Addictive Behaviors 112 (2021) 106519
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Addictive Behaviors
journal homepage: www.elsevier.com/locate/addictbeh
School-based e-cigarette education in Alabama: Impact on knowledge of ecigarettes, perceptions and intent to try
T
Shivani Mathur Gaihaa, Abigail Duemlerb, Lauren Silverwoodc, Anabel Razoa,
⁎
Bonnie Halpern-Felshera, Susan C. Walleyb,
a
Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
Division of Hospital Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
c
School of Public Health, University of Alabama at Birmingham, Birmingham, AL, United States
b
ARTICLE INFO
ABSTRACT
Keywords:
Electronic cigarette
Adolescent
Education
Evaluation
School-based tobacco prevention
Tobacco Prevention Toolkit
Background and objectives: Educational programs are needed to combat the sharp rise in adolescent e-cigarette
use. We assessed adolescent knowledge about e-cigarettes, perceptions of harmfulness and addictiveness and
intent to try e-cigarettes before and after an e-cigarette educational session.
Methods: We conducted a one-group pre- and post-test study among middle and high school students in Alabama
in 2019. The intervention included a 30-minute educational session based on the Stanford Tobacco Prevention
Toolkit on e-cigarette types, contents, marketing and advertising, health effects and nicotine addiction.
McNemar tests of paired proportions and multi-level, mixed-effects logistic regression models were used to
analyze intervention effects.
Results: Surveys were completed by 2,889 middle and high school students. The intervention was associated
with significantly increased knowledge about e-cigarettes and perceptions that e-cigarettes are harmful and
addictive, and with significantly lower intent to try e-cigarettes. At pre-test, middle school students had lower
knowledge, believed that e-cigarettes were not as addictive and showed higher intent to try both e-cigarettes and
cigarettes compared to high school students. Groups that were associated with lower perceived harmfulness and
addictiveness were: ever-users of e-cigarettes, ever-users of both e-cigarettes and cigarettes and prior users of
mint/menthol flavored e-cigarettes.
Conclusions: A school-based educational session was significantly associated with improved adolescent knowl­
edge about e-cigarettes, increased the perceived harmfulness and addictiveness of e-cigarettes, and reduced
intent to try e-cigarettes. E-cigarette education should be prioritized for middle school students due to lower
levels of knowledge and higher intent to try tobacco compared to high school students.
1. Introduction
Adolescent use of electronic cigarettes (also known as e-cigarettes or
vapes) has reached epidemic proportions in the US. Currently, e-ci­
garettes are the most commonly used tobacco product by youth
(Gentzke, Creamer, & Cullen, 2019). Although e-cigarettes arrived on
the U.S. market in 2007, adolescent use dramatically increased with
JUUL, Inc.’s introduction of pod-based e-cigarettes in 2015 (Huang
et al., 2019). National data show that from 2017 to 2019, past 30-day ecigarette use increased from 11.7% to 27.5% among high school stu­
dents and from 4.8% to 10.5% among middle school students (Cullen &
Sawdey, 2019). These trends in youth use of e-cigarettes are
concerning, as nearly all e-cigarettes sold in the US contain nicotine
(Marynak et al., 2017) and other chemicals known to harm health
(Alzahrani, Pena, Temesgen, & Glantz, 2018; Jenssen & Walley, 2019;
Margham, McAdam, & Forster, 2016; National Academies of Sciences
Engineering and Medicine, 2018; Osei et al., 2019; Riehm et al., 2019;
Wills, Pagano, Williams, & Tam, 2019). Further, nicotine-containing ecigarettes have a high addiction potential, and youth who use them are
more likely to subsequently use combustible cigarettes (Berry et al.,
2019; Chaffee & Glantz, 2018; Watkins, Glantz, & Chaffee, 2018) and
cannabis (Dai, Catley, Richter, Goggin, & Ellerbeck, 2018; Morean,
Kong, Camenga, Cavallo, & Krishnan-Sarin, 2015).
Adolescents use e-cigarettes due to the appeal of flavors (including
Abbreviations: e-cigarette, electronic cigarette; Toolkit, Stanford Tobacco Prevention Toolkit
⁎
Corresponding author at: 1600 7th Avenue South, Mcwane Suite 108, Birmingham, AL 35233, United States.
E-mail address: swalley@peds.uab.edu (S.C. Walley).
https://doi.org/10.1016/j.addbeh.2020.106519
Received 29 March 2020; Received in revised form 21 May 2020; Accepted 21 June 2020
Available online 26 June 2020
0306-4603/ © 2020 Elsevier Ltd. All rights reserved.
