The Journal of School Nursing2024, Vol. 40(2) 223–230© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211043127journals.sagepub.com/home/jsn
There is a public health epidemic in adolescents’ use of Electronic Nicotine Delivery Systems (ENDSs), also known as electronic cigarettes, vaping products, or JUULs. However, little is known about the level of knowledge school staff have about ENDS. The purpose of this study is to examine outcomes of a nurse-led educational intervention designed to increase school staff knowledge about ENDS. A descriptive, nonrandomly selected pre-test/post-test design was used with 125 Wisconsin school staff. Results revealed further educational needs of school staff in content areas including advertising to youth and flavoring of ENDS. Following the educational intervention, post-test results showed a significant overall improvement in participant knowledge scores. Recommendations include implementing nurse-led education about ENDS to a more diverse population of school staff. Providing nurse-led ENDS education to school staff offers an upstream, proactive approach for school nurses to help address this public health epidemic.
Keywords
health education, middle/junior/high school, school nurse education, Stanford tobacco prevention toolkit, electronic nicotine delivery systems or ENDSs, electronic cigarettes or vaping, adolescent nicotine addiction, nurse-led intervention
Nicotine addiction has reached epidemic proportions among adolescents who use electronic nicotine delivery systems (ENDSs). ENDSs include all cartridge-based devices such as electronic cigarettes (e-cigarettes/e-cigs) and vaping products, such as JUUL vaping pods. While there has been an overall decline in conventional cigarette smoking among adolescents in the United States, this progress is being undermined by use of ENDS. Between 2011 and 2015, use of ENDS among middle and high school students increased by over 900% (Centers for Disease Control and Prevention [CDC], 2020a). By 2020, 19.6% of high school students (3.02 million) and 4.6% of middle school students (550,000) reported current e-cigarette use (Cullen et al., 2020). In Wisconsin, where this study was conducted, 45.4% of high schoolers reported having tried vaping and 20.6% reported use of ENDS in the past 30 days (McCoy, 2020).
Although long-term effects of ENDS use are still unknown, detrimental health effects, adolescent susceptibility, and general knowledge about ENDS are well-established (Oliver et al., 2019; Vincent et al., 2018). There are several known adverse health effects of nicotine use in adolescents including impaired brain development, enduring cognitive and behavioral impairments, and damaging effects on memory and attention (England et al., 2015; USDHHS, 2016). In 2019, the CDC and Food and Drug Administration (FDA) noted an outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) (CDC, 2020c) and there is further evidence of other types of lung injury associated with e-cigarette use (Bonilla et al., 2019). Case reports have associated ENDS use with serious lung conditions such as bronchiolitis, acute eosinophilic pneumonia, pneumonitis, and pleural effusion (Landman et al., 2019). Adding to existing health concerns of ENDS use, a preliminary report from Stanford Medicine found that young people who had ever used e-cigarettes were five times more likely to be diagnosed with COVID-19 than never-users (Gaiha et al., 2020).
Given the serious potential health outcomes, it is important to understand adolescents’ motivation for using ENDS. Adolescents start ENDS use for many reasons including curiosity, experimentation, peer influences, entertainment (including tricks viewed on social media), and appealing flavors (Evans-Polce et al., 2018; Kong et al., 2015). The age young adults first use nicotine can influence their ability to successfully quit ENDS later in life (Fadus et al., 2019). Adolescents are more likely to become addicted to nicotine than adults and it acts as a gateway to other substance use (England et al., 2015). Only one-third of JUUL users are aware that JUUL contains nicotine (Oliver et al., 2019). Adolescents perceive ENDS use as less harmful than cigarettes placing them at risk of underestimating their chances of becoming addicted to nicotine (Gaiha et al., 2021; McKeganey et al., 2020). Level of perceived harm is a protective factor against ENDS use in adolescents that can be enhanced through school tobacco prevention programs (Oliver et al., 2019). Prevention efforts should be aimed at education about the health effects of ENDS and the social processes that encourage youth using these products (Kong et al., 2015). Examples of social processes include multimedia social networking services, messaging applications (apps), and platforms that promote ENDS use.
