appendix F A. Assurances: If approved, the researcher(s) agree to the following: 1. To adhere to the procedures of the project as approved by the District. Any changes to procedure must receive prior approval. 2. To furnish the District with progress reports upon request. 3. To provide the District with one copy of all publications, including dissertations, reports, summaries, articles, and papers resulting in the completed project. 4. The researcher(s) give permission for the District to cite the ongoing or completed project in its own publications, with credit given to the researcher(s). 5. Prior to the circulation of any report of research findings or conclusions in connection with this study, the District will have the final approval of the use of its name or references to the District, its staff, or its programs. 6. To comply with the Family Educational Rights and Privacy Act and amendments thereto. And, to comply with all applicable regulations and customary practices pertaining to participant privacy and the security of personally identifiable information. 7. To comply with Federal regulations and recognized professional practices relative to the protection of human subjects in research studies. 8. To report only aggregate data or pseudonyms in such a way so that information cannot be traced directly or by inference to a specific community neighborhood, staff member, student, family member of a student, or school attended. 9. To secure all data, including, audio and video recordings, electronic/digital data, and documents; and restrict access to the data to individuals approved in the application. 10. To destroy all materials gathered which contain personally identifiable information after the purposes for which the material was gathered have been completed. Failure to do so may subject researcher(s) to criminal prosecution. Entering your name and the name of the Project Director/Advisor/Supervisor, constitutes your electronic signature which signifies the information submitted is correct and you agree to abide by the assurances. TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 70 Teshia Mikesell 4/17/2020 Researcher(s) Date 04/17/202 Project Director/Advisor/Supervisor Date ------------------------------------------------------- For District Use Only ------------------------------------------------ ------ □ Project is approved. ☒ Project is approved following verification of requested modifications. ☐Project is not approved April 27,2020 Director of Assessment, Accountability & Research Date Email this form and other supporting documents to dbushek@tooeleschools.org TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 71 Appendix G March 29, 2020 Dear Teshia Haskell, Your project entitled “Vaping Study” has been reviewed and is approved as written. It is approved as “expedited”. Your study involves minors who will complete an online survey with a single point of contact, after parental consent has been granted. Notification of the study and how data will be reported are appropriate. The collection of consent/assent from the guardians and minors who will participate meets the expectation of Weber State University IRB policy. Anonymity and confidentiality are addressed appropriately, and the type of information gathered could not “reasonably place the subjects at risk of criminal or civil liability or be damaging to the subjects’ financial standing, employability, or reputation” (Code of Federal Regulations 45 CFR 46, Subpart D.) You may proceed with your study as written, once you receive approval from your research site. This IRB approval expires one year from today. Please remember that any anticipated changes to the project and approved procedures must be submitted to the IRB prior to implementation. Any unanticipated problems that arise during any stage of the project require a written report to the IRB and possible suspension of the project. A final copy of your application will remain on file with the IRB records. If you need further assistance or have any questions, call Dr. Williams at 626-8654 or e-mail her at nataliewilliams1@weber.edu Sincerely, Natalie A. Williams Natalie A. Williams, Ph.D. Chair, Institutional Review Board, Education Subcommittee TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 72 Title of Project: Vaping Survey Primary Investigator(s): Teshia Haskell Approval Number: 19-ED-036 Reviewer: Natalie A. Williams, Ph.D. Chair, Institutional Review Board Education Subcommittee Date: March 29, 2020 COMMITTEE ACTION YOUR PROPOSAL (PROJECT) AND CONSENT DOCUMENTS HAVE BEEN RECEIVED AND CLASSIFIED BY THE HUMAN SUBJECTS IN RESEARCH COMMITTEE AS: High Risk Moderate Risk X Low Risk BY THE FOLLOWING PROCESS: Full board review Expedited review X _ Exemption THE PROJECT HAS BEEN: X Approved Not Approv COMMENTS: See Attached Approval Letter TEEN VAPING EPIDEMIC AND THE RISING HEALTH CONCERNS 73 Natalie A. Williams 3/29/20 IRB EDUCATION SUBCOMMITTEE MEMBER REVIEW DATE INVESTIGATOR'S RESPONSIBILITY AFTER COMMITTEE ACTION The federal regulations provide that after the committee has approved your study, you may not make any changes without prior committee approval except where necessary to eliminate apparent immediate hazards to the subjects. Further, you must report to the committee any changes that you make and any unanticipated problems involving risks to subjects or others that arise.