Addictive Behaviors 112 (2021) 106519
S.M. Gaiha, et al.
fruit, candy and dessert flavors), targeted advertising and perceptions
that e-cigarettes are less harmful than cigarettes (Gorukanti, Delucchi,
Ling, Fisher-Travis, & Halpern-Felsher, 2017; Kim, Ling, Ramamurthi, &
Halpern-Felsher, 2019; Kim, Halpern-Felsher, & Ling, 2019; McKelvey
& Halpern-Felsher, 2018; McKelvey, Baiocchi, & Halpern-Felsher, 2018;
Roditis, Cash, & Halpern-Felsher, 2016). Additionally, access to un­
reliable sources of information (Kong, Morean, Cavallo, Camenga, &
Krishnan-Sarin, 2015; Roditis & Halpern-Felsher, 2015), and a skewed,
short-term understanding of risks and benefits (Roditis et al., 2016),
suggest that youth are curious about e-cigarettes, lack information
about the social and health harms of e-cigarettes and have a limited
understanding of relative risk. Youth who have previously used e-ci­
garettes also perceive these products as less harmful and having lower
addiction potential (Amrock, Lee, & Weitzman, 2016; Amrock et al.,
2016; Cooper, Harrell, Pérez, Delk, & Perry, 2016; Gorukanti et al.,
2017; Gorukanti et al., 2017; Gorukanti et al., 2017). Given high rates
of youth e-cigarette use and misperceptions, there is a need for edu­
cation to improve youth perceptions of social and health harms related
to e-cigarettes in order to prevent and reduce e-cigarette use.
The evidence from school-based tobacco prevention programs
shows mixed results, with some programs yielding a 12%-30% reduc­
tion in smoking initiation among never-smokers (Lantz et al., 2005;
Thomas, McLellan, & Perera, 2000; Peirson, Ali, Kenny, Raina, &
Sherifali, 2016; La Torre, Chiaradia, & Ricciardi, 2015), other programs
showing positive long-term effects (Flay, 2009), and others showing no
or limited effects (Backinger, Fagan, Matthews, & Grana, 2003;
Cuijpers, 2002; Wiehe, Garrison, Christakis, Ebel, & Rivara, 1996;
Rooney & Murray, 1988; Rundall & Bruvold, 2005). Most reviews em­
phasize that programs are effective when they focus on refusal skills
and address social influences, including social media and advertising, in
addition to providing information about health harms. As of 2019, at
least six school-based e-cigarette education curricula have been devel­
oped and used (O’Connor, Bayoumy, & Schwartz, 2019), some of which
include the CATCH My Breath Youth e-cigarette prevention modules,
Physician Advocacy Network’s Vaping and JUULing lesson plans and
the Stanford Tobacco Prevention Toolkit. Overall, research evaluating
prevention programs should aim at identifying effective components
and how educators can maximize their impact (National Academies of
Sciences Engineering and Medicine, 2020). However, we first need to
examine whether such programs are associated with improved adoles­
cent perceptions and reduced intent to try e-cigarettes.
Despite the recent development of e-cigarette education programs,
there is limited evidence of their impact on adolescent perceptions and
intentions to use such products. This study examined whether a schoolbased educational session based on the Stanford Tobacco Prevention
Toolkit changed middle and high school students’ perceptions of and
intentions to try e-cigarettes. We hypothesized that this educational
session would be associated with an (1) increase in students’ knowledge
about e-cigarettes, (2) increase in the perceived harmfulness and ad­
dictiveness of e-cigarettes, and (3) decrease in student intent to try ecigarettes for the first time. In addition, before the educational session,
we also assessed factors associated with perceptions of and intentions to
try e-cigarettes to understand the starting point of participants and
factors associated with perceptions of and intentions to try e-cigarettes
after the educational session to assess the extent of curriculum impact.
online educational resource to prevent adolescent e-cigarette use. The
Toolkit is primarily delivered by health educators to adolescents, al­
though adolescents and parents also use it directly.
2.1. Study setting and participants
Participants were recruited from schools in the Birmingham metro
and surrounding areas of central and northeast Alabama. The study
team contacted schools via email, telephone, and through shared con­
tacts to determine interest and feasibility of participation in the edu­
cational program. Agreement by a school representative was the only
inclusion criteria to conduct the intervention in schools with middle
and high school students. Selected schools represented a mix of public
and private, urban and rural, and different school sizes. Study partici­
pants were 6th-12th grade students belonging to the participating se­
lected schools.
2.2. Intervention design
The intervention included a 30-minute educational presentation on
e-cigarettes, which was designed based on the https://med.stanford.
edu/tobaccopreventiontoolkit/curriculums/1-session-curriculum.html
one-session suggested curriculum on the https://med.stanford.edu/
tobaccopreventiontoolkit.html Toolkit website. The Toolkit is a free,
online and comprehensive resource on tobacco education, including
specific curricula on e-cigarettes. This curriculum was originally de­
signed and implemented in California and is based on the Theory of
Planned Behavior (Ajzen, 1985, 1991) and Positive Youth Development
framework (Bonell & Dickson, 2016). The presentation included in­
formation about e-cigarette types, contents, health effects and nicotine
addiction and the tobacco industry’s manipulation of youth through
advertising and marketing and flavors (Lantz et al., 2000) (presentation
slide in Fig. 1 and complete presentation in Supplementary material S1;
updated since on the Toolkit website). At the end of each presentation,
students asked presenters questions for 10 minutes. All educational
sessions were delivered by a physician or a public health professional
with previous experience of conducting tobacco education.