Adolescents are more susceptible than adults to advertising and marketing strategies employed by the tobacco industry (CDC, 2020b; Duderstadt, 2015). Some marketing examples that lead to adolescent enticement include popular peer influencers, celebrity use and endorsement, and tobacco company sponsorship of popular sporting and music events. Kong et al. (2015) concluded about half of the vape trick videos on YouTube were industry-sponsored and all were youth-accessible. Basáñez et al. (2018) categorized and compared 1,205 vaping tweets. They found vaping-promoting themed tweets (“health-enhancing,” “youth-resonant,” “sensations,” or “harmless”) were statistically more likely to originate from a marketing source than smoking prevention tweets (cessation use or anti-vaping). Efforts in regulating the sales and marketing of ENDS products to adolescents are ongoing and need monitoring.
The FDA Commissioner and the U.S. Surgeon General called for immediate action to address this crisis of youth ENDS use, emphasizing the vital role of teachers, parents, and health care professionals (Office of the Surgeon General, 2018). U.S. federal, state, and local government officials passed legislation and continue to develop policy to deter adolescent tobacco use. The federal legal age to buy tobacco has increased from 18 to 21 years with state laws mirroring federal legislation in hopes of curtailing the number of adolescents using ENDS. In addition, the FDA has restricted manufacturing of popular ENDS flavors, such as bubble gum, cotton candy, birthday cake, iced blueberry, and thousands of other flavors that targeted adolescents, limiting ENDS flavors to tobacco and menthol (FDA, 2020a). Locally, government agencies have passed ordinances banning indoor ENDS use. With these efforts, there was a 7% decrease in e-cigarette use among adolescents from 2019 to 2020, however the 2020 usage rate (19.6%) is still high enough to be of great concern (Cullen et al., 2020). School staff members serve as a source of information for youth, but less than half of middle and high school educators could identify a photo of a JUUL as an ENDS (Cuccia et al., 2019). All school staff need to be equipped with accurate information about ENDS because they are positioned to influence youth through both education and enforcement of ENDS use policies (Baer et al., 2021; Oliver et al., 2019). Assessing and improving knowledge of ENDS among school staff can inform future development and implementation of interventions to reduce nicotine use in adolescents (Baer et al., 2021; Cullen et al., 2019).
The purpose of this study is to examine the effectiveness of a nurse-led educational intervention designed to increase knowledge of ENDS among school staff in two mid-sized Wisconsin school districts. The anticipated outcome of this nurse-led intervention is that school staff would demonstrate an increase in ENDS knowledge post-educational presentation. Research questions for this study include:
Research Question 1: What knowledge deficits do school staff have about ENDS?
Research Question 2: What knowledge strengths do school staff have about ENDS?
Research Question 3: Following an educational intervention, how did post–test scores improve compared to pre-test scores?
A descriptive pre-test/post-test design was employed to study ENDS knowledge levels before and after an ENDS educational initiative. University of Wisconsin-Eau Claire Institutional Review Board (IRB) approval was obtained prior to beginning the project. Participant names were not linked to their surveys to ensure confidentiality. Every participant received a cover letter explaining the study, time commitment, and voluntary nature of the study. Participants signed a consent form that was retained in a locked cabinet by the researchers.
This study was conducted in two school districts located in mid-sized cities in Southeastern Wisconsin. The combined student population of these school districts is approximately 4,500 students; 91% of these students are identified as Caucasian/white. The educational presentation was offered as one of several optional “break out” sessions that participants could choose to attend during a district-wide professional development seminar. Nurse researchers explained the voluntary and non-mandatory nature of the educational presentation. A total of 125 school staff members participated across two sessions. The mean age of participants was 41.8 years (SD = 9.2; range 23–64 years). There was an almost equal distribution of men (51.2%) and women (48.8%). Of the participants, 96 (76.8%) indicated they knew someone who engaged in vaping/e-cig use. Most participants served in a teaching position (79.0%). Most participants worked at the high school level (69.4%) (see Table 1).
The presentation used information and official statistics from the CDC, FDA, Stanford Medicine, and peer-reviewed journals. With permission from Stanford Medicine, the educational resources in their Tobacco Prevention Toolkit (2020) were adapted for the presentation. The Stanford Tobacco Prevention Toolkit is a research-based, evidence informed educational resource that is free for the public. The Toolkit includes PowerPoint slides, post-presentation quizzes, and other educational resources. This nurse-led presentation covered topics from all six major Toolkit content areas regarding ENDS use among the school-aged population.
The pre- and post-test instrument consisted of 20 multiple-choice and true/false questions obtained from the Stanford Tobacco Prevention Toolkit (see Appendix). Content validity has been in part established by the Stanford group through interviews with stakeholders (educators, teachers, students), experts in tobacco health education, and focus groups with students, teachers, and established tobacco prevention researchers during development of the toolkit (Stanford Medicine, 2020). Participants responded using a scantron form on which answers are indicated by filling in a lettered circle.
The following procedure was performed twice on the same day in two different school districts. Nurse researchers who delivered the presentations included one nursing professor and two nursing students. Focused training for students on delivery of health education and completion of survey protocols was completed by student nurse researchers. Resources available for research training was made possible through small grants awarded by a university sponsored studentfaculty collaborative research program. The purpose and procedures of the study were given verbally and in writing to all attendees. Participants signed the consent form and completed the pre-test, and demographic data forms. Pre-presentation activities were completed and submitted in approximately 20 min prior to the beginning of the presentation. Participants were not provided with the correct answers to the evaluation. The 45-min presentation was delivered to all attendees, with time for questions and discussion. Presentation topics included relevant statistics, basic vaping devices, health effects, advertising, and recommendations for talking with students about vaping. Nurse researchers followed a script to ensure that participants in each of the two sessions would receive the same presentation. After the presentation, participants completed the post-intervention assessment and submitted it to the nurse researchers.
Pre- and post-test responses were mechanically scored. Data were analyzed using the SPSS data analysis software program from IBM (version 24). For purposes of analysis, responses were coded as correct or incorrect. Knowledge strength in an item was defined as an overall group response of 90% correct or better. Knowledge deficit of an item was defined as an overall group response of 50% correct or worse. Simple descriptive statistics were used to analyze the data. McNemar chi-square analyses were used to analyze the dichotomous pre- and post-test scores.
The number of correct responses (%) of pre- and post-test scores is shown in Table 2. There were four items that scored fewer than 50% correct on the pre-test. Only 9.4% of participants could correctly identify the number of ENDS flavors, and only 17.2% correctly identified 18- to 25-year-olds as the target audience of ENDS companies’ advertisements. Of the sample, 24.2% correctly responded that e-cigs are devices that produce nicotine and/or additives in the form of an aerosol (most respondents indicating vapor); 31.9% knew that one JUUL pod has at least 41.3 mg of nicotine per pod.
At pre-test, respondents scored greater than 90% on seven questions (see Table 2). Of these, most respondents knew that nicotine is an addictive stimulant that changes brain chemistry (97.7%). Respondents scored well on pre-test scores related to aerosols flavors. Respondents knew that fruit-based e-cig/vape pen flavors can be harmful (96.9%), and that aerosol can be produced from deodorants, e-cigs/vape pens, and hair sprays.
Pre-test and post-test scores were compared. As a group, the school staff demonstrated an average improvement of 2.43 points (out of 20) from pre- to post-test. The overall mean pre-test score was 14.0 (SD = 1.8); the overall mean post-test assessment score was 16.4 (SD = 1.3). A one-way-t-test comparing post-test scores to the mean of pre-test scores showed a significant difference, t(121) = 20.0, p < .001.
Individual items were also examined using McNemar chi-square tests (see Table 2). Five items showed significant improvement from pre-test to post-test. These items included understanding of: (1) the number of e-cig flavors currently sold, (2) e-cigs producing nicotine additives in the form of an aerosol, (3) the amount of nicotine in a JUUL pod being equivalent to 1.5 to 2 packs of cigarettes, (4) vaping as an inaccurate term because it produces an aerosol, and (5) the similarities between current advertising of vaping and past advertising of cigarettes.
Our supposition that school staff would have increased knowledge of ENDS after participating in an interactive educational presentation was supported. The average increase in correct responses was 2.43 points (out of 20) from pre-test to post-test, a 12.2% increase. This finding is consistent with results from the Baer et al. (2021) pilot study which found that middle and high school teachers’ knowledge of ENDS increased following an educational workshop.
Participants had strengths in their awareness of the prevalence of ENDS use among youth and in their knowledge of a variety of topic areas. This sample’s mean estimate for the percentage of high-school students who use vapes or e-cigarettes was 37.01%. The actual percentage of high-school students who reported use of ENDS in 2020 was 19.6% (Cullen et al., 2020). The participants’ overestimation of the prevalence of ENDS use suggests that the school staff in this study were aware of the prevalence of vaping among high schoolers which concurs with findings from an earlier pilot study in a rural school setting (Baer et al., 2021). Additionally, school staff participants demonstrated content knowledge about aerosol and nicotine (see Table 2). These questions varied in their content matter, showing that school staff had a broad understanding of ENDS, which may assist them in offering fact-based education and informal conversations with students about ENDS.