2.3. Measures
Multiple-choice survey questions were designed to ascertain in­
formation about students’ perceptions about e-cigarettes and intent to
try e-cigarettes and cigarettes. The surveys were based on content from
the educational session and adapted from items in previous surveys
(McKelvey et al., 2018; Fadus, Smith, & Squeglia, 2019; Gorukanti
et al., 2017; Barrington-Trimis & Leventhal, 2018; Roditis, Lee, &
Halpern-Felsher, 2016). The following constructs and questions were
included in the survey:
2.3.1. Knowledge about e-cigarette contents
Participants were asked, “How much do you agree/disagree with…”
two statements: ‘e-cigarettes don’t contain tar’ and ‘e-cigarettes contain
nicotine.’ Response choices were on a 4-point Likert scale, from
1 = strongly disagree to 4 = strongly agree. Agreement with any of the
two statements, i.e. responses of (3) or (4) implied that participants had
correct knowledge (coded 1), all other responses were incorrect (coded
0). Three multiple-choice questions followed. A question, ‘Which in­
gredient in many pod-based systems makes them highly addictive?’ was
asked with four response-categories: a) benzoic acid, b) extracts and
flavors, c) glycerol and d) nicotine. Participant responses as d) nicotine
were correct (coded 1), all other responses were incorrect (coded 0).
Another question asked ‘The amount of nicotine in a JUULpod is
equivalent to: a) one cigarette; b) a pack of cigarettes; c) half a pack of
cigarettes and d) pack and a half of cigarettes. Participant responses as
b) a pack of cigarettes were correct (coded 1), all other responses were
incorrect (coded 0). Finally, a question, ‘How much nicotine do you
2. Method
A one-group pre- and post-study to assess the impact of e-cigarette
education was conducted among middle and high school students in
Alabama, United States of America. The educational sessions and data
collection were completed between February and May 2019. This study
was designed as an early stage evaluation (Stage I) based on the NIH
Stage Model for Behavioral Intervention Development (Onken, Carroll,
Shoham, Cuthbert, & Riddle, 2014), as part of refining and testing the
Stanford Tobacco Prevention Toolkit (hereon referred to as Toolkit), an
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Addictive Behaviors 112 (2021) 106519
S.M. Gaiha, et al.
Fig. 1. A slide from the educational presentation on e-cigarette flavors (available on the Stanford Tobacco Prevention Toolkit website).
did not increase because they intended to avoid e-cigarettes (as an
unintended consequence).
think JUULpods contain?’ was asked with six response categories: a)
0 mg/ml; b) 12 mg/ml; c) 36 mg/ml; d) 59 mg/ml; e) 72 mg/ml; and f)
Don't know. Participant responses as d) 59 mg/ml were correct (coded
1), all other responses were incorrect (coded 0). A new ordinal variable,
“knowledge about e-cigarette contents,” was created, with scores ran­
ging from 0 (all incorrect) to 5 (all correct).
2.3.5. Ever use and past 30 day use of tobacco products
Ever-use of tobacco products was asked in the question, “During
your entire life, about how many times have you ever… a) smoked a
cigarette, even 1 or 2 puffs; b) used JUULs or other pod-based e-ci­
garette or vape products such as Suorin Drop or Phix (even 1 or 2 puffs);
and c) used e-cigarettes/vapes, even 1 or 2 puffs (not including JUULs
or other pod-type e-cigarettes or vapes).” Response choices included
never, 1–2 times, 3–10 times, 11–19 times, 20–30 times, 31–99 times,
and 100 or more times. Past 30 day use of tobacco products was asked
in the question, “During the last 30 days, on about how many days, did
you… a) smoke a cigarette, even 1 or 2 puffs; b) used JUULs or other
pod-based e-cigarette or vape products such as Suorin Drop or Phix
(even 1 or 2 puffs); and c) used e-cigarettes/vapes, even 1 or 2 puffs
(not including JUULs or other pod-type e-cigarettes or vapes).”
Responses were categorized in four categories of users, i.e. those who
used: (1) cigarettes only, (2) e-cigarettes only (combining pod-based ecigarettes and other e-cigarettes in to a single category representing ecigarettes), (3) both e-cigarettes and cigarettes, and 4) never-users.
2.3.2. Harmfulness of e-cigarettes
Participants were asked “How much do you agree/disagree with…”
three statements: ‘e-cigarettes are not a tobacco product,’ ‘smoke from
e-cigarettes is just harmless water vapor’ and ‘e-cigarettes help people
quit conventional smoking.’ Response choices were on a 4-point Likert
scale, where (1) = strongly disagree, (4) = strongly agree.
Disagreement with any of the three statements (i.e., responses of (1) or
(2)) implied that participants identified e-cigarettes as harmful (coded
1) and disagreement with any of the four statements (i.e., responses of
(3) or (4)) implied that participants identified e-cigarettes as less
harmful (coded 0). An additional question, ‘What do we not know about
pod-based systems?’ was asked with four response-categories: a) all the
specific ingredients; b) long-term effects of using it; c) effects of nicotine
on the brain and d) both a & b. Participant responses as d) implied that
participants identified e-cigarettes as harmful (coded 1), all other re­
sponses implied that participants identified e-cigarettes as less harmful
(coded 0). A new, ordinal variable on “harmfulness of e-cigarettes,” was
created to include all four questions described above, with scores ran­
ging from 0 (did not identify e-cigarettes as harmful in any statement)
to 4 (identified e-cigarettes as harmful in all statements).
2.3.6. Flavors used
Participants were asked “What flavors of e-cigarettes have you ever
used?” with five response categories: tobacco; mint/menthol; candy,
fruit and dessert; alcohol or cocktail; and more than one flavor.
2.4. Data collection procedures
2.3.3. Addictiveness
Participants were asked a question: “How addictive do you think ecigarettes are?” and “How addictive do you think cigarettes are?”
Response choices were on a 5-point Likert scale, where 1 = not at all
addictive and 5 = extremely addictive.
E-cigarette education delivered in this study was during regular
health education classes in participating schools. Students were pro­
vided a parental opt-out form and students were asked to provide
verbal consent and assent to voluntarily participate in the educational
session and survey. All students provided verbal assent. Only five par­
ents opted their children out of this study. No students indicated that
they did not wish to participate.
Students were provided a paper-based survey immediately before
(pre-test) and immediately after the educational session (post-test).
Surveys were administered by the tobacco prevention educators who
conducted the educational session and school teachers. The surveys
2.3.4. Intent to try e-cigarettes and cigarettes in the future
Participants were asked: “How likely is it that you will ever try (ecigarettes, cigarettes) for the first time?” Response choices were on a 4point Likert scale, where 1 = very unlikely and 4 = very likely.
Measures on intent to try cigarettes were included to ensure that after
receiving the e-cigarette education, participant intent to try cigarettes
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S.M. Gaiha, et al.
3.3. Impact on adolescent perceptions about e-cigarette content,
harmfulness and addictiveness
took approximately 5–10 min to complete. The pre- and post-test survey
with correct answers highlighted can be accessed in Supplementary
material S2. Data were entered and reviewed by two team members
(AD and LS) and discrepancies were resolved by the senior author (SW).
This study was approved by the Institutional Review Board at the
University of Alabama at Birmingham.
The educational session was significantly associated with an in­
crease in participants’ knowledge about e-cigarettes, an increase in the
perceived harmfulness of e-cigarettes and increase in the perceived
addictiveness of both e-cigarettes and cigarettes (Table 1). Most parti­
cipants knew that nicotine is the addictive ingredient in pod-based
systems (~96%), and the educational session did not significantly im­
prove such knowledge among participants.
2.5. Statistical analysis
Summary tables of pre-test and post-test results on perceptions and
intent to try tobacco products were developed, with corresponding
McNemar’s chi-squared exact tests of paired proportions. Next, multilevel mixed-effects ordered logistic regression models were generated to
assess factors associated with variables related to each study outcome:
knowledge about e-cigarette contents, perceived harmfulness, per­
ceived addictiveness of e-cigarettes and cigarettes and intent to try ecigarettes and cigarettes, both at pre-test and at post-test. Independent
variables included school level (high school vs middle school), use of
tobacco products (ever-used vs never-used). For models related to
perceived addictiveness, flavors were added as a covariate since pre­
vious studies showed that flavored e-cigarette users find e-cigarettes
less addictive (Cooper et al., 2016). All models were adjusted for
varying class-size and school-level clustering effects. Data were missing
completely at random due to participants’ returning surveys with in­
complete questions; a pairwise deletion of missing data between pretest and post-test was conducted for all survey variables. Analyses were
conducted in Stata/SE Version 15.1 (Statistical, 2017). To avoid re­
porting bias and to provide adequate information from this initial study
for future research, precise p-values were reported (up to three decimal
places) (Chan, Hróbjartsson, Haahr, Gøtzsche, & Altman, 2004).
3.4. Impact on adolescent intent to try e-cigarettes
Participants’ intent to try e-cigarettes was significantly lower at
post-test compared to pre-test (Table 2). Overall, middle school stu­
dents’ intent to try e-cigarettes and combustible cigarettes was higher
than high school students’ intent to try these products. Among middle
school students, the intent to try combustible cigarettes also reduced
significantly between pre-test and post-test, and there was no change
among high school students.
3.5. Factors influencing adolescent perceptions and intent to try at pre-test
To understand the starting point of participants prior to the edu­
cational session, we ran models to assess factors associated with pre-test
perceptions and intent to try tobacco products (Table 3). In a model,
pre-test knowledge of e-cigarette contents was 22% lower among
middle school students compared to high school students and ap­
proximately 2.5 times higher if participants had ever used e-cigarettes
and both cigarettes and e-cigarettes. At pre-test, participants were 60%
less likely to believe that e-cigarettes were harmful if they had everused e-cigarettes only and 76% less likely to perceive that e-cigarettes
were harmful if they had ever used both e-cigarettes and cigarettes.