Participants showed some awareness and knowledge, but also demonstrated opportunities for improvement. For example, in response to the pre-test question E-cigs are devices that produce nicotine and/or additives in the form of _____, only 24.2% (n = 31) of the group responded with the correct answer aerosol in contrast to 73.4% (n = 94) of the group who incorrectly chose vapor. This misconception may be related to the use of the term “vaping” by big tobacco companies, the media, and the public. The distinction between aerosol and vapor is important because vapors are pure gases while aerosols are particles of liquids and/or solids suspended in a gas. The aerosol that is inhaled by an ENDS user may appear to be a harmless vapor but can deposit small particles in the lungs and environment. After the educational intervention 96.1% (n = 123) of participants correctly chose the answer aerosol on the post-test. This 71.9% (n = 92) improvement in correct responses from pre-test to post-test suggests that education may be a useful tool for ENDS staff development.
A strength of this pilot study was the relative novelty of assessing knowledge levels of school staff related to ENDS in contrast to the many surveys done on students’ knowledge. Another strength of this study was that items used in the assessment tool were selected from the Stanford Tobacco Prevention Toolkit, a recommendation by Baer et al. (2021).
Limitations of the current study include the lack of a control group and potential bias related to the staff retaking the same test within a short time frame. The convenience sampling method and limited geographical area decrease the generalizability of the findings. In addition, another limitation is that school staff self-selected the ENDS session over other available topics at the district-wide professional development day reflecting an interest in learning more about ENDS. This creates the possibility of self-selection bias. Participants who selected to attend the ENDS session might have different pre-test knowledge than other school staff who chose a different session on another topic.
The significant increase in correctly answered assessment questions following the educational intervention suggests that a short nurse-led intervention can be helpful in improving school staff knowledge of ENDS. Baer et al. (2021) stated that no formal teaching modules to train teachers or other school support staff about ENDSs exists. With tobacco prevention toolkits being used in many schools, it is crucial that all school staff are educated in ENDS and actively supporting tobacco prevention efforts. School nurses are positioned to coordinate ENDS activities including education for staff and students while also providing recommendations for cessation and school policy. Using the knowledge assessment tool (see Appendix) and other resources from the Stanford Tobacco Prevention Toolkit, school nurses can reinforce ENDS education through staff training and cessation program development. Suggested activities to engage both staff and students include development of health career clubs, tobacco prevention peer education groups, and tobacco prevention campaigns (posters, social media, guest speakers, etc.).
In future studies, it is recommended this nurse-led educational intervention be repeated in other school districts, rural and urban, to better represent diverse populations. Future educational presentations should emphasize local and regional statistics to reinforce that tobacco continues to be a problem in their own communities, and possibly strengthen content areas in ENDS flavors, targeted advertising, and aerosol/vapor differences based on our findings. Additionally, future study designs should match demographic data to participant pre-test/post test scores to enable analysis by subgroup (teachers, administrators, etc.).
The authors pay special tribute to anchoring author, Dr. Diane Marcyjanik, who was an esteemed colleague, educator, and mentor. She initiated and led this research project until she passed away unexpectedly and far too early in life. The authors also thank Dr. Rosemary Jadack for her consultation and expertise in data analyses and Heidi Pardon, BSN, RN for her collaboration on field research. We also appreciate all the Wisconsin school personnel who participated in our research project.
The authors received financial support for this research from the University of Wisconsin-Eau Claire: Office of Research and Sponsored Programs, James R. Larson and Vicki Lord Larson Undergraduate Research Fellowship and the College of Nursing and Health Sciences.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received financial support for this research from the University of Wisconsin-Eau Claire James R. Larson and Vicki Lord Larson Undergraduate Research Fellowship and the College of Nursing and Health Sciences. The project was also supported by a Student-Faculty Research Collaboration grant awarded through the University of Wisconsin-Eau Claire Office of Research and Sponsored Programs.
Lorraine M. Smith https://orcid.org/0000-0002-2749-5248
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Lorraine M. Smith, DNP, MSN, RN, CCHP is an Assistant Professor at the University of Wisconsin-Eau Claire College of Nursing and is currently co-chair of the Eau Claire County Alliance for Prevention of Substance Misuse and was a career correctional health nurse with juvenile detention, jail and prison nursing experience.