Participants were 57% less likely to perceive e-cigarettes as addic­
tive at pre-test if they previously used both cigarettes and e-cigarettes
and 29% less likely to perceive e-cigarettes as addictive at pre-test if
they had previously used more than one flavor of e-cigarettes. At pretest, middle school students were 25% less likely to perceive cigarettes
as addictive compared to high school students and participants were
less likely to perceive cigarettes as addictive: by 56% if they had ever
used cigarettes only; by 49% if they had ever used e-cigarettes only; and
by 62% if they had ever used both e-cigarettes and cigarettes. At pretest, ever-use of e-cigarettes only and of both cigarettes and e-cigarettes
were common factors associated with lower perceived harmfulness
from e-cigarettes and lower addictiveness of cigarettes compared to
never users. Intent to try e-cigarettes and cigarettes at pre-test was
about 1.5 times higher among middle school students compared to high
school students.
3. Results
3.1. Delivery of educational sessions
The educational session was delivered to 3,073 students in 11
schools, with 94% of all participants completing both pre- and post-test
surveys (n = 2,889). The maximum percentage of missing data for any
question in surveys returned by participants was 20%. The schools in­
cluded seven high schools and four middle schools; six public schools,
four private schools and one magnet school. Nine schools were from
urban areas and two schools were from rural areas (as per US Census
categorization); the school size based on the number of students per
school ranged from 317 to 1,661.
3.2. Patterns of tobacco use among participants
3.6. Factors influencing adolescent perceptions and intent to try at post-test
Ever use of tobacco products reported by middle and high school
students is summarized in Fig. 2. Among middle school students, 20%
had ever-used any tobacco product (either a cigarette, e-cigarette or
both) and among high school students, 34% had ever-used any tobacco
products. Exclusive use of pod-based e-cigarettes accounted for 52% of
all e-cigarette use, use of both pod-based e-cigarettes and other e-ci­
garettes accounted to 41% of all e-cigarette use while exclusive use of
other e-cigarettes only contributed 7% of all e-cigarette use. Thus, podbased e-cigarettes contributed the most to e-cigarette use. Past 30 day
use of any tobacco product among middle school students was 10% and
past 30 day use of any tobacco product among high school students was
15%. Across all participants, 21% of participants had previously used a
flavored e-cigarette product, including 16% who used more than one
flavor; 3% who used candy, fruit and dessert flavors; 1.5% used mint/
menthol; and < 1% used tobacco and alcohol or cocktail flavors.
To assess the extent of impact from the educational session, our
models assess other factors associated with participant post-test per­
ceptions and intentions (Table 4). In a model, knowledge of e-cigarette
contents at post-test was significantly more likely to improve by 130%
if participants were already aware of some information at pre-test,
however, post-test knowledge was 21% lower among middle school
students compared to high school students. At post-test, participants
were 2.7 times more likely to believe that e-cigarettes were harmful if
they believed these products were harmful at pre-test, however, middle
school students were 25% less likely to believe that e-cigarettes were
harmful compared to high school students and users of both e-cigarettes
and cigarettes were 45% less likely to believe that e-cigarettes were
harmful compared to never-users.
Participants were 3.5 times more likely to perceive e-cigarettes as
addictive at post-test if they believed that e-cigarettes were addictive at
4
Addictive Behaviors 112 (2021) 106519
S.M. Gaiha, et al.
Fig. 2. Types of tobacco ever users, by school level (%, n = 2,647).
Table 1
Comparison of adolescent perceptions at pre-test and post-test (% agreeing with statements)*
Perceptions
Knowledge about e-cigarette contents
E-cigarettes don’t contain tar
E-cigarettes contain nicotine
Nicotine is the addictive ingredient in pod-based systems
One JUUL pod contains 59 mg/ml of nicotine
A JUUL pod contains nicotine equivalent to one pack of cigarettes
Harmfulness
E-cigarettes are a tobacco product
The specific ingredients in pod-based systems and their long-term effects are not known
E-cigarette smoke is not harmless water vapor
E-cigarettes do not help with cessation
Addictiveness of…
Cigarettes
E-cigarettes
Pre-test (%)
Post-test (%)
N
p-value
23.81
95.79
91.33
22.35
72.05
17.36
96.09
93.13
81.74
83.88
2591
2614
2548
2689
2698
< 0.001
0.554
0.002
< 0.001
< 0.001
79.31
63.22
90.66
60.14
89.71
65.94
93.66
81.00
2605
2613
2666
2632
< 0.001
0.008
< 0.001
< 0.001
74.29
84.55
84.51
88.54
2672
2706
< 0.001
< 0.001
*Higher % agreeing with statements at post-test compared to pre-test indicates higher knowledge about e-cigarette contents, higher perceived harmfulness of ecigarettes and higher perceived addictiveness, respectively.
Table 2
Comparison of adolescent intent to try tobacco products at pre-test and post-test (in %)*
Intent to try…
E-cigarettes
Cigarettes
All participants
Middle school
High school
Pre-test (%)
Post-test (%)
N
p-value
Pre-test (%)
Post-test (%)
N
p-value
Pre-test (%)
Post-test (%)
N
p-value
17.96
8.38
14.76
7.58
1998
2255
< 0.001
0.176
19.30
10.03
16.89
8.27
1036
1136
0.022
0.049
16.52
6.70
12.47
6.88
962
1119
< 0.001
0.900
*Lower % at post-test compared to pre-test indicates decreased intent to try.
middle school students compared to high school students. Intent to try
cigarettes at post-test was 34 times higher among participants who
intended to try cigarettes at pre-test.
pre-test and were 59% less likely to perceive e-cigarettes as addictive at
post-test if they had previously used mint/menthol flavors and 95% less
likely to perceive e-cigarettes as addictive if they reported previously
using alcohol flavored e-cigarettes. Participants were 3.5 times more
likely to perceive cigarettes as addictive if they believed that cigarettes
were addictive at pre-test, and were 49% less likely to perceive cigar­
ettes as addictive if they ever-used both e-cigarettes and cigarettes. At
post-test, ever-use of both cigarettes and e-cigarettes was a common
factor associated with lower perceived harmfulness of e-cigarettes and
lower addictiveness of cigarettes compared to never users. Intent to try
e-cigarettes at post-test was 36 times higher among participants who
intended to try e-cigarettes at pre-test and 1.5 times higher among
4. Discussion
4.1. Summary of evidence
Overall, the 30-minute educational session based on the Stanford
Tobacco Prevention Toolkit curriculum on e-cigarettes was associated
with significant changes in nearly all study outcomes related to
knowledge about e-cigarette contents, perceptions of harmfulness of e5
Addictive Behaviors 112 (2021) 106519
S.M. Gaiha, et al.
Table 3
Factors associated with pre-test knowledge, perceptions and intent to try to­
bacco products.*
OR
95%CI
Table 4
Factors associated with post-test outcomes of knowledge, perceptions and in­
tent to try tobacco products*
p-value
OR
Pre-test knowledge of e-cigarette content associated with…
Middle school vs high school
Ever-use of tobacco products
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
0.78
0.65, 0.93
0.006
0.89
2.41
2.64
0.46, 1.72
1.93, 3.00
2.11, 3.25
0.744
< 0.001
< 0.001
Pre-test knowledge of e-cigarette contents
Middle school vs high school
Ever-use of tobacco products vs no use
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
0.87
0.73, 1.04
0.154
0.53
0.40
0.24
0.26, 1.05
0.32, 0.49
0.19, 0.31
0.073
< 0.001
< 0.001
Prior use of flavors
Tobacco
Mint/menthol
Candy, fruit or dessert flavors
Alcohol
More than one flavor
0.93
0.78, 1.11
0.468
0.57
1.13
0.43
0.30, 1.08
0.83, 1.54
0.30, 0.62
0.085
0.422
< 0.001
0.37
1.47
0.79
–
0.71
0.11, 1.29
0.72, 3.01
0.47, 1.32
0^
0.51, 0.99
0.122
0.286
0.385
–
0.044
Perceived harmfulness of e-cigarettes at
pre-test
Middle school vs high school
Ever-use of tobacco products vs no use
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
0.75
0.63, 0.89
< 0.001
0.44
0.51
0.38
0.24, 0.82
0.41, 0.62
0.30, 0.49
0.009
< 0.001
< 0.001
Perceived addictiveness of e-cigarettes at
pre-test
Middle school vs high school
Ever-use of tobacco products vs no use
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
Prior use of flavors
Tobacco
Mint and menthol
Candy, fruit or dessert flavors
Alcohol
More than one flavour
1.09, 1.85
0.007
1.42
Perceived addictiveness of cigarettes at
pre-test
Middle school vs high school
Ever-use of tobacco products vs no use
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
Intent to try cigarettes at pre-test associated with…
Middle school vs high school
1.56
1.15, 2.13
< 0.001
0.026
1.65
1.22
1.01
0.72, 3.74
0.94, 1.59
0.74, 1.37
0.917
0.130
0.228
2.71
2.46, 2.99
< 0.001
0.75
0.62, 0.92
0.006
0.77
0.85
0.55
0.37, 1.59
0.67, 1.09
0.42, 0.73
0.494
0.216
< 0.001
3.54
3.20, 3.92
< 0.001
0.95
0.77, 1.18
0.685
1.08
1.15
0.87
0.48, 2.39
0.80, 1.65
0.57, 1.33
0.844
0.442
0.543
0.42
0.41
0.69
0.05
0.82
0.10, 1.99
0.19, 0.87
0.38, 1.27
< 0.01, 0.61
0.60, 1.35
0.253
0.020
0.223
0.016
0.343
Perceived addictiveness of cigarettes at post-test associated with…
Intent to try e-cigarettes at pre-test associated with…
Middle school vs high school
2.05, 2.55
0.64, 0.97
Perceived addictiveness of e-cigarettes at post-test associated with…
Perceived addictiveness of cigarettes at pre-test associated with…
Middle school vs high school
Ever-use of tobacco products vs no use
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
2.29
0.79
Perceived harmfulness of e-cigarettes at post-test associated with…
Perceived addictiveness of e-cigarettes at pre-test associated with…
Middle school vs high school
Ever-use of tobacco products
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
p-value
Knowledge of e-cigarette contents at post-test associated with…
Perceived harmfulness of e-cigarettes at pre-test associated with…
Middle school vs high school
Ever-use of tobacco products
Cigarettes only
E-cigarettes only
Both cigarettes and e-cigarettes
95%CI
0.004
3.52
3.20, 3.87
< 0.001
0.95
0.78, 1.16
0.650
0.74
0.80
0.51
0.35, 1.53
0.62, 1.02
0.39, 0.67
0.417
0.079
< 0.001
Intent to try e-cigarettes at post-test associated with…
*Significant p-values are shown in bold; ^too few responses.