Lindsey Boehm, BSN, RN is a new graduate working on the medical telemetry unit at a major medical tertiary care facility with aspirations to pursue graduate education in Nursing.
Lyndsey V. Strang, BSN, RN is a DNP graduate student at the University of Wisconsin-Eau Claire.
Chelsea DeMarre, DNP, RN, FNP-C has clinical experience in school and camp nursing and is establishing her Nurse Practitioner practice.
Diane Marcyjanik, PhD, RN was an Assistant Professor at the University of Wisconsin-Eau Claire College of Nursing on the cusp of tenure and promotion. She designed and initiated this study and the data she collected were being processed at the time of her sudden passing.
Note: Adapted with permission from the Stanford Tobacco Prevention Toolkit. Correct answers have been bolded.
(1) Which advertising techniques have been used by tobacco companies?
(a) Claims they are doctor recommended
(b) Sexist marketing
(c) Using cartoon characters
(d) All of the above
(2) E-cigs are devices that produce nicotine and/or additives in the form of a
Vapor
Aerosol
Steam
Liquid
(3) E-cigs are also referred to as …
(a) Vape pens
(b) E-hookah
(c) Mods
(4) How many flavors of E-cigs are currently being sold
12
100
500
7,000 +
(5) Which of the following chemicals have been found in E-cigs/vape pens?
Formaldehyde
Arsenic
Lead
d. All of the above
(6) E-cigarette and vape pen products labeled “Nicotine Free” …
(a) May contain nicotine
(b) Are vegan
(c) Do not contain nicotine
(7) The term “vaping” is inaccurate because ….
(a) Small vape shops are not Big Tobacco
(b) E-Cigarettes/Vape Pens produce a water vapor
(c) E-Cigarettes/Vape Pens produce aerosol not water vapor
(d) Vaping is only a “hipster” term
(8) Aerosol can be produced from…
Deodorants
b. E-Cigarettes/Vape Pens
c. Hair Spray
d. All of these
(9) Thirdhand smoke…
(a) Chemicals are left in the environment after smoking
(b) Smoke that comes from a hookah
(c) A mythical term invented by the Cancer Society
(d) Occurs when smokers share cigarettes
(10) E-Cigs/Vape pens have nicotine
Never
Sometimes
Always
d. None of these
(11) Nicotine…
(a) Changes brain chemistry
(b) Is a stimulant
(c) Is highly addictive
(d)
All of these
(12) E-Cigs/Vape pen flavors are fruit based and therefore not harmful
True
False
(13) Diacetyl is related to popcorn lungs and…
(a) Is reversible
(b) Aids breathing
(c) Is found in e-cigarettes/vape pen flavors
(d) Does not scar the lungs
(14) Tobacco companies guide their advertising to the ___ age group
(a) 16-21
(b) 18-25
(c) 14-24
(d) 11-16
(15) The primary appeal of E-cigarettes/vape pens is…
(a) No nicotine
(b) Multiple flavors
(c) Red and white packaging
(d) Sex ads
(16) If you look at cigarette ads of yester-year and ads today, you will notice…
(a) They look extremely similar
(b) They are appealing to youth
(c) They sell freedom
(17) It is cheaper to smoke E-cigarettes/vape pens than cigarettes
(a) True
(b) False
(18) The amount of nicotine in a JUUL pod is equivalent to:
(a) 1 cigarette
(b) 1.5 to 2 packs of cigarettes
(c) Half a pack of cigarettes
(d) 5 packs of cigarettes
(19) Which of the following statements about JUULs and PHIX is TRUE?
(a) Some contain nicotine
(b) All contain nicotine
(c) None contain nicotine
(d) There are no flavors
(20) Market e-juices range from 0-25 mg of nicotine, while one JUUL pod has at least __mg of nicotine per pod.
(a) 4.13
(b) 5
(c) 25
(d) 41.3
1 College of Nursing, University of Wisconsin-Eau Claire, Eau Claire, WI, USA
Corresponding Author:Lorraine M. Smith, DNP, RN, University of Wisconsin–Eau Claire, College of Nursing–NUR 270, 105 Garfield Ave. P.O. Box 4004, Eau Claire, WI 54702, USA.Email: smithlm@uwec.edu