Intent to try e-cigarettes at pre-test
Middle school vs high school
cigarettes, addictiveness of e-cigarettes and cigarettes and intent to try
e-cigarettes. The educational session was also significantly associated
with lower intent to try cigarettes among middle school students at
post-test, which is especially important since middle school students’
intent to try cigarettes was higher than for high school students. The
educational session was not associated with any increase in participant
intent to use cigarettes, as a potential unintended consequence. After
the educational session, participants felt that e-cigarettes were less
addictive if they had previously used mint/menthol or alcohol flavors,
which implies that participants understood session content that candy,
fruit and dessert flavors attract youth and were potentially addictive.
Given the short time frame from pre-test to educational exposure and
post-test, changes in perceptions and intent may be wholly attributed to
the educational session, although could be due to other factors.
Common factors associated with poor knowledge about e-cigarettes and
perceptions that e-cigarettes are not harmful that may perpetuate use of
e-cigarettes at post-test include use of both e-cigarettes and cigarettes
and attending middle school versus high school. While the educational
session changed perceptions and intent between pre- and post-test, a
strong association between post-test perceptions and intent to try ecigarettes and pre-test perceptions and intent to try e-cigarettes
36.19
1.52
26.21, 49.97
1.07, 2.15
< 0.001
0.018
23.49, 50.75
0.65, 1.48
< 0.001
0.961
Intent to try cigarettes at post-test associated with…
Intent to try cigarettes at pre-test
Middle school vs high school
34.53
0.98
*Significant p-values are shown in bold.
demonstrates a need for additional, more intensive educational pro­
gramming or booster sessions in the future.
4.2. Study strengths and limitations
Our study provides evidence that a brief, one-time school-based
educational session on tobacco, including e-cigarettes, is associated
with improved knowledge about e-cigarette contents, perceptions of
harmfulness and addictiveness, and reduced intent to try e-cigarettes.
Studies evaluating other e-cigarette education have the following
drawbacks: post-test only designs (Morrill, Abel, Januszweski, &
Chamberlain, 2017; Pentz, Hieftje, & Pendergrass, 2019); limited to
either high school (Morrill et al., 2017) or middle school only (Ly,
2015) and not both; provide individualized interventions only instead
6
Addictive Behaviors 112 (2021) 106519
S.M. Gaiha, et al.
perceptions of harmfulness and addictiveness and intent to try e-ci­
garettes, taking forward recommendations from a core components of
programs approach to evidence-based practice (National Academies of
Sciences Engineering and Medicine, 2020). As development and im­
plementation of these e-cigarette-related modules and programs is re­
latively new (< 5 years), development of booster sessions to prolong
the effects of such education and short-term and long-term evaluation
of all such curricula should be conducted. In the medium to long-term,
assessing self-reported actual behavior may be preferred to intentions to
try tobacco products as a proximal outcome. Finally, since e-cigarette
use among high school students in Alabama is similar to national rates
(approximately 24% in 2015) (Centers for Disease Control and
Prevention), there likely exists a need and potential to implement ecigarette education in other states.
of classroom-based prevention in groups (Pentz et al., 2019); and report
limited numbers (maximum 357 participants) (Ly, 2015).
Our study has several advantages over previous studies in terms of
evaluation design due to the use of pre- and post-assessment methods
and number of participants reached. Implementation of the educational
session in multiple middle and high schools with varying classroom
sizes highlight that the intervention is feasible and flexible for educa­
tors to readily adapt. Further, organizing sessions during school hours
offers the potential for integration within the school schedule, and
likely future sustainability. Unlike other tobacco education interven­
tions that only affect a single participant at a time (Pentz et al., 2019),
our group-educational session potentially helped to address social
norms and social influences, especially from peers. Finally, this study
shows that middle school students particularly require educational
sessions as they have poor knowledge of e-cigarette contents and are
less likely to believe that e-cigarettes are harmful.
There are some limitations to the study. Due to concerns over par­
ticipant confidentiality, the only demographic information obtained
from students was their grade level. Small class sizes in some schools
made it challenging to collect demographic information as it could lead
to potentially identifying information on individuals. As a first step
towards evaluation of an e-cigarette education program, this study used
a non-randomized, no control group design to assess feasibility and test
for changes between pre- and post-test perceptions and intent at-scale.
Cluster randomized controlled trials, with an intention to treat analysis,
are needed to determine whether the impact of this intervention is
generalizable. Future studies may also assess actual use behaviors in­
stead of intent to try e-cigarettes, which was the most proximal out­
come in the time period to reasonably assess impact of the educational
session on participants.
5. Conclusion
This study demonstrates that school-based, one-session e-cigarette
education was associated with improved knowledge about e-cigarettes,
perceptions of harmfulness and addictiveness and lower intent to try ecigarettes. Middle school students had lower levels of knowledge and
higher intent to try tobacco products compared to high school students.
Educating middle school students about e-cigarette contents, harms and
addictiveness may prevent or delay e-cigarette and even cigarette use.
This study may be utilized to expand and refine curricula specifically on
e-cigarettes, by focusing on mint/menthol flavors and tailoring educa­
tion to middle school students. Future research may also include a
controlled experimental study to examine further effectiveness of e-ci­
garette education.
6. Role of the funding source
4.3. Implications from implementing e-cigarette education
The research reported in this paper was supported by California’s
Tobacco-related Disease Research Program to conduct an evaluation of
the Tobacco Prevention Toolkit (27IR-0043 [BHF]) and the Alabama
Department of Public Health Youth Tobacco Prevention Program Grant
(SW). The funding sponsors had no involvement in the design, collec­
tion, analysis, or interpretation of data, writing the manuscript, and the
decision to submit the manuscript for publication.
The design and implementation of this educational session has
practical implications for the modification of the Toolkit and design of
future tobacco education curricula specifically on e-cigarettes. First, ecigarette education should be initiated among middle school students,
as they reported poorer knowledge and misperceptions compared to
high school students. Second, e-cigarette education curricula must ex­
plicitly state that mint/menthol and alcohol are flavors that are used to
appeal to youth, especially since they are the next, most popular after
candy, fruit and dessert flavors (McKelvey et al., 2018; Soneji, Knutzen,
& Villanti, 2019; Vogel, Prochaska, Ramo, Andres, & Rubinstein, 2019).
In our study, the educational session was effective in persuading stu­
dents that e-cigarettes were addictive; however, after the session, par­
ticipants who used mint/menthol and alcohol flavors were less likely to
find e-cigarettes addictive. These results may be due to the fact that the
visual elements in our educational presentation extensively discussed
candy, fruit and dessert flavors, but mint/menthol and alcohol flavors
were only mentioned orally. Third, since some students suggested that
they previously used Cannabidiol (CBD) flavored e-cigarettes, and as
the link between vaping-related lung illnesses and Vitamin E in THCcontaining e-cigarettes emerges (Tetrahydrocannabinol, THC) (Centers
for Disease Control and Prevention, 2019), future curricula should ad­
dress THC and CBD as e-cigarette additives. Fourth, prior use of tobacco
products, and specifically pod-based e-cigarettes, likely influences how
participants engage with curriculum terms and content. For example,
knowledge about e-cigarettes at post-test increased among prior users
compared to non-users of tobacco. Thus, content may be modified to
explain more about e-cigarettes to non-users and focus on harmfulness
and addictiveness among ever-users. These content and design mod­
ifications will help to better align tobacco education to youth in­
formation needs, perceptions and behavior.
Future studies should focus on evaluating diverse activities and
expanded durations of the educational curricula to identify which
components are effective in improving knowledge of e-cigarettes,
7. Contributors’ statement
Dr. Gaiha drafted the initial manuscript, and collectively with Ms.
Duemler, Dr. Halpern-Felsher, Ms. Razo, Ms. Silverwood and Dr. Walley
reviewed and revised the manuscript. Ms. Razo, Ms. Duemler, Ms.
Silverwood, Dr. Halper-Felsher and Dr. Walley designed the data col­
lection instruments and procedures. Dr. Halpern-Felsher and Dr. Walley
adapted the Stanford Tobacco Prevention Toolkit to develop the edu­
cational session in this study. Ms. Duemler and Dr. Walley implemented
the educational session, collected data and carried out preliminary
analyses. Dr. Walley and Dr. Halpern-Felsher conceptualized and de­
signed the study, and critically reviewed the manuscript for important
intellectual content. All authors approved the final manuscript as sub­
mitted and agree to be accountable for all aspects of the work.
Declaration of Competing Interest
Bonnie Halpern-Felsher is the founder and executive director of the
Stanford Tobacco Prevention Toolkit, a free, online resource that was
used as the foundation of the educational session in this study. The
authors declare that they have no other conflict of interest.
Acknowledgements
We would like to thank all participating schools and students.
7
Addictive Behaviors 112 (2021) 106519
S.M. Gaiha, et al.
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